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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 4  |  Page : 117-123

Assessing the effect of pomegranate fruit seed extract mouthwash on dental plaque and gingival inflammation


1 Oral and Dental Disease Research Center, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran
2 Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
3 Students' Research Committee, School of Dentistry, International Branch, Shiraz University of Medical Sciences, Shiraz, Iran

Date of Web Publication13-Feb-2017

Correspondence Address:
Farin Kiany
Oral and Dental Disease Research Center, School of Dentistry, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2915.200016

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  Abstract 

Background: Utilizing natural products in the prevention and treatment of periodontal diseases has been increased recently and could be of benefit to low-socioeconomic level communities. Mouthwashes are very useful in the reduction of microbial plaque and gingival inflammation. Pomegranate (Punica granatum ) is an essential medicinal plant with various pharmacological properties. In this study, the efficacy of a mouthwash prepared from the extract of pomegranate fresh fruit, was evaluated in the reduction of dental plaque and gingival bleeding. Materials and Methods: One hundred and four participants diagnosed as mild to moderate gingivitis participated in this double-blind clinical trial. Two weeks after thorough scaling and root planing, the participants were randomly and equally divided into four groups: group 1 - Persica, Group 2 - Matrica, Group 3 - pomegranate mouthwashes, and Group 4 - placebo. The participants were instructed to use the prescribed mouthwashes, twice daily, for 1 month. Pomegranate mouthwash was prepared from seeds of fresh pomegranate fruit. Periodontal parameters including plaque and bleeding indices were assessed at baseline (2 weeks after Phase I of treatment) and 1 month after using mouthwashes. Results: Comparison of the plaque index showed a significant reduction from baseline to 1 month in all groups (P < 0.05). However, there was no significant difference in reduction of plaque when comparing four groups. Assessment of the bleeding on probing revealed a significant decrease from baseline to 1 month in all groups (P < 0.05). The three herbal mouthwashes reduced the bleeding index significantly more than the placebo (P < 0.05). Conclusion: Pomegranate mouthwash was beneficial in improving gingival status, including reducing plaque and bleeding indices. Its effect was comparable to two routinely used herbal mouthwashes.

Keywords: Dental plaque, Matrica, mouthwash, Persica, pomegranate, Punica granatum


How to cite this article:
Kiany F, Niknahad H, Niknahad M. Assessing the effect of pomegranate fruit seed extract mouthwash on dental plaque and gingival inflammation. J Dent Res Rev 2016;3:117-23

How to cite this URL:
Kiany F, Niknahad H, Niknahad M. Assessing the effect of pomegranate fruit seed extract mouthwash on dental plaque and gingival inflammation. J Dent Res Rev [serial online] 2016 [cited 2017 Jun 24];3:117-23. Available from: http://www.jdrr.org/text.asp?2016/3/4/117/200016


  Introduction Top


Good oral health has a major influence on one's general health and quality of life. Several chronic and systemic diseases have been attributed to poor oral health. Dental caries and gingivitis are the most important multifactorial diseases of the oral cavity. With the increasing incidence of oral diseases, the global need for alternative prevention and treatment methods and safe, effective, and economical products has been expanded. The maintenance of oral health can be achieved mainly by mechanical and chemical means.[1] Recently, the use of natural products for the prevention and treatment of oral pathologic conditions has been increased, and it could be beneficial to low-socioeconomic level urban and rural communities.[2]

Periodental diseases start with plaque, which is a sticky film of food, saliva, and bacteria. Dental plaque is usually a pale yellow biofilm, which is naturally developed on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to the tooth's smooth surface. Researchers have shown that many of the mouthwashes are very useful in the reduction of microbial plaque, by the way of inhibiting the formation of plaque polysaccharide matrix.[3] Among available mouthwashes, chlorhexidine is usually used as a positive control to compare the efficacy of other products in most studies since it is believed to be an excellent choice.[4],[5] However, the incidence of side effects such as undesirable tooth discoloration, unpleasant taste, dryness, and burning sensation in the mouth discourage patients to use this mouthwash.[6],[7]

Recently, the use of herbal mouthwashes is increasing in the world. Persica and Matrica are two available herbal mouthwashes in Iran. Persica is prepared mainly from Salvadora persica extract, commonly known as “miswak” that belongs to the family of Salvadoracea. Persica mouthwash contains two other medicinal plants, yarrow and mint in its formulation.[8],[9] The beneficial effects of miswak in respect to oral hygiene and dental health are partially due to its mechanical action and partially due to its pharmacological effects.[10] It has been claimed that miswak sticks may have antiplaque effects and may also affect the pathogenesis of periodontal diseases by reducing the virulence of periodontal pathogens. In the form of mouthwash, it has been shown to decrease gingival bleeding and cariogenic bacteria significantly.[11] Matrica is another herbal mouthwash that contains herbal extract of Chamomile flower (Matricaria chamomilla). This plant is a member of Asteraceae/Compositae family.[12] Different studies have shown that the use of these herbal medicines or their extracts would support periodontal health and reduce the accumulation of microbial plaque and bleeding during brushing, thus controlling gingivitis and periodontal diseases.[13],[14]

In this research, a new mouthwash produced from pomegranate (Punica granatum) seed extract was evaluated for its antiplaque and anti-inflammatory effects.

Pomegranate is mostly native to Iranian plateau and Himalayas in Northern India, and its fruit is a common edible fruit, especially in Iran.

Pomegranate is an important medicinal plant in Iran. Its flowers are used as astringent, hemostatic, antibacterial, antifungal, and antiviral agent. Powder prepared from its rind is used as tooth powder and also as medicine in cosmetic industries. Actually pomegranate components have been used as a strong astringent and a popular remedy in folk medicine throughout the world.[15],[16]

Clinical studies have shown that pomegranate antioxidant contents can attack the causes of tooth decay at the biochemical level.[17],[18],[19],[20],[21],[22]

As it was emphasized, it has previously been demonstrated that different parts of pomegranate (bark, peel, flower, seed, pomace, etc.,) contain many components that have direct and indirect antioxidant, anti-inflammatory, and antibacterial effects.[19],[23]

A number of researches have indicated that pomegranate and its extract may serve as natural alternatives to chemical antimicrobial products due to their potency against a wide range of bacterial and viral pathogens. Nearly, every part of the pomegranate plant has been tested for antimicrobial activities, including the fruit juice, peel, arils, flowers, and bark. Many studies have utilized pomegranate peel with success. In some cases, the combination of the pomegranate constituents offers the most benefit. The positive clinical results on pomegranate and suppression of oral bacteria are intriguing and worthy of further studies.[13]

In this clinical trial, the anti-inflammatory and plaque-reducing activity of extract of pomegranate seed was compared to two regularly used herbal mouthwashes in Iran, Persica, and Matrica.


  Materials and Methods Top


This double-blind parallel design clinical trial study was conducted on 104 volunteers from both sexes (58 females and 46 males), age ranging from 15 to 45 years, with mild or moderate gingivitis. The volunteers were randomly selected from dental students of the International Branch of Shiraz Dental School and from patients who were referred for periodontal treatment to periodontology department of this dental school. Patients with systemic disorders, participants with a history of antimicrobial or corticosteroid therapy for 2 months before the study, those with a history of periodontal treatment or mouthwash usage for 6 months before the study, smokers, pregnant or breastfeeding women, and persons with fixed or removable orthodontic appliances or removable partial dentures were excluded from the study. All of the volunteers had at least twenty teeth (except wisdom teeth). Informed consents were obtained from all of the participants. After thorough scaling, root planing, and polishing, the participants were randomly distributed into the following groups and instructed to use 15 ml of prescribed mouthwashes twice daily (morning and night, for 40 s) for 1 month:

  • Group 1 (n = 26): Persica mouthwash
  • Group 2 (n = 26): Matrica mouthwash
  • Group 3 (n = 26): Pomegranate mouthwash
  • Group 4 (n = 26): Placebo.


The participants were advised to avoid from eating, drinking, and brushing at least 1 h after using mouthwashes.

Data were collected at baseline (2 weeks after scaling) and 1 month after utilizing the mouthwashes using the following indices:

  • Plaque index (Tureskey – Gilmore–Glickman modification of Quigley-Hein)[24]
  • Bleeding index (Lenox).[25]


Scaling and root planing were performed to establish standardized conditions of the periodontium for all the participants. The first measurement of indices was performed 2 weeks after the baseline scaling and root planning, to let reepithelialization of the gingival sulcus. During the trial, no emphasis was placed on oral hygiene procedures and each participant kept on his/her own oral hygiene performance.

Scaling and root planing and measurement of indices were performed by one clinician who was blind to the groups. The mouthwashes were prescribed and handed by a second person and were prepared in a uniform preparation. After 2 weeks, all the participants were recruited and the compliance was checked and their complaints about the taste of the mouthwashes or any sensitivity reaction after its usage were recorded.

Preparation of pomegranate mouthwash

Pomegranate mouthwash was prepared from the extract of the pomace of fresh fruit of pomegranate that were cut into small pieces, after removing the rind of the fruit. After cold pressing and blending of the pieces, the blend was filtered and the seeds were separated from the extract. The obtained extract was filtered through several layers of gauze, and then, it was diluted by adding equal volume of distilled water containing 0.4% methylparaben as preservative and 0.04% sodium saccharine. The extract was then pasteurized and prepared as ready to use solution in the form of drop dosage form in 60 ml containers.

Placebo had the same volume of distilled water plus all the other contents of the formulation except the fruit seed extract.

Matrica (Bareej Essence, Iran) and Persica (Poursina, Iran) were purchased from a local pharmacy.

Statistics for analyzing data

Kruskal–Wallis H-test (Pairwise comparisons) and Mann–Whitney U-test were used for statistical analysis. P value was adjusted at <0.05.


  Results Top


A total of 104 participants (58 females and 46 males) participated in this study with the mean age of 25.3 ± 0.123 years.

Plaque index

Comparison of plaque index showed a significant reduction from baseline to 1 month in all groups (P < 0.05) [Table 1].
Table 1: Plaque index of four mouthwashes at baseline and after 1 month

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There was no significant difference in reduction of plaque when comparing four groups [Table 2].
Table 2: Comparison of decrease in plaque index from baseline to 1 month in four groups

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Bleeding index

Analysis of bleeding on probing revealed a significant decrease from baseline to 1 month in all groups (P < 0.05) [Table 3].
Table 3: Bleeding index of four mouthwashes at baseline and after 1 month

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By comparing the mean of decrease in four groups, it was shown that the three herbal mouthwashes reduced the bleeding index significantly more than the placebo (P < 0.05) [Table 4].
Table 4: Comparison of decrease in bleeding index from baseline to 1 month in four groups

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Comparison of both indices from baseline to 1 month with P value is reported in [Table 5].
Table 5: Comparison of decrease in plaque and bleeding indices from baseline to 1 month in 4 groups

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Analyzing the questionnaire that was about the taste and acceptability of the mouthwashes revealed that pomegranate had the best taste and tolerability among three mouthwashes plus placebo. 92.3% of the users of pomegranate mouthwash declared good taste [Table 6].
Table 6: Comparison of the taste of mouthwashes and placebo

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  Discussion Top


Dental plaque is the primary etiologic factor in gingival inflammation. Hence, daily and effective supragingival plaque control is necessary to arrest its progression to periodonitis.[26] Although mechanical plaque control methods have the potential to maintain adequate levels of oral hygiene, studies have shown that such methods are not being employed accurately.[27] Therefore, several chemotherapeutic agents have been developed to control bacterial plaque. In an urge of looking for better antiplaque and antigingivitis agents with limited side effects as compared to chemical products, various herbal mouthwashes have been tried with fruitful results.

It has been shown that pomegranate contains agents, especially polyphenolic flavonoids, with pharmalogical actions that could be considered conductive to good oral health, particularly in relation to gingivitis development. It has been suggested that reduction of oxidative stress, direct antioxidative activity, anti-inflammatory effects, antibacterial activity, and direct removal of plaque from the teeth are the mechanisms involved in this action.[20],[28],[29],[30],[31],[32] Effectiveness of the extract of pomegranate in inhibiting prostaglandin and leukotriene formation through inhibition of the eicosanoids enzymes, cyclooxygenase and lipoxygenase, raises the possibility of use of pomegranate derivatives in anti-inflammatory preparations.[33]

This study was conducted to evaluate the clinical efficacy of pomegranate seed extract in comparison to two routinely used herbal mouthwashes.

Analysis of plaque index values of this study suggested that the three mouthwashes were helpful in reducing the plaque to the same extent and there was no significant difference between them.

There is no study in literature comparing the antiplaque and anti-inflammatory effect of pomegranate seed extract with Persica and Matrica.

In the study of Ahuja et al., pomegranate mouthwash was compared with chlorhexidine mouthwash. Pomegranate was effective in reducing plaque but not to the extent that chlorhexidine was.[34]

In a microbiologic study, Menezes et al. showed that after a single 1 min mouth rinsing, more reduction in plaque was observed with pomegranate (84%) as compared with chlorhexidine (79%).[19]

Analysis of the bleeding scores of the current study revealed that the effect of three mouthwashes on the bleeding index was the same and better than placebo.

In the study of Ahuja et al., pomegranate mouthwash was more efficient in reducing gingival score and bleeding on probing than chlorhexidine.[34]

As the positive effect of Persica and Matrica in reducing dental plaque and gingival inflammation has been shown in different studies,[35],[36],[37] the results of this study emphasized that pomegranate mouthwash could be as effective as these two customarily used herbal mouthwashes.

In this study, placebo also reduced plaque and gingival bleeding to some extent while in comparison to three mouthwashes, the reduction in bleeding index was less significant in placebo group.

This positive effect of placebo partly can be related to hawthorne effect. This effect (also referred to as the observer effect) refers to a phenomenon whereby the participants in a study improve or modify an aspect of their behavior in response to the fact of change in their environment. This effect is more noticeable in studies observing hygiene procedures. According to hawthorne effect, the participants in the placebo group would improve their hygiene procedures unintentionally because of their awareness about participating in a study that is evaluating their competence in hygiene performance procedures.[38] By the way, rinsing with placebo has a flushing effect removing food debris and material alba from the mouth and by this way can interfere with organization of the dental plaque.

By assessing the measurements of plaque and bleeding indices at baseline, it can be implicated that the majority of the participants had mild gingivitis with even some healthy parts of the gingiva. This is to some extent due to involvement of dental students in this study, who were young and moderately watchful about their oral hygiene. The authors presume that the statistically equal effect of placebo in reducing plaque, in relation to mouthwashes, partly can be because of relatively satisfactory level of oral hygiene performance in a number of the participants.

There are various studies that P. granatum was used in other forms, different from mouthwash, or in combination with other herbal medications.

A study by Salgado et al. on 10% pomegranate gel showed that the gel was not efficient in preventing supragingival plaque formation and gingivitis.[27] It may be speculated that because the gel was placed into a tooth shield in a nondiluted form, it could not be solubilized with saliva to exert its antimicrobial action.

Sastravaha et al. used combination of Centella asiatica and pomegranate as biodegradable chips in deep pockets after scaling and root planing and found a significant decrease in bleeding and plaque scores.[20]

In a study by Rudney et al., it was shown that mouth rinsing with pomegranate mouthwash resulted in lowering of total protein content in saliva in relation to placebo. Total saliva protein is normally higher among people with gingivitis and may correlate with plaque-forming bacterial content. Pomegranate-treated participants also experienced significant decreases in the salivary activity of the enzyme aspartate aminotransferase that is considered a reliable indicator of cell injury and is elevated among patients with periodontitis.[39]

Most of the previous studies evaluated the effect of extract of pomegranate on microorganisms of dental plaque in vitro. Vasconcelos et al. in an in vitro study showed that pomegranate gel had greater efficiency in reducing microbial adherence of Streptococcus sanguis, Streptococcus mitis, Streptococcus mutans, Candida albicans to glass surface, in comparison to miconazole gel. It was mentioned that pomegranate inhibit species of streptococci and prevent them from producing chemicals that create favorable conditions for fungi and other microorganisms to thrive. These researchers suggested that this phytotherapeutic agent might be used in the control of adherence of different microorganisms in the oral cavity.[17]

Furthermore, Menezes et al. in an in vitro study showed that hydroalchoholic extract of pomegranate had antibacterial activity against selected bacteria of dental plaque.[19]

Abdollahzadeh et al. in an in vitro study showed the efficacy of different concentrations of methanolic extract of pomegranate against common oral pathogens responsible for caries, stomatitis, and periodontal diseases.[40]

Some other researchers also reported that extracts of pomegranate peel in different concentrations have antibacterial activity against some oral pathogens.[41],[42],[43]

It has been demonstrated that antibacterial activity of pomegranate may be related to the presence of hydrolysable tannins and polyphenolics in the pomegranate extract, especially punicalagin and gallagic acid.[17],[44]

It is cited that the antimicrobial effect of tannins is related to its molecular structure and toxicity for bacteria. Tannins may act on the cell wall and cell membrane of bacteria.[17],[41]

It is noteworthy that this toxicity of juice and seeds of pomegranate would appear to be very low, owing to the use of these components as common items of dietary commerce.[45]


  Conclusion Top


This study concluded that pomegranate mouthwash was effective against dental plaque to the same degree as Persica and Matrica were. Furthermore, its effect in reducing bleeding tendency of gingiva was comparable to two-mentioned mouthwashes. Its usage in daily oral hygiene prophylactic procedures and periodontal treatments can be encouraged because it is easy to prepare, has profound styptic action, and shows acceptable reduction in plaque and bleeding scores. More clinical trials are required to know the effectiveness of pomegranate and its advantages over chemical plaque control agents, especially chlorhexidine which is still a gold standard for reduction of plaque scores and gingivitis.

Acknowledgment

This paper has been extracted from Mr. Mohammad Niknahad's DDS thesis which was conducted under supervision of Dr. Farin Kiany and Dr. Hossein Niknahad.

The study was approved, registered with ID 8592044, and supported by the International Branch of Shiraz University of Medical Sciences.

Furthermore, We would like to thank Dr. Mehrdad Vossoughi for his help with the statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
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