ORIGINAL ARTICLE
Year : 2023 | Volume
: 15 | Issue : 1 | Page : 7--12
To determine therapeutic effect of curcuma gel on gingivitis as an adjunct to scaling: A randomized control trial
MV Devarathnamma1, Anunay Bhaskarrao Pangarikar2, Prachi Gurunath Parab3, Shivanand Aspalli4, Nagappa Guttiganur4, Janavathi Rangappa5,
1 Department of Periodontology, S. B. Patil Dental College, Bidar, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, ESIC Dental College, Gulbarga, Karnataka, India
3 Avni Dental Clinic, Al-Badar Rural Dental College, Gulbarga, Karnataka, India
4 Department of Periodontology, AME's Dental College, Raichur, Karnataka, India
5 Department of Conservative Dentistry and Endodontics, Al-Badar Rural Dental College, Gulbarga, Karnataka, India
Correspondence Address:
Anunay Bhaskarrao Pangarikar
Flat No. 108, Block 3, VBHC Vaibhava Apartment, Chandapura-Anekal Main Road, Byagadadenhalli, Anekal, District, Bengaluru - 562 106, Karnataka
India
Abstract
Context: Gingivitis is among the most prevalent periodontal disease occurring in the oral cavity, which is plaque induced and if untreated, can progress to periodontitis. Various adjunct chemotherapeutic agents are available for plaque control with their own pros and cons. Hence, a plaque-controlling therapeutic agent which is readily available at low cost and without any side effects is the need of the hour. According to the ancient texts, Ayurveda and the traditional culture of India, Curcuma longa is used externally for inflammation of skin and mucosa. Aims: To evaluate the therapeutic effect of curcuma gel on gingival health and its possible usage in the treatment of gingivitis. Settings and Design: This study comprises hundred participants with gingivitis which were divided randomly in two groups. Subjects and Methods: Experimental group – Scaling and topical application of curcuma gel and control group – Scaling alone without the topical application of curcuma gel. Clinical parameters (Gingival Index, Gingival Bleeding Index, and Plaque Index) were assessed at different time intervals (0, 7, 14, and 21 days) in both experimental and control groups. Statistical Analysis Used: Within groups, a repeated measures ANOVA model was used for repeated observations over a period which is followed by the Dunnett test for multiple comparisons. Experimental and control groups were compared for normally distributed data by Student's t-test. Whereas for skewed data, the Wilcoxon test or Mann–Whitney U-test was employed. Results: Statistically significant improvement of gingival health parameters was seen in the group which received topical curcuma oral gel application after scaling compared with the control group. Conclusions: Significant improvement in clinical parameters of gingivitis on the application of Curcuma oral gel after scaling with no obvious adverse effects suggesting its possible use as a topical adjunct treatment in clinical or community level prevention as well as treatment programs in the future.
How to cite this article:
Devarathnamma M V, Pangarikar AB, Parab PG, Aspalli S, Guttiganur N, Rangappa J. To determine therapeutic effect of curcuma gel on gingivitis as an adjunct to scaling: A randomized control trial.Indian J Dent Sci 2023;15:7-12
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How to cite this URL:
Devarathnamma M V, Pangarikar AB, Parab PG, Aspalli S, Guttiganur N, Rangappa J. To determine therapeutic effect of curcuma gel on gingivitis as an adjunct to scaling: A randomized control trial. Indian J Dent Sci [serial online] 2023 [cited 2023 Nov 28 ];15:7-12
Available from: http://www.ijds.in/text.asp?2023/15/1/7/369893 |
Full Text
Introduction
Periodontal disease is considered among the most common public health problems worldwide and also a leading cause of tooth loss in adults.[1] It is a complex, inflammatory disease characterized by soft and hard tissue destruction of the periodontium.[2] As an inflammatory disease, histologically, it features “an ulceration of the sulcus epithelium and an inflammatory cell infiltration of the underlying connective tissue.”[3] As periodontal diseases and bacterial infection are linked with each other, effective antibiotics may be helpful in improving the condition of inflamed tissues.[4] Several antibacterial chemicals, such as chlorhexidine, triclosan, essential oils, and metronidazole are proved useful as an adjunctive treatment to operative therapy. However, deleterious effects such as discoloration of teeth and unpleasant taste of topical antibacterial agents, and development of resistance and/or drug interactions limit the use of systemic antibiotics. Therefore, the interests in herbal medication with antibacterial and anti-inflammatory activity have been increasing to avoid such side effects. During the 20th century, herbalism became mainstream worldwide.[5] Curcuma longa is the scientific name of Turmeric belonging to the Zingiberaceae family, and it has a wide range of physiologic properties such as “anti-platelet aggregation, anti-cholesterol activity, and fibrinolytic action.”[6]
According to ancient Indian literature, curcuma possesses numerous therapeutic properties such as anti-inflammatory and anti-microbial. As curcuma is easily available at a lower cost with no known deleterious effect on health, we decided to determine its therapeutic effect on gingival inflammation. Thus, the present study was conducted to evaluate the influence of curcuma gel when applied topically after scaling for the treatment of gingivitis.
Subjects and Methods
The Institutional Ethical Clearance was obtained before the initiation of the study. The patients of the outpatient department from the Department of Periodontology of our Institute were selected for this study. The study was designed as randomized controlled clinical trial, parallel-group type. It included a total of 100 patients with clinical signs of gingivitis with probing depth <3 mm. The sample size was calculated with an expected population standard deviation (SD) of 5, ratio of case to control (k) as 1, power (1−β) of 0.5, Type I error of 0.16, allowable difference and drop rates was taken as zero.
Selection criteria for the patient
Inclusion criteria
Systemically healthy controls between 16 and 55 yearsOn clinical examination, presence of bleeding on probingDentition must have a minimum of 20 teethPatient who had no history of any periodontal treatment within the past 6 monthsProbing depth ≤3 mm.
Exclusion criteria
Patient giving the history of consuming antibiotics or any other drugs within the past 3 monthsPregnant and lactating womenMedically compromised or patient with systemic diseasePatient who is known smokerPatient with known hypersensitivity to curcuma.
Material used
Curcuma oral gel
Curcuma gel (Curenext oral gel, Abbot Health care Ltd.) each gram of gel contains C. longa extract 10 mg. “Chemistry-Curcumin (1, 7– bis [4– hydroxyl– 3– methoxyphenyl]– 1, 6– heptadiene– 3, 5– dione) as principal component of C. longa Linn.”[7]
Curcuma mechanism of action
As stated by Jayaprakasha in 2006, “Curcumin has a strong antioxidant activity facilitated by enzymes such as superoxide dismutase, catalase, and glutathione peroxidase. It proved to reacting with glutathione and thioredoxin. These interactions of curcumin lead to a reduction of intracellular glutathione. It also reduces lipid peroxidation, thereby suppressing the inflammation.”[8]
“Curcumin has anti-inflammatory and immunomodulatory actions as it effectively inhibits transcriptional and translation expression of pro-inflammatory cytokines like interleukin, tumor necrosis factor (TNF), arachidonic acid metabolism, cyclooxygenase (COX), lipoxygenase and nuclear factor kappa-light-chain-enhancer of activated B cells.”[9],[10],[11],[12]
Group distribution
A total of 100 participants were included in the study, 55 females and 45 males participated in the study. A detailed medical and dental history was recorded for each patient. After explaining the study to the participants, a written consent was obtained. Participants selected were divided into the following groups randomly.
Experimental group – Scaling and topical application of curcuma gelControl group – Scaling alone without the topical application of curcuma gel.
Clinical parameters
Before scaling, the periodontal examination was carried out in each subject with Mouth mirror and Williams graduated periodontal probe and following clinical factors were assessed.
Plaque Index (PI) (Silness P. and Loe H, 1964)[13]Gingival Index (GI) (Loe H. and Silness J, 1963)[13]Gingival Bleeding Index (GBI) (Ainamo and Bay, 1975).[13]
Clinical parameters for each participant were recorded. With the help of Ultrasonic scalers, a complete scaling was done in both groups. In the experimental group, after scaling, participants were instructed to apply curcuma oral gel over gums and teeth, minimum for 10 min after brushing, two times a day for the next 21 days. Patients were instructed not to swallow the gel and thoroughly mouth rinse with plain water to clear off left over gel after the stipulated period. Clinical parameters were assessed at different time intervals (0, 7, 14, 21 days) in both experimental and control groups. As all the 100 participants were followed till the completion of study, there are no attrition in number of participants due to loss of follow up.
Kolmogorov–Smirnov test were employed to examine the normality of the data. Nonparametric test was utilized for the data, which was not normally distributed. Within groups, a repeated measures ANOVA model was used for repeated observations over a period, which is followed by the Dunnett test for multiple comparisons. Experimental and control groups were compared for normally distributed data by Student's t-test. Whereas for skewed data, the Wilcoxon test or Mann–Whitney U-test were employed. All data are expressed as mean ± SD. A two-tailed P value was considered significant when it was less than 0.05. “SPSS version 16.0” (Chicago, USA, SPSS Inc) was used for all data analysis.
Results
Both test and experimental groups after scaling showed a decrease in PI, GI and GBI scores [Table 1] and [Graph 1], [Table 2] and [Graph 2], and [Table 3] and [Graph 3], respectively]. However, on comparison between test and control group, a substantial drop in PI scores, GI scores, and GBI scores were observed in the test group [Table 4], [Table 5], [Table 6], [Table 7] and [Graph 1], [Graph 2], [Graph 3]. No adverse effects were observed on clinical examination and as reported by patients.{Table 1}[INLINE:1]{Table 2}[INLINE:2]{Table 3}[INLINE:3]{Table 4}{Table 5}{Table 6}{Table 7}
Discussion
Bacterial plaque and its byproducts are often investigated to be the primary etiology factor for chronic gingival inflammatory conditions. Plaque levels are proved to be directly related with severity of gingival inflammation.[14] Universally followed method for the prevention of gingivitis is effective plaque removal through personal and professional oral hygiene methods regularly that include mechanical and chemical plaque control measures.
Majority of population are unable to achieve satisfactory mechanical plaque control which leads to the pursuit of chemical therapeutic means such as mouth rinses, toothpastes, and other locally applicable oral gels. These agents help in controlling dental plaque, which sequentially reduces gingival inflammation.[15] Chemotherapeutic compounds such as fluorides, quaternary ammonium compounds, triclosan, bis-biguanides, essential oils, and sanguinarine are useful ingredients of such products. Among these, chlorhexidine gluconate is considered most effective plaque controlling agent.[14] However, this potent chemical has some unpleasant effects such as bitter taste, oral mucosal erosions, and discoloration of teeth on prolonged use.[16],[17] Hence, a substitute medicine already embroiled within the Indian culture with anti-inflammatory and antibacterial properties, with relatively low cost and medically safe, is essential in preventing gingivitis in the larger population.
Today, the efficacy and safety of various herbal medicines have scientific evidence in the literature.[18] Advantages of using these herbs include “(1) Unique mechanisms of action, (2) Typically low side effect profiles, (3) Low cost, (4) High level of acceptance.”[18] C. longa (Turmeric) has been used in Ayurvedic medicine as a remedy for inflammation and for the care of teeth and gums.[19] Turmeric constituents apart from volatile oils (tumerone, atlantone, and zingiberone), sugars, proteins and resins include the three curcuminoids, namely curcumin (diferuloylmethane; the main constituent which imparts yellow color), demethoxycurcumin, and bisdemethoxycurcumin.[20] Curcumin not only downregulates the activity of COX-2, Lipoxygenase and inducible Nitric Oxide Synthase (iNOS) enzymes but also inhibits the production of the inflammatory cytokines TNF-α, IL-1, -2, -6, -8, and -12, Monocyte Chemoattractant Protein, and migration inhibitory protein. NF-κB activation and pro-inflammatory gene expression are blocked by curcumin by hindering the phosphorylation of inhibitory factor I-kappa B kinase, which consequently reduces COX-2 and iNOS expression and hence preventing the inflammatory process.[12],[21]
Curcumin has proven clinical effects such as anti-oxidant,[22],[23] anti-inflammatory,[12],[20],[21],[23],[24] antibacterial, antiviral, antifungal, antitumor, antispasmodic and hepato-protective.[24],[25] Even though studies in animals and in vitro have shown the antimicrobial, anti-inflammatory, analgesics, anti-viral properties of curcuma, literature documents have shown limited human studies on the usage of curcuma in the oral cavity.
In the current study, we attempted to evaluate the effectiveness of curcuma oral gel for treating plaque-induced gingival inflammation as an adjunctive therapy to scaling. This randomized single-blind study included 100 participants with moderate-to-severe gingivitis divided in two groups, namely the control group and the experimental (study) group. Participants of both the groups were age and gender matched. The clinical observations such as PI, GI, and GBI were recorded on 0, 7, 14, and 21 days, along with any adverse reactions to the gel.
The severity of gingivitis cannot be assessed by any one benchmark test. Many studies conducted in the past utilized GI for evaluating the efficacy of oral hygiene products.[15] Hence, GI was used in our study for ease of comparison with other studies; nevertheless, this parameter need not be an accurate indicator of gingivitis.[15] Bearing this in mind, GBI was also employed in the present study.
In the control group, the mean plaque difference from day “0” to 21 day was 0.41 ± 0.55 and in the experimental group was 0.47 ± 0.30, which was statistically highly significant (P < 0.0001). However, the comparison between the control and the experimental group showed a mean difference of 0.12 at 0 day, indicative of the insignificant difference between the two groups (P > 0.05, t = 1.55) and at 21 day the mean difference between the groups was 0.19 indicative of statistically significant difference (P < 0.008, t = 2.73). This clinical observation suggests there was a reduction in plaque scores from day “0” to 21 day both in control and experimental groups, but statistically significant reduction was seen in the experimental group as compared to the control group. Hence proves that curcuma gel is effective in plaque reduction.
When GI and GBI were analyzed, the control group from 0 day to 21 day showed a mean GI score difference of 0.78 ± 0.43 and in the experimental group, the mean difference was 1.01 ± 0.38, suggestive of high statistical significance (P < 0.0001). However, the comparison of the control and experimental groups' GI scores showed a mean difference of 0.04 at 0 day, indicative of the statistically insignificant difference in the groups (P > 0.05, t = 0.65) and at 21 day, the mean difference between the groups was 0.18 (P < 0.007, t = 2.72) indicative of statistically significant difference. Similarly, the GBI showed a mean score difference of 47.56 ± 15.9 and 66.13 ± 17.16 in the control and experimental groups, respectively, indicative of high statistical significance (P < 0.0001). Comparison between the groups at 0 day, the mean difference was 2.45 and 21 day, the mean difference was 16.13, indicative of a statistically highly significant difference (P < 0.0001, t = 4.86). The clinical observation suggests the decline in GI and GBI scores from 0 day to 21 day both in control and experimental groups, but a significant reduction was seen in the experimental group. The above result supports the effect of curcuma gel in improving gingival health along with reduction in the plaque indices.
The present results were in line with that of Waghmare et al. 2011, which also showed drop in PI, GI, and GBI scores in the experimental group who used turmeric mouthwash as an adjunct for a period of 21 days after scaling.[26] We decided to use curcuma gel over the mouthwash as the former way of application is more localized and restricted to gingiva only as compared to mouthwash, where the entire oral cavity is exposed to the therapeutic agent.
A similar attempt was made by Behal et al.[27] 2011, who used 2% of turmeric gel after scaling and root planning and obtained results showing fall in PI, GI and GBI scores which are in accordance with the present study. Despite similar outcomes, completely adequate and effective comparison between the present study and previous studies is not possible owing to different study design, method, and other limitations. However, every possible effort are taken to compare it with other studies rationally.
Neither any patient reported any kind of adverse reaction to the curcuma gel, nor was any reaction observed during clinical examinations. This supports the clinical safety of curcuma gel. Similar studies done in the past where curcuma gel and mouthwash was used showed no adverse effects and hence strengthens the safety of curcuma gel.[26],[27] Thus, curcuma gel can be used safely more frequently and by a larger population or in community-based prevention or treatment programs if standardized. Other herbal gels containing Acacia Arabica,[28],[29] Neem (Azadirachtaindica) leaf extract gel,[30] Tea tree oil gel,[31] pomegranate gel[32] used along with the periodontal therapy have shown similar results to present study. Curcuma is more readily available and conventionally used medicine, so is evoking more faith among patients as well as clinicians and is hence preferred for this study.
The favorable results obtained in the present study suggest that the curcuma oral gel proved to be a promising agent as an adjunctive remedy post scaling for successful treatment of gingival diseases. Numerous clinical trials are currently in progress; in the future, it will provide a better knowledge about the clinical properties of curcuma. The major area to be concentrated on in the future is quality control of standardized curcuma gel to extract maximum therapeutic benefits of curcuma. More systematic and large-scale study has to be undertaken to support the usage of curcuma oral gel in routine clinical practice.
Conclusions
Within the limitation of the present study, we can conclude that curcuma gel is an effective, easily accessible, low-cost, and natural anti-plaque agent with no proven side effects. It also improves signs of gingivitis clinically, and hence, it may be used as an adjunct to treat gingivitis or as a plaque controlling agent in the clinic as well as in community-based prevention and treatment programs in the future.
Ethical statement
Institutional ethical committee of AME's Dental College, Raichur, Karnataka.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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