Triphala-An Indigenous Ayurvedic Mouthwash As An Anti-Inflammatory Agent-A Clinical Study

Background: An antiplaque agent with minimal side effects that can be used as an effective adjunct to mechanical plaque control is needed. Mouthwash has been used for centuries for medicinal and cosmetic purposes, but in recent years, the rationale behind the use of chemical ingredients has been subjected to scientific research and clinical trials. Herbal medicines are in great demand in the developed as well as in developing countries for primary health care because of their wide biological and medicinal activities, higher safety margin, and lower costs. Triphala mouthwash used in Ayurveda since ancient times, is well-known for its anti-plaque, anti-gingivitis and anti-microbial properties. Aim: To evaluate and compare the effects of an indigenously prepared 0.6% triphala mouthwash on dental plaque and gingival inflammation with a commercially available chlorhexidine mouthwash. Materials and Methods: 20 subjects in the age group of 20-40 years with mild to moderate gingivitis were selected and divided into two equal groups in the study. Following oral prophylaxis, Group I (n=10) subjects were instructed to rinse with 10 ml of 0.2% chlorhexidine mouthwash, Group II (n=10) subjects with 10 ml of 0.6% triphala mouthwash twice daily for 14 days. Oral Hygiene Index-Simplified, TureskyGilmore-Glickman modification of Quigley-Hein-Plaque index and Gingival Index were recorded at baseline, 7 and 14 days respectively. Results: Group I and Group II subjects showed statistically significant results in the reduction of the clinical parameters (p < 0.001). Group I subjects showed statistically significant results in reduction of the plaque status (p < 0.05) whereas; Group II subjects showed significant reduction in the gingival inflammation (p < 0.05). Conclusion: Although, 0.2% chlorhexidine mouthwash yielded better results, 0.6%Triphala mouthwash may be used for short duration of time without any potential side-effects as an alternative to chlorhexidine mouthwash in reducing gingival inflammation.


INTRODUCTION
Gingival and periodontal diseases appear to occur when pathogenic microbial plaque acts on a susceptible host. 1 Supra-gingival plaque control is fundamental to the prevention and management of periodontal diseases, 2 either mechanically or by means of different chemical agents.
Mechanical plaque control becomes hazardous in patients who are medically compromised patients because of poor oral hygiene habits. Certain teeth surfaces receive minimum attention while tooth brushing. Thus, an adjunctive use of chemical agents has been practised. Chemical supragingival Dr. Shibam Chatterjee, 1 Dr. Balaji Manohar, 1 Dr. Neema Shetty, 1 Dr. Aditi Mathur, 1  plaque control has been the subject of extensive research for the last 3 to 4 decades now. Various antimicrobial agents preventing the bacterial proliferation have been introduced recently. 3 Chlorhexidine, a cationic bisbiguanide is gold standard among all mouthwashes, 4-8 particularly because of its substantivity and broad-spectrum antibacterial activity. [9][10][11] However; it has been reported to have a number of side effects like brown discoloration of teeth, salt taste perturbation, oral mucosal erosions and enhanced supragingival calculus formation, which limit its long-term use. 3 16 The antioxidant activity of the extract was indicated by the reduction of lipid peroxide levels in wounds that were already treated. 17 The dry fruits of these plants as well as triphala are easily available and are socioeconomic as well. Antioxidants present in triphala slow down the process of excess oxidation and protect cells from the damage caused by free radicals. 18,19 Thus, the proven activity of these antioxidants is very helpful in modern medicine as well as for the treatment of diseases related with oxidative stress, particularly premalignant conditions. 15,20 These antioxidants have also been scientifically proven to be safe and effective medicine against various oral health problems such as bleeding gums, halitosis, and mouth ulcers and for preventing tooth decay. One of the advantages of these natural herbs is that, no side effects of their use have been reported. 21 Sushruta Samhita, in its 20th shloka, states that triphala can be used for gargling in dental diseases. Abraham S et al. 22 reported the strong inhibitory activity of triphala against the polymorphonuclear leukocytes-type collagenases, particularly matrix metalloproteinase, 9 and confirmed the use of triphala in periodontal diseases. Triphala has been reported to have antimicrobial, antiseptic, anti-inflammatory and antioxidant properties. 16,17,[23][24][25] The present study was undertaken to evaluate and compare the effects of an indigenously prepared 0.6% triphala mouthwash on dental plaque and gingival inflammation with a commercially available 0.2% chlorhexidine mouthwash.

MATeRIAlS AND MeThODS
In this clinical study, 20 subjects 26  p value of < 0.05 was considered statistically significant.

ReSUlTS
A total of 20 subjects (9 males, 11 females) were selected for this clinical study. There were no drop-outs in the study.
The mean OHI-S scores in control group at baseline was 2.68 ± 0.16 which reduced to 1.20 ± 0.13 and 1.28 ± 0.12 after 7 and 14 days postoperatively respectively; which was significant (p value < 0.001) when compared to the baseline (Table 1, 2). The mean OHI-S scores from 7 to 14 days was also observed to be significant (p value < 0.001) ( Table 3).
Whereas in the test group, the mean OHI-S scores at baseline Chatterjee et al. : Triphala -an indigenous ayurvedic mouthwash as an anti-inflammatory agent -a clinical study was 2.68 + 0.16 which reduced to 1.37 ± 0.14 and 1.46 ± 0.15 after 7 and 14 days postoperatively respectively; which was seen to be significant (p value < 0.001) when compared to the baseline (Table 1, 2). The mean OHI-S scores from 7 to 14 days was also significant (p value < 0.001) ( Figure 2, Table   3). When the mean OHI-S scores at baseline (p value = 1.00) was compared to 7 days (p value = 0.65) and 14 days postoperative scores (p value = 0.25) between the two groups, the difference was found to be non-significant (Table 4).
The mean PI scores of control group at baseline of 2.68 ± 0.22 which reduced to 1.36 ± 0.12 and 1.42 ± 0.14 after 7 and 14 days postoperatively respectively; which was significant (p value < 0.001) when compared to the baseline (Table 1 & 2). The mean PI scores from 7 days to 14 days were seen to be significant (p value < 0.05) (  Figure 3, Table 3). When the mean PI scores at baseline (p value = 0.57) was compared to 7 days (p value = 0.47) and 14 days post-operative scores (p value = 0.35) between the two groups, the difference was found to be non-significant (Table 4).
The mean GI scores of control group at baseline was 1.88±0.12 which reduced to 1.63±0.12 and 1.70±0.13 after 7 and 14 days postoperatively respectively; which was seen to be significant (p value <0.001) when compared to the baseline ( Table 1, 2).
The mean GI scores from 7 to 14 days was significant (p value < 0.001) ( which was also significant (p value < 0.001) when compared to the baseline ( Table 1, 2). The mean GI scores from 7 to 14 days was significant p value < 0.05) ( Table 3). When the mean Gingival index scores at baseline (p value = 0.30) was compared to 7 days (p value = 0.23) and 14 days postoperative scores (p value = 0.83) between the two groups, the difference was found to be non-significant ( Figure 4, Table 4).

DISCUSSION
The present clinical study was done to evaluate the efficacy of 0.6% triphala mouthwash and to compare it with 0.2% chlorhexidine mouth rinse on oral hygiene status, plaque accumulation and gingival inflammation. Study participants were randomly allocated into two groups. Clinical examination was done to record plaque and gingival scores at baseline and post-rinsing according to the study by Bajaj et al. 27 The purpose of recording was to observe any soft tissue changes such as increase or decrease in inflammation occurring due to the use of agent. Plaque and gingival scores were recorded for all participants at baseline, 7 days and 14 days post-operatively. The effect of triphala extract mouth rinse was intended to be studied in a real life situation and pre-operative oral prophylaxis was performed. This is in accordance with the study conducted by Chainani SH et al. 28 Tiphala has been used as a mouth rinse in healthy, gingivitis and periodontitis patients. 29,30 Triphala presented an antiplaque efficacy similar to that of chlorhexidine and was more effective in inhibiting plaque formation with lesser or no side effects. 31 Sushruta Samhita has emphasized that triphala has hemostatic, anti-inflammatory, analgesic, and wound healing properties. Haritaki is the most efficacious for bleeding gums and gingival ulcers as well as carious teeth. On the other hand, Amalaki contains a large amount of vitamin C, which is very effective in preventing bleeding from gums. 32 Jagadish L et al. 29  Effectiveness of chlorhexidine can be attributed to its bactericidal and bacteriostatic effects and its substantivity within the oral cavity (8 hours after rinsing). In group using 0.2% chlorhexidine mouthwash, the mean difference in OHI-S, PI and GI scores from baseline to 14 days postoperatively were 1.28 ± 0.12; 1.42 ± 0.14 and 1.7 ± 0.13 respectively which was significant (p < 0.001). In group using 0.6% Triphala mouthwash, the mean difference in OHI-S, PI and GI scores from baseline to 14 days post-operatively were 1.46 ± 0.15; 1.60 ± 0.15 and 1.68 ± 0.21 respectively which was statistically significant (p < 0.001). This is in accordance with the study conducted by Moran J et al. 35 and Quiren M36 in which chlorhexidine was found to be effective in reducing plaque and gingival scores.

CONClUSION
Triphala is a novel drug with an array of therapeutic effects gifted by Ayurveda to the world. It has potential to treat a variety of human ills with minimal or no side-effects.
Dentistry is still in search of a drug for diseases affecting hard and soft tissues of oral cavity. Triphala seems to fulfil most of these requirements without any adverse effect   Although, chlorhexidine mouthwash yielded better results than the triphala mouthwash in the present study, the latter may be used for short-term duration without any potential side-effects as an alternative to chlorhexidine in reducing gingival inflammation. Triphala can be used as a mouthwash in conjunction with scaling and root planing. Further studies are required with larger sample size to evaluate the long term effects of triphala as a mouthwash.