Comparative Evaluation of the Effect of Chlorhexidine Gluconate, Raw Propolis and Hydrogen Peroxide on Dental Plaque and Gingival Inflammation

Background: Plaque is the soft deposit that forms the biofilm consisting of microorganisms adhering to the tooth surface and is proved beyond doubt to be the initiator of gingival and periodontal disease. Plaque control is the mainstay in periodontal disease. Aim: To compare the effect of 0.2% chlorhexidine gluconate, raw propolis and 3% hydrogen peroxide mouthwash on dental plaque and gingival inflammation. Materials and Methods: Thirty subjects in the age group of 20-40 years were enrolledin the study. Plaque index and Modified Gingival Index were recorded at baseline and oral prophylaxis was performed. Subjects were then randomly divided into three groups (n=10) and were asked to rinse with 10ml mouthwash twice daily for 15 days. Group I received 0.2% chlorhexidine gluconate mouth wash, Group II raw propolis diluted with distilled water (1:1), and Group III 3% hydrogen peroxide (1:1) mouthwash. Subjects were recalled on 7 day and 28 day for reevaluation and recording plaque index and modified gingival index. Statistical analysis was done to evaluate the efficacy of all the three mouthwashes. Results: The results showed that all the three mouthwashes were effective in reducing plaque and gingival inflammation. Chlorhexidine gluconate 0.2% showed to be the most effective in reduction of dental plaque. Propolis was observed to be the most effective in reducing gingival inflammation over a period of 28 days. Conclusion: Propolis can be effectively used as a mouthwash without any potential side effects as an alternative to chlorhexidine mouthwash in reducing gingival inflammation.


INTRODUCTION
Periodontal diseases are infections of the structures surrounding the teeth. These include the gingiva, the cementum that covers the root, the periodontal ligament and the alveolar bone.
Approximately 95% of the Indian population suffers from periodontal disease. In the earliest stage of periodontal disease, gingivitis, affects only gingiva. In more severe forms Evidence exist that the degree of motivation and skill required with the oral hygiene products such as toothbrushes, dental floss, toothpicks, and interdental brushes may be beyond the ability of majority of the patients. There are also groups of individuals such as temporarily disabled individuals including non-ambulatory patients and handicapped people, for whom adequate oral hygiene is a problem. 4 Therefore, an alternative method of plaque control would be desirable.
Thus,chemical control may be relevant.
The purpose of the present study was to compare the effect of 0.2% chlorhexidine gluconate, raw propolis and 3% hydrogen peroxide mouthwash in inhibiting the development of plaque and gingivitis.
The present study was undertaken to evaluate and compare the effects of to compare the effect of 0.2% chlorhexidine gluconate, raw propolis and 3% hydrogen peroxide mouthwash on dental plaque and gingival inflammation.

MATERIALS AND METHODS
In this clinical study, 30 subjects in the age group of 20-40 years were enrolled from the out-patient Department of Periodontics. An informed consent from the subjects participating in this study was obtained before the commencement of this study and Ethical Clearance was obtained. III. Allergy to ingredients used in the study.
V. Pregnant or lactating females.
VI. Patient with poor compliance.
Before allocating the subjects to the groups, they underwent thorough scaling and root planing.     At baseline no significant difference was observed in both the plaque index and modified gingival index in all the three groups (p>0.05).
When intra group comparison in Group I from baseline to 7 days and baseline to 28 days was done, it was observed that the plaque index and modified gingival index values reduced from 3.26 ± 0.53 to 1.10 ± 0.35 at 7 days to 0.82 ± 0.45 at the end of 28 days and from 3.04 ± 0.23 to 0.50 ± 0.25 at 7 days to 0.54 ± 0.35 at the end of 28 days respectively. The overall percentage reduction in plaque score was 74.84% from baseline to 28 days and for the modified gingival index it was 82.23% from baseline to 28 days. When intra group comparison for Group I was done statistically significant difference was found from baseline to 7 days for plaque index (p = 0.001) whereas; highly significant difference (p <0.0001) was found for modified gingival index. When compared from baseline to 28 days statistically significant difference was found for plaque index (p = 0.001) and a   Group II and Group III, Group II was found to be better in the reduction of modified gingival index after 28 days.
The results showed that all the three mouthwashes were effective in reducing the plaque and inflammation. 0.2% chlorhexidine gluconate being the most effective for reduction in dental plaque. Raw propoliswas observed to be the most effective in reducing gingival inflammation over a period of 7 days and 28 days.
The results of our study suggest that raw propolis has a plaque inhibitory effect which is statistically equal to chlorhexidine mouthwash and is more potent than chlorhexidine gluconate and 3% hydrogen peroxide in reducing gingival inflammation.

DISCUSSION
Among the evaluated agents for chemical plaque control, chlorhexidine is the gold standard, as supported by a large body of evidence, produced since 1970. Chlorhexidine is a cationic bis-biguanide biocide with low mammalian toxicity and broad-spectrum antibacterialactivity, was first described in 1954. 7,8 The primary mechanism of action of this biocide is membrane disruption, causing concentration-dependent growth inhibition and cell death. 9 Secondary interactions causing inhibition of proteolytic and glycosidic enzymes may also be significant. 10 With respect to dental hygiene applications, the cationic nature of chlorhexidine enables it to bind to tooth surfaces and oral mucosa, reducing pellicle formation and increasing substantivity through controlled release of the agent. 11 The efficacy of chlorhexidine in reducing oral bacterial viability 12-14 strongly inhibiting plaque regrowth and preventing gingivitis 15 has been demonstrated in many studies. 16 Though chlorhexidine is considered as the best agent for plaque control and gingivitis, many patients find its initial The propolis-containing rinse was marginally better than the negative control, but this difference was not significant.
However, the results of our study showed that both chlorhexidene and propolis are equally effective in reducing plaque but propolis is more effective in reducing gingival inflammation when compared with other mouthwashes.

Mundo et al, 2004 18 stated that hydrogen peroxide has been
shown to form in honey by the action of the enzyme glucose oxidase that produces gluconic acid and hydrogen peroxide from glucose.
Oxygenating agents have been employed for supragingival plaque control and in the treatment of acute ulcerative gingivitis without any harmful side effects on the tissues. 19 1.5% Hydrogen peroxide has been shown to have a good stain removing capability both in vitro and in vivo. The use of Hydrogen peroxide as an adjunct to chlorhexidene has been found to be very effective in reducing plaque scores and in preventing the stain development. 20 In the present study there was no significant difference in dental plaque reduction between propolis and chlorhexidine mouthwash. Gusberti 24 showed the subjects rinsing with 0.12% chlorhexidine showed 95% reduction in gingivitis incidence, 100% reduction in bleeding sites, and 80% reduction in plaque scores compared to the subjects rinsing with placebo.
Conversely, the group using 1% hydrogen peroxide showed a marginal reduction in gingivitis incidence of 15% and a 28% reduction in bleeding sites compared to the placebo group, but no significant reduction in plaque scores. However our study showed no significant difference in plaque score among subjects using 0.2% chlorhexidine and 3% hydrogen peroxide. The group using 0.2% chlorhexidine showed greater reduction in gingival inflammation as compared to the group using 3% hydrogen peroxide. Singh 25  3. When inter group comparison was done between Group I and Group II, no stastistically difference was found for both the groups at baseline, 7 days and 28 days 4. Propolis was found to be better in reducing Modified gingival index at 7 days when compared to chlorhexidine.
Propolis was also seen to be better in Modified gingival index reduction after 28 days when compared to 3% hydrogen peroxide.
5. Chlorhexidine gluconate users the most effective for dental plaque reduction. Propolis was observed to be the most effective in reducing gingival inflammation over a period of 7 days and 28 days.
6. The results of our study suggest that propolis has a plaque inhibitory effect which is statistically equal to 0.2% chlorhexidine mouthwash and is more potent than chlorhexidine gluconate and 3% hydrogen peroxide in reducing gingival inflammation.
7. Use of propolis in the treatment of various diseases and ailments is well known from ancient times, but the use of propolis in oral disease is not much documented.
Present study suggests that propolis can be effectively used in reduction of gingival inflammation without any potential side effect.