|Year : 2017 | Volume
| Issue : 1 | Page : 15-18
Assessment of the efficacy of licorice versus 0.2% chlorhexidine oral rinse on plaque-induced gingivitis: A randomized clinical trial
Prateek Jain, Priyanka Sontakke, Satinder Walia, Pramod Yadav, Gautam Biswas, Diljot Kaur
Department of Public Health Dentistry, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh, India
|Date of Web Publication||17-Jul-2017|
Senior Lecturer, Department of Public Health Dentistry, Maharana Pratap College of Dentistry and Research Centre, Putlighar Road, Gwalior - 474 001, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Supragingival plaque control is elementary to the prevention and management of periodontal diseases. Conversely, significant proportions of all individuals fail to practice a high standard of plaque removal. The adjunctive use of chemicals would therefore appear a way of overcoming deficiencies in mechanical tooth cleaning habits. This prospective, randomized positively controlled clinical trial was aimed to evaluate the short-term clinical effects of a licorice oral rinse in the reduction of plaque and gingival inflammation in individuals with gingivitis. Materials and Methods: A total of 104 individuals, 12–15 years of age diagnosed with chronic generalized gingivitis, were selected and randomly divided into two groups: Group 1: chlorhexidine mouthwash and Group 2: licorice mouthwash. Clinical evaluation was undertaken using the gingival index, the plaque index, and bleeding on probing at baseline, 1st, 2nd, and 4th week. Results: Both chlorhexidine and licorice mouthwash showed a significant reduction in plaque and gingival index scores from baseline to 1st, 2nd, and at 4th week. However, the improvement in plaque and gingival index scores were better in chlorhexidine group than herbal mouthwash. Both mouthwashes were found to be equally effective in reducing bleeding on probing. Conclusion: Unlike chlorhexidine mouthwash, licorice mouthwash was not associated with any discoloration of teeth or unpleasant taste and was effective in reducing plaque accumulation and gingival inflammation. However, chlorhexidine still remains a gold standard in reducing plaque, gingivitis, and bleeding on probing.
Keywords: Chlorhexidine, gingivitis, licorice, plaque
|How to cite this article:|
Jain P, Sontakke P, Walia S, Yadav P, Biswas G, Kaur D. Assessment of the efficacy of licorice versus 0.2% chlorhexidine oral rinse on plaque-induced gingivitis: A randomized clinical trial. Indian J Oral Health Res 2017;3:15-8
|How to cite this URL:|
Jain P, Sontakke P, Walia S, Yadav P, Biswas G, Kaur D. Assessment of the efficacy of licorice versus 0.2% chlorhexidine oral rinse on plaque-induced gingivitis: A randomized clinical trial. Indian J Oral Health Res [serial online] 2017 [cited 2017 Sep 25];3:15-8. Available from: http://www.ijohr.org/text.asp?2017/3/1/15/210921
| Introduction|| |
Periodontal diseases are among the most common infectious diseases disturbing human kind and can lead to the demolition of the periodontal ligament, cementum, gingiva, and alveolar bone. Plaque is the primary etiological factor in gingival inflammation. Thus, control of dental plaque holds the key to bring to a standstill the progression of periodontal disease. Since a majority of the population is not able to execute plaque control effectively, the onus lies on the dental health-care provider to impart the correct knowledge about the oral hygiene aids and adjunctive use of various chemical plaque control agents. Chemotherapeutic mouthrinses endow with chemically significant benefit in the reduction of plaque-induced gingivitis. Mouthrinses encompass the ability to deliver therapeutic ingredients and benefits to all accessible surfaces in the mouth including interproximal surfaces. They also remain effective for unmitigated period of time depending on their substantivity. Chlorhexidine has been prescribed by dentists for decades and accepted as the gold standard in reducing dental plaque as it has reflective anti-plaque and antibacterial properties.,,, However, it has few detrimental side effects primarily brown staining of the teeth  and transient impairment of taste sensation. Recently, numerous studies have been conducted to verify the enormous wealth of medicinal plants. These herbal mouthwashes are gaining popularity as they contain naturally occurring ingredients called as phytochemicals that achieve the desired antimicrobial and anti-inflammatory effects. Herbal formulations may be more appealing because they work without alcohol, artificial preservatives, flavors, or colors. One other mouthwash is licorice (manufactured privately). This mouthrinse contains licorice with significant anti-inflammatory properties. The principal ingredient is Glycyrrhiza Glabra (Licorice); the key therapeutic compound in licorice is glycyrrhizin. It prevents the breakdown of adrenal hormones such as cortisol (the body's primary stress-fighting adrenal hormone), making these hormones more available to the body, hence acting as immunostimulant. Licorice flavonoid constituents mainly include flavones, isoflavones, and chalcones which show antioxidant, anti-inflammatory, and antibacterial properties.
Thus, the present study was undertaken to compare the clinical efficacy of 0.2% chlorhexidine with licorice mouthwash on gingival health status over a period of 4 weeks.
| Materials and Methods|| |
This study was designed and conducted in a private school, Jaipur, India. One hundred and four children with clinical signs and symptoms of chronic plaque-induced gingivitis were selected from the various classes. All patients were systemically healthy and between 12 and 15 years of age. Approval from the Institutional Ethics Committee of Dental College, Jaipur, was obtained before initiating the study. An informed consent was obtained from all the parents of participants. The individuals were randomly assigned to one of the 2 treatment groups, i.e., 0.2% chlorhexidine (HEXIDINE by ICPA Health products Ltd.) and licorice mouthwash (a Private company manufactured, Jaipur, Rajasthan, India) and were followed for 4 weeks.
In the majority of cases, participants were examined at the same time of day to reduce extraneous variables in plaque accumulation, such as the length of time between home care and data collection. Fifty-two individuals (27 males and 25 females) were instructed to use 10 ml of 0.2% chlorhexidine mouthwash twice daily and 52 individuals (19 males and 33 females) were instructed to use 10 ml of licorice mouthwash twice daily. Individuals were given the same type of toothbrush (by Oral B) and toothpaste (Pepsodent) and were also given appropriate oral hygiene instructions.
Data were collected at baseline, 1st, 2nd, and 4th week utilizing the following:
- Plaque index 
- Gingival index 
- Bleeding on probing (percentage of bleeding sites).
Statistical analysis was carried out by means of SPSS 21. Paired comparison tests were used to confirm the results with P < 0.05. Mean and standard deviation was calculated using the paired t-test and mean difference was calculated at each week to yield significant results.
| Results|| |
One hundred and four participants (58 females and 46 males) participated in the study, and the response rate to the study was 100%.
Analysis of plaque indices showed that both chlorhexidine and licorice mouthwash were helpful in reducing mean plaque accumulation from baseline to 4 weeks. The mean plaque index scores reduced from 3.8 ± 0.7 to 1.24 ± 0.92 in chlorhexidine group and from 3.88 ± 0.83 to 2.28 ± 0.93 in the licorice group [Figure 1].
|Figure 1: Reduction in plaque index with chlorhexidine and licorice mouthwash from baseline to 4 weeks|
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Analysis of gingival scores indicated that chlorhexidine and licorice mouthwash independently showed a statistically significant improvement from baseline to 1st week with further improvement at 2nd and 4th week. The reduction in gingival index scores in chlorhexidine and licorice mouthwash group was 2.0 ± 0.00–0.28 ± 0.45 and 1.96 ± 0.20–0.6 ± 0.5 (from baseline to 4 weeks), respectively [Figure 2].
|Figure 2: Reduction in gingival index with chlorhexidine and licorice mouthwash from baseline to 4 weeks|
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Intergroup comparisons depicted that chlorhexidine was significantly more persuasive in reduction of plaque accumulation and gingivitis as compared to licorice mouthwash, signifying that chlorhexidine still remains a gold standard.
Bleeding on probing
Although results do not reach to level of significance when intergroup comparisons were made, individually both chlorhexidine and licorice mouthwash were effective in reducing bleeding sites. The mean percentage of bleeding sites reduced from 84.0% ± 37.2%–44.2% ± 50.3% in chlorhexidine group and 87.4% ± 48.23%–56.1 ± 33.5% in licorice mouthwash group at 4 weeks. Licorice mouthwash contains certain ingredients with astringent property, so a steady fall in bleeding sites was noticed as compared to chlorhexidine [Figure 3].
|Figure 3: Reduction in percentage of bleeding sites with chlorhexidine and licorice mouthwash from baseline to 4 weeks|
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| Discussion|| |
The study was conducted to authenticate the efficacy of licorice mouthwash versus chlorhexidine mouthwash on gingival status and plaque biofilm accumulations over a period of 4 weeks. Chlorhexidine remains the gold standard anti-plaque and antigingivitis agents. Its efficiency can be endorsed to its bactericidal and bacteriostatic effects and its substantivity within the oral cavity. Licorice has shown promising results with minimal side effects. Furthermore, their additional effect on inflammatory pathways and antioxidant potential make them eligible to be used as effective antigingivitis agents. The licorice ingredients are abundantly available, easily accessible, economically feasible, and culturally acceptable. They possess minimal side effects and hence can be recommended for long-term use. Although around 6000 plants in India are used as herbal medicine, little research has been conducted to evaluate the efficacy, safety, and properties of herbal products. Hence, more clinical trials are required to know the effectiveness of natural products and their advantage over the prototype chemical plaque control agents.
Numerous studies have reported the efficacy of chlorhexidine in reducing plaque accumulation and gingival inflammation.,
Azadirachta indica has been shown to be efficient in reducing the plaque index and bacterial count. In a comparative study between A. indica and chlorhexidine, it was established that A. indica-based mouth rinse was highly efficacious in reducing plaque index, gingival index, and gingival bleeding index and that it may be used as an alternative therapy in the treatment of periodontal disease. Neem extract has also revealed to effectively reduce interleukin-2 and interferon-gamma levels in gingival tissue of patients with chronic gingivitis.
Methanolic extract of Quercus has shown to have a considerable antibacterial activity against Streptococcus mutans, Streptococcus salivarius, and Lactobacillus which play a major role in plaque development and its activity against caries and gingivitis. Bajaj et al. stated that 0.6% triphala has an inhibitory effect on plaque, gingivitis, and growth of S. mutans and Lactobacillus and was found to be equally effective as 0.1% chlorhexidine. Similar results were reported by Gupta et al. wherein 0.6% triphala was found to be highly effective in preventing plaque accumulation and gingivitis.
Tulsi extract has also shown to demonstrate a significant antimicrobial potential against S. mutans. Goultschin et al. tested the effect of glycyrrhizin, the main saponin of licorice on gingival health as a supplemental agent in toothpaste. The toothpaste, however, failed to show any significant reduction in plaque, gingival, and bleeding indices. A study by Jayashankar et al. also demonstrated that a herbal toothpaste containing Mimusops elengi, Syzygium aromaticum, and Quercus infectoria significantly reduced plaque index and bleeding on probing.
A study by Pistorius et al. showed that subgingival irrigation with an herbal-based mouthrinse (containing salvia officinalis, metha piperita, menthol, Matricaria chamomilla, Commiphora myrrha, Carum carvi, Eugenia caryophyllus, and Echinacea purpurea) proved to be fruitful in reducing gingival inflammation as it leads to significant reduction in both bleeding and gingival score. In the present study, analysis of plaque index suggests that both the mouthwashes were helpful in reducing plaque, but chlorhexidine reduced plaque scores to greater extent as compared to licorice mouthwash group. These findings are similar to previous studies., The reduction in plaque score in chlorhexidine group was due to antibacterial action. In a microbiological study, it was reported that herbal mouthwash had less potent antibacterial action than chlorhexidine. Chlorhexidine has antibacterial activity against actinomyces species, periodontal pathogens Eubacterium nodatum, Tannerella forsythia, and Prevotella species, as well as the cariogenic pathogen S. mutans. However, variations in the plaque accumulation may also have been influenced by the Hawthorne effect or the tendency of participants to improve behavior because of the expectation created by the situation.
Chlorhexidine was also more efficient in improving gingival inflammation. Both chlorhexidine and licorice mouthwash were found to be helpful in reducing bleeding score, but results were not significant statistically. This substantial reduction in bleeding score in herbal group might be because of its ingredients M. elengi, Acacia catechu, and Mentha spicata which reduce bleeding because of their astringent action. These results are consistent with other findings by Scherer et al. 1998 who demonstrated that herbal mouthwash reduces gingival bleeding over a period of time.
| Conclusion|| |
The results of the present study indicate that both mouthwashes were effective in improvement of plaque and gingivitis scores, though chlorhexidine showed better clinical improvement. Licorice mouthwash was found to be comparable to chlorhexidine in reducing bleeding on probing.
Thus, licorice mouthwash can be effectively used as an alternative to chlorhexidine and can be prescribed for longer duration without any side effects for the management of periodontal diseases.
I want to acknowledge all the participants of the study who voluntarily participated in our study group. I want to thank our institution for constant support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loe H, Theilade E, Jensen SB. Experimental gingivitis in man. J Periodontol 1965;36:177-87.
Löe H, Schiött CR, Karring G, Karring T. Two years oral use of chlorhexidine in man. I. General design and clinical effects. J Periodontal Res 1976;11:135-44.
Segreto VA, Collins EM, Beiswanger BB, De La Rosa M, Isaacs RL, Lang NP, et al
. A comparison of mouthrinses containing two concentration of chlorhexidine. J Periodontal Res 1986;21 Suppl 16:23-32.
Grossman E, Reiter G, Sturzenberger OP. Six month study on the effects of a chlorhexidine mouth rinse on gingivitis in adults. J Periodontal Res 1987;58:827.
Lang NP, Hotz P, Graf H, Geering AH, Saxer UP, Sturzenberger OP, et al.
Effects of supervised chlorhexidine mouthrinses in children. A longitudinal clinical trial. J Periodontal Res 1982;17:101-11.
Zhang Q, Ye M. Chemical analysis of the Chinese herbal medicine Gan-Cao (licorice). J Chromatogr A 2009;1216:1954-69.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of Victamine C. J Periodontol 1970;41:41-3.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Becerik S, Türkoglu O, Emingil G, Vural C, Ozdemir G, Atilla G. Antimicrobial effect of adjunctive use of chlorhexidine mouthrinse in untreated gingivitis: A randomized, placebo-controlled study. APMIS 2011;119:364-72.
Corbet EF, Tam JO, Zee KY, Wong MC, Lo EC, Mombelli AW, et al.
Therapeutic effects of supervised chlorhexidine mouthrinses on untreated gingivitis. Oral Dis 1997;3:9-18.
Pai MR, Acharya LD, Udupa N. Evaluation of antiplaque activity of Azadirachta indica
leaf extract gel – A 6-week clinical study. J Ethnopharmacol 2004;90:99-103.
Botelho MA, Santos RA, Martins JG, Carvalho CO, Paz MC, Azenha C, et al
. Efficacy of a mouthrinse based on leaves of the neem tree (Azadirachta indica
) in the treatment of patients with chronic gingivitis: A double-blind, randomized, controlled trial. J Med Plants Res 2008;2:341-6.
Sharma S, Saimbi CS, Koirala B, Shukla R. Effect of various mouthwashes on the levels of interleukin-2 and interferon-gamma in chronic gingivitis. J Clin Pediatr Dent 2008;32:111-4.
Vermani A; Navneet; Prabhat. Screening of Quercus infectoria
gall extracts as anti-bacterial agents against dental pathogens. Indian J Dent Res 2009;20:337-9.
] [Full text]
Bajaj N, Tandon S. The effect of triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, and microbial growth. Int J Ayurveda Res 2011;2:29-36.
] [Full text]
Gupta K, Tandon S, Rao S, Malagi KJ. Effects of triphala mouthwash on the oral health status. Malays Dent J 2004;25:27-46.
Agarwal P, Nagesh L; Murlikrishnan. Evaluation of the antimicrobial activity of various concentrations of Tulsi (Ocimum sanctum
) extract against Streptococcus mutans
: An in vitro
study. Indian J Dent Res 2010;21:357-9.
] [Full text]
Goultschin J, Palmon S, Shapira L, Brayer L, Gedalia I. Effect of glycyrrhizin-containing toothpaste on dental plaque reduction and gingival health in humans. A pilot study. J Clin Periodontol 1991;18:210-2.
Jayashankar S, Panagoda GJ, Amaratunga EA, Perera K, Rajapakse PS. A randomised double-blind placebo-controlled study on the effects of a herbal toothpaste on gingival bleeding, oral hygiene and microbial variables. Ceylon Med J 2011;56:5-9.
Pistorius A, Willershausen B, Steinmeier EM, Kreislert M. Efficacy of subgingival irrigation using herbal extracts on gingival inflammation. J Periodontol 2003;74:616-22.
Overholser CD, Meiller TF, DePaola LG, Minah GE, Niehaus C. Comparative effects of 2 chemotherapeutic mouthrinses on the development of supragingival dental plaque and gingivitis. J Clin Periodontol 1990;17:575-9.
Haffajee AD, Yaskell T, Socransky SS. Antimicrobial effectiveness of an herbal mouthrinse compared with an essential oil and a chlorhexidine mouthrinse. J Am Dent Assoc 2008;139:606-11.
Scherer W, Gultz J, Lee SS, Kaim J. The ability of an herbal mouthrinse to reduce gingival bleeding. J Clin Dent 1998;9:97-100.
[Figure 1], [Figure 2], [Figure 3]