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Clinical Evaluation of Centella Asiatica(Gotukola)
mouthwash as an adjunct to mechanical plaque control.
Dr. Talat Mohammadi*, Dr. Shivamurthy Ravindra**, Dr. Marenahally Rangaraju
Vivekananda***, Dr. Dasappa Shivaprasad****, Dr. Aratrika Mukherjee*
*PG student, **Prof and HOD, ***Associate Professor, ****Assistant Professor,
Dept of Periodontics,
Sri Hasanamba Dental College and Hospital.
Hassan, Karnataka.
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Abstract
Objective: To evaluate the clinical effect of Centella asiatica (gotukola) in the
reduction of plaque and gingival inflammation
Materials and Methods: Thirty-six subjects diagnosed with chronic generalized
gingivitis were selected and randomly divided into three groups: Group 1- Scaling
+ gotukola, Group 2- Scaling only, Group 3- gotukola only. Clinical evaluation
was done at baseline and after 15 days using plaque index (Silness and Loe) and
gingival index (Loe and Silness)
Results: Gotukola mouthwash when used as an adjunct to mechanical therapy
(scaling) showed significant improvements in plaque index and gingival index
scores compared to other groups
Conclusion: Gotukola mouthwash may be useful herbal formulation for
chemical plaque control and for improvement in plaque scores and gingival status
Keywords: Anti-plaque agents, Clinical trial, gotukola, gingivitis, plaque.
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INTRODUCTION
Studies conducted throughout the world have proved that the incidence and
prevalence of periodontal diseases is increasing and bacterial plaque is the
primary etiological factor for it.(1,2) The initial microbial challenge and the host
susceptibility are the main contributing factors to the development of
inflammatory periodontal disease. Experimental gingivitis studies have already
proved the role of plaque in the etiology of periodontal infections and
demonstrated the direct relationship between plaque levels and development of
human gingivitis.(1,2) Thus the status of oral hygiene bears a direct relationship
with gingival health.
Mechanical Plaque control by tooth brushing is considered to be the ideal way of
preventing plaque associated gingivitis and periodontitis, but unfortunately due to
various factors many of the individuals fail to perform an adequate quality of self
performed mechanical plaque control.(3) In order to overcome these limitations,
chemical plaque control measures have been advocated which can be used as
adjuncts to mechanical plaque control measures.(4) Evidence from a meta-analysis
strongly support the adjunctive use of antimicrobial agents compared to
mechanical plaque control.(5) Although a number of chemical plaque control
agents have been suggested, there is still a lack of anti-plaque agent that can be
used on a daily basis with minimum side effects.
Recently Complementary and Alternative medicine has become more popular due
to the natural way of curing various ailments.(6) These herbal formulations can
provide an option for safe and long term use.(7)
Certain plants used in alternative medicine serve as a source of therapeutic agent
by having multipotential effects, in addition to their antimicrobial property.
Among several plant species presenting biological activities, Centella asiatica,
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popularly known as gotukola calls attention. Centella asiatica belongs to the
kingdom Plantae, Family of Mackinlayaceae and Genus Centella. This species has
been reported to own a wide range of biological activities desired for human
health such as neuroprotective,(8)woundhealing,(9)anti-inflammatory,(10)
antipsoriatic,(11)antiulcer,(12)hepatoprotective,(13)anticonvulsant,(14)
immunostimulant,(15)cardioprotective,(16)antidiabetic,(17)antiviral,(18)
antibacterial,(19) antifungal, (20)antioxidant,(21)and venous deficiency treatments.(22)
In this perspective, the present randomized controlled clinical trial investigated
the clinical efficacy of an experimental mouthwash containing Centella asiatica
(gotukola) in reducing plaque and gingival inflammation in subjects with bio-film
induced gingivitis.
MATERIALS AND METHODS
A parallel designed randomized controlled clinical trial was conducted among
patients with chronic generalized plaque-induced gingivitis visiting the
Department of Periodontology, Sri Hasanamba Dental College and Hospital,
Hassan. A total of 36 patients (18 males, 18 females, Mean age 21.3 ± 0.2134
years) were screened from the out-patient Department of Periodontics.
Inclusion Criteria
Minimum of 22 natural teeth
Participants with Chronic generalized gingivitis
Participants with plaque index score ≥1
Exclusion Criteria
Participants with fixed or removable appliances
Participants with more than full coverage restorations
Medically compromised participants
Participants on long term medications
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Smokers
Participants who had used any type of antibacterial mouthwash in 4weeks of
commencement.
Patients with history of recent periodontal therapy.
The protocol for the study was approved by the institutional ethics committee and
written informed consent was obtained from the participants before the
commencement of the study. The selected subjects were divided randomly into
three groups (group 1, 2 and 3) using the chit method. Clinical assessments were
performed by a single examiner who was blinded to the study groups.
Group 1: Scaling + gotukola
Group 2: Scaling only
Group 3: gotukola only
On day1, all participants received a careful oral examination and those belonging
to group 1 and 2 received thorough Scaling and polishing and participants in
group 1 and group 3 were advised to use the mouthwash two times a day, each
time 10 ml rinsed for 60 seconds (morning and evening after food) and the
patients were not given any additional brushing instructions. The Plaque index
(Loe & Silness), gingival index (Silness and Loe) of each patient was recorded at
baseline and 15th day postoperatively. A flow chart based on the patient
allotment and study protocol has been described as follows
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Inclusion/exclusion
criteria
Randomization by
Chit method
Gr
Preparation of Mouthwash
The plant specimens (leaves of gotukola) for the proposed study were collected.
The leaves were cleaned and sun dried for three days. The dried leaves were then
grounded to powdered form. Preparation of extract was done using Soxhlet
extractor. The extractions were filtered using Whatman no 4 filter paper and then
dried in rotary evaporator for 5-6 hrs at 60 degree C. The dried extract was
converted into powder form which was utilized for the preparation of desired
concentration of the extracts. The required concentration was prepared by adding
Subjects screened
Sample size (n= 36)
Plaque index and gingival
index recorded at baseline
Group 2(n=12)
Subjects received
only scaling without
mouthwash
Group 1 (n=12)
Subjects
received scaling
and Mouthwash
Group 3 (n=12)
Subjects received
only mouthwash
without scaling
Plaque index and gingival index
recorded at 15th day for all the
three groups.
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0.68gm(23) of powder in 10 ml of distilled water .Subjects were asked to rinse
10ml of prescribed mouthwash for 60 seconds twice daily
Statistical analysis
Descriptive statistics was computed by using mean and standard deviation.
Multiple groups were compared by using Analysis of variance followed by
Tukey’s post hoc test. Baseline to post operative comparison was done by using
paired t test. A p < 0.05 was considered as statistically significant. Statistical
analysis was performed by using SPSS software version 20.
RESULTS
A total of 36 participants (18 males and 18 females) participated in the study
with the mean age of 21.3 ± 0.2134 years without any dropouts.
Plaque Index
On analyzing the plaque index, it was seen that all the three groups lead to
significant reduction in plaque scores (P<0.001). Mean decrease in group 1 was
from 1.817± 0.187 at baseline to 1.127±0.111 at 15 days (P<0.001), in group 2
was from 1.910± 0.271 at baseline to 1.602±0.160 at 15 days (P <0.001) and in
group 3 was from 1.867± 0.334 at baseline to 1.551±0.188 at 15 days (P<0.001)
[Table 1 and 3, Graph 1 and 2]
Inter group comparisons was done at post therapy. The results revealed that group
1 had statistically significant reduction in the value of plaque index compared to
group 2 (P< 0.001) and group 3 (P<0.001). However, group 2 and group 3
revealed that there was no statistically significant reduction in plaque index value
between the both groups. (P<0.700) [Table 2, Graph 1 and 2]
Hence, gotukola mouthwash was as effective as scaling with respect to anti
plaque property and when used as adjunct to scaling it showed better antiplaque
property compared to scaling alone.
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Gingival index
On analyzing the gingival index, it was seen that all the three groups lead to
significant reduction in gingival scores (P<0.001). Mean decrease in group 1 was
from 1.847± 0.283 at baseline to 1.148±0.110 at 15 days (P<0.001), in group 2
was from 1.902± 0.234 at baseline to 1.527±0.277 at 15 days (P <0.001) and in
group 3 was from 1.854± 0.328 at baseline to 1.517±0.333 at 15 days (P<0.001)
[Table 4and 6, Graph 3 and 4]
Inter group comparisons was done at post therapy, The results revealed that
group 1 had statistically significant reduction in the value of gingival index
compared to group 2 ( P= 0.003),and group 3 (P =0.004).However, group 2 and
group 3 revealed that there was no statistically significant reduction in gingival
index value between the both groups ( P=0.994) [ Table 5, Graph 3 and 4]. Hence,
gotukola mouthwash was as effective as scaling with respect to antigingivitis
property and when used as adjunct to scaling it showed better antigingivitis
property compared to scaling alone.
Table 1- Comparative data of three groups- PI at Baseline and at 15 days
Variable Group Mean+ SD P value
PI-
Baseline
Scaling+gotukola 1.817±0.187 0.706
Scaling 1.910±0.271
Gotukola 1.867±0.334
PI-15
days
Scaling+gotukola 1.127±0.111 <0.001
Scaling 1.602±0.160
Gotukola 1.551±0.188
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Table 2-Intergroup comparisons –PI at 15 days
Sl.no Group Compared
with group
P
value
1 Scaling+gotukola Scaling <0.001
2 Scaling+ gotukola gotukola <0.001
3 Scaling gotukola 0.700
Table 3- comparative data of three groups from baseline to post-therapy -PI
Group Variable (PI) Mean+S
D
P value
Scaling+
gotukola
Baseline 1.817+0.
187
<0.001
15 days 1.127+0.
111
Scaling Baseline 1.910+0.
271
<0.001
15 days 1.602+0.
160
gotukola Baseline 1.867+0.
334
<0.001
15days 1.551+0.
188
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Graph 1- Comparative data of three groups- PI at Baseline
Graph 2- Comparative data of three groups- PI at 15 days
Table 4- Comparative data of three groups- GI at Baseline and at 15 days
Variable Group Mean+ SD P value
GI-
Baseline
Scaling+gotukola 1.847±0.283 0.135
Scaling 1.902±0.234
gotukola 1.854±0.328
GI-15
days
Scaling+gotukola 1.148±0.110 <0.001
Scaling 1.527±0.277
gotukola 1.517±0.333
Scaling+gotukola
Scaling gotukola
PLAQUE INDEX BASELINE
Series1 1.817666667 1.910333333 1.867166667
00.5
11.5
22.5
PI
Sco
reComparative data of PI-Baseline
Scaling+gotukola
Scaling gotukola
PLAQUE INDEX- 15 DAYS
Series1 1.127583333 1.602916667 1.551333333
00.5
11.5
2
PI
-Sco
re
Comparative data of PI -15days
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Table 5--Intergroup comparisons –GI at 15 days
Sl.no Group Compared
with group
P value
1 Scaling+gotukola Scaling 0.003
2 Scaling+ gotukola gotukola 0.004
3 scaling gotukola 0.994
Table 6- comparative data of three groups from baseline to post-therapy -GI
Group Variable (GI) Mean+ SD P value
Scaling+gotukola Baseline 1.847+0.283 <0.001
15 days 1.148+0.110
Scaling Baseline 1.902+0.234 <0.001
15 days 1.527+0.277
gotukola Baseline 1.854+0.328 <0.001
15 days 1.517+0.333
Graph 3- Comparative data of three groups- GI at Baseline
Scaling+gotukola
Scaling gotukola
GINGIVAL INDEX BASELINE
Series1 1.847083333 1.902333333 1.853583333
0
0.5
1
1.5
2
GI
Sco
re
Comparative data of GI -Baseline
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Graph 4- Comparative data of three groups- GI at 15 days
DISCUSSION
The chemical plaque control is generally considered to be an adjunct to
mechanical oral hygiene practices. Agents being most commonly delivered in
toothpaste or mouthrinse vehicles.(24) The classic experiments of Loe et al 1965(1)
demonstrated that accumulation of microbial plaque results in the development of
gingivitis and its removal and control results in resolution of the lesions in
humans, thereby plaque proving as the microbial etiology of the disease as
mentioned by Page 1986.(25) Research centers and World Health Organization
prepare lots of programs to make use of plant extracts.(26) Usage of such natural
preparations has added advantage of fewer side effects and also they are more
economical.
Centella asiatica has been widely used in traditional medicine in Africa, India,
China, Japan, Indonesia, Sri lanka and in South pacific for the treatment of
microbial infections. It has small fan shaped green leaves with white or light
purple to pink flowers. It bears small oval shaped fruits. The stems are slender,
Scaling+gotukola
Scaling gotukola
GINGIVAL INDEX-15 DAYS
Series1 1.148833333 1.527916667 1.517
00.20.40.60.8
11.21.41.61.8
GI
Sco
reComparative data of GI-15days
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creeping stolons, green to reddish green in color, interconnecting one plant to
another. Centella asiatica is often called one of the miracles elixers of life because
legend has said that an ancient Chinese herbalist lived for more than 200 years as
a result of using this herb. Researchers reported that American and Europeans
herbal list used Centella asiatica for disorders that cause connective tissue
swelling such as Scleroderma, Ankylosing Spondylitis, Rheumatoid arthritis,
Depression and to improve memory. Another research reported that Centella
asiatica has been used traditionally in lowering of high blood pressure, treating of
various insufficiency, boosting of memory and intelligence ,easing anxiety and
wound healing.
The primary active constituents of Centella asiatica are saponins (also called
triterpenoids), which include asiaticosides in which a trisaccharide moiety is
linked to the aglycone asiatic acid, madecassoside and madasiatic acid.(27) These
triterpene saponins and their sapogenins are mainly responsible for the wound healing
and vascular effects by inhibiting the production of collagen at the wound site. Other
components isolated from Centella asiatica, such as brahmoside and brahminoside, may
be responsible for CNS and uterorelaxant actions. In addition, the total extract contains
plant sterols, flavonoids, with no known pharmacological activity28 namely abundant
tannins (20-25%), essential acid (0.1% with beta-chariophylen, trans-beta-pharnesen and
germachrene D), phytosterols (campesterol, sitosterol, stigmasterol), mucilages, resins,
free aminoacids (alanine, serine, aminobutyrate, aspartate, glutamate, lysine and
treonine), flavonoids (derivates of chercetin and kempferol), an alkaloid (hydrochotine),
a bitter component (vallerine), fatty acids (linoleic acids, linolnelic, oleic, palmitic and
stearic acids).
Hence the present study was conducted in order to evaluate the clinical effect of
Centella asiatica (gotukola) in the reduction of plaque and gingival inflammation.
The best results in the present study were obtained when gotukola was used as an
adjunct to scaling. It showed a statistically significant reduction in the value of
both plaque and gingival indices. This can be attributed to the mechanical
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removal of microbial plaque by scaling procedure with the added benefits of anti-
inflammatory and antimicrobial actions exerted by gotukola mouthwash and also
reduction in plaque and gingival indices was not statistically significant among
the patients who underwent scaling alone and who used mouthwash alone without
scaling, suggesting that gotukola may be as efficient as scaling procedure.
A similar study was conducted by Sastravaha et al 2003.(29) where they clearly
showed the significant improvements in probing pocket depth, attachment level,
bleeding on probing, plaque and gingival indices value in the sites which were
treated with local drug delivery of Centella asiatica and Punica granatum after
scaling and root planning .The same authors conducted a study in 2005 (30) where
they additionally monitored the levels of IL-1 and IL-6 in maintenance patients
and they showed statistically greater reduction of IL-1beta at both 3 and 6 months
and lower IL-6 concentration, which almost reached the level of significance at 6
months in test group. Thus gotukola can be used as an adjunct to scaling in
patients susceptible to gingivitis.
The varied benefits of gotukola such as easy availability, commonly used
vegetable, reduced cost, no staining, antibacterial property and less resistance
make this herbal product an effective therapeutic agent against periodontal
disease. Further long-term trials with large samples and antibacterial action
against specific periodontopathogens are needed to provide more promising
evidence.
Conclusions
Within the limitations of the study it can be concluded that gotukola mouthwash
is an effective anti-plaque agent and also can be used to prevent gingivitis in
subjects diagnosed with chronic generalized gingivitis. Thus it can be used an
effective adjunct to mechanical plaque control.
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