Clinical Evaluation of Centella Asiatica(Gotukola) …Mechanical Plaque control by tooth brushing is...

MOHAMMADI ET AL : CENTELLA ASIATICA

MOUTHWASH WORLD J ADV SCI RES

VOL. 1 ISSUE 2 NOV – DEC 2018 59

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.




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.




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,




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




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




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.




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.




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




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




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




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




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




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




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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Clinical Evaluation of Centella Asiatica(Gotukola) …Mechanical Plaque control by tooth brushing is...

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