ORIGINAL ARTICLE
Efficacy of Curcumin in the Treatment of Chronic Gingivitis: A Pilot Study Sangeeta Muglikara/Kalpak Chandrakant Patilb/Sumanth Shivswamic/Rashmi Hegded Purpose: To evaluate the efficacy of curcumin mouthwash as an adjunct to scaling and root planing in the treatment of chronic gingivitis and to compare curcumin to chlorhexidine in terms of its anti-inflammatory and anti-microbial properties. Materials and Methods: Thirty patients aged 20–40 years with generalised chronic gingivitis were included in the study. They were randomly divided into 3 groups of 10 each. In group 1, patients underwent scaling and root planing followed by chlorhexidine mouthwash (SRP/CHX Gr-1); in group 2, patients underwent scaling and root planing followed by curcumin mouthwash (SRP/CUR Gr-2); in group 3, patients underwent only scaling and root planing (SRP Gr-3). Gingival and plaque indices were recorded at baseline (day 0) and 7, 14 and 21 days. Differences between the groups were statistically analysed. Results: The clinical parameters showed improvement in all the three groups compared to baseline. When compared to the scaling and root planing group (Gr-3), both curcumin and chlorhexidine groups were found to have statistically significantly better results (P < 0.05). However, when curcumin and chlorhexidine groups were compared, the gingival (Löe and Silness) and plaque index (Silness and Löe) scores were not found to be statistically significant (P > 0.05). Conclusion: Curcumin is comparable to chlorhexidine as an anti-inflammatory mouthwash. Thus, it can be considered as an effective adjunct to mechanical periodontal therapy. Key words: chlorhexidine, curcumin, dental plaque, gingivitis Oral Health Prev Dent 2013; 11: 81-86
M
icrobial plaque plays a fundamental role in the pathogenesis of periodontal diseases (Addy et al, 1987; Bascones, 1994). Mechanical plaque control has been commonly used as a primary preventive measure. Thus, conventional periodontal therapy can improve the overall gingival health and in general halt the progression of attachment loss. However, gingival inflammation persisting at some sites may lead to future attachment loss. There-
a
Postgraduate Student, Department of Periodontology and Implantology, M.A. Rangoonwala Dental College, Puna, India.
b
Professor and Head of Department of Periodontology and Implantology, M.A. Rangoonwala Dental College, Puna, India.
c
Reader, Department of Periodontology and Implantology, M.A. Rangoonwala Dental College, Puna, India.
d
Senior Lecturer, Department of Periodontology and Implantology, M.A. Rangoonwala Dental College, Puna, India.
Correspondence: Kalpak Chandrakant Patil, Department of Periodontology and Implantology, M.A.Rangoonwala Dental College, Hidayatullah road, Pune, 400 001 India. Tel: +91 9923610061. Email:
[email protected]
Vol 11, No 1, 2013
Submitted for publication: 01.03.12; accepted for publication: 16.05.12
fore, chemotherapeutic agents are commonly used during the maintenance phase of therapy. A number of different antiseptic substances have been incorporated in mouthrinses and dentifrices to improve the outcome of mechanical oral hygiene procedures. One of the most frequently used compounds is chlorhexidine (CHX), which is a broadspectrum antiseptic with pronounced antimicrobial effects both on gram-positive and gram-negative bacteria as well as on fungi and some viruses (Sekino, 2004). However, the use of synthetic compounds has certain disadvantages, for example, the staining of teeth and alteration of taste sensation has been reported with CHX use (Flotra, et al, 1971). Due to the clinical drawbacks of synthetic agents, the availability of relatively safe herbal extracts has led to their use in various fields as an alternative therapy. Various authors have studied use of herbal extracts – with active ingredients such as Salvia officinalis, Mentha piperita, menthol, Chamomilla, Cemmiphora myrrha, Carum carvi, Eugenia caryophyllus and Echinacea purpura – in for-
81
Muglikar et al
mulations for treating subgingival irrigation (Suhag et al, 2007). Curcuma longa is a spice that contains polyphenolic curcumin in its rhizome. It has been reported that curcumin has anti-inflammatory, anti-oxidant, anti-microbial and anti-bacterial properties (Suhag et al, 2007). These beneficial properties of curcumin justify its use in the treatment of periodontal diseases. The present study was designed to evaluate the efficacy of an anti-inflammatory and anti-plaque curcumin mouthwash (20%) as an adjunctive therapy and to compare it with commonly used chlorhexidine mouthwash (0.2%).
r Group 2: Scaling and root planing followed by curcumin mouthwash (20%) twice daily for a period of 21 days. Curcumin mouthwash (20%) was prepared by mixing 1 teaspoon of curcumin extract in 2 cups of water, boiling until it reduced to half the original volume and then filtering for use as mouthwash. One teaspoon (containing 5.139 g curcumin) was mixed in 50 ml of distilled water, boiled down to 25 ml and filtered using filter paper. This yielded a curcumin concentration of 20%. The method of preparation of this mouthwash (decoction) was adopted from Sharangdhar Samhita (ancient ayurvedic book on medicine preparation). r Group 3: Scaling and root planing only.
MATERIALS AND METHODS
The patients were advised to rinse with the respective mouthwash twice daily, rinsing with 10 ml of mouthwash for 1 min mornings and evenings, 10 minutes after brushing. They were advised not to eat for half an hour after rinsing. The gingival (Löe and Silness) and plaque indices (Silness and Löe) were measured at baseline (0) and 7, 14 and 21 days.
Study population Thirty subjects fulfilling the criteria established for the study were selected from the outpatient Department of Periodontology and Implantology, M. A. Rangoonwala Dental College and Research Centre, Pune, India. Subjects suffering from chronic generalised gingivitis manifesting change in the colour and bleeding on probing but no signs of periodontitis (e.g. true pockets, loss of attachment and alveolar bone) were selected. Patients on systemic antibiotic therapy, tobacco users, pregnant/lactating women or those having undergone periodontal therapy in the last 6 months were excluded from the study. The nature, duration and purpose of the study was explained to all selected patients, and informed consent was obtained. They were also trained in the techniques to maintain good oral hygiene. The modified Bass brushing technique was demonstrated and the subjects were trained to brush in the clinics. They were advised to use a soft-bristle toothbrush. In addition to this, they were trained to use dental floss. The study was approved by the local human research review board and ethics committee. The clinical examinations were carried out by a single trained observer who was blinded to all the three groups. The therapy was carried out by another trained clinician. Supra- and subgingival scaling was performed in all the subjects and gingival (Löe and Sillness) and plaque (Sillness and Löe) indices were recorded.
Statistical analysis Values on indices are shown as means (± SD). Within-group comparison of indices was performed using the paired t-test. Between-group comparison of indices was done with one-way ANOVA plus Tukey’s correction for multiple group comparisons. P < 0.05 was considered statistically significant. Data were statistically analysed using SPSS (version 11.5 for MS Windows; SPSS; Chicago, IL, USA). A statistical power calculation was done using SPSS software version 11.5 (Chicago, IL, USA); a sample size n = 10 in each group yielded 81% power with 5% type I error.
RESULTS The results of this study were based on gingival and plaque indices recorded at baseline, 7, 14 and 21 days.
Gingival index r Group 1: Scaling and root planing followed by 0.2% chlorhexidine mouthwash twice daily for a period of 21 days.
82
In the intra-group comparison, the gingival index scores had significantly reduced from baseline to
Oral Health & Preventive Dentistry
Muglikar et al
Table 1 Gingival index Day 0
Day 7
Day 14
Day 21
P-value*
Group 1 (n = 10)
2.29 (0.12)
1.58 (0.23)
1.26 (0.15)
1.09 (0.13)
0.001
Group 2 (n = 10)
2.37 (0.19)
1.62 (0.25)
1.36 (0.18)
1.19 (0.17)
0.001
Group 3 (n = 10)
2.55 (0.19)
1.61 (0.17)
1.64 (0.13)
1.65 (0.12)
0.001
Values are mean (SD). Paired t-test (comparing day 0 vs day 21).
Table 2 Gingival index (% change) Group
day 0
day 7
day 14
day 21
1 (n = 10)
-
31.1 (9.4)
44.9 (5.8)
52.5 (5.9)
2 (n = 10)
-
31.5 (8.6)
42.8 (5.2)
49.5 (4.6)
3 (n = 10)
-
36.8 (6.7)
35.7 (4.3)
35.3 (5.1)
P-values* Group 1 vs group 2
-
0.993
0.630
0.416
Group 1 vs group 3
-
0.296
0.001
0.001
Group 2 vs group 3
-
0.348
0.013
0.001
Values are mean (SD) of % change from baseline (day 0). *One-way ANOVA with Tukey’s correction for multiple group comparisons. % change = (day 0 index value – follow up index value) x 100 / (day 0 index value).
21 days in all the groups. In group 1, the values decreased from 2.29 ± 0.12 at baseline to 1.09 ± 0.13 at 21 days. In group 2, the gingival index decreased from 2.37 ± 0.19 at baseline to 1.19 ± 0.17 at 21 days, and in group 3, the values dropped from 2.55 ± 0.19 at baseline to 1.65 ± 0.12 at 21 days. The changes in all these groups were found to be statistically significant (P < 0.001) (Table 1). At day 7, the percentage reductions in the gingival index scores for groups 1, 2 and 3 were 31.1% ± 9.4%, 31.5% ± 8.6% and 36.8% ± 6.7%, respectively, but the inter-group comparison did not show statistically significant differences (P > 0.993). The percentage reductions in the scores at day 14 in groups 1, 2 and 3 were 44.9% ± 5.8%, 42.8% ± 5.2% and 35.7% ± 4.3%, respectively. The results for groups 1 and 2 differed statistically significantly from group 3 (P = 0.001) at day 14, but the difference between groups 1 and 2 were not statistically significant (P = 0. 630). The percentage reduction in the scores at day 21 in groups 1 and 2 (52.5% ± 5.9% and 49.5% ± 4.6%, resp) was significantly greater than in group 3 (35.3% ± 5.1%; P = 0.001). Groups 1 and 2, how-
Vol 11, No 1, 2013
ever, did not differ significantly from each other (P > 0.416) (Table 2). Thus, the gingival index reduced significantly for all groups from baseline to day 21.
Plaque index In the intra-group comparison, the plaque index decreased significantly from baseline to 21 days for all groups. In group 1, the values dropped from 2.33 ± 0.24 at baseline to 1.57 ± 0.18 at 21 days. In group 2, the plaque index decreased from 2.32 ± 0.25 at baseline to 1.54 ± 0.11 at day 21. In group 3, the values decreased from 2.27 ± 0.22 at baseline to 1.57 ± 0.13 at day 21. The changes in all these groups were found to be statistically significant (P = 0.001) (Table 3). In the inter-group comparison, all the groups showed a similar change in the plaque index at day 7. The percentage reductions in the scores at day 7 in groups 1, 2 and 3 were 40.5% ± 2.9%, 41.4% ± 4.2% and 41.9% ± 4.5%, respectively, which are not statistically significantly different from each other (P = 0.853). Furthermore, at days
83
Muglikar et al
Table 3 Plaque index Group
day 0
day 7
day 14
day 21
P-value*
1 (n = 10)
2.33 (0.24)
1.39 (0.12)
1.47 (0.12)
1.57 (0.18)
0.001
2 (n = 10)
2.32 (0.25)
1.36 (0.13)
1.43 (0.12)
1.54 (0.11)
0.001
3 (n = 10)
2.27 (0.22)
1.31 (0/12)
1.43 (0.12)
1.57 (0.13)
0.001
Values are mean (SD). *Paired t-test (comparing day 0 vs day 21).
Table 4 Plaque index (% change) Group
day 0
day 7
day 14
day 21
1 (n = 10)
-
40.5 (2.9)
36.6 (5.4)
32.5 (5.6)
2 (n = 10)
-
41.4 (4.2)
37.9 (5.1)
33.2 (5.0)
3 (n = 10)
-
41.9 (4.5)
36.8 (4.3)
30.7 (4.8)
P-values* Group 1 vs group 2
-
0.853
0.798
0.946
Group 1 vs group 3
-
0.681
0.995
0.711
Group 2 vs group 3
-
0.951
0.847
0.516
Values are mean (SD) of % change from baseline (day 0). *One-way ANOVA with Tukey’s correction for multiple group comparisons % change = (day 0 index value – follow up index value) x 100 / (day 0 index value).
14 and 21, groups 1, 2 and 3 did not differ statistically significantly from each other. The percentage reductions in the scores at day 14 were 36.6% ± 5.4%, 37.9% ± 5.1% and 36.8% ± 4.3% (groups 1, 2 and 3, resp); these values were statistically similar (P > 0.798). Likewise, at day 21, groups 1, 2 and 3 remained statistically similar (P > 0.946) with percentage reductions of 32.5% ± 5.6%,33.2% ± 5.0% and 30.7% ± 4.8%, respectively. Thus, the plaque index decreased significantly for all the groups from baseline to day 21 (Table 4).
DISCUSSION Curcumin is the principal curcuminoid of the popular Indian spice turmeric, which is a member of the ginger family (Zingiberaceae). The other two curcuminoids are desmethoxycurcumin and bis-desmethoxycurcumin. The curcuminoids are polyphenols and are responsible for the yellow colour of turmeric.
84
Curcumin can exist in at least two tautomeric forms, keto and enol. The enol form is more energetically stable in the solid phase and in solution (Kolev et al, 2005). Turmeric has been used historically as a component of Indian Ayurvedic medicine since 1900 BC to treat a wide variety of ailments (Aggarwal et al, 2007). In vitro and animal studies have suggested that curcumin may have antitumor (Aggarwal et al, 2006; Choi et al, 2006) antioxidant, antiarthritic, antiamyloid, anti-ischemic (Shukla et al, 2008) and anti-inflammatory properties (Suhag et al, 2007). Numerous clinical trials in humans are underway, studying the effect of curcumin on various diseases, including multiple myeloma, pancreatic cancer, myelodysplastic syndromes, colon cancer, psoriasis and Alzheimer‘s disease (Hatcher et al, 2008). Chlorhexidine is an antimicrobial agent, and although it has side effects, it is still used as a gold standard. It is a cationic bis-biguanide with broad antibacterial activity, low mammalian toxicity and a strong affinity for binding to skin and mucous membranes (Denton, 1991). Chlorhexidine has a wide spectrum of activity encompassing gram-positive
Oral Health & Preventive Dentistry
Muglikar et al
and gram-negative bacteria, yeasts, dermatophytes and some lipophilic viruses (Denton, 1991). Its antimicrobial effect is membrane active, i.e. it damages the inner (cytoplasmic) membrane (Jenkins et al, 1993; Joyston-Bechal and Hernaman, 1993). A clinical study of similar design could not be found for comparisons. A previously conducted study evaluated the clinical and microbiological effects of scaling and root planing (SRP) alone or in combination with 0.12% CHX rinsing and concluded that the combination of CHX rinses and SRP leads to better clinical results (Faveri et al, 2006). Another study on the role of curcumin as a subgingival irrigant concluded that subgingival irrigation is a useful adjunct and 1% curcumin solution is able to cause better resolution of inflammatory signs (bleeding on probing and redness) and probing pocket depth reduction than chlorhexidine and saline irrigation as adjunctive therapy (Suhag et al, 2007). In the present study, no statistically significant difference between scaling and root planing followed by chlorhexidine mouthwash vs scaling and root planing followed by curcumin mouthwash was seen. Chlorhexidine and curcumin yielded a statistically significant change in comparison to only scaling and root planing. These results with curcumin mouthwash could be due to its anti-inflammatory, anti-oxidant properties, which resolve inflammation, while CHX acts as an antibacterial agent only (Mendieta et al, 1994; Anderson et al, 1997). Curcumin acts similarly to aspirin and aspirin-like antiinflammatory drugs in diminishing inflammatory mediators of arachidonic acid metabolism (Suhag et al, 2007). Curcumin has an advantage over aspirin, as it selectively inhibits synthesis of prostaglandin E 2 and thromboxane, while not affecting the synthesis of prostacyclin. By virtue of its anti-inflammatory property, curcumin reduces inflammatory mediators and causes shrinkage of inflammatory oedema and vascular engorgement of connective tissue. It also promotes migration of fibroblasts into the wound bed and results in reduction of vascularisation by bringing about fibrosis of connective tissue. It enhances wound healing by causing an increase in fibronectin and transforming growth factor ` transcription (Sidhu and Singh, 1998). Due to its diverse range of actions, curcumin-treated sites shows faster resolution of inflammatory signs. Curcumin incorporated in collagen, which acts as supportive matrix for slow release, promotes wound reduction and enhances cellular proliferation (Gopinath et al, 2004).
Vol 11, No 1, 2013
CONCLUSION The results of this pilot study on patients with gingivitis indicate that curcumin (20%) and chlorhexidine mouthwash (0.2%) are equally effective in the treatment of gingivitis. The present study provides the justification for curcumin as a mouthwash and an efficaceous herbal approach to supplementing mechanical debridement in order to reduce inflammatory gingival signs. Furthermore, the present findings suggest that curcumin mouthwash may play a role in the management of gingivitis, as measured using gingival and plaque indices. The present study was a short-term pilot study with a small sample size. Further studies with larger sample size are required to ascertain whether the effect of curcumin on gingivitis is clinically and microbiologically statistically significant over a longer period of time and whether using higher concentrations of curcumin provide better clinical benefits.
REFERENCES 1. Addy M, Hunter L. The effects of a 0.2% chlorhexidine gluconate mouthrinse on plaque, toothstaining and candida in aphthous ulcer patients. A double-blind placebo-controlled cross-over study. J Clin Periodontol 1987;14:267–273. 2. Aggarwal BB, Shishodia S. Molecular targets of dietary agents for prevention and therapy of cancer. Biochem Pharmacol 2006;71:1397–1421. 3. Aggarwal BB, Sundaram C, Malani N, Ichikawa H. Curcumin: the Indian solid gold. Adv Exp Med Biol 2007;595:1–75. 4. Anderson GB, Bowden J, Morrison EC, Caffesse RG. Clinical effects chlorehexidine mouthwashes on patient undergoing orthodontic treatment. AM J Ortho Dentofac Orthop 1997;111:666–612. 5. Bascones A, Manso FJ. Chlorhexidine in dentistry: Actual concepts and bibliography review. Advances Odontoestomatol 1994;10:685–708. 6. Choi H, Chun YS, Kim SW, Kim MS, Park JW. Curcumin inhibits hypoxia-inducible factor-1 by degrading aryl hydrocarbon receptor nuclear translocator: a mechanism of tumor growth inhibition. Molecular Pharmacol 2006;70:1664– 1671. 7. Denton GW. Chlorhexidine. In: Block SS (ed). Disinfection, sterilization and preservation, ed 4. Philadelphia: Lea and Febiger, 1991: 274–289. 8. Faveri M, Gursky LC, Feres M, Shibli JA, Salvador SL, de Figueiredo LC. Scaling and root planing and chlorhexidine mouthrinses in the treatment of chronic periodontitis: a randomized, placebo-controlled clinical trial. J Clin Periodontol 2006;33:819–828. 9. Flotra L, Gjermo P, Rölla G, Waerhaug J. Side effects of chlorhexidine mouthwashes. Scandinavian Journal of Dental Research 1971;79,119–125.
85
Muglikar et al 10. Gopinath D, Ahmed MR, Gomathi K, Chitra K, Sehgal PK, Jayakumar R. Dermal wound healing processes with curcumin incorporated collagen films. Biomaterials 2004;25:1911–1917. 11. Hatcher H, Planalp R, Cho J, Torti FM, Torti SV. Curcumin: from ancient medicine to current clinical trials. Cell Mol Life Sci June;65:1631–1652. 12. Jenkins S, Addy M, Newcombe R. Evaluation of a mouthrinse containing chlorhexidine and fluoride as an adjunct to oral hygiene. J Clin Periodontol 1993;20:20–25. 13. Joyston-Bechal S, Hernaman N. The effect of a mouthrinse containing chlorhexidine and fluoride on plaque and gingival bleeding. J Clin Periodontol 1993;20:49–53. 14. Kolev TM, Velcheva EA, Stamboliyska BA, Spiteller M. DFT and experimental studies of the structure and vibrational spectra of curcumin. Int J Quantum Chem 2005;102:1069– 1079.
86
15. Mendieta C, Vallcorba N, Binney A, Addy M. Comparison of 2 chlorhexidine mouthwashes on plaque regrowth in vivo and dietary staining in vitro. J Clin Periodontol 1994;21:296– 300. 16. Sekino S, Ramberg P, Guzin Uzel N, Socransky S, Lindhe J. The effect of a chlorhexidine regimen on de novoplaque formation. J Clin Periodontol 2004;31:609–614. 17. Shukla PK, Khanna VK, Ali MM, Khan MY, Srimal RC. Antiischemic effect of curcumin in rat brain. Neurochem Res 2008;33:1036–1043. 18. Sidhu GS, Singh AK. Enhancement of wound healing by curcumin in animals. Wound Repair Regen 1998;6:167–177. 19. Suhag A, Dixit J, Dhan P. Role of curcumin as a subgingival irrigant. Periodontal Practices Today 2007;4:115–121.
Oral Health & Preventive Dentistry
