Comparative effect of neemstick and toothbrush on plaque removal and gingival health A clinical trial

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1 J.Adv Oral Research All Rights Res ORIGINAL RESEARCH Comparative effect of neemstick and toothbrush on plaque removal and gingival health A clinical trial Ajay Bhambal* Sonal Kothari SudhanshuSaxena Manish Jain *M.D.S, Professor and Head, Post Graduate Student, M.D.S, Senior Lecturer, Department of Public Health Dentistry, People s College of Dental Sciences and Research Centre, Bhopal, India. drabhambal@gmail.com Abstract: Introduction: The 80 percent of the population in India who live in rural areas still start their day with the chewing stick. Researchers believe that the use of neem stick is responsible for the healthy teeth of Indian villagers, people who never had access to any modern dental care facilities or fancy toothbrushes. Aim: The aim of this study was to compare the effect of neem stick and toothbrush on plaque removal and gingival health. Materials and Method: A single blind, randomized cross-over study conducted among 30 study subjects regularly attending the out patient department of the People s College Of Dental Sciences and Research Centre, Bhopal. Quigley- Hein plaque and Loe-Silness gingival index were taken at baseline and again following 3 weeks use of either neemstick or toothbrush. Professional tooth cleaning was done 7 days before the start of study and repeated after a further 3 weeks. Statistical analysis was done using t- tests and one way analysis of variance (ANOVA). P value <0.05 was considered statistical significant. Result: No significant difference has been found between toothbrush and neemstick. But, both has resulted in significant reduction in plaque and gingival scores compared to baseline. Conclusion: Neemstick is equally effective as Serial Listing: Print ISSN( ) Online-ISSN ( ) Formerly Known as Journal of Advanced Dental Research Bibliographic Listing: Indian National Medical Library, Index Copernicus, EBSCO Publishing Database,Proquest., Open J-Gate. toothbrush in reducing plaque and gingival inflammation. Key words: Neemstick, Chewing stick, Toothbrush, Plaque, Gingivitis. Introduction: Oral hygiene measures have been practiced by different populations and cultures in a different way around the world. In various parts of the world where tooth brushing by modern method is uncommon or not possible, the practice of tooth cleaning by chewing sticks has been commonly observed. The 80 percent of the population in India who live in rural areas still start their day with the datun. There are at least six types of datun use in India viz., Neem, Babul, Mango, Guava, Dandarasa and roots of Pilu. Among all, neemdatun is most commonly in use 1. Neem tree, the "tree of a thousand uses" have been used for medicinal, cosmetic, agricultural and other purposes due to its antifungal, antibacterial, antiviral, pest-control, sedative and many more effects. Neem extracts can also be found in Ayurvedic and other toothpastes. 2 This tree, (in Sanskrit, Nimba and Arishta) is a native of India, and is cultivated in all parts of the subcontinent on account of its medicinal properties. In 1942 SalimuzzamanSiddiqui first time extracted three bitter compounds from neem oil, named as nimbin, nimbinin, and nimbidin respectively. 2 Azadirachtin is a chemical compound belonging to the limonoids. It is a secondary metabolite present in the Neem tree seeds 2. Neem mouth rinse is also very effective in the treatment of infections, tooth decay, bleeding and sore gums. A mouthwash, using Neem oil, has been manufactured and used for the treatment of mouth ulcers 3.Lack of oral hygiene results in accumulation

2 52 of plaque and calculus, which is the major etiological factors for gingivitis and periodontitis. Poor oral hygiene also increases the incidence of caries. There is overwhelming evidence that periodontal disease and dental caries affect the majority of the populations, their prevalence and severity vary according to age, sex, race, geographic areas, socioeconomic factors, local and systemic factors and methods of oral cleansing 4. The invitrostudy have showed that Neem extracts affect some bacterial properties which may alter bacterial adhesion and the ability of some streptococci to colonize tooth surfaces. Specifically, the Neem stick extracts exhibited broad bacterial aggregating activity among the oral streptococci 5. Alsoneem extracts showed higher antimicrobial activity against Gram-positive bacteria compared to Gram-negative bacteria except for V. parahaemolyticus, P. aeroginosa, and A. hydrophila. 6 There is abundance of invitro studies which demonstrate the beneficial effects of neem extract on plaque bacteria but no invivo study has been reported till date as per our literature search. Hence, this clinical trial was planned with an aim, to compare the effect of neemstick and toothbrush on plaque removal and gingival health. Materials and method: The present study was conducted among 30 subjects of age years who were regularly attending the People s College of Dental Sciences and Research Centre. The sample size was decided based on the American Dental Association. Acceptance Program Guidelines for Chemotherapeutic Products for Control of Gingivitis, The study was approved by Ethical Committee of the People s College of Dental Sciences and Research Centre and participants were informed about the aim and purpose of the study. A signed written consent was taken from each one of the study subject. The study went for the period of 2 months and was designed as a single blind, randomized crossover study. All participants had to undergo two sessions of oral hygiene practices in a crossover manner. Half of the participants were instructed to use toothbrush and half of them were instructed to use neemstick, twice daily in the morning and in the evening, and to refrain from other oral hygiene aids during the period. The participants were assigned even or odd numbers randomly. Each participants were given new, conventional toothbrush and 10 fresh sticks taken from flexible branch of neem measuring 15 to 20 cm long, and 15 to 20 mm thick and instructed to store unused sticks in a refrigerator. The Neem twigs were first shown for any disease to the botanist. Fifteen days before starting the study, participants were instructed regarding the proper use of neemstick and were asked them to use for a 7 days to get habitual with the same. All participants were interviewed for their oral hygiene habits. Inclusion criteria : Participants without the evidence of periodontitis, without any orthodontic appliances, with good manual dexterity and not under any antibiotic coverage were included in the study. 1 week 3 weeks 1 week 3 weeks Method: One week before the start of the study, participants received an intraoral examination and oral prophylactic treatment. The participants were then instructed to continue their usual oral hygiene routine for the following week. One week later, participants underwent baseline registration of gingival inflammation and plaque deposits. Participants were then instructed to use either the neemstick or toothbrush for the following three weeks. After three weeks, participants again underwent registration of gingival inflammation and plaque deposits followed by professional tooth cleaning. The participants then instructed to continue their routine oral hygiene routine for the following week (Washout period) to avoid the carry over effect previously used material. One week later, again registration of gingival inflammation and plaque deposits was done. Now, the cross-over of the material was done and participants were instructed to use either toothbrush or neemstick for the following three weeks. After three weeks later, recording of gingival inflammation and plaque deposits was done. Clinical examination: Cinical examination was comprises of Loe and Silness gingival index(1964) and Turesky Quigley Hein Plaque index plaque index.(1962). It was done by the trained and calibrated examiners. Inter and Intra-examiner reliability was assessed by using kappa statistics and the values obtained was excellent (>0.91) for both.

3 53 Plaque was stained using 1% Erythrosine solution and scored according to Turesky Quigley Hein Plaque index 8. The status of gingival health was assessed by Loe and Silness for selected teeth 9. Statistical Analysis: Data was statistical analysed using Statistical Package for Social Science (SPSS) version 17. Mean and standard deviation of plaque and gingival scores were calculated. Further statistical analysis was done by using Unpaired and Paired t-test and One way Analysis of variance (ANOVA). The p values of <0.05 were considered statistical significant. Result: Table 1 shows overall means and stardard deviation at baseline and after 3 weeks use for both neemstick and toothbrush. No significant difference has been seen between toothbrush and neemstick. Table 2 shows the paired t test value before and after use of neemstick and toothbrush. There was significant reduction in plaque and gingival scores after the use of both except in case of gingival score on distal aspect of tooth. Table 1: Overall means and standard deviation for both neemstick and toothbrush at baseline and after 3 weeks use. QHPI B QHPI L GI B GI L GI M GI D Baseline Neemstick 0.52± ± ± ± ± ±0.24 Toothbrush 0.53± ± ± ± ± ±0.21 P value >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 After 3 weekneemstick 0.46± ± ± ± ± ±0.04 use Toothbrush 0.48± ± ± ± ± ±0.05 P value >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 QHPI B- Quigley Hein Plaque Index for Buccal site, QHPI L - Quigley Hein Plaque Index for Lingual site, GI B Gingival Index for Buccal aspect of tooth, GI L - Gingival Index for Lingual aspect of tooth, GI M Gingival Index for Mesial aspect of tooth, GI D Gingival Index for Distal aspect of tooth Table 2: Paired t test value of before and after use of neemstick and toothbrush. QHPI B QHPI L GI B GI L GI M GI D Neemstick t value P value <0.05 <0.05 <0.05 <0.05 <0.05 >0.05 Toothbrush t value P value <0.05 <0.05 <0.05 <0.05 <0.05 >0.05 QHPI B- Quigley Hein Plaque Index for Buccal site, QHPI L - Quigley Hein Plaque Index for Lingual site, GI B Gingival Index for Buccal aspect of tooth, GI L - Gingival Index for Lingual aspect of tooth, GI M Gingival Index for Mesial aspect of tooth, GI D Gingival Index for Distal aspect of tooth. Table 3: Difference at baseline and after use with both Neemstick and toothbrush QHPI-B QHPI-L GI-B GI-L GI- M GI-D N 0.05± ± ± ± ±0.19 T 0.05± ± ± ± ±0.16 P value >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 QHPI B- Quigley Hein Plaque Index for Buccal site, QHPI L - Quigley Hein Plaque Index for Lingual site, GI B Gingival Index for Buccal aspect of tooth, GI L - Gingival Index for Lingual aspect of tooth, GI M Gingival Index for Mesial aspect of tooth, GI D Gingival Index for Distal aspect of tooth, N Difference in before and after scores with neemstick, T Difference in before and after scores with toothbrush. Table 3 compares the reduction in plaque score and gingival scores with both neemstick and toothbrush and it shows that when we compared the two modes of tooth cleaning, no significant difference was seen.

4 54 One way Analysis of variance showed no significant difference in gingival scores for different sites with both neemstick and toothbrush. Similarly Independent t-test detected no significant difference in Plaque scores with both neemstick and toothbrush for buccal and lingual sites. Discussion: This study has compared the neemstick and the toothbrush in their efficiency of plaque removal and improving gingival health. All participants were asked to use either neemstick or the toothbrush in a cross-over manner for a period of 3 weeks and thereafter instructed to continue their regular oral hygiene routines for the following week (wash out period) 10 Participants has been asked to use the material for the 3 weeks because study has shown that after 9 21 days without proper oral hygiene, healthy gingiva develops heavy accumulations of plaque and generalized mild gingivitis 11. The experimental trial condition was standardized by instructing all subjects on how to use the identical conventional toothbrushes and neemsticks under direct supervision. The use of chewing stick has been taught properly to avoid the damage to gingiva. The validity of the results is related to the applied methodology. The study has been designed such that each study subject act as his own control and subjects were refrain from the use of toothbrush during the neemstick use or vice versa. Study subjects have resulted in the improvement of oral hygiene with each session due to the impact of prophylaxis and oral hygiene instruction at the beginning of each experimental period. A third person randomized the order of experimental periods and this information was not accessible to the examiners. Individual subjects were asked not to disclose which oral hygiene measure they had been using to the examining dentists. The result showed a significant reduction in plaque and gingivitis after both toothbrush and neemstick but no significant difference has been noticed between toothbrush and neemstick which suggest that neemstick is equally efficient as toothbrush in plaque removal. Till date no such study has been reported as per our literature search, which can be used to compare the result of the same. However, various studies have been done to evaluate the effect of Miswak and toothbrush. Some studies have reported no difference 12, 13, 14 between the two. It is claimed that the mechanical plaque-removing properties of chewing sticks may be similar to that of a conventional toothbrush 15,16. Study conducted among the Indian population concluded that the miswak is more effective in reduction of gingivitis compared to toothbrush but no statistically significant difference in oral hygiene index has been seen between miswak users, toothbrush users and the combined users. This may be explained by the fact that the miswak, in addition to its mechanical cleansing effect, release a variety of beneficial chemicals such as fluoride, saponins and sterol which posses antibacterial properties that inhibit plaque formation. Additionally, the miswak is generally used for longer periods of time than the toothbrush. 17. However, some studies showed higher prevalence of gingivitis among users of chewing sticks 18. Another retrospective study showed that Miswak users had deeper pockets and more prevalence of periodontal diseases 19. This study showed no difference in plaque and gingival scores for different sites with both neemstick and toothbrush which is in line with the study conducted by Danielsen B et al. which showed that the chewing stick remove plaque from interproximal sites to virtually the same extent as from other more accessible sites 20. The value of chewing sticks is believed to be in their mechanical cleansing action. However, the use of chewing stick has also been reported to inhibit the formation of dental plaque chemically and exert antimicrobial effect against many oral bacteria 21. One study has showed that Neem extract produced the maximum zone of inhibition on Streptococcus mutans at 50% concentration. Even at 5% concentration neem extract showed some inhibition of growth for all the four species of organisms, i.e. Streptococcus mutans, Streptococcus salivavius, Streptococcus mitis and Streptococcus sanguis 22. Study done by Bhuiyan et al. has showed that acetonic extract from the bark of Neem was bactericidal at concentration <1% (w/v) which indicate that neem bark constituents are considered to have the ability to suppress the growth of cariogenic bacteria. 23. The Monitor is require to observe whether participants are using the given materials or not, this is one of the limitation of the study. Another limitation is subjects should be ask to use toothbrush along with toothpaste, as chewing a neemstick releases bacteriacidal content from it. This opens vistas for further study. Recommendation: Primary health care- Chewing stick can be set as a criteria for primary oral health care in the areas where it is difficult to afford commercial toothbrushes and toothpastes. Chewing stick can be recommended as health promotion tool for developing countries.

5 55 Proper method of using chewing stick should be taught to the users in order to prevent injury to the oral mucosa. Further research needs to be conducted in order to substantiate these chewing sticks. Conclusion: The use of chewing stick fullfil the basic requirement of primary health care and can be a good alternative to the toothbrush as a means of preventing oral diseases. It is suitable for cleaning all the teeth, it is cheap, possesses various medicinal properties, is available in most urban and rural areas of developing countries. The use of chewing sticks will be a great help in developing countries with financial constraints and limited oral health care facilities for their population. References: 1. Johri. M. Neem: Rightly Called the 'Village Pharmacy', IST :42: Mohammad Yaheya Mohammad Ismail, Nagwa M. Assem, Mohammad Zakriya. Botanicals Promoting Oral and Dental Hygiene: A Review. Research Journal of Pharmaceutical, Biological and Chemical Sciences. 2010;2(1): Almas K, Al-Lafi TR. The natural toothbrush.world Health Forum. 1995;16(2): World Health Organization. Epidemiology, etiology,and prevention of periodontal diseases. Geneva.Technical report series 1978; Wolinsky L.E, Mania S., NachnaniS.and LingS. The Inhibiting Effect of Aqueous Azadirachtaindica (Neem) Extract Upon Bacterial Properties Influencing in vitro Plaque Formation. J Dent Res : MahfuzulHoque MD, Bari ML, Inatsu Y, Juneja VK, Kawamoto Antibacterial activity of guava (Psidiumguajava L.) and Neem (Azadirachtaindica A. Juss.) extracts against foodborne pathogens and spoilage bacteria. S. Foodborne Pathog Dis Winter;4(4): Acceptance Program Guidelines Toothbrushes, American dental association, council on scientific affairs, 2009; p Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc 1962;65: Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition.actaodontologicascandinavica 1964;22(1): Jayakumar A, Padmini H, Haritha A, KrishnanjaneyaPathakota Reddy. Role of dentrifice in plaque removal: A clinical trial. Indian J Dent Res 2010;21(2): Theilade Else, Wright W. H., Jensen S. Börglum, LöeHarald Experimental gingivitis in man II. A Longitudinal Clinical and Bacteriological Investigation; Journal of Periodontal Research 1966;1(1): Nörmark S, Mosha HJ. Relationship between habits and dental health among Tanzanian children. Community Dent Oral Epidemiol 1989; 17, Meshari Al-Otaibi, Mohammed Al-Harthy, BirgittaSoder, Anders Gustafsson, Birgit AngmarMansson. Comparative effect of chewing sticks and toothbrushing on plaque removal and gingival health. Oral Health Prev Dent 2003;1: Batwa Mohammed, The effectiveness of chewing stick miswak on plaque removal. Saudi Dental Journal 2006;3(18): Hardie J, Ahmad K. The miswak as an aid in oral hygiene. J. Phillipp Dent Assoc1995 ; 4 : Hattab FN. Miswak : The natural toothbrush. J Clin Dent 1997 ; 8 : Shetty M. Raghavendra. Comparative study to assess the effect of chewing stick and toothbrush on oral hygiene and periodontal status among Indian population. International Journal of Public Health Dentistry 2010;1:1; Norton MR, Addy M. Chewing sticks versus toothbrushes in West Africa. ClinPrev Dent 1989; 11: Gazi M, Saini T, Ashri N and Lambourne A. Meswak chewing stick versus conventional tooth- brush as an oral hygiene aid. Clin Preventive Dent 1990; 12: Danielsen B, Baelum V, Manji F, Fejerskov O. Chewing sticks, toothpaste, and plaque removal. ActaOdontolScand 1989; 47: Al-Lafi T, Ababneh H. The effect of the extract of the Miswak (Chewing stick) used in Jordan and the Middle East on oral bacteria. Int dent J 1995; 45: GM Prashant The effect of mango and neem extract on four organisms causing dental caries: Streptococcus mutans, Streptococcus salivavius, Streptococcus mitis, and Streptococcus sanguis: An in vitro study, Indian J Dent Res 2007;18: BhuiyanMdMohashine, Antibacterial effects of the crude AzadiractaIndicaNeem bark extract on Streptococcus sobrinus; Pediatric Dental Journal 1997;7(1): Source of Support: Nil Conflict of Interest: No Conflict of Interest Received: March 2011 Accepted: June 2011

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