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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 16-23

Tinospora cordifolia in the treatment of chronic and aggressive periodontitis patients with and without dental fluorosis: A clinical, microbiological, and biochemical study


1 Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Pharmaceutics, Bapuji Pharmacy College, Davangere, Karnataka, India
3 Department of Pharmacognosy, Bapuji Pharmacy College, Davangere, Karnataka, India
4 Department of Microbiology, Maratha Mandal's N. G. H. Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India
5 Department of Public Health Dentistry, M. R. Ambedkar Dental College, Bengaluru, Karnataka, India

Date of Web Publication3-Jul-2017

Correspondence Address:
Kharidhi Laxman Vandana
Department of Periodontics, College of Dental Sciences, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_62_16

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  Abstract 


Purpose: Although inconsistent data prevail in literature, there may be an association of periodontitis with fluorosis (FL). Oxidative stress also contributes to the pathogenesis of periodontitis and is said to be higher in patients with dental FL. Evaluation of the effect of herbal product like guduchi with antimicrobial, antioxidant, and anti-inflammatory properties in the treatment of periodontitis patients with and without dental FL was the main aim of our study.
Materials and Methods: The study was a double-blind, split-mouth study with the control sites being treated with scaling and root planing (SRP) only and the test sites being treated with SRP + guduchi gel (SRP + G). Forty-eight patients who were diagnosed suffering from periodontitis with or without dental FL were divided into four groups and were subject to treatment. Clinical, microbiological, and biochemical parameters were recorded at 0–3 months after treatment.
Results: The clinical and microbiological parameters showed significant difference (P < 0.05) at 3 weeks and 3 months within the SRP + G and SRP treated sites in all the groups. The sites treated with SRP + G in all the groups showed clinically significant improvement than sites treated with SRP alone. However, the control and test sites of fluorosed and nonfluorosed periodontitic patients showed similar improvements in clinical, microbiological, and biochemical parameters.
Conclusion: Guduchi gel (6.25%) has clinically significant anti-inflammatory and antimicrobial effects along with SRP. Increasing the concentration of the gel on a larger sample size would render it more effective in the nonsurgical therapy of periodontitis.

Keywords: Dental fluorosis, oxidative stress, periodontitis, Tinospora


How to cite this article:
Ghosh S, Vandana KL, Thimmasetty J, Miskin N, Bhat KG, Sharma N. Tinospora cordifolia in the treatment of chronic and aggressive periodontitis patients with and without dental fluorosis: A clinical, microbiological, and biochemical study. Int J Oral Health Sci 2017;7:16-23

How to cite this URL:
Ghosh S, Vandana KL, Thimmasetty J, Miskin N, Bhat KG, Sharma N. Tinospora cordifolia in the treatment of chronic and aggressive periodontitis patients with and without dental fluorosis: A clinical, microbiological, and biochemical study. Int J Oral Health Sci [serial online] 2017 [cited 2019 Oct 17];7:16-23. Available from: http://www.ijohsjournal.org/text.asp?2017/7/1/16/209355




  Introduction Top


Periodontal disease is recognized as a major public health problem throughout the world and is the most common cause of tooth loss in adults. Furthermore, a study conducted by Vandana and Reddy et al. in 2007 showed that there is a strong association of occurrence of periodontal disease in high fluoride areas.[1] However, inconsistent data prevail in the literature. Susheela and Bhatnagarin 2002 observed that skeletal fluorosis (FL) can be reversed by the elimination of fluoride intake and supplementation of a diet rich in antioxidants, indicating that antioxidants may have a role to play in the treatment of FL.[2]

Similarly, oxidative stress is a major contributor to the pathogenesis of inflammatory diseases such as periodontitis. Panjamurthy et al. in 2005 stated that the disturbance in the endogenous antioxidant defense system due to over-production of lipid peroxidation products at inflammatory sites can be related to a higher level of oxidative stress in patients with periodontitis.[3] To reduce this oxidative stress, a variety of medicines have been used. However, herbal medicine is still the mainstay of majority of population in developing countries for primary healthcare because of its cultural acceptability, better compatibility with human body, and fewer side effects.

The silent “battle” between natural (herbal) and allopathic (pharmaceutical) healthcare systems has been raging for decades. The primary differences between the two systems are that allopathic medicine is primarily designed to treat the symptoms of disease and is most effective when treating chronic illnesses and conditions, whereas herbal medicine is effective both prophylactically as well as treating the issue of disease at a grassroots level and effective at bringing the system gently into balance. Scientists, doctors, and patients are now becoming wise to the fact that there need not be any conflict between the two systems - both have positive aspects and can be very effectively used in conjunction with each other.

Tinospora cordifolia(guduchi) is a large glabrous, succulent, deciduous climbing shrub belonging to family Menispermaceae. It is distributed throughout tropical Indian subcontinent, Sri Lanka, and China, ascending to an altitude of 300 m.[4]

T. cordifolia showed anti-inflammatory and analgesic actions in albino rats and immunosuppressive actions in albino rabbits,[5] antibacterial activity,[6] antioxidant properties,[7] and increase in antibody production in vivo.[8]

Currently, the uses and effects of guduchi extract have not been widely studied in dentistry. Since periodontitis is a multifactorial disease, usage of herbal products such as multipotential guduchi extract would have beneficial effect. Moreover, no allopathic drug has shown several multifaceted actions similar to guduchi. Furthermore, the attainment of resistance of microorganisms for herbal products is reported minimum. Hence, considering these points and also considering the strong association of occurrence of periodontal disease in high fluoride areas as suggested by Vandana and Reddy [1] evaluation of the effect of an efficient herbal product like guduchi in the treatment of periodontitis patients with and without dental FL is the main aim of our study.


  Materials and Methods Top


The subjects for this study were selected from the outpatient Department of Periodontics, College of Dental Sciences, Davangere, Karnataka. The study protocol was according the guidelines prescribed by Rajiv Gandhi University of Health Sciences, Bangalore, and approved by the Ethical Committee at College Of Dental Sciences, Davangere, Karnataka, India (IRB-CODS/2533/2012–2013) (CTRI acknowledgement no– REF/2015/08/009675). The duration of this clinical study was 1½ years. Informed consent was obtained from all the patients before the start of treatment.

Patients who were diagnosed as suffering from chronic or aggressive periodontitis (AP),[9] 18–50 years of age, with the presence of mild to moderate periodontal pockets (5–7 mm) clinically and radiographic evidence of bone loss, were selected for the study. For patients with fluorosed teeth, the fluorotic enamel stains were confirmed by clinical examination and history of patients hailing from natural high water fluoride areas in and around Davangere (fluoride concentration of 1.5–3 ppm).[1]

Patients with known systemic diseases, unacceptable oral hygiene during phase I, who received any surgical or nonsurgical therapy 6 months before the start of the study, tooth with intrinsic stains, pregnant females and lactating mothers, and smokers/alcoholic were excluded from the study.

A single-blind split-mouth study was designed where the control sites were being treated with scaling and root planing (SRP) only and the test sites were being treated with SRP + guduchi gel (SRP + G).[10] A total of 48 patients with generalized periodontitis were selected. The patients were divided into four groups of 12 patients in each group: chronic periodontitis with FL (FL-CP), AP with FL, CP with non-FL (NFL-CP), and AP with NFL [Table 1]. Random allocation was done by computer-generated random numbers.
Table 1: Study groups, gender-wise, and site-wise distribution

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After randomization of the sites, the selected test sites were treated with SRP followed by local application of 6.25% guduchi gel and the selected control sites were treated with SRP only without local drug delivery of guduchi gel.

Clinical parameters such as plaque index (PI), gingival index (GI), gingival bleeding index (BI), probing pocket depth (PPD), and clinical attachment level (CAL) were recorded at baseline before treatment and 21 days and 3 months after treatment. The passive drool method was used to collect whole mouth saliva from the oral cavity for antioxidant level evaluation. Biochemical analysis at baseline before treatment and after 21 days of treatment was done for the assessment of malondialdehyde levels (MDA), superoxide dismutase levels (SOD), and total antioxidant capacity levels (TAOC). The subgingival plaque samples were pooled using universal curette from the test and control sites. The plaque samples from the test and control sites were separately transferred into transporting media RTF 100 for transportation to the microbiology laboratory for analysis. The anaerobic culture analysis was done for Porphyromonas gingivalis and Prevotella intermedia atbaseline before treatment and after 21 days of treatment. Guduchi powder (1500 g) provided by the Himalaya Drug Company (drug registration no L-AUS 133) and the guduchi gel was prepared in Bapuji Pharmacy College. As the MIC of guduchi extract for the subjected organisms was found to be 3.125, the concentration of the gel which was prepared was 6.25%. The customized guduchi gel (6.25%) had hydroxyl propyl methyl cellulose (93.75 mg), an emulsified and suspending agent. Glycerin was added as preservative and resultant gel was packed in 5 ml aluminum tubes.

The SRP of whole mouth was performed using both hand instruments (Universal Gracey Curettes, 2R/2 L and 4R/4 L Hu-Friedy-USA) and ultrasonic scalers (Cavitron-BOBCAT PRO, DENTSPLY; Power-240AC 50/60 Hz 80VA). The guduchi gel was delivered into each periodontal pocket using sterile Dispo-Van single-use bent needle till the gel overflow the site. After nonsurgical therapy, the patients were instructed to perform regular oral hygiene habits, i.e. twice daily brushing by “roll-on technique” for a minimum of 2 min, using a regular tooth paste (STOLIN– R ® Dr. Reddy's Lab) and regular tooth brushes (ICPA ® soft tooth brush). The patients were dispersed and instructed to report on the subsequent 21st day and thereafter 3 months.

The analysis of variance test (one-way) was used for intragroup assessment. The intergroup comparison was done with the help of unpaired t-test.


  Results Top


The results of the study are depicted in [Table 1],[Table 2],[Table 3],[Table 4],[Table 5] and [Graph 1],[Graph 2],[Graph 3],[Graph 4],[Graph 5],[Graph 6],[Graph 7]. At baseline, the fluorosed and the nonfluorosed groups showed similar clinical, microbial, and biochemical parameters. Within the groups (FL-CP, FL-AP, NFL-CP, and NFL-AP), there was statistically significant reduction (P < 0.05) in all the periodontal parameters [Graph 1],[Graph 2],[Graph 3],[Graph 4],[Graph 5] and microbiological parameters (Pg and Pi) [Graph 6] and [Graph 7] at 3 weeks and 3 months after treatment with SRP + G and SRP alone.
Table 2: Comparison of superoxide dismutase, total antioxidant capacity, and malondialdehyde between aggressive periodontitis with fluorosis and aggressive periodontitis with nonfluorosis

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Table 3: Comparison of superoxide dismutase, total antioxidant capacity, and malondialdehyde between chronic periodontitis with fluorosis and aggressive periodontitis with fluorosis

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Table 4: Comparison of superoxide dismutase, total antioxidant capacity and malondialdehyde between chronic periodontitis with nonfluorosis and aggressive periodontitis with nonfluorosis

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Table 5: Comparison of superoxide dismutase, total antioxidant capacity, and malondialdehyde between chronic periodontitis with fluorosis and chronic periodontitis with nonfluorosis

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Between the groups (FL-CP vs NFL-CP) and (FL-AP vs NFL-AP), the sites treated with SRP + G in NFL-CP and NFL-AP group showed clinically significant reduction of clinical parameters at 3 weeks and 3 months [Graph 1],[Graph 2],[Graph 3],[Graph 4],[Graph 5] and microbiological parameters reduction at 3 weeks [Graph 6] and [Graph 7]. In FL-CP and NFL-CP group, sites treated with SRP only showed similar reduction of clinical parameters at 3 weeks and 3 months in both the groups, whereas in FL-AP and NFL-AP group, FL-AP showed clinically significant reduction [Graph 1],[Graph 2],[Graph 3],[Graph 4],[Graph 5]. Reduction of microbiological parameters between FL-CP and NFL-CP and FL-AP and NFL-AP groups was statistically significant at 3 weeks (P < 0.05) [Graph 6] and [Graph 7].

When the biochemical parameters in saliva were compared within FL-CP and FL-AP groups [Table 3], antioxidant SOD increased and oxidative products such as MDA decreased in both groups following nonsurgical treatment. Between the groups, the difference was not significant (P > 0.05). When the biochemical parameters in saliva were compared within NFL-CP and NFL-AP groups [Table 4], antioxidant SOD and TAOC increased and oxidative products such as MDA decreased in NFL-AP group following nonsurgical treatment. Between the groups, the difference was statistically significant. Between FL-CP and NFL-CP groups [Table 5], the difference in SOD and MDA salivary levels was not significant (P > 0.05). However, the difference in TAOC levels between the groups was statistically significant (P < 0.05). Between FL-AP and NFL-AP groups [Table 2], the difference in SOD, MDA, and TAOC salivary levels was not significant (P > 0.05).


  Discussion Top


The majority of the world's populations rely on nonconventional medicine mainly from herbal sources in their primary health care, according to a WHO report. In spite of popularity of the synthetic drugs and antibiotics, medicinal plants still constitute an important part of pharmacopoeias in both the developed and developing countries. These plants are important elements of traditional medicine as these plant extracts are more efficacious and free from undesirable side effects.[11]

The results of the study are discussed below. In the present study, the patients in FL and NFL groups were age and sex matched to minimize the bias. However, the mean age of AP groups was significantly lower than CP groups.[9]

The effect of guduchi gel application along with SRP resulted in higher percentage improvement of all clinical parameters (PI, BI, GI, PPD, and CAL) and microbial parameters (Pg, Pi) in FL-CP than FL-AP group. No comparative studies exist in the literature to compare the study results. Between the groups, the change in the PI, GI, PPD, and CAL on SRP in both FL-CP and FL-AP groups was similar. However, there was a significant decrease in BI levels in AP patients as compared to FL-CP following SRP. The Pg and Pi reduction was higher in FL-AP group. An animal study reported the inhibition of acute inflammatory response using guduchi in albino rats.[5] Previously, there have been studies on the inhibiting effect of Guduchi on microorganisms Salmonella typhi, Shigella dysenteriae, and Pseudomonas aeruginosa.[6] Escherichia coli,[6],[12] Staphylococcus albus[12] and Staphylococcus aureus bacteria.[6],[12],[13]

In NFL-CP, there was a significant reduction of all clinical parameters during the study within SRP + G and SRP treated sites. In SRP + G treated sites within the groups, NFL-CP group showed significant PPD reduction whereas remaining improvement in clinical parameters was similar in both NFL-CP and NFL-AP groups. SRP + G treated sites in NFL-AP showed higher Pg and Pi reduction. The significant improvement in clinical parameters of CP such as reduction of PI, BI, GI, PPD, and CAL improvement was reported after SRP.[14],[15]

The effective reduction of PI, GI, BI, PPD, and CAL improvement was reported after SRP in CP and AP without any significant difference between the groups.[16],[17]

When the reduction in Pg and Pi at 3 weeks in NFL-CP and NFL-AP sites treated with SRP was compared, higher percentage reduction in Pg and Pi was seen in NFL-AP group though not statistically significant. A reduction of Pg and Pi in both CP and AP has been reported in the literature. A study showed reduction in Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythensis, Prevotella intermedia, and Treponema denticola using polymerase chain reaction assays in smoker and nonsmoker chronic and generalized AP patients.[18] Similar results were found in a study comparing the effects of SRP in CP and AP patients.[16]

On intergroup comparison, our objective was to study and compare the effect of SRP and SRP + G on clinical, microbiological, and biochemical parameters in fluorosed and nonfluorosed CP and AP patients for the first time to see if these treatment modalities affected the outcome in fluorosed and nonfluorosed patients differently. There was no other relevant study to support the effects of SRP as well as guduchi in such patients.

On comparison of FL-CP vs. NFL-CP sites treated with SRP + G, FL-CP group showed higher percentage reduction in PI, BI, and GI at 3 weeks and 3 months from baseline but was not statistically significant. However, the percentage reduction in PPD and CAL gain was higher in NFL-CP group though not statistically significant. The higher percentage of Pg and Pi reduction was observed in FL-CP and NFL-CP, respectively. On comparison of FL-CP vs. NFL-CP sites treated with SRP, the BI reduction was significantly higher in NFL-CP group whereas other clinical parameters showed similar reduction in FL-CP and NFL-CP groups. The Pg and Pi reduction was significantly higher in FL-CP and NFL-CP groups, respectively.

On comparison of FL-AP vs. NFL-AP sites treated with SRP + G, the NFL-AP showed higher percentage reduction of all clinical parameters than FL-AP. The Pg and Pi reduction was higher in NFL-AP sites. On comparison of FL-CP vs. NFL-CP sites treated with SRP, the BI, PPD reduction and CAL improvement was significantly higher in FL-AP at 3 weeks and 3 months. There was significant reduction of Pg in FL-AP and the percentage Pi reduction was higher in NFL-AP.

In the current study, it was seen that there was a rise in SOD levels in both FL-CP and FL-AP groups though it was not significant between the groups. The TAOC levels rose in FL-AP but decreased in FL-CP group. MDA levels were found to decrease in both groups though the difference was not statistically significant between the groups. No such study was found till date which compared the SOD, TAOC, and MDA levels between CP and AP patients specifically with dental FL. It was also seen that there was rise in SOD and TAOC levels in NFL-AP group but decreased in NFL-CP group though it was not significant between the groups. MDA levels increased in NFL-CP group but decreased in NFL-AP group at 3 weeks from baseline. Guentsch et al. found higher SOD levels in chronic compared to aggressive cases.[19] Konopka et al. reported higher TAOC levels in aggressive patients compared to chronic in peripheral blood.[20] However, a direct comparison of the MDA levels between CP and AP patients was not found. The comparison of the levels of SOD, TAOC, and MDA in saliva of CP and AP patients with and without dental FL was done for the first time. In the current study, at 3 weeks, there was no significant change in SOD and MDA levels in FL-CP and NFL-CP groups. However, reduction in the TAOC levels in FL-CP group when compared to NFL-CP group was statistically significant. In the current study, at 3 weeks, the salivary SOD and TAOC levels were higher without significant change from baseline within the FL-AP and NFL-AP groups. MDA levels at 3 weeks were higher in FL-AP group but lower in NFL-AP group. Between the FL-AP and NFL-AP groups, the SOD, TAOC, and MDA salivary level changes were not significant.

Fluoride is an oxidizing agent which was evident in this study as the MDA level was higher at baseline in both FL-CP and FL-AP groups than NFL-CP and NFL-AP groups, respectively. A close association between chronic fluoride toxicity and increased oxidative stress has been reported in humans.[21] In erythrocytes of children afflicted with skeletal FL, increase in MDA levels and decrease in SOD activity were reported.[22] Fluoride inhibits the activities of SOD causing a heavy accumulation of free radicals and hydrogen peroxide resulting damage to various cells.[23] Wang et al. reported a decrease in antioxidants in patients with skeletal FL.[24]

Periodontitis is caused by multiple factors such as local factors such as dental plaque, plaque retentive factors, and cofactors such as traumatic occlusion. The systemic factors include genetic causes and systemic diseases. The various risk factors responsible for periodontitis are well discussed in literature. These risk factors are common to both periodontitis patients who hail from endemic fluorosed belt (FL-CP and FL-AP) and from nonendemic areas (NFL-CP and NFL-AP). However, effects of fluoride through FL on periodontal hard and soft tissue changes are unique.[25] The role of oxidative stress in causing periodontitis is reported to be a possible major factor in differentiating CP versus AP. Fluoride as an oxidizing agent and pronounced oxidative stress in fluorosed patients are reported by measuring oxidative markers such as MDA and lipid peroxidation. The possible role of fluoride-induced oxidative stress has to be investigated in FL and NFL periodontitis patients using larger sample size. The oxidative stress in FL patients remains distinct as an enhancer of pathogenic mechanism in periodontitis. Third, the genetic role of FL in causation of periodontitis through is effect on collagen and bone is a recent area of research. The important observation in the current study is the baseline higher level of MDA (a marker of oxidant) in fluorosed group than nonfluorosed group.

Considering the role of FL on hard and soft periodontal tissues,[17] oxidative stress influencing pathogenesis, gene polymorphism and all the risk factors of periodontitis, FL should be recommended strongly as an environmental risk factor for periodontitis in endemic fluorosed areas. The need of the hour is to study these fluorosed patients from periodontal prospective using standardized criteria to ascertain, determine, and dissect the role of fluoride in periodontal disease and implement modified treatment measures in fluorosed periodontitis patients as the treatment outcomes vary between FL and NFL subjects. The possible shortcoming of this study is smaller owing to safe funding.

According to the authors, the current study is first one to use 6.5% guduchi gel in periodontitis treatment. The rationale for using guduchi extract was its multipotent medicinal property on multifactorial periodontitis with multiple microbial induced clinical features due to inflammation. The need of this in periodontitis treatment is to implement a multipotent phytomedicinal drug such as guduchi. According to the current results, guduchi applications has produced higher percentage of improvement in most of chemical and microbial parameters at the given concentration (6.5%) which probably was adequate to improve periodontal parameters in vivo situations as clinically significant. However, based on these results, a higher concentration of guduchi in larger sample size as further directional study would confirm the medicinal activity of guduchi at statistical level.

Thus, clinical trial with a larger sample size with higher concentration of the guduchi gel is required in the future to further establish this drug (guduchi) as an effective mode of nonsurgical therapy in the treatment of periodontitis.


  Conclusion Top


The current study involved comparison of SRP and SRP + G groups for the first time in literature. The salivary oxidant (MDA) level was higher in fluorosed periodontitis patients. Guduchi has clinically anti-inflammatory and antimicrobial effects in the 6.25% gel formulation along with SRP used in the current study. The local use of multipotent guduchi in the treatment of periodontitis is recommended, instead of using individual anti-inflammatory, antimicrobial, and antioxidant allopathic drug.

Acknowledgment

We sincerely thank Ms. Jasmin Gosar, M. Pharm., Bapuji Pharmacy College, for her assistance in preparation of the guduchi gel. We sincerely thank Himalaya drug, India, for their support on Guduchi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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