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ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 696
Antibacterial efficacy of triphala against oral streptococci: An in vivo study


1 Department of Public Health Dentistry, DAPMRV Dental College and Hospital, Bangalore, Karnataka, India
2 Department of Public Health Dentistry, MS Ramaiah Dental College and Hospital, Bangalore, Karnataka, India
3 Department of Community Medicine, MS Ramaiah Medical College and Hospital, Bangalore, Karnataka, India

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Date of Submission25-Apr-2012
Date of Decision12-Jul-2012
Date of Acceptance18-Aug-2012
Date of Web Publication19-Feb-2013
 

   Abstract 

Background: Triphala is a botanical preparation consisting of equal parts of three herbal fruits. Much revered in Ayurveda, triphala has been proven to have antibacterial, antiviral, antifungal actions.
Aims and Objectives: The objective of this study was to investigate the effect of 6% triphala in a mouthwash formulation on the salivary streptococci levels at the end of 48 h and 7 days, of twice a day usage, and to compare the same with 0.2% chlorhexidine.
Materials and Methods: Sixty undergraduate student volunteers aged between 18 and 25 years were randomly allocated into three study groups. (a) 6% triphala mouthwash, 15 ml twice a day; (b) 0.2% chlorhexidine mouthwash, 15 ml twice a day (active control group); (c) passive control group asked to rinse with plain water, twice a day. The oral streptococci colony forming units/ml (CFUs/ml) was assessed by inoculating blood agar with saliva samples at the end of 48 h and at 7 days.
Results: The triphala group showed a 17% and 44% reduction, while the chlorhexidine group showed 16% and 45% reduction at the end of 48 h and 7 days (P < 0.001). The reduction in CFUs/ml seen in triphala group closely paralleled that of chlorhexidine group.
Conclusion: Triphala has been used in Ayurveda from time immemorial and has many potential systemic benefits. The promising results shown by Triphala call for further investigations of its antimicrobial effects against the numerous oral microorganisms.

Keywords: Antibacterial action, chlorhexidine, oral streptococci, triphala

How to cite this article:
Srinagesh J, Krishnappa P, Somanna SN. Antibacterial efficacy of triphala against oral streptococci: An in vivo study. Indian J Dent Res 2012;23:696

How to cite this URL:
Srinagesh J, Krishnappa P, Somanna SN. Antibacterial efficacy of triphala against oral streptococci: An in vivo study. Indian J Dent Res [serial online] 2012 [cited 2018 Dec 11];23:696. Available from: http://www.ijdr.in/text.asp?2012/23/5/696/107423
The "oral streptococci" are a very heterogeneous group of microorganisms inhabiting the oral cavity. Although they are considered commensals, most are opportunistic pathogens and have been linked with a variety of diseases, especially brain and liver abscesses and infective endocarditis. [1] From the oral health perspective, it is well established that microorganisms have an important role in caries etiology. The oral streptococci, especially Streptococcus mutans and Streptococcus sobrinus, have been consistently found to be associated with dental caries in humans. [2] Other microorganisms, such as Streptococcus mitis and Streptococcus salivarius, have also been linked with the disease or absence of it. Their interplay within the dental biofilm is an important feature for the establishment and maintenance of the oral micro flora and the development of a cariogenic dental plaque. [3]

The dental caries burden in India has been on the rise. And it is important to explore all avenues possible to reduce this disease burden. One of the commonly adopted techniques has been delivery of antimicrobial agents into the oral cavity through mouthwashes. Mouthwashes, in addition to mechanical plaque control measures, have been found to be very effective in reducing the oral microbial load. [4] Among the available mouthwashes, chlorhexidine has been considered as the "Gold Standard" and is highly effective in reducing the oral microbial load. [5] Unfortunately, chlorhexidine has its own inherent side effects - staining of teeth and composite restorations, altered taste perception, metallic taste, burning sensation, etc., [6] which lead to poor long-term compliance of the patient. In addition, the availability of chlorhexidine, in the rural and peri-urban areas of India, where the need for prevention of dental caries is high, is almost non-existent. A suitable alternative, which is effective in preventing dental caries and is locally available, culturally acceptable, and affordable, has to be identified.

Triphala is a key ingredient used in Ayurveda since time immemorial. It is a botanical preparation consisting of equal parts of three herbal fruits: Harada (Terminalia chebula), amla (Emblica officinalis), and bihara (Terminalia bellerica). Much revered in Ayurveda, triphala has been proven to have antibacterial, antiviral, and antifungal actions. It is also said to possess antihistamine, anti-inflammatory, antioxidant, antitumor, blood pressure lowering, cholesterol lowering, digestive, diuretic, and laxative properties. This magical preparation has action on all the three components considered in Ayurveda - Vata, Pitta, and Kapha. [7],[8] Such a wide array of actions of triphala is supposed to be because of the 47 tannins and 35 phytochemicals which have been so far isolated from it. [9],[10] The objective of this study was to investigate the antibacterial effect of triphala in a mouthwash formulation on the salivary streptococci levels.


   Materials and Methods Top


This study was conducted to measure the decrease in total oral streptococcal count after using 6% triphala in a mouthwash formulation at the end of 48 h and 7 days of twice a day usage and to compare the same with 0.2% chlorhexidine.

Ethical clearance was obtained from the Institutional Review Board. Informed consent was obtained from all the study participants.

All the undergraduate students of the institution were screened and those who had a frank carious lesion and/or active incipient caries lesion were included. Those who had taken antibiotics/corticosteroids for 5 consecutive days in the last 3 months/allergic to the mouthwashes used in the study were excluded. Sixty undergraduate student volunteers who fulfilled our inclusion and exclusion criteria, aged between 18 and 25 years, were recruited for the study. They were randomly allocated into three study groups by one of the research assistants who was blinded to the caries status of the participants. The three study groups were: (a) 6% triphala mouthwash, 15 ml twice a day; (b) 0.2% chlorhexidine mouthwash, 15 ml twice a day (active control group); and (c) passive control group asked to rinse with plain water, twice a day.

Preparation of triphala mouthwash

In a study conducted by Jagdish et al., [11] reduction in Mutans streptococci count at 5% and 10% of triphala concentration was reported. Jagtap and Karkera [12] reported that the Minimum Inhibitory Concentration of T. chebula, one of the component fruits of triphala, was 6%. Thus, in the present study, 6% triphala mouthwash was prepared. Sixty grams of pure triphala churna was dissolved in 1 L of distilled water to obtain 6% of the extract. To improve patient compliance, 2 ml of glycerine (sweetening agent) and 1 ml of Pudin Hara (flavoring agent) were added to the solution. The solution was brought to a boil for 10 min, cooled, and filtered. It was dispensed in white semi-transparent bottles. Triphala mouthwash was prepared in consultation with a senior Ayurvedic consultant.

0.2% Chlorhexidine: Commercially available, mint flavored, 20% concentrate of chlorhexidine was diluted to 1:1000 to obtain 0.2% concentrate solution. It was dispensed in white semi-transparent bottles.

The volunteers were instructed not to rinse/eat anything for 30 min after mouthwash use. A compliance diary was maintained to assess the usage. The study participants were regularly reminded through personal contact/phone calls/SMS regarding mouthwash use to improve the compliance.

Method of data collection

The demographics information and dental caries experience were recorded using DMFT (Decayed, Missing, Filled Teeth) index at baseline, following which the unstimulated saliva samples were collected and diluted to 1:1000. 0.01 ml of it was inoculated onto blood agar and incubated for 24 h at 37°C.

Salivary streptococci colony count was obtained by a microbiologist who was blinded to subject allocation. The colonies were counted using a colony counter and multiplied by 10 5 . Following baseline data collection, the study subjects were given mouthwashes of their respective groups and advised to use 15 ml of it twice a day for 7 days. A new tooth brush was given to each participant to prevent the re-inoculation of streptococci.

Unstimulated saliva samples were once again collected at the end of 48 h and 7 days. They were diluted to 1:1000 and inoculated onto blood agar. Salivary streptococci counts were obtained. All the microbiological procedures were performed in the microbiology lab under the guidance of the department head.

Statistical analysis

The data collected were entered into computer using excel, and later the data was exported and analyzed using SPSS version 11 software. The statistician was blinded to the group allocation. The reduction in colony count in all the three groups was compared between baseline, 48 h, and 7 days using repeated measures analysis of variance (ANOVA), and also post hoc test was performed for comparing between any two repeated measures. Probability (P) <0.05 was considered as statistical significant.


   Results Top


The subjects were all aged between 18 and 25 years, with a mean age of 22.3 years. Twenty-four males and 36 females took part in the study.

There was no significant difference between the mean baseline DMFT scores and salivary streptococcal counts [Table 1]. Following administration of 6% triphala and 0.2% chlorhexidine, there was a significant reduction in the colony forming units/ml (CFUs/ml) at 48 h and 7 days. The control group showed no decrease, but on the contrary showed a slight increase in the CFUs/ml. The triphala group showed a 17% and 44% reduction, while the chlorhexidine group showed 16% and 45% reduction [Figure 1].
Figure 1: Comparison of percentage reduction in CFU/ml in the triphala, Chlorhexidine and control groups at baseline, 48 h, and 7 days

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Table 1: Mean age, DMFT scores, and oral streptococci CFU/ml of groups 1, 2, and 3 at baseline*

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The reduction in colony count was statistically significant between triphala group and control group and between chlorhexidine and control group (P < 0.001). However, there was no significant difference between the triphala group and chlorhexidine group at either 48 h or 7 days (P = 0.507 and P = 0.995, respectively). It was also seen that the reduction in CFUs/ml seen in triphala group closely paralleled that of chlorhexidine group [Figure 2].
Figure 2: CFU/ml reduction from baseline scores in the triphala, Chlorhexidine and control groups*

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   Discussion Top


This study was conducted to assess the antibacterial efficacy of 6% triphala mouthwash against oral streptococci. In the present study, a statistically significant reduction of CFUs/ml of oral streptococci was seen after using triphala as well as chlorhexidine. This is quite similar to the results reported by Jagtap et al. and Jagdish et al.[11],[12] The reduction in CFUs/ml in the triphala group closely paralleled that of chlorhexidine group. This suggests that the anti-oral-streptococci efficacy of triphala is quite similar to that of chlorhexidine.

The patient compliance with both triphala and chlorhexidine was quite satisfactory, with more than 80% of study participants being satisfied with the taste of the mouthwashes. There was no staining of the teeth reported with triphala. Triphala was reported to taste like a raw fruit and this taste disappeared within a few minutes following rinsing of the mouth. On the contrary, use of chlorhexidine resulted in a lingering taste as well as some amount of staining of the teeth.

What is the advantage of triphala over chlorhexidine?

Triphala has been used in Ayurveda from time immemorial and has many potential systemic benefits. Triphala has been prescribed for systemic use by Ayurvedic practitioners to cure a host of systemic illnesses. Thus, even if the patient swallows the Triphala mouthwash, no harm is caused. On the contrary, it provides systemic benefits. This might prove to be beneficial in disabled and bedridden patients, and mentally or physically handicapped individuals in whom performing daily oral hygiene care poses various challenges.

Over the years, it has been reported that triphala is quite safe for use and does not have any side effects. Also, the ingredients which are used to prepare triphala are the commonly available fruit derivatives. The dried and powdered mixture of triphala constituted by amla, vibhitakai, and Haritakai in a 1:1:1 ratio is quite cost-effective. Thus, it could form a viable cost-effective alternative to our rural populace who find the commercially available toothpastes to be quite unaffordable.

Limitations of the study

In the present study, only the short-term effect of triphala against oral streptococci was assessed. The promising results shown suggest that further studies need to be undertaken to explore the antibacterial efficacy of triphala against various oral microorganisms. Furthermore, the long-term patient acceptability and compliance needs to be assessed.


   Conclusions Top


6% triphala used twice a day brought down the oral streptococci count by 17% and 44% at the end of 48 h and 7 days, respectively. The anti-streptococci action closely paralleled that of the "Gold Standard" chlorhexidine. The promising results shown by triphala call for further investigations, especially in this era when holistic integrated medicine approach is the need of the hour.


   Acknowledgments Top


The authors would like to thank all the study participants for having taken part in the study. We express our gratitude to Dr. Shama Rao, Principal, MS Ramaiah Dental College and Hospital, Bangalore, Prof. Indumathi, Head, Dept. of Microbiology and Serology, Gokula Metropolis Clinical Lab, MS Ramaiah Memorial Hospital, Bangalore, and Dr. Ananthraman N, MD (Ayu), Senior Ayurvedic Consultant and Prof., Dept. of Dravyaguna, Sri Sri College of Ayurvedic Sciences and Research, Bangalore, for their support and contribution in conducting this study.

 
   References Top

1.Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral infection. Clin Microbiol Rev 2000;13:547-58.  Back to cited text no. 1
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2.Tanzer JM, Livingston J, Thompson AM. The microbiology of primary dental caries in humans. J Dent Educ 2001;65:1028-37.  Back to cited text no. 2
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3.Marsh PD. Role of the oral microflora in health. Microb Ecol Health Dis 2000;12:130-7.  Back to cited text no. 3
    
4.Alada A, Ige A. Efficacy of different brands of mouth rinses on oral bacterial load count in healthy adults. African Journal of Biomedical Research 2004;7:125-12.  Back to cited text no. 4
    
5.Jones CG. Chlorhexidine: Is it still the gold standard? Periodontology 2000 1997;15:55-62.  Back to cited text no. 5
    
6.McCoy LC, Wehler CJ, Rich SE, Garcia RI, Miller DR, Jones JA. Adverse events associated with Chlorhexidine use: Results from the Department of Veterans Affairs Dental Diabetes Study. J Am Dent Assoc 2008;139:178-83.  Back to cited text no. 6
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7.Nadkarni AK. Dr. K. M. Nadkarni's Indian Materia Medica with ayurvedic, unani-tibbi, siddha, allopathic, homeopathic, naturopathic and home remedies, appendices and indexes. 3 rd ed. Bombay: Popular Prakashan;1976. p. 120.  Back to cited text no. 7
    
8.Juss SS. Triphala - The Wonder Drug. Ind Med Gaz 1997;131:194-6.  Back to cited text no. 8
    
9.Naik GH, Priyadarsini KI, Mohan H. Evaluation of antioxidant activity and phytochemical analysis of triphala. Bhabha Atomic Research Centre Founder's Day Special Issue. 2005;12:76-9.  Back to cited text no. 9
    
10.Vani T, Rajani M, Sarkar S, Shishoo CJ. Antioxidant properties of the Ayurvedic formulation Triphala and its constituents. Int J Pharmacogn 1997;35:313-7.  Back to cited text no. 10
    
11.Jagadish L, Anand Kumar VK, Kaviyarasan V. Effect of Triphala on dental bio-film. Indian J. Sci. Technol. 2009;2:30-3.  Back to cited text no. 11
    
12.Jagadish L, Anand Kumar VK, Kaviyarasan V. Effect of Triphala on dental bio-film. Indian J Sci Technol 2009;2:30-3.  Back to cited text no. 12
    

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Correspondence Address:
Jyotsna Srinagesh
Department of Public Health Dentistry, DAPMRV Dental College and Hospital, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.107423

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