Efficacy of Triphala and Chlorhexidine Mouthwashes on Gingival Inflammation and Dental Plaque in Children: A Systematic Review

Abstract

Aim: The aim of this study was to evaluate and compare the efficacy of Triphala and chlorhexidine mouthwashes in reducing gingivitis and dental plaque in children. Methodology: A literature search was confined to the English language using MeSH terms conferring to PICO format in PubMed, Cochrane Library, and Ovid ^(SP), covering the period from January 1960 to August 2022. A search in Google Scholar and the grey literature and a hand search of references was performed to find additional data. Suitable studies were selected based on the predefined inclusion and exclusion criteria. Quality analysis of the selected studies was performed using the Cochrane Risk of Bias Tool for Randomized Controlled Trials. Results: Seven hundred and forty-seven articles were retrieved from three databases (PubMed, Cochrane Library, Ovid ^(SP), and other sources). Results: A total of 747 studies were retrieved from electronic databases and hand searches. After removing duplications, 519 were available; among them, 495 irrelevant citations were excluded with inclusion and exclusion criteria. Twenty-four citations were eligible for abstract screening, and fourteen citations were excluded including invitational studies, narrative reviews, animal studies, and studies that involved adults. Finally, studies for full texts were screened for eligibility for the research question, and then only five studies were available upon full-text phase analysis. The five studies involved 1740 children to evaluate the efficacy of Triphala and chlorhexidine mouthwashes in reducing gingivitis and dental plaque in children. Among them, one article showed low risk, three articles showed moderate risk, and one article showed high risk. Conclusion: While Triphala and chlorhexidine both reduce gingivitis, reports indicate that Triphala is less effective than chlorhexidine in improving plaque index scores. Further controlled studies are needed to confirm the effectiveness of Triphala mouthwash in children.

1. Introduction

Oral health enhances an individual’s overall quality of life. Previous studies have discovered a connection between oral disease and heart problems such as coronary artery disease and myocardial infarction [1,2,3]. Mechanical methods like toothbrushing and flossing regularly maintain plaque removal, which is crucial for controlling and preventing dental caries, periodontitis, and gingivitis. Children require chemotherapeutic agents such as a therapeutic mouth rinse for mechanical plaque control, as they are unable to reach the interproximal sites on their own due to a lack of motivation or poor hand–eye coordination [4,5]. Loe [6] proved that chlorhexidine was able to control dental plaque growth. Chlorhexidine (CHX) is considered a “gold standard chemical plaque control agent” due to its effectiveness in maintaining oral health at various concentrations [7]. CHX is used in dentistry to manage gingivitis, periodontitis, peri-implant disease, root canal therapy, and oral surgery [7,8,9]. Furthermore, CHX serves as a pre-rinse to inhibit the spread of microbes and treat complications like oral mucosal disease [7,9]. However, it has side effects such as staining the surfaces of the tooth and tooth-coloured restorations, taste aberrations, and an increased tendency of calculus formation that hinders its long-term use [8,9].

Various herbs used in dentistry include Triphala, tulsi patra, jeshthamadh, neem, clove oil, and ajwain [10]. “Triphala” is among the most used formulas in traditional ayurvedic medicine as it has antibacterial, antiseptic, and anti-inflammatory properties. It comprises equal amounts of Terminalia chebula, Terminalia belerica, and Emblica officinalis; it is widely used in dentistry [11,12,13,14]. Biradar et al. chemically analyzed Triphala and reported tannic acid, chebulic acid, and flavonoids as its key constituents. Triphala contains tannins that help physically remove bacteria by clumping them together. This lowers the number of bacteria that stick to teeth in the early stages of plaque formation [15,16]. Triphala mouth rinse has broad antibacterial action against Gram-positive and -negative microorganisms. It also exhibits antioxidant activity that helps in reducing dental plaque and gingivitis. Triphala has demonstrated its antimicrobial and antioxidant properties in vitro by inhibiting Streptococcus mutans at concentrations as low as 50 g/mL [17]. According to one study, the tannic acid in Triphala may aid in plaque reduction by adhering to bacterial cell surfaces. This degrades proteins and kills the bacterial cells [18]. Studies have shown that 0.6% Triphala mouthwash has strong anti-caries activity, comparable to chlorhexidine, but without the disadvantage of tooth discoloration and at a significantly lower cost. However, there was no sign of dental structural remineralization [15,16,17]. Triphala inhibits PMN-type collagenase, particularly MMP-9, at a concentration of 1500 μg/mL, which is safe according to toxicology tests [19]. Studies have proven that Triphala exhibits substantial antibacterial activity against biofilms present for three to six weeks. Given the numerous disadvantages of NaOCl, using herbal alternatives as a root canal irrigation agent may be beneficial [20]. Based on the available information in the literature, the number of studies demonstrating the effectiveness of Triphala and chlorhexidine mouthwashes in reducing gingivitis and dental plaque in children is still quite high, despite the lack of sufficient data. These characteristics are essential to the efficacy of the chlorhexidine and Triphala mouthwash in children. Therefore, this systematic review aimed to evaluate and compare the efficacy of Triphala and chlorhexidine mouthwashes in reducing gingivitis and dental plaque in children.

2. Materials and Methods

2.1. Protocol Registration and Review Reporting

The present systematic review protocol of this review was registered at Prospero (CRD42022337377). We reported this review according to the PRISMA guidelines.

2.2. Search Methods for Identification of Studies

A comprehensive, detailed electronic database search was conducted independently by two investigators (A.S. and V.R.K.R) using “PubMed Central”, “Cochrane Library”, and “Ovid”. The search was restricted to articles published in English from the extant literature from the period up to August 2022. The search was performed using MeSH terms including “child”, “tooth”, “Triphala mouthwash”, “chlorhexidine mouthwash”, “gingival inflammation”, and “plaque index”. We searched for synonyms in multiple combinations using Boolean operators and truncations to broaden and narrow the search. In addition, we conducted a manual search for cross-references among the included and pertinent studies to prevent the omission of pertinent, undiscovered studies during an electronic search. The search terms that were used in the review are shown in

Table 1. PICO format used in the search strategy.

PICO	Population	Intervention	Comparison	Outcome
Characteristics	Children Dentition	Triphala mouthwash	Chlorhexidine mouthwash	Plaque control Reduction in Gingival inflammation
MeSH terms	Child Tooth	Triphala mouthwash Plant extracts Herbal mouthwash Triphala	Chlorhexidine mouthwash CHX mouthwash	Plaque control Gingival inflammation Microbial count Dental plaque index
Alternative terms	Children Pediatric Paediatric Pedodontics Primary dentition Deciduous teeth Primary teeth Permanent dentition Permanent teeth Adolescent	Triphala mouthwash Triphala expectorant Mouthwash Mouthrinse	Chlorhexidine mouthrinse Chlorhexidine CHX mouthrinse Chlorhexidine expectorant CHX expectorant	OHIS Debris index Calculus index Periodontal inflammation Microbial growth Oral plaque Antiplaque

in PICO format.

2.3. Selection Criteria

Two investigators (A.S. and V.R.K.R.) independently reviewed the titles of the studies they initially retrieved from the databases and conducted a manual search. The abstracts of the studies were assessed after removing the duplicates and irrelevant titles. The review included all the abstracts that seemed to meet the inclusion criteria. Further full-text review was accessed for the included studies or if the abstract of a study did not provide enough information. A third evaluator (S.N.) was involved in reaching a consensus on any unresolved issues regarding the inclusion of a study for the review after the full-text phase.

2.4. Eligibility Criteria

Randomized clinical trials on children using Triphala and chlorhexidine mouthwashes were included. Studies published in languages other than English and studies including adults were excluded. The studies involving treatments other than Triphala and chlorhexidine were also excluded.

2.5. Data Extraction

Data extraction was performed independently from the -studies that met the inclusion criteria and data were arranged in the following fields:

• General information (author’s name and year of publication).
• Study characteristics (type of study design and treatment comparison).
• Sample description (size and age).
• Mouthwash used for intervention.
• Mouthwash used for comparison.
• Frequency and duration of the mouthwash usage.
• Reported outcomes of interest.
• Intragroup analysis and intergroup analysis were used.
• Results of the studies.
• Conclusion of the studies.

2.6. Quality Analysis and Risk of Bias

The risk of bias in the included studies was also independently assessed by the same 2 authors using “the Cochrane Risk of Bias Tool” for Randomized Controlled Trials.

3. Results

We constructed a flowchart showing the retrieval, screening, and selection of items for review (Figure 1). After removing duplicate citations, the authors identified 519 articles from a total of 747 studies they retrieved from electronic databases (PubMed, Cochrane Library, and Ovid) and hand searches. The comprehensive screening of available article titles excluded 495 irrelevant citations. Twenty-four citations were eligible for abstract screening, and fourteen citations were excluded based on inclusion and exclusion criteria that included invitational studies, narrative reviews, animal studies, and studies that involved adults. Finally, studies for full texts were screened for eligibility for the research question, and then only five articles [4,5,17,18,19] were available upon full-text phase analysis.

3.1. Description of the Studies

The five studies involved 1740 children to compare and evaluate the efficacy of Triphala and chlorhexidine mouthwashes in reducing gingivitis and dental plaque in children. The participants included in the study were healthy children under 16 years of age. The characteristics of the five [4,5,21,22,23] studies are summarized in

Table 2. Analysis of final available studies.

Author (Year)	Place	Study Design	Age (Years)	Sample Size	Intervention	Comparison	Intervention
Bajaj and Tandon [21]	Bahadurgarh	RCT	8–12	1431	0.6% Triphala	0.1% Chlorhexidine	2 min, once daily
Bhattacharjee et al. [4]	Manipal	RCT	8–12	57	0.6% Triphala	0.12% Chlorhexidine	Minimum of 30 s, twice a day
Padiyar et al. [5]	Jaipur	RCT	9–12	60	6% Triphala	0.2% Chlorhexidine	Once, at night
Chainani et al. [22]	Mysore	RCT	13–16	120	10% Triphala	0.1% Chlorhexidine	30 s, once daily
Bhor et al. [23]	Pune	RCT	14–15	72	0.4% Triphala	0.02% Chlorhexidine	2 min, twice a day

RCT: Randomized control trial.

. Five studies from India [4,5,21,22,23] found that Triphala and chlorhexidine had comparable effects on gingival health in 1431 children aged 8–12. Within the realm of microbial count inhibition, the authors reported that Triphala had superior performance compared to chlorhexidine, except for Lactobacillus, which exhibited a noteworthy disparity (p < 0.05). In a study by Bhattacharjee et al. [4], gingival and plaque index scores were significantly lower in both the chlorhexidine and Triphala groups at the follow-up stage compared to the scores at the beginning (p < 0.001). The study groups, consisting of 57 children aged 8 to 12 years, showed a comparable percentage change in gingival index (p = 0.826).

The results indicated that the group receiving chlorhexidine had a greater mean plaque index percentage change than the group receiving Triphala (p = 0.048). Both Triphala and chlorhexidine were found to be more effective in reducing plaque and gingivitis, and their short-term administration has no negative side effects. This cost-effective method reduces both plaque and gingivitis. According to a study by Padiyar and colleagues [5], when Triphala and chlorhexidine were used together, there was a big drop in the scores for plaque and gingival health compared to the negative control (p < 0.001). There was no discernible difference in the scores for mouthwashes containing chlorhexidine and Triphala. Bajaj and Tandon [21] reported that Triphala and chlorhexidine exhibited comparable effects over three-month, six-month, and nine-month intervals. Triphala demonstrated better microbial count inhibition than chlorhexidine, except for Lactobacillus (p < 0.05). According to the authors, Triphala has antiplaque and anti-gingivitis capabilities that are comparable to those of chlorhexidine. The researchers Chainani et al. [22] conducted a mouthwash trial that lasted for fifteen days and discovered that chlorhexidine was more effective in reducing the number of Streptococcus mutans than the other three groups. The researchers compared the plaque index scores of Triphala, chlorhexidine, and garlic over 15 days. The results showed that all three of these mouthwashes were equally effective in preventing plaque. Although the authors thought that Triphala, chlorhexidine gluconate, and garlic mouthwash would all work to lower the number of S. mutans in the saliva and plaque score, chlorhexidine turned out to be the most effective. Bhor et al. [23] found that both 0.4% Triphala and 0.12% CHX inhibited the growth of plaque, gingivitis, S. mutans, S. sanguinis, and Lactobacilli in the same manner. Herbal mouthwash significantly reduced the number of germs on plaque and reduced plaque and gingival inflammation, paving the way for new opportunities in herbal dentistry and chemical plaque control. Triphala, chlorhexidine, and garlic plaque index scores were comparable after 15 days of mouthwash use. All three types of mouthwash reduced the salivary Streptococci mutans count and plaque score; nonetheless, chlorhexidine outperformed them [4]. Various authors used different indexes for measuring plaque index and gingival index. All the authors used Loe and Silness [24] to mess up the gingival index. Bhor et al. [23], Bhattacharjee et al. [4], and Bajaj and Tandon [21] used the Silness and Loe [25] index to measure plaque scores, while Chainani et al. [22] used the Turesky modification of the Quigley and Hein plaque index [26], and Padiyar et al. [5] used the Narayan and Mendon index [27]. There were no dropouts in the studies reported by Bhor et al. [23] and Padiyar et al. [5], while deaths were reported in the rest of the studies [4,21,22]. The Bajaj and Tandon studies reported that drop-outs for Triphala, chlorhexidine and distal water groups were 7.6%, 7.36% and 10.6%, respectively. Bhattacharjee et al. [4] reported values of 6.6% and 3.3% for the Triphala and chlorhexidine groups, while Chainani et al. reported values for Triphala, chlorhexidine, and placebo of 15%, 7.5%, and 10%, respectively. At follow-up, the Triphala and chlorhexidine groups showed significant reductions in gingival and plaque index scores compared to baseline. The chlorhexidine group showed a higher mean plaque index percentage than the Triphala group. Triphala and chlorhexidine, both mouthwashes, reduce plaque and gingivitis when used in the short term without causing any side effects. Triphala reasonably reduces plaque and gingivitis [5]. Both Triphala and chlorhexidine effectively remove plaque and gingivitis, but their respective reductions in plaque and gingival index scores were significantly greater than those of the negative control. Triphala’s and chlorhexidine’s mouthwash scores showed no significant difference [23]. The results showed that 0.4% Triphala and 0.12% CHX both stop the growth of plaque, gingivitis, Streptococcus mutans, Streptococcus sanguinis, and Lactobacillus. Herbal mouthwash reduces plaque bacteria levels and gingival irritation]. Triphala and chlorhexidine exhibited comparable effects over nine months. Triphala demonstrated better microbial count inhibition than chlorhexidine, except for Lactobacillus (p < 0.05) [21].

Table 3. Outcomes of the final available studies.

Authors	Sample	Study Period	Dropouts	Measurements and Index Used	Outcomes
Bajaj and Tandon [21]	1431	9 months	Triphala—7.6% Chlorhexidine—7.36% Distal water—10.6%	Gingival index: Loe and Silness [24] Plaque Index: Silness and Loe [25]	Triphala and chlorhexidine exhibited comparable effects over nine months. Triphala demonstrated better microbial count inhibition than chlorhexidine, except for Lactobacillus (p < 0.05).
Bhattacharjee et al. [4]	60	14 days	Triphala—6.6% Chlorhexidine—3.3%	Gingival index: Loe and Silness [24] Plaque Index: Silness and Loe [25]	Triphala and chlorhexidine groups showed substantial reductions in gingival and plaque index scores at follow-up compared to baseline (p < 0.001). Chlorhexidine increased mean plaque index scores more than Triphala (p = 0.048).
Padiyar et al. [5]	60	30 days	0	Gingival index: Loe and Silness [24] Plaque Index: Narayan and Mendon index [26]	Triphala and chlorhexidine both work to remove plaque and gingivitis, but Triphala and chlorhexidine both reduced plaque and gingival index scores by a lot more than the negative control (p < 0.001). There was no significant difference in the plaque and gingival index scores between Triphala and chlorhexidine.
Chainani et al. [22]	120	15 days	Triphala—15% Chlorhexidine—7.5% Placebo—10%	Gingival index: Loe and Silness Plaque Index: Turesky modification of the Quigley and Hein plaque index [27]	Triphala, chlorhexidine, and garlic plaque index scores were comparable after 15 days of mouthwash use. All three types of mouthwash reduced the salivary Streptococci mutans count and plaque score; nonetheless, chlorhexidine outperformed them.
Bhor et al. [23]	72	90 days	0	Gingival index: Loe and Silness [24] Plaque Index: Silness and Loe [25]	The results showed that 0.4% Triphala and 0.12% CHX both stop the growth of plaque, gingivitis, Streptococcus mutans, Streptococcus sanguinis, and Lactobacillus. Herbal mouthwash reduced plaque bacteria levels and gingival irritation.

details the results of the final studies.

3.2. Risk of Bias of Included Studies

The included studies were subjected to critical analysis following the Cochrane Risk of Bias tool for evaluating the risk of bias. The studies did not use the same indexes to measure the plaque and gingival index. There was a huge sample variation among the studies. The duration of the study also varied among the studies. The subject allocation was not clearly stated in two studies [5,22], while two studies did not clearly report the outcomes [4,21]. Among these five studies available for analysis, one article showed a low risk of bias [23], and the rest of the articles described having a moderate risk of bias [4,5,21,22] (Figure 2).

4. Discussion

Various researchers have studied CHX’s antimicrobial properties in the industry over the past few decades [28,29,30,31,32]. The literature has published numerous studies comparing chlorhexidine with herbal mouthwashes for the treatment of dental plaque and gingivitis [28,29,30]. To date, there has been no systematic review of the literature comparing chlorhexidine and Triphala for dental plaque and gingivitis in children. This systematic review included only randomized clinical trials. Both the test and control groups included a total of 1740 individuals. The patients’ mean age in the included studies ranged from 8 to 16 years. The authors found Triphala concentrations ranging from 0.4% to 10% in all five investigations. The follow-up ranged from 2 weeks to 9 months in the included studies. Participants in the included studies reported no side effects for any groups. The authors used the Cochrane Risk of Bias Tool for Randomized Controlled Trials to assess the quality of the included studies. In the included studies, the high risk of bias was mainly due to allocation concealment and incomplete outcomes. Different articles used different indices to assess dental plaque reduction. The included studies assessed dental plaque using the plaque index and the Silness and Loe Index [24], while they calculated gingival inflammation using the Loe and Silness Index [25] alone. Padiyar et al. [5] looked at how well Triphala, chlorhexidine gluconate, and garlic extract mouthwash cut down on the plaque index and the amount of Streptococcus mutans bacteria in saliva. They did not consider the reduction in gingival inflammation [5]. An intergroup comparison in this study revealed no significant difference between the three types of mouthwash at the 15-day follow-up. However, at the 30-day mark, chlorhexidine demonstrated a statistically significant difference from the other groups, indicating its substantial impact. However, the study does not consider this significant because the plaque scores of all individuals across all groups were set to 0 prior to the administration of the mouthwash. Bajaj and Tandon [21], in a study, compared the effects of Triphala with chlorhexidine mouthwash on gingivitis, plaque, and microbial count and concluded that there was no significant difference between both types of mouthwash. At 24 h, Narayan and Mendon compared the efficacy of Triphala, hi-Ora, and chlorhexidine mouthwashes in reducing plaque formation. They concluded that the antiplaque efficacy of Triphala and Hi-Ora was comparable to that of chlorhexidine [27]. Chainani et al. [22] compared the antiplaque and anti-gingivitis efficacy of Triphala and chlorhexidine mouthwashes in a study. The authors concluded that there was no significant difference in the effectiveness of both mouthwashes in reducing plaque and gingivitis for a period of one month. Jagadish et al. [30] conducted a study on the effect of Triphala on dental biofilm, which was similar to the results of this study.

Bhor et al. [23] compared the effects of 0.4% Triphala and 0.12% chlorhexidine on the reduction of dental plaque, gingivitis, and microbial growth for three months. At baseline, 1 month, and 3 months, the intergroup comparison revealed a similar reduction in mean plaque and gingival scores for both the Triphala and chlorhexidine groups, indicating no significant differences between the mouthwashes. In terms of the reduction in plaque scores, the results of this study were similar to those of Desai et al. [33]. However, the studies conducted by Bajaj et al. and Bhattacharjee et al. [4] showed contrasting results. While the results for gingivitis reduction were similar to those of Bajaj and Tandon [21] and Bhattacharjee et al. [4], the difference between the Bhor et al. study and the other studies could be due to the study period duration. The main outcome of this systematic review suggests that Triphala mouthwash showed a significant reduction in the plaque and gingival indices, similar to chlorhexidine in children. The present review suggests that Triphala mouthwash is equally effective in reducing dental plaque and gingival inflammation. While this systematic review endorses the use of Triphala, it is important to acknowledge the well-documented side effects of chlorhexidine, which do not apply to herbal mouth rinses. Therefore, it is necessary to conduct further studies, focusing on a gold standard comparison against preferred herbal products, to demonstrate their effectiveness and establish their merit [34,35,36,37,38]. The authors are conducting more clinical trials to demonstrate the toxic effect of the tested product. Nonetheless, each study calculated the plaque index and gingival index, and the reported values for baseline measurements differed significantly. Among them, Triphala mouthwashes seem to be effective in reducing the colony counts of cariogenic bacteria. The short-term impact of Triphala mouthwashes is inconclusive, and its long-term effects remain uncertain. Triphala mouthwashes are effective in decreasing plaque and gingival infection-related issues. The index is also uncertain in all the studies. Short-term application of chlorohexidine may be effective in reducing multiple microorganisms. CHX and herbal mouthwashes effectively reduce the gingival inflammation-related index, and there is also considerable agreement regarding the plaque-related index among the included studies [4,5,21,22,23]. Plaque removal is crucial for controlling dental caries and gingivitis, but in children, factors like lack of manual dexterity and individual motivation limit the effectiveness of toothbrushing [34,35]. Chemotherapeutic agents, such as therapeutic mouthrinse, are needed as an adjunct to mechanical plaque control [32,33,34,35,36]. Chlorhexidine (CHX) is the gold standard chemical plaque control agent, but excessive use can lead to bacteria becoming resistant and causing side effects. Herbal mouthwash has gained popularity for the prevention and treatment of oral conditions. Triphala, a common formula in traditional ayurvedic medicine, has antibacterial, antiseptic, and anti-inflammatory properties [16,17,18]. Investigating a suitable alternative like Triphala, which is locally available, renewable, culturally accepted, affordable, and effective against oral pathogenic microorganisms, is needed [17,18,23,39]. The research on other types of mouthwashes is relatively limited and requires further research. The certainty of evidence for most comparisons is too low to draw conclusions. The children that participated in the study were 8–16 years old. This systematic review concludes that the selection of children to participate in all the studies lacked proper criteria. This could have raised questions about reductions in plaque scores using Triphala and chlorhexidine mouthwashes provided from the start of the study to the follow-up phase. Furthermore, the included studies did not provide a detailed description of the recommended brushing and flossing strategies. A meta-analysis was not performed with the finally available studies; this can be considered a limitation of this systematic review. Various concentrations were used in all five studies and all the studies included in the final analysis were from India. The results warrant further prospective randomized control trails and studies with a large sample size to establish the clear effect of Triphala mouthwash in children.

5. Conclusions

The effectiveness of Triphala mouthwash appears to be equivalent to that of chlorhexidine in terms of its ability to reduce clinical gingival and plaque index scores in children. In the studies, modifications were made to the frequency and concentration of the mouthwashes that included Triphala and chlorhexidine. Further, high-quality clinical trials are still needed with a large sample size.