Brief resume of the intended work:
6.1 Need for the study:
Oral cavity is one of the most complex part of the human body that consists of hard and soft tissues and harbors a variety of microbial community which makes it vulnerable to infectious diseases.1 One of the most common infectious diseases of the oral cavity is dental caries, which has multi-factorial etiology such as diet, micro flora, host and time. It has been demonstrated that micro-organisms are one of the major etiological factors. Amongst the pathogenic flora streptococcus mutans is considered to be the main microorganism associated with dental caries2.
Chlorhexidine, a cationic bisbiguanide with a very broad antimicrobial spectrum is the most widely used over the counter mouth rinse. It is used as an adjunct to mechanical cleaning procedures as well as used alone. The major advantage of chlorhexidine over most other compounds lies in its substantivity. It binds to soft and hard tissues in the mouth, enabling it to act over a long period after application of a formulation. However, chlorhexidine has several side effects, such as staining and taste alteration, which limit its long term use. Therefore, chlorhexidine is used as a positive control in many clinical trials and is considered the gold standard3. There is always a quest for new and improved products, emphasis being placed on natural/nature identical products.
Oil pulling is an age-old process mentioned in Charaka Samhita and Sushrutha’s Arthashastra.. The process is called Kavala Gandoosha/ kavala Graha in Ayurveda. This process is said to cure about 30 systemic diseases 4. Oil pulling has been used extensively as a traditional Indian folk remedy for many years to prevent decay, oral malodor, bleeding gums, and dryness of throat, and cracked lips and for strengthening teeth, gums, and jaws5.
Oil-pulling therapy with sesame oil or sunflower oil has been extensively used as a traditional Indian folk remedy for many years. However recent scientific evidence from studies shows that coconut oil demonstrates antimicrobial activity against a wide range of gram positive and gram negative organisms including streptococcus mutans, the main causative agent of dental caries6.
Coconut oil is considered as a unique physically functional food, with the added health and nutritional benefits. There are two types of coconut oil available in the commercial market as potential oil-pulling agents: Refined bleached deodorized coconut oil and Virgin coconut oil.
Refined coconut oil is derived from copra the dried coconut kernel that is processed either by sun drying, smoke drying or hot air drying7. The crude coconut oil is subjected to chemical refining, bleaching and deodorization processes to make it fit for human consumption6, whereas Virgin Coconut Oil is obtained from fresh mature kernel of the coconut by mechanical or natural means, with or without the use of heat and without undergoing chemical refining8. It is also said to have many advantages, which include the health benefits from retained vitamins and antioxidants, the antimicrobial and antiviral activity from lauric acid9.
There is no documented literature comparing the efficacy of oil pulling therapy using refined coconut oil and virgin coconut oil in relation to streptococcus mutans count. Therefore this study is initiated to compare the antimicrobial property of these oils as effective oil pulling agents with chlorhexidine as the positive control.
Review of literature:
1 Amith HV et al (2007) conducted a study to assess the effect of oil pulling on plaque and gingivitis and to monitor its safety on oral soft and hard tissues. Ten subjects performed Oil pulling along with their other oral hygiene measures for 45 days, using “refined sunflower oil”. Plaque and gingival scores were assessed periodically by modified Patient hygiene performance index and Gingival indices. The results showed the reduction in plaque and gingival scores from baseline to 45 days4.
2. Asokan S et al (2008) conducted a study to evaluate the effect of oil pulling with Sesame oil” on the count of Streptococcus mutans in plaque and saliva of Children using the Dentocult SM Strip mutans test, and to compare its efficacy with that of chlorhexidine mouthwash. Results showed that there was a reduction in the S. mutans count in the plaque and saliva samples of both the study and the control groups12.
3. Anand DT et al (2008) conducted a study to evaluate the effect of oil-pulling on the reduction of total count of bacteria. There was a remarkable reduction in the total count of bacteria. The process of oil-pulling reduced the susceptibility of a host to dental caries. The in-vitro antibacterial activity of sesame oil against dental caries causing bacteria was determined. Streptococcus mutans and Lactobacillus acidophilus were found to be moderately sensitive to the sesame oil11.
4. Asokan S et al (2009) conducted a study to evaluate the effect of oil pulling with “sesame oil “on plaque induced gingivitis and to compare its efficacy with chlorhexidine mouthwash. Plaque index and modified gingival index scores were recorded for the 20 subjects and baseline plaque samples were also collected. Plaque samples were used to identify the microorganisms and to measure the total colony count of the aerobic microorganisms present. Reassessment of the index scores and collection of the plaque for measuring the colony count of the aerobic microorganisms was done after 10 days. Results showed a significant reduction in the pre and post values of plaque and modified gingival index scores in both the study and control groups and there was a considerable reduction in the total colony count of aerobic microorganisms present in both the groups10.
5. Thaweboon S et al (2010) conducted an invivo study in Bangkok, Thailand to investigate the effect of different oils on oral microorganisms in biofilm model formed by Streptococcus Mutans KPSK2, Lactobacillus casei ATCC 6363 and Candida albicans. The oils used were coconut oil, corn oil, rice bran oil, palm oil, sesame oil, sunflower oil and soy bean oil. It was found that coconut oil exhibited antimicrobial activity against S. mutans and C. albicans. Sesame oil had antibacterial activity against S. mutans whereas sunflower oil had antifungal activity against C. albicans6.
6. Asokan S et al (2011) conducted a study to evaluate the effect of oil pulling with sesame oil on halitosis and the microorganisms that could be responsible for it and to compare its efficacy with chlorhexidine mouthwash. Group I (oil pulling) and group II (chlorhexidine) included 10 adolescents each. The following parameters were assessed: marginal gingival index, plaque index, organoleptic breath assessment (ORG 1), self-assessment of breath (ORG 2), and BANA test from tongue coating samples on days 0 and 14 of the experimental period. The comparisons of the pre and post therapy values of plaque and modified gingival index score showed a statistically significant difference (P 0.005 and 0.007, respectively) in group I and II. There was a definite reduction in the ORG 1, ORG 2, scores and BANA test score in both groups I and II. Oil pulling therapy has been equally effective like chlorhexidine on halitosis and organisms, associated with halitosis5.
6.3 Objectives of the study:
To compare the efficacy of edible virgin coconut oil and edible refined coconut oil on streptococcus mutans count.
To compare the efficacy of edible virgin coconut oil and chlorhexidine on streptococcus mutans count.
To compare the efficacy of edible refined coconut oil and chlorhexidine on streptococcus mutans count.
Materials and methods:
7.1 Source of data:
60 healthy children with DMFT >2 reporting to A.J Institute of Dental Sciences, between the age group of 12-15 years will be divided randomly into 3 groups, of 20 each based on the mouthrinse prescribed :
Edible virgin coconut oil
Edible refined coconut oil
Chlorhexidine mouth rinse 0.12%
Edible virgin coconut oil.
Edible refined coconut oil
Commercially available (0.12%) chlorhexidine mouthrinse.
Measurement Plastic beakers.(10 ml)
Disposable plastic cups.
Small stainless steel kidney tray.
Sterile table spoons(10ml)
Sterile plastic tubes (for sample collection).
7.2 Method of collection of data:
1. Subjects in the age group of 12-15 years.(both boys and girls)
2. The DMFT scores >2.
Exclusion criteria :
1. Children who cannot expectorate completely.
2. Children with a history of taking antibiotics 3 months prior to and during the study period.
3. Children undergoing orthodontic treatment or with an intraoral prosthesis.
4. Presence of any intra oral pathology.
5. Medically compromised children.
8. Patients without parental consent.
9. Patients having allergy to coconut oil or chlorhexidine mouthrinse.
60 healthy children with DMFT >2 reporting to A.J Institute of Dental Sciences, Mangalore between the age group of 12-15 years will be selected.
They will be randomly divided into three groups of 20 each,
Group A - consists of 20 subjects who will be given edible virgin coconut oil.
Group B – consists of 20 subjects who will be given edible refined coconut oil.
Group C - consists of 20 subjects who will be given Chlorhexidine mouth rinse 0.12%.
- The subjects will be blinded about the aim of the investigation in order to avoid any possible bias.
- Signatures will be taken on the witnessed consent form by the subject’s guardians after explaining the full procedure.
Baseline Data collection
Participants were asked to refrain from eating and drinking one hour prior to saliva collection in order to obtain a relatively constant baseline. Resting drooling (minimal oral movements) was used to collect whole mouth saliva from the oral cavity. Participants were asked to sit comfortably in an upright position and tilt their heads down slightly to pool saliva in the mouth. The first expectoration was discarded to eliminate food debris and unwanted substance contaminating the sample that may cause analytical inaccuracy. The subsequent sample was then expectorated into a pre-labeled sterile container and 2 ml saliva was collected. The samples were then immediately transported for the microbiological analysis14.
OIL PULING PROCEDURE
10 ml of oil will be taken in a teaspoon, approximately 6 grams or till the mouth is half filled. The child will be asked to sip, suck and pull the oil through his/her teeth. The child will be asked to concentrate and imagine the liquid moving inside his/her mouth. Swishing will be done for approximately 8-10 minutes or till the child feels a fullness in his/her mouth. At the end the oil should be milky white, thin and frothy. The child will be asked to spit out the liquid4.
Group A will be subjected to oil pulling with 10ml edible virgin coconut oil for 8 min4.
Group B will be given 10ml of edible refined coconut oil for 8 min4.
Group C will be given 10ml of 0.12% chlorhexidine mouthrinse for 1 minutes.
The subjects will carry out the above procedure for 15 days.
The participants of all the three groups will be instructed to brush their teeth twice daily with non-fluoridated toothpaste as per their daily home oral hygiene schedule.
After 15 days the post-rinse salivary samples will be collected and tested for the colony forming units again in the same manner as described above.
The pre-rinse (i.e. at the commencement of the study) and post rinse(i.e. after 15 days of study period) total colony count for streptococcus mutans within the same group will be compared to check for the efficacy of the study.
Streptococcus mutans: 0.1 ml saliva sample would be spread on Mitis Salivarius agar supplemented with 0.2U/ml bacitracin and colony forming units(CFU) were identified by morphology, size and color, and were counted using a stereomicroscope13.
Statistical Analysis :
Results will be subjected for statistical analysis and data will be correlated using ONE WAY ANOVA test and paired t-test according to the need of the study.
7.3. Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, This study requires investigation to be conducted on children.
7.4. Has the ethical clearance been obtained from your institution in case of 7.3?
Yes, ethical committee clearance has been obtained.
7.5 INVESTIGATION DESIGN:
N – 60 healthy children 12-15 years with
Based on the mouthrinse prescribed-
Group B (N-20)
Edible refined coconut oil
Chlorhexidine mouthrinse 0.12%
Group A( N-20)
Edible Virgin coconut oil
Base-line non-stimulated saliva samples will be collected.
Microbiological evaluation, to determine Streptococcus mutans count
Each group will be given 10ml of refined coconut oil, virgin coconut oil and chlorhexidine mouthrinse respectively for 15 days.
After 2 weeks
Post therapy non-stimulated saliva samples will be collected after 15 days
Microbiological evaluation, to determine Streptococcus mutans count.
Data will be statistically analyzed by one way ANOVA and paired t-test
List of references:
Oyanagi T, Tagami J, Matin K. Potentials of mouthwashes in disinfecting cariogenic bacteria and biofilms leading to Inhibition of caries. Open Dent J. 2012; 6: 23-30.
Sundas S, Rao A. Comparative evaluation of chlorhexidine and sodium fluoride mouthwashes on streptococcus mutans. Journal of Nepal Dental Association. 2011; 12(1) Jan-Jun: 17-21.
Nagappan N, John J. Antimicrobial efficacy of herbal and chlorhexidine mouth rinse -a systematic review. IOSR journal of dental and medical sciences (JDMS). 2012; 2(4) nov-dec: 05-10.
Amith HV, Ankola AV, Nagesh L. Effect of oil pulling on plaque and gingivitis.
J Oral Health Comm Dent. 2007; 1(1):12-8.
Asokan S, Kumar RS, Emmadi P, Raghuraman R, Sivakumar N. Effect of oil pulling on halitosis and microorganisms causing halitosis: A randomized controlled pilot trial. J Indian Soc Pedo Prev Dent. 2011; 29: 90-4.
Thaweboon S, Nakaparksin J, Thaweboon B. Effect of Oil-Pulling on Oral Microorganisms in Biofilm Models. Asia J Public Health. 2011; 2(2):62-66.
Bawalan DD. Understanding coconut oil and its quality parameters. In: Secretariat of the pacific community. Processing manual for virgin cococnut oil, its products and by products for pacific island countries and territories. New Caledonia: Nowmea; 2011.p.11-16.
Marina AM, Che MYB, Amin I. Virgin coconut oil: emerging functional food oil. J.Tifs. 2009; 20(10): 481-487.
Mansor TST, Che MYB, Shuhaimi M, Abdul AMJ, Nurul FKM. Physicochemical properties of virgin coconut oil extracted from different processing methods. International Food Research Journal. 2012; 19(3): 837-845.
Asokan S, Emmadi P, Chamundeswari R. Effect of oil pulling on plaque induced gingivitis: A randomized, controlled, triple blind study. Indian J Dent Res. 2009; 20:47-51.
Anand DT, Pothiraj C, Gopinath RM, Kayalvizhi B. Effect of oil-pulling on dental caries causing bacteria. Afr. J. Microbiol. Res. 2008; 2: 63-66.
Asokan S, Rathan J, Muthu MS, Rathna P V, Emmadi P, Raghuraman C, et al. Effect of oil pulling on Streptococcus mutans count in plaque and saliva using Dentocult SM strip mutans test: A randomized, controlled, triple-blind study. J Indian Soc Pedod Prev Dent. 2008; 26:12-7.
Tehrani MH, Asghari G, Hajiahmadi M. Comparing streptococcus mutans and lactobacillus colony count changes following green tea mouth rinse or sodium fluoride mouth rinse use in children(randomized double-blind controlled clinical trial).Dent Res J.2011; 8(Suppl 1):58-63.
Mohamed R, Campbell JL, Cooper-White J, Dimeski G, Punyadeera C. The impact of saliva collection and processing methods on CRP, IgE, and Myoglobin immunoassays. Clin Transl Med. 2012; 1(1):1-19.