Research Article

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J Res Adv Dent 2015; 4:3:221-225.

Efficacy of Betel (Piper Betle) Rinse in the Prevention of Plaque

Against 0.12% Chlorhexidine Gluconate: A Comparative One
Week Randomized Controlled Trial
Anoop Kumar Paspula1* Sripriya Nagarajan2 Boya Savitha Rani3 Sharada Bodukani4 Neeraja
Suvari5 Gottumukkala Sujani6

1Senior Lecturer, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.
2AssociateProfessor, Department of Public Health Dentistry, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.
3Post Graduate Student, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.
4Post Graduate Student, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.
5Post Graduate Student, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.
6Post Graduate Student, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India.

ABSTRACT

Background: Aim: To study the efficacy of betel leaf rinse against 0.12% chlorhexidine gluconate in the
prevention of dental plaque.

Methodology: 66 systemically healthy individuals aged between 18-25years were randomly allocated to study
group (betel rinse) and control group (0.12% chlorhexidine gluconate). After 8 hours of oral hygiene abstinence
and collection of baseline plaque scores, the subjects were given a thorough oral prophylaxis and then
commenced supervised mouth rinsing regimen twice daily for one week as their sole oral hygiene measure. The
Turesky Gilmore modification of Quigley Hein plaque index was used the assess baseline and one week plaque
scores.

Results: A statistically significant reduction in plaque scores was seen from baseline to one week. The reduction
between the two groups were comparable (p>0.05) on all surfaces except the posterior surface where the
chlorhexidine group showed better reduction than betel group (p<0.02).

Conclusion: The results from the study show that the betel rinse can be used as a cost effective alternative to
chlorhexidine gluconate.

Key words: Piper betel, Rinse, Plaque prevention.

INTRODUCTION Mechanical approaches to oral hygiene can be

The role of dental plaque in the causation of
gingivitis and dental caries is a well-established fact.
Plaque control normally means preventive
measures aimed at removing dental plaque and
preventing it from recurring.[1] This can be
accomplished either mechanically or chemically:
sometimes the two procedures are combined.
supplemented by the use of chemotherapeutic
mouth rinses in order to achieve better plaque
control. Mouth rinses have shown an incremental
benefit in reducing both plaque, dental caries and
gingivitis.[2]
The role of chlorhexidine as an antiplaque
agent is a well-established fact. However, due to the

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Copyright ©2015
cost factor its use is limited to a select few of the
population. Several studies are therefore exploring
the role of cost effective natural products in
prevention of plaque. The role of several plant
products such as neem, miswak, eucalyptus as
antiplaque agent have been studied and their
efficacy been proven by many studies. The betel
(Piper betle) is the leaf of a vine belonging to the
Piperaceae family, which includes pepper and
kava. It is valued both as a mild stimulant and is
known for its medicinal properties. The medicinal
role of betel leaves has been known since ancient
times. Leaves of piper betel plant contain several
active compounds such as eugenol and its isomers,
chavibetol, hydroxychavicol, pentatriacontanol,
piperol, piperbetol, carotenes, and ascorbic acid [3].
The compound hydroxychavicol has been examined
as an antimicrobial ingredient, and it shows
promise for several applications. Sharma et al
(2009) conducted an in vitro study to assess the
possibility of using hydroxychavicol from piper
betel as an oral rinse and found that it caused
reduction in count of streptococcus mutans and
Actinomyces by preventing the formation of water
insoluble glucan.[4]
No studies till date have clinically assessed
the efficacy of the betel rinse in plaque reduction.
Hence, the aim of the study is to assess the efficacy
of betel rinse in plaque prevention as compared to
0.12% chlorhexidine gluconate.
MATERIAL AND METHODS
Study : the study was a single centre , examiner
blind parallel arm randomized controlled trial
conducted in the department of Public Health
Dentistry in January 2015.
Subjects : the study included 66 systemically
healthy subjects aged between 18-25 years.
Ethical clearance: ethical clearance was obtained
from the institutional review board (IRB).All
subjects understood and signed the written
informed consent.
Procedure : After 8 hours of oral hygiene abstinence
and collection of baseline plaque scores, the
subjects were given a thorough oral prophylaxis
and then commenced supervised mouth rinsing
regimen (15ml twice daily for one week) as their
sole oral hygiene measure. The Turesky Gilmore
modification of Quigley Hein plaque index was used
the assess baseline and 1week plaque scores.
Sample size: 66 patients are required to have a 80%
chance of detecting, as significant at the 5% level, a
decrease in the primary outcome measure from
95% in the control group to 70% in the
experimental group.
Random allocation: the subjects were allocated into
study and control group based on computer
generated randomization list.
Inclusion and exclusion criteria: Subjects were
generally healthy male and female volunteers over
18 years of age, with a baseline mean plaque index
1.95 according to the Turesky modification of the
Quigley Hein Plaque Index (PI). Exclusion criteria
were: presence of moderate or advanced
periodontitis based on clinical examination (ADA
Type III, IV) and presence of fixed or removable
orthodontic appliance or removable partial
dentures. Subjects were required to have a
minimum of 20 natural teeth with scorable facial
and lingual surfaces. Teeth that were grossly
carious, extensively restored, orthodontically
banded, abutments, exhibiting severe generalized
cervical and/or enamel abrasion, or third molars
were excluded in the tooth count.
Preparation of the rinse : 1kg of fresh piper betel
leaves was purchased from a local market. The
leaves were boiled in three litres of water with
continuous stirring until it was reduced to half its
original volume. The resultant solution was strained
through a muslin cloth and betel rinse was obtained
for use.[4,5]
Data collection: The plaque score was recorded at
baseline and after 1 week by using basic fuchsin dye
as a disclosing agent. The scoring of plaque was
performed using Turesky et al. modification of the
Quigley-Hein plaque index.[6] Plaque was assessed
the buccal and lingual surfaces of all teeth except
the third molar. The total score was obtained by
adding up all the buccal and lingual scores divided
by the number of surfaces examined.
Statistical analysis: data was analysed using SPSS
ver.21 statistical software package. Descriptive
statistics and frequency distributions were
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assessed. Paired t test was used to assess the scores Table 3: Intergroup comparison of one week mean
at baseline and at the end of 1week.unpaired t test plaque scores in anterior, posterior, buccal and
was used to compare plaque scores between betel lingual surfaces.
and chlorhexidine group. A p value<0.05 was
considered statistically significant. Surface Anterior Posterior Buccal Lingual
Betel 2.34±0.45 2.43±0.46 2.36±0.45 2.57±0.42
RESULTS Chlorhexidine 2.31±0.47 2.18±0.36 2.30±0.46 2.45±0.39
t-value 0.296 2.396 0.531 1.118
A total of 66 subjects participated in the p-value 0.768 0.02* 0.597 0.268
study.53% of subjects were males whereas 47% *statistically significant, analysis using unpaired t
were females. Mean age of subjects was 21.7 years. test
Comparision of mean plaque reduction from
baseline within the two groups showed that both DISCUSSION
the groups showed a statistically significant
Several studies have demonstrated the
reduction (p<0.001)
effectiveness of rinsing with an antimicrobial
Table 1: Intra group comparison of mean plaque mouthrinse in significantly reducing both salivary
reduction from baseline to one week. and mucosal levels of bacteria. The addition of an
antimicrobial mouthrinse to daily oral hygiene
Group Baseline One week regimens
Mean plaque helps t-valuereduce the total oral bacterial
p-value
burden and thereby could complement a direct
mean plaque mean plaque action on bacteria contained within the plaque
reduction
biofilm itself. [7,8,9]
Score Score
The role of betel leaf as an oral medication
Betel 3.47±0.32 2.44±0.40 was known and
1.02±0.48 practised since 400BC.However,
12.02 0.001 its
use as a beneficial agent was foreshadowed when
chlorhexidine 3.48±0.52 2.36±0.42 people combined
1.12±0.56 11.50it with carcinogenic
0.001 agents like
catechu, slaked lime, tobacco and arecanut as a
P<0.001.analysis using paired t test stimulant and aphrodisiac which promoted oral
cancer. [10] Studies have shown that betel leaf when
Comparision of mean plaque scores at used alone inhibited carcinogenesis (Rao et al). [11]
baseline between study and control groups showed Shetty et al (2013) demonstrated the advantage of
that they were similar (p>0.05)Comparision of betel leaf in maintaining salivary ascorbic acid
mean plaque scores at the end of one week showed levels in humans. Salivary ascorbic acid may help
that both the groups were similar in the amount of prevent carcinogenesis in the oral cavity.[12]
plaque reduction (p>0.05).
Sharma et al (2009), evaluated the
Comparision of mean plaque scores in antimicrobial, antioxidant, and anti-Inflammatory
anterior,posterior,buccal and lingual surfaces activities of hydroxychavicol for its potential use as
between the two groups showed that the scores an oral care agent and showed that, its efficacy
were similar in all areas except the posterior region against adherent cells of S. mutans in water-
wherein chlorhexidine group showed a statistically insoluble glucan in the presence of sucrose suggests
significant reduction when compared to the betel that hydroxychavicol would be a useful compound
group(p<0.02) for the development of antibacterial agents against
oral pathogens and that it has great potential for use
Table 2: Inter group comparison of mean plaque in mouthwash for preventing and treating oral
scores at one week infections.[4] Singgih et al (2014) assessed the
aantimicrobial property of ethanol extract of piper
Group One week t-value p-value betel (actifold) on streptococcus mutans and found
Betel 2.44±0.40 0.803 0.425 that Actifold 30x and 60x can inhibit the growth of
chlorhexidine 236± 0.42
tested oral microorganisms.[5]
p>0.05, analysis using unpaired t test
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 Geetashri et al (2014) [13] and Jose Maji et al
(2011) evaluated the efficacy of betel oil and
[14]
chewing betel on microbial inhibition and showed
there was a marked reduction in the microbial
count as well as reduction in biofilm. A study by
Maya sari et al who showed that betel leaf
toothpaste reduced plaque formation in fixed
orthodontic patients.[15] The results were in
conformity to the present study.
The present study evaluated the efficacy of
betel mouthrinse against the gold standard 0.12%
chlorhexidine in plaque reduction and found that
the results were comparable. The possible role of
betel in plaque reduction is due to Hydroxychavicol
which shows showed potent anti-inflammatory
activity by significantly inhibiting the expression of
the proinflammatory cytokine TNF-α. Additionally,
it was found that hydroxychavicol showed
significant antioxidant activity, measured in terms
of the inhibition of lipid peroxidation.
Hydroxychavicol not only exhibited an inhibitory
effect on the formation of biofilms by S. mutans and
A.viscosus but also reduced the preformed biofilm
by these pathogens.[4]
CONCLUSION
Within the limitations of the study it was
concluded that there was no statistically significant
difference between betel rinse and chlorhexidine
gluconate in plaque reduction and hence its use can
be explored as a cost effective alternative especially
in lower socioeconomic status population as an
effective home regimen for plaque control. The
shortcomings of the study were small sample size
and short duration of the study. More longitudinal
studies with larger sample size to test the efficacy of
betel rinses along with plaque microbial analysis
are warranted.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
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