Effect of Oil Pulling Using Extra Virgin Olive Oil on Plaque and Gingivitis Scores and Caries Activity Evaluated by Ora Test in Pediatric Dental Patients: An In Vivo Study

ABSTRACT

Aim

Oil pulling is well documented as an alternative therapy with many therapeutic benefits, both systemic and oral. Extra virgin olive oil (EVOO) has proved to be of much benefit because of its antioxidant effect and low caloric value. This study hypothesizes that olive oil can be used to reduce the caries activity in pediatric patients. The aim of the present study is to evaluate the effect of oil pulling using EVOO on plaque and gingivitis scores and caries activity evaluated by Ora test in pediatric dental patients.

Materials and methods

This is a prospective case−control study conducted on 20 children aged 6–12 years where olive oil was taken as the study group and chlorhexidine as the positive control group. Children were randomly selected and allocated to two groups. The baseline examination of plaque and gingivitis scores was evaluated by a single trained examiner, and the Ora test was performed on the same day. After 1 month of using olive oil, a second examination and Ora test were performed. Data were subjected to statistical analysis.

Results

There was a significant mean reduction of 0.46 ± 0.09 in plaque scores and 0.26 ± 0.04 in gingivitis scores in olive oil group after 1 month. There was no statistically significant difference when mean reduction of plaque scores was compared between both the groups, but significant reduction was noticed in gingivitis group (0.26 ± 0.04). There was a significant and comparable reduction of caries activity in both the groups after 1 month. Olive oil showed increased caries activity reduction compared to chlorhexidine.

Interpretation and conclusions

Both the groups showed substantial benefit of reduction in plaque scores and gingivitis scores after 1 month. Olive oil seems to have comparable results to chlorhexidine and also showed additional therapeutic benefit on gingival inflammation and reduction in caries activity.

Clinical significance

Olive oil in the form of oil pulling can be effectively used as a natural alternative to counteract poor oral hygiene status and high caries activity in pediatric dental patients.

How to cite this article

Valasingam SK, Kanikaram PL, Archana V, et al. Effect of Oil Pulling Using Extra Virgin Olive Oil on Plaque and Gingivitis Scores and Caries Activity Evaluated by Ora Test in Pediatric Dental Patients: An In Vivo Study. Int J Clin Pediatr Dent 2025;18(6):666–670.

INTRODUCTION

Dental caries and periodontal diseases are the most common oral health issues, which have a significant impact on the general well-being of the patient. Prevention is now the primary focus in dentistry rather than restoring carious lesions. Dental caries can be prevented by identifying the potential risk factors in a timely manner. Adequate plaque control and maintaining good oral hygiene are essential for achieving optimal oral health and preventing dental caries.¹

Plaque is the main cause of various oral diseases, such as caries and periodontal abnormalities. Proper plaque control using both mechanical and chemical methods is crucial for maintaining oral hygiene and preventing these diseases.² Chemical plaque control, in the form of mouth rinses, is used alongside mechanical control to achieve good oral hygiene goals.² Compounds such as chlorhexidine and betadine can have side effects such as dysgeusia and discoloration of teeth due to prolonged use.³ Traditional and natural compounds are being sought and investigated for use in medicine recently, which have fewer side effects and disadvantages, leading to development of a new branch called alternative medicine.⁴ Different methods for controlling plaque were tried, among which oil pulling is a remedy that can have a significant effect both topically and systemically.⁵

Oil pulling is a traditional practice that involves swishing oil in the mouth for topical and systemic health benefits. Charaka Samhita, an Ayurvedic text, reported its efficacy in curing various diseases, including headaches, migraines, diabetes, and asthma.⁶ Propelling oil with the tongue between teeth leads to interdental cleansing. Sunflower, sesame, and coconut oils are very effective.⁶ Coconut oil is a popular choice due to its medium-chain fatty acids such as lauric acid, which has antibiotic and anti-inflammatory properties. It has also been studied for its antiplaque effect and has shown benefits in multiple studies.⁷ Although economical and easily available, some people hesitate to use this oil for oral consumption as it is not commonly used. Thus, there is a search for alternative edible oils. Olive oil, on the contrary, is popular in many parts of the world for its health benefits.⁸

Olive oil is rich in antioxidants and vitamins and is often used in the Mediterranean diet. It has been found to reduce the risk of inflammatory diseases such as cardiovascular disease.⁸ Lipoxins are natural molecules derived from fatty acids such as olive oil that reduce proinflammatory mediators and modulate the host response to promote resolution of inflammation in the presence of periodontal pathogens.⁹

Extra virgin olive oil (EVOO) can encourage healing and modulate macrophage activity by directing polymorphonuclear leukocytes to inflamed sites.¹⁰ Olive oil contains polyphenols that act as antioxidants, delaying the oxidation of fatty acids and extending the shelf life and quality of the oil. Hydroxytyrosol, a polyphenol found in olives, has been certified by the European Food Safety Authority (EFSA) as a substance that protects blood lipids from oxidative stress.⁹ EVOO in recommended doses improves pancreatic beta cells, insulin secretion, and glycemic control in type 2 diabetes patients.¹¹ Hence, in this study, we used EVOO as an oil pulling natural substitute to determine its potential topical effects on reducing plaque and caries activity in patients.

Plaque impacts patients' caries activity. Tests to evaluate this are mostly microbiological, needing laboratory support.¹² Ora test is an easy and reliable chairside test to evaluate caries activity in patients. It involves rinsing the mouth with sterile milk, which is nontoxic and ideal for displacing microorganisms. The test has good sensitivity and specificity and is well-accepted by most children.¹³ The chairside test is a diagnostic tool for dentists that can also help with motivation, plaque control, and managing child behavior.¹⁴ The present study hypothesized that olive oil has therapeutic benefits when used topically in oil pulling.

MATERIALS AND METHODS

This study was conducted on 20 children aged between 6 and 12 years who attended the outpatient department (OPD) and were capable of oil pulling. Children were randomly selected and assigned into two groups. Group I used olive oil for oil pulling, while Group II used chlorhexidine. Exclusion criteria: Children with medical conditions, physical or cognitive impairments, muscle weakness, those taking medication, and those without parental permission were excluded. Parents were informed and consent was obtained. A standardized form was used to record plaque scores, gingivitis scores, and Ora test results.

Armamentarium

• Sets of mouth mirrors.

• Probes—Williams periodontal probe, dental explorer.

• Examination light.

• Sets of gloves and mouth masks.

• Specially designed proforma.

• Ora test: Test tubes, methylene blue dye, pasteurized milk, micropipette, beaker, test tube stand, and mirror bottom.

Dental examination was done on a reclined chair with artificial light. A single trained assistant recorded the plaque and gingivitis scores using the Löe and Silness Gingival index (1963)⁸ and Silness and Löe Plaque index (1964)⁸ on a specially designed proforma, followed by Ora test in the department. Children were given 8–10 mL of pasteurized cow milk to rinse their mouth for 60 seconds and then spit it into another beaker. Three milliliters of expectorate was collected using a micropipette and added to a sterile plastic test tube to which 0.125 mL of 0.1% methylene blue was added and mixed well. The test tube was placed on a stand with a mirror glass bottom in a well-lit area at room temperature. The tube was monitored every 10 minutes for any color change at the bottom. The time taken for color change within a 6 mm diameter circle on the bottom of the test tube was recorded on the data sheet. The child was advised to do oil pulling for 5–10 minutes every morning and night. A second evaluation and Ora test were scheduled after a month. After a month, the child was reexamined, and the data were recorded in MS Excel format for statistical analysis. Toothbrushes and toothpaste were provided to standardize the study process.

Statistical Analysis

Student's t-test was used for evaluation of change in mean reduction of plaque and gingival scores and Ora test results. p < 0.01 is considered a significant result.

RESULTS

Table 1 shows the reduction in plaque scores and gingivitis scores after the use of olive oil and chlorhexidine after 1 month. There is a mean reduction of 0.46 ± 0.08 in plaque scores and 0.11 ± 0.03 in gingivitis scores in the chlorhexidine group after 1 month, which was statistically significant (p < 0.001). There is a mean reduction of 0.46 ± 0.09 in plaque scores and 0.26 ± 0.04 in gingivitis scores in the olive oil group after 1 month, which was also statistically significant (p < 0.001).

Table 1:

Comparison of plaque and gingivitis scores before and after use of chlorhexidine and olive oil

	Sample	Mean plaque scores before	Mean plaque scores after	Mean reduction	T	Standard error of difference	p-value
Chlorhex idine group, N=10	Plaque scores	0.99 ± 0.45	0.52 ± 0.25	0.46 ± 0.08	4.90	0.09	0.0008
	Gingival scores	0.42 ± 0.10	0.30 ± 0.05	0.11 ± 0.03	3.02	0.03	0.01
Olive oil group, N=10	Plaque scores	1.06 ± 0.32	0.59 ± 0.28	0.46 ± 0.09	4.76	0.098	0.001
	Gingival scores	0.66 ± 0.17	0.39 ± 0.14	0.26 ± 0.04	5.57	0.04	0.0003

Table 2 shows the comparison of mean reduction of plaque and gingivitis scores between chlorhexidine and olive oil groups. There was no statistically significant difference when plaque scores were compared between both the groups. The mean reduction was almost same in both the groups. There was a statistically significant difference in gingivitis scores between olive oil and chlorhexidine groups. Olive oil seems to have more reduction in gingival scores compared to chlorhexidine (p < 0.001).

Table 2:

Comparison of mean reduction in plaque scores and gingivitis scores between olive oil and chlorhexidine

	Sample	Mean reduction	T	Standard error of difference	p-value
Plaque scores	Olive oil	0.46 ± 0.09	0.0000	0.038	1.00
	Chlorhexidine	0.46 ± 0.08
Gingivitis scores	Olive oil	0.26 ± 0.04	8.9	0.016	0.0001
	Chlorhexidine	0.118 ± 0.03

Table 3 shows the comparison of Ora test scores before and after the use of olive oil and chlorhexidine. Both the groups showed reduction in caries activity. Olive oil group showed 38.4 ± 6.07 marked effect of reduced caries activity compared to olive oil group (−18.8 ± 4.09). It was a statistically significant difference (p < 0.001).

Table 3:

Comparison of Ora test scores before and after use of olive oil and chlorhexidine

Sample	Mean Ora test scores before use	Mean Ora test scores after use	Mean reduction	T	Standard error of difference	p-value
Olive oil	98.8 ± 9.3	137.2 ± 14.1	−38.4 ± 6.07	6.32	6.07	0.0001
Chlorhexidine	115.1 ± 25.4	133.9 ± 25.5	−18.8 ± 4.09	4.52	4.09	0.001

Table 4 shows comparison of mean reduction in Ora test scores (in perspective of increased time) between olive oil and chlorhexidine, showing olive oil has increased effect compared to chlorhexidine. It was a statistically significant difference (p < 0.001).

Table 4:

Comparison of mean reduction in Ora test scores between olive oil and chlorhexidine

Sample	Mean reduction	T	Standard error of difference	p-value
Olive oil	−38.4 ± 6.07	8.4	2.315	0.0001
Chlorhexidine	−18.8 ± 4.09

DISCUSSION

Oil pulling is a natural remedy and can be a better substitute than chemical plaque control agents such as chlorhexidine, Listerine, or any alcohol-based rinsing agent owing to its substantial benefits both topically and systemically.⁵ A randomized controlled trial on 40 subjects for 2 weeks comparing the beneficial effect of sesame oil pulling to chlorhexidine proved sesame oil as an effective plaque control agent compared to chlorhexidine. Even though chlorhexidine has similar benefit in plaque control, it has the disadvantage of staining and altered taste sensation. Hence, the authors advocated sesame oil pulling as an alternative medicine without any disadvantages or complications. The result of the present study is concomitant with the earlier study showing comparable result of olive oil pulling on oral hygiene status compared to chlorhexidine.¹⁷ In a similar study done by Anand et al. in 2008 on exclusive bacterial count in plaque samples of patients using sesame oil as an oil pulling strategy adjuvant to mechanical plaque control, it was observed that there is a 20% reduction in bacterial count upon 40 days of oil pulling use. Both the above studies prove that organic oils such as sesame oil own good antimicrobial activity against common pathogens in the dental plaque such as Streptococcus mutans and Lactobacillus acidophilus. Reduced bacterial count is a direct evidence on reduced caries activity of the patient.¹⁸

A comparative study done by Jauhari et al. on 52 healthy children aged 6–12 years comparing the antibacterial activity of sesame oil pulling for 2 weeks to herbal and fluoridated mouth rinses showed insignificant results. Caries activity of the patients before and after the intervention was evaluated using Ora test and Dentocult SM kit. The authors concluded that the result may probably be due to the fact that oil pulling requires a minimum of 4 weeks of continuous use to show its beneficial effect. Hence, in our study, we advised the patients to use the olive oil for a minimum of 4 weeks to have its beneficial effect evaluated.¹⁹

Other organic oils such as coconut oil are also extensively reported in the literature for their beneficial effects when used as oil pulling materials. A systematic review of 4 randomized controlled trials done on 182 subjects on coconut oil used as oil pulling for 7–14 days revealed that coconut oil is helpful in reducing bacterial count and plaque scores and has the added advantage of minimizing any stains which can appear on prolonged use of chemical plaque control agents such as chlorhexidine.⁷ Similar study done by Peedikayil et al. involving 60 adolescents of age 16–18 years observed a statistically significant reduction of plaque and gingival scores upon oil pulling using coconut oil. The authors concluded that the therapeutic benefit of oil pulling is visualized only after 7 days of the intervention and is significant after 30 days or 4 weeks. This study observed 50% reduction in oral hygiene indices after 4 weeks of use which is comparatively similar to results produced by chlorhexidine. The above studies showed that oil pulling is more effective on gingivitis scores when used for a minimum of 4 weeks. Gingivitis score evaluation after the intervention is more sensitive way to know the effect of oil pulling than plaque scores because it gives the result of cumulative effect of the intervention. Plaque scores depend on the mechanical plaque control practiced on the day, and they are susceptible to bias depending on the brushing technique and other variables such as time of brushing, interdental cleansing, and toothpaste used. Hence, in our study, we advocated the use of olive oil for 4 weeks, which showed a significant effect on gingivitis scores compared to plaque scores. This effect can be due to the anti-inflammatory and host modulatory effect on gingiva by olive oil.²⁰

Asokan et al. in 2008 compared oil pulling using sesame oil and chlorhexidine mouthwash method in 20 adolescent subjects for 2 weeks and reported there was a statistically significant reduction in the S. mutans count in the plaque samples of sesame oil pulling group. However, this study noted that the reduction in S. mutans count is more in chlorhexidine group than oil pulling group. Evaluating only S. mutans levels can be attributed as a limitation of this study as S. mutans is not the only bacterium responsible for caries activity of the patient. There are other factors such as other species of bacteria, host-related, salivary-related, and diet-related factors that can influence the result of the study. Hence, evaluating the caries activity of the patient, which takes into consideration other factors as well, may be the best way to do so. Hence, in our study, we used Ora test as a way to evaluate the activity of the patient holistically. In our study, plaque scores reduced similar to chlorhexidine group compared to oil pulling group, showing equal effect and significant reduction in caries activity of the patient.²¹

A randomized controlled trial done by Dani et al. evaluating the antiplaque effect of sesame oil pulling on plaque-induced gingivitis in 40 subjects showed promising results similar to our study. Plaque index scores, gingival index scores, and total colony counts of aerobic bacteria were reduced significantly in oil pulling group after 14 days. They concluded that sesame oil was found to be as effective as chlorhexidine against plaque-induced gingivitis. This result is concomitant with our study where olive oil has significant effect on plaque-induced gingivitis when used for 4 weeks. This result exceeded chlorhexidine group as well.¹⁷ In another randomized controlled triple-blind study involving 20 age-matched subjects, the effect of sesame oil pulling on plaque-induced gingivitis and its efficiency was compared to 0.12% chlorhexidine mouthwash for a period of 10 days. This study found statistically significant reduction in postintervention values of the plaque and modified gingival index scores in both groups. Reductions in the total count of aerobic microorganisms were detected in both groups. Hence, it can be concluded that oil pulling with organic oils such as sesame and coconut oil can affect the oral hygiene levels of the patient and have a profound effect on gingival inflammation levels. The result of our study is also in line with the above studies.⁶

Similar study done by Kandaswamy et al. to evaluate the effectiveness of a probiotic mouthwash, sesame oil pulling therapy, and chlorhexidine-based mouthwash on plaque accumulation and gingival inflammation in school children aged 10–12 years showed significant reduction in plaque and gingivitis scores. But there was not much difference in between olive oil and chlorhexidine, showing comparable results. They showed that probiotic mouthwash, chlorhexidine mouthwash, and sesame oil were equally effective in reducing plaque and in improving the gingival status of children. There was a profound difference in scores between 15 and 30 days, showing good results after use for 30 days. Hence, in our study, the participants were instructed to use the intervention for 30 days and proved to be effective.²²

Hence, all the studies show substantial evidence that oil pulling definitely affects the plaque and gingivitis scores and has comparable results compared to chlorhexidine and other rinses. Our study also showed similar results with comparable reduction of plaque scores when olive oil was used. Even though it was not a significant difference, olive oil can be used as an adjuvant and a natural alternative to other chemical plaque control agents. There was a significant reduction of gingivitis scores when olive oil was used, correlating the host modulating properties on gingival inflammation of the gingiva.

Zumbo et al. evaluated the effectiveness of EVOO on treatment of plaque-induced gingivitis. EVOO was used in the form of mouthwash to patients with gingival inflammation in the form of daily application for 30 days, with three recalls 15 days apart. Mean plaque scores reduced by 48%, and the bleeding index showed a 64% reduction after 30 days of use. The authors did not conclude the mechanism by which the gingival inflammation was reduced. Similarly, in our study, the gingival scores reduced drastically compared to chlorhexidine group, correlating to the above study showing that olive oil either in the form mouthwash or oil pulling has a profound effect on gingivitis scores. It has demonstrable antibacterial and anti-inflammatory effects on the gingiva and host immune modulatory effect.⁸

Wiegand et al. in 2007 evaluated the beneficial effect of olive oil on enamel as well. Olive oil offered protection against enamel and dentin erosion when applied as 2% emulsion or 2% olive oil containing mouth rinse, but is not effective when applied as pure oil (100%). The above study proved that olive oil has both soft tissue and hard tissue advantages compared to chemical compounds.²³ EVOO in ozonated form showed enhanced antimicrobial property against S. mutans, suggesting that ozonized olive oil can inactivate S. mutans quite easily.²⁴

Singla in 2014 used olive oil as a gum massaging agent and evaluated its effect on common plaque pathogens such as S. mutans and Lactobacillus species. Oil gum massage therapy (massage of gingival tissues) was advocated in 32 subjects every day once daily for 3 weeks with sesame oil, olive oil, and coconut oil. It was reported that there was a significant reduction in mean S. mutans count, Lactobacillus count, plaque scores, and gingival scores in all four groups after 30 days. However, there was no significant difference found in percentage reduction of these variables between the four groups. These results are quite similar to our study, where olive oil demonstrated equal plaque reducing and significantly more gingivitis reducing capability compared with chlorhexidine.²⁵

Combinations of olive oil were also tested in many studies. Olive oil enriched with lycopene was successfully used to treat burning mouth syndrome patients. This study was done to evaluate the effect of lycopene-enriched virgin olive oil to treat inflammatory mucosal conditions. They concluded that lycopene-enriched virgin olive oil is a very safe and an effective similar way for treating patients with burning mouth syndrome. This study also supports the phenomenon that olive oil has more therapeutic benefit on soft tissue as proved in our study.²⁶

Another study showing the soft tissue effect of olive oil was done on oral mucositis patients under chemotherapy. This randomized control trial was done on 36 children between 6 and 9 years suffering from grades III or IV oral mucositis. Aloe vera, olive oil, or sodium bicarbonate were tested. They concluded that both aloe vera and olive oil showed significant differences in the management of chemotherapy-induced oral mucositis compared to sodium bicarbonate treatments.²⁷ Olive oil has antifungal and antibacterial properties as well. Another study used olive oil as denture adhesive in a multicenter randomized and placebo-controlled clinical trial. The experimental adhesive with olive oil showed longer effectiveness with a better inhibition capacity for the growth of Candida albicans.²⁸ All the above studies prove that EVOO has a potential benefit on soft tissues of the oral cavity when used in the form of gum massage or topical application, reducing the inflammation or modulating the host defense mechanism in a beneficial way. Our study proved the same, showing significant reduction in gingivitis scores compared to chlorhexidine.

CONCLUSION

In view of the present study, the following conclusions can be made:

• On comparison of plaque and gingivitis scores after intervention, it is proved that both olive oil and chlorhexidine are effective in reducing the oral hygiene scores and caries activity of the patients.

• On comparison of mean reduction in plaque scores between olive oil and chlorhexidine group, there was no significant difference between the groups, showing olive oil having comparable effect on plaque scores as that of chlorhexidine.

• On comparison of mean reduction in gingivitis scores between olive oil and chlorhexidine group, there was a significant difference between the groups. Olive oil group showed significant reduction of gingivitis scores compared to chlorhexidine.

• On comparison of caries activity of the patient before and after intervention, it is proved that both olive oil and chlorhexidine are effective in reducing the overall caries activity of the patients.

• On comparison of mean reduction in Ora test scores (caries activity) between olive oil and chlorhexidine group, there was a significant difference between the groups. Olive oil group showed significant reduction of Ora test scores (caries activity) compared to chlorhexidine.

Implications and New Aspects of the Study

• The present study proves that olive oil is a natural, holistic, and alternative remedy that can be used to improve oral hygiene of the pediatric patient and also has the profound effect of reducing the caries activity of the patient. Further studies are warranted in this area to find out the mechanism by which olive oil is affecting the caries activity of the patient.

• Limitations of the study may be the small sample size taken in this study.