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. 2017 Jan-Mar;16(1):6–12. doi: 10.4103/aam.aam_43_16

“Nature Cures:” An Alternative Herbal Formulation as a Denture Cleanser

R Sushma 1,✉, Tanuja Tanaji Sathe 1, Anand Farias 1, Pronob Kumar Sanyal 1, Shashi Kiran 2
PMCID: PMC5452698  PMID: 28300045

Abstract

Background:

Candida albicans is one of the microorganisms which harbor the oral cavity, especially in elderly. However, the incidence of existence of this increases in patients using removable dental prosthesis. There is therefore a need to test the anticandidal efficacy of these cost-effective, easily available products to be used as routine denture cleansers.

Aim and Objectives:

(1) To evaluate antifungal properties of triphala churna on the heat cure denture base material. (2) To evaluate the antifungal effect of chlorhexidine gluconate on the heat cure denture base material. (3) To compare the antifungal effect of triphala churna and chlorhexidine gluconate with a control. (4) To evaluate which among triphala churna and chlorhexidine gluconate has a better antifungal property on the heat cure denture base material.

Materials and Methods:

Study population consisted of sixty dentures wearers from those attending the Outpatient Department of Prosthodontics of the School of Dentistry, Krishna Institute of Medical Sciences Deemed University, Karad. Swabs were collected from the dentures before and after the use of triphala and chlorhexidine. The swabs were cultured on Sabouraud dextrose agar and the total Candida counts were determined.

Conclusion:

Triphala as an antifungal is shown to have more efficacy than the conventional chlorhexidine mouthwash.

Keywords: Candida, chlorhexidine, triphala churna, Candida, chlorexidine, triphala churna

Introduction

In India, the size of the elderly population age about 60 years and above is on the rise. This poses various problems such as socioeconomic front, health-care expenditures, and medical and psychological.[1] With this, India is becoming an aging society. However, about 75% of the elderly stay in rural areas.[2] Inadequate income is a major problem of elderly in India; another distressing fact is that elderly people are dependent on others for their living.[1] As the size of the dependent elderly population is fast growing, there is an emerging need to pay greater attention to aging-related oral health issues.

Among the elderly in the age group between 65 and 74 years, about 10.2% of the population had prosthesis in the upper arch and 11.1% of them had prosthesis on the lower arch and the use of complete denture was prevalent.[3] Candida-associated denture stomatitis is a common inflammatory process affecting around 60%–65% of denture wearers and is usually found on the palatal mucosa beneath the fitting surface of the upper denture. It has multifactorial etiology, but poor denture hygiene habit is one of the most prominent contributing factors.[4] Denture cleansing is an important aspect of denture maintenance for the maintenance of oral health. There are various commercial products available in the market. However, the rural and dependent elderly have minimum access to these. Hence, there is a need to for an alternative antimicrobial which is readily available in the rural setup.

Triphala is a tridoshic herbal formulation consisting of fruits of Terminalia bellirica (TB), Terminalia chebula (TC), and Emblica officinalis (EO) in a 1:1:1 ratio known for their medicinal properties being traditionally used in India as therapeutic and antimicrobial aids in various ailments and being potent antifungal products effective against Candida.[5]

Chlorhexidine is a gold standard against which other antimicrobials are tested. It is a cationic chlorophenyl bisbiguanide that binds to negatively charged surfaces. It has a broad spectrum of antimicrobial activity including Candida albicans. It is a biocide used extensively as a topical antiseptic in hospitals and for the treatment of periodontal diseases. Chlorhexidine has a broad spectrum of activity against a variety of organisms, including C. albicans. Susceptibility of C. albicans biofilms to chlorhexidine was shown to be significantly reduced compared to its action against suspended organisms.[6]

Hence, the objective of this study was to compare the anticandidal efficacy of triphala churna and 0.2% chlorhexidine on randomly selected complete denture wearers.

Materials and Methods

This study was conducted on a random sample of sixty dentures wearers who were selected among the patients visiting the Department of Prosthodontics of the School of Dentistry, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra. Ethical clearance was obtained from the University's Ethical Committee. All patients were informed about the study procedure in their mother tongue and made aware of the experimental design. Their written informed consent was taken before they enrolled in the study.

Inclusion criteria

  1. Volunteers consenting to participate in the study and those who have a complete heat polymerized acrylic dentures.

Exclusion criteria

  1. Partially dentate patient who had existing fixed partial dentures

  2. Patients with existing removable partial dentures

  3. Patients seeking or with existing implant dental prosthesis

  4. Patients seeking or with existing maxillofacial prosthesis

  5. Patients who have used a denture cleanser at least 2 weeks before enrolment in the study

  6. Patients already on antifungal agents or antiseptic mouthwashes

  7. Patients with denture stomatitis.

The total sample size was divided into two groups using a simple randomization method:

  1. Group I: Thirty patients who were asked clean the denture using cotton soaked in chlorhexidine (0.2%) (Hexidine, ICPA Health Products Ltd., Gujarat, India). Mouthwash by rubbing the material over all the surfaces of the denture and then dip in water

  2. Group II: Thirty patients who were asked to clean the denture by scrubbing the triphala churna (triphala churna, Dabur India Ltd, New Delhi, India) using fingers gently over the intaglio and outer surface of the dentures and then dipping the denture in water.

A baseline swab was taken at the first visit from the dentures of patients in both experimental groups and subjected to microbial analysis to establish a baseline for the number of Candida colonies as outlined below in the section on microbial analysis.

Patients in both groups were then instructed to clean their dentures, following the instructions given to them for 30 days and report back to the department on the 31st day for sample collection.

Microbial analysis of the dentures

Swab samples were taken from experimental Groups I and II. Swab samples were taken by rolling sterile cotton swabs across the tissue surface of the upper and lower dentures [Figure 1]. The swabs were placed in a test tube which was covered with a cotton plug [Figure 2]. Then, using a 4-mm loop, the swab sample was immediately smeared onto the surface of culture plate with Sabouraud dextrose agar (SDA) (with 10% chloramphenicol). All plates were aerobically incubated at 37°C for 72 h. Culture plates which were negative for candidal growth were left on the bench for further 72 h and then examined again before being discarded as negative.

Figure 1.

Figure 1

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Materials for sample collection - Test tube and swab stick

Figure 2.

Figure 2

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Sample collection from intaglio surface of dentures

The colonies were identified as follows:

  1. Colony morphology:

    1. SDA medium: The candidal colonies appear as cream, paste, and smooth colonies [Figure 3a and b]
    2. On Gram staining: They appear as Gram-positive oval yeast-like budding cells [Figure 4a and b]
    3. Germ tube test: Germ tube formation was seen under microscope in the case of C. albicans [Figure 5].

  2. Number of colonies: Number of Candida colonies was determined by counting colony forming units on SDA plates. The difference in the number of colony forming units of microorganisms between first swab (baseline before use of cleanser) and second swab (after use of cleanser) was noted to assess the effectiveness of cleansers in reducing the total Candida count.

Figure 3.

Figure 3

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(a and b) Candidal growth on Sabouraud dextrose agar plate (streaking method)

Figure 4.

Figure 4

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(a and b) Positive Gram staining showing budding of candidal species

Figure 5.

Figure 5

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Germ tube test showing Candida albicans

Results

A total of sixty denture wearers participated in the study, of which 30 N belonged to Group I (22 N [73.33%] males and 8 [26.67%] N females) were instructed to use chlorhexidine and the remaining thirty belonged to Group II (21 [70%] males and 9 [30%] females) were instructed to use triphala churna [Figures 6 and 7 and Table 1].

Figure 6.

Figure 6

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Sex-wise distribution of patients using chlorhexidine gluconate

Figure 7.

Figure 7

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Sex-wise distribution of patients using triphala churna

Table 1.

Gender distribution details of the study participants

Sex Chlorhexidine gluconate (Group I) number(%) Triphala churna (Group II) number(%)
Males 22 (73.33) 21 (70)
Females 08 (26.67) 09 (30)
Total 30 30
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Table 2 and Figure 8 show the age distribution of the study participants. The study participants were divided into five groups; ≥55, 56–60, 61–65, 66–70, ≥71. According to Kuppuswamy scale of socioeconomic status of the study participants, Table 3 shows that there were 21 (70%) patients in upper lower class in Group I and 23 (76.7%) patients belonged to the same from Group II. About 6 (20%) and 5 (16.7%) patients were in lower middle class for Groups I and II, respectively. Only 3 (10%) and 2 (6.7%) were in upper middle class for Groups I and II, respectively [Figure 9].

Table 2.

Age distribution of the study participants

Age group (in years) No %
≤55 4 6.7
56-60 13 21.7
61-65 20 33.3
66-70 15 25.0
≥71 8 13.3
Total 60 100
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Figure 8.

Figure 8

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Age-wise distribution of patients using chlorhexidine gluconate and triphala churna

Table 3.

Socio economic status of the study participants

Socio economic class Chlorhexidine gluconate (Group I) No. (%) Triphala churna (Group II) No. (%)
Lower 0 (0) 0 (0)
Upper Lower 21 (70) 23 (76.7)
Lower Middle 6 (20) 5 (16.7)
Upper Middle 3 (10) 2 (6.7)
Upper 0 (0) 0 (0)
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Figure 9.

Figure 9

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Socioeconomic class-wise distribution of patients using chlorhexidine gluconate and triphala churna

Table 4 shows the mean of Candida colony count of Group I before providing denture cleanser was 623.30 ± 315.45. After using medicine, it decreased to mean 424.96 ± 283.19. The paired t-test was used to test the significant difference between before and after using denture cleanser. It was found that there was significant decrease in Candida after having chlorhexidine gluconate (P = 0.00) [Figure 10].

Table 4.

Comparison of mean of candidal count before and after the use of both the denture cleansers

Denture cleansers Chlorhexidine gluconate (0.2%) Triphala churna Comparison
Before use After use Before use After use
Mean 623.30 424.96 664.00 379.37
Std. Dev. 315.45 283.19 355.24 246.62
Confidence interval 505.53-741.08 319.20-530.67 531.37-796.63 287.29-471.44
T statistic 3.64 7.22 0.66
P value 0.00 0.00 0.50
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Figure 10.

Figure 10

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Candida colony count wise distribution of patients using chlorhexidine gluconate before and after treatment

The mean of Candida colony count of Group II before providing medicinal herb (triphala churna) was 664 ± 355.24. After using medicine, it decreased to mean 379.37 ± 246.62. The paired t-test was used to test the significant difference between before and after having medicinal herb (triphala churna). It was found that there was significant decrease in Candida after having triphala churna (P = 0.00) [Figure 11]. The unpaired t-test was done to find out the significant difference between the antifungal effect of chlorhexidine gluconate and triphala churna. It was found that there was no significant difference between the two medicines (P = 0.50), which means that the two medicinal herbs are equally efficient.

Figure 11.

Figure 11

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Candida colony count-wise distribution of patients using triphala churna before and after treatment

The mean Candida colony count in patients having triphala churna was slightly lower than patients using chlorhexidine gluconate [Figure 12a and b].

Figure 12.

Figure 12

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(a and b) comparison of Candida colony count-wise distribution of patients using chlorhexidine gluconate and triphala churna before and after treatment

Discussion

Dental prosthesis is defined as an artificial replacement of one or more teeth and associated dental/alveolar structures.[7] The care and maintenance of the removable dental prosthesis are of utmost importance. If the proper home care protocol of the prosthesis is not followed on, serious health issues could result. There are various denture cleansers available in the market, of which chlorhexidine is marked as the gold standard.[6] Chemical cleansers may be defined as alkaline hypochlorites, alkaline peroxides, and dilute acids.[8] In various studies, many commercially available antimicrobials have been tested for its efficacy on Candida[9,10,11,12,13] and chlorhexidine is considered to be the “gold standard” antiplaque mouth rinses due to their prolonged broad-spectrum antimicrobial activity and plaque inhibitory potential.[6,10] However, chlorhexidine is known to produce brown discoloration of the teeth, restoration, and dorsum of tongue.[14,15]

Ayurveda is a medicinal science that has helped the humankind cure their ailments since time immemorial. The pharmacopoeias of many countries include a large number of drugs of plant origin. As the times are changing and like every aspect of life, even the health care system has also seen tremendous changes. However, Ayurveda is one such field which has stood the test of time. Even today, this particular field of medicine plays an important role in curing the oral diseases.[16,17,18,19] It has been reported in a number of in vitro studies that the herbals that are used to cure infectious diseases have wide antimicrobial spectrum.[20,21,22,23,24] However, in the light of today's world, lack of standardization and quality control are the major drawbacks that this form of medicine is facing however that about 80% of the population residing in the developing countries still has faith in this form of naturopathy.[25]

Every surface in the oral cavity, natural or synthetic, becomes covered within about 30 min with a 0.5–1.5 µ-thick precipitate of salivary glycoprotein and immunoglobulin that is termed “pellicle.”[26,27,28] The pellicle in turn provides a substrate to which oral debris (such as mucin, food particles, and desquamated epithelial cells) and microorganisms (bacteria and fungi) readily adhere.[29] This becomes even more important in patients wearing complete or partial removable dental prosthesis as the surface of the dental prosthesis provides a conducive atmosphere for the microorganisms to “house in,” of special consideration being the Candida harbor in the oral cavity. Candida is an important oral pathogen which can grow both on the hard and soft tissues. It forms complex biofilms which are aided by the surface texture of the denture base.[4] Radford et al.[30] described C. albicans as an asexual diploid fungus, which is yeast like with a unicellular method of growth and development.[30] Many studies have been done relating the surface texture of the denture base materials and the candidal growth.[31,32,33] High percentage of denture wearers are predisposed to the denture stomatitis.[34] Denture wearing is a predisposing factor for oral colonization by Candida and its prevalence can increase from 60% to 100%.[35]

Triphala is a tridoshic herbal formulation consisting of fruits of TB, TC, and EO in a 1:1:1 ratio.[5] This formulation is shown to have various medicinal properties which promote health, longevity of life when used in a proper manner. It is also shown to have anti-inflammatory, antioxidant, and antimicrobial properties (because of the gallic acid content), and is a known to be Hepatoprotective in nature.[36,37,38,39] It corrects constipation thus helping to improve digestion.[36] It can be ingested over a long period of time without any side effects. The phenolic and nonphenolic composition of triphala are active against both pathogenic and nonpathogenic bacterial strains;[40,41] when used as mouth wash, it effectively reduced the number of mutant streptococci in saliva.[42]

Various studies have been done to evaluate the antifungal property of triphala.[43,44,45,46] The present study was done to check the efficacy and ayurvedic composition against Candida on denture wearers. The results of this are in direct agreement with another study done by. Gautam et al.,[47] who through their study described that triphala had good antifungal potential. In a similar study done by Bajaj and Tandon,[48] they reported strong antifungal activity of triphala. Apoorva et al.[49] through their study suggested that triphala was effective against gingivitis. In the present study, majority were male population educating who would be easier compared to the rural female population, mean age of people was 64 years, and also, the majority belonged to the upper lower class showing the older age and low-income group, for whom acceptance of herbal composition is easier. Hence, in continuation and in agreement with the results of the other studies, the present study contributes to the fact that triphala has immense potential toward becoming a great denture cleanser as well a mouthwash. However, more studies are required to give a suitable concoction for its use as an antifungal mouthwash or a denture cleanser.

Conclusion

The results of the present study shows that among triphala churna and chlorhexidine gluconate, when used as a denture cleanser, triphala has a better antifungal property on the heat cure denture base material. Its availability in the rural setup, cost-effectiveness, and tremendous advantages makes this magical herb one of the best alternatives to the current antimicrobials that are being used. This study however has its limitations. The sample size used was small and the subjects were selected based on certain criteria that might limit the generalization of the results. It is doubtful whether patients strictly adhered to the set protocols although they were personally instructed to do so. More studies are required to evaluate the long-term effects of these natural-based products as denture cleansers. In the recent light of triphala emerging as an anticancer drug, it could be of some use in the oral cancer treatment, along with which triphala could also be breakthrough in terms of a mouthwash or a denture cleanser. Its easy availability and low cost make it a clear contender for this stake. In future, it can be rolled into the production of mouthwash which can be preserved for longer duration. For developing countries like India and many others worldwide where majority of the population is in the middle income range and elderly population is on the rise, this cost-effective and time-tested herb could prove as an effective mouthwash and a denture cleanser.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We would like to acknowledge the Department of Microbiology, Krishna Institute of Medical Sciences Deemed University, Karad, India.

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