Complementary Therapies in Clinical Practice 20 (2014) 93e98

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Clinical efficacy analysis of the mouth rinsing with pomegranate and

chamomile plant extracts in the gingival bleeding reduction
Ana Luzia Araújo Batista*, Ruthineia Diógenes Alves Uchôa Lins, Renata de Souza Coelho,
Danielle do Nascimento Barbosa, Nayara Moura Belém, Frayni Josley Alves Celestino
Paraíba State University, Department of Dentistry, Campina Grande, Paraíba, Brazil

a b s t r a c t
Keywords: Medicinal plants represent important therapeutic resources to health restoration, including the use of
Chlorhexidine herbal products in the mouth conditions treatment. A randomized controlled clinical trial was performed
Periodontal disease
in order to evaluate the effectiveness of mouth rinse with pomegranate and chamomile plant extracts,
Chamomile
Pomegranate
against chlorhexidine 0.12% in the gingiva bleeding condition. The mouth rinses with the herbal products
were effective for this case, showing thus, antimicrobial and anti-inflammatory properties similar to that
of chlorhexidine 0.12%.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction biofilm. Subsequently, the specific plaque hypothesis established

the role of some microorganisms such as Porphyromonas gingi-
Gingivitis, an inflammatory condition limited to the protection valis (Pg), Prevotella intermedia (Pi), Bacteroides forsythus (Bf),
periodontal tissue (marginal and attached gingiva), which is char- Agreggatibacter actinomycetemcomitans (Aa), Treponema denticola
acterized by redness, swelling and bleeding gingiva, and peri- (Td) and Fusubacterium nucleatum (Fn) in different forms of
odontitis, which also involves supporting periodontal tissues periodontal disease. Recently it was suggested that these peri-
(cementum, periodontal ligament and alveolar bone) especially odontal pathogens do not act alone and interactions between
characterized by the presence of periodontal pockets and alveolar species, as the balance between beneficial and pathogenic bac-
bone resorption, have as the primary etiologic agent dental biofilm teria, affect disease progression and tissue response to peri-
accumulation, resulting from poor oral hygiene [1,2]. odontal therapy. Nowadays it is well established that one of the
Biofilm is the determining factor for caries and periodontal goals of periodontal therapy is controlling these pathogens [6].
disease [3], representing a dense, non-calcified mass, composed Therefore, it is appropriate the use of dental biofilm control
of micro-organisms, being Streptococcus mitis and Streptococcus measures, being its removal an important factor for the peri-
sanguis the pioneers. They are involved in a matrix rich in odontal disease prevention and control.
bacterial extracellular polysaccharides and salivary glycoproteins, Brushing, a usual method of biofilm mechanical removal,
firmly attached to the teeth, stones and other hard surfaces of although practical sometimes becomes difficult, not allowing a
the oral cavity [4]. However, the pathogenesis of periodontal reasonable control since it requires time, motivation and manual
disease is determined not only by the accumulation of dental dexterity [4]. Thus, many patients have to call upon professional
biofilm, but also by the ratio of their pathogenic potential and practice to remove biofilm and of supra and under-gingival stones.
quality of immune response of the host organism [5], and other Thus, the procedures for scraping and root planing (SRP) may
factors such as the morphology of the gingival tissue, the pres- contain the progression of periodontal disease, providing
ence of different malocclusion types and factors related to tooth improvement of their clinical parameters such as reduction in
eruption [4]. probing depth and clinical attachment gain [7]. However, in some
Until the early ’70s, therapies based on the non-specific pla- cases, the SRP does not seem to be able to maintain periodontal
que hypothesis focused on reducing the amount of dental health, which can be explained by microorganisms’ recolonization.
Because of possible after-SRP recolonization of microorganisms,
it was proposed the non-surgical periodontal therapy, which con-
* Corresponding author. Rua José Branco Ribeiro, 840 apto 403-C, Bairro, Catolé sists in mouth cleaning and disinfection in a single stage, with the
CEP 58410-175, Campina Grande, Paraíba, Brazil. Tel.: þ55 3315 3326.
E-mail address: [email protected] (A.L.A. Batista).
root surface debridement concept, reducing the microbial load of

1744-3881/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctcp.2013.08.002
94 A.L.A. Batista et al. / Complementary Therapies in Clinical Practice 20 (2014) 93e98

the oral cavity in order to minimize the risk of reinfection of the medicinal importance, with different active ingredients and ther-
treated areas [8]. This treatment should promote the elimination apeutic indications [17]. For this reason, it is considered a great
and control of periodontal disease risk factors, such step is usually potential plant for preventing and fighting various diseases, with
performed with scraping and root planing per quadrant (SRP) or antioxidant, hypoglycemic, cholesterol reducer, antiviral, antipar-
sextant, with a one to two weeks break between sessions. However, asitic, antifungal and antidiarrhoeal properties, plus cancer pre-
the possibility of reinfection of treated sites by periodontal path- ventive, cell differentiation promoter, estrogen enhancer and even
ogens at sites not yet addressed, and even by pathogens present in antimicrobial (against Staphylococcus aureus and Salmonella typhi),
other intra-oral niches like tongue, saliva, oral mucosa and tonsils anti-inflammatory, healing and antiseptic for the large quantity of
have been the subject of much discussion and, on this basis, a new tannin in the fruit skin [12,14,17,18]. However, due to the presence
protocol was proposed, aiming at full mouth disinfection by of alkaloids in its composition, some precautions regarding
scrapíng and root planing in a short period of time [9]. poisoning should be considered since its use may produce nausea,
Due to the limitations of mechanical oral hygiene methods, dizziness and vision problems, and is contraindicated in pregnancy,
chemical control of dental biofilm acts as a supporting, through the lactation, children under 5 years, gastritis cases and gastroduodenal
use of antimicrobial agents in mouthwash, reducing the number of ulcer [19].
pathogenic microorganisms in the oral cavity and aiding in the Matricaria recutita Linn. (Chamomile) is a Europe and western
periodontal diseases prevention and treatment. However, in no Asia native plant and commonly used by northeastern Brazilian
case shall such antimicrobial agents replace the mechanical people. Belonging to the Asteraceae family and as a member of the
methods of oral hygiene [4]. daisy family, chamomile receives names such as: wild chamomile,
In order to obtain an antiplaque action, the antimicrobial Hungarian chamomile, pineapple weed (referring to the shape of
mouthwash agent should: reduce the bacterial adhesion to the the inflorescences), and scented mayweed. Chamomile is used
tooth surface, inhibit the growth and proliferation of microorgan- forever in popular culture and, therefore, represents one of the few
isms, inhibit the formation of the biofilm intercellular matrix, medicinal plants whose chemical constituents have been exten-
modify the bacterial biochemistry to reduce the cytotoxic products sively evaluated pharmacologically, including in clinical trials [20].
formation and modify the biofilm ecology to develop a less path- Chamomile is known to have a variety of active flavonoids, as
ogenic microbiota [4]. well as its volatile oil, which is rich in terpenoids, such as alpha-
Chlorhexidine is well characterized as an excellent antimicro- bisabolol, azulene, matricine and chamazulene. These compo-
bial agent used in the gingivitis treatment and prevention, and is nents provide the anti-inflammatory, antispasmodic and antibac-
also used as a reference in efficacy testing studies [10] and terial activity of the Chamomile [20].
considered the most effective chemical agent [11]. Although used Multiple therapeutic modalities have been tested and used over
in different formulas, in Brazil it is found in 0.12% and 0.20% time, with the purpose of fighting, inhibiting or reducing patho-
concentrations [4]. However, it presents local adverse effects when genic oral microbiota and, therefore, bleeding gingiva, with no real
used for prolonged periods [12], including: the teeth and resto- effectiveness to justify an indication to the general population [11].
rations staining, the tongue staining, the oral scaling and sensi- Therefore, the purpose of this study is to clinically evaluate the
tivity, and allergic reactions. The bitter taste and interference in effects of herbal mouthwash with extracts of chamomile and
the gustatory sense the solution caused some hours, after rinsing, pomegranate in reducing the gingival bleeding in periodontal dis-
have also been reported [13]. ease, comparing them with one another as well as with the chlor-
Given the adverse effects of chlorhexidine, one can see the need hexidine solution 0.12%.
to develop a substance with potent antimicrobial activity, capable
of interfering in the biofilm development and minimize side effects. 2. Method
In this context, there are natural agents that are effective and
economically viable alternatives [12], have wide popular accep- A comparative clinical study was performed, a randomized
tance, being used to fight diseases at low cost [14] and contribute to controlled trial, double blind, interventional, experimental, longi-
improving people’s access to prevention and treatment of peri- tudinal and prospective, with an inductive approach, all data being
odontal disease [4]. Lastly, the “Health for All” WHO strategy in the recorded in specific forms.
year of 2000, finally recognized the need to incorporate in the The universe of this study involves patients usually treated at
public health the principles, the resources and the techniques of the Department of Clinical Dentistry at the Paraíba State University
Natural Medicine, because beyond easing the sickness of millions of of Brazil. The sample is composed by individuals of both sexes, aged
people, it is a therapeutic alternative at virtually no cost [15]. over 18 years old, during October 2010 to June 2011 that after
So, medicinal plants represent important therapeutic resources clinical examination were diagnosed as having periodontal disease
for health restoration, including the use of herbal medicines for oral (gingivitis or chronic periodontitis), met the other criteria for in-
diseases treatment [4]. Among the natural substances used in clusion in the study (absence of periodontal treatment and anti-
dentistry, are noteworthy the Caesalpinia ferrea (“Jucá”), the Peru- biotics in the last three months) and were in accordance with the
vian mastic, ginger, basil, propolis, pomegranate and Cuban participation in it. We excluded patients with healthy perio-
oregano (Plectranthus amboinicus) that due to its therapeutic dontium, users of braces and patients with diseases or systemic
properties, have widespread use in folk medicine [12]. conditions with periodontal repercussions requiring antibiotic
The advantages of herbal medicine to justify its use are: the prophylaxis for the periodontal therapy completion as well as pa-
synergistic effect, due to its various phytochemicals that work best tients with diabetes mellitus, immunocompromised individuals,
in combination, the compounds interaction mechanisms that act on pregnant women, nursing mothers and drug users with peri-
different target molecules, providing diverse actions throughout odontal repercussions.
the body, the low risks of side effects due to low concentrations in Following the precepts of the CNS/MS 196/96 resolution which
which the active ingredients are present in the plants, and also the regulates the research ethics involving human subjects in Brazil, a
dose-time correlation and lower research costs, when comparing to total of 55 Brazilian adults with gingivitis [31] and chronic peri-
the development of a new drug [16]. odontitis [24] participated voluntarily in the study, in compliance
Punica granatum Linn. species, known as pomegranate, is a with the protocol (CAAE: 0076.0.133.000-10) approved by the
shrub of the Lythraceae family, and its parts have different Paraíba State University Ethics Committee.
 A.L.A. Batista et al. / Complementary Therapies in Clinical Practice 20 (2014) 93e98 95

The sample was randomly divided into three [3] groups e each Table 1
one of them containing individuals suffering from chronic gingivitis Sociodemographic profile of the studied population.

and perodontite e which showed equivalence in number, sex, and Variable N %

age of its components, divided as follows, according with the Total 55 100.0
mouthwash type used:  Age (years old)
Up to 29 25 45.5
➢ G1 (control group) e patients using chlorhexidine 0.12% solution 30 to 39 14 25.5
40 or over 16 29.1
mouthwash (n ¼ 18)
 Genre
➢ G2 e patients using chamomile extract mouthwash (n ¼ 19) Male 9 16.4
➢ G3 e patients using pomegranate extract mouthwash (n ¼ 18) Female 46 83.6
 Race
White 26 47.3
The ethanol extracts were prepared at the Pharmacy Depart-
Not White 29 52.7
ment Phytochemistry Laboratory, Paraíba State University. The
Pomegranate (Punica granatum L.) and Chamomile (Matricaria
recutita L.) specimens were purchased dried at Sao Paulo Flora reinforced. All data obtained from the second and third assess-
Santos Company (Brazil), reference in medicinal species sale, under ments were also recorded in the sheets drawn up for this work.
IBAMA registration No. 35867. The plant extracts were prepared We used the F (ANOVA) tests with Tukey comparisons, when the
with 100 g of herbal powder from each drug separately, and adding hypothesis of equal variances was verified; the Tamhane’s T2, when
900 g of ethanol 96%. The extraction begun by turbolysis, with a this hypothesis was rejected, the t-Student test with equal vari-
10 min shaking, divided into 5 min intervals, with a rest period of ances and t-Student with unequal variances. The verification of the
5 min between them. Then the material was packed in a container equal variances hypothesis was performed using the Levene’s F test.
with a screw cap and left in the maceration process for 5 days. After All tests were performed in the a statistical software#, with a 5%
that time, the plant extracts were obtained after filtration. At first, significance level.
two experiments were conducted in vitro: 1) a screening to check #
SPSS (Statistical Package for Social Sciences for Windows 15).
the extract with the best antimicrobial activity and 2) testing of the
extracts with Minimum Inhibitory Concentration (MIC) in 100%,
3. Results
50%, 25%, 12.5%, 6.25% and 5% dilutions. The 5% Minimum Inhibitory
Concentration (MIC) of the extract was used according to Srivastava
The age of respondents ranged from 18 to 56 years old, with a 33
and Sanjay15. The extracts were then diluted in sterile distilled
years old average, 31 years old median and a standard deviation of
water.
10.76 years old, with most of these (45.5%) were aged from 18 up to
The instrument used for clinical assessment of gingival
29 years old, while 25.5% corresponded to the 30e39 years old
bleeding was the gingival bleeding index (GBI) of Ainamo and Bay
range and 29.1% aged 40 or more years old. The female were more
(1975), which corresponds to the investigation of bleeding based
prevalent (83.6%) and 47.3% of the patients were white (Table 1).
on the bleeding/no bleeding on probing after 10 s of measurement.
Regarding the assessment of sample’s gingival bleeding index
According to this index, for a bleeding occurring after 10 s of
(GBI), Table 2 shows the statistical results for evaluation time and
probing along the gingival mouth and tongue margin (gingival
group as well as the differences (absolute changes between the
units) a positive score (þ) is assigned to the bleeding face, other-
evaluation times) between the groups. In the different periods of
wise a negative score () is assigned. The positive values of
assessment, all studied groups had statistically significant GBI
gingival units, related to bleeding faces, are added together and
reduction (p < 0.05) and, as the Chart 1 also reveals, all averages
divided by the total number of gingival units evaluated, and this
were higher in the initial evaluation than in the following two.
result multiplied by 100 to express the patient’s GBI as a
Comparing the groups, it is seen in Table 2 that the higher average
percentage.
The percentages of the GBI are grouped in the following scores:
Table 2
1 e no bleeding; 2e10 to 10% of bleeding faces; 3e11 to 25%; 4e26 GBI estatistics by evaluation periods according to the group.
to 50%; 5e51 to 75%; and 6eover 75% of bleeding faces. Considered
Evaluation Groups p value
to be with discrete gingival inflammation patients with score 2,
those with moderate gingival inflammation, score 3, and severe G1 G2 G3
those with scores above 3. Average  SD Average  SD Average  SD
(Median) (Median) (Median)
After defining the periodontal diagnosis and the groups distri-
bution, all patients were subjected, on the very first experiment 0 days 65.50  21.96 66.71  24.50 62.84  25.07 pa ¼ 0.882
(67.37)(A) (76.08)(A) (65.44)(A)
day, to the following procedures: completing the Ainamo and Bay
7 days 26.75  20.08 38.51  29.15 34.89  24.44 pa ¼ 0.350
gingival bleeding index (GBI); Dental Hygiene Orientation (DHO); (24.16)(B) (23.21)(B) (33.50)(B)
mouth scraping and root planing (SRP) all in a single session, using 15 days 20.25  19.86 31.55  21.87 23.60  17.07 pa ¼ 0.210
McCall universal curettes, and, finally, rinse with the substance for (9.93)(C) (26.68)(B) (18.93)(C)
the correspondent group, and the data obtained in the first p value pb < 0.001* pb < 0.001* pb < 0.001*
Absolute difference
assessment were recorded in specific forms. 0e7 days 38.75  21.00 28.20  24.81 27.95  27.08 pa ¼ 0.323
After the treatment, patients were advised to make two daily, (34.27) (25.00) (23.44)
1 min long, mouthwashes with 10 ml of the solution corresponding 0e15 days 45.25  23.20 35.16  16.94 39.23  26.39 pa ¼ 0.396
to their group, 30 min after morning and night brushing, and for a (44.65) (35.70) (36.86)
7e15 days 6.50  9.97 6.96  19.31 11.29  14.83 pa ¼ 0.586
15 days period. It was given to all patients in each group, individ-
(5.05) (6.89) (6.22)
ually, a recipe containing the prescription, how to use and dosage of
the substances used as a mouthwash. Obs.: If all the letters in parentheses are distinct, a significant difference is confirmed
between the corresponding measurements by Bonferroni pairwise comparisons.
After seven and 15 days, patients returned for the second and (*): Significant difference at the 5.0% rate.
third evaluations in which the gingival bleeding index (GBI) was a
Through the F (ANOVA) test.
b
repeated, and the Dental Hygiene Orientation (DHO) was Through the F (ANOVA) test for repeated measurements.
96 A.L.A. Batista et al. / Complementary Therapies in Clinical Practice 20 (2014) 93e98

the study by Lucena et al. (2009) [36] to assess, in a comparative

way, its anti-inflammatory effect with the chamomile, it was found
similar results regarding the efficacy of both substances in the
dental biofilm chemical control.
Chlorhexidine has a broad spectrum, acting against Gram-
positive and Gram-negative bacteria. At low concentrations, it
has a bacteriostatic effect, at high concentrations, has a bacteri-
cidal effect, causing cell lysis [4,37]. Complementing, Bastos et al.
(2004) [38] reported that chlorhexidine is the product that has
demonstrated the best clinical outcomes in the biofilm control
compared to other topical antimicrobial agents being used pro-
phylactically or therapeutically in gingivitis and chronic peri-
odontitis. In addition, because of its high effectiveness,
chlorhexidine is usually the standard product [4]. However, as
Chart 1. Gingival bleeding index according to the group and evaluation period.
noted by Smith et al. (2006) [12] and Vasconcelos et al. (2001)
[13], the undesirable side effects of the chlorhexidine use, such as
within the three evaluation times occurred in G2 and that from 0 to the teeth, tongue and restorations staining, and the loss of taste
7 days the greater reduction was in G1 and from 7 to 15 days in G3. sensitivity, its long term use is limited.
However, considering the 0 (zero) and 15 days periods, the best Within this context, phytotherapy has been highly publicized
effect in reducing the gingival bleeding was in G1. for therapeutic purposes because of its low cost, easy access, the
economic situation of the population, the absence of apparent
adverse effects and the search for a better life quality, besides the
4. Discussion broad popular acceptance and the World Health Organization
(WHO) support, motivating scientific research [4,14,17]. Plus,
Dental biofilm has an important role in the etiology of diseases Drummond et al. (2004) [26] and Marine and Araujo (2007) [4]
affecting the oral cavity, with major implications for the quality of state that about 20% of 250000 medicinal species, cataloged by
life and impact on systemic health. The first theories that oral UNESCO, are located in Brazil, facilitating the use of the plants
diseases were associated only to the amount of biofilm colonizing curative potential for the treatment of diseases, including
bacteria have been replaced by the realization that specific patho- dentistry.
gens could induce the disease [21]. Knowledge of the biofilm All these facts may also be associated with the indiscriminate
structure and composition, as well as about the main factors use of herbal medicine, since the data from WHO (2006) show that
involved in the periodontal disease pathogenesis, resulted in im- approximately 85% of the world population has used some plant for
provements in traditional approaches to control biofilm; encour- some painful or unpleasant symptoms, but only 30% under physi-
aging the development of new preventive and therapeutic cian orientation. Herbal medicine exists mainly in the informal
strategies [22]. market, representing a great danger to public health due to the
Several authors [4,23e28] are unanimous in stating that the marketing of vegetal drugs with no control, either phytosanitary,
biofilm is the primary etiologic factor for the development of whether of identity and/or purity [4,17].
periodontal disease, and its control being indispensable for its Herbal medicine has been used to treat various dental condi-
prevention. However, it is important to highlight the difficulties tions. Cloves, pomegranate, common mallow, plantain, mulberry,
exhibited by patients to maintain an adequate mechanical control sages, chamomile, among others, have been used in cases of gum
of dental biofilm [4,26,29,30]. disease, mouth abscesses, inflammation and ulcers. In accordance
Chaves et al. (2000) [31] and Golub et al. (2001) [32] agree with with Oliveira et al. (2007) [3], Salvia officinalis L. (sage), the Punica
the statement that conventional mechanical periodontal treatment granatum L. (pomegranate), the Althaea officinalis L., Calendula
usually does not completely eradicate the Periodontopathic bac- officinalis L., Malva sylvestris L. (mauve) and Plantago major L. were
teria, since sites as periodontal pockets, grooves, furcations and the most cited in the literature surveyed, all widely used in folk
concavities are difficult areas to access with periodontal in- medicine.
struments. Therefore, several therapeutic modalities have been Thus, this work seeks to examine the effects of herbal mouth-
proposed and studied in order to combat and control periodontal wash in reducing gingival bleeding in periodontal disease,
microbiota [10,11,33]. So, antimicrobial substances in the mouth- comparing it with the effect of 0.12% chlorhexidine solution, being
wash form can be used as adjuvants in an attempt to compensate noteworthy that none of the study participants developed adverse
for these difficulties [4,26,29,30]. or allergic reactions to the used rinse, even those belonging to the
In accordance with Bugno et al. (2006) [34], the mouth rinses group of chlorhexidine mouthwash, which according to Vascon-
have been used in chemical control of dental biofilm, as well as celos et al. (2003) [13], is usually followed by side effects when used
being facilitators for the placement of active compounds for specific for a period exceeding 15 days, which in fact did not occur in the
conditions treatment. However, for Rojas, Santos and Alemany experiment in question. That may be the reason for the absence of
(2005) [35] and Marine and Araujo (2007) [4], these rinses should such effects.
never override the mechanical removal of biofilm, but act as its Among the plants used to obtain extracts and chemical groups
assistants. surveyed in this study, the Matricaria recutita Linn (chamomile)
Several antimicrobial agents are used in the biofilm chemical species was positive for flavonoids and essential oils and the Punica
control in dentistry, including chlorhexidine, which has produced granatum Linn (pomegranate) species for the presence of tannins,
good results in biofilm reducing and in periodontal disease treat- which agrees to the description of other studies [20].
ment [10,11,33]. Chamomile has been used for centuries to treat various in-
Although it is scientifically proved that chlorhexidine signifi- flammatory diseases of the gastrointestinal tract, mucous mem-
cantly reduces and controls the gingival inflammation in patients branes and skin, as it has analgesic, antioxidant, antiparasitic,
exhibiting a poor oral hygiene, through its antibacterial action [33], anticancer and immunoregulatory properties [20].
 A.L.A. Batista et al. / Complementary Therapies in Clinical Practice 20 (2014) 93e98 97

In the oral cavity, multiple studies have been developed using [4] Marinho BVS, Araújo ACS. O uso de enxaguatórios bucais sobre a gengivite e o
biofilme dental. Int J Dent 2007;6:124e31.
chamomile with different purposes, such as the treatment of
[5] Lins RDAU, Godoy GP, Medeiros KB, Alves RDA, Figueiredo CRLV, Pinto LP.
thrush, mucositis, gingivitis and other [39]. Specifically for peri- Etiopatogenia da doença periodontal: o papel da resposta imunológica e
odontal diseases, Pourabbas et al. (2005) [40] and Lucena et al. considerações atuais. Parte II, J Health Sci Inst 2004;22:63e70.
(2009) [36], by using chamomile to treat chronic gum disease, [6] Feres M, Cortelli SC, Figueiredo LC, Haffajee AD, Socransky SS. Microbiological
basis for periodontal therapy. J Appl Oral Sci 2004;12:256e66.
found a reduction in the gingiva bleeding index, confirming the [7] Martins AG, Dantas ACAM, Pinto GR, Suaid FF, Nociti Jr FH, Sallum AW. Ava-
findings of this study, in which the mouthwash using Matricaria liação do tempo de instrumentação radicular com o uso de pontas sônicas
recutita Linn. (chamomile) extract also reduced the bleeding index, diamantadas. Periodontia 2007;17:92e7.
[8] Ribeiro EDP, Bittencourt S, Sallum EA, Nociti Jr FH, Casati MZ, Sallum AW.
both in gingivitis and in chronic periodontitis, showing statistically Novas abordagens da terapia periodontal não-cirúrgica. Peridontia 2006;16:
significant results (p < 0.05) in the different assessment periods (0, 27e32.
7 and 15 days). [9] Lima, RPE. Terapia periodontal não-cirúrgica convencional e desinfecção de
toda boca em um curto período de tempo. Belo Horizonte, 56 p. Tese Apre-
Literature points P. granatum (pomegranate) as a plant with sentada a Universidade Federal de Minas Gerais, Faculdade de Odontologia
great potential for preventing and fighting various diseases, high- para obtenção do grau de Especialista, 2007.
lighting its anti-inflammatory and antimicrobial properties. How- [10] Gunsolley JC. A meta-analysis of six-month studies of antiplaque and anti-
gingivitis agents. J Am Dent Assoc 2006;137:1649e57.
ever, most studies of this plant were carried out in vitro or in vivo. [11] Gjermo P, Bonesvoll P, Rolla G. Relationship between plaque inhibiting effect
Being a non-native and non-arable plant, certainly the use of and retention of chlorohexidine in the human oral cavity. Arch Oral Biol
pomegranate may arouse the interest of pharmaceutical and food 2000;19:1031e4.
[12] Soares DGS, Oliveira CB, Leal C, Drumond MRS, Padilha WWN. Susceptibili-
companies. The use of pomegranate and particularly its fruit is
dade in vitro de bactérias bucais a tinturas fitoterápicas. Rev Odonto Ciênc
relatively easily, without compromising its therapeutic properties 2006;21:232e7.
[14]. [13] Vasconcelos J. Uso da clorexidina na prática odontológica. JAO 2001;27:35e
Pomegranate (Punica granatum) has been used by several pop- 49.
[14] Werkman C, Granato DC, Kerbauy WD, Sampaio FC, Brandão AAH, Rode SM.
ulations in the treatment of oral diseases [3,41,42]. In recent Aplicações terapêuticas da Punica granatum L. (romã). Rev Bras Plantas Med
ethnobotanical studies, the pomegranate was the most often cited 2008;10:104e11.
plant by users and recommended by health professionals for the [15] Revilla J. Cultivando a saúde em hortas caseiras e medicinais. Manaus:
SEBRAE/AM, INPA; 2002.
treatment of several pathologies [14,43]. [16] Yunes RA, Pedrosa RC, Cechinel-Filho V. Fármacos e fitoterápicos: a neces-
Regarding the reduction in the gingival bleeding index in the sidade do desenvolvimento da indústria de fitoterápicos e fitofármacos no
groups of patients with gingivitis and chronic periodontitis, who Brasil. Química Nova 2001;24:147e52.
[17] Rodrigues ER, Martins CHG, Moreti DLC, Lopes RA, Vasconcelos MAL,
used pomegranate extract mouthwash, in the experiment in Taveira PMA, et al. Estudo de parâmetros bioquímicos em ratos sob ação de
question, results were as statistically significant (p < 0.001) as those planta medicinal. XVI. Punica granatum L. Revista Científica da Universidade
observed in groups of chamomile and chlorhexidine 0.12%, con- de Franca 2006;6:79e84.
[18] Sudheesh S, Vijayalakshmi NR. Flavonoids from Punica granatum e potential
firming the anti-inflammatory potential of pomegranate described antiperoxidative agents. Fitoterapia 2005;76:181e6.
in other studies [3,14,42]. [19] Rios DRA, Alexandre MM, Kuchne B, Silva LM. Estudo farmacobotânico das
Comparing the effects of the substances used to reduce the folhas da espécie vegetal Punica granatum L. Escola de Farmácia e Odonto-
logia de Alfenas/Centro Universitário Federal/EFOA/CEUFE. Disponível em:
bleeding index in patients with periodontal disease, it was found
<www.usp.br/siicusp/11osiicusp/bubarea_ tit_cl_16.htm> [Acesso em: 16
that both the 0.12% chlorhexidine, and chamomile and pome- ago 2010].
granate were effective, demonstrating statistically significant and [20] Albuquerque ACL, Pereira MSV, Pereira JV, Pereira LF, Silva DF, Macedo-
similar results (p < 0.001), suggesting that any of these three Costa MR, et al. Antiadherent effect of the extract of the Matricaria recutita
Linn. on microorganisms of dental biofilm. Rev Odontol UNESP 2010;39:
substances can be used to control bleeding gums in periodontal 21e5.
disease. [21] Beikler T, Flemmig TF. Oral biofilm-associated diseases: trends and implica-
Thus, considering that the chamomile and pomegranate ex- tions for quality of life, systemic health and expenditures. Periodontol 2000
2011;55:87e103.
tracts were as effective as the solution of chlorhexidine 0.12% in [22] Marsh PD, Moter A, Devine DA. Dental plaque biofilms: Communites conflict
reducing the bleeding index in subjects with chronic gingivitis and and control. Periodontol 2000 2011;55:16e35.
periodontitis, it can be inferred, sometimes, replacing the solution [23] Gebran MP, Gebert APO. Controle químico e mecânico de placa bacteriana.
Ciênc Cult 2002;26:45e58.
of 0.12% chlorhexidine by the herbal products tested or their [24] Moraes ES, Valença AMG. Prevalência de gengivite e periodontite em crianças
alternative use to control bleeding gums in periodontal disease. de 3 a 5 anos na cidade de Aracajú (SE). Ciênc Odontol Bras 2003;6:87e94.
[25] Santos MAV, Pereira SLS, Stefani CM, Mora OML, Carlos MX. O uso de iodo-
povidine em periodontia. Revista Odontológica de Araçatuba 2003;24:9e
5. Conclusion 16.
[26] Drumond MRS, Castro RD, Almeida RVD, Pereira MSV, Padilha WWN. Estudo
Comparativo in vitro da Atividade Antimicrobiana de Produtos Fitoterápicos.
Chamomile and pomegranate extracts mouthwashes were
Pesqui Bras Odontoped Clin Integr 2004;4:33e8.
effective in reducing gingival bleeding in periodontal disease, [27] Seabra EJG, Lima IPC, Barbosa SV, Lima KC. Atividade antimicrobiana “in vitro”
suggesting that both extracts have anti-inflammatory and antimi- de compostos a base de hidróxido de cálcio e tergentol em diferentes con-
crobial actions similar to those of the chlorhexidine 0.12%, and thus centrações sobre bactérias orais. Acta Cir Bras 2005;20:12e8.
[28] Pion FLB, Araújo MWB, Feres M, Cortelli SC. Condição periodontal de um
can also be used as additional therapeutic agents to reestablish- subgrupo populacional do município de Guarulhos, SP. Rev Bras Epidemiol
ment and maintenance of periodontal health. 2006;9:335e45.
[29] Tabchoury CPM, Pierobon CN, Cury JA. Concentração e biodisponibilidade do
fluoreto de enxaguatórios bucais preparados em farmácias de manipulação.
Conflict of interest J Appl Oral Sci 2005;13:41e6.
None declared. [30] Salgado ADY, Maia JL, Pereira SLS, Lemos TLG, Mota OML. Antiplaque and
antigingivitis effects of a gel containing Punica granatum L. extract. A double-
blind clinical study in humans. J Appl Oral Sci 2006;14:162e6.
References [31] Chaves ES, Jeffcoat MK, Ryerson CC, Snyder B. Persistent bacterial colonization
of Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actino-
[1] Paiva JS, Almeida RV. Periodontia: a atuação clínica baseada em evidências mycetemcomitans in periodontitis and its association with alveolar bone loss
científicas. São Paulo: Artes Médicas; 2005. after 6 months of therapy. J Clin Periodontol 2000;27:897e903.
[2] Newman MG, Takei HH, Klokkevold PR, Carranza JR. Periodontia Clínica. Rio [32] Golub LM, McNamara TF, Ryan ME, Kohut B, Blieden T, Payonk G, et al.
de Janeiro: Elsevier; 2007. Adjunctive treatment with subantimicrobial doses of doxycycline: effects on
[3] Oliveira FQ, Gobira B, Guimarães C, Batista J, Barreto M, Souza M. Espécies gingival fluid collagenase activity and attachment loss in adult periodontitis.
vegetais indicadas na odontologia. Rev Bras Farmacogn 2007;17:466e76. J Clin Periodontol 2001;28:146e56.
98 A.L.A. Batista et al. / Complementary Therapies in Clinical Practice 20 (2014) 93e98

[33] Herrera BS, Mendes GIAC, Porto RM, Rigato HM, Moreira LD, Muscará MN, [38] Bastos JRM, Bardal PAP, Castro RFM, Mendes HJ, Vilhena FV. Chlorhexidine use
et al. O papel da clorexidina no tratamento de pacientes com gengivite no at dentistry. Salusvita 2004;23:15e24.
distrito de São Carlos do JamarieRO. Periodontia 2007;7:60e4. [39] Singh MV, Dias LO, Baldini NLF, Silveira D, Zago R. Desenvolvimento farm-
[34] Bugno A, Nicoletti MA, Almodóvar AAB, Pereira TC, Auricchio MT. Enxagua- acotécnico e avaliação da estabilidade de gel com extrato aquoso de camomila
tórios bucais: avaliação da eficácia antimicrobiana de produtos comer- para uso bucal. Rev Bras Farm 2008;89:134e8.
cialmente disponíveis. Rev Inst Adolfo Lutz 2006;65:40e5. [40] Pourabbas R, Delazar A, Chitsaz MT. The effect of german chamomile
[35] Rojas FJE, Santos-Alemany A. Colutorios para el control de placa y gingivitis mouthwash on dental plaque and gingival inflammation. IJPR 2005;2:105e9.
basados en la evidencia científica. RCOE 2005;10:445e52. [41] Michelin DC, Moreschi PE, Lima AC, Nascimento GGF, Paganelli MO,
[36] Lucena RN, Lins RDAU, Ramos INC, Cavalcanti AL, Gomes RCB, Maciel MAS. Chaud MV. Avaliação da atividade antimicrobiana de extratos vegetais. Rev
Estudo clínico comparativo do efeito anti-inflamatório da Matricaria recutita e Bras Farmacogn 2005;15:316e20.
da clorexidina em pacientes com gengivite crônica. Rev Bras Pesqui Saúde [42] Machado TB, Pinto AV, Pinto MCFR, Leal ICR, Silva MG, Amara CF, et al. In vitro
2009;11:31e6. activity of Brasilian medicinal plants, naturally occurring naphthoquinones
[37] Souza ELC. Comparação do digluconato de clorexidina 0.12% sem xilitol com and their analougues, against methicilin-resistant Staphylococcus aureus. Int J
álcool e com xilitol sem álcool para controle do biofilme oral e efeitos Antimicrob Agents 2003;21:279e84.
adversos associados. Dissertação (mestrado). Rio de Janeiro: Universidade [43] Lima Júnior JF, Dimenstein MA. Fitoterapia na Saúde Pública em Natal/RN:
Veiga de Almeida, Mestrado em Odontologia, Reabilitação Oral; 2007. visão do odontólogo. Rev Saúde 2006;8:37e44.