Oncology

and Radiotherapy ©
18(6) 2024: 001-007 • RESEARCH ARTICLE

Evaluation the effectiveness of oral gel containing pomegranate

Pardis Amoozian1, Masoome Eivazi2, Reza Tahvilian3

1
Department of Dental Prostheses, School of Dentistry, Jundishapur University of Medical Sciences, Ahvaz, Iran
2
Department of Periodontitis, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
3
Department of Pharmaceutics, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran

Background and Aim: The goal of this project is to introduce an oral gel of
INTRODUCTION
ABSTRACT

plant origin for the treatment of gingivitis and periodontitis that is thought
to have significant therapeutic effects while not having the side effects of
common chemical agents. Due to no toxic and systemic side effects and on A person's quality of life and his physical and mental condition in
the other hand, given the antibacterial, antifungal, antiviral, anti-inflammatory,
antioxidant, and astringent components of this product, it is assumed to be
today's society depend highly on his oral and dental health. Also,
useful in clinical studies. studies have proven the association between many chronic and
Materials and Methods: The study was triple blinded. The study population systemic diseases, including cardiovascular diseases, etc., and poor
consisted of 32 patients (n=32) with moderate to severe periodontitis. The health conditions of the oral cavity [1]. Gingivitis and periodontitis
study included both men and women between the ages of 22 years-60 years
for three months. Initially, two teeth in two different quadrants with deep
are the most common types of gum disease. Gingivitis is only
pockets were considered in each patient. Each tooth and gels that has to been specific to the gums and does not invade the supporting tissues of
injected around teeth, were randomly selected. At the beginning, plaque index, the tooth (periodontal ligament, cementum, and alveolar bone)
gingival index, clinical attachment loss, pocket depth, bleeding index were
measured and recorded. All patients treated with scaling and root planning, [1]. Gingivitis can turn into periodontitis if it is not treated and
then one periodontal pocket of each patient was injected with pomegranate progresses [2]. Inflammatory mechanisms are also involved in
gel and another periodontal pocket was injected with placebo. The syringe
was 1 ml and 27 gauge, then Coe-pack placed on both teeth. The trial interval the occurrence of periodontitis in addition to bacteria [3]. The
was one and three months. After one and three months of the first session, worldwide prevalence of periodontal diseases is 20%-5% in the
variables were evaluated again.
adult population. Periodontitis is the second most common oral
Results: There was no statistically significant difference in plaque index, gingival health problem. It affects 10%-15% of the world's population. The
index, clinical attachment loss, pocket depth and bleeding index at baseline
between pomegranate gel and placebo. There was a statistically significant most severe forms of periodontal disease are significantly found
reduction in all mentioned variables one and three months after the beginning in adults aged 35 years-44 years with a prevalence of 19% [4].
of the study in the tooth containing pomegranate gel (p<0.001). There was a
significant reduction in plaque index, gingival index, clinical attachment loss,
Chronic periodontitis negatively affects people's beauty, chewing,
pocket depth and bleeding index in tooth containing pomegranate between the and speaking [5]. The treatment of periodontitis is a crucial issue
beginning of the study with one and three months follow-up (p<0.001). There that includes several stages depending on the severity of the gum
was a significant reduction in plaque index, gingival index, clinical attachment
loss, pocket depth and bleeding index in tooth containing placebo between the disease. The disease disappears in the initial stages of scaling and
beginning of the study with one and three months follow-up (p<0.001). root planing [6]. The treatment includes curettage or gum surgery
Conclusion: The results of this study show that gel containing pomegranate in more advanced stages.
peel extract can have good therapeutic effects on plaque index, gingival index,
clinical attachment loss, pocket depth and bleeding index. Antibiotics, mouthwash, and antimicrobial toothpaste are mostly
prescribed after the treatment of scaling and gum surgery [7].
Keywords: gingivitis, periodontitis, clinical attachment loss, scaling and root Plaque on the teeth contains bacteria. Thus, taking antibiotics
planing, punica granatum reduces the amount of plaque in the mouth [7]. These drugs may
have side effects [8]. Plants are a rich source of active and effective
compounds with countless therapeutic properties and minimal
side and unwanted effects [9]. The use of medicinal plants to
Address for correspondence:
treat various diseases has been developed in recent years. Much
scientific attention has been paid to herbal products to control
Pardis Amoozian,
oral and dental diseases. Studies have proven that some plants
Department of Dental Prostheses, School of Dentistry, Jundishapur University help to maintain the overall health of the mouth, in addition
of Medical Sciences, Ahvaz, Iran
to protecting the teeth and gums. The pomegranate plant with
E-mail: [email protected]
the scientific name Punica granatum L. is an ancient plant and
Word count: 6902 Tables: 05 Figures: 00 References: 24 the most abundant genus of the Punicaceae family. Pomegranate
is native to North India and Iran. It has been taken to all the
Received: 22 May, 2024, Manuscript No. OAR-24-136811
Mediterranean areas and cultivated [10]. Various uses have been
Editor Assigned: 24 May, 2024, Pre-QC No. OAR-24-136811(PQ) reported for it in Indian and Greek medicine. It has been used
Reviewed: 07 June, 2024, QC No. OAR-24-136811(Q) as an anti-parasitic agent, blood purifier, treatment of mouth
Revised: 14 June, 2024, Manuscript No. OAR-24-136811(R) sores, and digestive tract ulcers. It is also extensively applied in the
Published: 21 June, 2024, Invoice No. J-136811
Middle East, Iran, and India to treat diabetes [11].

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The present study aims to present an oral gel with a completely paper in different quadrants and placed in one pocket (example:
natural and herbal origin that has significant therapeutic impacts. 13, 36, 45, etc.), and in another pocket, the codes A and B were
Also, it does not have the side effects of common chemical written on the paper, was placed, which was the encrypted codes
treatments. The current chemical drugs available in the market of the gel tubes by the drug manufacturer. Tubes containing
failed to help much in the treatment of periodontitis. Due to the drugs named A and B were coded by the drug manufacturer and
limited side effects and the absence of toxic and systemic side provided to the project executor. Only the drug manufacturer was
effects and considering the antibacterial, antifungal, antiviral, aware of the pomegranate gel or placebo content of each A and
anti-inflammatory, antioxidant, and astringent effects of this B tube until the end of the study. Since the patients had chronic
product, it is assumed that this herbal product can be used in periodontitis at moderate to severe degrees, the treatment plan
the study. It clinically has significant therapeutic effects. This gel included scaling, complete oral health education, and the use of
can be recommended in phase 3 (treatment) for the treatment of a gel containing pomegranate and a placebo. Thus, the patients
periodontitis instead of similar external substances if its effect is were asked to take a sheet from the teeth pocket and select the
proven. The present study aims to investigate the effects of herbal sheet from the tube coding pocket of the drugs. The selected
gel obtained from the pomegranate peel and introduce it as a tooth information and the injectable gel were entered into the
product in the treatment of periodontitis. If favorable clinical checklist. Then, in the periodontal pocket of that tooth, the same
results are obtained, dentists can prescribe it by being sure of its selected gel was injected after the scaling and polishing treatment.
efficiency, and finally, its domestic production will be supported. Again, the patients were asked to select another tooth from the
pocket in the same order, if the second chosen tooth is from the
same quadrant as the first tooth. This sheet was discarded and
MATERIAL AND METHOD the patients were asked to select another sheet to ensure that the
second tooth was different from the quadrant of the first tooth.
The present study was conducted using an interventional method
After recording the information and scaling and polishing, the gel
in the form of parallel assignment, controlled clinical trial, and
that was not selected by the patient in the first step was injected
triple-blind. The statistical population of the study included
into the periodontal pocket of the second tooth.
patients with moderate to severe chronic periodontitis. The patients
who were referred to Kermanshah Dental Faculty were included The checklist included selected tooth number and injectable gel
in the study after being examined, confirming that they met the code and study variables, plaque index, gingival index, clinical
necessary criteria to participate in the study, and completing and attachment loss, pocket depth, and bleeding index. The injection
signing the consent form. The r esults o f p revious s tudies w ere was done with a 27-gauge 1 ml syringe around the tooth. Then,
used to calculate the sample size. In the study by Sastravaha et a coe-pack was placed on both areas and the patients were asked
al., the standard deviation of the PD variable in the SPT alone to observe their oral health during the study. However, they were
and apt+ med groups was S1=0.93 and S2=1.04, respectively, asked to avoid using dental floss in the studied area and using
with the means X 1=6.21 and X 2=6.93, respectively [12]. The mouthwash. After one week, the patients were called to remove
minimum sample size was estimated to be 32 people considering the dressing and evaluate the gum condition. The health education
α=0.05, 90% test power, and β=-1. The optimal pharmaceutical was given to them again. The test period was one month and three
form was prepared after evaluating and choosing the appropriate months after the start of the study. After one and three months
formulation by pharmaceutical colleagues. After packaging, it was from the initial session, the patients were called on. Based on the
used to conduct a clinical study. The efficacy and safety of the drug routine treatment plan for patients with periodontitis, the studied
were evaluated in clinical studies. The study was conducted as a variables were re-measured in the follow-up sessions. Then, the
triple-blind (patient, interventionist, and examiner of results). The results were analyzed using statistical software and relevant tests.
patients underwent initial examination and were selected based
The data were collected by clinical observation and the Williams
on the criteria of moderate to severe chronic periodontitis. The
probe was used to fill out the checklist. The goals of the study
studied population included 32 patients (n=32) with moderate
were fully explained to the subjects who entered the study. After
to severe periodontitis. This survey included both male and female
obtaining written consent from them by the project executor,
patients in the age range between 22 years and 60 years for three
information before the treatment 1 months and 3 months after the
months.
first session was entered into the checklist. The data of the study
The inclusion/exclusion criteria of the study are as follows: patients were analyzed in two sections: descriptive statistics and inferential
who did not receive any other periodontal treatment during the statistics. In the descriptive statistics section, central tendency
study other than the screening performed by the project executor, and dispersion criteria were reported along with the table. In the
no history of hypersensitivity reactions, not consuming tobacco inferential statistics section, the normality of the data was checked
and alcohol, not receiving antibiotics and any type of medicine using the kolmogorov-smirnov test. To compare two drugs, the
that affects periodontal conditions, not having systemic diseases paired samples T-test and Wilcoxon test were used. For follow-
that affect periodontal conditions (such as kidney, liver, or up comparisons, friedman and repeated measures tests were used.
rheumatic diseases), non-pregnant or non-lactating women, and For pairwise comparisons, posthoc tests with significance levels
not receiving any orthodontic treatment. The patients were asked adjusted by Bonferroni correction were used. Given the rank
to sign the consent form after a detailed study. Also, the patients nature of PI, GI, and BI variables, non-parametric tests were
were encouraged to refrain from performing dental treatment on used to analyze these variables. SPSS-24.0 software was used for
the studied teeth and their adjacent teeth during the study and data analysis. The significance level in this study was considered
postpone the treatment until the completion of the study. at 0.05. The project started after obtaining permission from the
Ethics Council of Kermanshah University of Medical Sciences.
First, the numbers of eligible teeth for the study were written on

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The written consent form was read and signed by the patients after regarding PI one month after the start of the study (p<0.001) so
providing a sufficient explanation. Then, the patients entered the the mean of this variable was lower in drug A than in drug B. There
study. was a statistically significant difference between drugs A and B
regarding PI three months after the start of the study (p<0.001)
so the mean of this variable was lower in drug A than in drug B.
RESULTS There was a statistically significant difference between the follow-
A total of 32 people participated in the present study. Among up times regarding PI in drug A (p<0.001), so the mean of this
them, 13 (40.6%) were male and 19 (59.4%) were female. The variable in one and three months of follow-up was lower than at
mean age of the participants was 41.38 ± 10.57. There was the beginning of the study. There was a statistically significant
no statistically significant difference between drugs A and B difference between follow-up times regarding PI in drug B
regarding PI at the beginning of the study (p=0.627). There (p<0.001) so the mean of this variable in one and three months of
was a statistically significant difference between drugs A and B follow-up was lower than at the beginning of the study (Table 1).
Treatment
Tab. 1. Descriptive statistics of PI and
its comparison between two treat- A B
ments over time p-value†
Med IQR Mean SD Med IQR Mean SD
Baseline 2.00 b 1 1.66 0.83 2.00 b 1 1.72 0.85 0.627
1MO F/U 1.00 a 0.5 0.31 0.59 1.00 a 1 0.91 0.69 <0.001
3MO F/U 1.00 a 0 0.13 0.34 1.00 a 1 0.78 0.66 <0.001
p-value‡
<0.001 s<0.001
Med: Median, IQR: Interquartile Range, SD: Standard Deviation
† Wilcoxon Signed Ranks Test
‡ Friedman test, followed by Post-hoc of Friedman test. In each column, medians with the same superscript
letter were not significantly different.
There was no statistically significant difference between drugs A A than in drug B. There was a statistically significant difference
and B regarding CAL at the beginning of the study (p=0.203). between the follow-up times regarding the mean CAL in drug A
There was a statistically significant difference between drugs (p<0.001), so the mean of this variable in three months of follow-
A and B regarding CAL one month after the start of the study up was lower than at the beginning of the study and one month of
(p<0.001), so the mean of this variable was lower in drug A than follow-up. There was a statistically significant difference between
in drug B. There was a statistically significant difference between the follow-up times regarding CAL in drug B (p<0.001), so the
drugs A and B regarding CAL three months after the start of the mean of this variable in 1 month and 3 month follow-ups was
study (p<0.001), so the mean of this variable was lower in drug lower than at the beginning of the study (Table 2).
Treatment
Tab. 2. Descriptive statistics of CAL
and its comparison between two A B
treatments over time p-value†
Mean SD Mean SD
Baseline 4.19 c 1.4 4.53 b 1.48 0.203
1MO F/U 1.78 b
1.52 3.44 a
1.66 <0.001
3MO F/U 1.59 a
1.36 3.28 a
1.59 <0.001
p-value ‡
<0.001 <0.001
SD: Standard Deviation
† Paired Samples T-Test
‡ Repeated Measures test, followed by Post-hoc test with Bonferroni adjustment. In each column, means with
the same superscript letter were not significantly different.
There was no statistically significant difference between drugs A and B regarding PD at the beginning of the study (p=0.209). There
and B regarding GI at the beginning of the study (p=0.499). There was a statistically significant difference between drugs A and B re-
was a statistically significant difference between drugs A and B re- garding PD one month after the start of the study (p<0.001), so
garding GI one month after the start of the study (p<0.001), so the mean of this variable was lower in drug A than in drug B. There
the mean of this variable was lower in drug A than in drug B. There was a statistically significant difference between drugs A and B re-
was a statistically significant difference between drugs A and B re- garding PD three months after the start of the study (p<0.001),
garding GI three months after the start of the study (p<0.001), so the mean of this variable was lower in drug A than in drug B.
so the mean of this variable was lower in drug A than in drug B. There was a statistically significant difference between the follow-
There was a statistically significant difference between follow-up up times regarding the mean of PD in drug A (p<0.001), so the
times regarding GI in drug A (p<0.001) so the mean of this vari- mean of this variable in three months of follow-up was lower than
able in one- and three-month follow-up was lower than at the be- at the beginning of the study and one-month follow-up. There was
ginning of the study. There was a statistically significant difference a statistically significant difference between the follow-up times
between the follow-up times regarding GI in drug B (p<0.001) so regarding PD in drug B (p<0.001) so the mean of this variable in
the mean of this variable in the three-month follow-up was lower one- and three-month follow-up was lower than at the beginning
than at the beginning of the study (Table 3). of the study (Table 4).
There was no statistically significant difference between drugs A

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Treatment
Tab. 3. Descriptive statistics of GI and
its comparison between two treat- A B
ments over time p-value†
Med IQR Mean SD Med IQR Mean SD
Baseline 1.00b 1.5 1.31 1 1.00 b 1 1.22 1.97 0.499
1MO F/U 0.00a 0 0.16 0.37 1.00 ab 1 0.72 0.58 <0.001
3MO F/U 0.00a 0 0 0 1.00 a 1 0.69 0.59 <0.001
P-value ‡
<0.001 <0.001
Med:Median, IQR: interquartile range, SD:Standard Deviation
† Wilcoxon Signed Ranks Test
‡ Friedman test, followed by Post-hoc of Friedman test. In each column, medians with the same superscript
letter were not significantly different.

Treatment
Tab. 4. Descriptive statistics of PD and
its comparison between two treat- A B
ments over time p-value†
Mean SD Mean SD
Baseline 3.84 c 1.48 3.53 b 1.39 0.209
1MO F/U 1.38 b
1.04 2.38 a
0.98 <0.001
3MO F/U 1.06 a 0.84 2.22 a 0.01 <0.001
p-value ‡
<0.001 <0.001
SD: Standard Deviation
† Paired Samples T-Test
‡ Repeated Measures test, followed by Post-hoc test with Bonferroni adjustment. In each column, means with
the same superscript letter were not significantly different.
There was no statistically significant difference between drugs A was a statistically significant difference between the follow-up
and B regarding BI at the beginning of the study (p=0.740). There times regarding BI in drug A (p<0.001) so the mean of this vari-
was a statistically significant difference between drugs A and B re- able in 1 month and 3 month follow-up was lower than at the be-
garding BI one month after the start of the (p<0.001), so the mean ginning of the study. There was a statistically significant difference
of this variable was lower in drug A than in drug B. There was a between the follow-up times regarding BI in drug B (p<0.001) so
statistically significant difference between drugs A and B regard- the mean of this variable in 1 month and 3 month follow-up was
ing BI three months after the start of the study (p<0.001), so the lower than at the beginning of the study (Table 5).
mean of this variable was lower in drug A than in drug B. There

Treatment
Tab. 5. Descriptive statistics of BI and
its comparison between two treat- A B
ments over time p-value†
Med IQR Mean SD Med IQR Mean SD
Baseline 2.00 b 1.5 2.38 1.13 2.00 b 1 2.34 1.04 0.74
1MO F/U 1.00 a
1 0.84 0.68 2.00 a
1 1.75 0.8 <0.001
3MO F/U 0.00 a
1 0.44 0.5 2.00 a
1 1.72 0.81 <0.001
p-value‡ <0.001 <0.001
Med: Median, IQR: Interquartile Range, SD: Standard Deviation
† Wilcoxon Signed Ranks Test
‡ Friedman test, followed by Post-hoc of Friedman test. In each column, medians with the same superscript
letter were not significantly different.

DISCUSSION loss, pocket depth, and bleeding index (For ease of understand-
ing the results, group A teeth mean teeth treated with scaling and
Periodontitis in males is more prevalent than in females, indi- pomegranate gel and group B teeth means the teeth treated with
cating the possible role of gender in the pathogenesis of the dis- scaling and placebo).
ease [13]. However, the ratio of females in the conducted study There was no significant difference between the two teeth selected
(59.4%) was higher than males (40.6%). The basic age groups by the patient at the beginning of the study, indicating the ho-
related to periodontal health are 15 years-19 years, 35 years-44 mogeneity of the condition of the two teeth in each patient. This
years, and 65 years-74 years [14]. The patients in this study were study showed that the mean plaque index in the teeth of group A
in the age range of 22 years-60 years. At the end of the study and (0.13) had a significant decrease compared to the teeth of group B
after data collection and statistical analysis by the statistician, the (0.78). A significant decrease in the mean plaque index occurred
producer of study gels was asked to announce the pomegranate in the teeth of group A since the beginning of the study compared
gel and placebo coded as A and B. The results of investigating the to 1 months and 3 months after the study. The reduction in the
effect of pomegranate gel A compared to placebo B on the study mean plaque index three months after the start of the study (0.13)
variables include plaque index, gingival index, clinical attachment was more than one month after the start of the study (0.31) in

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the teeth of Group A, but this decrease was not significant. The start of the study (1.38) in group A teeth. The mean depth of the
mean plaque index in the teeth of group B decreased significantly pocket in the teeth of group B at the start of the study decreased
over time from the beginning of the study compared to 1 months significantly compared to 1 months and 3 months after the start of
and 3 months after the beginning of the study. The mean plaque the study. The mean pocket depth decreased more than 3 months
index 3 decreased significantly three months after the start of the after the start of the study (2.22) compared to 1 month after the
study (0.78) than one month after the start of the study (0.91) in start of the study (2.38) in group B teeth. However, this reduction
the teeth of group B, but this reduction was not significant. Re- was not significant. The results revealed that scaling alone will im-
sults also showed that scaling alone will improve plaque index over prove pocket depth over time, but it is less effective than scaling
time, but it is less effective than scaling with pomegranate gel. The combined with pomegranate gel.
mean gingival index showed no significant difference between the The mean Clinical Attachment Loss (CAL) was not significantly
two teeth selected by the patient at the start of the study, indi- different between the two teeth selected by the patient at the start
cating the homogeneity of the condition of the two teeth in each of the study, indicating the homogeneity of the condition of the
patient. This study revealed that the mean gingival index in group two teeth in each patient. This study showed that the mean Clini-
A teeth (0.00) decreased significantly compared to group B teeth cal Attachment Loss (CAL) in group A teeth (1.59) decreased
(0.69). significantly compared to group B teeth (3.28). A significant de-
A significant decrease was found in the mean gingival index in the crease was found in the mean Clinical Attachment Loss (CAL)
teeth of group A at the start of the study compared to 1 months in the teeth of group A at the start of the study compared to 1
and 3 months after the start of the study. The mean gingival index months and 3 months after the start of the study. The mean Clini-
decreased significantly three months after the start of the study cal Attachment Loss (CAL) decreased significantly three months
(0.00) compared to one month after the start of the study (0.16) after the start of the study (1.59) compared to 1 months after the
in the teeth of group A. However, this decrease was not signifi- start of the study (1.78) in group A teeth. The mean Clinical At-
cant. A significant decrease in the mean gingival index was found tachment Loss (CAL) decreased significantly in the teeth of group
over time in the teeth of group B at the start of the study compared B at the start of the study compared to 1 and 3 months after the
to 1 months and 3 months after the start of the study. The mean start of the study. The mean Clinical Attachment Loss (CAL)
gingival index decreased significantly 3 months after the start of decreased more than 3 months after the start of the study (3.28)
the study (0.69) compared to 1 month after the start of the study and 1 month after the start of the study (3.44) in group B teeth.
(0.72) in the teeth of group B. However, this decrease was not sig- However, this decrease was not significant. It indicates that scaling
nificant. This indicates that scaling alone will improve the gingival alone will improve Clinical Attachment Loss (CAL) over time,
index over time, but it is less effective than scaling with pomegran- but it is less effective than scaling with pomegranate gel.
ate gel. In this study, the plaque index, bleeding index, and gingival in-
The mean bleeding index did not have a significant difference be- dex did not change significantly 1 months and 3 months after the
tween the two teeth selected by the patient at the start of the study, start of the study in both group A and group B teeth, indicating
indicating the homogeneity of the condition of the two teeth in that these variables are more affected by the oral health of the pa-
each patient. This study revealed that the mean bleeding index in tients. Also, when patients visit for longer periods, their motiva-
group A teeth (0.44) decreased significantly compared to group tion to control oral health at home is reduced and it can affect
B teeth (1.72). A significant decrease in the bleeding index in the these variables. Thus, it is recommended to examine these vari-
teeth of group A was found at the start of the study compared to 1 ables in shorter periods. In this study, pocket depth and clinical
months and 3 months after the start of the study. The mean bleed- attachment loss variables showed significant differences between
ing index decreased more three months after the start of the study the start of the study and 1 months and 3 months after the start
(0.44) than one month after the start of the study (0.84) in group of the study and between 1 months and 3 months after the start
A teeth. However, this decrease was not significant. The mean of the study. This indicates that these variables are mostly affected
bleeding index decreased significantly in group B teeth at the start over time and improvement in the periodontal attachment level
of the study compared to 1 months and 3 months after the start and pocket depth occurs over time. It is consistent with the re-
of the study. The mean bleeding index showed a greater decrease sults of our study. None of the patients required periodontal
3 months after the start of the study (1.72) than 1 month after the surgery 3 months after the start of the study. In other words, the
start of the study (1.75) in group B teeth. However, this reduction patients with Clinical Attachment Loss (CAL) of 3 mm or more
is not significant. The results also showed that scaling alone over were included in the study, and after scaling treatment in both the
time causes an improvement in the bleeding index compared to pomegranate gel-containing teeth and placebo gel, the depth of
scaling, but it is less effective than scaling combined with pome- the pocket decreased to the patients did not need additional treat-
granate gel. ment such as surgery.
No significant difference was found between the two teeth select- Sastravaha et al. conducted a study entitled "Periodontal adjuvant
ed by the patient regarding the mean depth of the pocket at the therapy with extracts of Centella Asiatica and Punica granatum."
start of the study, indicating the homogeneity of the condition of In the mentioned study, 20 patients with pocket depth of 5 mm-8
the two teeth in each patient. This study showed that the mean mm participated [15]. The reduction in pocket depth and im-
pocket depth in group A teeth (1.06) decreased significantly com- provement of CAL in this study are consistent with the results
pared to group B teeth (2.22). A significant reduction was found of our study, while other variables provided conflicting results.
in the depth of the pocket in the teeth of group A at the start of the The criteria for selecting patients with chronic periodontitis in
study compared to 1 months and 3 months after the start of the the mentioned study are patients with a pocket depth of 5 mm-8
study. The mean pocket depth 3 months after the start of the study mm, while the criteria for selecting patients in our study were pa-
(1.06) decreased significantly compared to 1 months after the tients with a CAL of 3 mm or more. Additionally, this study used

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Centella asiatica along with pomegranate, and it is and gingival index. The result of the improvement of the gingival
inconsistent with our study in some of the variables despite the index compared to the placebo was significant and consistent with
appropriate and long duration of the study. It can justify the our study. Regarding the plaque index, it is inconsistent with the
existing discrepancy. Salgado et al. conducted a study entitled result of our study. This is due to the difference in the method of
"Anti-plaque and anti-gingivitis effects of a gel containing conducting the study and other periodontal criteria that were not
pomegranate extract". This double-blind study was conducted investigated.
on 23 participants who were randomly divided into two Abullais et al. investigated the effectiveness of irrigation with dif-
control and intervention groups and received placebo gel and ferent antimicrobial drugs on periodontal health in patients treat-
pomegranate gel, respectively [16]. The results of this study ed with chronic periodontitis. This study investigated the effect
were inconsistent with those of our study. The reason for this of subgingival washing with waterpick with Herbal Extract (HE)
discrepancy in the results is related to differences in the in comparison with 0.2% Chlorhexidine (CHX) on periodontal
method of conducting the study. In our study, the gel was health [21]. The results of this study regarding plaque index are
injected into the periodontal pocket. consistent with those of our study and other variables are different
Grover et al. investigated the effect of subgingival gel containing from our study. In addition to the difference in the methods of
10% Emblica officinalis as an adjunctive treatment for Scaling implementation, this study used a different drug than our study.
and Root Planing (SRP) in the treatment of chronic It uses pomegranate, black pepper, and copper sulfate, which can
periodontitis" [17]. The results of this study regarding pocket provide results different from what pomegranate alone can do.
depth and CAL showed that pocket depth was improved only in Somu et al. investigated the effectiveness of herbal extract gel in
pockets of 5 mm and above although a different drug was used. It the treatment of gingivitis [22]. In their study, the patients suf-
was consistent with our study. The studied plant has the same fered from gingivitis, while the patients in our study suffered from
properties as the pomegranate plant. Thus, they are comparable periodontitis. Only the plaque index results were consistent with
in this respect. Also, in the mentioned study, like our study, the our study. In other variables, conflicting results were obtained,
gel was placed subgingivally. However, the depth of the primary which may be attributed to the methods of conducting the study
pocket of the teeth was not considered in the mentioned study, and the length of the study.
and any tooth that had a CAL above 3 mm was considered Megha et al. compared chlorhexidine gel and subgingival herbal
eligible for the study and the depth of the pocket of this tooth gel in the treatment of chronic periodontitis. In this study, herbal
may be different (exam-ple: a tooth with a pocket depth of 6 mm gel contained pomegranate extract, Spanish cherry (Mimusops
has a CAL of 3 mm and another tooth with a pocket depth of 1 elengi (Bakul), and Acacia Arabica peel. All the study variables in
mm has a CAL of 3 mm, PPD=5 mm-6 mm, PPD ≥ 7 mm, and the group of Scaling and Root Planing (SRP) with chlorhexidine
CAL ≥ 6 mm). However, in our study, a significant and Scaling Root Planing (SRP) with herbal gel had a significant
improvement in pocket depth occurred in all dental areas with improvement compared to the control group [23]. It is consistent
different pocket depths from 1 mm to 7 mm. with the results of our study. However, in this study, the variables
Hrishi et al. investigated the effect of adjunctive use of of the treatment group of Scaling and Root Planing (SRP) and
green tea toothpaste in patients with periodontitis [18]. The herbal gel and Scaling and Root Planing (SRP) with chlorhexi-
results of the mentioned study in the basic variables of the dine were not compared to see if the herbal gel was superior to
study, includ-ing GI, PI, PD, and CAL, are consistent with chlorhexidine or not. Also, in this study, the herbal gel in addition
those of our study. Although this study had a shorter to pomegranate contained two other plants. Masani et al. investi-
investigation period (4 weeks) than our study, and the method gated the effect of a gel containing Quercus brantii (Iranian oak)
of taking medicine was different from our study (toothpaste and Coriandrum sativum as an adjunctive treatment for Scaling
instead of injecting gel directly) and used toothpaste and Root Planing (SRP) in patients with moderate chronic peri-
containing green tea, which is similar to pome-granate due to odontitis. Quercus brantii and Coriandrum sativum both have
its antioxidant and phenolic properties, its satis-factory results antioxidant, anti-inflammatory, and antibacterial properties and
are not different from our study. Rahimabadi et al. investigated are similar to pomegranate in this respect [24]. No significant dif-
the mouthwash (Punica granatum var pleniflora) to control the ference was found between the control and intervention groups in
gums of diabetic patients [19]. This study investigated the any of the variables. Contradictory results were obtained although
variables relatively similar to the variables investigated in our the selected drug had properties similar to the properties of the
study. Only the gingival index showed a significant drug used in our study, the periods of the study were similar to our
improvement and was in line with our study. However, the study, and the method of transferring the drug to the teeth pockets
results of other vari-ables were inconsistent with the results of was almost similar [24].
our study. Some primary differences between this study and
our study are the method of conducting the study and the CONCLUSION
inclusion and exclusion criteria. In our study, patients with
systemic diseases including diabetes were excluded from the The results of this study indicate that the gel containing pome-
study and the patients participating in our study were suffering granate peel extract can have good therapeutic impacts on plaque
from periodontitis. However, in this study, the patients index, gingival index, gum attachment level, pocket depth, and
suffered from gingivitis. Kiani et al. investigated the effect of bleeding index.
pomegranate seed extract mouthwash on dental plaque and
gingivitis. A total of 104 patients with gingivitis participated in
this study [20]. This study only investigated the plaque index

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 Amoozian P. et al. Evaluation the effectiveness of oral gel…

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