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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 35-42

Efficacy of Carica papaya seed extract on periodontitis: A clinico-microbiological study


Department of Periodontics, Sri Hasanamba Dental College & Hospital, Hassan, Karnataka, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Vivekananda Marenahally Rangaraju
Department of Periodontics, Sri Hasanamba Dental College & Hospital, Vidhya Nagar, Hassan-karnataka-573202.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_28_19

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  Abstract 

Background and Objectives: Human breath is composed of highly complex substances with numerous variable odors, which can generate unpleasant situations such as halitosis. This study aimed to evaluate the clinical and microbiological efficacy of Carica papaya seed extract on clinical parameters, such as gingival index (GI), papillary bleeding index (PBI), probing pocket depth (PPD), and on oral malodor causing organisms, respectively. Materials and Methods: Thirty subjects with oral malodor score ≥3 were selected for the study. Subjects were divided into three groups: Group A––periodontally healthy subjects, Group B––gingivitis subjects, and Group C––periodontitis subjects with PPD ≥5mm. Ultrasonic scaling was performed for all the patients at the baseline and mouthwash was prescribed for 14 days. The clinical parameters such as plaque index (PI), GI, PBI, and PPD were recorded at baseline and 14th day (T14). Benzoyl-dl-arginine-B-naphthylamide (BANA) test and breath checker readings were taken at 0, 14th, and 21st days. Results: At T14, GI, PBI, PPD, malodor scores, and BANA test results showed a statistically significant reduction (P < 0.001) in all the three groups. Regarding the outcome variables, no significant intergroup differences were observed. Conclusion: Herbal mouthwash of dried seeds of C. papaya as an adjunct to scaling provides more favorable approach in the treatment of plaque-induced gingivitis, periodontitis and also oral malodor in all the groups. However, long-term studies with more number of subjects are required to evaluate the efficacy of this herbal mouthwash as an adjunct to scaling.

Keywords: Antimicrobial, benzoyl-dl-arginine-B-naphthylamide, breath checker, Carica papaya, halitosis


How to cite this article:
Rangaraju VM, Mousin S, Babu HM, Dasappa S. Efficacy of Carica papaya seed extract on periodontitis: A clinico-microbiological study. Int J Oral Care Res 2019;7:35-42

How to cite this URL:
Rangaraju VM, Mousin S, Babu HM, Dasappa S. Efficacy of Carica papaya seed extract on periodontitis: A clinico-microbiological study. Int J Oral Care Res [serial online] 2019 [cited 2019 Nov 15];7:35-42. Available from: http://www.ijocr.org/text.asp?2019/7/2/35/265818




  Introduction Top


Periodontitis is characterized by the destruction of supporting structures of teeth following an inflammatory host response secondary to infection by periodontal bacteria as a result of mixed microbial infections within which specific pathogenic bacteria coexist.[1],[2],[3] Malodor is often associated with the presence of these pathogens.

Volatile sulfur compounds (VSCs) produced by Gram-negative anaerobic bacteria are responsible for intra oral halitosis.[4],[5],[6] A number of antimicrobial agents have been used to control this.[7],[8]Carica papaya has proven antibacterial properties against  Escherichia More Details coli,  Salmonella More Details, and Staphylococcus infections.[9],[10] This study aimed to evaluate clinical and microbiological efficacy of C. papaya seed extract.


  Materials and Methods Top


All the 30 participants were given a brief description about the purpose of the study and informed consent was taken from the subjects before undertaking the study.

Source of data

Subjects presenting with malodor to the Department of Periodontics were screened for clinical signs consistent with the diagnosis of chronic generalized gingivitis and chronic generalized periodontitis, and also gingivally healthy subjects were considered for the sample selection. The study was approved by institutional ethical committee.

Method of data collection with sampling procedures, if any

A total of 30 subjects were selected and allotted into the following groups equally:

Group A:Healthy subjects with malodor score ≥3 given by breath checker at the baseline.

Group B:Gingivitis subjects with malodor score ≥3 given by breath checker at the baseline.

Group C:Periodontitis subjects with malodor score ≥3 given by breath checker and probing pocket depth (PPD) >5mm at the baseline.

Subjects in Groups A, B, and C were advised to use 10-mL mouth rinse prepared out of dried seeds of C. papaya twice daily for 14 days and to discontinue the use after 14th day and scaling were performed in all the groups on day 0 (baseline) [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Figure 1: Armamentarium for plaque sample collection

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Figure 2: Benzoyl-dl-arginine-B-naphthylamide kit and analyzer

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Figure 3: Digital breath checker

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Figure 4: Clinical appearance in Group B at the baseline

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Inclusion criteria

The inclusion criteria of the study were as follows:

  1. Subjects with healthy periodontium with chronic generalized gingivitis and chronic generalized periodontitis having a breath checker reading of >3.


  2. Subjects with bleeding on probing present.


  3. Subjects with no oral debridement within the previous six months.


  4. Subjects able or willingness to comply with the study protocol.


  5. Subjects having minimum of 20 teeth.


  6. Subjects with periodontitis having a PPD of >5mm.


Exclusion criteria

The exclusion criteria of the study were as follows:

  1. Subjects with any known systemic diseases or major oral lesions.


  2. Subjects who had received any antibiotic therapy in the last six months.


  3. Subjects who had received any chemotherapeutic mouth rinses and oral irrigation during the past one month.


  4. Subjects who were smokers, alcoholics, and with chewing habits.


  5. Pregnant and lactating females.


  6. Subjects with dietary halitosis from garlic and onion.


  7. Subjects with deep dentinal caries and food lodgment.


  8. Subjects with missing maxillary right first molar.


  9. Subjects unable or not willing to comply with the study protocol.


Immediately after scaling, 14 and 21 days after the treatment, the following clinical parameters were assessed: gingival index (GI; Loe and Sillness, 1963),[11] papillary bleeding index (PBI; Muhlemann, 1977),[12] and PPD. Among these, PPD was assessed using UNC 15 probe.

Oral malodor scores were checked using a breath checker which is an innovative palm-size monitor that detects and measures the presence of breath odors due to VSCs. On turning it on, after the elapse of 5s, start is displayed and the patient has to breathe into the sensor until it beeps (breath for about 4s). The opening has to be 1cm away from the mouth keeping the thumb on to the chin so that the sensor is right in front of the mouth and a reading appears on the digital display. It measures odor in seconds and results are displayed in six levels similar to organoleptic method. A 0 reading means no odor, 1 is slight odor, 2 is moderate odor, 3 is heavy odor, 4 is strong odor, 5 is intense odor, and E is error sign which means try again. Microbiological analysis was done using benzoyl-dl-arginine-B-naphthylamide (BANA) kit. This is a rapid, 5-min, chair side test for the detection of an enzyme in plaque samples that hydrolyze the synthetic peptide BANA. This enzyme is possessed by the three “red complex” anaerobic bacteria associated with adult periodontal disease, that is, Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola. The test kit comprises BANA-ZymeTM processor and BANA-ZymeTM reagent strips.[13]

Mouthwash for the study was prepared out of dried papaya seeds: 1000g, 90% ethanol equivalent for a 2000-mL solution.


  Result Top


The antimicrobial effect of C. papaya seed extract on primary colonizers, such as Streptococcus oralis (MTCC no. 2696) and Streptococcus spp. (MTCC no. 389), was analyzed by determining the minimum inhibitory concentration of the drug. The optimum concentrations required to attain maximum inhibition were recorded and used for the in vivo study.

The mean GI scores at the baseline were 1.624 with standard deviation 0.311 for Group A, 1.507 ± 0.368 for Group B, and 2.2310 ± 0.491 for Group C, respectively [Table 1]. The values after 14 days were 1.142 ± 0.314 for Group A, 0.993 ± 0.35 for Group B, and 1.4083 ± 0.373 for Group C, respectively. The mean reductions in GI score from baseline to 14th day were 0.4820 ± 0.316 for Group A, 0.51400 ± 0.40211 for Group B, and 0.82270 ± 0.39566 for Group C, respectively [Table 1] and [Table 2].
Table 1: One-way analysis of variance (ANOVA)

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Table 2: One-way analysis of variance (ANOVA)

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Statistically significant reduction in GI score was observed in all the three groups at 14th day as compared to baseline, whereas no any statistically significant reduction was observed between the groups. The mean PBI scores at baseline were 1.709 with standard deviation 0.264 for Group A, 1.507 ± 0.362 for Group B, and 2.2750 ± 0.37518 for Group C, respectively. The values after 14 days were 1.178 ± 0.224 for Group A, 1.207 ± 0.270 for Group B, and 1.5850 ± 0.41842 for Group C, respectively [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]. The mean reductions in PBI score from baseline to 14th day were 0.53100 ± 0.22830 for Group A, 0.30010 ± 0.4252 for Group B, and 0.69000 ± 0.33270 for Group C, respectively.
Table 3: Paired test

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Table 4: Friedman’s test

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Table 5: Wilcoxon signed-rank test

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Table 6: Chi-squared test

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Table 7: Paired test

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Statistically significant reduction in PBI score was observed in Groups A and C after 14 days as compared to baseline, whereas the reduction of PBI scores in Group B was not found to be statistically significant. The mean PPD score at the baseline was 6.000 with standard deviation 1.414 for Group C. The value after 14 days was 5.100 ± 1.523. Statistically significant reduction in PPD score was observed in Group C on 14th day as compared to baseline. The mean scores of breath checker readings at the baseline were 3.200 with standard deviation 0.421 for Group A, 3.100 ± 0.316 for Group B, and 3.000 ± 0.000 for Group C, respectively. The values after 14 days were 0.000 ± 0.000 for Group A, 0.100 ± 0.316 for Group B, and 0.000 ±0.000 for Group C, respectively [Tables 3-6]. The values after 21 days were 0.300 ± 0.483 for Group A, 0.700 ± 0.483 for Group B, and 0.500 ± 0.707 for Group C. Breath checker readings were compared between the time intervals.

The result of the BANA test was positive for 30.0% of subjects in Groups A and B, while the same was positive for 50% of subjects in Group C at the baseline. All the positive cases of BANA test became negative after 14 days and remained negative after 21 days, which shows a statistically significant reduction in scores of all the three groups. No statistically significant difference was found between the groups [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]. Statistically significant reduction was noted in malodor scores in all the groups between baseline and 14 days and also between baseline and 21 days. Meanwhile, there was a slight increase in malodor scores between 14 and 21 days but the increase was not found to be statistically significant [Table 11] and [Table 12] [Figure 5] and [Figure 6].{Table 7},
Table 8: Friedman’s test

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Table 9: Chi-squared test

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Table 10: Paired test

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Table 11: Friedman’s test

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Table 12: Chi-squared test

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Figure 5: Clinical changes seen in Group B on 14th day

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Figure 6: Clinical appearance in Group C at the baseline

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  Discussion Top


Periodontitis is an inflammation of the supporting tissues of the teeth. Usually, it is a progressively destructive change leading to the loss of bone and periodontal ligament.[14] Halitosis is formed by volatile compounds such as sulfur compounds, aromatic compounds, nitrogen containing compounds, amines, short-chain fatty acids, alcohols or phenyl compounds, aliphatic compounds, and ketones. Halitosis is a concern for millions of people, affecting interpersonal social communication with ensuing personal discomfort and social embarrassment. Use of mouth rinses with antimicrobial activity has been effective for controlling the colonization of oral bacteria, including periodontopathogens, and for reducing gingival inflammation.[15] But topical antimicrobial rinses containing chlorhexidine have restrictions owing to potential side effects, including staining and erosive and abrasive effects, as well as limitations on dosage scheduling.[16],[17]

Thus, there is a need to investigate the new formulations with similar or superior efficacy and possibly fewer side effects. Various herbal products and their extracts have shown significant advantages over the chemical ones. Several authors have evaluated the anti-inflammatory and antimicrobial properties of C. papaya seed extract. However, none of the studies to the best of authors’ knowledge have evaluated these properties of C. papaya on oral microbiota and malodor. Hence, the present randomized clinical trial was undertaken to assess and compare the anti-inflammatory and antimicrobial efficacy of C. papaya on periodontal pathogens as an adjunct to scaling. The result of this study showed a significant reduction in oral malodor, a marked improvement in clinical parameters of inflammatory periodontal, and gingival diseases. This depicts the anti- inflammatory properties of C. papaya seed extract. There is a marked improvement in the BANA scores depicting antimicrobial property of C. papaya seed extract in vivo.[18] [Figure 7],[Figure 8],[Figure 9],[Figure 10] Tannins have astringent properties that hasten the healing of wounds and inflamed mucous membrane. The presence of tannins in the seed of C. papaya can support its strong use in herbal medicines for healing of wounds and ulcers. The proportionate high amount of tannins in the seeds of C. papaya explains its strong antimicrobial activity. Tannins are metal chelators and can form complexes with macro molecule. Through this process, essential substrates, cofactor, and enzymes of microorganism are depleted leading to cell death.[19]
Figure 7: Clinical changes seen in Group C on 14th day

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Figure 8: Graphical representation of comparison of breath checker readings, depicted along y axis, and time interval along the x axis among Groups A, B, and C

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Figure 9: Graphical representation of comparison of gingival index (GI), depicted along y axis, and time intervals of baseline and after 14 days along x axis, among Groups A, B, and C

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Figure 10: Graphical representation of comparison of papillary bleeding index scores (PBI), depicted along y axis, and time intervals of baseline and 14 days along x axis, among Groups A, B, and C

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In this study, the use of C. papaya mouthwash as an adjunct to scaling was found to be more effective in treating malodor in subjects with healthy periodontium as well as subjects with gingivitis and periodontitis. Assessment of herbal mouthwash was found to be beneficial based on the clinical parameters and microbiological parameters of gingival inflammation and bleeding from gingiva. This anti-inflammatory, wound healing, antimicrobial properties would be attributed to the activity of active ingredients present in the mouthwash. Hence, the results of this study suggest that herbal mouthwash as an adjunct to scaling provides more favorable approach in the treatment of plaque-induced gingivitis, periodontitis, and oral malodor in all the groups studied.


  Conclusion Top


The study shows that all the three groups showed a statistically significant improvement in the clinical and microbiological parameters and a reduction in halitosis after intervention. Even though statistically irrelevant, there was an increase in breath checker scores on the 21st day, that is, 7 days after quitting the mouthwash use. Therefore, this study indicates that the use of C. papaya mouthwash as an adjunct to scaling provides more favorable approach in the treatment of plaque-induced gingivitis and periodontitis and also in reducing oral malodor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

We would like to thank our volunteers for their participation in this study and DR.Praveen.G Bio-statistician, Associate professor, Dept of Public Health Dentistry, Sri Hasanamba dental college and hospital Hassan, India, for his valuable assistance in statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ayanfemi AB, Bukola AO Antibacterial activity of Carica papaya leaves and seed extracts on some bacteria and their phytochemical characterization. Int J Bot Res 2015;5:15-22.  Back to cited text no. 9
    
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Mühlemann HR. Psychological and chemical mediators of gingival health. J Prev Dent 1977;4:6-17.  Back to cited text no. 12
    
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Loesche WJ, Bretz WA, Kerschensteiner D, Stoll J, Socransky SS, Hujoel P, et al. Development of a diagnostic test for anaerobic periodontal infections based on plaque hydrolysis of benzoyl-DL-arginine-naphthylamide. J Clin Microbiol 1990;28:1551-9.  Back to cited text no. 13
    
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Feng Z, Weinberg A Role of bacteria in health and disease of periodontal tissues. Periodontol 2000 2006;40:50-76.  Back to cited text no. 14
    
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Wennstrom J, Lindhe J The effect of mouthrinses on parameters characterizing human periodontal disease. J Clin Periodontol 1986;13:86-93.  Back to cited text no. 15
    
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Hepso HU, Bjornland T, Skoglund LA Side-effects and patient acceptance of 0.2% vs. 0.1% chlorhexidine used as postoperative prophylactic mouthwash. Int J Oral Maxillofac Surg 1988;17:17-20.  Back to cited text no. 16
    
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Pontefract H, Hughes J, Kemp K, Yates R, Newcombe RG, Addy M The erosive effects of some mouthrinses on enamel: A study in situ. J Clin Periodontol 2001;28:319-24.  Back to cited text no. 17
    
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Okoye EI Preliminary phytochemical analysis and antimicrobial activity of seeds of Carica papaya. J Basic Phys Res 2011;2:66-9.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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