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ORIGINAL ARTICLE

A comparative evaluation of efficacy of Punica

granatum and chlorhexidine on plaque and
gingivitis
Sakshi Ahuja, Vidya Dodwad, Bhavna Jha Kukreja, Praful Mehra1, Pankaj Kukreja2
Departments of Periodontics, 1Prosthodontics, and 2Oral and Maxillofacial Surgery, ITS-CDSR, Muradnagar, Ghaziabad, Uttar Pradesh, India

ABSTRACT
Background: Periodontal diseases are chronic bacterial infections that lead to gingival inflammation,
periodontal tissue destruction, and alveolar bone loss. Acting as powerful allies in the fight against periodontal
disease, natural compounds can help safeguard against lethal age-related diseases that emanate from our
mouths. Punica granatum (pomegranate) shrub belongs to the Punicaceae family which has been used as Access this article online

an astringent, hemostatic, antidiabetic, antihelmintic, and also for diarrhea and dysentery. The aim of the Website: www.jicdro.org
present work was to investigate the possible efficacy of hydroalcoholic extract from Punica granatum fruit as DOI: 10.4103/2231-0754.115776
an antiplaque and antigingivitis agent when compared with chlorhexidine. Materials and Methods: Twenty Quick Response Code:
subjects diagnosed with chronic generalized gingivitis were selected and randomly divided into two groups:
Group 1 – Pomegranate mouthwash and Group 2 – Chlorhexidine mouthwash. Punica granatum mouthwash
was prepared using raw Punica granatum fruit. Patients were instructed to use the prescribed mouthwash
for 15 days. Clinical evaluation was undertaken using the gingival index, the plaque index, and bleeding on
probing at baseline, 7 days, and 15 days. Results: The clinical study observed significant improvement in
gingival status in both the sites (P<0.05). Subjects using Punica granatum mouthwash showed significant
improvement in bleeding and gingivitis score as compared with chlorhexidine. In contrast, Punica granatum
was shown not to be so effective in reducing plaque scores. Chlorhexidine still remains as a standard in
the reduction of plaque in subjects with gingivitis. Conclusion: Punica granatum mouthwash is beneficial
in improving gingival status due to its profound styptic action, with sufficient reduction in plaque scores.

Key words: Chlorhexidine, gingivitis, mouthwash, Punica granatum, plaque

INTRODUCTION agents such as triclosan, essential oils, and chlorhexidine have

Gingivitis is a chronic inflammatory process limited to the
gingiva without either attachment loss or alveolar bone
loss. It is one of the most frequent oral diseases, affecting
more than 90% of the population, regardless of age, sex, or
race.[1] Plaque is the primary etiological factor in gingival
inflammation.[2] So, daily and effective supragingival plaque
control using tooth brushing and dental floss is necessary to
arrest its progression to periodontitis.
Although mechanical plaque control methods have the
potential to maintain adequate levels of oral hygiene,
studies have shown that such methods are not being
employed accurately.[1] Therefore, several chemotherapeutic
Address for correspondence:
Dr. Sakshi Ahuja, B-43, Sarvodaya Enclave,
New Delhi - 110017, India
E-mail: dr.sakshiahuja@gmail.com
been developed to control bacterial plaque. Among these,
chlorhexidine has been the gold standard since ages due to
its profound antibacterial and antiplaque activity.
As a consequence of the side effects of chlorhexidine, various
herbal products (like Astronium urundeuva, Calendula, Aloe vera,
Curcuma zedoaria) have been tested with effective results.
Among these, one of the recent herbal products is Punica
granatum, which literally translates to seeded (“granatus”) apple
(“pomum”). Punica granatum Linn belongs to family Punicaceae,
mostly known as “pomegranate.” It is a shrub native from Asia
where several of its parts have been used as an astringent,
haemostatic, and for diabetes control.[3] The genus name,
Punica, was the Roman name for Carthage, where the best
pomegranates were known to grow. The aim of the present
work was to investigate the possible efficacy of hydroalcoholic
extract (HAE) from Punica granatum fruit as an antiplaque and
antigingivitis agent when compared with chlorhexidine.

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Ahuja, et al.: Efficacy of Punica granatum and chlorhexidine on plaque and gingivitis

MATERIALS AND METHODS
This study was conducted in ITS-CDSR on 20 voluntary patients
from both sexes (10 females and 10 males), age ranging from
14 to 25 years, with moderate gingivitis. Patients with systemic
disorders, subjects under antimicrobial therapy, smokers, and
pregnant women were excluded from the study. Individuals
were given the same type of toothbrush and toothpaste with
standardized brushing technique instructions. After thorough
scaling and polishing, the subjects were randomly distributed
into the following 2 groups:
• Group 1 (n = 10): Subjects were instructed to use 10 ml
of Punica granatum mouthwash twice daily for 15 days.
• Group 2 (n = 10): Subjects were instructed to use 10 ml
of 0.2% chlorhexidine mouthwash (HEXIDINE by ICPA)
twice daily for 15 days.
was seen in chlorhexidine group, i.e., from 1.641 ± 0.1761 at
baseline to 1.295 ± 0.1686 at 7 days and 0.991 ± 0.2393 at
15 days with % reduction of 21.04% and 39.61%, respectively
(P<0.05). Hence, pomegranate mouthwash was a more
effective antigingivitis agent as compared with chlorhexidine
[Table 1 and Figure 2].
Plaque Index
Comparison of Plaque index between pomegranate and
pomegranate mouthwash revealed that significantly more
reduction in plaque score was seen in chlorhexidine group

Preparation of Punica granatum mouthwash

The HAE was prepared from whole fresh fruits (4-5 fruits)
that were cut into small pieces and blended with a mixture
of ethanol and distilled water (1 : 1, v/v). The material was
filtered through several layers of gauze, and evaporated at
60°C to one-third of its original volume or until all the ethanol
evaporated. The volume was restored with distilled water,
and 1 ml sample was completely evaporated in the oven, in
order to get the insoluble residues/ml (used to express the
final hydroalcoholic concentration, which ranged between Figure 1: Preparation of Punica granatum mouthwash
50 and 60 mg/ml), which was further used to adjust the
concentration of mouthwash [Figure 1]. Table 1: Gingival index of Punica granatum and chlorhexidine
group at baseline, 7th day, and 15th day
Data were collected at baseline, 7 days, and 15 days utilizing
Group Time Mean ± SD % Reduction P value
the indices, i.e.,
Punica granatum 0 Day 1.653 ± 0.1675 -
• Plaque index by Turskey Gilmore Glickman modification 7 Day 1.211 ± 0.1081 26.74 <0.05
of Quigley Hein plaque index,[4] 15 Day 0.928 ± 0.1823 43.86 <0.05
Chlorhexidine 0 Day 1.641 ± 0.1761 -
• Gingival index by Loe and Silness[5] and 7 Day 1.295 ± 0.1686 21.09 <0.05
• Bleeding on probing by Ainamo and Bay.[6] 15 Day 0.991 ± 0.2393 39.61 <0.05

Statistical Analysis
Student t test was used for inter-group and intra-group
comparison. P value was adjusted at <0.05.

RESULTS
A total of 20 participants (10 females and 10 males)
participated in the study with the mean age of 21.3 ± 0.2134
years without any dropouts.

Gingival Index
On analyzing the gingival index, it was seen that both
the groups led to significant reduction in gingival scores
(P<0.05). Mean decrease in pomegranate group was from
1.653 ± 0.1675 at baseline to 1.211 ± 0.1081 at 7 days and
0.928 ± 0.1823 at 15 days with % reduction of 26.74% and Figure 2: Comparison of plaque index between Punica granatum and
43.86%, respectively (P<0.05). Significantly less reduction chlorhexidine mouthwash within 15 days

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Ahuja, et al.: Efficacy of Punica granatum and chlorhexidine on plaque and gingivitis

as compared with pomegranate [P<0.05; Table 2 and Figure Table 2: Plaque index of Punica granatum and Chlorhexidine
3]. Mean ± SD for pomegranate group has decreased from group at baseline, 7th day, and 15th day
3.941 ± 0.257 at baseline to 3.498 ± 0.4206 at 7 days and Group Time Mean ± SD % Reduction P value

3.069 ± 0.4577 at 15 days with % reduction of 11.24% and Punica granatum 0 Day 3.941 ± 0.257 -
7 Day 3.498 ± 0.4206 11.24 <0.05
22.13%, respectively (P<0.05). Significantly greater reduction 15 Day 3.069 ± 0.4577 22.13 <0.05
was seen in chlorhexidine group, i.e., from 3.882 ± 0.42918 Chlorhexidine 0 Day 3.882 ± 0.42918 -
7 Day 3.26 ± 0.4356 16.02 <0.05
at baseline to 3.26 ± 0.4356 at 7 days and 2.667 ± 0.6360 15 Day 2.667 ± 0.6360 31.3 <0.05
at 15 days with % reduction of 16.02% and 31.3%, respectively
(P<0.05).

Bleeding on Probing
Analysis of bleeding on probing revealed mean decrease
in pomegranate group from 0.77 ± 0.0948 at baseline to
0.26 ± 0.843 at 7 days and 0.14 ± 0.069 at 15 days with %
reduction of 66.2% and 81.8%, respectively (P<0.05). Lesser
reduction in bleeding scores was seen in chlorhexidine group,
i.e., from 0.781 ± 0.0952 at baseline to 0.529 ± 0.09983
at 7 days and 0.293 ± 0.578 at 15 days with % reduction
of 32.27% and 62.48%, respectively (P<0.05). Pomegranate,
being a profound styptic, leads to significant reduction in
bleeding on probing as compared with chlorhexidine [Table
3 and Figure 4].

DISCUSSION Figure 3: Comparison of gingival index between Punica granatum and

chlorhexidine mouthwash within 15 days
Though around 6 000 plants in India are used in herbal
medicines, little research has been conducted on efficacy,
safety, and properties of herbal products. Over the decades, Table 3: Plaque index of Punica granatum and chlorhexidine
very few studies have been conducted to show the clinical group at baseline, 7th day, and 15th day
efficacy of Punica granatum. In the present study, it was Group Time Mean ± SD % Reduction P value

demonstrated that hydroalcoholic extract from pomegranate Punica granatum 0 Day 0.77 ± 0.0948 -
7 Day 0.26 ± 0.843 66.2 <0.05
fruit exerted a significant reduction in clinical parameters. 15 Day 0.14 ± 0.069 81.8 <0.05
Chlorhexidine 0 Day 0.781 ± 0.0952 -
Analysis of plaque index values suggests that both the 7 Day 0.529 ± 0.09983 32.27 <0.05
15 Day 0.293 ± 0.578 62.48 <0.05
mouthwashes were helpful in reducing it but chlorhexidine
reduced plaque scores to greater extent as compared
with pomegranate mouthwash group. These findings are
in agreement with the studies by Overholser et al.[7] and
Haffajee et al.[8] In a microbiological study, Menezes et al.
showed that after 1 minute mouth rinsing, more reduction in
plaque was observed with Punica granatum (84%) as compared
with chlorhexidine (79%),[3] contradicting our results. The
differences in the results may be because of difference in
the methodology employed, i.e., instead of plaque index,
colony-forming units were taken into consideration. Another
reason could be that the duration of their study was very
short and they recorded reduction only after a single mouth
rinsing session.

Analysis of gingival index scores revealed that Punica

granatum was more efficient in reducing gingival score and Figure 4: Comparison of bleeding on probing between Punica granatum and
bleeding on probing as well due to its strong styptic action. chlorhexidine mouthwash within 15 days

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Ahuja, et al.: Efficacy of Punica granatum and chlorhexidine on plaque and gingivitis
Similar results were reported by Hafajee et al.[8] A study by
Salgado et al. in 2006 on 10% Punica granatum gel does not
support our finding as this gel was not efficient in preventing
supragingival dental plaque formation and gingivitis.[1] Gel
was placed into tooth shield in a non-diluted form; it may
be speculated that gel solubilization with saliva would be
necessary for its antimicrobial action to take place. In our
study, direct interaction of saliva to Punica granatum led to
acceptable results.
In an urge of looking for better antiplaque and antigingivitis
agents with limited side effects as compared with
chlorhexidine, various herbal products have been tried with
fruitful results. Punica granatum is a recent herbal product
used in field of dentistry. So, more clinical and microbiological
studies on a long-term basis are required to know the precise
effectiveness of this product.
CONCLUSION
In the absence of vigilant oral care, plaque and tartar will
build up, resulting in gingivitis and possibly progressing to
periodontitis. So, various herbal products have been tried
and have shown promising results with minimal side effects.
Also, their additional effect on inflammatory pathways and
antioxidant potential make them eligible to be used as
effective antigingivitis agents. An explosion of interest in the
numerous therapeutic properties of Punica granatum over the
last decade has led to numerous in vitro, animal, and clinical
trials. Our study concluded that Punica granatum is a better
antigingivitis agent than chlorhexidine, but not as effective
against dental plaque as chlorhexidine. The treatment with
Punica granatum could be used as it is easy to prepare, has
profound styptic action, and shows acceptable reduction in
32 Journal of the International Clinical Dental Research Organization | January-April 2011 | Vol 3 | Issue 1
plaque scores. More clinical trials are required to know the
effectiveness of Punica granatum and its advantage over the
prototype chemical plaque control agent, i.e., chlorhexidine,
which is still a gold standard for reduction of plaque scores.
ACKNOWLEDGMENT
Our sincere thanks to Dr. Y Kumar, Director and Head of Department,
Department of Pharmacy of I.T. S dental college, for helping us
prepare the pomegranate mouthwash.
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Cite this article as: Ahuja S, Dodwad V, Kukreja BJ, Mehra P, Kukreja P. A
comparative evaluation of efficacy of Punica granatum and chlorhexidine on
plaque and gingivitis. J Int Clin Dent Res Organ 2011;3:29-32.
Source of Support: Nil. Conflict of Interest: None declared.