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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 59-65

Coconut oil pulling – The holistic medicine: Evaluation of efficacy of coconut oil pulling therapy as an adjunct to scaling in diabetic patients with chronic gingivitis – A clinical and microbiological study


1 Department of Periodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India
2 Department of Biotechnology, KET's V.G.Vaze College, Mumbai, Maharashtra, India
3 Department of Microbiology and Plant Biotechnology, KET's Scientific Research Centre, Mumbai, Maharashtra, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Shraddha Kode
S/3 “A” Chitralekha, Vikram Nagar, Kalwa West, Thane - 400 605, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_77_18

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   Abstract 


Context: Oil pulling is the traditional medicine practised in ancient India. Limited scientific data is present illustrating the role of oil pulling. Therefore, we conducted a study to introduce a natural ingredient which can be used as an adjunct in diabetic patients. Aim: To evaluate the efficacy of Coconut Oil as an adjunct to scaling in diabetic patients with chronic gingivitis. Material and Methods: 60 Diabetic patients with Chronic Gingivitis were divided into 3 groups: Group A: Scaling and root planing only (n=20), Group B: Scaling and root planing followed by Coconut Oil Pulling Therapy (n=20) and Group C: Scaling and root planing followed by rinsing with 0.2% Chlorhexidine mouthwash (n=20). The following clinical parameters were recorded at baseline after SRP and 15 days post-treatment : Plaque index (P.I.), Gingival index (G.I.) & Total colony forming units (CFU/ml). Results: The method used for statistical analysis was repeated measure ANNOVA followed by post-hoc test. The results of the study demonstrated the difference in the reduction of all the scores to be clinically significant and not statistically significant. Conclusion: Thus, this study shows the positive effects of coconut oil pulling in the control and prevention of progression of gingival disease.

Keywords: Coconut, diabetes, gingivitis, oil, oil pulling


How to cite this article:
Kode S, Kamble P, Karkhanis D, Khan R. Coconut oil pulling – The holistic medicine: Evaluation of efficacy of coconut oil pulling therapy as an adjunct to scaling in diabetic patients with chronic gingivitis – A clinical and microbiological study. J Interdiscip Dentistry 2019;9:59-65

How to cite this URL:
Kode S, Kamble P, Karkhanis D, Khan R. Coconut oil pulling – The holistic medicine: Evaluation of efficacy of coconut oil pulling therapy as an adjunct to scaling in diabetic patients with chronic gingivitis – A clinical and microbiological study. J Interdiscip Dentistry [serial online] 2019 [cited 2019 Dec 16];9:59-65. Available from: http://www.jidonline.com/text.asp?2019/9/2/59/268375




   Clinical Relevance to Interdisciplinary Dentistry Top


  • The community can benefit from the use of coconut oil which is a natural ingredient to resolve the inflammation and prevent further progression of gingival disease
  • Coconut oil can be used as a safe adjunct to scaling in diabetic patients with chronic gingivitis for control or regression of gingival inflammation
  • Coconut oil pulling is a home-based remedy which is beneficial to the society in preventing the adverse effects of gingival diseases, and thus improves the quality of life.



   Introduction Top


Oil pulling is an ancient practice that is receiving renewed interest due to its use as an adjunct in peoples' oral hygiene routine.[1] To reduce the side effects of modern medicine, people are increasingly shifting toward ancient medicine. Oil pulling has proven to be the home-based remedy due to its beneficial effects on general and oral health. In 1990's, in the Union of Soviet Socialist Republics, Ukranian Physician Dr. F. Karach popularized this procedure as oil pulling by proclaiming that he cured himself from a blood disease after experimenting with oil swishing. Hence, oil pulling is also known as Karach's therapy after its discoverer.[2],[3]

In ancient times, it was practiced as kavala graha and kavala gandoosha.[3],[4] Kavala graha or gandoosha is an Ayurvedic oral hygiene maintenance practice, wherein suitable amount of oil is held in the mouth on an empty stomach for some period of time and swished till it becomes thin and milky white after which it is spit out. Kavala graha involves comfortable amounts of oil and kavala gandoosha involves mouthful of oil used for swishing.[5],[6],[7]

Oil pulling should ideally be performed on an empty stomach and care should be taken that oil is not swallowed since the pulled oil contains bacteria and toxins.[1],[8],[9],[10] Oil pulling should best be practiced in sitting position with chin up.[8] It is usually contraindicated for children <5 years of age due to increased risk of aspiration of oil.[9],[10]

The aim of the study was to evaluate the clinical and microbiological efficacy of coconut oil pulling as an adjunct to scaling in diabetic patients with chronic gingivitis. In diabetic patients due to impaired wound healing and difficulty in adequately removing plaque by mechanical means, a great interest has been ensued in the use of adjuncts to mechanical approaches. Chlorhexidine has been so far considered as the gold standard treatment due to its superior antiplaque effect.[11] But due to the reported side effects, search for an alternative product continues and natural products are considered as good alternatives to these chemicals.[12]


   Subjects and Methods Top


This was a clinical, interventional, case–control, open-labeled, single-center study involving use of coconut oil and chlorhexidine mouthwash after scaling. The study was approved by the Ethics Committee and registered with the Clinical Trials Registry (CTRI/2018/03/012689).

A total of 60 patients in the age group of 25–70 years with chronic gingivitis and controlled diabetes (on oral hypoglycemic drugs) with glycosylated hemoglobin (HbA1c) levels <7 were selected. The patients on insulin therapy, pregnant and lactating mothers, patients with drug allergy, and any systemic disease or adverse habits were excluded from the study.

The patients fitting the inclusion criteria were divided into three groups using computer0assisted randomization method as follows [Figure 1]:
Figure 1: Schematic diagram showing three groups of patients fitting inclusion criteria

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  1. Group A – Scaling and root planing (SRP) only (n = 20)
  2. Group B – SRP followed by coconut oil pulling therapy (n = 20)
  3. Group B – SRP followed by rinsing with 0.2% chlorhexidine mouthwash (n = 20).


The following clinical parameters were recorded at baseline before SRP and 15 days posttreatment:

  1. Plaque index (PI) (Turesky–Gilmore-–Glickman Modification of Quigley–Hein, 1970)
  2. Gingival index (GI) (Loe and Silness, 1963)
  3. Total colony-forming units (CFU/ml).


Following the initial examination and assessment of HbA1c levels of diabetic patients with chronic periodontitis, baseline levels were recorded, and then, the patients were divided into three groups. SRP was performed on all the patients using ultrasonic scaler. Group B and Group C patients were given coconut oil sachets and chlorhexidine mouthwash bottles, respectively. The patients were recalled after 15 days to record the clinical parameters. Oral hygiene methods were standardized by providing standard toothpaste and standard toothbrush using modified Bass technique of tooth brushing twice daily.

In Group A, the control group was subjected to only SRP.

In Group B, the test group was instructed to perform oil pulling with coconut oil, one tablespoon of coconut oil on an empty stomach first thing in the morning for the next 15 days after undergoing SRP. The coconut oil was sipped, sucked, and pulled between the teeth for 15 min with rest in between. The swished oil was asked to be withdrawn into a glass and then again swished to avoid jaw ache and fatigue till the viscous oil turned thin and milky white. This oil was told not to be swallowed as it contains bacteria and toxins. Oil pulling therapy was instructed to be preferably done on an empty stomach in the morning, followed by brushing of the teeth for its maximum action.

In Group C, the control group was instructed to rinse with 0.2% Chlorhexidine mouthwash (Hexidine®, ICPA, Mumbai) for 30 s, twice daily for the next 15 days along with SRP.

For assessing the microbiological efficacy, two samples were selected for aerobic and anaerobic microorganisms processing. The patients were instructed to wash their mouth using physiological saline. This saline was collected in a sterile container and serially diluted and placed in Mueller Hinton agar plates [Figure 2]. The agar plates were incubated at 37°C for 48 h for aerobic sample processing. After the incubation period, the number of colonies present in 1 ml of saliva was calculated by the formula:
Figure 2: Sample collection for microbiological efficacy

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Number of bacteria/ml = Number of colonies × dilution factor × amount plated

For anaerobic sample processing, the teeth surfaces were dried using gauze piece to prevent saliva contamination. Subgingival samples were collected from four different sites using sterile Gracey curette by inserting it into the deepest portion of the gingival sulcus parallel to the long axis of the tooth and moving coronally by scraping along the tooth surface. They were then transferred to vials containing enriched Robertson's cooked meat broth for maintaining its viability during transport. This sample was then processed under anaerobic conditions on anaerobic blood agar plates [Figure 2]. For maintaining anaerobic conditions, anaerobic jar with anaerobic gas generating system (GasPak) was used for 37°C for 48–72 h.


   Results Top


It was observed that coconut oil pulling led to the improvement of oral health status. All the three groups showed significant difference in all the parameters measured at baseline and after 15 days. The statistical analysis method used was repeated-measure ANOVA followed by post hoc test.

The mean baseline PI scores were 3.28 (±0.48), 2.93 (±0.32), and 3.18 (±0.40) for Groups A, B, and C, respectively. The mean baseline GI scores were 1.92 (±0.20), 1.86 (±0.18), and 1.96 (±0.23) for Groups A, B, and C, respectively. The PI scores reduced to 2.62 (±0.52), 1.76 (±0.44), and 1.68 (±0.50) in Groups A, B, and C, respectively. Similarly, the GI scores reduced to 1.52 (±0.26), 1.18 (±0.19), and 0.92 (±0.22) in Groups A, B, and C, respectively. Thus, the results obtained showed that there was a significant reduction in Groups B and C posttreatment as compared to Group A [Table 1], [Table 2], [Table 3] and [Figure 3], [Graph 1] and [Graph 2].
Table 1: Significant reduction in the plaque index scores posttreatment

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Table 2: Significant reduction in the gingival index scores posttreatment

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Table 3: Percentage reduction in plaque index and gingival index scores posttreatment

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Figure 3: Improvement of clinical parameters in all the three groups posttreatment

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The aerobic colony-forming units also showed a significant reduction in Groups B and C posttreatment as compared to Group A. The baseline aerobic colony-forming units were 4.98 × 106, 4.13 × 106, and 4.59 × 106 CFU/ml for Groups A, B, and C, respectively. They reduced to 3.92 × 106, 2.42 × 106, and 2.95 × 106 CFU/ml in Groups A, B, and C, respectively. Thus, the microbiological results obtained showed that there was a significant reduction in Groups B and C posttreatment as compared to Group A [Table 4] and [Figure 4] and [Graph 3].
Table 4: Significant reduction in the aerobic colony-forming units posttreatment

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Figure 4: Significant reduction in aerobic colony-forming units posttreatment

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The anaerobic sample showed comparatively the same type of pinpoint colonies posttreatment. However, the matt texture of the colonies was reduced. There was reduction in the count seen visibly; however, the counts were not in the countable range [Figure 5].
Figure 5: Significant reduction in anaerobic colony-forming units posttreatment

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The scores were statistically assessed using repeated-measure ANOVA by post hoc test. The difference in the reduction of all the scores was found to be clinically and statistically significant (P ≤ 0.05) [Table 5].
Table 5: Comparison between experimental groups

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   Discussion Top


Plaque-induced gingivitis is the result of an interaction between plaque and the tissues and the inflammatory response of the host. It is associated with subtle microbial alterations as the plaque matures.[13],[14] Oral hygiene measures reduce the incidence of plaque-induced gingivitis by decreasing plaque accumulation. Teshome and Yitayeh, 2016, in a systematic review and meta-analysis showed significant reduction of glycated hemoglobin and fasting plasma glucose level on type 2 diabetic and periodontal patients present with nonsurgical periodontal therapy.[15]

Oil pulling is a folk remedy which is not widely practiced and lacks scientific basis. A systematic review by Bekeleski et al. in 2012 shows that oil pulling has certain benefits over commercially available mouthrinses such as nonchemical, nonalcoholic, low cost, and nonstaining, yet the effectiveness and the mechanism of action are unclear.[16] Whereas, a systematic review by Gbinigie et al. in 2016 shows that oil pulling may be as effective as chlorhexidine on certain oral hygiene markers and could serve as a low adjunct to toothbrushing.[17]

Similarly, this study shows oil pulling therapy to be as effective as chlorhexidine mouthwash in diabetic patients with chronic gingivitis. However, oil pulling does not replace dental therapy and is currently not recommended by the American Dental Association as the sole treatment.[18]

Chalke et al. 2018 in a clinical study concluded that significant decrease in pre- and post-treatment scores of PI and GI was noticed from baseline to 15th and 30th day by an ancient oil pulling method using coconut oil.[19] An interventional study by Kaliamoorthy et al. 2018 stated that coconut oil is very effective compared to sesame oil in the reduction of severity of gingivitis.[20]

Various types of oils such as sesame, coconut, sunflower, corn, soya bean, palm, rice bran, and olive oil can be used for oil pulling.[21],[22],[23],[24],[25] Coconut oil has been proved to have wonderful effects on oral health. It contains predominantly medium-chain fatty acids of which 45%–50% include lauric acid which is otherwise present in such great amounts in breast milk. Lauric acid is also known for its anti-inflammatory and antimicrobial properties.

Other oils contain long-chain fatty acids which are not metabolized as easily as medium-chain fatty acids, and hence, stored as fat. This changes the property of coconut oil. The other chemical constituents in coconut oil include myristic acid, caprylic acid, capric acid, caproic acid, palmitic acid, palmitoleic acid, stearic acid, and linoleic and oleic acid. A study by Peedikayil et al. in 2015 showed the effectiveness of oil pulling with coconut oil as an adjuvant to brushing in decreasing plaque accumulation and plaque-induced gingivitis.[3]

Coconut oil is also effective against  Escherichia More Details vulneris, Helicobacter pylori, Staphylococcus aureus, and predominantly against Candida albicans and Streptococcus mutans species.[18],[26],[27] Hence, we conducted a study using coconut oil as an adjunct to scaling in diabetic patients with chronic gingivitis.

Many hypotheses have been put forward regarding the mechanism of action of oil pulling which are as follows:

  1. Oil swishing action generates mechanical shear forces due to agitation which results in emulsification of oil. This further increases the surface area of oil and thus forms a thin film of oil over the tooth surface which can reduce plaque adhesion and bacterial coaggregation[28]
  2. Alkalis in saliva react with oil to result in saponification or soap-like substance formation which has a cleansing action. This reduces the plaque adhesion[29]
  3. Oil pulling results in significant reduction in gingivitis due to decreased plaque accumulation, emollient, and anti-inflammatory action
  4. Oil pulling activates salivary enzymes, and this absorbs all the toxins from the blood and brings it to the oral cavity, thus getting rid of them. However, oral mucosa is not a semipermeable membrane. Hence, this theory remains questionable.


The coconut oil chosen for the study involved refined, cold-pressed, and easily available Parachute® oil (Marico Company). Cold-pressed oil retains the nutrition, aroma, and flavor. Trans fats are absent in cold-pressed oil. Hence, oil pulling is best performed using cold-pressed oils.[2] Parachute® oil is a purely edible oil, completely natural with no additives, and Good Manufacturing Practice certified.

The disadvantages of oil pulling involved oily bland taste and jaw ache after swishing for 10–15 min. The complications of oil pulling could involve aspiration of microorganisms rich oil to resulting in lipoid pneumonia.[30]

Limitations of the study involved short sample size and short duration of follow-up. Therefore, extensive studies with larger samples, varying time periods, and long follow-up times should be carried out to establish the efficacy of oil pulling therapy.

Furthermore, although culture methods are considered to be the gold standard, the drawback involves that only cultivable bacteria can be cultured. Therefore, advanced molecular techniques are required for noncultivable and unidentified pathogens. Identification of specific microorganisms should be encouraged using special media, biochemical tests, and antimicrobial discs. This should be borne in mind by investigators in further studies.

Coconut oil pulling has following advantages over chlorhexidine mouthwash – no staining, no lingering after taste, no allergy, easily available, cost-effective, and better patient compliance. Thus, to avoid the deleterious effects of chemicals, it is better to switch to nature for its goodness.


   Conclusion Top


Based on the currently available research, it can be concluded that oil pulling can be safely used as an adjunct to maintain good oral hygiene. This study proved that oil pulling therapy has clinically significant effect on chronic gingivitis in diabetic patients. Hence, if practiced daily, it can be developed into a healthy oral hygiene habit. Thus, there is a need to promote awareness among people of the long-lost practice of oil pulling.

Acknowledgments

We would like to thank Dr. Nikita Patil for her assistance in the sample collection. Our sincere thanks to the Scientific Research Centre, Mithagar Road, Mulund, for the microbiological sample processing. We would like to extend our thanks to ICPA Company, Andheri, for supplying the chlorhexidine mouthwash used for this study and all the participants who willingly participated in this study.

Financial support and sponsorship

Chlorhexidine mouthwash (Hexidine®) sponsored by ICPA company, Andheri.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 5], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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