Traditional therapies in themanagement of periodontaldisease in India and China

NI T I S H SU R A T H U & AR U N V. KU R U M A T H U R

The practice of medicine has evolved over many

centuries to reach its current state. A recent survey

conducted by the World Health Organization esti-

mated that almost 70–80% of the population in the

developing world has resorted to traditional practices

for treatment of a variety of ailments (87). The pop-

ulations of the two most populous countries in the

world, China and India, have practised traditional

medicine for the management of oral diseases,

including periodontal disease, for well over

2000 years. Furthermore, as group living is still the

norm rather than the exception in both countries,

customs and practices have been preserved over the

generations. Thus, the World Health Organization

statistics are likely to be valid for periodontal dis-

eases. In a recent survey of a Chinese population, it

was concluded that more than 50% of the rural adult

population preferred to either ignore symptoms such

as gingival bleeding or try traditional treatments be-

fore approaching dental surgeons (95). Reliable sta-

tistics are not available for the Indian sub-continent,

but an Indian Dental Association survey reported that

only 25% of the rural Indian population sought

professional dental advice (19, 30, 49).

Unfortunately, most traditional techniques are

based on anecdotal experience rather than evidence-

based practice. Consequently, a comparative evalu-

ation of the efficacy and limitations of these practices

is almost impossible. However, the influence of these

traditional practices should not be ignored, especially

in a country such as India where almost 30% of the

population have no access to dental care (19, 30).

Given the almost bewildering range of techniques

and herbal products that are used to treat periodontal

disease, a fully comprehensive review is not possible

here. However, some of the more popular methods,

the rationale for their use, and the possibilities of

integrating them into present-day practice are

described in this review.

Traditional understanding ofperiodontal disease

Traditional Indian (Ayurveda) and Chinese medicine

recognize the existence of periodontal disease. Most

of the traditional medical practices in other parts of

Asia have been influenced by these two forms of

medicine. However, social, cultural and geographic

differences have resulted in the establishment

of separate systems, such as Japanese medicine

(kampo) (9).

Classical Ayurvedic texts such as the Charaka

Samhita (1500 BC) (73) and the Ashtanga Hridaya

(79) refer to periodontal disease and its management.

Periodontal disease is described in the chapter on

diseases of the face in the Charaka Samhita, while the

Ashtanga Hridaya categorizes it within ear-nose-

throat disorders (79). These texts recognized the

presence of Shithada (scorbutic gingivitis), Upakusha

(periodontitis), Danta papputaka (swelling, ab-

scesses of the teeth, and periodontal and peri-apical

abscesses), Adhimamsa (excess flesh, pericoronitis)

and Saushira (necrotizing lesions). Traditional Chi-

nese medicine texts describe periodontitis as Ya

Xuan, which literally translates as �loose teeth�, and

also refer to swelling in the gums and gingival

bleeding (Ya Nu) (23).

Etiopathogenic mechanisms have also been

described in these traditional texts. Ayurvedic medi-

cine considers that the human constitution (prakriti)

is controlled by three humors (vital elements),

namely vata (wind), pitta (bile) and kapha (phlegm).

Diseases were thought to occur as a result of an

14

Periodontology 2000, Vol. 56, 2011, 14–24

Printed in Singapore. All rights reserved

� 2011 John Wiley & Sons A/S

PERIODONTOLOGY 2000

imbalance between these vital elements. Periodontal

disease, resulting in swelling in the gingiva, bleeding

gingiva and protruding teeth (presumably patholog-

ical migration) was ascribed to an imbalance of the

pitta (8, 23).

Traditional Chinese medicine advocated that the

human body could be divided into five �organs�, each

of which regulated multiple physiological functions.

Pathogenic mechanisms of various diseases involved

disfunction affecting any of these five organs. Ac-

cordingly, periodontal diseases had different etio

pathogenic mechanisms depending on which of

these five organs were affected. The earliest described

etiopathogenic mechanism referred to a deficiency in

the kidney. The kidney was thought to produce a vital

essence that was critical for growth and development

of the body, reproductive and urinary functions,

hearing and bone marrow development, and thus

influenced osseous behavior. As teeth were consid-

ered to be outgrowths from bone, disorders of the

kidney were thought to result in an inability to pro-

vide an anchor for the teeth, and thus led to peri-

odontal disease. Subsequently, it was realised that

periodontal disease could also result from overstrain

(physical and ⁄ or mental stress) as well as improper

diet, poor oral hygiene, and weaknesses of Qi (a vital

force) and blood. Unhealthy lifestyle and dietary

patterns were thought to result in �stomach heat�,resulting in initiation of inflammation and gingival

bleeding. Weakness of Qi and blood was thought to

render the body vulnerable to exogenous pathogens,

including oral pathogens, resulting in periodontal

disease (23). Both forms of medicine (traditional Ay-

urvedic medicine and traditional Chinese medicine)

recognized the presence of deposits on the teeth

(presumably calculus), referred to as Gou in tradi-

tional Chinese medicine and Danta Shakkara in

traditional Ayurvedic medicine, as a possible etio-

pathogenic factor for periodontal disease.

The systemic influence on the periodontium was

thus recognized from early times, although the

underlying principles appear far removed from

current knowledge. As a result, it is difficult to

establish whether these forms of medicine under-

stood the nature of host response and inflammation

(72) and the concept of periodontitis as a risk factor

for systemic diseases (16). The role of dental plaque

in the etiopathogenesis of periodontal disease was

largely unknown. To put things in perspective,

unequivocal evidence for the role of plaque in the

etiopathogenesis of periodontal disease was obtained

only in the 1960s after Loe�s study on gingivitis in Sri

Lankan tea workers (52). Although periodontal dis-

ease is thought to be initiated by microbial flora

(75, 76) that are present in biofilms (55, 56), the exact

mechanisms involved in the complex disease process

are yet to be fully understood. Despite considerable

technological advancement, the plaque microflora

has yet to be fully characterized (55).

The lack of understanding of the plaque-mediated

disease process has had important health conse-

quences. A survey in south China concluded that over

40% of the population either held traditional beliefs

about the nature of periodontal disease or thought

that tooth exfoliation was part of the natural aging

process (49, 50). Similarly, traditional beliefs appear

to play an considerable role in understanding of

periodontal disease in rural India (19).

Traditional oral hygiene habits

Although the importance of dental plaque control

was not fully understood, traditional oral hygiene

devices were intended not only to cleanse the oral

cavity but also to arrest periodontal disease. Oral

hygiene practices in traditional Chinese medicine

were given importance from very early days. Tooth-

brushes were used as early as the Liao Dynasty (907–

1125 AD), and massaging of the gums with salt was

fairly prevalent in China. Powdered alum, frankin-

cense and mouthwashes were also used. Cool tea

leaves were used to alleviate heat in the gingiva

(thought to be related to stomach heat). The use of

toothpicks was also a prevalent traditional Chinese

practice, and these were perhaps the only interdental

device used in ancient times. They are still a popular

cleansing device, especially among socio-economi-

cally deprived sections of the Chinese population (50).

Traditional oral hygiene measures have not been

abandoned, and some of the dentifrices currently used

in China still contain herbal products. Herbs that are

commonly used include lotus leaves, tea polyphenols,

Radix Zanthoxyli and Flos Lonicerae (90).

Some of these traditional products have been

subjected to in vitro and in vivo studies to assess their

effectiveness. An extract of lotus leaves demonstrated

significant antibacterial activity against some of the

more common putative periodontopathogens such

as Aggregatibacter actinomycetemcomitans, Por-

phyromonas gingivalis and Fusobacterium nucleatum

(48). Tea polyphenols such as catechins have been

shown to have an inhibitory action on virulence

factors of both Prevotella intermedia (60) and

P. gingivalis (61). In addition, epigallocathechin has

been reported to inhibit matrix metalloproteinase

15

Traditional therapies and periodontal disease

activity, osteoclast formation (91, 92) and osteoclast

activity (57, 58). A local drug delivery system utilizing

green tea catechin has been shown to be effective in

improving clinical periodontal parameters (43).

A direct relationship has also been proposed between

intake of green tea and periodontal status (47).

Chewing sticks

Chewing sticks are an almost timeless method of

maintaining oral hygiene. Traditional Indian medi-

cine advocated the use of various chewing sticks

depending on the constitution of the person.

Accordingly, a person with a vata prakriti was

advised to use bitter-sweet astringent sticks such as

liquorice (Glycyrrhiza glabra) and black catechu

(Acacia catechu). Those with a preponderance of

pitta (bile) were advised to use chewing sticks with a

bitter taste, such as neem (Azadirachta indica) and

arjuna tree (Terminalia arjuna), while kapha prak-

riti required the use of pungent sticks such as fever

nut (Caesalpinia bonduc) and Calotropis procera

(73).

Although all these sticks have been mentioned in

the literature, the most commonly used chewing

sticks are obtained from neem, mango (Mangifera

indica), babul (Acacia arabica) and guava (Psidium

guajava). Miswak (Salvadora persica) remains pop-

ular as a chewing stick, especially among Muslim

communities in the Indian sub-continent and the

Middle East (7). Almost 40% of the population in

rural Pakistan has been reported to use miswak as an

oral hygiene aid (10).

The importance of mechanical plaque control in

prevention of periodontal disease is beyond question

(24, 85). It has been reported that chewing sticks may

be as effective as toothbrushes in the mechanical

removal of plaque (4, 6, 29, 38), but this evidence is

not conclusive (88). Irrespective of their mechanical

efficiency, these devices are the primary means of

prevention of onset and progression of periodontal

disease in India. Some of the postulated mechanisms

by which these sticks exert beneficial effects are

outlined below.

Chewing sticks are thought to increase salivation

and thereby assist in flushing out of oral microor-

ganisms. Miswak has been shown to have antibac-

terial effects against early colonizers in plaque such

as streptococci, and possibly against the periodon-

topathogen P. gingivalis (5). This effect is thought to

be partly mediated by the tannins and thiocyanate

released during chewing of this stick. The thiocya-

nate released in this manner is thought to be

capable of activating the salivary H2O2 ⁄ peroxi-

dase ⁄ thiocyanate system, thereby exerting a potent

antibacterial effect (14). It has also been suggested

that the comparatively low periodontal treatment

requirements in a Saudi Arabian population were

due to regular use of miswak for oral cleansing (3).

Mango contains tannins, bitter gums and resins,

while neem contains isoprenoids such as nimbin,

nimbinin and nimbidin in addition to chloride and

fluoride, all of which favor an antibacterial effect

against several oral streptococci (17, 46, 67). Wolin-

sky et al. (86) reported that pre-treatment of saliva-

conditioned hydroxyapatite with an extract from

neem sticks prior to exposure to bacteria resulted in

a significant reduction in bacterial adhesion. In

addition, neem extracts used in the form of gel and

mouthwash have been reported to be effective in

improving both clinical parameters and inflamma-

tory markers (20, 62, 74, 83) in gingivitis. Guava

leaves and twigs contain essential oils and the po-

lyphenols – pinene and avicularin, through which

they exert anti-inflammatory and antibacterial ef-

fects, as demonstrated in in vivo and in vitro studies

(33, 54).

In addition to their antibacterial effect, these

chewing sticks have also been suggested to exert an

antioxidant effect. Oxidative stress has been shown

to result in cellular and tissue damage in periodontal

disease, and is an important component of the host-

related destruction that occurs following antigenic

challenge (45, 84). Exogenous and endogenous

antioxidants may thus be expected to exert benefi-

cial effects on inflamed periodontal tissues. Most of

the chewing sticks analysed have demonstrated an

antioxidant effect comparable to that of vitamin C or

vitamin K. Neem has been reported to contain gallic

acid, gallocatechin, epigallocatechin abd catechin,

all of which can reduce the oxidative burst from

polymorphonuclear leukocytes (18).

Brushing ⁄ cleaning at night has never been a tra-

ditional practice, and, even today, is not a part of the

oral hygiene routine of a large proportion of the

Indian population. A survey performed across vari-

ous age and socio-economic groups in an Indian

population revealed that almost 90% of the

respondents brushed only once a day (30). It is not

certain whether this lack of brushing contributes to

periodontal disease. Current evidence remains

inconclusive about the optimal frequency of tooth-

brushing required for maintenance of periodontal

health. Although there is some evidence suggesting

that brushing once in 48 h may be adequate for

maintenance of periodontal health (51), it has been

16

Surathu & Kurumathur

postulated that it would be prudent to brush at least

once a day (26).

In traditional health practices, interdental cleaning

devices were unknown in the Indian sub-continent.

The necessity for use of interdental devices has been

reinforced recently (70), and the lack of this practice

continues to affect prevention and periodontal

maintenance programs in this part of the world (50).

Dentifrices used traditionally included abrasive

powders such as brick powder, tobacco and ash, used

in conjunction with a chewing stick or a finger (19). It

is estimated that approximately 30% of the popula-

tion in rural India use toothpowder and their fingers

to clean their teeth (30).

Tongue cleaning

Both Indian and Chinese traditional medicine con-

sider that examination of the tongue is important for

diagnostic purposes, so much so that an entire

chapter of the Charaka Samhita is devoted to this.

Both forms of medicine considered tongue cleaning

to be an integral part of a personal hygiene program.

Traditional Chinese practices include the use of

roughened scrubs for scraping the tongue (25). The

Indian practice of tongue cleaning using a variety of

implements ranging from coconut leaves to tongue

cleaners made from stainless steel and plastic

remains prevalent.

Periodontopathogens such as A. actinomycetem-

comitans have been shown to colonize parts of the

oral cavity in addition to the gingival crevice (28).

Prominent sites include the dorsum of the tongue,

soft palate and tonsils (11, 34). Current evidence

suggests that tongue cleaning could be important for

maintenance of periodontal health and control of

halitosis (27). Tongue cleaning is part of the full-

mouth disinfection protocol that has been suggested

to be effective for plaque control and maintenance of

periodontal health (68, 69). The time-honored prac-

tice of tongue cleaning is thus based on sound

scientific principles, and may have contributed to

control of periodontal disease.

Mouthwashes

Mouthwashes have been described in both Indian

and Chinese traditional medicine, but mostly as a

form of periodontal therapy rather than a plaque

control measure. Use of chemotherapeutic agents

such as mouthwashes for plaque control is not pop-

ular in traditional Ayurvedic medicine. However, due

to differences in socio-cultural habits, Indians tradi-

tionally eat with their hands, without using cutlery.

As part of the post-eating ritual, an estimated 50% of

Indians not only wash their hands but also rinse their

mouth after every meal (30). This practice is espe-

cially prevalent among the older population and

those with less exposure to western civilization and

its customs, and is sometimes accompanied by

brushing with the finger. Although conclusions can-

not be drawn in the absence of well-controlled trials,

it is difficult to ignore the beneficial effects of mouth

rinsing. The mere flushing effect of water, even in the

absence of any chemotherapeutic agent, may play a

role in prevention of food accumulation inside the

oral cavity.

Management of periodontaldiseases

Traditional methods of management of periodontal

disease include a number of topical and systemic

methods, depending on the nature of the disease. The

mainstay of many traditional medicine approaches

has been the use of mouthwash and topical appli-

cation of various herbal agents.

Traditional Indian methods for themanagement of periodontal diseases

Mouthwashes

The Charaka Samhita describes two types of

mouthwashes, gandoosha and kavalagra, which were

used for different purposes. Kavalagra consisted of

herbal preparations in a paste or bolus form, which

was subsequently diluted to form a liquid. The mouth

was then filled with the kavalagra, which was re-

tained until nasal discharge or lacrimation occurred.

Gandoosha, on the other hand, usually contained

liquids, mostly essential oils. The mouth was filled

three-quarters full with this form of mouthwash and

rinsed vigorously. Commonly used gandooshas con-

sisted of herbal products such as triphala, dasamo-

ola, guggulu, pippali and sarshapashunti. These were

ground, mixed in hot water for gargling, or else mixed

in honey or cow�s milk before use as a mouthwash.

Mouthwashes consisting primarily of essential oils,

such as sahacharadi taila and irimedadi taila were

also used for management of periodontal disease.

Sesame oil was used for oil pulling (retaining oil in

the mouth without rinsing for a few minutes prior to

spitting out), and this continues to be an important

oral hygiene practice in rural India. Its effectiveness

17

Traditional therapies and periodontal disease

as an antibacterial agent (13) and in improvement of

gingival parameters (12) has been documented. The

exact mechanism of action is yet to be fully eluci-

dated, but the lignans of sesame (sesamin, sesamolin

and sesaminol) have antioxidant properties and can

potentiate the action of vitamin E (59). The polyun-

saturated fatty acids in sesame oil have been reported

to affect lipid peroxidation and exhibit antiiflamma-

tory properties (71).

Essential oils have been used as mouthwashes and

are effective for control of both dental plaque and

gingival inflammation. The effectiveness and long-

term safety of these oils has been established in

several clinical trials (35, 40, 63, 66, 80). It has been

reported that essential oils may be more effective

than flossing in prevention of inter-proximal gingi-

vitis (15). Essential oils, especially those containing

omega 3 polyunsaturated fatty acids, have been re-

ported to have important effects on the resolution of

inflammation, and are thereby helpful in preventing

periodontal disease progression (41).

Topical applications (pratisarana) to the gingiva

were also used, and typically contained barks or

leaves of trees such as neem, triphala or arjuna.

Triphala, a potent rasayana, is so named because it

is derived from three fruits, namely amalaki (Phyl-

lanthus emblica), haritaki (Terminalia chebula) and

bibhitaki (Terminalia bellerica) is immensely popu-

lar as a traditional therapy. It importance was related

to its perceived ability to bring a balance between

the three vital elements (76). Triphala has been re-

ported to have potent antioxidant properties, caus-

ing both a decrease in free radical formation and an

increase in their clearance. It has been reported to

inhibit matrix metalloproteinase-9 activity, and may

prevent connective tissue destruction in periodontal

disease (1). This effect has been attributed to the

gallic acid and other phenols ⁄ polyphenols present

in the drug. Herbal products such as guggulu, arjuna

and dasamoola were recommended in traditional

medicine with the intention of correcting the

underlying problem (dosha – fault of one of the

three humors). Although the biological mechanisms

of several herbal products used in traditional Indian

medicine have yet to be subjected to a detailed

analysis, some of the known mechanisms are sum-

marized in Table 1.

As most of the procedures outlined above involved

topical applications, their efficacy is related to the

concentration and bioavailability of the drug at the

site of infection. There have been some questions

raised in the literature regarding the penetration of

agents such as mouthwashes into the depths of the

periodontal pocket (31, 65).

Table 1. Biological effects of traditional Indian medicine

Herbal product Active ingredients Mechanism of action Reference

Neem Nimbin, nimbinin, nimbidin Antibacterial effect against oral

streptococci

46, 67

Reduced bacterial adhesion

to tooth surface

86

Catechins Reduced oxidative burst from

polymorphonuclear leukocytes

18

Guava Essential oils, pinene,

avicularin and other

polyphenols

Anti-inflammatory and

antibacterial effect

33, 54

Triphala Amalaki, haritaki and bibhitaki Antioxidant effect 1

Gallic acid Reduction in matrix metallo-

proteinase 9 levels

Sesame oil Sesamin, sesamolin and

sesaminol

Antioxidant property

Potentiates vitamin E action 59

Miswak Tannins, thiocyanate Increased salivation

Inhibits P. gingivalis 5

Activates the salivary

H2O2 ⁄ peroxidase ⁄thiocyanate system

14

18

Surathu & Kurumathur

Procedures such as Dantalekhana (scaling) for re-

moval of Danta Shakkara (deposits on the teeth, i.e.

calculus) have been described, but these procedures

were very rarely performed, if at all, in everyday life.

The acceptance of scaling as a primary preventive

measure in periodontal disease is still relatively low

in most parts of rural Asia (19, 81).

Systemic therapy

Traditional treatments for periodontal disease did not

stop at local applications – refractory cases were

treated with drastic measures. For example, blood

letting (rakhta moksha) has been proposed to treat

periodontitis, especially in case of abscess formation

(papputaka). Bizarre treatment procedures such as

leech application have also been advised in severe

infections [saushira (necrotizing lesions) and shitada

(scorbutic gingivitis)]. These procedures were not

commonly used except as a last resort. Another form

of periodontal treatment, known as Nasya, which

may be peculiar to traditional Indian medicine,

consists of inhaling medicinal powders, oils or liq-

uids. These procedures were used with a view to

treating the underlying �dosha�. The concoctions used

differed according to the individual, but the most

common ones were oils such as sesame and powders

such as arjuna.

Although several therapeutic procedures have been

outlined by traditional practitioners, they were per-

haps under-utilized or are not as effective as claims

suggest. Whatever the reason, the prevalence of

periodontal disease in India has been reported to

Table 2. Biological effects of traditional Chinese medicine

Herbal product Active ingredients Mechanism of action Reference

Guchiwan, Guchigao,

Conth Su

Mixture of several herbs Antibacterial activity 57, 82

Antioxidant effect 89

Osteoclast inhibiting activity 22

Sho Saiko To Mixture of several herbs Inhibits periodontopathogens 9

Antioxidant effect

Lotus leaf Polyphenols Inhibits periodontopathogens 48

Green tea Catechins Inhibits virulence factors of

periodontopathogens

61

Epigallocathechin Inhibits matrix metallopro-

teinase 9 activity, osteoclast

formation and osteoclast

activity

30, 58, 92

Table 3. Effects on clinical parameters

Product Mode of delivery Clinical effect Reference

Miswak Chewing stick Decreased periodontal treat-

ment needs

3

Neem Gels and mouthwashes Improvement in clinical

parameters in gingivitis

20, 62, 74, 83

Guava Mouthwash Plaque inhibitory effect 33

Green tea Systemic intake Reduced periodontal

breakdown

47

Local drug delivery Improvement in clinical

periodontal parameters

43

Traditional Chinese medicine

formulations (Guchiwan,

Guchigao, Conth Su)

Systemic intake Improvement in clinical

periodontal parameters

21

19

Traditional therapies and periodontal disease

range from 20 to 50%, depending on the population

studied, well above global epidemiological levels (19).

Traditional Chinese methods for themanagement of periodontal diseases

The necessity for removal of calculus and subgingival

plaque was recognized in China 1300 years ago. In

752 AD, Wang Tao wrote �While treating the teeth,

one should look for the yellowish bone-like mass

attached on the teeth. Remove it with forceps or knife

before using medicine. At the inner side of the gum,

look for a thin layer of film covering the root that

looks like cicada�s wing or like the membrane in eggs

… Unless these materials are removed, the gum will

never attach to the root� (23).

Traditionally, Chinese methods of treating peri-

odontal disease were based on the use of herbs, as

well as acupuncture and moxibustion (36). As in

traditional Ayurvedic medicine, traditional Chinese

medicine advocated the use of herbs, which were

usually given as a mixture. A number of proprietary

formulae were also used. Traditional Chinese medi-

cine advocated various treatment protocols based on

the underlying cause of the periodontal disease and

the principle of host modulatory therapy. Herbal

preparations used to treat periodontal disease re-

sulting from kidney disorders would differ from those

that occurred as a result of stomach heat or blood or

Qi disorders. Thus management of stomach heat

syndrome would include (but was not restricted to)

use of �Coptis� and Rehmannia formulae, while defi-

ciency in kidney yin and Qi ⁄ blood disorders would

be treated by the Rehmannia Six formula and the

Ginseng and Tangkuei Ten combination, respectively.

A typical mixture used to treat periodontal disease

with an underlying disorder in the kidney yin con-

sists of Radix Rehmanniae Glutinosae (Shu Di),

Fructus Corni Officinalis (Shan Zhu Yu), Radix

Dioscoreae Oppositae (Shan Yao), Sclerotium Poriae

Cocos (Fu Ling), Rhizoma Drynariae (Gu Sui Bu),

Radix Dipsaci (Xu Duan), Radix Achyranthis Biden-

tatae (Niu Xi), Fructus Lycii Chinensis (Gou Qi Zi),

Rhizoma Alismatis (Ze Xie) and Cortex Radicis

Moutan (Dan Pi) (36).

Traditional Chinese medicine uses herbs such as

ginseng, wolfberry, Dong Quai, astragalus, cinnamon,

coptis, ginger, liquorice, rehmannia, rhubarb and

salvia in various proportions to obtain formulations

such as Guchiwan, Guchigao, Conth Su and Chi Tong

Ning. As periodontal disease was thought to be

multifactorial, beneficial effects were thought to

accrue when a combination of herbs was used, each

of which would have a therapeutic effect on one

underlying disorder.

However, herbal preparations were also prescribed

alone, as in the case of Scutellaria baicalensis (Huang

Chin), for both systemic and topical application for

treatment of periodontal disease. Beneficial clinical

effects, as well as antimicrobial effects on putative

periodontopathogens such as P. gingivalis, P. inter-

media, A. actinomycetemcomitans and F. nucleatum,

have been described (21).

Some of these formulations, such as Guchiwan

and Guchigao, have been subjected to clinical trials,

and it was concluded that clinical parameters of

periodontal disease showed improvement following

use of these drugs. Zhang et al. (93) reported

improvement in the dental plaque scores, gingival

index and periodontal index following use of Gu-

chiwan in a group of patients with chronic and

aggressive periodontitis. Similarly, Song et al. (77)

reported on the efficacy of Guchigao in control of

both clinical parameters as well as the interleukin-8

levels in gingival crevicular fluid from a group of 24

periodontitis patients. Antibacterial activity (57, 82),

antioxidant effects (89) and osteoclast inhibiting

activity (22) have been recorded following exposure

to these drugs in vivo. Significantly greater promo-

tion of attachment of gingival fibroblasts and peri-

odontal ligament fibroblasts was reported following

exposure to Herba Dendrobii and Radix Ophiopog-

onis (92). These effects appeared to be significantly

greater when these drugs were used as a combina-

tion than when they were used singly (22). Some

popular Chinese herbal preparations, e.g. Rehman-

nia Six (Liuwei Dihuang Wan) have also been used

for other ailments. Similarly, Yunu Jian has also

been used for other diseases, with a few modifica-

tions (23) (summarized in Table 2 and Table 3).

Other than herbal preparations, Traditional Chi-

nese medicine utilizes acupuncture and moxibustion

(a precursor of acupuncture) for management of

periodontal disease. However, detailed consideration

of these techniques is beyond the scope of this

review.

Concluding comments

The traditional systems of traditional Indian medicine

(Ayurveda) and traditional Chinese medicine relied

on their ability to improve endogenous defence sys-

tems rather than eliminate the exogenous pathogen.

Interestingly, the current concepts of host modula-

tion work on more or less similar principles (68).

20

Surathu & Kurumathur

The global resurgence of interest in herbal prepa-

rations in recent years has been attributed to their

low cost, easy over-the-counter availability and a

perceived sense of safety (2, 32). However, use of

herbal preparations is not entirely without adverse

effects. Traditional Indian medicine recognizes the

toxic effects of several herbs (73). As these medicines

are available over the counter, there is a need to

scrutinize the validity of concocting proprietary

preparations. Another potential hazard is the poten-

tial for herb–drug interactions, which may have del-

eterious effects (39). For example, ginseng, a herbal

product used for periodontal disease, may interfere

with the bioavailability of warfarin, leading to

potentially serious side-effects (37).

Not all of the traditional practices outlined above

are in current use, at least among the educated

population. However, a lasting influence of tradi-

tional medicine has been on the attitude of patients

to disease and treatment. Traditional medicine

placed considerable importance on a holistic

approach, with emphasis on self-care and lifestyle

management. Although these practices cannot be

faulted in principle, they have resulted in a reluctance

to approach healthcare professionals in the early

stages of disease and to attend follow-up visits (64,

95). As the concept of preventive health checks is

alien to traditional Indian medicine, self-reported

periodontal disease and seeking of primary dental

care is low (19). A similar phenomenon has been

reported in China, where fewer than 20% of the

population reported for preventive dental check-ups

(95).

Traditional customs die hard, especially if they

have been popular for several centuries. Even in the

more developed countries, it has been reported that

the percentage of people who floss regularly ranges

from 10 to 40% (53). It may be impractical to expect

populations with lesser awareness and greater socio-

economic constraints to readily start implementing

rigorous interdental cleansing protocols (42). Previ-

ous suggestions that newer oral hygiene practices

could be integrated into well-established customs

using behavioral methods (44) need to be put into

practice. One example could be the use of chewing

sticks and topical or systemic herbal applications as

an additional aid either before or after brushing in

populations that do not practice both methods si-

multaneously. This way, the habit of brushing daily

could also be encouraged. The scientific evidence

supporting their use requires closer scrutiny and

expansion before it can be fully accepted as part of

everyday practice. To summarize, even though not

every traditional custom has been scientifically val-

idated, they need not be summarily dismissed as

quackery. Proponents of both modern and tradi-

tional medicine need to shed long-held beliefs and

accept existing evidence before such practices can

be truly integrated into present-day periodontal

therapy. Given the enormity of the health problems

faced by countries with large populations, it may be

practical to devise oral healthcare delivery systems

that retain efficacious traditional techniques. How-

ever, well-controlled clinical trials are required to

validate the use of these traditional therapeutic

strategies.

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