Evaluation of Sodium Bicarbonate as an Adjunct to Non-Surgical Periodontal Therapy and its Effect on Oxidative Stress: A Clinico-Biochemical Study
Shaila Kothiwale* ,Meenal Kella ,Laxmi Hombal and Amrita Rathore
Department of Periodontics, KLE VK Institute of Dental Sciences, KLE University, Belgaum, India
*Corresponding author: Shaila V. Kothiwale, Professor, Department of Periodontics, KLE VK Institute of Dental Sciences, Belgaum. Phone: 9448822706, E-mail: shailakothiwale2000@yahoo.co.in
Received: June 24,2014; Accepted: June 30,2014; Published: July 02,2014
Citation: Kothiwale S, Kella M, Hombal L, Rathore A (2014) Evaluation of sodium bicarbonate as an adjunct to non surgical
periodontal therapy and its effect on oxidative stress: A clinico-biochemical study. J Dent Oral Disord Ther 2(2), 5. DOI: http://dx.doi.org/10.15226/jdodt.2014.00116
Abstract Top
Objectives: The purpose of the interventional study was to determine the effects of sodium bicarbonate as an adjunct to non surgical periodontal therapy in chronic periodontitis by measuring salivary malondiadehyde (MDA) levels.
Methods: The study included 30 chronic periodontitis patients
who were randomly assigned to test and control group. Patients
were subjected to scaling and root planing. In test group, subjects
were instructed to massage their teeth and gingiva with sodium
bicarbonate slurry twice daily after regular brushing. Clinical
parameters of Gingival Index, Plaque Index, Probing Pocket Depth
and Clinical attachment level and whole saliva samples were obtained
from both groups at baseline and 3 months. The salivary MDA levels
were measured using colorimetric assay procedure. The Student ttest
was used to analyze all parameters.
Results: At 3 months follow up all the clinical parameters in both the group were significantly reduced (p<0.001). The gingival index score showed statistically significant reduction in test group
(1.2 ± 4.8) and control group (0.28 ± 0.18) at 3 month interval. The difference in MDA levels at baseline and 3 months was (4.8 ± 1.94) in test group and (1.8 ± 0.81) in control group. The magnitude of difference in gingival index and MDA levels in the test group was greater on intergroup comparison.
Conclusions: The present study showed positive outcome in all the clinical parameters and significant reduction in salivary MDA levels with the adjunct use of sodium bicarbonate to non-surgical periodontal therapy.
Keywords: Sodium bicarbonate; Gingival massage; Nonsurgical therapy; Periodontitis; Malondiadehyde
IntroductionTop
Periodontits is a chronic inflammatory disease of supporting
tissues of the teeth resulting in progressive destruction of
the periodontal ligament and alveolar bone. Patients with
periodontal disease are more susceptible to an imbalance of
antioxidant-oxidative stress situation. Reactive oxygen species
released during oxidative stress can be measured by the final
product of LPO, such as MDA which is the principal and most studied product of polyunsaturated fatty acid peroxidation. As
whole saliva constitute a first line of defence against free radical
mediated oxidative stress.MDA that is realeased during oxidative
stress becomes one constituent of saliva and can be used as a
biomarker to asses the inflamatory condition as sampling of
saliva is easy, non invasive and it represents pooled sample with
contribution from all periodontal sites . Thus salivary MDA levels
were used to detect the inflammatory state in the study.
Bacterial plaque is generally considered to be the main etiological agent. When stimulated by bacterial pathogens, host
cells (eg., PMNs) release reactive oxygen species (ROS) as part
of the immune response. The interactions between pathogen and
host defensive capacity result in periodontal tissue breakdown.
Oxidative stress lies at the heart of this periodontal tissue damage
as a result of host microbial interactions [1] .
Hence, periodontal therapy has been directed at altering the
periodontal environment to one which is less conducive to the
retention of bacterial plaque in the vicinity of gingival tissue. It
comprises of non-surgical therapy and surgical therapy. Current
therapeutic guidelines for chronic periodontitis emphasize
the need for control of bacterial population by scaling and root
planning and maintenance of plaque control by means of patient
home care. In this form of disease, the inability to control the
clinical signs of disease results from either inadequate homecare
or inadequate access for subgingival cleaning. Therefore, nonsurgical
periodontal therapy remains the core component and
mainstay of successful periodontal therapy [2] .
The use of a chemical agent as an adjunct to the non
surgical therapy will greatly enhance patient's oral hygiene and
motivation. Sodium biocarbonate (NaHCO2, baking soda) is one
such agent which has been widely used. [3] The appeal of sodium
biocarbonate products seems to lie in its safety, low cost, low
abrasivity, water solubility, buffering ability, compatibility with
fluoride, and in high concentrations, antimicrobial properties [4] .
Over the years, antimicrobial agents, such as sodium
bicarbonate, have been incorporated into mouthrinses and
dentrifices in an attempt at providing a practical approach toward improving oral health. Moreover, bicarbonate in saliva buffers &
neutralizes plaque acids. Sodium bicarbonate tends to maintain a
pH of 8.1 when acids, which lower pH, or bases, which raise pH,
are added to the solution. In other words, sodium bicarbonate
should raise salivary pH that is lower than 8 (i.e. increase saliva
alkalinity). Additionally, sodium bicarbonate due to its slightly
abrasive consistency works as a mechanical cleanser of teeth and
gingival tissues. [5]
A close relationship exists between plaque and chronic
inflammatory periodontal disease and the effectiveness of
conservative treatments used to reduce the severity of disease,
is widely accepted. The study was carried out to assess the role
of sodium bicarbonate, applied as an adjunct, after an exquisite
full mouth scaling and root planning and to measure the levels
of salivary MDA to quantify the levels of oxidative stress. Thus,
the aim of this study was to determine the effects of sodium
bicarbonate on the clinical parameters of periodontal disease and
measure the levels of salivary MDA.
Material and MethodsTop
The study was randomized, controlled, double blinded
interventional trial which included 30 patients, both males and
females, with age ranging from 25-55 years who reported to the
Department of Periodontics. The research project was ethically
approved by the Institutional Review board. The study was
conducted in accordance with the World Medical Association
Declaration of Helsinki and after obtaining informed consent
from the participants.
The subjects with generalized chronic periodontitis
(moderate) according to the 1999 AAP classification were
included in the study. The sample size was determined based on
the statistical formula. The subjects were randomly allocated to
one of the two groups using a computer generated numbers and
allocation was concealed until interventions were assigned for
the interventional trial (Figure 1).
Subjects included in the study had at least 20 natural
teeth present. The exclusion criteria were subjects with a
history of smoking and/or alcoholism or tobacco chewers,
use of mouthwashes, any systemic diseases/illness, pregnant
women, subjects who had received antioxidant vitamins, antiinflammatory
drugs, antibiotics, nutritional supplements or any
other drugs over the past 6 months, those who had undergone
any periodontal treatment over the past 6 months.
Following selection, clinical data included Gingival Index
(GI), (Sillness and Loe 1963), Plaque Index (PI), Probing Pocket
Depth (PPD) and Clinical attachment level (CAL). The data were
assessed at the baseline and 3 months. Patients who participated
in the study were refrained from eating and drinking for one
hour and then asked to rinse their mouth with tap water. Then
2 ml of unstimulated whole saliva was collected by spitting into
sterile containers with subjects seated in an upright position.
Collected samples were then transported to the laboratory for
the measurement of MDA levels.
Full mouth scaling and root planning was performed by periodontist and all the clinical measurements were performed
by the same examiner. The prematurities, caries, overhang were
treated and home care oral hygiene instructions were given. In
test group, subjects were asked to massage their teeth and gingiva
with 1/2 teaspoon of Baking soda slurry (sodium Bicarbonate+
water) twice daily after routine brushing with toothpaste. Clinical
parameters and salivary samples were collected at 3 months
from both groups.
Assay procedureTop
In the present study, colorimetric assay procedure proposed
by Okawa H et al (1979) [6] and Satoh K (1978) [7] was used. It
is based on the reaction between thiobarbituric acid reactive
substances (TBARS) and thiobarbituric acid (TBA) reagent to
generate a pink colored product and determined at 535nm.
The value obtained was then calculated against the standard
curve and the results were estimated in mol MDA equivalents.
Tetraethoxypropane was used as an external standard.
The Student t- test was used to analyse all parameters
between study and control sites and to determine the significance
of changes over time. 95% of Confidence Interval (CI) was
calculated. The significant level was fixed at 0.05. SPSS version
17.0 was used to analyse the data.
Statistical analysisTop
The Student t- test was used to analyse all parameters
between study and control sites and to determine the significance
of changes over time. 95% of Confidence Interval (CI) was
calculated. The significant level was fixed at 0.05. SPSS version
17.0 was used to analyse the data.
ResultsTop
All the clinical parameters, GI, PI, PPD, CAL and salivary MDA
levels measured at baseline and at 3 months interval. The gingival
index score showed statistically significant reduction in test group
(1.2 ± 4.8) and control group (0.28 ± 0.18) at 3 month interval.
Post treatment scores showed statistically greater reduction in
test group. On comparison of test and control groups statistically
significant difference was observed (p < 0.001) (Table 1). The
plaque index score showed statistically significant reduction
in test group (1.75 ± 3.84) and control group (1.36 ± 0.76) at 3
month interval. The intergroup comparison revealed statistically
significant difference in plaque index score (p < 0.001).(Table
Gingival index | |||
GROUP |
Day 0 |
3 months |
Differences |
TEST |
2.2 ± .53 |
0.98 ± 0.46 |
1.2 ± 4.8 |
CONTROL |
0.023 |
2.27 ± 0.17 |
0.28 ± 0.18 |
P VALUE |
0.023 |
< 0.001 |
<0.001 |
Table 1: Comparison of gingival index scores at baseline and three
months interval between groups.
Plaque Index | |||
GROUP |
Day 0 |
3 months |
Differences |
TEST |
2.7 ± 2.6 |
0.95 ± 0.25 |
1.75 ± 3.84 |
CONTROL |
2.8 ± 2.2 |
1.44 ± 0.26 |
1.36 ± 0.76 |
P VALUE |
0.298 |
<0.001 |
<0.001 |
Table 2: Comparison of plaque index scores at baseline and three months
interval between groups.
2).The difference between the CAL values at baseline and 3
months in test group was 0.85 ± 0.42 and in control group was
0.28 ± 0.15. The significant difference (p < 0.001) in CAL values
was observed when intergroup comparison was made. (Table3).
The difference between the pocket probing depth values at
baseline and 3 months in test group was 2.1 ± 0.73 and in control
group was 1.4 ± 0.73 The intergroup comparison showed
statistically significant difference (p <0.05).(Table 4).
The difference in MDA levels at baseline and 3 months was
(4.8 ± 1.94) in test group and (1.8 ± 0.81) in control group.
Significantly lower MDA levels were seen in test group. The
significant difference (p < 0.001) was observed when intergroup
comparison was made. (Table 5).Thus the results showed that
the magnitude of difference observed in gingival index scores and
MDA levels was greater when intergroup comparison was done.
DiscussionTop
Periodontitis is a pathological condition in which chronic local
inflammation exhibits an exacerbated inflammatory/immune
response to the periodontopathogenic bacteria that accumulate
around the tooth and gingival tissues which may in turn lead to
tissue damage and may result in tooth loss. [8] The reactive free
radicals produced during chronic conditions like periodontitis
may damage cells by initiation of lipid peroxidation that causes
profound alteration in structural integrity and functions of cell
membranes. They can be measured by levels of malondialdehyde.
[9]
The present study was done to assess the effect of the
Clinical Attachment Level | |||
GROUP |
Day 0 |
3 months |
Differences |
TEST |
3.5 ± 0.28 |
3.8 ± 0.16 |
0.005 |
CONTROL |
2.7 ± 0.37 |
3.5 ± 0.18 |
<0.001 |
P VALUE |
0.85 ± 0.42 |
0.28 ± 0.15 |
<0.001 |
Table 3: Comparison of clinical attachment levels at baseline and three
months interval between groups.
Pocket probing depth | |||
GROUP |
Day 0 |
3 months |
Differences |
TEST |
7.2 ± 1.2 |
6.8 ± 0.96 |
0.509 |
CONTROL |
5.1 ± 0.96 |
5.4 ± 0.99 |
0.201 |
P VALUE |
2.1 ± 0.73 |
1.4 ± 0.73 |
<0.05 |
Table 4: Comparison of pocket probing depth scores at baseline and
three months interval between groups.
Salivary MDA | |||
GROUP |
Day 0 |
3 months |
Differences |
TEST |
10.9 ± 3.45 |
9.7 ± 3.59 |
0.347 |
CONTROL |
6.1 ± 3.55 |
7.9 ± 3.55 |
0.186 |
P VALUE |
4.8 ± 1.94 |
1.8 ±0.81 |
<0.001 |
Table 5: Comparison of salivary MDA levels at baseline and three months
interval between groups.
adjunctive use of sodium bicarbonate to scaling and root
planning on the established clinical parameters and to quantify
the decrease in the level of inflammation by measuring the
salivary MDA levels.
Sodium bicarbonate was widely used as a dentifrice before
the introduction of modern toothpastes. The merit of sodium
bicarbonate products seems to lie in its safety, low cost, low
abrasivity, water solubility, buffering ability, compatibility with
fluoride, and antibacterial properties in high concentrations.
[10] Sodium bicarbonate-containing dentifrice exhibits greater
bactericidal activity against Streptococcus mutans than other
dentifrice.[11] Additionally, sodium bicarbonate due to its
abrasive consistency (Relative dentin abrasivity =7) works as
a mechanical cleanser of teeth and gingival tissues. Thus, the
topical application of sodium bicarbonate makes the removal
of plaque more effective. Thus, keeping these pertinent benefits
of sodium bicarbonate in perspective, its clinical usage was
assessed. However, when the baseline values were compared to
the values at 3 months, there was significant improvement in the
clinical parameters of disease (p < 0.001) representing a marked
improvement with treatment rendered.
In the test group at 3 months all the parameters were reduced.
The GI and MDA levels showed significant improvement from
baseline (2.2 ± .53), (10.9 ± 3.45) to 3 months (0.98 ± 0.46), (6.1
± 3.55) respectively (Table 1, 5) in test group. The clinical studies
investigated the effect of periodontal treatment on oxidative
stress in the oral cavity. They have demonstrated that scaling and
root planing resulted in a decrease in malondialdehyde levels in
the saliva of patients with periodontitis. Thus improvement of
oxidative stress in the periodontium by periodontal treatment
would contribute to a reduction in circulating ROS.[12] In the
present study at 3 months, as compared to control group the
adjunctive use of sodium bicarbonate may have resulted in
marked decrease in MDA levels and GI index scores as compared
to control group. There was reduction in plaque index scores in
both the groups. The test group showed the increased reduction
of (1.75 ± 3.84) compared to the control group (1.36 ± 0.76).This
reduction could be attributed to the mild abrasive consistency
and buffering capacity of sodium bicarbonate.
There was reduction in the probing pocket depth in the test
group and control group. Our results showed additional decline in
PPD in test group (2.1 ± 0.73) as compared to control group (1.4 ±
0.73) which indicates the adjunct use of sodium bicarbonate can
aid in reducing inflammation and minimize the active periodontal
pocket depth.(Table 4). Christersson et al. has suggested that
sodium bicarbonate packed subgingivally enhances periodontal
healing when placed in periodontal pockets in conjunction with
scaling and root planning procedures. [13] The present study also
showed gain in clinical attachment levels which was statistically
significant. This was in accordance with a study conducted by
Takigawa S in which 12 month post- treatment results showed
that 81% of the sites that were initially 7 mm or deeper showed a
2 mm or more gain in clinical attachment after placing adjunctive
sodium bicarbonate .[15]
A change in the dietary carbohydrate of an individual
changes the microbial composition of supragingival plaque.
The carbohydrates reduce the pH level and create an acidic
environment thus favouring the colonization and growth of the
microbiota. This leads to development of caries and periodontal
disease. The creation of an alkaline environment with the use of
sodium bicarbonate will break this vicious cycle as an increase
in the level of salivary pH will prevent bacterial growth and
proliferation of the microbiota and reduces its pathogenicity.
Baking soda (sodium biocarbonate) due to its alkalinity (high
pH) will neutralize the acids in the mouth, kill microorganisms,
and remove unpleasant odours. Sodium bicarbonate tends
to maintain a pH of 8.1 (7 is neutral) even when acids, which
lower pH, or bases, which raise pH, are added to the solution.
In other words, sodium bicarbonate raise salivary pH that is
lower than 8 (i.e. increase saliva alkalinity). Acidic saliva furthers
demineralisation, while neutral or alkaline saliva furthers
remineralisation of teeth and makes them caries-resistant. This
alkaline pH in saliva will also prevent bacterial growth and
proliferation of the microbiota which have got affinity to grow
in acidic environment thereby reducing the pathogenicity of
microflora. Also it has an antiseptic and antibacterial activity.
Periodontal pathogens have lower MICs and MBCs than the
microflora from other sites, and are killed more rapidly. It was
found that the higher the concentration of bicarbonate ion, the
faster the organisms is killed. The antibacterial activity is solutespecific
and can be attributed to the bicarbonate ion. The precise
mechanism whereby bicarbonate inhibits bacterial growth is not
known, although it may be due to interference with oxidative
phosphorylation. The usual explanation for the growth-inhibiting
effects of high salt concentrations is that hypertonic conditions
create limiting water activities, whereby the cell becomes
dehydrated and cellular activity stops. [15]
Significant ROS generation by neutrophils requires a
minimum oxygen tension of about 1% and a pH of 7.0 ± 7.5.Both
these conditions are found within periodontal pockets, indicating
that chronic or excess ROS production is possible at the important
site of periodontal tissue damage.[16] The generalized condition
of the periodontium has an effect on the MDA levels in whole
saliva. Whole saliva constitute a first line of defence against
free radical mediated oxidative stress. [17] MDA that is realeased
during oxidative stress becomes one constituent of saliva and
can be used as a biomarker to asses the inflamatory condition.
The abundance of saliva, and collection of whole saliva is easy,
non-invasive and rapid and analysis of biomarkers in saliva may
provide an overall assessment of disease status.[18, 19]
In the present study a strong positive correlation between the
degree of change in the levels of salivary MDA and the gingival
index after scaling and root planing with the adjunctive use of
sodium bicarbonate. Feedback information was collected from
all the individuals in the test group to assess patient acceptance
and perception to this unique treatment modality. The patients
reported that massaging with sodium biocarbonate reduced
gingival bleeding, improved gingival consistency (a feeling of gum tightening) and decrease in bad breath from the mouth.
Hence resulting in better compliance and excellent clinical
outcome as sodium bicarbonate was used only as adjunct and the
regular brushing methods were not disturbed.
ConclusionTop
The present study showed positive outcome in all the clinical
parameters and significant reduction in salivary MDA levels
with the adjunct use of sodium bicarbonate to non-surgical
periodontal therapy. The merit of sodium bicarbonate products
seems to lie in its safety, low cost, low abrasivity, water solubility,
buffering ability, compatibility with fluoride, and antibacterial
properties. The above properties of sodium bicarbonate have
shown to improve the clinical outcomes and thus can be used as
an adjunct in patients who require additional periodontal care.
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