INTRODUCTION
Dental caries and periodontal disease are the two most widespread dental conditions globally; both are largely preventable. Accumulation of dental plaque on tooth surface is considered as a primary causative factor in both diseases.[1]
Studies have shown both mechanical and chemical plaque control can help in reducing plaque levels. Therefore, both methods may seem rational to have a simultaneous effect on gingivitis and caries, as there is independent evidence that both therapies are successful in managing gingivitis.[2] Thus, practicing a proper oral hygiene technique not only maintains good oral health it also influences the general health and quality of life of an individual.[3]
Tooth brushing with toothpaste is the most commonly practiced mechanical plaque control aid around the world for the maintenance of oral hygiene. However, traditional mechanical plaque control aids such as a manual toothbrush, chewing sticks, and dental flosses need manual dexterity and are time-consuming.[4]
Chemotherapeutic agents such as chlorhexidine-containing mouthwash (CHX) were considered gold standard clinical adjuncts in the treatment of both caries and periodontal diseases in addition to mechanical plaque regulation.[5] CHX induces a variety of local side effects, including taste disturbance, extrinsic tooth and tongue staining, enhanced supragingival calculus, oral mucosa desquamation, in addition to its good results in inhibiting plaque formation.[6,7] Such CHX side effects limit its widespread use and encourage interest in research to explore new antiplaque agents with minimal side effects.
Due to their natural origin, cost-effectiveness, zero side effects, and increased patient compliance, different types of complementary or conventional medicinal therapies, such as Ayurveda, have recently started to gain popularity.[8]
Oil pulling or oil swishing is an ancient natural healing activity originating in India, identified in Charaka Samhita and Sushruta Samhita's ayurvedic texts as Kavalagraha or Gandhoosha. The pulling of oil is achieved by taking a comfortable quantity of any form of oil and holding or swishing it in the mouth. The oil is spit out after a few minutes as it becomes thin and milky white.[9] Dr. F Karach was the person who familiarized the idea of oil pulling in the 1990s in Russia.[10] He believed that pulling oil can cure about 30 systemic diseases, including headache, migraine, thrombosis, eczema, intestinal infection, diabetes, and asthma.[11,12]
There are currently a variety of indigenous natural medicines that merit due recognition for their contribution to oral health development. Various products such as milk, gooseberry, mango extracts, edible oils such as coconut oil, corn oil, rice bran oil, palm oil, sesame oil, sunflower oil, and soybean oil have been used for oil pulling therapy.[13] Hierholzer and Kabara first documented the antimicrobial effects of coconut oil.[14] Evidence from recent studies has shown that coconut oil, including Candida albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, Candida stellatoidea, and Candida kruseii, has important antimicrobial activity against Escherichia vulneris, Enterobacter spp., Helicobacter pylori, Staphylococcus aureus, and Candida spp.[15]
Seasame oil (S. OIL) is also widely used for oil pulling because it produces no staining, no residual after taste, and no allergic reactions and is five to six times more cost-effective than commercially available mouthwashes and is also readily available in the household.[16] Thus, oil pulling with coconut oil, sesame oil, or sunflower oil therefore plays a crucial role in the treatment of plaque, gingivitis, and dental caries. Currently, the availability of objectively analyzed summaries on the efficacy of the oil pulling process for oral health promotion is missing in literature. Hence, this study was therefore aimed to systematically review the published literature with the purpose of knowing the oral health effects of oil pulling.
METHODS
This systematic review was performed following the guidelines set out by the Preferred Reporting Items for Systematic Reviews and Meta-analysis. The focused question for this systematic review was “Does oil pulling lead to a significant reduction in the score and bacterial count of indices compared to mouth wash containing CHX or any other control group.”
PARTICIPANTS-INTERVENTIONS-COMPARISONS-OUTCOMES – STUDY DESIGN
Population
Systematically healthy participants with or without gingivitis.
Intervention
Oil pulling procedure through sesame or coconut oil.
Control
Positive controls like CHX-containing mouthwashes or negative placebos without any active agents.
Outcome
Reduction in scores measuring any oral hygiene index as an outcome measure.
Inclusion criteria
- Studies carried out from January 2010 to March 2020
- Randomized control trial (RCTs)
- Intervention group using any of the conventional oil for oil pulling
- Any RCTs measuring one of the given indices an outcome variable: Index related to plaque, gingivitis, oral malodor colony count in both plaque and saliva.
Exclusion criteria
- Retrospective studies, cross-sectional studies letter to editor, case report, personnel proceedings, personal communications, and any types of reviews were excluded
- Systematic reviews and meta-analysis
- Reports in language other than English were also excluded
- Studies with no control groups.
Outcomes
The following outcomes were assessed for both the intervention arm and control arm of the studies:
- Mean reduction in debris and calculus score measured by Oral hygiene index simplified
- Mean reduction in the plaque score measured by Silness and Loe Plaque index or modified Quigley Hein Plaque index
- Mean reduction in gingival inflammation by Loe and Silness gingival index or modified gingival index
- Mean reduction in Subjective and Objective organoleptic breath assessment
- Mean reduction in Streptococcus mutans count or total colony count.
Search strategy
In the following databases, such as PubMed, PubMed Central, EMBASE, Google Scholar, Scopus, Campbell systematic review, and Cochrane, a comprehensive electronic search was carried out to find related studies. Studies conducted from January 2010 to March 2020 were included, and search for relevant studies were performed till July 30, 2020. In case of any relevant articles found without full text during the search process, the corresponding authors were contacted through E-mail to retrieve the article.
The following search string was employed based on the Participants-Interventions-Comparisons-Outcomes structure:
- Participants– (”gingivitis”[MeSH Terms] OR “gingivitis”[All Fields]) OR (”plaque, amyloid”[MeSH Terms] OR (”plaque”[All Fields] AND “amyloid”[All Fields]) OR “amyloid plaque”[All Fields] OR “plaque”[All Fields] OR “dental plaque”[MeSH Terms] OR (”dental”[All Fields] AND “plaque”[All Fields]) OR “dental plaque”[All Fields]) OR Bioflim[All Fields]
- Interventions– (”oils, volatile”[MeSH Terms] OR (”oils”[All Fields] AND “volatile”[All Fields]) OR “volatile oils”[All Fields] OR (”essential”[All Fields] AND “oils”[All Fields]) OR “essential oils”[All Fields]) OR (”coconut oil”[MeSH Terms] OR (”coconut”[All Fields] AND “oil”[All Fields]) OR “coconut oil”[All Fields]) OR (”sesame oil”[MeSH Terms] OR (”sesame”[All Fields] AND “oil”[All Fields]) OR “sesame oil”[All Fields]) OR (Chlorhexide[All Fields] AND (”mouth”[MeSH Terms] OR “mouth”[All Fields])) OR (Normal[All Fields] AND (”toothbrushing”[MeSH Terms] OR “toothbrushing”[All Fields] OR (”tooth”[All Fields] AND “brushing”[All Fields]) OR “tooth brushing”[All Fields]))
- Participants AND Interventions–(1) AND (2).
In the being, duplicate articles were excluded. Then the titles and abstracts of the study were independently assessed by two authors based on the eligibility criteria.
Finally the full text of the articles that were initially included was evaluated according to the inclusion and exclusion criteria. Along the process, the two authors reached a consensus through discussion if their options were different. Cohen's kappa was adopted to assess the interexaminer reliability. When the study results were published more than once or were detailed in multiple publications, the most complete data set was identified and included.
EXTRACTION OF DATA
In the being of the review, duplicate articles were excluded. Data from included studies wee extracted by the first author using a data extraction form which was validated through consensus with the second author. The following data were collected from each article: surname of the first author, year of article publication, place of study, study duration, age range, sample size, study groups, and outcomes measuring oral health status [Table 1 and Table 2]. Any disagreement was resolved between them, and consensus was reached in the end.
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Table 1: Characteristic feature of the included studies
Table 2: Summaries of outcomes measures of included studies
QUALITY ASSESSMENT
The studies included in the review were analyzed using the Cochrane Collaboration method driven by the Cochrane Handbook for Systematic Intervention Reviews (RevMan, version 5.3 The Cochrane Collaboration, Copenhagen, Denmark).[17] The risk of bias within the included studies were classified as “low,” “unclear,” or “high” risk of bias. To assess the risk of bias, the following seven aspects were analyzed for each study, and these include method of sequence generation, allocation sequence concealment, blinding of care providers and participants, blinding of outcome assessors, incomplete outcome data, selective outcome reporting, and other sources of bias. Any disagreements between the authors were resolved through discussion.
Data analysis
Review Manager (RevMan) Version 5.3 for Windows (The Nordic Cochrane Centre, Copenhagen, Denmark) was used for performing the analysis.
RESULTS
Two hundred and eighty-six records were found by preliminary screening through database search, and 27 records were discovered by additional sources. Out of 80 articles reviewed for analysis, 14 articles were included for the review. [Figure 1] shows the flow diagram for the selection of articles included in this review.
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta flow diagram showing literature search and identified article
Risk of bias within studies
Six studies[19,22,23,25,26,29] had a low and uncertain bias risk and eight studies[11,18,20,21,21,24,27,28,30] had a high bias risk [Figure 2 and Figure 3]. Ten studies[11,19,20,22,23,25,26,27,28,29] had a low risk of bias in the generation of random sequences, but all studies produced ambiguous information in terms of concealment of allocation. Seven studies[11,18,21,24,27,28,30] showed high risk of bias by failing to blind the participants and investigators.
Figure 2: Review author's judgment's about each risk of bias item presented as percentages across all included studies
Figure 3: Risk of bias overview for evaluating the judgments of the author on each risk of bias items for each study included. Green stands for a low bias risk, yellow reflects an unknown bias risk, and red suggests a high bias risk
DISCUSSION
The incidence of gingivitis and chronic periodontitis remains high in most populations, despite the fact that most individuals claim to brush their teeth at least twice a day.[31,32] While mouthwashes have been used both for prevention and healing purposes, their side effects and affordability are of increasing concern.[33] Hence, we assessed whether oil pulling using sesame or coconut oil improved oral health in comparison to CHX containing mouth wash.
For more than four decades, CHX has been known to be the primary agent for chemical plaque control. CHX, however, has many side effects, such as tooth staining, mucosal degradation, and disruption of taste.[34] Thus, people are gradually moving towards ancient medicine to reduce the side effects of modern medicines.[35] Because of its beneficial effects on general and oral health, oil pulling has proved to be a home-based remedy. In the 1990s, Ukrainian physicist Dr. F. Karach popularized this practice in the Union of Soviet Socialist Republics as oil pulling by saying that after experimenting with oil swishing, he healed himself from a blood disease.[36] The mechanism by which oil pulling achieves this role is poorly understood, but it has been postulated that sesame seed oil interacts with alkali in saliva, inducing a saponification process (soap formation), with a subsequent cleaning effect.[37]
Data from the included studies indicate a substantial decrease in simplified oral hygiene index,[24] plaque index,[20,25] objective organoleptic breath assessment (ORG1), subjective organoleptic breath assessment (ORG2),[29] and postintervention colony-forming unit scores[18,27,29] between oil pulling and CHX groups. However, the results were not statistically significant for scores which measured oral hygiene index simplified,[20] Plaque index,[11,24,29] Gingival Index,[24,29] Modified gingival index,[11] plaque and salivary S. mutans count[26] post intervention between oil puling and CHX groups.
It was also found that post intervention scores between oil puling group and group with routine oral hygiene practice showed statistically significant reductions for plaque index[19,30] gingival index,[19,30] modified gingival index,[21] and colony forming unit[23] scores at post intervention.
With a high risk of bias in multiple aspects and unclear reporting of others, the methodological consistency of the included studies was uncertain. Among the fourteen studies included studies in this systematic review, nine studies[18,24,25,26,27,28,29,30,31] compared oil pulling with CHX in the control group in which statistically significant reduction of scores was found in six studies,[18,24,25,27,29,30] two studies[26,31] showed a nonsignificant reduction and one study[28] did not report about the significant difference. This systematic analysis also offers clear proof of oil pulling benefits relative to the use of mouthwash with CHX. Hence it can be inferred oil pulling is found to be equally effective to the gold standard CHX. In addition, our findings were reported in accordance with the recent systematic review conducted by Gbinigie et al.[38]
Thaweboon et al.[12] evaluated the effect of oil pulling using coconut oil, corn oil, rice bran oil, palm oil, sesame oil, sunflower oil, and soybean oil on biofilm models developed by S. C. albicans, mutans, Lactobacillus casei. The findings demonstrated that coconut oil exhibited antimicrobial activity against S. mutans, C. albicans. Albicans. The antibacterial activity of sesame oil was against S. mutans, though C. albicans. Albicans. L. casei has been shown to be immune to sunflower oil. In our systematic review, similar results were also found where many authors[18,22,27,29,30] recorded a significant decrease in the total bacterial count by inhibiting S. mutans, L. acidophilus acidophilus growth. Therefore, this evidence suggests the use of edible oils as a home remedy for the treatment of tooth decay.
None of the included studies have documented adverse effects of oil pulling. However, two cases of exogenous lipoid pneumonia have been documented by Kuroyama et al.,[39] in patients who normally practice sesame oil pulling. Fever, weight loss, coughing, dyspnea, chest pain, and hemoptysis are the signs of exogenous lipoid pneumonia. The accidental aspiration of small quantities of oil has been correlated with these incidents, which usually does not pose any danger to general health as it is readily excreted by feces. Other types of oil compatible with them should be used by people allergic to a particular oil, and precaution should be taken not to swallow oil because it is heavily loaded with harmful microorganisms.[40]
There are several limitations which might temper the conclusions that are drawn from this study. (1) The present analysis contains papers written only in English, which may have omitted potentially useful evidence in other languages (2) There was no search done for the grey and unpublished literature, and this might likely to have excluded studies with significant results. (3) For convenience purpose, search was restricted from January 2010 to March 2020. (4) For dental plaque and gingivitis, different indices were used, and the period of assessment for the included studies was not standardized. (5) The meta-analysis was not used to summarize the data of the included studies due to the variability between the studies. In future, more systematic reviews should be undertaken to overcome these shortcomings.
CONCLUSION
The quality of evidence appears to be low to recommend oil pulling as a suitable adjunct to other conventional oral hygiene methods as most of the included studies had high or unclear risk of bias. However, oil pulling showed a large reduction in many oro-dental scores in our review, so it could be used as a preventive home therapy to maintain oral hygiene as it is natural, safe and has no side effects. For future recommendations of this therapy a well-designed high-quality clinical research with longer study duration is needed to improve the level of evidence in this area of research.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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