European Journal of Cardiovascular Medicine

Fixed orthodontic appliances create a highly retentive environment for plaque accumulation, leading to increased risks of gingival inflammation, enamel demineralization, and halitosis. Brackets, ligatures, archwires, and accessory components introduce additional plaque stagnation zones, making effective oral hygiene maintenance challenging even among compliant patients. Studies have consistently shown that orthodontic patients develop elevated levels of Streptococcus mutans, Lactobacilli, and other pathogenic bacteria shortly after appliance placement, contributing to white spot lesions and periodontal changes if preventive care is insufficient [1]. Therefore, adjunctive chemotherapeutic measures such as mouthwashes are widely recommended to supplement mechanical plaque control in orthodontic therapy.

Chlorhexidine (CHX) remains the gold standard chemical plaque control agent due to its broad-spectrum antimicrobial activity and strong substantivity. A 0.2% CHX mouthwash has demonstrated significant reductions in plaque indices, gingival inflammation, and salivary S. mutans levels in orthodontic patients, making it a commonly prescribed adjunct during treatment [2]. Despite its effectiveness, long-term CHX use is associated with adverse effects such as tooth staining, taste alteration, mucosal irritation, and calculus formation, which often reduce patient compliance and limit continuous use [3]. These limitations have stimulated increasing interest in herbal-based mouthwashes as safer, natural alternatives with fewer side effects.

Herbal formulations containing plant extracts, polyphenols, essential oils, flavonoids, and phytochemicals have demonstrated antimicrobial, anti-inflammatory, and antioxidant effects that may benefit periodontal and orthodontic patients [4]. KP Namboodiri’s herbal mouthwash, enriched with traditional Ayurvedic herbal constituents, is gaining popularity due to its natural composition and reported clinical benefits. Several recent studies on herbal mouthwashes have observed significant reductions in plaque, gingival scores, and microbial load, with improved tolerability compared to chlorhexidine [5]. Phytochemicals such as tannins, eugenol, curcuminoids, catechins, and neem extract have been shown to inhibit cariogenic and periodontopathogenic bacteria, modulate host inflammatory responses, and enhance oral ecological balance [6].

In orthodontic patients, herbal mouthwashes may offer meaningful advantages, especially because fixed appliances require a prolonged period of oral preventive measures. Evidence suggests that herbal rinses can reduce gingival bleeding and plaque accumulation without causing staining or taste disturbances, making them suitable for longer-term use [7]. A recent comparative study found that while CHX produces rapid antibacterial effects, herbal formulations provide a gentler yet sustained improvement in oral hygiene parameters when used over several weeks [8]. Furthermore, emerging data indicate that herbal products may exert prebiotic-like effects on the oral microbiome, supporting beneficial species while suppressing pathogens, thereby producing a more balanced ecological outcome [9].

Given the importance of maintaining optimal oral health during orthodontic treatment and the need for mouthwashes that are both effective and well tolerated, there is growing interest in evaluating herbal and chlorhexidine formulations side by side. Yet, there remains limited comparative clinical evidence assessing traditional herbal mouthwashes such as KP Namboodiri’s in orthodontic patients. Therefore, a structured 30-day comparative evaluation is necessary to determine whether herbal formulations can match or potentially approach the effectiveness of 0.2% chlorhexidine in controlling plaque and gingival inflammation in this specialized population.

The aim of the present study was to analogue and anatomize the effect of KP Namboodiri’s herbal mouthwash and 0.2% chlorhexidine mouthwash in orthodontic patients after 30 days of use, assessing changes in oral health parameters and determining their relative clinical impact.

This comparative clinical study was conducted among orthodontic patients undergoing fixed appliance therapy who reported to the Department of Orthodontics and Dentofacial Orthopedics. A total sample of 60 participants was selected based on predefined inclusion and exclusion criteria. Systemically healthy individuals between 12 and 25 years of age who had been undergoing fixed orthodontic treatment for at least three months and exhibited mild to moderate plaque accumulation were included. Patients with a history of recent periodontal therapy, systemic diseases influencing oral health, current use of antimicrobial mouthwashes, antibiotic intake within the previous four weeks, or hypersensitivity to chlorhexidine or herbal formulations were excluded. Ethical approval for the study was obtained from the institutional review board, and informed consent was secured from all participants or guardians in the case of minors.

Baseline examination of all 60 participants included recording of Plaque Index (PI), Gingival Index (GI), and Modified Gingival Bleeding Index (MGBI). Each participant was randomly assigned using a simple random allocation method into one of two groups, with 30 patients in each group. Group 1 received KP Namboodiri’s herbal mouthwash, and Group 2 received 0.2% chlorhexidine gluconate mouthwash. Both groups were instructed to use 10 mL of the assigned mouthwash twice daily after brushing, rinsing for 30 seconds each time. Participants were advised not to eat or drink for 30 minutes following rinsing. Oral hygiene instructions were standardized for both groups and were reinforced at every visit. No additional chemical plaque control aids were permitted during the study period.

Clinical examinations were performed at baseline and after 30 days. All parameters were recorded by a single calibrated examiner to minimize inter-examiner variability. Plaque Index assessed the thickness of plaque deposits around orthodontic brackets and gingival margins, while Gingival Index and Modified Gingival Bleeding Index evaluated gingival inflammation and bleeding tendency. Compliance was monitored through daily logs maintained by participants and cross-verified by measuring the volume of mouthwash remaining at the recall visit.

Microbial evaluation was also performed to investigate changes in oral bacterial load. Unstimulated saliva samples were collected at baseline and at 30 days between 9 a.m. and 11 a.m. to minimize circadian variations. Samples were immediately transported to the microbiology laboratory under controlled temperature conditions and processed for quantification of Streptococcus mutans colony-forming units using selective culture media. Serial dilution and standard plate count techniques were employed for microbiological analysis.

All data obtained were tabulated and subjected to statistical analysis. Descriptive statistics were used to summarize the clinical and microbiological findings. Intragroup comparisons between baseline and post-treatment values were performed using paired t-test or Wilcoxon signed-rank test based on data normality. Intergroup comparisons were analyzed using independent t-tests or Mann–Whitney U tests. A p-value less than 0.05 was considered statistically significant.

Table 1 shows the intragroup comparison of microbial colony counts in Group I and Group II at baseline and after 15 days for a total sample size of 60 participants. Each group consisted of 30 orthodontic patients. Both groups demonstrated a highly significant reduction in CFU levels after 15 days of mouthwash use. In Group I, which used the herbal mouthwash, the microbial count decreased considerably from baseline to the 15-day interval, showing strong anticariogenic activity. Similarly, Group II, which used 0.2% chlorhexidine, also showed a substantial reduction in microbial load from baseline to 15 days. The p-values remained <0.001, indicating a statistically significant intragroup reduction in bacterial colonies for both formulations, confirming the effectiveness of both mouthwashes in decreasing microbial activity during fixed orthodontic treatment.

Table 2 provides the intergroup comparison of CFU levels between Group I and Group II at baseline and after 15 days. At baseline, Group II exhibited slightly higher microbial counts compared to Group I, but this difference reached statistical significance due to the large sample size and minimal standard deviation. After 15 days, both groups showed similar reductions in microbial counts, and the difference in CFU values between the groups remained statistically significant with p<0.001. Although chlorhexidine is traditionally considered more potent, the herbal mouthwash demonstrated a comparable reduction, supporting its potential usefulness as an alternative formulation during orthodontic therapy.

Table 3 further represents an intragroup comparison highlighting the CFU changes from baseline to 15 days within each group presented separately for clarity. Both Group I and Group II exhibited substantial declines with significant p-values, reinforcing that consistent use of either herbal or chlorhexidine mouthwash contributes to an overall improvement in oral microbial health during fixed orthodontic treatment.

Table 1: Intragroup comparison of microbial colony count at baseline and after 15 days (n = 30 per group)

Table 2: Intergroup comparison of microbial colony count at baseline and after 15 days (n = 60)

Table 3: Intragroup comparison summary of CFU changes from baseline to 15 days

The findings of the present study demonstrated that both KP Namboodiri’s herbal mouthwash and 0.2% chlorhexidine produced significant reductions in microbial colony counts over a 15-day period in orthodontic patients. Although chlorhexidine has historically been recognized as the gold standard for chemical plaque control, the comparable reduction seen in the herbal group highlights the emerging potential of phytotherapeutic formulations in managing oral microbial load during fixed orthodontic treatment. Recent evidence has shown that herbal extracts rich in polyphenols, flavonoids, and essential oils exert antimicrobial activity by disrupting bacterial cell membranes, inhibiting enzymatic pathways, and suppressing biofilm maturation, making them effective adjuncts in plaque control [11]. The reduction observed in microbial colony counts in our study aligns with these findings, suggesting that the formulation used in Group I possesses potent antimicrobial constituents capable of inhibiting cariogenic and periodontopathogenic organisms.

The results further reflect the ecological benefits of herbal formulations, which modulate the oral microbiome without exerting harsh antibacterial effects. This is supported by contemporary clinical research demonstrating that herbal mouthwashes can reduce microbial activity while maintaining microbial diversity, thereby promoting ecological stability and minimizing adverse effects associated with long-term antiseptic use [12]. In orthodontic patients, where fixed appliances create complex niches for bacterial colonization, maintaining biofilm balance rather than complete microbial suppression is essential. The significant CFU reduction in both groups suggests that herbal mouthwash can serve as an effective and more tolerable alternative to chlorhexidine, especially for younger patients who require prolonged adjunctive therapy.

Chlorhexidine, on the other hand, continues to demonstrate superior and rapid antimicrobial action due to its potent cationic bisbiguanide structure and strong substantivity. However, recent studies have emphasized that its long-term use must be approached cautiously because of associated discoloration, altered taste perception, and mucosal irritation, all of which reduce compliance in orthodontic patients [13]. The comparable microbial reductions seen in our study, combined with the known side effects of chlorhexidine, indicate that herbal formulations may provide clinically meaningful benefits while ensuring better patient acceptability.

The statistically significant intergroup differences at baseline and after 15 days can also be attributed to subtle variations in microbial colonization patterns among orthodontic patients. Research has shown that orthodontic appliances alter salivary flow patterns and microbial composition depending on gender, age, appliance type, and hygiene practices [14]. Such variations may explain minor baseline differences, while the similar reductions after 15 days reinforce the therapeutic value of both agents. Importantly, the herbal formulation’s performance aligns with recent randomized clinical trials that demonstrated equivalent plaque reduction and gingival improvement when compared with chlorhexidine over short study durations [15].

Overall, the results suggest that while chlorhexidine remains a highly effective antimicrobial agent, herbal mouthwashes offer substantial benefits without the risk of unwanted effects and may be preferable for longer-term use. Their comparable effectiveness also makes them viable alternatives for patients who prefer natural products or who cannot tolerate chlorhexidine

The study demonstrated that both KP Namboodiri’s herbal mouthwash and 0.2% chlorhexidine effectively reduced microbial colony counts in orthodontic patients over a 15-day period. Although chlorhexidine displayed strong antimicrobial activity, the herbal mouthwash produced a comparable reduction, suggesting that it may serve as a clinically effective and well-tolerated alternative during fixed orthodontic treatment. Herbal formulations may therefore provide a promising adjunctive option for long-term plaque control, particularly for patients seeking natural, stain-free, and irritation-free alternatives

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