Betel leaf toothpastes inhibit dental plaque formation on fixed orthodontic patients

Background: Brackets, archwires, ligatures, and other fixed orthodontic appliance components complicate the use of conventional oral-hygiene measures. This often results in significant plaque accumulation around the bracket bases. The addition of betel leaf extract in toothpaste is expected to inhibit the growth of dental plaque. Purpose: The purpose of this study was to evaluate the effect of betel leaf toothpaste in inhibiting plaque formation on the fixed orthodontic patients. Methods: This study was done on dental student of Airlangga University aged 18–24 years, have been wearing fixed orthodontic appliances for 1–2 years, have no systemic diseases. The samples were divided into two groups, consisting of 20 samples. First group of samples brushed their teeth with betel leaf toothpaste and the second using placebo. The subjects were instructed to brush their teeth using Scrub method until reaching zero (0) scor of orthodontic plaque index (OPI). Plaque scores were taken again 4 hours after brushing. The statistical analysis was done by using paired t test. results: The average of accumulated plaque on group that use betel leaf toothpaste was 25.54 and placebo was 41.09. The result showed that there was significant difference in plaque accumulation between the group with betel leaf toothpaste and placebo 4 hours after brushing (p = 0.001). Conclusion: In conclusion, betel leaf toothpaste is effective in inhibiting the dental plaque formation on the fixed orthodontic patients.


introduction
Orthodontic fixed appliances is appliances that are attached to the patient's teeth so it can not be removed by the patient.Orthodontic treatment with fixed appliances alters the oral environment, increases plaque amount, changes the composition of the flora, and complicates the cleaning for the patients. 1Fixed orthodontic patients usually have difficulty in cleaning their teeth because there are certain parts of teeth that are difficult to clean.Whereas in patients using fixed orthodontic appliances, it is very important to maintain and improve oral hygiene, considering the device is attached in such a way that will facilitate the formation of bacterial accumulation in the area. 2 Brackets, archwires, ligatures, and other orthodontic appliances complicate the use of conventional oralhygiene measures.This often results in significant plaque accumulation arround the bracket bases. 3The presence of a fixed orthodontic appliance greatly inhibits oral hygiene and creates new retentive area for plaque and debris, which in turn predisposes to increased carriage of microbes and subsequent infection. 4rushing teeth helps controling plaque and is the first step to control caries and periodontal disease.Currently plaque control is equipped with additional types of active component that contain the basic ingredients of natural or synthetic material as antibacterial.Antibacterial agents are available in the form of mouth rinses and toothpaste. 5oothpaste contains antimicrobial agents such as triclosan and chlorhexidine as an active component that may provide direct inhibitory effect of plaque formation.Due to the progress of science and technology, many innovations to add other substances that are beneficial to dental health.One of the substances added to the toothpaste is betel leaf extract.
Betel leaf has been known by the people of Indonesia for a long time, as an ingredient that will strengthen teeth, stop gingival bleeding, and as a mouthwash remedy.Betel leaf could stop the bleeding (styptic), skinwound healing (vulnerary), gastrointestinal drugs (stomachic), and clear the throat.Betel leaf also has antiseptic, antioxidant, and antifungal effect.Essential oil and its extract are able to fight some gram-positive and negative bacteria. 6Betel leaf toothpaste contains essential oils with the active substances are phenol and cavicol.Toothpaste containing essential oil of betel leaf is considered relatively new.But actually the efficacy of betel leaf as antibacterial agent has long been known and proven.The addition of betel leaf extract in toothpaste is expected to inhibit the growth of dental plaque.This is related to the ability of betel leaf as an antibacterial agent. 7This study was undertaken to evaluate the effectivity of betel leaf toothpaste in inhibiting plaque formation on the fixed orthodontic patients.The benefits of this study to offer an alternative method for fixed orthodontic patients in maintaining their oral hygiene.

materials and methods
This study was done on dental student of Airlangga University aged 18-24 years, wearing upper and lower fixed applliances, used elastomeric modules, without caries, does d elastomeric modules, without caries, does not have systemic diseases, acute or chronic diseases in the oral cavity.The sample was determined through purposive random sampling of 20 students.
On the first visit, subjects were asked to brush their teeth using betel leaf toothpaste with scrub technique to obtain score zero (0).Score was measured after applying disclosing solution with microbrush on labial or buccal surface of the teeth.For four hours after brushing, the subject was not allowed to eat anything and gargling.After four hours of fasting, plaque score was measured again.Measurement of plaque used the orthodontic plaque index (OPI). 8Tooth surface that being examined is all part of the labial and buccal teeth with brackets except with brackets except for posterior teeth which had bands.Tooth surface being examined was divided into three areas by dividing the tooth surface horizontally (Figure 1).
The plaque of every area was recorded (Figure 2).Area III (occlusal) was multiplied with 1, area I (cervical) was multiplied with 2 and area II (central) was multiplied with 3, and then the total score were found.The OPI were determined as follows: Total score = OPI Total tooth being examined × 6 Plaque score was OPI multiplied 100.The criteria were: good: 0-25, average: 26-50, poor: >50 On the second visit, three days after the first visit, subjects were asked to brush their teeth with placebo tooth paste until got the score zero (0).Like the first visit, after four hours of fasting, plaque score was measured again.Data was collected and statistical analysis was done by statistical analysis was done by using paired t test.

results s
The result of this study could indicate that most of samples were in average criterion (60% of samples brushed with betel leaf toothpastes and 85% of samples brushed with placebo).Good criteria were found on 40% samples brushed with betel leaf toothpastes and only 5% samples brushed with placebo (Table 1).It was shown that the mean of plaque scores in group brushed with placebo was higher (41.09) than the group brushed with betel leaf toothpastes (25.54) (Table 2).
Before the paired t test was done to determine the significance of difference, this data needed to conduct normality test using Kolmogorov-Smirnov test.The result for group brushed with placebo was 0.978 (p > 0.05) and the group brushed with betel leaf toothpastes was p = 0.980 (p > 0.05).It means that both of the groups had normal distribution.From the result of paired t test, it is known that the p value is 0.001 < 0.05 so the data was significant differrent.
Based on this analysis it can be seen that there was significant different between the plaque score of subject who brush their teeth using betel leaf toothpaste and placebo.The plaque score in subject using placebo was higher than subject who brushed with betel leaf toothpaste.

discussion
This study was done on 20 subjects with fixed orthodontic appliances who were asked to brush their teeth until got the score zero (0) to make homogenized samples before treatment.Dental plaque can be formed within 4 hour after tooth cleaning, 9 so in this study, samples was asked to wait for 4 hours without eating, rinsing or drinking before the second measurement of plaque scores were done.
It was shown that the mean of plaque scores in group brushed with placebo was higher (41.09) than the group brushed with betel leaf toothpastes (25.54).From the paired t test analysis, it is known that the p value = 0.001 (p < 0.05), so the results showed that the plaque formation on fixed orthodontic patients brushed with placebo was significantly higher than the subject brushed with betell leaf toothpaste.The result are consistent with previous study that says that the betel leaf extract may inhibit the formation of colonies of Streptococcus mutans in plaque. 10Betel leaf extract also reduced the adherence of bacteria to the biofilm contained a layer on the surface of the tooth.This reduction is possible due to alteration of protein on the cell surface of bacteria by extract of betel leaf.
Based on laboratory test results, it was found that betel leaf extract in the toothpaste had chemical components as much as 31.80%flavonoids, alkaloids as much as 17.05%, polyphenate as much as 21.41%, anthocyanin as much as 8.62%, and oil essential as much as 2.86%.One of the largest classes of naturally-occuring polyphenolic compounds are flavonoids.A number of flavonoid, shows antibacterial and antiviral activity. 11They are known to be synthesized by They are known to be synthesized by plants in response to microbial infection and found in vitro to be effective antimicrobial substances against a wide array of microorganisms.Their activity is probably due to their ability to complex with extracellular and soluble proteins and to complex with bacterial cell walls.More lipophilic flavonoids may also disrupt microbial membranes. 12,13 2,13lkaloids are heterocyclic nitrogen compounds. 13 3Purified alkaloids as well as their synthetic derivatives are used as medicinal agents for their various biological effects such as analgesic, antispasmodic and bactericidal. 12nthocyanins and polyphenate is one kind of phenol which is both antibacterial and antioxidant. 13Several mechanisms of action in the growth inhibition of bacteria are involved, such as destabilization of cytoplasmic membrane, permeabilization of plasma membrane, inhibition of extracellular microbial enzymes, direct actions on microbial metabolism and deprivation of the substrates required for microbial growth. 15ssential oil of betel leaf is an effective antibacterial agent. 16Essential oil of betel leaf with phenol components include: carvacol, cineol, cariofilen, eugenol, and chavicol.Components of these phenols have a very strong antiseptic power.Bacterisid properties of carvacol efficacy has five times more powerful than other phenol component.Carvacol and cineol has the same efficacy as eugenol, which is antiseptic and topical analgesic.Cariofilen is antiseptic and local anesthetic. 17Chavicol is a major phenolic compound present in the aqueous extract of the Piper betle leaf.The compound is better known for its antioxidant and anticancer properties. 18Chavicol can behave as a desinfectant and antifungal.This is aninfluential component in inhbiting the growth of dental plaque. 19From the statement above, betel leaf has many ingredients with antibacterial, antiseptic, disinfectant, and anti fungal effect, which makes the plaque formation on fixed orthodontic patients brushed with betel leaf toothpaste was more difficult than with placebo.
Placebo also can reduce plaque accumulation in orthodontic fixed patients.This can be caused by mechanical process that occurs, ie brushing using a toothbrush.Another possibillity would be caused by detergent (sodium lauryl sulfate) and abrasive (calcium carbonate) contained in placebo.Detergent makes foam and also has antibacterial effect.However, the use of placebo in reducing plaque on fixed orthodontic patients are not as effective as the betel leaf toothpaste.
In conclusion, betel leaf toothpastes can inhibit dental plaque formation on fixed orthodontic patients.Mecanical prevention of dental plaque formation on fixed orthodontic patients by tooth brushing betel leaf toothpaste is effective.

figure 1 .
figure 1. Tooth surface was divided into three areas.I: cervical, II: central, III: occlusal

table 1 .
Criteria of plaque with orthodontic plaque index (OPI)

table 2 .
Average plaque score in each group