J. Res. Educ. Indian Med., 2017;23(1-2):24-30 ISSN 0970-7700

ROLE OF DANTASHODHANA CHURNA PRATISARANA IN PREVENTING THE RECURRENCE OF DANTASHARKARA (DENTAL CALCULUS) AFTER ULTRASONIC SCALING

Department of Shalakya Tantra, IPGT & RA, GAU, Jamnagaq Gujarat (India). Department of Shalakya Tantra, 0.H Nazar Ayuweda college, Surat, Gujarat (India). Department of Shalakya Tantraj3All India Institute of , Sarita Ehaq New Delhi (India).

Abstract: Introduction: Negligence or improper methods of oral hygiene leads to dental calculus which can be compared with Dantasharkara, a disease condition described in Ayurveda. Scaling is the first treatment for the removal of all kind of calculus. Prevention of plaque is most important after scaling to prevent recurrence of calculus. Ayurvedic recommended for oral hygiene can help to prevent it in better way. Aims and objectives: To assess the effectiveness of Dantashodhana Churna Pratisarana after scaling in preventing the recurrence of the Dantasharkara. Materials and methods: It was a randomized, open-label parallel group trial. Both the Groups were undergone ultrasonic scaling where in one group Dantashodhana Churna Pratisarana was applied twice daily 2 grams for one month. Total thirty patients, fifteen in each group, completed the treatment. Results: Both the Groups showed statistically highly significant results but Group managed with Dantashodhana Churna Pratisarana showed percentage wise better results in objective criteria. Conclusion: Application of Dantashodhana Churna Pratisarana after ultrasonic scaling can be recommended for better management of Dantasharkara. Keywords: Ayurvedic Medicines, Dantasharkara, Dantashodhana Churna Pratisarana, Dental Calculus, Oral hygiene, Scaling.

INTRODUCTION health. Apart fiom the impact on nutritional status, Ayurveda is a holistic system of poor dental health can also adversely affect speech which evolved in India some 3000-5000 years ago, and self-esteem. [3] a system of native to the Indian Improper methods for routine oral hygiene subcontinent, now practiced in other parts of the lead to Dantasharkara. Collection of tartar at the world as a form of complementary medicine. Over junction of teeth and gums and in between the the centuries, Ayurvedic practitioners developed large teeth is known as 'Dantasharkara'. When numbers of medicinal preparations and surgical 'Dantasharkara' is not treated at the appropriate procedures. Even though was not a separate time, Dantavalka i.e. enamel of teeth gets eroded branch of Ayurveda, it was included in Shalakya Tantra and detached fiom the teeth along with an overlying specialty. Problems such as deformities of the oral crust of tartar which is known as 'Kapalika '[4] cavity, plaque, and were being managed Ayurveda recommended many procedures for well in ancient India. [I] routme oral hygene viz. Pratisarana (Gentle massage The state of your teeth affects overall health, over tissues), Gandusha (), Dantadhavana with gum disease linked to lots of health problems (Cleaning of teeth), Jihvanirlekhana (Tongue in other parts of the body. Therefore, brushing teeth Scarpping), Tambula Bhahhana Peetle quid chewing). can prevent gum disease and improve overall health. Pratisarana is gently rubbing over teeth with the tip of [2] The health of teeth and mouth are llnked to overall a finger and its four types i.e. Kalka; Rasabycl, Madhu health and wellbeing in a number of ways. The ability and Chuma Pratisaarana.[5] Aacharya, Sushmta has to chew and swallow the food is essential for mentioned the 'Dantashodhana Chuma' as routme obtaining the nutrients which are needed for good dental cleaning remedy.[6]

1. M.S.(Ayu) Final Scholar 2. Assistant Professor 3. Professor and HOD Ayurvedic Medicine in Preventing Recurrence of Dental Calculus (Dantasharkara)

Dental calculus is a hard deposit formed by Inclusion criteria: mineralization of dental plaque and is usually covered - Patients between the age group of sixteen to by a layer of unmineralized plaque. Precipitation of fifty years and Patients having the calculus deposition mineral salts into plaque starts between the first and were selected for the study. the fourteenth day of plaque formation. Calculus can be classified as supragingival and subgingval. [7] Exclusion criteria: Scaling is the first treatment for the removal - Patient having acute inflammationlinfection, of supragingival or subgingival calculus. It removes mobile teeth, cardiac disorder and any blood disorder all of the irritants under the gums to eliminate and patients requiring surgical intervention were inflammation and . Manual scaling may excluded fiom the study. often be difficult and time-consuming due to the complex and unfavorable root morphology when Treatmentprotocol: working blindly at deep pocket sites. Sometimes All the patients were divided into two Groups plaque is so hard that manual scaling causes pain and using simple random sampling method. fatigue on the fiigers of the dentist making him want Group A: Ultrasonic scaling was done to stop. Taking these factors into consideration, followed by Dantashodhana Churna Pratisarana; ultrasonic scalers have come to be widely used in twice daily, early morning and before bedtime at night. recent years because of their simplicity of use, the Dantashodhana Chuma (Table-1) was taken in two time advantage and a reduction in physical effort. grams quantity and Tzla Taila and Madhu was taken Using a machine to clean teeth not only makes in two grams quantity to make a paste form. This cleaning faster and easier but also more thorough. paste was applied all over the teeth and gingva with 181 the index finger for three to four minutes in The removal of calculus by scaling is of clockwise, anticlockwise and round direction with transient benefit because it reforms again within a gentle pressure. short period.[9] Good oral hygene is maintained best After performing the Pratisarana, the patient by means of prevention. Ayurvedic aspect of oral was asked to perform Gandusha with lukewarm water. hygiene may be effective in prevention or recurrence The same procedure was done twice a day for thirty of the disease. Pratisarana with Dantashodhana days. Churna (Table 1) was selected for the present study, Group B: Ultrasonic scaling was done. which is a well-known formulation of Sushrut Proper brushing method i.e. Bass method, its Samhita. importance and routine oral hygiene hygiene were explained to the patients of both Groups. AIMS AND OBJECTIVES: The aim of the study is to assess the effectiveness Criteria for the assessmeat: of Dantashodhana Chuma Pratisarana after scaling The assessment was done on the basis of Oral in preventmg the recurrence of the disease. Hygiene Index (OHI) and gingival index (Table- 2).[10,11] MATERIALS AND METHODS OH1 = CI (Calculus Index) (Table-3) +DI It is a randomized, open-label parallel Group (Debris Index) (Ta ble-4). trial. For clinical study patients attending the Out Changes in the subjective parameter were also Patient Department OPD of Shalakya Tantra, 1.P.GT. recorded as noted in Table 5.1 to 5.4 & R.A., GA.U., Jamnagar (Gujarat) were selected on the basis of subjective and objective criteria for Overall assessmeat: diagnosis. Total 30 patients were registered, that The total effect of therapy was assessed on divided 15 patients in each Group; irrespective of the basis of subjective and objective criteria and sex, religion, race, occupation etc. Patient's informed patients were grouped into following five steps. consent was taken before starting the treatment. - Cured: 100% relief in the signs and Clinical study was started after getting permission symptoms. fiom Institutional Ethics Committee (IEC) [PGT/7I - Marked improvement: 76-99% relief in the -A/ethics/20 13-141767, (Registered on: 101091 signs and symptoms 2013)l. The study was registered in CTRI [CTRII - Moderate improvement: 51-75 % relief in 20 151071006033, (Registered on: 20107120 15)]. the signs and symptoms. Dhara Makwana, Piyush Agravat and Manjusha R

Table-1: Contents of Danta Churna Table-4: Debris Tndex (DT) Score Criteria 0 No debris or stain present Soft debris covering not more than one third of the tooth surface or the presence of extrinsic stains without other debris regardless of surface area covered

than two thirds of the exposed tooth surface Soft debris covering more than two thirds of the exposed tooth surface.

Table-5.1: Pain

I Score I Criteria I 0 No pain 1 Occasional pain with low intensity Table-2: Gingival Index (GI) 2 Frequent paln with moderate intensity Continuous pain with severe intensity which increases Score Criteria during mastication 0 Absence of inflammatroni Normal ginglval 131 Mild inflammation; slight change in color. slight edema; , no bleeding on probing. Table-5.2: Inflammation of gums Moderate inflammation, redness, edema, moderate Score Criteria glazing, hypertrophy Bleed~ngon problng 0 Absence of inflammation Severe inflammation; marked redness, edema and M~ldinflammatlon, slight change in color and in texture 3 hypertrophy, ulceration Tendency to spontaneous of the marginal or papillary gingival unit. bleeding. Moderate inflammation, glazlng redness, edema of the marginal or papillary gingival unit. Table- 3: Calculus Index (CT) Severe inflammatlon, marked redness, edema of the marginal or papillary gingival unit. Score Criteria 0 No calculus present Supraglng~val calculus covermg not more than one Table-5.3: Bleeding gums , third of the exposed tooth surface Supragingival calculus covering more than one third I score I Criteria I but not more than two thirds of the exposed tooth I 0 I No bleeding I 2 surface or the presence of individual flecks of Bleeding point appears on probing subg~ngivalc&ulus around the cervical port~onof the Several isolated bleeding points or a single fine line of tooth or both, Supraglngival calculus covering more than two thuds The interdental trrangle fills with blood shortly after of the exposed tooth surface or a continuous heavy probing. band of subgingival calculus around the cervical Profuse bleeding occurs after probing; blood flows portion of the tooth or both. I I immediately into the marginal sulcus. I

- Mild improvement: 26-50 % relief in the Table-5.4: Halitosis signs and symptoms. I Score I Criteria I - Unchanged: 0-25 % relief in the signs and I 0 I Absence ofhad odor I symptoms I 1 I Presence of mild bad odor I 1 2 1 Presence of severe bad odor I Statistical arzaly The values of data were expressed as a Table-6: Distribution of patients as per Teeth Examination. percentage of relief and mean standard error of the Examination I I Gryup Gyp Total % mean. The data were analyzed by Student's t-test for of Teeth I I I I I comparing before and after treatment obtained scores. Carious P 9 10 19 63% The level of significance are expressed as P>0.05 as I Teeth A 6 5 11 37% insignificant, PK0.05 and 0.01 as significant, P< Tartar P 15 15 30 100% 0.00 1 as highly significant. Deposition A 0 0 0 0% P 8 3 11 37% Sensitivity A 7 12 19 63% Ayurvedic Medicine in Preventing Recurrence of Dental Calculus (Dantasharkara)

Table-7: Distribution of patients as per Gingival Examination.

Gingival Examination Group-1 Group-2 Total YO Hard 0 0 0 OYO Consistency Soft 9 12 2 1 7 0% Normal 0 0 0 0% Color Abnormal 15 15 3 0 100% Normal 2 3 5 16.67% Contour Altered 13 12 25 83.33% Bleeding on Present 14 7 2 1 7 0% Palpation Absent 1 8 9 3 0% Supra 2 0 2 6.66% Calculus Sub 1 1 2 6.67% Both 12 14 26 86 67%

Table-8: Effect of therapy on chief complains in Group A.

Table-9: Effect of therapy on objective criteria in Group A. Mean Score Criteria Relief(%) S.D. S.E. Paired 't' P B.T. I A.T. Calculus Index 2.267 0.000 100% 0.5936 0.1533 14.789 c0.00 1 Debris Index 2.000 0.267 86.7% 0.5936 0.1533 7.597 10.001 Gingival Index 1 1.800 1 0.333 1 81.50% 1 0.5164 1 0.1333 1 7.643 1 10.001 1

Table-10: Effect of therapy on chief complains in Group B.

Table-11: Effect of therapy on objective criteria in Group B. Mean Score Criteria Relief('%) S.D. S.E. Paired (t' P B.T. A.T. Calculus Index 2.200 0.400 8 1 30% 0.4140 0.1069 10.649 <0.001 Debris Index 1 600 0 667 58.30% 0 4577 0 1182 5 137 10001 Gingival Index 1.800 0.933 48.10% 0.3519 0.0909 4.111 <0.001 OBSERVATIONSAND RESULTS taking Guru Guna dominant diet. All the patients Observations: were having the habit of Tea. 17% patients were A maximum number of the patients (43%) having the habit of pan and 10% were having the belonged to the age Group of 41-50 years. The addiction of supari. Cigarette and tobacco addiction majority of the patients were female (6O%).Maximum was observed in 6.7% each. 50 % of the patients number of patients (87%) were talung Madhura Rasa were having irregular bowel habit. dominant diet followed by 83% of patients taking In present study, maximum number of patients Lavana Rasa. 73% of patients were taking Ushna (95%) were cleaning the teeth only once in morning Guna dominant diet followed by 63% of patients and 72.5% were using hard tooth brush. Among them Dhara Makwana, Piyush Agravat and Manjusha R

73% of the patients were observed changing their 6.67% of the patients were noted unchanged. tooth brushes at the interval of 4 to 8 months while (Figure-3) 10% at the interval of 9 to 12 months. All the patients adopted horizontal brushing technique. DISCUSSION: All the patients were having inflammation of Various investigators have reported evidence gums as their chief complaint while halitosis 87%; of calculus accumulation in a vast segment of the Bleeding gums. All the patients were having calculus population. Four out of five people have periodontal deposition over their teeth. 86.67% of the patients disease and most people are not aware of it because were observed having both supragingival as well as the disease is painless.[l2] It is also observed that subgingival calculus deposition along with carious patients are frightened of the time consuming and teeth (63%), and sensitivity (37%). All the patients lengthy treatments like scaling. were having an abnormal color of gingiva. Soft Aacharya Sushruta has described ths disease consistency of Wgva and bleeding on palpation was as 'Dantanam Gunahari ' that means altered present in 70% each. 83.33% of the patients were properties of the teeth. Dental calculus causes yellow having altered contour of gingiva. (Table-6, Table-7) or brown stains on teeth.[l3] It is also mentioned that Dantasharkara should be scraped without RESULTS: injuring the gums.[l4] Neglecting it results in a In Group A, Statistically highly significant reduction was observed in pain in all patients i.e. loo%, while in Group B, 33% (p=0.638) relief was observed in pain whch was statistically insignificant. Statistically highly significant (p<0 .OO 1) results were obtained in inflammation of gums (Group A, 81%; Group B, 48%) and bleeding from gums(Group A, 81%; Group B, 80%) in both Groups. In Group-A, 100% (p<0.001) relief was observed in halitosis, while in Group-B, 91% (p<0.001) relief was observed. (Table-8, Table- 10, Figure- 1)

On objective criteria while comparing the improvement both of the study Groups showed statistically highly significant results (p<0 .OO 1) but, percentage wise more improvement was noted in Group A. Group A showed 100% (p<0.001) improvement of calculus index while 8 1.80% (p<0.001) in Group B. Group A showed 86.7% (p<0 .OO 1) improvement in debris index, while 58.30% (p<0 .OO 1) Group B. Highly significant CaIculvs Index improvement in bleeding index was observed among Group A patients (81.50%, p < 0.001) and in Group B 48.10% (p< 0.001). (Table-9, Table -1, Figure- 2) Overall effect: &therapy

In the present clinical study, in Group A, 53.34% patients were cured; 40% marked improvement and 6.66 % moderate improvement. None of the patients showed mild improvement or noted unchanged where on In Group-B, none of the Marked Mad1at8 Irhlld patients were cured. 33.33% and 46.67 % patients QM I-B* 1mnt showed marked and moderate improvement .Gra@A .;GmupB respectively, 13.33% showed mild improvement and Ayurvedic Medicine in Preventing Recurrence of Dental Calculus (Dantasharkara)

variety of periodontal diseases, oral care methods 1. In pratisarana mechanical pressure is mentioned in Ayurvedic texts should be followed exerted on gums in the direction of the gmgval sulcus to prevent oral diseases. In addition to Pratisarana which remove food debris, plaque some part of Modified Bass method of brushing was explained calculus too. By pressure, it clears sticky bio-film to the patients. The studies have shown that the on tooth surface which is responsible for growth of Modified Bass method is significantly more micro-organism. effective in removing plaque both in buccal and 2. In pratisarana gentle massage is done. This lingual sites. [15] stimulates the gingival epithelial cell and leads to In this clinical trial, total no. of 30 patients regeneration of the gingiva thus helping in were randomly regstered into two Groups where 15 keratinization and this process may help in retarding patients in each Group. All patients completed the the inflammation at vascular, cellular and immune whole treatment protocol. The present study shows level. It may increase the defense mechanism of that a maximum (87%) of patients were taking gmgtva. Madhura Rasa dominant diet followed by 83% of patients taking Lavana Rasa. Amla Rasa dominancy Probable mode of action of Dantashodhaiza was found in 70% of the patients. Excessive intake Churaa: of Madhura Rasa leads to increased Kapha, which As the name suggests, it cleanses the teeth plays an important role in the pathogenesis of and mouth. It tends to remove the bad smell from the Dantasharkara. [ 161 mouth and the uncleanliness of the teeth as well as Patients were having the habit of pan i.e. 17%; to subdue the Kapha. It also produces a good relish supari 10%; Cigarette and tobacco addiction i.e. 6.7%. for food and a cheerfulness of mind. [19] Studies show that people who smoke cigarettes or In the ingredients of Dantashodhana Churna use other tobacco products are more likely to have is having Katu (100%) Rasa; Laghu (85.71%), dental calculus on their teeth and under their gums. Tikshna (57.14%), Ruksha (42.85%) Guna; Ushna [17] Patients i.e. 95% were cleaning the teeth only (7 1.43%) Erya; Katu (57.14%) Epaka and Vata- once in the morning while only 05% patients at bed Kaphashamaka (85.71%). time also. This indicates lack of maintenance of oral Katu Rasa is having Shodhana, Lekhana, hygiene resulting in plaque formation and then Kledashoshaka, Krimighna and Kaphanashaka chronic periodontal disease leading to loss of support Karma. It may decreases the Kapha and purifies of teeth. Maximum numbers of patients (73%) were local blood. It may help to dry up the excessive observed changing their tooth brushes at the interval fluid and decreases the inflammation. Laghu- of 4 to 8 months while 10% at the interval of 9 to Ruksha-Tikshna Guna are Vatakapha Shamaka. 12 months. With regular use long after, the bristles The drugs by their Laghu, Tikshna properties lose their cleaning effectiveness. All the patients produce Chhedana of vitiated Kapha that can also adopted horizontal brushing technique. Due to lack be correlated with plaque. Ushna Erya exhibits of knowledge of the correct brushing technique, Vata-Kaphashamaka activity. Katu Vipaka plaque can not be removed completely. Retained normalizes vitiated Kapha and Vata. Most of the plaque results in calculus deposition. drugs possess anti-inflammatory, anti-bacterial All the patients were having ldammation of activities and may be helpful in preventing recurrent gums as their chef complaint. Other complains i.e. infections and reduces inflammation. halitosis 87%, bleeding gums 83% and pain 37%. Mammation is the result of physical irritation of gums CONCLUSION and presence of bacterial toxic by-products in the Dantashodhana Churna Pratisarana calculus. There is always a positive correlation between provides statistically significant result in preventing the calculus and prevalence of gmgvitis. [18] the recurrence of plaque and calculus as well as in maintaining oral hygiene. Adopting proper brushing Probable mode of action of Pratisarana: technique (Modified Bass Technique) and Pratisarana mainly exhibits two types of Pratisarana with Dantashodhana Churna after therapeutic effects by rubbing with finger locally. scaling, twice daily can prevent the plaque formation 1. Shodhana (Mechanical removal of food and tartar deposition, reduce the gum swelling and particles, plaque and calculus). 2. Massage prevent the infection. Dhara Makwana, Piyush Agravat and Manjusha R

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Corresponding author: Dr. Dhara M. Makwana, M.S. (Ayu) scholar, Department of Shalakya Tantra, IPGT & RA, Gujarat Ayurved University, Jamnagar, India. E-mail : dharapatelddd@,gmail.com ScopeMed UID 82-1496239010