o efeito antiplaca e antigengivite de um gel contendo extrato de rom a 10% foi avaliado utilizando um modelo de gengivite experimental parcial em humanos .
23 indivduos participaram voluntariamente deste estudo cruzado , duplo - cego , compreendendo dois perodos de 21 dias cada um .
uma moldeira de acrlico foi confeccionada para cada participante , a qual foi utilizada como carreadora dos gis sobre a rea a ser avaliada ( hemiarco inferior esquerdo ) .
os sujeitos foram aleatoriamente designados para usar o gel placebo ( grupo controle ) ou o gel teste ( grupo experimental ) , sendo instrudos a colocar o gel na moldeira e esta sobre os dentes teste , escovando os outros normalmente trs vezes ao dia .
no dia 0 e dia 21 os ndices de placa visvel ( ipv ) e ndice de sangramento gengival ( isg ) foram registrados .
os resultados no demonstraram diferena estatstica significante entre os grupos controle e experimental para nenhum dos ndices .
o gel contendo extrato de rom a 10% no foi eficiente em evitar a formao de placa bacteriana supragengival e prevenir a inflamao gengival .
gingivitis is a chronic inflammatory process limited to the gingiva and without either attachment or alveolar bone loss .
it is one of the most frequent oral diseases , affecting more than 90% of the population , regardless of age , sex or race .
the earliest clinical sign is the bleeding caused by a vasodilatory effect caused by an inflammatory response29 .
the prevention of gingivitis by daily and effective supragingival plaque control using toothbrushing and dental floss is necessary to arrest a possible progression to periodontitis3,11 .
although mechanical plaque control methods have the potential to maintain adequate levels of oral hygiene , clinical experience and population - based studies have shown that such methods are not being employed as accurately as they should by a large number of people .
therefore , several chemotherapeutic agents such as triclosan , essential oils and chlorhexidine have been developed to control bacterial plaque , aiming at improving the efficacy of daily hygiene control measures6,8,10,15 - 17,23,26 .
the interest in plants with antibacterial and antiinflammatory activity has increased as a consequence of current problems associated with the wide - scale misuse of antibiotics that induced microbial drug resistence7,18 .
natural products such as astronium urundeuva , calendula , aloe vera , curcuma zedoaria and other herbal products have been tested with effective results12,19,25,29 .
punica granatum linn ( family punicaceae ) , mostly known as " pomegranate " , is a shrub or small tree native from asia where several of its parts have been used as an astringent , haemostatic as well as for diabetes control5,13,24 . in brazil
, the fruit of this tree is known as " rom " and is commonly used for treatment of throat infections , coughs and fever due to its antiinflammatory properties13,14 . in the only study available evaluating the effects of pomegranate on gingivitis , pereira and sampaio21 ( 2003 ) showed a significant reduction of gingival bleeding after using a dentifrice containing pomegranate extract . however , a control group was not included in that study .
therefore , the purpose of the present investigation was to assess the effects of punica granatum linn extract on supragingival plaque formation and development of experimental gingivitis in comparison to a control formulation .
twenty - five dental students from the university of fortaleza ( unifor ) ( 12 male and 13 female aged 22 to 28 years ) were enrolled in this study .
all subjects had at least 20 natural teeth , among which the 4 posterior teeth in the lower left quadrant ( experimental teeth ) .
all participants , randomly screened , were informed about the nature of the study and signed an informed consent form in compliance with the guidelines of the brazilian health council .
students with medical disorders , severe periodontal disease and under antimicrobial therapy , as well as smokers , pregnant women and individuals presenting a probing depth 3 mm associated with any mandibular teeth were excluded from the trail .
the protocol was approved by the university 's ethics committee ( report cotica / unifor ) an alginate impression of the experimental teeth was taken and poured in die stone to obtain casts . on each stone
cast , a 0.3-mm - thick thermoplastic mouthguard material spacer was made using a vacuum former . upon the spacer
, an individual toothshield was made of a 2-mm - thick thermoplastic mouthguard material , using the same vacuum former .
the toothshield was trimmed 2 mm beyond the gingival margin to assure that gel would be in contact with the gingival margin of the experimental teeth during toothbrushing of the remaining teeth .
the control and experimental gels were formulated and packed into tubes in a commercial drugstore . the tubes were previously coded to warrant that neither the examiner nor the volunteers knew their content , which was revealed by the pharmacist only after the study was completed .
all students used both gels in alternate periods , according to a cross - over model .
an infusion was prepared with powdered material at a ratio of 100 g powder to 1000 ml distilled water , cooled at room temperature and filtered .
thereafter , 50 g of carboxymethylcellulose was added to the infusion ( 1000 ml ) and the mixture was kept boiling until complete dissolution to obtain the 10% gel concentration .
the pomegranate extract concentration used in this work was based on the findings of previous in vitro studies13,20 that tested the gel at different concentrations and found that the 10% concentration yielded the most favorable results . a glycerin / ethanol mixture ( 50 ml:50 ml )
was added and the solution was vigorously stirred during 15 minutes until gel formation . a very small amount of menthol ( flavoring ) and a conserving agent were then added .
this study was a randomized , double - blind comparison of 2 crossover groups of dental students performed in 2 experimental phases of 21 days each with a 1-month washout interval between them .
to standardize the groups , the students were submitted to a meticulous evaluation ( pre - experimental phase ) to score the visible plaque index ( vpi ) and the gingival bleeding index ( gbi)1 of each tooth .
all teeth of each subject were polished and flossed by the examiner to eliminate plaque remnants .
thirty days after the initial phase , the volunteers were randomly assigned to 2 groups and the experimental phase began . on day 0 of both experimental periods ,
vpi and gbi were recorded . a personal " kit " containing a toothshield , a tube with 90 g of control or experimental gel and a commercial dentifrice with no antigingivitis properties ( sorriso , kolynos do brazil ltda .
, osasco , sp , brazil ) was given to all students . during each 21-day experimental period
, the subjects were instructed to fill the toothshield with the gel prior to insertion in the mouth and seat it over the experimental teeth for at least 1 min .
the volunteers refrained from brushing the test quadrant , while the other teeth were normally brushed three times a day using the dentifrice ( same to all students ) .
in addition to verbal instructions , the subjects were given written recommendations to follow at home . on the last day of each period ( 21st day ) ,
vpi and gbi indexes were recorded by the same examiner on the mesiobuccal , buccal , distobuccal , mesiolingual , lingual and distolingual surfaces of the experimental teeth .
the gingival tissues were inspected for the presence of bleeding , recorded 10 seconds after running the tip of a who probe along the gingival margin ( 0.5-mm penetration into the sulci ) .
the values of six sites of each tooth were recorded to obtain the vpi and gbi means .
then , vpi and gbi means for the four test teeth were calculated to determine vpi and gbi means of each volunteer .
intra - examiner agreement for vpi and gbi was calculated by repeating the measurements in 10 patients , with at least 1 hour of interval4 .
twenty - five dental students from the university of fortaleza ( unifor ) ( 12 male and 13 female aged 22 to 28 years ) were enrolled in this study .
all subjects had at least 20 natural teeth , among which the 4 posterior teeth in the lower left quadrant ( experimental teeth ) .
all participants , randomly screened , were informed about the nature of the study and signed an informed consent form in compliance with the guidelines of the brazilian health council .
students with medical disorders , severe periodontal disease and under antimicrobial therapy , as well as smokers , pregnant women and individuals presenting a probing depth 3 mm associated with any mandibular teeth were excluded from the trail .
the protocol was approved by the university 's ethics committee ( report cotica / unifor )
an alginate impression of the experimental teeth was taken and poured in die stone to obtain casts . on each stone
cast , a 0.3-mm - thick thermoplastic mouthguard material spacer was made using a vacuum former . upon the spacer ,
an individual toothshield was made of a 2-mm - thick thermoplastic mouthguard material , using the same vacuum former .
the toothshield was trimmed 2 mm beyond the gingival margin to assure that gel would be in contact with the gingival margin of the experimental teeth during toothbrushing of the remaining teeth .
the control and experimental gels were formulated and packed into tubes in a commercial drugstore . the tubes were previously coded to warrant that neither the examiner nor the volunteers knew their content , which was revealed by the pharmacist only after the study was completed .
all students used both gels in alternate periods , according to a cross - over model .
an infusion was prepared with powdered material at a ratio of 100 g powder to 1000 ml distilled water , cooled at room temperature and filtered .
thereafter , 50 g of carboxymethylcellulose was added to the infusion ( 1000 ml ) and the mixture was kept boiling until complete dissolution to obtain the 10% gel concentration .
the pomegranate extract concentration used in this work was based on the findings of previous in vitro studies13,20 that tested the gel at different concentrations and found that the 10% concentration yielded the most favorable results . a glycerin / ethanol mixture ( 50 ml:50 ml )
was added and the solution was vigorously stirred during 15 minutes until gel formation . a very small amount of menthol ( flavoring ) and a conserving agent were then added .
this study was a randomized , double - blind comparison of 2 crossover groups of dental students performed in 2 experimental phases of 21 days each with a 1-month washout interval between them .
the students were submitted to a meticulous evaluation ( pre - experimental phase ) to score the visible plaque index ( vpi ) and the gingival bleeding index ( gbi)1 of each tooth .
all teeth of each subject were polished and flossed by the examiner to eliminate plaque remnants .
thirty days after the initial phase , the volunteers were randomly assigned to 2 groups and the experimental phase began . on day 0 of both experimental periods ,
vpi and gbi were recorded . a personal " kit " containing a toothshield , a tube with 90 g of control or experimental gel and a commercial dentifrice with no antigingivitis properties ( sorriso , kolynos do brazil ltda .
, osasco , sp , brazil ) was given to all students . during each 21-day experimental period
, the subjects were instructed to fill the toothshield with the gel prior to insertion in the mouth and seat it over the experimental teeth for at least 1 min .
the volunteers refrained from brushing the test quadrant , while the other teeth were normally brushed three times a day using the dentifrice ( same to all students ) .
in addition to verbal instructions , the subjects were given written recommendations to follow at home . on the last day of each period ( 21st day ) , vpi and gbi indexes were recorded and the teeth were polished with pumice .
vpi and gbi indexes were recorded by the same examiner on the mesiobuccal , buccal , distobuccal , mesiolingual , lingual and distolingual surfaces of the experimental teeth .
the gingival tissues were inspected for the presence of bleeding , recorded 10 seconds after running the tip of a who probe along the gingival margin ( 0.5-mm penetration into the sulci ) .
the values of six sites of each tooth were recorded to obtain the vpi and gbi means .
then , vpi and gbi means for the four test teeth were calculated to determine vpi and gbi means of each volunteer .
intra - examiner agreement for vpi and gbi was calculated by repeating the measurements in 10 patients , with at least 1 hour of interval4 .
the mann - whitney non - parametric test was used to evaluate statistical differences between control and experimental groups on days 0 and 21 . in each group ,
the mean scores of vpi and gbi were compared between baseline and the end of the trial by the wilcoxon test .
two students were excluded from the study during the experimental phase due to third molar extraction and restorative needs .
the experimental gel had good acceptance and did not show adverse effects , such as abscess , ulcerations or allergic reactions . on day 0 , in both experimental periods ,
the control and experimental groups did not show statistically significant difference to each other with respect to vpi ( p=0.5385 ) and gbi ( p=0.3392 ) means ( p>0.05 ) .
these results indicated that both groups were well balanced at baseline ( table 1 and 2 ) . at the 21st day ,
plaque ( p=0.4354 ) and gingival bleeding ( p=0.4685 ) were present in both groups , but the difference between them was not statistically significant ( table 1 and 2 ) .
* means followed by the same uppercase letters on day 0 and day 21 do not differ statistically ( p>0.05 ) * * means followed by different lowercase letters in a same column differ statistically ( p<0.05 ) * means followed by the same uppercase letters on day 0 and day 21 do not differ statistically ( p>0.05 ) * * means followed by different lowercase letters in a same column differ statistically ( p<0.05 ) comparing the means between day 0 and day 21 in each group , there was a statistically significant difference in the vpi ( p=0.0000 ) and gbi ( p=0.0001 ) indexes .
the inability of adult population to perform adequate mechanical toothcleaning has stimulated the search for chemotherapeutic agents added to dentifrices to improve plaque control and prevent gingivitis16 .
the antibacterial activity of punica granatum linn has been evaluated in previous studies with good results .
trivedi and kazmi28 ( 1979 ) , using extracts of fruit barks have observed an antibacterial activity of pomegranate extract against bacillus anthracis and vibrio cholerae while machado , et al.14 ( 2003 ) showed similar effect against staphylococcus aureus , in agreement with prashant and asha22 ( 2001 ) .
considering that flavoring agents can promote a moderate antiplaque effect16 and that the contents of test and control gels were different only with respect to the presence of pomegranate extract , this agent did not have additional effect in reducing dental plaque formation .
these data are not in agreement with those of a previous in vitro study20 that showed that a bacterial strain present in supragingival plaque , namely streptococcus sanguis , was sensitive to different concentrations of pomegranate extract , which demonstrated an inhibitory action similar to that of chlorhexidine2,9 .
it should be highlighted , however , that in vitro studies do not reproduce exactly the oral conditions . in the present study , the punica granatum linn
extract gel did not avoid plaque formation during the trial , as suggested by kakiuchi , et al.9 ( 1986 ) and pereira , et al.20 ( 2001 ) . as the gel was placed into on the toothshield in a non - diluted form , it may be speculated that gel solubilization by saliva would be necessary for its antimicrobial action to take place17 .
the antibacterial agents present in pomegranate - the hydrolysable tannins - form complexes of high molecular weight with proteins soluble , increase bacterial lysis and moreover interfere with bacterial adherence mechanisms to tooth surfaces9,13 - 14 .
there was no significant difference between the experimental and control groups in relation to gbi at the end of the trial .
these results are not consistent with those reported by pereira and sampaio21 ( 2003 ) , who showed a significant reduction on gingivitis in patients using a dentifrice containing pomegranate extract .
nevertheless , it is noteworthy that a control group was not included in that study , which does not allow accessing the actual gingivitis reduction rate related exclusively to mechanical plaque control . according to ross , et al.24 ( 2001 )
the antiinflammatory effect of pomegranate may be attributed to its considerable immunoregulatory activity over macrophages and t and b lymphocyte subsets .
however , in both experimental and control groups , there was a significant increase in marginal bleeding , showing that pomegranate did not avoid the development of gingivitis .
the binary score used in this study only evaluate the presence or absence of bleeding ; it does not allow the assessment of other characteristics of the inflammatory process , such as edema , changes in gingival contour and loss of tissue attachment .
therefore , the possible effect of punica granatum linn extract on controlling the severity of gingivitis can not be discussed . due to the lack of clinical trials with a similar design investigating the effect of pomegranate on gingivitis ,
the data of this study were evaluated by parallel inferences , taken off from non specialized articles .
therefore , more controlled trials using different concentrations of punica granatum linn extract are necessary to verify its action upon supragingival microflora in vivo and established gingivitis .
further research will be important to identify the real benefits of pomegranate as a therapeutic and preventive agent for gingivitis , in addition to its common use in popular medicine .
within the limits of this clinical study , it may be concluded that the gel containing 10% punica granatum linn extract was not efficient in preventing supragingival dental plaque formation and gingivitis .
 objectives : the antiplaque and antigingivitis effects of a gel containing 10% punica granatum linn extract were evaluated using a 21-day partial - mouth experimental model of gingivitis.methods:23 volunteers participated in this cross - over , doubleblind study , carried out in 2 phases of 21 days each . for each period of the experiment , 
 an acrylic toothshield was made for each volunteer to carry the test or placebo gel as well as to avoid brushing of the 4 experimental teeth ( posterior teeth in the lower left quadrant ) . 
 the subjects were randomly assigned to use either the placebo gel ( control group ) or the test gel ( experimental group ) and were instructed to brush the remaining teeth normally 3 times a day . on days 0 and 21 , the visible plaque index ( vpi ) and gingival bleeding index ( gbi ) were recorded.results:the results did not show statistically significant difference between control and experimental groups for either of the indices ( vpi and gbi).conclusion : the gel containing 10% punica granatum linn extract was not efficient in preventing supragingival dental plaque formation and gingivitis . 
Objetivos:
Mtodos:
Resultados:
Concluses:
INTRODUCTION
MATERIAL AND METHODS
Subjects
Toothshield fabrication
Test and control products
Preparation of Punica granatum Linn extract
Clinical design
Clinical assessment
STATISTICAL ANALYSIS
RESULTS
DISCUSSION
CONCLUSION