Does rubbing an essential oil on gums reduce inflammation for orthodontic patients? A Trial.

Do anti-oxidant essential oils reduce gingival inflammation for orthodontic patients?

Every now and then a paper is published that stands out because it reports on a study that is rather unusual for orthodontic research. This paper is clearly different as the authors report on new research using an anti oxidant and essential oil mixture for improving the gingival health of orthodontic patients. I think that it is great to see this type of research that may lead to changes in the advice that we may give to our patients.

images-10A randomized controlled trial evaluating antioxidant–essential oil gel as a treatment for gingivitis in orthodontic patients.

Benjamin J. Martin, Phillip M. Campbell, Terry D. Rees, and Peter H. Buschang

 

Angle Orthodontist advanced publication

http://dx.doi.org/10.2319/041515-251.1

In the introduction they explained that there is increasing evidence from periodontal research that antioxidants may be useful in treating gingivitis.

As a result the aim of this study was to;

“Evaluate the efficacy of the topical gel containing phloretin and ferulic and essential oils in the treatment of gingivitis in orthodontic patients”.

I was a little unclear as to what essential oils were; so I looked it up in Wikipedia. This is their definition:

“An essential oil is a concentrated hydrophobic liquid containing volatile aroma compounds from plants. Essential oils have been used medicinally in history. Medical applications proposed by those who sell medicinal oils range from skin treatments to remedies for cancer and often are based solely on historical accounts of use of essential oils for these purposes. Claims for the efficacy of medical treatments, and treatment of cancers in particular, are now subject to regulation in most countries”.

What did they do?

They randomly allocated 32 young adults who were having treatment with fixed appliances to receive a placebo gel or an active treatment which consisted of the same jail containing the antioxidants phloretin and ferulic acid in addition to essential oils.

They carried out a sample size calculation, they gave no details of randomisation method or concealment. This increases the possibility of bias.

The patients received oral hygiene instruction and they were asked to apply a pea sized amount of the gel to their gingivae twice a day immediately after brushing.

An examiner, who was blinded to the allocation, recorded  Probing Depth, Bleeding on Probing, Plaque Index and Gingival Index.

They collected this information at the start (T1) their next visit (T2) and a month later (T3). They asked the patients  to stop using the gel between (T2) and (T3). I was not sure why they did this and so I shall not expand on this data.

They carried out simple univariate tests with the man Whitney U test because of the small sample size.

What did they find?

I have extracted the data from T1 T2 to this table.

 Bleeding on probingProbing DepthGingival IndexPlaque Index
Treatment49.2 (40.5-57.8)2.53 (2.4 – 2.59)1.42 (1.3 – 1.5) 0.87 (0.73 – 1.0)
Control69.1 (59.8 – 78.3)2.64 (2.57 – 2.7)1.61 (1.49 – 1.72)1.17 (0.96 – 1.31)

If we now look at these differences and their confidence intervals (which I calculated) you can see that the confidence intervals are rather wide this indicates a degree of uncertainty. It is also important to note that for the Plaque Index, Gingival Index and Probing Depth data, the confidence intervals overlap, indicating that it is likely that these differences are not statistically significant. Furthermore, you can see that these differences are rather small and may not be clinically significant. However, there does appear to be a clinical and statistically significant difference for bleeding on probing. But it is  worth pointing out that at the start of treatment bleeding on probing occurred at fewer sites  for the treatment group (62.9%) than the control group (72.1%).

The investigators have also calculated the percentage change within the groups and this suggests that the intervention does have an effect.

What did I think?

Firstly I’m honestly not sure about their conclusions and while I accept that my analysis may be very critical, I wonder if the findings are robust? Unfortunately, they report some of their data as percentage change, which tends to mask differences that may be small. See my post on AcceleDent.

I have other concerns that the sample size is rather small and this leads to wide confidence intervals and uncertainty. Nevertheless, there may be something to this and I feel that this study is a really good pilot and a larger more precise investigation should be carried out before we all go out buying essential oils!

ResearchBlogging.org
Martin, B., Campbell, P., Rees, T., & Buschang, P. (2015). A randomized controlled trial evaluating antioxidant–essential oil gel as a treatment for gingivitis in orthodontic patients The Angle Orthodontist DOI: 10.2319/041515-251.1

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  1. Professor,
    Since you have calculated the confidence interval can you tell us what the sample size should have been to calculate a result of statistically significance please?
    Regards
    Ian

  2. These studies crack me up.
    When I was practicing, I gave patients oral hygiene instruction, free electric toothbrushes, free floss, free fluoride gel and even placed selant on teeth before bracketing but nothing works without patient compliance. In this entitled generation and absent parenting compliance and cooperation is the missing factor not voodoo magical gels.

    • I agree with you!
      If they would just comply and do as instructed!
      On the other hand since I teach and need good Intra oral photographs I have their teeth cleaned professionally at every visit free of charge….that keeps gingivitis down!

      • Nimet – I completely agree. Every potion, concoction and tool is worthless unless they are used. I see three problems with respect to oral hygiene – knowledge, tools and will. As with most things in life, will is the most critical ingredient, and without it, the other two are meaningless. I think the major issue is psychological and perhaps even spiritual – I am not being facetious. Most of our patients are struggling to grow up and define themselves. The oral hygiene issue can become a battleground in this, between patient and “authority”. I am working on an approach that tries to empower patients and reduce the significance of oral hygiene as a power issue.

        How many intelligent and “good kids” do you see with fair to poor oral hygiene as well as frequent broken brackets? I see lots. I consider us all healers number one, and I am working on healing the relationships that foster our patients doing what we know is best for them – or at least for their oral health. I’m not pushing them into treatment, but really supporting them when they are in treatment. Very much a work in progress. This is all a recent revelation of mine, so just starting out in this.

        Great to see you here Nimet!

  3. Dear Kevin,

    Thanks for another interesting point of view.

    Observing the methodology, I would like to talk about two other points:
    1-The current gold standard to treat gengivitis is use of chlorhexidine mouth rinse as the authors mentioned in their study. I think they should have used the gold standard as control group or a gel containing chlorhexidine (to permit blinding) instead of the placebo gel. Perhaps, they could have used both, the gold standard and placebo, but I think that to leave a group without the gold standard treatment an ethical problem…
    2-The interval from T1 to T2 was 35.7 ± 10.8 days and 42.6 ± 23.5 days for the treatment and control groups, respectively. I think that this variation from one week to three weeks from treatment to control group could affect the results, because cooperation decreases along time. Also, this information indicates a different follow-up between treatment and control groups.

    A last comment that I already have discussed with you, but that is still not clear for me. It is clear that is an obligation to perform the sample size calculation. In this paper, they performed the sample size calculation, which revealed that they needed 14 patients in each group with a power of 80% assuming an effect size of 1 (clinical relevance, I guess) and an alpha of 0.05. You suggested that this is a good pilot study and that they should increase the sample size. What happened, there was a mistake in their sample size calculation?

    Best regards,
    Klaus