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Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 332-337
Comparative effectiveness of herbal and conventional toothpaste on prevention of dental caries: systematic review and meta-analysis

1 Department of Public Health Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry, India
2 Department of Conservative Dentistry and Endodontics, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry, India
3 Department of Pediatric and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry, India
4 Department of Conservative Dentistry and Endodontics, Shree Balaji Dental College and Hospital, Chennai, Tamil Nadu, India
5 Department of Public Health Dentistry, Saveetha Dental College and Hospitals, SIMATS, Saveetha University, Chennai, Tamil Nadu, India

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Date of Submission03-May-2021
Date of Decision09-Mar-2022
Date of Acceptance06-Sep-2022
Date of Web Publication17-Jan-2023


Dental caries is a global oral health problem caused due to localized demineralization of the enamel. Chemical plaque control is used as an adjuvant to mechanical plaque control in removing biofilm, thereby preventing dental caries. In recent times, there has been a renewed interest in nature-based products. This systematic review aimed to analyse the existing literature to compare the effectiveness of herbal and conventional dentifrices on prevention of dental caries. A search was done in the databases of PubMed and Google Scholar in July 2020 for the related topic. A hand search was done from the references of primary studies and other clinical trial registry sites. Randomized control trials, comparative clinical trials, and in vitro studies in which the effectiveness of herbal and conventional dentifrices on prevention of dental caries were included after review by the reviewers. The systematic search revealed a total of thirty-two publications from which ten publications were included. Five studies were clinical studies and five were in vitro studies. All the studies used microbiological analysis for the determination of cariogenic microorganisms in plaque and saliva, whereas one study used pH of plaque and saliva. Among the included studies, all studies had a high risk of bias with level 2 evidence. With the evidence available, it can be concluded that herbal dentifrices and fluoride dentifrices have similar antimicrobial activity against cariogenic microorganisms.

Keywords: Demineralization, dentifrices, oral microflora, pH, plaque

How to cite this article:
Kengadaran S, Anusha D, Baskar K, Muthukrishnan K, Pooraninagalakshmi J, Prabakar J. Comparative effectiveness of herbal and conventional toothpaste on prevention of dental caries: systematic review and meta-analysis. Indian J Dent Res 2022;33:332-7

How to cite this URL:
Kengadaran S, Anusha D, Baskar K, Muthukrishnan K, Pooraninagalakshmi J, Prabakar J. Comparative effectiveness of herbal and conventional toothpaste on prevention of dental caries: systematic review and meta-analysis. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 5];33:332-7. Available from:

   Introduction Top

Dental caries is a global oral health problem that has a distinctive variation.[1] Dental caries is the most common oral disease that affects a significant portion of the Indian population. The prevalence of caries in India is reported to be from 31.5% to 89%.[2–8] Dental caries is widely recognized as a multifactorial infectious disease. The main aetiology of dental caries is (a) cariogenic bacteria, (b) fermentable carbohydrates, (c) a susceptible tooth and host, and (d) time.[9] Cariogenic microorganisms like Streptococcus mutans and Lactobacillus acidophilus are the primary causative microorganism for the development of dental caries. These cariogenic microorganisms encourage the accumulation and adherence of plaque biofilm by metabolizing sucrose into sticky glycan. The microorganisms in dental plaque degrade the dietary carbohydrates producing lactic acid, leading to localized demineralization and the eventual formation of dental caries.[10],[11]

Poor oral hygiene is one of the reasons for the accumulation of plaque in the oral cavity, thereby harbouring microbes. The methods used for plaque control are chemical and mechanical. Besides mechanical cleaning of the teeth, the use of chemical agents with antiplaque or antimicrobial activity into dental products has been proposed as a potential prophylactic method of reducing plaque-mediated disease by limiting the cariogenic bacteria in the oral cavity.[12]

Various chemically derived antimicrobial agents are incorporated into dentifrices which include triclosan, zinc chloride, etc. Other agents like fluoride and calcium phosphates are added to improve the anti-cariogenic properties of dentifrices. Fluoride was first added to toothpaste in the 1890s.[12] Consumers who wish to avoid the artificial ingredients commonly found in regular toothpaste use herbal toothpaste. Many herbal toothpastes do not contain fluoride or sodium lauryl sulphate. The ingredients found in natural toothpaste vary widely but often include baking soda, aloe, eucalyptus oil, myrrh, plant extract (strawberry extract), and essential oils.

In recent times, there has been renewed interest in naturally occurring products. A dozen brands claim or position themselves as natural, chemical-free, made of herbs. They claim to have the same or even more anticariogenic and antiplaque effect without adding any chemicals. Hence, the present systematic review aimed to compare the effectiveness of herbal and conventional toothpaste on prevention of dental caries among children and adults.

   Materials and Methods Top

The systematic review was conducted as per the Cochrane Handbook of Systematic Review and registered in PROSPERO (CRD42022315705), and the research question was set as follows: is there any difference between the effectiveness of herbal and fluoridated toothpaste on dental caries? PICO was then extracted from the research question: Population/Problem - dental caries; intervention - herbal toothpaste; comparison - fluoridated/commercial toothpastes; outcome - cariogenic microflora; re/demineralization; DMFT index. All types of studies in English including randomized control trials, clinical trials, and in vitro studies were included. Animal studies, reviews, case series, case reports, and studies evaluating the effectiveness of herbal and fluoridated dentifrices on gingivitis, periodontitis, oral malodour, and pericoronitis patients were excluded.

Search strategy

The review was done based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. The databases of PubMed and Google Scholar were searched up to July 2020 for the related topics using the search terms “dental caries” and “dentifrices”. Free-text terms were used to search the following ongoing trial registries: US National Institutes of Health Trials Register, WHO Clinical Trials Registry platform, and Clinical Trial Registry of India.

Data collection and analysis

Screening and selection

An electronic search yielded a total of 32 articles. Based on pre-set inclusion and exclusion criteria, the titles of the studies identified from the search were assessed independently by five review authors. Conflicts concerning the inclusion of the studies were resolved through discussions. Twenty-four titles were identified from the search after excluding duplications and nine articles were excluded after reading titles. Abstracts of selected articles were reviewed independently. Five articles were excluded after reading the abstract. Full-text articles were retrieved for 12 relevant studies. After reviewing the articles independently, two articles were excluded after full-text reading. Finally, 10 articles[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] were selected based on eligibility criteria.

The reference list of the full-text articles was reviewed for identifying additional studies. Titles of articles relevant to the review were selected by discussion. Abstracts of the selected articles were reviewed. Following a discussion, one article was eliminated after reviewing abstracts. Quality assessment criteria to evaluate the studies were decided by the review authors following the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The risk of bias for each study was independently assessed by the review authors and conflicts concerning the risk of bias were sorted through discussions.

Data extraction

Data extraction for general characteristics of studies and variables of outcome was done which included the Decayed, Missing, and Filled Teeth (DMFT) and Decayed, Missing, and Filled Surfaces (DMFS) indices, microbial counts, salivary pH and plaque pH, and minimum zone of inhibition.

Quality assessment

Higgins and Green criteria were followed. The quality assessment of included trials was undertaken independently as a part of the data extraction process. Four main quality criteria (method of randomization, allocation concealment, outcome assessors blinded to intervention, completeness of follow up) and four minor criteria (sample size calculation, comparability of groups at the start, clear inclusion or exclusion criteria, presence or absence of estimate of measurement error) were examined.

Statistical analysis

Data of the outcomes were extracted from each study. For continuous outcomes, mean differences and 95% confidence interval (CI) were used to summarize the results of each study. The meta-analysis was conducted using the fixed- or random-effects methods. Fixed-effects meta-analysis was used when the heterogeneity was small (I2 < 60%, P < 0.05). When the heterogeneity was large (I2 > 60%, P > 0.05), a random-effects model analysis was undertaken. All statistical analyses were conducted using JASP version

   Results Top

Description of studies

A total of 32 articles were retrieved from the electronic sources and hand search, of which 10 articles were included. Among them, five were clinical studies and five were in vitro studies [Figure 1].
Figure 1: Flowchart of article selection

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Assessment of quality of the articles

The general characteristics, data extraction, and level of evidence of the articles are tabulated in [Table 1]. All five clinical trials showed a high risk of bias, whereas all five in vitro trials showed a low risk of bias [Table 2]. The summation of outcomes of all the included studies is tabulated in [Table 3].
Table 1: Variables of interest

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Table 2: Risk of bias of clinical trial: Major and minor criteria

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Table 3: Summation of the outcome of variables

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Quantitative analysis of outcome

All the clinical trials had assessed more than one outcome parameter. However, salivary Streptococcus mutans was the only parameter that was common in the three studies that were included for meta-analysis. The I2 value was low (33%), which implied reduced heterogeneity across the studies. The reduction in S. mutans count between the herbal and fluoridated dentifrices was not statistically significant, with lower mean values for the fluoridated dentifrices group than the herbal dentifrices group (pooled effect size = −0.45, 95% CI: −1.13, 0.24; z = −1.28, P = 0.200) [Figure 2].
Figure 2: Forest plot comparing the effect of herbal and conventional dentifrice on oral microflora

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   Discussion Top

Dental caries, being a multifactorial disease, can be prevented by maintaining proper oral hygiene. Brushing is an important in-house method of maintaining oral hygiene. Often this mechanical plaque control method of brushing is associated with chemical plaque control of using toothpaste. Fluoride is the most popular active ingredient in toothpaste to prevent cavities. The additional fluoride in toothpaste has beneficial effects on the formation of dental enamel and bones. It is also reported that fluoride-containing toothpaste can be toxic if swallowed in large amounts. Reports have suggested triclosan, an active ingredient in many toothpastes can combine with chlorine in tap water to form chloroform, which the United States Environmental Protection Agency classifies as a probable human carcinogen. Sodium lauryl sulphate alters taste perception. It can break down phospholipids that inhibit taste receptors for sweetness, giving food a bitter taste.[13]

There is an increased migration of people using fluoride toothpaste to herbal toothpaste. The herbal products are extracted from medicinal plants which are antimicrobial.[23] These herbal products act as an alternative to commercially available synthetic products. In recent years, there has also been a growing trend of using natural products. Hence this systemic review was done to compare the effect of herbal and fluoridated toothpaste on prevention of dental caries.

The hierarchy of evidence has assessed randomized control trials (RCT) above other forms of study[24] but there was only one available RCT that compared the effectiveness of herbal and fluoridated toothpaste on dental caries. Hence, available clinical and in vitro studies were included in this systematic review.

The results of the clinical studies included for review compared herbal and fluoridated toothpaste in the reduction of cariogenic microflora and DMFT index, salivary pH, and plaque pH.[13–15] The results of the in vitro study included in the review compared the zone of inhibition for various cariogenic microflora.[18–21]

The RCT concluded that there was no difference in salivary pH following the use of herbal and fluoridated dentifrices. However, there was a decrease in the microbial count in the herbal group compared to the fluoride group.[17] A clinical study concluded that there was a steady decrease in the bacterial count for over 5 months, the overall percentage decrease in herbal toothpaste being 90.69% and fluoridated toothpaste being 89.69%.[14] However, between the toothpastes, there was no statistically significant difference in the bacterial count and both the toothpastes was efficacious in reducing the bacterial count. Another clinical study suggested that 71% of the toothpaste brands were found to significantly (P = 0.068) increase saliva bacteria counts.[13] No brand of toothpaste removed teeth bacteria by up to 50%. On average, the two triclosan-containing toothpaste brands exerted a greater reduction in mouth bacteria than non-triclosan toothpaste brands. This was followed by herbal toothpaste. The toothpaste brands that contained only fluoride were the least effective in reducing mouth bacteria. Another study suggested that there was no statistically significant increase in the mean plaque pH after using fluoridated toothpaste, whereas the miswak group showed a statistically significant increase in mean plaque pH after 2 weeks.[15] Although the mean saliva pH values of both groups increased slightly, it was statistically not significant. With regard to the fluoride group, there was a statistically significant reduction in mean log10 values of S. mutans colony forming unit (CFU) count after treatment. The miswak group showed no statistically significant reduction in mean log10 values of S. mutans CFU count after treatment. Both fluoride and miswak groups showed a statistically significant reduction in mean log10 values of Lactobacillus CFU count after treatment. The clinical study assessing the salivary amylase levels, which is an indirect indicator of caries activity, concludes that herbal dentifrices are superior to fluoride dentifrices in caries prevention.[16]

An in vitro study suggested that the antimicrobial activity of the toothpaste containing both triclosan and fluoride (1000 ppm) as active ingredients showed a significant difference (P < 0.05) against all four tested microflorae compared to that with lower fluoride-concentration or sodium monofluorophosphate.[18] Among herbal groups, the only dentifrice containing several phytochemicals was found to be significantly effective and comparable to triclosan-fluoride (1000 ppm) formulation. Another in vitro study suggested that there was a variation in antibacterial efficacy against S. mutans and L. acidophilus among various herbal and conventional dentifrices, which can be attributed to the effect of various components of the dentifrices and their efficacy to inhibit various organisms.[19] It was observed that the dentifrice with multiple herbal components (H4) was more effective in inhibiting both organisms. An in vitro study suggested that fluoride toothpaste had maximum antimicrobial activity at all concentrations when compared to herbal toothpaste which was statistically significant.[20] On the other hand, a study conducted by Kengadaran et al.[21] showed that herbal dentifrices had better efficiency compared to fluoride dentifrice. Another in vitro study showed that there was no difference in antifungal activity among herbal and fluoridated dentifrices.[22]

Interpretation of methodology

Standardization of the saliva collection technique was followed in a couple of studies.[14],[15] Stimulated saliva was collected in one clinical study,[14] whereas unstimulated saliva was collected in two clinical studies.[13],[15] The time between brushing and swabbing, toothbrush/cup type, amount of toothpaste used, brushing method, brushing time, and the bacterial count method used were kept constant in the study done by Okpalugo et al.[13] In the study done by Talha et al.,[15] pooled plaque samples were collected from the buccal surface of clinically sound upper incisors and molars using sterile toothpicks for the bacterial count.

In in vitro studies, salivary samples or pure culture of microorganisms were collected and incubated. Zone of inhibition was measured in all the studies.[18–21]

   Interpretation of results Top

There was one RCT and four clinical studies in this systematic review with a total sample size of 288 subjects predominantly consisting of children (140) with ages ranging from 4 to 9 years. The RCT showed reduction in microbial count in herbal compared to fluoride dentifrice.[17] Two studies concluded that both the herbal toothpaste and fluoridated toothpaste had the same level of antimicrobial effect and reduces  Streptococcus mutans Scientific Name Search up>[14],[15] whereas in one study toothpaste containing fluoride and triclosan reduced microbial count more efficiently followed by herbal and fluoride toothpaste.[13] The variation in the results between these studies may be due to the reason that Patil et al.[14] collected stimulated saliva and Okpalugo et al.[13] collected unstimulated saliva. There is a change in the salivary composition when stimulated. The meta-analysis of pooled data of microbial count in the clinical studies after the use of herbal and fluoridated toothpaste showed increased reduction in herbal toothpaste groups [Figure 2].

A couple of in vitro studies showed that the herbal toothpaste had similar and slightly better antibacterial activity compared to the conventional toothpaste.[19],[21] In one study, fluoridated toothpaste had more antimicrobial effect than herbal toothpaste.[20] A few studies showed that fluoride toothpaste exhibited a significant reduction in microbial count, and only one herbal toothpaste among three herbal toothpaste had a similar effect to fluoride toothpaste.[18],[22] This change in result between these studies may be because pure culture was used in a few studies,[18],[19] whereas in one study salivary samples were incubated for microbes.[20]

Report on the quality of evidence looked upon

Out of the seven studies, three were in vivo studies or clinical trials and had level 2 evidence; the remaining four studies were in vitro studies and had level 3 evidence.

Despite numerous numbers of clinical trials comparing herbal and commercial products on gingivitis, there are fewer clinical trials and almost no randomized control trials comparing the effectiveness of herbal and fluoridated toothpaste on dental caries. Hence, further studies should be encouraged in this field.


The present systematic review limits the studies included to be in English language only. In vitro studies were included in the review which reduced the level of evidence to 3. Due to a lack of studies, heterogeneous outcome variables were included in the study.

   Conclusion Top

A total of 10 studies were included in this review out of which one was a randomized control trial, four were clinical studies with level 1 and 2 evidence, respectively, and five were in vitro studies. Based on the Cochrane risk assessment, all five clinical trials had a high risk of bias. This review shows the lack of evidence in caries preventive effect of herbal dentifrices. However, with the available evidence, it can be concluded that herbal dentifrices have similar antimicrobial activity against cariogenic microorganisms.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Dr. Shivashankar Kengadaran
Department of Public Health Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.ijdr_404_21

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  [Table 1], [Table 2], [Table 3]


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