Periodontology 2000, Vol. 56, 2011, 1424 Printed in Singapore.

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2011 John Wiley & Sons A/S

PERIODONTOLOGY 2000

Traditional therapies in the management of periodontal disease in India and China

N I T I S H S U R A T H U & A R U N V. K U R U M A T H U R

The practice of medicine has evolved over many centuries to reach its current state. A recent survey conducted by the World Health Organization estimated that almost 7080% of the population in the developing world has resorted to traditional practices for treatment of a variety of ailments (87). The populations of the two most populous countries in the world, China and India, have practised traditional medicine for the management of oral diseases, including periodontal disease, for well over 2000 years. Furthermore, as group living is still the norm rather than the exception in both countries, customs and practices have been preserved over the generations. Thus, the World Health Organization statistics are likely to be valid for periodontal diseases. In a recent survey of a Chinese population, it was concluded that more than 50% of the rural adult population preferred to either ignore symptoms such as gingival bleeding or try traditional treatments before approaching dental surgeons (95). Reliable statistics are not available for the Indian sub-continent, but an Indian Dental Association survey reported that only 25% of the rural Indian population sought professional dental advice (19, 30, 49). Unfortunately, most traditional techniques are based on anecdotal experience rather than evidencebased practice. Consequently, a comparative evaluation of the efcacy and limitations of these practices is almost impossible. However, the inuence of these traditional practices should not be ignored, especially in a country such as India where almost 30% of the population have no access to dental care (19, 30). Given the almost bewildering range of techniques and herbal products that are used to treat periodontal disease, a fully comprehensive review is not possible here. However, some of the more popular methods, the rationale for their use, and the possibilities of

integrating them into present-day practice are described in this review.

Traditional understanding of periodontal disease

Traditional Indian (Ayurveda) and Chinese medicine recognize the existence of periodontal disease. Most of the traditional medical practices in other parts of Asia have been inuenced by these two forms of medicine. However, social, cultural and geographic differences have resulted in the establishment of separate systems, such as Japanese medicine (kampo) (9). Classical Ayurvedic texts such as the Charaka Samhita (1500 BC) (73) and the Ashtanga Hridaya (79) refer to periodontal disease and its management. Periodontal disease is described in the chapter on diseases of the face in the Charaka Samhita, while the Ashtanga Hridaya categorizes it within ear-nosethroat disorders (79). These texts recognized the presence of Shithada (scorbutic gingivitis), Upakusha (periodontitis), Danta papputaka (swelling, abscesses of the teeth, and periodontal and peri-apical abscesses), Adhimamsa (excess esh, pericoronitis) and Saushira (necrotizing lesions). Traditional Chinese medicine texts describe periodontitis as Ya Xuan, which literally translates as loose teeth, and also refer to swelling in the gums and gingival bleeding (Ya Nu) (23). Etiopathogenic mechanisms have also been described in these traditional texts. Ayurvedic medicine considers that the human constitution (prakriti) is controlled by three humors (vital elements), namely vata (wind), pitta (bile) and kapha (phlegm). Diseases were thought to occur as a result of an

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imbalance between these vital elements. Periodontal disease, resulting in swelling in the gingiva, bleeding gingiva and protruding teeth (presumably pathological migration) was ascribed to an imbalance of the pitta (8, 23). Traditional Chinese medicine advocated that the human body could be divided into ve organs, each of which regulated multiple physiological functions. Pathogenic mechanisms of various diseases involved disfunction affecting any of these ve organs. Accordingly, periodontal diseases had different etio pathogenic mechanisms depending on which of these ve organs were affected. The earliest described etiopathogenic mechanism referred to a deciency in the kidney. The kidney was thought to produce a vital essence that was critical for growth and development of the body, reproductive and urinary functions, hearing and bone marrow development, and thus inuenced osseous behavior. As teeth were considered to be outgrowths from bone, disorders of the kidney were thought to result in an inability to provide an anchor for the teeth, and thus led to periodontal disease. Subsequently, it was realised that periodontal disease could also result from overstrain (physical and or mental stress) as well as improper diet, poor oral hygiene, and weaknesses of Qi (a vital force) and blood. Unhealthy lifestyle and dietary patterns were thought to result in stomach heat, resulting in initiation of inammation and gingival bleeding. Weakness of Qi and blood was thought to render the body vulnerable to exogenous pathogens, including oral pathogens, resulting in periodontal disease (23). Both forms of medicine (traditional Ayurvedic medicine and traditional Chinese medicine) recognized the presence of deposits on the teeth (presumably calculus), referred to as Gou in traditional Chinese medicine and Danta Shakkara in traditional Ayurvedic medicine, as a possible etiopathogenic factor for periodontal disease. The systemic inuence on the periodontium was thus recognized from early times, although the underlying principles appear far removed from current knowledge. As a result, it is difcult to establish whether these forms of medicine understood the nature of host response and inammation (72) and the concept of periodontitis as a risk factor for systemic diseases (16). The role of dental plaque in the etiopathogenesis of periodontal disease was largely unknown. To put things in perspective, unequivocal evidence for the role of plaque in the etiopathogenesis of periodontal disease was obtained es study on gingivitis in Sri only in the 1960s after Lo Lankan tea workers (52). Although periodontal dis-

ease is thought to be initiated by microbial ora (75, 76) that are present in biolms (55, 56), the exact mechanisms involved in the complex disease process are yet to be fully understood. Despite considerable technological advancement, the plaque microora has yet to be fully characterized (55). The lack of understanding of the plaque-mediated disease process has had important health consequences. A survey in south China concluded that over 40% of the population either held traditional beliefs about the nature of periodontal disease or thought that tooth exfoliation was part of the natural aging process (49, 50). Similarly, traditional beliefs appear to play an considerable role in understanding of periodontal disease in rural India (19).

Traditional oral hygiene habits

Although the importance of dental plaque control was not fully understood, traditional oral hygiene devices were intended not only to cleanse the oral cavity but also to arrest periodontal disease. Oral hygiene practices in traditional Chinese medicine were given importance from very early days. Toothbrushes were used as early as the Liao Dynasty (907 1125 AD), and massaging of the gums with salt was fairly prevalent in China. Powdered alum, frankincense and mouthwashes were also used. Cool tea leaves were used to alleviate heat in the gingiva (thought to be related to stomach heat). The use of toothpicks was also a prevalent traditional Chinese practice, and these were perhaps the only interdental device used in ancient times. They are still a popular cleansing device, especially among socio-economically deprived sections of the Chinese population (50). Traditional oral hygiene measures have not been abandoned, and some of the dentifrices currently used in China still contain herbal products. Herbs that are commonly used include lotus leaves, tea polyphenols, Radix Zanthoxyli and Flos Lonicerae (90). Some of these traditional products have been subjected to in vitro and in vivo studies to assess their effectiveness. An extract of lotus leaves demonstrated signicant antibacterial activity against some of the more common putative periodontopathogens such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Fusobacterium nucleatum (48). Tea polyphenols such as catechins have been shown to have an inhibitory action on virulence factors of both Prevotella intermedia (60) and P. gingivalis (61). In addition, epigallocathechin has been reported to inhibit matrix metalloproteinase

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activity, osteoclast formation (91, 92) and osteoclast activity (57, 58). A local drug delivery system utilizing green tea catechin has been shown to be effective in improving clinical periodontal parameters (43). A direct relationship has also been proposed between intake of green tea and periodontal status (47).

Chewing sticks
Chewing sticks are an almost timeless method of maintaining oral hygiene. Traditional Indian medicine advocated the use of various chewing sticks depending on the constitution of the person. Accordingly, a person with a vata prakriti was advised to use bitter-sweet astringent sticks such as liquorice (Glycyrrhiza glabra) and black catechu (Acacia catechu). Those with a preponderance of pitta (bile) were advised to use chewing sticks with a bitter taste, such as neem (Azadirachta indica) and arjuna tree (Terminalia arjuna), while kapha prakriti required the use of pungent sticks such as fever nut (Caesalpinia bonduc) and Calotropis procera (73). Although all these sticks have been mentioned in the literature, the most commonly used chewing sticks are obtained from neem, mango (Mangifera indica), babul (Acacia arabica) and guava (Psidium guajava). Miswak (Salvadora persica) remains popular as a chewing stick, especially among Muslim communities in the Indian sub-continent and the Middle East (7). Almost 40% of the population in rural Pakistan has been reported to use miswak as an oral hygiene aid (10). The importance of mechanical plaque control in prevention of periodontal disease is beyond question (24, 85). It has been reported that chewing sticks may be as effective as toothbrushes in the mechanical removal of plaque (4, 6, 29, 38), but this evidence is not conclusive (88). Irrespective of their mechanical efciency, these devices are the primary means of prevention of onset and progression of periodontal disease in India. Some of the postulated mechanisms by which these sticks exert benecial effects are outlined below. Chewing sticks are thought to increase salivation and thereby assist in ushing out of oral microorganisms. Miswak has been shown to have antibacterial effects against early colonizers in plaque such as streptococci, and possibly against the periodontopathogen P. gingivalis (5). This effect is thought to be partly mediated by the tannins and thiocyanate released during chewing of this stick. The thiocyanate released in this manner is thought to be

capable of activating the salivary H2O2 peroxidase thiocyanate system, thereby exerting a potent antibacterial effect (14). It has also been suggested that the comparatively low periodontal treatment requirements in a Saudi Arabian population were due to regular use of miswak for oral cleansing (3). Mango contains tannins, bitter gums and resins, while neem contains isoprenoids such as nimbin, nimbinin and nimbidin in addition to chloride and uoride, all of which favor an antibacterial effect against several oral streptococci (17, 46, 67). Wolinsky et al. (86) reported that pre-treatment of salivaconditioned hydroxyapatite with an extract from neem sticks prior to exposure to bacteria resulted in a signicant reduction in bacterial adhesion. In addition, neem extracts used in the form of gel and mouthwash have been reported to be effective in improving both clinical parameters and inammatory markers (20, 62, 74, 83) in gingivitis. Guava leaves and twigs contain essential oils and the polyphenols pinene and avicularin, through which they exert anti-inammatory and antibacterial effects, as demonstrated in in vivo and in vitro studies (33, 54). In addition to their antibacterial effect, these chewing sticks have also been suggested to exert an antioxidant effect. Oxidative stress has been shown to result in cellular and tissue damage in periodontal disease, and is an important component of the hostrelated destruction that occurs following antigenic challenge (45, 84). Exogenous and endogenous antioxidants may thus be expected to exert benecial effects on inamed periodontal tissues. Most of the chewing sticks analysed have demonstrated an antioxidant effect comparable to that of vitamin C or vitamin K. Neem has been reported to contain gallic acid, gallocatechin, epigallocatechin abd catechin, all of which can reduce the oxidative burst from polymorphonuclear leukocytes (18). Brushing cleaning at night has never been a traditional practice, and, even today, is not a part of the oral hygiene routine of a large proportion of the Indian population. A survey performed across various age and socio-economic groups in an Indian population revealed that almost 90% of the respondents brushed only once a day (30). It is not certain whether this lack of brushing contributes to periodontal disease. Current evidence remains inconclusive about the optimal frequency of toothbrushing required for maintenance of periodontal health. Although there is some evidence suggesting that brushing once in 48 h may be adequate for maintenance of periodontal health (51), it has been

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postulated that it would be prudent to brush at least once a day (26). In traditional health practices, interdental cleaning devices were unknown in the Indian sub-continent. The necessity for use of interdental devices has been reinforced recently (70), and the lack of this practice continues to affect prevention and periodontal maintenance programs in this part of the world (50). Dentifrices used traditionally included abrasive powders such as brick powder, tobacco and ash, used in conjunction with a chewing stick or a nger (19). It is estimated that approximately 30% of the population in rural India use toothpowder and their ngers to clean their teeth (30).

tionally eat with their hands, without using cutlery. As part of the post-eating ritual, an estimated 50% of Indians not only wash their hands but also rinse their mouth after every meal (30). This practice is especially prevalent among the older population and those with less exposure to western civilization and its customs, and is sometimes accompanied by brushing with the nger. Although conclusions cannot be drawn in the absence of well-controlled trials, it is difcult to ignore the benecial effects of mouth rinsing. The mere ushing effect of water, even in the absence of any chemotherapeutic agent, may play a role in prevention of food accumulation inside the oral cavity.

Tongue cleaning
Both Indian and Chinese traditional medicine consider that examination of the tongue is important for diagnostic purposes, so much so that an entire chapter of the Charaka Samhita is devoted to this. Both forms of medicine considered tongue cleaning to be an integral part of a personal hygiene program. Traditional Chinese practices include the use of roughened scrubs for scraping the tongue (25). The Indian practice of tongue cleaning using a variety of implements ranging from coconut leaves to tongue cleaners made from stainless steel and plastic remains prevalent. Periodontopathogens such as A. actinomycetemcomitans have been shown to colonize parts of the oral cavity in addition to the gingival crevice (28). Prominent sites include the dorsum of the tongue, soft palate and tonsils (11, 34). Current evidence suggests that tongue cleaning could be important for maintenance of periodontal health and control of halitosis (27). Tongue cleaning is part of the fullmouth disinfection protocol that has been suggested to be effective for plaque control and maintenance of periodontal health (68, 69). The time-honored practice of tongue cleaning is thus based on sound scientic principles, and may have contributed to control of periodontal disease.

Management of periodontal diseases

Traditional methods of management of periodontal disease include a number of topical and systemic methods, depending on the nature of the disease. The mainstay of many traditional medicine approaches has been the use of mouthwash and topical application of various herbal agents.

Traditional Indian methods for the management of periodontal diseases

Mouthwashes The Charaka Samhita describes two types of mouthwashes, gandoosha and kavalagra, which were used for different purposes. Kavalagra consisted of herbal preparations in a paste or bolus form, which was subsequently diluted to form a liquid. The mouth was then lled with the kavalagra, which was retained until nasal discharge or lacrimation occurred. Gandoosha, on the other hand, usually contained liquids, mostly essential oils. The mouth was lled three-quarters full with this form of mouthwash and rinsed vigorously. Commonly used gandooshas consisted of herbal products such as triphala, dasamoola, guggulu, pippali and sarshapashunti. These were ground, mixed in hot water for gargling, or else mixed in honey or cows milk before use as a mouthwash. Mouthwashes consisting primarily of essential oils, such as sahacharadi taila and irimedadi taila were also used for management of periodontal disease. Sesame oil was used for oil pulling (retaining oil in the mouth without rinsing for a few minutes prior to spitting out), and this continues to be an important oral hygiene practice in rural India. Its effectiveness

Mouthwashes
Mouthwashes have been described in both Indian and Chinese traditional medicine, but mostly as a form of periodontal therapy rather than a plaque control measure. Use of chemotherapeutic agents such as mouthwashes for plaque control is not popular in traditional Ayurvedic medicine. However, due to differences in socio-cultural habits, Indians tradi-

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as an antibacterial agent (13) and in improvement of gingival parameters (12) has been documented. The exact mechanism of action is yet to be fully elucidated, but the lignans of sesame (sesamin, sesamolin and sesaminol) have antioxidant properties and can potentiate the action of vitamin E (59). The polyunsaturated fatty acids in sesame oil have been reported to affect lipid peroxidation and exhibit antiiammatory properties (71). Essential oils have been used as mouthwashes and are effective for control of both dental plaque and gingival inammation. The effectiveness and longterm safety of these oils has been established in several clinical trials (35, 40, 63, 66, 80). It has been reported that essential oils may be more effective than ossing in prevention of inter-proximal gingivitis (15). Essential oils, especially those containing omega 3 polyunsaturated fatty acids, have been reported to have important effects on the resolution of inammation, and are thereby helpful in preventing periodontal disease progression (41). Topical applications (pratisarana) to the gingiva were also used, and typically contained barks or leaves of trees such as neem, triphala or arjuna. Triphala, a potent rasayana, is so named because it is derived from three fruits, namely amalaki (Phyllanthus emblica), haritaki (Terminalia chebula) and

bibhitaki (Terminalia bellerica) is immensely popular as a traditional therapy. It importance was related to its perceived ability to bring a balance between the three vital elements (76). Triphala has been reported to have potent antioxidant properties, causing both a decrease in free radical formation and an increase in their clearance. It has been reported to inhibit matrix metalloproteinase-9 activity, and may prevent connective tissue destruction in periodontal disease (1). This effect has been attributed to the gallic acid and other phenols polyphenols present in the drug. Herbal products such as guggulu, arjuna and dasamoola were recommended in traditional medicine with the intention of correcting the underlying problem (dosha fault of one of the three humors). Although the biological mechanisms of several herbal products used in traditional Indian medicine have yet to be subjected to a detailed analysis, some of the known mechanisms are summarized in Table 1. As most of the procedures outlined above involved topical applications, their efcacy is related to the concentration and bioavailability of the drug at the site of infection. There have been some questions raised in the literature regarding the penetration of agents such as mouthwashes into the depths of the periodontal pocket (31, 65).

Table 1. Biological effects of traditional Indian medicine

Herbal product Neem Active ingredients Mechanism of action Reference 46, 67 86 18 33, 54

Nimbin, nimbinin, nimbidin Antibacterial effect against oral streptococci Reduced bacterial adhesion to tooth surface Catechins Reduced oxidative burst from polymorphonuclear leukocytes Anti-inammatory and antibacterial effect Antioxidant effect Reduction in matrix metalloproteinase 9 levels Antioxidant property Potentiates vitamin E action Increased salivation Inhibits P. gingivalis Activates the salivary H2O2 peroxidase thiocyanate system

Guava

Essential oils, pinene, avicularin and other polyphenols Amalaki, haritaki and bibhitaki Gallic acid

Triphala

Sesame oil

Sesamin, sesamolin and sesaminol Tannins, thiocyanate

59

Miswak

5 14

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Table 2. Biological effects of traditional Chinese medicine

Herbal product Guchiwan, Guchigao, Conth Su Active ingredients Mixture of several herbs Mechanism of action Antibacterial activity Antioxidant effect Osteoclast inhibiting activity Sho Saiko To Mixture of several herbs Inhibits periodontopathogens Antioxidant effect Lotus leaf Green tea Polyphenols Catechins Epigallocathechin Inhibits periodontopathogens Inhibits virulence factors of periodontopathogens Inhibits matrix metalloproteinase 9 activity, osteoclast formation and osteoclast activity 48 61 30, 58, 92 Reference 57, 82 89 22 9

Table 3. Effects on clinical parameters

Product Miswak Neem Guava Green tea Mode of delivery Chewing stick Gels and mouthwashes Mouthwash Systemic intake Local drug delivery Traditional Chinese medicine formulations (Guchiwan, Guchigao, Conth Su) Systemic intake Clinical effect Decreased periodontal treatment needs Improvement in clinical parameters in gingivitis Plaque inhibitory effect Reduced periodontal breakdown Improvement in clinical periodontal parameters Improvement in clinical periodontal parameters Reference 3 20, 62, 74, 83 33 47 43 21

Procedures such as Dantalekhana (scaling) for removal of Danta Shakkara (deposits on the teeth, i.e. calculus) have been described, but these procedures were very rarely performed, if at all, in everyday life. The acceptance of scaling as a primary preventive measure in periodontal disease is still relatively low in most parts of rural Asia (19, 81). Systemic therapy Traditional treatments for periodontal disease did not stop at local applications refractory cases were treated with drastic measures. For example, blood letting (rakhta moksha) has been proposed to treat periodontitis, especially in case of abscess formation (papputaka). Bizarre treatment procedures such as leech application have also been advised in severe

infections [saushira (necrotizing lesions) and shitada (scorbutic gingivitis)]. These procedures were not commonly used except as a last resort. Another form of periodontal treatment, known as Nasya, which may be peculiar to traditional Indian medicine, consists of inhaling medicinal powders, oils or liquids. These procedures were used with a view to treating the underlying dosha. The concoctions used differed according to the individual, but the most common ones were oils such as sesame and powders such as arjuna. Although several therapeutic procedures have been outlined by traditional practitioners, they were perhaps under-utilized or are not as effective as claims suggest. Whatever the reason, the prevalence of periodontal disease in India has been reported to

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range from 20 to 50%, depending on the population studied, well above global epidemiological levels (19).

Traditional Chinese methods for the management of periodontal diseases

The necessity for removal of calculus and subgingival plaque was recognized in China 1300 years ago. In 752 AD, Wang Tao wrote While treating the teeth, one should look for the yellowish bone-like mass attached on the teeth. Remove it with forceps or knife before using medicine. At the inner side of the gum, look for a thin layer of lm covering the root that looks like cicadas wing or like the membrane in eggs Unless these materials are removed, the gum will never attach to the root (23). Traditionally, Chinese methods of treating periodontal disease were based on the use of herbs, as well as acupuncture and moxibustion (36). As in traditional Ayurvedic medicine, traditional Chinese medicine advocated the use of herbs, which were usually given as a mixture. A number of proprietary formulae were also used. Traditional Chinese medicine advocated various treatment protocols based on the underlying cause of the periodontal disease and the principle of host modulatory therapy. Herbal preparations used to treat periodontal disease resulting from kidney disorders would differ from those that occurred as a result of stomach heat or blood or Qi disorders. Thus management of stomach heat syndrome would include (but was not restricted to) use of Coptis and Rehmannia formulae, while deciency in kidney yin and Qi blood disorders would be treated by the Rehmannia Six formula and the Ginseng and Tangkuei Ten combination, respectively. A typical mixture used to treat periodontal disease with an underlying disorder in the kidney yin consists of Radix Rehmanniae Glutinosae (Shu Di), Fructus Corni Ofcinalis (Shan Zhu Yu), Radix Dioscoreae Oppositae (Shan Yao), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Drynariae (Gu Sui Bu), Radix Dipsaci (Xu Duan), Radix Achyranthis Bidentatae (Niu Xi), Fructus Lycii Chinensis (Gou Qi Zi), Rhizoma Alismatis (Ze Xie) and Cortex Radicis Moutan (Dan Pi) (36). Traditional Chinese medicine uses herbs such as ginseng, wolfberry, Dong Quai, astragalus, cinnamon, coptis, ginger, liquorice, rehmannia, rhubarb and salvia in various proportions to obtain formulations such as Guchiwan, Guchigao, Conth Su and Chi Tong Ning. As periodontal disease was thought to be multifactorial, benecial effects were thought to accrue when a combination of herbs was used, each

of which would have a therapeutic effect on one underlying disorder. However, herbal preparations were also prescribed alone, as in the case of Scutellaria baicalensis (Huang Chin), for both systemic and topical application for treatment of periodontal disease. Benecial clinical effects, as well as antimicrobial effects on putative periodontopathogens such as P. gingivalis, P. intermedia, A. actinomycetemcomitans and F. nucleatum, have been described (21). Some of these formulations, such as Guchiwan and Guchigao, have been subjected to clinical trials, and it was concluded that clinical parameters of periodontal disease showed improvement following use of these drugs. Zhang et al. (93) reported improvement in the dental plaque scores, gingival index and periodontal index following use of Guchiwan in a group of patients with chronic and aggressive periodontitis. Similarly, Song et al. (77) reported on the efcacy of Guchigao in control of both clinical parameters as well as the interleukin-8 levels in gingival crevicular uid from a group of 24 periodontitis patients. Antibacterial activity (57, 82), antioxidant effects (89) and osteoclast inhibiting activity (22) have been recorded following exposure to these drugs in vivo. Signicantly greater promotion of attachment of gingival broblasts and periodontal ligament broblasts was reported following exposure to Herba Dendrobii and Radix Ophiopogonis (92). These effects appeared to be signicantly greater when these drugs were used as a combination than when they were used singly (22). Some popular Chinese herbal preparations, e.g. Rehmannia Six (Liuwei Dihuang Wan) have also been used for other ailments. Similarly, Yunu Jian has also been used for other diseases, with a few modications (23) (summarized in Table 2 and Table 3). Other than herbal preparations, Traditional Chinese medicine utilizes acupuncture and moxibustion (a precursor of acupuncture) for management of periodontal disease. However, detailed consideration of these techniques is beyond the scope of this review.

Concluding comments
The traditional systems of traditional Indian medicine (Ayurveda) and traditional Chinese medicine relied on their ability to improve endogenous defence systems rather than eliminate the exogenous pathogen. Interestingly, the current concepts of host modulation work on more or less similar principles (68).

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The global resurgence of interest in herbal preparations in recent years has been attributed to their low cost, easy over-the-counter availability and a perceived sense of safety (2, 32). However, use of herbal preparations is not entirely without adverse effects. Traditional Indian medicine recognizes the toxic effects of several herbs (73). As these medicines are available over the counter, there is a need to scrutinize the validity of concocting proprietary preparations. Another potential hazard is the potential for herbdrug interactions, which may have deleterious effects (39). For example, ginseng, a herbal product used for periodontal disease, may interfere with the bioavailability of warfarin, leading to potentially serious side-effects (37). Not all of the traditional practices outlined above are in current use, at least among the educated population. However, a lasting inuence of traditional medicine has been on the attitude of patients to disease and treatment. Traditional medicine placed considerable importance on a holistic approach, with emphasis on self-care and lifestyle management. Although these practices cannot be faulted in principle, they have resulted in a reluctance to approach healthcare professionals in the early stages of disease and to attend follow-up visits (64, 95). As the concept of preventive health checks is alien to traditional Indian medicine, self-reported periodontal disease and seeking of primary dental care is low (19). A similar phenomenon has been reported in China, where fewer than 20% of the population reported for preventive dental check-ups (95). Traditional customs die hard, especially if they have been popular for several centuries. Even in the more developed countries, it has been reported that the percentage of people who oss regularly ranges from 10 to 40% (53). It may be impractical to expect populations with lesser awareness and greater socioeconomic constraints to readily start implementing rigorous interdental cleansing protocols (42). Previous suggestions that newer oral hygiene practices could be integrated into well-established customs using behavioral methods (44) need to be put into practice. One example could be the use of chewing sticks and topical or systemic herbal applications as an additional aid either before or after brushing in populations that do not practice both methods simultaneously. This way, the habit of brushing daily could also be encouraged. The scientic evidence supporting their use requires closer scrutiny and expansion before it can be fully accepted as part of everyday practice. To summarize, even though not

every traditional custom has been scientically validated, they need not be summarily dismissed as quackery. Proponents of both modern and traditional medicine need to shed long-held beliefs and accept existing evidence before such practices can be truly integrated into present-day periodontal therapy. Given the enormity of the health problems faced by countries with large populations, it may be practical to devise oral healthcare delivery systems that retain efcacious traditional techniques. However, well-controlled clinical trials are required to validate the use of these traditional therapeutic strategies.

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