Ayurvedic review article on Shitada with special reference to Gingivitis

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REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 239 Ayurvedic review article on Shitada with special reference to Gingivitis Mahipal Singh Shekhawat 1 , Aparna Sharma 2 , Sharad Bhatnagar 3 1 Post Graduate Scholar, Dept. of Shalakya Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India. 2 Associate Professor, Dept. of Shalakya Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India. 3 Consultant Dentist, Dept. of Shalakya Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India. I NTRODUCTION Gingivitis is an inflammatory condition of the gingival tissue, most commonly caused by bacterial infection. Unlike periodontitis, there is no attachment loss and therefore no migration of the junctional epithelium. The condition is restricted to the soft-tissue area of the gingival epithelium and connective tissue [1] Among all the periodontal diseases, gingivitis is considered to be the commonest. There are various forms of gingivitis based on clinical appearance, duration of infection, Address for correspondence: Dr. Mahipal Singh Shekhawat Post Graduate Scholar, Dept. of Shalakya Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India. E-mail: ayushiksha 0601@gmail.com Submission Date: 09/11/2023 Accepted Date: 16/12/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.1.37 severity, and etiology. However, the chronic form of gingivitis that is caused by plaque is considered to be the most frequent variant. Clinically, the gingival tissues are characterized by swelling, redness, tenderness, a shiny surface, and bleeding upon gentle probing. Gingivitis seldom generates spontaneous bleeding and is commonly painless, therefore many patients do not recognize the disease and fail to seek attention [2] In Ayurveda medial science Susrutha Samhitha is an authentic text. It has been described Shitada is one of Danthamoolagatha Roga [3] (periodontal disease) out of 15 diseases. It is the early stage of periodontal disease that may progress later on to Danta Vesta and Upakusha state if untreated. Fast food culture, unhealthy habits like smoking, betel chewing and improper oral hygienic measures leads to vitiation of Kapha and Raktha Dosha which contributed to Shitada that manifested with Raktasrava (Bleeding gum), Krishnata (discoloration of gums), Prakledata (moistness), Mrudutha (sponginess), Shotha (gingival swelling), Mukha Daurgandhya (halitosis) as initial A B S T R A C T Oral cavity is a unique area of the body which is also known as the window of G.I.T. because many systemic disease can be clinically correlated upto some extent. If oral hygiene is not maintained properly than its sequelae can be quite dangerous. Without treatment gingivitis can progress to periodontitis, in which the inflammation of the gums results in tissue destruction and bone resorption around the teeth which is more serious and can eventually lead to loss of teeth in 40-45% of population of India. Food and plaque can get trapped in this space and cause a gum infection or it may leads to gingivitis on chronic accumulation of food or plaque. Plaque is a thin biofilm of bacteria which is continuously formed on the surface of teeth, as plaque advances it hardens and gets converted into tartar, when plaque extends below cervical line it may leads to bacterial infections like Gingivitis. If left untreated this bacterial infection can lead to detachment of gums from tooth surface and the tooth/teeth may become loose and unstable. Key words: Shitada, Dantamoola, Mukha Roga, Gingivitis

[Find the meaning and references behind the names: Debris, Mansha, Low, Main]

Mahipal Singh Shekhawat et al. Ayurvedic review article on Shitada w.s.r. to Gingivitis ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 240 clinical features [4] Paka (Suppuration), Danta Mansha Shiryamanata (gum recession) and Chalata (tooth mobility) may be seen in later stage. When compared with marginal gingivitis accumulation of debris, plaque, calculus at the tooth margin can be seen due to ignorance of oral care thus it progresses into periodontitis manifesting with the symptoms of firmness, altered contour of gums, mobile teeth, spacing and drifting. As per the modern dentistry causative local factors of marginal gingivitis are microorganisms, calculus, food impaction, faulty restorations, mouth breathing, tooth mal position and the systemic factors as nutritional deficiency (vitamins, minerals, protein), certain drug allergies (phenol, silver nitrate, aspirin)etc. endocrine dysfunctions, puberty, pregnancy, menstrual cycle irregularities and diabetes mellitus, hematological disorders like leukemia, thrombocytopenia, heredity, specific granulomatous infections and immunopathies (immune deficiency disorders-HIV). Scaling and polishing, root planning, gingivoplasty are the treatment options in management of marginal gingivitis. Etiology Gingivitis is caused by the microbial plaque deposits located in or close to the gingival sulcus. The microorganisms more strongly associated with the etiology of gingivitis include species of Streptococcus, Fusobacterium, Actinomyces, Veillonella, and Treponema. Bacteroides, Capnocytophaga, and Eikenella are also potentially linked to the etiology of the disease. There may be other local or systemic etiologic factors that intensify plaque deposition or the vulnerability of the tissue to the microbial attack [5] Gingivitis is the commonest of periodontal diseases. It is more prevalent in males as compared to females since it has been found that females tend to follow better oral care regimes. It is commonly seen in children and adults. Studies have found gingivitis to be more prevalent in people with low socioeconomic status as people with high socioeconomic status tend to show a more positive attitude towards the maintenance of oral hygiene. Also, they have better access to health care options. Studies reveal that gingivitis is more prevalent in pregnant women as compared to non-pregnant women. Moreover, more severe forms of gingivitis have been more often seen in pregnant women [6] The most frequently seen types of gingivitis are plaque-induced, hormonal, acute ulcerative necrotizing, drug-induced, or spontaneously presenting hyperplastic gingivitis. Categorically, the more predominant form of gingivitis is plaque-induced. In fact, this type accounts for far more cases than all other variants combined [7] Classification of Gingivitis In the latest International workshop for a classification of Periodontal Diseases and Conditions in 2017, gingival diseases have been classified as follow: ▪ Gingivitis - dental biofilm - induced ▪ Associated with dental biofilm alone ▪ Mediated by systemic or local risk factors ▪ Drug-influenced gingival enlargement ▪ Gingival diseases non-dental biofilm induced ▪ Genetic/ developmental disorders ▪ Specific infections ▪ Inflammatory and immune conditions ▪ Reactive processes ▪ Neoplasms ▪ Endocrine, nutritional, and metabolic diseases ▪ Traumatic lesions ▪ Gingival pigmentation [8] Samprapti (Pathogenesis) Though the Samprapti of Shitada has not been explained directly in Ayurvedic classics, keeping in mind all the etiological factors explained under common etiology of Mukharoga . An attempt has been made here to formulate and explain the pathogenesis of Shitada . Even though factors responsible for vitiation of Kapha and Rakta are the main factors in the manifestation of Shitada , the etiological factors responsible for the vitiation of Rasavaha (Plasma), Raktavaha (Blood), Mamsavaha (Muscular tissues)

[Find the meaning and references behind the names: Rasa, Rupa]

Mahipal Singh Shekhawat et al. Ayurvedic review article on Shitada w.s.r. to Gingivitis ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 241 Srotas (channels) and Pitta Dosha play a definite role directly or indirectly in the pathogenesis of Shitada . Hence these factors should not be neglected. Samprapti Ghataka of Shitada ▪ Dosha - Kapha, Rakta pradhana ▪ Dushya - Rasa, Rakta, Mamsa ▪ Srotas - Rasa Vaha, Raktavaha, Mamsavaha ▪ Srotodushti - Sanga, Atipravrti ▪ Agni - Jatharagnimandhya, Dhatwagnimandhya ▪ Rogamarga - Bahya ▪ Udbhavasthana - Amashaya ▪ Adhishtana - Dantaveshta ▪ Pratyatma Lakshana - Akasmat Raktasrava ▪ Sadhyasadhyata - Sadhya. Kapha and Pitta vitiation is the main culprit to initiate the pathology of Shitada (Gingivitis). Vitiation of these Doshas can take place due to the Aharaja (dietic) and Viharaja (lifestyle and environmental) factors. Ashrayidhatus of Kapha and Pitta i.e., Rasa, Mamsa and Rakta will also get disturbed quantitatively and qualitatively due to instability of Ashraya Doshas. Vitiated Rasa and Rakta will cause the local manifestations like swelling ( Shopha ), black discoloration ( Krishnata ), sponginess ( Mriduta ) and moistness of gingiva ( Kledata ). Vitiated Mamsa and Raktadhatu will cause the instability of gingiva which will manifest as spontaneous bleeding ( Akasmatraktasrava ), gum recession ( Shiryamanata ) and moistness of gingiva ( Prakledata ). Everyday a clear sticky film called plaque builds upon the surface of the tooth in the non-self-cleaning area of the teeth, particularly below the cervical convexity of the crown and in the cervical area. Many varieties of oral microorganisms grow as a bio-film or plaque. This is the first manifestation of gingival inflammation where vascular changes consisting essentially of dilatation of capillaries and increased blood flow. In most cases, a thorough professional cleaning and more attention to oral hygiene can reverse the inflammation and symptoms associated with gingivitis. Toxins and enzymes liberated by bacteria contained in plaque food debris or calculus seen into the crevicular epithelium and underlying connective tissue and cause an irritation, breakdown of tissue constituents and inflammation. Purvarupa of Shitada No specific Purvarupa has been mentioned in Shitada . Hence, here slight appearance of manifestation can be taken as Purvarupa of Shitada , which includes excessive salivation, halitosis, altered taste sensation etc. Rupa (Symptomatology) The main symptoms of gingival inflammation are gingival bleeding, gingival inflammation associated with swelling, discoloration, moistness, sponginess, gingival recession and halitosis. Gingival bleeding is the main and earliest visual sign of gingivitis and it varies in severity and duration. Bleeding can be present suddenly, when probing or without any cause. It is provoked by mechanical trauma or by biting solid foods, tooth brushing, tooth picks and food impaction. Management of Shitada Gingiva is an associated tissue of muscles, hence, in diseases like Shitada; Ahara, Vihara, Dantyarasayana (Dental tonic) and Aushada which acts on muscular tissue are useful i.e., Patola ( Trichosanthus cucumerina ), Nimba ( Azadirachta indica ), Triphala ( Terminalia chebula, Terminalia bellerica, Phyllanthus emblica ), Musta ( Cyperus rotondus ), Kutaja ( Holarrhena antidysenterica ), etc. should be given orally in the form of decoction or in medicated ghee form. Apart from this Dantya Rasayana i.e., dental tonics which includes Bakula ( Mimusops elengi ) fruits, Kakoli, Haritaki ( Terminalia chebula ), Black sesame seeds ( Sesamum indicum ), Nyagrodha ( Ficus bengalensis ), Arjuna ( Terminalia arjuna ) etc. should be administered to increase the strength and stability of the tooth supporting structures as curative measure in disease condition like Shitada . Its management can be broadly classified into local and systemic measures. DISCUSSION The prime objective of treating gingivitis is to reduce inflammation. This is achieved by the use of different

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Mahipal Singh Shekhawat et al. Ayurvedic review article on Shitada w.s.r. to Gingivitis ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 242 instruments to remove dental plaque deposits [9] Gingivitis, in its initial stages, can be easily managed if the patient starts following oral hygiene protocol, which includes regular tooth brushing with an appropriate technique and interproximal hygiene, such as dental flossing, or the use of interproximal brushes. The removal of plaque and calculus is also professionally achieved by scaling and root planning according to the severity of the condition. If it is a druginduced gingival overgrowth, the physician can change the medication to improve the outcome of treatment of the condition. If it is due to nutritional deficiency, supplements can be prescribed. Medications in the form of antiseptic mouthwash that contains chlorhexidine can also be prescribed in conjunction with the mechanical removal of plaque. It has been suggested that the use of chlorhexidine mouthwashes in addition to the usual toothbrushing and interproximal cleaning leads to a significant decrease in the build-up of dental biofilm. The concentration of the chlorhexidine rinse does not affect its effectiveness [10] There are studies on the effect of medicinal or herbal plants on the management of gingivitis. The mechanism of action of these plants on gingivitis is due to their anti-inflammatory property. Such medicinal plants include pomegranate, tea, and chamomile. The flavonoids and tannins present in these plants are potent anti-inflammatory and astringent phytochemicals. Therefore, they can resolve both gingival bleeding and inflammation [11] Some studies proved that there is a synergistic effect when the herbal plants are prescribed along with conventional mechanical procedures of plaque removal, such as scaling. Raktamokshana For the convenience of patient Prachchhana Vidhi is adopted by 26 no. needle. Prachchhana Karma is adopted when Doshas are situated in Twaka and Rakta remaining in vitiated state. Raktamokshana expels the impure blood and increase the fresh blood flow which regenerates the gingiva. Pratisarana By Pratisarana mechanical pressure is exerted on gums in the direction of the gingival sulcus which remove food debris, plaque and some part of calculus too. By pressure, it clears sticky bio-film on tooth surface which is responsible for growing micro-organism. Due to gingival massage during Pratisarana gingival epithelial cells are stimulated which leads to regeneration of the gingiva thus helping in keratinization and this process may help in retarding the inflammation at vascular, cellular and immune level. It may increase the defense mechanism of gingiva. Drugs to be used here should be of Katu - Kashaya Rasa, Laghu Ruksha Guna, Ushna Virya because of which it acts as Shodhana, Lekhana, Kleda Shoshaka, Raktasthambaka, Shothahara. Nasya After the drugs of Nasya spreads in the Murdha , it scrapes out the morbid Doshas and expel them out through the nose. Mainly Kapha is involved in Shitada and so by Nasya Karma vitiation of Kapha may decrease and thus symptoms of Shitada may subsides. By its Shodhana property it clears the micro channels ( Srotasa ) of supraclavicular part involving Dantamoola and by Snehana it nourishes the structures of supraclavicular part including Mukha . Gandusha [12-14] Gandusha is the process of holding any medicated liquid in the mouth to its full capacity for a specific time without making any movement inside and then asked to spit it out. Holding the medicated liquid up to its full capacity exerts mechanical pressure on the gums. As a result of this pressure, impacted foods particles get removed and biofilm get mixed with reserved fluid. Also, these mechanical pressures stimulate of salivary secretion and maintain the pH level of oral cavity. The normal pH helps in healing and reduces inflammation, halitosis, moistness and sponginess of gums. CONCLUSION To put it briefly, based on earlier studies, local therapeutic Yogas such as Pratisarana , or Bhadramustadi Choorna, Dashana Samskara Choorna, Lodradi Choorna, etc., are far more beneficial than other Yogas for the full recovery of Shitada (Gingivitis). These recipes help reduce the level of aggravated

[Find the meaning and references behind the names: Zhang, Sri, Silva, Patil, Vera, Tamil, Ayu, Cheung, Mar, Jun, Nil, Rao, Med, Rahimi, Prasad, James]

Mahipal Singh Shekhawat et al. Ayurvedic review article on Shitada w.s.r. to Gingivitis ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 243 Kapha and Pitta in the gum tissues because of the benefits of Katu, Kashaya, Tikta Rasa, and Ushna . In addition, research has shown that all of the above Yogas , medications have anti-inflammatory, antibacterial, and anti-microbial qualities. Gandusha formulations for maintaining periodontal health, such as Sahacharadi Taila , Irimedadi Taila, Triphala + Sphatika Jala , and Nagaradi Kwatha, have already been demonstrated to be effective. Due to the fact that Gandusha contains components like Mukhadaurgandyahara and Shothahara , it has a purifying effect. Because of the ingredients of Gandusha are Mukhadaurgandyahara , Shothahara hence by virtue of cleansing action and antiinflammatory property. So, it may act on microorganisms and might be helpful in alleviating the disease Shitada - Gingivitis. Although Gandusha increases the efficacy of Pratisarana and help to disintegrates the pathology of Shitada . From above descriptions and evidences, it can be concluded that “ Shitada - Gingivitis” is main disease problem effect on oral health. But due to lack of awareness among patients it is not showing as burning problem. However, Ayurvedic management is able to provide a holistic approach to this disease in all the aspects i.e., preventive and curative. REFERENCES 1 Marchesan JT, Girnary MS, Moss K, Monaghan ET, Egnatz GJ, Jiao Y, Zhang S, Beck J, Swanson KV. Role of inflammasomes in the pathogenesis of periodontal disease and therapeutics. Periodontol 2000. 2020 Feb;82(1):93-114. 2 Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: Case definition and diagnostic considerations. J Periodontol. 2018 Jun;89 Suppl 1: S 46-S 73. 3 Sushruta, Sushruta Samhita, with the Nibandhasangraha commentary of Sri dalhanacharya, edited by Yadavji Trikamji Acharya, Chaukhambha Orientalia, Varanasi, 4 th edition, (2008), Nidana sthan 16/13. 4 Sushruta, Sushruta Samhita, with the Nibandhasangraha commentary of Sri dalhanacharya, edited by Yadavji Trikamji Acharya, Chaukhambha Orientalia, Varanasi, 4 th edition, (2008), Nidana sthan 16/14-15 5 Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: Case definition and diagnostic considerations. J Clin Periodontol. 2018 Jun;45 Suppl 20: S 44-S 67. 6 Kashetty M, Kumbhar S, Patil S, Patil P. Oral hygiene status, gingival status, periodontal status, and treatment needs among pregnant and nonpregnant women: A comparative study. J Indian Soc Periodontol. 2018 Mar-Apr;22(2):164-170. [PMC free article] [PubMed] 7 Page RC. Gingivitis. J Clin Periodontol. 1986 May; 13(5):345-59 8 Pozo P, Valenzuela MA, Melej C, Zaldívar M, Puente J, Martínez B, Gamonal J. Longitudinal analysis of metalloproteinases, tissue inhibitors of metalloproteinases and clinical parameters in gingival crevicular fluid from periodontitis-affected patients. J Periodontal Res. 2005 Jun;40(3):199-207. 9 James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A, Whelton H, Riley P. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev. 2017 Mar 31;3(3):CD 008676. [PMC free article] [PubMed] 10 Safiaghdam H, Oveissi V, Bahramsoltani R, Farzaei MH, Rahimi R. Medicinal plants for gingivitis: a review of clinical trials. Iran J Basic Med Sci. 2018 Oct;21(10):978-991. [PMC free article] [PubMed] 11 Ajmera N, Chatterjee A, Goyal V. Aloe vera: It's effect on gingivitis. J Indian Soc Periodontol. 2013 Jul;17(4):435-8. 12 Clinical evaluation of Krimidanta Pratishedha (anti-caries) activity of Triphaladi Gandushain high risk dental caries patients; Achyuta G Atara: Dept. of Shalakya Tantra, Institute for Post Graduate Teaching and Research in Ayurveda, Jamnagar, India (PMCID: PMC 4213966) 13 Effect of Ayurvedic herbs on control of plaque and gingivitis: A randomized controlled trial: Kadam A, Prasad BS, Bagadia D, Hiremath VR. Ayu. 2011 Oct;32(4):532-5.; PMID: 22661849: PMC 3361930 14 A Clinical Evaluation of Shuntyādi Gandusha in Sitāda W.S.R to Gingivitis: P Pundareekaksha Rao: Asst. Prof., Dept. of Shalakya Tantra, Ayurveda College, Coimbatore, Tamil Nadu, India. How to cite this article: Mahipal Singh Shekhawat, Aparna Sharma, Sharad Bhatnagar. Ayurvedic review article on Shitada with special reference to Gingivitis. J Ayurveda Integr Med Sci 2024;1:239-243. http://dx.doi.org/10.21760/jaims.9.1.37 Source of Support: Nil, Conflict of Interest: None declared.

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