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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 519-532

Effects of coconut oil on oral health status of patients with poor oral hygiene: Systematic review and meta-analysis


1 Department of Conservative Dentistry, AB Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore, Karnataka, India
2 Department of Oral Biology and Genomic Studies, AB Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore, Karnataka, India
3 Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan; IRCCS Galeazzi Orthopedic Institute, Via Riccardo Galeazzi, Milano MI, Italy

Date of Submission11-Mar-2021
Date of Decision11-Jun-2021
Date of Acceptance17-Aug-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Shahnawaz Khijmatgar
Department of Oral Biology, A.B. Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University) Deralakatte, Mangalore, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_58_21

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  Abstract 

Aim: The present systematic review and meta-analysis aim to evaluate randomized control trials (RCTs) to answer the question “Can oil pulling with coconut oil help patients with poor oral health?”Materials and Methods: A literature search was conducted for RCTs till January 2021. A total of 47 articles were retrieved through five electronic databases, i.e., Web of Science, PubMed, Cochrane Review, SCOPUS, and Embase using key words related to the topic. The selection of articles was based on the PICOS criteria and the PRISMA protocol for systematic reviews. The studies which discussed coconut oil and its effect on the plaque, gingival index, and Streptococcus mutans count were included in the study. Results: The final selection included 13 articles from which data were extracted for further evaluation. The articles included show coconut oil’s efficiency as an antimicrobial agent to reduce bacterial colonization with significant improvement in oral hygiene by practicing oil pulling. However, the quality of evidence is low and more well-designed clinical trials with a wide range of oral health outcomes are required. Conclusion: Based on the results of the systematic review, there is a significant statistical difference in plaque and gingival index between individuals with and without using coconut oil. Hence, further research is mandatory to clearly explain the role of microbiota and their transformations in the oral cavity. We conclude that continued surveillance of patients in a long-term study design with holistic alternatives and early management of complications are important in lifelong care and well-being of patients with a compromised oral cavity.

Keywords: Coconut Oil, Cocos nucifera, Gingivitis, Oil Pulling, Periodontitis, Randomized Control Trial


How to cite this article:
Reddy U, Khijmatgar S, Hegde MN, Fabbro MD. Effects of coconut oil on oral health status of patients with poor oral hygiene: Systematic review and meta-analysis. J Int Oral Health 2021;13:519-32

How to cite this URL:
Reddy U, Khijmatgar S, Hegde MN, Fabbro MD. Effects of coconut oil on oral health status of patients with poor oral hygiene: Systematic review and meta-analysis. J Int Oral Health [serial online] 2021 [cited 2022 Jan 17];13:519-32. Available from: https://www.jioh.org/text.asp?2021/13/6/519/331587


  Introduction Top


A healthy oral cavity is essential for general well-being of an individual. Holistic and traditional medicine recommends oil pulling therapy as a preventive measure for most dental complications such as tooth decay, oral malodor, bleeding of gums, dryness of throat, mouth, and cracked lips. It has been mentioned umpteen times in our scriptures like the Ayurvedic text Charak Samhita as “kavalagraha” or “kavala gandoosha” as holy anointed oil due to its medicinal benefits.[1]

Coconut oil is used in the household of most Asian countries on a daily basis for cooking or for application over the body for medicinal reasons. It comprises a high percentage of medium chain fatty acids (MCFAs): 92% saturated acids and lauric acid as the primary component. Lauric acid attributes anti-microbial and anti-inflammatory properties to the oil.[2],[3] Similarly, newer studies on oil pulling therapy that uses edible oils such as sunflower oil, sesame oil, and coconut oil were found to promote oral health.[4],[5]

For oil pulling therapy, the patient is asked to take one to two tablespoons of oil in the mouth or till the mouth is half-filled, which is done on an empty stomach early in the morning. This quantity of oil is to be sipped and sucked and passes through while pulling between the teeth without swallowing for a period of 10–15 min, not longer than 20 min.[6] Doing so allows mixing of saliva with oil promoting the extraction of toxins out of the blood flow, which turns the oil into a thin consistency while inside the mouth and makes milky white in color, indicating that it is time to be spat out. The viscous nature of coconut oil promotes lubrication, thereby inhibiting adhesion of bacteria or its by-products on the mucosal tissues.[7]

There are a variety of edible oils such as corn oil, rice bran oil, palm oil, sesame oil, sunflower oil, and soya bean oil which have also been used for oil pulling therapy.[8] The exact antibacterial action of coconut oil has not been clearly explained. It is attributed to the presence of monolaurin and other MCFAs that act by altering the bacterial cell wall or penetration through it leading to disrupted cell membranes that inhibit enzymes involved in energy production and nutrient transfer, finally causing bacterial apoptosis.[9]

There is very little evidence in literature to support oil pulling therapy as a preventive strategy. Online searches in Web of Science, PubMed, Embase, and Cochrane review databases reveal a limited number of clinical trials done with oil pulling therapy, and there is no published meta-analysis, determining the effectiveness of coconut oil and its role in oral health. Therefore, the objective of this systematic review is to evaluate randomized control trials (RCTs) that determine the effectiveness of coconut oil pulling and report its efficiency in comparison to the commonly preferred mouth rinses such as chlorhexidine and fluoride-containing rinses.


  Materials and Methods Top


Protocol and registration

Review of literature was done as per the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement,[10] which is also used to assess the risk of bias in individual studies. The review is registered with Prospero (CRD42020211248), an International Prospective Register of Systematic Reviews, and it is an open access online database of systematic review protocols.

Source of data

This review focusses on potential preventative strategies and the effect of coconut oil for pulling among population with oral complications such as dry mouth, plaque regrowth, caries, and gingivitis. RCTs are taken into consideration which evaluated the effectiveness of coconut oil on plaque index, gingival index, and the Streptococcus mutans count in the mouth before and after oil pulling.

The authors conducted a systematic review regarding the effectiveness of coconut oil pulling based on a search for RCTs from Web of Science, PubMed, Cochrane, and EMBASE database (1970 to 2021) [Figure 1]. Primary search terms included coconut oil, cocos nucifera, oil pulling, periodontitis, gingivitis, streptococcus mutans, caries, Randomized control trial. The method of search strategy was ((((((((coconut oil) OR (cocus nucifera)) OR (oil pulling)) OR (coconut oil pulling)) OR (oil pulling dental)) OR (oil pulling oral health)) OR ((sesame) OR (sesame oil))) AND ((((dental plaque) OR (plaque)) OR (gingivitis)) OR (oral health))) AND ((((((clinical trial) OR (randomised controlled trial)) OR (randomised controlled clinical trial)) OR (RCT)) OR (randomized controlled trial)) OR (randomized controlled clinical trial)). The search generated 13 citations that were relevant to the topic and provided the foundation for this review [Table 1] and [Table 2].
Figure 1: PRISMA flow chart for the search strategy

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Table 1: Characteristics of studies reviewed

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Table 2: The studies excluded with reason for exclusion

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Study selection criteria

Inclusion criteria

Studies published during the period from 1970 till 2021 are considered. The selected studies are written in English language as per the PICOS—Population, Intervention, Comparator, Outcome, and Study design.[7]

  • Patients (P): individual with plaque, gingivitis, caries;


  • Intervention (I): oil pulling as a preventive and therapeutic agent in the management of high plaque, gingiva, and caries indices scores;


  • Comparator (C): participants using oil or placebo/any other agent used for comparison with coconut oil;


  • Outcome (O): prevention of plaque regrowth, gingivitis, and caries using oil as a therapeutic agent;


  • Study design (S): clinical trials, randomized control trial studies published in scientific journals.


  • Exclusion criteria

    The studies such as cohort studies, case–control studies, observational studies, epidemiological studies, case reports, in vivo studies, review articles, articles without abstract, book chapters, thesis, and guidelines have not been considered. Furthermore, following PRISMA criteria, a checklist was used to analyze the studies which had to be included in the review. Eight criteria were selected, and studies that presented only 8 out of 12 criteria were selected as low-risk bias [Figure 2].
    Figure 2: Risk of bias

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    Data synthesis and analysis

    The data that would allow in reasonable outcome from meta-analysis was included. STATA IC.16.1 version was used for estimating overall effect sizes. Mean difference (md) with 95% confidence interval (CI) on continuous outcomes will be estimated by employing random-effects model. An overall effect size with 0.2–0.5 was regarded as small, 0.5–0.8 as moderate, and more than 0.8 as large.[11] The mean, SD, and number of samples in each group were recorded.

    Assessment of heterogeneity

    I2 statistic was used to assess study heterogeneity and I² >30% equates to moderate heterogeneity, I² >50% equates to substantial heterogeneity, and I² >75% equates to considerable heterogeneity.[12],[13]


      Results Top


    Selection of studies for the review

    A total of 47 articles were retrieved through electronic database. After evaluating the title, abstract, and full text of these articles, 13 were selected for the present systematic review.

    Excluded studies

    Out of the 23 full-text articles evaluated, 9 were excluded as they were out of the scope of the present review. All narrative reviews have been excluded,[14],[15] four of the articles excluded were in-vitro studies,[16],[17],[18],[19] one clinical trial was excluded as it is an ongoing interventional study,[15] and a study by Nagilla et al.[9] has duplicates in Cochrane and PubMed databases. Therefore, a total of n = 13 studies were qualitatively assessed and n = 9 were quantitatively assessed and meta-analysis was performed.

    There are n = 8 studies [Figure 3] which included plaque as primary outcome, n = 4 studies [Figure 4] for gingivitis, and n = 2 studies for S. mutans [Figure 5]. The coconut oil vs. placebo comparison included five studies [Figure 6]. The overall effect size for plaque outcomes was -1.41 (-3.89, 1.08) [Figure 3], gingivitis was -0.26 (-0.71, 0.19) [Figure 4], and S. mutans was 2.21 (1.69, 2.73) [Figure 5].
    Figure 3: Forest plot for plaque index outcome

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    Figure 4: Forest plot for gingival index outcome

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    Figure 5: Forest plot for S. mutans outcome

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    Figure 6: Forest plot for coconut oil and placebo

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    The overall effect size for coconut oil vs. placebo was -0.30 (-1.99, 1.40) [Figure 6]. In all of the above, effect size is given in the form of Hedges’ g. It explains by what scale the magnitude differs between two studies. The effect size of 0.2 is considered as small, 0.5 as medium, and 0.8 as large.[11]

    [Figure 3] showed the forest plot for plaque index outcome, and [Figure 4] suggests the forest plot for gingival index outcome. The diamond shape (green) is the overall effect size and the size of the olive color square boxes is proportional to the study weight (larger size square, more precise studies). The line extending from both the sides of center of the squares is related to CI.

    [Figure 5] shows the forest plot for S. mutans outcome. An internal and external validity of the study is needed that assesses the S. mutans outcome. [Figure 6] shows the forest plot for coconut oil vs. placebo.

    [Figure 7] shows the funnel plot at different levels of significance for plaque index outcome (publication bias and small study effects), demonstrating study-specific effect sizes vs. measures of study precision. The majority of the studies lie in the darker shade area which is greater than P > 0.05, which is suggestive of more publication bias rather other factors (other factors such as presence of a moderator correlated with the study effect and study size or, more generally, the presence of substantial between-study heterogeneity).
    Figure 7: Funnel plot at different levels of significance for plaque index outcome (publication bias and small study effects)

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    [Figure 8] shows the funnel plot for the gingival index outcome at different levels of significance (publication bias). There is a publication bias as majority of them are in the area of darker shade.
    Figure 8: Funnel plot for the gingival index outcome at different levels of significance (publication bias). There is a publication bias since majority of them are in the area of darker shade

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    [Figure 9] suggests the funnel plot for S. mutans outcome. The studies should not be considered for interpretation as they are in white area, and the null hypothesis of no effect should be rejected at 1% significance level (P < 0.01).
    Figure 9: Funnel plot for S. mutans outcome. The studies should not be considered for interpretation as they are in white area and the null hypothesis of no effect should be rejected at 1% significance level (P < 0.01)

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    Quality assessment and risk of bias

    Studies were evaluated for bias according to the previously mentioned criteria using Cochrane Collaboration’s tool for assessing risk of bias.[20] The overall risk of bias is high, and there is a potential publication bias [Figure 2].

    Quality of evidence

    Although the studies included were RCTs which were considered to be high level of evidence, due to the low number of studies and bias, the evidence relating to oil pulling with coconut oil in relevant outcomes was considered to be of low quality. A well-designed clinical trial and further studies are required to generate enough evidence, so that it becomes feasible to provide recommendation.


      Discussion Top


    Radiation is the preferred treatment for majority of head and neck cancer patients along with surgery and chemotherapy.[21] After radiotherapy (RT), the pH of the oral cavity turns acidic and a dry mouth creates a cariogenic environment. There is no standard protocol to maintain oral hygiene for RT patients to follow during and after radiation therapy, and many of them develop periodontal and gingival complications along with radiation caries. Radiation caries is the side effect of radiation on the salivary glands and dentition. It weakens the dentin–enamel bonds causing a shear fracture with high levels of caries forming bacteria like S. mutans.[22] While most side effects of ionizing radiation are unavoidable, oil pulling during and after radiation can be used as a preventive strategy to reduce the risk of dental deterioration in such immunocompromised patients.[23]

    Oil pulling is an ancient remedy for tooth strengthening, prevention of decay, hydration of the oral cavity, and to treat dryness of throat and lips.[24] Coconut oil has 92% saturated MCFAs, the majority of which is lauric acid followed by other acids such as capric acid, caprylic acid, etc. Its glucolipid component sucrose monolaurate has an anti-cariogenic property due to reduced glycolysis and sucrose oxidation on S. mutans, which prevents plaque regrowth. The results of the present study suggest that the oil pulling therapy has the same inhibitory activity on plaque regrowth compared with CHX and may be a safe and natural alternative to commercially available mouth rinses.

    Coconut oil has a very effective anti-microbial action, where it stays on the tooth surface even after being washed out and cleared from saliva. On the bright side, it is a better alternative to regularly used mouthwashes containing chlorhexidine as it has no reported adverse effects. Those who suffer from loss of taste or brownish discoloration of teeth due to prolonged use of chlorhexidine can switch to oil pulling with coconut oil.[24] All the RCTs analyzed in the review demonstrate a decrease in mean plaque scores, gingival indices, and S. mutans count with oil pulling using coconut oil within a few days of use.[7],[25] Whereas results of one RCT showed the greatest reduction of 29% within a period of 7 days.

    Asokan et al.[7] have reported a positive effect on oral health using sesame oil for oil pulling therapy, whereas Nagilla et al.[9] have studied the effect of practicing pulling with coconut oil on plaque scores. Both studies conclude significant changes post-oil pulling, whereas Asokan et al. reported a reduction in the S. mutans count in plaque and saliva after oil pulling therapy. Nagilla et al. concluded that there was a reduction in mean percentage of plaque scores initially, at the third day as well as the seventh day among both the groups. These results prove that oil pulling performed with both coconut and sesame oil improves the condition of oral hygiene. This can be attributed to the viscous nature and antibacterial properties of the oil. The exact mechanism is still not known. Saponification takes place due to the alkali hydrolysis of fat. They act as natural cleansing agents through the process of emulsification.[7],[25]

    Although it was demonstrated in individual studies[1],[5],[7],[12] that there is a statistical reduction in the S. mutans count by coconut oil usage within few weeks similar to results from CHX rinsing proving its antibacterial efficacy, we cannot rely on this finding due to multiple confounding factors in the meta-analysis. However, the limitation of one report was the small sample population and a short time duration; hence, we cannot generalize the results.[22] In addition to this, the index used for recording plaque index was different in studies, due to which the study by Ripari et al.[26] was not considered for quantitative analysis. Ludwar et al.[27] used sunflower oil and compared with water as control (included for qualitative analysis). It had included the plaque index but could not include in the quantitative analysis because only one such comparator is available and was not possible to include in the meta-analysis.

    It should be considered that some studies chosen for this review have a short-term follow-up period, up to few days,[7],[17],[25] with a low level of specificity, in which the assessment of oil pulling on all the variables considered for this review was the main focus of the investigation. Most studies demonstrate the effect of practicing pulling with oil on plaque and soft tissues, and there is a need for further research to show a therapeutic effect of coconut oil on caries. Short studies have given immediate positive results, but we may not be able to predict their effectiveness in the long run.

    The evidence relating coconut oil to plaque, gingival, and S. mutans levels was considered to be of level 3 quality. Further studies are required for an updated periodic review to generate more evidence. Management of compromised patients provides an opportunity to implement preventive oral care[28],[29] and treatment of complications before their further manifestation; however, in the long run, we cannot predict their effectiveness until studies with routine follow-ups are performed.

    Our results have found that the overall effect estimate for coconut oil vs. placebo was -0.30 (-1.99, 1.40) [Figure 6] and favors coconut oil in comparison to other comparators. The overall effect estimate for oil pulling irrespective of coconut oil and other oils vs. control was -1.41 (-3.89, 1.08). However, due to the presence of factors such as a moderator correlated with the study effect and study size or presence of substantial between-study heterogeneity, a good clinical trial design with CONSORT statement guidelines reporting of trials is a need.

    The effect of coconut oil pulling has not been fully discovered and remains underrated so far in allopathic medicine. Its preventive potential on oral tissues is yet to be studied in detail. Few short studies have shown oil pulling to have similar results as chlorhexidine rinsing; however, we lack long-term studies on larger populations.[28],[29],[30]


      Conclusion Top


    Based on the results of the systematic review, we conclude that there are limited studies available currently in literature. Of the studies reviewed, there is a statistically significant difference between individuals with and without performing oil pulling and coconut oil. Taking into consideration the lack of research promoting the holistic benefits of coconut oil and its anti-carious potential, the authors of this study are pursuing a trial with the similar objectives and with a larger sample size. Our search was restricted to studies published in the English language; therefore, we encourage authors from different counties to conduct further reviews on the subject with articles and studies published in other languages.

    Due to many confounding factors among the selected studies, the results should be regarded with wariness. Within the limitations of the existing investigations, we conclude that continued surveillance of patients in a long-term study design, use of holistic alternatives easily acceptable to patients, and early management of complications are of prime importance in the long-term care and wellbeing of patients with a compromised oral cavity.

    Abbreviations

    1. Randomized control trials – RCT

    2. Risk of bias – ROB

    3. Chlorhexidine – CHX

    4. Virgin coconut oil – VCO

    5. Central Plantation Crops Research Institute – CPCRI

    6. Medium-chain fatty acids – MCFA

    7. Head and neck cancer – HNC

    8. Confidence interval – CI

    Acknowledgements

    The authors would like to thank Central Plantation Crops Research Institute (CPCRI) at Kasargod, Kerala for all the support. We also acknowledge the mother institute Nitte Deemed to be University, Deralakatte, Mangalore for the constant encouragement to pursue research.

    Financial support and sponsorship

    Self-funded.

    Conflicts of interest

    No conflict of interest to declare.

    Author contributions

    Upasana Reddy: Design, intellectual content, literature search, data acquisition, manuscript preparation, manuscript editing and review. Shahnawaz Khijmatgar: Intellectual content, literature search, methodology, data analysis, manuscript preparation, manuscript editing and review. Mithra N. Hegde: Intellectual content, validation; visualization, manuscript editing and review. Massimo Del Fabbro: Intellectual content, methodology, manuscript editing, manuscript review and resources.

    Ethical policy and Institutional Review Board statement

    Not applicable.

    Patient declaration of consent

    Not applicable.

    Data availability statement

    Data are available upon a valid request to the corresponding
author.

     
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        Tables

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