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Kumar K N, Srinath C, Mohan P C, Narayana B R, Sunder S S, Swathi V. Clinical and Biochemical
effects of Cocoa consumption in moderate Chronic Periodontitis . J Periodontal Med Clin Pract 2016;03: 65-74.
1 2 3 4 5 6Dr. Kiran Kumar. N, Dr. C. Srikanth, Dr. P. Chandra Mohan, Dr. B. Rama Narayana, Dr. S. Shyam Sunder, Dr. V.Swathi.
Clinical And Biochemical Effects Of Cocoa Consumption In Moderate Chronic Periodontitis
Original Research
Affiliation
1. Professor, Department of periodontics, Mamata Dental College, Khammam, India
2. Professor & Head of Department, Department of periodontics, Mamata Dental College,
Khammam, India
3. Professor, Department of periodontics, Mamata Dental College, Khammam, India
4. Senior lecturer, Department of periodontics, Mamata Dental College, Khammam, India
5. Senior lecturer, Department of periodontics, Mamata Dental College, Khammam, India.
6. Post Graduate Trainee, Department of periodontics, Mamata Dental College, Khammam, India
Corresponding Author:
Dr.Kiran Kumar. N
Department of Periodontics, Mamata Dental College, Khammam.
65
ABSTRACT
Cocoa is produced from the seeds of the tropical tree
Theobroma cacao. Cocoa in the dark chocolate is
proven to have properties like antioxidant, anti-
inflammatory, anti-carcinogenic, anti-cariogenic,
anti-bacterial and anti-viral agent. Cocoa enriched
diet reduces the oxidative stress induced
periodontitis.
AIM: To evaluate the effect of cocoa consumption
in the treatment of patients with chronic
periodontitis.
MATERIALS AND METHODS: Study group
consists of 40 patients who are randomly divided in
to two groups namely, treatment group and control
group. Treatment group received 30gms/day dark
chocolate with cocoa and control group received
30gms/day white chocolate without cocoa for
4weeks after initial scaling and root planning.
Clinical parameters evaluated are gingival index,
modified papillary bleeding index, probing pocket
depth, clinical attachment loss. Saliva samples were
collected from patients at baseline and 4 weeks after
eating chocolate for total antioxidant status,
glutathione and lipid peroxidation of saliva.
RESULTS: Intra group comparison showed there
is significant decrease in clinical parameters in both
the groups after 4 weeks, with more significant
decrease in the test group. Test group showed there
is additional significant reduction in lipid
peroxidation when compared to the control group.
Total anti-oxidant status and glutathione levels
increased significantly in the dark chocolate group
than control group.
CONCLUSION: Consuming cocoa increases total
anti-oxidant status of saliva and decreases lipid
peroxidation, gingival bleeding and inflammation.
INTRODUCTION:
Periodontitis is a chronic inflammatory disease of
tooth supporting structures, initiated by oral
microbiota and their products. Polymorphonuclear
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leukocytes (PMN) act as first line of defense and
they release large amount of reactive oxygen
species (ROS). ROS are highly reactive molecules
originated from molecular oxygen, containing one 1or more unpaired electrons . These ROS are
neutralised by body's natural antioxidants, if not
leads to damage namely oxidative stress.
Polyunsaturated fatty acids (PUFA) in the
membrane lipids are the main targets of ROS
which thereby causes lipid peroxidation.
Peroxidation of PUFA results in the formation of
Malondialdehyde which is used as a biomarker of 2lipid peroxidation .
An antioxidant is any substance that when present
at concentrations below those of their oxidizable
substrate significantly delays or prevents
oxidation of that substrate. The different possible
mechanisms by which antioxidants may offer
protection against free radical damage include
:Inhibit the formation of free radicals, Scavenge
radicals to inhibit chain initiation and break chain
propagation, Repair of the damage caused by free 3radicals with the help of ''de novo'' enzymes .
Dark chocolate has been proven to be the diet with
maximum amount of antioxidants due to the
presence of 70-99% of cocoa. Cocoa is a
Polyphenolic flavonoids. Flavonoids possess
antioxidant, anti-allergic, anti-inflammatory, 4cytoprotective and antibacterial activity . Thus
dark chocolate has been discovered to have a
number of health benefits like alleviation of
cardiovascular disease, regulation of blood sugar,
antioxidant protection, alleviation of cold and
cough, reduced cancer risk, slowing aging, 5increased immune function etc .
Hence the aim of the study is to evaluate the effects
of cocoa rich dark chocolate on lipid peroxidation
and antioxidant status in saliva of chronic
periodontitis patients.
MATERIAL & METHODS:
PATIENT SELECTION:
This cross sectional observational study was
conducted on a total of 40 subjects reporting to the
department Periodontology, Mamata Dental
College, Khammam. The participants enrolled in
the study were belonged to the age group of 35-50
years. Regular dental check-ups were done on
consecutive series of patients and divided in to two
groups namely control (white chocolate) group
and test (dark chocolate) group. All the subjects
were explained about the study and written
informed consent were obtained.
INCLUSION CRITERIA:
1. Patients of age between 35-50 years.
2. Patients diagnosed with moderate form of
chronic periodontitis.
3. Patients without any history of previous
periodontal therapy.
Periodontal diseases classification is based on the
American Academy of Periodontology 1999 6classification system . The main diagnostic
criteria is clinical attachment loss (CAL) 3 – 4mm.
EXCLUSION CRITERIA:
1. Patients who took any medication in the
last 3 months.
2. Patients taking any nutritional and vitamin
supplements.
3. Patients with any other systemic diseases.
4. Pregnant and Lactating women.
5. Smokers and Alcoholic patients.
6. Patients allergic to cocoa products.
INTERVENTION:
All patients received phase I periodontal treatment
i.e., scaling and root planing along with oral
hygiene instructions. One week later, the patients
with less than 30% plaque index participated in the
study. Participants were assigned to two groups.
Group I participants received 30 grams of white
Clinical And Biochemical Effects Of Cocoa Consumption In Moderate Chronic Periodontitis
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chocolate without cocoa (MARCO company,
India) and group II receives 30 grams dark
chocolate rich in cocoa (MARCO company,
India) three times a day for 4 weeks. Chocolates
were packed in encoded packets.
Clinical parameters evaluated are gingival index
(GI), modified papillary bleeding index (MPB),
probing pocket depth (PD), clinical attachment
loss (CAL). Measurements are done with a UNC
15 probe. All the parameters were evaluated at
baseline and after 4 weeks.
SALIVA SAMPLE COLLECTION:
Prior to the collection procedure, the participants
began by rinsing their mouths thoroughly several
times with water and then resting quietly for a
while. Un-stimulated whole saliva (3 ml) was
collected by means of the spitting method. The
collection started with the instruction to rid the
mouth of saliva by swallowing. Subsequently,
saliva was allowed to accumulate in the floor of
the mouth, without stimulation of saliva secretion
by means of oro-facial movements. The
participant then spit the accumulated saliva into
an ice-chilled sterilized containers. All the
collected saliva samples are stored under -80̊C.
BIOCHEMICAL INVESTIGATIONS:
Malondialdehyde levels of saliva were estimated
using TBARS assay (Tiuborbituric acid reactive
substances), total anti-oxidant status of saliva
using FRAP assay (ferric reducing antioxidant
power) and glutathione (GSH) levels by DTNB
(5,5/-dithiobis-2 nitrobenzoic acid) through
spectrophotometric assay.
TBARS are measured at 532 nm after boiling with 7the thiobarbituric acid and FRAP after reaction
with 2,4,6-tripyridyl-s-triazinein hydrochloric 8acid, acetate buffer and ferric chloride at 593 nm .
GSH based on reduction of 5,5/-dithiobis-2 9nitrobenzoic acid at 412 nm .
Figure: LABINDIA – UV 3200 DOUBLE BEAM SPECTROPHOTOMETER.
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Clinical And Biochemical Effects Of Cocoa Consumption In Moderate Chronic Periodontitis
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STATISTICAL ANALYSIS:
Intra group comparison of clinical parameters and
biochemical parameters were analysed using
paired t test and Inter group using independent
sample t test.
RESULTS:
The mean values of the clinical parameters of
both the groups i.e., white chocolate and dark
chocolate groups at baseline and after 4 weeks are
shown in tables 1a and 1b respectively.
Significant difference was observed from base
line to 4 weeks in GI, MPB, FRAP, GSH and
TBARS values. There is decrease in GI, MPB,
TBARS and increase in FRAP values in both the
groups. No significant difference was observed in
terms of PD and CAL. Inter group comparison at
baseline and after weeks are shown in tables 2a
and 2b respectively. At baseline when both the
groups were compared significant difference was
observed only in FRAP values. Inter group
comparison after 4 weeks showed there is
significant difference in MPBI, FRAP, GSH and
TBARS.
Group Baseline 28 days p-value
Mean SD Mean SD
White GI 1.65 .16 1.29 .10 <0.001; Sig
MPB 1.55 .10 1.20 .08 <0.001; Sig
PD 2.97 .30 2.90 .23 0.11; NS
CAL 3.16 .19 3.14 0.14 0.526; NS
FRAP 238.86 16.95 263.81 12.62 <0.001; Sig
TBARS .32 .02 .29 .02 <0.001; Sig
GSH 0.59 0.06 0.61 0.14 <0.002; Sig
Table 1a: Intra-group.
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Group Baseline 28 days p-value
Mean SD Mean SD
Dark GI 1.73 .13 1.26 .08 <0.001; Sig
MPB 1.60 .12 1.13 .10 <0.001; Sig
PD 3.06 .14 2.98 .24 0.107; NS
CAL 3.23 .19 3.2 0.2 0.156; NS
FRAP 256.76 9.63 500.43 17.26 <0.001; Sig
TBARS .32 .03 .26 .05 <0.001; Sig
GSH 0.54 0.05 0.78 .08 <0.001; Sig
Table 1b: Intra-group
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Group p-value
White Dark
Mean SD Mean SD
Baseline GI 1.65 .16 1.73 .13 0.097; NS
MPB 1.55 .10 1.60 .12 0.121; NS
PD 2.97 .30 3.06 .14 0.207; NS
CAL 3.16 .19 3.23 .19 0.213; NS
FRAP 238.86 16.95 256.76 9.63 <0.001; Sig
TBARS .32 .02 .32 .03 0.59; NS
GSH 0.59 0.06 0.54 0.05 0.203;NS
Table 2a: Inter-group
Group p-value
White Dark
Mean SD Mean SD
28 days GI 1.29 .10 1.26 .08 0.336; NS
MPB 1.20 .08 1.13 .10 0.02; Sig
PD 2.90 .23 2.98 0.24 0.302; NS
CAL 3.14 .14 3.2 0.2 0.293; NS
FRAP 263.81 12.62 500.43 17.26 <0.001; Sig
TBARS .29 .02 .26 .05 0.044; Sig
GSH 0.61 0.14 0.78 .08 0.031; Sig
Table 2b: Inter-group
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DISCUSSION:
Only few studies evaluated the effect of cocoa
enriched diet on periodontium. This study has been
done as an attempt to correlate cocoa with
periodontal parameters. Daily consumption of
cocoa enriched diet can significantly reduce the
lipid peroxidation and also increase the total anti-
oxidant capacity. The results showed there is
decrease in gingival inflammation and bleeding in
both groups which may be due to scaling and root
planing along with oral hygiene instructions. But
this decrease was more significant in test group
those who have consumed dark chocolate. This is
because gut bacteria breaks down and ferments the
components in dark chocolate, converting them
into anti-inflammatory compounds like flavanols, 10catechins etc. with properties like scavenging
activity, inhibit lipid peroxidation, reduction in 11oxidative stress.
There is significant increase in the total
antioxidant and glutathione levels and significant
decrease in the lipid peroxidation in both the
groups. Cocoa in dark chocolate is rich source of
anti-oxidants that protect DNA by preserving the
cell membranes by scavenging the free radicals.
Procyanidins and their monomeric precursors,
epicatechin and catechin, contribute to the 12antioxidant activity of cocoa.
These results are in accordance with a similar 13study by Roodgaryan et al on moderate form of
chronic periodontitis patients. MPBI and GI were
significantly decreased in treatment group
compared to the control in the weeks of 4th, 6th thand 8 . Treatment group showed the increase in
FRAP, and decrease in TBARS, which were
statically significant when compared with control
group.14Takaaki Tomofuji et al investigated the levels of
8-hydroxydeoxyguanosine and reduced/oxidized
glutathione ratio to evaluate gingival oxidative
damage and antioxidant status, respectively. Rats
fed with cocoa enriched diet did not show any
change in 8-hydroxydeoxyguanosine and
reduced/oxidized glutathione ratio, whereas rats
with regular diet showed increased 8-
hydroxydeoxyguanosine level and decreased
reduced/oxidized glutathione ratio. Thus
supporting cocoa-enriched diet hampers
periodontitis-induced oxidative stress.15Wang et al studied the effect of Chocolate
consumption on plasma epicatechin and oxidative
Damage. Results showed that there is a direct
relationship between consumption of dark
chocolate and plasma concentration of
procyanidin and also the rise in plasma epicatechin
levels contributed to the ability of plasma to
dampen lipid peroxidation by preventing the free
radicals. The effect of Chocolate Consumption on 16Plasma Oxidation Status by Rein et al proved
that Consumption of chocolate can result in
significant increase in plasma epicatechin
concentrations and decreases in plasma oxidation
products.
Daily consumption of cocoa enriched diet resulted
in significantly higher levels of epicatechin and
increased resistance of human low density 17 18lipoproteins to oxidation . Dietrich Rein et al
stated that 2hours after consumption of chocolate
there was a significant increase in plasma total
antioxidant capacity by 31% and a decrease of in
plasma 2-thiobarbituric acid reactive substances
by 40%.
CONCLUSION:
Dark chocolate with cocoa enriched-polyphenol
have various properties, which endow them with
various positive effects. These properties inhibits
lipid peroxidation and increases total anti-oxidant
capacity of saliva in chronic periodontitis patients.
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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL
Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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