Abstract
Objective: Coenzyme Q10 (CoQ10) has been shown to be an effective ingredient in controlling
periodontal disease when used in supplement form or applied directly to the site. This study
explored its practical application in a toothpaste. Methods: To overcome the hydrophobic and
poor absorption characteristics of CoQ10, a more bioavailable, water-dispersible, commercially
available CoQ10–b-cyclodextrin inclusion complex (MicroActive® CoQ10) was used in a toothpaste
base at 1.5% concentration. A parallel-group, double-blind study tested a commercially available
fluoride toothpaste with the CoQ10–b-cyclodextrin complex manufactured by Perfect Smile
Corporation against the same formulation without the complex, as the control. After participants
brushed twice daily, the salivary immunoglobulin (sIgA) was measured at 4 and 8 weeks using the
GeneEx, Inc., Periodontitis ELISA kit. Oral tissue examinations were performed at the onset and
8-week visits. The study had 30 participants (15 in the experimental group and 15 in the control
group). Positive results in the ELISA analysis were defined as a 20% or greater reduction in the
sIgA level. Results: At the end of 4 weeks, 66.6% of the experimental group showed a 20% or
greater decrease in the sIgA while only 16.6% of the control group showed the same improvement
(P<.036). At the end of 8 weeks 66.6% of the experimental group showed improvement
by this standard, while 33.3% of the control group showed improvement but this did not
reach statistical significance. Measures of improvement in the gingiva related to changes in the
degree of edema at study onset versus 8 weeks revealed significant improvement in the experimental
group. Conclusions: CoQ10–b-cyclodextrin complex toothpaste formulation significantly
reduced moderate gingivitis. Further studies are warranted with increased sample size and also
to test the efficacy on a younger population. The CoQ10–b-cyclodextrin complex has the potential
to be incorporated into other oral care products such as gingival massage gels and chewing
gum, which result in longer exposure times and improved uptake of CoQ10 by the gingiva.
Introduction
Periodontal diseases are a group of common inflammatory
conditions that affect tooth-supporting tissues.1 These diseases
are broadly grouped into 2 major diagnostic categories in
patients: gingivitis and periodontitis. Whereas the former
condition is reversible and limited to superficial, gingival
tissues, the latter is nonreversible and features tissue destruction
extending to deeper tissues such as periodontal ligament
and alveolar bone.
Cumulative evidence from human studies demonstrates that specific oral bacteria play a significant role in the onset and progression of gingivitis and periodontitis in susceptible individuals.
Cumulative evidence from human studies
demonstrates that specific oral bacteria play a significant role
in the onset and progression of gingivitis and periodontitis in
susceptible individuals.2,3
A deficiency of Coenzyme Q10 (CoQ10) has been implicated
in the development and progression of periodontal diseases.
CoQ10, a lipid soluble antioxidant present in all the cells
including the gingival tissue, is essential for the maintenance
of cellular energy production and health of the tissue. Several
studies have found a deficiency of CoQ10 in gingival cells from
patients with periodontal disease.4,5 Hansen et al also found
leukocytic deficiencies of CoQ10, which indicate a systemic
nutritional imbalance and are unlikely caused by neglected
oral hygiene.6 Folkers et al similarly conclude that deficiencies
of CoQ10 can exist in human tissue because of nutritional
imbalances and inadequate intake of B vitamins and essential
minerals.7 Studies have also reported a reduction in the endogenous
CoQ10 levels as part of the aging process.8,9
A number of clinical studies have shown that dietary supplementation
of CoQ10 improves periodontal health in patients
with gingivitis and periodontitis. The positive results reported
by investigators include decreased periodontal scores and pocket
depth,10 improved oxygen utilization in the gingival cells,11
significant decreases in gingival index,12 significant increases in
CD4/CD8 ratios and IgG levels,13 and reduction in bleeding
and gingival inflammation.14
Beneficial effects of topical application of CoQ10 in patients
with periodontitis have also been reported in a study in which
CoQ10 was dissolved in soybean oil and applied to periodontal
pockets once a week for 6 weeks.15 The authors reported reduction
in many of the markers of inflammation and infection and
an overall improvement in periodontal condition.
Since the primary method for oral care is brushing, it is relevant
to test the application of CoQ10 in a toothpaste formulation.
CoQ10 is a lipid-soluble molecule with poor bioavailability.
Incorporation of therapeutic levels of CoQ10 in aqueous-based
oral care formulations is limited as CoQ10 is insoluble in water.16
Also the CoQ10 may not be bioavailable to the gingival cells
as they are exposed to the oral care formulations for relatively
brief periods of time and in an aqueous environment. Several
oral care compositions containing solubilized CoQ10 have been
described.17,18 The CoQ10 is generally solubilized in combinations
of oils and surfactants or in essential oils used to flavor the
composition. The solubilizing agents used have several disadvantages
in complex formulations used in oral care products.
For example, the oils have an unpleasant feel in the mouth, and
the flavoring agents may have limited solubility of CoQ10.19
The solubilizing effects of surfactants are overcome on dilution,
resulting in precipitation of CoQ10.
In order to overcome these problems, we used a highly
bioavailable, water dispersible form of CoQ10, MicroActive
® CoQ10 (CoQ10–b-cyclodextrin inclusion complex,
manufactured by BioActives, LLC, Worcester, MA, USA) in
the toothpaste formulation (Perfect Smile toothpaste, manufactured
by Perfect Smile Corporation, Taylor, MI, USA). The
cyclodextrin facilitates the uptake of lipid-soluble molecules by
the cell membrane.20 Since the complex is water-dispersible,
higher therapeutic levels of CoQ10 can be incorporated into
the formulation. CoQ10–b-cyclodextrin complex has also been
shown to increase the cellular CoQ10 levels by nearly 10 times
in an in vitro study using human gingival cells.21
The objective of this study was to determine whether a more
common form of topical application, brushing with a CoQ10-
containing toothpaste, has any effect in alleviating periodontal
disease. The overall hypothesis of the study was that subjects
with clinically established gingivitis who employ a twice-daily
brushing oral regimen with toothpaste containing CoQ10–
b-cyclodextrin complex will demonstrate a reduction in the
markers known to contribute to the onset and progression of
gingivitis and periodontitis.
Materials and Methods
Study Design
The study was approved the independent review board, Zeeba
Ambulatory Surgery Center, Cleveland, OH. This was a singlecenter,
double-blind, placebo-controlled, parallel-group study of the
efficacy of treatment with a fluoridated toothpaste base containing
CoQ10–β-cyclodextrin complex (experimental) compared with
fluoridated toothpaste alone (control) in adults presenting with
mild to moderate gingivitis. The study was conducted under the
direction of Dr. Babbush, an oral and maxillofacial surgeon at the
ClearChoice Dental Implant Center, Pepper Pike, Ohio.
The clinical effectiveness of the treatment was determined by
a salivary diagnostic testing kit for periodontitis called GeneEx
Periodontitis ELISA (GeneEx, Inc., Hialeah, FL, USA) and also
by an oral examination to determine changes in the gingival
edema. The GeneEx Periodontitis ELISA is a quantitative
kinetic immunoassay that detects the host salivary immunoglobulin
(sIgA) specific for virulence factors unique to Porphyromonas
gingivalis (P.g.) and Actinobacillus actinomycetemcomitans (A.a.),
two accepted oral bacteria implicated in periodontal disease.
The ELISA readings for sIgA specific for A.a. and P.g. virulence
factors (identified in vivo-induced gene products) are recorded as
kinetic rates (increase of milliAbsorbance Units/minute; mAU/
min) using an amplified alkaline phosphatase reporter reaction.
The lower level of detection for the assay in testing 120 archived
saliva samples was 4 mAU (observed in a healthy control).
Thirty volunteers with mild to moderate gingivitis and
moderate to elevated levels of sIgA specific for P.g. and A.a. virulence
factors were recruited from a patient pool at the Clear-
Choice Dental Center. After the subjects signed consent forms,
they were randomly assigned to either a control or treatment
group. Thirty kits containing a toothpaste, toothbrush, and
instructions for brushing twice daily were assembled. Fifteen
kits marked “A” contained the experimental treatment, and 15
marked “B” contained the control treatment. The oral surgeon
who subsequently evaluated the gingival edema was blind to the
group to which each subject belonged or the composition of
the A and B toothpastes. The salivary samples were analyzed by
GeneEx Inc. The efficacy and safety assessments were made at 4
and 8 weeks from the initiation of treatment.
Study Population
Table I presents the demographics of the study population. The
average age of the study population (adult males and females)
was 70 years. The inclusion criteria were general good health
based on medical history, mild to moderate gingivitis, and
moderate to elevated levels of sIgA. Older subjects were selected
due to more frequent occurrence of gingivitis and CoQ10 deficiency.
22,23 The baseline demographic features and the clinical
features of gingivitis in the 2 groups were comparable at entry.
Treatment and Administration
The experimental and control products were manufactured by
Perfect Smile Corporation, Taylor, MI, USA. The toothpaste
base formula contained sodium fluoride as the active ingredient;
the inactive ingredients were purified water, sorbitol, hydrated
silica, glycerin, tetrapotassium pyrophosphate, tetrasodium
pyrophosphate, sodium lauryl sulfate, PEG-6, cellulose gum,
citric acid, color, flavor, and sodium saccharin. The experimental
toothpaste contained 1.5% CoQ10 (w/w) in the formula.
Experimental Product: The CoQ10 toothpaste was supplied
in a 3 oz. tube labeled with the subject’s randomized number
and was accompanied by instructions to brush twice daily using
the toothpaste.
Control Product: The toothpaste base was supplied in a 3 oz.
tube containing no CoQ10, labeled with the subject’s randomized
number and was accompanied by instructions to brush
twice daily using the toothpaste.
Evaluation Criteria
The primary efficacy parameter was the change from baseline
sIgA level—in particular, the proportion of responders with
20% or greater reduction in the sIgA compared to baseline.
Secondary parameter was any change in the gingival edema as
determined by a trained oral surgeon in a double-blind examination.
The oral surgeon used a 3-point general observation
scale to assess swelling associated with gingivitis: no edema
(normal color of gums, normal gum architecture); slight edema
(tendency toward redness, puffiness of gums); and edema (red,
swollen gums). The sIgA was determined at baseline and at the
end of 4 and 8 weeks, while changes in the gingival edema were
determined at baseline and at the end of 8 weeks.
Statistical Analysis
All subjects who received study treatment and had at least
the 4-week and 8-week post-baseline efficacy assessment
were included in the efficacy population. Statistical conclusions
concerning the efficacy of CoQ10 were made using data
obtained from clinical observations on week 8 and the salivary
diagnostic (ELISA) data sets. All hypotheses were 2-sided. The
comparisons of interest were:
• Effect (change from baseline) of experimental versus
control at 4 weeks
• Effect (change from baseline) of experimental versus
control at 8 weeks
Statistical analysis was performed using Prism 4.0 for Macintosh
published by GraphPad Software, 2005 edition (GraphPad
Software Inc, La Jolla, California). The tool employed for this
analysis is the Fisher Exact Test, which compares the frequencies
of categorical responses between 2 (or more) independent
groups; in this case, response to treatment with toothpaste
containing CoQ10–β-cyclodextrin complex compared to the
toothpaste formulation without CoQ10.
Results
Twenty-four subjects (12 experimental and 12 control)
completed the 8-week study. The most common reason for early
withdrawal from the control group was sensitivity to the toothpaste
base. The positive responders were defined as subjects
showing both a 20% or greater reduction in the sIgA levels and
a reduction in edema by the end of 8 weeks.
Table I. Subject Demographics |
| Subject | Experimental | Control |
| Mean Age (years) | 68.7 | 71.2 |
| Completed 8 weeks | 12 | 12 |
| Reason for Withdrawal | ||
| Adverse Event None | None | 3 |
| Other reason+ | 3 |
+ Includes subjects withdrawn for protocol violations and lost to follow-up
Table II. Number of Subjects Who Benefited from Treatment with CoQ10 as Determined by Salivary Diagnostic (ELISA) Test at 4 weeks. |
| Subject | Improvement | No Improvement |
| Treated | 8 | 4 |
| Control | 2 | 10 |
(P<0.036 Fisher Exact Two Tailed)
Table III. Number of Subjects Who Benefited from Treatment with CoQ10 as Determined by Salivary Diagnostic (ELISA) Test at 8 Weeks. |
| Subject | Improvement | No Improvement |
| Treated | 8 | 4 |
| Control | 4 | 8 |
(P<0.22 Fisher Exact Two Tailed)
Table IV. Number of Subjects Who Benefited from Treatment with CoQ10 as Determined by Improvement in Level of Gingival Edema over 8 Weeks. |
| Subjects | Improvement | No Improvement |
| Treated | 9 | 3 |
| Control | 3 | 9
|
(P<0.039 Fisher Exact Two Tailed)
At the end of 4 weeks, 66.6% of the experimental group
showed improvement by this standard while only 16.6% of the
control group showed the same improvement (P<0.036 Fisher
Exact Two Tailed). (Table II).
At the end of 8 weeks, 66.6% of the experimental group
showed improvement by this standard, while 33.3% of the
control group showed improvement. The lack of significance
observed (P<0.22 Fisher Exact Two Tailed) might be due to the
small sample size. (Table III)
Measures of improvement in the gingiva related to changes
in the degree of edema were based upon the oral surgeon’s
3-point scale. The results at study onset versus 8 weeks post
treatment revealed significance in proportions (P<0.039 Fisher
Exact Two Tailed), with 75% of those in the experimental group
presenting with improved gingival, while only 25% of those in
the control group improved in the same timeframe. (Table IV)
The relationship between the reduction in sIgA levels and
improved gingiva was related in the experimental group with
7 of the 9 (78%) of the subjects showing reduced edema also
showing a 20% or greater reduction in sIgA levels at 8 weeks.
In the control group, however, the relationship between the 2
parameters was not evident, as only 1 of the 3 subjects who
showed a reduction in edema also showed a reduction in sIgA.
The small sample size may have contributed to these results.
Discussion
The results indicate that the CoQ10–β-cyclodextrin complex
toothpaste was superior to similar toothpaste without CoQ10
in reducing the specific immune response to bacterial virulence
factors and edema in the gums. The edema reduction provides
additional evidence that the CoQ10–β-cyclodextrin complex
toothpaste formulation significantly reduced moderate gingivitis.
Since regular brushing and use of a fluoride-containing toothpaste
also help alleviate gingivitis, some subjects in the control
group showed improvement in the symptoms. Yet it should be
emphasized that the significantly better improvements in the
experimental group were made in relation to a control toothpaste
with fluoride. Further studies are warranted with increased
sample size and to test the hypothesis on a younger population.
The CoQ10–β-cyclodextrin complex has the potential to
be incorporated into other oral care products such as gingival
massage gels and chewing gum, which result in longer exposure
times and improved uptake of CoQ10 by the gingiva.
Corresponding Author: Doddabele Madhavi, PhD, lmadhavi@
bioactives.com
Conflict of Interest Statement: Charles Babbush, DMD, is
an equity holder in Perfect Smile Corporation and sits on its
board of directors. Daniel Kagan, PhD, and D.L. Madhavi,
PhD, are managing partners at BioActives, LLC. MicroActive®
CoQ10 is a product developed by BioActives and licensed to
Perfect Smile Corporation for use in oral-care products. Alex
Rubido, PhD, is a principle in BioQuest Corporation, a paid
consultant to this project.
