Anti-gingivitis efficacy of a stabilized 0.454% stannous fluoride/sodium hexametaphosphate dentifrice. A controlled 6-month clinical trial

Randomized Controlled Trials Assessing Exposure Frequency Effects of Stannous Fluoride on Gingivitis

OBJECTIVE

To evaluate the exposure frequency effect of 0.454% stannous fluoride (SnF2) toothpaste in controlling gingivitis.

METHODS

Two randomized controlled trials enrolled generally healthy adults with gingivitis. The study duration was 1 mo (study 1) and 3 mo (study 2). Gingivitis was assessed using the Löe-Silness Gingival Index (LSGI) at baseline, 1 mo (both studies), and 3 mo (study 2); bleeding scores were derived from the LSGI. Study groups consisted of positive control (twice-daily use of 0.454% SnF2 toothpaste), experimental group (brushing in the morning with SnF2 toothpaste and in the evening with 0.76% sodium monofluorophosphate [SMFP] toothpaste), and negative control (twice-daily use of SMFP toothpaste). The primary endpoint was number of bleeding sites.

RESULTS

Study 1 and study 2 each enrolled and randomized 90 participants; 86 and 89 participants, respectively, completed the trials. At baseline, the mean (SD) number of bleeding sites was 47.6 (18.54) in study 1 and 41.5 (17.84) in study 2. At 3 mo (study 2), the positive control produced 51.3% fewer bleeding sites, and the experimental group produced 32.5% fewer bleeding sites versus the negative control (P < 0.001 for both). At 1 mo, the positive control produced 45.1% (study 1) and 45.8% (study 2) fewer bleeding sites versus the negative control (P < 0.001 for both), and the experimental group produced 33.0% (study 1) and 24.8% (study 2) fewer bleeding sites, respectively, versus the negative control (P ≤ 0.002 for both). The benefit was observed as early as 1 mo and was consistent with 3-mo results.

CONCLUSION

This research is to our knowledge the first to demonstrate a gingivitis-reduction response effect for the frequency of bioavailable SnF2 toothpaste use, with maximum benefit from twice-daily use, followed by a single-daily exposure versus the negative control. Clinical trial registration numbers: NCT05916508 and NCT05916521.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by dental professionals to guide their recommendations for therapeutic toothpaste for gingival health. Emphasis on the importance of twice-daily brushing with bioavailable stannous fluoride dentifrice will help patients optimize gingival health benefits achieved via self-care.

Remineralisation of enamel and dentine with stabilised stannous fluoride dentifrices in a randomised cross-over in situ trial

OBJECTIVES

To compare the remineralisation efficacy and ion bioavailability of two novel SnF2-containing dentifrices in a blinded, cross-over, randomised in situ clinical study.

METHODS

Six participants wore removal palatal appliances holding human enamel and dentine blocks with subsurface lesions. Appliances were worn for two treatment periods of 14 consecutive days each, with a one-week washout period in-between. Participants were randomly allocated to rinse with a 1:5 diluted coded slurry of one of two dentifrices containing either 5 % casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) +1100 ppm F as SnF2 [MIPOP], or 1100 ppm F as SnF2 [CT], for 1 min, four times a day. Saliva was collected post-treatment and analysed for tin, calcium, inorganic phosphate and fluoride ions using atomic absorption spectrophotometry and ion chromatography. Enamel and dentine lesions were analysed for percent remineralisation (%R) using transverse microradiography and percent surface microhardness recovery (%SMHR).

RESULTS

MIPOP released significantly higher F (3.00 ± 0.27 mM), Ca (15.23 ± 3.23 mM) and Sn (1.18 ± 0.13 mM) into saliva whereas CT released 2.89 ± 0.32 mM F and only 0.84 ± 0.11 mM Ca and 0.28 ± 0.10 mM Sn. MIPOP produced significantly higher %R than CT: 25.6 ± 1.5 % compared to 15.2 ± 0.7 % in enamel, and 33.6 ± 3.1 % compared to 20.6 ± 1.1 % in dentine. Additionally, MIPOP produced significantly higher %SMHR (18.2 ± 7.9 %) compared to CT (4.1 ± 0.6 %).

CONCLUSIONS

Both dentifrices promoted remineralisation, but the MIPOP dentifrice with added CPP-ACP and the ion-stabilising effects of CPP released higher amounts of bioavailable tin and produced significantly higher remineralisation and surface microhardness recovery.

CLINICAL SIGNIFICANCE

Modern dentifrices contain SnF2 for a range of oral health benefits. Challenges associated with stability of these formulations can affect ion bioavailability, reducing efficacy. Two dentifrices with SnF2 promoted remineralisation in situ, however the dentifrice with the added saliva biomimetic CPP-ACP was superior and therefore may produce greater health benefits.

Structural characterization of tin in toothpaste by dynamic nuclear polarization enhanced 119Sn solid-state NMR spectroscopy

Stannous fluoride (SnF2) is an effective fluoride source and antimicrobial agent that is widely used in commercial toothpaste formulations. The antimicrobial activity of SnF2 is partly attributed to the presence of Sn(II) ions. However, it is challenging to directly determine the Sn speciation and oxidation state within commercially available toothpaste products due to the low weight loading of SnF2 (0.454 wt% SnF2, 0.34 wt% Sn) and the amorphous, semi-solid nature of the toothpaste. Here, we show that dynamic nuclear polarization (DNP) enables 119Sn solid-state NMR experiments that can probe the Sn speciation within commercially available toothpaste. Solid-state NMR experiments on SnF2 and SnF4 show that 19F isotropic chemical shift and 119Sn chemical shift anisotropy (CSA) are highly sensitive to the Sn oxidation state. DNP-enhanced 119Sn magic-angle turning (MAT) 2D NMR spectra of toothpastes resolve Sn(II) and Sn(IV) by their 119Sn chemical shift tensor parameters. Fits of DNP-enhanced 1D 1H → 119Sn solid-state NMR spectra allow the populations of Sn(II) and Sn(IV) within the toothpastes to be estimated. This analysis reveals that three of the four commercially available toothpastes contained at least 80% Sn(II), whereas one of the toothpaste contained a significantly higher amount of Sn(IV).

A randomised clinical study investigating efficacy of a stannous fluoride toothpaste in improving gingival health after 3 weeks' use

BACKGROUND

This examiner-blind, stratified, parallel study aimed to evaluate the anti-gingivitis efficacy of a non-aqueous (anhydrous) 0.454% w/w stannous fluoride toothpaste ('Test') versus a sodium monofluorophosphate toothpaste ('Control') in people with clinically-confirmed mild-moderate gingivitis. Plaque-induced gingivitis can progress to irreversible periodontitis if left untreated. This can be controlled by an effective oral hygiene regimen such as one including toothbrushing with a toothpaste containing the chemotherapeutic agent stannous fluoride. Long-term studies over 4-12 weeks have shown the efficacy of stannous fluoride; however, shorter term studies are needed to examine if the effects on measures of gingivitis and plaque control occur sooner.

METHODS

Eligible participants were randomised to 3 weeks' twice-daily brushing (for 1 min) with Test or Control toothpastes. The primary efficacy variable was between-treatment difference in Bleeding Index (BI) at 3 weeks; secondary variables were between-treatment differences in number of bleeding sites, modified Gingival Index (MGI), and Turesky modification of the Quigley-Hein Plaque Index (TPI) at Weeks 2 and 3.

RESULTS

A statistically significant (p < 0.0001) lower BI score was reported for Test (n = 65) versus Control (n = 65) groups at Week 2 (mean difference: - 0.07 [95% CI - 0.9, - 0.05]; 32.7% difference) and Week 3 (mean difference: - 0.06 [95% CI - 0.8, - 0.04]; 29.2% difference). The Test group also demonstrated statistically significant lower (all p < 0.0001 versus Control) number of bleeding sites (Weeks 2/3 mean difference [95% CI]: - 10.04 [- 12.3, - 7.5]/ - 8.2 [- 11.1, - 5.3] sites; 33.0%/29.3% difference); MGI score (Weeks 2/3 mean difference [95% CI]: - 0.09 [- 0.13, - 0.06]/ - 0.10 [- 0.14, - 0.06]; 4.3%/4.7% difference); overall TPI score (Weeks 2/3 mean difference [95% CI]: - 0.45 [- 0.55, - 0.35/ - 0.42 [- 0.53, - 0.30] difference; 16.0%/15.1% difference) and interproximal TPI score (Weeks 2/3 mean difference [95% CI]: - 0.42 [- 0.52, - 0.30]/ - 0.41 [- 0.52, - 0.29]; 14.6%/14.1% difference). Both toothpastes were generally well tolerated.

CONCLUSION

Three weeks' twice-daily brushing with the 0.454% w/w stannous fluoride Test toothpaste compared to the Control toothpaste led to statistically significant lower gingival bleeding, gingival inflammation and plaque levels in adults with mild-moderate gingivitis. These results indicate that plaque and gingivitis-reducing benefits of 0.454% w/w stannous fluoride may be seen from 2 weeks' use. Trial registration ClinicalTrials.gov Identifier: NCT04050722; 08/08/2019.

Evaluating efficacy of a novel dentifrice in reducing probing depths in Stage I and II periodontitis maintenance patients: A randomized, double-blind, positive controlled clinical trial

BACKGROUND

Compliance to periodontal maintenance therapy (PMT) is essential for long-term periodontal health. Between PMT visits, patients must maintain good oral hygiene. A dentifrice with demonstrable clinical benefits for use between PMT visits would be highly desirable. The aim of this clinical study was to investigate the effect of a novel dental gel on probing depths (PD) and inflammation when used as a home care dentifrice in Stage I and II periodontitis patients.

METHODS

This double-blind clinical study randomized 65 subjects with Stage I and II periodontitis to the novel dental gel containing 2.6% EDTA, and a commercially available anti-gingivitis dentifrice with 0.454% stannous fluoride. Primary endpoint was PD at 6 months for those sites with baseline PD ≥ 4 mm and secondary endpoints included whole mouth mean scores of modified gingival index (MGI), modified sulcus bleeding index (mSBI) and plaque index (PI). No SRP was performed at baseline.

RESULTS

Subjects using the novel dentifrice showed significant PD reductions of 1.18 mm (from 4.27 mm at baseline to 3.09 mm at 6 months) compared to 0.93 mm (from 4.23 mm at baseline to 3.30 mm at 6 months) shown for those using the positive control dentifrice. Difference between treatments at 6 months was 0.21 mm with P-value = 0.0126. Significant improvements in MGI (P = 0.0000), mSBI (P = 0.0000), and PI (P = 0.0102) were also observed in 6 months.

CONCLUSION

The novel dentifrice showed significant reductions in PD and gingival inflammation over 6 months solely as a home care dentifrice without baseline SRP in Stage I and II periodontitis maintenance patients.

Clinical and Immunological Efficacy of Mangosteen and Propolis Extracted Complex in Patients with Gingivitis: A Multi-Centered Randomized Controlled Clinical Trial

Background: Mangosteen and propolis extracts (MAEC) have been potential therapeutic agents known to exhibit powerful antioxidant and anti-inflammatory properties. The aim of the current study was to evaluate the clinical and immunological efficacy of MAEC as well as safety and patient-reported outcomes (PROMs) on gingivitis and incipient periodontitis. Methods: This study was performed on 104 patients diagnosed with gingivitis or incipient periodontitis. At baseline, the participants were randomly allocated to either the test group, with daily intake of a single capsule containing 194 mg of MAEC for eight weeks, or control group, with placebo. Clinical periodontal evaluation and immunological parameters from saliva and gingival sulcular fluid were assessed at baseline, four, and eight weeks. Individual PROMs were assessed by OHIP-14 questionnaires. Results: There was a significant difference of modified gingival index at four and eight weeks between the test and control groups. In the test group, crevicular interleukin (IL)-6 was reduced, and the salivary matrix metalloproteinase (MMP)-9 was increased after eight weeks. PROMs were improved up to four weeks compared to placebo. Conclusion: Oral administration of MAEC would have a potential to reduce gingival inflammation clinically and immunologically in the patients with gingivitis and incipient periodontitis.

Recent Development of Active Ingredients in Mouthwashes and Toothpastes for Periodontal Diseases

Periodontal diseases like gingivitis and periodontitis are primarily caused by dental plaque. Several antiplaque and anti-microbial agents have been successfully incorporated into toothpastes and mouthwashes to control plaque biofilms and to prevent and treat gingivitis and periodontitis. The aim of this article was to review recent developments in the antiplaque, anti-gingivitis, and anti-periodontitis properties of some common compounds in toothpastes and mouthwashes by evaluating basic and clinical studies, especially the ones published in the past five years. The common active ingredients in toothpastes and mouthwashes included in this review are chlorhexidine, cetylpyridinium chloride, sodium fluoride, stannous fluoride, stannous chloride, zinc oxide, zinc chloride, and two herbs—licorice and curcumin. We believe this comprehensive review will provide useful up-to-date information for dental care professionals and the general public regarding the major oral care products on the market that are in daily use.

Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis

AIM

To evaluate the efficacy of adjunctive therapies in reducing gingivitis and plaque by means of a systematic review of randomized clinical trials (RCTs).

MATERIAL AND METHODS

A search protocol was designed to identify 6-month RCTs that investigated the efficacy of adjuncts to mechanical plaque control on gingivitis and plaque. Following screening, relevant information was extracted, and quality and potential risk of bias were estimated. Mean treatment differences were calculated to obtain standardized mean differences and weighted mean differences (SMD and WMD) as appropriate.

RESULTS

Meta-analyses included 70 studies of adjunctive antiseptics. Compared with mechanical plaque control alone, adjuncts yielded statistically significant reductions in gingival index (n = 72; SMD = -1.268; 95% CI [-1.489; -1.047]; p < .001; I²  = 96.2%), bleeding (%) (n = 26, WMD=-14.62%; 95% CI [-18.01%; -11.23%]; p < .001; I²  = 95.1%), plaque index (n = 93, SMD = -1.017; 95% CI [-1.194; -0.840]; p < .001; I²  = 95.3%) and plaque (%) (n = 23; WMD = -18.20%; 95% CI [-24.00%; -12.50%]; p < .001; I²  = 96.9%). Mouthrinses resulted in greater reductions in per cent plaque compared with dentifrices (meta-regression, coefficient = 13.80%; 95% CI [2.40%; 25.10%]; p = .020). The antiseptic agents were similarly effective in reducing gingivitis and plaque in patients with dental plaque-induced gingivitis (intact periodontium) or previously treated periodontitis with gingival inflammation.

CONCLUSION

Adjunctive antiseptics in mouthrinses and dentifrices provide statistically significant reductions in gingival, bleeding and plaque indices.

Effect of stannous fluoride and zinc phosphate dentifrice on dental plaque and gingivitis: A randomized clinical trial with 6-month follow-up

OBJECTIVE

The objective of this study was to compare a stabilized stannous fluoride (SnF₂) dentifrice with zinc phosphate (Colgate Total^SF) with SnF₂ with zinc lactate and control fluoride dentifrices for gingivitis and plaque control over a 6-month period.

METHODS

A total of 135 adult participants were enrolled in this study. After randomization and blinding of examiners and patients, enrolled participants were provided instructions for use of assigned dentifrice. At 3 visits (0, 3, and 6 months), various gingival and plaque indexes were collected to determine the clinical efficacy of a stabilized SnF₂ dentifrice. These results were compared with a SnF₂ with zinc lactate dentifrice and with a control fluoride dentifrice.

RESULTS

A total of 135 participants completed the study. All groups reported statistically significant reductions in gingival inflammation and improvement in plaque control at 3- and 6-month follow-up. Both SnF₂ dentifrices showed statistically significant reductions in all indexes compared with the control dentifrice (P < .001). However, the test dentifrice showed higher but nonsignificant improvements in plaque and gingival indexes compared with the other SnF₂ dentifrice.

CONCLUSIONS

This study reports similar efficacy of a test dentifrice to a commercial SnF₂-containing dentifrice for plaque control and reduction in gingival inflammation and provides supporting evidence that the test dentifrice maintains its clinical efficacy with change of formulation.

PRACTICAL IMPLICATIONS

This newly formulated SnF₂ stabilized with zinc phosphate dentifrice may be of benefit to patients in controlling plaque biofilm and gingivitis.

Solving the problem with stannous fluoride: Formulation, stabilization, and antimicrobial action

BACKGROUND

Stannous fluoride (SnF₂) is a compound present in many commercially available dentifrices; however, oxidative decomposition negatively impacts its efficacy. Stannous oxidation is often mitigated through the addition of complexing agents or sources of sacrificial stannous compounds. The authors have found that the addition of zinc phosphate significantly improved stannous stability more effectively than other stabilization methods. The authors evaluated the chemical speciation of stannous compounds within a variety of formulations using x-ray absorption near edge spectroscopy (XANES), a technique never used before in this manner. These data were compared and correlated with several antimicrobial experiments.

METHODS

XANES data of various commercially available compounds and Colgate Total^SF were performed and analyzed against a library of reference compounds to determine the tin chemical speciation. The antibacterial assays used were salivary adenosine triphosphate, short-interval kill test, plaque glycolysis, and anaerobic biofilm models.

RESULTS

XANES spectra showed a diverse distribution of tin species and varying degrees of SnF₂ oxidation. In vitro antimicrobial assessment indicated significant differences in performance, which may be correlated to the differences in tin speciation and oxidation state.

CONCLUSIONS

Driven by the excipient ingredients, SnF₂ dentifrices contain a distribution of tin species in either the SnF₂ or Sn(IV) oxidation state. The addition of zinc phosphate provided significant robustness against oxidation, which directly translated to greater efficacy against bacteria.

PRACTICAL IMPLICATIONS

The choice of inactive ingredients in a dentifrice with active SnF₂ can dramatically impact product stability.

Effects of stabilized stannous fluoride dentifrice on dental calculus, dental plaque, gingivitis, halitosis and stain: A systematic review

Objectives

The aim of the present systematic review was to examine the scientific evidence for the efficacy of stabilized stannous fluoride (SnF₂) dentifrice in relation to dental calculus, dental plaque, gingivitis, halitosis and staining.

Data and sources

Medline OVID, Embase.com, and the Cochrane Library were searched from database inception until June 2017. Six researchers independently selected studies, extracted data, and assessed methodological quality. A meta-analysis of the 6-month gingivitis studies was done. Risk of bias was estimated using a checklist from the Swedish Agency for Health Technology Assessment (SBU, 2018).

Study selection

Two studies on dental calculus, 21 on dental plaque and gingivitis, 4 on halitosis, and 5 on stain met the inclusion criteria. Risk of bias was high for the studies on dental calculus, halitosis, and stain, and varied for the dental plaque and gingivitis studies. Significant reductions in dental calculus and in halitosis were reported for the SnF₂ dentifrice; no differences in stain reduction were noted. A meta-analysis on gingivitis found better results for the SnF₂ dentifrice compared to other dentifrices, though the results of the individual trials in the meta-analyses showed a substantial heterogeneity.

Conclusions

The present review found that stabilized SnF₂ toothpaste had a positive effect on the reduction of dental calculus build-up, dental plaque, gingivitis, stain and halitosis. A tendency towards a more pronounced effect than using toothpastes not containing SnF2 was found. However, a new generation of well conducted randomized trials are needed to further support these findings.

Clinical relevance

Adding a SnF₂ toothpaste to the daily oral care routine is an easy strategy that may have multiple oral health benefits.

The effects of bioavailable gluconate chelated stannous fluoride dentifrice on gingival bleeding: Meta-analysis of eighteen randomized controlled trials

AIM

To estimate gingivitis effects of a bioavailable gluconate chelated 0.454% stannous fluoride (SnF2 ) family of dentifrices in adult subjects versus positive (triclosan) and negative (NaF or MFP) controls when used ≤3 months.

MATERIALS AND METHODS

A meta-analysis evaluated bioavailable gluconate chelated SnF2 dentifrices versus a negative or positive control for gingival bleeding.

RESULTS

In 18 randomized controlled trials (RCTs) with 2,890 subjects assessing SnF2 paste versus a negative or positive control, the average number of bleeding sites was reduced by 51% and 31%, respectively. The average change (95% CI) in number of bleeding sites was -16.3 (-27.8, -4.9) versus the negative control and -3.6 (-5.4, -1.8) versus the positive control. Subjects with localized or generalized gingivitis had 3.7 times better odds (95% CI [2.8, 5.0]) of shifting to generally healthy using SnF2 versus a negative control and 2.8 times better odds (95% CI [2.1, 3.9]) of shifting to generally healthy using SnF2 versus a positive control. The individual study risk of bias was deemed to be low in all categories of bias.

CONCLUSION

This meta-analysis demonstrates significant gingivitis benefits of bioavailable SnF2 dentifrices when used ≤3 months versus positive (triclosan) and negative (NaF or MFP) controls.

Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analyses

AIM

The aim of this network meta-analysis (NMA) was to compare the efficacy of different oral hygiene products for chemical biofilm control, in 6-month home-use, randomized clinical trials (RCTs), in terms of changes in gingival index (GI).

MATERIAL AND METHODS

Six-month RCTs assessing GI were identified and screened for inclusion. Relevant information was extracted, and quality and potential risk of bias were estimated. Mean differences between baseline and end were calculated to obtain standardized mean differences (SMDs). NMA protocols were applied to assess direct and indirect comparisons among products using Löe & Silness GI, modified GI and gingival severity index.

RESULTS

Fifty-three papers were included, 19 studies for mouth rinses, 32 for dentifrices, comprising data from 5,775 and 2,682 subjects, respectively. When ranking treatments, similar results were observed for all tested dentifrices, with the lowest effect observed for sanguinarine and baking soda. For mouth rinses, essential oils, triclosan-copolymer, chlorhexidine (at concentrations ≥ 0.10%) and cetylpyridinium chloride (>0.05%) demonstrated the greatest effect.

CONCLUSION

Although NMA revealed significant differences when comparing placebo versus some active agents, when comparing among active agents, no differences were found for dentifrices, while mouth rinses containing essential oils showed the greatest effect on GI scores.

In vitro efficacy of essential oil mouthrinse versus dentifrices

OBJECTIVES

To compare the antimicrobial efficacy and kill penetration of essential oils (EO) mouthrinse versus stannous fluoride, and triclosan dentifrice slurries on saliva-derived biofilms using confocal laser scanning microscopy (CLSM).

METHODS

Saliva-derived biofilms were grown for 48h on hydroxyapatite discs using pooled, homogenized saliva from 8 healthy volunteers as the inoculum. The mean thickness of these biofilms was 84μm (range, 23-241μm). CLSM with viability mapping was used to visualize the antimicrobial kill penetration of each treatment regime within a biofilm.

RESULTS

At 30s treatment durations, CLSM imaging revealed greater antimicrobial activity and kill penetration of EO mouthrinse compared to sodium fluoride-, stannous fluoride-, and triclosan-containing dentifrice slurries. Quantification of biovolume revealed that EO mouthrinse treatment at 30s resulted in a greater non-viable biovolume proportion (84.6%±15.0%) than other treatment groups. Increasing the treatment duration of the triclosan dentifrice (to 60 and 120s) resulted in better penetration and an increased reduction of viable cells, comparable to EO mouthrinse treatment at 30s duration. Further, CLSM imaging showed that the combined treatment of a non-antimicrobial dentifrice (45s) with EO mouthrinse (30s) showed superior antimicrobial activity (96.2%±3.7%) compared to the antimicrobial triclosan-containing dentifrice used without a mouthrinse step (26.0%±32.0%).

CONCLUSIONS

Within typical exposure times, the EO-containing mouthrinse can penetrate deep into the accumulating plaque biofilm compared to the chemotherapeutic dentifrice slurries, and may provide an efficacious alternative to triclosan, when used as an adjunct with a mechanical oral care regimen.

CLINICAL SIGNIFICANCE

Using viability mapping and CLSM, this study demonstrated that EO-containing mouthrinse penetrates and kills microorganisms deeper and more effectively in plaque biofilm in typical exposure times when compared to dentifrice chemotherapeutic agents, providing an efficacious alternative to triclosan or stannous fluoride when used as an adjunct to mechanical oral care.

Efficacy of adjunctive anti-plaque chemical agents: a systematic review and network meta-analyses of the Turesky modification of the Quigley and Hein plaque index

AIM

The aim of this systematic review and network meta-analysis (NMA) was to compare the efficacy of different anti-plaque chemical agents, in 6-month, home-use, randomized clinical trials (RCTs), in terms of plaque index (PlI) changes.

MATERIAL AND METHODS

RCTs assessing PlI were identified, screened, and evaluated for inclusion. Relevant information was extracted, and quality and risk of bias were assessed. Mean differences between baseline-end were calculated to obtain weighted mean differences and 95% confidence intervals. NMA protocols were applied to assess direct and indirect comparisons among products using Turesky PlI.

RESULTS

Eighty-three papers were included: 49 examined dentifrices, 32 mouthrinses and 2 both. The NMA analysed 51 studies including data from 4242 and 4180 subjects for dentifrices and mouthrinses respectively. For dentifrices, triclosan-copolymer and chlorhexidine showed the greatest effect, with significant differences when compared with stannous fluoride. For mouthrinses, essential oils and chlorhexidine showed the greatest effect, with significant differences when compared with delmopinol, alexidine and cetylpyridinium chloride.

CONCLUSION

Within the limitations of this study (including the severe imbalance in the amount of evidence), dentifrices containing triclosan-copolymer or chlorhexidine and mouthrinses containing essential oils or chlorhexidine showed the greatest effect on PlI scores as assessed with NMA.

Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis

AIM

The aim of this systematic review was to evaluate the efficacy of anti-plaque chemical formulations for managing gingivitis, in 6-month, home-use, randomised clinical trials (RCTs).

MATERIAL AND METHODS

A protocol was designed, including inclusion and exclusion criteria to identify RCTs assessing gingival and/or bleeding indices. Electronic and hand-searches identified relevant papers, which were screened and evaluated for inclusion. Full-papers were retrieved and relevant information was extracted (also plaque indices), including quality and risk of bias. Mean treatment effects were calculated to obtain weighted mean differences (WMD) and 95% confidence intervals.

RESULTS

After the process of screening and selection, 87 articles with 133 comparisons, were included in the review. The additional effects of the tested products were statistically significant in terms of Löe & Silness gingival index (46 comparisons, WMD -0.217), modified gingival index (n = 23, -0.415), gingivitis severity index (n = 26, -14.939%) or bleeding index (n = 23, -7.626%), with significant heterogeneity. For plaque, additional effects were found for Turesky (66 studies, WMD -0.475), Silness & Löe (n = 26, -0.109), and plaque severity (n = 12, -23.4%) indices, with significant heterogeneity.

CONCLUSION

Within the limitations of the present study, formulations with specific agents for chemical plaque control provide statistically significant improvements in terms of gingival, bleeding and plaque indices.

Simultaneous Assessment of Acidogenesis-Mitigation and Specific Bacterial Growth-Inhibition by Dentifrices

Dentifrices can augment oral hygiene by inactivating bacteria and at sub-lethal concentrations may affect bacterial metabolism, potentially inhibiting acidogenesis, the main cause of caries. Reported herein is the development of a rapid method to simultaneously measure group-specific bactericidal and acidogenesis-mitigation effects of dentifrices on oral bacteria. Saliva was incubated aerobically and anaerobically in Tryptone Soya Broth, Wilkins-Chalgren Broth with mucin, or artificial saliva and was exposed to dentifrices containing triclosan/copolymer (TD); sodium fluoride (FD); stannous fluoride and zinc lactate (SFD1); or stannous fluoride, zinc lactate and stannous chloride (SFD2). Minimum inhibitory concentrations (MIC) were determined turbidometrically whilst group-specific minimum bactericidal concentrations (MBC) were assessed using growth media and conditions selective for total aerobes, total anaerobes, streptococci and Gram-negative anaerobes. Minimum acid neutralization concentration (MNC) was defined as the lowest concentration of dentifrice at which acidification was inhibited. Differences between MIC and MNC were calculated and normalized with respect to MIC to derive the combined inhibitory and neutralizing capacity (CINC), a cumulative measure of acidogenesis-mitigation and growth inhibition. The overall rank order for growth inhibition potency (MIC) under aerobic and anaerobic conditions was: TD> SFD2> SFD1> FD. Acidogenesis-mitigation (MNC) was ordered; TD> FD> SFD2> SFD1. CINC was ordered TD> FD> SFD2> SFD1 aerobically and TD> FD> SFD1> SFD2 anaerobically. With respect to group-specific bactericidal activity, TD generally exhibited the greatest potency, particularly against total aerobes, total anaerobes and streptococci. This approach enables the rapid simultaneous evaluation of acidity mitigation, growth inhibition and specific antimicrobial activity by dentifrices.

Assessment of dentifrices against Candida biofilm

The invasion of opportunistic pleiomorphic Candida albicans into oral cavity environment leads to development and progression of its resistance to both naturally occurring antifungal peptides in human saliva as well as commercially available antifungal therapies. As a result of this, the usage and popularity of natural medicine and dentifrices had increased significantly in the last decade. In the present investigation, we have assessed the action of locally available dentifrices against C. albicans biofilm. Disk diffusion test showed maximum zone of inhibition (20 mm) by herbal dentifrice (D-5) as compared to other dentifrices when incubated at 37 °C and 48 h. Assessment of dentifrice D-5 for its effectiveness against C. albicans was further shown in MIC(90) (3.12 mg mL(-1)) and SMIC(90) (6.2 mg mL(-1)) values for planktonic and sessile cells (biofilm forming), respectively. Our data depicted 80% reduction in the cell surface hydrophobicity when 6.2 mg mL(-1) of herbal dentifrice D-5 was used against 48-h grown Candida biofilm at 37 °C. Visualization of herbal dentifrice D-5-treated C. albicans biofilm under SEM revealed drastic reduction in the dense network of yeast, hyphae, and pseudohyphae enclosed in its ECM as compared to its control biofilm. The data were further supported by CLSM analysis which depicted C. albicans architecture disruption by herbal dentifrices. From the above data, it is inferred that these studies would provide researchers and medical practitioners with better insight into the antifungal effect of natural herbal dentifrices.

The clinical efficacy of triclosan/copolymer and other common therapeutic approaches to periodontal health

The maintenance of an effective level of oral hygiene is the cornerstone of all attempts to prevent and control periodontal disease, and yet the widespread prevalence of the disease indicates the inability of most people to maintain a level of plaque control commensurate with periodontal health. The inclusion of antibacterial agents, such as chlorhexidine and triclosan, in oral care products has provided a means to improve oral health. Randomised, controlled clinical trials have demonstrated that the unsupervised use of a dentifrice (toothpaste) containing triclosan/copolymer significantly improves gingival health, prevents the onset of periodontitis and reduces further progression of tissue destruction. The delivery of such benefits has positive implications for the oral health of individuals and populations.

Comparative Efficacy of Stabilized Stannous Fluoride/Sodium Hexametaphosphate Dentifrice and Sodium Fluoride/Triclosan/Copolymer Dentifrice for the Prevention of Periodontitis in Xerostomic Patients: A 2-Year Randomized Clinical Trial

BACKGROUND

The primary objective of this study was to compare the efficacy of a stannous fluoride (SnF2) dentifrice relative to a positive control triclosan dentifrice for prevention of clinical attachment loss (CAL) in xerostomic patients. A secondary objective was to compare the dentifrices for root caries remineralization.

METHODS

This was a 2-year, randomized, double-masked, parallel-group study. A 0.454% SnF2/sodium hexametaphosphate dentifrice was tested versus a positive control dentifrice (sodium fluoride/0.30% triclosan/copolymer) in 440 medication-induced xerostomic adults identified in a 1-year, run-in phase (no treatment) as high risk for periodontitis and root caries. During the study phase, subjects were stratified based on gender and attachment level into two groups. Subjects brushed twice a day for 60 seconds using their assigned product. Clinical examinations including probing depth, attachment level, bleeding on probing, and root caries remineralization were performed at baseline and 1 and 2 years.

RESULTS

A total of 334 subjects were evaluable. During run-in, average CAL relative to initial examination was 1.33 mm. Probing depth increased 0.95 mm. At year 2 in the treatment phase, attachment gain was 0.77 mm for the test group and 0.79 mm for the control group versus baseline. Probing depth decreased 0.57 mm for the test group, similar to the control group (0.53 mm). These changes versus baseline were statistically significant (P <0.01) for each group. Products were not statistically significantly different from each other. Both treatments resulted in similar remineralization for root caries lesions at study completion (P = 0.40).

CONCLUSION

The results establish comparable benefits for the SnF2 dentifrice in preventing CAL and root caries versus the sodium fluoride/triclosan/copolymer control in xerostomic patients.

A controlled 6-month clinical trial to study the effects of a stannous fluoride dentifrice on gingivitis

OBJECTIVES

This study was conducted to assess anti-plaque and anti-gingivitis benefits of a stabilized stannous fluoride (SnF(2))/sodium hexametaphosphate (SHMP) dentifrice versus a negative control.

MATERIAL AND METHODS

This was a randomized, 6-month, stratified, single-centre, double-blind, parallel group, clinical study conducted in harmony with the guidelines for evaluating chemotherapeutic products for the control of gingivitis outlined by the American Dental Association. A stabilized 0.454% SnF(2)/SHMP dentifrice was tested against a commercially available negative control dentifrice. Following baseline measurements, subjects received a dental prophylaxis. Subjects were instructed to brush twice daily for 60 s using their assigned product. Efficacy measurements were obtained at baseline, 3 and 6 months post treatment using the Modified Gingival Index, Gingival Bleeding Index and the Turesky Modified Quigley-Hein Plaque Index. Oral tissue examinations were performed at all visits.

RESULTS

A total of 140 subjects were enroled and 128 completed the study. RESULTS after 6 months showed the SnF(2) dentifrice delivered a 16.9% reduction in gingivitis (p<0.001), a 40.8% reduction (p<0.001) in gingival bleeding, and an 8.5% reduction in plaque (p=0.001) versus the negative control. Both treatments were well tolerated.

CONCLUSIONS

Twice daily use of the SnF(2)/SHMP dentifrice over 6 months provided statistically significant anti-plaque and anti-gingivitis benefits relative to a negative control.

A meta-analysis of six-month studies of antiplaque and antigingivitis agents

BACKGROUND AND METHODS

The author conducted a systematic review of the literature to evaluate the efficacy of antigingivitis and antiplaque products in six-month trials. He searched electronic databases for six-month randomized clinical studies that evaluated both antiplaque and antigingivitis properties of dentifrices or mouthrinses. In addition, the author solicited unpublished studies from manufacturers.

RESULTS

Seventeen studies support the antiplaque, antigingivitis effects of dentifrices containing 0.30 percent triclosan, 2.0 percent Gantrez copolymer. There was no evidence of efficacy for triclosan products containing either soluble pyrophosphate or zinc citrate. Dentifrices with stannous fluoride had statistically significant, but marginally clinically significant, evidence of an antiplaque effect; however, there was both a statistically and clinically significant antigingivitis effect. The largest body of studies (21 studies) supported the efficacy of mouthrinses with essential oils. A smaller body of studies (seven) supported a strong antiplaque, antigingivitis effect of mouthrinses with 0.12 percent chlorhexidine. Results for mouthrinses with cetylpyridinium chloride varied and depended on the product's formula.

CONCLUSIONS

The studies in this systematic review provide strong evidence of the antiplaque, antigingivitis effects of multiple agents. These results support the use of these agents as part of a typical oral hygiene regimen.

The effect of toothbrushing regimens on the plaque inhibitory properties of an experimental cetylpyridinium chloride mouthrinse

OBJECTIVE

The objective of this study was to determine the effect of various toothbrushing regimens with a standard fluoride dentifrice on the plaque inhibitory properties of an alcohol-free, high bioavailable 0.07% cetylpyridinium chloride (CPC) mouthrinse.

MATERIALS AND METHODS

The study was a randomized, single-centre, examiner blind, four-period cross-over study involving 29 healthy subjects. Four treatment regimens were evaluated: (1) Toothbrushing with dentifrice followed by a water rinse (B-W, negative control); (2) Toothbrushing with dentifrice followed by a CPC mouthrinse use (B-CPC); (3) Toothbrushing with dentifrice followed by a water rinse and then a CPC mouthrinse use (B-W-CPC); and (4) Toothbrushing with dentifrice and waiting 60 min. prior to a CPC mouthrinse use (B-60 min.-CPC). Three days before the baseline exam of treatment periods, subjects were instructed to brush only the lingual surfaces of their teeth for up to 60 s twice daily. At baseline, subjects received a plaque exam using the Turesky modification of the Quigley-Hein index (MQH) followed by a polishing on the lingual and buccal surfaces of their teeth. During treatment periods, subjects were asked to brush only the lingual surfaces of their teeth with a standard fluoride dentifrice. Rinsing with 20 ml of the experimental CPC solution was done for 30 s twice daily. The evening before the last day of treatment periods (Day 4), subjects were asked to refrain from any oral hygiene, eating, and drinking after brushing. On Day 4, plaque was scored using the MQH Index. A 10-day wash-out of normal oral hygiene was allowed between each of the four treatment periods. The data were analysed using analysis of covariance for cross-over designs.

RESULTS

Twenty-five to 29 subjects were evaluable at any given visit. With respect to unbrushed buccal and brushed lingual surfaces, all three CPC regimens had highly significantly (p < or = 0.0006) lower mean plaque scores than the B-W regimen, reductions ranging from 20% to 38% in magnitude. With respect to unbrushed surfaces, there was a significant difference between the B-CPC regimen and the B-60 min.-CPC regimen (p < 0.01) in favour of the latter regimen. No other pairwise treatment comparisons were statistically significant for unbrushed sites. Results for brushed surfaces and all sites combined showed that both the B-W-CPC and the B-60 min.-CPC groups reduced mean plaque levels significantly (p < or = 0.013) more than B-CPC. There were no statistically significant differences between B-W-CPC and B-60 min.-CPC for measurements of brushed, unbrushed, or all sites combined.

CONCLUSIONS

Results show that the alcohol-free, 0.07% high bioavailable CPC rinse provides an additive anti-plaque benefit beyond toothbrushing with a standard fluoride dentifrice regardless of the regimen. Of the regimens, a water rinse between toothbrushing and CPC rinsing enhances therapeutic efficacy while fitting into the patient's typical oral hygiene routine.

Anti-gingivitis effect of a dentifrice containing bioactive glass (NovaMin) particulate

BACKGROUND

The objective of this pilot clinical trial was to evaluate the anti-gingivitis and anti-plaque effects of a dentifrice containing bioactive glass (NovaMin) compared with a placebo control dentifrice in a 6 weeks clinical study.

METHODS

The study design was a randomized, double-blinded, controlled clinical trial. One hundred volunteers took part in the study and were matched for plaque index (PLI), gingival bleeding index (GBI), age and gender. The protocol was reviewed and approved by the Ethical Committee of the University. The subjects received a supragingival prophylaxis to remove all plaque, calculus and extrinsic stain. Following the baseline examination, subjects were instructed to brush with their assigned dentifrice and toothbrush. The PLI and GBI were determined for the baseline and 6 weeks. The data were analysed using a repeated-measures anova conducted on the two dependent measures to compare the effect between the test and control group.

RESULTS

Ninety-five subjects finished the study. The results showed that the PLI (baseline=1.54, 6 weeks=1.29) and GBI (baseline=1.14, 6 weeks=0.47) were significantly reduced, respectively, over the 6 weeks period in the test group (p<0.001 for each measure). There was a 58.8% reduction in gingival bleeding and a 16.4% reduction in plaque growth. There was no difference of the PLI (baseline=1.60, 6 weeks=1.57) and GBI (baseline=1.18, 6-week=1.02) over the 6 week period in the control group.

CONCLUSION

This study demonstrated that a dentifrice containing NovaMin significantly improves oral health as measured by a reduction in gingival bleeding and reduction in supragingival plaque compared with a negative dentifrice over the 6 weeks study period.

A review of the effects of stannous fluoride on gingivitis

AIM

To review the literature on the effects of stannous fluoride on gingivitis.

MATERIAL AND METHODS

The Medline and cochrane central register of controlled trials were searched up to August 2005 to identify appropriate studies. The primary outcome measure was gingivitis.

RESULTS

Independent screening of titles and abstracts of 542 papers resulted in 36 publications (inter-reviewer ê score of 0.76), out of which 15 papers finally fulfilled the criteria of eligibility. For SnF(2)dentifrices, a statistically significant reduction in gingivitis was noted in comparison with control (weighted mean difference (WMD) of 0.15 (gingival index) and 0.21 (gingivitis severity index) (test for heterogeneity p<0.00001, I(2)=91.1% and p=0.03, I(2)=80.1%, respectively)). With regard to plaque reduction inconsistent results existed. On using the plaque index no differences were found, whereas meta-analysis of the Turesky index provided a WMD of 0.31 (p=0.01, test for heterogeneity p<0.0001, I(2)=91.7%). Because of insufficient data, a meta-analysis for SnF(2)mouth rinse and dentifrice/mouthrinse formulations was not performed.

CONCLUSIONS

The use of SnF(2) dentifrices results in gingivitis and plaque reduction when compared with a conventional dentifrice. The precise magnitude of this effect was difficult to assess because of a high level of heterogeneity in study outcomes.