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

Chemical plaque control might be necessary in those subjects who are not capable of properly controlling supragingival biofilms using conventional mechanical procedures. The use of chemical formulations especially antiseptics to control levels of plaque and gingivitis has been widely evaluated. The efficacy of different formulations has been reported in several systematic reviews. However, none of the available systematic reviews have included all available of agents. Most of them just focused on a specific agent or a limited group of agents.

Principal findings: Dentifrices, mouthrinses or the combination of both, containing specific agents for gingivitis and/or plaque control, provide statistically significant improvements in terms of gingival, bleeding and plaque indices.

Practical implications: There is weak but consistent evidence that the adjunctive use to mechanical plaque control of specific agents administered as dentifrices, mouthrinses or the combination, helps to control gingival inflammation and plaque levels.

Dentifrices
SnF (0.454%) has demonstrated significant effects without SHMP(Sodium hexametaphosphate) and with SHMP.Significant differences were also observed in previous systematic reviews (Gunsolley 2006, Paraskevas & van der Weijden 2006)

For tric/cop( triclosan/copolymer) (Davies et al. 2004, Hioe & van der Weijden 2005), similar results were observed for plaque and for gingivitis

For different formulations with CHX(Chlorhexidine), significant differences were found,difficulties in formulating CHX in dentifrices are well known, due to the high risk of inactivation, but the results of this study suggest the activity of the tested formulations.

Three meta-analyses, with two studies each, were available for Tric/pyro(triclosan/pyrophosphate) , indicating the lack of significant effects on the different scores.

For Tric/ZnCit, one meta-analysis was available with limited but significant differences which agrees with a previous review (Hioe & van der Weijden 2005) .No significant differences were observed in another review (Gunsolley 2006).

ZnCit showed significant benefits but it is an active agent that is seldom formulated alone.

Mouthrinses


For EEOO(essential oils), two meta-analyses can be highlighted.These results are similar to those found in previous systematic reviews (Gunsolley 2006, Stoeken et al. 2007)

Meta-analyses for CHX (Chlorhexidine), and their results are in agreement with a previous meta-analysis (Gunsolley 2006). CHX has been formulated in mouthrinses at high concentrations 0.1–0.2%, in order to achieve the ideal dosage of 18–20 mg/use of CHX. However, in formulations with lower concentrations (≤0.06%), the resulting dosages will be approximately 5 mg/use. Therefore, both formulations were tested separately. Low Conc CHX achieved a non-significant effect ,while High Conc-CHX showed significant benefits .For plaque scores, significant differences were found for both concentrations, with 2 studies each .


For CPC( Cetylpyridinium chloride)mouthrinses. A previous meta-analysis, with 3–4 unpublished studies, revealed significant benefits for plaque and gingivitis, (Gunsolley 2006). In another meta-analysis, a significant effect on plaque was observed, in agreement with our data (Haps et al. 2008). For the comparison of different dosages, two meta-analyses of 2 studies each, with significant benefits both for Low Concentration CPC ( ≤0.05%) and High Concentration CPC ( ≥0.07%).


Four meta-analyses, of 3 studies each, were performed for mouthrinses with Tric/cop(triclosan/copolymer), indicating significant improvements.. Mouthrinses with Tric/cop have also been evaluated as pre-brushing agents, and showed significant benefits (Angelillo et al. 2002).

Tric/ZnS (Triclosan/Zinc sulphate)has been evaluated in two meta-analyses of 2 studies each, demonstrating significant differences.

Combination

AmF/SnF ( Amine fluoride and Stannous fluoride) has been tested in dentifrices, mouthrinses and in combination. The available meta-analyses suggest that the mouthrinse can be more effective than the dentifrice or the combination.

Sanguinarine has been tested as a combined use of dentifrice and mouthrinse, with some significant effects. However, its use is now limited due to its association with oral leukoplakia (Mascarenhas et al. 2002).

In conclusion and, within the limitations this study, formulations with specific chemical agents for the management of plaque and gingivitis provided statistically significant improvements in gingival, bleeding and plaque indices, when compared with negative controls. This is true for dentifrices and mouthrinses, although a high degree of heterogeneity and risk of bias from different aspects make it necessary to interpret the data with caution.