The prevention of gingivitis requires and effective home care plaque removal regimen. Dentifrice and mouthwashes with anti-plaque agents have been develop to assist plaque removal and a number of these agents have been tested in clinical trials.
The aim of this review and network meta-analysis (NMA) was to compare the efficacy of different anti-plaque chemical agents, in 6-month, home-use, in terms of gingival index (GI) changes.
Methods
A search was conducted in PubMed central database up to 14th Jan 2019. Randomised controlled trials (RCTs) with at least 6 months follow up evaluating the use of test products used in mouthrinses, toothpastes or gels as adjuncts to mechanical oral hygiene (including toothbrushing) were considered.
Two reviewers selected studies abstracted data and assessed risk of bias using the Cochrane tool. Gingival index and bleeding scores were summarised. Mean differences between baseline and end were calculated to obtain standardized mean differences (SMDs). Pairwise random effects meta-analyses(PMA) were conducted for each delivery format followed by a network meta-analysis (NMA).
Results
- 53 papers were included, 19 for mouthrinses, 32 for dentifrice, with two papers reporting on both formats.
- Dentifrices were divided into 13 categories/clusters and mouth rinses into 10 categories/clusters.
- Dentifrice
- 34 studies involving were included in dentifrice groups. Gingival status was measured using Löe & Silness GI (n = 27), modified GI (n = 4) and GSI (n = 3).
| Active agent | No of studies | No of patients |
| Triclosan copolymer (tric_cop) | 17 | 1,202 |
| Stannous fluoride (SnF) | 4 | 570 |
| Chlorhexidine (CHX) at concentrations ≥ 0.10% (CHX_H) | 2 | 214 |
| Stannous fluoride/sodium hexametaphosphate (SnF_SHMP) | 2 | 126 |
| Baking soda | 1 | 147 |
| Essential oils (EEOO) | 1 | 95 |
| Thiocyanate/carbamide peroxide (SCN_H2O2) | 1 | 70 |
| Sanguinarine | 1 | 56 |
| Zinc citrate (ZnCit) | 1 | 55 |
| Amine and stannous fluoride (AmF_SnF) | 1 | 51 |
| Sodium metafluoride phosphate with zinc (SMFP_Zn) | 1 | 42 |
| CHX at concentrations < 0.10% (CHX_L) | 1 | 30 |
| Aloe vera | 1 | 28 |
- All active agents showed greater reductions in GI than placebo control.
- Significant differences were found between SnF, SMFP_Zn, SnF_SHMP and tric_cop versus placebo in the NMA and PMA. The differences resulting from the indirect comparison of SCN_H2O2 against placebo control in the NMA were not statistically significant.
- From the NMA the ranking of treatments according to SUCRA was; AmF_SnF (0.7), SMFP_Zn (0.7), SnF_SHMP (0.7), EEOO (0.6), SCN_H2O2 (0.6), ZnCit (0.6), aloe vera (0.6), tric_ cop (0.6), CHX_H (0.5), SnF (0.4), CHX_L (0.3), baking soda (0.3), sanguinarine (0.2) and placebo (0.1).
- Mouthrinse
- 21 studies were included in the mouthrinse group. Gingival status was measured using Löe & Silness GI (n = 11), modified GI (n = 10).
| Active agent | No of studies | No of patients |
| EEOO | 11 | 1,009 |
| Cetylpyridinium chloride (CPC) at concentrations ≤ 0.05% (CPC_L) | 4 | 429 |
| CPC at concentrations > than 0.05% (CPC_H) | 3 | 292 |
| Delmopinol | 1 | 289 |
| CHX_H | 5 | 167 |
| Tric_cop | 3 | 166 |
| EEOO without alcohol (EEOO_noAlc) | 1 | 107 |
| Alexidine | 1 | 102 |
| AmF_SnF | 2 | 67 |
| CHX_L | 1 | 33 |
- All active agents showing greater reductions in GI than placebo control.
- The ranking of treatments according to SUCRA results from NMA was; EEOO_noAlc (1.0), EEOO (0.7), tric_cop (0.7), CHX_H (0.6), CPC_H (0.6), CHX_L (0.5), AmF_SnF (0.4), CPC_L (0.3), alexidine (0.3), del‐ mopinol (0.2) and placebo (0.2)
Conclusions
The authors concluded: –
Within the limitations of the present study, including the severe imbalance in the amount of evidence, although NMA revealed significant differences when comparing placebo versus some active agents (SnF, SMFP_Zn, SnF_SHMP or tric_cop as dentifrices and CHX_H, EEOO, EEOO_noAlc or tric_cop as mouth rinses), when comparing among active agents, no differences were found for dentifrice, and mouth rinses containing EEOO_noAlc showed the greatest effect on GI scores, as assessed by NMA.
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.
Comments
We looked at a companion review to this one reporting on the efficacy of anti-plaque agents on the plaque index from this group of authors back in 2016 (Dental Elf – 18th Oct 2016). This review focuses just on the impact on gingival indices with a Medline search update to January 2019. While all the dentifrices and mouthwashes with active agents performed better than placebo, triclosan copolymer toothpastes and essential oils mouthwashes account for a majority of the studies with many of the active agents only being assessed in single studies. The NMA surface under the cumulative ranking (SUCRA) curve is a method of ranking the included treatments. However, the evidence supporting the ranking may be of low quality e.g. EEOO without alcohol (EEOO_noAlc) is the highest ranked mouthwash but the evidence come from a single trial. Also this review only considers gingival indices and there are other relevant outcomes for periodontal diseases.
The findings from the review are expressed in mean difference between baseline and 6 months and while all the active agents demonstrate a difference it is not clear how important this is clinically. Additional research is needed on the less studied anti-plaque agents to clarify their effectiveness and to quantify the benefits of longer term use of these agents.
Links
Primary Paper
Figuero E, Herrera D, Tobías A, Serrano J, Roldán S, Escribano M, Martín C. Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analyses. J Clin Periodontol. 2019 Jul;46(7):723-739. doi: 10.1111/jcpe.13127. Epub 2019 May 31. PubMed PMID: 31058336.
Other references
Dental Elf – 18th Oct 2016
Dental Elf -Chlorhexidine blogs
Dental Elf -Triclosan copolymer blogs
