73766770 Clinical Effects of Toothpowder on Gingivitis
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Transcript of 73766770 Clinical Effects of Toothpowder on Gingivitis
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Evaluation of the Clinical Effects of Toothpowder on Plaque Induced Gingivitis
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INTRODUCTION
Background
Importance of Oral Hygiene Tools and Dentifrices
Contemporary prevalence of oral related diseases such as oral cysts, sabluxation,
gingivitis, periodontitis and dental traumas just to name a few remain a major concern despite the
continued emphasis on enhanced dental hygiene and health through community nursing and in
modern education (Maripandi, Kumar & Ali 2011). Despite this phenomenon, evidence-based
literature documents that efforts to curb this menace are escalating particularly with the
development of tech-savvy dental care that is precise and more adequate. Other alternatives to
curb this menace such as the adoption of good dietary habits and continuous regulation of
fluoride intake are also on course. There is thus an imperative need to encourage the use of oral
hygiene tools particularly as self-administrative oral hygiene at home for effective orthodontic
treatment, control and management.
The use of oral hygiene tools and dentifrices occurs, as the most researched method in the
maintenance of good oral hygiene owing to its common utility is a common phenomenon. Cury
et al (2004) in a study conducted in Brazil confirm that efforts to use fluoridated water as a
substitute to manage such diseases are preexistent and ongoing although the use of dentifrices
and dental hygiene tools remain the most preferred methods. Clarkson et al (2009) also
vehemently ascertains and reinforces this opinion in a clinical trial affirming that such efforts of
intervention using such tools and behavioral change showed timely cognition and prevention of
such oral ailments. The use of dentifrices such as toothpowder and toothpaste and its
underestimation is impossible owing to their role in assuring dental health. Similarly, Zero
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(2006) also confirms the efficacy of these dentifrices although he is quick to highlight that
modern day varieties are becoming questionable since they are not clinically tested but instead
only fulfill FDA monograph stipulations for preclinical and laboratory tests using murine and in-
vitro assays respectively (Zamani 2006). The use of dentifrices in fighting dental disorders
though minimally researched on appears to help in effective management of dental diseases.
Evidence using in-situ and in-vitro studies show affirmative results. This is primarily because
they abridge enamel demineralization and concurrently improve re-mineralization (Cury et al
2004). The re-mineralization potential in dentifrices is crucial in eradicating dental caries among
other dental diseases but at 5 000ppm since an overdose would lead to tooth decay and
subsequently dental caries development. A study by Anil (2007) confirms such adverse effects to
be the causatives of gingivitis in the plasma cell a benign condition particularly in three different
patients on using herbal dentifrices and concurrently receiving periodontal disease medication.
As such, the cautious use of dentifrices is imperative particularly the herbal ones whose long-
term ramifications remain unknown due to limitations in time. Karlinsey et al (2010) too also
confirm these suppositions using a sodium-fluoridated dentifrice in combination with pH cycling
representation containing tricalcium phosphate. The effect of increased acidity in the mouth for
such dentifrices antagonizes their initial goal hence other than reducing demineralization they
escalate it inducing tooth decay.
To make dentifrices essential oils that are more effective are now reinforcing their
efficacy in treatment and management of periodontal inflammation. In addition, the
incorporation of other dental hygiene tools such as mouthwash and mouth rinse makes the
outcome more promising. In a database exploration study by Fawad (2012), use of such
dentifrices show positive results in comparison with placebo groups owing to the microbiological
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potency to reduce periodontal associated pathogens. Although this is the case, clinical
confirmatory tests remain inconsistent regarding this prospect making inference making
problematic. Okpalugo et al (2009) ascertains the antimicrobial potency of toothpastes and
toothpowders in preventing dental plaque that consequently induce dental caries, periodontal
disease and gingivitis. Such dentifrices are classified as drugs instead of cosmetics owing to their
constituent components such as “Triclosan 2, 4, 4’ trichloro-2'-hydroxydiphenyl ether”, that
confers antibacterial properties reducing the affiliated dental flora (Okpalugo et al 2009, p.72).
Dentifrices are confirmed to reduce the multiplication potency in fusobacteria, diphtheriod and
porphyromonas gingivalis among other harmful mouth bacteria that induce dental diseases
(Okpalugo et al 2009). Agrawal and Ray (2012) also affirm that dentifrices are drugs although
from a negating opinion that they contain nicotine components making them injurious to long-
term users. As such, they advise for stringent pharmaceutical regulation of such products through
effective government policies and intensive health education to the community.
Highlighting the role of fluoridated dentifrices in the maintenance of oral hygiene, Cronin
et al (2000) terms it as a cleansing agent with potency to remove stained pellicle although its
effectiveness is facilitated by its abrasive’s mechanical action using oral hygiene tools such as
toothbrushes. This opinion contrasts majority of the authors’ prospects since it accentuates that
tooth brushing as more effective in plaque removal than the exclusive use of dentifrices.
Toothbrushes as dental hygiene tools are thus equally imperative particularly with their design to
remove dental plaque efficaciously without causing injuries on the mouth tissues and gingival
(Turksel et al 2004). According to Fiona (2009), ideal toothbrushes are core in delivering
dentifrices on tooth surface. In addition, such brushes that are sonic, powered or manual
eliminate dental biofilm on dentition surfaces hence impede bleeding and reduce plaque as
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evident in clinical studies. Dentifrice efficacy can only transpire if the application of ideal
brushing protocols and approaches transpire (Turksel et al 2004; Fiona 2009).
According to Jaksha (2011), tooth brushing maintains and controls an enhanced bacterial
environment intra-orally reducing the potency and survival capacity of pathogens. These results
are confirmatory after a comparative study of Luria bertani, Todd Hewitt and Trypticase soy
bacterial cultures was done prior to and after brushing indicating significant reduction in the
counts (Jaksha 2011). The practice is strongly recommendable as indispensable and a pivotal
daily regiment owing to these advantages. Zamani (1998) highlights that despite the fact that a
toothbrush is a vital oral hygiene tool, it is vulnerable to contamination acting as a health
etiology and as such, its prevention from contamination should be crucial. Although toothbrushes
remove dental plaque with their vertical bristles from accessible and flat surfaces of the teeth
they are less effective in approximal areas of the gingival margins encouraging gingivitis and
periodontal disease. This is primarily so because only about 30% of the teeth is exposed while
the remaining is within the gingival. With this outlook it is evident that dental hygiene tools are
not exclusive guarantees of oral health and as such, the induction of other alternatives that are
more efficient in dental health maintenance is core. Such ideas include frequent dental check ups
to ascertain sound health and early disease recognition for effective management and complete
clearance. Furthermore, contemporary healthcare is focusing on optimizing the design of the
toothbrush to improve its ability to remove plaque even in inaccessible areas of the teeth (Zero
2006). Modern efforts are focusing on designing toothbrushes with crisscrossed bristles, power
tips and angulated tufts to optimize tooth polishing and dental biofilm removal. Despite these
efforts tooth brushing has many inconsistencies and variations making the effectiveness of the art
vary among individuals. Contemplating that each individual has a distinct mouth, then
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formulating a standard technique of tooth brushing is impossible, although the circular technique
is strongly advisable for the best outcomes. Biesbrock, Bartizek and Walters (2008) affirm this
during a clinical study on the efficacy and safety of two divergent manual toothbrushes with
improved designs and with the overall motive to reduce dental plaque more efficiently.
Other oral health tools also imperative in dental care include toothpicks and sponge
toothettes. These tools facilitate respiratory pathogen and dental biofilm colonization, remove
subglottic discharge and in oropharyngeal bacteria colonization. They are useful in dental care of
ICU and intubated patients. According to Grap et al (2003), clinical evidence proofs that they are
ineffective in dental plaque elimination despite their increased preference. There is thus a need
for profound selection of dental products and tools to use for such patients to prevent such
diseases and guarantee oral health. Antiseptic solutions as OTC oral products in maintenance of
dental care are also available. Smith et al (2003) highlights a number of such products available
including Listerine, plax, corsodyl, flourigrad , oral B mouth washes among others with various
anti-microbial properties. These have been proven effective in controlling Staphylococcus aureus
in in-vivo studies but the mechanisms mediating therapy are unknown.
Importance of Dental Plaque
Dental plaque as a pale yellow biofilm naturally occurring on teeth and colonizing
bacteria on the smooth surface facilitate a defense mechanism to impede microorganisms, which
are pathogenic (Ebrahim, Abdolhamid & Mahdi 2009). The plaque also helps in tooth shedding
regulation owing to its composition of thousands of bacterial ecosystems. Plaque generation also
entails important steps other than a sporadic process. These include adsorption of bacteria and
proteins for film formation, reversible adhesion through the action of electrostatic and Van Der
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Waal’s forces, irreversible adhesion, secondary and primary colonization via intermolecular
interactions finalized by cell division to generate a biofilm (Ebrahim, Abdolhamid & Mahdi
2009). The importance of the dental plaque is to confer immunity to the gingival owing to its
constituent lymphocytic cells such as macrophages, leukocytes and epithelial cells. These
originate from saliva and bacterial products all that form the extracellular matrix.
Dental plaque has an imperative role in development of gum-affiliated diseases since as
an oral microorganism haven it mineralizes to tartar commonly known as calculus through
calcification processes. According to Walsh (2008), the dental plaque facilitates carbohydrate
fermentation causing teeth demineralization and the production of organic acids that reduce the
pH in the mouth. Under these conditions, the survival of bacteria such as those of lactobacilli,
mutans and streptococci improves since more supragingival plaque from cariogenic substrates is
accommodated. The ramification of this phenomenon is the production of formate, pyruvate and
lactate among other organic acids, which facilitate enamel demineralization and ultimate
development of dental caries among other dental ailments. Walsh (2008) asserts that modern
medicine is focusing on plaque reduction through controlled acid production in the buccal on
reduced sucrose and sugar intake and their subsequent replacement with non-fermentable
materials such as trehalose, sucralose, xylitol and sorbitol among others. The dental plaque is
also imperative in the denitrification process that reduces nitrate (NO3) to nitrite (NO2) then nitric
oxide (NO) and finally nitrous oxide (N2O) (Schreiber et al 2010). Through the application of
microsensor measurements and molecular detection, in-vivo increase in nitrous is shown to be
dependent on dental plaque amounts under the control of its pH in aerobic conditions. To dental
health, these events influence nerve signaling, blood flow and gum inflammation processes
hence regulating the prevalence of periodontal disease by determining the activity of the gingival
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cells. The process of denitrification of dental plaque thus mediates nitrogen cycling, controls the
development of systemic diseases, and thus has the potency to alter the entire human physiology
hence its close monitoring is requisite.
Dental plaque as a store for pathogens of infectious diseases often aggravates dental
diseases. Although it is unavoidable, clinical trials show it can be reduced using antimicrobial
compounds, professional cleaning and good oral hygiene hence managing and eliminating dental
ailments. According to Loe (1981), supragingival plaque, which is less accessible using dental
hygiene tools, depicts bacteria accumulation and a pre-pathological characteristic in many dental
diseases since it encourages bacterial colonization. Khuller (2009) takes a divergent view on the
role of the dental plaque in controlling the exacerbation of dental ailments. This however can
transpire on its reduction by maintaining normal buccal flora and in decreasing the oral
bioburden through flossing, use of mouth-rinses that have antimicrobial property and on
effective tooth brushing. This outlook guarantees the maintenance of natural dentition throughout
an individual’s life. The dental plaque also consists of fluid channels located in a slime layer
allowing bacterial products and chemical movements (Nield-Gehrig & Willmann 2003). In
addition, the dental plaque acts as a communication system for chemical signal communication
of microcolonies and bacteria. This is crucial in symbiotic relationships that enhance their
survival.
In another pilot study by Cheung, Zid, Hunt and McIntyre (2005), the pellicle layer
commonly known as the dental plaque serves as a diffusion barrier owing to its semi permeable
nature. As such, it selectively limits the transport of phosphorous and calcium ions among other
acid ions through the hard tissue hence determining the enamel’s surface solubility
predisposition. Correspondingly, by acting as a store for these ions particularly as concentrates, it
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controls the dentine cementum and enamel from erosive demineralization hence a determinant of
the development of dental diseases. To reinforce these suppositions an “in vivo-in vitro model”,
conducted by Cheung, Zid, Hunt and McIntyre (2005) demonstrates the potency of the dental
biofilm in reducing enamel erosion owing to the intake of fermentable foods such as gastric acids
and wine. Confirmations on dental plaque as an etiological factor in many other diseases that
may not necessarily be dental also occur in evidence-based studies. Respiratory pathogens for
instance often colonize on dental pellicle particularly in patients that are home-nursed and those
in the ICU. In the buccal, aspiration to the lung can occur inducing an infection (Marsh 2005).
Fourrier et al (1998) in their clinical study assert that dental plaque reserves nosocomial
infections and colonization pathogens particularly the aerobic ones in 40% and 60% of
hospitalized and home-cared patients respectively. In several incidences dental plaque resulting
to nosocomial pneumonia, ventilator affiliated pneumonia and oropharyngeal infections result
from dental plaque accumulation (Marsh 2005). Accentuation on the practice of oral hygiene
using appropriate tools and effective dentifrices as the preventative measure for the accumulation
of dental plaque is imperative, if such disease risks will be avoided (Fourrier et al 1998).
Importance of Dental Extrinsic Stains on Tooth Surfaces
Teeth are also vulnerable to pigmented deposits that appear on the surface due to
oral flora consisting of chromogenic deposits. Such stains occur on the tooth surface due to
topical agents such as medication, metals, chromogenic bacteria, tobacco, beverages, calculus,
foods and dental plaque (Keitel & Soentgen 1995). Such stains often appear on the gingival’s
margin, at the incisal region and on the inter-proximal. Stains are also a ramification of poor
dental hygiene as well as the use of mouthwashes with chlorhexidine antibacterial that reacts
with teeth (Keitel & Soentgen 1995). As a multi-factorial etiology that is chromogen mediated,
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extrinsic stains’ main causative is a dietary derivative. The dental plaque takes up the
chromogens and their natural color is imparted on teeth surface hence extrinsic staining is
distinct based on the specific chromogen. Indirect extrinsic staining also signifies the increased
presence of metal salts and antiseptics. These are constituent components of the foods, drugs and
dentifrices in taken and their subsequent reaction with the enamel.
Extrinsic stains act as disease etiologies particularly in mediating and
propagating acquired dental defects. Such stains show physical teeth trauma often manifest as
enamel cracks and loss, gingival recession and tooth wear characteristic in majority of dental
ailments. Furthermore, such stains are evident in dental caries progression. The initial stage of
lesion development ranges from white spots to opaque color on the teeth surface. During the
protein-sugar reaction stage, teeth browning occur due to the non-enzymatic Maillard reaction
(Watts & Addy 2001). These are clinical symptoms in development and subsequent exacerbation
of dental caries. Extrinsic stains are also important indicators of reactions between the teeth and
restorative material such as amalgam and other phenolic and eugenol containing components
(Khozeimeh, Khademi & Ghalayani 2009). These are induced in the dental system during root
canal treatment and on the use of some poly-antibiotic toothpaste. Similarly, mercury reacts with
sulfide ions of tin salts causing its displacement into tubules and the induction of extrinsic stains.
With the problem of extrinsic stains being, common and persistence, its reduction is feasible
through good dental practices particularly the brushing of teeth using whitening toothpastes,
flossing and taking whitening chewing gums. Although such stains’ removal through
professional bleaching is possible, it is quite exorbitant unlike the intrinsic stains that in most
cases are permanent. Medical evidence shows that prophylaxis mainly done during dental visits
aims at polishing and scaling teeth to remove stain as stated by Geza et al (2008). Such a
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protocol is holistic and removes both subgingival and supragingival plaque preventing gingivitis
development.
Importance of Gingivitis
Gingivitis as a gingival inflammation occurs as a response to bacterial dental plaque,
which adheres on the surface of teeth. As non-destructive, it occurs as a preliminary stage to the
progression of periodontitis that is deleterious and precedes gingivitis, which is plaque-induced
(Nwhator & Ayanbadejo 2011). Other causatives of this anomaly include malnutrition,
medication and systemic factors, all which play a crucial role in aggravating the pathological
condition. Furthermore, this pathological condition is not only affiliated with poor oral hygiene
but also lower social-economic stature owing to poor diet and lack of health precedence among
such groups.
Gingivitis often indicates many clinical processes other than the exclusive sign of early
stage of periodontal disease. Gingivitis is manifest in pregnancy and often poses as a risk for
premature or undersized birth and advanced gum ailment following birth (Singh et al 2011). This
occurs when bacterial inducing the gingivitis enter the circulation to the uterus prompting
prostaglandins production and eventual induction of uterine contractions hence premature birth.
The problem is further compounded by hormonal changes evident in pregnancy thus dental
hygiene maintenance must be an indispensable practice in such incidences (Singh et al 2011).
Gingivitis manifest by gum swelling is common among individuals with this dental
anomaly. A case testimony conducted by Hou and Tsai (1998) on a pregnant Chinese female
attests to these speculations showing this kind of gingivitis to be a myelomonocytic leukemia
indicator particularly of acute nature. A one-week follow up showed increased immune response
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with the escalated production of leucocytes hence confirming the primary presence of the
disease. Swelling of such gums characterized by pale pink color also indicates adverse effects of
certain drugs such as antagonists of the calcium channel such as amlodipine, nifedipine and
felodipine, phenytoin and cyclosporine. Taylor (2003) reinforces this opinion highlighting that
25-80% and 50% cyclosporine and phenytoin users respectively are diagnosed with swollen gum
gingivitis. Gingival swelling also indicates inflammation particularly when plaque accumulation
occurs. Such gums become vulnerable to bleeding are soft and redden. Similarly, this ailment
may occur in childhood as a hereditary fibromatosis making the gum to have exuberant
overgrowth and displacing the outer teeth surface (Lee et al 1995). Furthermore, gum swelling
and subsequent enlargement is induced systemically in incidences such as pyogenic granuloma
and hormonal imbalance. According to Antonio (2010), other systemic conditions indicated by
gingivitis include lichen planus a mucocutaneous disease, pemphigoid, which is the detaching of
the epithelium from basal membrane that is antibody mediated and pemphigus an autoimmune
disease caused by the inability of keratinocytes to coalesce between tissues. In addition,
erythema multiforme a disease mediated by immune complexes and lupus erythematosus that
involves formation of anti-self antibodies against body cell components are indicated by
gingivitis (Antonio 2010).
Gingivitis manifest by bleeding, reddening and swelling of the gums often signifies the
presence of other dental complications. These include advanced periodontitis that eventually
leads to decay and loss of teeth. This condition often is recurrent and spread to the entire buccal
gradually. In other incidences, it depicts abscess, which is a deposit of dead neutrophils on the
gum owing to the defensive action against dental plaque pathogens (Zero 2006). Trench mouth
disease that manifests as ulcerations on the gingival owing to the accumulation of many buccal
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bacteria that are normal also occurs with close affiliation to gingivitis. Gingivitis is a significant
indicator of fungal infections such as histoplasmosis, erythema that is linear and candidiosis.
Conversely, the disease also manifests in viral infections particularly those of herpes simplex,
varicella zoster and in some incidences HIV. Gingival inflammation also indicates anaphylactic
reactions, diabetes mellitus as well as the presence of trauma (Antonio 2010). An evidence based
research shows that gingivitis is an indicator of a variety of diseases and disorders hence its
prevention is imperative. This is however feasible with the maintenance of sound oral hygiene
and the use of such dental hygiene tools appropriately. This research seeks to assess the efficacy
of toothpowder as an important oral dentifrice in reducing and managing gingivitis that is plaque
induced. Aggravation of gingivitis is often an indicator of systemic diseases since it triggers the
production of cytokines such as interleukins, prostaglandins and cancer necrosis factors. The
ramification of this event is the interference of several pathways causing premature parturition,
mucosal inflammation, atherosclerosis due to derangements in metabolism as Panagakos and
Scannapieco (2003) observe.
Statement of the Problem
Previous researches seeking to assess the efficacy of dentifrice on plaque-induced
gingivitis are existent in literature. Despite their limitations in numbers and less specific focus on
toothpowders other than focusing on dentifrices holistically, they show affirmative results
regarding the issue in question. In essence, published articles on the efficacy of toothpowder in
reducing plaque-induced gingivitis are not identifiable despite the problems being predominant
in contemporary societies. According to Shamikh and Dweiri (2011) gingivitis incident occur in
9%-85% of Jordanian children aged 5-7. In addition, 23% and 75% of Icelandic and global
children showed positive but mild gingivitis between the age of 5-9 years (Shamikh & Dweiri
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2011). In one study by Botelho et al (2007), plaque-induced gingivitis is rated at epidemic levels
with a majority 80% Brazilian geriatrics being affected with less consideration in adults being
underscored. Despite the inconsistent reporting, it is evident that the situation is dire and
demands urgent mitigation to reduce these escalating incident rates.
An evaluation of literature also shows knowledge gaps regarding the efficacy of
dentifrices as a whole including toothpowder on gingivitis. This is primarily so since they
elucidate less on the mechanisms of actions that confer plaque reduction despite existent studies
showing positive results on their use. Agrawal and Ray (2012) accentuate to these sentiments
highlighting a need for intensive research if the present scenario is bound to change for the
better. The existent studies also seem less representative of the entire population since they use
small sample sizes and manifest the blatant problem of Hawthorne effect making the inferences
made dubious and questionable. Another evident problem on literature analysis is inconsistent
and contradictory reporting particularly on the efficacy of herbal dentifrices in reducing plaque-
induced gingivitis confounding the readers. Cullinan et al (1997) attest to these studies with their
declaration that Sanguinaria does not have antigingival properties. This is in contrast with a
study by Hannah and Johnson (1989) and another by Harper et al (1990) vehemently attesting to
the herb’s safety and efficacy in reducing gingival inflammation and inhibiting dental plaque
accumulation. Similarly, preexistent literature focuses more on toothpaste and mouth rinse and
derelicts toothpowder despite its difference owing to the absence of humectants. Documented
studies also appear less considerate of extrinsic variables such as the consistency of tooth
brushing, its technique and frequency all of which are crucial factors in the determination of
efficacy towards plaque-induced gingivitis. Subjectivity in gender, age and environmental factors
are also evident despite their imperativeness in the prevalence of the disease hence the need for
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intensive research. With the intention to advance the knowledge on this issue as well as close the
highlighted gaps, this study seeks to evaluate the efficacy to toothpowder in alleviating
gingivitis, controlling dental plaque, inhibiting extrinsic stains and periodontal pocket and
concurrently putting the crucial factors that interfere with inference making in consideration.
Aims of the Study
a) Determine the efficacy of toothpowder in gingivitis management and control following
its use.
b) Determine the efficacy of toothpowder in reducing and eliminating dental plaque
following its use.
c) Determine the efficacy of toothpowder in removing extrinsic stains following its use.
Objectives of the Study
1. To find out how the outcome of toothpowder incorporated with essential oils and calcium
carbonate use in reducing plaque induced gingivitis
2. To approximate the discrepancies between gingivitis patients who are toothpowder users
and non-users following periodontal therapy that is non-surgical.
3. To find out how the outcome of toothpowder incorporated with essential oils and calcium
carbonate use in reducing extrinsic stains on gingivitis patients.
Significance of the Study
The scope of this study regarding the efficacy of toothpowders on plaque-induced
gingivitis seeks to add knowledge to the medical field hence recommend on its encouraged
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use or otherwise. Similarly, it seeks to decipher, elucidate and make explicit the gaps in
existing literature particular on inconsistent reporting and subjectivity in studies of dentifrice
efficacy in reducing plaque-induced gingivitis. This achievement will diversify, equip and
intensify future research efforts when dealing with issues pertaining dental illnesses.
Furthermore, for the patients a new recommendation for effective therapy or otherwise will
transpire based on the results obtained. The study will also act as an eye opener for scientists
to indulge in similar studies intensively hence add more knowledge on the issues in question
for better comprehension.
LITERATURE REVIEW
Limited researches on the efficacy of toothpowders in plaque-induced gingivitis
treatment have been researched on hence limited inference on its imperativeness. Conversely,
toothpaste a closely related dentifrice whose clinical efficacy is widely researched on despite the
inconsistencies in the inferences made. A randomized single-blind research using a 24-subject
sample size conducted by Claydon et al (2004) accentuates this opinion using whitening
toothpaste. In this case, affirmative results on reduced extrinsic dental staining transpired.
Furthermore, the reinforcement of these results occurred through comparative testing in the
presence of a placebo water-control group and another group with commercial toothpaste. The
study however fails to elucidate the mechanism which stain inhibition occurred and in an
antagonizing case concludes that existent whitening toothpastes accelerate extrinsic stains
(Claydon et al 2004). In addition, the study fails to establish a definitive timing when the effects
of inhibited staining occurred. In another related randomized clinical trial triclosan (Colgate) and
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stannous (Crest Gum-care) dentifrices, manifest similar results in reducing extrinsic stains (He et
al 2010). This study used a sample size of 96 subjects in a 5-week follow up where stain
inhibition was monitored. The study infers no significant difference between the uses of the two
types of toothpastes although it reports that they reduced tooth staining significantly particularly
after a dental prophylaxis (He et al2010). Despite highlighting tolerance on using these
dentifrices, little regarding the degree of efficacy is clarified.
Comparative assessment of perlite (calcium carbonate) and silica containing toothpastes
on extrinsic stain elimination efficacy occurs in a study by Collins et al (2005). Using stratified
sampling with 152 subjects and applying the double blind and parallel group study in a
fortnight’s time, affirmative results transpired (Collin et al 2005). Using Macpherson
modification technique to change the Lobene stain indicator, confirmation of this supposition
was evident. Despite the ability to produce consistent results, the study only evaluates on the
ability of dentifrices to remove stains without taking a holistic look by evaluating on prevention
of stain induction and the build up of natural stain hence is subjective. Joiner et al (2002) have
demonstrated a similar study evaluating the efficacy of white systems on extrinsic stains.
Furthermore, comparative assessment using silica containing toothpastes that have similar
potency to effect enamel abrasion also occur. A four-week study using an in situ model shows
that whitening paste has higher potency to remove in-vitro stain unlike the silica one. Although
highlighting these discrepancies, Joiner et al (2002) show equal potency to reduce enamel wear
in the two. Although conclusive, the study exclusively applies laboratory experiments to make
inferences despite the fact that they are models hence less representative of the real case
scenario. In addition, it only qualifies the efficacy of toothpastes in extrinsic stain removal
without quantifying it. In a related study, Daiva et al (2011) also comparatively evaluates the
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efficacy of whitening toothpaste with conventional fluoridated dentifrice using the Loben stain
indicator, as was the case with Collins’ et al (2005). In a 2 to 4 week, study with 33 subjects’
deductions regarding the potency of the three divergent toothpastes showed that whitening pastes
(Colgate and Elgydium) produced better results than conventional paste. Despite these
deductions, the study is quick to highlight subjectivity owing to the Hawthorne effect where a
sample makes great effort to produce the best results since they know they are participating in a
study. The study is also subjective since it accentuates on the pastes’ producing the best results
other than the quality of its efficacy.
Despite the escalating prevalence in dental diseases, mass prevention remains a
challenge. Moran (1997) attests to this opinion highlighting the need to use chemicals to control
dental plaque that propagates these diseases. With this outlook, novel alternatives to current
formulations that are more effective will emerge. One such proposition is the incorporation of
mouth rinse in dentifrices. However, observational studies show the infeasibility of this idea with
the strong held perception that mouth rinse is a toothpaste and toothbrush substitute. Despite the
practicability in Moran’s (1997) suggestions, their effect requires warranting. The study also fails
to establish the long-term ramifications of its opinions towards enhancing dental health despite
recommending them for use. In a randomized control study, Paraskevas (2005) seeks to find an
alternative to the weaknesses affiliated with self dental hygiene through the incorporation of
chemical agents in mouth rinse and dentifrices. Such chemicals include those that are organic
cations, metal salts, phenolics that are non-charged, agents that are surface modifying and
oxygenating agents. Although revelations show that several of them induce anti-gingivitis
properties their efficacy remain questionable since long-term effects are yet to be established
(Paraskevas 2005). Similarly, clinical trials reveal that patients using them end up having dental
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diseases hence their significance is limited. The study also seems less conclusive owing to
limited information regarding the phenomenon in question.
Evidence-based research continues to accentuate to the importance of toothpaste among
other dental tools in preventing dental diseases. Santos (2003) comparatively evaluates the
efficacy of essential oils, Peridex and Listerine in eliminating plaque and gingivitis. Results
indicate a 16-45% and 27-80% potency for the products to reduce dental plaque and gingivitis
respectively. Although this is the case, such dentifrices also induce extrinsic stains and increase
supragingival calculus making their use less preferable an aspect that the study ignores explicitly
(Santos 2003). The study also fails to establish a definitive time when affirmative results on
using such pastes can transpire with inconsistencies being evident on observation of patients at
divergent timeframes. West and King (1983) comparatively evaluate the efficiency of tooth
brushing with water, toothpowder and H2O2-sodium bicarbonate in reducing periodontitis
suppuration and in dental plaque staining inhibition. Using a sample size of 15 subjects,
inconsistent results were obtained with some cases showing positive results while other showed
negating results hence inference making was difficult (West & King 1983). Although non-
effectiveness in the H2O2-sodium bicarbonate, wrong deductions are likely owing to the
incongruities in the study. This highlights the need for comprehensive and intensive studies to
make conclusions regarding this prospect.
In another evidence-based study, sodium fluoride and chlorhexidine containing mouth
rinses were assessed in gingivitis that is plaque induced among teenagers control (13 to15 years)
in Bangalore town (Jayaprakash, Veeresha & Hiremath 2007). Within a differential time range of
a month, 3 and 6 months, significant reduction in the disease was realized at an increasing trend.
However, the study experienced discrepancies since the placebo group also decreased its
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prevalence rate in gingivitis manifesting errors in the study. The study was also partial since its
emphasizes was on competitive therapeutic outcomes inducing the perception of better efficacy
in one dentifrice compared to the other (Jayaprakash, Veeresha & Hiremath 2007). Gunsolley
(2006) conducts a theoretical survey regarding the efficacy of dentifrices in alleviating gingivitis.
Using electronic databases to source published articles and from manufacturers for unpublished
articles inference making was feasible. Although inconsistent, the studies showed the preference
of mouth rinse with stannous fluoride, essential oils and chlorhexidine as anti-gingival. Despite
the reliance on unpublished data, which at times is subjective, the systemic review accentuates
that dental hygiene is wide and cannot be effective with the application of one approach but
rather a holistic approach. The meta-analysis also highlights the need to increasingly research on
the efficacy of dentifrices on dental diseases to prevent the blatant variations in deductions of
different researches.
The efficacy of either toothpaste or toothpowder in removing dental plaque depends on
its characteristic abrasivity. Baxter, Davis and Jackson (1981) evaluate on this phenomenon and
its effective execution to avoid tissue damage. Abrasion as the cleaning power is then co-related
with in-vitro dentine to express the efficacy of the dentifrice in metrics. The optimal choice in
this case should be cosmetically acceptable and able to remove extrinsic stains on a daily routine
adoption. This contradicts sentiments by Okpalugo et al (2009) who perceive dentifrice as drugs
other than cosmetically acceptable products. Although the study highlights that dentifrices are
effective in dental pellicle removal, it focuses on abrasion power without considering other
factors such as the quality of toothpaste and the technique of brushing all that are considerable
factors. Hosein et al evaluates a similar concept on pellicle removal efficacy but comparatively
using toothpowder and toothpaste and not applying brushes using an “examiner-blind crossover
21
study” (2009, p.147). By randomly dividing a 36 volunteer sample twice, using the Loe and
Silness plaque index and using the finger and the split mouth procedure for each group collating
of results occurred. The findings show that toothpowder is a significantly stronger dentifrice
compared to toothpaste in pellicle removal (Hosein et al 2009). Although this deduction is made,
little elucidation regarding the increased potency in absence of liquid humectants in the powder
is provided hence questioning a need for explicit substantiating.
With much accentuation on dentifrice use other than tooth brushing, Shrama et al (2004)
also assess the adjunctive benefit and efficacy of using mouth rinses with essential oils in
reducing gingivitis that is plaque induced. By comparing brushing and flossing subjects in a
study with a 237-sample size followed by a baseline prophylaxis, results are obtained after a 6-
month follow-up. Using the plaque index and modified gingival indicator as the metrics
incorporation of essential oils in mouth rinse shows significant alleviation of gingivitis but
without any significant difference in brushing and flossing subjects (Shrama et al 2004). The
study however remains inexplicit on the mechanism of action that essential oils confer to effect
better efficacy. Kozak and White (2000) also explain the effect of dentifrice in eliminating dental
staining, a characteristic in plaque-induced gingivitis. This was possible by applying an apatite
substrate on cycled saliva tea and chlorhexidine in comparison to a commercial dentifrice and
polypyrophosphate (Kozak & White 2000). The results show abridged stain adsorption due to the
polyphosphate action with dental plaque. Although the protocol is a model (in-vitro) it explains
the mechanism under which staining reduction occurs although its application in in-vivo assays
remains questionable.
With the motive to evaluate the whitening power of toothpastes, a pilot study by Ozcan,
Pinar and Bulent (2009) to ascertain this supposition clinically occurs. Using non-smokers and
22
smokers in a 4-week follow up and several whitening toothpastes, collection of data transpired.
80% of all subjects reported affirmative results while higher numbers in smokers than non-
smokers were observed (Ozcan, Pinar & Bulent (2009). The discrepancies in this study are
attributes of subjectivity since different toothpastes were used in the two groups. Quantification
of results was also a problem since the study used observations instead of standard measures.
This made inferences such as a 100% stain reduction for smokers impractical. In another study
by Swaminathan, Moran and Addy (1996), a variety of oral products including toothpowders,
toothpastes and mouth rinses containing chlorhexidine antiseptic were applied in extrinsic stain
elimination. Although in in-vitro assays using spectrometric (optical density) readings
affirmative results were obtained in all cases though less quantified. Despite this, the study
remains unclear on the chemical components in the oral products and their subsequent
mechanism of action with the stains that confer increased efficacy in stain removal when
compared with a control group using water (Swaminathan, Moran & Addy 1996). Despite
highlighting a significant difference in the chlorhexidine used in mouth rinse and dentifrices the
study concludes of no significant difference between the users hence subjective reporting.
A double blind and onetime use clinical assessment seeks to compare the efficacy of
commercial Colgate toothpaste with one that contains silica in reducing bad odor a
characteristics in gingivitis patients. Using a hedonic scale that was nine pointed, the 83 subjects
were subjected to brushing using soft-bristled brushes (Naresh et al 2000). Following this,
evaluation for bad breath transpired after 12 hours. Results positively showed reduced bad breath
although no significant difference in the two toothpastes. The study’s inferences are however
limited by the method of evaluating bad breath, which could be subjective owing to the use of
examiners and the lack of a standard method of brushing an aspect that is unique to every
23
individual. Sheen, Pontefract and Moran (2001) reinforce the opinion that toothpastes have great
efficacy in controlling a variety of dental ailments including oral malodour, calculus, plaque,
gingivitis and periodontitis owing to their chemical composition. They highlight the presence of
abrasives, detergents and active ingredients such as silica, sodium lauryl-sulfate and fluoride
respectively, all which aid in dental health maintenance (Sheen, Pontefract & Moran 2001). The
study however fails to decipher the mechanisms of action and reactions that such components
mediate to enhance dental health. They also highlight inconsistent and contrasting reporting on
the long-term ramifications of some of the components.
An in-vivo assay by White, Barker and Klukowska (2008) also accentuates of the
efficacy dentifrices and mouth rinse that have antimicrobial property in managing dental plaque.
The study takes place in three phases entailing holistic use of dentifrice, randomized used of an
antimicrobial containing dentifrice and finally randomized use of a mouth rinse. Results indicate
reduced pellicle on using the three oral products exclusively but a synergistic outcome on
combining the three with plaque reduction being beyond 50% (White, Barker and Klukowska
2008). The study however points outs limitations of uncontrollable factors such as disease
susceptibility and consistent hygiene observation that are distinct for individuals. In another
study, the presence of alcohol as an additive in mouth rinse is also evaluated as an agonist to its
efficacy. Using a crossover clinical trial that is randomized and double-masked Marchetti et al,
(2011) evaluate on this aspect in a plaque accumulation representation of 3 days. Using 30
volunteers grouped in to two, the subjects undergo a fortnight washout prior to data collation.
Results indicate increased efficacy in presence of alcohol contrary to its absence. The results of
this study spark new controversies since alcohol is considered a potential co-carcinogen hence
24
prompting development of carcinomas such as oral cancer among others hence the need for
intensified research on the purported suppositions (Marchetti et al 2011).
Increased assessment on the efficacy of mouth rinse in antigingivitis and antiplaque
occurs in Amini et al’s (2009) study. This is evident in a randomized clinical study within a
fortnight using 3 mouth rinses each containing essential oils (EO), cetylpyridinium chloride
(CPC) and alcohol. Using a sample size of 103 and 56 females and males respectively grouped
subjects with EO, CPC that is alcohol free, CPC with alcohol and a control group data collection
occurred and measurements were taken with the modification gingival and Quigley Hein-plaque
indicators as metrics. The results indicate that essential oil incorporation in enhanced
antigingival and anitplaque properties by 16% of mouth rinse despite being unclear on the
mechanism. This is in contrast with other groups that reported 13.3%, 6.3% and 6.6% reduction
respectively. Al-Talib, Abdullah and Al-Khatib (2004) also evaluate the efficacy of different
mouth rinses containing phenolic compounds, chlorhexidine digluconate and salt comparatively
in reducing plaque-induced gingivitis. In a randomized clinical trial using 45 subjects divided
equally in three groups and assessed using the Loe and Silness measures data collation occurred
following a 2-month monitoring. Results indicate a significant decrease in disease on
incorporating phenol and chlorhexidine in mouth rinse but with chlorhexidine having greater
superiority contrary to the use of salts that show no significant difference. Despite underscoring
the potency in chlorhexidine mouth rinse no explanation regarding the mechanism in which it is
conferred is given.
Weijden and Slot (2011) also affirm the efficacy of oral hygiene dentifrices and tools in
guaranteeing reduced periodontal diseases and ultimately eliminating gingivitis incidents.
Accentuating of their mechanical power to remove food debris among other biofilms particularly
25
in occlusal pits and interproximal spaces, toothbrushes are highlighted as crucial. Similarly the
emphasis on the incorporation of dentifrice such as toothpowder also occurs. Quantitative
analysis show excusive use of dentifrice reduces plaque by 59% although incorporation of a
toothbrush reinforces the outcome to 67%. Although deriving its deductions from a
comprehensive literature analysis, the study does not use empirical and experimental data that is
more pragmatic. Watanabe et al (2006) in another study, evaluates the cariostatic efficacy of
whitening toothpaste in reducing the dental pellicle. Using a 5-toothpaste comparison and 95
tooth fragments the study embarks on a micro-hardness evaluation for 2 weeks in a daily 10-
minute toothpaste application. The results manifest potential cariostatic power in all the pastes
with no significant difference. This was due to reduced demineralization owing to reduced acid
decalcification. The study’s inferences could weaken due to the evident pH cycling that controls
re-mineralization and demineralization patterns (Watanabe et al 2006). The study also
qualitatively analyses the efficacy making it less factual.
The effect of toothpaste in reducing sensitivity of the dentinal cervix particularly in
disease presence is also evident in Walsh’s (2009) study. In this case, he comparatively assesses
the efficacy of a mouth crème with conventional Colgate paste in a 10-week randomized clinical
survey with 89 subjects. The results are affirmative indicators of reduced hypersensitivity with
less significant difference in terms of superior efficacy. Despite highlighting that the two oral
products have different mechanisms of action, less elucidation regarding this prospect occurs to
substantiate the inferences further. A literature review evaluation by Hasson, Ismail and Neiva
(2008) also compares the efficacy of an OTC toothpaste with a placebo group in reducing dental
plaque and gingivitis. The study utilized the EMBASE, MEDLINE and CENTRAL libraries to
acquire its data dated between 1966 and 2005. The focus was on quasi and randomized
26
controlled studies and screened the titles, data extracted and abstracts of independent and
replicable articles. Of the 416 available articles, positive results regarding the use of whitening
toothpaste contrary to a placebo transpired. The study however accrued the weaknesses of the
evaluated studies particularly regarding wrong inference making.
In a pilot clinical, study by Tai et al (2006), assessment on the effect of a dentifrice with
particulate bioactive glass as a constituent component in reducing dental plaque and gingivitis
occurs. In a 6-week study, four factors including age, gender, gingival bleeding and plaque
indices were assessed. A 16.4% and 58.8% reduction in plaque accumulation and gingival
bleeding respectively was evident among toothpaste users without discrepancies in gender and
age compared to a control group that brushed with water (Tai et al 2006). Despite these
deductions, the study admits of discrepancies particularly in the group not using toothpaste
despite brushing attributing them to the Hawthorne effect. Using a whitening dentifrice with
sodium hexametaphosphate (polypyrophosphate) the efficacy to reduce extrinsic tooth
discoloration and gingivitis assessment occurred (Baig et al 2005). This is a systematic review of
laboratory and clinically published data regarding similar studies. The results indicate positive
results despite the use of sodium polypyrophosphate in divergent delivery systems and
formulations. Although the study focuses more on stain inhibition potency of such dentifrices, it
neglects gingivitis prospects. Furthermore, it has a qualitative other than quantitative focus hence
is less pragmatic and factual. A similar study by Sensabaugh and Sagel (2009) focuses on the
efficacy of a stannous fluoride toothpaste with the same polypyrophosphate using practice-based,
clinical and laboratory data in enhancing tooth whitening. Results accentuate that clinical
evidence regarding such dental formula in reducing extrinsic stains, calculus, plaque gingival
bleeding and gingivitis using information from 1000 and 1200 dental patients and professionals
27
respectively. Despite highlighting the holistic benefit of such dental formulas by conferring
cosmetic and therapeutic effects, its components’ mechanisms of action, remain inexplicit. In
addition, quantification of the efficacy lacks.
A clinical study by Archilla et al (2000) examines the comparative efficacy of abrasive
and ordinary toothpaste in calculus removal in vivo. Using 52 healthy subjects from Guatemala
grouped in to two and subjected to ordinary and vigorous brushing respectively for a minute
daily a four week follow up transpired. Assessment of calculus occurred with VMI and Lobene
metrics with grading occurring each week (Archilla et al 2000). The results indicate no
significant relationship between the use of the two toothpastes and on the brushing technique
used to calculus reduction superiority despite recording positive results in each case. Ayad et al
(2002) also compares the efficacy of two toothpastes in reducing dental staining using a parallel,
randomized and double blinded set clinical survey in 8 weeks time. An oral prophylaxis and a
recording of baseline scores of stains preceded this using a trained examiner. Lobene index
further ascertained the results from the 126 volunteers. The findings of the study show that
addition of silica, an abrasive and a pyrophosphate helps in improving the efficacy of toothpaste
to remove extrinsic stains as contrasted to a conventional one (Ayad et al 2002). The inferences
are however limited since they do not focus on the method of application of toothpaste and
consistency of brushing factors that are core in enhanced efficacy.
In a randomized clinical study, the efficacy of three toothpastes with special additives
(sodium fluoride, PVM copolymer and triclosan) in controlling supragingival plaque and
gingivitis evaluation also occurs in Surendra et al’s (2010) study. On random assignment of the
available toothpastes, subjects issuing of soft-bristled brushes and subjection to brushing twice a
day occurred. After a six week follow up gingival examination occurred in the 171 subjects with
28
results indicating a 0.243%, 2.0% and 0.3% efficacy against gingivitis in the groups using PVM
copolymer, triclosan and sodium fluoride respectively. Despite these observations and
inferences, elucidation on the mechanism is inexplicit. Standardization of tooth brushing is less
contemplated. The results of the study concur with similar findings in a study by Nordbo et al
(1988) that reinforce alleviation of tooth discoloration is feasible using dentifrices despite having
less quantification regarding this supposition. Conversely, Oliveira et al (2008) focuses on the
additive Aloe Vera in controlling gingivitis and dental plaque accumulation in a clinical study,
which was double blind. Using gingival bleeding and plaque index comparison with
conventional toothpaste occurred in a month’s period on subjecting the sample to a three-time
brushing daily. The findings depict no significant difference between the two groups in terms of
efficacy accentuating that Aloe Vera has no additional value in dental health. The study however
highlights the Hawthorne effect that could induce subjective inference making (Oliveira et al
2008). In addition, the inferences contest previous perception that herbal products have
additional value in efficacy of dentifrices.
The antimicrobial efficacy of dentifrices containing 5.25% sodium hypochlorite and 2.0%
chlorhexidine gluconate in inhibiting a myriad of dental disorders such as discolorations, odor
and toxicicty is ascertained in Jeansonne and White’s (1994). This is particularly core in root
canal therapy. In in-vitro settings, treatment of human teeth using the two dentifrices occurred
and exposed in anaerobic conditions for a day prior collection of microbiological samples.
Results on culturing the collated samples show reduced bacterial counts contrary to control
samples with chlorhexidine showing much superiority but with less significant difference to
sodium hypochlorite. The mechanism conferring the antimicrobial properties is vague. Jarrar
(2006) comparatively evaluates the efficacy of two mouth rinses with chlorhexidine and essential
29
oil (Listerine) additives in preventing plaque re-growth in the inter-proximal. Following a 4 day,
pellicle re-growth random treatment with the dentifrice to 60 subjects followed by a 2-week
observation. Results showed a 13%, 25% and 54% efficacy in plaque removal for sterile water,
Listerine and chlorhexidine dentifrices respectively. Despite these deductions, the mechanism in
which antimicrobial properties are conferred is incomprehensible. Furthermore, consideration on
the method of brushing that determines the amount of plaque removed did not occur.
In a pilot study by Freitas, Fernandes and Attstrom (1992), efficient removal of dental
plaque, proximally accumulated using chlorhexidine gel incorporated in toothpicks was assessed.
In a design, that was double blind and using the Loe and Silness plaque index, a 7-subject follow
up occurred. In addition, their normal oral hygiene practices continued with the toothpick use
occurring daily for a week. When compared to a placebo group no significant difference
occurred hence limited efficacy in eliminating dental plaque. Despite making conclusions
concerning its aim, the study’s incorporation of normal brushing habits among the subjects could
cause errors since such habits were distinct in each of them. The efficacy of dentifrices with
amine fluoride additives in their organic and inorganic forms are also tested for their efficacy
towards reduced oral sucrose accumulation and in inhibiting Streptococcus sanguis (Embleton,
Newman & Wilson 1998). In an in-vitro setting, samples collected from dental plaque were
cultured following their incubation with amine fluorides. The results indicate reduced biofilm
growth in the presence of amine fluoride but more superior in the presence of sucrose. As in
other studies, the mechanism, which this process occurs, remains unsubstantiated.
Barnett (2006) evaluates the lucid in daily mouth-rinse use against bacterial accumulation
owing to its efficacy. Using a systematic analysis of literature review Bernett (2006) evaluates
studies regarding the risk of pellicle accumulation to gingivitis, mechanical control of plaque
30
accumulation through tooth brushing and the ecology of microorganisms in the mouth as
conferred by the use of various dentifrices in a 6-month evaluation. The findings reveal a solid
rationale of using mouth rinse using evidence-based scientific research. This is due to its potency
to deliver antimicrobial agents to inaccessible oral areas and the inadequacy affiliated with
exclusive mechanical control of plaque through brushing. Although such strong conclusions are
made, adequate support lacks since only six published articles confirmed this supposition
affirmatively. Among Egyptians, Hassan, Mobarak and Fawzi (2008) assess chlorhexidine
regimens as efficient in reducing plaque-induced gingivitis owing to their antimicrobial
properties in a clinical study. Using 21 females, monitoring of daily intakes, use of mouth rinse
with chlorhexidine, a 1-3 month follow up finalized with Mutans streptococci evaluation
transpired. The findings show significant reduction of bacterial count on using chlorhexidine
mouth rinse ranging from 82.3%-85.4% compared to a control group hence the recommendation
on its continued and consistent use for better efficacy. The deductions made in the study could be
subjective since standardization of dietary intake did not occur hence accumulation of dental
plaque and subsequent removal was not uniform.
In vivo tests regarding the efficacy of dentifrices with special additives for optimal
outcomes against gingivitis and other dental ailments is also of focus. Fine et al (2006) assess the
efficacy of triclosan dentifrice comparatively with a control group administered conventional
dentifrice in reducing Fusobacteria and Veillonella species using 15 subjects in a randomized
study. Superior efficacy of 88-96% compared to 74-85% was realized on inculcating triclosan
contrary to the controls after a 12-hour follow up. Despite highlighting that microorganism levels
vary in individuals, the study declines to use the crossover design to standardize the obtained
results hence erroneous deducing. Cullinan et al (1997) undertake a similar study but incorporate
31
Sanguinaria herbal extract to enhance the potency against periodontitis. Using a parallel,
randomized and double-blinded study involving 34 subjects the pocket depths, plague and
gingival indices are taken after a fortnight and 6-week follow up respectively. Contrary to
expectations, the two groups do not show any significant difference in efficacy despite recording
affirmative results. Despite making these deductions, the study highlights inconsistencies with
previous clinical studies that have ascertained affirmative anti-gingival activities in Sanguinaria
hence the need for further research. It is evident on literature analysis that gaps regarding the
efficacy of toothpowder in eliminating plaque induce gingivitis exist and this study seeks to close
these gaps and add more knowledge in this field.
32
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