Selection Criteria #2: Gingivitis Prevention/Reduction?
#2 – Another major consideration is the need for gingivitis prevention/reduction.
Figure 3 highlights a second key decision point in selecting a toothpaste: Is optimizing gingival health via the prevention or reduction of gingivitis and bleeding relevant to the patient? For many, the answer will be yes. You have seen the commercials: A drop of blood is shown in a sink near a toothbrush, or a dental professional in a white coat comments that bleeding after oral hygiene is never normal. Despite strong messaging to the public about the link between bleeding gums and gingivitis with the origin being unremoved plaque, unawareness of the link, or belief that it is normative and not a significant concern, is still prevalent.51 Regardless, epidemiological assessments show gingivitis and bleeding gingiva are common.
Gingivitis has pervasive prevalence estimates ranging from one-half to almost nine-tenths of adults impacted.52,53 If not arrested, susceptible individuals will see gingivitis progress to periodontal disease with the potential for alveolar bone and tooth loss. About 42% of American adults have periodontitis according to the CDC’s National Health and Nutrition Examination Survey (NHANES) survey,54 and an estimated 743 million people, worldwide, suffer from the most severe form (Figure 7).6 In adults between 65 and 74 years of age, about one-third are edentulous primarily due to periodontal disease.6
Figure 7. Estimated Global Prevalence of Severe Periodontitis.
Additionally, robust associations with systemic disease involvement like cardiovascular disease and diabetes – either directly with bacteria entering the bloodstream or via the resultant inflammation – are being increasingly substantiated.55,56 With the potential of tooth loss to adversely affect chewing function and quality of life, and the whole-body common inflammatory pathway threat, the FDI has warned that periodontitis “…represents a major global oral disease burden with significant social, economic and health-system impacts.”6,32
Harald Löe’s oft-cited, classic experimental gingivitis study in 1965 convincingly established evidence of the plaque/disease connection; oral hygiene was withheld for three weeks in volunteers with previously healthy gingivae. Consequently, generalized gingival inflammation was observed in 10 to 21 days as bacterial counts and pathogenicity in the now heavy plaque colonizing the teeth grew dramatically with time.57
Recognizable signs of established gingivitis include red, edematous, bleeding gums.
Importantly, these sequelae were reversible. Löe remarked, “When good oral hygiene was reinstituted, the original sparse microflora was reestablished and the inflamed gingiva reverted back to normal.”58 Future similar experiments would confirm these findings.59-61
Why then, is mechanical home oral hygiene (toothbrushing plus interproximal cleaning) not the end all for staving off gingivitis? For a minority of motivated, conscientious patients, meticulous daily plaque removal – regardless of what dentifrice is used – could be sufficient to keep the periodontium disease-free. But research (including video-taped assessments) has generally shown that many individuals are not sufficiently committed or do not have the manual dexterity or skill to remove the volume of plaque (including in the higher risk gingival margin and approximal regions) required to prevent gingival inflammation with the standard manual toothbrush. They are therefore at risk of developing gingivitis, and subsequently periodontitis if they are susceptible. Consider the following research findings in Table 1.
Table 1. Self-care Plaque Removal Effectiveness.
- Few individuals use dental floss routinely and about one-third never floss.62-64
- A typical brushing session removes less than 50% of all plaque.65
- The longer the brushing session, the more plaque is removed, yet many don’t brush long enough and overestimate how long they brushed.65-69
- Many don’t follow through long-term with the brushing methods they were professionally instructed in.70
- Some individuals appear to be hypersensitive to lesser amounts of plaque based on unique host factors.71,72
These realities provide context for the high global prevalence of gingivitis and periodontal disease and the need for additional treatment modalities. In response to the challenge, some toothpaste manufacturers have harnessed the utility of toothbrushing with dentifrice as a vehicle for oral health chemotherapeutics in the same way as fluoride for caries prevention: an anti-plaque/anti-gingivitis therapeutic agent has been incorporated to optimize gingival health alongside routine mechanical oral hygiene practices like manual or power toothbrushing and flossing. Again, this provides the benefit of piggybacking upon an already-utilized practice – toothbrushing – without requiring additional steps and products.