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Re-examining the Plaque-Gingivitis Connection and the Role of Stannous Fluoride

Course Number: 579

How Can This New Knowledge Benefit Your Patients?

Since gingivitis is a highly prevalent condition50 why is it that so many don’t recognize it and/or take action when they encounter signs like overt bleeding during toothbrushing (“My gums have always bled!”), and aren’t aware of the risks of ignoring gingivitis?51,52 The role of dental professionals in addressing this disconnect is integral because they conduct and interpret clinical assessments that patients cannot, including:

  • Obtaining a thorough medical history to determine any contributory role of underlying conditions or medications.


  • Performing a visual examination to assess the ‘Three C’s’ of gingival presentation: Color, Consistency, and Contour.

  • Evaluating plaque accumulation, including hard-to-reach areas that patients can’t visualize.

  • Measuring periodontal pocket depths to assess attachment loss. Concurrent bleeding on probing will be observable and can serve as an additional springboard to discuss gingivitis etiology and the fact that gingival bleeding is never normative.

It has been commonly presumed that there is a fairly predictable correlation between the age and/or the quantity (mass) of unremoved plaque and the severity of the corresponding gingival disease. Because of this, clinicians have typically taken the first-line approach for intervention by encouraging patients to reduce the amount of undisturbed plaque, namely through oral hygiene instruction in proper toothbrushing and flossing techniques and recommending more frequent preventive appointments.

A second (and often combined) professional strategy for addressing gingivitis beyond mechanical plaque control targets plaque regrowth through adjunctive antimicrobial chemotherapeutic products (e.g., dentifrices and mouthrinses) that can be incorporated into the patient’s home care regimen. For example, optimally-formulated SnF2 dentifrices have been shown across studies to provide significant plaque inhibition effects versus controls on both brushed and unbrushed surfaces.58 Cetylpyridinium chloride (CPC), chlorhexidine, and bioavailable SnF2 are common oral chemotherapeutics in use today and prescribed or recommended to patients. The respective modes of action, relative benefits, and notes of interest are outlined in Table 2 .

Table 2. Common Oral Chemotherapeutics.

Chemotherapeutic Oral AntimicrobialDelivery Mode*Method of Action(s)Notes
Cetylpyridinium Chloride (CPC)

[e.g., Crest® Pro Health Advanced Oral Rinse Multi-Protection,a
Philips Sonicare Breath Rx,b
ClōSYS® Healthy Gums,c
Therabreath Healthy Gums Oral Rinsed]
Mouth rinseLysis of cell walls; inhibits/disrupts cell growth and metabolism.59
  • Proper formulation needed for maximum substantivity and bioavailability
  • Published anti-plaque and anti-gingivitis efficacy60-62
  • Patients must comply with an additional mouth rinse step
Chlorhexidine Gluconate (CHX)

[e.g., Peridex™c; Periogard®f]
Mouth rinseBactericidal; also inhibits glycosidic and proteolytic enzymes63
  • Prescription-only 0.12% rinse
  • Well-established clinical plaque and gingival health benefits; a ‘gold standard’ for gingivitis treatment64,65
  • Staining and taste often limit patient acceptance
Stannous Fluoride (SnF2)

[e.g., Crest® Gum Detoxify;a
Colgate® Total® Pro Gum Health;f
Crest® Pro-Health paste,a
Sensodyne Sensitivity & Gum;g
Crest® Pro-Health Advanced Gum Restorea]
DentifriceBacteriostatic and bactericidal; substantive; blocks inflammatory precursors25-27,30,31
  • Only common anti-caries agent that is also antimicrobial
  • Multiple studies show anti-plaque/gingivitis efficacy for a 0.454% SnF2 bioavailable formula vs. various controls6,7,36,45,66‑70
  • Skilled formulation is critical for optimal bioavailability and esthetics

aThe Procter & Gamble Company bPhilips Oral Healthcare cRowpar Pharmaceuticals Inc. dChurch & Dwight CO e3M Oral Care fColgate Palmolive Company gHaleon

Patients are consumers who regularly encounter a plethora of product advertising through media in the drug store oral health aisle. When patients feel overwhelmed by all the choices, they rely on a trusted professional for product guidance. Evidence-based recommendations from published peer-reviewed research are paramount to help patients choose a well-tested and efficacious product with the best likelihood of addressing their particular needs. In the case of bioavailable SnF2, there is a significant body of research supporting its use for a variety of indications, including plaque and gingivitis.6,7,36,45,66-70 A systemic review by Johannsen and colleages of 32 trials evaluating stabilized SnF2 dentifrices concluded that “… stabilized SnF2 toothpaste had a positive effect on the reduction of dental calculus build-up, dental plaque, gingivitis, stain and halitosis.”71