|Year : 2022 | Volume
| Issue : 1 | Page : 16-24
Antiplaque efficacy of toothpaste – A systematic review and meta-analysis of randomized controlled trials
Sneha Nachu, Srinivas Ravoori, Srinivas Pachava
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India
|Date of Submission||24-Jul-2021|
|Date of Decision||14-Nov-2021|
|Date of Acceptance||27-Dec-2021|
|Date of Web Publication||25-Feb-2022|
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Different toothpastes of the corresponding active ingredients could have variable extent of effectiveness; this raises the amount of choices with the marketplace for toothpaste containing these agents and makes it more difficult to gauge their effectiveness. Therefore, the purpose of this systemic review and meta-analysis was to gauge the antiplaque efficacy of different toothpaste agents in studies involving randomized clinical trials published over a span of January 2015-May 2020. Materials and Methods: A comprehensive and systematic electronic search via PubMed, TRIP, Cochrane, and Google scholar prompted in 593 articles. Subsequently screening titles and abstracts for applicability, 31 Randomized controlled trial (RCT) articles were enclosed in the review. With the aid of the Cochrane Collaboration's tool, the risk of bias of each study was assessed. Results: A total of 2467 individuals partake in 31 RCT studies. Triclosan toothpaste was superior over sodium fluoride/monofluorophosphate toothpaste (standard mean difference, SMD − 1.36, 95% confidence interval [CI] (2.81–0.10), P = 0.007) in plaque reduction. Long-term utilization of stannous fluoride toothpastes reduced dental plaque superior than monofluorophosphate toothpaste (SMD − 0.61, 95% (CI 1.04–0.18), P = 0.005). There was no discernible difference in plaque reduction. Conclusion: Within the confines of the current study's limitations (which embody the severe imbalance within the quantity of evidence), once scrutiny among products, triclosan and stannous fluoride in dentifrices seem to be the foremost efficacious plaque controlling active agents.
Keywords: Antiplaque efficacy, randomized controlled trial, toothpaste
|How to cite this article:|
Nachu S, Ravoori S, Pachava S. Antiplaque efficacy of toothpaste – A systematic review and meta-analysis of randomized controlled trials. J Indian Assoc Public Health Dent 2022;20:16-24
|How to cite this URL:|
Nachu S, Ravoori S, Pachava S. Antiplaque efficacy of toothpaste – A systematic review and meta-analysis of randomized controlled trials. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2022 May 23];20:16-24. Available from: https://www.jiaphd.org/text.asp?2022/20/1/16/338509
| Introduction|| |
Dental plaque is a biofilm harboring innumerable microorganisms and is a requisite factor for the inception and furtherance of periodontal diseases. The pioneer cariogenic microorganisms strains present in the plaque are the strains of Streptococcus mutans. They bring about alterations in the plaque metabolism, causing demineralization to predominate. Interruption of dental biofilm by mechanical debridement is pivotal to overseeing plaque and gingivitis. The two standard compelling techniques are mechanical plaque and chemical plaque control.
One of the most quintessential oral hygiene care strategies is to use a toothbrush in conjunction with a dentifrice to limit plaque accumulation and the risk of plaque-related diseases, including periodontitis and caries. Microbial infections are liable for a substantial percentage of dental problems. Dental issues are predominantly of development of dental plaque, dental caries, and periodontal diseases.
Different components have been incorporated as active ingredients in toothpaste concoctions, pertaining to the therapeutic claim. Contingent upon their activity, they can be assorted as antimicrobial, plaque inhibitory, antiplaque, or antigingivitis. Antiplaque agents are those able to impinge gingivitis and plaque significantly, and they ought to be favored in the therapeutics of gingivitis and the interception of periodontal diseases.
The precise formulation of the active agents into toothpaste is essential to maintain the agents' bioaccumulation and, in certain instances, to amelioration their substantivity. Thus, different concoctions of the corresponding active ingredients may have varying extent of effectiveness, this raises the number of options in the marketplace for products containing these agents and makes it more difficult to gauge their effectiveness. Therefore, the purpose of this systemic review and meta-analysis was to gauge the antiplaque efficacy of different toothpaste agents in studies involving randomized clinical trials published over a span of January 2015–May 2020.
| Materials and Methods|| |
Framing of a research question and protocol registration
Using the PICO plan, the pursuit technique was done by an inquiry mirroring the point of the investigation: “what is the comparative efficacy of various toothpastes on the reduction of dental plaque in different groups of the population?”
Protocol registration: CRD42021246121 (https://www.crd.york.ac.uk/prospero/#myprospero).
The search was confined to randomized controlled trial (RCT) articles published from 2015 until 2020. This data confinement was preselected due to the rapid advancement of new toothpaste formulations. A comprehensive and systematic electronic search via PubMed, TRIP, Cochrane, and Google scholar using combinations of keywords antiplaque, efficacy, toothpaste, dentifrices, plaque resulted in 593 articles. Two reviewers removed duplicates from emanate obtained and independently scrutinized the remaining articles in terms of title and abstract. Subsequent to screening titles and abstracts for applicability, 31 RCT articles were enclosed in the review [Figure 1].
- Research limited to RCTs
- Articles published in English
- Articles published within the span of 5 years, i.e., 2015-2020
- The publications which were available as full reports
- Studies conducted in any country on the general population with no restrictions on age and gender.
- In vitro studies, abstracts, case reports, pilot studies, narrative reviews, and letters to editors were excluded.
Assessing the quality of the included studies
An aggregate of 31 articles have been chosen per the defined criteria. All the 31 articles were assessed with respective CONSORT checklists. With the aid of the Cochrane Collaboration tool, the risk of bias of each study was evaluated. Cochrane Review Manager Version 5.4 was used to generate risks of bias figures.
Cochran's Q coefficient, a Chi-square test, and a significance cutoff of 10% were used to determine the data's heterogeneity. For continuous data, a random-effects model was accustomed to combine the primary outcome variables from each study. To assess the consistency of the results, the I2 statistic and forest plots were employed. Overall outcome were assessed as standardized mean differences (SMD) (95% confidence interval [CI]). Review manager (RevMan), version 5.4.1 for Windows, The Cochrane Collaboration, Copenhagen, Denmark has been used to analyze data.
| Results|| |
A total of 2467 individuals took part in 31 RCT studies. A conspectus of the selected studies and their characteristics is presented in [Table 1].
Study design and subject characteristics
The proportions of researches conducted using parallel and cross-over designs were 90% and 10%, respectively. Only one study was triple blinded, 17 studies,,,,,,,,,,,,,,,, were double blinded, four studies,,, were single blinded, whereas nine studies,,,,,,,, had not mentioned blinding. Twenty-eight studies were organized in clinical settings with adult participants, while in contrary two studies, included children as participants and one study with dental students.
Risk of bias
The quality assessment is depicted in [Figure 2].
|Figure 2: Risk of bias graph and summary: review authors' judgments about each risk of bias item presented as percentages across all included studies|
Click here to view
For random sequence generation, no bias was ascertained. Blinding of personnel and participants, as well as incomplete outcome data, showed a substantial risk of bias more than 75%. Blinding of outcome assessment and allocation concealment disclosed a >50% unclear risk of bias 26% low-risk bias was seen for selective reporting [Figure 2].
Interventions and regimens
Out of 31 studies, 16 were herbal interventions, four were Triclosan interventions, three were stannous fluoride interventions, two were Probiotics interventions, two were plaque indicating dye interventions, and one was chlorhexidine intervention. Out of 16 herbal intervention studies, 11 studies were compared with conventional toothpaste. In all the studies, manual toothbrushes were used. Most of the researches forbade the utilization of any auxiliary oral hygiene practice.
As the outcome evaluation methods were different and there was a loss of quantitative data, only 18 articles were included in the meta-analysis. Triclosan toothpaste was superior over sodium fluoride/monofluorophosphate toothpaste (standard mean difference [SMD] −1.36, 95% CI (2.81–0.10), P = 0.007) in plaque reduction [Figure 3]. Long-term use of stannous fluoride toothpastes reduced dental plaque superior than monofluorophosphate toothpaste (SMD − 0.61, 95% (CI 1.04–0.18), P = 0.005) [Figure 4]. There was no significant difference (SMD − 0.38, 95% (CI − 0.82, −0.06), P = 0.009) in plaque reduction between herbal and conventional toothpaste [Figure 5].
|Figure 3: Forest plot of comparison: Triclosan versus control toothpaste|
Click here to view
|Figure 4: Forest plot of comparison: Stannous fluoride versus control toothpaste|
Click here to view
|Figure 5: Forest plot of comparison: Herbal versus conventional toothpaste|
Click here to view
| Discussion|| |
Although the fact that most populace assert to brush their teeth at least once daily, gingivitis and chronic periodontitis are still pervasive in the majority of the population. Maintaining an adequate degree of plaque control with conventional mechanical procedures and dentifrices is manifestly challenging; nonetheless, it is presently the sole realistic means of enhancing community periodontal health from a preventive standpoint. In an attempt to find answers for clinical enquires, it is necessary to conduct an evidence-based literature search.
The active ingredients in the herbal dentifrices used in the present systematic review are myrrh, sage, chamomile, eucalyptus, essential oils, 4% Tulsi extract, 0.6% Ilicis Rotundae cortex, Pistacia lentiscus, papain, bromide, miswak, and neem acts by penetrating the biofilm, resulting in disruption of plaque and has antibacterial properties. There is substantiation that herbal dentifrices may be efficacious toward dental plaque, so one would anticipate accord on which dentifrice to choose. The review enclosed eleven randomized control trials encrusting a total populace of 703 qualified for the assessment of mean plaque depletion. The presence of predisposition in 11 enclosed studies, three of which had a low risk of bias, can be attributed to the existence of heterogeneity. Apart from blinding of participants and personnel, which showed a low risk of bias across all studies, all domains demonstrate a high risk of bias. None of the studies have a follow-up period of >3 months. With a high I2 esteem (I2 = 87%), the results of various studies can be inconclusive. The estimates favored neither herbal nor conventional dentifrices because the risk of predisposition was detected to be high and the methodological quality was identified to be low. Ultimately, there is inconsistency in documenting any adverse effects associated through use of exploratory herbal products. These findings are similar to the Mehta et al. (SMD 2.14; 95% CI: 0.88–3.41, P = 0.0009), which delineated there is no high-quality evidence supporting or contradict the herbal dentifrice's antiplaque efficacy.
There was moderate quality evidence that toothpastes containing triclosan/copolymer with fluoride reduced plaque in comparison to fluoride toothpastes that did not contain triclosan/copolymer (SMD 1.36, 95% CI (2.81–0.10), P = 0.007).
Although the findings of discrete trials in the meta-analyses exhibited significant heterogeneity, the SnF2 dentifrice performed better than other dentifrices (SMD −0.61, 95% CI (1.04–0.18), P = 0.005). The findings of the current research are consistent with those of the Johannsen et al. research which found that SnF2-containing dentifrices diminished dental plaque and gingivitis (SMD − 0.63, 95% CI (1.11–0.15), P = 0.010).
The methods used to gauge the plaque vary widely across the included studies: 26.5% of researches used Silness and Loe plaque index (PI); 55.9% utilized Turesky–Gilmore–Glickman modification of Quigley–Hein PI; 5.9% of studies used MGMPI; 2.9% studies used O'Leary PI; 5.9% used Turesky–Gilmore–Glickman PI and 2.9% used image analysis, whereas a study done by Mitra et al. did not specify the type of plaque scoring index. Significant statistical heterogeneity due to methodological diversity in outcome assessment tools indicates that the researches are not all reckoning the same quantity, but it does not certainly imply that the actual intervention effect varies.
The majority of researchers (76.4%) did not use proper sample size calculations when enlisting the research populace. The findings of the meta-analysis may be influenced by the limited sample size. Apart from the toothpaste interference, the provisions were distinctive since various sorts of manual toothbrushes have been used, which may have contributed in an additional disparity in all of the research findings. Different concoctions of the test and control group have varying efficacy levels and would have affected intervention outcomes. Furthermore, a thorough review of the data revealed variations within the consistency of methodological approaches, populace, and rate of attrition. About 17.8% of the study population was lost in follow-up, which could have influenced the study results.
Limitations of this review
The considerable variance in the quantity of researches collating each active agent and the various risks of bias necessitates caution when analyzing the results. A severe imbalance in the amount of evidence for each intervention may affect the overall analysis's power and reliability.
The implication for future research
Future RCTs evaluating auxiliary chemotherapeutics must include at least a 6-month follow-up period to establish the efficacy and safety of patients' chemical agents and compliance and compensate for the Hawthorne effect, with outcome measures assessed at baseline, 6 months, and an intermediate time point. It is foremost to maintain a proper interpretation of the baseline clinical idiosyncrasy and periodontal diagnosis, as well as the pertinent outcome measures reported.
| Conclusion|| |
Within the confines of the current study's limitations (which embody the severe imbalance within the quantity of evidence and data confinement to time restrain), once scrutiny among products, triclosan and stannous fluoride in dentifrices seem to be the foremost efficacious plaque controlling active agents. The literature supporting the use of herbal-based antiplaque preparations is generally weak, since most observations suffered from a lack of experimental design and a dearth of pertinent controls and comparisons. It is critical to understand that, in the absence of a negative monitor, head-to-head distinctions with existing products with known competence are not an adequate experimental design.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cvikl B, Lussi A, Gruber R. The in vitro
impact of toothpaste extracts on cell viability. Eur J Oral Sci 2015;123:179-85.
Lippert F. An introduction to toothpaste-its purpose, history and ingredients. Monogr Oral Sci 2013;23:1-14.
Iafolla TJ, Dye BA
. Effectiveness of herbal oral care products in reducing dental plaque and gingivitis-a systematic review and meta-analysis. BMC Complement Med Ther 2020;20:43.
Prasanth M. Antimicrobial efficacy of different toothpastes and mouthrinses: An in vitro
study. Dent Res J 2011;8:85-94.
Sanz M, Serrano J, Iniesta M, Santa Cruz I, Herrera D. Antiplaque and antigingivitis toothpastes. Monogr Oral Sci 2013;23:27-44.
Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. J Am Dent Assoc 2006;137:1649-57.
Moran JM. Chemical plaque control-prevention for the masses. Periodontol 2000 1997;15:109-17.
Abhishek KN, Supreetha S, Sam G, Khan SN, Chaithanya KH, Abdul N. Effect of neem containing toothpaste on plaque and gingivitis-a randomized double blind clinical trial. J Contemp Dent Pract 2015;16:880-3.
Mitra D, Shah S, Shah R, Silvia R, Pathare P, Vijayakar H. Evaluation of the clinical efficacy of a herbal toothpaste in comparison with a triclosan containing toothpaste in a population of dental college students: A double-blind randomized controlled trial. Indian J Contemp Dent 2015;3:67-70.
Sälzer S, Rosema NA, Martin EC, Slot DE, Timmer CJ, Dörfer CE, et al.
The effectiveness of dentifrices without and with sodium lauryl sulfate on plaque, gingivitis and gingival abrasion-a randomized clinical trial. Clin Oral Investig 2016;20:443-50.
Bayoumi M, Hanno A, Sharaf A. Effect of triclosan toothpaste on gingivitis and plaque accumulation in children wearing fixed orthodontic appliances: A randomized clinical trial. Alex Dent J 2015;40:94-100.
Tadikonda A, Pentapati KC, Urala AS, Acharya S. Anti-plaque and anti-gingivitis effect of Papain, Bromelain, Miswak and Neem containing dentifrice: A randomized controlled trial. J Clin Exp Dent 2017;9:e649-53.
Ayad F, Mateo LR, Dillon R, Miller JM, Pilch S, Stewart B. Randomized clinical trial of two oral care regimens in reducing and controlling established dental plaque and gingivitis. Am J Dent 2015;28:27A-32A.
Liu H, Yin W. Reducing dental plaque and gingivitis with 0.6% cortex ilicis rotundae toothpaste: A randomized, double-masked clinical trial. J Periodontol 2016;87:327-33.
Shanmugapriya R, Arunmozhi U, Kadhiresan R, Sabitha S, Anirudhya R, Sujatha G. Comparison of antiplaque effectiveness of herbal toothpaste: A randomized triple-blinded cross-over clinical trial. Ayu 2019;40:109-13. [Full text]
Stevens K, Belavsky B, Evans CA, Viana G, Wu CD. Evaluation of plaque removal efficacy of a novel dye-containing toothpaste: A clinical trial. Int J Dentistry Oral Sci 2016;3:185-9.
Mina B, Mohtavipour S, Eslami G, Akbarzadeh A. Comparison of effects of a herbal toothpaste with crest complete toothpaste on Streptococcus mutans
of saliva and plaque index: A randomized clinical trial. J Islam Dent Assoc Iran 2017;29:29-35.
Singh P. Comparative analysis of efficacy of two commonly available dentifrices in controlling supragingival plaque. J Adv Med Dent Sci Res 2017;5:64-7.
Arabsolghar M, Roshanzamir M, Lashkarizadeh M. Evaluation of zinc as an adjunct in chlorhexidine containing toothpaste on gingival and plaque index. J Oral Health Oral Epidemiol 2017;6:115-20.
Sangeetha KM. Effect of triclosan containing tooth paste and conventional fluoride tooth paste on plaque and gingivitis: A randomized clinical trial. Int J Sci Stud 2017;4:58-61.
Arat Maden E, Altun C, Açikel C. The efficacy of xylitol, xylitol-probiotic and fluoride dentifrices in plaque reduction and gingival inflammation in children: A randomised controlled clinical trial. Oral Health Prev Dent 2017;15:117-21.
Hosadurga R, Boloor VA, Rao SN, MeghRani N. Effectiveness of two different herbal toothpaste formulations in the reduction of plaque and gingival inflammation in patients with established gingivitis-a randomized controlled trial. J Tradit Complement Med 2018;8:113-9.
Rusminah N, Pribadi I, Thillainathan K. The efficacy of miswak (Kayusugi) containing toothpaste on dental plaque accumulation. Padjadjaran J Dent 2018;30:24-8.
Daly S, Seong J, Newcombe R, Davies M, Nicholson J, Edwards M, et al
. A randomised clinical trial to determine the effect of a toothpaste containing enzymes and proteins on gum health over 3 months. J Dent 2019;80 Suppl 1:S26-32.
Rangrej UH, Vidyapeeth S, Dave D, Vidyapeeth D, Saraiya K. Clinical effect of commercially available two herbal dentifrices on the control of plaque and gingivitis. Int J Sci Res 2018;7:39-41.
Hu D, Li X, Liu H, Mateo LR, Sabharwal A, Xu G, et al.
Evaluation of a stabilized stannous fluoride dentifrice on dental plaque and gingivitis in a randomized controlled trial with 6-month follow-up. J Am Dent Assoc 2019;150:S32-7.
Lorenz K, Hoffmann T, Heumann C, Noack B. Effect of toothpaste containing amine fluoride and stannous chloride on the reduction of dental plaque and gingival inflammation. A randomized controlled 12-week home-use study. Int J Dent Hyg 2019;17:237-43.
Menon LU, Varma RB, Kumaran P, Xavier AM, Govinda BS, Kumar JS. Efficacy of a calcium sucrose phosphate based toothpaste in elevating the level of calcium, phosphate ions in saliva and reducing plaque: A clinical trial. Contemp Clin Dent 2018;9:151-7.
] [Full text]
Pentapati KC, Kukkamall MA, Siddiq H, Sabnis N. Effectiveness of novel herbal dentifrice in control of plaque, gingivitis, and halitosis-randomized controlled trial. J Tradit Complement Med 2019;10:565-9.
Amaornchat C, Mateo LR,
Sabharwal A, et al
. Effect of stannous fluoride and zinc phosphate dentifrice on dental plaque and gingivitis: A randomized clinical trial with 6-month follow-up. J Am Dent Assoc 2019;150:S25-31.
Cheng L, Liu W, Zhang T, Xu T, Shu YX, Yuan B, et al.
Evaluation of the effect of a toothpaste containing Pudilan extract on inhibiting plaques and reducing chronic gingivitis: A randomized, double-blinded, parallel controlled clinical trial. J Ethnopharmacol 2019;240:111870.
Koshy A, Kesavappa S, Eshwar S, Jain V, Chinna S. A comparative evaluation of anti-plaque efficacy and consumer satisfaction of a herbal toothpaste and a commercially available non-herbal toothpaste: A randomised controlled trial. Int J Sci Res 2019;8:1-3.
Valones MA, Silva IC, Gueiros LA, Leão JC, Caldas AF Jr., Carvalho AA. Clinical assessment of rosemary-based toothpaste (Rosmarinus officinalis
Linn.): A randomized controlled double-blind study. Braz Dent J 2019;30:146-51.
Singh PK, Prasad KV, Kotian A. Efficacy of herbal and non-herbal toothpaste in the reduction of plaque, gingivitis and salivary neutrophil count-a randomized clinical study. Int J Sci Res 2019;5:588-94.
Cunha EJ, Auersvald CM, Deliberador TM, Gonzaga CC, Florez FL, Correr GM, et al.
Effects of active oxygen toothpaste in supragingival biofilm reduction: A randomized controlled clinical trial. Int J Dent 2019;2019:3938214.
Shenoy B, Prabakar J. Comparative evaluation of plaque removal efficacy of plaque-indicating dye dentifrice vsnon-dye dentifrice in enhancing oral hygiene among orthodontic patients. A double blind randomized clinical trial. Indian J Public Health 2019;10:2022-7.
Ramesh MV, Kumar PG, Allamaprabhu CR, Kumar NN, Yasmeen SA, Praveen G, et al.
Evaluation of dentifrices of complementary and alternative medicinal systems on plaque formation and gingivitis: A randomized controlled clinical trial. J Clin Exp Dent 2020;12:e227-34.
Kaur J, Gupta D, Manchanda A, Arora G. Clinical efficacy of a probiotic fluoride dentifrice: A comparative clinical and microbiologic study. Int J Oral Health Dent 2020;6:131-6.
Mehta V, Shetiya SH, Kakodkar P, Janakiram C, Rizwan SA. Efficacy of herbal dentifrice on the prevention of plaque and gingivitis as compared to conventional dentifrice: A systematic review and meta-analysis. J Indian Soc Periodontol 2018;22:379-89.
] [Full text]
Johannsen A, Emilson CG, Johannsen G, Konradsson K, Lingström P, Ramberg P. Effects of stabilized stannous fluoride dentifrice on dental calculus, dental plaque, gingivitis, halitosis and stain: A systematic review. Heliyon 2019;5:e02850.
Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ. Cochrane Handbook for Systematic Reviews of Interventions Version 6.1. Cochrane; 2020. Available from: https://www.training.cochrane.org/handbook
. [Last accessed on 2020 Mar 25].
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]