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Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 16-24

Antiplaque efficacy of toothpaste – A systematic review and meta-analysis of randomized controlled trials

Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Submission24-Jul-2021
Date of Decision14-Nov-2021
Date of Acceptance27-Dec-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
Sneha Nachu
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_140_21

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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 2023 Jun 1];20:16-24. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2022/20/1/16/338509

  Introduction Top

Dental plaque is a biofilm harboring innumerable microorganisms and is a requisite factor for the inception and furtherance of periodontal diseases.[1] 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.[2]

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.[3] 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.[4]

Different components have been incorporated as active ingredients in toothpaste concoctions, pertaining to the therapeutic claim.[5] 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.[6]

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.[7] 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 Top

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).

Search strategy

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].
Figure 1: PRISMA flow diagram

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Inclusion criteria

  • 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.

Exclusion criteria

  • 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.

Statistical analysis

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 Top

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].
Table 1: An overview and characteristics of included studies

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Study design and subject characteristics

The proportions of researches conducted using parallel and cross-over designs were 90% and 10%, respectively. Only one study[31] was triple blinded, 17 studies[8],[9],[11],[12],[13],[14],[21],[22],[24],[26],[28],[29],[30],[32],[34],[35],[36] were double blinded, four studies[7],[16],[23],[37] were single blinded, whereas nine studies[10],[15],[17],[18],[19],[20],[25],[27],[33] had not mentioned blinding. Twenty-eight studies were organized in clinical settings with adult participants, while in contrary two studies[10],[20] included children as participants and one study[8] 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

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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

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Figure 4: Forest plot of comparison: Stannous fluoride versus control toothpaste

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Figure 5: Forest plot of comparison: Herbal versus conventional toothpaste

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  Discussion Top

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.[28] 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.[39] (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.[40] 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.[8] 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.[41]

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 Top

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.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]

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