Periodontology 2000, Vol. 48, 2008, 23–30
Printed in Singapore. All rights reserved
Toothpaste in the control of
plaque/gingivitis and
periodontitis
R O B I N M. D A V I E S
Periodontal diseases are infections initiated by bac-
terial biofilms that form on the surfaces of teeth in
close proximity to their supporting tissues. The
inflammatory and immune responses to these bio-
films are primarily responsible for the subsequent
destruction of the periodontal tissues. Gingivitis and
periodontitis are a continuum and although the
susceptibility of an individual to periodontitis is
influenced by many factors, such as smoking, dia-
betes and genetics, the weight of evidence indicates
that the prevention of gingival inflammation prevents
periodontitis (39).
Periodontal diseases are prevalent in populations
around the world (3). In the USA, 82% of adults
have gingivitis affecting one or more teeth (4) and,
in western Europe, 36% of those aged 35–44 years
have moderate periodontitis and approximately
10% have severe periodontitis (62). The prevalence
and severity of periodontitis increases with age (48)
and as the increasing elderly population retain
more of their teeth into later life, periodontal dis-
ease will pose an increasing threat to their natural
dentition.
The focus of any attempt to prevent and control
periodontal disease is the maintenance of an
effective level of plaque control by the individual at
home. Toothbrushing is a societal norm (7, 33, 48).
In the UK, 74% of adults claimed to brush their
teeth twice a day and yet, despite this acceptable
frequency of toothbrushing, 72% were found to
have visible plaque on at least one tooth;
25–34 year olds had a mean of 30% of teeth
affected and those aged 65 years had 44% of teeth
affected (48). The available evidence indicates that
most people find it difficult to maintain a level of
plaque control commensurate with periodontal
health, and there is a need to improve the oral
 2008 The Author.
Journal compilation  2008 Blackwell Munksgaard
PERIODONTOLOGY 2000
cleanliness of the majority of the population if
periodontal health is to be improved.
The principle and benefits of adding chemical
agents to dentifrices is exemplified by the inclusion
of fluoride in dentifrices, which has been a major
factor in reducing the prevalence of dental caries
worldwide (12). Given the importance of plaque
bacteria in initiating periodontal disease, the incor-
poration of an agent into toothpaste that would
reduce the formation of plaque and ⁄ or its patho-
genicity is a logical development.
The potential of an agent to enhance plaque
control and periodontal health is assessed in a
number of stages (1). Following encouraging results
from in vitro tests, clinical studies, of up to 1 month
in duration, are undertaken to assess the potential of
an agent to improve plaque control and gingival
health. If positive, then randomized controlled
clinical trials of at least 6 monthsÕ duration are
undertaken to provide regulatory bodies with evi-
dence of effectiveness and safety. An agent with
antiplaque activity must have demonstrated a sig-
nificant benefit on gingival health in randomized
controlled studies of at least 6 monthsÕ duration if it
is to receive approval (6, 13). This requirement will
be adopted in this review and, given the increasing
importance of evidence-based dentistry, priority will
be given to systematic reviews rather than to tradi-
tional reviews.
Metal salts
The most widely used metals in oral health care
products are tin (Sn2+) and zinc (Zn2+). They have the
ability to limit bacterial growth and plaque formation
(26).
23
Davies
Tin
Stannous fluoride dentifrices were launched initially
in the 1950s to deliver the anticaries benefit of fluo-
ride and it was only found later that Sn2+ had anti-
microbial effects (69). Seven randomized controlled
clinical trials (9, 10, 44–46, 53, 74) of SnF2 dentifrices
fulfilled the entry criteria for a systematic review (52).
Gingivitis
All seven studies reported a statistically significant
reduction in gingivitis in favor of SnF2 compared
with placebo or an NaF formulation. The reductions
ranged from 18 to 22% (Table 1).
The systematic review (52) concluded that stan-
nous fluoride resulted in a significant reduction in
gingivitis when compared with the control: weighted
mean difference were obtained of )0.15 (gingival
index) and )0.21 (gingivitis severity index).
Plaque
Only three studies reported a statistically significant
plaque reduction (7–23%) compared with the control
(Table 1). A meta-analysis of the Turesky index pro-
vided a weighted mean difference of )0.31 (52).
Staining
The use of a stannous fluoride toothpaste is associ-
ated with an increase in tooth staining (9, 10, 46, 53).
Zinc
Zinc is retained within the oral cavity after tooth-
brushing (27), and clinical studies, of short duration,
suggested that dentifrices containing zinc citrate
inhibited plaque, particularly in heavy plaque form-
Table 1. Studies of 6 monthsÕ duration involving stannous fluoride toothpastes
Study Active
Beiswanger et al. (9) SnF
Beiswanger et al. (10) SnF
Mankodi et al. (44) SnF
Mankodi et al. (45) SnF
McClanahan et al. (46) SnF
Perlich et al. (53) SnF
Williams et al. (74) SnF
NaF, sodium fluoride; MFP, sodium monofluorophosphate; SnF, stannous fluoride.
*Statistically significant.
24
ers (30, 58, 59). Following 3 years of use of a fluoride
toothpaste containing 0.5% zinc citrate, a significant
reduction in plaque was maintained when compared
with a control toothpaste (35). One 6-month study in
adults compared two fluoride toothpastes (one of
which contained 2% zinc citrate) for their effective-
ness in reducing plaque and improving gingival
health (75). After 6 months the toothpaste containing
zinc citrate had reduced plaque by 25%, heavy
plaque by 50%, gingivitis by 19% and gingival
bleeding by 67% when compared with the control
toothpaste.
Antibacterial agents
Chlorhexidine
Chlorhexidine digluconate is a powerful antiplaque
agent and numerous clinical trials have demon-
strated that mouthrinses containing this agent are
very effective in improving plaque control and
gingival health (2, 34). Attempts to formulate a
toothpaste have proved difficult because of the
inactivation of chlorhexidine by anionic ingredients.
However, the results of two randomized controlled
trials involving chlorhexidine toothpastes have been
published. One involved a toothpaste containing 1%
chlorhexidine (77) the other 0.4% chlorhexidine and
0.34% Zn2+ (57). The studies demonstrated that, in
each case, the chlorhexidine toothpastes significantly
reduced plaque and gingivitis but were accompanied
by an increase in calculus and tooth staining.
Triclosan
Triclosan is a nonionic molecule with a broad spec-
trum of antibacterial activity. It can be formulated in
Control Plaque percentage Gingivitis percentage
reduction vs. control reduction vs. control
NaF 3 19*
NaF )2 18*
NaF 20* 21*
MFP 7* 22*
NaF 3 21*
NaF 3 21*
NaF 23* 22*
 Toothpaste in the control of plaque/gingivitis and periodontitis

conventional toothpastes but is not retained in the
mouth for more than a few hours and therefore does
not deliver a sustained level of antiplaque activity and
clinical benefit. To overcome this problem, manu-
facturers have adopted different approaches.
Triclosan/copolymer
The addition of a copolymer (polyvinylmethyl ether
maleic acid) increases the uptake and retention of
triclosan (23) to oral surfaces (plaque, teeth and
mucosa). Subsequent studies have demonstrated that
Colgate Total, containing 0.3% triclosan, 2.0%
copolymer and fluoride (1100 ⁄ 1450 p.p.m. F),
maintains concentrations of triclosan in plaque that
exceed the minimum inhibitory concentration values
of many plaque bacteria for up to 12 h (24).
The effectiveness of this dentifrice in reducing
plaque and improving gingival health has been as-
sessed in numerous randomized, controlled clinical
trials (5, 11, 14, 19, 20, 25, 32, 37, 42, 43, 51, 55, 70, 71)
and the results have been summarized in a number
of traditional reviews (21, 72). The range of percent-
age reductions (Table 2) for the triclosan ⁄ copolymer
toothpaste vs. a fluoride control were as follows:
plaque, 0–59%; and gingivitis, 0–32%.
Three systematic reviews (18, 29, 31) have been
published that compared the effectiveness of a den-
tifrice containing 0.3% triclosan, 2% copolymer and
sodium fluoride (Colgate Total) with that of a con-
ventional fluoride dentifrice. In a meta-analysis of
data from 16 studies (18), the weighted mean differ-
ence of )0.48 for the Quigley–Hein Plaque Index
corresponds to a 23% reduction in plaque when
compared with a fluoride dentifrice. The weighted
mean difference of )0.15 for heavy plaque deposits
corresponds to a 15% reduction of plaque. In relative
terms, there was a 49% reduction in the proportion of
sites that had heavy plaque. The weighted mean
difference of )0.26 for gingival inflammation corre-
sponds to a 23% reduction. The weighted mean
difference of )0.34 for gingival bleeding corresponds
to a 12% reduction, which in relative terms corre-
sponds to a 49% reduction in the proportion of sites
with bleeding. The systematic reviews (18, 29, 31)
have confirmed Colgate Total to be significantly more
effective than a standard fluoride toothpaste in
improving plaque control and gingival health.
The progression of gingivitis to periodontitis is an
unpredictable event but bleeding sites are more likely
to progress to periodontitis than nonbleeding sites
(41). Because Colgate Total significantly reduced
gingival bleeding, further studies have assessed
whether the dentifrice could also have beneficial ef-
fects on periodontitis.
A 3-year randomized clinical trial involving
adolescents who were at risk of developing early
periodontitis, demonstrated that Colgate Total was
indeed significantly more effective than a fluoride
toothpaste in preventing the onset of periodontitis

Table 2. Studies of 6 monthsÕ duration involving triclosan ⁄ copolymer (Tric ⁄ copoly) toothpaste
Study Active Control Plaque percentage Gingivitis percentage
reduction vs. control reduction vs. control
Allen et al. (5) Tric ⁄ copoly NaF 30* 23*
Bolden et al. (11) Tric ⁄ copoly NaF 17* 29*
Cubells et al. (14) Tric ⁄ copoly NaF 25* 20*
Deasy et al. (19) Tric ⁄ copoly NaF 32* 26*
Denepitiya et al. (20) Tric ⁄ copoly NaF 18* 32*
Garcia-Godoy et al. (25) Tric ⁄ copoly NaF 59* 30*
Grossman et al. (28) Tric ⁄ copoly NaF 14* 4
Kanchanakamol et al. (37) Tric ⁄ copoly NaF 12* 1
Lindhe et al. (42) Tric ⁄ copoly NaF 31* 27*
Mankodi et al. (43) Tric ⁄ copoly NaF 12* 20*
McClanahan et al. (46) Tric ⁄ copoly NaF 0 2*
Palomo et al. (51) Tric ⁄ copoly NaF 11* 21*
Svatun et al. (68) Tric ⁄ copoly NaF 19* 25*
Triratana et al. (70) Tric ⁄ copoly NaF 35* 26*
Winston et al. (76) Tric ⁄ copoly NaF 9 0
NaF, sodium fluoride.
*Statistically significant.

25
Davies
(22). After 3 years, Colgate Total reduced the amount
of attachment loss (early periodontitis) per subject by
50% and the number of affected sites by 41%. In
another study, patients who already had periodontitis
received oral hygiene instruction, but no subgingival
instrumentation, at 3-monthly intervals for 3 years.
Colgate Total was significantly more effective than a
fluoride dentifrice in reducing pocket depth and
further attachment loss (56).
Data from a 5-year clinical trial in Australia dem-
onstrated that Colgate Total could slow the progres-
sion of periodontitis in a normal adult population
(15). Finally, Colgate Total significantly improved the
gingival health and periodontal status in smokers
when compared with a standard fluoride dentifrice (38).
No adverse events were reported in any of the
studies, and no shifts in the microflora of supragin-
gival plaque favoring the growth of either opportu-
nistic or pathogenic bacterial species were observed
(16, 73, 78, 79).
Initially the benefits of Colgate Total were attrib-
uted solely to the antibacterial activity of triclosan,
but a number of studies have demonstrated that tri-
closan may also exert an anti-inflammatory effect.
Triclosan reduces skin and mucosal inflammation (8,
40, 63) and there is clinical evidence that this may
also occur in the gingiva. The study was a crossover
design in which subjects stopped all mechanical
measures and rinsed for 2 weeks with 0.06% triclosan
plus Tween or 0.06% triclosan plus sodium lauryl
sulfate (54). As predicted, after 2 weeks the plaque
scores indicated that Tween had significantly re-
duced the antibacterial ⁄ antiplaque effect of triclo-
san. However, both mouthrinses had a comparable
effect on gingival inflammation, which suggested that
triclosan had an anti-inflammatory effect. Further
in vitro studies have demonstrated that triclosan
reduces the production of prostaglandinE2 by cells
stimulated with either interleukin-1b or tumor
Table 3. Studies of 6 monthsÕ duration involving triclosan ⁄ zinc citrate toothpastes
Study Active (%)
ZCT Tric
Palomo et al. (51) 0.5 0.2
Saxton (58) 0.5 0.2
Stephen et al. (64) 0.5 0.2
Svatun et al. (65) 1.0 0.2
Svatun et al. (66) 0.5 0.2
Svatun et al. (67) 0.75 0.3
MFP, sodium monofluorophosphate; NaF, sodium fluoride; Tric, triclosan; ZCT, zinc citrate.
*Statistically significant.
26
necrosis factor-a (47) and the production of inter-
leukin-1b from fibroblasts (49) stimulated by tumor
necrosis factor-a. More recently (50), it has been re-
ported that triclosan reduces the expression of
microsomal prostaglandin E synthase-1 in human
gingival fibroblasts.
Triclosan/zinc citrate
The second approach to overcoming the lack of
substantivity and efficacy of triclosan has been to
combine triclosan with zinc citrate (17), the latter
having been shown to be substantive and inhibit
plaque (30, 59) and gingivitis (75). A number of
clinical studies of at least 6 monthsÕ duration (64–68)
have generally shown that dentifrices containing
varying concentrations of zinc citrate and triclosan
are significantly more effective than a fluoride den-
tifrice in controlling plaque and gingivitis (Table 3).
No evidence of a shift in the normal oral flora or
development of bacterial resistance to triclosan was
observed after 7 months of daily use (35, 36).
Triclosan/pyrophosphate
A third approach has been the addition of pyro-
phosphate, a clinically proven anticalculus agent.
Five randomized controlled clinical trials have com-
pared this formulation with a fluoride dentifrice (28,
51, 55, 68, 76). In comparison to the control denti-
frice, only one study (28) reported a significant
reduction (13.9%) in plaque, and two studies (28, 68)
reported a significant reduction in gingival bleeding
(Table 4).
Amine fluoride/stannous fluoride
Most clinical trials have assessed a combination of
amine fluoride ⁄ stannous fluoride toothpaste and
Control Plaque % reduction Gingivitis % reduction
vs. control vs. control
NaF )6 )4
MFP 33 52*
MFP 25 50*
MFP 37* 34*
NaF 26* 42*
MFP 28* 50*

Table 4. Studies of 6 monthsÕ duration involving triclosan ⁄ pyrophosphate toothpaste
Study Active (%)
Tric Pyro
Grossman et al. (28) 0.28 5.0
Palomo et al. (51) 0.3 5.0
Renvert & Birkhed (55) 0.3 5.0
Svatun et al. (68) 0.3 5.0
Winston et al. (76) 0.28 5.0
MFP, sodium monofluorophosphate; NaF, sodium fluoride; Tric, triclosan; Pyro, pyrophosphate.
*Statistically significant.
rinse on plaque and gingivitis. Two randomized
controlled clinical trials of the amine fluoride ⁄ stan-
nous fluoride toothpaste have been published. The
first involved adolescents with a sodium fluoride
toothpaste serving as a control group (60). After
6 months there was no difference in plaque scores,
but the amine fluoride ⁄ stannous fluoride toothpaste
had reduced gingivitis by 7.6% and gingival bleeding
by 15.8% when compared with the control. Another
study involving adults (61) reported no significant
differences after 6 months between the amine fluo-
ride ⁄ stannous fluoride and control toothpaste with
respect to the plaque and gingival indices, but did
observe a significant reduction in the percentage of
bleeding sites.
Concluding remarks
In the UK the volume sales of toothpaste have
changed little over the past 10 years; in 1995, total
toothpaste sales were 15.7 million litres compared
with 17.9 million litres in 2004. What has changed,
however, is that the percentage sale of regular fluo-
ride toothpastes has declined from 45.1% of volume
in 2000 to 38.4% in 2004 whilst, at the same time,
volume sales of Ôall in oneÕ toothpastes have increased
from 24 to 27.8%. This reflects the development and
marketing by the oral care industry of toothpastes,
many of which deliver oral health benefits in addition
to caries prevention.
The toothpastes considered in this review vary in
their effectiveness in improving plaque control and,
more importantly, gingival health, when compared
with a conventional fluoride dentifrice. Toothpastes
containing triclosan ⁄ copolymer and triclosan ⁄ zinc
citrate improve plaque control and gingival health,
both safely and effectively, in studies of 6 monthsÕ
duration. A recent systematic review questioned the
public health significance of such relatively short-
Toothpaste in the control of plaque/gingivitis and periodontitis
Control Plaque % reduction Gingivitis % reduction
vs. control vs. control
NaF 14* )4
NaF )2.5 0
MFP 0 20
MFP 9.5 24*
NaF 12 6
term improvements (80). However, the unsupervised
use of a triclosan ⁄ copolymer toothpaste has been
shown to prevent the onset and progression of peri-
odontitis in studies of at least 3 yearsÕ duration (15,
22, 55).
However, the data supporting the effectiveness of
triclosan ⁄ pyrophosphate are weak.
Stannous fluoride toothpastes have been incon-
sistent in their effect on dental plaque but have
consistently improved gingival health. Their use,
however, is accompanied by staining of the teeth.
The data on toothpastes containing zinc citrate and
amine fluoride ⁄ stannous fluoride are insufficient to
make firm recommendations regarding their efficacy.
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