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Evaluation of the Clinical Effects of Toothpowder on Plaque Induced Gingivitis

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2 INTRODUCTION Background Importance of Oral Hygiene Tools and Dentifrices Contemporary prevalence of oral related diseases such as oral cysts, sabluxation, gingivitis, periodontitis and dental traumas just to name a few remain a major concern despite the continued emphasis on enhanced dental hygiene and health through community nursing and in modern education (Maripandi, Kumar & Ali 2011). Despite this phenomenon, evidence-based literature documents that efforts to curb this menace are escalating particularly with the development of tech-savvy dental care that is precise and more adequate. Other alternatives to curb this menace such as the adoption of good dietary habits and continuous regulation of fluoride intake are also on course. There is thus an imperative need to encourage the use of oral hygiene tools particularly as self-administrative oral hygiene at home for effective orthodontic treatment, control and management. The use of oral hygiene tools and dentifrices occurs, as the most researched method in the maintenance of good oral hygiene owing to its common utility is a common phenomenon. Cury et al (2004) in a study conducted in Brazil confirm that efforts to use fluoridated water as a substitute to manage such diseases are preexistent and ongoing although the use of dentifrices and dental hygiene tools remain the most preferred methods. Clarkson et al (2009) also vehemently ascertains and reinforces this opinion in a clinical trial affirming that such efforts of intervention using such tools and behavioral change showed timely cognition and prevention of such oral ailments. The use of dentifrices such as toothpowder and toothpaste and its underestimation is impossible owing to their role in assuring dental health. Similarly, Zero (2006) also confirms the efficacy of these

3 dentifrices although he is quick to highlight that modern day varieties are becoming questionable since they are not clinically tested but instead only fulfill FDA monograph stipulations for preclinical and laboratory tests using murine and in-vitro assays respectively (Zamani 2006). The use of dentifrices in fighting dental disorders though minimally researched on appears to help in effective management of dental diseases. Evidence using in-situ and in-vitro studies show affirmative results. This is primarily because they abridge enamel demineralization and concurrently improve re-mineralization (Cury et al 2004). The re-mineralization potential in dentifrices is crucial in eradicating dental caries among other dental diseases but at 5 000ppm since an overdose would lead to tooth decay and subsequently dental caries development. A study by Anil (2007) confirms such adverse effects to be the causatives of gingivitis in the plasma cell a benign condition particularly in three different patients on using herbal dentifrices and concurrently receiving periodontal disease medication. As such, the cautious use of dentifrices is imperative particularly the herbal ones whose long-term ramifications remain unknown due to limitations in time. Karlinsey et al (2010) too also confirm these suppositions using a sodiumfluoridated dentifrice in combination with pH cycling representation containing tricalcium phosphate. The effect of increased acidity in the mouth for such dentifrices antagonizes their initial goal hence other than reducing demineralization they escalate it inducing tooth decay. To make dentifrices essential oils that are more effective are now reinforcing their efficacy in treatment and management of periodontal inflammation. In addition, the incorporation of other dental hygiene tools such as mouthwash and mouth rinse makes the outcome more promising. In a database exploration study by Fawad (2012), use of such dentifrices show positive results in comparison with placebo groups owing to the microbiological potency to reduce periodontal associated pathogens. Although this is the case, clinical confirmatory tests remain inconsistent

4 regarding this prospect making inference making problematic. Okpalugo et al (2009) ascertains the antimicrobial potency of toothpastes and toothpowders in preventing dental plaque that consequently induce dental caries, periodontal disease and gingivitis. Such dentifrices are classified as drugs instead of cosmetics owing to their constituent components such as Triclosan 2, 4, 4 trichloro-2'-hydroxydiphenyl ether, that confers antibacterial properties reducing the affiliated dental flora (Okpalugo et al 2009, p.72). Dentifrices are confirmed to reduce the multiplication potency in fusobacteria, diphtheriod and porphyromonas gingivalis among other harmful mouth bacteria that induce dental diseases (Okpalugo et al 2009). Agrawal and Ray (2012) also affirm that dentifrices are drugs although from a negating opinion that they contain nicotine components making them injurious to long-term users. As such, they advise for stringent pharmaceutical regulation of such products through effective government policies and intensive health education to the community. Highlighting the role of fluoridated dentifrices in the maintenance of oral hygiene, Cronin et al (2000) terms it as a cleansing agent with potency to remove stained pellicle although its effectiveness is facilitated by its abrasives mechanical action using oral hygiene tools such as toothbrushes. This opinion contrasts majority of the authors prospects since it accentuates that tooth brushing as more effective in plaque removal than the exclusive use of dentifrices. Toothbrushes as dental hygiene tools are thus equally imperative particularly with their design to remove dental plaque efficaciously without causing injuries on the mouth tissues and gingival (Turksel et al 2004). According to Fiona (2009), ideal toothbrushes are core in delivering dentifrices on tooth surface. In addition, such brushes that are sonic, powered or manual eliminate dental biofilm on dentition surfaces hence impede bleeding and reduce plaque as evident in clinical

5 studies. Dentifrice efficacy can only transpire if the application of ideal brushing protocols and approaches transpire (Turksel et al 2004; Fiona 2009). According to Jaksha (2011), tooth brushing maintains and controls an enhanced bacterial environment intra-orally reducing the potency and survival capacity of pathogens. These results are confirmatory after a comparative study of Luria bertani, Todd Hewitt and Trypticase soy bacterial cultures was done prior to and after brushing indicating significant reduction in the counts (Jaksha 2011). The practice is strongly recommendable as indispensable and a pivotal daily regiment owing to these advantages. Zamani (1998) highlights that despite the fact that a toothbrush is a vital oral hygiene tool, it is vulnerable to contamination acting as a health etiology and as such, its prevention from contamination should be crucial. Although toothbrushes remove dental plaque with their vertical bristles from accessible and flat surfaces of the teeth they are less effective in approximal areas of the gingival margins encouraging gingivitis and periodontal disease. This is primarily so because only about 30% of the teeth is exposed while the remaining is within the gingival. With this outlook it is evident that dental hygiene tools are not exclusive guarantees of oral health and as such, the induction of other alternatives that are more efficient in dental health maintenance is core. Such ideas include frequent dental check ups to ascertain sound health and early disease recognition for effective management and complete clearance. Furthermore, contemporary healthcare is focusing on optimizing the design of the toothbrush to improve its ability to remove plaque even in inaccessible areas of the teeth (Zero 2006). Modern efforts are focusing on designing toothbrushes with crisscrossed bristles, power tips and angulated tufts to optimize tooth polishing and dental biofilm removal. Despite these efforts tooth brushing has many inconsistencies and variations making the effectiveness of the art vary among individuals. Contemplating that each individual has a distinct mouth, then formulating a standard technique of

6 tooth brushing is impossible, although the circular technique is strongly advisable for the best outcomes. Biesbrock, Bartizek and Walters (2008) affirm this during a clinical study on the efficacy and safety of two divergent manual toothbrushes with improved designs and with the overall motive to reduce dental plaque more efficiently. Other oral health tools also imperative in dental care include toothpicks and sponge toothettes. These tools facilitate respiratory pathogen and dental biofilm colonization, remove subglottic discharge and in oropharyngeal bacteria colonization. They are useful in dental care of ICU and intubated patients. According to Grap et al (2003), clinical evidence proofs that they are ineffective in dental plaque elimination despite their increased preference. There is thus a need for profound selection of dental products and tools to use for such patients to prevent such diseases and guarantee oral health. Antiseptic solutions as OTC oral products in maintenance of dental care are also available. Smith et al (2003) highlights a number of such products available including Listerine, plax, corsodyl, flourigrad , oral B mouth washes among others with various antimicrobial properties. These have been proven effective in controlling Staphylococcus aureus in invivo studies but the mechanisms mediating therapy are unknown. Importance of Dental Plaque Dental plaque as a pale yellow biofilm naturally occurring on teeth and colonizing bacteria on the smooth surface facilitate a defense mechanism to impede microorganisms, which are pathogenic (Ebrahim, Abdolhamid & Mahdi 2009). The plaque also helps in tooth shedding regulation owing to its composition of thousands of bacterial ecosystems. Plaque generation also entails important steps other than a sporadic process. These include adsorption of bacteria and proteins for film formation, reversible adhesion through the action of electrostatic and Van Der

7 Waals forces, irreversible adhesion, secondary and primary colonization via intermolecular interactions finalized by cell division to generate a biofilm (Ebrahim, Abdolhamid & Mahdi 2009). The importance of the dental plaque is to confer immunity to the gingival owing to its constituent lymphocytic cells such as macrophages, leukocytes and epithelial cells. These originate from saliva and bacterial products all that form the extracellular matrix. Dental plaque has an imperative role in development of gum-affiliated diseases since as an oral microorganism haven it mineralizes to tartar commonly known as calculus through calcification processes. According to Walsh (2008), the dental plaque facilitates carbohydrate fermentation causing teeth demineralization and the production of organic acids that reduce the pH in the mouth. Under these conditions, the survival of bacteria such as those of lactobacilli, mutans and streptococci improves since more supragingival plaque from cariogenic substrates is accommodated. The ramification of this phenomenon is the production of formate, pyruvate and lactate among other organic acids, which facilitate enamel demineralization and ultimate development of dental caries among other dental ailments. Walsh (2008) asserts that modern medicine is focusing on plaque reduction through controlled acid production in the buccal on reduced sucrose and sugar intake and their subsequent replacement with non-fermentable materials such as trehalose, sucralose, xylitol and sorbitol among others. The dental plaque is also imperative in the denitrification process that reduces nitrate (NO3) to nitrite (NO2) then nitric oxide (NO) and finally nitrous oxide (N2O) (Schreiber et al 2010). Through the application of microsensor measurements and molecular detection, in-vivo increase in nitrous is shown to be dependent on dental plaque amounts under the control of its pH in aerobic conditions. To dental health, these events influence nerve signaling, blood flow and gum inflammation processes hence regulating the prevalence of periodontal disease by determining the activity of the gingival cells. The process of

8 denitrification of dental plaque thus mediates nitrogen cycling, controls the development of systemic diseases, and thus has the potency to alter the entire human physiology hence its close monitoring is requisite. Dental plaque as a store for pathogens of infectious diseases often aggravates dental diseases. Although it is unavoidable, clinical trials show it can be reduced using antimicrobial compounds, professional cleaning and good oral hygiene hence managing and eliminating dental ailments. According to Loe (1981), supragingival plaque, which is less accessible using dental hygiene tools, depicts bacteria accumulation and a pre-pathological characteristic in many dental diseases since it encourages bacterial colonization. Khuller (2009) takes a divergent view on the role of the dental plaque in controlling the exacerbation of dental ailments. This however can transpire on its reduction by maintaining normal buccal flora and in decreasing the oral bioburden through flossing, use of mouth-rinses that have antimicrobial property and on effective tooth brushing. This outlook guarantees the maintenance of natural dentition throughout an individuals life. The dental plaque also consists of fluid channels located in a slime layer allowing bacterial products and chemical movements (Nield-Gehrig & Willmann 2003). In addition, the dental plaque acts as a communication system for chemical signal communication of microcolonies and bacteria. This is crucial in symbiotic relationships that enhance their survival. In another pilot study by Cheung, Zid, Hunt and McIntyre (2005), the pellicle layer commonly known as the dental plaque serves as a diffusion barrier owing to its semi permeable nature. As such, it selectively limits the transport of phosphorous and calcium ions among other acid ions through the hard tissue hence determining the enamels surface solubility predisposition. Correspondingly, by acting as a store for these ions particularly as concentrates, it controls the dentine cementum and enamel from erosive demineralization hence a determinant of the

9 development of dental diseases. To reinforce these suppositions an in vivo-in vitro model, conducted by Cheung, Zid, Hunt and McIntyre (2005) demonstrates the potency of the dental biofilm in reducing enamel erosion owing to the intake of fermentable foods such as gastric acids and wine. Confirmations on dental plaque as an etiological factor in many other diseases that may not necessarily be dental also occur in evidence-based studies. Respiratory pathogens for instance often colonize on dental pellicle particularly in patients that are home-nursed and those in the ICU. In the buccal, aspiration to the lung can occur inducing an infection (Marsh 2005). Fourrier et al (1998) in their clinical study assert that dental plaque reserves nosocomial infections and colonization pathogens particularly the aerobic ones in 40% and 60% of hospitalized and homecared patients respectively. In several incidences dental plaque resulting to nosocomial pneumonia, ventilator affiliated pneumonia and oropharyngeal infections result from dental plaque accumulation (Marsh 2005). Accentuation on the practice of oral hygiene using appropriate tools and effective dentifrices as the preventative measure for the accumulation of dental plaque is imperative, if such disease risks will be avoided (Fourrier et al 1998). Importance of Dental Extrinsic Stains on Tooth Surfaces Teeth are also vulnerable to pigmented deposits that appear on the surface due to oral flora consisting of chromogenic deposits. Such stains occur on the tooth surface due to topical agents such as medication, metals, chromogenic bacteria, tobacco, beverages, calculus, foods and dental plaque (Keitel & Soentgen 1995). Such stains often appear on the gingivals margin, at the incisal region and on the inter-proximal. Stains are also a ramification of poor dental hygiene as well as the use of mouthwashes with chlorhexidine antibacterial that reacts with teeth (Keitel & Soentgen 1995). As a multi-factorial etiology that is chromogen mediated, extrinsic stains main causative is a dietary derivative. The dental plaque takes up the chromogens and their natural color

10 is imparted on teeth surface hence extrinsic staining is distinct based on the specific chromogen. Indirect extrinsic staining also signifies the increased presence of metal salts and antiseptics. These are constituent components of the foods, drugs and dentifrices in taken and their subsequent reaction with the enamel. Extrinsic stains act as disease etiologies particularly in mediating and propagating acquired dental defects. Such stains show physical teeth trauma often manifest as enamel cracks and loss, gingival recession and tooth wear characteristic in majority of dental ailments. Furthermore, such stains are evident in dental caries progression. The initial stage of lesion development ranges from white spots to opaque color on the teeth surface. During the proteinsugar reaction stage, teeth browning occur due to the non-enzymatic Maillard reaction (Watts & Addy 2001). These are clinical symptoms in development and subsequent exacerbation of dental caries. Extrinsic stains are also important indicators of reactions between the teeth and restorative material such as amalgam and other phenolic and eugenol containing components (Khozeimeh, Khademi & Ghalayani 2009). These are induced in the dental system during root canal treatment and on the use of some poly-antibiotic toothpaste. Similarly, mercury reacts with sulfide ions of tin salts causing its displacement into tubules and the induction of extrinsic stains. With the problem of extrinsic stains being, common and persistence, its reduction is feasible through good dental practices particularly the brushing of teeth using whitening toothpastes, flossing and taking whitening chewing gums. Although such stains removal through professional bleaching is possible, it is quite exorbitant unlike the intrinsic stains that in most cases are permanent. Medical evidence shows that prophylaxis mainly done during dental visits aims at polishing and scaling teeth to remove stain as stated by Geza et al (2008). Such a protocol is holistic and removes both subgingival and supragingival plaque preventing gingivitis development.

11 Importance of Gingivitis Gingivitis as a gingival inflammation occurs as a response to bacterial dental plaque, which adheres on the surface of teeth. As non-destructive, it occurs as a preliminary stage to the progression of periodontitis that is deleterious and precedes gingivitis, which is plaque-induced (Nwhator & Ayanbadejo 2011). Other causatives of this anomaly include malnutrition, medication and systemic factors, all which play a crucial role in aggravating the pathological condition. Furthermore, this pathological condition is not only affiliated with poor oral hygiene but also lower social-economic stature owing to poor diet and lack of health precedence among such groups. Gingivitis often indicates many clinical processes other than the exclusive sign of early stage of periodontal disease. Gingivitis is manifest in pregnancy and often poses as a risk for premature or undersized birth and advanced gum ailment following birth (Singh et al 2011). This occurs when bacterial inducing the gingivitis enter the circulation to the uterus prompting prostaglandins production and eventual induction of uterine contractions hence premature birth. The problem is further compounded by hormonal changes evident in pregnancy thus dental hygiene maintenance must be an indispensable practice in such incidences (Singh et al 2011). Gingivitis manifest by gum swelling is common among individuals with this dental anomaly. A case testimony conducted by Hou and Tsai (1998) on a pregnant Chinese female attests to these speculations showing this kind of gingivitis to be a myelomonocytic leukemia indicator particularly of acute nature. A one-week follow up showed increased immune response with the escalated production of leucocytes hence confirming the primary presence of the disease. Swelling of such gums characterized by pale pink color also indicates adverse effects of certain drugs such as antagonists of the calcium channel such as amlodipine, nifedipine and felodipine,

12 phenytoin and cyclosporine. Taylor (2003) reinforces this opinion highlighting that 25-80% and 50% cyclosporine and phenytoin users respectively are diagnosed with swollen gum gingivitis. Gingival swelling also indicates inflammation particularly when plaque accumulation occurs. Such gums become vulnerable to bleeding are soft and redden. Similarly, this ailment may occur in childhood as a hereditary fibromatosis making the gum to have exuberant overgrowth and displacing the outer teeth surface (Lee et al 1995). Furthermore, gum swelling and subsequent enlargement is induced systemically in incidences such as pyogenic granuloma and hormonal imbalance. According to Antonio (2010), other systemic conditions indicated by gingivitis include lichen planus a mucocutaneous disease, pemphigoid, which is the detaching of the epithelium from basal membrane that is antibody mediated and pemphigus an autoimmune disease caused by the inability of keratinocytes to coalesce between tissues. In addition, erythema multiforme a disease mediated by immune complexes and lupus erythematosus that involves formation of anti-self antibodies against body cell components are indicated by gingivitis (Antonio 2010). Gingivitis manifest by bleeding, reddening and swelling of the gums often signifies the presence of other dental complications. These include advanced periodontitis that eventually leads to decay and loss of teeth. This condition often is recurrent and spread to the entire buccal gradually. In other incidences, it depicts abscess, which is a deposit of dead neutrophils on the gum owing to the defensive action against dental plaque pathogens (Zero 2006). Trench mouth disease that manifests as ulcerations on the gingival owing to the accumulation of many buccal bacteria that are normal also occurs with close affiliation to gingivitis. Gingivitis is a significant indicator of fungal infections such as histoplasmosis, erythema that is linear and candidiosis. Conversely, the disease also manifests in viral infections particularly those of herpes simplex, varicella zoster and in some incidences HIV. Gingival inflammation also indicates anaphylactic reactions, diabetes

13 mellitus as well as the presence of trauma (Antonio 2010). An evidence based research shows that gingivitis is an indicator of a variety of diseases and disorders hence its prevention is imperative. This is however feasible with the maintenance of sound oral hygiene and the use of such dental hygiene tools appropriately. This research seeks to assess the efficacy of toothpowder as an important oral dentifrice in reducing and managing gingivitis that is plaque induced. Aggravation of gingivitis is often an indicator of systemic diseases since it triggers the production of cytokines such as interleukins, prostaglandins and cancer necrosis factors. The ramification of this event is the interference of several pathways causing premature parturition, mucosal inflammation, atherosclerosis due to derangements in metabolism as Panagakos and Scannapieco (2003) observe. Statement of the Problem Previous researches seeking to assess the efficacy of dentifrice on plaque-induced gingivitis are existent in literature. Despite their limitations in numbers and less specific focus on toothpowders other than focusing on dentifrices holistically, they show affirmative results regarding the issue in question. In essence, published articles on the efficacy of toothpowder in reducing plaque-induced gingivitis are not identifiable despite the problems being predominant in contemporary societies. According to Shamikh and Dweiri (2011) gingivitis incident occur in 9%85% of Jordanian children aged 5-7. In addition, 23% and 75% of Icelandic and global children showed positive but mild gingivitis between the age of 5-9 years (Shamikh & Dweiri 2011). In one study by Botelho et al (2007), plaque-induced gingivitis is rated at epidemic levels with a majority 80% Brazilian geriatrics being affected with less consideration in adults being underscored. Despite the inconsistent reporting, it is evident that the situation is dire and demands urgent mitigation to reduce these escalating incident rates.

14 An evaluation of literature also shows knowledge gaps regarding the efficacy of dentifrices as a whole including toothpowder on gingivitis. This is primarily so since they elucidate less on the mechanisms of actions that confer plaque reduction despite existent studies showing positive results on their use. Agrawal and Ray (2012) accentuate to these sentiments highlighting a need for intensive research if the present scenario is bound to change for the better. The existent studies also seem less representative of the entire population since they use small sample sizes and manifest the blatant problem of Hawthorne effect making the inferences made dubious and questionable. Another evident problem on literature analysis is inconsistent and contradictory reporting particularly on the efficacy of herbal dentifrices in reducing plaque-induced gingivitis confounding the readers. Cullinan et al (1997) attest to these studies with their declaration that Sanguinaria does not have antigingival properties. This is in contrast with a study by Hannah and Johnson (1989) and another by Harper et al (1990) vehemently attesting to the herbs safety and efficacy in reducing gingival inflammation and inhibiting dental plaque accumulation. Similarly, preexistent literature focuses more on toothpaste and mouth rinse and derelicts toothpowder despite its difference owing to the absence of humectants. Documented studies also appear less considerate of extrinsic variables such as the consistency of tooth brushing, its technique and frequency all of which are crucial factors in the determination of efficacy towards plaque-induced gingivitis. Subjectivity in gender, age and environmental factors are also evident despite their imperativeness in the prevalence of the disease hence the need for intensive research. With the intention to advance the knowledge on this issue as well as close the highlighted gaps, this study seeks to evaluate the efficacy to toothpowder in alleviating gingivitis, controlling dental plaque, inhibiting extrinsic stains and periodontal pocket and concurrently putting the crucial factors that interfere with inference making in consideration.

15 Aims of the Study a) Determine the efficacy of toothpowder in gingivitis management and control following its use. b) Determine the efficacy of toothpowder in reducing and eliminating dental plaque following its use.
c) Determine the efficacy of toothpowder in removing extrinsic stains following its use.

Objectives of the Study

1. To find out how the outcome of toothpowder incorporated with essential oils and calcium

carbonate use in reducing plaque induced gingivitis 2. To approximate the discrepancies between gingivitis patients who are toothpowder users and non-users following periodontal therapy that is non-surgical.
3. To find out how the outcome of toothpowder incorporated with essential oils and calcium

carbonate use in reducing extrinsic stains on gingivitis patients. Significance of the Study The scope of this study regarding the efficacy of toothpowders on plaque-induced gingivitis seeks to add knowledge to the medical field hence recommend on its encouraged use or otherwise. Similarly, it seeks to decipher, elucidate and make explicit the gaps in existing literature particular on inconsistent reporting and subjectivity in studies of dentifrice efficacy in reducing plaque-induced gingivitis. This achievement will diversify, equip and intensify future research efforts when dealing with issues pertaining dental illnesses. Furthermore, for the

16 patients a new recommendation for effective therapy or otherwise will transpire based on the results obtained. The study will also act as an eye opener for scientists to indulge in similar studies intensively hence add more knowledge on the issues in question for better comprehension.

LITERATURE REVIEW Limited researches on the efficacy of toothpowders in plaque-induced gingivitis treatment have been researched on hence limited inference on its imperativeness. Conversely, toothpaste a closely related dentifrice whose clinical efficacy is widely researched on despite the inconsistencies in the inferences made. A randomized single-blind research using a 24-subject sample size conducted by Claydon et al (2004) accentuates this opinion using whitening toothpaste. In this case, affirmative results on reduced extrinsic dental staining transpired. Furthermore, the reinforcement of these results occurred through comparative testing in the presence of a placebo water-control group and another group with commercial toothpaste. The study however fails to elucidate the mechanism which stain inhibition occurred and in an antagonizing case concludes that existent whitening toothpastes accelerate extrinsic stains (Claydon et al 2004). In addition, the study fails to establish a definitive timing when the effects of inhibited staining occurred. In another related randomized clinical trial triclosan (Colgate) and stannous (Crest Gum-care) dentifrices, manifest similar results in reducing extrinsic stains (He et al 2010). This study used a sample size of 96 subjects in a 5-week follow up where stain inhibition was monitored. The study infers no significant difference between the uses of the two types of toothpastes although it reports that they reduced tooth staining significantly particularly after a

17 dental prophylaxis (He et al2010). Despite highlighting tolerance on using these dentifrices, little regarding the degree of efficacy is clarified. Comparative assessment of perlite (calcium carbonate) and silica containing toothpastes on extrinsic stain elimination efficacy occurs in a study by Collins et al (2005). Using stratified sampling with 152 subjects and applying the double blind and parallel group study in a fortnights time, affirmative results transpired (Collin et al 2005). Using Macpherson modification technique to change the Lobene stain indicator, confirmation of this supposition was evident. Despite the ability to produce consistent results, the study only evaluates on the ability of dentifrices to remove stains without taking a holistic look by evaluating on prevention of stain induction and the build up of natural stain hence is subjective. Joiner et al (2002) have demonstrated a similar study evaluating the efficacy of white systems on extrinsic stains. Furthermore, comparative assessment using silica containing toothpastes that have similar potency to effect enamel abrasion also occur. A four-week study using an in situ model shows that whitening paste has higher potency to remove in-vitro stain unlike the silica one. Although highlighting these discrepancies, Joiner et al (2002) show equal potency to reduce enamel wear in the two. Although conclusive, the study exclusively applies laboratory experiments to make inferences despite the fact that they are models hence less representative of the real case scenario. In addition, it only qualifies the efficacy of toothpastes in extrinsic stain removal without quantifying it. In a related study, Daiva et al (2011) also comparatively evaluates the efficacy of whitening toothpaste with conventional fluoridated dentifrice using the Loben stain indicator, as was the case with Collins et al (2005). In a 2 to 4 week, study with 33 subjects deductions regarding the potency of the three divergent toothpastes showed that whitening pastes (Colgate and Elgydium) produced better results than conventional paste. Despite these deductions, the study is quick to highlight subjectivity owing to the Hawthorne

18 effect where a sample makes great effort to produce the best results since they know they are participating in a study. The study is also subjective since it accentuates on the pastes producing the best results other than the quality of its efficacy. Despite the escalating prevalence in dental diseases, mass prevention remains a challenge. Moran (1997) attests to this opinion highlighting the need to use chemicals to control dental plaque that propagates these diseases. With this outlook, novel alternatives to current formulations that are more effective will emerge. One such proposition is the incorporation of mouth rinse in dentifrices. However, observational studies show the infeasibility of this idea with the strong held perception that mouth rinse is a toothpaste and toothbrush substitute. Despite the practicability in Morans (1997) suggestions, their effect requires warranting. The study also fails to establish the long-term ramifications of its opinions towards enhancing dental health despite recommending them for use. In a randomized control study, Paraskevas (2005) seeks to find an alternative to the weaknesses affiliated with self dental hygiene through the incorporation of chemical agents in mouth rinse and dentifrices. Such chemicals include those that are organic cations, metal salts, phenolics that are non-charged, agents that are surface modifying and oxygenating agents. Although revelations show that several of them induce anti-gingivitis properties their efficacy remain questionable since long-term effects are yet to be established (Paraskevas 2005). Similarly, clinical trials reveal that patients using them end up having dental diseases hence their significance is limited. The study also seems less conclusive owing to limited information regarding the phenomenon in question. Evidence-based research continues to accentuate to the importance of toothpaste among other dental tools in preventing dental diseases. Santos (2003) comparatively evaluates the efficacy of essential oils, Peridex and Listerine in eliminating plaque and gingivitis. Results indicate a 1645% and 27-80% potency for the products to reduce dental plaque and gingivitis respectively.

19 Although this is the case, such dentifrices also induce extrinsic stains and increase supragingival calculus making their use less preferable an aspect that the study ignores explicitly (Santos 2003). The study also fails to establish a definitive time when affirmative results on using such pastes can transpire with inconsistencies being evident on observation of patients at divergent timeframes. West and King (1983) comparatively evaluate the efficiency of tooth brushing with water, toothpowder and H2O2-sodium bicarbonate in reducing periodontitis suppuration and in dental plaque staining inhibition. Using a sample size of 15 subjects, inconsistent results were obtained with some cases showing positive results while other showed negating results hence inference making was difficult (West & King 1983). Although non-effectiveness in the H2O2-sodium bicarbonate, wrong deductions are likely owing to the incongruities in the study. This highlights the need for comprehensive and intensive studies to make conclusions regarding this prospect. In another evidence-based study, sodium fluoride and chlorhexidine containing mouth rinses were assessed in gingivitis that is plaque induced among teenagers control (13 to15 years) in Bangalore town (Jayaprakash, Veeresha & Hiremath 2007). Within a differential time range of a month, 3 and 6 months, significant reduction in the disease was realized at an increasing trend. However, the study experienced discrepancies since the placebo group also decreased its prevalence rate in gingivitis manifesting errors in the study. The study was also partial since its emphasizes was on competitive therapeutic outcomes inducing the perception of better efficacy in one dentifrice compared to the other (Jayaprakash, Veeresha & Hiremath 2007). Gunsolley (2006) conducts a theoretical survey regarding the efficacy of dentifrices in alleviating gingivitis. Using electronic databases to source published articles and from manufacturers for unpublished articles inference making was feasible. Although inconsistent, the studies showed the preference of mouth rinse with stannous fluoride, essential oils and chlorhexidine as anti-gingival. Despite the reliance

20 on unpublished data, which at times is subjective, the systemic review accentuates that dental hygiene is wide and cannot be effective with the application of one approach but rather a holistic approach. The meta-analysis also highlights the need to increasingly research on the efficacy of dentifrices on dental diseases to prevent the blatant variations in deductions of different researches. The efficacy of either toothpaste or toothpowder in removing dental plaque depends on its characteristic abrasivity. Baxter, Davis and Jackson (1981) evaluate on this phenomenon and its effective execution to avoid tissue damage. Abrasion as the cleaning power is then co-related with in-vitro dentine to express the efficacy of the dentifrice in metrics. The optimal choice in this case should be cosmetically acceptable and able to remove extrinsic stains on a daily routine adoption. This contradicts sentiments by Okpalugo et al (2009) who perceive dentifrice as drugs other than cosmetically acceptable products. Although the study highlights that dentifrices are effective in dental pellicle removal, it focuses on abrasion power without considering other factors such as the quality of toothpaste and the technique of brushing all that are considerable factors. Hosein et al evaluates a similar concept on pellicle removal efficacy but comparatively using toothpowder and toothpaste and not applying brushes using an examiner-blind crossover study (2009, p.147). By randomly dividing a 36 volunteer sample twice, using the Loe and Silness plaque index and using the finger and the split mouth procedure for each group collating of results occurred. The findings show that toothpowder is a significantly stronger dentifrice compared to toothpaste in pellicle removal (Hosein et al 2009). Although this deduction is made, little elucidation regarding the increased potency in absence of liquid humectants in the powder is provided hence questioning a need for explicit substantiating. With much accentuation on dentifrice use other than tooth brushing, Shrama et al (2004) also assess the adjunctive benefit and efficacy of using mouth rinses with essential oils in reducing

21 gingivitis that is plaque induced. By comparing brushing and flossing subjects in a study with a 237-sample size followed by a baseline prophylaxis, results are obtained after a 6-month followup. Using the plaque index and modified gingival indicator as the metrics incorporation of essential oils in mouth rinse shows significant alleviation of gingivitis but without any significant difference in brushing and flossing subjects (Shrama et al 2004). The study however remains inexplicit on the mechanism of action that essential oils confer to effect better efficacy. Kozak and White (2000) also explain the effect of dentifrice in eliminating dental staining, a characteristic in plaque-induced gingivitis. This was possible by applying an apatite substrate on cycled saliva tea and chlorhexidine in comparison to a commercial dentifrice and polypyrophosphate (Kozak & White 2000). The results show abridged stain adsorption due to the polyphosphate action with dental plaque. Although the protocol is a model (in-vitro) it explains the mechanism under which staining reduction occurs although its application in in-vivo assays remains questionable. With the motive to evaluate the whitening power of toothpastes, a pilot study by Ozcan, Pinar and Bulent (2009) to ascertain this supposition clinically occurs. Using non-smokers and smokers in a 4-week follow up and several whitening toothpastes, collection of data transpired. 80% of all subjects reported affirmative results while higher numbers in smokers than non-smokers were observed (Ozcan, Pinar & Bulent (2009). The discrepancies in this study are attributes of subjectivity since different toothpastes were used in the two groups. Quantification of results was also a problem since the study used observations instead of standard measures. This made inferences such as a 100% stain reduction for smokers impractical. In another study by Swaminathan, Moran and Addy (1996), a variety of oral products including toothpowders, toothpastes and mouth rinses containing chlorhexidine antiseptic were applied in extrinsic stain elimination. Although in in-vitro assays using spectrometric (optical density) readings affirmative

22 results were obtained in all cases though less quantified. Despite this, the study remains unclear on the chemical components in the oral products and their subsequent mechanism of action with the stains that confer increased efficacy in stain removal when compared with a control group using water (Swaminathan, Moran & Addy 1996). Despite highlighting a significant difference in the chlorhexidine used in mouth rinse and dentifrices the study concludes of no significant difference between the users hence subjective reporting. A double blind and onetime use clinical assessment seeks to compare the efficacy of commercial Colgate toothpaste with one that contains silica in reducing bad odor a characteristics in gingivitis patients. Using a hedonic scale that was nine pointed, the 83 subjects were subjected to brushing using soft-bristled brushes (Naresh et al 2000). Following this, evaluation for bad breath transpired after 12 hours. Results positively showed reduced bad breath although no significant difference in the two toothpastes. The studys inferences are however limited by the method of evaluating bad breath, which could be subjective owing to the use of examiners and the lack of a standard method of brushing an aspect that is unique to every individual. Sheen, Pontefract and Moran (2001) reinforce the opinion that toothpastes have great efficacy in controlling a variety of dental ailments including oral malodour, calculus, plaque, gingivitis and periodontitis owing to their chemical composition. They highlight the presence of abrasives, detergents and active ingredients such as silica, sodium lauryl-sulfate and fluoride respectively, all which aid in dental health maintenance (Sheen, Pontefract & Moran 2001). The study however fails to decipher the mechanisms of action and reactions that such components mediate to enhance dental health. They also highlight inconsistent and contrasting reporting on the long-term ramifications of some of the components.

23 An in-vivo assay by White, Barker and Klukowska (2008) also accentuates of the efficacy dentifrices and mouth rinse that have antimicrobial property in managing dental plaque. The study takes place in three phases entailing holistic use of dentifrice, randomized used of an antimicrobial containing dentifrice and finally randomized use of a mouth rinse. Results indicate reduced pellicle on using the three oral products exclusively but a synergistic outcome on combining the three with plaque reduction being beyond 50% (White, Barker and Klukowska 2008). The study however points outs limitations of uncontrollable factors such as disease susceptibility and consistent hygiene observation that are distinct for individuals. In another study, the presence of alcohol as an additive in mouth rinse is also evaluated as an agonist to its efficacy. Using a crossover clinical trial that is randomized and double-masked Marchetti et al, (2011) evaluate on this aspect in a plaque accumulation representation of 3 days. Using 30 volunteers grouped in to two, the subjects undergo a fortnight washout prior to data collation. Results indicate increased efficacy in presence of alcohol contrary to its absence. The results of this study spark new controversies since alcohol is considered a potential co-carcinogen hence prompting development of carcinomas such as oral cancer among others hence the need for intensified research on the purported suppositions (Marchetti et al 2011). Increased assessment on the efficacy of mouth rinse in antigingivitis and antiplaque occurs in Amini et als (2009) study. This is evident in a randomized clinical study within a fortnight using 3 mouth rinses each containing essential oils (EO), cetylpyridinium chloride (CPC) and alcohol. Using a sample size of 103 and 56 females and males respectively grouped subjects with EO, CPC that is alcohol free, CPC with alcohol and a control group data collection occurred and measurements were taken with the modification gingival and Quigley Hein-plaque indicators as metrics. The results indicate that essential oil incorporation in enhanced antigingival and

24 anitplaque properties by 16% of mouth rinse despite being unclear on the mechanism. This is in contrast with other groups that reported 13.3%, 6.3% and 6.6% reduction respectively. Al-Talib, Abdullah and Al-Khatib (2004) also evaluate the efficacy of different mouth rinses containing phenolic compounds, chlorhexidine digluconate and salt comparatively in reducing plaque-induced gingivitis. In a randomized clinical trial using 45 subjects divided equally in three groups and assessed using the Loe and Silness measures data collation occurred following a 2-month monitoring. Results indicate a significant decrease in disease on incorporating phenol and chlorhexidine in mouth rinse but with chlorhexidine having greater superiority contrary to the use of salts that show no significant difference. Despite underscoring the potency in chlorhexidine mouth rinse no explanation regarding the mechanism in which it is conferred is given. Weijden and Slot (2011) also affirm the efficacy of oral hygiene dentifrices and tools in guaranteeing reduced periodontal diseases and ultimately eliminating gingivitis incidents. Accentuating of their mechanical power to remove food debris among other biofilms particularly in occlusal pits and interproximal spaces, toothbrushes are highlighted as crucial. Similarly the emphasis on the incorporation of dentifrice such as toothpowder also occurs. Quantitative analysis show excusive use of dentifrice reduces plaque by 59% although incorporation of a toothbrush reinforces the outcome to 67%. Although deriving its deductions from a comprehensive literature analysis, the study does not use empirical and experimental data that is more pragmatic. Watanabe et al (2006) in another study, evaluates the cariostatic efficacy of whitening toothpaste in reducing the dental pellicle. Using a 5-toothpaste comparison and 95 tooth fragments the study embarks on a micro-hardness evaluation for 2 weeks in a daily 10-minute toothpaste application. The results manifest potential cariostatic power in all the pastes with no significant difference. This was due to reduced demineralization owing to reduced acid decalcification. The studys inferences could

25 weaken due to the evident pH cycling that controls re-mineralization and demineralization patterns (Watanabe et al 2006). The study also qualitatively analyses the efficacy making it less factual. The effect of toothpaste in reducing sensitivity of the dentinal cervix particularly in disease presence is also evident in Walshs (2009) study. In this case, he comparatively assesses the efficacy of a mouth crme with conventional Colgate paste in a 10-week randomized clinical survey with 89 subjects. The results are affirmative indicators of reduced hypersensitivity with less significant difference in terms of superior efficacy. Despite highlighting that the two oral products have different mechanisms of action, less elucidation regarding this prospect occurs to substantiate the inferences further. A literature review evaluation by Hasson, Ismail and Neiva (2008) also compares the efficacy of an OTC toothpaste with a placebo group in reducing dental plaque and gingivitis. The study utilized the EMBASE, MEDLINE and CENTRAL libraries to acquire its data dated between 1966 and 2005. The focus was on quasi and randomized controlled studies and screened the titles, data extracted and abstracts of independent and replicable articles. Of the 416 available articles, positive results regarding the use of whitening toothpaste contrary to a placebo transpired. The study however accrued the weaknesses of the evaluated studies particularly regarding wrong inference making. In a pilot clinical, study by Tai et al (2006), assessment on the effect of a dentifrice with particulate bioactive glass as a constituent component in reducing dental plaque and gingivitis occurs. In a 6-week study, four factors including age, gender, gingival bleeding and plaque indices were assessed. A 16.4% and 58.8% reduction in plaque accumulation and gingival bleeding respectively was evident among toothpaste users without discrepancies in gender and age compared to a control group that brushed with water (Tai et al 2006). Despite these deductions, the study admits of discrepancies particularly in the group not using toothpaste despite brushing

26 attributing them to the Hawthorne effect. Using a whitening dentifrice with sodium hexametaphosphate (polypyrophosphate) the efficacy to reduce extrinsic tooth discoloration and gingivitis assessment occurred (Baig et al 2005). This is a systematic review of laboratory and clinically published data regarding similar studies. The results indicate positive results despite the use of sodium polypyrophosphate in divergent delivery systems and formulations. Although the study focuses more on stain inhibition potency of such dentifrices, it neglects gingivitis prospects. Furthermore, it has a qualitative other than quantitative focus hence is less pragmatic and factual. A similar study by Sensabaugh and Sagel (2009) focuses on the efficacy of a stannous fluoride toothpaste with the same polypyrophosphate using practice-based, clinical and laboratory data in enhancing tooth whitening. Results accentuate that clinical evidence regarding such dental formula in reducing extrinsic stains, calculus, plaque gingival bleeding and gingivitis using information from 1000 and 1200 dental patients and professionals respectively. Despite highlighting the holistic benefit of such dental formulas by conferring cosmetic and therapeutic effects, its components mechanisms of action, remain inexplicit. In addition, quantification of the efficacy lacks. A clinical study by Archilla et al (2000) examines the comparative efficacy of abrasive and ordinary toothpaste in calculus removal in vivo. Using 52 healthy subjects from Guatemala grouped in to two and subjected to ordinary and vigorous brushing respectively for a minute daily a four week follow up transpired. Assessment of calculus occurred with VMI and Lobene metrics with grading occurring each week (Archilla et al 2000). The results indicate no significant relationship between the use of the two toothpastes and on the brushing technique used to calculus reduction superiority despite recording positive results in each case. Ayad et al (2002) also compares the efficacy of two toothpastes in reducing dental staining using a parallel, randomized

27 and double blinded set clinical survey in 8 weeks time. An oral prophylaxis and a recording of baseline scores of stains preceded this using a trained examiner. Lobene index further ascertained the results from the 126 volunteers. The findings of the study show that addition of silica, an abrasive and a pyrophosphate helps in improving the efficacy of toothpaste to remove extrinsic stains as contrasted to a conventional one (Ayad et al 2002). The inferences are however limited since they do not focus on the method of application of toothpaste and consistency of brushing factors that are core in enhanced efficacy. In a randomized clinical study, the efficacy of three toothpastes with special additives (sodium fluoride, PVM copolymer and triclosan) in controlling supragingival plaque and gingivitis evaluation also occurs in Surendra et als (2010) study. On random assignment of the available toothpastes, subjects issuing of soft-bristled brushes and subjection to brushing twice a day occurred. After a six week follow up gingival examination occurred in the 171 subjects with results indicating a 0.243%, 2.0% and 0.3% efficacy against gingivitis in the groups using PVM copolymer, triclosan and sodium fluoride respectively. Despite these observations and inferences, elucidation on the mechanism is inexplicit. Standardization of tooth brushing is less contemplated. The results of the study concur with similar findings in a study by Nordbo et al (1988) that reinforce alleviation of tooth discoloration is feasible using dentifrices despite having less quantification regarding this supposition. Conversely, Oliveira et al (2008) focuses on the additive Aloe Vera in controlling gingivitis and dental plaque accumulation in a clinical study, which was double blind. Using gingival bleeding and plaque index comparison with conventional toothpaste occurred in a months period on subjecting the sample to a three-time brushing daily. The findings depict no significant difference between the two groups in terms of efficacy accentuating that Aloe Vera has no additional value in dental health. The study however highlights the Hawthorne effect

28 that could induce subjective inference making (Oliveira et al 2008). In addition, the inferences contest previous perception that herbal products have additional value in efficacy of dentifrices. The antimicrobial efficacy of dentifrices containing 5.25% sodium hypochlorite and 2.0% chlorhexidine gluconate in inhibiting a myriad of dental disorders such as discolorations, odor and toxicicty is ascertained in Jeansonne and Whites (1994). This is particularly core in root canal therapy. In in-vitro settings, treatment of human teeth using the two dentifrices occurred and exposed in anaerobic conditions for a day prior collection of microbiological samples. Results on culturing the collated samples show reduced bacterial counts contrary to control samples with chlorhexidine showing much superiority but with less significant difference to sodium hypochlorite. The mechanism conferring the antimicrobial properties is vague. Jarrar (2006) comparatively evaluates the efficacy of two mouth rinses with chlorhexidine and essential oil (Listerine) additives in preventing plaque re-growth in the inter-proximal. Following a 4 day, pellicle re-growth random treatment with the dentifrice to 60 subjects followed by a 2-week observation. Results showed a 13%, 25% and 54% efficacy in plaque removal for sterile water, Listerine and chlorhexidine dentifrices respectively. Despite these deductions, the mechanism in which antimicrobial properties are conferred is incomprehensible. Furthermore, consideration on the method of brushing that determines the amount of plaque removed did not occur. In a pilot study by Freitas, Fernandes and Attstrom (1992), efficient removal of dental plaque, proximally accumulated using chlorhexidine gel incorporated in toothpicks was assessed. In a design, that was double blind and using the Loe and Silness plaque index, a 7-subject follow up occurred. In addition, their normal oral hygiene practices continued with the toothpick use occurring daily for a week. When compared to a placebo group no significant difference occurred hence limited efficacy in eliminating dental plaque. Despite making conclusions concerning its

29 aim, the studys incorporation of normal brushing habits among the subjects could cause errors since such habits were distinct in each of them. The efficacy of dentifrices with amine fluoride additives in their organic and inorganic forms are also tested for their efficacy towards reduced oral sucrose accumulation and in inhibiting Streptococcus sanguis (Embleton, Newman & Wilson 1998). In an in-vitro setting, samples collected from dental plaque were cultured following their incubation with amine fluorides. The results indicate reduced biofilm growth in the presence of amine fluoride but more superior in the presence of sucrose. As in other studies, the mechanism, which this process occurs, remains unsubstantiated. Barnett (2006) evaluates the lucid in daily mouth-rinse use against bacterial accumulation owing to its efficacy. Using a systematic analysis of literature review Bernett (2006) evaluates studies regarding the risk of pellicle accumulation to gingivitis, mechanical control of plaque accumulation through tooth brushing and the ecology of microorganisms in the mouth as conferred by the use of various dentifrices in a 6-month evaluation. The findings reveal a solid rationale of using mouth rinse using evidence-based scientific research. This is due to its potency to deliver antimicrobial agents to inaccessible oral areas and the inadequacy affiliated with exclusive mechanical control of plaque through brushing. Although such strong conclusions are made, adequate support lacks since only six published articles confirmed this supposition affirmatively. Among Egyptians, Hassan, Mobarak and Fawzi (2008) assess chlorhexidine regimens as efficient in reducing plaque-induced gingivitis owing to their antimicrobial properties in a clinical study. Using 21 females, monitoring of daily intakes, use of mouth rinse with chlorhexidine, a 1-3 month follow up finalized with Mutans streptococci evaluation transpired. The findings show significant reduction of bacterial count on using chlorhexidine mouth rinse ranging from 82.3%-85.4% compared to a control group hence the recommendation on its continued and consistent use for

30 better efficacy. The deductions made in the study could be subjective since standardization of dietary intake did not occur hence accumulation of dental plaque and subsequent removal was not uniform. In vivo tests regarding the efficacy of dentifrices with special additives for optimal outcomes against gingivitis and other dental ailments is also of focus. Fine et al (2006) assess the efficacy of triclosan dentifrice comparatively with a control group administered conventional dentifrice in reducing Fusobacteria and Veillonella species using 15 subjects in a randomized study. Superior efficacy of 88-96% compared to 74-85% was realized on inculcating triclosan contrary to the controls after a 12-hour follow up. Despite highlighting that microorganism levels vary in individuals, the study declines to use the crossover design to standardize the obtained results hence erroneous deducing. Cullinan et al (1997) undertake a similar study but incorporate Sanguinaria herbal extract to enhance the potency against periodontitis. Using a parallel, randomized and double-blinded study involving 34 subjects the pocket depths, plague and gingival indices are taken after a fortnight and 6-week follow up respectively. Contrary to expectations, the two groups do not show any significant difference in efficacy despite recording affirmative results. Despite making these deductions, the study highlights inconsistencies with previous clinical studies that have ascertained affirmative anti-gingival activities in Sanguinaria hence the need for further research. It is evident on literature analysis that gaps regarding the efficacy of toothpowder in eliminating plaque induce gingivitis exist and this study seeks to close these gaps and add more knowledge in this field.

31

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32 Anil, S 2007. Plasma cell gingivitis among herbal toothpaste users: A report of three cases. The Journal of Contemporary Dental Practice, 8 (4), pp.1-5 Antonio, B et al. 2010. Etiology of gingivitis. European Journal of Dentistry, pp. 55-71 Ayad, F et al 2002. The stain prevention efficacy of two tooth-whitening dentifrices. Compend Contin Educ Dent. 23 (8), pp.733-736 Baig, A et al. 2005. Extrinsic whitening effects of sodium hexametaphosphate- A review including dentifrice with stabilized stannous fluoride. Compendium, 26 (9), pp. 47-53 Barnett, M. 2006. The rationale for the daily use of an antimicrobial mouth rinse. JADA, 137 (11), pp. 1621 Biesbrock, A. et al. 2008. Improved plaque removal efficacy with a new manual toothbrush. The Journal of Contemporary Dental Practice, 9 (4), pp.1-9 Botelho, M et al. 2007. Effect of a novel essential oil mouth rinse without alcohol on gingivitis: a double blinded randomized controlled trial. Journal of Applied Oral Science, 15 (3), pp.175-180 Cheung, A. et al. 2005. The potential for dental plaque to protect against erosion using an in vivo-in vitro model- A pilot study. Australian Dental Journal, 50 (4), pp. 228-234 Clarkson, J et al 2009. How to influence patient oral hygiene behavior effectively. Journal of Dental Research, 88 (10), pp. 933-937 Collins, L. et al (2005). The effect of a calcium carbonate/ perlite toothpaste on the removal of extrinsic tooth stain in two weeks. International Dental Journal, 55, pp.179-182

33 Claydon, N et al. 2004. Clinical study to compare the effectiveness of a test whitening toothpaste with a commercial whitening toothpaste at inhibiting dental stain. Journal of Clinical Periodontology, 31, pp.1088-1091 Cronin, M. et al 2000. Relative role of dentifrice and the toothbrush in plaque removal. Journal of Dental Research, 77, p.572 Cullinan, P et al. 1997. Efficacy of a dentifrice and oral rinse containing sanguinaria extract in conjuction with initial periodontal therapy. Australian Dental Journal, 42 (1), pp.47-51 Cury, J et al 2004. The importance of fluoride dentifrices to the current dental caries prevalence in Brazil. Brazilian Dental Journal, 15 (3), pp.167-174 Daiva, A et al 2011. The effectiveness of whitening toothpastes in reducing extrinsic dental stain. Biomedicina, 21 (2), pp.57-60 Ebrahim, B., Abdolhamid, A., & Mahdi, A. 2009. Antimicrobial effects of four medicinal plants on dental plaque. Journal of Medicinal Plants Research, 3 (3), pp. 132-137. Embleton, J., Newman, H & Wilson, M. 1998. Influence of growth mode and sucrose on susceptibility of Streptococcus sanguis to amine fluorides and amine fluoride-inorganic fluoride combinations. Applied and Environmental Microbiology, 64 (9), pp. 3503-3506 Fawad, J et al 2012. Role of dentifrices with essential oil formulations in periodontal healing. American Journal of the Medical Sciences, 343 (5), pp. 411-417 Fiona, C. 2009. Toothbrush technology, dentifrices and dental biofilm removal. Journal of Periodontology, 36, pp.1-7

34 Fine, D et al. 2006. The antimicrobial effect of a triclosan/copolymer dentifrice on oral microorganisms in vivo. JADA, 137, pp. 1406-1413 Fourrier, F et al 1998. Colonization of dental plaque a source of nosocomial infections in intensive care unit patients, Critical Care Medicine, 26, pp.301-308 Freitas, L., Fernandes, C. & Attstrom, R. 1992. The effect of 1% chlorhexidine gel delivered with toothpicks on proximal dental plaque. A pilot study. Brazilian Dental Journal, 3, pp.17-23 Geza, T et al. 2008. A clinical evaluation of extrinsic stain removal: a rotation oscillation power toothbrush versus a dental prophylaxis. The Journal of Contemporary Dental Practice, 9 (5), pp. 18 Grap, M et al. 2003. Oral care Intervention in critical care: frequency and documentation. American Journal of Critical Care, 12, pp.113-118 Gunsolley, J. 2006. A meta analysis of six month studies of antiplaque and antigingivitis agents. Journal of the American Dental Association, 137, pp.1649-1657 Hannah, J et al. 1989. Long-term clinical evaluation of toothpaste and oral rinse containing Sanguinaria extract in controlling plaque, gingival inflammation, and sulcular bleeding during orthodontic treatment. American Journal of Orthodontics Dentofacial and Orthopedics, 96 (3), pp.199-207 Harper, S., et al., 1990. Clinical efficacy of a dentifrice and oral rinse containing Sanguinaria extract and zinc chloride during 6 months of use. Journal of Periodontology, 61 (6), pp. 352-358. Hasson, H., Ismail, A. & Neiva, G. 2008. Home-based chemically-induced whitening of teeth in adults (review). Cochrane Database of Systematic Reviews, 4, pp. 1-58

35 Hassa, S., Mobarak, E. & Fawzi, E. 2008. The efficacy of different regimens of chlorhexidine as an antimicrobial agent for a group of Egyptians. Journal of Egypt Public Health Association, 83 (5 & 6), pp. 1-16 He, T. et al. 2010. A randomized clinical study to assess the extrinsic staining profiles of stannous and triclosan containing dentifrices. American Journal of Dentistry, 23 (2), pp. 22-26 Hosein, T et al. 2009. Comparison of the plaque removing efficacy of toothpaste and toothpowder. Journal of International Academy of Periodontology, 11 (1), pp. 147-150 Hou, G. & Tsai, C. 1988. Primary gingival enlargement as a diagnostic indicator in acute myelomonocytic leukemia: A case report. Journal of Periodontology, 59 (12), pp.852-855 Jaksha, S. 2011. The role of a toothbrush in tooth brushing, inter-oral bacteria. Oral Systemic Healthcare, 3, pp. 1-11 Jarrar, A. 2006. Comparison of an essential oil mouth rinse and chlorhexidine on a 4-day interproximal plaque re-growth. Journal of Clinical Periodontology, 16, pp. 311-315 Jayaprakash, K., Veresha, K. & Hiremath, S. 2007. A comparative study of two mouth rinses on plaque and gingivitis in school children in the age group of 13-16 years in Bangalore city. Journal of Indian Soc Pedod Prevent Dent, pp. 126-129 Jeansonne, M. & White, R. 1994. A comparison of 2.0% chlorhexidine gluconate and 5.25% sodium hypochlorite as antimicrobial endodontic irrigants. Journal of Endodontics, 20 (6), pp.276-279 Joiner, A et al. 2002. Whitening toothpastes: effects on tooth stain and enamel. International Dental Journal, 52, pp.424-430

36 Joiner, A 2006. The bleaching of teeth: a review of the literature. Journal of Dentistry, 34, pp. 412-419 Karlinsey, R. et al. 2010. Re-mineralization potential of 5,000 ppm fluoride dentifrices evaluated in a pH cycling model. Journal of Dentistry and Oral Hygiene, 2 (1), pp. 1-6 Keitel, G. & Soentgen, M. 1995. Dental staining and antimicrobial therapy. Canadian Medical Association Journal, 93, pp. 1 Khozeimah, F., Khademi, H., & Ghalayani, P. 2008. The prevalence of etiologic factors for tooth discoloration in female students in Isfahan high schools. Dental Research Journal, 5 (1), pp. 13-16 Khuller, N. 2009. The biofilm concept and its role in prevention of periodontal disease. Rev Clin Pesq Odontol. 5 (1), pp.53-57 Kozak, K. & White, J. 2000. Dentifrice effects towards chemical stain prevention: an in vitro comparison. 78th General Session of the IADAR. Pp. 1-2 Lee, S. et al 1995. Nifedipine induced gingival enlargement around dental implants: A clinical report. Journal of Oral Implantology, 12 (2), 116-121 Loe, H. (1981). The role of bacteria in periodontal diseases. Bulletin of the World Health Organization, 59 (6), pp.821-825 Marchetti, E et al. 2011. Efficacy of essential oil mouthwash with and without alcohol: a 3-day plaque accumulation model. Trials, 12, pp. 262-270 Maripandi, A., Kumar, A. & Al-Salamah, A. 2011. Prevalence of dental caries bacterial pathogens and evaluation of inhibitory concentration effect on different toothpastes against streptococcus species. African Journal of Microbiology Research, 5 (14), pp. 1778-1783

37 Marsh, P. et al. 2005. Dental plaque as a biofilm and a microbial community-Implications for health and disease. BMC Oral Health, 6 (14), pp. 1-7 Moran, J. 2000. Chemical plaque control-prevention for the masses. Periodontology, 15, pp.109-117 Naresh, C et al. 2000. The clinical efficacy of Colgate total plus whitening toothpaste containing a special grade of silica and Colgate toothpaste for controlling bad odor twelve hours after brushing; A single use clinical study. The Journal of Clinical Dentistry, 13 (2), pp. 73-77 Nield-Gehrig, S. & Willmann, J. 2003. Dental plaque biofilms. Foundations of Periodontics for the Dental Hygienist, pp. 67-73 Nordbo, H et al. 1988. The capacity of a new dentifrice to prevent and remove extrinsic tooth discoloration. A clinical study. Clinical Prevention Dentistry, 10 (5), pp.15-17 Nwhator, S. & Ayanbadejo, P. 2011. Uncommon causes of gingivitis. Journal of Dentistry and Oral Hygiene, 3 (5), pp. 65-68 Okpalugo, J. 2009. Toothpaste formulation efficacy in reducing oral flora. Tropical Journal of Pharmaceutical Research, 8 (1), pp.71-77 Oliveira, S. et al. 2008. Effect of a dentifrice containing Aloe Vera on plaque and gingivitis control. A double blind clinical study in humans. Journal of Applied Oral Science, 16 (4), pp.293-296 Ozcan, C., Pinar, Y & Bulent, F. 2009. Clinical evaluation of whitening effect of whitening toothpastes: A pilot study. 8 (4), pp. 6-13 Panagakos, F & Scannapieco, F. 2003. Periodontal inflammation: From gingivitis to systemic diseases. Periodontology, 14, pp.33-43

38 Paraskevas, S 2005. Randomized controlled clinical trials on agents used for chemical plaque control. International Journal of Dental Hygiene, 3, pp.162-178 Santos, A. 2003. Evidence based control of plaque and gingivitis. Journal of Clinical Periodontology, 30 (5), pp.13-16 Schreiber, F et al 2010. Denitrification in human dental plaque. BMC Biology, 8 (24), pp. 1-11 Sensabaugh, C & Sagel, E. 2009. Stannous fluoride dentifrice with sodium hexametaphosphate: review of laboratory, clinical and practice based data. The Journal of Dental Hygiene, 83 (2), pp. 70-80 Shamikh, H. & Dweiri, A. 2011. Prevalence of gingivitis in 6-7 years old Jordanian children. Pakistan Oral and Dental Journal, 31 (1), pp.168-170 Sheen, S., Pontefract, H & Moran, J. 2001. The benefits of toothpaste-real or imagined? The effectiveness of toothpaste in the control of plaque, gingivitis, periodontitis, calculus and oral malodor. Dental Update, 28, pp. 144-147 Singh, S. et al 2011. Periodontal disease and adverse pregnancy outcome- A study. Pakistan Oral and Dental Journal, 31 (1), pp. 165-167 Smith, A et al. 2003. Efficacy of oral hygiene products against MRSA and MSSA isolates. Journal of Antimicrobial Chemotherapy, pp. 738-739 Smith, A et al. 2003. Efficacy of oral hygiene products against MRSA and MSSA isolates. Journal of Antimicrobial Chemotherapy, pp. 738-739 Surendra, S et al. 2010. A clinical investigation of the efficacy of three commercially available dentifrices for controlling established gingivitis and supragingival plaque. Journal of Clinical Dentistry, 21 (1), pp. 105-110

39 Swaminathan, D., Moran, J. & Addy, M. 1996. Inhibition of stain by some commercially available oral hygiene products. Annals of Dentistry, 3, pp. 19-21 Tai, B et al. 2006. Antigingivitis effect of a dentifrice containing bioactive glass (Novamin) particulate. Journal of Clinical Periodontology, 33, pp.86-91 Taylor, B. 2003. Management of drug induced gingival enlargement. Australian Prescriber, 26 (1), 11-13 Turksel, D et al 2004. Dental plaque removal efficacy of a battery powered and manual toothbrush. 3 (1), pp. 7-11 Walsh, L 2008. Dental plaque fermentation and its role in caries risk assessment. International Journal of Dentistry, 8 (5), pp. 34-41 Walsh, L 2009. The effects of GC tooth mousse on cervical dentinal sensitivity: a controlled clinical trial. International Journal of Dentistry SA, 12 (1), pp. 4-12 Watanabe, M et al. 2006. In vitro cariostatic effect of whitening toothpastes in human dental enamelmicrohardness evaluation. Quintessence International, 36 (6), pp. 467-473 Watts, A. & Addy, M. 2001. Tooth discoloration and staining: a review of the literature. British Dental Journal, 190 (6), pp. 309-317 Weijden, F. & Slot, E. 2011. Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontology, 55, pp.104-123 West, T & King, W (1982). Tooth brushing with hydrogen peroxide sodium bicarbonate compared to toothpowder and water in reducing periodontal pocket suppuration and dark field bacterial counts. Journal of Periodontology, pp.339-346

40 White, D et al. 2008. In vivo antiplaque efficacy of combined antimicrobial dentifrice and rinse hygiene regimens. American Journal of Dentistry, 21 (3), pp.189-196 Zamani, R. 2006. Fact sheets for families. Toothbrush care is important. American Academy of Pediatric Dentistry, 22 (5), p.1 Zero, D. 2006. Dentifrices, mouthwashes and re-mineralization/ caries arrest strategies. BMC Oral Health, 6 (1), pp. 1-13