What is the first line of treatment for gingivitis (early-stage gum disease)?

First-Line Treatment for Gingivitis

The first-line treatment for gingivitis is proper mechanical plaque removal through effective brushing technique and interdental cleaning, supplemented by chlorhexidine gluconate oral rinse (0.12%) as an adjunctive therapy for persistent cases. 1, 2

Treatment Algorithm for Gingivitis

Step 1: Mechanical Plaque Control

• Toothbrushing: Brush twice daily for at least 2 minutes using proper technique

  • Recommended technique: Modified Bass method 3
  • Power toothbrushes (especially rechargeable oscillating-rotating types) provide small but significant additional benefits over manual brushing 2

• Interdental Cleaning: Once daily cleaning between teeth

  • Interdental brushes (IDBs) are the device of choice where they can fit without trauma 2
  • Dental floss should be used only for tight spaces where IDBs cannot pass 2

Step 2: For Persistent or Moderate-to-Severe Gingivitis

• Chemical Plaque Control: Add antimicrobial mouthwash
  • First choice: Chlorhexidine gluconate (0.12%) rinse twice daily 1
    • FDA-approved specifically for gingivitis treatment
    • Use 10-15mL for 30-60 seconds, twice daily
    • Use between dental visits as part of professional program
  • Alternative options (if chlorhexidine causes staining or taste alterations):
    • Green tea-containing mouthwash (1% tannin) 3
    • Triphala mouthwash (10mL twice daily) 3
    • Aloe vera mouthwash 3

Step 3: Professional Intervention

• Professional dental cleaning (scaling) to remove calculus and plaque
• Reinforcement of oral hygiene instructions
• Follow-up to assess improvement

Evidence Strength and Considerations

The strongest evidence supports mechanical plaque removal as the foundation of gingivitis treatment 2. A 2021 randomized controlled trial demonstrated that a comprehensive oral hygiene regimen (stannous fluoride dentifrice, electric toothbrush, antimicrobial rinse, and floss) reduced gingival bleeding by 28-39% compared to usual care over 24 months 4.

Chlorhexidine gluconate (0.12%) has FDA approval specifically for gingivitis treatment and is supported by robust clinical evidence 1. It works by disrupting bacterial cell membranes and reducing plaque formation.

Important Caveats and Pitfalls

• Duration of brushing: While 2 minutes is recommended for general population, patients with gingivitis likely need longer brushing times 2
• Chlorhexidine side effects: Can cause tooth staining, taste alteration, and increased calculus formation with prolonged use
• Compliance issues: Interdental cleaning has low adherence rates; patient education on proper technique and importance is critical
• Systemic considerations: Untreated gingivitis can progress to periodontitis, which has been associated with systemic health issues 5
• Monitoring: Regular follow-up is essential as experimental evidence shows plaque accumulates faster in the presence of gingival inflammation 6

If gingivitis does not improve with these measures, evaluation for underlying systemic conditions (diabetes, immunosuppression) or progression to periodontitis should be considered, as these may require additional interventions.