What is the recommended treatment for a patient with gingivitis?

Gingivitis Treatment

The cornerstone of gingivitis treatment is professional mechanical plaque removal (scaling) combined with twice-daily brushing using proper technique, interdental cleaning with interdental brushes, and adjunctive use of 0.12-0.2% chlorhexidine mouthwash for 60 seconds twice daily, with mandatory reassessment at 2-4 weeks. 1, 2

Initial Professional Treatment

• Professional scaling and plaque removal must be performed first to establish baseline oral health before initiating home care 2
• Patient education on proper oral hygiene techniques is essential and should include demonstration of correct brushing and interdental cleaning methods 1, 3

Daily Mechanical Plaque Control Protocol

Toothbrushing Technique

• Brush twice daily (after meals and before sleep) for at least 2 minutes using the Bass or modified Bass technique 1, 2
• Use a soft-bristled toothbrush with mild fluoride-containing, non-foaming toothpaste 1, 2
• Rechargeable power toothbrushes provide additional reductions in gingival inflammation and plaque beyond manual brushing 1, 2, 4
• Replace toothbrushes monthly 1, 2

Interdental Cleaning

• Interdental brushes are the device of choice for interproximal plaque removal 4
• Flossing should only be used for sites where interdental brushes will not pass through without trauma 4
• Clean interdentally once daily 4
• Critical caveat: Do not initiate interdental cleaners in patients receiving active cancer therapy due to risk of epithelial barrier disruption 1, 2

Adjunctive Chemical Plaque Control

Chlorhexidine (First-Line Adjunctive Agent)

• Use 0.12-0.2% chlorhexidine gluconate oral rinse for 60 seconds twice daily 1, 2, 5
• This is FDA-approved for treatment of gingivitis between dental visits 2, 5
• Critical timing requirement: Wait 30 minutes after toothbrushing before using chlorhexidine to prevent inactivation by toothpaste ingredients 1, 2
• Use 15 mL of alcohol-free formulation, gargle, then spit out 1, 2
• Avoid eating or drinking for 30 minutes after rinsing 1, 2
• Common side effects: tooth staining, taste alteration, and increased calculus formation with prolonged use 1, 3

Natural Product-Based Alternatives (Equal Efficacy)

When chlorhexidine side effects are problematic or for long-term maintenance, evidence-based alternatives include:

• Triphala mouthwash (10 mL twice daily): Cost-effective with no reported side effects and comparable efficacy to chlorhexidine 1, 2, 3
• Aloe vera mouthwash (100% concentration, twice daily for 1 minute): Effectively reduces plaque and gingival inflammation 1, 2, 3
• Turmeric mouthwash (0.1% concentration, twice daily for 1 minute for 21 days): Demonstrates effectiveness similar to chlorhexidine 1, 2, 3
• Lemongrass oil (0.25% concentration, twice daily for 1 minute for 21 days): Shows comparable results to chlorhexidine 1, 3
• Green tea mouthwash (1-5% concentration): Demonstrates similar anti-plaque and anti-gingivitis effects to chlorhexidine 1, 3

All natural alternatives show comparable efficacy to chlorhexidine with minimal side effects, particularly no tooth staining 1, 3

Antibiotic Use: Strict Limitations

• Antibiotics are NOT recommended for routine gingivitis treatment 1, 2
• Consider antibiotics ONLY if systemic involvement is present: fever, malaise, lymphadenopathy, or extension into facial spaces 1, 2
• When necessary, amoxicillin is first-line, with amoxicillin-clavulanic acid as second-line 1
• Chlorhexidine has not been tested in acute necrotizing ulcerative gingivitis (ANUG) 5

Mandatory Follow-Up

• Reassessment of gingival health after 2-4 weeks is crucial for adjusting the treatment plan 1, 2, 3
• This reassessment determines whether the current regimen is adequate or requires modification 1

Common Pitfalls to Avoid

• Never use antibiotics unnecessarily for routine gingivitis—this is the most common error 1, 2
• Never rinse with chlorhexidine immediately after toothbrushing—the 30-minute wait is essential to prevent inactivation 1, 2
• Never discontinue treatment prematurely before complete resolution of inflammation 1
• Never recommend flossing as primary interdental cleaning when interdental brushes can be used without trauma 4
• Most studies on natural product mouthwashes are short-term; long-term efficacy requires further investigation, but they remain viable alternatives for patients experiencing chlorhexidine side effects 3