What is the appropriate treatment for an adult patient with inflammation of the gum (gingivitis), assuming no underlying medical conditions?

Treatment of Gingivitis in Adults

The appropriate treatment for gingivitis consists of professional mechanical plaque removal (scaling) combined with improved daily oral hygiene practices and adjunctive chlorhexidine 0.2% mouthwash used twice daily for 60 seconds, with reassessment after 2-4 weeks. 1

Primary Treatment Strategy

The cornerstone of gingivitis management is professional mechanical plaque removal through scaling, which must be paired with patient education on proper oral hygiene techniques. 1 This approach directly addresses the bacterial plaque that causes gingival inflammation and prevents progression to periodontitis. 2, 3

Daily Oral Hygiene Protocol

• Brush teeth twice daily for at least 2 minutes using a soft toothbrush with mild fluoride-containing, non-foaming toothpaste, employing the Bass or modified Bass technique. 1
• Replace toothbrush monthly to maintain effectiveness. 1
• Rechargeable power toothbrushes provide statistically significant additional reductions in gingival inflammation and plaque compared to manual brushing. 1, 2
• Brush after meals and before sleep for optimal plaque control. 1

Interdental Cleaning

• Use interdental brushes (IDBs) as the device of choice for interproximal plaque removal once daily. 1, 2
• Flossing should only be used at sites where interdental brushes cannot pass through without trauma. 2

Adjunctive Chemical Plaque Control

Chlorhexidine Mouthwash (First-Line Adjunctive Agent)

• Use 0.2% chlorhexidine mouthwash twice daily for 60 seconds to reduce plaque and gingival inflammation. 1
• Wait 30 minutes after toothbrushing before using chlorhexidine to avoid inactivation by toothpaste ingredients. 1
• Be aware that chlorhexidine may cause tooth staining, taste alteration, and increased calculus formation with prolonged use. 1

Natural Product Alternatives (Comparable Efficacy)

If chlorhexidine side effects are problematic, evidence-based alternatives include:

• Triphala mouthwash (10mL twice daily) - cost-effective with no reported side effects. 1
• 0.1% turmeric mouthwash (10mL twice daily for 21 days) - comparable efficacy to chlorhexidine. 1
• 100% aloe vera mouthwash (twice daily for 1 minute) - effective for plaque and inflammation reduction. 1
• 0.25% lemongrass oil or green tea mouthwash - show comparable anti-plaque and anti-inflammatory effects without tooth staining. 1

Antibiotic Use: Critical Caveat

Antibiotics are NOT recommended for routine gingivitis treatment. 1 This is a common pitfall that must be avoided. 1

Antibiotics should only be considered if:

• Systemic involvement is present (fever, malaise, lymphadenopathy). 1
• Infection extends into facial spaces. 1
• When necessary, amoxicillin is first-line, with amoxicillin-clavulanic acid as second-line. 1

The American Heart Association strongly discourages prescribing antibiotics for nonspecific or unproved febrile syndromes, as this practice is a major cause of culture-negative infective endocarditis. 4

Follow-Up and Reassessment

• Reassess gingival health after 2-4 weeks to evaluate treatment response and adjust the plan accordingly. 1
• This timing is crucial for determining whether the current regimen is adequate or requires modification. 1

Clinical Context and Rationale

Poor oral hygiene leads to gingivitis, which can progress to periodontitis with irreversible bone loss and tooth loss. 4, 3 The evidence demonstrates that poor oral hygiene and periodontal diseases—not dental procedures—are responsible for the vast majority of oral-origin bacteremia and associated complications. 4

While gingivitis is highly reversible with proper treatment, the threshold for plaque accumulation to trigger disease progression may be low in high-risk patients, making adjunctive chemical plaque control particularly valuable. 2 Mechanical plaque removal remains the bedrock of successful management, but adjunctive agents offer meaningful advantages in controlling inflammation. 2

Common Pitfalls to Avoid

• Never prescribe antibiotics for routine gingivitis without systemic involvement. 1
• Do not discontinue treatment prematurely before complete resolution of inflammation. 1
• Avoid rinsing immediately after toothbrushing when using chlorhexidine—wait 30 minutes. 1
• Do not overlook patient education on proper brushing and interdental cleaning techniques, as behavior change is essential for long-term success. 1, 2