What is the recommended management for gingivitis in a generally healthy adult?

Gingivitis Treatment

The primary treatment for gingivitis in healthy adults is professional mechanical plaque removal (scaling) combined with twice-daily toothbrushing for at least 2 minutes using fluoride toothpaste, daily interdental cleaning with interdental brushes, and adjunctive 0.2% chlorhexidine mouthwash used twice daily for 60 seconds. 1

Core Treatment Algorithm

Step 1: Professional Mechanical Plaque Removal

• Professional scaling and root planing is the foundation of gingivitis treatment 1
• This must be performed before initiating home care regimens for optimal results 2
• Scaling alone at 6-month intervals is insufficient without patient behavior change 2

Step 2: Daily Mechanical Plaque Control

Toothbrushing Protocol:

• Brush twice daily for at least 2 minutes with fluoride toothpaste 1, 3
• Use the Bass or modified Bass technique with a soft toothbrush 1
• Replace toothbrush monthly 1
• Rechargeable power toothbrushes provide small but statistically significant additional reductions in gingival inflammation and plaque compared to manual brushing 1, 3

Interdental Cleaning:

• Interdental brushes (IDBs) are the device of choice for interproximal plaque removal 3, 4
• Use once daily 3
• Moderate evidence supports that IDBs reduce both plaque and gingivitis when combined with toothbrushing 4
• Dental floss should only be used at sites where interdental brushes cannot pass through without trauma 3
• Flossing has weak evidence and fails to demonstrate effectiveness in plaque removal in most studies 4

Step 3: Adjunctive Chemical Plaque Control

Chlorhexidine (First-Line Adjunctive Agent):

• Use 0.2% chlorhexidine mouthwash twice daily for 60 seconds 1
• Critical timing: Wait 30 minutes after toothbrushing before using chlorhexidine to avoid inactivation by toothpaste ingredients 1
• Avoid eating or drinking for 30 minutes after rinsing 1
• Side effects include tooth staining, taste alteration, and increased calculus formation with prolonged use 1

Natural Product Alternatives (Comparable Efficacy):

• 0.1% turmeric mouthwash (10 mL twice daily for 21 days) 1
• Triphala mouthwash (10 mL twice daily for 2 weeks) - cost-effective with no reported side effects 1
• 100% aloe vera mouthwash (twice daily for 1 minute) 1
• 0.25% lemongrass oil mouthwash 1
• Green tea mouthwash 1

Step 4: Reassessment and Follow-up

• Reassess gingival health after 2-4 weeks to adjust the treatment plan 1
• Long-term reinforcement of oral hygiene is essential to prevent relapse 2
• Regular professional maintenance is necessary as motivation alone is insufficient without repeated reinforcement 2

Critical Pitfalls to Avoid

Do NOT prescribe antibiotics for routine gingivitis:

• Antibiotics are generally not recommended for gingivitis treatment 1
• Only consider antibiotics if there is systemic involvement (fever, malaise, lymphadenopathy) or extension into facial spaces 1
• If antibiotics are necessary, amoxicillin is first choice, with amoxicillin-clavulanic acid as second option 1

Do NOT discontinue treatment prematurely:

• Treatment must continue until complete resolution of inflammation 1
• Patients require ongoing motivation and instruction on a person-to-person basis 2

Do NOT use chlorhexidine immediately after toothbrushing:

• This inactivates the chlorhexidine; a 30-minute gap is mandatory 1

Evidence Quality Considerations

While natural product-based mouthwashes show promising results in multiple RCTs, there is currently insufficient evidence to shift from regulatory-approved products (like chlorhexidine) to natural oral hygiene products as first-line therapy 5. However, they represent viable alternatives when chlorhexidine side effects are problematic or patient preference dictates 1.

The evidence base for mechanical plaque removal remains the strongest, with professional instruction and patient compliance being the most critical factors for successful gingivitis resolution 3, 6, 2.