How should gingivitis be managed?

Management of Gingivitis

Gingivitis should be managed with professional mechanical plaque removal (scaling) combined with twice-daily brushing using a soft toothbrush, interdental cleaning once daily, and adjunctive 0.2% chlorhexidine mouthwash used twice daily for 60 seconds, with reassessment at 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 biofilm that causes gingival inflammation and is reversible with appropriate intervention. 2

Professional Intervention

• Professional scaling and root planing is the essential first step to remove established plaque and calculus that patients cannot eliminate through home care alone. 1
• Professionally administered plaque control significantly improves gingival inflammation and lowers plaque scores. 3
• Reassessment after 2-4 weeks is mandatory to determine if the treatment plan requires adjustment. 1

Daily Oral Hygiene Protocol

Toothbrushing Technique

• Brush teeth twice daily (after meals and at bedtime) for at least 2 minutes using a soft toothbrush with the Bass or modified Bass method. 4, 1
• Use a mild fluoride-containing, non-foaming toothpaste. 4, 5
• Replace the toothbrush monthly to maintain effectiveness and reduce bacterial colonization. 4, 5
• Rechargeable power toothbrushes provide additional benefit, offering small but statistically significant reductions in gingival inflammation and plaque beyond manual brushing. 1, 3

Interdental Cleaning

• Clean between teeth once daily using interdental brushes (IDBs) as the device of choice for interproximal plaque removal. 1, 3
• Dental floss should only be used at sites where interdental brushes cannot pass through without trauma, typically in areas of gingival and periodontal health with tight contacts. 3
• Critical pitfall to avoid: Do not initiate interdental cleaning if you have not been doing it regularly, as starting during active inflammation can disrupt the epithelial barrier and cause bleeding. 4

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 prevent 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

If chlorhexidine side effects are problematic, several evidence-based natural alternatives demonstrate comparable efficacy without tooth staining: 1

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

Mouthwash Application Protocol

• Rinse with 15 mL of alcohol-free mouthwash upon awakening and at least four times daily after brushing. 4, 5
• Rinse for approximately 1 minute, gargle, then spit out. 4
• Avoid eating or drinking for 30 minutes after rinsing to maximize contact time and efficacy. 4, 5

When to Consider Antibiotics

Antibiotics are NOT recommended for routine gingivitis treatment. 1 This is a critical point that prevents unnecessary antibiotic exposure and resistance development.

Rare Indications for Antibiotics

Antibiotics should only be considered if: 1

• Systemic involvement is present (fever, malaise, lymphadenopathy)
• The infection extends into facial spaces
• First choice: Amoxicillin
• Second choice: Amoxicillin-clavulanic acid

Lifestyle Modifications and Preventive Measures

Eliminate Irritants

• Stop smoking and alcohol consumption, as both impair healing and promote inflammation. 4, 5
• Avoid irritating foods including tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods. 4, 5

Address Mechanical Trauma

• Have a dental professional eliminate sources of trauma such as ill-fitting dentures, fractured teeth, or sharp dental restorations. 4, 5
• Address habits like lip or cheek biting that can perpetuate inflammation. 5

Maintain Oral Moisture

• Drink ample fluids throughout the day to keep the mouth moist. 4
• For patients with dry mouth, consider sugarless chewing gum, candy, or salivary substitutes. 5

Special Considerations for Denture Wearers

• Remove dentures before performing oral care. 4, 5
• Brush dentures with toothpaste and rinse thoroughly with water. 5
• Limit wearing dental prostheses until oral tissues heal if active inflammation is present. 5
• For hospitalized patients, soak dentures in 0.2% chlorhexidine for 10 minutes before insertion. 5

Common Pitfalls to Avoid

1. Do not use antibiotics for routine gingivitis - this is unnecessary and promotes resistance. 1
2. Do not discontinue treatment prematurely before complete resolution of inflammation, as this leads to recurrence. 1
3. Do not rinse immediately after toothbrushing if using chlorhexidine - wait 30 minutes. 1
4. Do not use chlorhexidine for established oral mucositis - it is ineffective in this context. 6
5. Do not start interdental cleaning during active inflammation if you haven't been doing it regularly. 4

Clinical Significance

Gingivitis represents a reversible inflammatory condition that, if left untreated, can progress to periodontitis with irreversible bone loss and tooth loss. 7, 2 Experimental studies demonstrate that even short-term gingivitis (21 days) induces systemic inflammatory markers including hsCRP, IL-6, and MCP-1, which are also surrogate markers for atherosclerotic plaque development. 8 Importantly, reinitiation of proper oral hygiene almost completely reverses these inflammatory markers, underscoring the critical importance of consistent plaque control. 8