Oral Hygiene Improvements by a Novel Zinc Toothpaste—Results from a 6-Week Randomized Clinical Study amongst Community-Dwelling Adults

Abstract

Objective: This clinical investigation evaluated oral health improvements after the use of a novel zinc toothpaste in comparison to a control after 3 weeks and 6 weeks of use. Clinical assessments of gingivitis, bleeding and dental plaque evaluated oral health. Methods: Healthy adults meeting the study criteria (plaque index scores ≥ 1.5 and gingival index scores ≥ 1.0) were randomized into a treatment group with 74 participants assigned to the test and 73 participants assigned to the control groups. With the assigned toothpaste, subjects were instructed to brush at home twice a day for one minute. Subjects were evaluated clinically for gingivitis, plaque and bleeding at the baseline, employing 3-week and 6-week examinations. Results: All one hundred and forty-seven (147) subjects completed the 6-week study with no significant differences between groups at baseline (p > 0.05). The test demonstrated progressive improvements at the 3-week and 6-week evaluations as compared to the control (p < 0.001). In comparison to the control, the test demonstrated reductions of 13.4%, 17.0% and 55.3% for gingivitis, dental plaque and gingival bleeding, respectively, at the final visit (p < 0.001). Conclusions: Clinical improvements in gingivitis, dental plaque and gingival bleeding were registered in the group assigned the test toothpaste as compared to the control. The test toothpaste demonstrated statistically significant and progressively improving gingivitis, dental plaque and gingival bleeding scores that were all statistically significant versus the control at each post-treatment assessment.

1. Introduction

Common oral diseases are widespread, with global estimates suggesting half the world’s population is afflicted with some form of untreated disease [1,2]. Some of the most commonly reported oral conditions include caries, gingivitis and periodontal disease [3,4,5,6,7,8]. Together, common oral diseases have significant impacts on quality of life with significant deleterious influences on health [1,3,5,7,8]. Current evidence in clinical dentistry stipulates that many common oral conditions are preventable with appropriate steps leading to reductions in chronic oral diseases such as periodontitis [4,5,6,7,8].

The oral microbial burden represents an important etiological factor in the progression of gingivitis with microbial populations found on the distinct surfaces of the human mouth [2,4]. Many studies have examined the dental plaque biofilm, its microbiological composition and the extracellular matrix that aids its adherence to the dental hard tissues [1,2,3,4,5,6]. A distinctive characteristic of the dental biofilm is the large diversity and dense populations of microorganisms [1,2,4,6]. In addition to the dental biofilm on hard tissues, microbial populations are found in saliva and the oral soft tissue surfaces such as the tongue, cheeks and gingiva [1,2,4]. Notable features of these populations include their spread by saliva to different regions of the mouth. A variety of microbial metabolites, acids and components with inflammatory attributes are produced during the growth and proliferation of oral microorganisms [1,2,4,5,6]. Advancing microbial accumulation in these distinct sites leading to an increasing oral inflammatory burden can manifest clinically as gingivitis [1,2,3,6]. The unique anatomic features of the human mouth, offering a variety of distinct surfaces with hard and soft tissue regions, aid the accumulation of microbial populations and their inflammatory signals. Food intake and dietary residues in the various areas of the human mouth represent an additional exogenous component influencing microbial outcomes [1,2,3,5].

Dental professionals identify effective routine oral hygiene as an important means to control the dental biofilm and mitigate the harmful effects of microbial accumulations in the human mouth [1,2,5,6]. Despite research advances in the preventative attributes of routine self-care, surveys reveal inadequate oral hygiene by most individuals [3,4,5].

An approach to improve oral hygiene is the use of efficacious toothpaste and mouthwash formulations with effective antimicrobial agents [7,8,9,10]. Ongoing clinical trials aim to assess the effectiveness of extra active ingredients with anti-plaque and antibacterial properties [4,7,8]. Utilizing therapeutic agents in toothpaste and mouthwashes to inhibit plaque formation is now a firmly established method for enhancing gingival health [4,7,8,9,10]. Metal salts were among the initial groups of compounds investigated [3,4,7,8]. Among these, zinc and tin salts have garnered significant attention, primarily due to their acknowledged antibacterial properties and relatively high safety profile [8,10]. Toothpaste formulations incorporating antimicrobial agents alongside fluoride are formulated to decrease plaque levels and the presence of harmful bacteria while preserving the natural balance of the oral environment [4,5,6,7,8,9,10]. Specifically, reductions in pathogenic bacteria have been linked to decreases in periodontal diseases like gingivitis [1,3]. The astringency of zinc at clinically effective levels limits the utilization of numerous zinc salts. Nonetheless, opting for citrate salt, which has low solubility in water but higher solubility in dentifrice formulations, enables the incorporation of zinc at levels adequate for antiplaque efficacy while ensuring a palatable product [7,8,9]. Many studies have shown that the use of dentifrice containing zinc salts inhibits plaque formation and includes a variety of formulations with zinc alone or in combination with other agents [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22].

This 6-week, single-center, double-blind, randomized and parallel-design clinical study evaluated the efficacy of a new zinc toothpaste with natural ingredients as compared to a control toothpaste on the reduction and control of established dental plaque and gingivitis after 3-weeks and 6-weeks of twice-daily toothbrushing.

2. Materials and Methods

This clinical study employed a double-blind, randomized, two-treatment, parallel-group design. Adult male and female subjects from the Mysore, India area were enrolled in the study based on the study criteria. The study recruited community-dwelling adult subjects of either gender from the local area who were healthy and not seeking any medical or dental care. All study-related steps were commenced after the clinical study protocol was reviewed and approved by the ethical board of Jagadguru Sri Shivarathreeshwara Dental College and Hospital. Also approved were the informed consent forms provided to subjects. All study-related steps and subject examinations were conducted at the dental clinics of JSS Dental College by dentists who were calibrated in the dental indices selected.

2.1. Inclusion Criteria

Adults [between the ages of 18 and 70 (inclusive)], and in generally good health and adequate oral hygiene who voluntarily completed and signed the informed consent form were scheduled for a screening visit at the dental clinics of the JSS Dental College, Mysuru, Karnataka, India. Subjects were required to be available for the duration of the study and demonstrate a willingness to comply with all study procedures and clinical examination schedules. Subjects had to possess at least 20 natural teeth with facial and lingual score-able surfaces; and be in good periodontal health with no more than five (5) periodontal pockets over 5 mm. Subjects with gingival index scores (Löe–Silness gingival index [23]) greater than or equal to (≥) 1.0 and plaque index scores (Turesky Modified Quigley and Hein plaque index [24,25]) greater than or equal to (≥) 1.5 were enrolled in the study.

2.2. Exclusion Criteria

Subjects who presented moderate to advanced periodontal disease, 5 or more decayed untreated dental sites at the dental screening examination or other diseases of the hard or soft oral tissues and salivary impairment were excluded. Subjects were excluded from the study if they presented orthodontic bands; or partial or removable dentures; or had received a dental prophylaxis in the month prior to the baseline examination. Other study exclusion criteria included participants who reported ongoing medical or dental procedures including prescription medications such as antibiotics or anti-inflammatory or anti-coagulants or reported completion of any health-care procedures in the three months preceding study enrollments.

Also excluded were subjects who were unable to comply with study requirements, adherence to study procedures and examinations, and excessive gagging during oral assessment. Reports of allergies to oral care/personal care consumer products or their ingredients, or a history of adverse effects following the use of oral hygiene products such as toothpaste and mouth rinse were also exclusion criteria. Subjects with existing medical conditions that prevented them from eating and drinking for periods up to four hours, were also excluded from the study.

Other exclusion criteria include those reporting pregnancy, ongoing lactation or impending pregnancy during the study period. Subjects reporting chronic conditions including diabetes, heart disease, and immune-compromised subjects (HIV, AIDS, immune suppressive drug therapy) were excluded. Individuals who were participating in any other clinical study or who had participated in a study within one month prior to enrollment of the study were not allowed to participate in the study, along with individuals with a history of alcohol or drug abuse.

2.3. Clinical Study Procedures

• Subject selection:

Prospective study subjects from the local area reported to the clinical facility having refrained from all oral hygiene procedures for 2-h prior to their visit (baseline). All prospective subjects who met the inclusion/exclusion criteria and signed an informed consent form received a baseline gingivitis, dental plaque and bleeding evaluation, along with an oral soft and hard tissue assessment.

2.

Randomization of subjects to treatment groups:

Using the baseline gingival index score and plaque index scores, qualifying subjects were randomized into two balanced groups. A computer-generated randomization list was used to allocate the subjects to their assigned treatment group.

3.

Study Treatments and blinding:

The two treatments employed in this study were the test and control toothpastes. The new test toothpaste was formulated with zinc salts and natural ingredients, i.e., Clove (Syzgium Aromaticum), Aloe Vera (Aloe Barbadensis), Amla (Emblica Officinalis), Neem (Azadirachta Indica), Tulsi (Ocimum Basillicum) and Honey (from Apis Mellifera). The control toothpaste was formulated with fluoride but without zinc or herbal ingredients. Both the test and the control toothpaste were formulated with 1000 ppm fluoride (sodium monofluorophosphate). All toothpastes were maintained in their original package, overwrapped and provided a unique code to maintain double-blind blinding. Study staff who were not associated with any other study-related activities maintained the test articles. Subjects were issued their treatments in an area separate from the dental clinic used for clinical evaluations.

4.

Subject Instructions:

Following the treatment assignment, subjects were provided a soft-bristle toothbrush [Colgate Extra Clean Toothbrush, Colgate-Palmolive Company, New York, NY, USA] and their assigned toothpaste. Using the toothbrush, all subjects were instructed to brush their teeth with their assigned toothpaste at least twice daily (morning and evening) for one minute. Subjects were instructed to not use any other oral hygiene formulations for the study period.

5.

Post-treatment clinical examinations after 3 weeks and 6 weeks of test article use:

After 3-weeks and 6-weeks use of assigned test products, all subjects returned to the clinical facility for gingivitis, plaque and bleeding examinations. Additionally, at each examination, subjects received an evaluation of their oral soft tissue by the examining dentist and were questioned for the occurrence of any adverse events. At their final visit, all subjects returned their assigned treatment to the clinical study staff. Shown in Figure 1 is the CONSORT diagram of the population screened, enrolled and evaluated over the study period.

6.

Clinical assessments:

Clinical assessments were performed at the dental clinics of JSS Dental College by calibrated examiners. The clinical indices for this study are described below.

  6.1.

Gingivitis Assessment

Gingivitis was assessed at 6 sites (disto-, mid-, mesio-buccal and disto-, mid-, mesio-lingual) of each tooth according to the criteria of the Gingival Index system [23].

  6.2.

Dental Plaque Assessment:

Dental plaque assessments were completed after all plaque were disclosed using a disclosing solution. The entire dentition was evaluated for dental plaque and plaque scored at the disto-, mid-, mesio-buccal and disto-, mid-, mesio-lingual surfaces of each tooth according to the criteria of the modified Quigley and Hein Index [24,25].

  6.3.

Gingival bleeding measurement

The Sulcus Bleeding Index was used to evaluate gingival bleeding [26].

2.4. Statistical Methods

There are no previous studies that evaluated these test articles with goals that resemble those of this investigation. Reductions in gingivitis were used to determine sample size using a mean score of 1.6 and a standard deviation of 0.2 from historical data. The study sought to detect a 10% difference between the two treatment groups at 80% power, β = 0.2 and α = 0.05 at the post-treatment evaluations. To detect inter-group differences of 10% and above, calculations estimated a sample size of 73 subjects in each treatment group. Sample size calculations for this study were estimated using commercially available software [GraphPad 9.0, Boston, MA, USA].

Statistical analyses of study results were performed separately for the following outcome measures gingivitis, dental plaque and bleeding index scores. Treatment groups were compared with respect to gender and age by Chi-Square and independent t-test, respectively. Comparisons of the treatment groups with respect to baseline gingival index scores, plaque index scores and bleeding index scores were performed using an independent t-test. Within-treatment comparisons of the baseline versus follow-up gingival, plaque and bleeding index scores were performed using paired t-tests. Comparisons of the treatment groups with respect to baseline-adjusted gingival, plaque and bleeding index scores at the follow-up examinations were performed using Analyses of Covariance (ANCOVA’s). All statistical tests were two-sided and employed a level of significance of α = 0.05.

3. Results

Demographic features of the study population who completed the entire study are presented in

Table 1. Demographics summary of study participants completing the entire study.

	Number of Subjects			Age 3
Treatment	Male	Female	Total 3	Mean	Range
Test group 1	35	39	74	37.1	20–59
Control group 2	41	32	73	38.2	23–59

¹ Zinc toothpaste with herbal ingredients and fluoride. ² Control toothpaste with fluoride. ³ No statistically significant differences noted between treatment groups, with gender evaluated by a chi-square and age evaluated by t-test (p > 0.05).

. One-hundred-forty-seven (147) subjects entered the clinical study and complied with the protocol and completed the 6-week clinical study. A summary of the gender and age of the study population is presented in Table 1. The treatment groups did not differ significantly with respect to either of these characteristics (p > 0.05). Throughout the study, there were no adverse events on the oral soft and hard tissue of the oral cavity observed by the examiner, or reported by the subjects when questioned.

A summary of the gingival, plaque and bleeding index score measured at the baseline examination from the subjects who completed the clinical study is shown in

Table 2. Summary of the 3-Week Clinical Scores from subjects who completed the entire clinical study.

Index	Toothpaste Treatment	N	Baseline Summary [Mean ± SD]	3-Week Summary [Mean ± SD] 3	Within Treatment Comparison 1		Between-Treatment Comparison vs. Control Toothpaste Group 2
					Percent Sig. Reduction		Percent Reduction Sig
Gingival Index	Test	74	1.62 ± 0.20	1.34 ± 0.15	17.3%	p < 0.001	8.2%	p < 0.001
	Control	73	1.66 ± 0.19	1.46 ± 0.17	12.0%	p < 0.001		p < 0.001
Dental Plaque	Test	74	2.18 ± 0.47	1.56 ± 0.28	28.4%	p < 0.001	9.8%	p < 0.001
	Control	73	2.16 ± 0.42	1.73 ± 0.31	19.9%	p < 0.001		p < 0.001
Bleeding Index	Test	74	0.81 ± 0.33	0.44 ± 0.24	45.7%	p < 0.001	32.3%	p < 0.001
	Control	73	0.85 ± 0.36	0.65 ± 0.30	23.5%	p < 0.001		p < 0.001

¹ Within treatment comparison, Analysis conducted by paired t-test. ² Between treatment comparisons. Analysis conducted by ANCOVA. ³ Significant differences between treatments at the 3-week evaluations (p < 0.001).

. At the baseline examination, no statistically significant differences were observed between the treatment groups for the gingival index or plaque index or bleeding index scores (p > 0.05).

Shown in Table 2 is a summary of the gingival, plaque and bleeding index scores measured after 3-weeks of treatment use. Both the test and the control treatments demonstrated reductions in all clinical scores from their corresponding baselines (p < 0.001). Higher percentage reductions in all clinical scores were observed for the test treatment as compared to the control. Between treatment comparisons by ANCOVA demonstrated significantly greater reductions by the test treatment for gingival, plaque and bleeding index scores as compared to the control (p < 0.001). The test treatment demonstrated reductions for gingival, plaque and bleeding index scores of 8.2%, 9.8% and 32.3%, respectively, (p < 0.001) at the 3-week examination as compared to the control. Additional analyses indicate significant differences between the test and the control treatments for gingival, plaque and bleeding index scores at the 3-week examination (p < 0.001).

Statistical analysis of the results from the clinical evaluations conducted after 6-week brushing with assigned treatments is shown in

Table 3. Summary of the 6-Week Clinical Scores from subjects who completed the entire clinical study.

Index	Toothpaste Treatment	N	Baseline Summary [Mean ± SD]	6-Week Summary [Mean ± SD] 3	Within Treatment Comparison 1		Between-Treatment Comparison vs. Control Toothpaste Group 2
					Percent Sig. Reduction		Percent Reduction Sig
Gingival Index	Test	74	1.62 ± 0.20	1.10 ± 0.12	32.1%	p < 0.001	13.4%	p < 0.001
	Control	73	1.66 ± 0.19	1.27 ± 0.13	23.5%	p < 0.001		p < 0.001
Dental Plaque	Test	74	2.18 ± 0.47	1.17 ± 0.17	46.3%	p < 0.001	17.0%	p < 0.001
	Control	73	2.16 ± 0.42	1.41 ± 0.21	34.7%	p < 0.001		p < 0.001
Bleeding Index	Test	74	0.81 ± 0.33	0.17 ± 0.08	79%	p < 0.001	55.3%	p < 0.001
	Control	73	0.85 ± 0.36	0.38 ± 0.19	55.3%	p < 0.001		p < 0.001

¹ Within treatment comparison. Analysis conducted by paired t-test. ² Between treatment comparisons. Analysis conducted by ANCOVA. ³ Significant differences between treatments at the 6-week evaluations (p < 0.001).

. Both treatment groups demonstrated progressively higher percentage reductions in gingival, plaque and bleeding index scores from the 3-week evaluations. In comparison to their baselines, both the test and control treatments demonstrated significantly greater reductions for gingival, plaque and bleeding index scores at the 6-week examination (p < 0.001). The test treatment also demonstrated higher percentage reductions for gingival, plaque and bleeding index scores than the control. Significantly greater reductions in gingival, plaque and bleeding index scores were observed in the test group than in the control at the 6-week assessment (p < 0.001). Additionally, statistical analyses indicate significant differences between the test and control treatments for the gingival, plaque and bleeding index scores at the 6-week examination (p < 0.001).

Shown in

Table 4. Summary comparing the results between the 3-Week and 6-Week Clinical Scores from subjects in the group issued the test toothpaste.

Index	Toothpaste Treatment	N	3-Week Summary [Mean ± SD]	6-Week Summary [Mean ± SD]	Comparisons between the 3-Week and 6-Week Evaluations
					Percent Sig. Reduction
Gingival Index	Test	74	1.34 ± 0.15	1.10 ± 0.12	17.9%	p < 0.001
Dental Plaque	Test	74	1.56 ± 0.28	1.17 ± 0.17	25%	p < 0.001
Bleeding Index	Test	74	0.44 ± 0.24	0.17 ± 0.08	61%	p < 0.001

is a comparison within the test group for post-treatment clinical evaluations. The test group registered progressively increasing improvements from the 3-week to the 6-week evaluations for all clinical results. Statistically significant improvements in gingival, plaque and bleeding index scores were observed at the 6-week assessments by the test group in comparison to the corresponding 3-week results (p < 0.001).

4. Discussion

Maintaining good oral hygiene hinges significantly on effective plaque control. Nevertheless, numerous patients struggle to attain optimal oral hygiene, thereby increasing their susceptibility to common oral conditions such as periodontal disease [2,3,4,5,6]. Controlling the growth and colonization of plaque bacteria is particularly crucial since they are the primary cause of periodontal diseases [1,2,3]. Toothpaste is a commonly used method to distribute chemotherapeutic agents throughout the oral cavity, inhibiting the growth of oral microorganisms [5,7,8,10]. Various antimicrobial agents have been included in toothpaste formulations, and their impact on plaque control has been investigated [8,10]. Several studies on zinc, conducted in accordance with widely accepted guidelines for testing the clinical efficacy of toothpastes, are available in the literature [8,9,10,11,12,13,14,15,16,17,18,19,20]. Toothpaste formulations containing a combination of triclosan and zinc citrate have been described since the 1980s [18,19,20,21]. Clinical trials have extensively documented the efficacy of this combination system, demonstrating its antimicrobial, antiplaque, and antigingivitis effects [7,8,18,19,20,21]. Moreover, the utilization of zinc as an antiplaque agent has been the focus of numerous literature reviews [7,8,9,10]. Regulatory agencies like the US FDA have evaluated the safety of these ingredients. Studies indicate that dentifrices formulated with zinc exhibit efficacy in subjects with both low and high rates of plaque growth [17,20]. Particularly, individuals with higher plaque growth rates tend to benefit more from zinc dentifrices compared to those with lower rates of plaque growth [17,18,19,20]. Zinc salts have been employed either in combination with other ingredients or as standalone agents in various studies [8,9,10,11,12,13,14,15,16,17,18,19,20,21]. Zinc citrate and zinc chloride, which are commonly utilized zinc salts, have demonstrated anti-plaque activity [7,8,10,12,17,18,19,20,21,22]. Toothpaste containing zinc citrate has been shown to inhibit the initial stages of in vivo biofilm formation, along with exerting effects on specific groups of oral bacteria [11,12]. Additionally, zinc dentifrice formulations have been reported to reduce the populations of oral bacteria in various areas of the mouth [15,16]. In a six-month study, it was found that a toothpaste containing 2% zinc citrate and 0.76% sodium monofluorophosphate led to notable reductions in plaque and gingival scores [24]. Over a 4-week period, an investigation comparing the effectiveness of herbal and non-herbal toothpaste revealed that both the experimental and control groups exhibited notable decreases in plaque and gingivitis, suggesting an improvement in oral health [27].

The current study employed a parallel design with randomized treatment assignment, following procedures consistent with previously published trials and widely accepted standards [8,13,17]. The study was conducted in a blinded manner, and participants were recruited from the general population of both rural and urban communities in the local area. These subjects are considered representative of the Indian population, as they typically have moderate utilization of dental services, with the majority reporting brushing their teeth once a day and low use of dental floss or mouth rinses. This pattern was observed across different education, employment, and financial statuses [28]. Subjects who provided written voluntary informed consent were enrolled in the study. The treatment groups were well-balanced in terms of demographic characteristics, with gingival index scores averaging approximately 1.6 and plaque index scores averaging 2.1. These scores suggest the presence of naturally occurring gingivitis in these subjects. The study evaluated the beneficial effects of unsupervised home use of the assigned toothpaste among participants who received no other oral hygiene instructions during the study period.

While most research studies have evaluated zinc in the form of zinc citrate or zinc chloride, the present investigation aimed to evaluate the efficacy of toothpaste formulated with zinc salts and herbal ingredients. This double-blind clinical study spanned a short observation period of 3 and 6 weeks, comparing the clinical efficacy of the test toothpaste, which contained zinc salts and herbal ingredients along with fluoride, to the control toothpaste, which contained fluoride alone.

The toothpastes evaluated in this study were formulated with calcium carbonate and other excipients [22]. During the study, the test group and the control groups exhibited statistically significant reductions in both plaque and gingivitis scores from their baselines. However, the effects of the test toothpaste were consistently greater than those of the control at each evaluation, indicating the superior therapeutic effects of the toothpaste formulated with zinc. The reductions in clinical scores corresponded with reductions in the frequencies of surface scores observed. Throughout the study duration, the test treatment consistently exhibited progressive effects, surpassing those of the control at each post-brushing evaluation. This study underscores the effectiveness of brushing with a dentifrice containing herbal ingredients and zinc in preventing naturally occurring gingivitis and dental plaque compared to using a control fluoride toothpaste.

An important attribute of this research is the compliance of participants to study procedures. Study compliance was maintained by periodic reminders to study participants. Adherence to the provided instructions represents a study constraint that can influence overall results. Notably, despite the reliance on subject compliance, results from this study demonstrate significant improvements in oral health amongst subjects assigned the zinc toothpaste. Similar to findings in previous studies, the control group also showed clinical improvements in oral hygiene measures [22]. These observations can be attributed to study enrollment and instructions provided during the study period, along with the scheduled clinical evaluation visits at the dental clinic.

There is a growing literature that seeks to evaluate new therapeutic possibilities represented by novel ingredients that likely have applications for managing oral diseases [29,30]. Natural products and ingredients are examined routinely since they represent attractive options for formulating new oral healthcare products for routine use [29,30]. The relative abundance of natural ingredients along with potential safety are some reasons that support their continued assessments. Many scientific investigations including clinical studies have sought to examine the beneficial outcomes of natural ingredients and products designed with these actives. Formulations with single components or mixtures representing polyherbal mixtures in conjunction with other proven ingredients comprise some of the advances in this area [29,30]. In addition to these assessments, other research has added to these directions reporting evaluations of hyaluronic acid [31] and ozone [32] as measures to improve periodontal health. Encouraging outcomes reported in these investigations support the design of clinical guidelines with these formulations that may progress to confirmatory studies that facilitate their beneficial application in clinical practice. Other lines of investigation include initiatives to compare the ingredients highlighted in this clinical study with those reporting clinical benefits in previous studies [29,30]. Efforts to augment beneficial outcomes of the active ingredients reported in this investigation with others to deliver unique formulation features and enhanced clinical efficacy are appropriate future research directions.

This study enrolled community-dwelling adults who presented with gingivitis and search demonstrate clinical improvements after only a few weeks of toothbrushing with effective toothpastes and can serve as an important attribute for patient engagement. Future research can extend this effort to determine outcomes amongst other groups of clinically stratified subjects including those with dental implants. Recent reports identify significant advances in the validation of oral biomarkers [5,6]. Results from future clinical studies with the toothpastes evaluated in this study may provide foundational information supporting evidence generation for oral biomarkers.

5. Conclusions

This study demonstrated that routine toothbrushing with a dentifrice containing herbal ingredients and zinc had a greater potential to inhibit plaque formation and concomitant improvement in gingival conditions when compared with that of fluoride-containing toothpaste. These results may be attributed to the antimicrobial properties of the test toothpaste. Since this study evaluated the efficacy of the dentifrices for 6 weeks, the results further substantiate the short-term use of these ingredients to reduce gingival inflammation.