What is the effect of active ingredients in dentifrice on inhibiting the regrowth of overnight plaque? A systematic review

Abstract Objectives The aim of this systematic review was to establish the adjuvant clinical effect of brushing with a dentifrice containing purported active ingredients as compared to a regular sodium fluoride dentifrice with respect to the inhibition of overnight dental plaque regrowth from studies with human participants. Methods MEDLINE‐PubMed, EMBASE and Cochrane CENTRAL were searched, up to June 2019. The inclusion criteria were controlled clinical trials with participants aged ≥ 18 years in good general health. Studies were included that evaluated the effect of toothbrushing with a dentifrice on the inhibition of overnight dental plaque regrowth when an active ingredient was added to the dentifrice as compared to a common sodium fluoride product. Data were extracted from the eligible studies, the risk of bias was assessed, and a meta‐analysis was performed where feasible. Result Independent screening of 213 unique papers resulted in 10 eligible publications that provided 14 comparisons. Stannous fluoride and triclosan dentifrices were found as the active ingredients. The descriptive analysis indicated that all, but two comparisons demonstrated an additional effect on the active‐ingredient dentifrice. The meta‐analysis supported and strengthened these findings. It showed that when plaque was scored digitally, a DiffM was −3.15(95% CI [−4.61:‐1.69], P < .001, prediction interval [−5.07;‐1.24]). When plaque was scored clinically, the difference of means (DiffM) was −0.33(95% CI [−0.49:‐0.16], P < .001, prediction interval [−0.87; 0.21]). Conclusion The results of this review demonstrate moderate‐quality evidence that brushing with an active‐ingredient dentifrice with stannous fluoride or triclosan does provide an added clinically relevant effect concerning plaque inhibition capabilities that surpass the effect of a regular sodium fluoride dentifrice.


| INTRODUC TI ON
Routine toothbrushing is perhaps the single most important step for an individual to take in order to reduce plaque accumulation and to reduce the consequent risk of plaque-associated diseases, such as periodontitis and caries. 1 In addition to toothbrushing, dentifrices can help with stain removal, breath freshening and provide a feeling of cleanliness. 2 Fluoride-containing dentifrices also play an essential role in caries prevention. 3,4 A recent systematic review concluded that dentifrice does not provide an added effect for the mechanical removal of dental plaque. In terms of plaque removal, toothbrushing is at least as effective as toothbrushing with a dentifrice. 5 In this respect, it seemed that the mechanical action provided by the toothbrush was the main factor in the plaque removal process. 6 However, despite brushing every day, people are typically not effective brushers and live with large amounts of plaque on their teeth. 7 It is here that chemical adjuncts to toothbrushing could be beneficial. Chemicals could prevent bacterial attachment, stop bacterial division and plaque growth, or may even remove plaque. 8 Although the long-term use of dentifrices with active ingredients intended for patients with gingivitis is associated with the prevention of bacterial biofilm formation, only a few of these products have been systematically evaluated in relation to gingival health. For example, the use of stannous fluoride or triclosan dentifrices resulted in greater gingivitis and plaque reduction than the use of a conventional dentifrice. [9][10][11][12][13][14] However, the primary aim of these studies had a focus on plaque removal and not on preventing plaque accumulation on the dentition. An important intervention target for chemotherapeutics is to optimize plaque control by inhibiting overnight plaque regrowth. 15 Since the use of dentifrices is widespread and available scientific literature suggests that dentifrices reduce plaque regrowth, 16 a further aspect of interest is whether following a brushing exercise dentifrices that contain purported active ingredients reduce overnight plaque regrowth more than regular sodium fluoride dentifrices. This overnight model was not included in a recent SR which demonstrated moderate-quality evidence in a 4-day non-brushing model with dentifrice slurry for a weak inhibitory effect on plaque regrowth in favour of the use of a dentifrice intended for daily use. 16 Therefore, the purpose of this paper was to systematically and critically appraise the literature concerning the adjuvant effect of a dentifrice on the inhibition of overnight plaque regrowth.

| MATERIAL S AND ME THODS
This systematic review was prepared and described in accordance with the Cochrane Handbook for Systematic Reviews of Interventions 17 and in the guidelines Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA statement). 18

| Protocol development
The protocol for this review was developed "a priori" and registered with the International Prospective Register of Systematic Reviews 19 under the registration number CRD42019126734. All post hoc changes were appropriately noted (see Appendix S14).

| Focused PICOS question
In healthy adults (P), what is the effect of brushing with a dentifrice containing purported active ingredients to inhibit overnight plaque regrowth (I) compared to a regular sodium fluoride dentifrice (C) according the clinical indices of dental plaque (O) using an overnight plaque accumulation model (S)?

| Screening and selection
The titles and abstracts of the studies obtained from the searches were screened independently by two reviewers (CV and DES) to select studies that potentially met the inclusion criteria. No language restrictions were imposed. Based on the title and abstract, the full-text versions of potentially relevant papers were obtained.
These papers were categorized (CV and DES) as definitely eligible, definitely not eligible or questionable. Disagreements concerning eligibility were resolved by referring to the original article. If no consensus could be reached, the decision was resolved through arbitration by a third reviewer (GAW). The papers that fulfilled all inclusion criteria were processed for data extraction.

| Inclusion criteria
The included studies were considered to meet the following criteria: (a) The study design was either a randomized controlled clinical trial (RCT) or a controlled clinical trial (CCT), and.
(b) the publications were available as full reports. Population: (c) The studies were conducted with humans, who were not institutionalized and who were 18 years of age or older, (d) in good general health (no systematic disorders), and without orthodontic appliances and/or removable prostheses. Intervention: (e) The intervention was toothbrushing with an active-ingredient dentifrice. Comparison: (f) The control was a standard fluoride dentifrice. Outcome: (g) The studies evaluated regrowth of plaque.

| Exclusion criteria
*Chlorhexidine was the active ingredient incorporated in a dentifrice. 20 *Additionally, rinsing with an antiseptic as part of the intervention or control regimen.
For details, see Appendix S2.

| Assessment of heterogeneity
The following factors were used to evaluate the heterogeneity of the outcomes of the different studies: study design, participant characteristics, study group details, side effects and industry funding.

| Assessment of methodological quality and risk of bias
All included studies were independently scored for their methodological quality by two reviewers (CV and DES) using the checklist presented in Appendix S3. Disagreement was resolved by consensus, and if disagreement persisted, the decision was resolved through arbitration by a third reviewer (GAW). The assessed items as detailed in Appendix S3 were used to classify a study as having an estimated low, moderate or high risk of bias. 21

| Data extraction
The characteristics of the population, intervention, comparison and the raw scale. 22 For those papers that provided insufficient data to be included in the analysis, the first or corresponding author was contacted to request additional data. If no response was received within a reasonable amount of time, the study was not included in the meta-analysis.

| Data analysis
As a summary, a descriptive data presentation was used for all studies. For studies that had multiple treatment arms and for which data from the control group were compared with more than one other group, the number of participants (n) in the control group was divided by the number of comparisons. The data are presented, and the modifications of the original indices [23][24][25] are provided. The difference of means (DiffM) between brushing with and without an activeingredient dentifrice was calculated using a "random-effects" model with an "inverse variance" method as proposed by DerSimonian and Laird. 26 For MA with more than two comparisons, 95% predictive intervals were calculated to quantify potential treatment effects in a future clinical setting. 27 Heterogeneity was tested using the chi-square test and the I 2 statistic with 95% confidence intervals around I 2 . 17 Inflation bias or "p-hacking" was tested with a P-curve analysis. 42,43 Post hoc sensitivity analysis was conducted to evaluate the influence of a single study on the overall effect estimate by stepwise omitting, one by one, each of the studies included in the meta-analysis and re-evaluating the summary effect estimates. [44][45][46] Post hoc analysis was conducted on study design. Computations for the MA were performed using R (https ://www.r-proje ct.org) with the packages meta 44,47 and metafor. 48 In order to judge the clinical relevance of study results, "distribution-based" methods were used. [49][50][51][52][53] The clinical relevance was

| Grading the "body of evidence"
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to rank the evidence. 55 Two reviewers (DES and GAW) rated the quality of the evidence and the strength and direction of the recommendations 56 according to the F I G U R E 1 Search flow chart following aspects: risk of bias, consistency of results, directness of evidence, precision and publication bias, and magnitude of the effect.

| Search and selection results
The search of the MEDLINE-PubMed and Cochrane CENTRAL databases resulted in 270 unique papers (for details, see Appendix S1).
Screening of the titles and abstracts resulted in 18

| Study characteristics and heterogeneity
The included studies exhibited considerable heterogeneity.
Information regarding the study characteristics is presented in detail in Appendix S2A. The demographic characteristics are summarized in Appendix S2B.
With the exception of two studies, 25,57 all reported to be randomized. Only two studies had a parallel design. 58,59 The others all used a crossover design. All the studies included evaluated overnight plaque scores in the morning before brushing. In one study, the period of no oral hygiene extended to 12 hours 59 and, in two other studies, to 24 hours. 57,60 A fourth study used a power brush. 61 The studies were carried out in several countries around the world, which included India, 59 China, 62 the UK 60,61 and the United States. 25,57,58,63,64 A total of 456 participants provided data for this review.
Participants ranged from experienced employee dentifrice panels 57,61,63-65 to non-dental populations. 58,59,62 In the studies, there were several dropouts. Two participants did not complete the study protocol, 62,64 and 15 participants were ineligible due to migration, unforeseen health events and other unspecified reasons. 59 One study did not describe dropouts. 58 The time for brushing varied in the studies. One study instructed participants to brushing for one minute twice per day 58,59 and two studies instructed participants to brush for two minutes twice per day. 61 The studies did not allow any additional oral hygiene products but in four studies, 15,61,63,64 floss users could continue to floss their posterior teeth only. In three studies, participants were explicitly instructed to brush only their lingual surfaces in the evening prior to the next appointment 25,63,66 and in one study, the participants were requested to swish the intra-oral dentifrice slurry over the facial surfaces for 30 seconds. 25 Compliance in using the dentifrice was not monitored in any of the studies. One study 62 provided, during the initial study visit, a full dental prophylaxis to remove all supragingival plaque and calculus.
The dentifrices used in the studies varied between the studies with regard to the following: percentage fluoride compound, percentage stannous fluoride and the difference in accurately describing the ingredients. One study used a stannous fluoride prototype dentifrice. 63 All the other dentifrice products were marketed at the time of the individual studies. Information on dentine abrasivity (RDA) was lacking in all studies.
In the included papers, two different indices for plaque scoring were used. Seven studies 25

| Industry funding
All studies mentioned the utilization of commercially available oral hygiene products (dentifrice, toothbrush

| Side effects
Three included papers did mention the recording of side effects 25,62,64 but did not observe any adverse events or side effects.

| Methodological quality and assessment of bias
To estimate the potential risk of bias, the methodological qualities of the included studies were used, as assessed in the checklist presented in Appendix S3. The procedures for allocation concealment were not described in any of the selected studies. Two studies provided explicit information on sample size calculation and power. 59,61 Blinding to the product was described in all the selected studies with the exception of one study. 25 Blinding of the examiner to the product however was unclear. Based on a summary of the proposed criteria, the estimated potential risk of bias was low for six studies, 58 The number of decimals to which the annotations have been rounded off is 2.
Plaque Index was assessed clinically, and outcomes according to the DPIA index 25 were scored digitally.

| Descriptive analysis
Appendix S5 provides a descriptive summary of the significant difference between an active-ingredient dentifrice compared to a regular sodium fluoride dentifrice on overnight dental plaque regrowth, as reported by the original authors. Twelve comparisons out of 14 demonstrated a significant difference between interventions in favour of the use of dentifrice with purported active ingredients, while one comparison with a stannous fluoride-containing dentifrice 59 and one comparison with a triclosan dentifrice 64 demonstrated no significant difference in comparison with a regular dentifrice.

| Meta-analysis
All studies except one 25 provided information on sample size, outcomes and standard errors/deviations. No additional data were obtained after contacting the authors. A random meta-analysis could be performed, but the studies were separately analysed based on the index used. A subgroup analysis was performed by dentifrice ingredient. Table 2 presents the outcomes.
The analysis of the available data from the modification of the

| Statistical heterogeneity
The percentage of variance in the meta-analysis attributable to study heterogeneity was high for the studies assessing the Q&H index by

| Publication bias detection
The test for funnel plot asymmetry, based on rank correlation 31 or linear regression method, 29 was not significant (P = .46 and P = .55).
Contour-enhanced funnel plots and plots with trimfill 33,68 are presented in Appendix S8A,B. Since most of the missing studies are located in regions of high significance, publication bias is unlikely to be the underlying cause of asymmetry. 68 A Copas selection model analysis was conducted to investigate, and attempt to correct for, selection/publication bias in the meta-analysis. 34

| Trial sequential analysis
Appendix S10 presents the results of the trial sequential analyses (TSA) per index used. TSA of this MA showed that the effect was conclusive and reliable, and that additional data are unlikely to affect the summary effect. 41

| Post hoc sensitivity analysis study design
Three post hoc sensitivity analyses of the crossover trials using stannous fluoride were performed in order to confirm the robustness of the results of the MA. 69 A within-patient correlation of 0.5 was assumed because information of the required matched outcome data was not available. 17,70 The sensitivity analysis of the crossover trials with correlation coefficients of 0, 0.25 and 0.5 is in agreement with the results of the MA. See Appendix S11 for the results of the post hoc sensitivity analysis.

| Additional analysis
The results of the influence or sensitivity analysis by calculating pooled estimates omitting one study at a time showed that no single study significantly influenced the pooled DiffMs. See Appendix S9 for supporting information. Concerning the inflation bias indicated the P-curve analysis evidential value and no indication for p-hacking, data-mining or "selective reporting". 42,43,71,72 See Appendix S8D for the P-curve plot.

| Clinical significance assessment
Because of the availability of sufficient data, calculation of the clinical significance or relevance was possible for three studies 58,59,62 with six comparisons. The final clinical relevance judgement was estimated to be clinically relevant for all but one. 59 When the studies with stannous fluoride or triclosan were pooled, the judgement was clinically relevant for the pooled triclosan experiments and potentially clinically relevant in the case of the stannous fluoride experiments. See Appendix S12 for the results of the clinical relevance assessment.

| Evidence profile
The data gathered are indirect as the model of interest is a research model for a proof of principle. However, the data are rather consistent and precise. Table 3 summarizes the various aspects that were used to rate the quality of the evidence as proposed by the GRADE working group. 55 Eight out of 10 studies included in this review were RCTs, which are widely considered the gold standard of study design when assessing effectiveness, assuming that they are methodologically sound. 14

| D ISCUSS I ON
The prevention of dental caries and periodontal diseases centres on dental plaque control. In this context, chemical agents could represent a valuable complement to mechanical plaque control. 73 Over recent decades, studies of various agents have provided information on their efficiency in controlling or inhibiting plaque growth. 3,11,12,14,74 However, differentiating between dentifrices in terms of their antiplaque properties also requires assessment of their ability to inhibit plaque regrowth, which is commonly measured as overnight plaque accumulation. 75 The purpose of this systematic review (SR) was to establish to what extent a dentifrice inhibits overnight plaque regrowth.
In this SR, dentifrices containing the active ingredients stannous fluoride or triclosan were significantly more effective at inhibiting overnight plaque regrowth than regular dentifrices containing sodium fluoride. The effect of stannous fluoride was found to extend over a 24-hour period.
In the studies with the DPIA 25 index, no baseline scores were available, but all the participants received both interventions.
Therefore, the differences as revealed in the meta-analysis concerning the end scores demonstrated true differences in outcomes of the investigated products.
Colgate® Total® and Crest® Pro-Health® are currently the only two dentifrices with purported antiplaque properties accepted by the ADA. 76 Claims that chemotherapeutic products

Overall recommendation
With the interest to inhibit overnight regrowth of plaque, consider a dentifrice product that contains either triclosan or stannous fluoride TA B L E 3 Estimated evidence profile 55 regarding the effect on the inhibition of plaque regrowth of the adjunctive use of an active dentifrice with brushing control or modify plaque may be made only if it can also be demonstrated that there is a significant effect against gingivitis. 77,78 The criteria set are that studies should show a statistically significant proportional reductions of 20% or more in indices, referring to a comparison between the active therapy and the control at the end of the study. 79 In the present SR, the criteria of sufficient proportional reduction were only met by five out of 14 experiments. This contrasts with the studies using the digital DPIA index, 25 where one out of five studies did not meet this criterion. The weighted mean proportional reduction for the Q&H index by Turesky et al 24 was 12.9% and for the digital DPIA 25 index 25.0%. Several studies indicate that this difference may find its origin in the fact that computer-based plaque analyses are more precise, more objective and more sensitive than classic plaque indices. 80 The Q&H index by Turesky et al 24 is a 0-5 integer assessment of the plaque on labial, buccal and lingual surfaces of each individual tooth. 81 For example, if a particular tooth area is assessed as a score of one and a toothbrush removes 50% of the plaque at this site, the resultant is still one. In order for the index to be zero, the plaque must be completely removed. 25 It is envisioned that DPIA 25 will overcome this and other problems. 25,82 Another noteworthy difference is that DPIA 25 performs a partial plaque measurement (the facial surfaces of 12 anterior teeth). Data from a large cross-sectional study demonstrate that an efficient, partial mouth plaque measurement at visible sites (19% of total) was comparable to whole mouth plaque scores. 83 This is in concordance with earlier findings from Bentley & Disney. 84 All the studies in this SR are in some way related to the industry. Correlations between funding by industry and study outcomes are frequently observed in the literature. 85 Studies that report positive or significant results are more likely to be published and statistically significant outcomes have higher odds of being fully reported. 86 On the other hand, especially from renowned manufactures, the quality of the research is high because the procedures are ensured according to the criteria of good clinical practice. Moreover, several studies concluded that positive conclusions in dentifrice trials are not associated with conflict of interest or funding. 87 Stannous fluoride and triclosan are agents known to have antimicrobial properties. 63,75,85,88,89 The exact ingredients of the dentifrices of the included studies in this SR were not always clear. There were also differences in ppm fluoride levels in the comparisons. This may be a concern in the comparisons of dentifrices because fluoride and sodium lauryl sulphate (SLS) also have antibacterial potential. 90 Different formulations of the same active agents may have different effect sizes. 12 Moreover, the compositions of a dentifrice product changes in time. The current formulation of Crest® Pro-Health® has since 2005 incorporated stabilized stannous fluoride and an ingredient for whitening benefits, sodium hexametaphosphate. 91 In combination with zinc citrate, triclosan does not seem to be as effective as when it is formulated with Gantrez TM . Which effect versus a control was demonstrated to be non-significant. 12,85 The complex compositions of dentifrices should be considered when evaluating individual ingredients.
Recently, the FDA has banned triclosan and certain other antiseptic chemicals. Products containing triclosan should now be subject to a premarket review. The US FDA, the European

Commission and several national health authorities have reviewed
Colgate Total with triclosan on several occasions and have approved Colgate Total as a safe and effective medicinal dentifrice up to the approved level of 0.3%. However, its effectiveness as an antimicrobial agent, the risk of antimicrobial resistance and its possible role in hormonal developmental disruption remain controversial. 92 Beginning of 2019, Colgate has changed its formulation and has removed triclosan and has now a completely new formulation with L-arginine and zinc. 93 A chlorhexidine dentifrice can also be effective for plaque control. However, the inclusion of chlorhexidine in a dentifrice formulation can pose problems because chlorhexidine can be inactivated by ingredients such as flavours and anionic detergents. 94 The side effects and tooth discoloration are an obstacle to the generalized use of chlorhexidine products and may have a negative impact on patient compliance, which limits its usefulness in daily practice. 20,95 Therefore, it was decided "a priori" not to include chlorhexidine in the present review.

| Prediction intervals
Besides the difference in means (DiffM) and 95% confidence intervals, we also calculated 95% prediction intervals. The prediction interval can help understand the uncertainty about whether or not an intervention works. 27 A prediction interval quantifies the dispersion of effect estimates of the interventions. In the experiments using the DPIA 25 index, the effect of a new study will be within an interval of −5.07 and −1.24 with 95% confidence. For the studies using the Q&H index the effect of a new study will be within an interval of −0.87 and 0.21 with 95% confidence. In the latter case, the estimated probability that the true effect of the use of a dentifrice with triclosan or stannous fluoride in comparison with a regular dentifrice will be null or higher in a new study is 94%. 27

| Influence analysis
The leave-one-out method can be used in a random-effects context to informally investigate the influence of specific studies 96 by assessing whether these studies have a very high influence on the overall results of the meta-analysis effect sizes. The plot highlights influential studies, as when they are left out of the analysis, the overall estimate will be notably distorted. When a sensitivity analysis shows that the overall result is not affected to a large extent, the results of the meta-analysis give more confidence. In this review, the results of the sensitivity analyses showed that no single study significantly influenced the pooled estimates. See Appendix S9 for supporting information and plots.

| Inflation bias analysis
Inflation bias, also known as "p-hacking" or "selective reporting," is assumed to occur when researchers try out several statistical analyses and/or data eligibility specifications and then selectively report those that produce significant results. 42,43,71,72 The P-curve is a plot of the distribution of p-values reported in a set of scientific studies.
Comparisons between ranges of p-values have been used to evaluate fields of research in terms of the extent to which studies have genuine evidential value, and the extent to which they suffer from bias in the selection of variables and analyses for publication. 97 For details, see Appendix S8D.

| Trial sequential analysis
Most systematic reviews with meta-analyses are underpowered. 98,99 TSA is a cumulative random-effects meta-analysis method that es- the studies with stannous fluoride. Therefore, TSA suggests that the statistical evidence of these meta-analyses is firm for both products.
The conclusion of sufficient statistical power is supported by the P-curve in Appendix S8D-2.

| Post hoc sensitivity analysis study design
In a crossover trial, each participant serves as his/her own control. Between-patient variation is removed from the treatment comparison resulting in a smaller number of patients to achieve the same statistical power. Using a crossover design results in a gain in precision in all trials. 44

| Clinical significance assessment
Statistical significance analysis provides only a dichotomous answer.
It may or may not be statistically significant and does not offer an indication of how important the result of the study is. 53

| Limitations related to the evidence that emerges from this review
Several limitations were identified for this review.
• While there is an emerging evidence base in public health, the data in support can often be difficult to find. Indexing of journals in MEDLINE has assisted those conducting systematic reviews to more easily identify published studies. However, information technology and the processes associated with indexing are not infallible. Studies may not be correctly marked by study design which may mean they are missed in the electronic searching process. 104 • The more resources searched, the higher the yield, and thus time and consequently the costs required to conduct a systematic review. While there is an abundance of evidence to suggest how extensive a search for randomized controlled trials (RCTs) should be, it is neither conclusive nor consistent. 105 • Another limitation may be the use of published research papers only. The authors of this review did not have the resources to obtain data that are kept "on file" by the various dentifrice manufacturers. This is known as the "file drawer problem," as a form of publication bias. 106,107 • Due to the focused question of this SR, no long-term studies were involved. As a representative of home-use, longer-duration studies of antimicrobial properties of dentifrice are required. 108 • The compliance of the participants to the given protocols may be considered as an important factor in the study outcomes. None of the studies mentioned that compliance was evaluated.
• Various toothbrush types were used in the studies included, and therefore, evaluation of the added benefit of the dentifrice between studies might be influenced by this diversity.
• The populations selected for studies of dental plaque assessment, in most cases, would be individuals with mild to moderate gingivitis. 79 The question is whether it corresponds to the average person in the population. It is quite conceivable that some people with significant plaque formation benefit substantially more from a dentifrice with active ingredients than individuals do with little plaque formation.
• The clinically subjective indices are limited because inconsistent application of the index, especially in long-term clinical trials, often leads to greater variation in the data. Also lack of sensitivity of the scale may require larger study populations to define averages. 25 • All the included studies became available during the last two decades. However, in the majority of cases, the manner of reporting did not follow current standards, such as CONSORT 2010 and TIDieR 2014. This limitation is also reflected in the results of the risk of bias assessment. This systematic review reinforces the importance of correct and complete reporting and adherence to standards, particularly the new TIDieR checklist regarding the description and replication of interventions. 109

| CON CLUS ION
This systematic review demonstrates, based on existing data, that brushing with a dentifrice with a purported active ingredient to inhibit plaque regrowth, such as stannous fluoride or triclosan, provides a significant and clinically relevant effect that surpasses the effect of a regular sodium fluoride dentifrice.

| Scientific rationale for the study
Dentifrice does not provide an added effect for the mechanical removal of dental plaque. The question is whether purported active ingredients in dentifrices may inhibit dental plaque regrowth more effectively than a regular sodium dentifrice.

| Principal findings
Active ingredients in dentifrice such as stannous fluoride or triclosan do provide an inhibiting effect on overnight plaque scores that surpass the effect of a regular sodium fluoride dentifrice.

| Practical implications
Dentifrice does not significantly contribute to the mechanical removal of plaque but may serve as a carrier for active ingredients. The use of a dentifrice with the specific ingredient's stannous fluoride or triclosan inhibits overnight plaque regrowth more than a regular fluoride dentifrice.