Reflections on Dentifrice Ingredients, Benefits and Recommendations a Peer-Reviewed Publication Written by Fiona M
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Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants. Reflections on Dentifrice Ingredients, Benefits and Recommendations A Peer-Reviewed Publication Written by Fiona M. Collins, BDS, MBA, MA This course has been made possible through an unrestricted educational grant from Colgate-Palmolive, Co. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives dentifrice use. Recommendations should be based on an The overall goal of this article is to provide dental profession- individual patient’s specific needs and desires as well as the als with information on the active and inactive ingredients in scientific support for a dentifrice. Both the Food and Drug dentifrices and their benefits. Administration (FDA) and the American Dental Associa- Upon completion of this course, the clinician will be able tion (ADA) have played roles in controlling (FDA) and ac- to do the following: cepting (ADA) dentifrices. 1. List active ingredients in dentifrices and their therapeutic benefits. Dentifrice Ingredients 2. List inactive ingredients in dentifrices and their functions. Dentifrices contain both active and inactive ingredients. Ac- 3. Know the roles of the FDA and ADA with respect to tive ingredients are those that offer a therapeutic benefit, while over-the-counter dentifrices. inactive ingredients are non-therapeutic and also contribute 4. Understand the considerations involved and importance of to the physicochemical properties of the dentifrice – its feel, recommending OTC dentifrices for individual patients. consistency, sweetness, flavor, pH, texture, abrasiveness and appearance. Abstract The first major active ingredient introduced into modern- Active Ingredients day, over-the-counter dentifrices was fluoride. Since then, Active ingredients help prevent caries, sensitivity, plaque/ dentifrices have been developed with ingredients offering gingivitis, calculus formation and halitosis (Table 1). The first anti-plaque/anti-gingivitis, anti-halitosis, whitening or de- active ingredient included was fluoride. sensitizing benefits, or a multiplicity of benefits. Given the range of dentifrices currently available, and their differences, Table 1. Active ingredients and function a recommendation is important; this should be based on the Anti-caries Sodium fluoride individual patient’s specific needs and desires and the scien- Sodium monofluorophosphate tific support for a dentifrice. Stannous fluoride Introduction Amine fluoride Toothpastes existed as early as 5,000 B.C., and a toothpaste Xylitol made from iris flowers was created in the fourth century Anti-plaque/ A.D.1,2 Early modern toothpastes and tooth powders in Eu- anti-gingivitis Triclosan/copolymer rope and America often contained highly abrasive materials Stannous fluoride such as ground shells, salt, charcoal and chalk.3 Develop- Zinc citrate ments continued until the present day. One of the first mod- Anti-calculus Tetrapotassium pyrophosphate ern toothpastes contained hydrogen peroxide and baking Tetrasodium pyrophosphate soda – ingredients still used in dentifrices today. The collaps- Sodium hexametaphosphate ible toothpaste tube, invented by Dr. Washington Sheffield, revolutionized the use of toothpastes and was a primary factor Zinc compounds in their increased popularity. Fluoride, the first major active Triclosan/copolymer ingredient, was initially introduced in 1914, and in 1955 Anti-halitosis Essential oils fluoride toothpaste demonstrating anti-caries efficacy was Chlorine dioxide introduced (Crest with fluoride). Triclosan/copolymer Current over-the-counter (OTC) dentifrices variously Stannous fluoride/sodium offer preventive, esthetic and treatment benefits. Preven- hexametaphosphate tive benefits against caries, plaque/gingivitis, tartar, and Desensitizers Potassium citrate halitosis are available, and treatment benefits are offered Potassium nitrate for dentinal hypersensitivity. Esthetic benefits, which are Potassium chloride not considered therapeutic, include both cleaning and whitening. While some dentifrices offer only cleaning Stannous fluoride benefits together with fluoride for anti-caries benefits, in Strontium chloride recent years dentifrices with multiple benefits aimed at of- fering solutions to as many potential problems as possible Anti-caries Dentifrices have been introduced. The vast range of available products Fluoride raises the issue of confusion in the eyes of consumers. This In the United States, sodium fluoride, sodium monofluoro- increases the need to understand dentifrice ingredients and phosphate and stannous fluoride are all used as anti-caries benefits, to be able to give patients recommendations on actives. In Europe, amine fluoride is also used and dominates 2 www.ineedce.com the market in some countries, marketed under the brand fluoride concentration was reduced by more than 50% using name Elmex. By supplying topical fluoride on a regular basis, the pea-sized dose. They concluded that reduced amounts fluoride dentifrices help prevent demineralization and help should be limited to preschool children, as they are more at promote remineralization. If acid attacks occur and result risk for toothpaste ingestion and fluorosis.12 in the loss of ions from the hydroxyapatite crystals, fluoride The American Dental Association Council for Scientific can be taken up to form fluorapatite crystals. In addition, Affairs found from an evidence-based analysis that for indi- loss of fluoride ions from the tooth structure is inhibited. viduals with a low risk for caries, use of a regular OTC fluo- The concentration of fluoride in OTC dentifrices in the ride dentifrice may provide sufficient anti-caries protection. United States is typically 1,000–1,100 ppm fluoride, which Regular fluoride dentifrice and in-office topical fluorides are equates to 0.23% sodium fluoride, 0.76% sodium mono- recommended for medium and high risk patients.13 fluorophosphate or 0.4% stannous fluoride. The maximum allowable fluoride in OTC dentifrices in the United States is Xylitol 1,450 ppm. In contrast, in Europe the typical level of fluo- Xylitol offers anti-caries benefits in dentifrices as well as ride in dentifrices is 1,500 ppm. In either case, the therapeu- chewing gums and other vehicles. Xylitol occurs naturally tic level of fluoride in the dentifrice is higher than the level and is found in woods, cereal crops, fruits and vegetables. found in OTC fluoride mouthrinses, which typically ranges Acidogenic bacteria are unable to ferment xylitol, reducing from 250–900 ppm. Sodium fluoride and sodium monofluo- their ability to produce the acids necessary for tooth demin- rophosphate dentifrices in particular have been extensively eralization. It is also believed that the bacteria cannot thrive researched in clinical trials. The use of fluoride dentifrices (a starvation effect) and that over time xylitol-resistant bac- (as well as community-based water fluoridation programs) teria that are less cariogenic may dominate. In clinical trials, has resulted in substantial declines in caries rates since their xylitol dentifrices have been found to reduce caries. A three- introduction, in both urban and isolated communities (for year double-blind study, by Sintes et al., in Costa Rica in example, a remote island off the west coast of Scotland).4,5 children 8–10 years of age using a sodium fluoride dentifrice The profound effect of the use of fluoride-containing containing 10% xylitol found an additional 12.3% reduction dentifrices on caries reductions in the developed world has in DFS after three years of twice-daily use compared to a been well recognized.6 Marinho et al. conducted a meta- control dentifrice containing the same level of sodium fluo- analysis of 70 clinical trials on fluoride dentifrices found in ride but no xylitol.14 A similar three-month trial in Costa the Cochrane Database. Only studies that were controlled, Rica using sodium monofluorophosphate as the fluoride blinded, randomized (or “quasi-randomized”) and con- active with 10% xylitol also found DFS reductions of more ducted in children under 17 years of age were included. than 10% compared to a non-xylitol control dentifrice.15 Their conclusion was a pooled 24% reduction in D(M)FS, with a range of 21% to 28%. No differences were found in Anti-microbial (Anti-plaque/Anti-gingivitis) comparing the use of the dentifrices in fluoridated versus Dentifrices non-fluoridated communities. As has been found in studies Anti-microbial dentifrices offer anti-gingivitis benefits and of topical in-office fluoride agents, the response varied with may also offer an additional anti-caries benefit depending on the level of caries in the population being studied.7 Fluoride the agent used. The primary anti-microbial used in OTC dentifrices have also been found to be effective in reducing dentifrices in the United States is a triclosan/copolymer for- root caries; Jensen and Kahout found a 67% reduction in root mulation also containing fluoride (Colgate Total). Stannous surface DFS in a one-year trial using a 1,100 ppm sodium fluoride and zinc citrate are also used in dentifrices. fluoride dentifrice.8 Daily use of a fluoride dentifrice has also been found to be effective in school-based programs, Triclosan/copolymer including in disadvantaged communities.9,10 This formulation contains 0.3% triclosan, a broad-spectrum Some