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UPDATE ON ORAL HEALTH PRODUCTS: LATEST AND GREATEST?

Karen Baker, M.S.Pharm., Associate Professor I. Regulation and Evaluation A. Federal Trade Commission (FTC) D. Canadian Dental Association (CDA) B. Food and Drug Administration (FDA) E. Health Protection Branch of Canada C. American Dental Association (ADA) II. Information Sources for Dental Professionals A. ADA . Headquarters phone (312) 440-2500, (800) 621-8099 . Internet: http://www.ada.org . Council on Scientific Affairs, Ext. 2840 . Professional Product Review published quarterly at www.ada.org/goto/ppr B. ADA Additional Oral Health Benefit Required for Demonstration of Superiority . Manual/powered , floss and interdental cleaners, oral irrigators – 15% . Chemotherapeutic agents to control gingivitis – 20% gingivitis . -containing dentifrices – 10% improvement in caries reduction . Regeneration of periodontal tissues – 25% gain in periodontal attachment levels C. Dental Product Comparison Websites . www.dentalproductshopper.com . www.dentalcompare.com . www.dentalcare.com; www.colgateprofessional.com; . www.walgreens.com D. Professional Newsletters and Evidence-Based Resources  "National Dental Practitioner Based Research Network”-NationalDentalPBRN.org . Monthly newsletter on practitioner database study results . Adds credibility and excitement to your practice without undue time demands  "Clinician’s Report and Dental Report" – www.cliniciansreport.org . edited by Dr. Gordon Christensen and published each month . paper or online subscriptions available. Cost is $95/$165 or $35/$165 (DH)  "Nutrition Action Health Letter" – www.cspinet.org . edited by Michael Jacoboson – nonprofit “food police” . to order Fax 202.265.4954, cost is $24/year, $42/ 2 years for both US and CA versions  "Dental Advisor and Dental Advisor Plus"-www.dentaladvisor.com . edited by Drs. John Farah and John Powers and published 4/6 times yearly . "Dental Advisor" $59/year with first year online subscription FREE E. Promotional Literature/Product Ingredient Sources . www.dentaldepot.com,, www.dentist.net. www.dentalcare.com . Dental Products Report is free online and paper at www.dentalproductsreport.com . Reality. Product Evaluations Publications. www.realityesthetics.com . Dentistry Today ,free at www.dentistrytoday.com . Just4Teeth.com,wide assortment of mechanical and chemical products F. Alternative Dental Product and Healthcare Quackery Prevention Resources . Natural Medicines Comprehensive Database,800.995.8712, www.naturaldatabase.com . PhytoNet-www.exeter.ac.uk/phytonet, e-mail: [email protected] . www.foodnews.org; www.ific.org, www.quackwatch.org, www.naturowatch.org . www.consumerlab.com, www.mskcc.org/mskcc/html/11570.cfm . free sites like www.science-basedmedicine.org and www.supplement-geek.com.

III. Mechanical Plaque Removal Products

A. Powered Devices Available for Retail Sale

Available Powered Devices

Brand (DA rating%) ADA Gingivitis [most useful] Manufacturer Price Seal? Reduction Product Characteristics Oral-B Vitality Oral-B Labs $29T No Yes Compact, non-slip grip with small, cup-shaped Precision Clean USA 800.543-2577 oscillating brush. Two minute timer. Full [C,G] charge lasts 5 days. 7600rpm.

Braun Oral-B Vitality Oral-B Labs $29T Yes Yes (1) Two moving brush heads, two minute Sensitive Clean[C,G] timer. Full charge lasts 5 days. 7600rpm

Oral-B Black 7000 with Oral-B Labs $219T No Yes Sonic pulsations with ultra-speed oscillations. Bluetooth wireless (39) (8800rpm) Pressure sensor,40,000/minute, Smartguide(C,G,O) speed control settings

Oral-B Genius 8000 Oral-B Labs $175T No Yes Customized brushing experience Oral-B Oral-B Labs $99T No Yes 40,000 pulsations/min, 8800rpm ProfessionalCare 3000 (30) Pressure sensor, three brushing modes [G,I,P]

Oral-B Prof Care 1000 Oral-B Labs $65T No Yes 40,000 pulsations/min, 8800 rpm, pressure [C,G,O] sensor, one brushing mode

Braun Oral-B Oral-B Labs $160T No Yes 40,000/8800,4 speeds, “Smart Guide Displays” Professional Care Pro Series is Bluetooth enabled with phone app Smart Series 5000 -with SmartGuide No Yes Visible timer for enhanced compliance

Braun Oral-B Oral-B Labs $15 No No Replaceable brush heads, bristle indicator for CrossAction PowerMax replacement, rechargeable power

Braun Oral-B Oral-B Labs $6 No No Replaceable brush heads, bristle indicator for CrossAction Power replacement, battery powered

Braun Oral-B Pulsar Oral-B Labs $6 No No Battery powered, pivots & pulses, fully Vibrating Micropulse disposable-product not designed to be opened 35 Soft or 40 Medium

Braun Oral-B Stages Oral-B Labs $7 No No Rotating power head brushes in 6 ways, for Kids disposable handle, battery powered, brush head NOT replaceable

Crest Spinbrush Church&Dwight (1) $5 No Yes (1) Brush heads replaceable, battery powered (1) Classic www.spinbrush.c (2) $6 (2) Spinning head & multi level bristles, battery (2) Classic Clean om (3) $6 powered, replaceable head (3) MultiAngle (4) $6 (3) Spinning head and stationary “V” cut (4) Kids bristles which are angled in 3 directions, color signaling bristles, battery powered, replaceable head 2 ©Karen Baker, M.S. Pharm, 02/07/17

(4) Brush heads NOT replaceable, battery Spinbrush Pro Church&Dwight (1) $7 No Yes (1) Replaceable brush head, combination of (1) Clean (2) $8 spinning head and up-n-down bristle (2) Whitening movement, battery powered (2AA) (2) Dual action brush head w/ whitening bristles, battery powered, replaceable head

Interplak Power Plaque Conair (1) $60T Yes Yes (1) 2 speeds, no power base, 2 minute auto- (DPI9) [C,G,I,O,P] (92) (25) shutoff, travel case, 1 yr warranty, CRA-2.3 (2) RTG3CSR 800-633-6363 (2) $28 (2) Color Indicator Ring, rechargeable (3) NT7CS www.conair.com (3) $28 (3) 8-Tuft Brush head, rechargeable, grip handle Time Machine Oralgiene USA $40 Yes No Cleans 6 dental surfaces at once, entire mouth [C,G,DEX] (86) www.timemachin in 1 minute. Any TP OK. 300 strokes/min etoothbrush.com

Plaque Control 3000 Waterpik Tech $39 Yes No Circular brushing motion and contoured [G,O] (87) bristles. Any TP OK. Reach Power Brush J & J $16 Yes No Center bristles rotate 3,000rpm www.jnj.com Outer blue bristles don’t move

Rota-dent DenMat $150T W/D Yes Most tested in perio maint.pts. office training [I,O,P] Lompoc, CA ($55) needed. 3 brush types available. Any TP is OK www.denmat.com Microfilament brush tips, 90,000 filament sweeps per second Motion Colgate Palmolive $7 No No Dual action head, rotating bristles, curved neck, Company replaceable heads www.colgate.com Colgate Motion Colgate Palmolive $8 No No Dual action head, rotating bristles, soft rubber Whitening Company polishers remove stains

GUM Kids Butler Company $7 No No Oscillating action bristles, larger handle, replaceable heads, battery powered

Wisdom Spinbrush II Wisdom $8 No No Oscillating movements, battery powered, non- Toothbrushes replaceable brush heads, angled neck, two Limited power cleaning settings

SONIC ACTION Aura Clean Sonic TB Tao Clean $199 No No 2 speeds up to 40,000 vibrations/minute,UV light charger base,waterproof for use in shower Baby Buddy Sonic 360 Compac Ind. $40 No No Battery-powered, 2 minute timer with flashers every 30 secs. Round gentle brush for children 3-8 years and can be used without toothpaste.

Issa Sonic Silicone TB Foreo $199 No No 11,000 vibrations/minute, 2 types of brush Issa Mini for Kids $119 No No heads, 30 sec and 2 minute timers, waterproof Issa Mikro for Babies $99 No No for use in shower, 365 uses on one charge and each brush head lasts a year Sonicare Diamond Phillips Sonicare $179 No Yes 31,000 vibrations per minute, 5 speeds, Clean [G,I,P] Holds charge for 3 weeks, has charging function in travel case. High end of Sonicare product line.

3 ©Karen Baker, M.S. Pharm, 02/07/17

Sonicare For Kids Phillips Sonicare $70T No Yes Kid-friendly ramp up to 2min brushing over [C] Sonicare.com 90 days. Two speeds and two brushhead sizes. Three different front plates to customize. Cushions on brushhead and easygrip. Sonicare FlexCare Both T (1)RS930 1) $169 (1) integrated sanitizer, smart timer, (2)R910 2)$149 (2) smart timer, Quadpacer No Yes Sonicare Xtreme e3000 $39.99T 2 AA batteries, for pre-teens and teens

Sonicare HealthyWhite Both T No Yes 3 modes – clean, sensitive, clean&white R732 $139.99 2 modes-clean, clean&white R710 $119.99 No Yes Sonicare Essence and P Phillips (1) Quadpacer 30-sec interval timer, recharge (1) e5500 $120T No Yes indicator, 2 minute smartimer, angled neck (2)e5300 $100T No Yes (2)No quadpacer, only 1 brushhead

Supersonic American $80 No No Not available retail, 31,000strokes/minute, [C,G,O] (87) Dentronics (40) Brush and floss are available. 760.757.5380 Sonic-1 Cybersonic Amden Inc. $70T No No 47,000 strikes/min, uses harmonic resonance, 2 Oral Care brush heads, 2 attachments, “done-in-one” timer

UltraSonex (84) Salton-(Sonex Int) $39T No No Manual brush with 1.6 mil cycles per min. Preset for 3 minutes. Avoid if cardiac 800.233.9054 pacemaker pt. Any TP OK. CRA- 2.6 www.saltoninc.com Ultima Salton $119 No No 18,000 strokes/min. plus 1.6 mill cycles/min.

C = child, G = gingivitis, I = implants, O= ortho, P = periodontitis, Dex = dexterity not required

B. Patient Selection Considerations for Powered Toothbrushes

1) Orthodontic Bands – smallest and least expensive brush heads with a 2 minute TIMER 2) Diffuse Sensitivity – sonic motion instead of rotation/oscillation 3) Stain Removal – small brush heads and timer designed to motivate for 2-3 minutes 4) Older Patients – inexpensive and reliable devices with little vibration 5) Young Children – motivational appearance and changing music for brushing period 6) – no powered toothbrush completely replaces interdental and subgingival devices

Recent Powered Brush Comparisons: i) Am J Dent. 2013 Apr;26(2):68-74. Plaque removal efficacy of oscillating-rotating power toothbrushes: review of six comparative clinical trials. Grender J1, Williams K, Walters P, Klukowska M, Reick H.

ii) Cochrane Database Syst Rev. 2014 Jun 17;6:CD002281. doi: 10.1002/14651858.CD002281.pub3. Powered versus manual toothbrushing for oral health. Yaacob M1, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, Glenny AM

iii) A 12-week clinical comparison of an oscillating-rotating power brush versus a marketed sonic brush with self-adjusting technology in reducing plaque and gingivitis. Klukowska M, Grender JM, Conde E, Goyal CR. J Clin Dent. 2013;24(2):55-61. 4 ©Karen Baker, M.S. Pharm, 02/07/17

IV. Chemotherapeutic Products for Home Use Chemotherapeutic Categories 1. General Mechanisms of Action . Decrease rate of new plaque accumulation . Decrease or remove existing plaque . Suppress growth of pathogenic microflora . Inhibit production of virulence factors

2. Application Method Brush on dentifrices or : pre-brushing or postbrushing Mouthwash: pre-procedural Irrigation: supra-gingival or sub-gingival Local application reservoir

CHEMICAL CATEGORIES OF SPECIFIC AGENTS AND PRODUCTS CATEGORY SPECIFIC AGENTS PRODUCT NAMES Anionic Detergents such as sodium lauryl Pre-brushing rinses, almost all sulfate and cocamidopropylbetaine Almost all toothpastes that foam in the mouth Bisbiquanides * Peridex, Periogard, ProSoL Paroex free, generics Chelation Agents EDTA (edathamil) Livionex Inc. Dental , Los Gatos, CA Halogens Chloramine-T Chlorazene Dioxide Oxyfresh Rinse/, Clos-Sys IIRinse/Paste, etc. - - - Fluoride MFP= 14% F , NaF= 45% F , SnF2= 24% F , Iodine/Iodophors* Ora-5, iClean Mouthrinse, Oxychlorosene Kasdenol Povidone-iodine Betadine, Perimed Metal Zinc Citrate or TC (Aim, Close-Up,Tom’s of Maine)Lavoris, Zinc Chloride Listermint, Viadent Advanced Care TP, Crest Pro- Tin* HealthTP,

Herbal Extracts Melaleuca* Confident Paste and Rinse, Tea Tree Products, etc. Sanguinaria AKA Bloodroot but can cause Oxygenating Agents Carbamide Peroxide Gly-Oxide, Proxigel, Triology Debriding Rinse Perborates Amosan Peroxides Ortho-Fluor, Perimed, Peroxyl, “White Bottle” rinses Phenolic Compounds Hexylresorcinol S.T. 37 * (, , Many generic formulations also available , methylsalicylate) Phenol Cepastat, Chloraseptic, Carmex * Mentadent-P (zinc citrate, NaF), Colgate Gum Protection (Tufts Newsletter- Oct. 1998, Volume (2% copoLymer,NaF) Colgate Total (2% copolymer, NaF) 16, (8) $3.00) Quaternary Benzethonium Chloride , Crest Toothpaste with Scope Ammonium * Cepacol, Crest Pro Health Viadent Rinse,BreathRx, Compounds Colgate Total Advanced ProShield, Smart Mouth Domiphen Bromide Scope Surface modifying Delmopinol* PerioShield Mouthrinse by Sunstar Butler GUM Agents Simethicone, dimethicone AP-24, Control Rx by Omnii

*Denotes a chemical proven to reduce gingivitis at least 20% more than brush twice daily with fluoride toothpaste B. Dentifrices [Approximately $1.8 Billion spent in 2015] 1. Types ANTI-CAVITY ANTI-GINGIVITIS ANTI- BAKING SODA "NATURAL" KID'S MOUTHWASH DESENSITIZING DEODORIZING WHITENING PROTECT ENAMEL 5 ©Karen Baker, M.S. Pharm, 02/07/17

2. DENTIFRICE PRODUCT TABLES WITH IMPORTANT CHARACTERISTICS a. ADA Accepted Fluoride Dentifrice Characteristics Product F- Compound Cleaning* * RDA+ Aim Cavity Protection (Church&Dw) .80 MFP /58 M 80 A&H Dental Care Advanced Cleaning .24 NaF - M 106 with Baking Soda (Church&Dwight) Aqua-Fresh Fl Protection (GSK)+++ .76 MFP 59 (3) M 108+ Colgate Cavity Protection gel/paste+++ .76 MFP 39/(4/3) M/L 68+ Colgate Enamel Health (Colgate) - - - Colgate For Kids gel/paste (CP)+++ .243NaF 40/(4/3) M/ 77+ Crest Pro-Health “For Me” paste .243NaF Crest Cavity Protection paste/gel .243 NaF 69/70(4) M 115/96+ (P&G)+++ Crest Kids Sparkle Fun (P&G) .243 NaF - - 80 Enamelon TP with ACP (Premier) .45 SnF - - 39 Shane AloeSense (Aloesense.com) .243 NaF - - 90 Tom’s of Maine Natural BS Fl TP .80 MFP - - 49 Tom's of Maine Natural Fluoride .80 MFP 59/(4) 93+ or Wintermint (Colgate) Tom’s of Maine Natural Fluoride for .76 MFP - M 57 Children SillyStrawberry,OutrageousOM . *Consumer Reports, 9/1992 or 8/1998 +ADA Council on Dental Therapeutics, May 1993 -Journal of Dentistry 20:283-286, 1992 ++Oral Health Research Institute, Indiana Univ. RDA 92-69 #Available Rx only, not ADA accepted +++ CDA Accepted ~Reported by Manufacturer ( ) Cleaning score in Consumer Reports 8/1998 on 1-5 scale

PATIENT POINTS: 1. NaF is the best fluoride compound for caries risk and recession patients 2. SnF 0.4% is really about 970ppm which is similar to other OTC fluoride dentifrices 3. NaF is 45% fluoride, MFP is 14% fluoride, SnF is 24% fluoride

b. Prescription Strength Fluoride Dentifrice Characteristics Product F- Compound Additional RDA+ Ingredients ClinPro 5000 1.1% NaF (3M ESPE) 1.1% NaF 5% Novamin 68 Control Rx (Omnii)# 1.1% NaF Dimethicone 80 (Microdent) Cypress SF 5000 Plus (Cypress) 1.1% NaF - - Fluoridex (Discus)# 1.1% NaF May have KNO3 - Prevident 5000 Plus (CP)# 1.1% NaF - 80 Prevident Dry Mouth (CP)# 1.1% NaF No SLS 110 Prevident Booster (CP)# 1.1% NaF Penetrating Formula 110 Prevident Sensitive (CP)# 1.1% NaF 5% KNO3 90 Pro-Dentx (Pro-Dentec)# 1.1% NaF - 90 Topex Renew (Sultan Healthcare)# 1.1% NaF 5% Novamin . *Consumer Reports, 9/1992 or 8/1998 +ADA Council on Dental Therapeutics, May 1993 #Available Rx only, not ADA accepted

PATIENT POINTS: 1. 5000ppm NaF remineralizes 25-35% better than 1000-1100ppm NaF 2. ClinPro and Renew haven’t been evaluated in human clinical trials as of 7/8/2010 3. Prevident Booster formula is primarily to increase compliance 4. 5000ppm NaF does not effectively REVERSE white spot lesions

6 ©Karen Baker, M.S. Pharm, 02/07/17

c. ANTI-PLAQUE AND GINGIVITIS DENTIFRICES (*Two are ADA Accepted for Plaque/Gingivitis) Product* Cleaning F- RDA Other Ingredients AP-24 (Nu-Skin) - MFP - Dimethicone, surfactants , 338 A&H Advanced Breath Care 29 MFP Zinc citrate 2%, baking soda Biotene paste and gel (GSK) - MFP 78 oxidase, lactoperoxide,CMPB Biotene PBF paste (GSK) MFP 78 lactate, mucinase, dextranase,CMPB Close-Up Anti-Plaque (C&D) 62 SnF 85 Stannous pyrophosphate, zinc citrate CloSys II (Rowpar) - - 53 Stabilized chloride dioxide 0.1%, no SLS Colgate Total (CP)* +++ 60/(3) NaF 70 Triclosan 0.3%, Gantrez 2% Colgate Total Antigingivits NaF Triclosan 0.3%, Gantrez 2% Colgate Total Gum Defense NaF Triclosan 0.3%, Gantrez 2% Crest ProHealth (PG) - SnF 155 Stannous Fluorite, Sodium hexametaphosphate Crest ProHealth EnamelShield - SnF 144 Stannous Fluorite, Sodium hexametaphosphate Crest Pro Health for Life - SnF 140 Stannous Fluorite, Sodium hexametaphosphate Listerine EC paste/gel (J&J) 60/(4) MFP 85 ingredients as in the rinse Livionex Dental Gel(Livionex) - - - “Activated” edathamil (EDTA) to chelate calcium Oral Defense (BioGlobe Tech) - NaF - Cetylpyridiumium Cl, no SLS Oxyfresh (Oxyfresh USA) - - 45 Stabilized chloride dioxide SmartMouth Advanced - MFP - Zinc Chloride 2% , .81% MFP Clinical Formula (Triumph) Tom’s of Maine Antigingivitis - - 68 Zinc citrate 2%, , baking soda Viadent Adv. Care (C-P) - MFP - Zinc citrate 2%, no sanguinaria (bloodroot) * Colgate Total and Crest ProHealth are ADA accepted for plaque/gingivitis reduction beyond regular fluoride toothpaste

PATIENT POINTS 1. Triclosan toothpaste reduces mild/moderate gingivitis 20-30% compared to regular fluoride toothpaste 2. Essential oils or zinc are about 16-19% effective at reducing gingivitis so are not ADA accepted. 3. Chlorine Dioxide toothpaste is NOT effective at reducing gingivitis but reduce oral malodor 4. Crest Pro-Health reduces mild/moderate gingivitis about 25% compared to regular fluoride toothpaste 5. Biotene toothpastes do not have specific anti-gingivitis ingredients other than fluoride. 6. Activated edathamil (EDTA) is a common food additive which is safe and may inhibit plaque formation. d. BAKING SODA DENTIFRICES % Baking++ % Hydrogen++ Cleaning+ Product F- RDA* Soda Peroxide A&H Dental Care Smooth Spearmint (Church & Dwight) NaF 57 30 - 24 Aquafresh Baking Soda (GSK) MFP 65 .5 - (3) Arm & Hammer Baking Soda (Church &Dwight) - 7 100 - - A&H Dental Care Gel (Church &Dwight) NaF 62 30 - 55 A&H Dental Care Paste (Church &Dwight) NaF 35 65 - 28(2) A&H Enamel Care with Calcium (C&Dwight) NaF 65 30 - - Aim Baking Soda Gel (Church & Dwight) MFP - .5 - - Close-Up Baking Soda Paste (Church&Dwight) MFP 80++ .5 - - Colgate Baking Soda Paste (Colgate)** NaF 120 25 - 51 Colgate TC Baking Soda and Peroxide Paste (Colgate) NaF 92 12 0.50CaPeroxide (4) Mentadent Baking Soda and HP Combo (Church&Dwi) NaF 118 5 .75 (4) with Baking Soda Paste (Church&Dwight) NaF 80++ 5 - - Peroxicare (Church & Dwight) NaF 52 52 0.75NaCarbPerox 25 Baking Soda (GSK) NaF 67 - - (3) Tom’s of Maine BS /Gingermint (Colgate) MFP 68 5 - - *Indiana Oral Health Research Institute, 1999 +Consumer Reports 9/98,++Per Manufacturer,**ADA Accepted for Caries Reduction PATIENT POINTS 1. Higher baking soda content to lower 2. Baking Soda and have no cleaning scores therapeutic effect singly or in combinatio .

7 ©Karen Baker, M.S. Pharm, 02/07/17 e. “Natural” OR HERBAL DENTIFRICES Product/Manufacturer Claims “Active Ingredients” Auromere (www.auromere.com) Invigorates/purifies Neem, Peelu, 24 herbal extracts DentiCare Polish (Melaleuca, Inc.) Benefits bleeding gums Melaleuca, propolis, Dentaforce (Bioforce) Astringent/stimulant Echinacea, , essential oils - Eco-Dent (Eco-Dent 888.Eco.Dent) Hardens enamel w/o F BS, tartaric acid, CaCo3, myrrh Cool Mint (Nature’s Gate) Antiseptic/ “free” calcium Sage, vitamin C, Calcium Carrot Pwd. Healthy Teeth & Gums toothpaste Prevent cavities/fight gingivitis MFP, vera, echinacea, goldenseal, (www.thenaturaldentist.com) calendula,propolis,grapefruit seed extr. Homeodent (Boiron-Borneman) No-mint Calendula, plantain, , witchhazel Jason Toothpaste (www.jason- Best tasting natural toothpaste! CoQ10, , Sea , Melaleuca, natural.com) Gum support/perio protection Perilla Seed Extract Kiss My Face (KMF) Pure and natural NaMFP,aloe vera,micronized silica MCT Oil Toothpaste (The Dirt) Blows others out of the water oil, bentonite clay, theobromin MouthFx (www.mouthfx.com) 97% effective in 41 countries 100% natural essential oils Nutribiotic Dental Gel Supports teeth and gums, No Grapefruit Seed Extract, Zinc Citrate, (www.nutribiotic.com/dentalgel) fluoride which is toxic sanguinaria, aloe vera, stevia -F (www.parodontax.de) GSK Soothing /mineral plus Fl- Rhatany, ,myrrh,fluoride Peelu (Peelu Products) /Siwak chewing stick Peelu fiber, natural sorbo fruit juice Propolis TP (Beehive Botanicals) Protects hive, benefits mankind Propolis, xylitol, flavoring oils TP (Desert Essence) Especially good for gingivitis/perio Melaleuca, propolis, Tea Tree TP (Thursday Plantation) Healthy gums, decrease tartar 0.4% melaleuca, chlorophyllin-copper The Dirt Natural Toothpowder Paleo friendly and xylitol free Bentonite clay,baking soda, myrrh gum Tom’s of Maine (Colgate) No dyes, preservatives, sweetners Some with F-, xylitol, many formulas Tooth and Gum Paste (DHC) No SLS, “natural F source” ( tea) Echinacea, green tea, essential oils

PATIENT POINTS: 1. Non-Fl: Dabur, Denticare, Dentaforce, Propolis, , Tea Tree Toothpaste 2. Fl: Denticare, Healthy Teeth&Gums , Jason Healthy,Tom’s of Maine Fl-, Tooth&Gum Paste

f. TARTAR CONTROL DENTIFRICES Product F- Cleaning+ RDA* Other Ingredients Aim TC (Church&Dwight) .80 MFP - 108 Zinc citrate 0.5% Aquafresh TC (GSK) .24 NaF (4) 124 Tetra NA pyrophosphate 3.3% A & H TC Toothpaste (Church&Dwight) .24 NaF - 34 Napyrophosphate, Naphosphate A&H TC Gel (Church&Dwight) .24 NaF - 71 Napyrophosphates Close-Up TC Paste (Church&Dwight) .76 MFP 62 98 Zinc citrate 0.5% Close-Up TC Gel (Church&Dwight) .76 MFP 63 - NaCl, zinc citrate 0.5% Colgate TC Gel (CP) .24 NaF 74 87 3.3% tetraNapyrophosphate, PVM/MA Colgate TC Paste (CP) .24 NaF 62 165 3.3% tetraNapyrophosphate, PVM/MA Colgate TC Gel/Paste MCF (CP) .24 NaF - 87/113 3.3% tetraNapyrophosphate, PVM/MA Colgate TC Micro Cleansing (CP) .24 NaF (4) 112 3.3% tetraNapyrophosphate, PVM/MA Kiss My Face TC with Zinc Citrate - Zinc citrate, aloe vera, lemon flavored Listerine EC TC Gel/Paste (J&J) .76 MFP (4) 90 Zinc citrate trihydrate, essential oils Natural White TC (Natural White) .24 NaF - 113 TetraK pyrophosphate Pepsodent Complete Care(Ch&Dwight) .76MFP - - Zinc citrate, silica Rembrandt TC Paste (J&J) .80 MFP - 55 "Citroxain" = alumina, papain, citric acid Sensodyne TC/Plus Whitening (GSK) .24 NaF - 100 KNO3, tetra Kpyrophosphate, silica Tom’s of Maine TC&Whitening (Colgate - - 90 Zinc citrate, xylitol, hydrated silica Ultra-Brite All in One (C-P) .24 NaF - - Pyrophosphates, no alumina PATIENT POINTS: 1. Pyrophosphates are associated with dentinal sensitivity and soft tissue lesions. 2. Sodium Hexametaphosphate produces adverse effects equivalent to standard pyrophosphates. 3. Switch to zinc salts to get calculus reduction without sensitivity and soft tissue lesions.

g. DESENSITIZING DENTIFRICES Product F- Densensitizer Cleaning+ RDA++ AquaFresh Sensitive (GSK)* NaF 5% KNO3 (3) 91 A&H Dental Care Sensitive Formula NaF 5% KNO3 50/(2) 54 Biotene Sensitive Toothpaste (Laclede) MFP 5% KNO3 - 55 ClinPro 5000 1.1% NaF Dentifrice with Calcium and Phosphate NaF Ca and Phos - 68 Colgate Enamel Health Sensitivity Relief (CP) NaF 5% KNO3 - - Colgate Sensitive Pro Relief 1500ppm (CP) NaF 5% KNO3 - 62 Crest Pro-Health (P&G) SnF SnF 100 Crest Sensi Relief (P&G) NaF 5% KNO3 (3) 107 Crest Sensi Repair and Prevent (P&G) SnF SnF - - Denclude Desensitizing Dental with Sensistat (Ortek) - Sensistat - - Dr. Collins Restore with Novamin - Novamin - - Enamelon Preventive Treatment Gel (Premier) .45SnF Ca and Phos - 39 Kiss My Face Sensitive Fluoride-Free with Aloe (KMF) - 5% KNO3 - - Level OralCare Sensitivity Herbal with Xylitol (Level Oral Care) .76MFP 5% KNO3 - - Orajel Sensitive (Del)* 1%MFP 5% KNO3 - - Prevident Sensitive (P&G) NaF 5% KNO3 - 90 Sensodyne Baking Soda (GSK) NaF 5% KNO3 (3) 55 Sensodyne Cavity Prevention (GSK)* MFP 5% KNO3 (3) 89 Sensodyne Complete Protection (GSK) SnF - - - Sensodyne Fresh Mint* (GSK) MFP 5% KNO3 - 89 Sensodyne Cool Gel (GSK) NaF 5% KNO3 - 92 Sensodyne Original (GSK) MFP 5% KNO3 80 100 Sensodyne Pronamel (GSK) NaF 5% KNO3 - 39 Sensodyne Repair and Protect (GSK) SnF - - - Tom’s of Maine Sensitive Teeth Natural Toothpaste (Colgate) - 5% KNO3 - 68 Topol Plus Sensitive Teeth (Dep) MFP 5% KNO3 - -

PATIENT POINTS: 1. and SnF are most effective for OTC twice daily use. 2. Patient should consult dentist after 4 weeks of twice daily use with no positive effects. 3. Abrasivity should be selected at an RDA of 120 or below

h. WHITENING” DENTIFRICES (# ADA Accepted for Extrinsic Stain Removal) Product F- Cleaning Abrasion+ RDA “Whitening Ingredients” Aquafresh Whitening TC (GSK) # NaF (4) M 113 Na tripolyphosphate Aquafresh Iso-active Whitening NaF Na tripolyphosphate, Isopentane A&H Dental Care Adv. Whitening NaF (3) L 106 TetraNapyrophos,BS Napercarbamate A&H Truly Radiant Enamel Strength NaF - - - BS, silica, cal sulfate, cal peroxide Close-Up Paste/Gel (Church&Dw) MFP 85/72(4) H 110/80 Silica, in Clear Colgate Fresh Confidence Whitening NaF 75 M 124 TetraNa pyrophosphate,Ultra mint Colgate Sensitive Plus Whitening SnF 51 120 Micronized Silica Colgate Optic White Anticavity MFP - - - Hydrogen Peroxide,pyrophosphates Colgate Pro-Clinical Daily Cleaning NaF - - - Silica, 2 pyrophosphates Colgate Pro-Clinical Daily Renewal MFP - - - Silica, 1 pyrophosphate,PVM/MA Colgate Pro-Clinical Whitening NaF - - - Silica, 2 pyrophosphates Colgate Sparkling White BS, Per MFP - - - Silica, BS, pentaNa triphos, pyropho Colgate Sparkling White TC # NaF 69 - 190 Silica, pentaNa triphosphate, pyropho Colgate Total Adv Cleaning Plus NaF - H 210 Triclosan, Gantrez, silica Whitening # Colgate Total Advanced Whitening NaF - H 180 Triclosan, Gantrez, Colgate Whitening BS, Per, TC MFP (5) M 145 BS, alumoxide, pyrophos, td, Caperox Crest Extra Whitening (P&G) NaF - M 130 Silica, Crest Multicare Whitening (P&G) # NaF 62 M 144 Silica 31%, BS 1.5%, pyrophosphate Crest Pro-Health Whitening (P&G) SnF 155 Silica,sodium hexametaphosphate 9 ©Karen Baker, M.S. Pharm, 02/07/17

Crest Pro-Health HD 2 step (P&G) SnF SnF followed by hydrogen peroxide Crest 3D White Vivid (P&G) NaF 205 Silica, disodium pyrophosphate Crest Whitening Plus Scope (P&G) NaF 52 M 125 Scope MW ingredients,pyrophosphate Gleem (P&G) NaF 79 M 118++ Silica, triNaphosphate, titanium diox Luster Premium Deep Stain Eraser NaF - - - Silica, Urea peroxide, corn starch Natural White (Natural White) - - M 101++ Silica, glycerin, titanium dioxide Pearl Drops BS Paste (C&D) NaF - - - TetraK&Na pyrophosphates, BS, td Pearl DropsPaste (C&D) NaF 74 195 Silica Pearl Drops Toothpolish (C&D) NaF (4) H 227++ Silica, AlHydroxide, triNaphosphate Pepsodent F- (Church&Dwight) MFP 58 M 150 Silica Plus White (CCA) MFP - M 94++ TriNaphosphate, monoNaphosphate Rembrandt Plus # (J&J) MFP 53(3) L 55++ Citroxain(papin, alumina, NaCitrate)Carbamide peroxide Rembrandt Plus Premium Whit. Gel MFP - L 70+ Carbamide peroxide < 3% citroxain with Peroxide (J&J) Rembrandt Whitening Cankersore NaF - L 55++ Citroxain, hydrated silica Rembrandt Intense Stain Removal NaF - - 94 ,silica,alumina Sensodyne Extra Whitening (Block) MFP - - 150 KNO3, calcium peroxide Supersmile (Robell Research) MFP - L 62+ Calcium peroxide, titanium diox, BS Topol Plus BS (Topol-Dep) MFP - - - Silica, BS, diNaphosphate, titan diox Topol Smoker’s Fluoride Gel (Dep) MFP 82 H 207++ Silica, Zirconium silicate, titandiox - Topol Smoker’s Toothpaste/Fl (Dep) MFP 76 H 227++ Silica, Zirc. silicate, titan. diox., tetra NaPyrophosphate Marvis Whitening Toothpaste MFP - - - TetraNaPyro,SLS,xylitol,ITALIAN Ultra-Brite BS (C-P) MFP - M - Silica, BS, alumina, titanium dioxide Ultra-Brite BS &Peroxide (C-P) MFP (3) M - Silica, BS, prop glycol, Caperoxide Ultra-Brite Paste/Gel (C-P) MFP 86/72(5) M/M 133++ Silica, alumina, titan. dioxide, pyro Ultra-Brite Advanced Whitening MFP - M 260 *Consumer Reports 9/92 or 8/98 -Journal of Dentistry 20:283-286, 1992, +Reported by the manufacturer 5/95 (L=low, M=moderate, H=high), ++Oral Health Research Institute, Indiana University, RDA 92-69, # = ADA ACCEPTED FOR REMOVAL OF SURFACE STAIN

PATIENT POINTS: 1. Toothpastes cannot effectively bleach teeth and can only remove extrinsic stain. 2. Cleaning ability does not necessarily correspond to abrasivity. 3. Chronic exposure to peroxides should be avoided in users. 4. FDA recommends RDA limit of 200 while ADA recommends limit of 250.

5. FDA recommends RDA limit of 200 while ADA recommends limit of 250.

a. Options for Whitening is Based on Patient Preference and Tolerance  Least effective are whitening toothpastes because they only polish off stained pellicle  Next most effective is OTC Whitestrips with the most effective being Crest“Advanced”  At-Home or In-Office Bleaching Using Custom Trays are Equally Effective  At-Home Bleaching leads to longer shade maintenance than In-Office Bleaching b. Patient-Specific Whitening Product Recommendations 1. Pellicle stain/ no exposed / no canker sores  Colgate Whitening BS, Per, TC/ / Crest Multicare Whitening/Ultra-Brite Paste 2. Pellicle stain/ exposed roots/ no canker sores  Aquafresh Whitening// Gleem/ 3. Pellicle stain/ exposed roots/ canker sores or BMMP or LP  No pyrophosphates, SLS, CMPB or high detergent content

10 ©Karen Baker, M.S. Pharm, 02/07/17

 Tom’s of Maine Botanically Bright, Squigle Enamel Saver, 3. Smokers or Chewing Tobacco Users  Avoid, Colgate Whitening/ Rembrandt / Stay White/ Supersmile/ BS & Peroxide/ White Step (any toothpaste with peroxides) V. CREST WHITESTRIPS: WHAT ARE THEY CALLED NOW?? A. Retail Purchase:

1. Crest Whitestrips Classic is now Crest 3D White Whitestrips Vivid 10% HP in 20 strips for 10 days of once daily use –No Advanced Seal but cheapest 2. Crest Whitestrips Premium is now Crest 3D White Whitestrips Advanced Vivid – 9.5% HP in 28 strips for 14 days of once daily use. Contains Advanced Seal 3. Crest Whitestrips Pro Effects is now 3D White Whitestrips Professional Effects – 10% HP in 40 strips for 20 days of once daily use. Contains Advanced Seal 4. Crest Whitestrips Advanced Seal is now Crest 3D White Whitestrips Advanced Vivid - 10% HP in 28 strips for 14 days of once daily use as listed above 5. Crest Daily Whitening Multicare is now Crest 3D White Whitestrips Stain Away - 6.0% HP plus 2% pyrophosphate in 28 treatments for 5minutes once daily use 6. New Crest 3D White Whitestrips Gentle Routine – 6% HP for 5minute per day -28 treatments to be used for 5 minutes daily. Use for four weeks. B. Dental Office Dispensed: 1. Crest Whitestrips Professional – 6.5% HP in 84 strips for 21 days of twice daily use -has been discontinued 2. Crest Whitestrips Supreme – 14% HP in 84 strips for 21 days of twice daily use

C. Effectiveness 1. Original Whitestrips – overall color improvement 2.96 in 14 days 2. Whitestrips Premium – overall color improvement 3.2 in 7 days

3. Professional Whitestrips – overall color improvement 4.20 in 21 days-discontinued?? 4. Supreme Whitestrips – overall color improvement 40% better than Professional in 21 days

D. Adverse Events 1. Localized a. Tooth sensitivity – a little higher with Supreme Whitestrips b. Gingival irritation-lowest with Supreme Whitestrips c. Resolution in 24-48 hours without treatment is typical

VI. SALIVA ENHANCERS

A. NeutraSal (OraPharma) and SalivaMax (Forward Science) –supersaturated calcium phosphate as a packet for immediate rinsing.

B. Novamin (calcium sodium phosphosilicate) by NovaMin Technology Inc. of Alachua, FL.

Calcium Sodium-phosphosilicate ( Novamin) A synthetic mineral composed of calcium, sodium, phosphorous and silica, all elements naturally occurring in the body. Silica (glass) containing Ca and PO is the driving mechanism that binds to the tooth surface

11 ©Karen Baker, M.S. Pharm, 02/07/17

1. Omnii Oravive Tooth Revitalizing Paste (Oravive) 2. DenShield Tooth Sensitivity Therapy (Novamin) 3. Butler NuCare Tooth Root Conditioner (Butler) 4. SootheRx Sensitivity Therapy (Omnii) 5. Dr. Collins Restore Toothpaste for Home Use 6. Topex Renew by Sultan is Novamin plus NaF 5000ppm C. Tri-Calcium Phosphate – ClinPro with NaF 5000ppm – 3M Espe

D. Recaldent (casein phosphopeptide-amorphous calcium phosphate)

Casein phosphopeptide and amorphous calcium phosphate (CPP-ACP) Casein phosphopeptide is a milk protein peptide that is bound to amorphous calcium phosphate The milk derived peptide containing amorphous Ca and PO is the driving mechanism that binds to the tooth surface. 5. Sugarless gum – Trident White and Trident for Kids 6. MI paste and MI PastePlus with 5:3:1 mineralization ratio by GC America

E. Soluble Calcium Sulfate 7. Arm & Hammer Enamel Care Toothpaste (Church and Dwight)

F. Amorphous Calcium Phosphate (ACP) ACP is inorganic amorphous calcium phosphate, made by combining soluble salts of calcium and phosphorous 1. Relief ACP Oral Care Gel by Discus Dental -NaF 0.22% -Potassium Nitrate 5% - Amorphous Calcium Phosphate 0.375%

G. Arginine Bicarbonate and (Sensistat) – Now Pro-Argin (Colgate) Arginine bicarbonate is an amino acid complex found in saliva that is bound to calcium carbonate 1. Proclude (Ortek) 2. Denclude (Ortek) 3. Tom’s of Maine Rapid Relief Sensitive Toothpaste

VII. BLEACHING OF VITAL TEETH A. Mechanism 1. Hydrogen peroxide is an oxidizing agent which produces free oxygen radicals (unpaired electron). 2. Free oxygen radicals are unstable and electrophilic. They can react with most unsaturated bonds, resulting in disruption of electron conjugation and a change in the absorption energy of the organic molecules in . Simpler molecules that reflect less light are formed which causes whitening 3. Saturation point is reached when only hydrophilic colorless structures exist. Bleaching then results in breakdown of enamel with subsequent tooth brittleness and increased porosity.

B. Chemicals Used for Bleaching 1. Hydrogen peroxide 1 .5% - 10% (pH of 3% hydrogen peroxide is 2.7) 2. Carbamide peroxide 10% - 40% (10% CP = 3.6% hydrogen peroxide and 16% CP = 5.76% H2O2 -a.k.a. urea peroxide, perhydrol urea, carbamide, carbamide urea 3. Carbamide peroxide products contain either a carbopol, glycerin base, or base.

12 ©Karen Baker, M.S. Pharm, 02/07/17

C. Factors that Affect Bleaching Effectiveness 1. Surface debridement 2. Hydrogen peroxide concentration - highest is 50% 3. Temperature - an increase of 10 degrees centigrade doubles rate of oxidation reaction 4. The pH - slightly acidic pH is ideal for shipping. storage but best oxidation is at pH 9.5 – 10.8 5. Time period - Longer exposure results in greater shade changes 6. Seated environment - increases efficiency of the bleaching process

D. Contraindications for Bleaching Vital Teeth 1. Extremely large pulps which cause sensitivity 2. Hypersensitivity - exposed root surfaces or transient hyperemia due to orthodontic treatment 3. Severe enamel Loss 4. Extensive Restorations - greatest damage to glass ionomers and least to porcelain 5. Pregnancy, lactation, peroxide allergy, allergy with power bleaching 6. Transient hypersensitivity with prolonged application of home use get 7. Hypersensitive reactions or allergic reactions caused by extended exposure to chemicals and appliances such as burning sensation, sore throat, , irritation, or edema. 8. Lack of compliance- either through inability or unwillingness to wear the necessary time

E. Predictors of Bleaching Success 1. Discoloration is fairly light, evenly distributed, and on the surface, not in dentin. 2. Teeth are yellowed as a consequence of aging. 3. Matching large amalgams or crowns is not required. 4. Enamel is fairly heavy and even with no pits, fissures, or grooves. 5. There is no need to change tooth structure. 6. How Long Does it Last?

 At 1.5y – 74% are satisfied, at 3y – 64% are satisfied with shade lightening  Minimum “lock out” period of 6 months is recommended for pulp health

VIII. CHARACTERISTICS OF IN-OFFICE AND AT-HOME BLEACHING PRODUCTS

NEW BLEACHING MATERIALS PRODUCT OTHER ACTIVE TREATMENT # SESSIONS Home Tx Rec Before INGREDIENTS TIME TO or After COMPLETION TREATMENT Assisted Bleaches (light or heat) Biolase Tech Laser and HP 38% KNO3 20 min 2 Optional Den-Mat LUMIBrite HP 35% NaF/KNO3 60 min 1 No Den-Mat LUMIBrite Bleach Free NaF 35min 1 No Discus Dental Zoom Advanced Power Relief ACP 3 x 15min 1 Yes, before and after Plus Lamp HP 25% treatment GC America GC TiON 3% HP mixed MI Paste 60 min 3 x 20min Optional with 30% CP = 20% HP LumaLite w LumaCool System HP 35% nothing 3 x 8min 1 x 24min Yes, afterward Chairside Unassisted Bleaches Dentsply NUPRO White Gold HP 36% Nothing 15-45 min 1 No Life-Like In-Office HP 35% Nothing 40 min 4 x 10min Yes, included Premier Perfection White HP 35% Nothing 1 hour 1 Yes, afterward

13 ©Karen Baker, M.S. Pharm, 02/07/17

SDI Pola Office+ HP 37.5% KNO3 3 x 8 min 1 x 24 min No but optional SDI Pola Zing CP 35% Na and KNO3 30 min 1 but home tx Yes, afterward Ultradent Opalescence Boost HP 38% NaF and KNO3 15 min 3-4 x 15 min Yes, afterward At-Home Carbamide Peroxide 3M ESPE White&Brite CP 10,16,22% Carbopol 1.5-2h 7-14days TouchUp Avail DenMat LUMIBrite 16%, 22%, 32% Carbomer 2h/1h/3min 14 days TouchUp Avail GC America GC TiON CP 15% NaF/KNO3 2-4h, max 10h 14 days TouchUp Avail Heraeus Kul Natural Elegance CP 16,22 NaF/KNO3 22%-1hperday 10-14days TouchUp Avail Life-Like CP 10%,15%,20%,30% Nothing 20-60min 10-14 days TouchUp Avail Nuvora White CP 17% Cellulose 1-2h 10-14days TouchUp Avail SDI Pola Night CP 10%,16%, 22% NaF/KNO3 1-8h 10-14 days TouchUp Avail SDI Pola Paint CP 8% NaF/KNO3 30min 2x daily Up to 14 days It Is a TouchUp Ultradent Opalescence PF CP 10%, NaF/KNO3 30min for 35%, 10-14 days TouchUp Avail 15%, 20%, 35% others 4-8 h At-Home Hydrogen Peroxide Discus Dental Zoom Weekend HP6% NaF/KNO3 4-8 h 2-3 days Yes, included Premier Perfecta Bravo HP 9% Carbomer 30 minutes 10-14 days TouchUp Avail Premier Perfecta REV HP 14% Carbomer 15 minutes 7-14 days TouchUp Avail SDI Pola Day HP 3%,7.5%,9.5% NaF/KNO3 30-90 min 7-14 days TouchUp Avail WOW SPRAYWHITE PRO HP 17.5,35 KNO3 1-90 sec 1-7 days TouchUp Avail At-Home HP/CP Combination Dentsply Nupro White gold HP 15%, NaF/carbopol 15min- 7-14 days TouchUp Avail CP 15% or 10% overnight Discus Dental NightWhite ACP and NaF/KNO3 Night-8hmax 7-14 days TouchUp Avail DayWhite ACP HP 6-9.5%, CP 10-38% Day 15-30min 1-2x daily

IX. ADA Professional Product Review of 6 Chairside Whitening Systems  BIOLASE LaseSmile System  BriteSmile Whitening System  Den-Mat Sapphire System  Discus Dental Zoom2  Life-Like 35% HP System  UltraDent Opalescence Extra Boost

X. USED FOR COSMETIC AND THERAPEUTIC EFFECTS A. PROPERTIES OF SELECTED OVER-THE-COUNTER MOUTHWASHES Product (Manufacturer) Alcohol (%) PH Active Ingredients Advance Breath Care (Arm&Hammer) 15 9.1 Baking Soda, Zince Citrate, Cetylpyridinium Cl Biotene (Laclede) 0 6.5 Glucose oxidase, lactoperoxidase, lysozyme Cepacol (SKB)+++ 14.5 6.0 Cetylpyridinium chloride 0.05% Colgate Dry Mouth Relief (Colgate) 0 6.0 NaF -.048%, Glycerin, PG, CPC, once daily Crest Pro-Health Complete (P&G) 0 6.0 NaF-.0219%, CPC for twice daily use Crest Pro-Health Mouthrinse (P&G) 0 4.7 Cetylpyridinium chloride 0.07% Crest Pro-Health Enamel Shield (P&G) 0 6.4 0.02% for 10ml twice daily use Crest 3D White Multicare Whitening Rinse 0 5.4 H2O2, sodium hexametaphosphate Lavoris Crystal Fresh (Dep) 5 6.0 Citric acid, , sodium hydroxide, zantrate Listerine Antiseptic Mouthrinse (J&J) 21.6 4.2 Four essential oils in a hydroalcoholic rinse Listerine Total Care Anticavity Rinse(J&J) 21.6 3.2 NaF 0.0221% for 10ml 2x daily use, NO EOs Listerine Total Care Mouthrinse (J&J) 21.6 6.0 NaF 0.0221% for 10ml 2x daily use, SLS,No EOs Listerine Whitening Pre-Brushing (J&J) 8 5.8 Hydrogen Peroxide 2%, castor oil, No EOs Listerine Whitening Plus Restoring Fluoride 10.5 4.0 NaF 0.0221% for 10ml 2x daily use,H2O2,castor oil Listerine Zero Less Intense (J&J) 0 4.3 Sodium lauryl sulfate, benzoic acid,sorbitol Listermint Arctic Mint (Pfizer) 0 5.8 Sodium lauryl sulfate, zinc chloride 14 ©Karen Baker, M.S. Pharm, 02/07/17

Natural Dentist Anti-Gingivitis 0 3.3 Peppermint,sage,aloe vera, xylitol Natural Dentist Anti-Cavity 0 7.0 Sodium Fluoride 0.05%, aloe vera, xylitol Natural Dentist Whitening/Gingivitis 0 6.0 Peppermint,sage,citric acid,betaine Oral-B Anti-Plaque Rinse 0/6.6 7.0 Cetylpyridinium chloride 0.05% Oral Max Oral Rinse (Novus Natural ) 0 3.0 Natural from Peroxyl (Colgate) 0 3.7 Hydrogen peroxide 1.5% Rembrandt Premium Whitening Plus (J&J) 0 4.0 .05% NaF, H2O2, castor oil, glycerin for once daily Rembrandt Whitening with Fluoride (J%J) 0 6.4 0.02% NaF, H2O2, Castor oil for twice daily Scope Outlast Long Lasting (P&G) 13 6.0 Concentrated flavoring oils, CPC, benzoic acid Scope with Baking Soda (P&G) 9.9 8.4 Baking Soda, cetylpyridium chloride, domiphen br Scope Sparkle Mouthrinse (P&G) 0 5.0 Hydrogen Peroxide, sodium hexametaphosphate Signal (Chesebrough-Ponds) 14.5 6.8 Sodium lauryl sulfate, sodium chloride SuperSmile (Robell Res) 0 8.2 NaMFP, BS, pyrophosphates, calcium peroxide Targon (Block) 6 5.5 Castor oil, detergents Therasol (Oratec) 8 5.5 0.3% C31G, NaF 0.02%, glycerin Tom’s of Maine Wicked Fresh (Colgate) 0 3.1 Tom’s of Maine Natural Cleansing(Colgate) 0 2.7 Vitamin C, aloe vera, glycerin, witch hazel Tooth and Gum Tonic (Dental Co.) 0 4.7 Oils of peppermint,red ,,

PATIENT POINTS: 1. Listerine must say “Antiseptic” on the yellow banner in order to significantly reduce gingivitis. 2. Mouthwash containing peroxide cannot significantly whiten vital teeth. 3. Breath freshening effects of high concentration flavoring oils last about 1 hour. 4. Effective oral malodor agents are zinc salts, chlorine dioxide & antimicrobial essential oils. 5. Many fluoride rinses now contain 0.02% NaF to be used twice daily instead of 0.05% once daily.

B. PROPERTIES OF “THERAPEUTIC” MOUTHWASH PRODUCTS Product Plaque Reduction Toxicity Alcohol PH Substantivity Chlorhexidine (Peridex, Periogard, generics)) High Low 11.6% 5.6 High Delmopinol (PerioShield,ButlerGUM.) Moderate Low 0% 5.7 Mod Phenolics (Listerine gold/blue or green, TC) Moderate Low 26.9%/21.6% 4.4 Low Sanguinarine (Viadent Original) Low-moderate Low 11.5% 4.5 Low Quat. Ammon. Comp.++ (Scope/Cepacol, Low Low 18%/14% 6.5/6.0 Low Viadent Advanced Care, Crest Pro Health) Low-moderate Low 0% 6.0 Low-Mod Oxygenating Agents (H2O2/chlorine dioxide) Low Unsure 0% 2.7/8.4 Low Pre-brushing (Plax/New Plax) Low low 7.5%8.5% 8.2 Low

C. THERAPEUTIC MOUTHRINSE: FLUORIDE TOPICAL/HOME-USE RINSES Nonprescription Prescription Generally 0.05% NaF designed for 10ml once daily use Generally 0.2% NaF designed for 10ml once weekly use which exposes teeth to 2.23mg F- per day which exposes teeth to about 9mg F- per day Act Restoring-11% alcohol in icy cool mint, cinnamon, NaFrinse Acidulated Oral Rinse and Systemic Supplement, mint, icy spearmint by Chattem Orachem Pharmaceuticals Act for Kids Fluoride Anti-Cavity Treatment for Kids-BB NaFrinse, 0.05%,, Orachem Pharmaceuticals Act Anti-Cavity ETOH-free mint or cinnamon for adults Fluorigard Anti-Cavity Dental Rinse, Colgate-Palmolive NaFrinse, 0.2%, Medical Products Laboratories, Oral Co. Pharmaceuticals Div. Oral-B Rinse Therapy Anti-Cavity Treatment, Oral-B Lab Phos-Flur® Oral Rinse Supplement, Cherry, Cinnamon, Fluorinse by Oral-B Grape, , Colgate-Hoyt Laboratories, Div. Of Colgate-Palmolive Co. NaFrinse Acidulated Oral Rinse 0.05%, Colgate Oral PreviDent Dental Rinse, 0.2% Colgate Oral Pharmaceuticals Pharmaceuticals NaFrinse Neutral Rinse, 0.05%, colgate Oral Pro- Dentx 0.02% Neutral Sodium Fluoride Rinse (Pro- Pharmaceuticals Dentec) 15 ©Karen Baker, M.S. Pharm, 02/07/17

COCHRANE LIBRARY REVIEW 2012 “Fluoride mouthrinses for preventing dental caries in children and adolescents” Regular supervised use of fluoride mouthrinses by children would reduce their , even if they drink fluoridated water and use fluoridated toothpaste. Fluoride is a mineral that prevents tooth decay (dental caries). Since widespread use of fluoride toothpastes and , the value of additional fluoride has been questioned. Fluoride mouthrinse is a concentrated that needs to be used regularly to have an effect. The review of trials found that regular use of fluoride mouthrinse reduces tooth decay in children, regardless of other fluoride sources. One in two children with high levels of tooth decay (and one in 16 with the lowest levels) would have less decay. However, more research is needed on adverse effects and acceptability of mouthrinses.

D. Therapeutic Mouthrinses: Anti-Plaque/Anti-Gingivitis

i. Efficacy of Crest ProHealth Mouthrinse for Gingivitis Reduction ii. Oxyfresh (Oxyfresh USA) – toothpaste and mouthwash for halitosis CloSys II mouthrinse and Closys II toothpaste (Rowpar Pharmaceuticals) ProxiPure (Dentist Preferred Inc., 1.800.997.7694) – contains chlorophyll Ingredients: stabilized chlorine dioxide (Purogene)< pH = 8.4-9.2

Smart Mouth Advanced Clinical Formula contains CPC 0.05% and is promoted for Maximum Plaque and Gingivitis Protection along with breath odor reduction.

Smart Mouth Original Formula contains and zinc chloride.

iii. Listerine Mouthrinses (J&J) – Only those that say “ANTISEPTIC” on the yellow banner areADA/CDA accepted for plaque and gingivitis reduction: Cool Mint, Freshburst, Naturals, Original, Soft Mint and UltraClean are all effective in reducing gingivitis by 25-36% in addition to toothbrushing.Don’t dilute!!

Directions: Rinse with 20ml twice daily for 30 seconds, pH = 4.2

LISTERINE WHITENING PLUS RESTORING – 2% H2O2, alcohol 10.5%, and 0.0221% NaF designed for 10ml 2x daily use. Contains NO anti-gingivitis (EO) ingredients LISTERINE AGENT COOl BLUE – alcohol free disclosing rinse for use prior to brushing twice daily. FD&C Dye No. 1 is the disclosing agent. LISTERINE TOTAL CARE – has 21.6% alcohol and 0.0221% Fl for 10ml 2x/day

iv. Chlorhexidine 0.12% [Peridex (Omnii)], [Periogard (CP)], [Chlorhexidine 0.12% rinse (Teva or Barre)] – ADA/CDA accepted anti-plaque and gingivitis

The standard for comparison for plaque and gingivitis reduction. Ingredients: Chlorhexidine gluconate 0.12%, 11.6% ETOH, pH =5.6 Directions: Rinse with 15ml twice daily. Foaming agents inactivate chlorhexidine. Advantages: Substantivity, lack of toxicity, broad spectrum of antimicrobial activity Disadvantages: Staining, increased calculus formation, alcohol content, , unstable in toothpaste due to inactivation by anionic surfactants such as SLS Chlorhexidine 0.12% alcohol free and therapeutically equivalent (Sunstar America) and pH is 5.1

16 ©Karen Baker, M.S. Pharm, 02/07/17