Toothpastes in Dentistry: A Review

ABSTRACT

Toothpastes have evolved substantially over the past few decades. Major strides have been made in the industry with the introduction of novel formulations that have the potential to provide significant clinical benefits. The main components of toothpastes are surfactants, abrasives, and active ingredients. Of these, the active ingredients dictate the therapeutic indications of the toothpaste. Modern formulations may contain one or several active ingredients which can be classified as anti-caries, anti-calculus/anti-tartar, anti-erosion, anti-halitosis, anti-microbial, anti-plaque/anti-gingivitis, desensitizing, and whitening. The Canadian Dental Association (CDA) does not recognize all commercial toothpastes, nor active ingredients, offered on the market today. Hence, caution should be taken with certain formulations to avoid their misuse. The current literature has demonstrated potential clinical benefits for several novel active ingredients; however, further research is required to verify their efficacy and safety for everyday use. Ultimately, toothpaste recommendations should be evidence-based and made in accordance with the CDA Seal of Approval. Such recommendations should be justified by the active ingredients contained within the toothpaste, and prescribed on a patient-specific basis considering factors such as chief complaint, caries risk, periodontal risk, risk for non-carious cervical lesions (NCCLs) (e.g., erosion, abrasion), halitosis, and cosmetic demands, to foster the utmost quality of care.

INTRODUCTION

Dental biofilm is composed of a complex, pathogenic, microbial network which plays an influential role in the development and progression of dental caries and periodontal inflammatory diseases.^1-3 As such, the mechanical and chemical disruption of dental biofilm is integral to maintaining a clinically healthy dentition and periodontium. Toothpastes are an essential component of everyday oral hygiene, and a key factor to achieving and maintaining excellent oral health. With the abundance of over the counter (OTC) products sold on the market today, selecting a single toothpaste can be overwhelming for patients. Moreover, patients with specific oral conditions may benefit from certain medicinal toothpastes that are unbeknownst to them. Recently, there has been a surge in the literature on toothpastes, including the development of novel formulations and multi-functional active ingredients.^4-7 Hence, this work aims to provide a comprehensive review of the progressive literature on toothpastes to aid dental professionals while selecting appropriate products for their patients based on evidence and patient-specific factors.

WHAT IS THE FUNDAMENTAL PURPOSE OF TOOTHPASTES?

The fundamental purposes of toothpastes are twofold: to act as an antimicrobial adjunct in the removal of pathogenic dental biofilm, and to subsequently provide a protective barrier to the teeth, thereby increasing resistance to future dental and periodontal diseases.^4,5 It is important to note that toothpastes are an adjunct to excellent oral hygiene, including proper tooth brushing and flossing techniques. As toothpastes have evolved, there has been an increasing demand for additional requirements. Given the persistence of oral diseases and conditions, including dentinal hypersensitivity (DH), non-carious cervical lesions (NCCLs) (e.g., dental erosion), halitosis, and extrinsic tooth staining, modern toothpastes are required to be versatile and multi-functional to address these clinical conditions.⁸ As a result, toothpastes may aim to achieve a secondary goal, such as reducing DH (i.e., desensitizing), eliminating odourous reath (i.e., anti-halitosis), and/or enhancing tooth esthetics (i.e., whitening).⁴

COMPOSITION OF TOOTHPASTES

Toothpastes may be in the form of a gel, foam, paste, or liquid, and their composition includes several medicinal and non-medicinal ingredients.^4,9 Regardless of consistency, the average toothpaste is composed of humectants, water, abrasives, binders, buffers, surfactants, flavouring agents, colours and preservatives, and active ingredients. The three main components are surfactants, abrasives, and active ingredients.^4,9 In comparison, surfactants and abrasives typically compose a larger proportion of toothpastes. Even in their inactive forms, certain surfactants and abrasives may have similar properties to active ingredients, allowing them to achieve therapeutic outcomes.^10,11

In contrast, the active ingredients only compose a small fraction of the overall volume of toothpastes; however, these provide the major therapeutic benefits. The bioavailability of active ingredients is essential to maximize their efficacy.⁴ In general, the therapeutic benefits of toothpastes can be categorized into anti-caries, anti-calculus/anti-tartar, anti-erosion, anti-halitosis, anti-microbial, anti-plaque, anti-gingivitis, desensitizing, and whitening. The concentrations of active ingredients within these categories vary, which may alter the applicability of certain toothpastes depending on patient-specific factors.

SURFACTANTS

Surfactants, or detergents, produce a foaming action which decreases the surface tension in the oral cavity. This leads to greater dispersion of the active ingredients throughout the oral cavity, better wetting of the teeth, and collection of biofilm products in a suspension which can later be expectorated.⁹ The foaming effect produced by surfactants also contributes to dispersion of the flavouring agents within a toothpaste, which leads to an overall feeling of cleanness after tooth brushing. When an enhanced foaming action is desired, for example patients with xerostomia, it is recommended to prescribe a toothpaste with a combination of surfactants along with a mucosal protectant, such as betaine, to relieve dry mouth symptoms.^4,12,13

SODIUM LAURYL SULFATE

Sodium lauryl sulfate (SLS) is an anionic surfactant used in several everyday cleaning and hygiene products, including toothpastes.¹¹ SLS is thought to have active ingredient-properties, specifically bacteriostatic capabilities making it an anti-plaque agent.⁹ Although the majority of toothpaste ingredients are known to be bioavailable, it has been postulated that SLS may be cytotoxic to the oral mucosa leading to epithelial desquamation.¹⁴ Specifically, SLS has been shown to have a correlation with recurrent aphthous ulcers (RAU).¹⁵ Thus, given the available evidence, it is currently recommended that SLS hygiene products should be avoided for patients with RAU.^9,15 For patients without a history of RAU, it would be prudent to monitor and assess for symptoms, recommending SLS-free products as appropriate.

ABRASIVES

Abrasives are micrometer-sized particles which aid in the mechanical removal of dental biofilm and other substances which adhere to the tooth pellicle.¹⁰ This includes chromophores, or coloured compounds found in foods and beverages which become incorporated into the tooth structure resulting in extrinsic staining.^9,10,16 Some common examples of abrasives include aluminum hydroxide, calcium carbonate, calcium phosphate, calcium phosphate dihydrate, polyethylene microbeads, silica (anhydrous), and silica hydrates.^9,16 Certain whitening toothpastes use abrasive particles to facilitate the mechanical removal of extrinsic stains, which in turn leads to cosmetic benefits.10 Specifically, polyethylene microbeads have been identified as a promising abrasive agent for their clinical efficacy in achieving tooth whitening.¹⁰

Aside from this, however, there are significant biological risks associated with the use of mechanically abrasive materials for tooth whitening. This includes the potential for tooth wear, DH and gingival irritation, the risks of which are exacerbated in combination with inappropriate brushing techniques.¹⁶ Toothpastes which contain abrasives for this purpose should therefore be avoided, if possible, especially for patients at increased risk for tooth wear, DH, and gingival inflammation. The relative dentin abrasion (RDA) rating is a useful and practical tool for quantifying the abrasivity of toothpastes.^17,18 In general, toothpastes with a RDA value of less than 250 are considered safe with the appropriate use of soft-bristled brushing products.¹⁶

ACTIVE INGREDIENTS

Active ingredients provide the main therapeutic benefits of toothpastes. It is important to note, as with any medicinal ingredient or pharmaceutical, there are specific clinical indications for their use. Additionally, there is a potential for adverse effects (AEs) if used incorrectly. Currently, there is an increasing number of active ingredients being used in modern toothpastes. For the purposes of this review, the most clinically relevant and recently reported active ingredients will be discussed to provide a comprehensive and practical synopsis of the current literature.

ANTI-CARIES AGENTS

Fluoride is arguably the most effective known topical substance for arresting and preventing dental caries.^5,19 By the incorporation of fluoride into the crystal lattice structure of the enamel, the formation of fluorapatite (FAP) from hydroxyapatite (HAP) reduces the critical pH at which demineralization of the tooth occurs, thereby increasing resistance to dental caries and aciderosion.^19-21 Fluoride alone is cariostatic; however, in toothpastes fluoride must be combined with an aqueous carrier/ fluoride vehicle to improve its stability and therapeutic effects.⁵ Many carriers exist to deliver fluoride topically to the tooth surface;⁴ however, sodium is one of the most commonly employed fluoride carriers and is broadly used in today’s toothpastes.

SODIUM FLUORIDE

Sodium fluoride (NaF) is a highly bioavailable active ingredient which has been widely used as an anti-caries agent in toothpastes, mouthwashes, and water fluoridation.²² In conventional formulations the effective concentration of NaF is 0.243% w/w; however, it is also available as high as 1.1% w/w. NaF toothpastes are mainly used for prophylaxis and routine oral hygiene; however, they also play a role for high caries risk patients.⁵ A systematic review and meta-analysis demonstrated NaF may exhibit desensitizing properties in addition to anti-caries effects, which can aid in reducing DH following bleaching treatment.²³It has also been postulated that NaF may have antimicrobial effects on oral streptococci and other cariogenic bacteria;^22,24 however, these have yet to be proven with sufficient clinical evidence. Besides its clinical advantages, NaF has the potential to cause AEs with its misuse. Although it is relatively rare, dental fluorosis has been documented with high concentrations of NaF in children younger than 6 years of age.²⁵The risk for dental fluorosis is true for all fluoridated toothpastes, regardless of the fluoride vehicle. As such, the current literature suggests a reduced volume of 0.243% NaF be used for this paediatric dental population, to reduce the likelihood of developing dental fluorosis.²⁵

SODIUM MONOFLUOROPHOSPHATE

Sodium monofluorophosphate (SMFP) is an alternative fluoride vehicle also used in many toothpastes on the market. Like NaF, SMFP enables the remineralization potential of the tooth via the formation of FAP. Historically, there has been some debate whether NaF or SMFP may outperform one another as an anti-caries agent. One study demonstrated NaF may be superior at increasing enamel microhardness following demineralization in in vitro;²⁶ however, subsequent research has shown they are comparable in a clinical setting.²⁷The effective concentration of SMFP used in today’s toothpastes is 0.76% w/w SMFP. SMFP has a relatively minor risk of dental fluorosis; however, some studies have demonstrated a low incidence of soft tissue aberration and increasing gingival inflammation for patients using an SMFP + silica abrasive toothpaste.^5,28 In a follow-up study, it was subsequently concluded that no hard or soft tissue AEs were noted with an SMFP + calcium carbonate abrasive toothpaste;^5,29 therefore, such reported AEs are more likely to be attributed to the abrasives within the toothpaste rather than SMFP.

STANNOUS FLUORIDE

Stannous fluoride (SnF2) has recently emerged as a multi-functional active ingredient; however, its use in toothpastes is not necessarily novel. Original uses of SnF2 date back to the mid-1950’s, but it wasn’t until recently that a stabilized formulation was invented, which significantly increased its bioavailability.^4,30-32 Since this invention, SnF2 has been revived and studied extensively due to its potential to have improved therapeutic benefits over traditional fluoride vehicles such as NaF and SMFP. SnF2 formulations are commercially available at 0.454% w/w. Current studies suggest SnF2 toothpastes are capable of a variety of therapeutic benefits, including anticaries,^4,8,33-35 anti-erosion,⁷ anti-microbial,³⁶ anti-plaque/anti-gingivitis33 and desensitization.^34,35,37-39

A recent systematic review and meta-analysis noted the antibacterial properties of stannous offer a favourable benefit in combination with fluoride toothpaste. In comparison to other fluoridated nonstannous products, SnF2 has shown to produce favourable reductions in plaque and calculus accumulation, and bleeding indices.⁴⁰ The combination of tin and fluoride further provides a higher efficacy to protect against dental erosion when compared to tin or fluoride alone.⁴⁰ This is due to the production of protective molecules which form when SnF2 is exposed to HA at the enamel pellicle.⁴¹SnF2 toothpastes have shown to inhibit plaque and glucose transport metabolism, which suppresses the metabolic virulence of cariogenic bacteria and provides a bacteriostatic effect.³⁰Also, they have proven to demonstrate a significant reduction in gingivitis compared to NaF, and reduced gingival bleeding scores versus triclosan.³³ Moreover, SnF2 has shown promise at managing DH.^35,42 While it has tremendous potential to become a future gold standard active ingredient, currently, there is a lack of large-scale meta-analyses to support the clinical efficacy of SnF2.⁴⁰ Furthermore, some AEs have been identified. Specifically, the deposition of tin-containing by-products within the tooth pellicle has the potential to cause extrinsic tooth staining with long-term use of SnF2 products.⁴¹

HYDROXYAPATITE

In contrast to the previous fluoride-containing active ingredients, HAP is a bioactive synthetic enamel-restorative material that has been studied for use in non-fluoridated toothpastes.^43,45 As the major constituent of the inorganic portion of bone and teeth, HAP is non-toxic and bioavailable with a high safety profile, which makes it an attractive alternative to fluoride.^45,46 HAP is available in both micro- and nano-HAP formulations; however, research suggests the smaller the particle size, the better HAP is able to penetrate the enamel and facilitate remineralization.^45,46 Although this has yet to be proven with large-scale clinical trials, current studies have demonstrated HAP-containing toothpastes offer comparable anti-caries activity to fluoridated alternatives in vitro, in situ, and in vivo.^45-47 HAP-containing toothpastes are not predominantly offered on the Canadian market today; however, these are readily available on an international scale.⁴⁵ The clinical benefits of HAP may extend beyond anti-caries; numerous studies have highlighted nanoHAP toothpastes are highly effective at reducing DH.^6,43,48,49 HAP has also been shown to have tooth whitening abilities.⁴⁵ Additionally, a recent review noted HAP has both bacteriostatic and bactericidal abilities which can reduce and inhibit pathogenic biofilm formation, while simultaneously preserving the normally occurring oral flora.⁴⁷ Aside from the multi-functional benefits of HAP, there are some drawbacks including a potentially lower clinical anti-caries efficacy in comparison to fluoride. Since HAP does not reduce the critical pH of the tooth in the same manner as FAP, studies suggest it may be less effective at arresting and preventing future caries, especially for high caries risk patients.^45,46 Nonetheless, HAP-containing toothpastes may be an appropriate alternative for specific clinical indications (e.g., children under age 6 at risk for dental fluorosis).⁴⁷

WHITENING AGENTS

HYDROGEN PEROXIDE

Tooth whitening is a process which increases the value, or brightness, of the teeth for cosmetic purposes. Whitening involves the removal of extrinsic staining of the teeth and can be achieved mechanically, chemically, or through a combination of both. Perhaps, the most common modality of tooth whitening is chemical treatment with hydrogen peroxide (H2O2). H2O2 chemically degrades the chromophores which accumulate in the tooth structure to produce extrinsic stains.^11,50,51 This process involves oxidation of the chromogens’ organic layer at the dentinoenamel junction, which ultimately yields a lighter perceived tooth shade. The effective concentration of H2O2 in toothpastes is 1% w/w; and studies have demonstrated H2O2 is effective at decreasing yellowness and increasing lightness of teeth significantly when compared to abrasives, such as silica and sodium bicarbonate toothpastes.⁵⁰ A common AE of H2O2 whitening is post-treatment hypersensitivity.⁵² Furthermore, aggressive use of this chemical agent in high concentrations can damage the organic matrix, thus mechanically weakening the tooth.¹⁶ As such, these products should be used with caution and are not recommended for children under the age of 12.

POLYPHOSPHATES & SODIUM CITRATES

Another method of whitening is via anti-redeposition agents, which act to prevent the redeposition of chromogens after whitening treatment. Anti-redeposition agents may also inhibit future calculus formation.^16,51 Some examples of anti-redeposition agents include polyphosphates, sodium citrates, pyrophosphate, sodium trimetaphosphate (STP), and sodium hexametaphosphate (SHMP). These agents have a strong adsorption affinity to the tooth surface where they bind chromogens to prevent redeposition.¹⁶ There is some controversy with the use of anti-redeposition agents in toothpastes, though. One study demonstrated sodium citrate toothpaste containing papain and alumina was clinically effective at removing chlorhexidine-induced extrinsic stains.^11,50 However, another clinical study determined that the combination of papain/alumina/sodium citrate did not statistically outperform the control group.11 This garners the need for additional research to provide more reliable evidence in terms of the use of anti-redeposition agents for tooth whitening.

BLUE COVARINE

Tooth whitening can also be achieved with optical manipulation. Blue covarine (BC) is an optical modifying pigment which deposits a thin, semitransparent film on the tooth surface. This film shifts the reflected color of the teeth from the yellow-region to the blue-region on the visual scale resulting in a tooth shade with more favourable chroma and value.^10,16 A clinical study determined that brushing once with BC-containing toothpaste can result in an immediate reduction in yellowness and increased tooth whitening compared to an abrasive silica-based toothpaste;^11,50 however, compared to other methods of whitening, including H2O2 and microbead abrasives, BC was found to be inferior.^10,16 Therefore, although the science behind BC is quite novel, it seems there is more work to be done to optimize its whitening abilities.

ACTIVATED CHARCOAL

A recent addition to the arsenal of whitening agents is activated charcoal (C+). C+ is a nanocrystalline form of carbon with a large surface area and numerous nanometer-sized pores. In theory, C+ achieves tooth whitening by adsorbing and retaining chromogens in the oral cavity which can later be expectorated. As a novel whitening agent, though, C+ is relatively understudied. The clinical efficacy of the whitening abilities of C+ remains unknown. Furthermore, studies which have been performed have identified alternative methods of whitening, including microbead abrasives, BC and H2O2, to be more effective at achieving tooth whitening when compared to C+.^10,16 Thus, it is unknown whether C+ currently plays a significant role in the removal of extrinsic staining for tooth whitening purposes.

PAPAIN & BROMELAIN

Proteolytic enzymes, papain and bromelain, have also been studied for use as whitening agents. Papain is a sulfhydryl protease enzyme originating from the Carica papaya plant; while, bromelain is a proteolytic enzyme originating from Ananas cormosus. These enzymes have anti-adhesive properties to oral microorganisms which facilitates their ability to increase the value of tooth shades.⁵³ When papain is combined with bromelain, these agents covalently attach to target proteins within chromophores on the tooth surface and subsequently denature them. This protein degradation changes the characteristics of the chromophores to absorb less light in the visible range, thereby decreasing the perceived degree of extrinsic staining.9,16 When compared to perlite/hydrated silica abrasives, papain and bromelain were found to significantly decrease extrinsic tooth staining.53 An additional advantage to papain is its ability to penetrate interproximal areas and along the gingival sulcus, which has shown to be effective at reducing gingival bleeding and inflammation.^53,54 Therefore, although more research is needed to confirm their clinical efficacy proteolytic enzymes may be useful as whitening agents, and possibly anti-gingivitis agents.

DESENSITIZING AGENTS ARGININE & CALCIUM CARBONATE

DH is a highly prevalent condition with a relatively complex etiology triggered by thermal, physical, chemical, and acidic stimuli.6 As such, desensitizing toothpastes have been designed to address this clinical condition. There are two main mechanisms to reduce DH: physical occlusion of the dentin tubules, and depolarization of the dental nerve. Arginine (Ar) is an α-amino acid naturally found in the saliva along with calcium carbonate (CaCO3), a salivary buffer. The combination of Ar and CaCO3 in toothpastes, known as Pro-Argin technology,^55-57 has been extensively studied and shown to be highly effective at reducing DH by occluding the dentinal tubules.^6,55,58 This mechanism involves the accumulation of salivary glycoproteins along with Ca2+ and PO43- ions which forms a plug that seals the dentinal tubules, providing resistance to acid and thermal attacks which can trigger DH.^{6,55,56,58,59} In comparison to other desensitizing agents, research suggests Ar and CaCO3 are superior at reducing long-term effects of DH; while other active agents such as SnF2 and nano-HAP may provide better short-term relief.^6,55 A network metaanalysis studying the relative effects of desensitizing toothpastes for DH concluded Ar and CaCO3 provide benefits for DH provoked by air-stimuli, while other agents provided better results for tactile stimuli inducing DH. Ultimately, Pro-Argin technology is clinically proven for desensitization; however, there may be some limitations for its use including immediate or short-term relief of DH.

STRONTIUM (CHLORIDE & ACETATE)

Unlike Ar and CaCO3, strontium salts are not typically found in the saliva. Strontium salts, including strontium chloride (SrCI2) and strontium acetate (C4H6O4Sr) are insoluble metal compounds which reduce DH by precipitating on the surface of exposed dentin and physically occluding the dentinal tubules.^6,39,55,58 Previous studies hypothesized an alternative mechanism for the desensitizing effect of these strontium salts via nerve depolarization;^59,60 however, recent studies suggest dentinal tubule blockage is more likely responsible for its therapeutic benefits.⁶ Interestingly, the desensitizing effect appears to be especially effective with strontium acetate/artificial silica (Sr/Si) formulations which plug the dentinal tubules with an acid-resistant Sr/Si deposit.³⁸ Sr/Si is commercially available at a therapeutic concentration of 8% C4H6O4Sr.³⁹ Although there are several studies in support of Sr/Si products, there is some controversy regarding their use for reducing DH.³⁹ The current literature suggests strontium is comparatively inferior to other desensitizing agents, particularly for air stimulation^39,58 and there is a lack of reliable evidence to determine the clinical efficacy of strontium in relieving symptoms of DH.⁶¹

POTASSIUM (CHLORIDE, CITRATE & NITRATE)

Potassium salts are also used to reduce DH; however, this is achieved through nerve depolarization which reduces pulpal nerve activity, thereby relieving the perception of painful symptoms of DH.^59,61-63 Potassium nitrate (KNO3) is most used in OTC products at a therapeutic concentration of 5% KNO3 w/w. Potassium salts have been well-studied in the literature, including a Cochrane review,63 systematic reviews,^23,61 and meta-analyses.^6,23 Despite these efforts, though, the efficacy of potassium toothpastes is up for debate.³⁸ In comparison to other desensitizing agents, these studies have identified a lack of reliable clinical evidence to suggest potassium toothpastes are effective at reducing DH on their own. It has been suggested that other agents may be responsible for the desensitizing properties of potassium-containing toothpastes containing other active ingredients, including SMFP and nano-HAP.^62,64

BIOACTIVE GLASSES

Bioactive glasses have been identified as a novel agent for several uses in healthcare, from bone regeneration to healing of chronic wounds.^65,66 In toothpastes, bioactive glasses such as calcium sodium phosphosilicate (CSPS) and fluoro calcium phosphosilicate (FCPS) are used for their desensitizing properties.^65,66 CSPS (NovaMin®) and FCPS (BioMin-F®) are used clinically at a therapeutic concentration of 5% w/w. Both agents reduce DH by physically occluding dentinal tubules;^65-68 however, BioMin-F® also has the advantage of remineralization by releasing fluoride at the enamel surface, facilitating the formation of FAP.^65,66,69 Furthermore, recent clinical studies have shown that 5% BioMin-F® is significantly effective at reducing symptoms of DH as compared to 5% NovaMin®, 5% KNO, and 8% Ar & 35% CaCO3.^64,70 This promising evidence may suggest that bioactive glasses, specifically BioMin-F® may be useful to alleviate symptoms of DH and provide additional benefits such as anti-caries and anti-erosion;^64,70 nonetheless, further clinical research is required to ensure its safety for everyday use.

ANTI-PLAQUE & ANTI-GINGIVITIS AGENTS

TRICLOSAN

Triclosan is an antiseptic substance which has a prominent history in toothpastes. With broad spectrum efficacy against both gram-positive and gram-negative bacteria, triclosan has proven to be an effective anti-microbial agent in toothpastes.⁷¹ The anti-plaque capabilities of triclosan are enhanced when in combination with poly(methylvinylether/maleic anhydride) (PVM/MA) and zinc citrate.^4,9 The effective clinical concentration of triclosan is 0.3% w/w with 2% w/w PVM/MA. Triclosan has also shown to reduce SLS-induced irritation of the oral mucosa and have a direct anti-inflammatory effect on the gingiva via inhibition of the cyclooxygenase and lipoxygenase pathways.^4,8,9 Despite these benefits, the current literature has identified potential serious AEs associated with triclosan, including endocrine-related disturbances, gastrointestinal issues, and as a risk factor for breast cancer.^71-73 As such, it has since been removed from several OTC products and alternative anti-plaque agents are currently being studied, including natural and herbal products.⁷⁴

HERBAL PRODUCTS

Herbal toothpastes are a recent hot topic for their potential antimicrobial benefits and relatively low risk for AEs.⁷⁴ Their composition mainly involves natural extracts or essential oils including clove, cinnamon, black pepper, and/or other antimicrobial botanicals.⁷⁵ Herbal products are believed to have an advantage over synthetic pharmaceuticals as they are relatively inert;⁷⁵ however, these substances are still medicinal and should be treated as such. Some studies suggest herbals may be helpful as anti-plaque/ anti-gingivitis agents;^75,76 while, others acknowledge their plaque-inhibitory effects may be limited as compared to commercial toothpastes.⁷⁴ Herbal products have also been proposed to combat halitosis; however, a recent systematic review noted there is a lack of evidence and long-term follow-up studies to validate such claims.⁷⁷ Therefore, further studies are needed to prove the efficacy of herbal products for clinical use. Currently, SnF2 seems to be the industry standard for its anti-plaque properties.^40,76

ANTI-HALITOSIS AGENTS

ZINC (CITRATE & CHLORIDE)

Halitosis, or oral malodour, is a highly prevalent condition which can have negative social consequences out of stigma and embarrassment.⁷⁷ Halitosis is mainly caused by the presence of anaerobic bacteria and microorganisms which produce volatile sulfur-containing compounds (VSCs) emitting an unpleasant smell.⁹ Zinc (Zn) is a trace element which is used in toothpastes for its anti-halitosis properties. In the oral cavity, Zn salts react with VSCs to produce non-volatile, odourless by-products which eliminates odorous breath.⁴ Zn is commonly found in toothpastes as Zn citrate and Zn chloride, both of which are readily soluble. Zn citrate and Zn chloride are used at a therapeutic concentration of 2% w/w and 0.5% w/w, respectively.⁴ Alternative therapies have been identified to treat halitosis, including essential oils, fluorides, and herbal substances; however, a recent review concluded that there is insufficient evidence to suggest these therapies are effective at treating halitosis compared to traditional therapies, including Zn.⁷⁷

ANTI-CALCULUS/ANTI-TARTAR AGENTS

PYROPHOSPHATES

Dental biofilm is the primary cause of many dental and periodontal problems, especially periodontal inflammatory diseases and conditions.^1,2 Calculus is an indirect factor for these conditions, as it promotes biofilm retention and maturity. As such, anti-calculus agents have been proposed in toothpastes to reduce the negative effects biofilm, which are exacerbated by the presence of calculus. Pyrophosphate is a commonly used antitartar agent which takes several forms in toothpastes, including tetra-sodium pyrophosphate and di-sodium pyrophosphate.⁹ Pyrophosphates chelating agents are found in the saliva which act to inhibit the conversion of dental biofilm into calculus. To effectively inhibit crystal growth in calculus formation, a PVM/MA co-polymer is combined with pyrophosphate formulations to improve its stability and extend its period of action. Aside from these benefits, AEs have been reported with the use of pyrophosphates. Specifically, pyrophosphates inhibit calcium phosphate formation which delays the remineralization process of the tooth.^8,11 In their presence, teeth may remain in a demineralized state which makes them vulnerable to NCCLs, dental caries, and dentinal hypersensitivity.⁹ As such, current studies suggest that children under the age of 12 should not use pyrophosphate-containing toothpastes.⁷⁸ Regardless of age, these benefits and drawbacks must be thoroughly considered prior to recommending such anticalculus products to patients.

CLINICAL CONSIDERATIONS: RECOMMENDING TOOTHPASTES

Dental professionals should be familiar with these active ingredients, their clinical indications, and therapeutic concentrations to recommend appropriate toothpastes to patients. (Table 1) Although there is an abundance of novel active ingredients on the market and described in the current literature, dentists are encouraged to recommend toothpastes as outlined by the CDA.⁷⁹ Additionally, dentists may consult guidelines which have been proposed by other reputable organizations including the American Dental Association (ADA) and the Centre for Disease Control and Prevention (CDC)^80,81 to aid in selecting toothpastes for patients.

Table 1: Active ingredients used in commercial toothpastes with their therapeutic concentrations and clinical indications for their use.

The CDA has a Seal Program which validates manufacturers’ claims regarding the oral health benefits of their products.⁷⁹ Manufacturers are required to support such claims with sufficient evidence to obtain the CDA Seal of Approval. The evidence is then reviewed rigorously by the CDA to confirm the manufacturer’s claims for safe and effective use by the Canadian consumer. Numerous toothpastes on the market today bear the CDA Seal of Approval; however, some novel toothpaste formulations and manufacturers are not currently recognized. This includes some of the active ingredients previously discussed in this review. It is important to consider the clinical practicality and applicability of these novel products, including their known benefits and potential AEs, prior to recommending them to patients. Dentists should fulfil their fiduciary duty to patients by aiming to recommend currently recognized CDA Seal toothpaste products, to maintain an evidence-based approach to patient care. That said, certain patients may potentially benefit from novel formulations where traditional toothpastes simply do not meet their treatment needs.

While selecting toothpastes for patients in the general population, a fluoridated anti-caries toothpaste is sufficient.¹⁹ For patients with specific clinical conditions, as outlined in Table 1, prescribing toothpastes with additional, or multi-functional, active ingredients may be more appropriate. The clinical conditions which would warrant an alternative toothpaste recommendation include, but are not limited to high caries risk, high periodontal risk, calculus, dental erosion, halitosis, dentinal hypersensitivity, extrinsic tooth staining and xerostomia.

It is important to re-iterate the primary goal of oral hygiene is to maintain good oral health and prevent oral diseases. Toothpastes are an essential adjunct to maintaining good oral health; however, they are limited in their abilities to address all patient-specific needs. Mechanical debridement with optimal brushing and flossing techniques are of utmost importance to disrupt dental biofilm and prevent oral diseases. Furthermore, additional preventive measures including regular dental visits for scaling and root planing, professional fluoride application, dental education, and monitoring and assessing/re-evaluating patient’s risk factors are fundamentally important to limit the progression and future onset of dental diseases.

CONCLUSION

In summary, toothpaste recommendations should be evidence-based and patient-specific. There are many active ingredients used in modern toothpastes which have associated benefits and drawbacks. Currently, there is not a strong enough body of evidence to suggest that any particular active ingredient, nor type of toothpaste, is superior to another.^4,8,40 Therefore, it is the dentist’s duty to understand the indications, benefits, and drawbacks for each active ingredient to be able to prescribe suitable products to their patients. Recommending a specific type of toothpaste relies on patient-specific factors, such as the chief complaint, caries and periodontal risks, esthetic concerns, and bearing in mind practical applications for their use. Ultimately, though, achieving and maintaining good oral health relies on patient compliance and efficient mechanical disruption of plaque and biofilm deposits, regardless of the type of toothpaste used. Chemical biofilm disruption is only an adjunct to good oral hygiene. Therefore, dental education and oral hygiene instructions, such as describing proper brushing and flossing techniques, are extremely important preventive measures which should be employed in conjunction with toothpaste recommendations to optimize patient outcomes.

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About the Authors

Braedan R. J. Prete* is a fourth-year student in the Doctor of Dental Surgery (DDS) program at the Faculty of Dentistry, University of Toronto.

 

 

Fady Barsoum* is a fourth-year student in the Doctor of Dental Surgery (DDS) program at the Faculty of Dentistry, University of Toronto.

 

 

Dr. Aviv Ouanounou is an associate professor of Pharmacology & Preventive Dentistry at the Faculty of Dentistry, University of Toronto, and a clinical instructor and Treatment Plan Coordinator in the clinics. He is the recipient of the 2014-2015 Dr. Bruce Hord Master Teacher Award for excellence in teaching and the 2018-2019 National W.W. Wood Teaching Award for Excellence in Dental Education. He is a Fellow of the International College of Dentists, American College of Dentists and Pierre Fouchard Academy. Dr. Ouanounou maintains a private practice in Toronto. Dr. Ouanounou is the corresponding author in this article and can be reached at aviv.ouanounou@dentistry.utoronto.ca.

*These authors contributed equally to this work.