by Sondra M. Nickolson, RDH, MEd. RF
How to determine what is best for your patient
With so many different toothpaste choices on the market, each performing a unique function, it is often difficult for patients to determine the best option. For this reason, many patients turn to us - their dental health-care professional - for recommendations. Helping patients select the right toothpaste means more than simply distributing samples your office has on hand. By considering each patient’s needs, you can ensure they’ll be satisfied with their choice, and this may increase the likelihood of them consulting you when their needs or preferences change.
An old substance with a new image
The earliest record of actual toothpaste was in 1780 and involved a formula containing burnt bread. In the 19th century, charcoal became very popular for cleaning teeth, and most toothpaste was in the form of a powder. Just like today, the purpose of 19th century tooth powder was to clean teeth and freshen breath.1
Today’s toothpaste is defined as a substance used with a toothbrush or other applicator to remove the dental biofilm, materia alba, debris, and stain from the teeth, tongue, and gingiva for cosmetic, therapeutic, or preventative purposes.2 The specific type of dentifrice recommended to a patient depends on a number of factors, including need, preexisting oral health conditions, and desired outcome. For many patients, the outcome is as simple as the prevention of dental caries and the maintenance of good oral health. Others, however, select toothpaste designed to reduce or eliminate painful sensitivity, help relieve canker sore flare-ups, or improve the esthetic appearance of their teeth.
The American Dental Association outlines four guidelines that demonstrate a correlation between particular toothpaste ingredients and their effects on patients’ oral health:3
- Decreased incidence of caries with toothpaste containing fluoride
- Decreased incidence of dentin hypersensitivity with desentisitizing toothpaste
- Decreased plaque accumulation with antibacterial/antimicrobial toothpaste
- Cosmetic whitening with products containing agents that alter enamel color
Fluoride in toothpaste
For more than 30 years, fluoride has been a critical ingredient in toothpaste, used to inhibit the development of dental caries.4 Multiple research findings spanning decades have proven that fluoride use slows the onset of caries. The protective role of fluoride against dental caries, or tooth decay, was first recognized in the mid-1930s, when studies showed that children drinking fluoridated water developed caries less frequently than children with drinking water supplies low in fluoride concentration.5 General Richard H. Carmona, former U.S. Surgeon General, has joined with many previous U.S. Surgeon Generals in endorsing community water fluoridation as a cost-effective public health measure for preventing tooth decay.
Fluoride can perform both preventive and restorative functions, halting the development of carious lesions caused by harmful bacteria, and aiding remineralization of demineralized tooth surfaces.6 Toothpaste containing fluoride, when used twice daily, can be an effective way to enhance the remineralization process and control the development of caries.7 In fact, reports state that there is roughly a 30 percent reduction in caries when fluoride is used daily.8 Fluoride works by incorporating itself into tooth enamel, making teeth more resistant to acids produced by bacterial plaque and acids found in juices, sodas, and certain foods. In addition, the frequent use of a low-concentration fluoride, such as toothpaste, has been demonstrated to be an effective public health measure to prevent caries.9
Dentinal hypersensitivity and desensitizing toothpastes
Dentin hypersensitivity is highly prevalent, affecting approximately 22 percent of adults in the United States.10 The condition is defined as a short, sharp, painful response from exposed dentin in response to stimuli that cannot be ascribed to any other form of dental defect or pathology.11 Tooth wear, particularly erosion and abrasion of the tooth surface, is frequently related to dentinal hypersensitivity.
Erosion and abrasion can weaken the integrity of the enamel surface, making it vulnerable to wear, resulting in the dentinal tubules being exposed to outside stimuli and exhibiting greater tooth sensitivity.12 Erosion, defined as the pathological wear of teeth from a chemical dissolving process, can result from the frequent consumption of acidic fruits and soft drinks. Abrasion, or the pathological wear of teeth from a mechanical or rubbing process, can result from “toothpaste abuse,” a term used to describe overzealous and repeated brushing with toothpaste. Studies show that all toothpastes have the ability to cause abrasion, regardless of the type of brush used.13
Antisensitivity toothpaste containing 5 percent potassium nitrate (KNO3) can reduce intradental nerve activity and interrupt pain impulses, thereby reducing pain.14 Patients should be advised to brush with an antisensitivity toothpaste twice a day, and continue everyday use for long-term relief. In addition, dental professionals should ask specific questions during every routine cleaning to determine if patients are suffering from dentin hypersensitivity.
Antibacterial and antimicrobial toothpastes
Toothpastes containing antimicrobial agents successfully prevent plaque and gingivitis.15 The key ingredient in these toothpastes, called triclosan, is a clinically tested antibacterial agent designed to remove harmful bacteria that can cause periodontal disease.16 Used extensively in consumer products such as deodorants and soaps, triclosan has recently been included in oral care products, specifically toothpastes and mouth rinses. Though only one brand of triclosan-containing toothpaste is currently available in the United States, this figure is expected to increase.
Triclosan works by inhibiting the growth of anaerobic bacteria that are responsible for gingivitis and periodontal disease. Additionally, its antimetabolic and anti-inflammatory properties further reduce plaque build-up and gingivitis.16 A recent study found a 52 percent reduction in salivary bacteria four hours after brushing with a toothpaste containing triclosan.17 Another study revealed a significantly slower progression of periodontal disease in patients brushing with toothpaste that contains triclosan.18
Cosmetic whitening toothpastes
Tooth whitening is quickly becoming one of the most popular dental treatments, both in the dental office and at home with over-the-counter (OTC) treatments. According to the American Academy of Cosmetic Dentistry, tooth whitening is the most requested cosmetic dental procedure by patients between the ages of 20 and 50.19 Unfortunately, most whitening patients don’t know that tooth sensitivity is the most common side effect of professionally dispensed and OTC whitening treatments. Data suggest that up to 75 percent of patients who undergo professional tooth whitening may experience sensitivity.20 Patients can help prevent and reduce whitening-related sensitivity by brushing with an antisensitivity toothpaste containing potassium nitrate for two weeks prior and during professional whitening.21
Whiter teeth can also be achieved by using whitening toothpastes, and can be used in conjunction with in-office whitening treatments. While some whitening toothpastes use abrasives that remove plaque and debris from the enamel surface, others contain compounds that break down discolored debris that can build up on the enamel surface. Guidelines for whitening toothpastes have been developed by the ADA’s Council on Scientific Affairs (CSA).22 The CSA states that a whitening claim may be used if teeth lighten by two or more shades over six months. Only products that have been granted the ADA Seal of Acceptance for whitening toothpaste are currently on the market.23
For patients concerned about whitening-related sensitivity, toothpastes that simultaneously whiten and guard against sensitivity may be the best option. Sensodyne Full Protection Plus Whitening Toothpaste (GlaxoSmithKline Consumer Healthcare) and Colgate Sensitive Maximum Strength Plus Whitening (Colgate-Palmolive Company) both contain fluoride and potassium nitrate agents to prevent dental caries and provide relief for patients with sensitive teeth.24
Guide your patients
Dental health care professionals can help patients determine which toothpaste is best for them by listening to their preferences and being mindful of their unique oral health-care needs. When making recommendations to your patients, it is important to take their overall oral health into consideration, including any preexisting conditions that may affect the specific type of toothpaste they need. When facing a multitude of toothpaste options in the oral care aisle of the neighborhood store, patients may feel lost and confused with the wide variety of choices. You can help them sort through the complexity, and in the process foster a positive patient relationship that keeps them coming back to you for further oral care guidance.
1 Toothpaste History. www.toothpasteworld.com.
2 Wilkins EM. Clinical practice of the dental hygienist, 9th ed.. Baltimore, Md.: Lippincott Williams & Wilkins 2005; 440-445.
3 American Dental Association: Mouthrinses and dentifrices In: ADA Guide to Dental Therapeutics, 2nd ed. ADA Publishing, Chicago, 2000; 221-229.
4 Pader M. Fluoride In: Oral Hygiene Products and Practice, Vol. 6, Cosmetic Science and Technology Series. Marcel Dekker, Inc., New York, p 389.
5 Dean HT, Arnold FA Jr, Elvove E. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4,425 white children aged 12 to 14 years of 13 cities in 4 states. Public Health Rep 1942; 65:1403-1408.
6 Fejerskov O, Thylstrup A, Larsen MJ. Rational use of fluorides in caries prevention: a concept based on the possible cariostatic mechanisms. Acta Odontol Scand 1981; 39:241-249.
7 U.S. Public Health Service, Office of the Surgeon General, National Institute of Dental and Craniofacial Research. Oral health in America: A report of the Surgeon General. Rockville, Md.: Department of Health and Human Services, U.S. Public Health Service; 2000. National Institute of Health publication 00-4713.
8 Wilkins EM: Interdental care and chemotherapy In: Clinical Practice of the Dental Hygienist, 7th ed. Williams & Wilkins, Media, 1994; 367-369.
9 Fluorides and oral health: report of a WHO Expert Committee on oral health status and fluoride use. World Health Organ Tech Rep Ser 1994; 846:1-37.
10 Data on File, GlaxoSmithKline Consumer Healthcare.
11 Holland GR, Narhi MN, Addy M, et al. Guidelines for the design and conduct of clinical trials on dentine hypersensitivity. J Clin Periodontal 1997; 24:808-813.
12 Zero D. Erosion - chemical and biological factors of importance to the dental practitioner. Int Dent J. 2005; 55:285-290.
13 Anticaries drug products for over-the-counter human use; final monograph, final rule. Washington, D.C. Food and Drug Administration, Department of Health and Human Services Oct. 6, 1995; Federal Register, Part II, 21 CFR Part 310 et al.
14 Haywood VB. Contemporary Esthetics and Restorative Practice 1993;3 (suppl 1) 2-11.
15 Moran J, Addy M, Newcombe R. The antibacterial effect of toothpastes on the salivary flora. J. Clin Periodontol March 1988; 15(3):193-199.
16 Triratana T, Rustogi K, Volpe A, et al. Clinical effect of a new liquid dentifrice containing triclosan/copolymer on existing plaque and gingivitis. JADA Feb. 2002; 133:219 -224.
17 Sreenivasan P. The effects of a triclosan/copolymer dentifrice on oral bacteria including those producing hydrogen sulfide. Eur J Oral Sci 2003; 111(3):223-227.
18 Cullinan MP, Westerman B, Hamlet SM, et al. The effect of a triclosan-containing dentifrice on the progression of periodontal disease in an adult population. J Clin Periodontol 2003; 30 (5):414-419.
19 American Academy of Cosmetic Dentistry membership poll, 2000. Available at http://www.aacd.com/media/market_research_data.aspx. Accessed: April 21, 2005.
20 Haywood VB. Contemporary Esthetics and Restorative Practice 1993; 3 (suppl.):2-11.
21 Haywood VB, Cordero R, Wright K, et al. Brushing with a potassium nitrate dentifrice to reduce bleaching sensitivity. J Clin Dent 2005; 16:17-22.
22 American Dental Association: Mouthrinses and Dentifrices In: ADA Guide to Dental Therapeutics, 2nd ed. ADA Publishing, Chicago, 2000; 221-229.
23 Daniel SJ, Harfst SA, Hill M, Moore RL. Dentifrices In: DENTAL HYGIENE Concepts, Cases and Competencies, 1st Ed. Mosby, Inc., St. Louis, p 411.
24 Fisher SW, Tavss EA, Gambogi RJ, et al. Anticaries efficacy of a new dentifrice for hypersensitivity. Am J Dent 2003; 16 (4)219-222.
Sondra M. Nickolson, RDH, MEd, RF, has been a full-time dental hygienist in a general dental practice for 13 years. She is a member of the American Dental Hygienists’ Association, Minnesota Dental Hygienists’ Association, American Dental Assistants Association, and Minnesota Dental Assistants Association.