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Reflections on Dentifrice Ingredients, Benefits and RecommendationsA Peer-Reviewed Publication Written by Fiona M. Collins, BDS, MBA, MA

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Educational ObjectivesThe overall goal of this article is to provide dental profession-als with information on the active and inactive ingredients in dentifrices and their benefits.

Upon completion of this course, the clinician will be able to do the following:1. List active ingredients in dentifrices and their therapeutic

benefits.2. List inactive ingredients in dentifrices and their functions. 3. Know the roles of the FDA and ADA with respect to

over-the-counter dentifrices.4. Understand the considerations involved and importance of

recommending OTC dentifrices for individual patients.

AbstractThe first major active ingredient introduced into modern-day, over-the-counter dentifrices was fluoride. Since then, dentifrices have been developed with ingredients offering anti-plaque/anti-gingivitis, anti-halitosis, whitening or de-sensitizing benefits, or a multiplicity of benefits. Given the range of dentifrices currently available, and their differences, a recommendation is important; this should be based on the individual patient’s specific needs and desires and the scien-tific support for a dentifrice.

IntroductionToothpastes existed as early as 5,000 B.C., and a toothpaste made from iris flowers was created in the fourth century A.D.1,2 Early modern toothpastes and tooth powders in Eu-rope and America often contained highly abrasive materials such as ground shells, salt, charcoal and chalk.3 Develop-ments continued until the present day. One of the first mod-ern toothpastes contained hydrogen peroxide and baking soda – ingredients still used in dentifrices today. The collaps-ible toothpaste tube, invented by Dr. Washington Sheffield, revolutionized the use of toothpastes and was a primary factor in their increased popularity. Fluoride, the first major active ingredient, was initially introduced in 1914, and in 1955 fluoride toothpaste demonstrating anti-caries efficacy was introduced (Crest with fluoride).

Current over-the-counter (OTC) dentifrices variously offer preventive, esthetic and treatment benefits. Preven-tive benefits against caries, plaque/gingivitis, tartar, and halitosis are available, and treatment benefits are offered for dentinal hypersensitivity. Esthetic benefits, which are not considered therapeutic, include both cleaning and whitening. While some dentifrices offer only cleaning benefits together with fluoride for anti-caries benefits, in recent years dentifrices with multiple benefits aimed at of-fering solutions to as many potential problems as possible have been introduced. The vast range of available products raises the issue of confusion in the eyes of consumers. This increases the need to understand dentifrice ingredients and benefits, to be able to give patients recommendations on

dentifrice use. Recommendations should be based on an individual patient’s specific needs and desires as well as the scientific support for a dentifrice. Both the Food and Drug Administration (FDA) and the American Dental Associa-tion (ADA) have played roles in controlling (FDA) and ac-cepting (ADA) dentifrices.

Dentifrice IngredientsDentifrices contain both active and inactive ingredients. Ac-tive ingredients are those that offer a therapeutic benefit, while inactive ingredients are non-therapeutic and also contribute to the physicochemical properties of the dentifrice – its feel, consistency, sweetness, flavor, pH, texture, abrasiveness and appearance.

Active IngredientsActive ingredients help prevent caries, sensitivity, plaque/gingivitis, calculus formation and halitosis (Table 1). The first active ingredient included was fluoride.

Table 1. Active ingredients and function

Anti-caries Sodium fluoride

Sodium monofluorophosphate

Stannous fluoride

Amine fluoride

Xylitol

Anti-plaque/ anti-gingivitis Triclosan/copolymer

Stannous fluoride

Zinc citrate

Anti-calculus Tetrapotassium pyrophosphate

Tetrasodium pyrophosphate

Sodium hexametaphosphate

Zinc compounds

Triclosan/copolymer

Anti-halitosis Essential oils

Chlorine dioxide

Triclosan/copolymer

Stannous fluoride/sodium hexametaphosphate

Desensitizers Potassium citrate

Potassium nitrate

Potassium chloride

Stannous fluoride

Strontium chloride

Anti-caries DentifricesFluorideIn the United States, sodium fluoride, sodium monofluoro-phosphate and stannous fluoride are all used as anti-caries actives. In Europe, amine fluoride is also used and dominates

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the market in some countries, marketed under the brand name Elmex. By supplying topical fluoride on a regular basis, fluoride dentifrices help prevent demineralization and help promote remineralization. If acid attacks occur and result in the loss of ions from the hydroxyapatite crystals, fluoride can be taken up to form fluorapatite crystals. In addition, loss of fluoride ions from the tooth structure is inhibited.

The concentration of fluoride in OTC dentifrices in the United States is typically 1,000–1,100 ppm fluoride, which equates to 0.23% sodium fluoride, 0.76% sodium mono-fluorophosphate or 0.4% stannous fluoride. The maximum allowable fluoride in OTC dentifrices in the United States is 1,450 ppm. In contrast, in Europe the typical level of fluo-ride in dentifrices is 1,500 ppm. In either case, the therapeu-tic level of fluoride in the dentifrice is higher than the level found in OTC fluoride mouthrinses, which typically ranges from 250–900 ppm. Sodium fluoride and sodium monofluo-rophosphate dentifrices in particular have been extensively researched in clinical trials. The use of fluoride dentifrices (as well as community-based water fluoridation programs) has resulted in substantial declines in caries rates since their introduction, in both urban and isolated communities (for example, a remote island off the west coast of Scotland).4,5

The profound effect of the use of fluoride-containing dentifrices on caries reductions in the developed world has been well recognized.6 Marinho et al. conducted a meta-analysis of 70 clinical trials on fluoride dentifrices found in the Cochrane Database. Only studies that were controlled, blinded, randomized (or “quasi-randomized”) and con-ducted in children under 17 years of age were included. Their conclusion was a pooled 24% reduction in D(M)FS, with a range of 21% to 28%. No differences were found in comparing the use of the dentifrices in fluoridated versus non-fluoridated communities. As has been found in studies of topical in-office fluoride agents, the response varied with the level of caries in the population being studied.7 Fluoride dentifrices have also been found to be effective in reducing root caries; Jensen and Kahout found a 67% reduction in root surface DFS in a one-year trial using a 1,100 ppm sodium fluoride dentifrice.8 Daily use of a fluoride dentifrice has also been found to be effective in school-based programs, including in disadvantaged communities.9,10

Some children’s dentifrices are formulated to provide lower levels of fluoride, for example 250 ppm. The rationale for this is to reduce the possibility of fluorosis due to inges-tion of toothpaste. In a Swiss study, Steiner et al. found a slightly reduced anti-caries benefit using a reduced fluoride level dentifrice but concluded that in preschool children the benefit of reduced risk of fluorosis outweighed this.11 A small study by DenBesten and Ko assessed fluoride levels in whole saliva in 10 children after use of either a pea-sized or regular amount (full brush) of a fluoride dentifrice (normal ppm fluoride). They found that the return to baseline levels was more rapid and the initial post-brushing whole saliva

fluoride concentration was reduced by more than 50% using the pea-sized dose. They concluded that reduced amounts should be limited to preschool children, as they are more at risk for toothpaste ingestion and fluorosis.12

The American Dental Association Council for Scientific Affairs found from an evidence-based analysis that for indi-viduals with a low risk for caries, use of a regular OTC fluo-ride dentifrice may provide sufficient anti-caries protection. Regular fluoride dentifrice and in-office topical fluorides are recommended for medium and high risk patients.13

XylitolXylitol offers anti-caries benefits in dentifrices as well as chewing gums and other vehicles. Xylitol occurs naturally and is found in woods, cereal crops, fruits and vegetables. Acidogenic bacteria are unable to ferment xylitol, reducing their ability to produce the acids necessary for tooth demin-eralization. It is also believed that the bacteria cannot thrive (a starvation effect) and that over time xylitol-resistant bac-teria that are less cariogenic may dominate. In clinical trials, xylitol dentifrices have been found to reduce caries. A three-year double-blind study, by Sintes et al., in Costa Rica in children 8–10 years of age using a sodium fluoride dentifrice containing 10% xylitol found an additional 12.3% reduction in DFS after three years of twice-daily use compared to a control dentifrice containing the same level of sodium fluo-ride but no xylitol.14 A similar three-month trial in Costa Rica using sodium monofluorophosphate as the fluoride active with 10% xylitol also found DFS reductions of more than 10% compared to a non-xylitol control dentifrice.15

Anti-microbial (Anti-plaque/Anti-gingivitis) DentifricesAnti-microbial dentifrices offer anti-gingivitis benefits and may also offer an additional anti-caries benefit depending on the agent used. The primary anti-microbial used in OTC dentifrices in the United States is a triclosan/copolymer for-mulation also containing fluoride (Colgate Total). Stannous fluoride and zinc citrate are also used in dentifrices.

Triclosan/copolymerThis formulation contains 0.3% triclosan, a broad-spectrum anti-bacterial agent, together with a copolymer (polyvinyl methylether/maleic acid) that increases the substantiv-ity of the triclosan, with the result it is present and active intraorally. Triclosan is bactericidal and targets the cell cy-toplasm. This results in gaps in the bacterial cell membrane and bacterial cell death. Plaque reductions and gingivitis reductions have been found in a number of studies, with an average plaque reduction of 48% and an average gingivitis reduction of 26% found in a review of clinical trials using the triclosan/copolymer formulation.16,17,18,19 One study found significantly reduced bleeding upon probing scores, with reduced gingivitis, and improved probing attachment levels

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following non-surgical periodontal therapy compared to the control group using a placebo dentifrice.20 Triclosan/copolymer dentifrice has also demonstrated improvements in healing and anti-inflammatory effects.21 In vitro, it has been shown to affect inflammatory pathways, specifically through reduced cytokine production, and to inhibit bone resorption.22 This has potential implications for patients with periodontal disease as reductions in these would reduce the destructive inflammatory response. A fluoride dentifrice containing 0.3% triclosan/0.23% copolymer was found in one study to offer additional caries reductions over and above the effect of fluoride, while a second study found it to be equivalent.23,24

Figure 1. Triclosan/copolymer dentifrice

Stannous fluorideStannous fluoride dentifrice, containing 0.4% stannous fluo-ride, also functions as an anti-microbial and is bactericidal. One small study using digital plaque imaging found statis-tically significant plaque reductions with use of a stannous fluoride dentifrice containing 0.454% stannous fluoride, compared to use of a sodium fluoride dentifrice.25

Figure 2. Stannous fluoride dentifrices

Tin retention in saliva was found in another study follow-ing in vivo use of stannous fluoride dentifrice.26 Binney et al. found no differences in plaque regrowth assessed in vivo between a triclosan/copolymer dentifrice and stannous fluo-ride dentifrice. It should be noted that the subjects involved in the study only rinsed with the dentifrice slurries without any brushing.27

Zinc citrateA dentifrice containing 2% zinc citrate together with sodium monofluorophosphate (MFP) for anti-caries benefits has

been found in clinical trials to reduce supragingival plaque and gingivitis over three- and six-month periods. Williams et al. found a 25.3% reduction in plaque and an 18.8% re-duction in gingivitis after twice-daily use for six months in adults, with greater reductions in more severely affected areas.28

Anti-calculus (Tartar Control) DentifricesDentifrices containing anti-calculus agents reduce the for-mation of calculus but do not reduce the levels of preexist-ing calculus. Calculus forms through calcification of dental plaque and oral epithelial cells by minerals from the saliva and gingival crevicular fluid, and also contains bacteria.29 Anti-calculus agents, marketed as anti-tartar ingredients, include tetrapotassium and tetrasodium pyrophosphates, sodium hexametaphosphate, and zinc. Pyrophosphates work by stabilizing the calcium level in saliva and interfere with the growth of the crystals that help form calculus. They have also been found to offer anti-microbial benefits.30

Zinc compounds used as anti-tartar agents include zinc citrate trihydrate and work by inhibiting crystal growth and controlling bacterial growth.31 Triclosan/copolymer dentifrice has also been found in several studies to reduce supragingival calculus formation. One study found a 26% at three months and 36% at six months.32 These function due to the zinc compounds or triclosan/copolymer, and do not contain pyrophosphates.

Figure 3. Anti-calculus dentifrices

Anti-halitosis DentifricesChlorine dioxide, essential oils and zinc chloride have all been used to reduce halitosis by inhibiting the production of volatile sulfur compounds. Essential oil dentifrice was found in one study to reduce halitosis.33 Triclosan/copolymer/fluoride dentifrice has also been found to control and reduce the bacteria associated with volatile sulfur compounds, as well as anaerobic periodontal bacteria, thereby reducing these compounds and halitosis.34,35,36 Stannous fluoride den-tifrice with sodium hexametaphosphate has also been found to reduce volatile sulfur compound production.37

Desensitizing DentifricesDesensitizing dentifrices may contain potassium nitrate, potassium citrate, potassium chloride, stannous fluoride or strontium chloride as the active ingredient. Sensitivity occurs

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when fluid flows in open dentinal tubules towards the surface of the tooth as a result of hydrodynamic forces (Brännström’s theory), in response to stimuli. This fluid flow is believed to result in the pain associated with hypersensitivity.38 There are two mechanisms by which desensitizing dentifrices can work. The first is by preventing the transmission of neural signals, thereby preventing pain, and the second is by block-ing the dentinal tubules.

Figure 4. Mechanisms of action of potassium nitrate and stannous fluoride

Stannous Fluoride

Blocks dentinaltubules

Stimulus

Fluid flow due to stimulus

Potassium NitrateBlocks nervesynapses

Potassium nitrate prevents the transmission of neural signals by increasing the level of extracellular potassium (derived from the potassium nitrate contained in the den-tifrice), thereby blocking synapses, and has been found in numerous studies over many years to provide effective relief from sensitivity.39 Potassium chloride works in a similar manner.40 Potassium nitrate dentifrice has also been shown to be effective in reducing sensitivity associated with tooth-whitening treatments.41 The FDA monograph considers only 5% potassium nitrate as the percentage required in a desensitizing dentifrice. Stannous fluoride blocks the dentinal tubules,42 and has been shown in several studies to be an effective desensitizer.43,44 It is contained in several dentifrices, including Crest Pro-Health and Gel-Kam gel. A clinical trial assessing stannous fluoride dentifrice (Crest Pro-Health) found a 44% reduction in the mean sensitivity score compared with use of a sodium fluoride dentifrice.45 Stannous fluoride and potassium nitrate are accepted under the ADA Seal of Acceptance program as desensitizers. A potential drawback of stannous fluoride is its propensity to stain teeth; this can be mitigated with cleaning agents.46

Figure 5. Desensitizing dentifrices

Potassium nitrate is the most common OTC desensitizer and is contained in several dentifrices (Sensodyne Pronamel; Colgate Sensitive; Butler Sensitive; Crest Sensitivity).

Inactive IngredientsInactive ingredients in dentifrices include binders, abrasives, surfactants, buffering agents, humectants, preservatives, sweeteners, flavorings and dyes (Table 2).

Table 2. Inactive ingredients and functionBinders Provide body

Prevent separationHumectants Retain moisture

Prevent dehydrationGive sweetness

Surfactants/detergents Cause foamingReduce surface tensionLoosen and suspend plaque

Buffering agents Control the pHSweeteners Sweeten the dentifriceFlavorings Provide flavorDyes Improve appearanceTitanium dioxide Give opacityPreservatives Preserve the dentifriceWater Form a paste with the ingredients

Binders are used to provide a dentifrice with body (bulk) and also help to prevent separation of the ingredients. Synthetic cellulose (carboxymethylcellulose), carageenan from seaweed, colloids from mineral sources, carbomers and xanthan gum have all been added as binders/thickening agents. Humectants help the dentifrice retain moisture and prevent it from dehy-drating; these include glycerol, which is commonly used, as well as polyethylene glycol, sorbitol and propylene. While not their primary function, humectants also contribute to the sweetness of the dentifrice. Surfactants/detergents reduce surface ten-sion, induce foaming, and help to loosen and suspend plaque

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and debris in an emulsion for easier removal during brushing and interdental cleaning. Common detergents/surfactants include sodium lauryl sulfate and sodium laurylsarcoside. The buffering agents control the pH of the toothpaste, ensuring that it is neither too acidic nor too alkaline. Sweeteners and flavoring agents used in dentifrices do not contain sucrose; sweeteners used include sodium saccharin and sodium cyclamate.47 Re-cently, xylitol has increasingly been used as a sweetening agent in toothpastes. FD&C dyes (# 1 and #5) are also included in dentifrices to improve their appearance and acceptability. The inclusion of titanium dioxide provides for opacity in a denti-frice. Finally, water is included to form the paste.

AbrasivesAbrasive ingredients used in dentifrices include finely ground calcium carbonate, various silicas, silicon dioxide, magnesium carbonate, dicalcium phosphate dihydrate, aluminum oxide and argonite.

The abrasiveness of a dentifrice is usually measured us-ing the Radioactive Dentin Abrasivity (RDA) test, which uses radioactive dentin and a standard brushing protocol in an in vitro test. The FDA considers an RDA under 250 to be safe and effective. In general, the risk of abrasion is associ-ated more with incorrect brushing technique and/or use of a hard bristled brush than with dentifrice RDA. However, in patients with erosion of the dentition, the lowest RDA den-tifrice that still provides cleaning ability should be utilized to avoid increasing the risk of abrasion. Teeth can accumulate stains over time, depending on several factors, including diet, smoking and oral hygiene. Aging also results in changes to the appearance of the color of the tooth. Surface roughness and loss of enamel surface structure alter light refraction, reflec-tion properties and light penetration, resulting in a darker appearance.48 Abrasives provide cleaning ability, with the intensity of cleaning depending on the type of abrasive used and amount contained in the dentifrice, thereby helping to remove plaque and debris from the tooth surface and also remove extrinsic stains. Without any abrasives, a dentifrice is unable to do this.49 Typically, the RDA level determines the cleaning ability, with the exception of baking soda, which has an RDA level of 30–40 yet still offers cleaning ability equivalent to more typical RDA levels, believed to be due to the sodium bicarbonate lifting stains as well as the abrasive action of the dentifrice.50

In addition to cleaning ability, abrasives with fine, rounded particles also help polish the enamel and thereby increase its luster and white appearance. This is the main mechanism for whitening dentifrices (Colgate Visible White; Crest Whiten-ing Expressions; Crest Vivid White; Colgate Total Advanced Whitening; Aquafresh Extreme Clean). A further option is a dentifrice containing amorphous calcium phosphate (ACP) and baking soda (ARM & HAMMER® Age Defying); the incorporation of ACP helps fill in surface defects, thereby smoothing the tooth surface, enhancing tooth luster and re-

sulting in a whiter appearance.51 Sodium hexametaphosphate, an anti-calculus agent, has also been found to help inhibit stains.52 Low levels of hydrogen peroxide have also been in-corporated into some whitening dentifrices, with the intent of generating oxygen bubbles that gently help lift debris and stain from the tooth surface. However, the hydrogen peroxide has a very short contact time in this situation.

Figure 6. Whitening dentifrices

Role of the Food and Drug AdministrationThe Food and Drug Administration (FDA) regulates fluoride dentifrices as OTC drugs through the Anti-Caries Mono-graph. The FDA does not require approval of OTC fluoride dentifrices as new drugs unless they contain ingredients and concentrations that do not fall under the monograph. New Drug Applications for dentifrices are rare, and the require-ments imposed by the FDA are stringent. The manufacturer must prove long-term microbiological safety and clinical tri-als must show efficacy and no toxicity associated with use of the product. Requirements include two clinical trials meeting FDA requirements; laboratory and biological testing. The only recent new drug application and approval for a dentifrice was for one containing the then-new active ingredient triclo-san/copolymer (Colgate Total).

Toothpaste LabelingToothpaste labels contain a list of the active and inactive ingre-dients, as well as directions and warnings. The dentifrice may or may not carry the ADA Seal. If recommending a dentifrice to a patient, it is important to read the labeling to check if there is any ingredient contraindicated for the patient (for instance, allergies to certain dyes) as well as the warnings section of the label. Stannous fluoride dentifrices are required by the FDA to carry a warning that staining may occur. Additionally, den-tifrices indicated as desensitizers carry the warning that the

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product should not be used for more than four weeks unless recommended by a dentist or physician.

The FDA does not test dentifrices, although it can carry out audits to check that manufacturers are complying with the monograph and good manufacturing practices.

The ADA SealManufacturers can choose whether or not to apply for an ADA Seal, which requires documentation, ADA-mandated standardized testing and considerable resources. Until recently, the ADA Seal was available for both professional and consumer products. The professional seal program was discontinued and phased out by the end of 2007.53 To qualify for an ADA Seal, the manufacturer must submit the list of ingredients, indications and claims; clinical trials; laboratory tests in accordance with the ADA Seal program requirements that document efficacy and safety and support marketing claims, as well as submit good manufacturing practices (GMP) and facilities documentation.54,55 The man-ufacturer must provide copies of all product packaging and labeling for review and approval by the ADA, and comply with the ADA’s standards for accuracy and truthfulness.

The ADA Seal for fluoride dentifrices is for anti-caries efficacy and safety – if a manufacturer wishes to have other indications considered, data must be submitted that backs up the indication and associated claims. The logo is always the same, while the wording alongside the logo differs and depends on what the ADA acceptance was for. Therefore, it is important to read the wording in the box by the seal. The standard statement is as follows: “The ADA’s Council on Scientific Affairs Acceptance of (Product Name) is based on its finding that the product is effective in helping prevent or reduce tooth decay when used as directed.”

For products carrying the seal, a new application must be made if the formulation changes, or every five years, which-ever is sooner. The ADA Seal program does not support plaque reduction as a claim since this is not the therapeutic benefit. Instead, the program supports an anti-plaque/anti-gingivitis claim if the manufacturer’s submitted documenta-tion supports such a claim and the manufacturer requests it. One of the ADA’s requirements is that manufacturers place a statement regarding use of a pea-sized amount by young children to help prevent fluorosis. The actual statement is as follows: “Do not swallow. Use only a pea-sized amount for children under six. To prevent swallowing, children under six years of age should be supervised in the use of toothpaste.”

Figure 9. ADA Seal of Acceptance

Patient-Specific Dentifrice RecommendationsDentifrice recommendations should be patient specific. Consid-erations include any complaint or request the patient may have as well as any potential contraindications or relative contrain-dications.. If a patient is allergic or sensitive to an ingredient, all dentifrices containing that ingredient should be avoided. For example, sensitivity to SLS or pyrophosphate would, respec-tively, indicate use of an SLS-free or low-SLS dentifrice or of a pyrophosphate-free dentifrice (for example, zinc compound or triclosan/copolymer dentifrice). If a patient is experiencing hy-persensitivity, a desensitizing dentifrice containing potassium nitrate or stannous fluoride can be recommended. However,

Figure 8. Stannous fluoride dentifrice labeling

Figure 7. Labeling for sensitivity toothpaste

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if a desensitizing dentifrice is not required it may mask other problems such as early cavities or erosion – hence the four-week labeling requirement. If a patient requests a whitening denti-frice, recommending one may help patient compliance with oral hygiene and considerations should include determining what other needs the patient has – for instance, anti-plaque/anti-gingivitis and/or anti-tartar benefits. Is the patient’s desire for a whitening toothpaste due to surface staining or changes in the enamel surface that alter light properties – suggesting use of a dentifrice with fine polishing capability or use of an ACP dentifrice (to either remove or fill in microscopic defects in the enamel). If the patient suffers from erosion, a low RDA denti-frice should be selected.56 For multi-benefit dentifrices, which benefits would most help a specific patient? Does the patient acquire calculus readily or require a desensitizer or experience halitosis? Would the patient benefit from anti-microbials, and if so is the patient’s periodontal status such that anti-inflammatory activity would be desirable? Patients anticipate receiving recommendations. These can be explicit or implicit. If you provide patients with samples of toothpastes, this is an implicit recommendation even if you have not discussed or actively recommended a dentifrice. In all situations, dentifrice selection should consider the available supporting science.

SummaryThe range of OTC dentifrices available today enables con-sumers to use a dentifrice tailored to their individual needs and desires. Dental professionals play an important role in helping patients select an appropriate dentifrice. Dentifrices offer therapeutic and cosmetic benefits, with the range of benefits varying with the ingredients in a specific dentifrice. Considerations should include the support and documenta-tion for the dentifrice, and the needs of the patient.

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hygiene. Available at http://www.associated content.com/article/164851/a_brief_history_of_your_toothbrush.html. Accessed May 10, 2009.

4 Hargreaves JA, Cleaton-Jones PE. Dental caries changes in the Scottish Isle of Lewis. Caries Res. 1990;24(2):137-41.

5 Franke W, Künzel W, Treide A, Blüthner K. Caries prevention by means of aminofluoride after 7 years of collectively conducted oral hygiene. Stomatol DDR. 1977 Jan; 27(1):13-6.

6 Renson CE. Changing patterns of dental caries: a survey of 20 countries. Ann Acad Med Singapore. 1986 Jul; 15(3):284-98.

7 Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003; (1):CD002278.

8 Jensen ME, Kohout F. The effect of a fluoridated dentifrice on root and coronal caries in an older adult population. J Am Dent Assoc. 1988 Dec;117(7):829-32.

9 Hölttä P, Alaluusua S. Effect of supervised use of a fluoride toothpaste on caries incidence in pre-school children. Int J Paediatr Dent. 1992 Dec; 2(3):145-9.

10 Jackson RJ, Newman HN, Smart GJ, et al. The effects of a supervised toothbrushing programme on the caries increment of primary school children, initially aged 5-6 years. Caries Res. 2005 Mar-Apr; 39(2):108-15.

11 Steiner M, Helfenstein U, Menghini G. Effect of 1,000 ppm relative to 250 ppm fluoride toothpaste: a meta-analysis. Am J Dent. 2004 Apr; 17(2):85-8.

12 DenBesten P, Ko HS. Fluoride levels in whole saliva of preschool children after brushing with 0.25 g (pea-sized) as compared to 1.0 g (full-brush) of a fluoride dentifrice. Pediatr Dent. 1996 Jul-Aug; 18(4):277-80.

13 American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc. 2006; 137(8):1151-9.

14 Sintes JL, Escalante C, Stewart B, et al. Enhanced anticaries efficacy of a 0.243% sodium fluoride/10% xylitol/silica dentifrice: 3-year clinical results. Am J Dent. 1995 Oct; 8(5):231-5.

15 Sintes JL, Elías-Boneta A, Stewart B, et al. Anticaries efficacy of a sodium monofluorophosphate dentifrice containing xylitol in a dicalcium phosphate dihydrate base: a 30-month caries clinical study in Costa Rica. Am J Dent. 2002 Aug; 15(4):215-9.

16 Mankodi S, Walker C, Conforti N, et al. Clinical effect of a triclosan containing dentifrice on plaque and gingivitis: a six-month study. Clin Prev Dent. 1992; 14(6):4-10.

17 Bolden TE, Zambon JJ, Sowinski J, et al. The clinical effect of a dentifrice containing triclosan and a copolymer in a sodium fluoride/silica base on plaque formation and gingivitis: a six-month study. J Clin Dent. 1992; 3(4):125-131.

18 Deasy MJ, Singh SM, Rustogi KN, et al. Effect of a dentifrice containing triclosan and a copolymer on plaque formation and gingivitis. Clin Prev Dent. 1991 Nov-Dec;13(6):12-9.

19 Davies RM, Ellwood RP, Davies GM. The effectiveness of a toothpaste containing triclosan and polyvinyl-methyl ether maleic acid copolymer in improving plaque control and gingival health: a systematic review. J Clin Periodontol. 2004;31(12):1029-33.

20 Furuichi Y, Rosling B, Volpe AR, Lindhe J. The effect of a triclosan/copolymer dentifrice on healing after non-surgical treatment of recurrent periodontitis. J Clin Periodontol. 1999 Feb; 26(2):63-6.

21 Kerdvongbundit V, Wikesjö UM. Effect of triclosan on healing following non-surgical periodontal therapy in smokers. J Clin Periodontol. 2003 Dec; 30(12):1024-30.

22 Xu T, Deshmukh M, Barnes VM, et al. Effectiveness of a triclosan/copolymer dentifrice on microbiological and inflammatory parameters. Compend Contin Educ Dent. 2004 Jul; 25(7 Suppl 1):46-53.

23 Mann J, Vered Y, Babayof I, et al. The comparative anticaries efficacy of a dentifrice containing 0.3% triclosan and 2.0% copolymer in a 0.243% sodium fluoride/silica base and a dentifrice containing 0.243% sodium fluoride/silica base: a two-year coronal caries clinical trial on adults in Israel. J Clin Dent. 2001;12(3):71-6.

24 Hawley GM, Hamilton FA, Worthington HV, et al. A 30-month study investigating the effect of adding triclosan/copolymer to a fluoride dentifrice. Caries Res. 1995;29(3):163-7.

25 White DJ. Effect of a stannous fluoride dentifrice on plaque formation and removal: a digital plaque imaging study. J Clin Dent. 2007; 18(1):21-4.

26 Ramji N, Baig A, He T, et al. Sustained antibacterial actions of a new stabilized stannous fluoride dentifrice containing sodium hexametaphosphate. Compend Contin Educ Dent. 2005 Sep; 26(9 Suppl 1):19-28.

27 Binney A, Addy M, Owens J, Faulkner J. A comparison of triclosan and stannous fluoride toothpastes for inhibition of

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plaque regrowth. A crossover study designed to assess carry over. J Clin Periodontol. 1997 Mar; 24(3):166-70.

28 Williams C, McBride S, Mostler K, et al. Efficacy of a dentifrice containing zinc citrate for the control of plaque and gingivitis: a 6-month clinical study in adults. Compend Contin Educ Dent. 1998; 19(2 Suppl):4-15.

29 White DJ. Dental calculus: recent insights into occurrence, formation, prevention, removal and oral health effects of supragingival and subgingival deposits. Eur J Oral Sci. 1997; 105(5 Pt 2):508-522.

30 Drake D, Grigsby B, Krotz-Dieleman D. Growth-inhibitory effect of pyrophosphate on oral bacteria. Oral Microbiol Immunol. 1994 Feb; 9(1):25-8.

31 Sowinski J, Petrone DM, Battista G, et al. Clinical efficacy of a dentifrice containing zinc citrate: A 12-week calculus clinical study in adults. Compend Contin Educ Dent. 1998; 19(Suppl 2):16-19.

32 Lobene RR, Battista GW, Petrone DM, et al. Clinical efficacy of an anticalculus fluoride dentifrice containing triclosan and a copolymer: a 6-month study. Am J Dent. 1991 Apr; 4(2):83-5.

33 Olshan AM, Kohut BE, Vincent JW, et al. Clinical effectiveness of essential oil-containing dentifrices in controlling oral malodor. Am J Dent. 2000 Sep; 13(Spec No):18C-22C.

34 Vazquez J, Pilch S, Williams MI, Cummins D. Clinical efficacy of a triclosan/copolymer/NaF dentifrice and a commercially available breath-freshening dentifrice on hydrogen sulfide-forming bacteria. Oral Dis. 2005; 11 Suppl 1:64-6.

35 Hu D, Zhang YP, Petrone M, Volpe AR, DeVizio W, Proskin HM. Clinical effectiveness of a triclosan/copolymer/sodium-fluoride dentifrice in controlling oral malodor: a three-week clinical trial. Compend Contin Educ Dent. 2003 Sep; 24(9 Suppl):34-41.

36 Fine DH, Furgang D, Markowitz K, et al. The antimicrobial effect of a triclosan/copolymer dentifrice on oral microorganisms in vivo. J Am Dent Assoc. 2006 Oct; 137(10):1406-13.

37 Farrell S, Barker ML, Gerlach RW. Overnight malodor effect with a 0.454% stabilized stannous fluoride sodium hexametaphosphate dentifrice. Compend Contin Educ Dent. 2007 Dec; 28(12):658-61.

38 Brännström M. Etiology of dentin hypersensitivity. Proc Finn Dent Soc. 1992;88(Suppl 1):7-13.

39 Gillam DG. The efficacy of potassium salts as agents for treating dentin hypersensitivity. J Orofac Pain. 2000 Winter;14(1):9-19.

40 Salvato AR, Clark GE, Gingild J, Curro FA. Clinical effectiveness of a dentifrice containing potassium chloride as a desensitizing agent. Am J Dent. 1993;5(6):303-6.

41 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.

42 Ellingsen JE, Rolla G. Treatment of dentin with stannous fluoride – SEM and electron microprobe study. Scand J Dent Res. 1987; 95:281-286.

43 Blong MA, Volding B, Thrash WJ, et al. Effects of a gel containing 0.4 percent stannous fluoride on dentinal hypersensitivity. Dent Hyg (Chic). 1985; 59:489-92.

44 Snyder RA, Beck FM, Horton JE. The efficacy of a 0.4% stannous fluoride gel on root surface hypersensitivity. J Dent Res. 1985; 62:237.

45 Schiff T, He T, Sagel L, Baker R. Efficacy and safety of a novel stabilized stannous fluoride and sodium hexametaphosphate dentifrice for dental hypersensitivity. J Contemp Dent Pract. 2006; 7(2):1-8.

46 Wade W, Addy M, Hughes J, et al. Studies on stannous fluoride toothpaste and gel (1). Antimicrobial properties and staining potential in vitro. J Clin Periodontol. 1997 Feb;24(2):81-5.

47 http://www.ada.org/ada/seal/faq.asp. Accessed June 12, 2009.

48 Ten Bosch JJ, Coops CC. Tooth color and reflectance as related to light scattering and enamel hardness. J Dent Res. 1995; 74:374-80.

49 Dawson P L, Walsh J E, Morrison T et al. Dental stain prevention by abrasive toothpastes: A new in vitro test and its correlation with clinical observations. J Cosmet Sci 1998 49: 275-283.

50 Smith J, Ersen E, Coffman L, et al. Cyclic laboratory model to measure the chemical cleaning powder of seven grades of sodium bicarbonate. J Dent Res. 2003; 82:A #384.

51 Muñoz CA, Stephens JA, Proskin HM, Ghassemi A. Clinical efficacy evaluation of a fluoride dentifrice containing calcium, phosphate, and sodium bicarbonate on surface-enamel smoothness and gloss. Comp Cont Ed Dent. 2004; 25(9)(Suppl 1):32-43.

52 Baig A, He T, Buisson J, et al. Extrinsic whitening effects of sodium hexametaphosphate: a review including a dentifrice with stabilized stannous fluoride. Compend Contin Educ Dent. 2005 Sep; 26(9 Suppl 1):47-53.

53 http://www.ada.org/ada/seal/faq.asp. Accessed June 9, 2009.54 Ibid.55 http://www.ada.org/ada/seal/toothpaste.asp. Accessed June

9, 2009.56 Hooper S, West NX, Pickles MJ, et al. Investigation of erosion

and abrasion on enamel and dentine: a model in situ using toothpastes of different abrasivity. J Clin Periodontol. 2003; 30(9):802-808.

Author ProfileFiona M. Collins, BDS, MBA, MADr. Fiona M. Collins has authored and presented CE courses to dental professionals and students in the US and internationally. During her career she has worked in the United States, Middle East, The Netherlands and United Kingdom. In addition to clinical dentistry, she has held positions in academia, marketing,

professional relations, education and training, and general management while at Groningen University, Straumann, Colgate Oral Pharmaceuticals and Timken. Dr. Collins is a past member of the Academy of General Dentistry Foundation Strategy Board, and has been a member of the British Dental Association, Dutch Dental Association, and the International Association for Dental Research. Dr. Collins earned her dental degree from Glasgow University and holds an MBA and MA from Boston University. She has been an active consultant in the dental industry for several years, and a national and international speaker. Dr. Collins is a member of the American Dental Association and the Organization for Asepsis and Safety Procedures.

DisclaimerThe author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

10 www.ineedce.com

Questions1. Ancient toothpastes were formulated

containing _____________.a. ground shellsb. iris flowersc. carbamide peroxided. a and b

2. The collapsible toothpaste tube was invented by _____________.a. Dr. Alberto Gomezzob. Dr. Washington Sheffieldc. Dr. Sheffield Washingtond. Dr. Brian Thompson

3. The first active ingredient introduced into dentifrices was _____________.a. sodium lauryl sulfateb. fluoridec. zinc citrated. xylitol

4. An active ingredient in a dentifrice is one that offers _____________.a. an esthetic benefitb. a therapeutic benefitc. a higher level of the same benefit offered by an

inactive ingredientd. a benefit enhanced by physical activity

5. An inactive ingredient in a dentifrice is one that _____________.a. is nontherapeuticb. functions in the same way as an active ingredient

but at a lower levelc. contributes to the physicochemical properties of the

dentifriced. a and c

6. The supply of topical fluoride from regular use of a dentifrice _____________.a. helps prevent demineralizationb. helps promote remineralizationc. inhibits loss of fluoride ion from the tooth structured. all of the above

7. The use of fluoride dentifrices has resulted in substantial declines in the caries rate.a. Trueb. False

8. The use of 250 ppm fluoride dentifrice in children has been found to _____________, compared to use of regular fluoride dentifrices.a. reduce the risk for fluorosisb. slightly reduce the anti-caries benefit c. improve a child’s attitude to brushingd. a and b

9. The use of xylitol as an active ingredient in dentifrices has been found to reduce caries.a. Trueb. False

10. The mechanism of action for xylitol in-volves the bacteria which _____________.a. are not able to ferment xylitol, reducing their ability

to produce acidsb. cannot thrive on xylitolc. may shift over time to xylitol-tolerant, less

acidogenic bacteria dominating the florad. all of the above

11. Anti-microbials used in dentifrices in the United States include _____________.a. triclosan/copolymerb. stannous fluoridec. zinc citrated. all of the above

12. Triclosan _____________.a. is bactericidalb. attacks the bacterial cell cytoplasmc. results in gaps in the cell membrane and cell deathd. all of the above

13. Average plaque and gingivitis reductions of 48% and 26% respectively have been found in a review of triclosan/copolymer dentifrice.a. Trueb. False

14. In vitro, triclosan/copolymer dentifrice has been found to _____________.a. reduce cytokine productionb. inhibit bone resorptionc. affect inflammatory pathwaysd. all of the above

15. Using digital plaque imaging, statisti-cally significant plaque reductions have been found with use of a stannous fluoride dentifrice.a. Trueb. False

16. Tin retention in saliva has been found after using stannous fluoride dentifrice.a. Trueb. False

17. Plaque and gingivitis reductions of up to _____________ and _____________, respectively, were found in severely affected areas in a six-month clinical study of zinc citrate dentifrice used twice daily.a. 19.3%; 15.8%b. 22.3%; 18.8%c. 25.3%; 18.8%d. 28.3%; 23.8%

18. Anti-calculus agents used in dentifrices include _____________.a. pyrophosphatesb. zincc. sodium hexametaphosphated. all of the above

19. Anti-calculus (tartar control) dentifrices work variously by _____________.a. inhibiting, or interfering with, crystal growth of

calculusb. inhibiting bacterial growthc. stabilizing the level of calcium present in salivad. all of the above

20. If a patient is sensitive to pyrophos-phates, an anti-calculus dentifrice that does not contain these should be recom-mended and used, with options including one containing _____________.a. triclosan/copolymerb. charcoalc. zinc citrate trihydrated. a or c

21. The mechanisms by which desensitizing dentifrices work are by _____________.a. blocking nerve transmission of the response to

stimulib. blocking (occluding) the dentinal tubulesc. competitive stimulationd. a and b

22. The surfactant in a dentifrice _____________.a. causes foamingb. reduces surface tensionc. helps loosen and suspend plaqued. all of the above

23. Abrasiveness in a dentifrice _____________.a. Is measured in vitro by the Radioactive Dentin

Abrasivity (RDA) testb. Is considered safe and effective by the FDA at an

RDA below 250c. helps remove plaque, debris and stains from the

teethd. all of the above

24. A whitening dentifrice can work by _____________.a. polishing the surface of the enamel with fine,

rounded abrasivesb. removing microscopic surface defectsc. filling in microscopic surface defectsd. all of the above

25. While the ADA Seal for fluoride dentifrices is for anti-caries efficacy and safety, the manufacturer can have other indications considered provided data supporting the additional indication(s) and associated claims is submitted to the ADA. a. Trueb. False

26. The FDA labeling requirement for stannous fluoride dentifrices include a statement concerning the possibility of surface staining of the teeth.a. Trueb. False

27. Desensitizing dentifrices must carry a warning mandated by the FDA that the product should not be used for more than _____________ unless recommended by a dentist or physician.a. two weeksb. four weeksc. six weeksd. eight weeks

28. If a patient suffers from erosion, a low RDA dentifrice should be selected.a. True b. False

29. An implicit recommendation occurs when a dental professional provides a patient with a sample of, for instance, a dentifrice in the absence of an active recommendation, while an explicit recommendation involves an active rec-ommendation.a. Trueb. False

30. A dentifrice recommendation should consider _____________.a. the individual patient’s needs and desiresb. the scientific support and documentation for the

dentifricec. any patient-specific contraindications, allergies or

sensitivitiesd. all of the above

Online CompletionUse this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

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AGD Code 010/016

ANSWER SHEET

Reflections on Dentifrice Ingredients, Benefits and Recommendations

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Educational Objectives1. List active ingredients in dentifrices and their therapeutic benefits.

2. List inactive ingredients in dentifrices and their functions.

3. Know the roles of the FDA and ADA with respect to over-the-counter dentifrices.

4. Understand the considerations involved and importance of recommending OTC dentifrices for individual patients.

Course EvaluationPlease evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No

Objective #2: Yes No Objective #4: Yes No

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them.

___________________________________________________________________

11. Was there any subject matter you found confusing? Please describe.

___________________________________________________________________

___________________________________________________________________

12. What additional continuing dental education topics would you like to see?

___________________________________________________________________

___________________________________________________________________

AUTHOR DISCLAIMERThe author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

SPONSOR/PROVIDERThis course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMERThe opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $49.00 to $110.00.

Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

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CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

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