DENTIFRICES
THE TERM DENTIFRICE IS DERIVED FROM DENS
(TOOTH) AND FRICARE (TO RUB). A SIMPLE,
CONTEMPORARY DEFINITION OF A DENTIFRICE IS A
MIXTURE USED ON THE TOOTH IN CONJUNCTION WITH
A TOOTHBRUSH.
Dentifrices are marketed as
toothpowders,
toothpastes,
and gels.
All are sold as either cosmetic or therapeutic products. If
the purpose of a dentifrice is therapeutic, it must reduce
some disease-related process in the mouth..
Dentifrice Ingredients
Dentifrices were originally developed to provide a
cosmetic effect and deliver a pleasant taste. They are
effective in removing extrinsic stains, those that occur on
the surface of the tooth. These stains, which are often the
end-products of bacterial metabolism, range in color from
green to yellow to black. Stains may also result from foods,
coffee, tea, cola-containing drinks, and red wines.."
.
Toothpastes contain several or all of the ingredients.
Gel dentifrices are also marketed. Gels contain the
same components as toothpastes, except that gels
have a higher proportion of the thickening agents.
Both tooth gels and toothpastes are equally effective
in plaque removal and in delivering active ingredient
Abrasives
The degree of dentifrice abrasiveness depends on the inherent
hardness of the abrasive, size of the abrasive particle, and the
shape of the particle. Several other variables can affect the
abrasive potential of the dentifrice: the brushing technique, the
pressure on the brush, the hardness of the bristles, the direction of
the strokes, and the number of strokes.
9
Calcium carbonate and calcium phosphates were
previously the most common abrasives used. These
agents often reacted adversely with fluorides. Chalk
(calcium carbonate) and baking soda (sodium
bicarbonate) are also common dentifrice abrasives. New
silicas, silicon oxides, and aluminum oxides are being
introduced into dentifrice formulas, with additional
efficacy claims.-
Humectants
Toothpaste consisting only of a toothpowder and water results in a
product with several undesirable properties. Over time, the solids
in the paste tend to settle out of solution and the water
evaporates. This may result in caking of the remaining dentifrice.
Until the 1930s, most toothpaste had a short shelf-life because of
this problem. Once the tube was opened, the first expelled paste
was too liquid, but the last paste in the tube was either impossible
to expel or too hard to use. To solve this problem, humectants
were added to maintain the moisture. Commonly used
humectants are sorbitol, mannitol, and propylene glycol. nontoxic,
but mold or bacterial growth can occur in their presence.
Soaps and Detergents
Because toothpastes were originally manufactured to keep
the teeth clean, soap was the logical cleansing agent. As the
toothbrush bristles dislodge food debris and plaque, the foaming
action of the soap aids in the removal of the loosened material.
Soaps have several
disadvantages:
they can be irritating to the mucous membrane,
their flavor is difficult to mask and often causes nausea,
and many times soaps are incompatible with other ingredients,
such as calcium.
When detergents appeared on the market, soaps largely
disappeared from dentifrices. Today, sodium lauryl sulfate
(SLS) is the most widely used detergent. It is stable, possesses
some antibacterial properties, and has a low surface tension,
which facilitates the flow of the dentifrice over the teeth.
SLS is active at a neutral pH, has a flavor that is easy to mask,
and is compatible with the current dentifrice ingredients.
Flavoring and Sweetening Agents
Flavor, along with smell, color, and consistency of a product,
are important characteristics that lead to public acceptance of
a dentifrice. If dentifrices did not possess these characteristics,
they would probably be poorly accepted. For taste acceptance,
the flavor must be pleasant, provide an immediate taste
sensation, and be relatively long-lasting. Usually synthetic
flavors are blended to provide the desired taste. Spearmint,
peppermint, wintergreen, cinnamon, and other flavors give
toothpaste a pleasant taste, aroma, and refreshing aftertaste.
Sweetening Agents
In early toothpaste formulations, sugar, honey, and other
sweeteners were used. Because these materials can be
broken down in the mouth to produce acids and lower
plaque pH, they may increase caries. They have been
replaced with saccharin, cyclamate, sorbitol, and mannitol
as primary noncariogenic sweetening agents. Sorbitol and
mannitol serve a dual role as sweetening agents and
humectants. Glycerin, which also serves as a humectant,
adds to the sweet taste. A new sweetener in some
dentifrices is xylitol.
Essential-Oil Dentifrices
The essential-oil ingredients found in Listerine
mouthrinse are also available in a dentifrice formulation.
The clinical and laboratory data suggest a benefit to
gingival health and plaque reduction This product does
not carry the ADA Seal of Acceptance.
Therapeutic Dentifrices
The most commonly used therapeutic agent added to dentifrices
is fluoride, which aids in the control of caries.
The original level of fluoride in OTC dentifrices and gels was
restricted to 1,000 to 1,100 ppm fluoride and a total of no more
than 120 mg of fluoride in the tube, with a requirement that the
package include a safety closure. Therapeutic toothpastes,
dispensed on prescription, could contain up to 260 mg of fluoride
in a tube.
The following fluorides are generally recognized as 
effective and safe for OTC sales: 0.22% sodium
fluoride (NaF) at a level of 1,100 ppm, 0.76% sodium
monofluorophosphate (MFP) at a level of 1,000 ppm,
and 0.4% stannous fluoride (SnF2) at a level of 1,000
ppm.
Fluoride levels were increased to 1,500 ppm 
sodium monofluorophosphate in "Extra Strength
Aim," marketed OTC. In published studies,17,18
this product was 10% more effective than an
1,100 ppm NaF dentifrice. A recently introduced
prescription dentifrice, Colgate Prevident 5,000,
contains 5,000-ppm
At the present time, an agent (or agents) analogous to fluoride in
controlling caries is being sought to control plaque and gingivitis and to
prevent periodontitis. The properties of an ideal form of such an agent
are listed in Table 6-3. Although many OTC products are being
marketed with plaque-gingivitis claims, only two dentifrices are
currently marketed with ADA-accepted claims . Both contain triclosan
and will be discussed further in this chapter.
Stannous Salts
Stannous fluoride (SnF2), specifically the stannous ion, has reported
activity against caries, plaque, and gingivitis. While SnF2 has a long
record as an anticaries agent, long-term stability in dentifrices and
mouthrinses has been questioned since clinical antimicrobial activity
has only been demonstrated in anhydrous
Triclosan
Triclosan is a broad-spectrum antibacterial agent,, for use in oral products under the
trade name Irgacare. It is effective against a wide variety of bacteria and is widely
used as an antibacterial agent products in the United States, including deodorant
soaps and antibacterial skin scrubs. It has also been shown to be a useful antibacterial
agent in oral products. A review of the available pharmacological and toxicological
information concluded, "Triclosan can be considered safe for use in dentifrice and
mouth rinse products."27
A Unilever product containing zinc citrate and triclosan has also
received attention. Clinical evaluation has shown this to be
effective in reducing plaque formation and in preventing
gingivitis. A summary of the zinc citrate-triclosan studies has been
published.34 This product is not currently marketed in the United
States.
Anticalculus Dentifrices
Calculus-control dentifrice formulations are designed to interrupt the process
of mineralization of plaque to calculus. Plaque has a bacterial matrix that
mineralizes due to the super saturation of saliva with calcium and phosphate
ions. Crystal growth inhibitors may be added to dentifrices to provide a
reduction in calculus formation.
Antihypersensitivity Products
Many people experience pain when exposed areas of the root,
especially at the cemento-enamel junction, are subjected to heat
or cold. To address this issue the ADA has formed the Ad Hoc
Committee on Dentinal Sensitivity. Several OTC dentifrices have
been accepted with the active agents such as potassium nitrate,
strontium chloride, and sodium citrate. Currently accepted
products may be found on the . Potassium citrate has also been
accepted by the British Department of Health.
.
Whiteners
Considerable controversy surrounds the use of stain removers and tooth
whiteners. Products are being marketed for professional use or for use by the
patient at home. Many claims for efficacy and safety are under review by
agencies and government panels.
." These dentifrices control stain via physical methods (abrasives) and
chemical mechanisms (surface active agents or bleaching/oxidizing agents).
Although the public perceives these as more abrasive than ordinary
toothpastes, their abrasiveness is usually intermediate among the products
tested.
Cosmetic Mouthrinses
Halitosis
Further research and education is needed in this important area because
many practicing dental professionals still believe that bad breath usually
comes from the stomach. Identifying the cause of halitosis and developing an
appropriate treatment plan can be difficult. Published studies have
demonstrated that oral malodor usually derives from the mouth itself and
may be reduced following oral hygiene.
To motivate improvement in oral hygiene, dental professionals should advise
patients that bad breath might result from microbial putrefaction within the
mouth.
"Bad breath is a cause of concern, embarrassment, and frustration on the part
of the general public. Oral malodor, whether real or perceived, can lead to
social isolation, divorce proceedings, and even 'contemplation of suicide.'
Wooden or Plastic Triangular Sticks
Interproximal cleaning can be facilitated using sticks made of wood or plastic . A
reduction in inflammation and bleeding sites has been demonstrated utilizing wooden
or plastic sticks to reduce plaque accumulations.
They can be used for Type I, II, or III embrasures, but are best suite where the papilla
does not completely fill the embrasure space. These sticks are triangular in cross section
to slide easily between teeth and to reduce potential tissue trauma. The stick is inserted
interproximally from the buccal aspect with the flat surface, the base of the triangle,
resting on the gingiva. The tip of the stick is angled coronally and is moved in a buccolingual direction . Wooden sticks have an advantage over plastic in that the pointed end
can be softened in the mouth by moistening it with saliva.
Toothpicks
A comprehensive history of toothpick use suggests that toothpicks are one of the
earliest and most persistent "tools" used to "pick teeth." The toothpick may date back
to the days of the cavepeople, who probably used sticks to pick food from between
the teeth. The nobility and the affluent used elaborate toothpick kits of metal, ivory,
and carved wood; the less affluent whittled sticks for the same purpose.
Interproximal and Uni-tufted Brushes
Small interproximal brushes which are attached to a handle come in a variety of designs.
Some of the designs have a nonreplaceable brush; the entire device is discarded when the
brush is worn . Interproximal brushes can be utilized to clean spaces between teeth and
around furcations, orthodontic bands, and fixed prosthetic appliances with spaces that are
large enough to easily receive the device . They may also be used to apply
chemotherapeutic agents into interproximal areas as well as furcations. Foam tips initially
developed for use with implants are an ideal mechanism for delivery of medicaments
interproximally or at furcations.
REST
Pit-and-Fissure Sealants how sealants can provide a primary preventive means of reducing the need for operative
treatment as 77% of the children 12 to 17 years old in the United States have dental caries in
their permanent teeth.1
Introduction
Fluorides are highly effective in reducing the number of carious lesions
occurring on the smooth surfaces of enamel and cementum.
Unfortunately, fluorides are not equally effective in protecting the occlusal
pits and fissures, where the majority of carious lesions occur.2 Considering
the fact that the occlusal surfaces constitute only 12% of the total number
of tooth surfaces, it means that the pits and fissures are approximately
eight times as vulnerable as the smooth surfaces. The placement of
sealants is a highly effective means of preventing these.3
A sealant is probably indicated if:
• The fossa selected for sealant placement is well isolated from another fossa with a
restoration.
• The area selected is confined to a fully erupted fossa, even though the distal fossa is
impossible to seal due to inadequate eruption.
• An intact occlusal surface is present where the contralateral tooth surface is carious
or restored; this is because teeth on opposite sides of the mouth are usually equally
prone to caries.
• An incipient lesion exists in the pit-and-fissure.
• Sealant material can be flowed over a conservative class I composite or amalgam to
improve the marginal integrity, and into the remaining pits and fissures to achieve a
de facto extension for prevention.
Other Considerations in Tooth Selection
All teeth meeting the previous criteria should be sealed and resealed as needed. Where the
cost-benefit is critical and priorities must be established, such as occurs in many public
health programs, ages 3 and 4 years are the most important times for sealing the eligible
deciduous teeth; ages 6 to 7 years for the first permanent molars;14 and ages 11 to 13 years
for the second permanent molars and premolars.15 Currently, 77% of the children 12-to-17years-old in the United States have dental caries in their permanent teeth.1 Many school
days would be saved, and better dental health would be achieved in School Dental Health
Clinic programs by combining sealant placement and regular fluoride exposure.16
Background of Sealants
Buonocore first described the fundamental principles of placing sealants in the late
1960s.10,21 He describes a method to bond poly-methylmethacrylate (PMMA) to
human enamel conditioned with phosphoric acid. Practical use of this concept
however, was not realized until the development of bisphenol A-glycidyl methacrylate
(Bis-GMA), urethane dimethacrylates (UDMA) and trithylene glycol dimethacrylates
(TEGDMA) resins that possess better physical properties than PMMA. The first
successful use of resin sealants was reported by Buonocore in the 1960s.22
The Saliva Compartment
The saliva is derived mainly from the major salivary glands the parotid, submandibular, and
sublingual glands. Of these, the parotid elaborates a serous (watery, mucous-poor) fluid
containing eletrolytes, but is relatively low in organic substances. The parotid gland secretes the
majority of the sodium bicarbonate that is essential in neutralizing acids produced by cariogenic
bacteria in the dental plaque,6,7 and the majority of the enzyme amylase that initiates intraoral
digestion of carbohydrates. The submandibular gland secretes a mixed serous and mucuos fluid,
while the sublingual gland has a greater proportion of mucous output than the other major
glands. The minor glands palatal, lingual, buccal, and labial salivary glands empty onto the
mucus membrane in many locations on the palate, under the tongue, and on the inner side of
the cheeks and lips. These minor glands are mainly mucous secreting glands that lubricate these
surfaces and allows for improved mastication and passage of food substance into the
esophagus.3 The minor salivary glands also contribute fluoride that bathes the teeth and
enhances caries resistance.8,9,10
Pure saliva produced by the oral glands is sterile, until it is discharged into the mouth. When the
fluids from all major and minor glands mix with each other, this secretion becomes known as
whole saliva. Whole saliva is further altered by the presence of particles of food, tissue fluid,
lysed bacteria, and sloughed epithelial cells. It becomes even more complex with the inclusions
of living cells and their metabolic products, for example, bacteria and leucocytes, the latter
derived from the gingival crevices and tonsils.
Functions of saliva
The physical and chemical protective
functions of saliva can be divided into five
convenient categories (1) lubrication, (1)
flushing/rinsing, (2) chemical, (3) antimicrobial
(includes antibacterial, antifungal and
antiviral), and (4) maintenance of
supersaturation of calcium and phosphate
level batheing the enamel, helping to stymie
demineralization and/or to aid
remineralization of tooth structure.11,12 To
reinforce the concept expressed in (4), Peretz
aptly opined that saliva can be considered
similar to enamel but in a liquid phase.13
The salivary defensive system functions
continuously, but its secretion becomes
greatest and most active during foodstuff
ingestion. It has the lowest flow rate during
the sleep period of the daily 24-hour cycle.
Lubrication and Flushing
A very thin microscopic layer of mucus
protects the oral hard and soft tissues from
the often harsh and abrasive foods, as they
are being chewed and swallowed. It also
protects the soft tissues from dessication and
the teeth from abrasion. The moistening of
food by saliva facilitates chewing and
swallowing. Speech is enhanced by the
reduced friction between the dry tongue and
soft tissues. Coversely, a lack of saliva
(xerostomia) results in a greatly increased risk
of caries with its accompaniment of an
extremely annoying dry-mouth sensation.
Chewing, swallowing and speaking can all be
difficult and uncomfortable with dry-mouth
syndrome and often requires frequent
ameliorating sips of water.
Flow Rate
Providing a constant fluid flow is probably the
most important defense function of the
salivary glands, because it is the fluid that
transports the buffering agents, the
antimicrobials, and the mineral content of
saliva to help control the equilibrium between
the demineralization and remineralization of
tooth structure. Also, the fluid output of the
glands is essential for diluting acids, flushing
food particles embedded around the teeth,
clearing refined carbohydrates (acidproducing sugar substrates) and physically
removing any displaced bacteria12 Oral fluids
in contact with food particles results in
solubilizing food substances that interact with
the taste buds to provide an accurate
assessment of taste.2
Sugar and Other Sweeteners - Peter E. Cleaton-Jones Connie Mobley
Objectives
At the end of this chapter it will be possible to
1. Name the three sugars that are composed of molecules of glucose, fructose, or galactose,
all of which can produce caries.
2. Define sugars, sweeteners, and sugar replacers.
3. Describe the potential impact of an excessive intake of added sugars on the quality of the
human diet.
4. List three polyols that are sweeteners and cite their advantages and disadvantages in
influencing caries incidence.
5. Defend the Food and Drug Administration (FDA) for either removing or attempting to
remove saccharin and cyclamate from the marketplace.
6. Name a sweetener that has recently received FDA approval, and list three more that are
candidates for approval.
Introduction
Introduction
To most people the term sugar refers to the common household foodstuff table sugar
(sucrose). Yet sucrose is only one of many naturally occurring sugars used in the human
diet. Technically the term sugar applies to two classifications of carbohydrates. Free-form
monosaccharides (simple sugars) include the more common glucose, fructose, and
galactose. Disaccharides (two simple sugar molecules linked together) include the most
common sucrose, lactose, and maltose. Naturally occurring sugars are available in fruits,
vegetables, grains, and dairy foods.
Sweeteners are added sugars that are used as ingredients to both satisfy our taste and in
some cases provide added energy. Grouping sweeteners as "nutritive" or "non-nutritive"
acknowledges a difference in the amount of energy provided by the sweetener. Nutritive
sweeteners may be referred to as caloric and include sugars and sugar alcohols. Nonnutritive sweeteners offer no energy and can sweeten with little volume. Both the sugar
alcohols and non-nutritive sweeteners can replace the sugars and are sometimes referred
to as sugar substitutes, sugar replacers or alternative sweeteners.1 Table 14-1 lists
sweeteners available in the food supply and their unique characteristics.
Summary
There is little doubt that the consumption of
sugar is associated with the caries process, but
sugar alone is not the sole determinant of
whether food is cariogenic.62 Sweetness is
such a cultural characteristic, however, that
behavior modification to exclude it from the
diet is considered an impossibility. Also, the
nonsweetening benefits of sucrose in industry
would probably guarantee its continued use.
In many industrial applications in the
preparation and processing of food, other
caloric and noncaloric sweeteners are
preferable to sucrose. New sweeteners have
been introduced recently that are less
cariogenic and many hundred or thousand
times sweeter than sucrose. Many of them are
nonacidogenic and noncaloric. From a dental
standpoint these new sweeteners offer the
potential for a considerable decrease in caries
incidence. At the present time no one
sweetener dominates another from the
clinical perspective of caries prevention.43
Diet and Nutrition in Oral Conditions: Background and Counseling Strategies
Who Needs Diet Guidance Caries Prevention
Dietary education and guidance are important for the prevention and control of dental
caries. Patients should be carefully assessed to determine the level of prevention and
nutrition guidance needed following these Institute of Medicine prevention guidelines:46
Selective Prevention: This strategy targets subset of the total population that are deemed to
be at risk for caries for a variety of reasons. Examples include:
Adolescents at risk of caries because of high intake of soft drinks and snack foods.
Caries-prevention counseling for patients with xerostomia or cariogenic diet patterns.
Proactive diet suggestions for new denture wearers or those having jaw fixation.
Diet advice prior to radiation or chemotherapy.
Using current diet patterns as a basis for discussion, patients should be taught the role of
diet in caries, what are cariogenic and noncariogenic eating patterns, and how to adapt
current diet to lower cariogenic risk.