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1 Toothpastes

2 Monographs in Oral Science Vol. 23 Series Editors M.C.D.N.J.M Huysmans Nijmegen A. Lussi Bern H.-P. Weber Boston, Mass.

3 Toothpastes Volume Editor Cor van Loveren Amsterdam 18 figures, 9 in color, and 20 tables, 2013 Basel Freiburg Paris London New York New Delhi Bangkok Beijing Tokyo Kuala Lumpur Singapore Sydney

4 Cor van Loveren Department of Preventive Dentistry Academic Center for Dentistry Amsterdam (ACTA) University of Amsterdam and VU University Gustav Mahlerlaan 3004 NL 1081 LA Amsterdam (The Netherlands) This volume received generous financial support from Library of Congress Cataloging-in-Publication Data Toothpastes / volume editor, Cor van Loveren. p. ; cm. -- (Monographs in oral science, ISSN ; vol. 23) Includes bibliographical references and indexes. ISBN (hard cover : alk. paper) -- ISBN (e-isbn) I. Loveren, Cor van, editor of compilation. II. Series: Monographs in oral science ; v [DNLM: 1. Toothpastes. 2. Tooth Diseases--therapy. 3. Toothbrushing. W1 MO568E v / WU 113] RK dc Bibliographic Indices. This publication is listed in bibliographic services, including MEDLINE/Pubmed. Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Copyright 2013 by S. Karger AG, P.O. Box, CH 4009 Basel (Switzerland) Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel ISSN e-issn ISBN e-isbn

5 Contents VII Preface van Loveren, C. (Amsterdam) 1 An Introduction to Toothpaste Its Purpose, History and Ingredients Lippert, F. (Indianapolis, Ind.) 15 Fluorides and Non-Fluoride Remineralization Systems Amaechi, B.T. (San Antonio, Tex.); van Loveren, C. (Amsterdam) 27 Antiplaque and Antigingivitis Toothpastes Sanz, M.; Serrano, J.; Iniesta, M.; Santa Cruz, I.; Herrera, D. (Madrid) 45 The Role of Toothpastes in Oral Malodor Management Dadamio, J.; Laleman, I.; Quirynen, M. (Leuven) 61 Anti-Calculus and Whitening Toothpastes van Loveren, C. (Amsterdam); Duckworth, R.M. (Newcastle upon Tyne) 75 The Role of Toothpaste in the Aetiology and Treatment of Dentine Hypersensitivity Addy, M.; West, N.X. (Bristol) 88 Toothpaste and Erosion Ganss, C.; Schulze, K.; Schlueter, N. (Giessen) 100 Abrasivity Testing of Dentifrices Challenges and Current State of the Art González-Cabezas, C. (Ann Arbor, Mich.); Hara, A.T. (Indianapolis, Ind.); Hefferren, J. (Lawrence, Kans.); Lippert, F. (Indianapolis, Ind.) 108 Laboratory and Human Studies to Estimate Anticaries Efficacy of Fluoride Toothpastes Tenuta, L.M.A.; Cury, J.A. (Piracicaba) 125 Pharmacokinetics in the Oral Cavity: Fluoride and Other Active Ingredients Duckworth, R.M. (Newcastle upon Tyne) 140 After-Brush Rinsing Protocols, Frequency of Toothpaste Use: Fluoride and Other Active Ingredients Parnell, C.; O Mullane, D. (Cork) 154 Author Index 155 Subject Index V

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7 Preface The editors of the Monographs in Oral Science series asked me whether it would be worthwhile to produce a volume on toothpaste. I could only give a resounding Yes! because I always notice that most dentists and many dental researchers are unaware of the complexity of toothpastes and the science that goes into them. Questions about the relative effectiveness of different toothpastes are often vaguely answered. Furthermore, the last comparable publication dated from Although used for several thousand years, dentifrices have evolved rapidly over the last century from suspensions of crushed egg shells or ashes used by the ancient Egyptians and toothpowders of the 19th century to the complex toothpaste formulations of today. A landmark was the widespread mass-marketed introduction of fluoride in toothpaste in the 1950s. From then on, toothbrushing with fluoridated toothpaste became indispensable for good oral health. The use of toothpastes had no longer only a cosmetic but also a therapeutic effect. Fancy packaging, a variety of flavours and colours and commercials emphasising the benefits made oral hygiene attractive for consumers, with a pivotal role for toothpaste as it combines the delivery of active ingredients with the mechanical removal of dental plaque and food debris during use. Manufacturers have continuously improved formulations for better fluoride bioavailability, and also included other active therapeutic ingredients to fight gum disease, malodour, calculus, erosion and dentin hypersensitivity. The cosmetic effect of toothpastes improved as a result of tailored abrasives to clean and whiten teeth, ingredients to facilitate removal and prevention of extrinsic stain, flavours for the purpose of breath freshening and dyes for better visual appeal. The development and promotion of these latter cosmetic toothpastes fits into a switch in emphasis in dental practice and among patients to cosmetic dentistry and may therefore have an important function in stimulating consumers to use the pastes. However, this shift in emphasis from therapeutic toothpastes to ones marketed for their cosmetic benefits should not lead to the notion that such cosmetic benefits are more important than the therapeutic ones. Consumers should continue to realize that the first and global goal of using toothpaste is to fight caries: still the most prevalent oral disease. Other functions should not jeopardize this important task. Toothpastes have become truly multi-functional due to the incorporation of a range of active ingredients that aim to combat a variety of oral diseases and conditions and to provide cosmetic benefits. To be effective, such ingredients need to be delivered to the mouth and ideally be retained at target sites for as long as possible. Effective toothpastes are those that are formulated for maximum bioavailability of their actives. This, however, can be challenging as compromises have to be made when several different actives are formulated in one phase. Toothpaste development is by no means complete as many challenges and espe- VII

8 cially sub-optimal oral substantivity of active ingredients are yet to be overcome. Therefore, transparent quality control of manufacture to confirm the bioavailability of the ingredients is essential to support the credibility of efficacy claims. In this respect, established brands may be preferred over generic products. The intra-oral retention or substantivity of active ingredients in toothpastes is not only influenced by product-related but also by user-related factors. The latter factors include biological aspects such as salivary flow and salivary clearance, and behavioural aspects, such as frequency and duration of brushing, amount of toothpaste used and post-brushing rinsing behaviour. Whilst product-related factors are fundamental to the intrinsic efficacy of toothpaste, the user-related factors have the potential to significantly enhance or reduce effectiveness. Dentists are often asked about which toothpastes are the best or about the benefits of specific ingredients. Furthermore, dentists want to advise their patients on the best way to use toothpaste. After reading this book the dentist, and more generally all those who want to advise on the use of toothpaste, will be able to do so in an evidencebased manner. There are head-to-head comparisons of the effectiveness of toothpaste, but such comparisons are not available for all possible comparisons. It is not realistic to expect or demand head-to-head comparisons on all possible claims. Furthermore, head-to-head comparisons can be outdated because by the time the results are published manufacturers may have changed a poorly performing formulation. The limited number of such comparisons in relation to the large number of brands, types and claims of toothpastes implies that many answers will have to be given based on short-term clinical studies (e.g. 4-day plaque growth studies) or on model in vitro studies. A proper understanding of the wider validity of these outcomes is of paramount importance. For therapeutic claims that cannot be directly checked by consumers themselves, scientific evidence is essential; for cosmetic claims, subjective experience and appreciation may be overriding. As editor of this monograph, I was lucky to find so many distinguished colleagues willing to contribute their time and expertise. On behalf of myself and all readers, I would like to thank them for their hard labour and their willingness to share their knowledge with us. The monograph is structured such that after a general introduction on the purpose, history and composition of toothpaste, six chapters deal mainly with the clinical evidence of effectiveness in caries prevention, in reducing and preventing plaque, gingivitis, and halitosis, in preventing calculus formation, in facilitating removal and prevention of extrinsic stain, and in preventing dentine hypersensitivity and erosion. Later chapters deal with important issues that contribute to our understanding of why toothpastes do what they do. The relevant topics are the abrasiveness of the pastes, the substantivity of active ingredients in the oral cavity and the possible models to study effectiveness when full-scale clinical trials are not possible. The last chapter focuses on two of the user-related factors that have been most widely studied: frequency of toothbrushing and post-brushing rinsing behaviour. Whether for those new to the field or for the established worker, this monograph will prove to be a most valuable resource of the available knowledge on toothpaste effectiveness. Finally, I would like to thank Colgate and GABA for supporting the release of this book. Cor van Loveren, Amsterdam VIII Preface