Spoiled for choice with new stannous dentifrices

February 25, 2019

With so many options on the market, it’s important to apply scientific principles when evaluating products.

Having never been to an all-inclusive resort, I was totally unprepared for the fabulous restaurant selections at the Hilton Playa del Carmen in Cancun, Mexico. Spoiled for choice and ready to blow the daily rhythm of my usual restrictive meal selections, I was mesmerized by the entire experience.

Standing in the dental product aisle at a favorite store is a similar experience (minus the calories) because of the numerous colorful dentifrice choices. I’ve noticed, however, patient relief and thankfulness when I narrow down choices of dentifrices at recare appointments. Most of the time, I can follow up my toothpaste recommendation with a sample of the product I’m recommending, and patients act as though I’ve placed a new Rolex watch in their goody bag.

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A bit of dentifrice history

Dentifrices were originally designed to “clean” teeth, some of which used primitive materials such as ashes made from ox hooves, burnt egg shells, charcoal and pumice mixed with water.1 Druggists sometimes prepared their own powdered dentifrices or bought pre-made powders that they would place under their own label. Some of the common ingredients were orris root, powdered cuttlebone (from the internal shell of a fish), sodium bicarbonate, or carbonate (chalk). Oils of cinnamon, clove, rose, or peppermint were chosen as flavorings.2 I remember visiting Alcatraz Island with its infamous federal penitentiary with a group of dental hygienists and seeing a Colgate tooth powder as part of prison cell toiletries. (Alcatraz opened in the 1930s and was closed in the 1960s.) I remembered thinking then about how much dentifrice formulas had changed, and I tried to imagine what the first tooth powders were like, including the packaging. You can see some of the earliest tooth powders online at the Smithsonian Institution Oral Care Section.2

There was even an OTC liquid dentifrice called Sozodont that was highly successful during the late 19th century, due in part to its eye-catching advertisements.2 The product had a high percentage of alcohol (37.15 percent), and it contained abrasive and acidic ingredients that gradually destroyed tooth enamel.2

Today’s OTC dentifrices serve several functions in oral hygiene by the inclusion of different agents. Plaque/biofilm and stain removal agents include abrasives and surfactants. Tartar control properties result from the addition of pyrophosphates. Anti-caries and desensitization agents include  fluoride ( amine, stannous fluoride, sodium fluoride and sodium monofluorophosphate) and other agents like potassium nitrate. Several dentifrices have been marketed as remineralizing agents such as amorphous calcium phosphate-casein phosphopeptide.3 It’s also important to note that all dentifrices with the ADA Seal of Acceptance must contain fluoride.4 Products that earn the ADA Seal of Acceptance must provide scientific evidence demonstrating safety and efficacy, which the ADA Council on Scientific Affairs carefully evaluates according to objective criteria.4

New dentifrices containing stannous fluoride

Patients won’t always ask you which dentifrice you recommend, so I ask the following simple question of every patient or caregiver: “What toothpaste are you using and why?” In my mind, and after examining and treating the patient, I already know which OTC dentifrice to recommend. My suggestions are based on dentifrice ingredients that will benefit that particular patient.

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Stannous fluoride (SnF2) was first introduced in 1955 and is well known as an anti-caries agent.5 In addition to anti-caries activity, stannous fluoride dentifrices reduce gingivitis and plaque/biofilm formation in comparison to conventional dentifrices; however, the magnitude of the effect is still in question.6 A review of MEDLINE and the Cochrane CENTRAL Register were searched up to 2005 and included randomized controlled trials (RCTs) and controlled trials of at least six months’ duration that reported baseline and follow-up data were eligible for inclusion in the review.6 Studies evaluating formulations of tin combined with fluoride were eligible for inclusion. The included studies compared dentifrice or gel, mouth rinse, or combined dentifrice and mouth rinse containing SnF2 with dentifrices containing sodium fluoride (NaF) or sodium monofluorophosphate or placebo. These products were used by participants at home without supervision.6

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Colgate-Palmolive

One of the new dentifrice product offerings is Colgate Total®SF with the tagline “whole mouth health.” This new dentifrice is selling an idea and in this instance, it’s almost a mouth “fitness” message. I like it. Delivering a compelling message to the patient makes him or her want to know more about the dentifrice, and you can then educate the patient about the benefits of a healthy mouth. Most, if not all, patients are familiar with the oral/systemic health links that have made consumers acutely sensitive to messages promoting optimum oral health. Dental hygienists are ideally suited to be a patient’s oral fitness coach who personalizes a preventive care plan and considers each patient’s disease risk.

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At the end of 2018, Colgate Pharmaceuticals introduced the next generation of Colgate TotalSF as a new way to stabilize and deliver SnF2 by using zinc phosphate to prevent oxidation, which overcomes the challenge of staining and poor taste that used to be associated with SnF2 toothpastes. The new Colgate TotalSF formulation offers comprehensive benefits for the “whole mouth” and addresses the following indications: plaque/biofilm, gingivitis, caries, stain removal, whitening, calculus inhibition, sensitivity relief, enhanced enamel strength, and instant odor neutralization associated with halitosis.

The Colgate TotalSF formula is designed to protect the teeth, tongue, cheeks and gingiva by killing plaque/biofilm-causing bacteria that assists in reducing the overall bacteria load in the mouth.

A multi-benefit toothpaste designed for “whole mouth” health reminds me of the one-stop-shop cliché, and it’s a perfect fit for many patients. Many patients present with combinations of issues and three of the most common I’ve observed in adults are sensitivity and increased gingivitis and caries risk, especially in drug-induced xerostomia patients. Patients may moan and groan at being given too many choices, but they like having options. Be it a soft drink or a latte at Starbucks, companies continue to offer an array of choices and it’s no different in the dentifrice aisle of a supermarket.

GlaxoSmithKline

GlaxoSmithKline (GSK) recently introduced a couple of dentifrice formulations with stannous fluoride and both products have clearly defined taglines. Parodontax™ “helps prevent bleeding gums” by reducing plaque/biofilm. Most of my patients have already noticed this product on the store shelves and they can remember the box clearly because of its distinctive color (red/white) and toothpaste name. Yet another stannous fluoride formula by GSK is Sensodyne® with the tagline “rapid relief.” It promises sensitive teeth relief within three days as well as whitening, reducing staining, freshening breath and protecting against dental caries.

Procter & Gamble (P&G)

Procter & Gamble (P&G) is also selling the idea of promoting health with its Crest Pro-Health dentifrice line and has been doing so since the original launch in 2005. In the 1940s, the anti-caries benefit of fluoride was realized, but earlier stannous fluoride dentifrices stained with poorer taste. In the mid-1990s, a new stabilized stannous dentifrice (Crest Gum Care) focused on plaque/biofilm and gingivitis control, along with caries prevention, but there was a lack of anti-calculus effect as well as some extrinsic staining.7

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The first Crest Pro-Health dentifrice (2005) delivered an anti-sensitivity, plaque, gingivitis and caries formulation using stannous fluoride and sodium hexametaphosphate, a stain-fighting ingredient. The new Crest Pro-Health uses an anti-calculus ingredient called zinc citrate instead. Benefits in Crest Pro-Health are said to now include:

  • Effective reductions in gingivitis, plaque and halitosis due to anti-bacterial mechanisms of action

  • Effective anti-caries protection

  • Effective management of dentin hypersensitivity through tubule occlusion

  • Superior anti-erosion capabilities compared to other fluorides

  • Effective anti-calculus activity

  • Effective whitening (stain removal) and stain prevention8

P&G recently introduced a new stannous line of dentifrices called Crest Gum Detoxify Deep Clean Toothpaste. Names of new dentifrices and formulations often change quickly as companies innovate and reformulate ingredients.

Enjoy being a mouth “fitness” coach and consider OTC dentifrice recommendations a part of patient education. Customize your recommendations, knowing there’s something for everyone! Also make sure you’re a good detective while you’re at it and carefully read the literature that accompanies new products. Follow the scientific evidence in making decisions, and if you don’t know how to find “best” evidence, then start by watching the new American Dental Association video tutorial series where you can learn the basics: https://ebd.ada.org/en/education/tutorials

Ask companies for research on new products and carefully scrutinize claims by examining the history and strength of the evidence presented. Your patients will appreciate you if you guide them by applying scientific principles to preventing disease and disability. 

References:

1. http://www.oraljournal.com/pdf/2017/vol3issue4/PartE/3-4-42-955.pdf

2. https://www.si.edu/spotlight/health-hygiene-and-beauty/oral-care

3. https://www.sciencedirect.com/topics/medicine-and-dentistry/dentifrice

4. https://www.ada.org/en/science-research/ada-seal-of-acceptance/how-to-earn-the-ada-seal/guidelines-for-participation-in-the-ada-seal-progr

5. Sensabaugh C. Sagel ME. Stannous fluoride dentifrice with sodium hexametaphosphate: review of laboratory, clinical and practice-based data. J Dent Hyg. 2009 Spring;83(2):70-8.

6. Paraskevas S. van der Weijden GA. A review of the effects of stannous fluoride on gingivitis. Database of Abstracts of Reviews of Effects (DARE) 2006.

7. https://www.dentalcare.com/en-us/clinicals/stabilized-stannous-fluoride-dentrifice-manual/why-dentrifice-is-important

8. https://www.dentalcare.com/en-us/clinicals/stabilized-stannous-fluoride-dentrifice-manual/summary