Dentifrices are marketed as toothpowders, toothpastes, and gels.

1. Dentifricesthe 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.

2. 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..

3. 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.." .

4. 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

5. 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

6. 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.-

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. Therapeutic Dentifrices The most commonly used therapeutic agent added to dentifrices is fluoride, which aids in the control of caries.

14. 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.

15. 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.

16. 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

17. 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.

18. 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

19. 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

20. 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.

21. 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.

22. 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. .

23. 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.

24. 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.'

25. 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 bucco-lingual direction . Wooden sticks have an advantage over plastic in that the pointed end can be softened in the mouth by moistening it with saliva.

26. 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.

27. 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.

28. REST

29. 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

30. 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

31. 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.

32. 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-17-years-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

33. 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

34. 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.

35. 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.

36. 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.

37. 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 (acid-producing 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

38. 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

39. 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. Non-nutritive 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.

40. 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

41. 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.