Component 1: Cariology & Preventive Dentistry

Part 2: Preventive Dentistry

Topic 5: Home care fluoride products

Suggested prereading:
Kroon, J & Botha, FS. 2001. Laboratory analysis of fluoride containing toothpaste
available in South Africa. South African Dental Journal, 56 (1), p. 12-18.
Benzian, H, Holmgren, C, Buijs, M, Van Loveren, C, Van der Weijden, F & Van
Palenstein Helderman, W. 2012. Total and free available fluoride in toothpastes in
Brunei, Cambodia, Laos, the Netherlands and Suriname. International Dental
Journal, 62, p. 213-221.

1. Introduction
In the previous topics it was emphasised that the topical action of any fluoride product
post-eruption is most important in the prevention of dental caries. These products
aim to ensure a continuous presence of ionic fluoride in the saliva to counter any
demineralisation.

Toothpaste and mouthrinses are the two main commonly used fluoride containing
vehicles for use at home.

2. Community water fluoridation vs fluoridated toothpaste

Since the early 1970’s the addition of fluoride to toothpaste has become common and
is now the most frequently used source of topical fluoride. In the absence of community
water fluoridation, fluoride containing toothpaste is the only alternative to provide the oral
cavity with small amounts of fluoride on a daily basis to assist in the remineralisation of
demineralised lesions.

The major difference between these sources of topical fluoride is that fluoridated
toothpaste is an example of active prevention, where individuals must be motivated
and compliant for it to be effective. Water fluoridation on the other hand is an example
of passive prevention where the benefits are obtained without the person realising it
every time when fluoridated water is consumed.

3. General recommendations for the use of fluoridated toothpaste

Fluoridated toothpaste as part of biofilm control has either a specific protection or a
therapeutic function, over and above the cleaning properties of the paste. It is
recommended that fluoride containing toothpaste should be used twice per day to add
fluoride ions in a higher concentration to the oral environment than what is present in
community water fluoridation. When used in combination these two fluoride vehicles then
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Topic 5: Home care fluoride products
enhance each other’s effectiveness. To maximize the effect of the fluoride it is
recommended that you only spit out the excess amount of toothpaste and not rinse your
mouth with water after brushing.

4. Toothpaste ingredients
These can either be classified as active (therapeutic) or non-active. Active
ingredients directly influence a disease or condition, whereas non-active ingredients
only enhance the characteristics of the product (appearance, taste, etc).

4.1 Active ingredients

4.1.1 Fluoride
Its addition to toothpaste is widely attributed to the world-wide decline in dental caries.

The total fluoride content in adult toothpaste is approximately 1,000 to 1,500 ppm
(parts per million or mg/litre). This is the maximum allowed concentration for fluoride
containing toothpaste sold in supermarkets.

Paediatric toothpastes typically contain approximately 500-550 ppm total fluoride.

This is recommended for use in children younger than 6 to reduce the risk of dental
fluorosis when toothpaste is ingested during early brushing. Toothpastes for high
caries risk patients may contain up to 5000 ppm fluoride and can only be sold in
pharmacies.

An analysis of the 60 toothpastes/toothpaste groups available to the public from

supermarkets and pharmacies (see Appendix – Preventive Dentistry Topic 5 –
Home care fluoride products) shows the following:
Total fluoride concentration (ppm) Number of toothpastes
500ppm 5
1,000ppm 20
1,100ppm 1
1,300ppm 1
1,350ppm 3
1,450ppm 17
5,000ppm 1
Unknown 2
Fluoride free 10

Only a part of the total fluoride concentration is soluble and can become available in
ionic form for a topical action. Other ingredients of toothpaste are responsible for
binding some of the fluoride, rendering it inactive for caries prevention.

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The most common forms are:
• Sodium fluoride (NaF)
Sodium fluoride goes into solution very easily. It is therefore widely used in water
fluoridation, toothpaste, rinses and most professional fluorides.

• Sodiummonofluorophosphate (MFP)
MFP is commonly used in toothpaste and has a unique reaction due to its complex
structure to which the fluoride is bound. In this form fluoride is inactive since fluoride
need to be ionic form for effective remineralisation.

When pH drops in the mouth, as happens with the formation of acids from metabolic
processes occurring in the micro-organisms, the phosphatase enzyme in saliva is
activated. This enzyme is responsible for releasing the fluoride from this complex
molecule, which then makes the fluoride ion available for remineralisation in this low
pH environment.

• Stannous fluoride (SF)

SF can address tooth hypersensitivity as well as act as an anticaries agent.
Historically SF has been associated with staining, more recent products claim that his
has now been addressed by stabilising the SF.

• Organic fluorides (OF)

An example is amine fluoride. It is claimed that OF can lead to higher levels of ionic
fluoride and is more effective than inorganic fluorides. It also has an increased
antibacterial action due to the organic part of the molecule and not the fluoride alone.
It has a low surface tension which facilitates more effective interproximal penetration.

4.1.2 Abrasive agents

Abrasive agents assist with the cleaning action of the toothpaste and disturbing the
growth of the biofilm but binds fluoride which isn't then available for remineralisation.

Examples:
• Calcium-based abrasives: Calcium carbonate, Calcium pyrophosphate, Dicalcium
phosphate, Dicalcium phosphate dihydrate, Tricalciumphosphate;
• Silica-based abrasives: Silica, Hydrated silica, Silicon dioxide; and
• Diatomaceous Earth.

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4.1.3 Desensitising agents
Desensitising agents in toothpaste achieve the desired result through either:
• Influencing impulse transmission:
This will increase the pain threshold which will then decreases sensitivity of teeth.

Examples:
- Potassium chloride;
- Potassium citrate; and
- Potassium nitrate.

• Occluding (sealing) exposed dentinal tubules:

This is not permanent and a patient needs to continuously brush with this paste to
ensure that this layer remains in place.

Examples:
- Arginine: This is an amino acid naturally found in saliva. Combined with calcium
carbonate to form a calcium rich layer on the dentine surface and in the dentine
tubules to plug and seal them preventing transmission of pain producing stimuli;
- Novamin: Uses technology originally aimed at bone repair. With calcium
phosphate it builds a protective layer over exposed dentine tubules which blocks
them from the exposure to pain triggers; and
- Stannous fluoride.

4.1.4 Whitening agents

Some ingredients have higher abrasive properties to assist with cleaning, whereas
others claim to break down and remove stains. No whitening toothpaste however
bleaches teeth similar to professional or home care whitening kits.

Examples:
• Charcoal;
• Hydrogen peroxide;
• Papain;
• Pentasodium triphosphate;
• Sodium carbonate;
• Sodium chloride; and
• Titanium dioxide.

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4.1.5 Bacterial metabolism
Some ingredients influence the metabolism of organisms and therefore slows down
biofilm (and eventually) calculus formation, which then reduces gingivitis.

Examples:
• Potassium sorbate;
• Sodium gluconate;
• Totarol;
• Zinc citrate/ Zinc citrate trihydrate;
• Zinc lactate; and
• Zinc oxide.

4.1.6 Calculus control

These ingredients delay the formation of calculus by inhibiting crystal growth and
calcification of plaque and biofilms.

Examples:
• Disodium pyrophosphate;
• Potassium pyrophosphate;
• Sodium hexametaphosphate;
• Sodium polyphosphate; and
• Tetrasodium pyrophosphate.

4.1.7 Neutralises pH
Examples:
• Aluminium hydroxide;
• Magnesium hydroxide;
• Potassium hydroxide;
• Sodium bicarbonate; and
• Sodium hydroxide.

4.1.8 Herbal ingredients

The last number of years has seen a growth in toothpastes with a focus on herbal
ingredients.

Examples:
• Aloe vera: antibacterial;
• Calendula Officinalis: anti-plaque and anti-gingivitis properties;
• Cardamom: disinfects and eliminates bad breath;
• Castor oil: anti-inflammatory;
• Celery: antiseptic properties;

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• Clove: teething pain in children;
• Coconut oil: antibacterial;
• Coriander: antibacterial, eliminates bad breath;
• Dill: antibacterial, eliminates bad breath;
• Eucalyptus oil: antiseptic, antimicrobial, antiviral, antibacterial and antifungal
properties;
• Magnolia bark: eliminates bad breath and reduces bacteria;
• Menthol/Mint oil: prevents development of biofilm;
• Myrrh: relieve mouth sores and gum inflammation;
• Propolis: antiseptic and antibacterial;
• Rosehip oil: anti-inflammatory;
• Tea Tree oil: antiseptic properties; and
• Thyme: antibacterial.

4.1.9 Chlorhexidine gluconate

Toothpastes which contain chlorhexidine gluconate do not contain sodium lauryl
sulphate (SLS) as in combination they are not compatible. It is for this reasons that
patients who are required to use a chlorhexidine mouthrinse for a short term
indications should not use this within 30 minutes of having brushed with a SLS
containing toothpaste.

4.2 Non-active ingredients

These ingredients do not contribute to the prevention of any disease or condition, but
are aimed at market appeal, appearance and taste.

Similar to the abrasive agent these ingredients will bind fluoride to a larger or lesser
extent.

Examples:
• Water (20-35%);
• Surfactants (e.g. sodium lauryl sulphate): Responsible for the foaming associated
with toothpaste;
• Humectants: prevents the paste from drying out;
• Detergents: Reduces surface tension, enhances cleaning and loosens food
particles;
• Flavouring, colouring, lubricating, binding agents and thickeners;
• Artificial sweeteners; and
• Preservatives.

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Topic 5: Home care fluoride products
Exercise: Analysis of toothpaste ingredients
1) On L@G open the document Appendix – Preventive Dentistry Topic 5 –
Home care fluoride products
2) Section 1 Toothpaste brands will provide you with information on the main
function of the toothpaste as claimed by the relevant company on their website
3) Section 2 Toothpaste ingredients list all the ingredients for a
toothpaste/toothpaste group
4) Select any toothpaste at random from Section 2
5) On the table on the next page:
• Copy the ingredients from Section 2 for your selected toothpaste
• For each ingredient tick whether they are an active/non-active ingredient
• Investigate the benefit/function of the ingredient (Tip: Google “Benefit of
[ingredient name] in toothpaste” if not sure)
• If your toothpaste/toothpaste group contains fluoride, investigate the total
fluoride concentration (Tip: This information can be found on websites of
major supermarkets/pharmacies)
6) You are encouraged to repeat this exercise for at least 4 more toothpastes

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Topic 5: Home care fluoride products
Toothpaste/ toothpaste group brand and name:

Non-
Ingredient Active Benefit/function
active

If your toothpaste contains fluoride, list the total fluoride

concentration (ppm)

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Topic 5: Home care fluoride products
Exercise: Analysis of type of fluoride/abrasives combinations
The table below indicates the combination of the different types of fluoride with the
different types of abrasives for the 60 toothpastes/toothpaste groups in the document
Appendix – Preventive Dentistry Topic 5 – Home care fluoride products
Type of Abrasive
Calcium/ DE/
Type of Calcium- Silica- Diatomaceous
Silica Silica Total
Fluoride based based Earth (DE)
combo combo
NaF 29 1 30
MFP 1 7 6 1 15
NaF/MFP combo 1 1
NaF/SF combo 4 4
Fluoride free 3 3 3 1 10
Total 5 43 10 1 1 60
Explain the following:
1. Why either on its own, or in combination, sodium fluoride (n=35) seems to be
the type of fluoride of choice compared to MFP (n=16)

2. Why either on its own, or in combination, silica-based abrasives (n=54) seems

to be the type of abrasive of choice compared to calcium-based abrasives
(n=15)

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Topic 5: Home care fluoride products
5. Fluoride mouthrinses
Fluoride containing rinses are especially effective for high caries risk patients where
an additional fluoride containing product is indicated to create an environment which
is higher in fluoride ion concentration than what can been achieved by the use of
fluoridated toothpaste and/or community water fluoridation. These products are
relatively inexpensive and effective.

In the majority of oral mouthrinse studies an additional caries reduction of 20% was
achieved over and above other preventive programmes. Sodium fluoride is the type of
fluoride of choice due to the fluoride ion being in solution already. Similar to other
topical fluorides, percentage caries reduction is larger on free smooth tooth surfaces
and less on occlusal surfaces.

It is recommended that a patient rinses with 10ml of a 0.05% sodium fluoride daily.
It is suggested that a patient rinses just before going to bed to create a fluoride
environment for remineralisation while sleeping and salivary flow is reduced. It is also
suggested that you should not rinse within 30 minutes of brushing your teeth to provide
an opportunity for the active ingredients in toothpaste to perform their function before
you use a mouthrinse.

Variations include:
• 0.2% sodium fluoride on a weekly basis – this product was originally developed
for use in school rinsing programmes, but is safe for daily use for a few weeks for
extremely high risk caries patients;
• Some Listerine products contain 0.02% sodium fluoride;
• Curasept ADS 205/905 chlorhexidine mouthrinses also contain 0.05% sodium
fluoride.

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