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.

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