Toothpaste is just toothpaste, right?
What if I told you that that wasn’t quite the case? I used to be one those clinicians who said that ‘as long as your toothpaste contains fluoride then I am happy with whatever choice you make’. Or I’d mention specific ones based on what I had been told by reps about things like sensitivity for example. Being truly honest, other than knowing the benefits of fluoride in intricate detail, I hadn’t retained much else about toothpaste other than the ingredients which may cause issues such as sodium Lauryl Sulphate (SLS) or a high RDA. So, my old advice generally used to be to use any that had 1450-1500 ppm of fluoride. I personally liked Oral B Pro Expert, so I’d recommend that based on personal opinion, but I didn’t realise at the time that this advice was a good option for my patients.
Since working closely with Oral B on the Test Drive and its ability to enhance behaviour change in teaching the patient about the role of biofilm, I have been much more curious about biofilm in general and how to achieve optimal removal. I figured that despite the fact that mechanical removal is by far the best way to remove it, could a toothpaste be an essential part in its removal? Making a toothpaste far more than just a fluoride application breath freshening process.
In my search, what I found out revolutionised my toothpaste recommendations and I became passionate about ensuring other clinicians knew the same. I was wanting to find a toothpaste that had a therapeutic effect and one that I could recommend more confidently as a clinician than just ‘whatever contains the right amount of fluoride’. Delving into the different types of toothpaste on offer, I found that Oral B have a range of toothpastes that contain the ingredient stannous. This isn’t a brand-new concept, many years ago the benefits of stannous fluoride were accepted but without the ability to stabilise it, it caused staining, had an astringent taste, the stannous fluoride wasn’t fully bioavailable and so wasn’t widely used as a result. Oral B spent many years perfecting the stabilisation process of the stannous fluoride, which was eventually highly successful and as a result patented so that only they could utilise this process. And so once again stannous fluoride became an available choice on the market for patients.
Unknowingly to me, I was already a big fan of the toothpaste that contained this wonder ingredient. The funny thing was, I was already recommending Oral B Pro Expert toothpaste to my patients because, well- I just liked it. It tasted good; I liked the gritty feel when you initially used it. I knew it could help prevent stain but in honesty I didn’t truly know why this was (science wise), but nevertheless I recommended it anyway as it was my own personal choice of toothpaste. It seems odd to me now that I didn’t fully appreciate the workings of it and so simply put it in the same category as all other toothpastes in that it contained fluoride and so was good to use, but now I do fully appreciate why I recommend this product to my patients and I intend to pass it on.
First, the ‘sciencey’ bit…. sodium fluoride (the most widely known type of fluoride in the UK) splits very quickly in contact with water. This makes it a perfect choice for things like water fluoridation and why it is widely used in toothpaste. The sodium however is useless once it separates. Another alternative is Sodium Monofluorophosphate. This option sees a slower release in order for the fluoride to become accessible, thus it can be used with abrasives, but may require longer brushing periods. Amine fluoride is another form but is used mainly in countries such as the USA and Germany. And then there is Stannous Fluoride, where the stannous is just as, if not more useful than the fluoride when the separation occurs.
So, let’s discuss Stannous Fluoride, with it being my fluoride toothpaste formulation of choice… once split the fluoride provides the well-known remineralisation effects that prevents caries, (happy days). The revelation is that the stannous has a plethora of uses that deem toothpaste containing this ingredient an excellent choice for a whole host of dental related issues, some beneficial to the patient and some equally beneficial to the clinician.
Stannous is bactericidal as well as bacteriostatic. It causes bacterial cell death by its interaction with the bacterial membrane resulting in the leakage of cellular components which induces cell death, including streptococcal species responsible for caries. Its bacteriostatic properties come from its ability to inhibit bacterial growth. It achieves this by inhibiting the bacteria’s ability to perform glycolysis and metabolise sugar, thus reducing the production of short chain fatty acids. This reduces the release of the bacterial markers that initiate the immune response, (the initiation of which causes gingivitis and which may eventually lead to periodontal tissue damage in susceptible individuals). Stopping the metabolism of bacteria affects the adhesive and cohesive effects of the plaque biofilm, making it less sticky to dental surfaces. The biofilm loses the ability to adapt and overcome the stresses placed on it and therefore this makes it easier to remove.
Do you have sensitive teeth? Stannous also occludes dentinal tubules, getting right down into said tubules over time to prevent hypersensitivity. You have a patient with erosion? Stannous is proven to protect the teeth from erosion too. When the local pH drops below 4.5, the pellicle cannot protect the enamel surface and irreversible enamel damage can occur. Yes, any fluoride can offer a minimal benefit through the production of fluorapatite, but even this will dissolve under highly acidic conditions. Stannous fluoride however mixes this benefit with the added protection of the ability for stannous to adhere to the surface of tooth enamel to form a protective layer, able to shield the enamel from the effects of erosive acids. This formulation provides a significantly greater level of protection. (Is anyone else picturing Stannous in a cape or is it just me)?
Oral B Pro Expert toothpaste contains Sodium Hexametaphosphate, a polymer proven to help prevent stain and calculus adhesion. Is there anything this toothpaste cannot do? (I mean, it obviously it can’t take your dog for a walk at 6am in the rain or improve your finances, but I’m sure you can agree it is providing you a decent service here). The grittiness is thin slices of sodium hexametaphosphate (say that after a gin)! It breaks down and repels stain and actually softens calculus by preventing its adhesion. Whilst hand scaling is common practice again under the current climate, it’s a great idea to get your patients using this toothpaste to save your hands from hand scale induced exhaustion. It has an RDA value of 250 placing it within the safety range for abrasivity. A common misconception is that the gritty feeling must mean it is highly abrasive. This is wrong, infact these ‘gritty’ slices of sodium hexametaphosphate dissolve very quickly. It is also a misconception that a toothpaste with an RDA value under 100 is safer than one above 100. To clarify, toothpaste with an RDA value of up to 300 is deemed safe for a lifetime of use.
What is more, (there is more? Yep, I know), Oral B Gum and Enamel Repair toothpaste contains Stannous Fluoride and has the added ingredient and benefits of Stannous Chloride. This is the perfect solution for the patients who present to you with bleeding. It has 70% more stannous than Oral B Pro Expert toothpaste and so increases the potential for therapeutic biofilm control when recommended alongside your mechanical oral hygiene instruction.
Now you know all this information, I hope you agree (like I did when I did my research), that this is a best option to recommend to your patients in order to best prevent, support and maintain their periodontal and dental health.