In order to select a toothpaste from the almost unmanageable offer, which seems suitable for the individual needs, its cleaning effect with protection of the tooth substance and its respective indication (synonym: healing indication) must be considered. Brushing teeth is essential for the lifelong preservation of oral health. A suitable brushing technique, a toothbrush and toothpaste are useful additions to basic care, which should be supplemented by other aids such as interdental space brushes. When selecting suitable products for basic care, care must nevertheless be taken to ensure that the tooth substance is not damaged by excessive abrasion (mechanical wear), despite all the undeniable benefits. While healthy tooth enamel generally suffers almost no abrasion, tooth enamel demineralized by erosion (acid damage) or by initial caries (enamel softened by incipient tooth decay due to the dissolution of minerals) and exposed dentin (dental bone) in the area of the tooth necks must be reckoned with.
Requirements
Regardless of the dosage form (as paste, gel, or powder), the FDI (World Dental Federation, Fédération Dentaire Internationale; international dental association) has the following requirements for a toothpaste (in the International Standard for Toothpastes 1988):
- Under normal use, it must not be harmful to health
- It must not contain sucrose (synonyms: cane sugar, beet sugar, sugar) or other degradable carbohydrates
- Sweeteners such as sorbitol, xylitol or saccharin are allowed
- Ingredients, including preservatives, flavors and aromas must be listed on the tube
- The pH value (measure of the acidic or basic character of an aqueous solution) must be indicated
- An expiration date must be indicated if the paste should be usable for less than 30 months
- The abrasiveness (emery effect) should be indicated, for example, with the note “low abrasive”.
- Et al
Composition of toothpastes
- Water
- Cleaning agents (abrasive substances) – e.g. silica, alumina trihydrate, calcium carbonate / chalk, insoluble metaphosphates, calcium hydrogen phosphate, calcium hydrogen phosphate dihydrate, sodium hydrogen carbonate, silica, polyethylene beads.
- Humectants – e.g. glycerol, sorbitol, xylitol, propylene glycol).
- Binders (for stabilization) – e.g. alginates, carragenan, methyl cellulose, hydroxyethyl cellulose, sodium carboxymethyl cellulose.
- Surfactants (surface-active substances, form foam for better distribution of the paste) – e.g. amine fluoride, sodium lauryl sulfate, sodium lauryl sarcosinate.
- Sweeteners – e.g. saccharin, aspartame, xylitol, cyclamate.
- Flavor additives – e.g. peppermint oil, menthol, clove oil, anise oil, fennel oil, limonene.
- Therapeutically effective ingredients
- Dyes – e.g. white by titanium dioxide; patent blue V, chlorophyllin, quinoline yellow.
- Preservatives – e.g. baking soda / sodium bicarbonate, chlorhexidine digluconate, methyl paraben, p-hydroxybenzoic acid propyl ester.
Indications (areas of application)
The FDI (Fédération Dentaire Internationale, international dental association) provides the following definition: toothpastes are “preparations intended, regardless of their composition, to clean accessible tooth surfaces with a toothbrush. They may additionally be vehicles for the introduction of active ingredients to maintain oral (mouth) health.”
Contraindications
- Allergization to any of the ingredients
I. Mechanical cleaning effect
The use of toothpastes (synonym: toothpastes) thus primarily serves the purpose of mechanically well rid the teeth of plaque (microbial plaque). The brushing time required for tooth brushing is shortened by abrasive cleaning agents (abrasive substances) and surfactants (surface-active foaming agents for better distribution on the tooth surfaces). Nevertheless, the teeth must not be damaged by the abrasive behavior of the toothpaste. Abrasive particles differ not only in their volume share in the toothpaste, but also in hardness, particle shape and size (1/1,000 to 15/1,000 mm). A measure of the abrasiveness (emerizing effect) of a toothpaste is the so-called RDA value.Measuring the abrasion of tooth structure in the laboratory is a comparatively difficult task, as it depends not only on the toothpaste itself, but also on the bristles of the toothbrush and the dilution of the toothpaste in the aqueous oral environment. The very complex conventional method for measuring abrasiveness is the radiotracer method, on which the RDA (radioactive dentin abrasion) value is based. In this method, radioactively labeled dentin samples (dentine samples) are brushed, and the radiation intensity of the abraded paste-water-dentin mixture is then measured. Newer and comparatively less complex laboratory tests measure the abrasion depth of individual monofilaments (depth of the friction track in the tooth substance by individual toothbrush bristles) using so-called microtribological special devices. For the tests, monofilaments from different manufacturers are combined with different toothpastes. The test procedure shows that one and the same toothpaste can have different abrasive effects depending on the toothbrush used. However, the abrasiveness of the toothpaste itself is clearly of greater importance. The abrasive behavior of a toothpaste can be differentiated as follows with the aid of the RDA value, which can be obtained from the manufacturer and ranges from 30 to 200 depending on the product:
| Abrasiveness | RDA value | |
| high | > 100 | usually not recommended |
| medium | > 60 | Range corresponds to most clinically tested preparations |
| Low | < 60 | Preparations are gentle on the tooth structure and usually contain additives against hypersensitivities |
Table
II. therapeutically active ingredients
In addition to the mechanically acting cleaning agents to eliminate plaque (microbial plaque) as the main cause of dental and oral diseases, every toothpaste contains therapeutically active substances with different protective functions for oral health:
- Caries prophylaxis (prevention of tooth decay).
- Erosion protection (protection against loss of tooth structure due to acid attacks).
- Desensitization (reduction of sensitivity) sensitive necks of teeth.
- Protection against gingivitis (inflammation of the gums).
- Protection against extrinsic discoloration (discolored plaque).
- Protection against tartar formation
II.1 Fluorides
Fluorides have an inhibitory effect on caries via various mechanisms occurring in the oral environment, are therefore the mainstay of caries prophylaxis (prevention of tooth decay) and the most important active ingredient that toothpastes should contain. Toothpastes for children from school age, for adolescents and adults have a fluoride content of 1,000 to 1,500 ppm (parts per million, 0.1-0.15%). For children under six, the recommendation is to use a special children’s toothpaste with only 500 ppm, reflecting the greater likelihood that children will swallow toothpaste residue rather than spit it out or rinse it. From the eruption of the first milk teeth, a pea-sized amount of fluoridated toothpaste should be used once a day initially, and twice a day from the second year of life. In addition to caries prophylaxis, another important aspect is that teeth at risk from erosion or exposed tooth necks experience less abrasion with fluoride-containing toothpastes than with fluoride-free preparations, since fluoride has a remineralizing effect (promotes the incorporation of mineral substances into the crystal structure of the tooth substance) and thus increases hardness. Patients at risk should therefore be advised to use a fluoride-containing toothpaste. Toothpastes such as Duraphat toothpaste 5 mg/g (5,000 ppm, 0.5%) and gels such as Elmex gel (12,500 ppm) with a high fluoride concentration for home use are not hygiene products like toothpastes, but medicines and as such require a prescription. Fluorides are present in the following chemical compounds in toothpastes:
- Sodium fluoride
- Amino fluorides (e.g. Olaflur)
- Stannous fluoride (usually in combination with amine fluoride, which has a stabilizing effect on stannous fluoride).
- Sodium monofluorophosphate
II.2 Desensitization of sensitive tooth necks.
On the surface of exposed necks of teeth end thousands of minute tubules that cross the dentin (dentine) and in which are located odontoblast processes (outgrowths of dentine-forming cells at the boundary between the dentine and pulp), which are responsible for pain transmission to the pulp (to the pulp). Active substances that make the tooth necks less sensitive to cold, sweets or acids chemically inhibit this transmission of stimuli or close the tubules on their surface to the oral cavity so that osmotically active and thus pain-triggering substances such as sugar or acid cannot penetrate. Permanent freedom from symptoms cannot be achieved, so that appropriate toothpastes must be used in the long term. Toothpastes for the treatment of painful hypersensitivities (hypersensitivities) are generally low-abrasive (RDA 30-60). The desensitizing additives used are:
- Fluorides (sodium fluoride, amine fluoride, stannous fluoride).
- Potassium nitrate
- Strontium chloride
- Potassium chloride
- Tin chloride
- Hydroxyapatite
- Active ingredient combination of arginine and calcium carbonate (Pro-Argin in Elmex Sensitive Professional).
- Et al.
II.3 Whitening toothpastes.
Whitening substances in whitening toothpastes (synonyms: whitening toothpastes, whitening toothpastes, smokers’ toothpastes) act on so-called extrinsic discoloration: discolored dental plaque that is deposited on the tooth surfaces when consuming staining foods such as berries, beverages such as coffee, tea and red wine and tobacco use. The natural tooth surface and tooth color are freed from the organic deposits that have solidified due to mineral deposition, but they are not usually whitened. The effect of conventional (conventional) whitening toothpastes is based on mechanical cleaning by more or less abrasive cleaning agents, which often results in comparatively high RDA values (abrasion values). In addition, there are pastes whose additives act chemically on deposited discolorations, dissolving them and making them easier to remove mechanically. Another approach is to bind calcium ions in saliva, which makes soft plaque less mineralized and thus less solidified:
- Pentasodium triphosphate
- Tetracalcium pyrophosphate
- Sodium tripolyphosphate
- Tetrasodium pyrophosphate
- Disodium phosphate
- Papain (stain-dissolving enzyme)
For daily use, whitening toothpastes should have a medium RDA (abrasion value); a more abrasive preparation should be used no more than twice a week. Patients with exposed or hypersensitive tooth necks and root surfaces and with erosion problems (loss of tooth structure due to exposure to acids, e.g. from beverages or fruit, or gastric acid in the case of reflux disease) should avoid whitening toothpastes. II.4 Tartar inhibition
Tartar is plaque (microbial plaque) that is solidified by the incorporation of mineral substances. The formation of tartar is usually inhibited (prevented) by pyrophosphates, which are also found in whitening toothpastes, and zinc compounds. On the one hand, the incorporation of hydroxyapatite into the existing plaque (microbial plaque) is inhibited, and on the other hand, the crystallization process itself is disturbed. II.5 Chemical plaque control
Reduction of plaque (microbial plaque) by antibacterial additives is used for gingivitis prevention (prevention of gingivitis). Chlorhexidine digluconate (CHX) is the most effective substance against colonization of tooth surfaces with plaque (microbial plaque) and against gingivitis (inflammation of gums). It prevents bacteria from attaching to the pellicle (enamel epithelium) and thus from adhering to the tooth surface. It also has a bactericidal and bacteriostatic effect (kills bacteria and inhibits their metabolism). However, it is not suitable for continuous use due to its side effects (taste irritations, discoloration of teeth and mucous membrane, mucous membrane desquamation). In addition, the effect of CHX is disturbed by fluorides. Therapeutically relevant CHX concentrations are generally not achieved in toothpastes (0.12%).In higher concentrations, CHX is used, among other things, for temporary intensive prophylaxis: as a gel, it is brushed in twice daily instead of toothpaste as part of a two-week course of treatment. In cases of high caries risk or as part of primary prophylaxis for pregnant women or young mothers, the bacterial counts are reduced in this way. As further “softchemo” additives, essential oils or other plant substances such as chamomile, myrrh or sage have a disinfecting (germ-reducing), anti-inflammatory (anti-inflammatory) or bacteriostatic (inhibiting germ growth) effect on inflammatory processes in the gingiva (gums).
| Substance class | Examples | Mode of action |
| Bisbiguanide | Chlorhexidine (CHX) | Antimicrobial |
| Quaternary ammonium compounds | Cetylpyridinium chloride, benzalkonium chloride. | Antimicrobial |
| Phenols and essential oils | Thymol, menthol, eucalyptus oil, triclosan (+ copolymer for longer residence time). | Antimicrobial, anti-inflammatory (anti-inflammatory). |
| Metal ions | Tin, zinc, strontium, potassium | antimicrobial, desensitizer |
| Fluorides | Sodium fluoride, sodium monofluorophosphate, stannous fluoride (in combination with amine fluoride) amine fluoride | caries inhibiting, desensitizing, anti-inflammatory |
| Herbal products | Sanguinarin | Antimicrobial |
| Enzymes | Glucose oxidaseAmyloglucosidase | Antimicrobial |
| Aminoalcohols | Delmopinol | Reduces the formation of the biofilm |
Table in extracts
II.6 Additives against halitosis (bad breath)
Many nooks and crannies in the oral cavity (interdental spaces, caries, gingival pockets, posterior surface of the tongue, dentures) are insufficiently covered by moderate oral hygiene. The metabolic products of gram-negative anaerobes (bacteria), especially volatile sulfur compounds, can cause halitosis (bad breath). In addition to clarifying possible causes, it is necessary to intensify oral hygiene techniques, which must also include tongue cleaning. In addition, preparations such as Meridol Halitosis toothpaste are available, which neutralizes the odor-active substances by combining zinc lactate with amine fluoride and stannous fluoride as well as essential oils and has an antimicrobial effect on the causative germs. II.7. xylitol
Xylitol is a sugar (with 5 C atoms) which is absorbed by bacteria but, unlike caries-promoting sugars (6 C atoms), cannot be further metabolized. As a result, the germ population is reduced and plaque growth is inhibited. Xylitol is thus a sugar substitute with a therapeutic effect. As part of primary prevention, xylitol chewing gum is therefore recommended to pregnant women to reduce the number of germs in order to reduce the risk of transferring caries-active germs from the mother to the newborn. Xylitol is contained, for example, in Aminomed or Pearls & Dents.
III. flavors
Additives to improve the taste are not to be assigned to the therapeutically effective ingredients, but are of enormous importance for the therapeutic goal of adequate cleaning: an individual will brush the longest with the toothpaste whose taste appeals to him the most – and will thus inevitably achieve the greatest individual cleaning effect, regardless of other advantages of the toothpaste and regardless of his personal, more or less perfect toothbrushing technique. The supposedly best toothpaste is of little use if the unconsciously declared goal is to get rid of its taste as quickly as possible.
IV. Surfactants
As surface-active substances, surfactants support the cleaning action of the cleaning agents. They
- Keep the non-soluble substances of the preparation and also detached plaque (microbial plaque) in solution.
- Have a beneficial effect on fluoride incorporation into the tooth surface, by reducing the surface tension.
The common surfactant is sodium lauryl sulfate, which has also been shown to have antimicrobial and antiviral activity (against bacteria and viruses). As an inhibitor of chlorhexidine digluconate CHX, it must not be used simultaneously with preparations containing CHX. The surfactant effect of amine fluoride is particularly noteworthy, which means that toothpastes containing amine fluoride can dispense with further surfactant additives.Their use is thus particularly suitable in cases of allergy to other surfactants.
