This article is about toothpaste.
The primary needs for toothpaste are to reduce dental plaque or gingivitis and prevent gum disease. Others concerns such as sensitive tooth and whitening effects are not within the discussion here.
What are the main roles of toothpaste in oral care?
Plaque is a sticky deposit on teeth (formed by food) in which bacteria proliferate. Gingivitis, an early inflammation symptom of gum disease, occurs when a film of plaque accumulates on the teeth. Giving the root of the gum problems purely depends on the accumulation of the plaque, the main task of toothpaste is to remove the plaque.
What are the must-have active ingredients of toothpaste?
There are two main active ingredients, which acting as therapeutic agent + abrasive agent.
Fluoride is an evidence-based caries-controlling therapeutic agent that must be present in toothpaste. The importance of fluoride toothpaste for caries control is based on dozens of clinical studies, which you can find from reference 1 here.
Mode of action of fluoride?
When we talk about tooth care, it is mainly about preventing the formation of caries due to bacterial ingestion on our food residue (particularly carbohydrates) on the tooth.
The outermost part of a tooth is enamel, which consists of crystalline mineral hydroxyapatite (composed of phosphate ions (PO4^3-) and calcium ions (Ca^2+)). When the pH drops due to the bacteria ingestion on sugar, it causes dissolution of hydroxyapatite (called as demineralisation). When the pH back to normal by natural buffer capacity of saliva, minerals are reincorporated in the tooth through the process of remineralisation.
Caries form as a result of a series of demineralisation/remineralisation cycles over time, when demineralisation happens more frequently. With applying toothbrushing habit using fluoridated toothpaste, the fluoride ions released into the saliva help to form fluorapatite in the remineralization process. Fluorapatite is less soluble than hydroxyapatite, and thus it is more resistant to subsequent demineralisation when acid challenged.
Types of fluoride safely/effectively included in toothpaste?
Fluoride protects the dentine and enamel by reducing dental demineralization and enhancing remineralization of enamel.
There are three types of FDA-approved fluorides to prevent tooth decay: stannous fluoride, sodium fluoride, and sodium monofluorophosphate (MFP). A little note to stannous fluoride is, it is known to form stained teeth. However, with its protective effects on plaque/gingivitis, tooth sensitivity, and cavities, it is still preferred over the other two fluoride forms. With careful formulation, the side effect of toothpaste containing stannous fluoride can be overcome by adding whitening ingredients. Stannous fluoride and MFP can be used with abrasive that contain calcium, while sodium fluoride interacts with calcium-based abrasive to form low solubility calcium fluoride salts (and thus unable to release free fluoride ions in the saliva).
Should we worry about overexposure of fluoride from toothpaste or fluoridated water?
No. People concern overexposure of fluoride may alleviate the occurrence of dental fluorosis (the teeth somehow mildly discoloured or form pits), especially among children. In Malaysia, our piped water has been treated with fluoride with 0.7 ppm, which has been implemented since 1971 (from the Malaysian Dental Association, mda.org.my). Note that other countries in cooler climate have 0.8 - 1.2 ppm of fluoride level in the water.
Ideal concentration of fluoride in toothpaste?
Toothpaste has to contain at least 1,000 - 1,500 ppm of fluoride to significantly effective in reducing cavies. High-fluoride toothpaste (e.g. 5,000 ppm F) is clinically proven to have higher effectiveness to control root caries. No longitudinal study demonstrating that children exposed to a higher dose develop more severe levels of fluorosis. Therefore, young children should use fluoride toothpaste irrespective of age, but with a smaller amount compared to adults. It is more effective when performed toothbrushing at least twice a day.
What are the better-choice of toothpaste that can be found in Malaysia?
To my surprise, many toothpaste brands do not bother to put a full list of ingredients on the labelling, not mentioning the info for their concentrations.
Based on a Malaysian study in 2017 (reference 2), there is lack of standardisation in the labelling of toothpaste in Malaysia, including the type and concentration of fluoride, country of manufacture, and other necessary specifications needed for consumers to make an informed purchase.
Colgate is among the best role model in product labelling, they have products containing MFP (1000 ppm from Sensitive series; 1450 ppm from Maximum cavity protection, Sensitive Prof Relief series) and sodium fluoride (0.24% w/w from Triple Action and 1000 ppm from Advanced White and Optic White). Melaleuca Tooth Polish With Fluoride uses sodium fluoride (0.243% w/w), but note that direct-sale products always floated with lots of herbal/essential oils in reasoning the higher price. Oral B uses stannous fluoride (their signature ingredient) and sodium fluoride for all of the toothpaste series. I am quite disappointed with Darlie brand for it only lists MFP as its active ingredient, without stating the concentration and other ingredients on the packaging.
What more ironically is, herbal toothpaste is becoming more popular and some even market toothpaste that claims to be free of fluoride. A recent published (year 2020) systematic review in BMC concluded that herbal toothpaste is not as effective as fluoridated toothpaste in plaque reduction (reference 3).
If it is not up to any rare circumstance of not able to use a fluoridated product, I hope that you do not support any toothpaste product that absent of fluoride, nor those brands that do not bother to give the necessary information in the labelling.
Reference
1. Cury, J. A., & Tenuta, L. M. A. (2014). Evidence-based recommendation on toothpaste use. Brazilian oral research, 28(SPE), 1-7.
2. Gundavarapu, K. C., Ramachandra, S. S., Dicksit, D. D., & Gupta, V. V. (2017). The Specifications and Ingredients Found in Commercially Available Toothpastes. Makara Journal of Health Research, 21(3), 2.
3. Janakiram, C., Venkitachalam, R., Fontelo, P., Iafolla, T. J., & Dye, B. A. (2020). Effectiveness of herbal oral care products in reducing dental plaque & gingivitis–a systematic review and meta-analysis. BMC Complementary Medicine and Therapies, 20(1), 1-12.
Note:
The "Kepo" in "be a kepo consumer" series is a slang word commonly used by Malaysian Chinese, which means 'wanting to know in detail about something'.
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