Spring 2000 Presentation Summary:

Karen Baker is an Associate Professor in the Department of Oral Surgery at the University of Iowa College of Dentistry and at the Clinical Administrative Division of the College of Pharmacy. She lectures on dental therapeutics and devices and finds she has to make at least 20 changes to her outline every two weeks — this is a rapidly changing field with manufacturers releasing new products weekly.

She cautioned us to be aware that there are many sites on the Internet relating to healthcare and that there is little control over these sites, particularly with herbals and alternative care. Our patients are able to look up these sites and may come into the office with questions relating to this information. The FDA currently regulates drugs; however, herbal medications are not regulated. The ADA will only state which products have been accepted; they will not state if a product has been rejected. The ADA Accepted Seal is the current designation that the ADA has evaluated and accepted a product, but some companies are still using the outdated ADA Recognized Seal (the ADA Recognition Program was phased out five years ago).

Product Review

Use certain parameters when evaluating studies related to dental products:

1. The clinical sample should be similar to the population you are comparing.

2. The sample size should be large enough.

3. The application of the product should be realistic.

4. The length of the trial should be at least six months.

5. The statistical differences should be clinically relevant (a 20% change should be seen to affect a noticeable clinical change).

Ms. Baker recommends the following newsletters for collecting information on dental products:

• "Biological Therapies in Dentistry" (1-800-568-7281; $45/yr)

• "Clinical Research Associates Newsletter" (1-801-226-2121; $49/yr)

• "Nutrition Action Health Letter" (1-202-265-4954; $24/yr)

• "Dental Advisor and Dental Advisor Plus" (1-800-347-1330; $82/yr)

Recommended newsletters pertaining to Herbal Medicine were:

• "The Review of Natural Products (1-314-878-2515; $185/yr)

• "Herbs of Choice: The Therapeutic Uses of Phytomedicinals (1-800-429-6784; $40/yr)

Mechanical Plaque Removal Products

In reviewing products, one needs to carefully examine the parameters of the study. The type of plaque present is important because "new" plaque has a much different component base than "old" plaque. Gingivitis scores are much better for evaluating the response changes than plaque score.

Manual Toothbrushes

There are many types of toothbrushes available today, and new ones are introduced all the time. The quality of most toothbrushes is good; the quality of the nylon bristles is high and they are fast-drying. Any ADA accepted toothbrush will work well. In orthodontics, the wear of the toothbrush bristle increases dramatically. Tight-tufted bristles are the best for orthodontic patients (the new Oral-B cross-action toothbrush, although somewhat expensive, is the leader for this situation). Patients should change toothbrushes every two to three months and more frequently during orthodontic treatment.

Ms. Baker feels that toothbrushes can spread upper respiratory infections, making it desirable to disinfect the toothbrush (two cycles through the dishwasher) or alternate toothbrushes during these times.

The handle of the toothbrush should be comfortable to use. The basic brush handle is usually fine, although studies have shown that an angled head will increase the plaque removal on the lingual surfaces. Young individuals and those who are physically handicapped will benefit from a larger brush handle allowing a power grip to be used. Any design that increases motivation to brush is recommended.

Powered Toothbrushes

Ms. Baker feels that powered toothbrushes are only necessary with patients who are having trouble with plaque removal. The following criteria can be used to select individuals who will benefit most from powered toothbrushes:

• Orthodontic bands and poor plaque control

• Care givers perform oral hygiene

• Lack of manual dexterity

• Motivation needed to brush for two minutes

• Antimicrobials penetrate deeper with less staining

Powered toothbrushes come in many shapes and iterations; some cover a single tooth, while others cover many teeth and look more like a conventional manual toothbrush. Some manufacturers have added sonic vibrations, and more are following this lead. The powered toothbrushes most researched in regards to orthodontic patients are: Braun, Oral-B, Interplak and Sonicare. No evidence has been shown in the referenced literature indicating that one is better than the other. Currently, Sonicare and Rota-Dent have voluntarily withdrawn their participation in the ADA-accepted program (it does cost money to maintain this seal of approval). Of patients starting programs with powered toothbrushes, one-half to two-thirds are still using them after six months.

Dental Floss/Specialty Devices

Studies have shown that 5% to 10% of dental patients floss regularly (defined as three to four times per week). Flossing has been shown to predictably reduce interproximal bleeding by 32%. In patients with problems flossing (due to tight contacts, rough interproximal restorations, etc.), the sequence of floss types should be teflon floss followed by satin floss followed by regular floss. Regular floss is best and should be used if possible. A rubber stimulator and proxabrush have been shown to be as effective as floss.

Patients now have access to many types of interproximal cleaning devices, some of which are potentially dangerous to the health of both soft and hard tissues. Caution should be used and recommendations made against items such as sharp metal hooks, prophycup devices with pumice and hard-pointed plastic tips.

Tongue Cleaners

Tongue cleaning in the United States has not been typically associated with normal oral hygiene. However, adding tongue cleaning to a regular oral hygiene program can reduce or eliminate most bad breath (halitosis). The posterior area of the dorsal tongue is the culprit. Nasal secretions can accumulate and produce a foul odor. Ms. Baker offered an easy way to tell if you need help called the "wrist-lick" test. In this test, you lick the inside of your wrist with the back of your tongue, let the area dry and smell.

There are several devices on the market for tongue cleaning which range from the simple to the complicated. The recommended device in this presentation was the Orafresh Tongue Cleaner (Alwin Enterprises, Inc., Salisbury, Md 21803; 1-800-749-4553). If you recommend this cleaner, it should be stocked in your office as it is difficult to find in stores.

Zinc (found in Viadent) and chlorine dioxide (found in Oxyfresh and Rowpar products) consume volatile sulphur compounds. Patients under 12 should avoid oxidizing compounds, and use zinc compounds instead (Viadent Advanced Care Toothpaste). Care must be exercised in using zinc because ingesting too much can lead to nausea (Lavoris Crystal Fresh mouth rinse has zinc, as well).

Oral Irrigators

Ms. Baker does not recommend oral irrigators because she feels that a better option for the money would be a powered toothbrush combined with interdental cleaners.

Chemotherapeutic Products

The following criteria should be used in determining a candidate for chemotherapeutic products:

• The patient has an actual need for the product

• The product effectiveness (should be 20% more effective than brushing twice per day with a fluoride toothpaste)

• The physical properties and adverse side effects

• Patient compliance

Chemotherapeutic products act in the following ways:

• Decrease the rate of new plaque accumulation

• Decrease or remove existing plaque

• Suppress growth of pathogenic microflora

• Inhibit production of virulence factors

Chemotherapeutic products can be applied in the following ways:

• Brush on dentifrices or gels

• Mouthwash: pre-brushing or post-brushing

• Irrigation: supragingival or subgingival

• Local application reservoir

In evaluating what products to use, the clinician should be aware of the interactions of different chemicals. Chlorhexidine can be deactivated by flavoring (peppermint is the best flavoring to use, followed by spearmint). Chlorhexidine and Cepacol can be inactivated by components in toothpastes.

The current trend in manufacturing is to put as much into dental products as possible. We now have whiteners, plaque control products, desensitizers and baking soda added to dental products. The more products added, the more interactions and complications that exist. We know that adding baking soda will reduce the hardness of toothpaste, but will decrease its cleaning capability as well. Na lauryl sulfate creates a foaming action (very important in the American consumer market), but it seems to increase the likelihood of canker sores. Oxygenating compounds, such as bleaching components, can increase the likelihood of cancerous lesions if used chronically by smokers.

Dentifrices

There are hundreds of different toothpastes available, and even individual manufacturers have many different types (Crest alone has over 100 different varieties of toothpaste). The general categories for toothpaste include: fluoride, anti-plaque, anti-calculus, baking soda, natural, kids’, desensitizing, smokers’ and whitening. More and more "stuff" is being put into dentifrices to make the products do more and more.

Several factors are used to evaluate toothpaste. The most important are the RDA (Radioactive Dentin Abrasivity) and the cleaning factors. For people with no dentin exposed, the ADA recommends that the RDA factor be below 250, while the FDA recommends the RDA factor be below 200. Enamel is six times harder than dentin, so patients with exposed dentin should use a toothpaste with a much lower RDA factor, preferably below 120.

Use Na pyrophosphate or zinc for tartar control. Na pyrophosphate, however, seems to increase soft tissue sensitivity.

Baking soda has not been shown to do anything except decrease the hardness (RDA) of the toothpaste. Baking soda dissolves in the saliva and forms a "silky" layer on the teeth, giving them a "clean" feeling.

Na lauryl sulfate is added to increase the foaming action of the toothpaste, an important factor in the American marketplace. However, this compound seems to cause canker sores in susceptible people. Removal of this product may help reduce the number of canker sores in these individuals. (Biotene is a fluoride toothpaste without Na lauryl sulfate.)

Triclosan and zinc combined appear to be an effective anti-plaque, fresh breath toothpaste. Mentadent is currently marketing this product in Europe, as Mentadent-P, and it may soon be available in the United States. Potassium nitrate seems to be the most effective desensitizer used in toothpastes.

Whitening toothpaste incorporates an oxidizer to help remove extrinsic stain. These types of toothpaste are also acidic in nature. Smokers should not use these types of toothpaste long term, as they may enhance the formation of cancerous lesions. For younger people interested in whitening, Ms. Baker recommended Ultra-Brite Paste (in the royal blue box) which has an RDA of 133 and a cleaning score of 86. Problems occurring with whitening toothpaste can include soft tissue damage, hard tissue damage and misperceptions of cleaning effectiveness.

Topical Fluoride

SnF is recommended for reducing gingivitis. 1000 parts/million would be the recommended level to achieve this purpose. The tin binds with plaque to exert an anti-strep mutans activity for up to eight hours. SnF is not recommended for patients with demineralization or those prone to root caries. Staining can occur due to the tin component, especially in people with xerostomia.

NaF is best for treating patients with enamel demineralization. 5000 parts/million is the concentration best suited for this purpose. Karigel-N 1.1% NaF is the most inexpensive and most tolerated product. The clear liquid with neutral pH has a highly tolerable taste. Prevident, Gel-Kam and Stop-Gel are also available for this purpose.

Conclusion

A myriad of products exist and are increasing in number and changing weekly. Big business is driving these changes ($1.5 billion was spent on toothpaste in 1997) with many companies vying for a spot in the marketplace. As oral health care providers, it is important for dentists to be aware of the products available so that appropriate and educated advice can be given to our patients.

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