General Dental Practice

Enhanced CPD DO C

Cees Valkenburg

Fridus van der Weijden and Dagmar Else Slot

Dentifrices. Part 3:
Dentifrice Recommendations
Abstract: This article, the third in a series about dentifrices, emphasizes the essential role of dentifrices in oral healthcare, highlighting their
contributions beyond mechanical plaque removal to include plaque inhibition and delivery of therapeutic agents. Despite the sometimes-
limited impact on mechanical plaque removal, the importance of fluoridated dentifrices, must not be underestimated. The article reviews the
effectiveness and safety of dentifrices, including the challenges posed by subjective clinical indices and potential allergenic ingredients. It
discusses the potential of innovative dentifrice formulations to improve compliance and oral health outcomes. Additionally, it emphasizes the
critical role of dental care professionals in recommending dentifrices based on safety and effectiveness rather than cosmetic claims or cost.
Through an analysis of the literature and clinical guidelines, this work aims to guide healthcare providers in making informed decisions about
dentifrice recommendations for optimal oral health.
CPD/Clinical Relevance: Dentifrices are complex formulations that need to be proven effective in (clinical) trials and be appreciated by
end users.
Dent Update 2024; 51: 251–256

Given that the use of dentifrice Systematic reviews and decision-making.10 A synopsis or meta-
is an integral part of daily oral review summarizes the findings of high-
evidence-based guidelines
care, toothbrushing and dentifrice quality systematic reviews to provide
A systematic review can be referred to even stronger information to support
are inextricably linked. Brushing
as ‘research of research’ and is described clinical action.11
without dentifrice is experienced as
as the highest level of evidence to
unpleasant,1,2 and people are less
guide clinical practice.6,7 A systematic
likely to brush their teeth if they review summarizes the results from Clinical indices for plaque
cannot use a dentifrice.3 The dentifrice randomized clinical trials8 in response to a and gingivitis
must be perceived as acceptable and research question.7,9
pleasurable.3 Dental societies such A problem in dental research is that
Healthcare providers, researchers,
plaque and gingivitis indices can only
as the ADA in the USA, and the FDI and policymakers need systematic
be considered surrogates for oral health.
recommend brushing twice daily with a reviews to efficiently integrate existing
These indices are derived from subjective
fluoridated dentifrice.4,5 information and provide data for rational
ratings, not from actual measurements.12
Experiments indicate a relationship
between the construct of plaque indices
and gingival inflammation.13 Plaque
Cees Valkenburg, MSc, PhD, Dentist, Clinical Epidemiologist; Fridus van der Weijden, indices are often used in daily clinical
PhD, Dentist, Periodontist, Implantologist; Dagmar Else Slot, MSc, PhD, Dental
practice to monitor oral hygiene practices
Hygienist, Clinical Epidemiologist; Department of Periodontology, Academic Centre for
and motivate patients to improve their
Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam,
oral hygiene. However, the construct
Amsterdam, Netherlands
validity of the dental plaque index scores
email: [email protected]
is questionable because it is uncertain

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gingivitis, stomatitis, soreness, burning,

Frequency of dentifrice use
burning mouth syndrome, aphthous
It is well established that particularly the frequency of dentifrice use has a major
or non-aphthous ulcers, or lichenoid
influence on effectiveness.16,17,42,45 Self-reported infrequent brushers demonstrated
reactions.18 See Box 2 for an overview on
higher incidence and increment of carious lesions than frequent brushers did.45 Brushing
side effects of dentifrice.
twice per day or more has a greater preventive effect than once per day.16,17,42,45

Rinsing after toothbrushing The future of dentifrice

Rinsing behaviour after toothbrushing affects the amount of fluoride retained in the Dentifrices are ideal vehicles for
mouth16, 17, 46 and has been reported to affect caries experience.16 Brushing twice a day the delivery of therapeutic agents
or more, or afterward rinsing less thoroughly, or not rinsing at all would confer greater because they are ubiquitously used
caries reductions than brushing once a day or less, or rinsing with larger volumes of during routine toothbrushing. They
water after toothbrushing.17,43,47–49 However, a more recent, prospective study did not can be formulated to support user
show an effect of post-brushing rinsing regimen on caries incidence.44,50 The rinsing compliance with recommended brushing
behaviour after toothbrushing may also affect the safety of a product.42,43,47–49 instructions.22,23 Dentifrices are certainly
not finished products. Flavour balance,
Brushing time safety, stability efficacy, for example, are
The length of the brushing time determines how long the fluoride concentration in continuously evaluated, and adjustments
the dentifrice slurry stays in contact with the teeth and plaque, thus allowing fluoride are made as necessary to satisfy
uptake to take place.16,44 individual requirements.24
There is room for dentifrice products
that will encourage motivation by the
Shelf-life
intended user.24 A modern example is
Free ionic fluoride concentration in dentifrices varies with storage time and conditions.51
dentifrices containing plaque-disclosing
In addition, there may be variations in the quality of the ingredients used in different
agents and, therefore, allowing evaluation
manufacturing facilities globally, some of which may contain trace impurities that can
of toothbrushing efficacy by its user. This
affect fluoride ion concentration.51
might stimulate the accomplishment of
Globalization has produced a complex market for dentifrice where familiar brands
optimal toothbrushing.25,26
can be manufactured thousands of miles away from their traditional customer base.
Several studies demonstrated that
Moreover, familiar packaging can hide different details in the formulation and
plaque-indicating dye-containing
possibly even efficacy.51
dentifrices, together with proper
Box 1. Factors affecting the efficacy and impact of dentifrice use. use and oral hygiene instructions,
significantly increased the efficacy of
plaque removal.27–30 A barrier to its use
is mainly the high consumer costs. This
whether they actually measure the amount dentifrices can contain ingredients that sophisticated product is about 40 times
of plaque on a tooth surface.13,14 carry a risk of sensitization, resulting more costly than a white label dentifrice,
in allergic phenomena. Based on the and 10 times the price of a premium
number of publicly available case reports, brand product.
Factors affecting contact allergy to dentifrice seems to be Within the current knowledge, a
dentifrice effectiveness infrequent, but not rare, in the general dentifrice is not an agent that contributes
A dentifrice does not significantly population.18 It may be assumed that to mechanical plaque-control,15 but has
contribute to plaque removal during a some allergic reactions to dentifrices go more of a focus on plaque inhibition
brushing exercise but can support plaque unrecognized for the users themselves properties.31,32 It effectively offers extended
inhibition.15 In addition to the inherent and/or the dental care professional.18 Many care beyond the actual brushing. In
properties of a fluoride dentifrice product, food additives in oral hygiene products addition, it can also, for instance, help to
biological and behavioural factors can are potential allergens that may cause freshen the breath. It appears that there is
modify its anticaries effectiveness.16 allergic reactions.19 Manufacturers do not a future for the development of dentifrices
Behavioural factors include the frequency have to mention all ingredients on product as a carrier for effective ingredients to care
of dentifrice use, the time of day that labelling if the concentration falls below for and maintain oral health. After a careful
dentifrice is applied, the amount of the threshold stated in the EU Cosmetics assessment of the evidence obtained, one
dentifrice applied to the brush, length of Regulation, even if they are one of the 26 EC can state that the choice of a dentifrice
brushing, and the rinsing practices after (European Commission) -known allergens. should not be based solely or primarily
brushing.17 The most important factors The thresholds for rinse-off products, such on price or taste. This would be an
affecting the efficacy and impact of as dentifrice, is 0.01%. In contrast, this is injustice to the dentifrice manufacturers
dentifrice are summarized in Box 1. much higher for leave-on products such as that have, since the 1870s, made efforts
creams, at 0.001%.20,21 of to improve their ‘dentifrice cream’ in
Allergic reactions usually manifest order to achieve overall oral health. The
Side effects of dentifrice as cheilitis, with or without dermatitis formulation of the modern therapeutic
Although dentifrices should not have around the lips, and less frequently cause fluoride dentifrices has evolved into a
side effects or adverse effects, modern oral mucosal symptoms such as glossitis, sophisticated art and science.16

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Oral mucosal peeling Based on the available literature, the

Oral mucosal peeling induced by oral hygiene products seems to be a relatively following basic recommendations on
common finding in daily clinical practice.52 This also is often unrecognized by the users dentifrice use can be given:
themselves and/or the dental care professional. A recent SR on oral mucosal peeling  Use a fluoride dentifrice
concluded that there is a causal relationship with dentifrices but also mouthwashes. The for toothbrushing42,71–74
degree of desquamation is linked to the concentration of SLS.53 High concentrations of  Use a dentifrice to obtain
SLS, as well as other constituents of oral hygiene products, can also be held responsible, a longer-lasting effect
albeit, in much lower frequencies. Most cases are painless, leaving normal mucosa following toothbrushing31
after desquamation.  Consider a dentifrice with other
Idiopathic asymptomatic desquamation has been observed with a dentifrice with a active ingredients upon product
low water content formulation compared to other dentifrices.54 indication or recommendation of the
dental care professional31,75
 Consider a stannous fluoride
Recurrent aphthous ulcers dentifrice for an additional effect on
Recurrent aphthous ulcers are a painful recurring condition and the most common oral gingival health75
mucosal disease.55 In patients suffering from recurrent aphthous ulcers, SLS appears to  Consider a dentifrice that is
increase the incidence and duration of the lesions.56 A recent systematic review suggests specifically formulated for tooth
that patients may benefit from using SLS‐free dentifrices for their daily oral care.55 whitening to reduce tooth
Some manufacturers have replaced SLS with other less irritant surfactants.57–59 Owing surface discolouration38
to its dehydrating and irritating effects on mucous membranes, SLS may be contra-  For manual toothbrushes, use at
indicated for bedridden patients or for those with a dry mouth and sensitive mucosa.56 least 1 cm of dentifrice; and for
Reformulating dentifrices towards compositions without SLS might be the first step power toothbrushes, use a dose of
towards low-allergen dentifrice formulations. 0.5 cm twice 76
 Brush your teeth twice per day5,17,77
Crohn’s disease  Brush your teeth for at least
The use of dentifrice has been proposed to be associated with Crohn’s disease.60 The 2 minutes or longer13,78,79
metal additives in dentifrice were presumed to be linked to the disease, which was  Rinse with no more than a handful of
water after brushing76
further explored.61,62 At present there is limited substantiating scientific evidence.63 A
 Do not ingest unnecessary amounts
direct relationship has not been observed, although the biological impact of aluminium
of dentifrice16,40,80
and iron on the microbiota has been confirmed in several studies.64–66
Box 3. Recommendations for patients from
dental care professionals.
Flavouring substances
While flavouring substances in dentifrice make brushing with a dentifrice more
enjoyable, they may also be responsible for allergic contact cheilitis.67–70
Box 2. Side effects of dentifrice. regular dentifrice.39 It should be noted that
in the two dentifrices compared, both also
differed in their abrasive composition.
While the dental care professional
Dentifrice and daily practice to promote appropriate oral must remain abreast of the ever-increasing
development and marketing of dental
dental practice hygiene behaviour.35–37
Dental care professionals generally cleaning products, it is not motivating
Members of the dental team are and easy if these developments are purely
presume that the effect of whitening
advocates for obtaining good oral health. cosmetic claims. In the past, dental care
dentifrices is mainly based on abrasivity.
An important pathway to better oral In a recent systematic review, it was found professionals had to rely on data obtained
health is the use of therapeutic oral care that it was not feasible to differentiate from clinical trials, some of which were of
products that supplement mechanical products based on their abrasive poor quality. The regulatory bodies have
plaque-control measures to ultimately ingredients. It was synthesized that a done much to improve the quality of trials
prevent dental caries and periodontal combination of factors makes whitening and to review and approve manufacturer
disease. Healthcare providers can take a dentifrices effective on extrinsic tooth claims. Much of the improvement in the
leadership role in helping their patients discolouration.38 Also, despite what is often oral health of individuals, communities,
filter through the excessive advertising and suggested by dental care professionals, and populations can be attributed to the
recommend only dental products proven the same systematic review did not report widespread availability and use of safe and
to be safe and effective.33 People value any adverse events or side effects.38 effective dentifrices.40 Assessing claims,
various factors, such as pleasant taste or However, another recent systematic review ingredients, and efficacy, as well as what
perception of a clean feeling, in order to feel concluded that when using whitening is needed and what the patient wants
fresh and confident in social situations.34 dentifrice, side effects, such as tooth are key considerations in recommending
These patient-reported outcomes can be sensitivity and the effects on soft tissues, dentifrices.41 Understanding the labelling
the focus of attention in the daily dental were almost twice as likely as when using and ingredients listed on the packaging

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