Perhaps the most popular personal hygiene product in history is toothpaste, or at least some version of it. Throughout the centuries different substances and combinations have been used, some based on science, some based on personal beliefs, and others based on superstition or just plain quackery. Modern toothpaste is the result of years of scientific research and measured studies, but is still not without its critics and controversies. The most common toothpaste brands and formulations all have the same basic types of ingredients, and in this post I attempt to break things down to provide a better analysis of exactly what we’re putting in our mouth every morning and night.
When looking at the ingredient list on a tube of tooth paste you’ll notice one or two active ingredients and a long list of inactive ingredients. What you won’t see is a nutrition label as is present on all foods. That’s because the FDA doesn’t consider toothpaste a food, in fact it is in the unusual category of a cosmetic and a drug. The reason for this is that toothpaste is not meant to be ingested (granted that some will accidentally be swallowed or absorbed through the oral tissues during use). Fluoride is very helpful in small doses but not so much in large doses, so it is important to emphasize spitting and rinsing afterwards, especially for kids.
The active ingredients are obviously doing the main job of keeping your mouth clean and healthy, but the inactive ingredients are there for a reason too. It’s kind of like a chocolate chip cookie: the chocolate chips are the main attraction, but the rest of the cookie has its charms. Anyhow, I’ll also cover the most common inactive ingredients and why they’re in there.
There’s a common misconception about how much toothpaste is really necessary to get the job done. The advertisers would have you believe you need to squeeze out something that looks like a giant caterpillar. Here’s the reality: the most you need is a dab no bigger than the size of a pea. Emphasis on the no bigger than; kids need even less. I heard a statistic a while ago that 97% of Visine ends up running down the side of your face. Don’t commit the same crime with your toothpaste; if you see blobs of it in your sink when you’re done brushing, you’re using too much.
I’d like to make an important point at this … uh … point: when it comes to choosing the right toothpaste, you are not alone! Your dental team is there to help find the best product based on your particular set of needs. We even have access to products that can’t be purchased over the counter. Also, if you are having issues such as tooth sensitivity, don’t rely on a toothpaste to mask the symptoms. If your teeth are sensitive, there’s a reason. Don’t be the person trying to fix the hole in their tooth with Sensodyne.
A final word before we get started: just about anything that is currently in toothpaste, or ever was in toothpaste, has come under attack from time to time as being useless to harmful to deathly toxic by one group or another (with the possible exception of water, but that’s probably just a matter of time). I’m not an alarmist, but I will identify any potential controversies as we go through the list and try to provide some perspective.
So without any further ado, I present to you the:
I think it’s pretty well known that the main purpose of toothpaste is to give your teeth a good coating of fluoride when you brush. When it comes to fluoride in toothpaste, the most common form is Sodium Fluoride, or NaF. It’s effective, cheap, and doesn’t mess with the taste. Some brands use fluoride in a different form, Stannous Fluoride, or SnF. Stannous is the chemical name for tin. Stannous fluoride is actually more effective at delivering the cavity-fighting effects of fluoride to the teeth and it also has been shown to help with sensitivity, but it’s more expensive, can produce mild staining, and can alter the taste. For people who need a little extra help in keeping cavities in check or sensitivity control, finding a brand with SnF as opposed to NaF may be worth it. Another less common form of fluoride is Monofluorophosphate, or MFP, and studies show it is equal to NaF in fighting cavities.
Some brands include another active ingredient called Triclosan. Triclosan helps control bleeding gums (gingivitis) by killing the bacteria that causes it. Although effective in this role, there is some controversy as to its use in toothpaste. The FDA has banned triclosan for use in hand wash products for two reasons: lack of proven efficacy and potential adverse health effects. It is still allowed in toothpaste, and it is proven to help control gingivitis, but its effect on the rest your body is disputed. Bottom line, if you don’t have a major issue with bleeding gums you may not notice any real benefit and it may be smart to stick to products without it. Often included with triclosan is PVM/MA copolymer which simply helps it work better.
Zinc citrate is included in some brands to help control the bacteria that causes bad breath. This is the same zinc citrate that is included in multivitamins. Some brands use it alone or in combination with triclosan. Studies show it works quite well.
Just about all brands have a line of “sensitivity” toothpastes, with the most common desensitizer being Potassium Nitrate, or KNO3. Potassium nitrate is useful ingredient in many products, including fertilizer, gunpowder, rocket propellant, and, of course, toothpaste. It turns out the potassium part does the real work in reducing sensitivity and the nitrate part is just along for the ride. That’s why you might see other potassium-containing agents such as potassium chloride (KCl) or potassium citrate used instead. Science is still trying to figure out exactly how potassium works as a desensitizer and it turns out to be effective for some but not all. Numerous other compounds are used to control sensitivity, usually in the form of something blocking access to the nerve by “clogging up” microscopic channels in the tooth structure, again with moderate and varied success. In my experience, sensitivity products do work for most people, the key is to find a product or combination thereof that works the best for you.
Yes, there are abrasives in toothpaste, and yes, they can constitute up to 50% of the volume. The abrasives help clean the teeth and allow the fluoride to do its job better, but typically are mild enough not to damage the teeth. The most common abrasive is hydrated silica (or other silicas), followed by the carbonates – Sodium bicarbonate (NaHCO3 or baking soda), calcium carbonate (CaCO3) and magnesium carbonate (MgCO3), alumina and several phosphate complexes. I’m not going to go into the specifics of each, but I will make some useful generalizations.
The enamel on your teeth is the hardest substance in the body. Using the Mohs Scale of hardness (from 1 to 10, where 1 is talc and 10 is diamond), tooth enamel ranks a 5, about the same as glass. Tooth enamel can generally hold up very well to any of the abrasives listed above during normal brushing. However, the inner part of your teeth, called dentin, is much softer. Dentin ranks a 2.5 on the Mohs Scale, and based on how the scale works, it means that dentin is about five and a half times softer than enamel. If dentin gets exposed anywhere in the mouth it is susceptible to wear. The most common path of exposure is gum recession; the exposed root surface is unprotected dentin and is very vulnerable to wearing away at an accelerated rate.
If you don’t have any gum recession in your mouth, or any areas where the enamel is worn away, abrasives shouldn’t be a concern for you. For the rest of us, here’s what to look for. The mildest abrasive on the list is sodium bicarbonate, or baking soda. It still cleans your teeth effectively and will go gentle on your precious dentin. Regular toothpastes without any “enhancements” (whitening, tartar control) will have relatively mild abrasives. Whitening toothpastes will have medium-to-strong abrasives. Why? Basically what whitening toothpastes do is remove surface stains from the teeth, and in doing so, the teeth look whiter and shinier without any actual “whitening” taking place. I’ll discuss whitening more later. Toothpastes with the strongest abrasives are typically the tartar control varieties. Tartar, also known as calculus, is the hard stuff that builds up on your teeth and needs to be removed by your hygienist. Strong abrasives will help wear it down and limit its buildup, but they will also wear down anything that gets in their path, including exposed dentin.
A final note on abrasives: One very easy way to limit the amount abrasives getting on your teeth is to use a very small amount of toothpaste. Remember – pea, not caterpillar.
These are ingredients to help the toothpaste “foam up” and spread out evenly over the teeth. The same ingredients are often found in shampoo and some soaps. The most common, and the most problematic, is Sodium Lauryl Sulfate, or SLS. For people who tend to get mouth ulcers (aka canker sores) frequently, SLS may be the culprit. Most manufacturers offer a line without any SLS for this reason. Another less-common detergent is Cocamidopropyl Betaine which is derived from coconut oil. I’ve never heard anybody say it causes mouth sores, probably because nobody knows how to pronounce it.
A humectant is a substance that helps preserve moisture. They are added to keep your toothpaste smooth and creamy (good) instead of dry and crumbly (bad). Glycerin and sorbitol, both common food additives, are the most used. Some of the abrasives, such as hydrated silica, also contribute to water retention.
Also often used is propylene glycol, a cousin of ethylene glycol which also known as antifreeze. Propylene glycol is actually used in a similar fashion to de-ice aircraft wings or as an antifreeze in environmentally-sensitive applications such as boat engines. Before you get too excited and try to sue Procter & Gamble for poisoning your mouth, you should know that you’ve likely been consuming propylene glycol in other products all your life. The FDA has labeled it “generally recognized as safe” (GRAS) and it is used as an additive in ice cream and other frozen desserts, and in the pharmaceutical industry in making drugs such as Valium and Ativan and certain formulations of artificial tears.
The only real concern with propylene glycol is that some people develop an allergic reaction to it in the form of inflammation or redness, called a contact dermatitis.
Polyethylene glycol, another non-toxic version of ethylene glycol and often abbreviated as PEG-8 or PEG-12, is sometimes used as well. PEG is normally used in medicine as a laxative.
Thickeners serve a similar role as humectants in determining the texture and viscosity of your toothpaste. The most common ones are types of cellulose, which is the basic building block of all plants (think: wood). Carrageenan (made from edible seaweed), carboxymethyl cellulose (CMC, also known as cellulose gum), and xanthan gum (made from the fermentation of sugars) are the most common. Xanthan gum therefore may be derived from products to which some people may be allergic, such as corn, soy or wheat. Other “gum” thickeners include guar gum and locust bean gum.
Many of the above-mentioned ingredients in toothpaste provide some sweetening ability along with their main roles, such as sorbitol and glycerin. Saccharin used to be commonly used in food as an artificial sweetener before suffering some bad PR and is now largely replaced by aspartame. Still, it is considered very safe in small doses and is a common sweetener in toothpaste, especially since it’s not meant to be ingested. A less common one is Potassium Acesulfame.
By far the best sweetener is Xylitol (pronounced zy-li-tol). Xylitol is a natural sweetener derived from common plant sources. Unlike artificial sweeteners, which have no calories, xylitol actually has 2.43 calories per gram (sugar has 3.87) but is considered safe for diabetics because its effect on blood sugar is minimal. The best part of xylitol is that the bacteria in your mouth can’t process it, and it actually inhibits the growth of certain bacteria, providing a one-two punch in the battle against tooth decay. The reason you don’t see it much in toothpaste is because it’s fairly expensive, but if you can find it it is an excellent choice.
One word of caution: xylitol can be fatal to dogs. Come to mention it, fluoride is harmful to dogs too. If you have a dog that will actually let you brush his teeth, they make toothpaste specifically for pets which can be found at most pet stores, in exciting flavors like poultry and bacon.
As mentioned above, the primary method by which whitening toothpaste makes your teeth appear whiter is removing surface stains. It accomplishes this through abrasives and other ingredients meant to dissolve common stains from foods and beverages.
The main ingredient in any true whitening product, or “bleaching” product, is hydrogen peroxide (or its more stable cousin, carbamide peroxide). Toothpaste contains no peroxide (at least the ones I’ve seen) and therefore doesn’t do any true “whitening” of the teeth.
Tartar control agents
Names of tartar control agents take the form of __Sodium __Phosphate, such as pentasodium triphosphate or tetrasodium pyrophosphate. Sometimes Calcium Phosphate is used instead. Basically they act like the rock salt in your water softener. Here’s how it works: Your saliva contains a lot of minerals like Magnesium (Mg) and Calcium (Ca) that like to build up on your teeth, forming tartar (or calculus as it’s known in some circles). Tartar makes a perfect home for bacteria, allowing them to set up shop and wreak havoc in your mouth. Controlling tartar = controlling bacteria. The __sodium __phosphate will interact with these minerals and prevent them from building up on your teeth, just like your water softener interacts with the minerals in your water and washes them down the drain, making your water “soft.” Thus you could say that tartar control toothpaste is like “saliva softener.” It works pretty well, too, if you can get past the taste.
Here’s the rub. The minerals in your saliva, specifically calcium, play a role in “repairing” teeth in areas where a cavity is getting started. The decay process starts when acid removes minerals from your tooth enamel, and the calcium in your saliva can bond back on and “heal” the spot. However, if you’re using tartar control toothpaste, you’re removing calcium from your saliva and limiting your ability to heal those areas. My recommendation: for patients who are more cavity-prone I usually try to steer them away from tartar control toothpaste. For the rest of us it’s fine and probably helpful.
Polyethylene is a fancy name for plastic. Some manufacturers used to put tiny, colorful plastic beads in the toothpaste to enhance its appearance. I’m not sure any of them do anymore. You probably have the following questions: Q: Do I need plastic beads in my toothpaste? A: No, they serve absolutely no purpose. Q: Then why are they in there? A: To make your toothpaste look pretty. Q: Does my toothpaste need to look pretty? A: No, unless you’re using it to decorate a cake. Q: So I can use toothpaste to decorate a cake? A: No, toothpaste is not a food (see above).
The most common coloring additive is Titanium Dioxide (TiO2). Although listed as Generally Recognized as Safe (GRAS) by the FDA there has been some controversy as to it possibly being a carcinogen (cancer-causing). Titanium Dioxide starts off as a white powder and performs two main roles in the food and healthcare industry. For food products it makes things white and opaque (non- see through) and is often used in frosting, powdered sugar and other candies and sweets. It turns out that titanium dioxide also reflects the sun’s UV rays quite well so it is included in skin creams and sunscreen. However we don’t want to be walking around with white, opaque lotion on our skin (I’m just making an assumption here) so they grind the powder into very, very small particles, called nanoparticles. In this nanoparticle form the titanium dioxide still blocks UV rays but is now transparent (invisible) on the skin.
The nanoparticle form is also the potential cancer-causing form, but only when it’s a powder and inhaled into the lungs. Bottom line, titanium dioxide is only potentially dangerous (speculation, not proven) in a powder form (which toothpaste isn’t) of nanoparticles (not used in toothpaste). More research is needed and is currently underway, but at this point I just can’t justify being concerned about it.
If your toothpaste isn’t plain white then it’s probably some shade of blue, in which case the likely other color additive is FD&C Blue No. 1, also known as Brilliant Blue FCF, a very common food colorant. The only concern ever noted by the FDA regarding its use is the potential for an allergic reaction in people with asthma.
Flavorants: Various natural and synthetic additives, such as mint oil (often listed just as “flavor”).
Preservative: Sodium benzoate (a common food preservative).
pH neutralizer: Sodium hydroxide (lye).
Granted there are likely other ingredients that have made it into a tube of toothpaste from time to time that are not explicitly listed here, but whatever they may be they would fall into one of the above categories. I hope this article has been informative and provided some clarity in what to look for in a toothpaste. If you have any questions, I’m certain your dental team will be happy to discuss further!
Patrick McGann, DDS
McGann Family Dental
In 1804 a man by the name of Richard Trevithick built the world’s first fully-functional steam locomotive, ushering in the era of mass transit for people and goods. Ninety-nine years later the Wright Brothers were “First in Flight” with the launch of their flying machine, taking the world of mass transit across oceans and continents in record time.
Ever since the airplane came on the scene it was certainly “newer” than the locomotive, and I think anyone would agree modern airplanes are more “technologically advanced” as well. Terms like “state-of-the-art” and “high-tech” can also be used. So if modern airplanes are so much superior to the locomotive, the obvious question is why are we still using trains?
The reality is that trains still do an important job in our society and they do it very well. Just because a newer technology comes along doesn’t mean we automatically abandon previous one. When it comes to dental care, there are older technologies that are tried-and-true, newer technologies just being introduced, and future technologies to be anticipated. An example of an older technology would be the commonplace dental crown. While the materials have changed (ceramics, bonding agents) over the years, the basic principle is the same as it was decades ago. An example of a newer technology is the dental implant, a titanium post that is placed in the jaw to replace a missing tooth. I’m sure when dental implants first came on the scene some of the “experts” forecast the end of dental crowns. But the truth is that implants, while very reliable and often the preferred treatment option, are simply not appropriate for every person and every situation. The reality is that crowns aren’t going anywhere.
One possible future technology often discussed is the ability to grow a new tooth via stem cells. Obviously any time the future is discussed we can only guess as to when it will be available and how it will work. Given that, there are two predictions I can make rather confidently: first, growing a new tooth from stem cells implanted in your jaw will take at least a year (total treatment time), possibly much longer, and second, the total cost of this procedure will be well in excess of a crown or an implant.
If and when growing new teeth becomes a reality, it will be an exciting new option for patients to consider. But that’s all it will be, an option. Our current treatment options will remain an excellent choice, and often the preferred choice, as we continue to improve upon them with better materials and protocols. The future of dentistry is exciting, but the dentistry of today will continue to serve us very well for years to come.
To floss or not to floss?
Flossing. We all know we should do it but none of us like to. “It’s messy, it makes my gums bleed, and it takes too long” are common objections. And now with a recent report coming out that flossing hasn’t been proven to do any good, for some of us that’s all we need for an excuse to give it up completely.
But what did these studies actually say? Basically that no conclusive study has been done that proves that flossing is beneficial to oral health. That may seem a bit surprising since dental floss has been around since 1874. I believe that there are two reasons for this: common sense and ethics.
Each tooth has five surfaces: the chewing surface, cheek/lip side, tongue side, and two sides that contact adjacent teeth (front and back). Brushing effectively cleans three of these five surfaces. That’s 60%. Add flossing and you clean the other two. That’s 100%. For an analogy: what if you had a dishwasher that only cleaned 60% of each plate, fork, glass, etc.? Would that be acceptable? Common sense tells us “no” whether it’s our dishes or our teeth.
We all know that seat belts save lives, and studies have been done on crash-test dummies to show the benefits of wearing one. But what about studies in the real world? Why hasn’t anyone conducted a study where half of a group of people wears a seat belt all the time and the other half is required to drive around without wearing one. Then when they get in accidents we can see which group suffers the most significant injuries. A study like this has never been done because it would be unethical. In a less dramatic sense, conducting a similar study on flossing/not flossing could be considered unethical too. Thus for real-world results we rely on the observations of professionals. Ask any police officer or EMT whether seat belts save lives and you’ll get an unequivocal “yes;” ask any dental professional whether flossing helps prevent cavities and gum disease and you’ll get a unanimous “yes” as well.
Ultimately the decision is yours, we just make recommendations, but those recommendations are made to give you the best chance for a healthy set of teeth for life. Remember, we’re on the same team. And as a final thought: whether you decide to floss or skip it, we can always tell.
The number two dental fear patients have is pretty obvious, but may surprise some people that it’s not number one. I see it on the faces of many adult patients, but only the kids will actually blurt it out: “Is this going to hurt?”
At this point I’d like to relate a story about a survey I first heard about maybe 25 years ago. The survey asked people what their greatest fears are. Twenty five years ago the number one response was public speaking, not a big surprise there. Number two was going to the dentist. Out of curiosity I looked up the same survey recently and found that public speaking was still number one, but going to the dentist was not even in the top ten! Why is that? What caused this dramatic change in public perception over the last two and a half decades?
Quite simply, I think people have shed the idea of dentistry as a “necessary evil” and embraced the idea that dental care is an important part of their overall health and appearance. Instead of begrudingly showing up for their cleaning or fillings, people actually seek out dental care now. How has the dental profession participated in this paradigm shift in patients’ attitudes? By embracing new technology and new techniques that has made today’s patient experience vastly superior than even a generation ago. But the bottom line for most people is: the dental injection.
People know needles aren’t fun. But here’s the good news: by putting our focus on the best materials and techniques, we’ve been able to make the whole experience nearly or even completely pain free for most people. And here’s the better news: technology is still advancing at a rapid pace, and I expect the patient experience will continue to improve by leaps and bounds. I’m looking forward to treating a generation of patients who have never feared their dental visit, and I believe that generation is now upon us.
As far as the fear of public speaking, I don’t see that going away anytime soon.*
* Here’s my trick when speaking to an audience, don’t look at the whole audience, look at one person in the audience, as if you’re talking only to her or him. Finish your sentence, move to someone else and speak directly to that person. Speaking to an individual is much less intimidating than speaking to a group.
Throughout my years of practice I’ve always had the mindset of constant improvement: learning new procedures, improving on the procedures I already perform, adding new technology when it can improve outcomes, and many other avenues. While all of these are important to help achieve better clinical results, perhaps the most important skill I can seek to master is my ability to communicate with and understand my patients.
The fact that there’s still a great many people who have dental fear and anxiety is not going to surprise anybody. Everybody who sits in my chair has had a dental experience before (well, almost everyone), which means they also have feelings about it; good, bad or otherwise. Throughout my years of listening to what my patients liked and didn’t like I’ve been able to identify what I believe are the three main causes of dental fear and anxiety. If dental anxiety is something you’ve ever experienced, I encourage you to read on and see if any of these resonate. I’ll start with the third-most common.
Fear number three: Financial cost
I’m going to come right out and say it: dentistry can be expensive. And unless you just won the lottery, we know that the financial considerations of getting your dental work done will play a role in the treatment planning. I encourage you to check out our page on affordability where I outline the various services, discounts, and financing options we offer to make your dental care more manageable.
Beyond the immediate financial concerns of dental care there is another money-related concern many patients have; it’s what I call the “doctor-knows-best” experience, and it’s even more insidious and disconcerting. I can’t tell you how many times a patient has told me about an experience where their dentist said something like: “This tooth needs a crown, let’s get it scheduled in two weeks. See you soon!” And that represents the beginning, middle and end of the conversation. What the patient hears is “I don’t care about your thoughts on the matter” and “I just want to do the most expensive treatment.” While that approach may have been the norm for previous generations, today it’s as archaic as wooden dentures. It blocks communication and erodes trust, the two most important pieces of the dentist-patient relationship.
Our treatment plans are not a one-way communication, they are a discussion about what is right and what is recommended for treatment. They are a discussion of options, with nothing absolute, only the pros and cons of each choice. And there is one choice that is always an option but rarely mentioned, the choice of doing nothing. You are the final decision maker for your dental care, our job is to present findings, have a discussion on what is going on, make recommendations for treatment, and present the pros and cons of each choice. We will never presume to know what’s best for you and make your treatment decisions for you. In fact, I only want to proceed with treatment when you fully understand why we’re doing it and you request that it be done.
Money is a difficult topic to discuss. Trust us to walk you through the process in an understanding and professional manner. Coming up next: the number two dental fear. You may be surprised it’s not number one!
I’m guessing there’s a number of people out there who would love the chance to stick a needle in their dentist instead of the other way around. “I just hope he knows what it feels like so he can be extra careful with me” is probably the feeling they have.
While you may never get the opportunity to do so, plenty of other people do. About once a month I need to submit a blood sample for the management of my Graves’ disease, a condition where the thyroid gland produces too much thyroid hormone. I have definitely come to appreciate the skill and compassion of an experienced phlebotomist (blood-draw person).
On the other hand, I’ve had some experiences with an uncaring and inattentive provider that left my arm bruised and sore all day long. Admittedly, managing Graves’ disease isn’t fun, but it’s relatively easy when compared to the management of other more serious medical conditions. I’m not going to complain.
On the contrary, I’ve actually realized a silver lining through the whole process. Once a month I get a reminder of what it’s like to be on the receiving end of a needle; a reinforcement of the importance of compassion, awareness, and empathy with what my patients are experiencing. I’m hoping one day I can get my patients numb without a needle, but until then I will do my best to make it as comfortable as possible, as I hope others would do for me.
There’s an urban legend out there that claims a frog placed in a pan of boiling water will quickly jump out, while a frog placed in a pan of room-temperature water, with the heat then slowly increased, will just sit there until cooked.
While I have my doubts as to the scientific accuracy of this claim, it serves a useful analogy to your teeth. No, I’m not kidding. The key is the difference between an acute attack on a tooth and a chronic attack. An example of an acute attack would be a large piece suddenly breaking off. One second everything’s fine, the next second your tooth is screaming “Ahhhhhh! Fix me!”
On the other hand, an example of a chronic attack would be a slow-growing cavity; this type of attack is sneaky and most often painless, sometimes even when the cavity gets into the nerve and kills it. This happens because the body has a remarkable ability to adapt and avoid pain, for better or worse. The difficulty is that many people believe if something doesn’t hurt it must be OK; unfortunately most dental issues are painless until it’s too late, and then the cost to fix it will typically go up by a factor of ten.
The old medical axiom “an ounce of prevention is worth a pound of cure” is particularly appropriate to your dental health, and this is the basis of our philosophy of care at McGann Family Dental.