Chapter 14

Anti-plaque agents

INTRODUCTION

Anti-plaque agents (particularly, toothpastes, mouthwashes and chewing gum) have been a large growth industry in the UK consumer market over the last two decades.

In view of the role of bacterial plaque in periodontal disease, clinicians and manufacturers have been interested in the potential value of anti-plaque/anti-bacterial agents in both toothpastes and mouthwashes, and there are now so many on the market that patients can easily become confused. They will often ask oral health educators (OHEs) what toothpastes and mouthwashes they recommend, and it is therefore important to know some background information about the most frequently used products.

TOOTHPASTE

Toothpaste comes in the form of pastes, gels or striped combinations of the two, and manufacturers compete with each other to include new ingredients in their products. There are now different anti-plaque and anti-calculus agents; fluoride in most pastes; a range of products for sensitivity and dry mouths; whitening and anti-erosion properties, and homeopathic pastes for those seeking no chemical additives.

It is impossible to advise the OHE on what to recommend to patients – the dental professional will often be guided by what the dentist suggests and what the practice sells. If patients have always used a particular brand, they will probably not want to be persuaded otherwise. However, OHEs should stress the benefits of fluoride in toothpaste, particularly for children.

Children up to the age of three should use a smear of toothpaste containing 1000 ppm and adults should ensure that the paste is not swallowed in large amounts. Children over 3 years old and adults should use a pea-sized amount of toothpaste containing 1500 ppm [1].

Toothpastes with a greater concentration of fluoride, 2800 ppm (for high caries risk patients aged 10 years or over) and 5000 ppm (for high caries risk patients over 16 years), are available on NHS prescription.

Constituents of toothpaste

Toothpaste contains as many as 20 different ingredients, but the main ones are:

• Polishing agents – mild abrasives to remove/reduce plaque (e.g. calcium and sodium salts and gels containing silica).
• Binding agent – controls stability, consistency and dispersion of paste in the mouth (e.g. seaweed extracts, cellulose, silica).
• Foaming agent – a mild detergent that lowers surface tension and loosens debris, aids dispersion and psychological benefits (mouth feels clean). It is usually sodium lauryl sulphate (this reacts with chlorhexidine, which is why patients are advised not to use toothpaste and mouthwash at the same time). Some patients may find that they develop ulcers if this is included in their toothpaste (see Chapter 8).
• Humectant – reduces moisture loss, sweetens and keeps consistency (e.g. glycerine, sorbitol).
• Flavouring (often peppermint or spearmint) – masks the flavour of other components and important to consumer. It can be difficult to find non-mint flavours, in which case recommend homeopathic toothpastes, which can be found in health shops.
• Therapeutic agents:
  • Fluoride. Quantities in non-prescription toothpastes are regulated to 1500 ppm maximum for adults and 1000 ppm for children under 3 years old.
  • Desensitising agents – such as strontium chloride, strontium acetate, potassium nitrate, potassium citrate, arginine and calcium carbonate (e.g. Colgate® Pro-Relief™).
  • Anti-plaque agents – e.g. triclosan.
  • Anti-calculus agents – e.g. pyrophosphates, ureates, zinc citrate.
  • Bicarbonates – reduce the acidity of plaque.

Functions of toothpaste

There are six principal functions of toothpaste (in conjunction with toothbrushing):