Toothpastes have been known as such since remote times and have been used to contribute in dental hygiene. Until a few years back, the cosmetic benefit of toothpastes was the only consideration, but technological advances have made it possible to add therapeutic benefits as well.

This is why, nowadays, there are a great quantity of toothpastes in the market with diverse effects on teeth and gums.

This chapter pretends to make knowledge available regarding the different types of toothpastes and the understanding of their indications at every step of dental hygiene.

When the web user is faced with a prescription or has acquired a toothpaste, he will know by the chemical composition, the precise directions and if its use should and could be used by the entire household, common mistake, since in general, the toothpastes used should differ according to age and according to dental pathologies tendencies. That is why, for example, a person with a low tolerance for cold water can not use the same toothpaste as a person with bleeding gums.

The elimination of dental plaque is done by mechanical means. Dental plaque is adhered to the teeth and therefore, with an adequate brushing, it may be set loose from the dental surface. In the case that it has already calcificated, then it is necessary to visit a dentist or a dental hygienist. In view of this comment, it is easy to think that toothpastes are unnecessary for dental hygiene and actually there are some professionals that reject the use of toothpastes and preach the exclusive use of toothbrushes.

In some occasions, we can do without the use of a toothpaste but given the therapeutic effects they posses, their use is recommended in the majority of cases.

There is a wide range of toothpastes available in the market

TOOTHPASTES' COMPONENTS

Toothpastes are composed of various substances and each one has a different function. They are:

• Detergents
• Abrasives
• Moisturizers
• Aromizers and Sweeteners
• Dyes
• Preservatives and Anti corrosives for the Tube's Maintenance
• Anti Dental Plaque Substances
• Substances that increase the enamel's resistance: Fluorine
• Desensitizing Substances
• Whitening Substances
  
• Anti-swelling and Epitheliums Substances
• Enzymes
• Substances Carrying Calcium
  
• Natural Substances

DETERGENTS

They are tensioactive agents in charge of decreasing the superficial tension, penetrate and dissolve the deposits that form on the tooth's surface and facilitate the dispersion of the active agents in the toothpastes.

The principal detergents are:

• Lauryl sodium sulfate, most commonly used and compatible with fluorine
• N-Lauryl sodium sarcosinate (Gardol), antibacterial action
• Cocomonogliceride sodium sulfanate (greasy acids from coconut oil)

ABRASIVES

The abrasives are substances that once applied on the dental piece, during brushing, eliminate the accumulated deposits.

This may arouse the idea that they might damage the dental tissue but there are studies and there is an abrasive scale that shows the amount of abrasive allowed. Toothpastes must have an abrasive index between 50 and 200 RDA (Radioactive Dentine Abrasion).

The most common abrasives are:

• Sodium bicarbonate micronized
• Calcium carbonate
• Benzoat sodium
• Phosphate sodium
• Phosphate calcium (meta y piro)
• Sodium Metaphosphate
• Hydroxide de Aluminum and lactate de aluminum
• Alumine
• Silicats: xerogel and aerogel of sylice

MOISTURIZERS

Agents that avoid the toothpastes from hardening, they most commonly used are:

• Glycerin
• Sorbitol
• Xilitol
• 1,2 propilenglicol

AROMIZERS AND SWEETENERS

This are substances used to give toothpastes a better taste (flavor), they are:

• Mint
• Menthol
• Cinnamon
• Strawberry
• Tamil
• Eucalyptus

	Different flavored toothpastes

As sweeteners:

• Sacarosa
• Sacarina (Benzosulfimida)
• Xilitol
• Ciclamates

DYES

The same dyes commonly used in foods and beverages

PRESERVATIVES AND ANTI CORROSIVES FOR THE TUBE'S MAINTENANCE

Ingredients used:

• Silicate sodium
• Formaldehid
• Benzoats
• Diclorofenol
• Hidroxibenzoates

Toothpastes with formaldehid

THERAPEUTIC SUBSTANCES

ANTI DENTAL PLAQUE SUBSTANCES

Agents that act upon bacterial plaque, eliminating the microorganisms that cause it, inhibiting the formation of the plaque's matrix and eliminating the already formed plaque.

The most commonly used are:

• Clorhexidyne (digluconat of)
• Triclosan
• Sanguinarina
• Hexetidyne
• Citrate of zinc
• Fluorures: fluorure of pewter
• Essential Oils
• Lauryl sodium sulfate (tensioactive substance with anti plaque effects)

Clorhexidyne has been the most used and is the strongest of the ones mentioned. It is used in concentrations of 0.12%, 0.2% and 0.5%, it is bacteriostatic and bactericide. It acts on the mutans streptococcus (cavities) and candida albicans (mycosis), it has a substantiation (acting time) of 7-12 hour. No known resistances have been found nor alterations on the oral bacterial equilibrium.

	Different mixtures with clorhexidyne

Although there are some secondary effects:

• Dental Coloring (reversible and easy eliminated)
• Tongue Coloring
• Bitter taste, metallic taste
• Possible peeling of the oral mucous

Dental colorings are accentuated if the patient drinks wine, coffee, tea, and a smoker.

The variety of concentrations and abrasives included in toothpastes along with clorhexidina help make the teeth's colorations and tincions less frequent.

Low lingual tincion with clorhexidyne

Currently concentrations of 0.05% mixed with other anti plaque substances, for example cetilpiridin clorure, help reduce clorhexidyne's secondary effects.

Clorhexidyne 0.05% with cetilpiridin clorure

The combination of clorhexidyne with zinc acetate helps reduce the possible colorations. The zinc ions react to the clorhexidyne forming zinc sulfate, this new substance is white and covers the tinctions. Clorhexidyne is available in different forms: toothpastes, mouthwashes, gels, sprays, glosses, and gums.

Clorhexidyne in gloss form

It is frequently used in treating periodontal diseases, as a co helper to the treatments done in a dental clinic, in cavity prevention, in oral mycosis, and in oral surgery. It should not be used in periodontal diseases if it has not previously been treated since it induces to calculus accumulations.

Dental spotting by continuous use of clorhexidyne

Clorhexidyne spotting in patient surgically treated with implants, and calculus in the inferior arch

TRICLOSAN is fenolic derivate that has an antiflamatory action; it is antibacterial, with a high substantiation (acting period 14hrs) and does not show the secondary effects present in clorhexidyne. It is an agent that can be used continuously and daily since resistances have not been found either.

The joint use of TRICLOSAN with copilimers of metoxietilen and maleic acid or with any zinc compound (sulfate or zinc citrate) is highly effective.
This is frequently recommended in patients with periodontal diseases, due to it's antiplaque and antiflogistic action.
It's effects as an antiplaque are a little less than those of clorhexidyne.

	Toothpastes with triclosan

SANGUINARINE is a vegetable substance that has not been widely studied, but it has been showed that it has an antiplaque action and that it's use reduces gingivitis.

HEXETIDINE is an antiseptic cationic highly used, with antiplaque action that increases when combined with zinc.

On ZINC SALTS, their efficiency has been already mentioned when joined with Triclosan or Hexeditine. These are zinc citrate, zinc sulfate, zinc clorure and zinc lactate. The zinc salts have an anticalculus effect, it seems they avoid the calcification of bacterial plaque.

Other salts, such as CETILPIRIDINE clorure, is an antiplaque agent.

FLUORIDES have an antiplaque effect also. The most efficient is pewter fluoride although it can cause dental stains and taste alterations. The other fluoride components will be mentioned later.

ESSENTIAL OILS are the oldest products used as an antiplaque agent. Their effect is lower than clorhexidine and can provoke a burning sensation. Today they are placed together with the zinc salts.

SUBSTANCES THAT INCREASE THE ENAMEL'S RESISTANCE: FLUORINE

To prevent cavities it has been already mentioned that fluorine allows the transformation of hydroxiapatite to fluoropatite. This is why the presence of fluorides in toothpastes and collutories is so important.
Tjhis transformation is obtained while the dental pieces are in the formative phase (calcification), but also fluorine is used as a dental sensitivity reducer and it also acts against bacterial plaque.

The principle fluorine components used in toothpasteas and mouthwashes are:

• Sodic Fluoride
• Mono fluoride sodium phosphate
• Nicometanol Fluorhydrate (Fluorinol)
• Pewter Fluoride
• Aminas Fluorine
  
• Potassium Fluoride

Toothpastes with Sodic Fluoride

Toothpastes with Fluorinol

DESENSITIZING SUBSTANCES

Dental sensitivity, also called dentinal hypersensitivity, (sensitive teeth), is an increase of the teeth's sensitivity to thermal changes (cold and hot), to acids (oranges, lemons, vinegars, etc.) and to sweets or to the simple touch of any mechanical instrument on the dental surface. Sometimes a simple brushing can be unbearable.

There are substances to fight against the increase on the sensitivity, they are generally very effective, but the treatment must be followed for long periods of time since when the products are longer used, the hypersensitivity tends to increase again.

The main substances against dentinal hypersensitivity are:

The different active principles can be combined to potentate their effect. Therefore, combinations of potassium nitrate with sodic fluoride, with sodium monofluorphosphate or with Nicometane Fluorihydrate can be found.

Toothpastes with sodic fluoride and potassium nitrate

Toothpastes with Potassium Nitrate and Fluorinol

WHITENING SUBSTANCES

There are some toothpastes that add whitening substances to the teeth.
The most frequent substances are:

Other whitening principles are:

To obtain the maximum effect from these substances, they must be applied after having received a whitening dental treatment at a dental clinic, therefore they will only be used as maintenance technique.

Whitening Toothpaste

Rembrand	Blanx

ANTI-SWELLING AND EPITHELIUMS SUBSTANCES

Toothpastes can also contain anti-swelling substances as part of their composition. In general, they are indicated in gingival swelling favoring the regeneration or epithelization of the mucus.
The most commonly used are:

• Alantoine
• Aldioxa
• Pro-vitamin B5 (Dexpanthenol or Panthenol)
• Vitamin P
• Hialuronic Acid
• Enoxolone
• Vitamine E (increases gingival defenses)

Toothpaste with Alantoina, clorhexidine, and Pro -vitamin B5

Toothpaste with Triclosan, zinc ciltrate, Pro-vitamin B5 and sodium fluoride

Toothpaste with Vitamin E

ENZYMES

Some toothpastes associate to their composition enzymes.
The most currently used are:

They act on the bacterial plaque's metabolism and on the glucolactoperoxidasa system. It acts on patients with dry mouth reestablishing the bacterial equilibrium altered in many cases, also associates with the quantity or saliva quality. This system generates a constant flow of hypotiocoanate ions that are basic to the saliva composition.

Enzymatic Toothpastes recommended in cases of dry mouth.

Enzymatic Toothpaste that reduces bacterial adherence

SUBSTANCES CARRYING CALCIUM

Calcium Glicerosphosphate is used.

NATURAL SUBSTANCES

There are some toothpastes that in their composition add natural substances. Some toothpastes add sanguinary which is a vegetable product, but other vegetable substances can de used that act upon the oral cavity, such as:

• Castor's Oil
• Vegetable Extracts from Rhem Palmatum
  
• Peppermint
• Sage
• Mir
• Chamomile
• Bedellium
• Wild marjoram essence
• Clove
• Thyme
• Eggplant

Homeopathic Toothpaste

Nowadays, you can fin in the market toothpastes that combine natural substances with fluorides and Clorhexidyne.

Gel for periodontal diseases made with Clorhexidine and natural products

GELS

Gels are thicker, they do not make foam and do not contain abrasives. They are used in cavity prevention at a professional level (see cavity prevention).

The most interesting gels are those with therapeutic action and that act during longer periods of time compared to toothpastes. The recommended use it to apply the gel over the dental surface or gums before going to sleep.

There are some gels that carry clorhexidine, highly recommended in periodontal problems, they are used and co-helpers in the treatments done by professionals.

Gels with Clorhexidyne

Other gels carry substances against dental hypersensitivity, such as fluorinol, potassium nitrate, sodic fluoride, etc. that act for longer periods of time on the dental surface and improve sensitiviy faster.

Gels for dentinal hypersensitivity

COLLUTORIES

These are liquids used to make mouth rinses and practically have the same composition as toothpastes, although they do not contain abrasives.
There are for types of collutories:

Fluorine Collutories (see cavity prevention), are very effective during the teeth's calcification and have contributed to the decrease in the number of cavities.

Fluorine Collutories (daily or weekly rinses)

Collutories with substances against bacterial plaque are very effective in prevention and in the treatment of periodontal diseases, although gels, most recent method, are used more and more each day.

Collutories with Clorhexidyne

Collutories with Hexetidine

Collutories with Clorhexidyne with zinc acetate

Collutories with essential oils

Collutories with triclosan

Collutories with essential oils and zinc cloruro

Halitosis or bad breath in 80% of the cases the origin of the cause is buccal due to an excess of bacteria, being periodontal disease, deep cavities or retained bacteria at the tongue the principle causes.

When referred to it as chronic Halitosis, it is differentiated form temporal which is due to the intake of certain foods such as garlic, onion, etc.

The treatment of the buccal origin is etiologic (treat the dental or buccal disease causing halitosis) and it is accompany by mouthwashes with special collutories plus the use of a tongue scraper. This improves halitosis on a 100% of the cases that are of buccal origin. This is why, in halitosis the patient must always consult with a professional such as a dentist.

Collutories against halitosis and it's composition

Tongue scraper and it's application