Dental Health Education Module: Dentifrices, Mouth Rinses, & Tongue Cleaning
Dentifrice and Its Role in Oral Hygiene
Definition of Dentifrice
Dentifrice is equivalent to toothpaste.
Functions include:
Assists in removing biofilm, stain, and other soft deposits.
Application of therapeutic agents.
Provides a superficial cosmetic effect.
Types of Dentifrice:
Pastes
Gels
Powders
Availability:
Can be over-the-counter (OTC) or prescription (Rx).
Preventive and Therapeutic Benefits of Dentifrices
Key benefits include:
Prevention of dental caries.
Remineralization of early noncavitated dental caries.
Reduction of biofilm formation using agents such as:
Zinc citrate
Stannous fluoride
Reduction of gingivitis/inflammation.
Reduction of dentin hypersensitivity.
Reduction of supragingival calculus formation.
Cosmetic Effects of Dentifrices
Primary cosmetic effects include:
Removal of extrinsic stain.
Mechanical removal of stains, with RDA (Relative Dentin Abrasivity) < 250.
Delivery of bleaching agents.
Reduction of oral malodor (halitosis) by:
Certain ingredients can reduce the production of volatile sulfur compounds (VSCs).
Ingredients such as chlorhexidine (CHX), cetylpyridinium chloride (CPC), and zinc are effective.
Stannous fluoride in combination with hexametaphosphate.
Basic Components of Dentifrices: Inactive Ingredients
Table 28-1: Ingredients and Function of Commercially Available Dentifrices
Function
Surfactant/Detergent:
Purpose: Foaming and cleansing.
Average formulation percentage: 1-2%.
Abrasive:
Purpose: Cleaning and polishing.
Average formulation percentage: 20-40%.
Binder:
Purpose: Thickening.
Average formulation percentage: 1-2%.
Humectant agent:
Stabilizes formula and prevents water loss/hardening of dentifrice.
Average formulation percentage: 20-40%.
Preservative:
Purpose: Prevents microorganisms from destroying the dentifrice in storage.
Average formulation percentage: 2-3%.
Sweetener:
Purpose: Maintains the pleasant flavor for the patient.
Average formulation percentage: 1-1.5%.
Dentifrices: Inactive Ingredients/Detergents (Foaming Agents or Surfactants)
Purposes:
Lower surface tension, penetrate and loosen deposits.
Suspend debris for easy toothbrush removal.
Emulsify/disperse flavor oils.
Contribute to foaming action.
Substances used:
Sodium lauryl sulfate USP
Sodium N-lauroyl sarcosinate
Dentifrices: Inactive Ingredients/Cleaning & Polishing Agents (Abrasives)
Purposes:
Cleans without damaging the tooth surface.
Produces a smooth tooth surface which helps prevent or delay accumulation of stains and deposits.
Primary abrasives used:
Silica, silicates, hydrated silica gels.
Calcium carbonate.
Dicalcium phosphate.
Sodium bicarbonate.
Dentifrices: Inactive Ingredients/Binders (Thickeners)
Purposes:
Stabilize the formula.
Prevent separation of solid and liquid ingredients during storage.
Types Used:
Mineral colloids.
Natural gums.
Seaweed colloids.
Synthetic celluloses.
Dentifrices: Inactive Ingredients/Humectants (Moisture Stabilizers)
Purposes:
Retain moisture in formulas.
Prevent hardening when exposed to air.
Substances used:
Xylitol, glycerol, sorbitol.
Dentifrices: Inactive Ingredients/Preservatives
Purposes:
Prevent bacterial growth.
Prolong shelf life.
Substances used:
Alcohol, benzoates, dichlorinated phenols.
Dentifrices: Inactive Ingredients/Flavoring Agents (Sweeteners)
Purposes:
Imparts a pleasant flavor for increased patient acceptance.
Masks unpleasant flavors from other ingredients.
Substances used:
Essential oils (peppermint, cinnamon, wintergreen, clove).
Artificial noncariogenic sweeteners (xylitol, glycerol, sorbitol).
Active Ingredients in Dentifrices
Table 28-2: Therapeutic Active Ingredients in Dentifrices
Benefit
Antibiofilm/antigingivitis:
Active ingredients include stannous fluoride and zinc citrate.
Anticalculus:
Active ingredients include tetrapotassium pyrophosphate, tetrasodium pyrophosphate, sodium hexametaphosphate, and zinc compounds.
Desensitizer:
Active ingredients include potassium nitrate, potassium citrate, potassium chloride, stannous fluoride, strontium chloride.
Oral malodor:
Active ingredients include essential oils, chlorine dioxide, stannous fluoride/sodium hexametaphosphate.
Dentifrice Selection for Prevention or Reduction of Oral Disease
Considerations include:
Dental Caries:
Use fluoride dentifrice for remineralization program.
Dentinal hypersensitivity:
Select appropriate desensitizing agents.
Gingivitis:
Look for active antimicrobial ingredients.
Calculus formation:
Incorporate anti-calculus agents.
Oral Malodor:
Focus on reducing VSCs.
Dentifrice Selection: Considerations for Pediatric Patients
Birth to first tooth eruption:
Caregivers can clean gingiva using a soft infant toothbrush or cloth and water.
Eruption of first tooth:
Caregivers can brush twice a day with a rice-sized smear of fluoride toothpaste for children under 3 years of age.
Ages 2-5 years:
Use a pea-sized amount of toothpaste for children over 3 years.
Caregiver performs or assists in brushing.
Caregivers should brush their own teeth at the same time as the child.
Supervision:
Children should be supervised until they can adequately remove plaque biofilm, spit out toothpaste, and not swallow excess toothpaste during brushing.
Patient-Specific Dentifrice Recommendations
Consider the following factors:
Patient's current oral condition.
Any patient complaints or concerns.
Sensitivities or allergies to specific ingredients.
Propensity of staining (e.g., stannous fluoride-containing dentifrices).
Patient's nontherapeutic or cosmetic preferences.
Expectations of compliance (is taste or texture appealing to the patient?).
Personal trial may be necessary before recommending a product.
Mouthrinses and Their Benefits
Types of benefits:
Preventive
Cosmetic
Therapeutic (chemotherapeutic), such as reduction of inflammation.
Availability:
Many are OTC, while some require a prescription (Rx).
Purposes and Uses of Mouthrinses
Before Professional Treatment:
Reduce intraoral microorganisms in aerosols.
Minimize aerosol contamination during the use of dental handpieces or ultrasonic scalers.
Self-Care:
As part of personal oral self-care to address specific needs:
Biofilm control.
Dental caries prevention through remineralization of noncavitated early dental caries.
Prevention of gingivitis.
Contribute to control of oral malodor.
Post-treatment therapy following nonsurgical periodontal therapy.
Functions of Chemotherapeutic Agents
Box 28-1: Functions of Chemotherapeutic Agents
Remineralization: Restore mineral elements.
Antimicrobial: Bactericidal or bacteriostatic effects.
Biofilm Control: Maintain gingival health and reduce/prevent gingivitis.
Astringent: Shrink tissues.
Anodyne: Alleviate pain.
Buffering: Reduce oral acidity.
Deodorizing: Neutralize odors.
Oxygenating: Cleanse oral tissues.
Preventive and Therapeutic Agents in Mouthrinses (Active Ingredients)
Active ingredients include:
Fluoride:
Functions for anticaries and remineralization.
Chlorhexidine:
Functions as an antimicrobial and antigingivitis agent.
Phenolic-Related Essential Oils:
Functions as antiplaque and antigingivitis agents.
Quaternary Ammonium Compounds (QAC):
Functions as antimicrobial/antigingivitis agents.
Oxygenating Agents:
Hydrogen peroxide and sodium perborate for wound healing and short-term debridement.
Oxidizing Agents:
Chlorine dioxide and zinc compounds for oral malodor control and neutralizing VSCs.
Typical Commercial Mouthrinse Formulation
Table 28-3: Typical Commercial Mouthrinse Formulation
Ingredient and Function:
Alcohol: Enhances flavor impact and contributes to cleansing.
Flavor: Used to enhance taste and temporarily freshen breath.
Humectant: Adds "body" and inhibits crystallization around the closure.
Surfactant: Solubilizes flavor and provides foaming action.
Water: Major vehicle to carry other ingredients.
Preservative: Preserves aqueous formulations.
Dyes: Add color.
Sweeteners: Contribute to overall flavor perception.
Active or functional ingredients: Provide therapeutic and/or cosmetic benefits.
Characteristics of Effective Chemotherapeutic Agents
Box 28-2: Characteristics of an Effective Chemotherapeutic Agent
Nontoxic:
Does not damage oral tissues or create systemic problems.
No or Limited Absorption:
The action is confined to the oral cavity.
Substantivity:
Ability to bind to pellicle and tooth surface, released over time while retaining potency.
Bacterial Specificity:
Broad-spectrum, with affinity for pathogenic organisms in the oral cavity.
Low-Induced Drug Resistance:
Low or no development of resistant organisms.
Therapeutic Agent: Chlorhexidine
Description:
Cationic bisbiguanide with broad-spectrum antibacterial activity.
Binds to hard and soft tissues inducing cell lysis.
Substantivity:
Lasts 8–12 hours.
Functions as an antimicrobial & antigingivitis agent.
A 0.12% rinse requires Rx and has limited use of 1-2 weeks unless otherwise specified; can stain teeth.
Therapeutic Agent: Phenolic-Related Essential Oils
Example:
Listerine.
Mechanism: Disrupts cell walls and inhibits bacterial enzymes.
Functions as antimicrobial and antigingivitis.
Can cause burning.
Available in alcohol (21.6% - 26.9%) and alcohol-free formulations.
Substantivity:
Poor (up to 4 hours).
Therapeutic Agent: Fluoride
Fluoride Variants:
Stannous fluoride:
Antimicrobial effects; helps reduce gingivitis but may stain.
Sodium fluoride:
Cariostatic; inhibits demineralization and enhances remineralization.
Both types deposit fluoride ions on enamel, enhancing remineralization.
Therapeutic Agent: QAC (Quaternary Ammonium Compounds)
Active Ingredient:
Cetylpyridinium chloride (CPC) at 0.05% - 0.07%.
Mechanism: Binds to oral tissues, ruptures cell walls, decreases bacteria's ability to attach to the pellicle.
Substantivity:
Low (3–4 hours), with potential staining of teeth and tongue.
May cause burning sensation and possible desquamation.
Therapeutic Agents: Oxygenating Agents
Mechanism:
Alters bacterial cell membranes.
Substantivity:
Generally poor.
Ingredients include 10% carbamide peroxide and 1.5% hydrogen peroxide.
Recommended for short-term usage in conditions like pericoronitis & necrotizing ulcerative gingivitis (NUG).
Therapeutic Agents: Oxidizing Agents
Purpose:
Target volatile sulfur compounds (VSCs) contributing to oral malodor.
Common oxidizing agents include chlorine dioxide alone or combined with zinc.
Act to neutralize malodor-causing compounds and aid in management of halitosis.
Oxidizing vs Oxygenating Agents
Oxidizing Agents:
Target VSCs, main cause of halitosis.
Neutralize odor at the source.
Examples: Chlorine dioxide, chlorine dioxide + zinc.
Oxygenating Agents:
Release oxygen into tissues.
Disrupt anaerobic bacteria under the gumline and cleanse infected tissue.
Examples: Hydrogen peroxide, carbamide peroxide.
Halitosis Causes
Statistics:
Most causes (80-90%) are intraoral.
Common Factors:
Poor hygiene, tongue coating, plaque buildup.
Gum disease/periodontal pockets.
Dry mouth (reduced saliva), mouth breathing.
Contributing factors include smoking, alcohol, and consumption of pungent foods.
Less common causes: sinus/tonsil issues, systemic diseases.
Tongue Cleaning
The tongue is a major source of oral bacteria and VSCs.
Benefits include reduction of halitosis, plaque, and bacteria contributing to periodontal disease.
Methods include:
Toothbrush: Use back-and-forth or sweeping motion.
Tongue scraper: More effective at removing coating.
Clean gently from back to forward.
Ideally performed daily as part of oral hygiene routine.
Halitosis Management
Strategies:
Maintain good daily hygiene plus tongue cleaning.
Treat gum disease if present.
Use oxidizing rinses (chlorine dioxide ± zinc) to neutralize VSCs.
Use oxygenating rinses (hydrogen peroxide, carbamide peroxide) to disrupt anaerobes and provide short-term tissue cleansing.
Use antimicrobial dentifrices (e.g., SnF₂) to reduce bacteria & odor at the source.
Regular pastes/flavoring agents should only mask odor.
Mouthrinses: Patient Education
Mouthrinses should never replace brushing.
Some agents are not suitable for children under 6 (who cannot spit).
Patients with cognitive or physical challenges should avoid mouth rinses (e.g., special needs, advanced Parkinson’s or Alzheimer’s, dementia).
Patients must be shown how to rinse effectively.
Dry Mouth Rinses (Xerostomia Management)
Provide moisture and comfort for patients with dry mouth.
They often contain:
Lubricants (e.g., glycerin, xylitol).
Fluoride for additional caries protection.
Enzymes or mild antimicrobials to support oral health.
Formulated to be alcohol-free since alcohol worsens dry mouth.
They improve speech, swallowing, and comfort, as well as contribute to caries prevention.
Examples: Biotène, ACT Dry Mouth, CloSYS Hydrating Rinse, Salivea.
Mouthrinses: Homemade Saline Rinses (1 of 2)
Isotonic Sodium Chloride Rinse:
Recommended concentration: ½ tsp. of salt in 1 cup warm water.
Instructions: Mix, swish and/or gargle for 30-60 seconds and expectorate.
Hypertonic Sodium Chloride Rinse:
Recommended concentration: ½ tsp. of salt in ½ cup warm water.
Instructions: Mix, rinse, and/or gargle for 30-60 seconds and expectorate.
Mouthrinses: Homemade Saline Rinses (2 of 2)
Alkaline Effect:
Reduces bacterial growth as they prefer acidic environments.
Astringent Properties:
Helps shrink tissues, reduce inflammation, and promote healing.
Gentle & Soothing:
Supports healing after dental treatment, and helps with ulcers and sore throat.
Note:
Not recommended for patients with high blood pressure or on a salt-restricted diet.
Mouthrinses: Oil Pulling
Procedure: Swish with 10 mL (1 Tbsp) of sesame or coconut oil.
May reduce biofilm and bacteria linked to caries, gingivitis, halitosis, and oral thrush.
Note: Research is limited; not a substitute for brushing/flossing with fluoride.
Suggested duration: ~10 minutes (no added benefit beyond 20 minutes; may cause jaw fatigue).
Important: Must expectorate into garbage, as oil can clog the sink.
Sometimes recommended as a supportive option for patients with dry mouth.
Patient Recommendations for Dentifrice and/or Mouthrinse
Consideration for patients concerned with bad breath.
A comprehensive evaluation is necessary to determine appropriate recommendations based on individual needs and cases.
ADA Seal of Acceptance
Description:
Indicates a product's safety & effectiveness backed by a scientific review by the ADA.
The Seal signifies that claims are supported by research, not merely marketing.
Must be re-reviewed every 5 years.
Products without the Seal may still be safe; the manufacturer may not have applied for the Seal.
Factors to Teach the Patient
ADA/CDA Seal:
Shows safety and effectiveness; lack of Seal does not imply unsafe (the company may not have applied).
Encourage patients to consult a dental professional before trying new products to ensure they fit their needs.
Caution against impulse buys: Some products may be inappropriate for specific oral conditions or restorations.
Emphasize that chemotherapeutics are not a substitute for daily biofilm removal.
Key Takeaway
Match oral hygiene products to individual patient needs, prioritize seeking the ADA Seal, and guide patients with evidence-based recommendations.
Case Study Quiz
Scenario:
Patient is a 45-year-old complaining of persistent bad breath.
They brush once daily with mint-flavored sodium fluoride toothpaste and use breath mints throughout the day.
They do not clean their tongue.
Gum disease is not detected.
Question:
What products would you recommend?