Patients often ask, “What type of toothpaste should I be using to clean my teeth?” This is a loaded question. In order to properly answer this question, we must consider the following discussion below.
The first and foremost goal of any toothpaste is to promote oral hygiene. Most toothpastes have abrasive aids to remove plaque (bacteria) debris and food from accumulating on your teeth and gums, ultimately helping to reduce gum diseases (gingivitis & periodontitis). Additionally, most toothpastes deliver active ingredients, most commonly fluoride to help prevent tooth decay (dental caries). The second goal of a toothpaste is that it should not damage your teeth and gums. According to the literature, repeated acid exposure (whether dietary or due to dental products), combined with abrasive (abnormal wearing away of tooth structures by causes other than tooth-tooth contacts) and flexural forces (back & forth movement) on teeth, may lead to dentin (layer of tooth structure) exposure and the formation of non-carious cervical lesions(1,2,3). These non-carious cervical lesions can be seen as V-shaped notches on the necks of teeth (Figure 1).
Measuring Abrasivity: Relative Dentin Abrasivity Value (RDA)
In 1970, the American Dental Association (ADA) began creating a standardized system for measuring the abrasiveness of toothpastes that were on the market relative to a standardized control sample. They assigned their control paste, calcium pyrophosphate, a value of 100 on their Relative Dentin Abrasivity (RDA) scale.4 The higher the RDA number the more abrasive the toothpaste. (Table 1)
The FDA supported these studies and deemed that no toothpaste should exceed 2.5 times the abrasiveness of the control standard, or an RDA value of 250. Since studies at the time showed that 80 to 90 percent of extrinsic stains could be removed with a toothpaste of an RDA between 100 and 200, this seemed reasonable.5 Their upper limit of an RDA value of 250 was based on research that showed that lab-simulated brushing with such a toothpaste would cause 1mm of dentin wear after 100,000 strokes – what they deemed a lifetime of a brushing, and an acceptable loss of tooth structure.6
While the ADA webpage on toothpastes states that the RDA scale “should not be used to rank the safety of dentifrices with RDA values below 250” and that “these values do not correspond to potential clinical effects, like abrasion,” some studies have shown that there is a direct correlation between the RDA value of a toothpaste and the amount of abraded dentin.7,8
CAUTION: Toothpaste manufacturers regularly measure their product’s abrasivity. It is not necessary to obtain FDA approval, and it is usually not required to be disclosed on the product label.
LOSS OF TOTH STRUCTURE & GUM RECESSION
The correlation between gum recession (exposed root surfaces) and the abrasion of the resulting exposed root surfaces has been documented.9 These can often be seen as cervical notches on the necks of the teeth (Figure 2). The question we have to ask ourselves is, what is the cause of cervical abrasion? Is it the toothpaste, toothbrush or both? The answer is not so straightforward due to many confounding factors to consider such as brushing technique, brushing force, brushing frequency, brushing time, type of brush, and bristle stiffness. The majority of studies conducted suggest that soft, medium or hard brushes did not damage tooth structure when used with water as the control. However, when toothpaste was added to the studies, cervical abrasion was observed on the teeth9.
DENTAL IMPLICATIONS FOR PATIENTS
By listening to and asking patients about their dietary and beverage habits, one may find a positive relationship between the frequency of acidic exposures (acidic foods, soda, carbonic beverages etc.) and the wearing away of their tooth structure. Many times patients are often completely unaware of the acid reflux, while remembering that some reflux is “silent” and does not present with typical symptoms of acid indigestion, bloating, and stomach pain. If a patient has any of the above signs and or symptoms, a referral to a physician or gastroenterologist should be given for further evaluation with an endoscopic evaluation of the esophagus. This type of exam can literally save a life by looking for changes to the lining of the esophagus, termed “Barrett’s Esophagus”, which is often associated with an increased risk of cancer.
TMJ & Bite Analysis
If a thorough Temporo-Mandibular Joint (TMJ) and a Occlusal (Bite) analysis reveal abnormal pain involving the TMJ or there is obvious wear of the of teeth or cervical lesions, one approach is to fabricate an occlusal (bite) guard fabricated to wear at night to protect against undue bite forces. These bite forces can be damaging to the both the teeth and gums and could accelerate the loss of tooth wear and gum recession. A properly constructed occlusal bite guard is done by the use of a centric related bite record and with a leaf guage (Figure 3) to capture the joint position of the patient (Figure 4). Once this is completed, the appropriate type of occlusal appliance can be designed, fabricated and customized to fit the patient (Figures 5,6). There is not a “one size ” fits all when prescribing the appropriate bite guard. A careful diagnosis is made so that the appropriate guard is chosen to meet the specific requirements of the patient.
Gum recession (exposed root surfaces) could be accelerated by using an improper brushing technique, an abrasive wrong toothpaste, as well as a grinding habit. The gum recession can be regenerated using a minimally invasive microsurgical approach(Figures 7,8), however the long-term success of the gum grafting procedure will depend on the management of oral hygiene, dietary intake and bite forces.
Figure 7: Before- Cervical nothces with gum recession.
Figure 8: After- Gum recession & cervical notches corrected by Not using patient’s own tissue & using a minimally invasive technique.
PRESTIPINO & SFONDOURIS RECOMMEDATIONS
Given that there are many variables to consider when choosing a toothpaste, we recommend using the softest toothpaste that allows patients to manage their stain levels over 3-6 month periods between cleanings. For most people, that may mean an RDA value around 100-200. The next time you go to the store to buy your toothpaste, review this list (Table1) and see which toothpaste may not be Too Hard on Your Teeth and Gums!
Drs. Sfondouris & Prestipino are dental specialists who have the dental knowledge and expertise to help you to achieve Dental Health & Wellness. We have built a dental practice based upon excellence. We have an experienced team of Dental Hygienists who have been with our practice for 20 plus years which provides patients comfort and continuity.
Please contact our practice today at 301-652-2300 and schedule your next dental cleaning and exam!
- Grippo JO, Chaiyabutr Y, Kois JC. Effects of Cyclic Fatigue Stress-Biocorrosion on Noncarious Cervical Lesions. Journal of Esthetic and Restorative Dentistry. 2013:25(4):265-272.
- West N, Hooper S, Osullivan D, et al. In situ randomized trial investigating abrasive effects of two desensitizing toothpastes on dentine with acidic challenge prior to brushing. Journal of Dentistry. 2012;40(1):77-85
- Abrasivity of Current Dentifrices. The Journal of the American Dental Association. 1970;81(5):1177-1178.
- Kitchin PC, Robinson HB. How Abrasive Need a Dentifrice Be? Journal of Dental Research. 1948;27(4):501-506.
- John, Samuel & White, Donald. (2015). History of the Development of Abrasivity Limits for Dentifrices. The Journal of Clinical Dentistry. 2015: 26(02). 50-4.
- Oral Health Topics- Toothpastes. Toothpastes. http://www.ada.org/en/member-center/oral-health-topics/toothpastes. Accessed October 29, 2017.
- Wiegand A, Kuhn M, Sener B, Roos M, Attin T. Abrasion of eroded dentin caused by toothpaste slurries of different abrasivity and toothbrushes of different filament diameter. Journal of Dentistry. 2009;37(6):480-484.
- Ervin JC, Bucher EM. Prevalence of tooth root ecposure and abrasion among dental patnets. Dent items Interest 1944;66:760-9.