What is in your Toothpaste?

By Jackie Willis, Chief of Staff, The Center for Special Dentistry® in New York City.

In 2010, global industry analysts forecasted the global toothpaste market to reach $12.6 billion in 2015 (“Toothpaste,” 2012). While there is an apparent trend toward improved personal hygiene, at least part of this growth can be attributed to biotechnological advances that expand on the function and benefits of traditional toothpaste. Consumers can now purchase toothpaste customized to their particular needs or preferences, such as enamel protection, whitening, and treatment of sensitivity. Different types of toothpastes include many different types of ingredients. It is helpful to understand what purposes the ingredients in your toothpaste serve. This article will educate you on common ingredients found in toothpaste.

Fluoride is a naturally occurring mineral and active ingredient in toothpaste that is proven to prevent tooth decay (Higham, 2011). Fluoride protects the teeth by stopping or even reversing the tooth decay process and by strengthening the enamel. Eating sugar and refined carbohydrates would normally remove the minerals from teeth. Fluoride helps to remineralize the tooth surface. Following the remineralization, fluoridated hydroxyapatite and fluorapatite embed in the tooth surfaces, strengthening the tooth enamel, and preventing cavities (Higham, 2011). A study in the Journal of the American Dental Association finds that even the highest fluoride toothpaste does not appear to prevent enamel erosion (Rios D. et al., 2008). Therefore, patients with highly acidic diets or who are at high risk for enamel erosion or cavities should take other preventative measures with the help of a dentist than just seeking out the local fluoride toothpaste.

Sodium fluoride, stannous fluoride, or sodium monofluorophosphate are ingredients classified as a drug by the FDA, and are considered unsafe to ingest in large amounts, in which dental fluorosis may occur. Fluorosis is an abnormal condition in the appearance of the tooth’s enamel. “It can result when children consume higher-than-recommended amounts of fluoride during the teeth forming years, age 8 and younger” (“Community water fluoridation,” 2012). A 2012 study about Topical Fluoride says, “there is overwhelming evidence that reports not only the significance and importance of the use of fluoride as a caries-preventive agent, but also how safe fluoride application is when used appropriately, particularly in higher risk individuals and populations” (Miller et al, 2012). Therefore, it is not only important to prevent cavities and remineralize the enamel with fluoride, but it is also important to follow the safety directions on fluoride toothpaste to prevent fluorosis.

Many U.S. states provide community water fluoridation as a way of preventing tooth decay. The Center for Disease Control and Prevention (CDC) has recognized water fluoridation as safe, healthy, and one of ten of the United States’ greatest public health achievements (“Ten great public,” 1999). The CDC also recognizes that ‘almost all water contains some naturally occurring fluoride, but usually at levels too low to prevent tooth decay’ (“Community water fluoridation,” 2012). Results from a study involving U.S. children show how water fluoridation has played a dominant role in the decline and prevention of dental caries (Brunelle & Carlos, 1990). It is recommended to use fluoride toothpaste in addition to drinking fluoridated water as it offers more cavity prevention.

Toothpaste manufacturers often use abrasive ingredients in their product for the removal of debris, plaque and stains that accumulate on surfaces of teeth. Common abrasive include calcium phosphates, alumina, calcium carbonate, and silica. Toothpaste should be abrasive enough to remove plaque or stains and to polish teeth; however, they must not be abrasive enough to damage tooth enamel. Factors such as aggressively brushing teeth, teeth grinding, acidic diets and toothpastes with high abrasivity may grind down the enamel over time, which could lead to sensitivity, gum recession and damaged enamel. Damaged tooth enamel also causes yellowing as the thinned enamel reveals the yellowish dentin layer below. Strong whitening toothpastes use abrasion to remove external stains as opposed to changing tooth color. In vitro studies find that whitening toothpastes appear to be more abrasive to dentin (Schemehorn, Moore & Putt, 2011). A scale for measuring abrasiveness is called the Relative Dentin Abrasivity (RDA) scale. The RDA scale ranges from 0 to 250 with the low number being least abrasive and the high number being most abrasive.

Detergents or surfactants produce foam to help clean out the fatty films and food debris. Sodium lauryl sulfate (SLS) is a common toothpaste detergent which provides foam, helps to clean teeth, has anti-bacterial properties and can disintegrate plaque. However, detergents can dry the inside of the mouth, which may directly cause irritation of oral membranes and canker sores (Herlofson & Barkvoll, 1996). A published article in the International Journal of Dental Hygiene found data that suggests while detergents may have the potential to cause soft tissue damage, the saliva in the mouth could possibly neutralize such effects (Moore, C., Addy, M., Moran, J., 2008). There is a substitutive ingredient which does not evoke gum irritation called Sodium N-Lauryl sarcosinate, a milder detergent than sodium lauryl sulfate. Certain toothpastes such as Tom’s of Maine are SLS free and can include a gentle ingredient called glycyrrhizin for natural low foam. SLS-free toothpaste is a common recommendation for people who frequently get canker sores.

Triclosan is an antimicrobial agent, which is effective in reducing plaque bacteria and gingivitis when combined with a retentive agent. It is also anti-fungal, anti-viral and compatible with other agents in toothpaste as it is non-ionic. Many household products such as soaps and hygiene products contain triclosan as well.

Interestingly, a 2004 controversial study from Virginia Tech found that soaps containing triclosan can combine with chlorine in tap water to form chloroform (Vikesland, 2004). According to The United States Environmental Protection Agency (as cited in Vikesland, 2004), chloroform is classified as a probable human carcinogen, or cancer-causing agent targeting the liver, kidney, and central nervous system. There is a great deal of concern over the small amounts of dioxins created because it is a high risk to one’s health. Because triclosan is an ingredient in soaps and toothpaste, there was health concern on whether triclosan in toothpaste was combining with chlorinated tap water to produce potentially harming effects.

The American Dental Association published a response to these concerns stating that the Virginia Tech study, as designed and conducted, is not relevant to toothpaste. The study showed that the amount of chloroform generated was less than amounts often present in chlorinated drinking waters. According to an American Dental Association archive, Dr. Vikesland, study’s lead author announced, “It is highly premature to presume that there is a problem associated with the use of triclosan-containing toothpastes. In order for the reactions that we studied to occur, you would need excess amounts of chlorine–which usually doesn’t occur when you are brushing your teeth, which is a little bit of tap water, a lot of toothpaste and saliva.” (Berthold, 2005).

Toothpaste includes sweeteners such as saccharin or sorbitol to improve the taste. Most toothpaste sweeteners are artificial and contribute little to no cavity formation. Coloring agents and artificial dyes are used to make toothpaste more colorful and aesthetically pleasing to the eye. Thickeners such as xantham gum, cellulose gum, and carrageenan help to create the texture and thickness of toothpaste. Thickeners help to stabilize all the chemicals together in the toothpaste tube. Humectants prevent water loss by attracting and holding water molecules within toothpaste. Glycerin, sorbitol, xylitol and water are common humectants. Xylitol is a humectant and natural sugar that fights tooth decay and gum disease instead of enhancing it as most sugars do. A study in the Journal of Oral Science found that the combination of fluoride with xylitol is more effective than either ingredient alone (Sano et al, 2007).

Diethylene Glycol (DEG), an ingredient used in antifreeze, is a toxic and lethal sweet-tasting substance that should not be found in U.S. toothpaste. After diethylene glycol was found in Chinese-made toothpaste sold in the Dominican Republic and Panama in 2007, the U.S. Food and Drug Administration (FDA) made preventative measures to test and sample all Chinese-made toothpaste entering the U.S. (as cited in CNN report, 2007). Diethylene Glycol, or diglycol, was known to be used as a substitute for the more so expensive ingredient glycerin in toothpaste. Although there were no U.S. reports of poisonings from toothpaste containing diethylene glycol, the FDA took precautions and warned populations about potential risks from chronic exposure, unintentional swallowing or ingestion of toothpaste containing DEG (“FDA,” 2007).

In 2007, FDA inspected and tested toothpastes labeled “Made in China,” which FDA found to contain about 3 percent DEG (“FDA,” 2007). The DEG containing toothpastes did not have diethylene glycol labeled in its ingredients. Furthermore, counterfeit toothpaste falsely packaged as “Colgate” had been found in several dollar-type discount stores in New York, New Jersey, Pennsylvania, and Maryland (Klimerman, 2007). These counterfeit products were typically sold at low-cost, bargain retail outlets. As a precaution, FDA urged American consumers to immediately stop using Chinese-made toothpaste products and either throw them away or return them to the place of purchase (“FDA,” 2007).

It is very interesting to learn about the scientific research behind the ingredients in health products such as toothpaste. Rarely do we think about the risks and dangers of using toothpaste other than the benefits of using it to combat cavities and stains. However, it is helpful for us to continue educating ourselves about new information, new products, new ingredients, and new technology. The more consumers are able to learn what they use, the better their decisions will be upon purchasing products. When in doubt, always ask your local dentist, Dr. Jeffrey Dorfman.

• (2007). FDA advises consumers to avoid toothpaste from china containing harmful chemical. U.S. food and drug administration. [Press Release].
• (2007). U.S. checking all toothpaste imports from China. Health section on CNN.com.
• (2010). Toothpaste – a global strategic business report. Global Industry Analysts, Inc.,
• Berthold, M. (2005). Triclosan study not relevant to toothpaste. American dental association.
• Brunelle, JA, Carlos, JP. (1990). Recent trends in dental caries in U.S. children and the effect of water fluoridation. Journal of dental research, 69 820-3.
• Department of Health and Human Services, (1999). Ten great public health achievements — united states, 1900-1999. Retrieved from Centers for Disease Control and Prevention website.
• Department of Health and Human Services, (2012). Centers for Disease Control and Prevention. Community water fluoridation.
• Fotek, P. (2012). Periodontitis. A.D.A.M. medical encyclopedia,
• Herlofson, BB, Barkvoll, P. (1996). The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers. Acta odontologica scanidavica, 54(3), 150-3.
• Higham, S. (2011). Caries process and prevention strategies: demineralization/remineralization. American dental association continuing education recognition program, 1-18.
• Klimerman, A. Paolella, T. (2007). Counterfeit colgate toothpaste found. U.S. food and drug administration, [Firm Press Release].
• Miller, FY., et al. (2012). Topical fluoride for preventing dental caries in children and adolescents. Current pharmaceutical design, 18(34), 5532-41.
• Moore, C., Addy, M., Moran, J., (2008). Toothpaste detergents: a potential source of oral soft tissue damage? International journal of dental hygiene. 6(3), 193-198.
• Perlich, M., et al. (1995). The clinical effect of a stabilized stannous fluoride dentifrice on plaque formation, gingivitis and gingival bleeding: a six-month study. The journal of clinical dentistry, 6, 54-8.
• Rios, D., et al. (2008). The efficacy of a highly concentrated fluoride dentifrice on bovine enamel subjected to erosion and abrasion . The journal of the american dental association, 139(12), 1652-1656.
• Sano H et al. (2007) Effect of a xylitol and fluoride containing toothpaste on the remineralization of human enamel in vitro. Journal of oral science, 49(1), 67-73.
• Schemehorn, B., Moore, M., & Putt, M. (2011). Abrasion, polishing, and stain removal characteristics of various commercial dentifrices in vitro. The journal of clinical dentistry, 22(1), 11-8.
• Vikesland,P. (2004). Evaluation of triclosan reactivity in monochloraminated waters. [Doctoral dissertation]. 

Categorised in: Dr. Dorfman Says

This post was written by Dr. Jeffrey Dorfman