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abstract
Article history:
Objectives: To review and summarise the whitening agents contained within tooth whiten-
ing toothpaste formulations, their mode of action in tooth whitening, and the in vitro and
16 May 2010
Methods: Original scientific full papers or reviews listed in ISI Web of Science and Medline
were included in this review using the search terms white*, toothpaste and dentifrice.
Conclusions: Due to the reported consumer and patient dissatisfaction with their perceived
tooth color, toothpaste manufacturers have responded by developing a vast array of
Keywords:
Tooth whitening
toothpastes is the abrasive system. In general, these have been designed to give effective
Bleaching
removal of extrinsic stains and help prevent tooth stains from reforming without undue
Perception
abrasivity towards the dental hard tissues. Whitening toothpastes may contain additional
Aesthetics
agents that augment the abrasive cleaning by aiding the removal and/or prevention of
Toothpaste
extrinsic stains, for examples, peroxide, enzymes, citrate, pyrophosphate and hexameta-
Dentifrice
phosphate, or optical agents such as blue covarine which can improve tooth whiteness
following tooth brushing. In vitro methods used to evaluate tooth whitening efficacy
typically determine the ability of a toothpaste formulation to remove/prevent model
extrinsic stains on substrates such as enamel or hydroxyapatite or changes in the intrinsic
color of tooth specimens. Clinical protocols for evaluating the efficacy of whitening toothpastes typically determine either stain removal or prevention, where changes in natural
stain or chlorhexidine/tea induced stain are measured typically over 26 weeks. In some
clinical studies the overall tooth color change was measured using techniques such as Vita
shade guides, colorimeters and image analysis of digital photographs of teeth.
# 2010 Elsevier Ltd. All rights reserved.
1.
Introduction
* Tel.: +44 0151 641 3000; fax: +44 0151 641 1800.
E-mail address: Andrew.Joiner@Unilever.com.
0300-5712/$ see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.05.017
e18
tooth color ranges from 17.9 to 52.6%. This desire for whiter
teeth has given rise to a growing trend in the increased use of
tooth whitening products.12,13 Manufacturers of oral care
products are constantly developing improvements and new
approaches for tooth whitening in order to meet the
demanding expectations of patients and consumers. Thus,
today there is a huge range of product types and technologies
addressing the problem of tooth discoloration available on the
market. The majority of these products work in one of two
ways, either by bleaching of the teeth, or by the removal and
control of extrinsic stain. Tooth bleaching typically involves
the application of hydrogen peroxide or carbamide peroxide
containing gels to the teeth through various formats, including
a mouth guard or strip or even painting directly on. The
peroxide causes decolorisation or bleaching of the colored
materials found within the tooth giving rise to whiter teeth.14
In order to optimise the removal and control of extrinsic stain,
specific abrasives and/or chemical agents can be added to
toothpaste. These improved stain removal/prevention products are termed whitening toothpastes.
The purpose of the current review is to summarise the
available literature concerning the technology contained in
tooth whitening toothpaste formulations, their role in tooth
whitening, and in vitro and clinical methods used to evaluate
and demonstrate their efficacy. Only original scientific full
papers or reviews listed in ISI Web of Science and Medline
were included in this review using the search terms white*,
toothpaste and dentifrice. The total number of studies
identified which described the technology behind whitening
toothpastes and their efficacy was 57, of which 22 were in vitro
studies and 35 were clinical studies. The majority of studies
(89%) were published from 1998 onwards. Most of the clinical
studies investigated natural extrinsic stain removal and/or
prevention (69%), with clinical sample sizes in the range 22
219 subjects, although typically of the order 3060 subjects and
durations typically of 26 weeks, but sometimes prolonged for
12 weeks or more. Other clinical studies investigated the
impact of whitening toothpastes on chlorhexidine induced
stain (20%) or to a lesser extent on intrinsic tooth color (11%).
2.
Whitening toothpastes
Hydrated silica
Calcium carbonate
Dicalcium phosphate dihydrate
Calcium pyrophosphate
Alumina
Perlite
Sodium bicarbonate
Chemical
Hydrogen peroxide
Calcium peroxide
Sodium citrate
Sodium pyrophosphate
Sodium tripolyphosphate
Sodium hexametaphosphate
Papain
Optical
Blue covarine
3.
4.
e19
5.
Abrasives
e20
6.
Chemical agents
Phosphate materials, such as pyrophosphate, tripolyphosphate and hexametaphosphate, tend to have a strong binding
affinity for enamel, dentine and tartar, and during adsorption
they have been shown to desorb stain components.86,87
Sodium pyrophosphate alone has been utilised in whitening
toothpastes, although primarily for their anti-tartar activity.19
Sodium tripolyphosphate (STP) has been incorporated into
whitening toothpastes either on its own or in combination
with pyrophosphate.43,8890 In a direct comparison, a whitening toothpaste containing a combination of STP and pyrophosphate gave a significantly greater reduction of preexisting extrinsic stain than a whitening toothpaste containing only STP, with both products significantly better than a
regular silica toothpaste.89,90 In other clinical studies, the STP/
pyrophosphate containing whitening toothpaste has also
been shown to remove significantly more pre-existing extrinsic stain than a non-whitening silica control.43,88
Sodium hexametaphosphate (HMP) is a longer chain
variant of pyrophosphate containing 1012 repeating pyrophosphate subunits. It has multiple binding sites which have
the potential to increase its retention and substantivity to
tooth surfaces compared to pyrophosphate and potentially
reduce stain-chromogen adsorption to the tooth surface.77
Indeed, in vitro studies have shown the ability of HMP to reduce
the adsorption of tea chromogens onto hydroxyapatite
powder and discs.91 A toothpaste containing 5% HMP as anion
was shown in clinical studies to significantly remove
chlorhexidine/tea induced stain versus control toothpastes
after 3 and 6 weeks product use.40,41 Stain prevention benefits
of HMP in a toothpaste have also been demonstrated in a 6week clinical study.47 In addition, HMP has been incorporated
into other whitening toothpaste formulations where it has
also been shown in clinical studies to give improved stain
removal benefits.37,38,92,93
7.
Optical routes
8.
e21
Concluding remarks
e22
Conflict of interest
The author is an employee of Unilever plc.
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