Today’s Science Based Medicine post will leave you foaming at the mouth. Not from excitement, organophosphate pesticide poisoning, or rabies, but because our topic today is toothpaste! You may find yourself asking “Why toothpaste?” followed by “Didn’t you bore us a while back with a post about flossing?” Indeed I did! We dentists aren’t the most titillating people around, so to us, brushing and flossing are really stimulating topics. We really should get out more often.
For years, I’ve seen adverts for “natural” toothpastes, and patients often ask me if such and such brand is better for them than Crest® or Colgate® since they read somewhere on the internet that fluoride causes[insert every possible illness imaginable here], or that sodium lauryl sulfate causes [insert every possible illness imaginable here], or that the little “plastic beads” found in some products, including some toothpastes are decimating our environment like some small scale dental Silent Spring.
But what really prompted me to write this article was a fun discussion I had with Myles Power and James Gurney on their excellent podcast The League of Nerds. Myles purchased a tube of “homeopathic toothpaste” as a joke to break the ice and get our conversation going. But after he examined it more closely, Myles – a chemist by training and trade – noticed some disparities between what was claimed vs. what the toothpaste actually contained, as well as some questionably-misleading labeling. This observation allowed the three of us to wander off into a more in-depth analysis of what these products are and how they can often make specious claims that can fool consumers that they are getting more health benefits from their toothpaste than are possible. Not long after that, another friend (and former guest on Clay Jones and my podcast) Lydia Finch Segebrecht sent me some absurd toothpaste ads that had popped up on her Facebook timeline and suggested that I write an SBM post about it. Voila!
Introduction to Dentifrice-ology
When we are at cocktail parties or dental conferences, we dentists refer to toothpaste as a dentifrice. We do this primarily to identify ourselves as members of our tribe and to solidify our social status therein, but also because we health care people think we have to have fancy sounding words for everything just to try to appear intelligent.
A dentifrice is defined as “A substance, such as a paste, powder, or liquid for cleaning the teeth.” Now that you know, you can put it in the “I’ll never use that word again” file. Some form of tooth cleaning substance has likely been used since prehistoric times, and while we don’t know exactly what was in them, it is believed that such things as ash, crushed oyster shells, bone, and even oxen hooves and other abrasive ingredients were used. While occasional cleaning concoctions are mentioned in history dating from around the 9th century CE and earlier, it wasn’t until the mid-1800s when dentifrices (in the form of tooth powders) were introduced to the public. It was during this time when soaps and other surfactants were added to the powder, followed by the introduction of tooth creams in the 1850s, and Colgate getting into mass production of their tooth cream in the 1870s. Grandma swore by peroxide and baking soda, or even brushing with pure, unadulterated Morton’s salt, but then again, Grandma was probably in dentures by the time she was 45.
Fast forward to 2017 and if you look on the toothpaste aisle of your pharmacy or grocery store, you’ll find a mind-numbing selection of toothpastes from which to choose. And that vast selection is but a small sampling of the choices you have online and in other venues such as health food stores and the like. Despite the plethora of choices, toothpastes have some basic ingredient characteristics in common. First I’ll discuss the basic formula for the majority of toothpastes, then I will lay out the case for “science-based toothpastes” followed by giving some examples of “alternative” or “natural” toothpastes and why they may not do what they claim to do.
So what’s in dentifrice toothpaste?
The four basic components of toothpastes are:
- Abrasives – Abrasives serve an important role in toothpaste. But instead of oyster shells and oxen hooves, modern abrasives are gentler and typically include calcium carbonate, dehydrated silica gels and hydrated aluminum oxides. The goal of the abrasives in today’s toothpaste is to scrub the surface of the teeth without damaging your tooth’s enamel.
- Flavoring – Artificial sweeteners (not decay causing sucrose!) and flavorings make the toothpaste palatable so people will be more inclined to brush for the proper amount of time. (People usually don’t brush for the proper amount of time, but at least the flavoring makes them more inclined to.)
- Humectants – Humectants are chemicals that help retain the water in the toothpaste so you get that nice smooth gel consistency when you squeeze the tube. Sorbitol (also a flavoring agent) and glycerol are examples of humectants.
- Detergents – Detergents are used to promote foaming and act as a surfactant to help clean the teeth. Sodium lauryl sulfate is the most common detergent.
These are the four main cornerstones of dentifrice chemistry. Sometimes sodium lauryl sulfate is removed because some people believe it is toxic or allergenic, but for the most part, almost all toothpastes contain these ingredients.
The fifth basic component of toothpaste, which I deliberately omitted, is fluoride. Fluoride is a mineral that is in most “mainstream” toothpastes, and as we all know, it plays a vital role in strengthening enamel and reducing the likelihood of getting a cavity. I omitted it because fluoride can be removed from toothpaste without noticeably affecting the characteristics of it. It is also the Mason-Dixon line between what I will call “Science-Based Toothpastes” vs. “Natural Toothpastes.”
So let’s discuss the concept of the Science-Based Toothpaste.
The American Dental Association Seal of Acceptance
A good place to start is with the American Dental Association (ADA) Seal of Acceptance. According to the ADA website:
When you see the ADA Seal, you can be sure the product inside has been scientifically evaluated to be safe and effective. In fact, to obtain the ADA Seal companies frequently are asked to meet higher standards than what is required by law. Not all products submitted for the Seal meet the ADA’s stringent requirements.
The ADA Seal is never sold. No profit goes to the ADA when a company earns the Seal. The ADA Seal is not an endorsement of a particular product; rather it is designed to help you know that claims made on the label say what they do and do what they say.
Science-based toothpastes often add one or more active ingredients to their product to accomplish a certain goal. Fluoride to reduce tooth decay, for example. Another example is the addition of tetrasodium pyrophosphate, which is in “tartar control” toothpastes. Tetrasodium pyrophosphate acts by removing calcium and magnesium from saliva, thus reducing calculus (i.e. tartar) accumulation on the teeth.
Which brings us back to the ADA Seal of Acceptance. If a toothpaste manufacturer decides to put some ingredient in their toothpaste and claims said ingredient confers some benefit, then the ADA requires that the manufacturer demonstrate those claims scientifically. For example, it’s not enough to put fluoride in toothpaste; to get the ADA Seal, it must be shown that the proper, stated amount and type of fluoride is present and that the toothpaste actually delivers that fluoride to the tooth surface.
All this is to say that most dentists advise their patients to purchase whatever toothpaste they want. Whatever tastes best, whatever the kids like, whatever is on sale – it doesn’t matter as long as it has the ADA Seal on it. That way we, as health care professionals, know that together we are helping our patients maximize their dental health, and that the consumer/patient is getting what he/she believes they are getting.
So, does this mean that all toothpastes without the ADA Seal of Acceptance are worthless and should be avoided at all costs? Actually, no. One thing to keep in mind is that most of the benefits of toothbrushing (and flossing for that matter) derives from the mechanical action of the brush, floss, or pick on the tooth, which physically disrupts and removes the biofilm (aka “plaque”). The suds and the taste, and yes, even the fluoride are all ancillary benefits to brushing. It’s more important that you brush with something – anything! – and do it well, than to not brush enough or effectively, no matter how much toothpaste you use.
Which leads me to my final section – the “alternative” or “natural” toothpastes. This is the Science-Based Medicine blog, by god, and we hate everything that doesn’t fit into our neat Science-Based Boxes, right? Anyone who isn’t science-based is an ignorant fool and should be ridiculed, right? Anyone who brushes their teeth with a “natural” toothpaste should suffer the consequences of tooth loss and putrefying gums, right?
Not so fast.
As I mentioned before, the brand or type of toothpaste is secondary to the importance of actually using your toothbrush properly and for the correct amount of time. I say this because I’m going to call out a handful of “natural” toothpastes below and shed them in a somewhat unfavorable light. But this isn’t necessarily because they are bad toothpastes, not at all. It’s because many of them make health claims that not only don’t pass ADA Seal of Acceptance muster, but they don’t even pass the sniff test for biological plausibility, much less passing any test of scientific validity.
Let’s take a look, shall we?
Toothpaste or woo-thpaste?
(Do you know how long I’ve been waiting to say woo-thpaste? I can now die happy.)
Anyway, let’s discuss some of the “natural” toothpastes out there. As many regular readers of the SBM blog already know, the term “natural” has been co-opted by alternative medicine people to imply and infer that natural is good, artificial is bad. It resonates with those whose ideology demands that one only ingests or imbibes substances that come directly from the earth and not indirectly synthesized in a laboratory. While evidence-based individuals are aware of this appeal to nature fallacy, many either are not familiar with the finer point of what it actually means, or they choose to not believe it.
Let’s begin with perhaps the most popular of the alternative toothpastes- Tom’s of Maine.
Tom’s is one of the “good guys” in natural products. The company was formed in 1970, and it appealed to the burgeoning natural movement of the 70s. They offer many oral health care products, and their “claim to fame” was that they manufactured a high-quality toothpaste that didn’t contain that awful fluoride neurotoxin. Of course we dentists bristled at that, but patients are free to purchase whatever they want to purchase. The admirable thing about this company is that they also manufactured toothpaste that contained fluoride (consumer choice), and they went through the arduous and not-inexpensive process of becoming ADA certified. So, despite holding themselves out to be a “natural” alternative to the Crests and Colgates of the world, they never made unwarranted claims or advertised themselves as anything other than what they were.
The next toothpaste on the list is the one that Myles brought up when he interviewed me on his podcast. This lil gem is called Bilka Homeopathic Toothpaste. Homeopathic toothpaste, you say? How can that be? Is it just a tube of water that had all the toothpasty stuff succussed right out of it? Well, Myles contacted the company, and they said “No, no, what we mean is that this is a good toothpaste to take if you are also taking homeopathic remedies.” OK then.
- Toothpaste Bilka Homeopathy Lemon is a natural product created for people who prefer the natural-friendly way of life. It does not contain mint and fluoride or harmful-for-the-health colors and sweeteners. It contains xylitol – a natural ingredient, which protects the theeth [sic] from caries and plaque.
- It is suitable for people using homeopathic remedies.
- With pure natural lemon aroma.
- Ingredients (INCI): Calcium Carbonate, Aqua, Sorbitol, Glycerin, Xylitol, Hydrated Silica, Xanthan Gum, Aroma, Sodium Lauryl Sulfate, Sodium Bicarbonate, 2-Bromo-2-Nitropropane-1,3 Diol, Limonene, Citral.
Notice the ingredients. Not a lot of “natural” stuff there, is there? This, of course, is marketing pure and simple. And bad marketing at that.
Moreover, they imply a lot of shady stuff. “Mint free!” Is mint bad for you? Why are they touting this as a benefit?
If you’re like me (or Lydia), you’ve gotten a rash of ads on social media about this miracle charcoal toothpaste that claims to:
- detoxify your mouth
- whiten teeth
- “restores tooth enamel at the same time”
This toothpaste uses activated charcoal, and apart from the unsubstantiated claims listed above, its marketing ploy is to show (via viral videos) people from around the globe brushing their teeth with this black paste, which is shocking and effective in its approach. “How can brushing your teeth with this black crap be good for you? But it is!!” It’s that counter-intuitive thought that lodges the meme in one’s mind and makes one susceptible to the messages promoted above.
Conclusion: Toothpaste totally matters!
First off, I realize that talking about toothpaste isn’t like talking about chemotherapy or anything else in life that really matters. However, most of us reach for that tube of toothpaste at least once per day (and hopefully more!), and squeeze that concoction of fluoride, flavoring, humectants, detergents, and abrasives (from the bottom up for god’s sake!) onto our nylon bristles in order to stave off the ravages of tooth decay and gum disease, as well as to freshen our breath. Hopefully, this will shed a little light on what to look for when purchasing toothpaste, and to realize that while most “alternative” toothpastes confer no real benefits, some make outrageous claims which can be unethical, and flat out wrong.