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INTRODUCTION

The care and health of the mouth is an area of therapeutics that has for centuries been the purview of dental professionals. As a result, it is largely ignored in mainstream medical care and general pharmacy practice. Even though many of the dentifrices, devices, rinses, and other products used in maintaining oral health are purchased in community pharmacies, the positioning of pharmacists in an enclosed pharmacy department often limits conversations with patients seeking advice on nonprescription medicines and over-the-counter (OTC) products.

When searching for the best oral care product for their conditions and symptoms, consumers can be confused by the profusion of marketing claims. Nearly all toothpastes claim “whitening” properties, yet large numbers of patients have gum recession, caries, and other problems that might cause or worsenz tooth sensitivity as they whiten teeth. Allergies and sensitivities occur in some patients, and these can manifest in a variety of situations with differing symptoms.

The best uses of dental products are often obvious, based on their ingredients as listed in product labels, but labels can be difficult to interpret, even for pharmacists who are well trained in chemistry and biology. Pharmacists can better counsel consumers on oral products when they know the purposes and best uses of the ingredients in these products.

In this program, current information is provided about common active and inactive ingredients contained in toothpastes and other dentifrices and mouth rinses, as well as products marketed for tooth sensitivity, xerostomia (dry mouth), and denture cleaning and adhesion.

IMPORTANCE OF ORAL HEALTH TO GENERAL HEALTH

Oral health care is a natural complement to medication therapy management services in patients with systemic diseases, such as diabetes, asthma, chronic obstructive pulmonary disease, and cardiovascular disease, and also in older adults with numerous diseases requiring pharmacotherapy with multiple medications. The relationship between general health and oral health is increasingly recognized as important, and is in some cases bidirectional, as when diabetes puts patients at risk for periodontal disease, and vice versa.¹

As the number of Americans in older adulthood increases, oral health challenges are also growing. About one-fifth of Americans lose all their natural teeth by age 60, and periodontal disease is very common among older adults.^2,3 Restorative dental work that is decades old begins to fail, creating a need for bridges, dentures, and implants. With these changes and challenges, patients need to translate advice about a dental cleaning regimen provided by dentists and hygienists into a product selection decision as they confront a merchandise display with dozens of product options. Helping with these dilemmas is a natural role for community pharmacists.⁴

In addition, younger Americans in their child-bearing years need to maintain a healthy mouth and also learn to care for their young children. Daily care of their own teeth becomes more complicated just as they also need to know when to introduce their children to fluoride products and flossing.

The pandemic has increased oral health challenges. Prophylactic cleanings and examinations have been delayed or skipped, people endured minor oral health problems because of fear of the coronavirus or lack of income, and multistep procedures such as implants, bridges, and crowns have been interrupted. Some patients have broken teeth from stress-induced grinding, and oral care of older adults in long-term care facilities declined as staff dealt with waves of viral illness among residents.⁵

Pharmacists, while not well trained in oral health during pharmacy school, are becoming partners with dental professionals through outreach programs conducted by colleges of pharmacy in conjunction with organizations of dentists and dental hygienists. Helping to make the mouth an important part of the focus of nondental professionals is a goal for truly interprofessional health care teams.^6–8

CATEGORIES OF INGREDIENTS IN DENTIFRICES

Case 1: A 55-year-old man presents with bleeding gums and asks about dental products that are “more gentle” than the ones he is currently using. He is a long-time patient of the pharmacy with current prescriptions for hypertension, dyslipidemia, and gastroesophageal reflux disease. You ask about the patient’s most recent physical, and he says his provider was concerned about an elevated glucose level and weight gain. Using the Collect/Assess/Plan/Implement/Follow-up patient care process, outline your approach to this consumer. (See suggested responses at the end of the text of this program.)

To help consumers find the best oral health product for their specific conditions, pharmacists can use the Patient Care Process as described in a recently published chapter of Pharmacotherapy: A Pathophysiologic Approach⁹:

• Collect patient characteristics, patient and family medical history, social history and dietary habits (including smoking status), current medications
• Assess factors such as hydration status, precipitating factors, emotional status, quality of life, severity of condition, willingness to quit smoking (if applicable), ability and willingness to try and also topay for pharmacologic or nonpharmacologic options
• Plan through patient education, self-monitoring of symptoms, and referrals to other providers when needed
• Implement by providing patient education, using motivational interviewing/coaching strategies, and scheduling a follow-up
• Follow-up by monitoring and evaluating resolution of symptoms, treatment-specific adverse effects, adherence to treatment plan

Therapeutic dental products — those with active ingredients with specific pharmacologic actions — carry the Drug Facts labels required on all OTC products recognized as safe and effective by the U.S. Food and Drug Administration (FDA). This ensures that each label carries a list of active ingredients, separate from other “inactive” ingredients that are used for nonpharmacologic actions such as controlling pH, whitening teeth through abrasive activity, reducing plaque through foaming actions, thickening or stabilizing of the products, or more general purposes such as providing color, flavor, or fragrance. However, cosmetic mouthwashes and certain other oral care products provide general lists of ingredients rather than a Drug Facts label. In these cases, the list of ingredient must be examined closely when helping consumers find the best product for their purposes. These ingredients may act through general actions such as soothing, moisturizing, or freshening the mouth.

When consumers seek oral health products for specific uses, they sometimes need to look beyond marketing claims to decide whether conditions such as tooth sensitivity, gum recession, or xerostomia will be alleviated. People allergic to common ingredients such as sodium lauryl sulfate (SLS) should examine the list of ingredients to find products without this common foaming agent.^10–12

Pharmacists are adept at navigating ingredient lists and will be prepared to assist consumers in this search. To do so, they need to know the uses and adverse effects of common active ingredients as well as clinical considerations for other ingredients used in oral care products.

Active Ingredients

The most common products used for routine oral hygiene are toothpastes, mouthwashes (also called mouth rinses), whitening products, and products for denture care, such as cleaners and adhesives.

The American Dental Association (ADA) recommends that adults use a toothpaste or gel containing fluoride. Potassium nitrate, which decreases tooth sensitivity, is used in some products instead of a fluoride compound. . Antimicrobial ingredients in toothpastes (e,g., stannous fluoride, cetylpyridinium chloride) can reduce gingivitis and reduce the build-up of calculus (pyrophosphates and zinc citrate). Triclosan, an ingredient once used for preventing caries, plaque, and gingivitis, is no longer commercially available.¹¹

As listed in Table 1, dental care products can also contain ingredients that decrease tooth sensitivity, provide a mild abrasion (such as calcium carbonate or silicates), harden enamel with fluoride, prevent water loss through a humectant effect (e.g., glycerol, propylene glycol, or sorbitol), flavor the products (e.g., saccharin or other sweeteners), thicken the product (e.g., gums or colloids), and detergents (most often SLS).^11,13

• As discussed in more detail in the Clinical Considerations section, dentifrices for xerostomia are formulated to moisturize the mouth and provide lubrication while avoiding harsh ingredients such as alcohol and SLS. If fluoride rinses are also needed, patients can alternate fluoride rinses with products for dry mouth at different times of the day.

COMMON DENTIFRICE INGREDIENTS: CLINICAL CONSIDERATIONS

Case 2: A 41-year-old woman develops sensitivity to hot and cold beverages secondary to gum recession. She has tried several toothpastes with potassium nitrate that reduce her sensitivity but seem to produce a sloughing of oral tissues. Her dental professional suggests this could be a sensitivity to SLS, and the patient asks for your help in identifying an alternative product. Using the Collect/Assess/Plan/Implement/Follow-up patient care process, outline your approach to this consumer. (See suggested responses at the end of the text of this program.)

To maintain a healthy mouth for a lifetime, people consult oral health professionals who will provide education about the need for a schedule of daily oral hygiene with regular cleanings and examinations. Toothbrushing, flossing, and mouth rinsing form the core of daily hygiene regimens, and a variety of products are used to help patients in this effort. Pharmacists contribute as members of the oral health team by suggesting products that address needs and problems and referring patients to dental professionals when needed.^7,8

Fluoride

Recognized since the middle of the 20^th century, fluoride is one of the greatest public health successes in oral health. Consumption of appropriate levels of fluoride during childhood — often through fluoridation of community water supplies — and its application throughout life have enabled people to maintain healthier mouths even as lifespans have increased.¹⁴

As shown in Table 1, toothpastes and mouthwashes can contain sodium fluoride, sodium monofluorophosphate, or stannous fluoride. The first 2 are largely interchangeable, having similar properties and uses. Patients should be instructed to use fluoride-containing toothpastes for at least 2 minutes in the morning and at night, at a minimum, and to expectorate afterwards to avoid fluorosis. Proper brushing with a fluoride-containing toothpaste and cleaning between teeth each day are very important in maintaining a healthy mouth.

Stannous fluoride is chemically SnF₂, and the tin confers antibacterial properties and provides efficacy for gingivitis. Stannous fluoride is proven safe and effective in reducing and preventing plaque. However, stannous fluoride also stains the teeth; some research shows that a 2-step regimen can minimize staining: stannous fluoride dentifrice followed by a whitening gel.¹⁵

Stannous fluoride is also promoted as an antisensitivity agent; products with this form of fluoride are marketed as being useful for protecting against caries, plaque/gingivitis, and sensitivity. Stabilized forms of stannous fluoride have been studied for relieving tooth sensitivity, and a systematic review reported that 6 trials of 8 weeks showed overall significant effects of stannous fluoride on sensitivity in comparison with control products.¹⁶

Potassium Nitrate

• Potassium ions reduce tooth sensitivity by depolarizing neurons. Dentifrices for those with sensitivity often contain potassium as the nitrate salt, although some use stannous fluoride, which acts by blocking dentinal tubules. Toothpastes marketed for sensitive teeth also use less abrasive cleaners.¹³

When tooth sensitivity is not adequately managed by desensitizing toothpastes, pharmacists should refer patients to dental professionals who can ensure symptoms are not caused by cavities, tooth damage, or defective restorations.

Sodium Lauryl Sulfate and Other Allergenic Ingredients

Detergents such as SLS can produce allergic reactions when included in dentifrices. The symptoms of such contact allergies vary among patients, and demonstrating that symptoms are caused by SLS or other allergens is often a process of exclusion. When products with the ingredient cause the symptom and those without it do not, SLS or another allergen sensitivity is presumed. Possible symptoms include cheilitis (chapped lips) with or without dermatitis around the mouth, stomatitis, glossitis, gingivitis, buccal mucositis, burning, soreness, and possibly burning mouth syndrome and recurrent aphthous ulcers.¹⁷

Because SLS is commonly included in toothpastes, finding an SLS-free product that meets the patient’s needs and preferences (e.g., pastes versus gels, sufficient foaming action, desensitizers, dry mouth) can be challenging. New formulations have been marketed in recent years, and by systematically asking consumers about their preferences in toothpastes, acceptable products without SLS will emerge.

Chlorhexidine

Chlorhexidine, an effective antibacterial chemical, is an ingredients in prescription mouthwashes for use in patients with gingivitis or following dental procedures such as tooth scaling or root planing. Chlorhexidine often leaves brown stains on teeth, and patients should not eat or drink for several hours after using chlorhexidine rinses . Some patients are allergic to chlorhexidine; since allergic reactions can be severe, health professionals considering use of chlorhexidine should be sure to ask patients if they have had reactions to this medication.¹⁸

Cetylpyridinium

The antimicrobial chemical cetylpyridinium chloride is widely used in mouthwashes and other dentifrices for its effectiveness in preventing and reducing gingivitis and plaque. This monocationic quaternary ammonium compound is also used for its antiseptic properties in foods, and microbial resistance to this medication is a concern, partly because of its widespread use.¹⁹

Like stannous fluoride and chlorhexidine, cetylpyridinium can stain teeth. While it is effective, people who value whiter teeth find the tradeoff between a fresher mouth from cetylpyridinium mouthwash and the resulting staining of teeth is not acceptable.²⁰

Eucalyptol, Menthol, Methyl Salicylate, and Thymol

Recognized by FDA for antigingivitis and antiplaque activity, the fixed combination of eucalyptol, menthol, methyl salicylate, and thymol has been shown to be safe and effective in numerous studies cited in the FDA’s OTC monograph for this category of oral health products. Individually, components of the combination have anesthetic/analgesic (eucalyptol) and bactericidal/fungicidal (thymol) properties; FDA recognizes menthol and methyl salicylate as safe when used as rinses.²¹

Clinical studies of the eucalyptol, menthol, methyl salicylate, and thymol combination show efficacy over a 6-month period for improving gingival health and reducing bleeding.^22–24

Alcohol

Case 3: A 25-year-old woman inquires about the safety of mouthwashes containing alcohol. She adds that she is using an alcohol-based mouthwash for smoker’s breath. Upon questioning, the woman says she drinks 2 or more alcoholic drinks most days of the week. Using the Collect/Assess/Plan/Implement/Follow-up patient care process, outline your approach to this consumer. (See suggested responses at the end of the text of this program.)

Ingestion of alcohol and the resulting increase in acetaldehyde levels is associated with greater risk of cancers of the mouth, pharynx (throat), larynx (voice box), esophagus, liver, colon, rectum, and breast (in women). Based on cohort or case–control studies, the relative risks of oral or pharyngeal cancer are increased by 3.2- to 9.2-fold in patients consuming 4 or more drinks per day (60 g of alcohol).^25,26

A heightened risk of cancer and other findings have led to concern about use of alcohol-containing mouthwashes, some of which are 26.9% alcohol. The data are mixed, however, with some case–control studies finding associations between mouthwash use and cancers, while others do not. One review article concluded that in patients at high risk, use of alcohol-containing mouthwashes should be restricted until newer findings provide other guidance.²⁷

Oxidizing Agents and Whitening Ingredients

Many consumers want bright, white teeth, and marketers of dental products are ready to help them with that wish. The problem is that large numbers of people today have periodontal disease, receding gums, tooth sensitivity, and other oral conditions that make abrasives and whitening agents painful and inadvisable to use. Patients with sensitivity secondary to exposed roots or tooth decay should be evaluated by a dentist before attempting to whiten their teeth on their own.^28,29

Whitening claims are common for toothpastes, and many contain ingredients that whiten enamel through relatively mild actions suitable even in patients with tooth sensitivity and/or receding gums. Patients considering use of dentifrices that make whitening and/or tartar control claims should remember that whitening will not change the color of fillings or crowns, and some stains are not removed by whitening.³⁰

Common ingredients in home-based whitening products include hydrogen peroxide, carbamide peroxide, sodium percarbonate, sodium hexametaphosphate, sodium tripolyphosphate, and calcium peroxide. Peroxides act through oxidation (bleaching) to whiten the teeth; sodium hexametaphosphate and sodium tripolyphosphate are chelating agents that soften stains. These ingredients are available in kits with gels in trays, strips, paint-on gels, chewing gums, and mouthwashes. Research into the use of tooth desensitizers with chemical whiteners such as carbamide peroxide is ongoing, including some formulations prepared by compounding pharmacies. The best advice for most patients with moderate-to-severe gum recession and tooth sensitivity is to work with a dental professional to identify the best options for whitening products that will maximize results based on pretreatment tooth color, amount of exposed dentin, and tolerance of adverse effects.^28,31,32

In addition, evidence supporting the effectiveness of home-based products is low to very low, according to a Cochrane Oral Health review, and common adverse effects, including tooth sensitivity and oral irritation, occur more often in products with higher concentrations of whitening ingredients.³³

Xylitol and Other Xerostomia Therapies

Case 4: A 68-year-old man is picking up refills for his antihypertensive medications, triamterene–hydrochlorothiazide and lisinopril. He mentions that he is waking up each morning with an extremely dry mouth — “bone dry,” he says — and asks whether the products for dry mouth “are any good.” Using the Collect/Assess/Plan/Implement/Follow-up patient care process, outline your approach to this consumer. (See suggested responses at the end of the text of this program.)

Older adults take more medications than younger people and thus are most likely to be in the pharmacy multiple times each month. Numerous medications can contribute to xerostomia, including anticholinergics, antihistamines, angiotensin receptor blockers, angiotensin converting enzyme inhibitors, beta blockers, diuretics, opioids, antidepressants, and antipsychotic medications. In addition, radiation and chemotherapy treatments can interfere with salivary flow, as can Sjögren’s syndrome, diabetes, methamphetamine abuse, and other clinical conditions.^9,34

Xerostomia is a particularly important condition for older adults to recognize and address. Without adequate salivary flow, the process of mastication is impaired, and digestion — which begins in the mouth — may not be as effective. In addition, lack of salivary flow prevents the mouth from cleansing itself of cariogenic bacteria, leading to tooth or root decay and increasing the possibility of tooth fracture and loss. Xerostomia can occur with aging, as a side effect of medications that dry the mouth, or as a complication of diseases or cancer treatments.³⁵

Xylitol and other sugar alcohols are commonly used in OTC products for dry mouth. These include mouthwashes, gels, lozenges, and tablets that provide action over a few hours during the day and while sleeping. Tablets with adhesive backing that slowly dissolve when placed between the cheek and gingiva are particularly effective for overnight use. Sugar-free candies can also be used during the day. Since these products contain sugar alcohols, which can cause intestinal bloating and loose stools, patients should limit their use.^34,35

Silicas and Other Abrasives

Toothpastes contain mild abrasives to help in removing plaque and stains from surfaces. Common ingredients in toothpastes that confer this erosive action are hydrated silica, hydrated aluminum oxides, calcium carbonate, and magnesium carbonate. The effects of these compounds, measured as relative dentin abrasion (RDA), is most relevant in patients with exposed dentin secondary to gum recession; intact enamel is the hardest substance in the human body and is not affected by normal abrasive levels in toothpastes.¹³

RDA values of abrasives used in toothpastes range from 0 to 250. A rule of thumb is that toothpastes should have RDA values of about 100, but any value of 250 or less is considered acceptable for patients with natural teeth or implants.³⁶

Dentures

Edentulism — loss of all of the natural teeth — is common in older adulthood in the United States, occurring in about one-fifth of older adults. Tooth loss has a number of implications for people’s ability to eat a healthy diet, interact socially, communicate, and maintain a positive self-image.⁴

To replace lost teeth, dental appliances such as dentures and bridges are commonly provided for patients. These require special care and maintenance, as they are made with materials that are softer than the enamel coating of natural teeth. Adhesives are needed to keep dentures in place, and patients may develop mouth ulcers if bridges and dentures do not fit well.³⁷

Cleansers used in denture care include sodium hypochlorite, sodium bicarbonate, and potassium monopersulfate. Stains are removed by citric acid, sodium perborate, and sodium polyphosphate. An ingredient to which small but substantial numbers of people are sensitive is persulfate; it can cause local reactions when in contact with the skin or mouth tissues, and it can be responsible for systemic effects such as hypotension and difficulty breathing. More serious systemic reactions to persulfate include soft tissue burns, stomach pains, hematuria, and/or internal bleeding. Because of these effects, persulfate is recommended only for smokers who need its action to remove tobacco stains from their dentures.^38,39

CONCLUSION

Through education about the ingredients and scope of products marketed for oral health, pharmacists will be better prepared to assist consumers seeking guidance in this often-overlooked therapeutic area and fulfill their roles as partners on the oral care team. Given the association between oral and systemic health, a greater focus on oral health is a natural extension of medication therapy management services provided in community pharmacies.

RESOURCES

Mouth Health: Consumer-oriented website of the American Dental Association (www.mouthhealthy.org)

Smiles for Life: Resources useful for professionals in teaching students in the health professions or interacting directly with patients about oral health (www.smilesforlifeoralhealth.org)

Oral Health: American Academy of Pediatrics (www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Oral-Health.aspx)

American Academy of Pediatric Dentistry: Practice checklists and resources for patients and professionals (www.aapd.org)

Oral Health: An Essential Element of Aging: The Gerontological Society of America Oral Health Workgroup (https://www.geron.org/programs-services/alliances-and-multi-stakeholder-collaborations/oral-health-an-essential-element-of-healthy-aging)

Love the Gums You’re With: Patient resources on the website of the American Academy of Periodontology (www.perio.org/consumer/patient-resources) and the organization’s GUMBLR website for “all things gums” (loveyourgums.tumblr.com)

Mouth Care Without a Battle: An evidence-based approach to person-centered daily mouth care for persons with cognitive and physical impairment (www.mouthcarewithoutabattle.org)

Oral Health: Federal resources are listed on the Health Resources and Services Administration website (https://www.hrsa.gov/sites/default/files/hrsa/oralhealth/oral-health-highlights.pdf)

Wisdom Tooth Project: Health resources, originally developed by the Oral Health America and now available from Authority Dental, for older adults regarding the importance of oral health, finding dental care services, and paying for care (www.toothwisdom.org)

SUGGESTED RESPONSES TO CASES

Case 1

Collect: Chief complaint of bleeding gums. Concurrent chronic conditions, elevated glucose, weight gain. Nonsmoker. Consumes alcohol regularly (1–2 drinks per day). Currently using a hard toothbrush and regular toothpaste twice daily and waxed floss at bedtime.

Assess: Possible signs of periodontal disease and prediabetes. When feasible and appropriate in the pharmacy setting, look at the patient’s mouth for signs of gum disease and recession, and notice if any signs of oral cancer are present. Ask about other dental devices currently in use, including inappropriate objects such as toothpicks.

Plan: Suggest use of a toothbrush with soft or ultrasoft bristles, demonstrate proper flossing technique, and identify a toothpaste for sensitive gums and teeth that is acceptable to the patient. Review appropriate daily oral hygiene.

Implement: Advise the patient about the causative relationship between gum disease and diabetes, and obtain permission to share these concerns with both his dentist and primary care provider. Reinforce the need for and structure of adequate daily oral hygiene.

Follow-up: Contact the patient 1 to 2 weeks later to confirm that he has made contact with his dentist and primary care provider. Ask him how he likes the new toothbrush and toothpaste and address any new concerns.

Case 2

Collect: Chief complaint of sloughing of gum tissues with multiple new brands of toothpaste. Patient has recently been diagnosed with gum recession and tooth sensitivity, necessitating use of toothpastes with potassium nitrate.

Assess: Possible sensitivity to SLS.

Plan: Determine patient preferences for taste, consistency, and foaming action of toothpaste. Using this information, identify an SLS-free product for her to try.

Implement: Recommend that the patient use an SLS-free toothpaste, and suggest use of a product likely to be acceptable based on patient preferences.

Follow-up: Contact the patient 1 to 2 weeks later to ask how she likes the new toothpaste and address any new concerns.

Case 3

Collect: Chief complaint of concerns about use of mouthwashes containing alcohol. Smoker with excess alcohol intake. No other current conditions or medications.

Assess: Patient at high risk of cancers secondary to tobacco and alcohol use.

Plan: Explain that there is a theoretical concern with use of alcohol in mouthwashes, but much stronger evidence links both smoking and alcohol consumption with a number of cancers.

Implement: Using motivational interviewing, assess the woman’s readiness for smoking cessation and reducing daily alcohol intake. Describe your pharmacy’s wellness programs. Introduce the woman to alcohol-free mouthwashes that can freshen the breath without further alcohol exposure.

Follow-up: Contact the patient 1 to 2 weeks later to ask about how she likes the mouthwash. Assess her willingness to join a smoking cessation program and move toward reduced use of alcoholic beverages.

Case 4

Collect: Chief complaint of dry mouth.

Assess: Review the patient’s medication history for any other agents associated with dry mouth and ask about other drugs used previously for hypertension. Gather information about his daily oral hygiene regimen.

Plan: Educate patients about dry mouth and ways of managing it, including adequate hydration, medication changes (in collaboration with prescriber), mouthwashes, and long-acting products.

Implement: Explain that products for dry mouth are very effective and that it is important to oral health to maintain hydration status during the day and salivary flow during sleeping hours. Recommend a mouthwash that improves salivary flow and a product for sustained action through the night. Also share that the patient’s medications could be contributing to dry mouth and that a medication change could help. The patient agrees that you can contact his physician to discuss this possibility. Contact the patient’s physician to recommend alternative antihypertensive agents not associated with xerostomia.

Follow-up: Contact the patient 1 to 2 weeks later to ask about how the patient’s dry mouth symptoms are on the new regimen and to be sure he is in contact with his primary care provider about the antihypertensive regimen.

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