Price and Availability of Prescription Fluoride Toothpaste in US Pharmacies

Dental caries remains one of the most common chronic diseases in children. A report by the National Institute of Dental and Craniofacial Research found that 42% of children ages 2 to 11 have had dental caries in the primary dentition.1 The overall prevalence of dental caries in children significantly declined between 1970 and 1990 due to preventive measures taken to control the caries.1 Fluoride has been used systemically and topically to help prevent occurrence of dental caries. Fluoride obtained through the systemic route enters into the blood serum and gets deposited into the developing teeth. In contrast, topical fluoride has a direct effect on the teeth. Most of the topical fluorides are available from sources such as community water, toothpastes, mouth rinses, gels, foams, and varnishes.2

Fluoride-containing toothpastes come with varying degrees of fluoride ion concentrations, ranging from 850 ppm to 5,000 ppm. Several studies have shown superiority of 5000 ppm fluoride-containing toothpastes over other concentrations.3,4 In an in vitro study conducted by Diamanti et al, 5,000-ppm fluoride-containing toothpaste showed significantly less tooth volume mineral loss compared to 1,450-ppm and 2,800-ppm toothpastes.3 In a clinical study, Ren et al. found improved resistance to acid erosion on enamel surfaces after treatment with 5,000-ppm fluoride toothpaste over 1,450-ppm toothpaste.4 Some studies found that 5,000-ppm fluoride toothpastes were more effective than other caries-inhibiting milk-protein-containing pastes.5,6 Prabhakar et al, in their in-vitro study, reported greater remineralization potential and dentinal tubule occlusion ability of 5,000-ppm fluoride-containing toothpastes.5 Similarly, Oliveira et al found that 1.1% sodium fluoride dentifrice demonstrated overall greater remineralization ability than 10% Calcium Phospho Peptide-Amorphous Calcium Phosphate (CPP-ACP) crème.6 The American Dental Association recommends the use of 5,000-ppm fluoride toothpaste to arrest or reverse non-cavitated and cavitated lesions on root surfaces of permanent teeth.7 A most recent systematic review and network meta-analysis found 5,000-ppm fluoride toothpaste was most effective for arresting or reversing non-cavitated occlusal and approximal lesions as well as non-cavitated and cavitated root carious lesions in primary and permanent teeth.8

In the United States, fluoride-containing toothpastes are primarily categorized as non-prescription (over-the-counter) and prescription products based on the concentration of fluoride in the toothpastes. Commercially available over-the-counter fluoridated toothpastes are composed of fluoride concentrations around 1,000 ppm. In contrast, toothpastes containing over 5,000 ppm of fluoride ion, or 1.1 % sodium fluoride, are available only as prescription products provided by registered dental professionals. Several 1.1% sodium fluoride toothpaste formulations are currently available in the market and are primarily dispensed through pharmacies. However, it is unclear if the prescription toothpaste products are in inventory at all pharmacies. It is important to perform a market evaluation of commercially available 1.1% sodium fluoride toothpaste products to be able to make appropriate recommendations to patients, dental professionals, and pharmacy companies. Hence, this study aimed to evaluate the distribution and cost of 1.1% sodium fluoride toothpaste across pharmacies in the US.

Based on United States Census Bureau data, the areas were categorized as rural, suburban, and urban.9 The pharmacies across these areas in the US were identified through a stratified random sampling method. The product details and cost of 1.1% sodium fluoride toothpaste currently available in their stock was obtained through walk-in and telephone interviews. Information obtained included demographic data such as the name of the pharmacy, city, state, and area (rural, suburban, urban), as well as product details including name of the brand, product name, and retail selling cost.

In total, 192 pharmacies were interviewed across 47 states and territories in the US, and the information of 360 products was obtained. Out of 192 pharmacies interviewed, 79 (41%) were in urban areas, followed by 61 (32%) in rural areas and 52 (27%) in suburban areas (Table 1). Based on the distribution of products, 153 (41%) were in suburban areas, (41%), 114 (32%) were in rural areas, and 93 (27%) were in urban areas (Table 2).

The minimum cost of the product was $3 in Phoenix, Arizona. The costliest product was at $40, sold in Pasadena, California. The average minimum cost of the product was observed in Oklahoma and maximum cost was in Honolulu, Hawaii.

The average costs of 1.1% sodium fluoride toothpaste in the rural, suburba,n and urban areas were $19.65, $20.77, and $20.44, respectively. A One-way ANOVA showed no significant difference between the cost of the products sold in the pharmacies across rural, suburban, and urban regions of the US (p>0.05). Independent sample t-tests showed no significant difference between the cost of 1.1% sodium fluoride toothpaste sold in the pharmacies in the rural and suburban areas (p>0.05). Similarly, no significant difference in the cost was observed between the suburban and urban areas (p>0.05) and between rural and urban areas (p>0.05, Table 3).

The cost of the products was obtained from four common and accessible pharmacies across the US (Costco, CVS, Walgreens, Walmart). In total, 49 products were analyzed in Walgreens, followed by 40 in CVS, 28 in Walmart and 20 in Costco. The minimum cost of the 1.1% sodium fluoride toothpaste formulation was $7.99 in a CVS pharmacy and the maximum cost was $39.00 in a Costco pharmacy. One-way ANOVA indicated a statistically significant difference in the cost of products sold across major pharmacies in the US (p<0.05; Table 4).

In the overall global economy, the toothpaste market alone was valued at $26.09 billion in 2018 and it is estimated to reach $36.98 billion by 2024.10 Different formulations of toothpastes are available in the market, primarily driven by the brand presence, cost, and formulations. Similar to non-prescription toothpaste brands, prescription toothpastes are produced and marketed by different pharmaceutical companies. Unlike non-prescription brands that are freely available in stores, prescription brand toothpastes are exclusively sold either at the dental office or at pharmacies. Hence, it is found appropriate to understand the brands, and costs of the products available across the pharmacies in the United States. In this survey, the authors found that several brands of 1.1% sodium fluoride products are available, with different formulations and varying costs.

In addition to brand and cost factors, it is important to understand the importance of dispensing 1.1% sodium fluoride toothpaste products at the dental office. Storage and dispensing could incur additional costs at the pharmacies that is usually added to the selling price on the toothpaste. There is a possibility that this could be reduced by directly dispensing in the dental office at a relatively cheaper price. In addition to the lower cost, eliminating trips to the pharmacy is helpful for patients, particularly during the COVID-19 pandemic, when it is advised to avoid unnecessary travel.

In this survey, the authors found varying practices of dispensing 1.1% sodium fluoride toothpaste products. Although the toothpaste comes in different formulations including gel, cream, and paste, some of the products came with different sizes. Although 3.4-ounce (100 grams or 100 ml) is considered as the standard size of a 3-month supply (brushing twice daily), some of the generic brands are sold in 1.8-ounce (51 grams) tubes. If applied twice daily at about 0.5 grams per brushing, one 1.8-ounce tube is expected to last for only 51 days.11 That means three to four pharmacy visits might be required in between 6-month recall appointments to the dentist.

During the survey, it was found that 54% of the time, either no brand was stocked or only a single brand was available. This leaves no option for the patient to choose from; they are forced to buy the product that is provided or nothing. In addition, some of the 1.1% sodium fluoride toothpaste products sold at the pharmacies do not contain abrasive. Patients, at times, unknowingly use the prescribed toothpaste as an alternative to regular toothpaste, and use of non-abrasive dentifrice might compromise effective plaque control and overall oral health. Since most of the offices do not direct the patient to buy from a specific pharmacy, the office is challenged to know the brand, tube size, and abrasiveness of what the patient purchases. Furthermore, studies have consistently shown that 20% to 30% of medication prescriptions are never filled, and that approximately 50% of medications for chronic disease are not taken as prescribed.12 All of these factors could be addressed if the 1.1% sodium fluoride prescription toothpaste could be dispensed at the dental office, customized to the need of individual patient.

Although the authors attempted to cover all the aspects pertaining to brands, cost, and dispensing practice of 1.1% sodium fluoride toothpaste, some confounding factors could not be avoided. First, most of the surveys were conducted over the telephone and the accuracy of answers received could not be verified. The responses could have varied based on the competence of the pharmacist dispensing the medication. Second, there were several interviewers involved in the survey and hence they could not be calibrated for examiner reliability. Despite these drawbacks, this study provided valuable information on the distribution, cost, and dispensing of one of the most commonly prescribed toothpastes in the marketplace.

Several brands of 1.1% sodium fluoride toothpastes are currently available across pharmacies in the US. There is no difference in the cost of the products sold in the rural, suburban, and urban areas. There is a significant difference in the cost among different brands and between pharmacies. In addition, varying practices of dispensing toothpaste were observed across the pharmacies and hence it is plausible that prescription toothpaste could be more cost effective if dispensed in the dental office, customized to the need of individual patients.

Jayakumar Jayaraman, BDS, MDS, FDSRCS, PhD
Department of Developmental Dentistry
University of Texas San Antonio School of Dentistry
San Antonio, TX

Kevin Donly, DDS, MS
Department of Developmental Dentistry
University of Texas San Antonio School of Dentistry
San Antonio, TX