Advanced Oral Health Protection: A Multifunctional Dentifrice Designed to Prevent Oral Diseases and Conditions

Cassiano Kuchenbecker Rösing, DDS, MSc, PhD

Oral diseases are a public health problem that impair quality of life and generate increased costs and demands.² The World Economic Forum reported this year that almost half the world's population suffers from oral diseases that impact daily life and subject the population to a higher risk of systemic health issues.³ It is time for radical policy action. Governments, industries, academic institutions, and scientific organizations must help change the burden of oral diseases.⁴ Concerned about the lack of attention to oral health, a historic resolution was adopted by the World Health Assembly in 2021 stating that oral health should be firmly embedded within the noncommunicable disease agenda and that oral healthcare interventions should be included in universal health coverage programs.⁵

The most prevalent oral diseases-caries and periodontal diseases-are considered noncommunicable chronic illnesses that share risk factors with other diseases of the body and are strongly related to lifestyle and behaviors.⁶ Dental caries and periodontal diseases, which are largely preventable, stem from the accumulation of dysbiotic biofilms frequently worsened by modern-day dietary choices, such as increased sugar consumption, frequent snacking, tobacco use, and acidic/alcoholic beverages.⁷ In the United States more than 40% of adults present with some level of periodontitis, which evidence suggests is likely the result of poor oral healthcare, brushing irregularity, and ineffective dentifrice.^8,9 Modern dietary habits and lifestyle choices pose continuous challenges to the oral cavity, necessitating a protective approach that can preserve the delicate balance of the oral ecosystem and prevent disease.

Preventive programs based on change in lifestyle-notably, increasing the quality of oral hygiene-reduce the occurrence of caries and periodontal diseases and lead to diminished tooth loss.¹⁰ More recently, preventive practices have also been demonstrated in periodontitis treatment.¹¹ However, balancing dysbiotic biofilms and plaque control as it is performed by the majority of the population has limitations. It is of interest to create mechanisms to compensate for difficulties in plaque control. Even in clinical studies, with strict protocols, it is important to warrant good standards of plaque control.¹² It is well understood both in clinical practice and in research that there are clear limitations for good standards of plaque control. This is not only the reality for physically impaired individuals and an aging population, but plaque control for many people is suboptimal due to difficult-to-reach areas that demand dexterity. Thus, there is an opportunity to provide tools to compensate for such difficulties. While plaque debridement through toothbrushing and enamel protection with fluoridated toothpaste are fundamental, evidence suggests that suppression of biofilms with an antibacterial toothpaste can provide the preventive care needed to control caries development.⁹ Active prevention, through the use of an advanced antibacterial fluoride toothpaste that not only offers cavity protection but also fights gingivitis, can play a pivotal role in reducing this burden by impeding the onset and progression of oral diseases and the development of potential systemic health issues linked to poor oral hygiene. Importantly, antibacterial toothpastes have the advantage of offering continued efficacy between brushing.

Stannous fluoride (SnF₂) has been studied in depth and widely indicated for antibacterial, antiplaque, anticaries, and antigingivitis effects.^13-15 However, the antiplaque and antigingivitis clinical efficacy of SnF₂ is dependent on maintaining the 2+ oxidation state of stannous.^14-16 In the past, this has proven to be a challenge since SnF₂ readily hydrolyzes and oxidizes in aqueous solutions to form Sn⁴⁺ ions, which are therapeutically inactive.^16-19 Many approaches to prolong the stabilization of stannous in a 2+ oxidation state (Sn(II)) have been attempted with deleterious effect. For example, preventing hydrolysis through the removal of water reduces product desirability and is difficult to process; adding more Sn(II), such as stannous chloride, increases Sn(II) availability but also increases the potential for tooth stain and compromises the taste; and processing the formula under N₂ removes oxidation pathways but has limited long-term storage stability.²⁰

The development of a multifunctional SnF₂ toothpaste stabilized by nitrate and phosphates (SNaP) is a breakthrough technology with the potential to improve oral health in individuals and populations. This technology increases stability and bioavailability of SnF₂ with the potential of increasing the quality of plaque control.²¹ This advanced formula allows more flexibility to offer benefits, such as various flavors, foam, and esthetics, that people expect from mainstream dentifrices. This approach also aligns with the contemporary trend toward minimalism in consumer goods, which prioritizes ingredient transparency and efficacy. New formulations must not only demonstrate clinical efficacy but also garner positive consumer feedback, which drives compliance. This dual focus enables the product to be effective in preventing oral diseases and also appealing to patients, helping facilitate better oral health outcomes on a broad scale. The development of a therapeutic toothpaste like SNaP is informed by user trends (eg, increased interest in health), scientific research, and global oral health shifts reported by authoritative bodies such as the World Health Organization, World Dental Federation, Pan American Board of Oral Health Examiners, and European Federation of Periodontology. This helps ensure that the product meets consumer demands while addressing the current oral health context by delivering a highly efficacious product with the potential to reduce the incidence of oral diseases and, consequently, the need for more invasive and costly dental treatments.

In short, the effectiveness of active prevention in fighting oral diseases lies in being able to empower individuals, maximize efficacy, and improve adherence to oral hygiene practices. The development of advanced toothpaste formulations that are both effective and appealing to consumers can significantly reduce the burden of oral diseases, contributing to the overall health and well-being of the population. Empowering patients to maintain their oral health is crucial, as it fosters a sense of personal responsibility and proactive behavior toward oral hygiene. The use of advanced toothpaste formulations such as the one presented in this special issue can help redefine the standards of preventive dentistry and public health. The aim of the present article is to review the evidence supporting this dentifrice and help translate the results of research into clinical practice.

The studies presented in this special issue support the development of a multifunctional toothpaste. These studies broadly support different potential benefits of Colgate Total^®. The studies were delineated under contemporary research paradigms, and diseases/conditions were approached with clinical research that follows all laboratory work that supports the principles and mechanisms of action.

The antimicrobial potential of SNaP, including both in vitro and in vivo methods, was conceived under the concept that dysbiosis needs to be controlled and that biofilm is a natural colonizer of the human body.²² In this sense, one should not aim at eliminating the biofilm, but maintaining the biofilm in a symbiotic relation with the host. Elimination of oral biofilms would have negative outcomes, such as the occurrence of opportunistic infections (eg, fungal infections). A dysbiotic biofilm initiates an inflammatory process in the gingival tissues, leading to the occurrence of gingivitis and even periodontitis. In this sense, helping to disrupt oral biofilms with chemical agents is of extreme interest. A symbiotic relationship with oral biofilms is, therefore, an aim in preventive dentistry.

Therapeutic approaches for controlling oral biofilms may include the use of chemical agents. For this purpose, oral biofilm derived from saliva of healthy individuals was used and cultured on hydroxyapatite discs. This biofilm was transferred and toothpaste was applied to it. Treatment consisted of SNaP as the test treatment, a non-antibacterial toothpaste containing 0.24% sodium fluoride and 5% potassium nitrate as a negative control, a toothpaste containing 0.454% stannous fluoride stabilized with sodium gluconate (SnF₂ + SG) as a positive control, and no treatment. Antibacterial performance was measured by monitoring bacterial metabolic function for bacterial respiration and glycolysis. The results clearly demonstrated bacterial suppression by SNaP as compared to controls, showing the potential of SNaP to reduce bacterial load in the mouth. This result has the potential of helping reduce oral problems that are related to dysbiotic biofilms.

In the same article, the authors also clinically tested the antibacterial potential demonstrated in the in vitro model.²² A randomized controlled clinical trial was performed comparing SNaP to a non-antibacterial toothpaste. Bacterial samples were collected from the tongue, cheek, dental plaque, gingival tissues, and saliva. The results were analyzed 12 hours post-brushing at 2 and 4 weeks. In all timepoints and for all bacterial samples, statistically significant differences were observed when test and control groups were compared, in favor of SNaP. The clinical experimental model confirmed the results from the in vitro methods. Therefore, it was demonstrated that the SNaP technology prevents regrowth of the biofilm for prolonged periods after brushing. These results support the potential benefits in prevention and treatment, being considered an active preventive approach, of the most prevalent oral diseases with a dentifrice containing SnF₂ stabilized with nitrate and phosphates.

Since gingival diseases are prevalent in clinical dentistry, the SNaP dentifrice was clinically tested on a plaque and gingivitis model.²³ Such a model is used to give support for clinical effects of oral health products, demonstrating potential in prevention and treatment. This study was a randomized controlled clinical trial performed over 6 months, with intermediate analysis at 3 months. Plaque was assessed by Quigley-Hein plaque index (Turesky modification) and gingivitis was assessed by the Löe and Silness gingival index. SNaP was compared to a regular fluoride-containing toothpaste. The results were stratified to all tooth surfaces and also specifically for interproximal surfaces, which are the most difficult-to-reach areas and where oral diseases tend to be more pervasive. To provide a more clinically relevant result, severity of both plaque and gingival indices were calculated.

At all timepoints, for all analyses, SNaP performed better than the regular fluoride-containing toothpaste. For example, in terms of gingival severity index, which is extremely relevant clinically, a 90% difference was obtained comparing both groups at 6 months. In gingival interproximal areas (remembering that individuals did not floss during the period), the difference between SNaP and the control group was 35.3%. These results need to be understood in a perspective of disruptive knowledge: a chemical agent helps the user control the dysbiotic biofilm in difficult-to-reach areas, which is a clear limitation of sole mechanical plaque control. This was demonstrated over a 6-month period, which is a considerable amount of time to prove the dentifrice's effect in preventing occurrence of gingival inflammation.

Dentin hypersensitivity is a common oral condition that impairs quality of life, as it is one of the chronic pains of the body. Dentin hypersensitivity occurs after the exposure of dentin due to both gingival recession and the loss of dental hard tissues such as enamel. The presence of fluoride has an active potential in preventing dental erosion and treating dentin hypersensitivity. In this sense, stabilized SnF₂ not only is a preventive agent but also serves as a therapeutic approach. The potential of SNaP dentifrice in alleviating dentin hypersensitivity was tested both in vitro and in vivo.²⁴ By means of confocal microscopy, occlusion of dentin tubules was measured in extracted human teeth treated either with SNaP or with a regular fluoride-containing toothpaste. Dentin specimens were brushed with the designated toothpaste for 30 seconds and this procedure was repeated 5 times. The results demonstrated an occlusion of dentin tubules of 86% and 35% for SNaP and the control dentifrice, respectively.

In a randomized controlled clinical trial the antisensitivity effect was tested, comparing SNaP (test group), a potassium nitrate desensitizing dentifrice (positive control), and a non-desensitizing sodium monofluorophosphate dentifrice (negative control). Analyses were performed at baseline and days 1, 3, and 7. Both air blast and tactile stimuli were used. The results indicate that SNaP significantly reduced hypersensitivity pain after 1, 3, and 7 days. After 7 days, individuals that used SNaP dentifrice exhibited an additional reduction in tactile hypersensitivity of 79.8% as compared to the positive control group, and 90.2% as compared to the negative control group with tactile stimulus. These values were 47.1% and 47.9%, respectively, when air blast stimulus was considered.

A dentifrice is also useful in the management of oral malodor. Halitosis is a prevalent condition that impacts quality of life and causes social restraint. It primarily originates in the mouth and is related to the presence of dysbiotic biofilms. It is also considered an esthetic problem, because it impairs social relationships. The understanding of this point can also improve compliance with its management. The antimicrobial effect of SNaP, mitigating bacterial load on oral surfaces, including hard and soft tissues, is crucial in managing halitosis. The effect of SNaP dentifrice on oral malodor was tested by means of a randomized controlled clinical trial compared with a regular fluoride-containing toothpaste.²⁵ The trial lasted 3 weeks and organoleptic measurements were used to assess malodor. After 3 weeks of trial, a reduction of 32.7% on overnight malodor score reduction as compared to baseline was observed for the SNaP group while the control group exhibited a 9.4% reduction. Additionally, 85.7% (42 out of 49) of the subjects who brushed with SNaP toothpaste entered the pleasant breath zone (organoleptic score ≤ 5), while none from the control group achieved such a result.

Additionally, a consumer test of preference for flavor and freshening attributes was performed. Participants preferred the flavor and freshening attributes of the new SNaP toothpaste over the in-market formulation of Colgate Total. This demonstrates the dentifrice meeting patient preferences and beliefs as part of evidence-based healthcare.

Esthetic outcomes have grown considerably in clinical dentistry. In addition to halitosis, patients indicate that tooth stain reduction and whitening play an important role in personal confidence. Esthetic demands are growing worldwide and the use of dentifrices has been included in the management of esthetic conditions. The effect of SNaP dentifrice on extrinsic tooth staining was tested in a randomized controlled clinical trial.²⁶ The comparative group was a regular fluoride-containing toothpaste. The trial lasted 6 weeks and demonstrated additional stain reduction by SNaP dentifrice of 24.3% at 3 weeks and 39.1% at 6 weeks compared to the control.

In all studies supporting the clinical effects of SNaP dentifrice, no adverse effects were reported.

The concept of active prevention with SNaP dentifrice technology is supported by studies of different design, addressing its capability of acting against the cause of the most prevalent oral conditions. Studies performed in different research centers around the world have clinically demonstrated its effect on plaque, gingivitis, dentin hypersensitivity, tooth staining, and oral malodor, among other oral conditions. SNaP toothpaste is clinically proven to support oral health with high-quality evidence and should be part of the standard of oral hygiene care, helping to prevent and treat the most prevalent oral health conditions.

Technical writing assistance for this article was provided by Meghan A. Berryman, PhD.

The author acts as an independent consultant to Colgate Palmolive Co.

Cassiano Kuchenbecker Rösing, DDS, MSc, PhD
Professor of Periodontology, Federal University of Rio Grande do Sul, Brazil

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