US Pharm. 2012;37(10):12-15.
Pharmacists routinely recommend nonprescription products
for active treatment of a host of specific medical conditions (e.g.,
headache, tinea pedis, allergic rhinitis).1 However, in a few instances, pharmacists can provide valuable advice about preventing
medical problems through the use of OTC products and devices.
Preventive products sold by pharmacists include sunscreens to prevent
Another major group of preventive products maintain and
improve oral health, specifically by fighting caries and gingivitis.
Manufacturers market thousands of different devices and products for
these purposes. The consumer is bombarded with advertisements for
toothpastes, toothbrushes, powered cleaning devices, etc. These ads
seldom present a coherent overall strategy for maintaining oral health.
For this reason, when consumers ask the pharmacist about oral cleansing
products, it is prudent to ask whether a dentist has recommended those
products. If not, the pharmacist should next ask the consumer if he or
she keeps regular appointments for dental checkups and cleanings. If the
patient does not see a dentist regularly, the pharmacist should stress
the value of doing so, in order that the patient may obtain the best
advice on an overall dental care program.
How Plaque Becomes Tartar
Each human body contains millions of organisms, collectively referred to as the microbiome.2 The oral cavity is no exception. Within a few minutes of complete dental cleansing, a sterile film known as the pellicle forms on all surfaces.1
During the day, the microbiome inside the mouth (primarily
gram-positive cocci) adheres to the pellicle, proliferating to form
plaque.3 The intraoral surfaces in this process are no
different from an agar-filled Petri dish inoculated with bacteria and
placed in an incubating oven, with the tooth surfaces taking the place
of the Petri dish.
Plaque is a gel-like material that can easily be removed
by the patient with proper attention. However, millions of patients do
not undertake proper tooth care, so that the plaque remains present for
considerable periods. If it is not removed, it can lead to caries (i.e.,
cavities), a disorder that is second in incidence only to the common
cold.3,4 Further, by day 3 or 4, filamentous organisms
infiltrate the plaque, producing calcium phosphate and depositing it on
tooth surfaces. This is calculus (tartar), and safe and thorough removal
of this rock-like material requires a dental appointment and the
services of a dental hygienist. Thus, the patient must constantly strive
to remove plaque before it morphs into tartar.
Tartar can extend below the gumline, destroying the
periodontal ligament that attaches teeth to the adjacent, surrounding
alveolar bone (i.e., the tooth socket). If this process is not arrested,
ligamental destruction becomes so pervasive that tooth mobility is
inevitable.5,6 Tooth mobility leads in many cases to tooth loss.
Oral care products should remove dental plaque when used
properly. Dental care professionals stress that there are three
cornerstones to home dental care: toothbrushing, flossing, and using a
Toothbrushing is mandatory to disrupt plaque, and it is the most common oral care activity the average American undertakes.7
Some people brush too seldom (e.g., only once or twice weekly) and
others do it poorly, neglecting such areas as the inside surfaces of the
teeth and the back molars. Patients whose brushing habits are suspect
should be referred to a dentist for appropriate advice on brushing
frequency and techniques. If a dentist has recommended a specific brand
of brush or dentifrice, the pharmacist can point it out and answer any
questions remaining from the dental visit.
If it becomes clear that the patient will not seek dental
care, the pharmacist should at the very least suggest that the patient
clean the teeth with a soft-bristle brush and a reputable brand of
fluoridated toothpaste twice daily, in conjunction with daily flossing
and the daily use of a periodontal aid. The pharmacist can also suggest
that the patient search the Internet for diagrams that demonstrate
optimal toothbrushing methods. This is not a fully acceptable substitute
for a dentist visit, but it is better than letting patients guess at
optimal cleaning methods.
Patients may ask about the efficacy of “tartar control”
toothpastes. The manufacturers of these products were never able to
prove that they actually accomplish removal of hardened calculus, and
the FDA finally decided to consider them cosmetic products only.1
Daily flossing is as critical as brushing, in that it cleans plaque that is not removed by brushing alone.8 However, surveys reveal that most people do not floss.1
Some are uninformed about its benefits, others may have initiated
flossing but failed to establish a routine, and some simply refuse to
consider flossing. If these patients do speak to the pharmacist, it is
important to stress the value of flossing and refer them to a dentist
for further information. A final group of patients may have tried
flossing at one time but were unable to do it successfully, although
they still have a desire to floss. Pharmacists can make a great impact
on the oral health of this group through knowledge of the common
problems encountered in flossing and the method(s) to counter them.
Patients who have been unsuccessful in flossing usually
have encountered several common problems that can be overcome. One is
floss that shreds or breaks. This is common when the teeth are extremely
tight against each other. Patients may find that switching to waxed
floss (e.g., Reach Waxed Floss) or dental tape (e.g., Oral-B Satintape)
will solve the problem. Another option is the use of nonshred floss
(e.g., Glide Pro-Health Floss). Some patients cannot manage the standard
two-handed flossing method. They may have the use of only one hand due
to a stroke or amputation. In this case, they may be able to use such
flossing accessories as prethreaded forks (e.g., GUM Eez-Thru Flossers,
Oral-B Floss Picks) or forklike devices that can be threaded with one
hand (e.g., GUM Flossmate).1
Periodontal cleansing aids are the third cornerstone of
dental and gingival health. Patients should carry out thorough
periodontal cleansing once daily, using a device that does not harm the
teeth or gums. Wooden devices (e.g., Stim-U-Dent) are straight and
nonflexible, making it exceedingly difficult to remove plaque from inner
(lingual) areas or the back molars. Rubber devices and flexible plastic
picks may not effectively remove plaque, and metal scrapers can damage
enamel and gums.
Perio-Aid #2 is a safe and effective periodontal cleansing device that can be obtained through certain dentists.1
The patient inserts a toothpick into a plastic handle, breaking it off
at a 90-degree angle. Then the end of the toothpick is run around all
spots where the teeth and gums meet (the gingival sulcus), removing
plaque before it converts to tartar.
The use of fluoridated mouthwashes may be necessary for
some people, especially if the patient lives in a city where fluoride is
not added to water, or in a rural area where well water does not
contain sufficient fluoride.9,10 These mouthwashes can also
be helpful for patients who decline to drink fluoridated city water or
prefer nonfluoridated bottled water. Fluoridated mouthwashes include
such products as ACT Anticavity Fluoride Rinse, Colgate Phos-Flur,
Colgate Plax, Listerine Tooth Defense, and Listerine Smart Rinse.
Patients are advised to use the mouthwash once daily after brushing,
swishing 10 mL around the mouth and between the teeth for one minute
before expectorating it. Patients should not eat or drink for 30 minutes
to allow better binding of the fluoride to the tooth enamel.
To prevent excess fluoride (i.e., dental fluorosis),
fluoridated mouthwashes carry age limits against unsupervised use in
those too young to understand the requirement not to swallow the liquid.
Those aged 6 to 12 years should use the products only with adult
supervision, and those under the age of 6 years should not use them
without a specific recommendation from a dentist or physician.
Several ingredients are proven to reduce or prevent plaque
and gingivitis. One is cetylpyridinium chloride, found in Cepacol
Antibacterial Mouthwash. Patients aged ≥12 years should vigorously swish
20 mL around the mouth and between the teeth for 30 seconds each day
and then expectorate. Those aged 6 to under 12 years should be
supervised in its use, and the product should not be used in those under
the age of 6 years.1
Another plaque preventive is a mixture of eucalyptol
0.092%, menthol 0.042%, methyl salicylate 0.060%, and thymol 0.064%.
Listerine is a proprietary product containing this mixture. Patients
should rinse full strength for 30 seconds with 20 mL of solution morning
and night before expectorating.
Patients should not use plaque preventives if gingivitis,
bleeding, or redness persists for more than 2 weeks, or if there are any
of these signs of periodontitis: painful or swollen gingiva, pus
issuing from the gumline, loose teeth, or increasing space between the
Patients who visit dentists are familiar with the process
of swishing a colored dye solution around the mouth and expectorating.
The dye preferentially adheres to and stains plaque. The dental team
checks for these uncleaned areas and instructs the patient to try to pay
attention to them. Patients may wish to purchase home disclosing agents
to check their own cleaning regimen between dental checkups. Disclosing
agents include GUM Red-Cote, Inspector Hector Plaque Detector, and
Listerine Agent Cool Blue.1 If patients are unable to cleanse
stained areas, they should make an interim dental appointment so that
their cleaning regimen can be examined.
Patients occasionally ask the pharmacist for help with
dental pain. Tooth pain can arise from such causes as a cracked tooth,
lost filling, sinus infection, tooth abscess, or eroded dental enamel.1
Dental pain requires a referral to discover the cause. If the cause is
dental erosion, pain begins when the erosion nears the nerve, causing
pulpitis. If the erosion is caught early enough, a restoration may save
the tooth. If the patient continues to procrastinate, nerve damage may
be irreversible, and the tooth may have to be extracted or subjected to a
root canal. Neither of these is preferable to saving a vital tooth.
Thus, even though patients may object to the advice, a referral for
dental pain is a prudent choice.
Adults can decide for themselves whether to prevent
cavities and gingivitis by proper tooth and gum care, or to be negligent
and suffer tooth pain, tooth loss, and gum disease. However, children
are dependent on their parents and caregivers to help keep them disease
free until they reach a responsible age.
Why Baby Teeth Need Care
Some people unwisely think that baby teeth are not
important, as they will be lost in a short time anyway. Children need
healthy baby teeth so they can chew food properly, speak words as they
should, and keep sufficient space in the mouth for their adult teeth to
come in straight.
Foods and Drinks That Cause Decay
The major culprit in cavities and gum disease is sugar.
Bacteria use the sugar for food and produce acids that erode the teeth.
Breast milk is the healthiest food for babies, as it helps stop
bacteria. All sugary foods and drinks promote tooth and gum damage. This
includes milk, formula, fruit juices, and sugar-containing baby food.
Experts discovered that alternating these sugary drinks with breast milk
is actually worse than giving children sugar alone! For this reason,
parents should avoid offering sugary foods and drinks as much as
It is also important to watch how long sugary substances
remain in the mouth. Giving a child a “sippy cup” or bottle with these
products in it allows greater exposure over the course of the day.
Giving a bottle at night that allows a baby to suck while asleep causes
cavities in the teeth exposed to the sugar, a condition known as nursing-bottle mouth.
Cavity Prevention in Babies and Children
To prevent cavities in babies and children, follow this
advice. For children aged 6 to 12 months, be sure not to put anything in
the bottle except formula. Never fill a bottle with sugary fluids
(e.g., fruit punch, soft drinks) and never let children walk around with
a bottle of juice or milk for a pacifier. Never dip a pacifier in
honey, sugar, or syrup. Put children to bed with a bottle containing
water and never juice, milk, or formula. After the child is asleep,
remove the bottle. Introduce drinking from a cup when the baby is 6
months of age and stop using the bottle when the baby is 12 to 14 months
Start tooth care as soon as teeth appear. Remove plaque
from baby teeth after each feeding by wiping the teeth and gums gently
with a clean washcloth or gauze pad. Wipe infant and toddler teeth with a
washcloth with a small amount of nonfluoridated toothpaste on it. When
the child is old enough to comply with instructions to spit toothpaste
out, switch to fluoridated toothpaste. Start brushing when the child is
older and begin flossing when all of the baby teeth are in place (around
2½ years of age). At 6 months of age, start fluoridated water or
fluoride supplements. Use bottled water only if it has fluoride. Start
dental visits by age 2 or 3 years or earlier if all of the baby teeth
are in place.
Remember, if you have questions, Consult Your Pharmacist.
1. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
2. Zarco MF, Vess TJ, Ginsburg GS. The oral microbiome in
health and disease and the potential impact on personalized dental
medicine. Oral Dis. 2012;18:109-120.
3. Dental cavities. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/001055.htm. Accessed August 26, 2012.
4. Forssten SD, Björklund M, Ouwehand AC. Streptococcus mutans, caries and simulation models. Nutrients. 2010;2:290-298.
5. Gingivitis. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/001056.htm. Accessed August 26, 2012.
6. Seneviratne CJ, Zhang CF, Samaranayake LP. Dental plaque biofilm in oral health and disease. Chin J Dent Rsch. 2011;14:87-94.
7. Davies R, Scully C, Preston AJ. Dentifrices—an update. Medicina Oral Patolog Cirug Bucal. 2010;15:e976-e982.
8. Sambunjak D, Nickerson JW, Poklepovic T, et al.
Flossing for the management of periodontal diseases and dental caries in
adults. Cochrane Database Syst Rev. 2011;(12):CD008829.
9. Pessan JP, Toumba KJ, Buzalaf MA. Topical use of fluorides for caries control. Monograph Oral Sci. 2011;22:115-132.
10. Demke R. Plaque inhibition: the science and association of oral rinses. Dent Today. 2012;32:96-101.
11. Cotti E, Dessì C, Piras A, Mercuro G. Can a chronic
dental infection be considered a cause of cardiovascular disease? A
review of the literature. Intl J Cardiol. 2011;148:4-10.
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