Oral Care Innovation: Toothpastes and Biofilms

Innovation in oral care presents a challenge. When looking at new toothpaste technologies, it is important to consider that toothpaste is used to enhance the effectiveness of cleaning with a toothbrush. Toothbrush type, technique, duration and frequency of brushing play a great role in oral health, e.g. using a powered toothbrush is significantly more effective in reducing plaque, bleeding and gum inflammation than using a manual toothbrush.[i]

Adherence to the routine is essential. Consumer sensory perceptions are key, the drivers behind the habit of cleaning teeth has been beautifully illustrated by The Pepsodent Story. In the early 20th Century America, people hardly brushed their teeth; and marketing, led by Claude Hopkins, thought they created a craving for toothpaste by linking teeth brushing with a beautiful smile. The reason being that vanity is a much stronger reward than just oral health. However, Pepsodent’s real secret to creating a habit was its mint flavor; it created the tingly feeling that brushing your teeth gives. Consumers missed that feeling when they forgot to brush their teeth, their brains started to crave the reward of that sensation. [ii]

Young people have to be reminded to brush their teeth, yet conventional education with ‘normative advice’ often fails to bring about behavioural change for a longer period of time. Clinicians change patterns of behaviour with involving the person by motivational interviewing or an interactive risk assessment tool, also providing oral health education via a video game; a storybook, or a supervised programme delivered via a text message, seems to prove beneficial.

The toothpaste market is a saturated one; the leading players enjoy a dominant presence worldwide – to name a few, GlaxoSmithKline, Aquafresh (which has been available since 1979), Sensodyne, which is endorsed by professional dentists for hyper-sensitivity and pain relief, Colgate-Palmolive (with Colgate as the first toothpaste in a collapsible tube, (introduced in 1896 and the US Ultra-Brite promoting tooth whitening), Procter & Gamble’s Oral-B, Unilever’s Signal (and more recently Zendium) and Johnson and Johnson’s Euthymol.

Traditional Technologies Perform Well

Advances in the understanding of oral microbial ecology should allow for development of pre- and pro-biotic approaches that interfere with the plaque formation process and disrupt bacterial communication networks.[iii] However, traditional fluoride technology – the link between fluoride and oral health dates back to the 1930s, still remains one of key preventative strategies today. Evidence of effectiveness of topical fluoride interventions has been demonstrated in a series of Cochrane Reviews. The typical strength of regular toothpaste for adult permanent teeth is around 1000 parts per million (ppm) fluoride, with other strengths available worldwide. There are also different maximum permissible fluoride concentrations (for use in children carrying a risk of enamel damage and chronic ingestion), higher classed as a prescription‐only medicine and rarely available over the counter. A variety of fluoride technologies (e.g. sodium fluoride, sodium monofluorophosphate, amine fluoride and stannous fluoride) act by promoting re-mineralisation of early decay lesions and reduce tooth enamel solubility and mineral loss. Long-term sustained fluoride concentrations in oral fluids are beneficial for balancing the de/re-mineralisation cycle. [iv] Whereas fluoride enhances resistance of tooth minerals to low pH and reduce acid production in oral biofilms, arginine acts as substrate for alkali production for oral biofilms and promotes high pH homeostasis and modifies favourably oral biofilm composition[v][vi]. Combined with fluoride, 1.5% arginine has shown superior anti-caries efficacy to fluoride alone.[vii] Higher concentrations of arginine (8%), whilst not producing impacting on the plaque microbiome, do shift the salivary microbiome composition towards a healthy ecology.[viii] Traditionally, abrasive baking soda, Indian Acacia nilotica (Babool) tree extract, clove oil and the ionic surfactant, sodium lauryl sulfate, were used. Whilst pure baking soda does not meet the needs of a balanced oral care product, toothpaste formulations including it in the composition are now widely available again (e.g Colgate and Arm & Hammer).

New Technologies Driven by Consumer Preferences

Consumer choice of toothpaste is influenced by a perceived performance, product attributes (e.g. taste) but also brand awareness, the credibility of the company, availability of product information, and natural sustainable ingredients. The rise in premium products and consumers seeking more targeted solutions (with plant extracts or whitening functionality), are accelerating market growth. New trends inspire the launch of products without artificial flavours, sweeteners, preservatives and colours, as consumer preferences shift towards less artificial ingredients and avoiding harsh chemicals use in toothpaste. It should always be remembered with toothpaste innovation that the product has to also be safe to eat, as there is a chance small quantities will be swallowed.

As the main players focus to leverage opportunities posed by the specific markets requirements to expand their product portfolio, new toothpaste technologies aim to attain a long-term symbiosis in oral microbiome supported by research. Also casein phosphopeptide-amorphous calcium phosphate and polyphenol-rich cranberry extract have shown to cause a species-level shift towards a microbial community less associated with dental caries.[ix] Australian Melaleuca alternifolia oil (tea tree oil) and propolis have been reported to stabilise oral microbiome [x] and d-Tagatose acts on both early and late colonizers to prevent and remove plaque development and alter oral biofilm formation.[xi]

Research by Unilever studied an effect of toothpaste containing enzymes and proteins to augment natural salivary defence and shift the oral microbiome ecology at species level, towards gum health.[xii] Zendium, manufactured by Unilever, is a toothpaste designed to nurture the mouth, support a healthy microbiome and boost immune system. The ingredients are enzymes (amyloglucosidase, glucose oxidase, lactoperoxidase) to promote beneficial oral bacteria and proteins (from colostrum, lactoferrin and lysozyme) support oral immunity and ward off dysbiotic species. Sodium fluoride helps to strengthen the enamel protecting teeth from cavities. Naturally present in saliva, potassium thiocyanate, increases the level of oxygen and with zinc gluconate helps active ingredients to respect and enhance the natural protective power of the delicate ecosystem.[xiii]

Ingredient manufacturers are also following this trend, Givaudan, markets Bucovia™ as a natural bio-guided fractionated active with anti-biofilm properties against mixed fungal-bacterial biofilm. The active is said to balance the oral microbiota against opportunistic pathogens, and have no biocidal activity. Their research into the Solidago virgaurea (European Goldenrod) plant extract has reported a reduction in total bacterial load, in particular species Streptococcus mutans and Candida albicans.[xiv]

Brighter smiles of consumers are the manufacturers’ top priority. The newly launched Colgate Zero portfolio also embraces clean oral care embracing natural and gentle ingredients. The toothpaste claims to help protect against decay, strengthen tooth enamel and freshen breath by utilizing a micro-foaming formula and natural peppermint flavour.[xv] Working with the organic oral care trend, American manufacturer ORL Labs market organic toothpaste with cannabidiol (CBD) oil to promote oral health, encourage re-mineralization, and fresh breath. [xvi][xvii]

Nowadays the science is great, but not enough to gain new business. Understanding consumer needs, communicating with experts and building connections with the oral health specialist community provides competitive advantage in the crowded space. We asked Dr David Bradshaw, Principal Scientist at GlaxoSmithKline, for their R&D priority in advancing toothpaste business.

“Delivering scientifically-proven solutions that also connect with consumers’ basic needs and wants from a ‘simple’ product like toothpaste”

Creatively, companies focus on visualisation of oral biofilms to explain in lay terms to people how oral hygiene works as well as capturing consumer insights about their sensitivity, acid erosion or dental plaque. The future lies in promoting oral care based on advanced scientific evidence but also encouraging consumers to acquire responsibility for their oral health and hygiene habits.

References

[i] The Effects of Use of a Powered and a Manual Home Oral Hygiene Regimen on Plaque and Gum Health in an Orthodontic Population

[ii] The Minty Fresh Psychology Behind America’s Toothpaste Obsession

[iii] New Aspects and New Concepts of Maintaining “Microbiological” Health

[iv] Fluoride toothpastes of different concentrations for preventing dental caries

[v] Metabolic Profile of Supragingival Plaque

[vi] The Effect of Arginine on Oral Biofilm Communities

[vii] The Anticaries Efficacy of a 1.5% Arginine and Fluoride Toothpaste

[viii] Changes in the Oral Ecosystem Induced by the Use of 8% Arginine Toothpaste

[ix] Randomized Controlled Study to Evaluate Microbial Ecological Effects of CPP-ACP and Cranberry on Dental Plaque

[x] The Influence of Toothpaste Containing Australian Melaleuca Alternifolia Oil and Ethanolic Extract of Polish Propolis on Oral Hygiene and Microbiome in Patients Requiring Conservative Procedures

[xi] Removal and Prevention of Dental Plaque With D-Tagatose