Hygiene Tribune Middle East & Africa No. 2, 2015

Stannous Fluoride Dentifrice with Sodium Hexametaphosphate: Review of Laboratory - Clinical and Practice-Based Data / Extrinsic tooth discoloration - an updated review

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                            [title] => Stannous Fluoride Dentifrice with Sodium Hexametaphosphate: Review of Laboratory - Clinical and Practice-Based Data

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            [1] => 







lem was resolved with the introduc- proved esthetic qualities over the
tion of stabilized stannous fluoride original stannous fluoride formulain the 1990s which rendered more tion, and delivers a broad range of
available stannous fluoride and re- therapeutic and cosmetic benefits
sulted in a renewed interest in the (Figure 1). The remainder of this paribune Middlewide
Eastrange
& Africa
Edition
summary review of reof benefits
offered| March-April
by per provides a2015
6
search on stannous fluoride, sodium
stannous fluoride in dentifrices.
Sodium hexametaphosphate was hexametaphosphate and, especially,
first introduced in a dentifrice in the unique SFSH formulation.
2000.13 It is a chemical whitening
agent in the same class as pyrophosphate, which has long been used to Antibacterial and Antiinhibit calculus, but the molecule is inflammatory Action
about 10 times longer than that of
pyrophosphate. Sodium hexametaMost of the oral health benefits
phosphate therefore provides better of stannous fluoride result from its
coverage and retention on the tooth antibacterial efficacy, particularly
surface, thus increasing its ability against bacteria associated with dento inhibit both calculus and stain tal caries, periodontal disease, and
formation on the enamel surface.14 oral malodor. Laboratory and cliniStability of the dentifrice can be cal studies have shown that stannous
an issue with the inclusion of poly- fluoride, unlike other fluorides, inphosphates if ingredients are not hibits bacterial growth by a variety of
properly balanced. Like other poly- mechanisms, including interference
phosphates, sodium hexametaphos- with metabolic pathways, thus rephate does not usually show good ducing bacterial acid formation, and
long-term stability in aqueous den- inhibition of bacterial cohesion and
tifrices. However the novel single- adhesion.15-17 The Plaque Glycolysis
phase SFSH formula, which uses a and Regrowth Model (PGRM) is an

Dental T

ed with the use of stannous fluoride
dentifrice versus a standard sodium
fluoride control dentifrice.18,19 Using the same methodology, Liang
et al. found that a stannous fluoride
dentifrice, as compared to a control
placebo, greatly reduced the amount
of plaque acid and also inhibited
plaque regrowth.20
Comparable results have been
obtained in studies of the antibacterial action of this SFSH formula.
Ramji et al. carried out a series of in
vitro and in vivo studies of this new
formulation.21 In a Live/Dead assay21 they found that the new SFSH
dentifrice had killed over 90% of
the salivary bacteria 16 hours after
a single exposure, thus showing
strong and lasting antibacterial activity (Figure 2).
In a second study, using PGRM,
the SFSH dentifrice produced statistically significant reductions in
plaque acid production and plaque
regrowth at 15 and 45 minutes after
brushing versus a standard sodium
fluoride control dentifrice.21 Other
research demonstrated the presence of soluble tin, which serves
as a marker for the active stannous
fluoride, at levels above the minimum concentration required for
the inhibition of salivary bacterial
activity.21
Another related value of stannous fluoride is its effect on inflammatory markers, independent
of its action on bacteria. In vivo,
antibacterial activity also helps reduce inflammation since the inflammatory response should diminish
with
reduced
levels ofactivity
pathogenic
Figure
2. Bactericidal
assessment 16 hours after exposure. Left;
bacteria.
A
study
was
conducted
water control. Right; stannous fluoride/sodium hexametaphosphate
with
16 healthy
subjects tocells
measure
dentifrice.
Green-stained
are live microbial cells; red-stained cells
inhibition of several host and bacare dead cells (from Ramji et al21).
terial pro-inflammatory enzymes
by stannous fluoride.22 Following a
one-week period of using a standard
of stannous
fluoride
from bacterial growth by a variety of
sodium
fluoride
paste result
and manuits antibacterial efficacy, particu- mechanisms, including interferlarly against
Volumebacteria
83 Issue IIassociated
Spring 2009 ence with metabolic pathways,
with dental caries, periodontal thus reducing bacterial acid fordisease, and oral malodor. Labo- mation, and inhibition of bacteratory and clinical studies have
shown that stannous fluoride,
> Page 2B
unlike other fluorides, inhibits

hygiene tribune 1B

Stannous Fluoride Dentifrice with Sodium
Hexametaphosphate: Review of Laboratory, Clinical and
Practice-Based Data
By Cynthia Sensabaugh, RDH,
BS; Mary Elizabeth Sagel, BS, MA

Stannous fluoride

Sodium
hexametaphosphate

A

bstract
Dentifrice was originally
used to promote oral hygiene by cleaningteeth. However, with advances in product
formulation, it has become a
valuable vehicle for the delivery of agents offering health
and cosmetic benefits. Stannous
fluoride, introduced in 1955 in
dentifrice, is one of the longest
established of such agents. The
well-known anti-caries efficacy
of stannous fluoride is based on
its impact on the tooth surfaces
and on its antibacterial activity.
More recently, the demand for
tooth whitening products has
increased and sodium hexametaphosphate has been shown to
be helpful in whitening surface
stains and in controlling calculus. A dentifrice formulation
which combines the benefits of
stannous fluoride with those of
sodium hexametaphosphate is
now available. A review of the
evidence shows that in addition
to effective anti-caries action,
this formulation is effective in
fighting plaque, gingivitis, and
gingival bleeding while inhibiting calculus and extrinsic stain.
A practice-based evaluation including data from over 1,200
dental professionals and 1,000
patients demonstrates the product’s benefits and excellent
acceptability. Collectively, the
research shows this stannous
fluoride/sodium hexametaphosphate dentifrice provides multiple benefits to meet the oral
health and cosmetic needs of
patients.
Key Words: stannous fluoride,
dentifrice, gingivitis, caries, sensitivity, calculus
Introduction
Patients today represent one of
the most heterogeneous groups
in history in terms of age, health
status, oral hygiene habits and
other factors.
While certain oral health conditions are more prevalent among
specific patient groups, such as
periodontal disease among diabetic patients,1 many oral health
conditions affect the broad population. According to U.S. surveys, virtually all adult patients
have had dental caries, more
than half experience gingivitis,
and roughly one in three suffer
from dental sensitivity.2-4 Fortunately, home care products are
available to help prevent and
treat many common oral health
conditions in conjunction with

• Antibacterial activity against species
associated with plaque, gingivitis,
cavities and malodor
• Reduces plaque
• Reduces gingival inflammation and
bleeding
• Protects against hypersensitivity
• Remineralizes enamel and protects
against demineralization

• Inhibits calculus formation
• Protects against new stain formation
• Removes extrinsic stain

Figure 1.1.Benefits
Benefitsofofstannous
stannousfluoride
fluorideand
andsodium
sodium hexametaphosFigure
phate
hexametaphosphate
2

routine professional care.
Dentifrice is one important example. Many years ago, the benefits of dentifrice were limited to
cleaning and the prevention of
tooth decay. It was common for
professionals to tell patients to
“use any dentifrice with fluoride
and the ADA Seal.” However,
formulators today can design
dentifrices to provide numerous
other benefits, both for health
and cosmetic purposes.
In 2005, a stannous fluoride sodium hexametaphosphate (SFSH)
formula* was introduced offering protection against a broad
range of health and cosmetic
conditions commonly experienced by patients.5 The present
report reviews the laboratory,
clinical and practice-based assessments evaluating the efficacy of this dentifrice formulation.
Stabilized stannous fluoride/
sodium hexametaphosphate
formulation
The SFSH formula combines the
therapeutic benefits of 0.454%
stabilized stannous fluoride with
the calculus and stain-control
characteristics of sodium hexametaphosphate in a low-water
formulation dentifrice. Stannous
fluoride, which unlike sodium
fluoride can be used in combination with calcium-based abrasives, has been incorporated in
dentifrices since the 1950s to
provide protection against caries, pathogenic bacteria, gingivitis, hypersensitivity, and the
development of plaque. There
is considerable evidence for its
efficacy as a therapeutic agent
with a wide spectrum of beneficial properties.6-12 However,
its clinical usage was limited
because of astringent taste and
in some patients its use resulted
in extrinsic staining of the teeth.
Stannous fluoride was also
somewhat unstable in aqueous
solution. The latter problem was

The Journal of Dental Hygiene
resolved with the introduction of
stabilized stannous fluoride in
the 1990s which rendered more
available stannous fluoride and
resulted in a renewed interest
in the wide range of benefits
offered by stannous fluoride in
dentifrices.6
Sodium
hexametaphosphate
was first introduced in a dentifrice in 2000.13 It is a chemical
whitening agent in the same
class as pyrophosphate, which
has long been used to inhibit calculus, but the molecule is about
10 times longer than that of pyrophosphate. Sodium hexametaphosphate therefore provides
better coverage and retention
on the tooth surface, thus increasing its ability to inhibit both
calculus and stain formation on
the enamel surface.14 Stability
of the dentifrice can be an issue
with the inclusion of polyphosphates if ingredients are not
properly balanced. Like other
polyphosphates, sodium hexametaphosphate does not usually
show good long-term stability
in aqueous dentifrices. However
the novel single-phase SFSH formula, which uses a low-water
system in a silica-based formulation, significantly reduces the
hydrolysis of sodium hexametaphosphate and helps to maintain effective levels of whitening
activity.5
The resulting dentifrice has improved esthetic qualities over
the original stannous fluoride
formulation, and delivers a
broad range of therapeutic and
cosmetic benefits (Figure 1).
The remainder of this paper
provides a summary review of
research on stannous fluoride,
sodium
hexametaphosphate
and, especially, the unique SFSH
formulation.
Antibacterial and Anti-inflammatory Action
Most of the oral health benefits




            [2] => 







plaque samples were taken immediately post-rinsing and 12 hours later.
An analysis of the samples showed
that stannous fluoride inhibited several pro-inflammatory enzymes,
including mammalian matrix met-

analysis, enough stannous fluoride
was retained to inhibit about 40%
of most enzymes measured.
These studies demonstrate the
sustained antibacterial and antiinflammatory effects of this SFSH

2B hygiene tribune

tions.35 A 2-year study investigated
the periodontitis prevention efficacy
of a dual-phase stabilized 0.454%
SFSH dentifrice compared to a positive control (sodium fluoride/tricloMiddle East & Africa Edition | March-April 2015
san dentifrice) in aental
population ribune
of

D

T

 Page 4B


            [3] => 

            [4] => 
control (n=45) (Figure 5).46 At 8
weeks, the SFSH showed improvements of 71% and 44% versus the
negative control for tactile and thermal measurements, respectively.
These studies support that the
SFSH dentifrice shares the anti


            [5] => 










            [6] => 







6B hygiene tribune

Dental Tribune Middle East & Africa Edition | March-April 2015

Extrinsic tooth discoloration, an updated review
By Dr. Kassis Cynthia DDS,
DESCO, DUDRE, department
of Esthetic and Restorative
Dentistry – Saint Joseph University Dr. Khoury Pierre DDS,
DESS, department of Prosthodontics – Lebanese University
- Dr. Zogheib Tatiana, DDS,
Oral Imaging Center, OMFSIMPATH research group, Dept
Imaging & Faculty of Medicine, University of Leuven and
Oral & Maxillofacial Surgery,
University Hospitals Leuven
Prof. Mehanna Carina DDS,
CESA, PhD, FICD, Director of
Esthetic and Restorative Dentistry Postgratuated Program
Saint Joseph University, President of the continuing Education committee - Lebanese
Dental Association

A

bstract
The appearance of the
dentition is of concern to a
large number of people seeking
dental treatment and the color
of the teeth is of particular cosmetic importance. Discolored
teeth are seen frequently in the
dental office and present a major challenge to dentists. The
causes of tooth discoloration
are varied and complex. Basically, there are two types of tooth
discolorations: those caused
by extrinsic factors and those
caused by intrinsic congenital
or systemic influence. The majority of tooth discolorations are
extrinsic in nature and appear
as brown integuments. Dental
treatment of tooth discoloration
involves identifying the etiology
and implementing therapy. An
overview of the extrinsic etiologies and the clinical appearance
of tooth discoloration are discussed in this review.
Key-words:
Discoloration,
stains, etiology, whitening, chromogenic product.
Introduction
Ever since the ancient times,
mankind has been questing for
beauty through the perfection
of every detail. Ancient Romans,
for example, used urine and
goat milk in an attempt to whiten their teeth. There has been
a recent increase in interest in
the treatment of tooth staining
and discoloration as shown by
the large number of tooth whitening agents appearing on the
market.1
Teeth discolorations are associated with many clinical and
esthetical challenges. They can
have an impact on a person’s
self-image and self-confidence
in today’s society, where most
people place tooth color high.
The correct diagnosis of the
cause of discoloration is important as it has a profound effect on
treatment outcomes.
Normal enamel is colorless and
translucent, and the color of the
dentin is mainly responsible for
the color of the tooth. The dentin influences more on the tooth
color where it consists of thick
layers and where the enamel
layer is thin (cervical margins).

A variety of colors can typically
be seen in a tooth and from the
gingival margin to the incisal
edge of the tooth a gradation of
the color occurs. Any changes
of tooth structure is likely to
cause an alteration in outward
appearance of the tooth caused
by changes of light transmitting and reflecting properties2:
Some discolorations are located
on the outer surface of the tooth
structure, others are caused by
stain taken up by the enamel
or dentin, and some occur during tooth development and result in an alteration of the light
transmitting properties of the
tooth structures. Tooth discolorations are caused by multiple
factors: medications, genetic
defects, diseases, trauma, caries
and normal aging processes are
some examples. It is important
to understand what staining is
in order to be able to prevent it.
There are two types of tooth discoloration: extrinsic which affects teeth from the outside and
intrinsic which affects the teeth
from the inside.
Extrinsic discoloration lies on
the tooth surface or in the acquired pellicle. The majority
of tooth discolorations are extrinsic in nature and appear as
brown integuments. Extrinsic
staining of a single tooth is unusual. The distribution is usually
generalized. The stains are usually found on surfaces with poor
tooth brush accessibility. Smoking, tea or coffee consumption
and increasing age are promoting factors and such discolorations are frequently seen
in connection with oral use of
antibacterial plaque-inhibiting
mouthrinses. Chemical alteration of the acquired pellicle appears to be the major reason for
these brown integuments.3
The causes of extrinsic staining
can be divided into two categories; those compounds which
are incorporated into the pellicle
and produce a stain as a result
of their basic color 2 and those
which lead to staining caused by
chemical interaction at the tooth
surface.4
Direct staining has a multi-factorial etiology with chromogens
derived from dietary sources or
substances habitually placed in
the mouth. These organic chromogens are taken up by the pellicle and the colour imparted is
determined by the natural colour of the chromogen. The origin of the stain may be metallic
or non-metallic.5 6
The aim of this review is to systematically search the literature
for data concerning extrinsic
tooth discoloration etiologies in
order to establish the right treatment plan.
1 - Tobacco
For ages, tobacco has been popular and its use is significantly
increasing in spite of alarming
health hazards.7
Tobacco smoking and chew-

ing (chewing of betel morsel:
piper betel, Pan) are known to
cause staining.8 Smoking leads
to not only tobacco and nicotine
stains on teeth (yellowed teeth)
but it also leads to gum disease
and oral cancer.9 There are all
sorts of chemicals in cigarettes,
including tobacco, nicotine and
tar that could harm gum tissue
cells, weakening it in the face of
periodontal diseases and infections. This is true of cigarettes,
pipes, chewing tobacco, waterpipe and cigars to varying degrees, all will cause bad breath,
crippled teeth and ugly brownish-yellowish stains. Tobacco is
rich with nicotine10,11 which is
named after the tobacco plant
Nicotiana tabacum.7 It is an inherently colorless substance that
turns yellow when put in contact
with oxygen. When cigarette
smoke is inhaled, the insides of
the mouth is coating not only
with tar from the tobacco smoke
but with nicotine. Nicotine penetrates the nooks and crannies of
the teeth leading to teeth stains.
Tobacco smoke contains carbon
monoxide, thiocyanate, herbicide, fungicide and pesticide
residues, tars, and many other
substances which promote diseases and impair the body’s defense mechanism and functions.
Toxic substances in the tobacco
smoke affect virtually every viable cell type.7
A quantitative synthesis of the
limited human data from 117
adults from Lebanon, Jordan,
Kuwait, and India indicates that
daily waterpipe use produces
nicotine absorption of a magnitude similar to that of daily use
of cigarettes. This equivalence
with cigarette use of about 10
cigarettes/day.10
Smoking cessation support interventions with an added stain
removal or tooth whitening effect may increase motivation to
quit smoking. Oral health professionals are well placed to provide smoking cessation advice
and support to patients. A study
evaluated the effect of a gum
used in a smoking cessation
program administered in a dental setting, on extrinsic stain and
tooth shade among smokers. At
week 6, the gum-group experienced a reduction in mean stain
scores whilst the tablet-group
experienced an increase. The
change in mean tooth shade
scores was statistically significantly greater in the gum-group
than in the tablet group at 2, 6
and 12 weeks with greater lightening in the gum-group at each
examination period.12
2 - Dark Drinks
From black coffee to red wine,
food and beverages can cause
the pearly whites to become ellows.The foods that are most
likely to stain or discolor teeth
are:
a - Black Coffee
Although melanoidins from coffee possesses antioxidant capacity,13 deposition of tannins found
in tea, coffee, and other beverages cause brown stains. The
darker the coffee, the more it
stains the teeth. Adding milk or

cream will actually help. A study
done by JZ Bazzi showed that
toothbrushing resulted in a significantly reduced color change
only for cigarette smoke–stained
specimens and not for coffee
stained teeth, which means that
coffee stains teeth more indelibly than tobacco.14
According to Pirolo, the exposure to coffee after bleaching
causes less color changes than
the exposure to a cola-based soft
drink regardless of the time after
bleaching.15
A study evaluated the colour stability of three laminate veneer
materials with tea, coffee and
cigarette. It was found that cigarette smoke was the most staining agent.16
The aim of an in vitro study done
by Mutlu-Sagesen et al was to
compare the color stability of
commercially available denture
teeth materials.The filtered coffee solution was found to be
more chromogenic than the tea,
and cola staining solutions.17
b - Tea
Tea, the commonly consumed
beverage, is gaining increased
attention in promoting overall
health. In specific, green tea is
considered a healthful beverage due to the biological activity of its polyphenols.18,19 There
are three main varieties of tea
- green, black, and oolong, all
derived from the leaves of the
C. sinensis plant. The difference
between the various teas lies
in their processing. Green tea
is prepared from unfermented
leaves, the oolong tea leaves are
partially fermented and black
tea is fully fermented.20
Lee R et al have shown that the
addition of milk to tea significantly reduces the tea’s ability
to stain teeth. Casein was determined to be the component
of milk that is responsible for
preventing tea-induced staining of teeth to a similar order of
magnitude that can be obtained
by vital bleaching treatments.21
Bovine teeth were immersed for
one week in a solution of tea,
coffee or red fruits respectively.
Tests showed that diode laser
was effective only at bleaching
teeth stained with coffee meanwhile the KTP laser was efficient
at bleaching teeth with coffee,
tea and red fruits stain. This
study suggests that a relation between the laser wavelength and
the type of staining on the dental
enamel and the efficacy of the
whitening treatment exists.22
In a work done by Young N et
al of the basic interactions between whitening agents and tea
stain molecules, it was shown
that the reaction rates between
chromogens in the tea solution
and hydrogen peroxide can be
accelerated significantly using
ferrous gluconate activator and
blue light irradiation.23
As for all colored beverages,

in order to minimize the staining effect of tea, it can be drunk
through a straw.
c - Red Wine
Red wine is packed with polyphenols24 that help prevent
periodontal diseases that damage the gums and bone around
teeth.25, 26, 18 Nevertheless red
wine causes tooth staining. In
addition, the alcohol content
is very acidic and wears away
tooth enamel.
A research aimed to investigate
bleached enamel susceptibility
to coffee and red-wine staining
at different time periods after
bleaching. No differences were
observed between the exposure
times of 30 and 150 min after
bleaching for both beverages (p
> 0.05). Although coffee did not
stain the surface, red wine significantly darkened previously
bleached enamel.27
Attia et al have quantified the
change in color of human and
bovine teeth exposed to a coffee
solution during a 16% carbamide peroxide (16% CP) home
application bleaching treatment
using photoreflectance analysis.
When the teeth were exposed to
a coffee solution during home
bleaching treatment, the whitening effect was observed to be
less stable (P < 0.05).
Bovine and human enamel
substrates behaved similarly in
terms of staining and bleaching
effects, although they presented
inherent differences in color.28
A study has examined the surface staining mechanism of a
photopolymerized composite by
coffee, oolong tea, and red wine.
Dental composite was subjected to an experimental 24-hour
staining cycle: 17-hour immersion in artificial saliva solution
containing 0.3% mucin followed
by 7-hour immersion in coffee,
tea, or wine. Wine caused the
most severe staining, followed
by tea and coffee. Chlorhexidine
increased the staining effect of
tea and coffee when compared
to the control specimens. Common drinks stained the dental
composite, but each by a specific mechanism that depended
on external conditions such as
the presence of chlorhexidine.29
Cortes et al have evaluated the
influence of coffee and red wine
staining on tooth color during
and after bleaching. Blocks obtained from human molars were
divided into 11 groups in accordance with the bleaching treatment-peroxide carbamide 10%,
15% or 20%- and in accordance
with the stain therapy-coffee,
wine or without staining (control). During bleaching, remineralization of the enamel with
artificial saliva and the subsequent bleaching were effective
in preventing enamel staining.
After the whitening procedures,
both
stain
therapies-coffee

> Page 8B




            [7] => 







Ultra-low abrasion for your patients who need
sensitivity relief and seek gentle whitening
Clinically proven relief from the pain
of sensitivity*1-4
Gently lifts stains and help prevent
new stains from forming5-7
Ultra-low abrasive formulation
appropriate for your patients
with exposed dentine8

Recommend Sensodyne – specialist expertise
for patients with dentine hypersensitivity

*With twice-daily brushing
References.. 1. Jeandot J et al. Clinc (French) 2007; 28: 379–384. 2. Nagata T et al. J Clin Periodontol 1994; 21(3): 217–221. 3. GSK data
on file. DOF Z2860473. 4. Leight RS et al. J Clin Dent 2008 19(4) 147-153. 5. Schemehorn BR et al. J Clin Dent 2011 22(1) 11-18.
6. Shellis RP et al. J Dent 2005 33(4) 313-324. 7. GSK data on file. DOF Z2860415. 8. GSK data on file. DOF Z2860435.
Arenco Tower, Media City, Dubai, U.A.E.
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For full information about the product, please refer to the product pack.
For reporting any adverse event/side effect related to GSK product,
please contact us on contactus-me@gsk.com
Prepared: December 2014, CHSAU/CHSENO/0034/14f.
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404




            [8] => 







8B hygiene tribune

Dental Tribune Middle East & Africa Edition | March-April 2015

< Page 6B
and wine-caused enamel color
changes; however, the wine led
to greater staining than did coffee.30

Other articles found greater
enamel dissolution occurring
in flavored and energy (sports)
drinks than in cola drinks.35, 36

d - Cola Drinks
Dark-colored colas not only
stain teeth, but also erode tooth
enamel and cause tooth decay,31,
32, 33
although a new article found
no significant differences in the
frequency of the consumption
of foods and beverages and the
presence of dental erosion.34

The influence of coffee, tea,
cola, and red wine staining on
the color of teeth after home
bleaching has been evaluated.
A total of 45 samples were obtained from 45 sound maxillary
central incisors. The samples
were immersed in four staining
solutions (coffee, tea, cola, and

red wine) or artificial saliva. Following 15 min and 6 h of immersion on the first day and next day
of all the staining solutions, the
lowest ΔE values were observed
with coffee staining versus artificial saliva (control group), for
all time intervals evaluated after
whitening. There were statistically significant differences between the red wine, cola, and tea
solutions.37
A study assessed the influence of

surface sealant on the color stability of composite resins.
Red wine resulted in the highest
level of discoloration. Intermediate values were found for orange
juice, and the cola soft drink.38
e - Cranberry Juice
Some drinks that may be relatively good for health may not
be so good for teeth in terms of
staining them. Cranberry juice,
grape juice and other darkcolored fruit juices are very
good at staining teeth because
they contain pigments--and lots
of them--that can yellow teeth,
probably the same way they
stain composite resin.39
Cranberry Juice contains potential anticaries agents (highmolecular-weight polyphenols)
that inhibit the production of organic acids and the formation of
biofilms by cariogenic bacteria.
The polyphenols of cranberries
interfere with various activities
(including formation of biofilm and adhesion) of Porphyromonas gingivalis, the main
etiologic agent in chronic periodontitis.40, 41
In order to avoid these stains,
straws should be used and
mouthwash followed by tooth
brushing should be done.
f - Soy Sauce
Soy sauce is a condiment made
from a fermented paste of boiled
soybeans, roasted grain, brine,
and Aspergillus oryzae or Aspergillus sojae molds.42
Iron-fortified foods can help
prevent iron deficiency so can
iron-fortified soy sauce due to
the relatively high iron absorption from soy sauce.43, 44 But soy
sauce sticks to teeth, and the
deep-colored pigment can cause
very bad stains. In a study done
by Chan KC, the discoloration
of enamel caused by food substances was found to be superficial and ingressive for dentin
and cementum. Discoloration
of cementum exceeded that of
dentin, and dentin stained more
than enamel. Coffee and soy
sauce stained the calcified dental tissues more than the cola
beverage and tea. The longer
the staining time, the deeper
was the discoloration.45
g - Balsamic Vinegar
Balsamic vinegar is made from
grapes and generally consumed
in the Mediterranean region.
Oxidized low-density lipoprotein
(LDL) is believed to contribute to
atherosclerosis. Studies results
showed that balsamic vinegar
contained abundant polyphenols and inhibited LDL oxidation.46, 47 Thus, balsamic vinegar
reduces lipotoxicity, and it has
an anti-diabetic effect.48
In spite of these health benefits,
Balsamic vinegar is deeply pigmented causing teeth discoloration.
h - Tomato Sauce
Lycopene is the pigment principally responsible for the characteristic deep-red color of ripe tomato fruits and tomato products.

Lycopene is a micronutrient
with important health benefits,
because it contains natural antioxidant compounds like phenolics hydroxytyrosol and appears
to provide protection against a
broad range of epithelial cancers.49, 50
But the tomato sauce is highly
acidic and it attaches to the teeth
and causes unsightly stains.
i - Blueberries
Berries are a rich source of a
wide variety of non-nutritive,
nutritive, and bioactive compounds such as flavonoids, phenolics, anthocyanins, phenolic
acids, stilbenes, and tannins,
as well as nutritive compounds
such as sugars, essential oils, carotenoids, vitamins, and minerals. Bioactive compounds from
berries have potent antioxidant,
anticancer, antimutagenic, antimicrobial, anti-inflammatory,
and
antineurodegenerative
properties, both in vitro and in
vivo.51
Wild blueberries are rich in
polyphenols and have several
potential health benefits.52 For
example Blueberry extracts may
reverse the declines of cognitive and behavioral function in
the ageing process.53 Anthocyanin- and proanthocyanidin-rich
botanical extracts, present in
berries, may alleviate neurodegeneration in Parkinson‫׳‬s
disease.54 Polyphenols found in
the wild blueberries help in reducing the expression of pro-inflammatory genes in vitro55 and
current evidences are promising concerning the role of berry
(poly) phenols to support cardiovascular health.56
Even if the deep berry blue color
can cause deep staining, aren’t
all the benefits cited above
worth staining teeth?
3 - Betel leaf: India,Pakistan
The betel (Piper betle or Paan)
is the leaf of a vine belonging
to the Piperaceae family, which
includes pepper and kava. Explored for their unique medicinal properties, the leaves of Piper betel, an evergreen perennial
vine, are a reservoir of phenolics
with antimutagenic, antitumor
and antioxidant activities.57 It is a
compound of natural substances
chewed for its psychostimulating effects. Studies showed that
oral feeding of betel leaf extract
(BLE) significantly inhibited the
growth of human prostate.58, 59
It is believed that chewing betel quid could reduce stress,
strengthen teeth and maintain
oral hygiene.60
Approximately
200
million
persons chew betel regularly
throughout the western Pacific
basin and south Asia. There is
copious production of a bloodred saliva that can stain oral
structures. After years of chewing, the teeth may become redbrown to nearly black.61
4 - Liquorice
It is a uniquely tasting herb derived from Glycyrrhiza glabra,
and has been used in medicine

> Page 9B




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Dental Tribune Middle East & Africa Edition | March-April 2015

hygiene tribune 9B

Conservative Care and Treatment of TMJ
Dysfunction in Dental Patients
By Shivani Sarsthi, Physical
Therapist (TMJ Specialist)

E

ach year, the number of
reported cases of TMJ
dysfunction patients increases. Whether the cause is
from stress, trauma to the jaw,
post-dental procedures, or other
factors, the number of TMJ sufferers is growing. TMJ dysfunction is defined as a term covering pain and dysfunction of the
muscles of mastication and the
temporomandibular joints.
The symptomatic picture of a
TMJ patient does vary significantly, but often includes: muscle, joint, and facial pain, difficulty with chewing, joint sounds,
headaches and tinnitus. Recent
studies show that more females

than males suffer from TMJ
symptoms, most of which, are in
their childbearing years.
The conventional methods
used to treat TMJ dysfunction
include: Botox to relax specific
muscle groups (masseters), orthodontics (braces, retainers,
mouth guards), and in some
cases, surgery.
There exist options in the field
of physical therapy for patients
looking for an alternative health
approach. Specialized treatment
using soft tissue release and
joint mobilization, alone, has
had a profound affect on the relief of symptoms from a number
of TMJ sufferers. Application of
intra-oral technique to release
the lateral pterygoid and myofascial release to the anterior

neck component are two examples of treatment goals. Both
techniques help to relieve pressure on the jaw caused by hypertoned muscle groups.

further benefits the patient with
help of pain management and
restoration, optimal and functional range of motion of the
TMJ.

There is a demand placed on
oral surgeons and dentists,
to address TMJ related complaints, specifically after oral
surgery, and dental procedures
in which the jaw is open and
overstretched (beyond normal
range), for a long period of time.
A patient may experience trauma to the jaw due to an overstretch injury or invasive dental
procedure that has indirectly
impacted the jaw. The effects of
manual, soft tissue work has
had positive effects on majority
of patients and serve for a noninvasive treatment option. This

Current research shows a link
between stress and the TMJ.
Specific triggers such as alcohol
intake and smoking, for example, have an effect on sleep quality, and therefore, may promote
bruxism at night. Bruxism, is
a neurologic, sleep movement
disorder characterized by grinding or clenching of the teeth in
our sleep. This disorder is very
damaging to the teeth and the
jaw joints, and also causes fatigue and pain to the facial muscles. Lifestyle changes and sleep
hygiene techniques are reinforced by the physical therapist,

tongue or other oro-dental signs
of intraoral chewing tobacco
abuse combined with elevated
blood pressures, should alert
dentists to the possibility of morbidity arising from liquorice toxicity or abuse.74

containing alcohol and chlorhexidine.71
A study showed that CHX
mouthrinse was more effective
in controlling plaque and gingivitis than chlorhexidine containing toothpaste but caused
greatest deposition of extrinsic
stains. Supragingival calculus
deposition was least in triclosan
NaF+ group followed by CHX +
triclosan + NaF + ZnCl(2) and
CHX. More than half of the subjects reported adverse events
during the experimental phase.72

tion reactions leading to discolourationof the acquired pellicle.
Chlorhexidine may accelerate
formation of the acquired pellicle and also catalyze steps in the
Maillard reaction.2

Thus,although chlorhexidine digluconate (CHX) is currently the
most effective mouthwash for
reducing plaque and gingivitis,
one of its side effects is extrinsic
tooth staining. Interestingly, oxygenating agents may reduce this
staining. A review done by Van
Maanen-Schakel NW, searched
the literature for data concerning the inhibiting effect of an oxygenating agent (OA) on CHXinduced tooth staining. There
was moderate evidence that a
combination of CHX and an OA
reduces tooth staining without
interfering with plaque growth
inhibition.73

Polyvinylpyrrolidone (PVP) (a
polymer used as a synthetic
blood plasma substitute and in
the cosmetic, drug, and foodprocessing industries) was
shown in vitro to reduce chlorhexidine induced, dietary staining without affecting the uptake
of the antiseptic to the test substrate. A study in vivo aimed to
determine whether PVP affected
plaque and dietary staining by
a low concentration chlorhexidine rinse. Tooth stain areas
were comparable for placebo,
0.03% and 0.06% chlorhexidine
rinses, but significantly reduced
with the PVP/chlorhexidine
rinses compared to the 0.06%
chlorhexidine rinse. Tooth stain
intensity was significantly increased with 0.06% chlorhexidine rinses compared to placebo and chlorhexidine/PVP
rinses. PVP, at the concentrations tested, reduced the stain
propensity of a 0.06% chlorhexidine rinse but at the expense of
some loss of plaque inhibition.78

to help maintain optimal TMJ
functioning and help manage
pain and discomfort.
Treatment and management of
TMJ is a joint effort between patients, the dental and professionals and can be effectively treated
through specialized physical
therapy modalities.

Contact Information
Shivani Sarsthi, Physical
Therapist / TMJ Specialist
Breath and Health Alternative
Medical Center
1080 Al Wasl Road
Umm Suqeim 2, Jumeirah, Dubai
www.breathandhealth.net
email: shivani.sarsthi@gmail.com
t: 055 307 9405

< Page 8B
for thousands of years.62 Glycyrrhizin is 50 times sweeter than
sucrose. It retains, when sapid,
a singular liquorice flavour. The
liquorice sweetness has a slower onset than sugar and lingers.
Unlike artificial sweeteners like
aspartame, saccharine, and cyclamates, it contains no sulfur
molecule.63
For the treatment of bronchial
asthma, the root of liquorice
(Glycyrrhiza glabra) has been
used as a traditional medicine in
the East and West. Licochalcone
A is the predominant, characteristic chalcone in liquorice root
which might be involved in the
pathogenesis of virus-exacerbated asthma.64
Liquorice is used as a flavorant
in a variety of edibles, medicine, and tobacco, and is often
innocently consumed in vast
amounts without any regard or
only with vague concepts of side
effects. When imbibed, liquorice acts like hyperaldosteronism which presents with typical
symptoms including high blood
pressure, low blood potassium,
muscle pain and weakness.65
Liquorice may induce hypertension62 because excessive licorice
consumption can precipitate
a severe hypertensive event
through activation of renal mineralocorticoid receptors.66
Besides the hypertension problem, liquorice can stain the
tongue and teeth. Glycyrrhyzin
by itself does not stain teeth,
but when combined with dark
food dyes, tobacco and/or curries, liquorice is associated
with stains. Tooth staining from
black liquorice is known, but the
tooth staining derives mainly
from added dyes to liquorice
confections and from liquoriceflavoured tobacco. Liquorice
sweets are generally health
promoting, pleasurable to eat,
and in moderation on their own
rarely stain teeth. Accumulation
of extracellular polysaccharides
from microbial activity contributes to biofilm formation and

bacterial plaques. This allows
for a tacky gummy surface of
muco-polysaccharides to stick
to stagnant areas on teeth, and
with adherent chromogenic
bacteria, liquorice tobacco products discolour teeth and accelerate adjacent gingival breakdown. Quitting the tobacco habit
with safe stain removal through
scaling and polishing from teeth
is feasible.67
Heavy tobacco dental staining
can be noticed from pipe smoking with Liquorice as an additive.
It contributes to increased tobacco staining, especially when
included in aromatic pipe tobaccos; the dental stain is directly
proportional to the amount and
frequency of the pipe smoking.
Not only is the palatal and lingual side of teeth prone to accumulating dark tobacco stain
but also the mucosa undergoes
specific changes. Gingival recession, alveolar bone loss, and
periodontal pockets result from
the deleterious effect of the tobacco smoke.
Combined with chewing tobacco, liquorice additives enhance
and prolong the flavour of the
chewing tobacco experience,
and consequently damage from
longer contact time onto the
gingiva, seeming to derive more
from tobacco contents rather
than just liquorice. Adjacent recession, cervical dentinal staining, and thickening with hyperkeratosis of mucosa are seen.74
Frequently liquorice is mixed
with dark caramel and food
colorings which leave a surface
brownish/black tongue stain.
This tongue stain is water soluble and usually disappears after
a few hours.74
Health care workers, including
all in the dental team, discovering new hypertension patients,
or noting a history of taking diuretics, should always enquire
about consumption or use of any
liquorice containing product.67
Unduly stained teeth, a stained

5 - Curry
Curry powder is commonly used
spice in many countries of the
world. This spice can stain teeth
and, if inhaled, it could lead to
health problems. Hypersensitivity pneumonitis (HP) is a group of
immunologically mediated lung
diseases caused by the inhalation of environmental agents
(organic dusts from vegetable or
animal products), in susceptible
individuals.68 S
Ando reported a case of a man
who had worked in a factory
that produced curry sauce for
13 years and developed a nonspecific interstitial pneumonia
(NSIP) with bronchiolar lesions
associated with curry powder
and ground pepper.69
6 - Portobello Mushrooms
Mushrooms are valuable sources of vitamins such as retinol,
thiamine, riboflavin, pyridoxine,
and niacin. Portobello has the
highest riboflavin and niacin
contents.70 These items are wonderful additions to the entree,
but they are also known to stain
and discolor teeth.
7 - Mouthwashes that contain
Chlorhexidine or Cetylpyridinium chloride:
a - Chlorhexidine:
Chlorhexidine
anti-plaque
mouthrinses (CHX) remained
for a long time as the gold standard for mouthrinses but staining side effects can be seen with
this formulation. The tongue is
stained a dark blue-gray color
but it is not permanent and will
fade over time after CHX use is
stopped. As for teeth, the stain
would have to be polished off by
the dentist or hygienist.
Caustic burns of the lips, mouth
and tongue have been seen in
patients who use mouthwashes

Most of the search into stain formation has been carried out on
chlorhexidine, although there
are other antiseptics which
cause staining to a lesser extent
and the mechanism proposed
could be applicable to staining found with polyvalent metals. The characteristic staining
of the tongue and teeth noted
by Flotra74 is not peculiar to
chlorhexidine, it has been reported in other cationic antiseptics,75 an essential oil/phenolic
mouthrinse76 and following
prolonged use of delmopinol
mouthrinses. There is great individual variation in the degree of
staining from person to person,
this makes explanation more
difficult as it may be caused by
intrinsic factors, differences in
extrinsic factors or both .Berk
suggested that the protein and
carbohydrate in the acquired
pellicle could undergo a series
of condensation and polymerisa-

The results of a recent study
demonstrated
that
regular
use of CPH and chlorhexidine
mouthrinses resulted in extrinsic stain accumulation after six
weeks, with increased accumulation after 12 weeks versus
brushing alone.77

Addy et al wanted to determine
whether a co-polymer antiadhesive agent would prevent
staining by a low concentration chlorhexidine solution. Additionally, the possibility that
an essential oil/phenolic rinse
product may cause staining.
Tooth and tongue staining was
significantly increased with
0.2% chlorhexidine compared
to the essential oil/phenolic
rinse which in turn was signifi-

> Page 10B




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10B hygiene tribune

Dental Tribune Middle East & Africa Edition | March-April 2015

< Page 8B
cantly increased compared to
the other 3 rinses. The antiadhesive/chlorhexidine rinse produced no more staining than the
anti-adhesive or water rinse.
However, the parallel plaque regrowth study suggested this inhibition of staining resulted from
the vitiation of the chlorhexidine
activity by the anti-adhesive.79
b - Cetylpyridinium chloride:
Cetylpyridinium chloride (CPC)
is a cationic quaternary ammonium compound used in some
types of mouthwashes, toothpastes, lozenges, throat sprays,
breath sprays, and nasal sprays.
It is an antiseptic that kills bacteria and other microorganisms.
It has been shown to be effective
in preventing dental plaque and
reducing gingivitis.80, 81 It has
also been used as an ingredient
in certain pesticides. Cetylpyridinium chloride may cause
brown stains between the teeth
and on their surfaces.82 However, these stains can be easily
removed by a dental hygienist
during a routine check-up.
As known, Cationic antiseptics
such as chlorhexidine (CHX)
and cetyl pyridinium chloride
(CPC) interact with dietary chromogens to produce extrinsic
stain, and this can be used as a
measure of activity of products.
A study was done in vitro to determine if toothpaste influenced
the tea staining effects of CHX
and CPC as a predictor of action
in vivo. Little staining was seen
with toothpaste (TP) and water combinations. TP followed
by CHX reduced the activity of
CHX. Toothpaste appears to adversely affect the activity of CHX
and CPC particularly if used immediately after the antiseptics.
The data further supports the
concept of separating the use of
antiseptics until sometime after
the use of toothpaste, and the
idea of developing mouthwash
friendly toothpastes.83
8 - Chromogenic Bacteria
Chromogenic Bacteria cause
stains mostly when the child has
received liquid Ammoxicillin
for a prolonged period of time.84
Chromogenic stains are a type
of extrinsic stains of the teeth
which can be seen in children
and can sometimes be intrinsec
if the bacteria affect the tooth
during development stage. The
black stains in the cervical region are due to the Actinomyces
species bacteria. The bacteria
produce hydrogen sulfide, responsible for oral malodour,85
which reacts with iron in the
saliva and gingival exudates to
form a bacterial plaque that is
usually black or has black discoloration to it.86 Green stains
are attributed to fluorescent bacteria and fungi such as Penicillium and Aspergillus species.87
A recent study has investigated the presence of the blackpigmented bacteria Prevotella
nigrescens and Prevotella intermedia, the non-black-pigmented bacteria Actinomyces
spp and particularly the cariogenic pathogen Streptococcus
mutans in the dental biofilms of
patients with or without black
extrinsic tooth stains, using the
multiplex polymerase chain
reaction (PCR) technique. The

result showed that the similar
bacterial composition of dental
biofilms of black tooth stains and
healthy tooth surfaces indicates
that black tooth stains are not
free of cariogenic bacteria.88
9 - PROFESSIONAL INTOXICATION: Iron dust Copper
dust
Iron deficiency is estimated to
be the most common nutritional
deficiency in both developed
and underdeveloped nations.89
Iron supplements are generally
consumed in the form of syrups
or drops for children. Besides its
undesirable taste, one of its main
problems is black discoloration
of teeth after consumption.90
The quality of the consumed
drinking water may also affect
oral health. For example, the
presence of iron in drinking water can cause aesthetic problems
related to changes in dental
enamel color. Rebelo de Sousa
has assessed the prevalence of
extrinsic enamel color changes
and their relationship with the
quality of the water.91
Staining is more obvious on hypomineralized and decalcified
areas. Tooth staining due to iron
supplement might be caused by
an insoluble ferric compound
such as ferric sulfide produced
by interaction between Fe ions
or gingival fluid composition
and hydrogen sulfide produced
by bacteria.92
This staining on the teeth surfaces can deposit in the form
of insoluble ferric like ferric
sulfide93 and is thought to result
from a chemical interaction between hydrogen sulfide producing micro-flora and iron.94, 95 So
combining the iron intake with
water or other liquids such as
fruit juice and drinking it with
straw or dripping the drops on
posterior parts of mouth can
prevent tooth discoloration.
Brushing teeth before consuming iron supplements is effective
on decreasing the rate of staining96 and a simple scaling by the
dentist is sufficient to remove
these stains as reported by K.
Adcock et al.97 Copper causes a
green stain in mouthrinses containing copper salts and in workers in contact with the metal in
industrial circumstances.98, 99
As already mentioned, the stain
production is related to the production of the sulphide salt of
the metal involved. The extrinsic stain coincide with the colour
of the sulphide of the metal concerned.98
Even the margin of the gums,
at the base of the teeth, can present stains like the Burton line or
Burtonian line which is a clinical
sign found in patients with lead
poisoning.100, 101
Drug-induced tooth discoloration can be prevented by avoiding prescriptions of well-known
offender drugs known to cause
tooth discoloration during pregnancy and in young children.102
Conclusion
The etiology of tooth staining is
important in making a proper
diagnosis, in clarifying the causes of discoloration to the patient
and, in some instances, in helping the dentist establish a treatment plan. He may even refuse
to perform the whitening pro-

cedure in cases of rapid relapse
risk such as in heavy smokers.
Different clinical indices and
photometric techniques have
been used in order to evaluate
extrinsic discolorations. Many
promoting factors are incriminated.
In order to differentiate between
extrinsic and intrinsic discoloration, the scratch test may be
used with a dental explorer or
scaler instrument over discolored tooth surfaces. Weakly adherent plaque will be removed
by a light scratching. Tenacious
stains require removal with a
sharp dental scaler. Intrinsic discoloration cannot be removed
by using the scratch test.
Tooth discoloration is a major
problem in our society today because of the presence of numerous chromogenic products on
the market as well as environmental chemicals. In addition
to that, esthetics has become a
top priority for patients, because
a bright smile is now a must for
social integration and strengthened self-esteem.
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Editorial note:
Full list of references is available
from the publisher.




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