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Extrinsic staining on the tooth surface can result from the diet, smoking, and poor oral hygiene. Extrinsic stain can be removed by mechanical means and by chemical means. The use of abrasives in toothpaste helps to remove stain mechanically during toothbrushing (St. John & White, 2015). All Crest dentifrice meets the International Standards Organization specifications for Relative Dentin Abrasivity (RDA), which has an upper limit of 250. Dentifrices at or below 250 RDA are considered safe and effective.

Chemical cleaning agents in the toothpaste can help to displace surface stains from the tooth pellicle (Figure 23). In addition, some chemical compounds have a high enough affinity for the tooth surface and pellicle to actually help prevent new stain from adhering. Polyphosphate molecules, such as sodium hexametaphosphate, that are used for calculus control have also been shown to both prevent stain and whiten teeth (Baig et al. 2005). Hydrogen peroxide is another highly effective antistain ingredient under appropriate formulation and usage conditions (Gerlach et al. 2015).

Binding of pyrophosphates to calcium hydroxyapatite at the tooth surface

Figure 23. Binding of pyrophosphates to calcium hydroxyapatite at the tooth surface

Figure 24. Stain prevention and displacement

Stain prevention and displacement

Mechanism of action

The stain prevention and whitening effects of many stabilized stannous fluoride formulations in Procter & Gamble’s portfolio are provided by an advanced, high cleaning silica system and sodium hexametaphosphate (polyphosphate). The high cleaning silica gently removes stain mechanically during brushing, while the sodium hexametaphosphate works chemically. The sodium hexametaphosphate provides for excellent stain removal and prevention (Baig et al. 2005; Terezhalmy et al. 2007):

  • Sodium hexametaphosphate has a strong affinity for and attraction to the tooth surface and the pellicle film at the tooth surface to which surface stain is attached.
  • - The sodium hexametaphosphate molecule is negatively charged while the calcium ions in the pellicle and enamel are positively charged. Since opposites attract, the polyphosphate is strongly attracted to these calcium sites.

  • The sodium hexametaphosphate adsorbs to the pellicle, disrupting it.
  • - As a result of disruption of the pellicle, the stain that was attached to and trapped in it becomes displaced, released and lifted away from the tooth surface.

  • Thirdly, the retention of sodium hexametaphosphate at the tooth surface and in the tooth pellicle prevents new stain from binding and accumulating at the tooth surface. (Figure 24)

The 2-step stabilized stannous fluoride formula contains hydrogen peroxide in the second step to provide whitening by disruption of carbon bonds. Stain is composed of materials containing carbon bonds that reflect back only the wavelengths of light that appear colored. Hydrogen peroxide breaks the carbon bonds, so the stain then reflects back more wavelengths of light, making the stain appear white (Goldstein & Garber, 1995). The smooth texture stabilized stannous fluoride formula uses a combination of silica and zinc citrate for stain prevention. The silica gently removes surface stains while the zinc citrate indirectly protects against stains by preventing calcification of plaque into tartar, thereby reducing the surface area that can attract stains.

Stannous fluoride and stain prevention

Whitening Research Summaries

The following study summaries represent a sample of research demonstrating the anti-stain and extrinsic whitening benefits of stabilized stannous fluoride dentifrice.

Extrinsic Stain Removal Efficacy of a Stannous Fluoride Dentifrice With Sodium Hexametaphosphate

Reference: He T, Baker R, Bartizek RD, et al. J Clin Dent. 2007;18(1):7-11.

CONCLUSION

In 2 studies, Crest® PRO-HEALTHdemonstrated significant extrinsic stain removal vs baseline and comparable stain removal to the positive control dentifrice.

Also refer to A Randomized Clinical Trial to Assess Gingivitis, Plaque, and Tooth Color after Use of a Daily Two-Step Dentifrice and Gel System versus Chlorhexidine Rinse, Page 20.

OBJECTIVE

To compare stain removal of a dentifrice containing stabilized stannous fluoride and sodium hexametaphosphate to a positive control dentifrice in 2 independent, double-blind, randomized 6-week trials.

The following dentifrices were tested in each study:

  • Crest® PRO-HEALTH (0.454% stabilized stannous fluoride + sodium hexametaphosphate).
  • Positive control dentifrice (Colgate Total Plus Whitening with sodium fluoride).

MATERIALS AND METHODS

  • Both studies followed the same protocol.
  • Study subjects were healthy adults with visible extrinsic tooth stain.
  • The modified Lobene Stain Index was used to measure stain on the facial surfaces of the 8 central and lateral incisors at baseline.
  • Oral soft and hard tissue examinations were also conducted.
  • Subjects were randomized to either the stabilized stannous fluoride + sodium hexametaphosphate toothpaste or positive control toothpaste.
  • Subjects used their assigned dentifrice twice a day for 6 weeks.
  • Patients were examined again for stain and safety at weeks 3 and 6.

RESULTS

  • 52 subjects completed Study 1; 58 subjects completed Study 2
  • Lobene composite stain scores were not statistically significantly different between the 2 dentifrice groups at all 3 time points (baseline, week 3, and week 6) in each study.
  • Relative to baseline scores, both dentifrice groups showed statistically significant reductions in Lobene composite stain scores at week 3 (P<0.0001) and week 6 (P<0.0001).

Study 1. Lobene Composite Stain Score, Evaluable Subjects

Lobene Composite Stain Score, Evaluable Subjects

Study 2. ILobene Composite Stain Score, Evaluable Subjects

Lobene Composite Stain Score, Evaluable Subjects, Week 3 and 6

Extrinsic Stain Removal Efficacy of a Stabilized Stannous Fluoride Dentifrice

Reference: L Friesen, T He, R. Eusebio. J Dent Res 2017; 96 (Spec Iss A): Abstract 1941.

KEY CLINICAL FINDINGS

  • After 2 week of use, the experimental stabilized stannous fluoride (SnF2) group demonstrated significantly less Interproximal Modified Lobene (IML) stain overall (see Figure) and interproximal surface stain than the positive control dentifrice group (P<0.0012).
  • Both groups showed statistically significant reductions in IML stain scores at Week 2 (P<0.0001) relative to Baseline. The median percent change reductions were 57% for the positive control and 70% for the SnF2 dentifrice.

Figure. Interproximal Modified Lobene Stain Scores per Group.

Interproximal Modified Lobene Stain Scores per Group

OBJECTIVE

To assess the extrinsic stain removal benefit delivered by a SnF2 dentifrice and a positive control dentifrice over a two-week period.

METHODS

  • This study utilized a randomized, two-week, double-blind, parallel group design.
  • At Baseline, an IML examination was performed on the facial surfaces of the twelve anterior teeth. The two teeth with the highest IML composite scores were selected as the test teeth.
  • Subjects were stratified on stain scores of the test teeth, and gender, and randomized to one of two treatment groups:
  • - Experimental 0.454% stabilized stannous fluoride dentifrice (Crest® PRO-HEALTH Clean Mint [Smooth Formula], Procter & Gamble); or

    - 0.243% sodium fluoride/0.3% triclosan positive control whitening dentifrice (Colgate® Total® Whitening, Colgate-Palmolive).

  • Subjects were instructed to use their respective test product following the manufacturer’s instructions at home over the two week study duration.
  • Tooth color was reassessed at Week Two.
  • Baseline to post-treatment change in stain score was tested using paired t-tests. Analysis of covariance (ANCOVA) with treatment as a factor and Baseline Lobene score as the covariate was used to assess treatment differences post-treatment. All comparisons were two-sided using a 5% level of significance.

CLINICAL COMMENT

Stabilized SnF2 dentifrice has been shown to provide significant oral health benefits, including protection against caries, plaque, gingivitis and sensitivity.§ SnF2 formulations have also been developed to provide esthetic benefits consumers desire, including extrinsic stain removal. This high silica containing toothpaste is uniquely formulated to provide effective cleaning and surface stain removal.

‡ Friesen L, et al. Am J Dent 2016; 29:20-24.
§ Baig A and He T. Compend Contin Educ Dent. 2005;26 (Suppl 1): 4-11.

Clinical Significance: Stains

Stannous Fluoride Clinical Significance
  • The stabilized stannous fluoride dentifrice formulations not only prevent stain from forming, but they actually provide whitening by removing surface stains, an esthetic benefit that is important to the patient.
  • Now the health benefits of stannous fluoride are fully realized without the esthetic drawback of potentially causing stain in some individuals.

CASE STUDIES

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Patient Profile: Patient is a 68year old White Caucasian male who is semiretired from farming.

Chief Complaint: “My teeth feel rough, look brown and my mouth is dry. I also have a sore spot behind my last tooth on the lower right side.”

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Patient Profile: Patient is a 50year old White Caucasian male in good health.

Chief Complaint: “I am very concerned about the stain on my front teeth.”

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CLINICAL STUDIES

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In-Office Research of Stain Removal Efficacy of Stannous Fluoride Dentifrice

Purpose: An in-office trial compared use of three dentifrices on cleaning/stain removal, while also obtaining subjects’ assessment of the perceived occurrence of tooth staining.

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Extrinsic Stain Removal Efficacy of a Stabilized Stannous Fluoride Dentifrice

Purpose: To assess the extrinsic stain removal benefit delivered by a SnF2 dentifrice and a positive control dentifrice over a two-week period.

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Effects of Paste/Gel Sequence on Post-Prophylaxis Stain, Calculus and Plaque

Purpose: A randomized controlled trial was conducted to assess the effectiveness of a daily 2-step dentifrice and gel system to prevent stain, calculus and plaque after a dental prophylaxis.

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PATIENT EDUCATION

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TEETH WHITENING

When dental professionals asked people what they’d most like to improve about their smile, the most common response was whiter teeth.

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