Erosion: A Call for Action and the Role of Stannous Fluoride

Did you know if you performed check-ups on ten adult patients per day for five days, your week would look like this:

• 1.5 days of patients with untreated decay

• 1 days of patients with severe periodontal disease 

• 2.5 days of patients experiencing erosive tooth wear.^[1-3]

The gold standard to reduce incidence of caries^[4] and periodontal disease^[5] is to brush twice a day with a standard Fluoride-containing toothpaste. However, non-carious tooth loss caused by erosion is challenging, and standard Fluoride-containing toothpastes mitigates erosion in a limited way compared with the research-backed use of polyvalent fluorides^[6]. Given nearly half of your patient population are likely to experience erosive toothwear, the question then arises what toothpaste can you actively recommend to help your patients manage erosive non-carious tooth?

Experts note that variability in toothpaste formulations and consequent effectiveness suggest that "All fluorides are not equal"  when it comes to protection from erosion^{[3, 7, 8]}.

Most standard toothpastes contain monovalent fluorides like sodium fluoride or sodium monofluorophosphate. When applied to the tooth surface, monovalent pastes form calcium fluoride. However, polyvalent compositions, such as those containing stannous fluoride (SnF₂ ), form a SnF₂ layer on the tooth and this has a key advantage when it comes to protection against erosion, as it creates an acid resistant protective layer^[6].

SnF₂  toothpastes are proven to; 

1. Prevent erosive wear and remineralise tooth surfaces.

2. Alter the bacterial profiles of plaque .

Two weeks of polyvalent SnF₂  toothpaste use remineralises tooth surfaces by enhancing bioavailable fluoride deposition on the tooth surface^{[9, 10]}. Furthermore, monovalent calcium fluoride dissolves easily in an acid-challenged environment, while polyvalent SnF₂  resists and protects the hard tissue to prevent erosion by a^{[6, 9, 11]}.modifying the salivary pellicle to influence the attachment of oral bacteria^{[11, 12]}.

While the primary focus of this article is erosion,  SnF₂ toothpastes are effective antibacterial agents. Studies have reported that  two months of brushing with a SnF₂toothpaste significantly reduces bacterial plaque growth and composition compared to monovalent pastes^[9]; plaque compositions change to increase  protective S. salivarius and reduce S. mutans and P. gingivalis populations.^{[8, 12, 13]}

The effectiveness of SnF₂ toothpastes to address erosion and other oral care concerns have been known for over fifty years^[10]. Yet  SnF₂ toothpaste stability and consequent bioavailability^[14] has historically challenged the large-scale manufacture and distribution of stable SnF₂  toothpastes^[15].

Environmental oxygen exposure to pastes, both during packing and storage increases exponentially each time the tube lid is opened to break down SnF₂^[15-17]. Unlike monovalent toothpastes, SnF₂ formulations exposed to environmental oxygen or heat, high water-containing formulations break down into biologically ineffective stannous species^{[15, 18]}. The retention of stannous ions is essential to improve bioavailability^[19]. How can we stabilise stannous ions in toothpaste?

To maintain water solubility, stability and bioavailability, Colgate has developed a novel SnF₂  toothpaste.  The new SnF₂ formulation is stabilised with nitrates to block stannous conversion in variable environmental conditions, and phosphates to maintain water solubility^{[14, 19]}. The Colgate Total Active Prevention stabilised with nitrate and phosphate (SNaP) maintains high bioavailability of stannous species over time^[19].

The key takeaway? Colgate Total Active Prevention offers multifaceted benefits.  The improved bioavailability of stannous ions significantly benefits patients who need erosion protection. Consequently, Colgate Total Active Prevention should be a high priority as part of your erosion management plan for your patients.