UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
LITERATURE REVIEW DOI: https://doi.org/10.4322/bds.2023.e3688
1
Braz Dent Sci 2023 Jan/Mar;26 (1): e3688
Effects of different toothpaste formulations on erosive tooth wear
prevention: systematic review
Efeitos de diferentes dentifrícios na prevenção do desgaste dentário erosivo: revisão sistemática de literatura
Sara Caldas NOLASCO
1
, Lorena Castro ROCHA
1
, Patrícia Santos SILVA
1
, Sheyla Márcia AUAD
1
,
Fernanda de Morais FERREIRA
1
, Cristiane Meira ASSUNÇÃO
1
1 - Universidade Federal de Minas Gerais, Departamento de Saúde Bucal da Criança e do Adolescente. Belo Horizonte, MG, Brazil.
How to cite: Nolasco SC, Rocha LC, Silva PS, Auad SM, Ferreira FM, Assunção CM. Effects of different toothpaste formulations on
erosive tooth wear prevention: systematic review. Braz Dent Sci. 2023;26(1):e3688. https://doi.org/10.4322/bds.2023.e3688
ABSTRACT
Objective: erosive tooth wear is a multifactorial condition that results in loss of dental hard tissue, caused by
a chemical and mechanical process. This paper aims to carry out a systematic review presenting the effects of
different toothpaste formulations on the loss of dental enamel surface
in vitro
. Material and Methods: the
searches were performed in the databases PubMed, Web of Science, LILACS and Scielo. Articles published from
2010 to 2020 were ltered, without language restriction. Articles that included abrasion and erosion protocols
were searched, as they were more similar to clinical reality, since toothpaste is applied through tooth brushing.
The searches with descriptors and free terms on the topic resulted in 992 articles, however only 12 were within
the search criteria. Results: the selected studies appointed that association of conventional uorides (NaF) with
metallic uorides can be a promising strategy for the reduction of surface loss by erosive tooth wear. Toothpastes
containing sodium uoride, as well as tin without chitosan, showed a reduction in surface loss, considered sufcient
for individuals with medium exposure to acids. In children’s toothpastes, the one containing sodium uoride
showed a reduction in surface loss when compared to non-uoride dentifrices. Conclusion: different protocols
may result in less or greater loss of enamel surface, and methodological differences should be considered. To
clarify the effects of dentifrices on erosive tooth wear, other properties of dentifrices should be investigated.
KEYWORDS
Erosive tooth wear; Tooth erosion; Fluoride; Toothpastes; Termo; Systematic review.
RESUMO
Objetivo: o desgaste erosivo é uma condição multifatorial que resulta em perda de tecido duro dentário, causado
por um processo químico e mecânico. Este trabalho tem como objetivo realizar uma revisão sistemática de literatura
apresentando os efeitos de diferentes formulações de dentifrícios na perda de superfície de esmalte dentário
in
vitro
. Material e Métodos: a busca foi realizada nas bases de dados PubMed, Web of Science, LILACS e Scielo.
Foram ltrados artigos publicados no intervalo de 2010 a 2020, sem restrição de idioma. Buscou-se artigos que
incluíssem protocolos de abrasão e erosão, por mais se assemelhar a realidade clínica, uma vez que o dentifrício
é aplicado através da escovação dentária. A busca com descritores e termos livres sobre o tema encontrou 992
artigos, entretanto somente 12 estavam dentro dos critérios da pesquisa. Resultados: os estudos selecionados
apontaram que associação dos uoretos convencionais (NaF) com os metálicos pode ser uma estratégia promissora
para a redução de perda de superfície pelo desgaste dentário erosivo. Dentifrícios contendo uoreto de sódio,
assim como estanho sem quitosana, apresentaram redução na perda de superfície, sendo considerada suciente
para indivíduos com exposição média aos ácidos. Em dentifrícios infantis, aquele que continha uoreto de sódio
apresentou uma redução de perda de superfície quando comparado com dentifrícios sem uoreto. Conclusão:
diferentes protocolos podem resultar em menor ou maior perda de superfície de esmalte e as diferenças
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3688
Nolasco SC et al.
Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
INTRODUCTION
Erosive tooth wear is a multifactorial and
irreversible condition caused by a chemical and
mechanical process, not associated with bacteria,
that results in loss of dental hard tissue [1,2].
The chemical erosion process occurs with the
tooth surface softening through exposure to
acidic substances in a frequent, severe way and
for long periods to be considered a clinically
signicant risk [1,2]. The mechanical process,
on the other hand, occurs when, affected by
acids, the tooth surface becomes softer and more
susceptible to abrasion. Abrasive mechanical
forces remove the softened enamel and generates
signicant irreversible loss of hard tissue, which
characterizes erosive tooth wear [1,3].
Substantial preventive measures should
be proposed to patients, such as dietary advice
aiming to reduce the frequency of acidic foods and
drinks, intake of drinks with high concentrations
of calcium, prophylactic measures with the
application of fluoride agents, stimulation of
salivary ow, use of medications for tamponade
effect, and gently brushing with anti-erosion
toothpaste [4-6].
Toothpastes feature active ingredients
that protect against tooth decay and other oral
diseases and conditions, such as erosive tooth
wear. However, inadequate oral hygiene habits
and the interaction between erosion and abrasion
can increase wear. The combination of brushing
with abrasive toothpaste is a relevant factor for
erosive tooth wear [7].
High concentrations of uoride have been
shown to increase the abrasion resistance of
eroded enamel and decrease the development
of enamel erosion [8]. Fluorides prevent erosive
demineralization due to the formation of a
calcium fluoride layer that acts as a physical
barrier or mineral reservoir. The formation of
this layer depends on pH, concentration, type
of fluoride and frequency of application, and
the released calcium and uoride increase the
saturation level in relation to the enamel, besides
preventing dissolution [9].
Monovalent and polyvalent uorides offer
little protection in situations of frequent acid
challenges and require frequent applications
[9,10]. In a systematic review that evaluated the
effect of different types of uoride and vehicles
for
in situ
studies, Zanatta et al. [11] concluded
that sodium uoride (NaF) in toothpastes offer
limited protection.
Polyvalent metallic compounds may be more
effective to protect against erosive tooth wear if
compared to conventional uorides. For better
results, active ingredients such as amine and
tin uorides, phosphates and biopolymers have
been tested [12]. However, there is still no
consensus on which toothpaste formulation has
the best preventive action against erosive tooth
wear. The objective of this work is to carry out
a systematic review presenting the effects of
different toothpaste formulations on the loss of
dental enamel surface
in vitro
.
MATERIALS AND METHODS
This review was conducted using the
Preferred Reporting Items for Systematic Reviews
and Meta-analysis (PRISMA).
Eligibility criteria
The question to be answered on this
systematic review was: “What uoride toothpaste
has the better preventive effect against erosive
tooth wear in enamel?”
P (Patients) = enamel samples.
I (Intervention) = Erosion and abrasion
protocols with conventional uoride toothpaste.
(Comparison) = Erosion and abrasion
protocols with antierosion uoride toothpaste.
(Outcome) = Surface loss.
Inclusion criteria:
in vitro
(laboratory)
studies that evaluated the effect of uoridated
toothpastes in preventing enamel erosive wear,
using prolometry as a method for surface loss
assessment.
metodológicas devem ser consideradas. Para esclarecer os efeitos dos dentifrícios no desgaste erosivo, outras
propriedades dos dentifrícios devem ser investigadas.
PALAVRAS-CHAVE
Desgaste dentário erosivo; Erosão dentária; Flúor; Dentifrício; Termo; Revisão sistemática.
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Braz Dent Sci 2023 Jan/Mar;26 (1): e3688
Nolasco SC et al.
Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Exclusion criteria: clinical studies, studies
that did not evaluate erosive tooth wear, studies
that did not subject the samples to an abrasive
challenge, studies that did not include dentifrice
in any experimental group, studies that evaluated
erosive tooth wear in dentin only, studies that
evaluated erosion and attrition, and studies that
employed surface loss assessment methodologies
apart from prolometry.
Search strategy
The searches were performed in March
2021 in the electronic databases: PubMed, Web of
Science, Latin American and Caribbean Literature
on Health Sciences (LILACS) and Scielo. Articles
published between 2010 and 2020 were ltered,
without language restriction. The search strategy
was made using descriptors and free terms on the
topic, following the search rules of each platform.
On Chart I the terms used in each database are
detailed.
Selection of articles and data collection
Duplicates – articles present in more than
one database – were considered only once. After
searching the electronic databases, the articles
were initially selected based on the title and
later by the abstract. After selection by abstract,
the articles were read in full to ensure that
they met the eligibility criteria. All these steps
were performed by two researchers (C.M.A.
and S.C.N.) who discussed possible questions and
reached a consensus on whether to include the
articles. All data were collected and organized in
a specic form.
RESULTS
The searches performed resulted in a total of
992 articles, with 790 remaining after duplicates´
exclusion. From these, 120 articles were selected
by title, and subsequently, 29 by abstract. Twelve
articles met the eligibility criteria and were fully
read for data collection (Figure 1).
Table I describes the selected articles
regarding the number of samples and type
of samples (bovine, human enamel). Table II
presented the data regarding erosive agent,
protocol of erosive and abrasive cycles, and
method of surface loss assessment.
Chart I - Search Strategies
PubMed
(Erosive Tooth Wear OR Tooth Erosion OR Erosion OR Enamel Erosion OR Dental Erosion OR Erosive
lesion OR Erosive lesions OR Softening OR Tooth Wear OR Dental Wear OR Enamel wear OR Acid
wear) AND (Fluorides OR Fluoride OR Fluorides, Topical OR Topical Fluorides OR Fluoride Toothpastes
OR Toothpastes OR Fluoride Dentifrice OR Dentifrice OR Fluoride varnish OR Fluoride varnishes OR Tin
Fluorides OR Stannous Fluoride OR SnF2 OR SnCl2 OR Stannous OR Stannous gel OR Tin Compounds
OR Tin OR Acidulated Phosphate Fluoride OR APF OR fluorophosphate OR monofluorophosphate OR
sodium phosphate OR Sodium Fluoride OR NaF OR Calcium Fluoride OR CaF2 OR TiF4 OR Tetrafluoride
OR Tetrafluorides OR Titanium OR Amines OR Amine fluoride OR AmF OR amine fluoride gel)
AND (in vitro OR In Vitro Techniques OR laboratorial studies)
Web of Science
TS=(“Erosive Tooth Wear” OR “Tooth Erosion” OR “Erosion” OR “Enamel Erosion” OR “Dental Erosion”
OR “Erosive lesion” OR “Erosive lesions” OR “Softening” OR “Tooth Wear” OR “Dental Wear” OR “Enamel
wear” OR “Acid wear”)
AND
TS=(“Fluoride*” OR “Fluorides, Topical” OR “Topical Fluorides” OR “Fluoride Toothpastes” OR
“Toothpaste*” OR “Fluoride Dentifrice*” OR “Dentifrice*” OR “Fluoride varnish” OR “Fluoride varnishes”
OR “Tin Fluorides” OR “Stannous Fluoride” OR “SnF2” OR “SnCl2” OR “Stannous” OR “Stannous gel”
OR “Tin Compounds” OR “Tin” OR “Acidulated Phosphate Fluoride” OR “APF” OR “fluorophosphate” OR
“monofluorophosphate” OR “sodium phosphate” OR “Sodium Fluoride” OR “NaF” OR “Calcium Fluoride”
OR “CaF2” OR “TiF4” OR “Tetrafluoride” OR “Tetrafluorides” OR “Titanium” OR “Amines” OR “Amine
fluoride” OR “AmF” OR “amine fluoride gel”)
AND
TS=(“in vitro” OR “In Vitro Techniques” OR “laboratorial studies”)
LILACS
(erosive tooth wear) OR (tooth erosion) OR (erosion) OR (tooth wear) OR (enamel erosion) AND
(dentifrices) OR (toothpastes) OR (fluorides) OR (fluoride dentifrice) OR (tin fluorides) OR (stannous
fluorides) OR (snf2) OR (sncl2) OR (acidulated phosphate fluoride) OR (APF) OR (fluorophosphate) OR
(monofluorophosphate) OR (sodium phosphate) OR (sodium fluoride) OR (naf) OR (calcium fluoride) OR
(caf2) OR (tif4) OR (tetrafluoride) OR (tetrafluorides) OR (titanium) OR (amines) OR (amine fluoride) OR
(amf) AND (in vitro) OR (laboratorial studies) OR (in vitro techniques)
Scielo
(erosive tooth wear) OR (tooth erosion) OR (tooth wear) AND (dentifrices) OR (toothpastes) AND (in
vitro) OR (in vitro techniques) OR (laboratorial studies)
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Nolasco SC et al.
Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Erosive challenges were performed with
different soft drinks, concentrated orange juice,
citric and hydrochloric acids, being citric acid
the most frequently used (six studies). Erosive
challenges ranged from 1.5 to 5 minutes. Abrasive
challenges differed in application time (if before
or after erosion, and if after the whole erosive
challenge or interchangeably), duration and load.
Table III describes data collected from the
selected articles as to the groups of dentifrices
tested and the values of surface loss found in the
different erosion and abrasion protocols.
Moretto et al. [8] showed that experimental
toothpastes with high concentration of sodium
uoride (5000 ppm F) and low concentration
of sodium fluoride associated with sodium
trimetaphosphate had less enamel surface loss
when compared to placebo (without uoride),
followed by toothpaste with regular concentration
(1100 ppm F).
Comar et al. [15] pointed out that the
association of conventional and metallic uorides
may be a promising strategy to reduce surface
loss by erosive tooth wear. Both experimental
toothpastes (TiF4 and SnF2) and the commercial
toothpaste ProHealth (SnF2+NaF) were similarly
able to reduce surface loss [15].
Ganss et al. [16] analyzed the effectiveness
of adding tin ion and chitosan in fluoride
toothpastes. Toothpastes containing sodium
uoride, as well as those containing tin without
chitosan, showed enough reduction in surface
loss for individuals with average exposure to
acids. Toothpastes containing tin and without
chitosan showed similar amounts of fluorine
and tin ions and presented similar results. When
compared to the gel form in the control group,
they showed less efcacy, which, according to
the authors, was due to the lower amount of
active ingredients available and the presence of
abrasives [16].
Ganss et al. [13] demonstrated that the
dentifrices evaluated had limited protection
against abrasive brushing, and anti-erosion
formulas were not superior and sometimes
even less effective than conventional formulas.
In addition, the toothpastes with tin content, when
tested only through slurry (without abrasion), had
its effect neutralized with brushing. The authors
point out that due to methodological differences,
the two experiments (only erosion and erosion
followed by abrasion) could not be compared.
The study by Ganss et al. [18] demonstrated
that among toothpastes containing sodium
Figure 1 - Fluxogram showing strategy for articles search and
selection.
Table I - Description of the selected articles regarding the number and type of samples
Author, year
Number of samples per
group
Substrate type
1. Moretto, Magalhães, Sassaki, Delbem and Martinho (2010) n=15 Bovine enamel
2. Ganss, Lussi, Grunau, Klimek and Schlueter (2011) n=18 Human permanent enamel
3. Rochel, Souza, Silva, Pereira, Rios, Buzalaf and Magalhães (2011) n=10 Bovine enamel
4. Comar, Gomes, Ito, Salomão, Grizzo and Magalhães (2012) n=12 Bovine enamel and dentine
5. Ganss, Von Hinckeldey, Tolle, Schulze, Klimek and Schlueter (2012) n=15 Human permanent enamel
6. Moron, Miyazaki, Ito, A Wiegand, Vilhena, Buzalaf and Magalhães (2013) n=12 Bovine enamel and dentine
7. Ganss, Marten, Hara and Schlueter (2016) n=15 Human permanent enamel
8. Mosquim, Souza, Foratori, Wang and Magalhaes (2017) n=12 Bovine enamel
9. Soares, Magalhães, Fonseca, Tostes, Silva and Coutinho (2017) n=20 Human permanent enamel
10. Wegehaupt, Schleich, Hamza, Wiedemeier and Attin (2018) n=12 Bovine enamel
11. Simões, Dionizio, Câmara, Sabino-Arias, Levy, Ventura, Buzalaf, Batista,
Magalhães, Groisman and Buzalaf (2020)
n=12 Bovine enamel
12. Passos, Sousa, Melo, Gomes, Santiago and Lima (2020) n=8 Human deciduous enamel
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Nolasco SC et al.
Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Table II - Description of the articles regarding the erosive agent, protocol of erosive and abrasive cycles, and method of surface loss assessment
Erosive agent Erosive-abrasive cycle Surface Loss Assessment Method
1. Morettoetal. [8] Sprite, pH 2.8
7 days: 10 mL Sprite 4x/dia 5 min. Contact profilometry
Dentifrice treatment: 15s in the
slurry
dentifrice.
5 measurements and average (in
micrometers)
Abrasion: 15s/load 30 g.
Storage in 10 mL of artificial saliva pH 7.0 2h
between cycles.
2. Ganssetal. [13] Citric acid pH 2.4
10 days: 250 mL citric acid 6x/day 2 min. Optical profilometry
Dentifrice treatment: immersion in 200 mL
of the slurry for 2 min after the first and last
erosive challenge.
3 lines at intervals of 0.2mm and 2mm in
length, 2 regression lines 0.5mm long on
each line, tissue loss value referring to the
vertical distance between regression lines in
micrometers
Abrasion: 15s during the 2 min immersion in
the slurry, 200 g load. 150 oscillations/min.
Storage in mineral salt solution pH 6.7 1.5h
between cycles.
3. Rocheletal. [14] Coke pH 2.3
7 days: 30 mL Coke 4 x/day 2 min. Contact profilometry
Dentifrice treatment: immersion in 0.5 mL
of the slurry for 15s after the first and last
erosive challenge.
3 measurements and average (in
micrometers)
Abrasion: 15s, 166 oscillations/second and
1.5N load.
Storage in artificial saliva pH 6.8 2h
between cycles.
4. Comaretal. [15] Sprite Zero pH 2.6
7 days: 30 mL Sprite Zero 4x/day 90s. Contact profilometry
Dentifrice treatment: immersion in 0.5 mL
of the slurry for 15s after the first and last
erosive challenge.
4 measurements and average (in
micrometers)
Abrasion: during the 15s seconds of
immersion in the slurry. Load 1.5N.
Storage in artificial saliva pH 6.8 2h
between cycles and overnight after the last
cycle.
5. Ganssetal. [16] Citric acid pH 2.5
10 days: 250 mL citric acid 6 x/day 2 min. Optical profilometry
10 mL of the slurry 2 min. Abrasive brushing
15s during the 2 min immersion in the slurry
after the first and last erosive cycle of the
day. Load 200 g, 150 oscillations/min.
3 lines with intervals of 0.2mm and 2mm
in length, regression lines 0.5mm in length,
tissue loss value referring to the average of
the 3 lines in micrometers
1 hr interval between cycles in
remineralizing solution pH 6.7.
6. Moronetal. [17] Sprite Zero pH 2.6
7 days: 30 mL Sprite Zero 4x/day 90s. Contact profilometry
Dentifrice and abrasion treatment: brushing
15s after the first and last erosive challenge
of the day. 166 oscillations/s, load 1.5 N.
4 measurements and average (in
micrometers)
Storage in artificial saliva pH 6.8 2h
between cycles and overnight after the last
cycle.
7. Ganssetal. [18] Citric acid pH 2.5
10 days: 250 mL citric acid 6x/day 2 min. Optical profilometry
Dentifrice treatment: slurry for 2 min.
3 lines with intervals of 0.2 mm and 2 mm in
length, regression lines 0.5 mm long, tissue
loss value (in micrometers) referring to the
average of the vertical distance between
the regression lines of the 3 lines
Abrasion: for 15s in the 2 min immersion
in slurry after the first and last erosive
challenge of the day. Load 200 g.
1h interval between cycles in remineralizing
solution pH 6.7.
8. Mosquimetal. [19] Citric acid pH 2.5
7 days: citric acid 4x/day 90s. Contact profilometry
After the first and last erosive challenge day
15s abrasive brushing with the slurry, load
1.5 N.
5 measurements 5mm
2
at the beginning
and after the experiment, at the end the
measurements were compared and the
depth in micrometers was calculated
Storage in artificial saliva pH 6.8 2h
between cycles.
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Table II - Continued...
Erosive agent Erosive-abrasive cycle Surface Loss Assessment Method
9. Soaresetal. [20] Cola drink pH 2.6
5 days: 30 mL cola drink 4x/day 5 min. Contact profilometry
Immediately after erosive challenge or after
30 min: immersion in slurry and abrasion
60s. 280 strokes/min, load 100 g.
5 measurements and average (in
micrometers)
1h in 6.8 pH artificial saliva between each
cycle.
10. Wegehauptetal.
[21]
Hydrochloric acid
pH 2.6
21 days: immersion in 20 mL slurry 100s and
abrasive brushing 20s (20 strokes, load 2.5
N). Storage in artificial saliva pH 1h. 2 mL
HCL 2 min 9 times/day.
Contact profilometry
1h after last erosive challenge: immersion
in 20 mL slurry 100s and abrasive brushing
20s (20 strokes, load 2.5 N).
5 repeated lines at 7, 14, and 21 days. The
surface loss was calculated in micrometers
by overlapping the traces, with reference to
those made at the beginning
11. Simõesetal. [22] Citric acid pH 2.5
3 days: 30 mL citric acid 3x/day 90s. Contact profilometry
Treatment: abrasive brushing with the slurry
15s (load 1.5 N).
5 measurements 5mm
2
at the beginning
and after the experiment, at the end the
measurements were compared and the
depth in micrometers was calculated
2h in artificial saliva pH 6.8 between erosive
challenges and overnight.
12. Passosetal. [23]
Concentrate
Orange juice pH
3.38
5 days: concentrated orange juice 3x/day 2
min. Artificial saliva 60s.
Contact profilometry
Abrasion: brushing on slurry 150 strokes
(200 g load, 4.5 movements).
4 measurements and average (in
micrometers)
Table III - Description of studies data about tested toothpastes and surface loss values. (n=12)
Tested toothpastes Surface loss
1. Morettoetal. [8]
1. Placebo (without fluoride) pH 8 1. 4.63μm ± 0.54
2. 1100 μg F/g pH 8 2. 3.43μm ± 0.38
3. 500 μg F/g + TMP pH 6.97 3. 2.28μm ± 0.26
4. 5000 μg F/g pH 7.75 4. 2.18μm ± 0.30
2. Ganssetal. [13]
1. Theramed Natural White 1450 ppm F NaF pH 7.1 1. 25.5 μm ± 3.2
2. Perlodent Kraeuter 1450 ppm F NaF pH 8.1 2. 17.5 μm ± 4.7
3. Theramed 2in1 Original 1450 ppm F NaF pH 7.3 3. 17.2 μm ± 2.8
4.Odol Med 3 Pro Clean 1400 ppm F NaF pH 7.1 4. 20.6 μm ± 4.7
5. Blend-A-Med Classic 1450 ppm F NaF pH 6.3 5. 20.1 μm ± 4.1
6. Sensodyne MultiCare 1400 ppm F NaF pH 6.0 6. 22.1 μm ± 4.3
7. GUM Original White 1490 ppm F NaF pH 7.2 7. 17.6 μm ± 5.0
8. Dentagard Original 1450 ppm F NaF pH 7.0 8. 22.3 μm ± 5.8
9. Pronamel KN03, 1450 ppm F NaF pH 7.0 9. 15.7 μm ± 3.2
10. ApaCare 1450 ppm F NaF, 1% hydroxyapatite nanoparticles pH 6.7 10. 22.1 μm ± 3.6
11. BioRepair zinc carbonate and hydroxyapatite, fluoride-free pH 7.8 11. 28.9 μm ± 5.2
12. Chitodent chitosan, fluoride-free pH 6.3 12. 20.7 μm ± 4.3
13. ProExpert Gum Protection 1450 ppm F: 1100 SnF2, 350 NaF; 3436 ppm Sn
SnF2 pH 6.0
13. 19.2 μm ± 9.2
Control toothpaste
14. 6.3 μm ± 2.1
Aronal fluoride-freebrand without fluoride pH 7.5
Control group
Negative control – erosion
and abrasion with Aronal
without fluoride: 24.8 μm
± 3.4
3. Rocheletal. [14]
1. Placebo 1. 7.3 μm ± 0.9
2. 10% xylitol 2. 4.9 μm ± 1.2
3. 10% xylitol + 1030 ppm F (NaF) 3. 3.9 μm ± 1.1
4. 1030 ppm F (NaF) 4. 4.6 μm ± 0.8
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Table III - Continued...
Tested toothpastes Surface loss
4. Comaretal. [15]
1. Placebo (without fluoride) pH 5.6 1. 5.0 μm ± 0.9
2. Experimental NaF 1450 ppm F pH pH 6.0 2. 2.9 μm ± 0.7
3. Experimental TiF4 1450 ppm F pH 3.8 3. 2.3 μm ± 0.7
4. Experimental SnF2 1450 ppm F pH 3.7 4. 2.8 μm ± 1.1
5. Experimental SnF2 (1100 ppm F) + NaF (350 ppm F) pH 3.9 5. 1.7 μm ± 0.7
6. Experimental TiF4 (1100 ppmF) + NaF (350ppm F) pH 4.4 6. 1.5 μm ± 0.4
7. Pro Health SnF2 (1100 ppm F) + NaF (350 ppm F) pH 5.7 7. 2.9 μm ± 1.0
8. Crest NaF 1500 ppm F pH 6.9 8. 4.1 μm ± 0.9
5. Ganssetal. [16]
1. Experimental 1400 ppm F NaF pH 4.7 1. 16.5 μm ± 3.0
2. Experimental 1400 ppm F NaF pH 6.5 2. 14.0 μm ± 2.7
3. Dentagard 1450 ppm F NaF pH 7.3 3. 12.6 μm ± 3.9
4. ProExpert enamel shield NaF/SnCl2 (1400 ppm F NaF) pH 5.3 4. 14.7 μm ± 5.1
5. Meridol AmF/SnF2 (1400 ppm F – 350 AmF, 1050 SnF2; Sn2+ - 3280 SnF2
pH 4.5
5. 13.5 μm ± 4.8
6. Experimental AmF/NaF/SnCl2 (1400 ppm F – 700 AmF, 700 NaF; Sn2+ -
3500 SnCl2) pH 4.4
6. 12.4 μm ± 4.2
7. Experimental AmF/NaF/SnCl2/chitosan (1400 ppm F – 700 AmF, 700 NaF;
Sn2+ - 3500 SnCl2) pH 4.4
7. 6.6 μm ± 3.5
8.. Experimental placebo (without fluoride) pH 6.4
Placebo (negative control):
20.2 μm ± 3.8
6. Moronetal. [17]
Experimentals 1. 5.6 μm ± 0.8
1. 550 ppm F NaF pH 4.5 2. 5.5 μm ± 0.8
2. 1100 ppm F NaF pH 4.5 3. 5.5. μm ± 0.9
3. 5000 ppm F NaF pH 4.5 4. 9.6 μm ± 1.2
4. Placebo (without fluoride) pH 4.5 5. 6.4 μm ± 0.4
5. 550 ppm F NaF pH 7.0 6. 5.5 μm ± 1.2
6. 1100 ppm F NaF pH 7.0 7. 5.7 μm ± 1.0
7. 5000 ppm F NaF pH 7.0 8. 9.8 μm ± 1.0
8. Placebo (without fluoride) pH 7.1
9. 9.3 μm ± 1.0
10. 8.8 μm ± 0.9
Comercials
11. 9.8 μm ± 0.8
9. Colgate Baby Barney 500 ppm F NaF pH 7.0
10. Crest 1100 ppm F NaF pH 7.0
11. Prevident 5000 ppm F NaF pH 7.0
7. Ganssetal. [18]
1. Dentifrice Emofluor 1000 ppm F SnF2 pH 4.6 1. 5.4 μm ± 2.3
2. Elmex Erosion Protection 1400ppm F AmF e NaF, SnCl2 pH 4.0 2. 9.0 μm ± 2.7
3. Oral-B ProExpert Enamel Shield 1450ppm F NaF e SnCl2 pH 6.2 3. 8.5 μm ± 1.4
4. Chitodent chisotan pH 6.3 4. 12.8 μm ± 4.3
5. Biorepair hydroxyapatite pH 8.7 5. 13.4 μm ± 3.3
6. ApaCare 1450ppm F NaF and hydroxyapatite pH 7.4 6. 7.6 μm ± 2.6
7. ActiSchmelz NaF and hydroxyapatite pH 8.2 7. 14.1 μm ± 2.0
8. Sensodyne Pronamel 1450 ppm F NaF pH 7.8 8. 7.9 μm ± 2.1
9. Sensodyne Multicare 1450 ppm F NaF pH 7.7 9. 12.4 μm ± 2.1
10. Elmex Sensitive 1400 ppm F AmF pH 4.8 10. 10.2 μm ± 1.9
11. Theramed Natural White 1450 ppm F NaF pH 7.5 11. 13.6 μm ± 4.9
12. Theramed ProElectric 1450 ppm F NaF pH 7.6 12. 12.2 μm ± 2.9
13. Theramed Original 2in1 1450 ppm F NaF pH 7.7 13. 12.4 μm ± 3.3
14. Theramed Interdental 1450 ppm F NaF pH 7.3 14. 22.5 μm ± 4.4
15. Pearls&Dents 1200ppm F AmF e NaF pH 6.0 15. 14.6 μm ± 1.6
8. Mosquimetal. [17]
1. Oral B 3D White 1450ppm F NaF 1. 3.68 μm ± 1.06
2. Close up Diamond Attraction Power White 1450ppm F NaF 2. 1.51 μm ± 0.95
3. Sorriso Xtreme White 4D 1450ppm F NaF 3. 3.17 μm ± 0.80
4. Colgate Luminous White 1100ppm F NaF 4. 3.44 μm ± 1.29
5. Crest Convencional 1500ppm F NaF 5. 2.35 μm ± 1.44
8
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
Table III - Continued...
Tested toothpastes Surface loss
9. Soaresetal. [20]
1. Sensodyne Pronamel Potassium nitrate 5%, 1425ppm F NaF pH 7.0 Erosion+Abrasion
2. Crest Cavity Protection 1100ppm F NaF pH 7.0 1. 7.25 μm ± 0.76
3. Sensodyne Original Strontium chloride 10% and calcium carbonate, without
fluoride pH 7.4
2. 7.24 μm ± 0.88
Control group:
3. Sensodyne Original:
10.40 μm ± 1.13
Erosion+30’+Abrasion
1. 6.61 μm ± 0.83
2. 5.84 μm ± 0.90
Control group:
3. Sensodyne Original: 7.45
μm ± 1.87
10. Wegehauptetal. [21] 1. Elmex Erosion Protection
1. 7 days – 0.32 μm ± 0.26
14 days – 0.50 μm ± 0.65
21 days – 0.81 μm ± 0.80
Control group
(no toothpaste)
7 days – 2.36 μm ± 0.35
14 days – 4.47 μm ± 0.89
21 days – 6.63 μm ± 1.46
11. Simõesetal. [22]
1. Crest Anti-cavity regular 1500 NaF 1. 1.32 μm (1.25-146)
2. Crest 3D White 1500 NaF 2. 1.11 μm (1.00-1.38)
3. Colgate Total 12 Clean Mint 1450 NaF 3. 1.31 μm (1.28-1.45)
4. Colgate Optic White 1300 Monofluorphosphate of sodium 4. 1.08 μm (1.04-1.14)
5. Placebo (without fluoride) 5. 2.28 μm (2.18-2.39)
12. Passosetal. [23]
1. Toothpaste without fluoride 1. 3.62 μm ± 2.06
2. 1100 ppm F NaF 2. 1.88 μm ± 0.71
uoride, only two showed less surface loss than
the negative control (erosion only), while the
others containing similar uoride concentration
increased the surface loss. The tin toothpastes
resulted in lower surface losses when compared
to the negative control. Regarding the abrasive
particles, their size had no impact, while their
quantity was relevant.
In the study by Soares et al. [20], the
association of potassium nitrate with sodium
uoride was not more effective when compared
to conventional uoride toothpaste with only
sodium uoride. When compared to non-uoride
toothpaste (
Sensodyne Original
), used as a
control,
Crest Cavity Protection
(1100ppm F NaF)
reduced tissue loss by an average of 25.8% and
Sensodyne Proenamel
(potassium nitrate and
1425 ppm F NaF) by 20.5% [20].
The study by Passos et al. [23] tested the
effect of two toothpastes for kids, one non-
uoridated and one uoridated (1100 ppmF NaF)
in erosive-abrasive cycles in deciduous teeth.
The two dentifrices presented similar results to
the control group (abrasion with distilled water),
but they were signicantly different from each
other, with the uoride dentifrice showing less
loss of enamel surface.
Mosquim et al. [19] tested fluoride
whitening toothpastes containing hydrated
silica as an abrasive agent. Three of the four
whitening toothpastes under test contained
pyrophosphate in their composition, and the
whitening toothpaste that showed the least loss
of enamel surface was the only one without
pyrophosphate in its composition. Similarly
to hydrated silica, pyrophosphate is also an
abrasive agent [29]. The whitening toothpaste
without pyrophosphate in its composition
showed similar surface loss when compared
to the conventional uoride toothpaste tested.
9
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
It demonstrates that the association of silica
and pyrophosphate abrasive agents can lead to
greater surface loss since the concentration of all
tested toothpastes was similar, varying between
1100 and 1500 ppm F [19]. Thus, whitening
dentifrices, due to their greater abrasiveness,
should not be indicated for patients at risk of
erosive tooth wear, emphasizing the importance
of adequate dentifrice prescription for different
patient profiles. On the other side, the study
by Simões et al. [22] analyzed conventional
and whitening toothpastes. The authors
concluded that whitening dentifrices did not
increase erosive tooth wear when compared to
conventional toothpastes. Unlike the study by
Mosquim et al. [19].
DISCUSSION
Systematic literature reviews are designed
to answer a specic question about a problem
through a rigorous synthesis, outlined by
a protocol. The literature review helps the
researcher to identify gaps, consensus and
controversies regarding a research object [24].
Tooth tissue loss and surface hardness
can be assessed by (optical and contact)
prolometry [25]. This method has its limitations,
such as the possibility of creating scratches on the
softened surface of tooth enamel [19]. However,
it is a widely used method because it can assess
early and advanced losses [20], so it was chosen
as an inclusion criterion for this review.
The erosion and abrasion protocol were
selected for it resembles the clinical reality more
closely, since the toothpaste is applied through
tooth brushing [26]. When studies that analyzed
only the application of slurry toothpaste and
the studies in which slurry application was
associated with brushing were compared, it
was observed that samples abrasion led to the
greatest loss of enamel surface in experimental
groups [8,13,14,18,20,21,27].
Rochel et al. [14] concluded that the
addition of 10% xylitol to 1030 ppm F (NaF)
fluoride toothpaste increases its protective
effect, while NaF only toothpastes and 10%
xylitol only toothpastes showed similar surface
losses. The results of the association between
NaF toothpaste and 10% xylitol cannot be
related to the action mechanism of this added
substance, as the toothpaste containing only 10%
xylitol showed inferior and similar results to the
toothpaste containing only NaF. Therefore, the
effect of xylitol may be linked to the abrasive
procedure, acting as a lubricant and reducing the
impact of brushing eroded enamel [14].
Moron et al. [17] evaluated the effect of
experimental and commercial dentifrices with
acidic and neutral pH in different fluoride
concentrations. Liquid (experimental) toothpastes,
regardless of their pH, similarly reduced enamel
wear when compared to placebo (no uoride)
and commercial groups. Based on the study by
Buzalaf et al. [28], the authors point out that it
is possible to speculate that liquid (experimental)
toothpastes allow greater formation of a calcium
fluoride layer when compared to commercial
toothpastes [17]. Unlike Moretto et al. [8] who
demonstrated a greater preventive effect of the
experimental toothpaste with a concentration of
5000ppm F when compared to that of 1000ppm
F, Moron et al. [17] did not nd this difference
between experimental toothpastes with the same
uoride concentration, which may be related to
the liquid consistency of the toothpastes.
Wegehaupt et al. [21] compared the
toothpaste Elmex Erosion Protection, a new
gel system, and a fluoride-free toothpaste.
The new products tested showed no reduction
in surface loss, while the Elmex toothpaste
signicantly reduced the loss of enamel surface
when compared to the control group (erosion
and abrasion without toothpaste). The protection
offered by this toothpaste may be related to the
incorporation of tin into the dental structure,
as well as fluoride, forming a shield against
acid attacks [9,30]. However, it is important to
emphasize that this study did not use a placebo or
conventional toothpaste for control, thus making
it difcult to compare the real preventive effect of
this toothpaste, which has already been pointed
out in other studies as having a good anti-erosion
effect.
Similarly, in the study by Moretto et al. [8],
the use of uoride toothpaste containing sodium
uoride showed a reduction in surface loss when
compared to toothpastes without uoride. This is
probably due to the calcium uoride layer formed
on the enamel, which partially reduced wear in
the erosion and abrasion cycles [23]. The fact
that both toothpastes did not present signicant
differences when compared to the control group
was not an expected result, and the authors relate
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
this to the fact that children’s toothpastes have
lower abrasiveness and their pH is similar to that
of water [23].
Besides human permanent teeth, some
studies used bovine teeth as samples. It is
acceptable given that the enamel surface loss
was evaluated in comparison to a control
group [31]. One study carried out experiments
with deciduous enamel. Deciduous enamel is less
mineralized and erosion progression occurs faster
if compared to permanent tooth enamel [32]. This
fact highlights the importance of early diagnosis
of erosive tooth wear in primary dentition and
the correct indication of low-abrasive uoride
toothpastes.
Exposure to acids in erosive challenges
varied in duration, days and cycles, which makes
it difficult to compare different studies. Soft
drinks, concentrated orange juice, and citric and
hydrochloric acids were used as erosive agents.
Regarding the abrasive challenges, in addition
to different loads, they varied in terms of time
of application.
Of the twelve studies included in this review,
eight used non-fluoride placebo toothpastes
(experimental or commercial) as controls.
The other studies [17,18,21,23] did not use
toothpastes as a control group. However, all
tested conventional fluoride toothpastes or
non-fluoride toothpastes in the groups and
that could allow some comparison, except for
Wegehaupt et al. [21]. These divergences, along
with the different protocols in the erosion and
abrasion cycles, make it difcult to compare the
studies results.
As to fluorides and their association
with different active ingredients, the studies
by Moretto et al. [8] and Rochel et al. [14]
demonstrate that the association of different active
ingredients to dentifrices with low concentration
of sodium uoride may be promising to prevent
erosive tooth wear. Moreover, the results found by
Comar et al. [15] demonstrate that the association
of conventional uorides with metallic ones is
also promising. The study by Ganss et al. [16]
demonstrated that the association of chitosan
with tin ion and conventional uorides forms
layers of each active ingredient and together
these layers bring better results in preventing
erosive tooth wear.
Wegehaupt et al. [21] and Ganss et al. [18]
tested the same toothpaste (
Elmex Erosion
Protection
) and concluded that it reduced
surface loss compared to the control group. It is
important to emphasize that in both studies,
the erosion and abrasion protocols, as well as
the control group, were different and showed
promising results for the same toothpaste.
By analyzing the composition of the toothpaste,
it is possible to think that the incorporation of tin,
as well as that of uoride, forms a shield against
acid attacks [9,30]. Still, in Ganss et al. [18],
Elmex Erosion Protection
was not as efcient as
Emouor TP
(tin uoride) or as
ApaCare
(sodium
uoride and hydroxyapatite), which presented
similar results to the positive control (gel without
abrasive particles).
Formula differences in toothpastes
containing the same concentration of the same
active ingredient (sodium fluoride) showed
divergent results, e.g., Moretto et al. [8] and
Moron et al. [17], which draws attention to the
implications of changing toothpaste consistency.
In the study by Simões et al. [22], the
toothpaste that showed less surface loss had
pyrophosphate abrasive in its composition, which
in Mosquim et al. [19], was the agent responsible
for greater enamel surface loss, and also MFP as
uoride. Sodium monouorophosphate requires
enzymatic degradation to release uorine ions,
and the slurry preparation in the study does
not have enzymes for MFP degradation. Also,
several characteristics of dentifrices are related
to the prevention or not of erosive tooth wear.
The effects of active ingredients present in
dentifrices are interdependent on other chemical
and physical characteristics they have [33].
Chemical and physical impact on enamel is
difcult to interpret as toothpastes composition
is complex [13].
CONCLUSION
The studies evaluated a large number of
fluoride composites regarding surface loss in
enamel samples submitted to erosion and abrasion
protocols. Conventional fluoride toothpastes
(NaF) presented similar results compared to
anti-erosion formulations. The selected articles
presented different erosion and abrasion protocols,
making it difcult to compare them, given that
different protocols can result in less or greater
loss of enamel surface. In addition, different
11
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
Nolasco SC et al.
Effects of different toothpaste formulations on erosive tooth
wear prevention: systematic review
commercial and experimental toothpastes with
active ingredients and varied indications were
tested. The results must be interpreted carefully
due to methodological differences and also
because toothpastes have complex formulas that
are related to their performance. Other properties
of dentifrices need to be investigated to clarify
the effects of dentifrices on erosive tooth wear.
Acknowledgements
The authors are grateful to professors for
contributions, critical review and support in
writing the manuscript.
Author’s Contributions
SCN: Data collection, data analysis and
interpretation, drafted manuscript, critically
revised manuscript. LCR: Data analysis and
interpretation, critically revised manuscript. PSS:
Data analysis and interpretation, critically revised
manuscript. SMA: Contributed to conception
and design, critically revised manuscript. FMF:
Contributed to conception and design, critically
revised manuscript. CMA: Contributed to
conception and design, data collection, data
analysis and interpretation, drafted manuscript,
critically revised manuscript.
Conict of Interest
The authors have no conicts of interest.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Regulatory Statement
Not applicable since systematic review do
not need ethics comitté.
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Effects of differ ent toothpaste formulations on erosive tooth wear prevention: systematic r eview
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Effects of different toothpaste formulations on erosive tooth
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Date submitted: 2022 Nov 06
Accept submission: 2023 Mar 07
Sara Caldas Nolasco
(Corresponding address)
Universidade Federal de Minas Gerais, Faculdade de Odontologia, Departamento de
Saúde Bucal da Criança e do Adolescente, Belo Horizonte, MG, Brazil
Email: nolascocsara@gmail.com
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