Sunday, May 4, 2014

Fluoride- & Chlorhexidine-Free Tooth Hygiene For You: What Alternatives are There? And How Effective are Natural and Not-So-Natural Fluoride-Free Products?

There are alternatives and adjuncts to fluoride you just have to know them.
To start off with the most important information not in, but about this article: This is not an anti-fluoride article.  I am not even going to mention the ongoing debate about the usefulness and safety of fluoride in toothpaste and co.

What I am offering is a concise list of natural agents with similar anti-bacterial properties as fluoride anyone of you can use to improve his tooth hygiene - this includes those of you who believe the whole fluoride scare is another overweight child of the hype generating online health community.

Various anti plaque agents, and other agents like enzymes have been effectively used as prevention of
dental caries. Ever since 1970‘s researchers started to search for non-fluoride agents for the  prevention of dental caries. And as Agarwal write in a recent article in Oral Hygiene & Health, "fluoride agents may serve as adjunctive therapeutics for preventing, arresting or even reversing dental caries" (my emphasis in Agarwal. 2014).

Against that background, the items in the following list should be understood as suggestions; agents I suggest you may want to try to improve your dental health, irrespective of whether you combine them with a fluoride containing toothpaste or not:
  • Essential oils: Essential oils have been used for centuries. Only, recently however, has this practice caught scientific attention and scientists began to study the antimicrobial activity against caries-related bacteria.

    Thyme with it's main active ingredient thymol is one of the essential oils you could use in an anti-bacterial mouth wash.
    Essential oils derived from plants are typically a complex mixture of approximately 20-60 compounds that are in solution at various concentrations. Overall, the main chemical group is primarily composed of terpenoids, followed by aromatic and aliphatic constituents. Thymol and eugenol are two of the better known agents from essential oils of thyme and clove oil or basil. They have been shown to inhibit the growth of a wide range of oral microorganisms including mutans streptococci, in vitro. Convincing data on their efficacy from in vivo studies, on the other hand is scarce (Agarwal. 2014).
  • Ocimum sanctum aka "Tulsi": Tulsi, Ocimum sanctumis a plant of Indian origin and chances are you've already read it's name. It's a time tested premier medicinal herb that's usually used diabetes mellitus, arthritis, bronchitis and skin diseases. Luckily tulsi does also have potent antimicrobial properties, against a whole variety of microorganisms like Staphylococus aureus, Klebsiella, candida albicans, E. coliandproteus sp.

    The antimicrobial activity of tulsi is attributed to its constituents namely ursolic acid and carvacrol. Agarwal et al. (Agarwal. 2010) in their study demonstrated an antimicrobial potential of tulsi extract at various concentrations and achieved maximum antimicrobial potential at 4% concentration level. That's not much, but something we can work with... as only one ingredient of our toothpaste and mouth-wash, obviously ;-)
  • Figure 1: Prunis is not as potent as  0.2% chlor- hexidine (CHX) and phosphate-buffered saline (PBS), but inhibits the growth of human oral keratinocytes within 5 minutes (Seneviratne. 2011)
    Prunus mume: Prunus mumeis is like Tulsi a TCM staple, It is, just like Tulsi not usually used for tooth hygiene.

    In vitro data from studies such as the one the data of which you see in Figure 1, would yet suggest that it is rightly considered to be a candidate for develo- ping an oral antimicrobial agent to control or prevent dental diseases associated with oral pathogenic bacteria like Strepto- coccus mutans, S. sobrinus, S. mitis, S. Sanguinis, Lactobacillus acidophilus, P. gingivalis, Aggregatibacter actino- mycetem comitans (Seneviratne. 2011)
  • Green and black tea (Camellia sinensi): No reason to tell you what these are, right? Well, various component in green and black tea (leaves of Camellia sinensis), notably the simple catechins, have anticariogenic activity.

    Among the pathogens that have been shown to suffer from the exposure to these tea catechins are also S mutans and S sobrinus. In addition, there is evidence that tea does not only plaster your teeth with black tar, but that this black tar inhibits the adherence of bacteria to your teeth (lucky you ;-) - this works by the inhibition glucosyl transferase and the consequent reduction in biosynthesis of sticky glucan. And above all, a recent paper in the Journal of the Indian Society of Peridontology confirm sthe "effectiveness of green tea catechin mouthwash as an antiplaque agent" in man (Kaur. 2014).
Listen up tea haters! In their 2004 paper, Taylor et al. do yet conclude that *surprise* tea shares its anticariogenic effects (this is anti-caries not anti-cancer, folks ;-) against alfa hemolytic streptococci with cocoa and coffee!
  • Oleic acid, Linoleic acid and epicatechin polymer fom Cacao bean husk: Have all been shown to have anti-cariogenic activity. Just like green tea, coffee and cacao, they inhibit the adherence of the bacteria to your teeth and best of all, there is even evidence that this stuff works - in rodents, at least (Ooshima. 2000; Osawa. 2001)
  • Proanthocyanidins, phenolic acids, flavonols from Cranberry: These shows antimicrobial activity against biofilm cells of mutans streptococci. They will disrupt the acidogenic/aciduric properties of planktonic and biofilm cells of S. mutans and have rodent studies to back up their efficacy as in vivo inhibitors of caries development in rats infected with S. mutansis (Koo. 2002)
  • Meswak chewing sticks (Twigs of Salvadora persica): The name already gives it away. This is another tool from traditional medicine, which is supposed to have been used by the Babylonians some 7000 years ago (Al Sadhan. 1999).
    Table 1: Miswak is not the only type of chewing stick that's used world-wide (Sukkarwalla. 2013)
    In this case, however, one that is in fact use to prevent caries! And in fact, the sticks have strong antibacterial effects against all relevant bacteria (Almas. 2004) - no wonder they have been used for tooth hygiene after being embedded in agar forever.

    What should be said, though, is that you could also use other anti-microbial substances as "toothpaste" on a Miswak stick, after you've made it bacteria proof with agar (agar is a polysaccharides that cannot be metabolised by bacteria).
    Figure 2: Marked reduction in levels of Streptococcus mutans in Miswak as compared to toothbrush users (left) and overview of Antimicrobial effects of Miswak (right; both from Sukkarwalla. 2013)
    Its effects, and the illusration in Figure 2 makes this quite clear, does still go way beyond the one of a classic toothbrush (Sukkarwalla. 2013).
  • Trace elements: Actually, the initially mentioned fluoride would belong into this category as well... what? Yeah, you are right: It's note exactly smart to replace it with zinc, tin, aluminium, copper, iron, strontium, barium, manganese and molybdenum, gold, or lead, all of which have been investigated as weapons in our never-ending battle against tooth decay (hard to believe, I know).

    Of these trace elements, aluminum, copper, and iron have been used most commonly as cariostatic agents. Unfortunately, these agents are about as unhealthy for its user, as they are for the bacteria, when they are used in oral care products as simple salts. Moreover, the toxicity of many metals like aluminum, copper, barium molybdenum, would restrict the concentration at which they could be safely used.
  • Propolis, the resinous mixture that honey bees collect from tree buds, sap flows, or other botanical sources: Propolis is a natural beehive product that serves a double purpose. It is used to make honey, and it keeps the hive bacteria-free.

    Propolis shows potent anti-bacterial activity against S. mutans and/or S. sobrinus in vitro ad has been used successfully as part of a a mouthwash with in vivo antimicrobial activity against S. mutans (Duailibe. 2007). Moreove, topical applications of chemically characterized Propolis extracts have also been shown to be highly effective in reducing the incidence and severity of smooth surface and sulcal caries in rats (Koo. 1999). 
What you should know about propolis, thoug is that as with every natural product, though, propolis does not come "standardized" like a phamaceutical. Accordingly, its cariostatic effectsare highly variable depending on its chemical composition and geographical origin. In other words: It owes its antimicrobial potency to the plants - worst case scenario: The bees fly around in a GMO area and collect no natural antimicrobials at all ;-)
  • There are many other reports in the literature concerning the antimicrobial activities that various plant extracts may have against cariogenic bacteria, although the majority of these studies provide limited or incomplete information due to the lack of chemical characterization of the extracts. However, there are a few exceptions. For example, Li et al. (1999) have identified gallotannins from Melaphis chinensis and triterpenes (ceanothic acid and ceanothetric acid) from Ceanothus americanus as antimicrobial agents that harbor activity against mutans streptococci.

    Furthermore, a chemically characterized extract of Galla chinensis (containing gallic acid and methyl gallate) has been demonstrated to impede the growth of S. mutans and other caries- related organisms, including Lactobacillus rhamnosus and Actinomyces naeslundii, within biofilms. Recently, established that naturally occurring phenolic compounds generally display antibacterial activity by disrupting the membrane lipid-protein interface as nonionic surface-active agents (Greenberg. 2008) and  Ramakrishna et al. (2011) studied various natural alternatives derived from plants and plant products and concluded that it can serve as a prevention and treatment option against cariogenic bacteria. 
  • They certainly don't look like it, but being filled with licorice extract, these lollipops are good for your teeth.
    Chinese Licorice Root: As a SuppVersity reader you know that it can help you lean out, by keeping your cortisol levels up(!). What you may have read as an aside, only, is that it will also help fight caries, if it is consumed as a "teeth hygiene lollipop" that contains a special herbal formula extracted from the Chinese licorice root.

    These orange flavoured herbal lollipops was discovered by microbiologist at the UCLA school of dentistry should be consumed twice a day- one in the morning after breakfast and another after professional teeth cleaning between two and four times a year (Agarwal. 2010). 
  • Xylitol: Xylitol is last on the list, and probably an agent may of you know. It's - unlike most people think - 100% natural and was first used as a tooth-friendly sweetener in chewing gums, lollipops and other stuff more than 80 years after its discovery in 1891 by German chemist Emil Fischer.

    Dental benefits of xylitol were first recognized in Finland in 1970 using animal models. The first chewing gum developed with the aim of reducing caries and improving oral health was released in Finland in 1975 and in United States shortly after. Xylitol is not fermented by cariogenic plaque bacteria and thus does not lower the pH of the plaque. It reduces the accumulation of plaque on the surface of the tooth.

    In contrast to many other marketing claims the efficacy of xylitol based chewing gum is scientifically established (Isokangas. 1987) and its effect to inhibit enamel dissolution, another claim you may have heard already has in vitro data to back it up (Arends. 1990). In children reporting caries experience, consumption of xylitol containing lozenges or hard candy reduces incidence of coronal caries (Alanen. 2000).

    For children below age two, in addition to the study that evaluated xylitol tablets, the xylitolcontaining syrup among children in the Marshall Islands and reported a statistically significant difference in favor of xylitol syrup (Milgrom. 2009) - for children unde rthe age of 2, on the other hand, there is insufficient evidence that xylitol syrup prevents caries. The same lack of convincing evidence exists with respect to xylitol dentrifrice, of which we cannot tell if it's the xylitol or another agent that's responsible for the inhibition of dental caries.
"Hardcore tooth hygiene" ;-)
Now that you've got a long list, all you'd need is a plan of attack. The latter will certainly depend on the availability of the previously mentioned agents and your personal preferences, but in general it will probably look somewhat like this:

Assuming you have already abandoned regular, fluoride-containing toothpaste, I suspect that you will be using a different product for tooth hygiene. Aside from buying Meswak chewing stick and replacing your toothbrush your best chance to increase your tooth hygiene would thus be (a) the use of xylitol logenes and chewing gums or licorice lollipops and (b) using some cacao bean husk (extracts), in a thyme oil spiked green tea mouthwash after you brushed your teeth (you remember the "protective film" the tea will create on your teeth?).

And if you are really hard core you do both: Brush with meswak sticks first, flush with a green tea + thyme oil mixture, afterwards. But don't complain about "green tea colored teeth" ;-)

  • Agarwal, Pooja, and L. Nagesh. "Evaluation of the antimicrobial activity of various concentrations of Tulsi (Ocimum sanctum) extract against Streptococcus mutans: An in vitro study." Indian Journal of Dental Research 21.3 (2010).
  • Agarwal, R., et al. "Prevention of Dental Caries-Measures beyond Fluoride." Oral Hyg Health 2.122 (2014): 2332-0702.
  • Al Sadhan, Ra'ed I., and Khalid Almas. "Miswak (chewing stick): a cultural and scientific heritage." Saudi dental journal 11.2 (1999): 80-87. 
  • Alanen, Pentti, Pauli Isokangas, and Kristjan Gutmann. "Xylitol candies in caries prevention: results of a field study in Estonian children." Community dentistry and oral epidemiology 28.3 (2000): 218-224.
  • Arends, J., et al. "Combined effect of xylitol and fluoride on enamel demineralization in vitro." Caries Research 24.4 (1990): 256-257.
  • Duailibe, Silvana Alves de Carvalho, Azizedite Guedes Gonçalves, and Fernando Jorge Mendes Ahid. "Effect of a propolis extract on Streptococcus mutans counts in vivo." Journal of Applied Oral Science 15.5 (2007): 420-423. 
  • Greenberg, Michael, Michael Dodds, and Minmin Tian. "Naturally Occurring Phenolic Antibacterial Compounds Show Effectiveness against Oral Bacteria by a Quantitative Structure− Activity Relationship Study." Journal of agricultural and food chemistry 56.23 (2008): 11151-11156. 
  • Isokangas, Pauli. "Xylitol chewing gum in caries prevention. A longitudinal study on Finnish school children." Proceedings of the Finnish Dental Society. Suomen Hammaslääkäriseuran toimituksia 83 (1987): 1.
  • Kaur, H., S. Jain, and A. Kaur. "Comparative evaluation of the antiplaque effectiveness of green tea catechin mouthwash with chlorhexidine gluconate." Journal of Indian Society of Periodontology 18.2 (2014): 178.
  • Koo, H., et al. "Effect of Apis mellifera propolis from two Brazilian regions on caries development in desalivated rats." Caries Research 33.5 (1999): 393-400. 
  • Li, Xing-Cong, Linin Cai, and Christine D Wu. "Antimicrobial compounds from< i> Ceanothus americanus</i> against oral pathogens." Phytochemistry 46.1 (1997): 97-102.
  • Ooshima, T., et al. "Caries inhibitory activity of cacao bean husk extract in in-vitro and animal experiments." Archives of Oral Biology 45.8 (2000): 639-645.
  • Osawa, K., et al. "Identification of cariostatic substances in the cacao bean husk: their anti-glucosyltransferase and antibacterial activities." Journal of Dental Research 80.11 (2001): 2000-2004.
  • Ramakrishna, Y., et al. "Decreasing cariogenic bacteria with a natural, alternative prevention therapy utilizing phytochemistry (plant extracts)." Journal of Clinical Pediatric Dentistry 36.1 (2011): 55-64.
  • Seneviratne, Chamida J., et al. "Prunus mume extract exhibits antimicrobial activity against pathogenic oral bacteria." International Journal of Paediatric Dentistry 21.4 (2011): 299-305. 
  • Sukkarwalla, Adnan, et al. "Efficacy of Miswak on Oral Pathogens." Dental research journal 10.3 (2013): 314.
  • Taylor, Peter W., J. M. Hamilton-Miller, and Paul D. Stapleton. "Antimicrobial properties of green tea catechins." Food science and technology bulletin 2 (2004): 71-81.