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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 11  |  Issue : 5  |  Page : 249-255

Effects of Toothpaste Containing Granular Calcium Carbonate on Oral Health


1 Department of Special Needs Dentistry, Nihon University School of Dentistry At Matsudo, Chiba, Japan
2 Takayanagi Dental Clinic, Saitama, Japan
3 Fujiseki Dental Clinic, Tokyo, Japan
4 Health Care Products Research Laboratories, Kao Corporation, Tokyo, Japan

Date of Web Publication24-Sep-2019

Correspondence Address:
Dr. Mami Endoh
Department of Special Needs Dentistry, Nihon University School of Dentistry at Matsudo, 2-870-1Sakaecho-Nishi, Matsudo city, Chiba prefecture.
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_37_18

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  Abstract 

Aims and Objectives: To investigate the oral health effects of using toothpaste containing granular calcium carbonate (CaG). Materials and Methods: The subjects were adult volunteers. Two kinds of toothpaste, Paste P and Q were used. Paste P contained 13% CaG, which had a mean diameter of 250 µm and a breaking strength of 20 gf. Paste Q had the same formulation without CaG. Study 1 was to evaluate the ability to remove dental plaque by toothpaste with a single use, and it was a crossover study. The subjects were 50 adults. Plaque levels were assessed using the Quigley–Hein Index (QHI). Study 2 was to investigate the effects of CaG in toothpaste on gingival health. The subjects were 60 adults. The subjects used Paste P for 3 days before the baseline assessment. On the baseline assessment, the subjects whose gingival sulci were found to contain CaG were asked to continue using the Paste P for 6 months. The pocket depth, the gingival index (GI), the QHI, and the presence of CaG in the gingival sulci at 1, 3, and 6 months from the baseline were examined. Results: In study 1, the CaG-containing toothpaste produced a significantly lower mean QHI than the control. In study 2, the QHI and GI of the gingival sulci in which CaG was detected were significantly lower than those of the gingival sulci in which CaG was not detected. Conclusion: Toothpaste containing CaG removed greater amounts of plaque and did not have adverse effects on periodontal tissue.

Keywords: Gingival Condition, Granular Calcium Carbonate, Oral Health, Toothpaste


How to cite this article:
Endoh M, Takayanagi A, Fujiseki M, Eda Y, Itano M, Yano Y. Effects of Toothpaste Containing Granular Calcium Carbonate on Oral Health. J Int Oral Health 2019;11:249-55

How to cite this URL:
Endoh M, Takayanagi A, Fujiseki M, Eda Y, Itano M, Yano Y. Effects of Toothpaste Containing Granular Calcium Carbonate on Oral Health. J Int Oral Health [serial online] 2019 [cited 2019 Nov 19];11:249-55. Available from: http://www.jioh.org/text.asp?2019/11/5/249/267714


  Introduction Top


Oral diseases, such as dental caries and gingivitis, are caused by oral microorganisms on the surfaces of the teeth or the oral mucosa. Good oral hygiene is the best way to prevent oral diseases. Therefore, in daily life, it is necessary to reduce the number of oral microorganisms via proper oral hygiene. Toothbrushing using toothpaste not only feels refreshing and comfortable but also is effective at removing dental plaque.[1],[2] However, some studies reported that brushing with toothpaste does not increase instant plaque removal.[3],[4],[5] We have developed toothpastes that improve cleaning efficacy in hard to reach spaces with bristles. These toothpastes contain cleaning agents such as zeolite or calcium carbonate granules. Regarding the cleaning effects of granular cleaning agents, several studies[6],[7],[8] have shown that such granules improved cleaning efficacy when all the subjects used the same type of toothbrush and brushing method. However, in daily life, people use various kinds of toothbrushes and brush their teeth in different ways.[9] Therefore, the “real-life” plaque-removing effects of using toothpaste containing a granular cleaning agent are unclear. Thus, we needed to know the effort of CaG in each real situation. Furthermore, some granular cleaning agents might penetrate into the gingival sulci. However, no previous studies that have evaluated the condition of the gingiva after toothbrushing with toothpaste containing a granular cleaning agent are available. Hence, we thought that we should check the condition after using that.

The purpose of this study was to investigate the effects and the condition of the gingiva after using toothpaste containing calcium carbonate granules, which had a mean diameter of 250 µm and disintegration properties as a cleaning agent on oral health.


  Materials and Methods Top


The presented comparative analytical study was approved by the Kyushu Dental University Ethics Committee (approval number: 14–22) and the Kao Corporation Ethics Committee (approval number: 14–06). These studies were performed in the year 2014–2015. The subjects were adult volunteers. They had at least 20 present teeth, which were in good general health, and did not have any overt oral health problems or acute oral inflammation. Written informed consents were obtained from the subjects after they were made to understand the purpose of study.

Two kinds of toothpaste, Paste P and Paste Q were used. Only Paste P was commercially available and contained 13% granular calcium carbonate (CaG). The calcium carbonate granules had a mean diameter of 250 µm whose size was close to the diameter of the bristles and a breaking strength of 20 gf, which corresponds to the strength at which granules disintegrate when subjected to brushing force. Paste Q had the same formulation but contained regular calcium carbonate (mean particle diameter: ≤40 µm) instead of CaG.

This study contained two independent interventional studies, study 1 and 2, regarding toothbrushing using Paste P and Paste Q. All the subjects in both the studies were requested to not change their brand or type of toothbrushes and to brush their teeth as they normally did.

Study 1 was the test concerning the plaque-removing effects of toothpaste containing CaG. The subjects were 50 adult volunteers aged between 30 and 68 years (mean age: 50.0 ± 11.0 years). This study was a single-use, double-blind, and crossover study. The subjects were instructed to refrain from all oral hygiene procedures for approximately 24h before their appointment. The subjects were given new toothbrushes to brush their teeth using 1g of Paste P or Paste Q. Their brushing time was measured with a stopwatch. The subjects’ plaque levels were assessed using the Quigley–Hein Index (QHI).[10] Plaque levels were evaluated only after brushing. Each tooth was evaluated on six areas of the tooth surface: the mesial-buccal, mid-buccal, distal-buccal, mesial-lingual, mid-lingual, and distal-lingual regions. The subjects performed the same procedure using the other toothpaste after an interval of 1 week.

Study 2 was the test of the effects on toothpaste-derived CaG in the gingival sulci on oral health. The subjects were 60 adult volunteers aged between 30 and 68 years (mean age: 51.4 ± 11.1 years). The subjects used Paste P for 3 days before the baseline assessment. On the baseline assessment, their gingival sulci were examined using a periodontal pocket probe[11] to determine whether they contained CaG. The probe was inserted into the sulci and moved along the soft tissue pocket wall with light pressure. We asked the 23 subjects whose gingival sulci contained CaG on baseline assessment to continue using Paste P for 6 months.

We examined periodontal health based on pocket depth (PD), the condition of gingival tissue using the gingival index (GI),[12] and plaque levels using the QHI at 1, 3, and 6 months from the baseline. Furthermore, an examiner checked whether CaG was present in the subjects’ gingival sulci using a periodontal pocket probe at the same time intervals.

The Wilcoxon signed-rank test was used for comparison study of the plaque level. Logistic regression analysis of the factors associated with the detection of CaG in the gingival sulci was performed using the Mann–Whitney U test. P values ≤0.05 were considered statistically significant. We performed all statistical analyses (95% confidence interval) using the Statistical Package for the Social Sciences (SPSS) (ver. 16.0) (IBM, Tokyo, Japan).


  Results Top


The initial oral condition of the subjects is shown regarding study 1 [Table 1]. The overall QHI for all tooth surfaces after brushing using Paste P or Paste Q is shown in [Figure 1]. The use of Paste P resulted in a significantly lower QHI than Paste Q (P < 0.01). The QHI for each tooth surface was recorded [Figure 2],[Figure 3],[Figure 4]. Paste P resulted in significantly lower QHI than Paste Q on the buccal, lingual, and proximal surfaces (buccal surface: P < 0.01, lingual surface: P < 0.05, and proximal surface: P < 0.01).
Table 1: Initial oral condition of the subjects in study 1 (n = 50)

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Figure 1: Quigley–Hein Index (QHI) for all tooth surfaces after brushing

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Figure 2: Quigley–Hein Index (QHI) for buccal tooth surfaces after brushing

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Figure 3: Quigley–Hein Index (QHI) for lingual tooth surfaces after brushing

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Figure 4: Quigley–Hein Index (QHI) for interdental tooth surfaces after brushing

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The brushing times associated with the use of Paste P or Paste Q are shown in [Table 2]. No significant difference in brushing time was found between Paste P and Paste Q. The QHI for all toothpastes was shown according to the brushing time [Figure 5]. In the group in which the brushing time was ≥2min but <3min and the group in which the brushing time was <2min, Paste P resulted in significantly lower QHI than Paste Q (P < 0.05). Furthermore, among the cases involving shorter brushing times, the difference in the mean QHI between Paste P and Paste Q was larger.
Table 2: Brushing time in study 1 (n = 50)

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Figure 5: Quigley–Hein Index (QHI) relative to brushing time

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In study 2, the results regarding the detection of CaG in the gingival sulci after the use of Paste P were analyzed after the use of Paste P for 3 days [Table 3]. CaG was detected in 38% of subjects (23/60 subjects) and at 1.5% of examined sites (50/3, 258 sites). In addition, no significant differences were observed in age, the number of present teeth, or the mean PD, GI, or QHI between the subjects in which CaG was and was not detected.
Table 3: Status of the study 2 subjects

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Effects of the continuous use of Paste P for 6 months on oral health were also analyzed. The results regarding PD, GI, and QHI at the sites at which CaG was or was not detected in the gingival sulci at 1, 3, and 6 months from the baseline are shown in [Figure 6],[Figure 7],[Figure 8]. No harmful effects, such as damage to the gums or teeth, which were considered to be caused by Paste P were recognized during the study period. With respect to PD, no difference was found between the sites at which CaG was and was not detected. However, the GI at the sites at which CaG was detected was lower than those seen at the sites at which CaG was not detected, and the GI was significantly reduced at 1 and 3 months after the baseline (P < 0.01). The sites at which CaG was detected showed significantly lower QHI than the sites at which CaG was not detected throughout the study (P < 0.01–0.05). The number (and percentage) of sites at which CaG was repeatedly detected in the gingival sulcus across the four oral examinations, that is, the initial oral examination and the oral examinations conducted after 1, 3, and 6 months are shown in [Table 4]. CaG was detected at least once at 9.9% of the tested sites. In addition, CaG was detected in the same gingival sulci ≥2 times at 1.7% of sites, but no sites were observed at which CaG was detected in all four oral examinations.
Figure 6: Changes in pocket depth (PD) at the sites at which granular calcium carbonate (CaG) was and was not detected

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Figure 7: Changes in the Quigley–Hein Index (QHI) at the sites at which granular calcium carbonate (CaG) was and was not detected

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Figure 8: Changes in the gingival index (GI) at the sites at which granular calcium carbonate (CaG) was and was not detected

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Table 4: Percentage of sites at which granular calcium carbonate was repeatedly detected in the gingival sulci

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The total frequency of the detection of CaG in the gingival sulci is shown according to tooth type [Figure 9]. CaG was frequently detected around the mandibular teeth. In particular, CaG was detected at the highest frequency on the buccal side of the mandibular first molar. Logistic regression analysis was performed using the presence or absence of CaG in the gingival sulcus as a dependent variable, and the results are shown in [Table 5]. CaG was detected much more frequently around the molars than that around the incisors (odds ratio [OR]: 4.4, P < 0.001). In addition, CaG was detected around the mandibular teeth much more frequently than that around the maxillary teeth (OR: 3.6, P < 0.001). No statistically significant difference was observed in the frequency of CaG detection between the right and left sides, but CaG was detected less frequently on the lingual side of the teeth than that on the buccal side (OR: 0.2, P < 0.001). As for PD, the detection of CaG was significantly less common at sites with PD of ≥4mm than that at sites with PD of ≤3mm (OR: 0.4, P < 0.05). CaG was detected less frequently at sites with QHI of ≥3 than that at sites with QHI of ≤2 (OR: 0.5, P < 0.001) and it was detected less frequently at sites with GI of ≥1 than that at sites with GI of 0 (OR: 0.6, P < 0.005).
Figure 9: The overall frequency of the detection of granular calcium carbonate (CaG) in the gingival sulci by tooth type

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Table 5: Logistic regression analysis of the factors associated with the detection of granular calcium carbonate in the gingival sulci

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  Discussion Top


This study was performed to investigate the oral health effects of the use of toothpaste containing CaG. Valkenburg et al.[3] performed meta-analysis of plaque removal effect of toothpaste and reported that no significant difference was observed in brushing with or without toothpaste groups. However, Nishigawa et al.[6] reported that dental plaque removal improved by the use of a toothpaste containing a granular cleaning agent, which was produced by subjecting zeolite to granulation, and this effect was particularly enhanced in the interdental regions. The latter study showed that the use of toothpaste, containing a cleaning agent that had been subjected to granulation, improved the cleaning efficacy of brushing in the spaces that toothbrush bristles are unlikely to reach. However, the subjects in the latter study were directed to use the same type of toothbrush and the same brushing method.[6] In daily life, people use various kinds of toothbrushes and brush their teeth in different ways, and therefore, the design of the latter study was considered different from conditions found in real life. Thus, the “real-life” effect of using toothpaste containing a granular cleaning agent on dental plaque removal remains unknown; hence, we investigated this. In this study, the subjects used their own toothbrushes and their own normal brushing methods.[7]

In study 1, the use of Paste P was found to result in lower amounts of dental plaque on tooth surfaces compared with the use of Paste Q (P < 0.01). Therefore, we could hypothesize that Paste P, which contained CaG, had a strong dental plaque-removing effect. Both toothpastes contained calcium carbonate as a cleaning agent. However, Paste P contained a granular cleaning agent, that is, the calcium carbonate had been processed into granules with a mean particle diameter of 250 μm and disintegration strength of 20 gf, which indicated that the granules would disintegrate when subjected to the mechanical force generated by toothbrushing. Yamagishi et al.[9] reported that toothpaste containing calcium carbonate with a particle diameter of about 200 μm showed the greatest dental plaque-removing effect and the greater the disintegration strength of the granules the higher the dental plaque-removing effect was. The latter study indicated that the plaque-removing effects of such toothpastes are affected by the disintegration properties of the granules they contain and the delivery of the particles to tooth surfaces by toothbrushing.

In this study, no differences were observed in the brushing time between the Paste P and Paste Q groups, even though the subjects used their normal brushing methods. Paste P showed a greater dental plaque-removing effect and this effect was especially pronounced in the interdental regions. This suggests that the use of toothpaste containing CaG, which had a mean diameter of 250 µm, and disintegration properties result in greater dental plaque removal, even when no special brushing technique was used, which supports the findings of previous studies concerning conventional toothpastes containing CaG.[6],[7] In this study, Paste P caused a significant reduction in the amount of dental plaque among the subjects with brushing time of <3min (P < 0.05). It is considered that many people only brush their teeth for short period. Therefore, the use of a toothpaste containing CaG, such as Paste P might be an effective way of improving the cleaning effects of toothbrushing, especially among subjects with short brushing time. Eda et al.[8] reported that if the amount of toothpaste was more than 0.5g, the plaque removal rate was significantly higher when brushing using toothpaste containing granule-shaped cleaning agents than granule-free toothpaste among the group that brushed for a short time. The brushing time of this group was under 169s. The plaque removal effect of toothpaste with granule-shaped cleaning agents was considered to be affected by both brushing time and amount of usage. In our study, the subjects were instructed to brush with 1g of toothpaste. Seventy-six percent of the subjects in study 1, in which the subjects were instructed to brush with 1g of toothpaste, had brushing time of ≤3min, therefore it was suggested that brushing using a toothpaste containing CaG be recommended.

In study 2, we assessed the penetration of CaG into the gingival sulci and its subsequent retention. The gingival sulci are opened to oral cavity, thus various substances such as piece of foods or toothpaste components can come into there.[13] In the results of study 2, CaG in the gingival sulci was detected in 38% of the subjects. The overall frequency of detection of CaG in the gingival sulci was higher for molars than that for incisors. Molars have multiple roots, and an enamel projection (where part of the enamel extends toward the furcation area of the tooth) is present at the enamel cement junction in such teeth. Epithelial attachments can easily be lost around enamel projections.[14] Spaces that toothpaste components can enter often form in the regions around enamel projections, which are considered to facilitate the penetration of granules into the gingival sulci. CaG was detected in the gingival sulci more frequently on the buccal side than that on the lingual side. This was because it is easier to perform toothbrushing on the buccal side than that on the lingual side, and so the likelihood of CaG penetrating into the gingival sulci was higher on the buccal side. In addition, CaG was detected more frequently in the mandibular gingival sulci than that in the maxillary gingival sulci. One possible explanation for this was that the weight of CaG is greater than that of saliva. In particular, we found that CaG was detected most frequently in the gingival sulcus on the buccal side of the mandibular first molar. This could be explained by the following three factors: the presence of an enamel projection, the fact that it is a mandibular tooth, and the fact that this area can be easily reached with a toothbrush.

There were 113 sites (9.9%) at which CaG was detected at least once in four examinations for 6 months. CaG was only detected two or more times at 15 sites (1.7%) and there were no sites at which CaG was detected in all four examinations for 6 months. These results suggest that CaG that has penetrated a gingival sulcus does not remain there for longer than 6 months.

Thus, it is considered that CaG that penetrates a gingival sulcus is subsequently discharged via the secretion of gingival sulcus liquid[15] or the turnover of the gingival epithelium[16] and disintegrates under the physical force associated with brushing or mastication.

Finally, we examined the effects of oral conditions such as inflammation caused by the continuous use of Paste P during 6 months. The results of study 2 indicated that compared with the sites at which CaG was not detected, the sites at which CaG was detected had low QHI and low GI and showed excellent gum health. Therefore, we recognized that CaG does not function as a nutritional source for oral microorganisms and is biologically inactive in the gingival sulcus. Tomotake et al.[17] evaluated the effect of penetration of granule components in toothpaste on inflammation of peri-implant tissue and reported that no correlation was found with the presence of inflammation and the penetration of granule components. Those results were mirrored in this study.

The results of this study showed that even when CaG penetrated a gingival sulcus and remained there, it did not have direct harmful effects on the gums. To allow CaG to penetrate the gingival sulcus via toothbrushing, it is necessary that the bristles on the toothbrush are able to reach the gingival sulcus. By contrast, inflammation of the gingiva is known to depend on the amount of dental plaque present.[18] The sites at which CaG were detected were the cervical margins of the gingiva. Thus, it was presumed that the cervical margins of the gingiva had been cleaned by CaG in toothpaste, and consequently had low GI and showed good gum health.

On the contrary, it has been reported that toothbrushing without the use of toothpaste was slightly more effective in removing plaque than that with the use of toothpaste.[4] The reason was the film formed between the bristles of toothbrush and the tooth surface. The viscosity of the toothpaste interferes with the tooth surface contact. It is thought that using the toothpaste containing particles bigger than the thickness of the films can prevent this problem. If size of the particle is too large, it may interfere with the movement of the brushing. The particle size is important to remove plaque. Thus, it is necessary to study the best size of particle for effective plaque removal.

Furthermore, the effect of improving plaque removal of the toothpaste containing baking soda[19] or arginine[20] had been investigated. It was reported that the plaque removal effect is improved by blending baking soda into toothpaste.[19] It may be possible to get good effects by combined CaG and other components such as baking soda. Therefore, further studies are needed to find the most effective components of toothpaste with CaG.

The following conclusion was obtained from this study:

  1. Toothpaste containing CaG was shown to be more effective at removing dental plaque.


  2. The penetration of CaG into the gingival sulci was detected, but the CaG did not remain in the gingival sulci for long period.


  3. The continuous use of the toothpaste containing CaG resulted in greater dental plaque removal, and this effect was especially noted in the interdental regions. By using the toothpaste containing CaG, a healthy gingival state was achieved, and no harmful effects, such as damage to the gums or teeth, were recognized during this study.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Eda Y, Takayanagi A, Yano Y Effects of the toothpaste containing granule-shaped cleaning agents on daily dental hygiene. J Jan Soc Dent Hygiene 2019;13:32-42.  Back to cited text no. 8
    
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Löe H The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:610-6.  Back to cited text no. 12
    
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Tomotake Y, Goto T, Ishida Y, Naitou Y, Araki A, Kiyono M, et al. An investigation of the penetration of granule components in toothpaste into peri-implant sulcus. J Jpn Soc Oral Impantology 2018;31:309-19.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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