Marketing ingenuity or beneficial dentifrice?

Are you curious about the trend of activated charcoal in toothpastes? Are you skeptical about the claims? Can we adequately inform our patients about the proper use? Are we just inserting opinion or “what we’ve heard?” Whether you use charcoal toothpaste personally or dispense from your office, you have patients that are using a charcoal dentifrice in one form or another.

Charcoal-based teeth whitening is both intriguing and cool—the uniqueness of the ingredient itself, especially its color, is likely the main driver behind the recent surge in popularity of activated charcoal for dental use. In discussions with our patients, it is in our best interest to understand the available data, the pros and cons of use, and key questions to ask regarding the safety of charcoal for whitening the teeth.

In January 2017, a literature review in JADA concluded that there is “insufficient clinical and laboratory data to substantiate the safety and efficacy claims of charcoal and charcoal-based dentifrices. Larger-scale and well-designed studies are needed to establish conclusive evidence.” This article also urged dental professionals to advise their patients to be “cautious when using charcoal and charcoal-based dentifrices with unproven claims of efficacy and safety.”1

Let’s begin with what is activated charcoal? First, it is not the same as the briquettes used for summer barbecues! When charcoal is heated to high temperature—then activated by infusing an oxidizing gas—a porous substance is created that is able to adsorb toxins such as bacteria, stains and VSCs.2A medical dictionary states that “activated carbon is purecarbonspeciallyprocessed to make it highlyadsorbent of particlesandgases” by increasing the surface area available for adsorption.

Adsorption differs from absorption. Absorption is a reaction of elements which allows assimilation into the blood stream.3 Adsorption binds to a surface due to a negative electric charge, causing positive toxins to bond without internal resorption.

Activated carbon’s history

Activated carbon, which is charcoal that’s been treated to increase its adsorbency, isn’t new. Charcoal has numerous benefits and has long been used in medicine and cosmetics. BuyActivatedCharcoal.com notes, “The first recorded use of charcoal for medicinal purposes comes from Egyptian papyri around 1500 B.C.” In an article titled, “Universal Antidote and Detoxifier,” Dr. Richard Kaufman said, “After the development of the charcoal activation process (1870 to 1920), many reports appeared in medical journals about activated carbon as an antidote for poisons and as a cure for intestinal disorders.”

It has been used in trauma centers across the world to treat drug overdose and poisoning. 2 In some instances, activated carbon is considered better treatment than gastric lavage (stomach pump), according to eMedicineHealth.com.

Activated carbon is considered to be antibacterial, to alter pH, as well as being anti-inflammatory. Activated carbon has the capacity to extract dirt and grime from the pores of the skin without being absorbed into the skin itself and is known to “absorb 100 to 200 times its weight in impurities, an excellent natural ingredient to help purify and deep-clean,” according to Refinery29.com. These properties are cited in many product claims.

Activated carbon is used for anti-aging, cleansing of wounds, to combat oily skin, prevent gastric bloating, and gas. It has been successfully used on insect stings, tooth whitening,2 purifies the water we drink, the air we breathe, and detoxifies the soil we grow our food in.

BuyActivatedCharcoal.com claims, “By the end of the 20th century activated carbon was employed by every modern hospital, clinic, research department, and poison control center in the world in hundreds of applications.” The website added, “From wound dressings to ostomy bags, from drug overdose to kidney dialysis units, from the treatment of anemia in cancer patients to breast cancer surgery, the role of activated charcoal as a medicinal continues to grow.”

While activated carbon is mostly beneficial when taken internally, it can also reduce the absorption of different medications.4 The Mayo Clinic advises, “Certain medicines should not be used at or around the time of ingestion of charcoal since interactions may occur” (see Table 1). The small amount potentially ingested with toothpaste, though, is unlikely to have any serious effects on the body or health in general.

Where does the activated carbon come from and what is the source? Coconut shells are the most common origin, but a question that begs to be asked is: Where is the activated carbon made? Patients may be advised to sticking with products that are produced in the United Kingdom or the United States. Some foreign brands of toothpaste have contained toxic ingredients.

Whitening claims

Whitening is the removal of surface stains vs. bleaching which changes the inherent color of teeth. Professional bleaching definitely has longer lasting effects and is more profitable to the dental practice. This may be one reason the dental industry is slow to embrace these dentifrices. The long-lasting white smile that many patients may be looking for and that is being promised through advertising for activated carbon can be misleading. For an individual who consumes coffee, tea, red wine, and other foods containing tannic acids, however, its use can obtain positive outcomes.

The activated carbon is often described as acting as a “sponge,” extracting the stains off your teeth.The use of activated carbon in a dentifrice is intended to be used as a day-to-day maintenance. Products are available that contain an ingredient that coats the tooth surface with a blue tint that influences light reflection and reduces the yellow discoloration, thereby providing an additional whitening effect without the use of chemical agents.

All toothpastes rely on mild abrasion to remove surface stains. Some contain polishing or chemical agents to achieve this.5 Silica, which in higher grades, is known to be extremely abrasive, peroxides whose long-term use can be drying to the tissues, or cariogenic sweeteners are commonly found ingredients. Charcoal is abrasive in the instance of direct application. Thus, activated carbon can potentially cause damage due to its grainy substance.

Many dental professionals express concerns about abrasivity with long-term use that can result in enamel wear, gingival recession, and increased sensitivity, citing the “insufficient evidence” available.6 Granted, many products available to consumers are considered extremely abrasive. Most commercial toothpaste formulations have an RDA in the range of 70-190, with whitening pastes coming in around 125-175. There are numerous anecdotal descriptions from hygienists who have removed flecks subgingivally from the use by a patient of the coarser formulations sold in discount stores and flea markets.

How a particular manufacturer has determined the safety and abrasivity is a legitimate question to ask. Most requests for comment from manufacturers went unanswered before this article was written. Manufacturers that you think would have done testing have not. While yet to be proven in a clinical trial, a toothpaste is considered less damaging as the activated carbon is a smaller component within a mix of other ingredients.

The powdered formulations usually require a longer brushing time to achieve the whitening effect and tend to be messy to use. Powders, rather than pastes tend to be recommended for use for shorter periods (on average once a day for three to five days) rather than every day and used in conjunction with a fluoridated paste to combat decay. The majority of products on the market today do not contain any fluoride, in particular the DIY products that are intended for internal use and are seen frequently on the Internet. Many of these products contain sodium laurel sulfate (SLS), which can cause gingival irritation in some individuals and which has been reported in consumer product reviews.

Activated carbon is odorless and tasteless, yet many products contain flavorings, using citric acid which may cause additional sensitivity to some (see Table 2).7 Likewise, the use of citric and stearic acid raises pH concerns. There are pastes available that contain nano-hydroxyapatite that assists in the remineralization process and, when combined with sodium fluoride, greatly enhance remineralization and increase the microhardness of the tooth.8 This combination serves as a protective layer and has a remedial effect on damaged enamel. Lactoperoxidase is a natural antibacterial salivary enzyme found in our mouths. This enzyme boosts the saliva’s antibacterial and antiviral functions and helps to combat dry mouth.

Professional response

Many professionals have taken the stance of not backing any charcoal dentifrice and suggest staying away from them because they do not have the clinical evidence to confirm or deny claims. In order to best serve our patients, it is prudent to become informed on what products are on the market and what our patients are using. Being aware of any contraindications for that individual and the use of these products is important. As a dental professional we should be determining our “why” in regards to desired outcomes in addition to a patient’s risk level for periodontal disease and decay before recommending or dismissing any product.

What are the expectations of the patient? What have they been using, and what changes do you see that have occurred in their mouth since the last visit, good or bad? Different people can and will react differently to a product containing activated carbon just as they will with a regular toothpaste.

Advertising claims that a product “contains” activated carbon/charcoal doesn’t mean it’s an active ingredient, and the rest of the product’s ingredients should be considered as well. By looking at individual products and not rejecting the entire concept, we can offer our patients information to make the best decision for them. Using charcoal toothpaste from a reputable brand to avoid inflicting damage to that perfect smile is recommended!

Kris Potts, RDH, FAADH, is a clinician, speaker, and author. She is the owner of Oral Health Promotion Strategies, LLC. If you would like a comprehensive list of available xerostomia products and their indications or to book a course on Oral Prehabilitation for the Oncology Patient, her website is krispottsrdh.com. She can be contacted at [email protected]. She is a professional educator or Waterpik and Curaden USA.

References

1. Brooks JK, et al. Charcoal and charcoal-based dentifrices. The Journal of the American Dental Association, Volume 148 , Issue 9 , 661-670.

2. http://www.hollandandbarrett.com/the-health-hub/5-reasons-using-activated-charcoal/

3. https://draxe.com/activated-charcoal-uses/

4. https://www.mayoclinic.org/drugs-supplements/charcoal-activated-oral-route/before-using/drg-20070087

5. http://www.epostersonline.com/agd2015/node/72

6. http://www.vanhaywood.com/uploads/articlespage/2017ActivatedCharcoal.pdf

7. http://www.electricteeth.co.uk/charcoal-toothpaste/#Is_charcoal_toothpaste_and_powder_safe_to_use

8. J Dent (Tehran). 2014 Jul; 11(4): 406–410. Published online 2014 Jul 31. PMCID: PMC4283741. “Comparison of Nano-Hydroxyapatite and Sodium Fluoride Mouthrinse for Remineralization of Incipient Carious Lesions.