TOOTHPASTES AVAILABLE IN THE MALAYSIAN MARKET

S Musa, R Saub. Toothpastes available in the Malaysianmarket, Annals Dent Univ Malaya 1998; 5: 45-48

ABSTRACTThis study was undertaken to investigate the number andtypes (fluoride or non-fluoride) of toothpaste products avail-able in the Malaysian market based on the label. Thirty-fivebrands of toothpaste were identified, of which ten (29%) werespecifically recommended for children. Two of the chil-dren's toothpaste recommended that children below sevenyears old use a pea size amount of toothpaste. One (3%) wasrecommended for both children and adult. The remaining 24(69%) did not state if they were recommended for either chil-dren or adults. To improve the flavour of the toothpastes, avariety of flavours had been added especially in children'stoothpaste. Almost half of the toothpastes were for preventionof tooth decay and gum disease. Other indications were fortooth sensitivity, tooth whitening and stain removal. Twenty-seven (77%) of the toothpastes were imported, while eight(23%) were made in Malaysia. Twenty-six (74%) of thetoothpaste contained fluoride and the most common type offluoride used was sodium monofluorophosphate (NaMFP).The fluoride concentration was not labeled in more than half(63%) of the fluoridated toothpaste. Of those that were flu-oridated, different units of measurement were used. As thereis no uniformity in the labelling of these products, it is rec-ommended that the responsible authorities should take moreaction in enforcing proper labelling of the fluoride concen-tration in the toothpaste using standardized units.

Keywords: fluoride toothpaste, children, labelling

INTRODUCTIONThe prevalence of dental caries especially among school-children has declined worldwide (1). In Malaysia, the meanDMFf for 12-year-old children has decreased from 3.7 in1971 to 2.4 in 1988 (2). Several factors have been thought tobring about this reduction and fluoride in drinking water andin toothpaste have been shown to contribute to this decline(3).

Numerous studies have shown that water fluoridation hasa great impact on the reduction of dental caries prevalence(1). However, in areas where the water supply is not fluori-dated, toothpaste has become a source of fluoride for cariesprevention. The WHO in 1993 (3) reported that in industri-alized countries, the decline in the prevalence of dental cariesin the past 20 years was attributed mainly to the widespreaduse of fluoride toothpaste. Fluoridated toothpaste has beensuggested to be responsible for 20-35 per cent of cariesreduction in developed countries (4).

Although fluoride has been shown to be an effectiveagent in caries prevention, overdoses can lead to unwantedeffect such as developmental defects of enamel and bones.Although fluoridation of water supplies in Malaysia is wide-spread, toothpastes are also easily accessible since 1970's(2,5).

Several studies have been conducted to determine the

1 Sabri Musa, 2 Roslan Saub

Lecturer.1 Department of Children's Dentistry and Orthodontics2 Department of Community Dentistry

Faculty of DentistryUniversity of Malaya50603 Kuala Lumpur

prevalence of the enamel defects. Razak and Hussein (6) in1986 examined 11-12-year-old children from a fluoridatedarea in Selangor. They found that the prevalence of enameldefects was 72.5% and over 90% of the affected teeth havethe diffuse patchy type, which has been related to a mild formof fluorosis. In 1986, a study by the Dental Division,Ministry of Health (7) in lohore, on 12-year-old childrenfound that 81.2% of the children from the areas with fluori-dated water supply had diffuse opacities, while only 56.0%of the children from areas with unfluoridated water supplyexhibited diffuse opacities. In addition, the children whowere involved in those studies grew up at the time when thefluoride toothpaste was widely used in Malaysia. Most stud-ies had found that the prevalence of the developmental enam-el defects was high, however, one study had found that gen-erally its psychosocial impact on 16-year-old school childrenwas low (16).

In Malaysia recently, the issue of fluoride in the tooth-paste has received considerable public attention in discussion,claiming that fluoride is a poison. In fact, all chemical prod-ucts are poisonous when consumed in large amounts. For allchemical products there is a recommended therapeutic doseand this also applies to the use of fluoride in fluoridated tooth-paste.

The influx of toothpastes of all kinds and brands into theMalaysian market seems to be occuning without any control.With the increasing concern from the public on the fluorideissue, it seems necessary that precautionary actions areundertaken to ensure safe and continued use of fluoridetoothpaste. In developed countries however, while realizingthat the impact of fluoridated toothpaste has led to cariesdecline, action has been taken to prevent fluorosis i.e throughlabelling and messages containing advice on the box.However different standards have been used in Malaysia.

Therefore the purpose of this study was to investigate thenumber and types (fluoride or non-fluoride) of toothpasteproducts available in the Malaysian market based on the label.

Materials and MethodFive selected supermarkets and four selected pharmaciesaround Petaling laya, Selangor were visited. The selection ofthe supermarket and pharmacies was based on the locationand popularity. The assumption made in this study was alltypes of toothpastes available in any part of Malaysia will beavailable in the study area. All types of toothpastes sold wereidentified. The following information written on thebox/pack were recorded

Table 2: Fluoridated toothpastes in the Malaysian market

46 Annals of Dentistry, University of Malaya Vol. 5 1998

Manufacturer

AustraliaJapanIndiaUSAFranceSingaporeMalaysiaMalaysiaMalaysia

Brand name

SensodyneZactDaburUncle DocPyodontylTollyjoyZaitun (adult)Zaitun (children)Promisce

Table 3: Non fluoridated toothpastes inMalaysian market

123456789

[FI]

Not givenNot givenNot givengivenNot given7.6mg/g4.0mg/g17.0%

0.02%w/wNot givenNot givenNot given0.1%Not given0.76%0.76%Not givenNot given0.8%0.683%0.022%Not given0.025%Not givenNot givenNot givenNot given

Type of toothpaste Manufacturer

Imported Local Totaln % n % n %

Fluoridated 21 77.8 5 62.5 26 74.3Nonfluoridated 6 22.2 3 37.5 9 25.7

Total 27 77.1 8 22.9 3S 100.0

Table I: Number and percentage of local and importedtoothpastes in Malaysian market

mended for children. One was recommended for both chil-dren and adult while the remaining twenty-four (69%) did notstate whether they were recommended for either children oradult or both. Two brand of the children's toothpastes had amessage "children below seven years old use only a pea sizeamount of toothpaste" written on the box.

Twenty-six (74.3%) of the toothpastes contained fluoride(Table I). The most common type of fluoride used was sodi-um monofluorophosphate (59%). Other fluoride compoundsused in the toothpaste were sodium fluoride (19%), stannous

fluoride (15%), hydroxyapatite sodiumfluoride (4%), fluoride mineral (4%) and'2 fluoride system' (4%). However, 16 ofthe 26 fluoridated toothpastes did not indi-cate the fluoride concentration. For thosewhich indicated the fluoride content, dif-ferent units of labelling the concentrationwere used such as mg/g, %w/w and %.The concentration of fluoride in the tooth-pastes was clearly labelled for 11 out of 26toothpastes which contained fluoride.These were Sensodyne-F (7.6mg/g), Oral-B (for tooth and gum care, 4mg/g; forsensitive teeth, 17%), Rembrandt (0.76%),Clinomyn (0.76%), Mentadent-P (0.8%)and Fluocaril bifluore (0.683%,0.0221 %).For the children's toothpaste the concen-tration of fluoride were stated by Oral-B(0.02%w/w), Zwitsal (0.1 %) and Boots(0.025% ).

MFP and NaFNaF2 Fl systemNotNaMFPNaMFPStannous FLHydroxyapatiteNaFNaFNot givenNaMFPNaMFPNaMFPNaMFPNaMFPNaMFPNaMFPNaMFPNaMFPNaMFPNaFNaMFPNaPNaMFPFl mineralNot givenNaMFP

Manufacturer Type of Fluoride

MalaysiaMalaysiaMalaysiaNaMFPHong KongAustraliaCanadaCanada

Brand name

ColgateColgate TotalFresh end whiteSparkelIndonesiaDarlieSensodyne-FOral- BOral- B

I2345678

9 Oral-B Canada10 Kodomo Lion Japan11 Zact Japan12 Tooty Malaysia13 Zwitsal Indonesia14 Uncle Doc USA15 Rembrandt USA16 Clinomyn UK17 Clinomyn Singapore18 Topol Plus USA19 Mentadent P UK20 Fluocaril Bi-fluore France

21 Zoothpaste Korea22 Boots UK23 Chicco Italy24 Daun Sirih Indonesia25 Polleney China26 Dent Fresh Malaysia

[FL] denote fluoride concentration

1. the brand name2. place of manufacture3. the type and fluoride content in units used4. flavours5. recommendations for use6. the endorsement by the Malaysian Dental Association

RESULTSThirty-five brands of toothpaste were identified available inthe market. Out of these, twenty-seven (77%) were import-ed. This included two herbal toothpastes, and only eight(23%) were made locally (Table I). Among the importedtoothpastes, four were from USA; three from UK, Canada,Japan and Indonesia; two from Australia, Singapore andFrance; one from India, Hong Kong, Korea, Italy and China(Table 2 and 3).

Fourteen (40%) of the toothpastes were recommendedfor prevention of tooth decay and gum diseases. Other useswere for sensitive teeth (15%), as teeth whitening agents (5%)and stain removal (9%). Nine (26%) of the toothpastes didnot state any special usage indications.

Ten (29%) of the toothpastes were specifically recom-

Eight out of 9 children's toothpastes contained differentfruit flavours such as banana, strawberry, melon, grape,orange, apple, mixed fruit, tropical fruit and chewing gumflavour.

Only three toothpastes had the endorsement from theMalaysian Dental Association. These were Colgate, ColgateTotal and Sparkle.

DISCUSSIONIn Malaysia, there are many varieties of toothpastes sold inthe market. However, most of the brands are imported. Thefluoride concentration in the imported toothpastes may not bevery suitable for the Malaysian use. Thus the responsiblebody should analyse and ensure that the fluoride concentra-tion in the toothpastes is suitable and safe before they areallowed to be marketed in this country.

Out of 35 brands available, only three brands were giventhe endorsement by the Malaysian Dental Association(MDA), two were locally manufactured (Colgate andColgate Total) and one was imported (Sparkle). Althoughthey have been endorsed, these products were not uniform-ly labelled. Furthermore, these brands do not indicate the usefor either children or adults. Studies have shown that childrentend to swallow the toothpaste while brushing and it hasbecome one of the sources of fluoride intake (10-14). Theamount of fluoride intake during the first 6 years is criticalin children because it can cause enamel opacities in the per-manent dentition (8,9,13,14). This is important because thefluoride concentration which are recommended for use bychildren are different from that of an adult. From the resultsof several scientific studies and evidence at present, childrenunder the age of 6 years who were found to be at low risk ofdeveloping dental caries are recommended to use a toothpastecontaining no more than 600 parts per million (ppm) of flu-oride (15). Those with a higher risk of developing cariesshould use the toothpaste containing 1000 ppm of fluoride(15).

Most of the toothpastes sold in Malaysia indicated thetype of fluoride content such as monofluorophosphate, sodi-um fluoride, and sodium monofluorophosphate. However, theconcentration of the fluoride was not stated. Several westerncountries have made labelling of fluoride concentration andcomposition mandatory. However, this study found that dif-ferent manufacturers used different units in labelling.Therefore, to avoid confusion to the customers and even tothe dentists, standardised unit such as in ppm should beused (14,15).

This study also identified several toothpastes labelled as"family packs" being sold in the market. These toothpasteswere meant for use by the whole family including children.Although it is much cheaper, the toothpaste may not be suit-able for use by children due to the different concentrations offluoride which is recommended for children and adults.Therefore, any toothpaste sold in the market should clearlystate whether it is indicated for use by children or adults.

Herbal toothpastes were also available in the market.Two brands were identified, both were imported, one wasfrom India (Dabur) and the other from Indonesia (Daun

Toothpastes available in the Malaysia Market 47

Sirih). However, no known clinical study has been carried outon these products. Therefore, the safety and the effectivenessof these products are questionable. Although the manufacturerclaimed that their products are effective, there is no scientif-ic evidence to support their claims. Moreover, concentrationof fluoride in such products are not known. Hence, it is sug-gested that before these products are allowed to be market-ed, the manufacturers have to provide scientific evidence toshow the safety and effectiveness of the products.

Developmental enamel defects will only develop whenexcessive amount of fluoride is ingested during the formationof teeth. If excessive fluoride intake occurs during the first sixyears of life, all permanent teeth will be at risk, whilst if thisoccurs during the first three years of life, only permanentincisors will be at risk (8,9). Therefore, parents are advisedto supervise and train their children to use only a small pea-sized amount of toothpaste. A simple message of advice forpa~nts on the label is highly recommended./

CONCLUSIONThere are many types of toothpastes which are available inthe Malaysian market. They are sold either for cosmetic ortherapeutic purposes. To enable a potential consumer tomake his/her selection easily and safely, proper labelling isrecommended. Authorities such as the Ministry of Health andthe Malaysian Dental Association should play their role inmonitoring and ensuring that these products are safe forpeople to use.

ACKNOWLEDGEMENTSWe would like to thank Associate Prof. Dr Nik Noriah NikHussein for her comments and advice.

REFERENCES1. Murray JJ, Naylor MN. Fluorides and dental caries. In:

Murray JJ, Prevention of Oral Diseases. 3rd. ed., OxfordUniversity Press, 1993: 32-67.

2. Reports of Dental Epidemiology Surveys in Malaysia,Dental Services Division, Ministry of Health Malaysia,1991.

3. WHO. Fluorides and Oral Health. Report of a WHOExpert Committee on Oral Health Status and FluorideUse, Geneva, 1993.

4. Rahimah Kadir. What's in a toothpaste. New StraitsTime, 22 February 1998.

5. Majid Z. Hussein NN, Bagramian RA. The prevalenceof caries and developmental enamel defects in an adultpopulation in Malaysia. Dent J Malaysia 1995; 16 (1):33-39.

6. Razak lA, Hussein NN. A study of enamel defects in 12years old subjects in a fluoridated area. Dent J Malaysia1986; 9: 21-26.

7. Dental Division, Johore, Malaysia. EpidemiologicalSurvey of developmental defects of dental enamel inJohore 1986. Johore Bahru: Government Printers 1986.

8. Evans RW, Stamm JW. An epidemiologic estimate of thecritical period during which Human maxillary centralincisors are most susceptible to fluorosis. J Public Health

48 Annals of Dentistry, University of Malaya Vol. 51998

Dent 199]; 51 (4): 251-9.9. Evans RW. Refining the estimate of the critical period for

susceptibility to enamel fluorosis in human maxillarycentra] incisors. J Public Hea]th Dent 1995; 55 (4): 238-49.

10. Pendrys DO. Risk of fluorosis in a fluoridated popu]a-tion. Imp]ications for the dentist and hygenist. J Am DentAssoc ]995 ;126: ]617-24.

11. Osuji 00, Leake JL, Chipman ML, Nikiforuk O. LockerD, Levine N. Risk factors for dental fluorosis in a fluo-ridated community. J Dent Res 1988; 67: 1488-92.

12. Mi]som K, Mitropou]os CM. Ename] defects in 8-year-old children in fluoridated and non-fluoridated parts ofCheshire. Caries Research 1990; 24: 286-9.

13. Rock WP. Young children and fluoride toothpaste. BrDent J 1994; 177: 17-20.

]4. Holt RD, Murray 11. Developments in fluoride tooth-pastes - an overview. Comm Dent Health 1997; 14: 4-10.

15. Holt RD, Nunn JH, Rock WP, Page J. British Society ofPaediatric Dentistry: A Policy Document on FluorideDietary Supplements and F]uoride Toothpastes forChildren. Int J of Paed Dent 1996; 6: ]39-] 42.

16. Sujak SL, Mohd-Dom TN, Abdul-Kadir R. Prevalenceand psychosocial impact of developmental defects in asample of Ma]aysian adolescents. In Proceedings, 12thIADR Congress of South East Asian Division, Phuket,Thailand. ]997 pg 95.

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