A popular program on HGTV is Fixer Upper with Chip and Joanna Gaines. On a recent program, they took to the high seas and helped a friend turn a houseboat into a home. To protect the houseboat’s wood, they introduced a technique called shou sugi ban. This term describes the centuries-old Japanese technique of charring cedar planks.(1-2) Charred wood has the surprising properties of fire and bug resistance, durability in harsh environments, and more.(2) The question is, could charcoal have surprising properties for oral health?
The color of teeth
Tooth color is primarily determined by the reflectance of the dentin, modified by the absorption, scattering, and thickness of the enamel. (3) Staining can be intrinsic, extrinsic, or both. What our patients don’t realize is if composites or crowns are present, no whitening product will change a crown or veneer. Depending on the nature of the discoloration, the treatment approach and outcome can vary significantly. No single answer exists.
Do-it-yourself whitening is promoted on a myriad of websites that suggest remedies such as rubbing crushed strawberries, bananas, apples, or activated charcoal onto the teeth. Our patients are interested in DIY whitening products that can save them money. Last year, a YouTube video showed how to use activated charcoal as a toothpaste. Within a few days, it went viral with 1.5 million views. When you search the Internet for "activated charcoal for tooth whitening," there are more than 11,000 video results.
One mom has gotten attention with an over-the-counter product that she developed because her child was getting too many cavities. She claimed her child was born with a condition that made her susceptible to cavities and tooth sensitivity. We know that not to be the case, but our patients might feel desperate for different modalities and could find this appealing.
Activated charcoal—not for your barbecue
These DIY products contain activated charcoal so the question should follow: what’s the difference between activated charcoal and regular charcoal?
Charcoal is made from coal, wood, or other substances. It becomes activated charcoal when high temperatures are combined with a gas or activating agent to expand its surface area. This turns it into a powerhouse of porous material that sucks in impurities from the environment around it. (4) This "sucking in" is a very rough way of describing what it does. Adsorption is different than absorption. Basically, it means that the porous surface of activated charcoal attracts (mostly unwanted) material a bit like a magnet and holds it in its pores. This leaves the area around it clean. (5)
In the early 1900s, the World Health Organization listed activated charcoal as an essential medicine for the treatment of poisoning and overdoses. (6) Activated charcoal has become very popular once again; this time, it is being touted as a potent natural treatment used to trap toxins and chemicals.
Aside from treatment for poisoning, nondental uses include reducing intestinal gas (flatulence), lowering cholesterol levels, preventing hangovers, and treating bile flow problems (cholestasis) during pregnancy. It is also hyped for internal cleansing, weight loss, mold cleansing, skin and body health, and tooth whitening. (7)
Evidence-based use versus off-label use
When asked about products, procedures, or therapies we don’t know much about, a common, perhaps reflexive, behavior among professionals is to deny safety and efficacy and wrap up the conversation with evidence that only supports our individual beliefs and biases. Evidence-based dentistry (EBD) is a patient-centered approach to making treatment decisions and providing personalized dental care based on the most current scientific knowledge. (8) EBD is an important tool, yet biases can be so strong that even with evidence, professionals still can deny the science they don’t personally know and believe.
A related confusion involves the off-label use of products. Many products have appeared on the dental market recently that can support healing the tooth structure. The use of the words "healing the tooth structure" is new. These products include different fluoride formulations and delivery systems, amorphous calcium phosphate products, and more. The confusion can stem from how the companies producing these products choose to position themselves with the Food and Drug Administration (FDA). (9)
The FDA process is long and expensive. It is often more cost effective to submit a new produce or device as a predicate device. What that means is the new product or device can be proved substantially equivalent to a legally marketed device. When compared to the legally marketed device, the new device must have the same intended use, and its technological characteristics must either be the same or must not raise questions of safety or effectiveness. Product claims must fall within the guidelines of this approval process. Currently many of the products dental professionals use and recommend have gone through this process.
But clinician, beware! Many times we think a product has been approved for something when, in fact, it may not have been. This is defined as "off-label" use. The most common example involves the claims and explanations we give to patients about fluoride. (10) Yet when something new or different comes along, we demand more. In a world of increasing patient knowledge and resources, we have to ask ourselves: are we being limited by old beliefs?
The yin and yang of DIY tooth whitening
The yin-yang symbol is familiar to almost everyone. It is a fundamental concept in ancient Chinese philosophy that posits all things exist as inseparable and contradictory opposites. These opposite or contrary forces may be complementary, interconnected, and interdependent to one another.
Our yin-yang question here is: Can black toothpaste using activated charcoal safely make teeth white?
There are no known research studies to show the effectiveness of activated charcoal for tooth whitening. The concern with DIY products is that there is no way of knowing how safe or effective they are for the tooth surface and gingival tissues. We know it activated charcoal is safe for absorbing toxins in the gut, but we have no idea what crushing a tablet, mixing it with water, and brushing your teeth can do. When consumers try one of these DIY methods, they often get excited and think they will show us they can do it for less money, so they brush longer and more vigorously—and maybe that explains why some look better afterward. Many times, photo editing software is what really created the improvement.
What we do know, as of this writing, is there is only one toothpaste containing activated charcoal that appears to be safe. Black is White toothpaste (Curaprox Inc.) uses activated carbon for whitening and stain removal. It also contains an ingredient that coats the tooth surface with a blue tint to influence light reflection and provide an additional whitening effect. Remember when your mom used laundry bluing for whiter whites? It is the same principle.
One property that differentiates this toothpaste from DIY products is that it contains 950-ppm fluoride and nanohydroxyapatite (nHA). Studies show the following: "[. . .] Scanning electron microscopic (SEM) analysis showed that nanohydroxyapatite particles were regularly deposited on the cellular structure of the demineralized enamel surface, which appeared to form new surface layers. It was concluded that nanohydroxyapatite had the potential to remineralize initial enamel lesions." (11-12)
Further distinction can be demonstrated with the relative dentin abrasivity (RDA) index. This product has an RDA of 59, which is low compared to the majority of other commercial toothpaste formulations, which have RDAs ranging from 70–190.
Black is White is also differentiated from other activated charcoal products by what it does not contain. It does not contain sodium laurel sulfate (SLS), triclosan, bleaching or chemical agents, or plastic particles.
Stretching beyond your EBD boundaries
If your patients are interested in trying an activated charcoal product, you can have a new response. Chip and Joanna Gaines stretched beyond their usual boundaries in fixing houses to remake a houseboat. They introduced an old technique and a different way of thinking to a new audience. Dental professionals can learn from this example. The yin-yang response is that black can become white.
References
1. Shou Sugi Ban: The Traditional Art of Charred Cedar. Shou Sugi Ban website. http://www.shousugiban.com. Accessed February 17, 2017.
2. What is the History of the ‘Shou Sugi Ban’ Charred Wood Treatment? Charred Wood website. http://charredwood.com/history-of-shou-sugi-ban-charred-wood-treatment. Published December 12, 2013. Accessed February 17, 2017.
3. Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J. 2001;190(6):309-316. http://www.nature.com/bdj/journal/v190/n6/abs/4800959a.html. Accessed February 17, 2017.
4. Natural Standard. Activated Charcoal: Bottom Line Monograph. Nat Med J. 2013;5(8). http://www.naturalmedicinejournal.com/journal/2013-08/activated-charcoal-bottom-line-monograph. Accessed February 17, 2017.
5. Nowicki H, Nowicki G. The Basics of Activated Carbon Adsorption. Water Technology Solutions website. http://www.watertechonline.com/the-basics-of-activated-carbon-adsorption. Published February 1, 2016. Accessed February 17, 2017.
6. Lowry J. Use of Activated Charcoal In Pediatric Populations. Presented at: Second Meeting of the Subcommittee of the Expert Committee on the Selection and Use of Essential Medicines; September 29–October 3, 2008; Geneva, Switzerland. http://www.who.int/selection_medicines/committees/subcommittee/2/charcoal_rev.pdf. Accessed February 17, 2017.
7. Natural Cures Using Activated Charcoal. Earth Clinic website. https://www.earthclinic.com/remedies/charcoal.html. Updated November 12, 2016. Accessed February 17, 2017.
8. ADA Center for Evidence-Based Dentistry. American Dental Association website. http://ebd.ada.org/en. Accessed February 17, 2017.
9. Premarket Notification 510(k). Food and Drug Administration website. http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/HowtoMarketYourDevice/PremarketSubmissions/PremarketNotification510k. Accessed February 17, 2017.
10. Landers B. FDA misunderstandings. RDH magazine website. http://www.rdhmag.com/articles/print/volume-32/volume-12/columns/fda-misunderstandings.html. Accessed February 17, 2017.
11. Huang SB, Gao SS, Yu HY. Effect of nano-hydroxyapatite concentration on remineralization of initial enamel lesion in vitro. Biomed Mater. 2009;4(3):034104. https://carifree.com/media/wysiwyg/pdf/EvidenceBasedResearch/Effect_of_nano_hydroxyapatite_concentration_on_remineralization_of_initial_enamel_lesion_in_viro.pdf. Accessed February 17, 2017.
12. Pepla E, Besharat LK, Palaia G, Tenore G, Migliau G. Nano-hydroxyapatite and its applications in preventive, restorative and regenerative dentistry: a review of literature. Ann Stomatol. 2014;5(3):108-114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4252862/. Accessed February 17, 2017.
Patti DiGangi, RDH, BS, is an international speaker and author helping dental professionals to embrace the opportunities and understand the metrics that accurate insurance coding provides. This increases practice profitability while improving the oral-systemic health of the patients we serve. Patti holds publishing and speaking licenses with the American Dental Association (ADA) for Current Dental Terminologyand SNODENT diagnostic coding. She is an ADA Evidence-Based Champion and a member of the National Speaker’s Association. She is the author of the DentalCodeology series of bite-sized books to help dental professionals prepare for the transition toward oral medicine efficiently and profitably. Patti can be reached at [email protected].
Judy Zack Bendit, RDH, BS, was born and raised in a dental office and has more than 40 years of experience in dentistry. She is a speaker, an author, a clinician, a faculty member at the Temple University School of Dentistry, an alumni board member at the University of Pennsylvania Dental School, and an advisory board member for Palm Beach State College's dental hygiene program. She is also a longstanding member of American Dental Hygienists' Association and a Distinguished Academy member of the Pennsylvania Dental Hygienists' Association, and she is a volunteer clinician both at home and abroad.
