Toothpaste, Mouth Rinse, and Floss: How Common Products Compare With ADA Recommendations

The store aisle offers hundreds of products, and the claims on the packages are not all equal. This article compares common over-the-counter oral care products with the recommendations and standards published by the American Dental Association (ADA). It covers toothpaste, mouth rinse, and products for cleaning between the teeth.

The ADA standard

The ADA recommends brushing the teeth twice a day for two minutes with a fluoride toothpaste, and cleaning between the teeth once a day. For children, the amount of toothpaste matters: a smear the size of a grain of rice for children under age 3, and a pea-sized amount for children ages 3 to 6. [1][3]

The ADA also runs the Seal of Acceptance program. A manufacturer submits its product data to the ADA Council on Scientific Affairs. If the data show that the product is safe and does what it claims, the product may carry the Seal. The program is voluntary. A product without the Seal is not automatically a poor product, but a product with the Seal has submitted its evidence for review. One rule is absolute: every toothpaste that carries the ADA Seal for cavity protection contains fluoride. [1][4]

One label habit helps with every product below. Whether a product is regulated as a drug or as a cosmetic depends on its intended use and the claims made for it, not on any single feature of the package. A toothpaste or rinse marketed to prevent cavities, reduce gingivitis, or reduce sensitivity is regulated as a drug. An over-the-counter drug product carries a Drug Facts panel that names the active ingredient. A product sold only to clean the teeth or freshen the breath is a cosmetic. Cosmetics do not require FDA approval before sale, but the manufacturer is responsible for the safety of the product and must have adequate evidence to support that safety. The Drug Facts panel is therefore a useful guide to what a product is claiming. It is not, by itself, proof of FDA approval. The U.S. Food and Drug Administration recognizes three anticavity active ingredients for toothpaste: sodium fluoride, sodium monofluorophosphate, and stannous fluoride. [17]

Toothpaste

Fluoride toothpaste

A Cochrane review of 96 studies supports fluoride toothpaste for preventing cavities. Most standard toothpastes contain around 1,000 to 1,500 ppm fluoride; the appropriate strength depends on age and cavity risk. [5] Most standard adult toothpastes sold in the United States, such as Crest Cavity Protection and Colgate Cavity Protection, contain fluoride in this range and meet the ADA recommendation.

Prescription toothpaste with 5,000 ppm fluoride is a different product. It is used for patients at high risk of decay, such as patients with dry mouth, exposed root surfaces, or repeated new cavities. Current ADA guidance on nonrestorative treatment of decay supports 5,000 ppm fluoride toothpaste or gel as a treatment option for root surface lesions. [20] It is not a substitute for standard toothpaste in a low-risk patient, and it is not sold over the counter.

Stannous fluoride toothpaste

Stannous fluoride is a fluoride source that also acts against bacteria. It is the active ingredient in Crest Pro-Health, Colgate Total, and Parodontax. Systematic reviews report reductions in plaque, gingivitis, calculus, and bad breath compared with standard fluoride toothpaste, and added protection against acid erosion and sensitivity. [15][16] The results are not uniform across studies. Some outcomes rest on studies with a higher risk of bias, part of the research was supported by manufacturers, and part of the calculus effect came from formulas that combine stannous fluoride with other ingredients, so that part of the effect cannot be credited to stannous fluoride alone. [15] The known drawback is that stannous fluoride can cause surface stain on the teeth in some users. The stain is on the surface and is removed at a professional cleaning. [15] For a patient with bleeding gums, a stannous fluoride toothpaste is a reasonable first change. Persistent or unexplained bleeding should be evaluated; changing toothpaste does not replace a periodontal assessment.

Sensitivity toothpaste

Sensitivity toothpastes use one of two approaches. Potassium nitrate calms the nerve response inside the tooth. Stannous fluoride blocks the small openings in exposed dentin. These products take days to weeks of twice-daily use to reach their full effect. Sensitivity that is new, limited to one tooth, or present with biting pain should be examined rather than treated with toothpaste alone, because those patterns can indicate a crack, a failing filling, or decay. [1]

Whitening toothpaste

Most whitening toothpastes work by removing stain from the surface of the tooth, using abrasives and surface-active ingredients. Some also contain peroxide. Removing surface stain is the main effect a toothpaste delivers. A larger change in the internal color of a tooth requires a bleaching product that contains peroxide, used as directed. [19] Abrasiveness is measured as relative dentin abrasivity (RDA). The ADA requires an RDA of 250 or less for a toothpaste to carry the Seal. [19]

Charcoal toothpaste

A literature review published in the Journal of the American Dental Association found insufficient clinical and laboratory evidence to support the safety and effectiveness claims made for charcoal toothpastes. [10] A review in the British Dental Journal found that most charcoal toothpastes contain no fluoride, and that the charcoal can inactivate fluoride in products that do contain it. [11] No charcoal toothpaste carries the ADA Seal. A patient who uses one may be giving up fluoride protection without gaining a demonstrated benefit.

Hydroxyapatite toothpaste

Hydroxyapatite is the mineral that makes up tooth enamel. Toothpastes that contain it, such as Boka, are sold as a fluoride-free option. A systematic review pooled three randomized trials and estimated a protective effect against decay. [12] In an 18-month trial, 89.3 percent of the hydroxyapatite group and 87.4 percent of the fluoride group had no increase in decayed, missing, and filled surfaces, among the 171 participants in the final per-protocol analysis. The trial was designed to test whether hydroxyapatite was worse than fluoride by no more than a set margin of 20 percentage points. Its result shows that hydroxyapatite was not worse by more than that margin. It does not prove that the two are equal. [13] A 2024 systematic review and meta-analysis reached a similar conclusion and noted that the number of long-term trials remains small. [14]

Hydroxyapatite is not one of the anticavity active ingredients recognized by the FDA [17], and no hydroxyapatite toothpaste carries the ADA Seal for cavity protection, because the ADA requires fluoride for that claim. [1] Fluoride toothpaste rests on 96 trials. [5] Hydroxyapatite rests on a small number of trials. Patients who prefer to avoid fluoride should know that this is the current state of the evidence, and that their cavity risk should be watched more closely.

Mouth rinse

The ADA divides mouth rinses into two groups. A cosmetic rinse freshens the breath for a short time and does not treat a condition. A therapeutic rinse contains an active ingredient that helps control a condition, such as cavities, plaque, or gingivitis. [2] The Drug Facts panel is the practical way to tell them apart: a rinse that makes a treatment claim carries one, and a rinse sold only to freshen the breath does not.

Fluoride rinse

Over-the-counter fluoride rinses, such as ACT, contain 0.05 percent sodium fluoride. A Cochrane review of 37 trials found that fluoride rinse use in children and adolescents reduced decayed, missing, and filled permanent tooth surfaces by 27 percent compared with placebo or no rinse. [6] The patients who gain the most are those at higher risk of decay: patients with braces, dry mouth, exposed roots, or repeated new cavities. The ADA advises that children under age 6 should not use a mouth rinse unless a dentist directs it, because young children swallow rinse. [2]

Essential oil rinse

Several essential oil rinses, including Listerine Antiseptic formulas, carry the ADA Seal for helping to reduce plaque and gingivitis. The Seal belongs to an exact product, so a buyer should confirm it on the package of the version being bought. A meta-analysis of 29 studies found that after six months of use, 36.9 percent of essential oil rinse users reached a level of at least 50 percent plaque-free tooth sites, compared with 5.5 percent of control users. [8] A network meta-analysis ranked essential oils and chlorhexidine as the most effective rinse ingredients against plaque and gingivitis. [9] The original formulas contain alcohol. Alcohol-free versions exist for patients with dry mouth.

Cetylpyridinium chloride rinse

Cetylpyridinium chloride (CPC) is the active ingredient in rinses such as Crest Pro-Health. It reduces plaque and gingivitis, with a smaller measured effect than essential oils in the network analysis. [9] Many CPC rinses are alcohol-free.

Chlorhexidine rinse

Chlorhexidine rinse is available by prescription only in the United States. It is used for limited periods, for example after periodontal treatment or during treatment of significant gum inflammation. Its known effects with extended use are tooth and tongue staining, altered taste, and increased calculus formation. It is not a long-term home product. [2]

No rinse replaces brushing and cleaning between the teeth. Rinses reach surfaces that a brush and floss have already cleaned, and their measured effects are in addition to mechanical cleaning, not instead of it. [2]

Cleaning between the teeth

The Cochrane review of interdental cleaning found that using floss in addition to toothbrushing may reduce gingivitis compared with toothbrushing alone. The certainty of the evidence was low. The effect on plaque was inconsistent across studies. No trial in the review measured cavities between the teeth as an outcome. [7] Interdental brushes performed at least as well as floss, and better on plaque scores at one and three months in the trials that compared them. A European consensus report on the prevention of periodontitis names interdental brushes as the first choice for cleaning between the teeth where the brush fits the space. [21] The Waterpik water flosser was the first powered interdental cleaner to earn the ADA Seal of Acceptance, in 2017. [18]

The practical reading of this evidence is direct. Where an interdental brush fits, it is the best-supported tool. Where the contact is tight, floss is the tool that fits. Floss picks are acceptable if a patient uses them daily and would not use string floss at all. The best tool is the one that fits the space and gets used.

Patients sometimes ask whether cleaning between the teeth twice a day is better than once a day. The ADA advises once a day, and states that the time of day can be whichever time fits the patient’s routine. No trial in the Cochrane review compared twice-daily cleaning with once-daily cleaning, so this review does not establish whether twice-daily cleaning provides additional benefit. [3][7] The defensible advice is to clean thoroughly between the teeth once a day. Individual needs may differ, for example for patients with braces or places where food collects, and those patients should ask at their visit.

Summary

Product type	Common examples	Active ingredient	Guidance and evidence	Main limit
Standard fluoride toothpaste	Crest Cavity Protection, Colgate Cavity Protection	Sodium fluoride or sodium monofluorophosphate	Meets the ADA recommendation; look for the Seal	Use twice daily as recommended
Stannous fluoride toothpaste	Crest Pro-Health, Colgate Total, Parodontax	Stannous fluoride	Several formulas carry the Seal; added plaque and gingivitis benefit in reviews [15]	Can cause surface stain
Sensitivity toothpaste	Sensodyne, Colgate Sensitive	Potassium nitrate or stannous fluoride	Seal available for sensitivity claims	Takes days to weeks to reach full effect
Whitening toothpaste	Colgate Optic White, Crest 3D White	Fluoride plus abrasives, some with peroxide	Seal requires RDA of 250 or less	Main effect is surface stain removal; confirm it contains fluoride
Charcoal toothpaste	Various	Charcoal	No Seal; evidence insufficient for its claims [10]	Most contain no fluoride [11]
Hydroxyapatite toothpaste	Boka	Hydroxyapatite	No Seal; not an FDA-recognized anticavity ingredient	Small number of trials [12][14]
Fluoride rinse	ACT Anticavity	Sodium fluoride 0.05 percent	Anticavity claim; several ACT formulas carry the Seal, confirm the exact product	Not for children under 6 unless directed [2]
Essential oil rinse	Listerine Antiseptic	Essential oils	Antiseptic formulas in this line carry the Seal for plaque and gingivitis; confirm the exact product	Contains alcohol in the original formula; alcohol-free versions exist
CPC rinse	Crest Pro-Health rinse	Cetylpyridinium chloride	Therapeutic rinse for plaque and gingivitis	Smaller measured effect than essential oils [9]
Chlorhexidine rinse	Peridex, Periogard	Chlorhexidine 0.12 percent	Prescription only; used for limited periods	Staining, altered taste, increased calculus
Interdental brush	TePe, GUM Soft-Picks	None	First choice where it fits [21]	Does not fit tight contacts
Water flosser	Waterpik	None	First powered interdental cleaner to earn the Seal [18]	Cost; requires counter space and power

Look past the front label: check the active ingredients, intended use, and directions. For most people, that means a fluoride toothpaste used twice a day, a tool for cleaning between the teeth used once a day, and a rinse only when there is a reason for one, such as high cavity risk or gum inflammation that persists after brushing and interdental cleaning are correct.

Evidence matters. Individual assessment matters. If you want help choosing products for your mouth, bring what you are using to your next visit, and let’s talk.

References

1. American Dental Association. Toothpastes. Oral Health Topics. ADA
2. American Dental Association. Mouthrinse (Mouthwash). Oral Health Topics. ADA
3. American Dental Association. Floss and Other Interdental Cleaners. Oral Health Topics. ada.org. See also MouthHealthy, Flossing. MouthHealthy
4. American Dental Association. ADA Seal of Acceptance. ADA
5. Walsh T, Worthington HV, Glenny AM, Marinho VCC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database of Systematic Reviews. 2019;3:CD007868. Cochrane
6. Marinho VCC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinse for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2016;7:CD002284. DOI
7. Worthington HV, MacDonald L, Poklepovic Pericic T, et al. Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews. 2019;4:CD012018. Cochrane
8. Araujo MWB, Charles CA, Weinstein RB, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. Journal of the American Dental Association. 2015;146(8):610-622. DOI
9. Figuero E, Herrera D, Tobias A, et al. Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and network meta-analysis. Journal of Clinical Periodontology. 2019;46(7):723-739. PubMed
10. Brooks JK, Bashirelahi N, Reynolds MA. Charcoal and charcoal-based dentifrices: a literature review. Journal of the American Dental Association. 2017;148(9):661-670. DOI
11. Greenwall LH, Greenwall-Cohen J, Wilson NHF. Charcoal-containing dentifrices. British Dental Journal. 2019;226:697-700. PubMed
12. Limeback H, Enax J, Meyer F. Biomimetic hydroxyapatite and caries prevention. Canadian Journal of Dental Hygiene. 2021;55(3):148-159. PubMed
13. Paszynska E, Pawinska M, Enax J, et al. Caries-preventing effect of a hydroxyapatite-toothpaste in adults: an 18-month double-blinded randomized clinical trial. Frontiers in Public Health. 2023;11:1199728. PubMed Central
14. Pawinska M, Paszynska E, Amaechi BT, et al. Clinical evidence of caries prevention by hydroxyapatite: an updated systematic review and meta-analysis. Journal of Dentistry. 2024;151:105429. DOI
15. Johannsen A, Emilson CG, Johannsen G, et al. Effects of stabilized stannous fluoride dentifrice on dental calculus, dental plaque, gingivitis, halitosis and stain: a systematic review. Heliyon. 2019;5:e02850. PubMed Central
16. Nicholson JW. Stannous fluoride in toothpastes: a review of its clinical effects and likely mechanisms of action. Journal of Functional Biomaterials. 2025;16(3):73. PubMed
17. U.S. Food and Drug Administration. Anticaries drug products for over-the-counter human use. 21 CFR Part 355. See also U.S. Food and Drug Administration. Is It a Cosmetic, a Drug, or Both? FDA
18. American Dental Association. Waterpik Water Flosser first in its class to earn ADA Seal. ADA News. February 20, 2017. ADA News
19. American Dental Association. Whitening. Oral Health Topics. ADA
20. Slayton RL, Urquhart O, Araujo MWB, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions. Journal of the American Dental Association. 2018;149(10):837-849. PubMed
21. Chapple ILC, Van der Weijden F, Doerfer C, et al. Primary prevention of periodontitis: managing gingivitis. Journal of Clinical Periodontology. 2015;42(Suppl 16):S71-S76. PubMed