Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride

Effect of 10% fluoride on the remineralization of dentin in situ

Objective The purpose of this randomized, cross-over, in situ study was to determine the remineralization of demineralized dentin specimens after the application of a 10% fluoride (F-) or a 1% chlorhexidine-1% thymol (CHX-thymol) varnish. Material and Methods Twelve individuals without current caries activity wore removable appliances in the lower jaw for a period of four weeks. Each appliance contained four human demineralized dentin specimens fixed on the buccal aspects. The dentin specimens were obtained from the cervical regions of extracted human third molars. After demineralization, half the surface of each specimen was covered with a nail varnish to serve as the reference surface. The dentin specimens were randomly assigned to one of the three groups: F-, CHX-thymol, and control (no treatment). Before the first treatment period and between the others, there were washout periods of one week. After each treatment phase, the changes in mineral content (vol% µm) and the lesion depths (µm) of the dentin slabs were determined by transverse microradiography (TMR). Data analysis was accomplished by the Kruskal-Wallis test and the Mann-Whitney U test (p<0.05). Results The medians (25th/75th percentile) of integrated mineral loss were 312.70 (203.0-628.7) for chlorhexidine varnish, 309.5 (109.8-665.8) for fluoride varnish, and -346.9 (-128.7 - -596.0) for the control group. The medians (25th/75th percentile) of lesion depth were 13.6 (5.7-34.5) for chlorhexidine varnish, 16.5 (5.6-38.1) for fluoride varnish, and -14.2 (-4.5- -32.9) for the control group. Use of the 10% F- or 1% CHX-1% thymol varnishes resulted in significantly decreased mineral loss and lesion depth in dentin when compared with the control group. There were no statistically significant differences among the test groups. Conclusions Within the limitations of this study, the results suggest that the effect of the treatment of demineralized dentin with 10% F- or 1% CHX-1% thymol is better than without any treatment.

Validation of a Cariogenic Biofilm Model to Evaluate the Effect of Fluoride on Enamel and Root Dentine Demineralization

Due to gingival recession both enamel and root dentine are at risk of developing caries. Both tissues are exposed to a similar environment, however there is not a validated model to evaluate the effect of fluoride on these dental substrates simultaneously. Hence, this study aimed to validate a caries model to evaluate the effect of fluoride to prevent demineralization on enamel and root-dentine. Streptococcus mutans UA159 biofilms were formed on saliva-coated bovine enamel and root dentine slabs (n = 12 per group) mounted in the same well of culture plates. The biofilms were exposed 8×/day to 10% sucrose and treated 2×/day with fluoridated solutions containing 0, 150, 450, or 1,350 ppm F; thus, simulating the use of low to high fluoride concentration toothpastes. The pH values of the culture medium was monitored 2×/day as a biofilm acidogenicity indicator. After 96 h, biofilms were collected for fluoride concentration analysis. The percentage of surface hardness loss (%SHL) was calculated for slabs. The fluoride uptake by the enamel and dentine was also determined. The model showed a dose-response because the biofilm and fluoride uptake increased and %SHL decreased at increasing fluoride concentrations (p < 0.05). Fluoride in the biofilm formed on dentine and fluoride uptake by dentine were higher than those for enamel. With the same fluoride concentration treatment, the percentage of reduction of demineralization was lower for dentine than for enamel. In conclusion, the model was validated in terms of a dose-response effect of fluoride on enamel and root dentine. Furthermore, the findings support the clinical data, suggesting that higher fluoride concentrations are necessary to control caries of root dentine than of enamel.

Delivering the evidence--skill mix and education for elder care

OBJECTIVES

To review the current status of dental curricula on elder care, and the current curricula regarding elder care, and it's effect on altering practitioner behaviors while addressing the needs of a growing North American elder population.

BACKGROUND

An impending crisis is looming over the oral healthcare of our aging population. At the same moment that life expectancy is being extended through increasingly complex healthcare improvements, the numbers of trained dental providers capable and interested in delivering the needed care is failing to grow at an adequate rate.

DISCUSSION

The skills necessary to manage these increasingly complex patients require an interprofessional approach capable of delivering care to sicker patients, in a variety of living accommodations, while managing a variety of care givers. The dental skills necessary to treat these elderly are modifications of skills students routinely learn in dental school. As a matter of fact, the skills students acquire to treat an adult patient population may be contrary to the basic skills necessary to manage the elderly dependent adult patient. Teaching students the nuance differences needed to properly diagnose and care for this population is a difficult task that must be taught in a contextual environment.

CONCLUSION

Significant changes in the teaching of dental management of the elderly are critical within much of the education community. Just as teaching students to care for the pediatric population as general dentists, the clinical education must involve a sufficient number of quality experiences to address issues of both competency, that of the graduate to perform care independently, and attitudes, the actually willingness to treat the elderly.

Developing pathways for oral care in elders: evidence-based interventions for dental caries prevention in dentate elders

BACKGROUND

Dental caries is becoming an ever-growing challenge as the number of elders maintaining their teeth increases. There is a need for low-cost, effective preventive interventions to retain natural teeth for elders.

OBJECTIVE

The purpose of this article is to evaluate evidence based interventions for dentate elders, specifically the adjunct therapies of fluoride, chlorhexidine, xylitol, casein phosphopeptide-amorphous calcium phosphate, ozone, and herbal liquorice.

RESULTS

Fluoride interventions have demonstrated prevention and remineralization of dental caries in elders. Systematic reviews of the literature are unable to establish definitive conclusions regarding the effectiveness of other adjunct therapies in dental caries prevention.

CONCLUSIONS

Further research with elders requires improved study design with well designed multi-center trials. Considerations for new strategies for research of the effectiveness of therapies to reduce dental caries include the development and evaluation of combinations of therapeutic interventions and dental caries management by risk assessment.

Non-surgical treatment of dentin caries in preschool children--systematic review

Background

Untreated dentin caries in primary teeth is commonly found in preschool children worldwide. Recently, the use of simple non-surgical approaches to manage the situation has been advocated.

The aim of the study was to systematically review and evaluate the literature on effectiveness of non-surgical methods in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children.

Methods

A systematic search of the main electronic databases (Pubmed, Cochrane Collaboration, EMBASE) was conducted to identify peer reviewed papers published in English in the years 1947–2014. Keywords and MeSH terms used in the search were “dental caries”, “primary dentition” and various non-surgical treatments (fluoride, sealant, resin infiltration, xylitol, chlorhexidine, CPP-ACP, ozone, etc.). The inclusion criteria were clinical studies conducted in children under 6 years old, and reported findings on caries arrest or caries progression in primary teeth. Retrieved papers were read by two reviewers independently to assess suitability for inclusion, and the final decision was made by consensus. Quality of the included studies was assessed and data were extracted for analysis.

Results

The search identified 323 papers for screening. Among these, 290 papers did not satisfy the study inclusion criteria. Consequently, 33 full papers were retrieved and reviewed. Finally, 4 studies were included. Three studies reported that topical applications of silver diammine fluoride (SDF) solution could arrest dentin caries in preschool children. One study supported that having a daily toothbrushing exercise in kindergarten using toothpaste with 1000 ppm fluoride could stabilize the caries situation in young children.

Conclusions

There is limited evidence to support the effectiveness of SDF applications or daily toothbrushing with fluoride toothpaste in arresting or slowing down the progression of active dentin caries in primary teeth in preschool children. More well-designed randomized controlled trials are required to confirm these findings.

Salivary fluoride levels after use of high-fluoride dentifrice

The aim of the study was to evaluate salivary fluoride (F) availability after toothbrushing with a high-F dentifrice. Twelve adult volunteers took part in this crossover and blind study. F concentration in saliva was determined after brushing with a high-F dentifrice (5000 µg F/g) or with a conventional F concentration dentifrice (1100 µg F/g) followed by a 15 mL distilled water rinse. Samples of nonstimulated saliva were collected on the following times: before (baseline), and immediately after spit (time = 0) and after 1, 2, 3, 4, 5, 10, 15, 20, 30, 45, 60, 90, and 120 min. F analysis was performed with a fluoride-sensitive electrode and the area under curve of F salivary concentration × time (µg F/mL × min⁻¹) was calculated. At baseline, no significant difference was found among dentifrices (P > 0.05). After brushing, both dentifrices caused an elevated fluoride level in saliva; however salivary F concentration was significantly higher at all times, when high-F dentifrice was used (P < 0.01). Even after 120 min, salivary F concentration was still higher than the baseline values for both dentifrices (P < 0.001). High-F dentifrice enhanced the bioavailability of salivary F, being an option for caries management in patients with high caries risk.

Intraoral fluoride levels after use of conventional and high-fluoride dentifrices

OBJECTIVES

This study aimed to evaluate saliva and plaque as indicators of intraoral fluoride (F) levels after the use of conventional and high-fluoride dentifrices.

MATERIALS AND METHODS

Subjects were randomly assigned to brush their teeth with conventional (1000 ppm F), high-fluoride (5000 ppm F), and placebo dentifrices (fluoride free) for 10 days, following a double-blind, crossover protocol. Saliva and plaque samples were collected on the morning of the 5(th) and 10th days, respectively at 1 and 12 h after brushing, and analyzed with an ion-selective electrode after HMDS-facilitated diffusion. Data were analyzed by two-way repeated measures ANOVA, Tukey's test and Spearman's correlation coefficient (p < 0.05).

RESULTS

Plaque and salivary F levels were significantly increased after the use of conventional and high-fluoride dentifrices when compared to values obtained for placebo, except plaque 12 h after the use of conventional dentifrice. A positive and significant correlation was found between fluoride concentrations in plaque and saliva for both times of sample collection.

CONCLUSION

Both indicators assessed were able to detect significant differences among treatments and between times after brushing. The use of a high-fluoride dentifrice is able to significantly increase intraoral fluoride levels throughout the day, being therefore a useful therapy for patients at high caries risk.

CLINICAL RELEVANCE

A dentifrice with high fluoride concentration could be regarded as a useful therapy of F delivery for high caries-risk patients, since intraoral F levels were sustained throughout most of the day after using this formulation.

Systematic review on noninvasive treatment of root caries lesions

The present systematic review critically summarizes results of clinical studies investigating chemical agents to reduce initiation or inactivation of root caries lesions (RCLs). Outcomes were DMFRS/DFRS (decayed, missing, filled root surfaces), surface texture (hard/soft), and/or RCI (root caries index). Three electronic databases were screened for studies from 1947 to 2014. Cross-referencing was used to further identify articles. Article selection and data abstraction were done in duplicate. Languages were restricted to English and German. Mean differences (MD) were calculated for changes in DMFRS/DFRS. Risk ratios (RR) were calculated for changes in surface texture and RCI in a random effects model. Thirty-four articles with 1 or more agents were included; they reported 30 studies with 10,136 patients who were 20 to 101 y old; and they analyzed 28 chemical agents (alone or in combination). Eleven studies investigated dentifrices, 10 rinses, 8 varnishes, 3 solutions, 3 gels, and 2 ozone applications. Meta-analyses revealed that dentifrices containing 5,000 ppm F(-) (RR = 0.49; 95% confidence interval [95% CI] = 0.42, 0.57; high level of evidence) or 1.5% arginine plus 1,450 ppm F(-) (RR = 0.79; 95% CI = 0.64, 0.98; very low level) are more effective in inactivating RCLs than dentifrices containing 1,100 to 1,450 ppm F(-). Self-applied AmF/SnF2-containing dentifrice and rinse decreased the initiation of RCLs when compared with NaF products (standardized MD = 0.15; 95% CI = -0.22, 0.52; low level). Patients rinsing with a mouth rinse containing 225 to 900 ppm F(-) revealed a significantly reduced DMFRS/DFRS (MD = -0.18; 95% CI = -0.35, -0.01; low level) when compared with a placebo rinse. Significantly reduced RCI was found for CHX (MD = -0.67; 95% CI = -1.01, -0.32; very low level) as well as SDF (MD = -0.33; 95% CI = -0.39, -0.28; very low level) when compared with placebo varnish. Regular use of dentifrices containing 5,000 ppm F(-) and quarterly professionally applied CHX or SDF varnishes seem to be efficacious to decrease progression and initiation of root caries, respectively. However, this conclusion is based on only very few well-conducted randomized controlled trials.

The effect of a bioglass paste on enamel exposed to erosive challenge

OBJECTIVES

The current study is evaluating the effect of using a 45S5 bioglass paste and topical fluoride application on the cross sectional micro-hardness and the chemical surface changes of eroded enamel.

METHODS

Enamel discs were obtained from the buccal surface of one hundred extracted human non-carious third molars. The enamel surfaces were ground flat and each disc was coated with two layers of acid resistant nail varnish except for an exposed treatment window (3mm×2mm) on the buccal surface of the tooth. All specimens were challenged for 60 min by orange juice (Tropicana, Chicago, USA) pH 3.85+0.5. The specimens were divided into four groups: the 45S5 bioglass paste group, fluoride gel group (5 min application), fluoride gel group (24h application) while the rest of specimens served as control. The cross-sectional micro-hardness of 20 specimens from each group was measured. Five specimens from each group had their top eroded enamel surfaces examined by SEM-EDS. One-way ANOVA was used to compare the cross-sectional micro-hardness of the three groups p<0.05.

RESULTS

45S5 bioglass paste application significantly improved the sub-surface eroded enamel when compared to fluoride and control specimens (p<0.05).

CONCLUSION

45S5 bioglass paste can efficiently improve the micro-hardness of the sub-surface eroded enamel surface.

CLINICAL SIGNIFICANCE

The use of the 45S5 Bioglass paste can be used efficiently as a potent remineralizing agent for the sub-surface enamel lesions resulting from erosive challenges.

Saliva substitutes in combination with high-fluoride gel on dentin remineralization

OBJECTIVE

This study aimed to determine whether the application of a high-fluoride gel could increase the remineralization of subsurface dentin lesions stored in saliva substitutes.

MATERIALS AND METHODS

Demineralized bovine dentin specimens were stored in mineral water (W), Glandosane (G), or modified Saliva natura (SN). Different treatments were applied twice daily: no treatment, Elmex sensitive mouth rinse (E), ProSchmelz gel (P), Duraphat toothpaste (D), ED, PD, and EPD. Differences in mineral loss were evaluated by transversal microradiography after 2 and 5 weeks.

RESULTS

The treatments with E, D, and ED inhibited the mineral loss induced by G and enabled some mineral gain. ProSchmelz was not able to inhibit the demineralizing effect of G. This high-fluoride gel induced an erosive mineral loss in combination with G. The use of ProSchmelz in combination or not with other fluoride products did not increase remineralization of specimens stored in SN or W (p > 0.05). ProSchmelz resulted in an erosion of the specimens stored in W and revealed a lower mineralized surface layer of specimens stored in SN.

CONCLUSION

Topical application of high-fluoride gel reduced the mineral loss induced by G but resulted in an erosion of specimens' surface. In addition, ProSchmelz did not demonstrate beneficial effects in combination with SN on subsurface dentin lesion remineralization.

CLINICAL RELEVANCE

Within the limitations of an in vitro study, it was concluded that the application of a high-fluoride gel did not promote additional effects on remineralization of subsurface dentin lesions in combination with saliva substitutes when compared to products with lower fluoride concentration.

Effects of various toothpastes on remineralization of white spot lesions

Objective

The purpose of this in vitro study was to examine the effects of fluoridated, casein phosphopeptide.amorphous calcium phosphate complex (CPP-ACP)-containing, and functionalized β-tricalcium phosphate (fTCP)-containing toothpastes on remineralization of white spot lesions (WSLs) by using Quantitative light-induced fluorescence (QLF-D) Biluminator™ 2.

Methods

Forty-eight premolars, extracted for orthodontic reasons from 12 patients, with artificially induced WSLs were randomly and equally assigned to four treatment groups: fluoride (1,000 ppm), CPP-ACP, fTCP (with sodium fluoride), and control (deionized water) groups. Specimens were treated twice daily for 2 weeks and stored in saliva solution (1:1 mixture of artificial and human stimulated saliva) otherwise. QLF-D Biluminator™ 2 was used to measure changes in fluorescence, indicating alterations in the mineral contents of the WSLs, immediately before and after the 2 weeks of treatment.

Results

Fluorescence greatly increased in the fTCP and CPP-ACP groups compared with the fluoride and control groups, which did not show significant differences.

Conclusions

fTCP- and CPP-ACP-containing toothpastes seem to be more effective in reducing WSLs than 1,000-ppm fluoride-containing toothpastes.

Caries-risk profile variations after short-term use of 5000 ppm fluoride toothpaste

OBJECTIVE

To assess the caries risk following 6 weeks' use of 5000 ppm F toothpaste using 'Cariogram' software.

MATERIALS AND METHODS

A total of 34 participants, 17 mothers and their teenage children, were enrolled in a 6-week clinical trial in which they were given 5000 ppm F toothpaste. They were followed consecutively for 6 weeks with visits that were 2 weeks apart (four in total). A clinical examination was done at baseline and salivary chair-side tests to record the buffer capacity and mutans streptococci (MS) and lactobacilli (LB) counts were performed at each visit. Based on these data, seven caries-related variables were collected and inserted into the Cariogram software to calculate the actual chance of avoiding caries.

RESULTS

The use of 5000 ppm F toothpaste resulted in a statistically significant modification of the caries-risk profile, increasing the actual chance of avoiding caries in the future among the mothers and teenagers at each visit following baseline (p < 0.01). The changes essentially related to the salivary parameters (buffer capacity, MS and LB counts). A statistically significant linear trend was observed for MS counts (p < 0.01) and the number of subjects with a salivary concentration of MS < 10(3) increased at each visit. The same trend was also observed for LB and buffer capacity scores (p = 0.04 and p = 0.03, respectively).

CONCLUSIONS

The short-term use of 5000 ppm F toothpaste is able to reduce the caries risk, which can be clearly demonstrated using 'Cariogram' software.

High-fluoride toothpaste: a multicenter randomized controlled trial in adults

Objective

The aim of this single – blind, multicenter, parallel, randomized controlled trial was to evaluate the effectiveness of the application of a high-fluoride toothpaste on root caries in adults.

Methods

Adult patients (n = 130, ♂ = 74, ♀ = 56; mean age ± SD: 56.9 ± 12.9) from three participating centers, diagnosed with root caries, were randomly allocated into two groups: Test (n = 64, ♂ = 37, ♀ = 27; lesions = 144; mean age: 59.0 ± 12.1; intervention: high-fluoride toothpaste with 5000 ppm F), and Control (n = 66, ♂ = 37, ♀ = 29; lesions = 160; mean age: 54.8 ± 13.5; intervention: regular-fluoride toothpaste with 1350 ppm F) groups. Clinical examinations and surface hardness scoring of the carious lesions were performed for each subject at specified time intervals (T₀ – at baseline before intervention, T₁ – at 3 months and T₂ – at 6 months after intervention). Mean surface hardness scores (HS) were calculated for each patient. Statistical analyses comprised of two-way analysis of variance and post hoc comparisons using the Bonferroni–Dunn correction.

Results

At T₀, there was no statistical difference between the two groups with regard to gender (P = 0.0682, unpaired t-test), or age (P = 0.9786, chi-squared test), and for the overall HS (Test group: HS = 3.4 ± 0.61; Control group: HS = 3.4 ± 0.66; P = 0.8757, unpaired t-test). The anova revealed significantly better HS for the test group than for the control groups (T₁: Test group: HS = 2.9 ± 0.67; Control group: HS = 3.1 ± 0.75; T₂: Test group: HS = 2.4 ± 0.81; Control group: HS = 2.8 ± 0.79; P < 0.0001). However, the interaction term time-point*group was not significant.

Conclusions

The application of a high-fluoride containing dentifrice (5000 ppm F) in adults, twice daily, significantly improves the surface hardness of otherwise untreated root caries lesions when compared with the use of regular fluoride containing (1350 ppm F) toothpastes.

Root caries: a periodontal perspective

BACKGROUND AND OBJECTIVE

A prevailing dental problem in the periodontal patient is root caries. Specifically, periodontal involvement often results in root surfaces becoming exposed and at risk for this condition. Periodontal therapy often leads to increased gingival recession as well, and the associated increased root caries risk may compromise the long-term success and survival of periodontally treated teeth.This narrative review will address the topic of root caries in the periodontal patient, focusing on unmet research needs.

MATERIAL AND METHODS

The Medline database was searched to identify items dealing with root caries, in terms of clinical features, diagnosis, pathogenic mechanisms and histopathology, as well as epidemiology, focusing then on the relationship between root caries and periodontal disorders.

RESULTS

Although there is extensive literature on root caries, consensus is lacking regarding certain aspects, such as diagnostic criteria, prevalence within populations and indisputable risk factors. Advancing age could be an aggravating factor in susceptibility to root caries for the periodontal patient; however, definitive evidence in this regard is still missing. Similarly, full awareness of the increased risk of root caries in patients with periodontal disease or long-term periodontal treatment appears to be still lacking.

CONCLUSION

Research regarding root caries in age-specific (elderly) periodontal patients is needed. Improved oral hygiene practices, locally applied preventive measures, good dietary habits and regular dental check-ups are crucial approaches to prevent both periodontal disease progression and root caries. Periodontal patients with root exposure should follow a strict root caries prevention protocol, as an integral component of their periodontal maintenance therapy.

A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents

Root caries is prevalent in elderly disabled nursing home residents in Denmark. This study aimed to compare the effectiveness of tooth brushing with 5,000 versus 1,450 ppm of fluoridated toothpaste (F-toothpaste) for controlling root caries in nursing home residents. The duration of the study was 8 months. Elderly disabled residents (n = 176) in 6 nursing homes in the Copenhagen area consented to take part in the study. They were randomly assigned to use one of the two toothpastes. Both groups had their teeth brushed twice a day by the nursing staff. A total of 125 residents completed the study. Baseline and follow-up clinical examinations were performed by one calibrated examiner. Texture, contour, location and colour of root caries lesions were used to evaluate lesion activity. No differences (p values >0.16) were noted in the baseline examination with regards to age, mouth dryness, wearing of partial or full dentures in one of the jaws, occurrence of plaque and active (2.61 vs. 2.67; SD, 1.7 vs.1.8) or arrested lesions (0.62 vs. 0.63; SD, 1.7 vs. 1.7) between the 5,000 and the 1,450 ppm fluoride groups, respectively. Mean numbers of active root caries lesions at the follow-up examination were 1.05 (2.76) versus 2.55 (1.91) and mean numbers of arrested caries lesions were 2.13 (1.68) versus 0.61 (1.76) in the 5,000 and the 1,450 ppm fluoride groups, respectively (p < 0.001). To conclude, 5,000 ppm F-toothpaste is significantly more effective for controlling root caries lesion progression and promoting remineralization compared to 1,450 ppm F-toothpaste.

Cariotester, a new device for assessment of dentin lesion remineralization in vitro

This study aimed to evaluate the potential of a new device (Cariotester) for monitoring of incipient carious lesion remineralization in root dentin by topical fluoride in vitro. Demineralized bovine dentin specimens were treated by fluoride solutions (APF or neutral NaF) and remineralized for 4 weeks. Cariotester was used to measure penetration depth (CTR depth) of the indenter into the de- and remineralized specimen surface. The specimens were assessed by transverse microradiography (TMR) to determine lesion parameters (depth: LD, mineral loss: ΔZ). Pearson's correlation analysis showed an overall significant relationship between CTR depth and both TMR parameters. CTR depth appeared to distinguish the positive effect that topical fluoride application had on the remineralization of the outer zone of dentin lesions. Cariotester had the potential to serve as a quantitative tool for monitoring of incipient carious lesion remineralization in root dentin.

The role of fluoride in the preventive management of dentin hypersensitivity and root caries

Objective

The objectives were to bring light on fluoride to control dentin hypersensitivity (DHS) and prevent root caries.

Materials and methods

Search strategy included papers mainly published in PubMed, Medline from October 2000 to October 2011.

Results

Fluoride toothpaste shows a fair effect on sensitive teeth when combined with dentin fluid-obstructing agents such as different metal ions, potassium, and oxalates. Fluoride in solution, gel, and varnish give an instant and long-term relief of dentin and bleaching hypersensitivity. Combined with laser technology, a limited additional positive effect is achieved. Prevention of root caries is favored by toothpaste with 5,000 ppm F and by fluoride rinsing with 0.025–0.1 % F solutions, as the application of fluoride gel or fluoride varnish three to four times a year. Fluoride measures with tablets, chewing gum, toothpick, and flossing may be questioned because of unfavorable cost effectiveness ratio.

Conclusion

Most fluoride preparations in combination with dentin fluid obstruction agents are beneficial to reduce DHS. Prevention of root caries is favorable with higher fluoride concentrations in, e.g., toothpaste.

Clinical relevance

Fluoride is an effective agent to control DHS and to prevent root caries particularly when used in higher concentrations.

Prevention of root caries: a literature review of primary and secondary preventive agents

PURPOSE

This literature review summarizes the effectiveness of the seven leading root caries preventive agents and provides recommendations for use of those agents in clinical practice with older adults and vulnerable elderly.

METHOD

Studies were eligible if they assessed the effectiveness of either fluoride, chlorhexidine, xylitol, amorphous calcium phosphate, sealants, saliva stimulators, or silver diamine fluoride to prevent/control root caries in an English language articles between 1979 and 2010.

RESULTS

In the 31 eligible studies, the most effective primary (1°) prevention agents had reductions in RC incidence ranging from 72% to nearly 200% as compared to a placebo while for secondary (2°) prevention, the best agents demonstrated arrest rates between 67 and 80%.

CONCLUSION

For 1° prevention of root caries the recommended "best choice" is a 38% Silver Diamine Fluoride solution professionally applied annually, while for the 2° prevention of root caries, the recommended "best choice" is a 22,500 ppm Sodium Fluoride varnish professionally applied every 3 months.

Cheek bumper prosthesis for a patient with a neurofibromatous lesion in the left cheek

Neurofibromatous lesions of the oral cavity affect the chewing cycle by interposition of cheek mucosa during contact of opposing teeth. In this report, an intraoral prosthesis was fabricated to restore and improve oral function and reduce the incidence of cheek biting on the neurofibromatous lesion. The prosthesis successfully reduced the incidence of cheek biting and improved the patient's oral competency. This report describes the procedure for making an intraoral cheek bumper prosthesis to improve patient oral function.

Caries Clinical Trial Methods for the Assessment of Oral Care Products in the 21st Century

Traditionally, caries clinical trials of oral care products have focused on the prevention of caries in children and adolescents at the “cavitation” level. Because of a general reduction in caries incidence and the use of positive control comparators, studies have grown both in size and duration to improve statistical power. Currently, they tend to be of 2 to 3 years’ duration, with up to 2,000 high-risk individuals per group. During the past decade, there has been a shift in emphasis from a restorative approach to the treatment of dental caries to a therapeutic approach focused on the remineralization of early caries lesions. However, caries clinical trials of oral care products have not often reflected this paradigm change. This manuscript reviews alternative caries clinical trial methods for oral care products. It is concluded that methods focused on the detection and monitoring of enamel caries and root caries, by visual approaches such as ICDAS and instrumental methods such as QLF, Diagnodent, and Electrical Caries Monitors, provide viable alternatives to traditional methods. In particular, such approaches more accurately reflect the modes of action of many therapeutic agents and formulations and may reduce the cost and duration of product innovation.

Effective Use of Self-care Fluoride Administration in Asia

The caries-preventive benefits of fluoride are generally accepted by dental researchers and practicing professionals worldwide. The benefits of fluoride toothpastes and mouthrinses have been supported by several high-quality systematic reviews. The formulation of a fluoride toothpaste and biological (salivary flow rate) and behavioral factors (brushing frequency, brushing time, post-brushing rinsing practices, timing of brushing, and amount of toothpaste applied) can influence anticaries efficacy. Fluoride mouthrinses have simpler formulations and can have better oral fluoride retention profiles than fluoride toothpastes, depending on post-brushing rinsing behaviors. Fluoride continues to be the mainstay of caries control; however, there is still the need to determine the most effective approach for fluoride utilization in children and adults who remain caries-active.

Implications of oral biofilms in medically at risk persons

There is the need to understand the composition of oral biofilms so that appropriate preventive and treatment regimens, including using appropriate antimicrobials, can be developed further. Additionally, when the systemic effects from specific microorganisms in oral biofilms are better understood, more targeted preventive treatment options may be recommended for persons at high risk for potential systemic diseases such as cardiovascular disease, and for aspiration pneumonia. Hence, the possible association between periodontopathic microorganisms, and also between cariogenic microorganisms in high caries risk persons, and systemic diseases requires further research involving metagenomic and large well-designed clinical studies. Effective preventive oral care is important for reducing potential systemic diseases.

Reversal of primary root caries lesions after daily intake of milk supplemented with fluoride and probiotic lactobacilli in older adults

OBJECTIVE

To evaluate the effect of milk supplemented with fluoride and/or probiotic bacteria on primary root caries lesions (PRCL) in older adults.

MATERIALS AND METHODS

After informed consent, 160 healthy subjects, 58-84 years of age, with at least two PRCL were recruited and randomly assigned to one of four parallel study groups drinking 200 ml milk once daily for 15 months. Group A consumed standard milk (placebo); Group B ingested milk supplemented with 5 ppm F and probiotic bacteria (Lactobacillus rhamnosus LB21, 10(7) CFU/mL); Group C drank milk with only probiotic bacteria and group D milk contained only fluoride. Primary endpoints were Root Caries Index (RCI) and electric resistance measurements (ECM) carried out by one blinded single examiner. Secondary endpoints were mutans streptococci and lactobacilli counts in saliva and plaque estimated with chair-side tests. Data were compared within and between groups with non-parametric tests.

RESULTS

The drop out rate was 38%. At baseline there were no statistical differences between the groups. Significantly higher numbers of RCI reversals were found in groups B, C and D compared with group A (p < 0.05). The mean ECM values increased significantly (p < 0.05) in all groups except for the placebo group A, indicating that remineralization occurred. The effect was most beneficial in the two groups that contained fluoride. No significant alterations were displayed regarding the microbial counts. No severe adverse effects were reported during intervention.

CONCLUSION

Daily intake of milk supplemented with fluoride and/or probiotic bacteria may reverse soft and leathery PRCL in older adults.

Estimation of lesion progress in artificial root caries by swept source optical coherence tomography in comparison to transverse microradiography

This study aimed to investigate whether swept source optical coherence tomography (SS-OCT) could estimate the lesion depth and mineral loss quantitatively without the use of polarization sensitivity, and to examine a relationship between OCT data and transverse microradiography (TMR) lesion parameters. Twenty-four bovine root dentin specimens were allocated to three groups of 4-, 7-, and 14-day demineralization. Cross-sectional images of the specimens before and after the demineralization were captured by OCT at 1319 nm center wavelength. Following the demineralization, these specimens were cut into sections for TMR analysis. Correlations between the OCT data and TMR lesion parameters were examined. TMR images of the specimens showed cavitated lesions (lesion depth or LD(TMR): 200 to 500 μm, ΔZ or mineral loss: 10,000 to 30,000 vol % μm). The OCT images showed "boundaries," suggesting the lesion front. Integrated dB values before and after the demineralization and their difference (R(D), R(S), and ΔR, respectively) were calculated from the lesion surface to the corrected depth of boundary (LD(OCT)). A statistically significant correlation was found between LD(OCT) and LD(TMR) (p < 0.05, r = 0.68). Similarly, statistically significant correlations were found between ΔZ and R(D) or ΔR. The OCT showed a potential for quantitative estimation of lesion depth and mineral loss with cavitated dentin lesions in vitro.

The use of sodium trimetaphosphate as a biomimetic analog of matrix phosphoproteins for remineralization of artificial caries-like dentin

OBJECTIVES

This study examined the use of sodium trimetaphosphate (STMP) as a biomimetic analog of matrix phosphoproteins for remineralization of artificial carious-affected dentin.

METHODS

Artificial carious lesions with lesion depths of 300±30μm were created by pH-cycling. 2.5% hydrolyzed STMP was applied to the artificial carious lesions to phosphorylate the partially-demineralized collagen matrix. Half of the STMP-treated specimens were bonded with One-Step. The adhesive and non-adhesive infiltrated specimens were remineralized in a Portland cement-simulated body fluid system containing polyacrylic acid (PAA) to stabilize amorphous calcium phosphate as nanoprecursors. Micro-computed tomography (micro-CT) and transmission electron microscopy (TEM) were used to evaluate the results of remineralization after a 4-month period.

RESULTS

In absence of PAA and STMP as biomimetic analogs (control groups), there was no remineralization irrespective of whether the lesions were infiltrated with adhesive. For the STMP-treated experimental groups immersed in PAA-containing simulated body fluid, specimens without adhesive infiltration were more heavily remineralized than those infiltrated with adhesive. Statistical analysis of the 4-month micro-CT data revealed significant differences in the lesion depth, relative mineral content along the lesion surface and changes in ΔZ between the non-adhesive and adhesive experimental groups (p<0.05 for all the three parameters). TEM examination indicated that collagen degradation occurred in both the non-adhesive and adhesive control and experimental groups after 4 months of remineralization.

SIGNIFICANCE

Biomimetic remineralization using STMP is a promising method to remineralize artificial carious lesions particularly in areas devoid of seed crystallites. Future studies should consider the incorporation of MMP-inhibitors within the partially-demineralized collagen matrix to prevent collagen degradation during remineralization.

pH-cycling models for in vitro evaluation of the efficacy of fluoridated dentifrices for caries control: strengths and limitations

Despite a plethora of in situ studies and clinical trials evaluating the efficacy of fluoridated dentifrices on caries control, in vitro pH cycling models are still broadly used because they mimic the dynamics of mineral loss and gain involved in caries formation. This paper critically reviews the current literature on existing pH-cycling models for the in vitro evaluation of the efficacy of fluoridated dentifrices for caries control, focusing on their strengths and limitations. A search was undertaken in the MEDLINE electronic journal database using the keywords "pH-cycling", "demineralization", "remineralization", "in vitro", "fluoride", "dentifrice". The primary outcome was the decrease of demineralization or the increase of remineralization as measured by different methods (e.g.: transverse microradiography) or tooth fluoride uptake. Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were solved by discussion and consensus or by a third party. One hundred and sixteen studies were included, of which 42 addressed specifically the comparison of dentifrices using different pH-cycling models. The other studies included meta-analysis or reviews, data about the effect of different fluoride sources on de-remineralization, different methods for analysis de-remineralization and chemical variables and characteristics of dental hard tissues that might have influence on de-remineralization processes. Generally, the studies presented ability to detect known results established by clinical trials, to demonstrate dose-related responses in the fluoride content of the dentifrices, and to provide repeatability and reproducibility between tests. In order to accomplish these features satisfactorily, it is mandatory to take into account the type of substrate and baseline artificial lesion, as well as the adequate response variables and statistical approaches to be used. This critical review of literature showed that the currently available pH-cycling models are appropriate to detect dose-response and pH-response of fluoride dentifrices, and to evaluate the impact of new active principles on the effect of fluoridated dentifrices, as well as their association with other anti-caries treatments.

Strategies for noninvasive demineralized tissue repair

This article provides a state-of-the-art overview of clinically relevant evidence regarding effective, noninvasive management strategies to prevent, arrest, and remineralize caries lesions. With the rapidly increasing knowledge about oral biofilms and the process of caries in itself, the profession is embarking on new strategies. This is an exciting time, with several promising new agents and novel treatment modalities at the horizon to prevent and manage caries lesions. Some are already available in clinical practice. Studies, however, have yet to show conclusive evidence of clinical efficacy. None have shown to be more effective than fluoride and protection by sealant.

Combination of high-fluoride toothpaste and no post-brushing water rinsing on enamel demineralization using an in-situ caries model with orthodontic bands

OBJECTIVE

To compare the effects on enamel demineralization and fluoride (F) retention of two different brushing–rinsing regimens.

MATERIAL AND METHODS

An in-situ caries model with orthodontic bands was used for 8–9 weeks. A total of 20 orthodontic patients participated. They were randomized into two groups: (1) a test group using 5000 ppm F (n = 10) with no post-brushing water rinsing; and (2) a control group using 1450 ppm F (n = 10) with three sessions of post-brushing water rinsing. Orthodontic stainless-steel bands were applied to the two upper first premolars, leaving 2–3 mm of space away from the exposed buccal surface in order to accumulate plaque and provoke initial caries development. The teeth were extracted after 8 and 9 weeks, then analysed using quantitative light-induced fluorescence (QLF). Additionally, oral F retention was compared for the two groups.

RESULTS

In comparison to the control group, the test regimen resulted in a non-significant smaller QLF lesion area and a significantly lower average QLF loss of fluorescence (P < 0.05). The highest F retention concentration under the band was found in the test group (P < 0.001).

CONCLUSIONS

The combination of using a 5000 ppm F toothpaste and no post-brushing water rinsing had a greater anti-caries potential and resulted in elevated oral F retention compared to a 1450 ppm F toothpaste with three sessions of post-brushing water rinsing.

APF and dentifrice effect on root dentin demineralization and biofilm

Because dentin is more caries-susceptible than enamel, its demineralization may be more influenced by additional fluoride (F). We hypothesized that a combination of professional F, applied as acidulated phosphate F (APF), and use of 1100-ppm-F dentifrice would provide additional protection for dentin compared with 1100-ppm-F alone. Twelve adult volunteers wore palatal appliances containing root dentin slabs, which were subjected, during 4 experimental phases of 7 days each, to biofilm accumulation and sucrose exposure 8x/day. The volunteers were randomly assigned to the following treatments: placebo dentifrice (PD), 1100-ppm-F dentifrice (FD), APF + PD, and APF+FD. APF gel (1.23% F) was applied to the slabs once at the beginning of the experimental phase, and the dentifrices were used 3x/day. APF and FD increased F concentration in biofilm fluid and reduced root dentin demineralization, presenting an additive effect. Analysis of the data suggests that the combination of APF gel application and daily regular use of 1100-ppm-F dentifrice may provide additional protection against root caries compared with the dentifrice alone.

Design of the Prevention of Adult Caries Study (PACS): a randomized clinical trial assessing the effect of a chlorhexidine dental coating for the prevention of adult caries

BACKGROUND

Dental caries is one of the primary causes of tooth loss among adults. It is estimated to affect a majority of Americans aged 55 and older, with a disproportionately higher burden in disadvantaged populations. Although a number of treatments are currently in use for caries prevention in adults, evidence for their efficacy and effectiveness is limited.

METHODS/DESIGN

The Prevention of Adult Caries Study (PACS) is a multicenter, placebo-controlled, double-blind, randomized clinical trial of the efficacy of a chlorhexidine (10% w/v) dental coating in preventing adult caries. Participants (n = 983) were recruited from four different dental delivery systems serving four diverse communities, including one American Indian population, and were randomized to receive either chlorhexidine or a placebo treatment. The primary outcome is the net caries increment (including non-cavitated lesions) from baseline to 13 months of follow-up. A cost-effectiveness analysis also will be considered.

DISCUSSION

This new dental treatment, if efficacious and approved for use by the Food and Drug Administration (FDA), would become a new in-office, anti-microbial agent for the prevention of adult caries in the United States.

TRIAL REGISTRATION NUMBER

NCT00357877.

The chemistry of caries: remineralization and demineralization events with direct clinical relevance

Dental caries is a site-specific disease that undergoes many cycles of demineralization and remineralization during lesion development. Because of its developmental characteristics dynamics, the caries lesion can be arrested and even repaired at its early stages without operative intervention by increasing the net mineral gain during the demineralization and remineralization cycles. This result can be accomplished by reducing the effect of etiological factors such as cariogenic biofilms and diet, and increasing the efficacy of remineralizing agents such as saliva and fluoride.