Anticariogenicity of calcium phosphate complexes of tryptic casein phosphopeptides in the rat

A clinical efficacy of 30% ethenolic extract of Indian propolis and Recaldent™ in management of dentinal hypersensitivity: A comparative randomized clinical trial

Objective:

The aim of this study is to evaluate the efficacy of 30% ethenolic extract of Indian propolis compared with Recaldent^™ (casein phosphopeptide-amorphous calcium phosphate) in reduction of dentinals hypersensitivity, a randomized, double-blind, split mouth, controlled clinical trial was conducted among the patients residing in Central Jail.

Materials and Methods:

A sample of 73 teeth from 13 patients having at least three teeth with dentinal hypersensitivity (DH) were randomly allocated into three treatment groups: Group A: 30% ethenolic extract of Indian propolis, Group B: Recaldent^™, Group C: Sterile water. Verbal rating scale was used to record the degree of hypersensitivity based on patient's response to tactile and air blast stimuli. The baseline scores were obtained. Each intervention group received applications of their respective agents consecutively on 1^st, 7^th, 14^th, and 21^st day. After each application the scores were recorded.

Results:

Both the 30% Indian propolis and Recaldent^™ showed significant reduction in DH.

Conclusion:

Recaldent^™ was found to be significantly better in reducing the DH compared to propolis and sterile water (P < 0.01).

Effect of remineralizing agents on bond strength of orthodontic brackets: an in vitro study

Background

The purpose of this study is to evaluate the effect of casein phosphopeptide amorphous calcium phosphate (CPP-ACP) and CPP-ACP with fluoride (CPP-ACP-F) on the shear bond strength (SBS) of orthodontic brackets bonded with two different adhesive systems.

Methods

One hundred twenty-six human premolar teeth were selected. One hundred twenty teeth were used for SBS testing, and six teeth were used for scanning electron microscope (SEM) examination. One hundred twenty premolars were divided into mainly three groups: CPP-ACP (group A), CPP-ACP-F (group B), and control group (group C). Each group was sub-divided into two groups according to the bonding adhesive, light cure (groups A1, B1, and C1) and chemical cure (groups A2, B2, and C2). The teeth were pre-treated with the group-specified preventive agent 1 h/day for five consecutive days. Standard edgewise brackets were bonded with the respective adhesives. SBS evaluation was done with the universal testing machine. After debonding, all the teeth were scored for adhesive remaining on the buccal surface, in accordance to adhesive remnant index, under a stereomicroscope. The acid-etched enamel surfaces were observed under SEM after treatment with CPP-ACP, CPP-ACP-F, and artificial saliva.

Result

In light-cure adhesive group, CPP-ACP-F (B1) showed superior results compared to the control group (C1), whereas the CPP-ACP group (A1) showed lower mean SBS than the control group (C1). Both these differences were not statistically significant (p > 0.05). In chemical-cure adhesive group, control group C2 showed significantly superior results (p < 0.05) compared to group A2 and group B2. The results of two-way ANOVA showed highly significant difference due to adhesive types (p < 0.01), whereas enamel pre-treatment showed non-significant difference (p > 0.01).

Conclusion

The SBS of the orthodontic brackets was non-significantly affected when the brackets were cured with light-cure bonding system and treated with either CPP-ACP or CPP-ACP-F, whereas with chemical-cure adhesive, decreased bond strength was seen, which was within the clinically acceptable limits.

Effect of Two Desensitizing Agents in Reducing Dentin Hypersensitivity: An in-vivo Comparative Clinical Trial

OBJECTIVE

A randomized, double blind, split mouth, controlled clinical trial was conducted to evaluate the effect of two desensitizing agents on reduction of Dentin Hypersensitivity (DH).

MATERIAL AND METHODOLOGY

A sample of 73 teeth from 13 patients, among which at least 3 teeth had dentin hypersensitivity, was randomly allocated into 3 treatment groups: Group A: treated with 30% ethenolic extract of Indian Propolis, Group B: treated with GC tooth mousse, and Group C: treated with sterile water. A Verbal Rating Scale (VRS) was used to record the degree of hypersensitivity, based on patient's response to tactile and air blast stimuli. The baseline scores were obtained. Each intervention group received applications of their respective agents consecutively on 1(st), 7(th), 14(th) and 21(st) days. After each application, the scores were recorded.

RESULTS

Both the 30% Indian Propolis and GC tooth mousse showed significant reductions in dentin hypersensitivity.

CONCLUSION

GC tooth mousse was found to be significantly better in reducing the dentinal hypersensitivity as compared to Propolis and sterile water (p< 0.01).

A simple competitive enzyme-linked immunosorbent assay for the specific detection of the multiphosphorylated 1–25 β-casein fragment

A specific and simple competitive enzyme-linked immunosorbent assay (ELISA) was developed to determine bovine β-casein phosphopeptides (β-CPP) in casein phosphopeptides (CPP) or CPP complexes such as casein phosphopeptide amorphous calcium phosphate complexes added into dairy products. The method combines sample pretreatment designed for CPP enrichment and anti-β-CPP(f(1–25)) monoclonal antibody 1A5 (mAb 1A5). The mAb 1A5 bound specifically to the tryptic phosphopeptides from β-casein but not from αs1- or αs2-casein. Reactivity was also influenced by the extent of the phosphorylated form of serine residues. Based on the sequence-specific recognition and contribution of phosphorylated serine residues, the epitope of mAb 1A5 was found to reside within the cluster motif Ser(P)-Ser(P)-Ser(P)-Glu-Glu and the surrounding residues in β-CPP. The competitive ELISA developed here can be used as an alternative to specialised and expensive techniques such as mass spectrometry. In particular, it is suitable for the measurement of CPP or CPP complexes in dairy products, which contain closely related endogenous molecular species.

The effect of casein phosphopeptide amorphous calcium phosphate on the in vitro shear bond strength of orthodontic brackets

Objective

The purpose of this study was to evaluate the effect of casein phosphopeptide amorphous calcium phosphate (CPP-ACP) on the shear bond strength (SBS) of brackets bonded to non-demineralized teeth with either phosphoric acid etching or self-etching primer.

Methods

Sixty human premolars were randomly assigned to 1 of 4 treatment groups (n = 15 each): phosphoric acid etching (group 1); self-etching primer (group 2); CPP-ACP for 2 weeks + phosphoric acid etching (group 3), and CPP-ACP for 2 weeks + self-etching primer (group 4). After bonding of the maxillary premolar metal brackets, specimens were subjected to shear forces in a testing machine. Scanning electron microscopy was used to observe etching patterns on the enamel surfaces of all teeth. A 2-way analysis of variance was used to test for effects of CPP-ACP and etching system on SBS.

Results

Significantly higher mean SBSs were observed in groups subjected to phosphoric acid etching (i.e., groups 1 and 3; p < 0.05). On the other hand, SBSs did not appear to be influenced by CPP-ACP (i.e., groups 3 and 4; p > 0.05). We observed a uniform and clear etched pattern on the enamel surface of the phosphoric acid etching groups.

Conclusions

CPP-ACP does not significantly affect the SBS of orthodontic brackets bonded to non-demineralized teeth, regardless of which adhesive method is used to bond the brackets.

Optimization of calcium concentration of saliva with phosphoryl oligosaccharides of calcium (POs-Ca) for enamel remineralization in vitro

OBJECTIVE

Phosphoryl oligosaccharides of calcium (POs-Ca) are highly soluble calcium source made from potato starch. The aim of this study was to investigate the optimal concentrations of POs-Ca for the remineralization of subsurface enamel lesions in vitro.

DESIGN

Demineralized bovine enamel slabs (n=5) were remineralized in vitro for 24h at 37°C with artificial saliva (AS) containing 0-0.74% POs-Ca to adjust the Ca/P ratio to 0.4-3.0, then sectioned and analysed by transversal microradiography (TMR). The data were analysed by Scheffe's post hoc test. The Ca/P ratio with most remineralization was used to investigate the effect of calcium on enamel remineralization (n=11). The demineralized slabs were treated with AS with calcium-chloride- (CaCl2-) or POs-Ca with an identical calcium content, and sectioned for TMR and wide-angle X-ray diffraction (WAXRD) analyses to evaluate the local changes in hydroxyapatite (HAp) crystal content. The data were analysed using the Mann-Whitney U-test.

RESULTS

The highest mineral recovery rate resulted from addition of POs-Ca to adjust the Ca/P to 1.67. At this ratio, the mineral recovery rate for AS containing POs-Ca (24.2±7.4%) was significantly higher than that for AS containing CaCl2 (12.5±11.3%) (mean±SD, p<0.05). The recovery rate of HAp crystallites for AS containing POs-Ca (35.7±10.9%) was also significantly higher than that for AS containing CaCl2 (23.1±13.5%) (p<0.05). The restored crystallites were oriented in the same directions as in sound enamel.

CONCLUSIONS

POs-Ca effectively enhances enamel remineralization with ordered HAp at a Ca/P ratio of 1.67.

Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists

BACKGROUND

The authors investigated the prevention and treatment of white-spot lesions (WSLs) during and after orthodontic therapy from the perspective of general dentists and orthodontists.

METHODS

The authors administered a cross-sectional survey to general dentists (n = 191) and orthodontists (n = 305) in Virginia, Maryland and North Carolina.

RESULTS

Sixty-nine percent of general dentists and 76 percent of orthodontists recommended in-office fluoride treatment for patients with severe WSLs immediately after orthodontic treatment. Sixty-nine percent of general dentists reported that they had treated WSLs during the previous year, and 37 percent of orthodontists reported that they had removed braces because of patients' poor oral hygiene. Sixty percent of orthodontists referred patients with WSLs to general dentists for treatment. Eighty-five percent of orthodontists responded that they encouraged patients to use a fluoride rinse as a preventive measure. More than one-third of general dentists indicated that severe WSLs after orthodontic treatment could have a negative effect on their perception of the treating orthodontist.

CONCLUSIONS

WSLs are a common complication of orthodontic treatment and their presence can result in a negative perception of the treating orthodontist by the patient's general dentist. Clinical implications. General dentists and orthodontists should work together to prevent the development of WSLs in their patients. Treatment with fluoride supplements and motivating and training patients to practice good oral hygiene will help achieve this goal. Treatment after debonding should include the topical application of low concentrations of fluoride.

Biofunctional properties of caseinophosphopeptides in the oral cavity

Caseinophosphopeptides (CPPs), bioactive peptides released from caseins, have the ability to enhance bivalent mineral solubility. This is relevant to numerous biological functions in the oral cavity (promotion of tooth enamel remineralisation, prevention of demineralisation and buffering of plaque pH). Therefore, CPPs may play a positive role as prophylactic agents for caries, enamel erosion and regression of white spot lesions. Most in vitro and in situ studies demonstrate strong evidence for the bioactivity of CPPs in the oral cavity. Nevertheless, relatively little is known concerning their use as adjuvants for oral health and more particularly regarding their long-term effects on oral health.

Effects of demineralizaton-inhibition procedures on the bond strength of brackets bonded to demineralized enamel surface

Objective

To study and compare the effects of different demineralization-inhibition methods on the shear bond strength (SBS) and fracture mode of an adhesive used to bond orthodontic brackets to demineralized enamel surfaces.

Methods

Eighty freshly extracted, human maxillary premolars were divided into 4 equal groups and demineralized over the course of 21 days. Brackets were bonded to the demineralized enamel of teeth in Group 1. In Group 2, bonding was performed following resin infiltration (ICON®, DMG, Hamburg, Germany). Before bonding, pre-treatment with acidulated phosphate fluoride (APF) or solutions containing casein phosphopeptide-amorphous calcium phosphate with 2% neutral sodium fluoride (CPP-ACP/wF) was performed in Groups 3 and 4, respectively. The SBS values of the brackets were measured and recorded following mechanical shearing of the bracket from the tooth surface. The adhesive remnant index (ARI) scores were determined after the brackets failed. Statistical comparisons were performed using one-way ANOVA, Tukey's post-tests, and G-tests.

Results

Significant differences were found in some of the intergroup comparisons of the SBS values (F = 39.287, p < 0.001). No significant differences were found between the values for the APF-gel and control groups, whereas significantly higher SBS values were recorded for the resin-infiltrated and CPP-ACP/wF-treated groups. The ARI scores were also significantly different among the 4 groups (p < 0.001).

Conclusions

Tooth surfaces exposed to resin infiltration and CPP-ACP/wF application showed higher debonding forces than the untreated, demineralized surfaces.

In vivo remineralising effect of GC tooth mousse on early dental enamel lesions: SEM analysis

OBJECTIVE

Casein phosphopeptide-amorphous calcium phosphate nanocomplexes (CPP-ACP) exhibit anticariogenic potential in laboratory, animal and human experiments. The remineralising potential of synthetic CPPs on early enamel caries was investigated.

DESIGN

In vivo study.

SETTING

University of Naples 'Federico II', School of Dentistry, Department of Paediatric Dentistry, 2010, Italy.

PARTICIPANTS

40 volunteers (age range 10-16 years) were recruited and divided in two groups of 20 (Group A and B).

INTERVENTIONS

In Group A subjects two demineralised enamel specimens were placed on the buccal surfaces of the first molars and subjects were instructed to apply a commercial product containing CPPs (GC Tooth Mousse) only on the right-sided specimen and a placebo mousse on the left, for 1 month. In Group B subjects two enamel specimens were similarly placed into the mouth and used as controls.

RESULTS

SEM analysis revealed a diffuse and homogeneous mineral coating, reducing the surface alterations only in the demineralised specimens treated with synthetic CPPs into the mouth.

CONCLUSIONS

Results demonstrate that CPPs are able to promote remineralisation of early enamel lesions.

Do fluoride and casein phosphopeptide-amorphous calcium phosphate affect shear bond strength of orthodontic brackets bonded to a demineralized enamel surface?

OBJECTIVE

To compare the effects of fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) containing topical agents on shear bond strength (SBS) and fracture mode of orthodontic brackets bonded to demineralized enamel.

MATERIALS AND METHODS

Eighty freshly extracted human premolar teeth were randomly divided into four equal groups. The first group was the control, and no pretreatment was performed on this group. In the remaining three groups, demineralization process was performed and teeth were stored in artificial saliva. In group II, bonding was performed after demineralization. Pretreatment with fluoride and CPP-ACP gels was performed in groups III and IV, respectively. Brackets were bonded using a conventional system. The SBS of these brackets was measured and recorded in MPa. Adhesive remnant index (ARI) scores were determined after the brackets failed. Data were analyzed with analysis of variance (ANOVA), Tukey, and G-tests at the P < .05 level.

RESULTS

ANOVA comparison of four groups revealed statistically significant differences. No significant differences were found between control and CPP-ACP-treated groups. However, lower SBS values were recorded for group II (6.6 ± 3.9 MPa) and group III (17.1 ± 2.9 MPa). ARI scores were significantly different among the four groups (P < .001). No enamel detachment was found in the control group, and enamel detachment measured 75% for group II.

CONCLUSIONS

Fluoride and CPP-ACP gel applications showed higher debonding forces compared to bonding in untreated demineralized samples. CPP-ACP pretreatment resulted in comparable SBS values compared with the control group.

Self-reparability of glass-ionomer cements: an in vitro investigation

Despite the advantages of glass-ionomer cement (GIC) restorative materials, they exhibit low mechanical properties and are susceptible to dissolution. The purpose of this study was to investigate the existence of self-reparability of a GIC material. Thirty Fuji IX discs were fabricated and subjected to desiccation. The discs were randomly separated into three groups: one group was kept in air, a second group was soaked in water, and a third group was placed in casein phosphoprotein-amorphous calcium phosphate-containing solution (Dentacal; NSI, Hornsby, Australia). After 21 d of incubation, all specimens were subjected to biaxial flexure testing. One-way ANOVA revealed a statistical difference in the biaxial flexure strength between the groups. Weibull statistics revealed that the Dentacal group demonstrated a lower probability of failure than the other groups. The air group exhibited the highest probability of failure. The difference between the specimens was expected as a result of enhanced cross-linking between the polyalkenoate chains and the GIC particles, and the diffusion of ionic components to the set GIC. Therefore, perhaps a form of reparative mechanism exists for precrazed GIC when it is exposed to a remineralizing solution. In addition to the benefit on natural tooth structures, this study indicates that remineralizing solutions are also beneficial for maintaining the mechanical integrity of GIC restorations.

Effects of a fluoride-containing casein phosphopeptide-amorphous calcium phosphate complex on the shear bond strength of orthodontic brackets

The purpose of this study was to investigate the effects of enamel pre-treatment with a new fluoride-containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) complex on the shear bond strength (SBS) of brackets bonded with etch-and-rinse or self-etching adhesive systems. The material comprised 66 extracted human premolars randomly divided into six equal groups with respect to the enamel pre-treatment and adhesive system employed: 1. No pre-treatment and brackets bonded with the etch-and-rinse adhesive system (Transbond XT). 2. Pre-treatment with fluoride-containing CPP-ACP paste (MI Paste Plus) and Transbond XT. 3. Pre-treatment with non-fluoride CPP-ACP paste (MI Paste) and Transbond XT.4. No pre-treatment and brackets bonded with the self-etching adhesive system (Transbond Plus). 5 and 6. Enamel pre-treated as for groups 2 and 3, respectively, and the Transbond Plus. Bonded specimens were subjected to thermal cycling (×1000) before SBS testing. The residual adhesive on the enamel surface was evaluated after debonding with the adhesive remnant index (ARI). Data evaluation was made using one-way analysis of variance and Tukey test for SBS results, and Kruskal-Wallis test for ARI results. The results showed that enamel pre-treatment with either fluoride or non-fluoride CPP-ACP paste had no significant effect on the SBS of the self-etching adhesive system (P > 0.05). Enamel pre-treatment with non-fluoride CPP-ACP in group 3 significantly reduced the SBS of the etch-and-rinse adhesive (P < 0.001), while pre-treatment with fluoride-containing CPP-ACP paste (groups 2 and 5) did not affect debonding values (P > 0.05). The fluoride-containing CPP-ACP did not compromise the SBS of brackets bonded with the tested etch-and-rinse and self-etching systems, but its non-fluoride version significantly decreased the SBS of the etch-and-rinse adhesive system.

Elevated incidence of dental caries in a mouse model of cystic fibrosis

BACKGROUND

Dental caries is the single most prevalent and costly infectious disease worldwide, affecting more than 90% of the population in the U.S. The development of dental cavities requires the colonization of the tooth surface by acid-producing bacteria, such as Streptococcus mutans. Saliva bicarbonate constitutes the main buffering system which neutralizes the pH fall generated by the plaque bacteria during sugar metabolism. We found that the saliva pH is severely decreased in a mouse model of cystic fibrosis disease (CF). Given the close relationship between pH and caries development, we hypothesized that caries incidence might be elevated in the mouse CF model.

METHODOLOGY/PRINCIPAL FINDINGS

We induced carious lesions in CF and wildtype mice by infecting their oral cavity with S. mutans, a well-studied cariogenic bacterium. After infection, the mice were fed a high-sucrose diet for 5 weeks (diet 2000). The mice were then euthanized and their jaws removed for caries scoring and bacterial counting. A dramatic increase in caries and severity of lesions scores were apparent in CF mice compared to their wildtype littermates. The elevated incidence of carious lesions correlated with a striking increase in the S. mutans viable population in dental plaque (20-fold increase in CF vs. wildtype mice; p value < 0.003; t test). We also found that the pilocarpine-stimulated saliva bicarbonate concentration was significantly reduced in CF mice (16 ± 2 mM vs. 31 ± 2 mM, CF and wildtype mice, respectively; p value < 0.01; t test).

CONCLUSIONS/SIGNIFICANCE

Considering that bicarbonate is the most important pH buffering system in saliva, and the adherence and survival of aciduric bacteria such as S. mutans are enhanced at low pH values, we speculate that the decrease in the bicarbonate content and pH buffering of the saliva is at least partially responsible for the increased severity of lesions observed in the CF mouse.

MIH Supplementation Strategies

The use of calcium-phosphate casein on hypomineralized molars (molar incisor hypomineralization, MIH) has been proposed but not clinically investigated. Qualitative and quantitative effects of supplementation with a calcium-phosphate casein product on MIH molars were monitored over a period of three years. Molar replicas, minimally invasive biopsies and their SEM microphotographs, plus ESEM/EDX semi-quantitative peaks of elements present in affected enamel were evaluated. Mineralization, morphology, and porosity appeared markedly improved, with calcium and phosphate levels reaching almost normal levels at three years’ follow-up. The hypothesis tested was rejected, since calcium-phosphate casein improved enamel morphology in vivo.

Salivary pH level and bacterial plaque evaluation in orthodontic patients treated with Recaldent products

Dental caries and resulting tooth decay can produce a multifactorial destructive process with a very high incidence. Cariogenic bacteria attack enamel with acids that produce subsurface lesions, thereby weakening the enamel and allowing bacterial progression into the dentin. The formation of dental decay, because of demineralization of the tooth structure, can be prevented or delayed by increasing the rate of the tooth's remineralization and replacement relative to the tooth's rate of demineralization. This rebuilding of enamel may be accelerated by the addition of amorphous calcium phosphate (ACP) with the aid of casein phosphopeptide (CPP) (Recaldent molecule). In this study, the role of CPP in stabilizing and releasing ACP on the tooth surface has been investigated to better understand its efficacy in the prevention of tooth demineralization in orthodontic patients. Twenty-five patients who wore fixed orthodontic appliances were enrolled in this clinical trial. It was explained to the patients that CPP-ACP would be used for 3 weeks and then suspended for an additional 3 weeks. Salivary pH evaluation, plaque pH evaluation and oral hygiene index (OHI) were performed at T0, T1 and T2. Results showed an increase in OHI level and an increase of the salivary pH (76% of the patients). Instead of plaque pH level that showed trivial results, only 48% of the patients showed a bacterial plaque pH increase. In conclusion, this study has not provided unequivocal evidence for the protective properties of Recaldent molecule. Long-term studies are necessary to better understand the role of this molecule.

Comparison of the remineralization potential of CPP-ACP and CPP-ACP with 900 ppm fluoride on eroded human enamel: An in situ study

OBJECTIVE

The aim of this in situ study was to compare the remineralization potential of pastes containing CPP-ACP and CPP-ACP with 900 ppm fluoride on human enamel softened by a cola drink.

DESIGN

Forty-five enamel specimens obtained from human third molar teeth were eroded in a cola drink for 8 min and then attached to intra-oral devices worn by five volunteers. The specimens were subjected to three different in situ remineralization protocols using: (1) CPP-ACP (Group I), (2) CPP-ACP with 900 ppm fluoride (Group II), and (3) saliva (Group III, control). Vickers microhardness measurements were obtained at baseline followed by demineralization and remineralization stages.

RESULTS

The CPP-ACP, CPP-ACP with 900 ppm fluoride and saliva controls resulted in 46.24%, 64.25% and 2.98% increase in post-erosion microhardness values, respectively. One-way ANOVA revealed statistically significant differences in the mean microhardness values between pastes containing CPP-ACP and CPP-ACP with 900 ppm fluoride.

CONCLUSIONS

Both CPP-ACP and CPP-ACP with 900 ppm fluoride substantially remineralized the softened enamel, with the CPP-ACP and fluoride combination showing higher remineralization potential than CPP-ACP. This study confirmed the synergistic effect of fluoride with CPP-ACP on remineralization of eroded enamel.

Analysis of the effect of CPP-ACP tooth mousse on enamel remineralization by circularly polarized images

OBJECTIVE

To evaluate the effect of casein phosphopeptide-amorphous calcium phosphate tooth mousse on the remineralization of bovine incisor by circularly polarized images.

METHODS

Eighty bovine incisors, each with a 4 x 4 mm artificially demineralized area, were used. The samples were divided into four groups: Group A, casein phosphopeptide-amorphous calcium phosphate tooth mousse; Group B, fluoride toothpaste; Group C, casein phosphopeptide-amorphous calcium phosphate tooth mousse and fluoride toothpaste; and Group D, no treatment. Circularly polarized images were taken after the specimens were treated for 3, 6, 9, or 12 weeks, and the size of the demineralized area and the mean grey level were measured. Data analysis was done using repeated measures variance analysis. Pearson correlation coefficients were computed to evaluate the correlation between the size of the demineralized area and the mean grey level.

RESULTS

In all four groups, the size of the demineralized area and the mean grey level declined with time. The size of the demineralized area of Group C was significantly smaller than that of Group A at the end of the third and sixth weeks (P = .039, P = .000, respectively), and the mean grey level of Group C was lower than that of Group A at the end of the 6th and 12th weeks (P = .037, P = .004, respectively). At the end of the 6th, 9th, and 12th weeks, the size of the demineralized area of Group C was smaller (P = .000, P = .005, P = .005, respectively) and the mean grey level was lower (P = .000) than those of Group B. No statistically significant correlations were detected between the size of the demineralized area and the mean grey level.

CONCLUSION

Casein phosphopeptide-amorphous calcium phosphate tooth mousse can reduce the size and mean grey level of demineralized areas and promote the remineralization of bovine enamel. Combined application with fluoride toothpaste strengthens the effect.

New Approaches to Enhanced Remineralization of Tooth Enamel

Dental caries is a highly prevalent diet-related disease and is a major public health problem. A goal of modern dentistry is to manage non-cavitated caries lesions non-invasively through remineralization in an attempt to prevent disease progression and improve aesthetics, strength, and function. Remineralization is defined as the process whereby calcium and phosphate ions are supplied from a source external to the tooth to promote ion deposition into crystal voids in demineralized enamel, to produce net mineral gain. Recently, a range of novel calcium-phosphate-based remineralization delivery systems has been developed for clinical application. These delivery systems include crystalline, unstabilized amorphous, or stabilized amorphous formulations of calcium phosphate. These systems are reviewed, and the technology with the most scientific evidence to support its clinical use is the remineralizing system utilizing casein phosphopeptides to stabilize and deliver bioavailable calcium, phosphate, and fluoride ions. The recent clinical evidence for this technology is presented and the mechanism of action discussed. Biomimetic approaches to stabilization of bioavailable calcium, phosphate, and fluoride ions and the localization of these ions to non-cavitated caries lesions for controlled remineralization show promise for the non-invasive management of dental caries.

Effects of CPP-ACP paste on the shear bond strength of orthodontic brackets

OBJECTIVE

To evaluate the effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste on shear bond strength and debonding failure modes of orthodontic brackets.

MATERIALS AND METHODS

Freshly extracted premolars were randomly divided into four groups (n =18) as follows: in groups 1 and 3, the enamel was treated with a solution of CPP-ACP dissolved in artificial saliva; groups 2 and 4 served as controls, and the enamel was treated with artificial saliva. After conventional acid etching, in groups 1 and 2, brackets were bonded using a light-cured bonding system (Blugloo); while in groups 3 and 4, brackets were bonded using a conventional bonding system (Unite Bonding Adhesive). Bonded specimens were subjected to thermal cycling for 1000 cycles before debonding procedures. After debonding, teeth and brackets were examined under a stereomicroscope at 10x magnification to determine whether any adhesive remained, in accordance with the adhesive remnant index. The acid-etched enamel surfaces were also observed using scanning electron microscopy after treatment with and without CPP-ACP paste.

RESULTS

The shear bond strengths of group 1 were significantly higher than those seen in group 2 (P < .01). There was no significant difference in the shear bond strengths of groups 3 and 4 (P > .05). Scanning electron microscopic observation showed that the pretreated enamel surface was rougher than that of the control surface after acid etching.

CONCLUSION

The use of CPP-ACP can be considered as an alternative prophylactic application in orthodontic practice since it did not compromise bracket bond strength.

Regression of post-orthodontic lesions by a remineralizing cream

Orthodontic patients have an increased risk of white-spot lesion formation. A clinical trial was conducted to test whether, in a post-orthodontic population using fluoride toothpastes and receiving supervised fluoride mouthrinses, more lesions would regress in participants using a remineralizing cream containing casein phosphopeptide- amorphous calcium phosphate compared with a placebo. Forty-five participants (aged 12-18 yrs) with 408 white-spot lesions were recruited, with 23 participants randomized to the remineralizing cream and 22 to the placebo. Product was applied twice daily after fluoride toothpaste use for 12 weeks. Clinical assessments were performed according to ICDAS II criteria. Transitions between examinations were coded as progressing, regressing, or stable. Ninety-two percent of lesions were assessed as code 2 or 3. For these lesions, 31% more had regressed with the remineralizing cream than with the placebo (OR = 2.3, P = 0.04) at 12 weeks. Significantly more post-orthodontic white-spot lesions regressed with the remineralizing cream compared with a placebo over 12 weeks.

Combining casein phosphopeptide-amorphous calcium phosphate with fluoride: synergistic remineralization potential of artificially demineralized enamel or not?

Recaldent is a product of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP). The remineralizing potential of CPP-ACP per se, or when combined with 0.22% Fl gel on artificially demineralized enamel using laser florescence, is investigated. Mesial surfaces of 15 sound human molars are tested using a He-Cd laser beam at 441.5 nm with 18-mW power as an excitation source on a suitable setup based on a Spex 750-M monochromator provided with a photomultiplier tube (PMT) for detection of collected autofluorescence from sound enamel. Mesial surfaces are subjected to demineralization for ten days. The spectra from demineralized enamel are measured. Teeth are divided into three groups according to the remineralizing regimen: group 1 Recaldent per se, group 2 Recaldent combined with fluoride gel and ACP, and group 3 artificial saliva as a positive control. After following these protocols for three weeks, the spectra from the remineralized enamel are measured. The spectra of enamel autofluorescence are recorded and normalized to peak intensity at about 540 nm to compare spectra from sound, demineralized, and remineralized enamel surfaces. A slight red shift occurred in spectra from demineralized enamel, while a blue shift may occur in remineralized enamel. Group 2 shows the highest remineralizing potential. Combining fluoride and ACP with CPP-ACP can give a synergistic effect on enamel remineralization.

Evidence-based caries, risk assessment, and treatment

Dental caries is a dietary and host-modified biofilm disease process, transmissible early in life that, if left untreated, will cause destruction of dental hard tissues. If allowed to progress, the disease will result in the development of caries lesions on tooth surfaces, which initially are noncavitated (eg, white spots), and eventually can progress to cavitation. The "medical model," where the etiologic disease-driving agents are balanced against protective factors, in combination with risk assessment, offers the possibility of patient-centered disease prevention and management before there is irreversible damage done to the teeth. This article discusses how to use evidence supporting risk assessment and management strategies for the caries process.

Case definition, aetiology and risk assessment of early childhood caries (ECC): a revisited review

AIM

To provide a review of the existing literature on early childhood caries (ECC) with particular reference on the nomenclature, case definition, epidemiology, etiology and risk assessment.

METHODS

An electronic search was used to identify and critically review papers that have been published and are pertinent to the above issues, evaluate and compile the reported evidence.

RESULTS

The term ECC has been adopted to more accurately describe dental caries that affects primary dentitions, replacing previously used terminology that associated the disease with the nursing habit. Suggested ECC case definition uses caries patterns as defining criteria, however, further refinement to include different clinical expressions of a varying severity is necessary. Significant percentages of preschool child populations are affected by ECC today, with the disease concentrating disproportionately in deprived families. Early colonization by mutans streptococci (MS) is associated with increased ECC development, with bacteria being transmitted in both vertical and horizontal ways. Dietary factors related to sugar consumption predispose to early MS colonization and establishment and increase the risk for ECC development, being part of the causal chain. Inappropriate bottle and breast-feeding behaviors also increase the risk, without showing a direct causal relationship. High risk children belong to ethnic minority groups and to low income families with poor parental behaviors and attitudes.

CONCLUSIONS

Further high-quality studies are needed to explore the role bacteria other than MS may play in caries initiation and progression, elucidate the interaction of the saliva immune defence system with a potentially defective tooth, and investigate the effect distant behavioral factors have on the causal chain that leads to ECC development.

In vitro evaluation of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) effect on stripped enamel surfaces. A SEM investigation

OBJECTIVES

Interproximal enamel reduction (orthodontic stripping) leaves surface-roughness that encourages plaque adherence. Sealants and fluoride products have been recommended to avoid possible detrimental effects. The objective of this study was to qualitatively evaluate, by means of scanning electron microscopy (SEM), the effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on stripped enamel morphology after exposure to an acid solution.

METHODS

15 extracted lower incisors underwent stripping with metal strips (Horico, 80 microm) by 1 operator. Mesial and distal surfaces were sectioned into 30 samples (22 stripped; 8 unstripped) and assigned to 2 groups: Group A (2 stripped; 2 unstripped) served as control; in Group B (20 stripped; 6 unstripped) tooth mousse containing CPP-ACP was tested. For 8 days, teeth were placed in acid lactic solution for 2h three times a day (from 9a.m. to 9p.m.) with 2h water preservation in between. After each demineralizing bath, samples of group B were coated with CPP-ACP for 5 min before immersion into water.

RESULTS

In Group A, stripped samples exhibited greater demineralization compared to unstripped. In Group B, CPP-ACP reduced enamel dissolution on both intact and abraded samples compared to Group A.

CONCLUSIONS

Injuries to enamel morphology caused by stripping might predispose to greater demineralization in the event of exposure to acid environment. Topical applications of CPP-ACP could be effective in promoting enamel remineralization after interdental stripping.

Calcium phosphate-based remineralization systems: scientific evidence?

Dental caries remains a major public health problem in most communities even though the prevalence of disease has decreased since the introduction of fluorides. The focus in caries research has recently shifted to the development of methodologies for the detection of the early stages of caries lesions and the non-invasive treatment of these lesions. Topical fluoride ions, in the presence of calcium and phosphate ions, promote the formation of fluorapatite in tooth enamel by a process referred to as remineralization. The non-invasive treatment of early caries lesions by remineralization has the potential to be a major advance in the clinical management of the disease. However, for net remineralization to occur adequate levels of calcium and phosphate ions must be available and this process is normally calcium phosphate limited. In recent times three calcium phosphate-based remineralization systems have been developed and are now commercially available: a casein phosphopeptide stabilized amorphous calcium phosphate (Recaldent (CPP-ACP), CASRN691364-49-5), an unstabilized amorphous calcium phosphate (ACP or Enamelon) and a bioactive glass containing calcium sodium phosphosilicate (NovaMin). The purpose of this review was to determine the scientific evidence to support a role for these remineralization systems in the non-invasive treatment of early caries lesions. The review has revealed that there is evidence for an anticariogenic efficacy of the Enamelon technology for root caries and for the Recaldent technology in significantly slowing the progression of coronal caries and promoting the regression of lesions in randomized, controlled clinical trials. Hence the calcium phosphate-based remineralization technologies show promise as adjunctive treatments to fluoride therapy in the non-invasive management of early caries lesions.

Clinical efficacy of casein derivatives: a systematic review of the literature

BACKGROUND

The objective of this article was to review systematically the clinical trials of casein derivatives (specifically casein phosphopeptide-amorphous calcium phosphate [CPP-ACP] complex) used in dentistry.

TYPES OF STUDIES REVIEWED

The authors included clinical studies that examined the efficacy of casein derivatives in dentistry. They excluded in vitro studies, case series, case reports, letters to editors (not containing primary data), editorials, review articles and commentaries, but read them to identify any potential studies.

RESULTS

The authors searched 98 articles for relevance, determined according to title, abstract and full text, resulting in a yield of 12 original studies. Nine were clinical trials that focused on caries prevention, seven of which showed that CPP-ACP (as found in sugar-free pellet or slab chewing gum, lozenges, milk or mouthrinse) was effective in preventing dental caries by remineralizing subsurface carious lesions in situ in a dose-response fashion. One was a clinical trial with conflicting results regarding the effect of CPP-ACP on the regression of white-spot lesions; one was a survey of the relief of dry-mouth symptoms; and one was an uncontrolled clinical study that showed the lack of effectiveness and lack of short-term therapeutic effect in treating dentin hypersensitivity.

CLINICAL IMPLICATIONS

The quantity and quality of clinical trial evidence are insufficient to make conclusions regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.

Fluoride and casein phosphopeptide-amorphous calcium phosphate

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) slows the progression of caries and remineralizes enamel subsurface lesions. The aim of this study was to determine the ability of CPP-ACP to increase the incorporation of fluoride into plaque and to promote enamel remineralization in situ. Randomized, double-blind, cross-over studies involved mouthrinses and dentifrices containing CPP-ACP and fluoride. The mouthrinses were used for 60 sec, three times/day for 5 days, and supragingival plaque was collected and analyzed for F. The dentifrices were rinsed as a water slurry for 60 sec four times/day for 14 days in an in situ model. The addition of 2% CPP-ACP to the 450-ppm-F mouthrinse significantly increased the incorporation of fluoride into plaque. The dentifrice containing 2% CPP-ACP produced a level of remineralization similar to that achieved with a dentifrice containing 2800 ppm F. The dentifrice containing 2% CPP-ACP plus 1100 ppm F was superior to all other formulations.

Remineralization of enamel subsurface lesions in situ by sugar-free lozenges containing casein phosphopeptideamorphous calcium phosphate

BACKGROUND

The anticariogenic potential of casein phosphopeptide-amorphous calcium phosphate nanocomplexes (CPP-ACP) has been demonstrated using laboratory, animal and human in situ caries models. The aim of this study was to determine the effect of CPP-ACP incorporation into a sugar-free lozenge (pressed mint tablet) on enamel remineralization in a human in situ model.

METHODS

The study utilized a double-blind, randomized, cross-over design with four treatments: (i) a lozenge containing 56.4mg (3 per cent w/w) CPP-ACP; (ii) a lozenge containing 18.8mg (1 per cent w/w) CPP-ACP; (iii) a lozenge not containing CPP-ACP; and (iv) a no lozenge nil-treatment control. Ten subjects wore removable palatal appliances with four, human-enamel, half-slab insets containing subsurface lesions. Lozenges were consumed, without chewing, four times per day for 14 days duration. After each treatment period the enamel slabs were removed, paired with their respective demineralized control, embedded, sectioned and subjected to microradiography and computer-assisted densitometric image analysis to determine the level of remineralization.

RESULTS

The incorporation of CPP-ACP into the lozenge significantly increased enamel subsurface lesion remineralization with 18.8 and 56.4mg of CPP-ACP increasing remineralization by 78 and 176 per cent respectively, relative to the control sugarfree lozenge.

CONCLUSION

This study demonstrates that lozenges are a suitable vehicle for the delivery of CPP-ACP to promote enamel remineralization.

The effect of casein phosphopeptide-amorphous calcium phosphate on remineralization of artificial caries-like lesions: an in vitro study

BACKGROUND

The aims of this study were to investigate the efficacy of CPP-ACP containing Tooth Mousse on the remineralization of enamel lesions and to compare its efficacy to that of a fluoride-containing toothpaste.

METHODS

Permanent teeth were placed in demineralizing solution for 96 hours to produce artificial caries-like lesions 120-200 microm in depth. They were sectioned into 100-150 microm thick samples and randomly assigned to five groups: for Group A, a fluoridated toothpaste (1100 ppm) was used as a positive control and in Group B, a non-fluoridated toothpaste was used as a negative control. Tooth Mousse containing CPP-ACP was tested by three different means: as a toothpaste (Group C); as a topical coating (Group D); and (Group E) as a topical coating after treating the sections with the same fluoridated toothpaste as in Group A.

RESULTS

The lesion depth decreased significantly by 7 per cent in Group A, 10.1 per cent in Groups C and D, and 13.1 per cent in Group E (Paired t- test, p < 0.05), while in Group B the lesion depth increased significantly by 23 per cent.

CONCLUSIONS

Based on the data obtained, CPP-ACP containing Tooth Mousse remineralized initial enamel lesions and it showed a higher remineralizing potential when applied as a topical coating after the use of a fluoridated toothpaste.

Change in surface hardness of enamel by a cola drink and a CPP-ACP paste

OBJECTIVES

This in vitro study used surface microhardness to evaluate whether a paste containing casein phosphopeptide amorphous calcium phosphate (CPP-ACP) can reharden tooth enamel softened by a cola drink, and how different saliva-substitute solutions affect the enamel hardness.

METHODS

Twenty-four bovine incisors, each tooth consisting of treatment and control halves, were immersed in a cola drink (Coke) for 8 min, then placed under a 0.4 mL/min drip with various saliva-substitute solutions. The saliva-substitute solutions were: saliva-like solution (SLS) with 1 ppm fluoride, SLS without fluoride, and Biotene mouthwash. CPP-ACP paste was applied to the treatment halves for 3 min at 0, 8, 24, and 36 h. Knoop microhardness measurements were performed at baseline, after the cola drink immersion, and after 24 and 48 h contact with saliva-substitute solution.

RESULTS

Enamel hardness significantly decreased after immersion in cola drink (ANOVA, p<0.05). After contact with saliva-like solutions for 48 h, those treated with CPP-ACP paste were significantly harder than those untreated regardless of the presence of 1 ppm fluoride in the saliva-like solution (ANOVA, p<0.05). Biotene mouthwash significantly softened the enamel surface (ANOVA, p<0.05). Two-way ANOVA showed significant effects of the CPP-ACP paste application and types of saliva-substitute solutions on the changes in surface hardness of the softened enamel at a significance level of 0.05.

CONCLUSION

The application of CPP-ACP paste with continuous replenishment of saliva-like solution for 48 h significantly hardened enamel softened by a cola drink. Biotene mouthwash softened enamel surface after 48 h contact.

Effect of a CPP-ACP agent on the demineralization and remineralization of dentine in vitro

OBJECTIVES

The aim of this study was to determine in vitro the effect of a commercial paste based on CPP-ACP complex on the demineralization of sound human dentine and on remineralization potential of artificial caries-like lesions formed on dentine surfaces.

METHODS

Forty dentine specimens were prepared with hard tissue microtome. The specimens were divided in four groups the A, B, C and D (n=10). The specimen surfaces were subjected to surface analysis by Fourier transformance micro multiple internal reflectance infrared spectroscopy (micro MIR-FTIR). Tooth mousse was applied on surface specimens of A group, while no agent were applied on the specimens of B group. Afterwards, groups A, B, C and D were immersed in demineralization solution for 7 days. Afterwards, the surfaces were subjected to micro MIR-FTIR analysis and the mineral to matrix ratio was used to assess the extent of dentin demineralization (DM). Tooth mousse was applied on specimens of group C, while no agent was applied on specimens of group D. The groups C and D immersed in artificial saliva for 7 days and were subjected to analysis by micro MIR-FTIR and the mineral to matrix ratio was used to assess the extent of dentin remineralization (RM).

RESULTS

Group A showed significant lower %DM in comparison to group B. Group C resulted in a significant higher %RM compared to group D.

CONCLUSIONS

The presence of agent CPP-ACP on dentine surfaces provoked lower demineralization and higher remineralization in comparison with the dentine surfaces without agent.