Effect of added calcium phosphate on enamel remineralization by fluoride in a randomized controlled in situ trial

Remineralization effect of NaF, NaF with TCP, NaF with CPP-ACP and NaF with CXP varnishes on newly erupted first permanent molars: A randomized controlled trial

INTRODUCTION

The aim of this study was to evaluate the remineralization effect of NaF, NaF with TCP, NaF with CPP-ACP and NaF with CXP varnishes on newly erupted first permanent molars using laser fluorescence (LF) method. The study was a randomized, double-blind, controlled trial with four parallel groups.

METHODS

The study was carried out in 48 high caries-risk children (DMFS >8), aged 6-7 years with newly erupted permanent first molars (initial lesion with 13 < LF value<30). A total of 140 teeth were divided randomly into four groups (n = 35): G1.Duraphat Varnish containing 5% NaF, G2. Clinpro™ White Varnish containing 5% NaF with TCP, G3.Embrace™ Varnish containing 5% NaF with CXP, G4. MI Varnish containing 5% NaF with CPP-ACP. All dental treatments of the patients were completed before the varnish application. The varnishes were applied to the targeted teeth at baseline, 1 and 3 months. Patients were called for follow-up appointments at 1, 3 and 6 months, and LF scanning was used to monitor mineralization changes. Data were analysed statistically by Wilcoxon signed-rank and Mann-Whitney U-tests.

RESULTS

In total, 40 children (122 teeth) completed the trial. At the end of 6 months, the amount of reduction in LF values (indicating remineralization) are as follows: NaF with CXP(6.87 ± 4.32) < NaF with TCP(7.36 ± 7.05) < NaF(7.40 ± 7.03) < NaF with CPP-ACP(8.33 ± 4.90). All of the varnishes resulted in significant decrease in LF measurements and there was no significant difference between control (NaF alone) group and other groups. Only MI varnish had a significantly greater remineralization effect than Embrace™ Varnish (p < 0.05).

CONCLUSION

As a non-invasive approach, CPP-ACP, TCP and CXP containing NaF varnishes have the potential to remineralize initial caries lesions on permanent first molars in high caries-risk children.

Remineralisation of enamel and dentine with stabilised stannous fluoride dentifrices in a randomised cross-over in situ trial

OBJECTIVES

To compare the remineralisation efficacy and ion bioavailability of two novel SnF2-containing dentifrices in a blinded, cross-over, randomised in situ clinical study.

METHODS

Six participants wore removal palatal appliances holding human enamel and dentine blocks with subsurface lesions. Appliances were worn for two treatment periods of 14 consecutive days each, with a one-week washout period in-between. Participants were randomly allocated to rinse with a 1:5 diluted coded slurry of one of two dentifrices containing either 5 % casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) +1100 ppm F as SnF2 [MIPOP], or 1100 ppm F as SnF2 [CT], for 1 min, four times a day. Saliva was collected post-treatment and analysed for tin, calcium, inorganic phosphate and fluoride ions using atomic absorption spectrophotometry and ion chromatography. Enamel and dentine lesions were analysed for percent remineralisation (%R) using transverse microradiography and percent surface microhardness recovery (%SMHR).

RESULTS

MIPOP released significantly higher F (3.00 ± 0.27 mM), Ca (15.23 ± 3.23 mM) and Sn (1.18 ± 0.13 mM) into saliva whereas CT released 2.89 ± 0.32 mM F and only 0.84 ± 0.11 mM Ca and 0.28 ± 0.10 mM Sn. MIPOP produced significantly higher %R than CT: 25.6 ± 1.5 % compared to 15.2 ± 0.7 % in enamel, and 33.6 ± 3.1 % compared to 20.6 ± 1.1 % in dentine. Additionally, MIPOP produced significantly higher %SMHR (18.2 ± 7.9 %) compared to CT (4.1 ± 0.6 %).

CONCLUSIONS

Both dentifrices promoted remineralisation, but the MIPOP dentifrice with added CPP-ACP and the ion-stabilising effects of CPP released higher amounts of bioavailable tin and produced significantly higher remineralisation and surface microhardness recovery.

CLINICAL SIGNIFICANCE

Modern dentifrices contain SnF2 for a range of oral health benefits. Challenges associated with stability of these formulations can affect ion bioavailability, reducing efficacy. Two dentifrices with SnF2 promoted remineralisation in situ, however the dentifrice with the added saliva biomimetic CPP-ACP was superior and therefore may produce greater health benefits.

Comparative Evaluation of Remineralizing Potential of Topical Cream Containing Casein Phosphopeptide-Amorphous Calcium Phosphate and Casein Phosphopeptide-Amorphous Calcium Phosphate with Fluoride: An In Vitro Study

The requirement for clinically effective treatments to remineralize early enamel caries lesions is dictated by the principles of minimally invasive dentistry. Numerous studies outlined the significance of treating early carious lesions with different remineralizing agents. This study aimed to evaluate and compare the remineralization potential of topical cream containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and CPP-ACP with fluoride in remineralizing artificial carious lesions on enamel. Forty-five freshly extracted human premolar teeth were selected as samples. These samples were divided into three groups: Group I-regular toothpaste without specific remineralizing agent; Group II-topical cream containing CPP-ACP and Group III topical cream containing CPP-ACP with fluoride. All the samples were viewed under scanning electron microscope (SEM) to assess the topographical pictures of the enamel surface and also subjected to energy dispersing X-ray analysis (EDX) for quantitative estimation of minerals, calcium (Ca), and phosphorous (P). In the result of the study, Group I does not show any increase in the Ca and P after applying toothpaste without any remineralizing agent but Group II and Group III showed a net increase in Ca and P- values after applying concerned remineralizing agents. Intergroup comparison showed Group III yielded higher net Ca and P- values than Group II. Two remineralizing agents showed remineralization potential on samples. Descriptive statistics were used to calculate the mean and standard deviation. Mann-Whitney test was used. The level of significance was set at 0.05. CPP-ACP containing fluoride showed better remineralizing potential than CPP-ACP. Hence, CPP-ACP containing fluoride can be considered the material of choice in remineralizing early enamel carious lesions.

Remineralization potential of dentifrices with calcium sodium phosphosilicate and functionalized tri-calcium phosphate in the deeper incipient carious lesions: An in vitro study

OBJECTIVES

This study evaluated the remineralization potential of calcium sodium phosphosilicate and functionalized tri-calcium phosphate (f-TCP) dentifrices in deeper incipient carious lesions (ICLs).

MATERIALS AND METHODS

Artificial ICLs were created by placing premolars into demineralizing solutions. Teeth were randomly assigned into four groups: calcium sodium phosphosilicate (Group 1), f-TCP (Group 2), 1450 ppm fluoride (Group 3), and distilled water (Group 4), which were subjected to 10-day pH cycling. Mineral density (MD) was assessed using microcomputed tomography (Micro-CT), while hardness (H) and elastic modulus (EM) were assessed using nanomechanical testing.

RESULTS

MD % gain was higher in Groups 1-3 than in Group 4. In addition, Groups 1 and 2 exhibited significantly higher MD % gain than Group 3. Also, Groups 1-3 showed significantly higher EM and H values than Group 4 in the outer enamel area; yet, Groups 1 and 2 displayed significantly higher EM and H values than Groups 3 and 4 in the inner enamel.

CONCLUSIONS

The MD, EM, and H of ICLs significantly increased with the addition of calcium sodium phosphosilicate or f-TCP to fluoridated dentifrices compared to standard fluoride dentifrices. The added active ingredients remineralized the deeper parts of the ICLs, while remineralization at the lesion surface was similar between tested dentifrices.

Comparative evaluation of remineralization potential of four different remineralization agents on human enamel: An in vitro study

Aim

The study aimed to assess the remineralizing potential of four different commercially available agents using a Scanning Electron Microscope (SEM), energy dispersive X-ray (EDX) analysis, and Vickers Microhardness (VMH) Test.

Materials and Methods

Forty-four specimens (n = 11 per group) were prepared from extracted teeth. A window of 6 mm × 4 mm was made on all the specimens that represented three zones, namely, sound enamel, demineralized enamel, and remineralized enamel. The zone for demineralized enamel was subjected to four different remineralizing agents; casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF), tricalcium phosphate fluoride (TCP-F), calcium sucrose phosphate (CSP), and self-assembling peptide (P11-4). Remineralization (REM) was assessed using VMH; the structural changes were assessed using SEM that was analyzed using EDX analysis. The specimens were subjected to a newer regimen of demineralization. One-way ANOVA followed by post hoc Tukey test was used with a level of significance at P ≤ 0.05.

Results

There were no significant differences in VMH between the groups for sound enamel (P = 0.472) and demineralized enamel (P = 0.116). VMH was statistically significantly more for P11-4 and the least for CPP-ACPF (P = 0.011). A post hoc analysis revealed higher VMH for P11-4 compared to CPP-ACPF (P = 0.014) and TCP-F (P = 0.035). SEM showed a homogeneous layer of minerals for all groups except CPP-ACPF. TCP-F reported a higher degree of REM, followed by P11-4 as assessed using EDX analysis.

Conclusion

Self-assembling peptide (P11-4) exhibited a higher degree of REM than other remineralizing agents followed by CSP.

A Spectrophotometric comparative evaluation of the sealing ability of various perforation repair materials with a novel eggshell modified GIC

Objectives

The objective of this study was to evaluate and compare the sealing ability of mineral trioxide aggregate (MTA), Biodentine, glass ionomer cement, and glass ionomer cement modified with Chicken Eggshell Powder when used as furcation perforation repair material.

Materials and Methods

In the present study, 80 human lower first molars were used. Collected teeth had no caries or restoration, and none had fused roots. Every molar had an endodontic access cavity made utilizing a high-speed, long-shank round bur for the initial entry and an Endo-Z for lateral extension and finishing the cavity walls. Each canal's orifice was covered with a temporary filling material. The pulpal floor and cavity walls of every molar were thoroughly coated with two successive coats of clear nail polish. A significant perforation was made between the orifices to the furcation area using a high-speed long shank round bur #4. The perforation centered between the mesial and distal orifice. They were divided into four experimental groups: Group I: 20 molars were repaired using MTA, Group II: 20 molars with Biodentine, Group III: 20 molars were repaired with glass ionomer cement, and Group IV was repaired using glass ionomer cement modified with 7% chicken eggshell powder. Moist cotton pellets were placed over the repair materials, and molars were kept in 100% humidity for 24 h to allow materials to set. Then, according to each group, molars were put in Petri dishes. Methylene blue dye was applied inside the access cavity of all samples for 24 h. Molars were placed under running tap water for 30 min to remove all residues of methylene blue, and then varnish was removed with a Parker blade #15 and polishing discs. Molars were placed in vials containing 1 mL of concentrated (65 wt%) nitric acid for 3 days. Vials were centrifuged at 14,000 rpm for 5 min. The supernatant from each sample was transferred in a quantity of 200 L to a 96-well plate. Sample absorbance was read by an automatic microplate spectrophotometer at 550 nm using concentrated nitric acid as a blank. Statistical analysis was performed using one-way analysis of variance. When the analysis of variance test was significant, the pairwise comparison of the means was done using a Duncan post hoc test. The significance level was set at P < 0.05. Statistical analysis was performed with SPSS 14.0 (SPSS Inc., Chicago, IL, USA) for Windows (Microsoft, Redmond, WA, USA).

Results

The highest dye absorbance was seen in Group III, followed by Groups IV, II, and I.

Conclusion

Within the limitations of study it was concluded that maximum sealing ability was seen in Biodentine followed by MTA, Glass Ionomer Cement modified with 7% Chicken Eggshell powder and Glass Ionomer Cement.

Evaluation of the antibacterial activity of Enamelast® and Fluor defender® fluoride varnishes against Streptococcus mutans biofilm: an in vitro study in primary teeth

PURPOSE

The aim of the current work was to compare the antibacterial activity of Enamelast® and Fluor defender® fluoride varnish on biofilm generation by Streptococcus mutans on extracted primary teeth.

METHODS

Thirty-six primary molars were collected and sliced into seventy-two test model disks. All specimens were examined, and the cracked or broken ones were discarded. A total number of specimens (n = 54) were divided into two experimental analyses viz; biofilm formation (n = 27) and microscopic examination (n = 27). Specimens of each analysis were tested under different experimental conditions: a negative control group (n = 9), Fluor defender group (n = 9), and Enamelast group (n = 9). Following treatment, biofilms were generated by adherent Streptococcus mutans on the test model disks on three time intervals: 24 h (n = 3), 48 h (n = 3), and 72 h (n = 3) for each analysis. Then, for biofilm formation analysis, the biofilm was detected spectrophotometrically at 620 nm after being stained by crystal violet. For microscopical analysis, the surfaces of the test model disks were visualized by scanning electron microscopy (SEM), and each image was processed and analyzed using ImageJ software.

RESULTS

At 48 and 72 h, Enamelast® and Fluor defender®-treated group showed significantly (p < 0.001) slight adhered bacterial cells when compared with the negative control group as revealed by the absorbance and SEM. Compared with the Fluor defender®-treated group, the absorbance of the Enamelast®-treated group showed a significant (p < 0.001) increase by approximately 7- and 16.5-fold at 48 and 72 h, respectively. Similarly, SEM showed that the number of bacterial cells adhered to enamel surfaces in the Fluor defender®-treated group was significantly (p < 0.001) fewer than the Enamelast®-treated group by approximately 36.55% and 20.62% at 48 and 72 h after exposure, respectively.

CONCLUSION

We conclude that the anti-biofilm activity of Fluor defender® against Streptococcus mutans was significantly (p < 0.001) greater than Enamelast® fluoride varnish. The use of Fluor defender® is encouraged as a preventive measure in children with the high risk of developing dental caries.

A novel orthodontic adhesive containing zinc-doped phosphate-based glass for preventing white spot lesions

OBJECTIVES

This study aimed at demonstrating the remineralization effect of the enamel around the brackets to aid reduction in white spot lesions (WSLs) with use of zinc-doped phosphate-based glass (Zn-PBG) containing orthodontic adhesives.

METHODS

Zn-PBG powder was synthesized, and particle morphology, size, and density were evaluated. Orthodontic adhesives with increasing loading percentage of Zn-PBG powder were prepared: ZnPG3 (3 wt.%), ZnPG6 (6 wt.%), and ZnPG9 (9 wt.%). Brackets were bonded on the etched enamel surface and stored in distilled water (DW) for 1 h. Following, Shear bond strength (SBS) along with adhesive remnant index were analyzed. The release of calcium (Ca), phosphorus (P), and zinc (Zn) from adhesive specimens in DW was evaluated after 7, 15 and 30 days of immersion. The remineralization effect was confirmed by microhardness and surface morphology analysis with scanning electron microscopy.

RESULTS

The SBS value was observed between 20 and 22 MPa on enamel surface. The concentration of Ca, P and Zn released in DW increased with loading percentage of Zn-PBG. The microhardness increased in the experimental groups after immersion in artificial saliva for 7 days. Apatite-like crystal formation was observed after 30 days in the ZnPG 9 group.

CONCLUSIONS

The orthodontic adhesive containing Zn-PBG with an optimal SBS performance has an enamel remineralization effect, and therefore can aid in prevention of WSLs.

CLINICAL SIGNIFICANCE

The orthodontic adhesive containing Zn-PBG is clinically advantageous as it can promote remineralization and resist the formation of WSLs that may occur during orthodontic therapy.

Comparative Efficacy of Novel Biomimetic Remineralising Technologies

Biomimetic technologies for the remineralisation of enamel subsurface lesions (ESLs) have been developed and include: fluorocalcium phosphosilicate bioglass (BG/F); casein phosphopeptide-amorphous calcium phosphate (CPP−ACP) and with fluoride (CPP−ACFP); and self-assembling oligopeptide P11-4 (SAP). The aim of this study was to compare the remineralisation of ESLs in vitro using these technologies. Human enamel slabs with ESLs were cut into two half-slabs; one half-slab was untreated (control), and the other half was treated by exposure to one of the four technologies with artificial saliva (AS) or AS alone for 14 days at 37 °C. The technologies were applied to the ESL surface according to the manufacturer’s instructions. At the completion of each treatment, the treated half-slabs and their paired control half-slabs were embedded, sectioned and the mineral content was determined using transverse microradiography. The change in mineral content (remineralisation) between treatments was statistically analysed using one-way ANOVA. The order from highest to lowest remineralisation was CPP−ACFP (52.6 ± 2.6%) > CPP−ACP (43.0 ± 4.9%) > BG/F (13.2 ± 2.5%) > SAP (5.8 ± 1.6%) > AS (2.1 ± 0.5%). Only CPP−ACFP and CPP−ACP produced remineralisation throughout the body of the lesions. All four biomimetic technologies had some effect on the remineralisation of ESLs; however, CPP−ACFP with calcium, phosphate and fluoride ions stabilised by CPP was superior in the level and pattern of remineralisation obtained.

Comparison of calcium-based technologies to remineralise enamel subsurface lesions using microradiography and microhardness

Assessment of enamel subsurface lesion remineralisation is essential for the evaluation of novel remineralisation technologies. The gold standard to assess subsurface mineral gain of enamel lesions is transverse microradiography (TMR). However, some studies have utilised surface microhardness (SMH) to evaluate efficacy of remineralisation agents. The aim of this study was to assess remineralisation of enamel subsurface lesions using TMR and SMH after in vitro treatment with calcium-containing technologies, and to test correlation between the TMR and SMH measurements. The parameters obtained from the TMR and SMH analyses of enamel subsurface remineralisation were not significantly correlated. Furthermore, the enamel subsurface remineralisation as measured by TMR was significantly correlated with the water-soluble calcium concentration of the remineralisation products. Scanning electron microscopy revealed surface precipitates formed by specific remineralisation treatments obfuscated accurate assessment of remineralisation by SMH. It was concluded that TMR is a more appropriate method for analysis of enamel subsurface remineralisation, and that SMH values of remineralised enamel should be interpreted with caution. Using TMR the level of remineralisation (%R) by the different technologies was CPP-ACP/F (31.3 ± 1.4%); CPP-ACP (24.2 ± 1.4%); CaSO₄/K₂HPO₄/F (21.3 ± 1.4%); f-TCP/F (20.9 ± 1.0%); Nano-HA/F (16.3 ± 0.3%); Nano-HA (15.3 ± 0.6%) and F alone control (15.4 ± 1.3%).

Novel trends, challenges and new perspectives for enamel repair and regeneration to treat dental defects

Dental enamel is the hardest tissue in the human body, providing external protection for the tooth against masticatory forces, temperature changes and chemical stimuli. Once enamel is damaged/altered by genetic defects, dental caries, trauma, and/or dental wear, it cannot repair itself due to the loss of enamel producing cells following the tooth eruption. The current restorative dental materials are unable to replicate physico-mechanical, esthetic features and crystal structures of the native enamel. Thus, development of alternative approaches to repair and regenerate enamel defects is much needed but remains challenging due to the structural and functional complexities involved. This review paper summarizes the clinical aspects to be taken into consideration for the development of optimal therapeutic approaches to tackle dental enamel defects. It also provides a comprehensive overview of the emerging acellular and cellular approaches proposed for enamel remineralization and regeneration. Acellular approaches aim to artificially synthesize or re-mineralize enamel, whereas cell-based strategies aim to mimic the natural process of enamel development given that epithelial cells can be stimulated to produce enamel postnatally during the adult life. The key issues and current challenges are also discussed here, along with new perspectives for future research to advance the field of regenerative dentistry.

Remineralizing Potential of Milk and GC Tooth Mousse on Demineralized Human Enamel: An In Vitro Comparative Evaluation

Introduction Caries initiation is associated with demineralization of the subsurface tooth enamel. Today, bioactive agents based on milk products have been developed to enhance remineralization under cariogenic conditions. However, there is limited information on the remineralization potential of milk.

Materials and Methods Fifty enamel specimens were prepared from sound human premolars. All enamel specimens were then placed in demineralizing solution for 4 days at 37°C to produce artificial carious lesion. Baseline surface microhardness (SMH) was evaluated using Vickers indenter. Enamel specimens were then randomly divided into three groups. Group 1 specimens were kept in artificial saliva, whereas group 2 and 3 enamel specimens were treated with milk and GC tooth mousse, respectively, for 5 minutes twice daily for 21 days. Post-treatment SMH measurements of all specimens were evaluated on the 7th, 14th, and 21st day. Data was statistically analyzed using one-way analysis of variance test and Tukey honest significant difference post-hoc test.

Results There were no significant differences in the SMH values in the control group at any time interval. There were statistically significant increases in the post-SMH values in milk and GC tooth mousse (p < 0.001) at the end of 21st day of remineralization.

Conclusion Milk showed remineralization potential comparable to that of GC tooth mousse.

Advanced non-fluoride approaches to dental enamel remineralization: The next level in enamel repair management

In modern dentistry, a minimally invasive management of early caries lesions or early-stage erosive tooth wear (ETW) with synthetic remineralization systems has become indispensable. In addition to fluoride, which is still the non-plus-ultra in these early caries/ETW treatments, a number of new developments are in the test phase or have already been commercialized. Some of these systems claim that they are comparable or even superior to fluoride in terms of their ability to remineralize enamel. Besides, their use can help avoid some of the risks associated with fluoride and support treatments of patients with a high risk of caries. Two individual non-fluoride systems can be distinguished; intrinsic and extrinsic remineralization approaches. Intrinsic (protein/peptide) systems adsorb to hydroxyapatite crystals/organics located within enamel prisms and accumulate endogenous calcium and phosphate ions from saliva, which ultimately leads to the re-growth of enamel crystals. Extrinsic remineralization systems function on the basis of the external (non-saliva) supply of calcium and phosphate to the crystals to be re-grown. This article, following an introduction into enamel (re)mineralization and fluoride-assisted remineralization, discusses the requirements for non-fluoride remineralization systems, particularly their mechanisms and challenges, and summarizes the findings that underpin the most promising advances in enamel remineralization therapy.

Effects of Fluoride and Calcium Phosphate-Based Varnishes in Children at High Risk of Tooth Decay: A Randomized Clinical Trial

BACKGROUND

The aim of this study was to investigate the effect of the application of two varnishes-MI Varnish (5% sodium fluoride with CPP-ACP) and Clinpro White Varnish (5% sodium fluoride with fTCP)-applied every three months in children with high caries risk for 12 months on plaque indexes, salivary pH, salivary lactic acid and chemical elements concentrations.

METHODS

We included 58 children aged 4-12 years, assigned to control (placebo), Clinpro and MI groups. Baseline and three-month saliva samples were taken. We assessed changes in pH, lactic acid concentrations and chemical elements in saliva.

RESULTS

At 12 months, all groups showed a nonsignificant increase in pH levels and a reduction in lactic acid, which was greatest in the placebo group. There was a significant reduction in ²⁴Mg (p = <0.001), ³¹P (p = 0.033) and ⁶⁶Zn (p = 0.005) levels in the placebo group (p ≤ 0.05), but not in the other elements studied: ²³Na, ²⁷Al, ³⁹K, ⁴⁴Ca, ⁵²Cr, ⁵⁵Mn, ⁵⁷Fe, ⁵⁹Co, ⁶³Cu, ⁷⁵As, ¹¹¹Cd, ¹³⁷Ba, ²⁰⁸Pb and ¹⁹F.

CONCLUSIONS

Neither pH, lactic acid concentrations or most salivary chemical elements were useful in defining patients at high risk of caries or in monitoring the effect of MI Varnish and Clinpro White Varnish after three-month application for 12 months. However, the appearance of new cavities was stopped, and the hygiene index improved, probably due to hygienic and dietary measures and the use of fluoridated toothpaste.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN13681286.

In vitro mineral apposition analysis of two Colombian plant extracts on Amelogenesis imperfecta teeth

OBJECTIVE

To determine if native Colombian Piper marginatum Jacq. and Ilex guayusa Loes plant extracts have a remineralizing effect on teeth with Amelogenesis imperfecta in comparison with the commercial products Clinpro-3M and Recaldent™.

MATERIAL AND METHODS

An in vitro study was carried out with 128 human teeth slices (64 healthy and 64 with Amelogenesis imperfecta) on which an initial Raman spectroscopy was performed followed by Raman spectroscopies at 0, 24, 48, and 72 h to determine possible remineralization by observing mineral increase or decrease as a result of P. marginatum Jacq. and I. guayusa Loes extract application in comparison to control substance (Clinpro and Recaldent™) application. Obtained data were analyzed using a bivariate method with a t unidirectional test. Significant differences among groups were determined by an ANOVA with Dunnett post hoc tests.

RESULTS

Native I. guayusa Loes and P. marginatum Jacq. Colombian plants extracts exhibited phosphate and orthophosphate mineral apposition, where P. marginatum Jacq. presented better results.

CONCLUSIONS

Native Colombian I. guayusa Loes and P. marginatum Jacq plant extract might in the future be useful for dental tissue remineralization, as they induced phosphate and orthophosphate mineral apposition, main components of tooth enamel. These types of natural compounds can become an alternative to fluorine, whose ingestion is harmful to the human body.

The Efficacy of Non-fluoridated Toothpastes on Artificial Enamel Caries in Primary Teeth: An In Vitro Study

Aims

The aim of this study was to evaluate the remineralizing effect among various non-fluoridated toothpastes on artificial caries in primary teeth.

Materials and Methods

Fifty sound primary incisor teeth were embedded in self-curing acrylic resin and immersed in demineralizing solution for 4 days forming artificial caries. All teeth were divided into five groups (10 teeth/group): Group I deionized water (control); Group II 1000 ppm F (Kodomo^®); Group III non-fluoridated toothpaste containing calcium glycerophosphate and calcium lactate (Dokbuaku^®); Group IV casein phosphopeptides-amorphous calcium phosphate (CPP-ACP) paste (GC Tooth Mousse^®), and Group V non-fluoridated toothpaste containing nanohydroxyapatite (NHA) (Apagard^®). The specimens were subjected to pH-cycling and immersed in toothpaste slurry twice for 7 days. Baseline, before, and after pH-cycling surface microhardness (SMH) values were measured by Vickers hardness numbers, and the percentage recovery of SMH (%SMHR) was calculated. Data were analyzed by one-way analysis of variance and Tukey's multiple comparison at 95% confidence intervals.

Results

The SMH values of test groups were significantly higher than those of the control group (p = 0.00). The %SMHR was -5.72±7.03% in the control group, Group II was significantly higher than Group III but there were no significant differences among Groups II, IV, and V (p > 0.05).

Conclusion

Non-fluoridated toothpastes containing CPP-ACP or NHA for young children had efficacy in remineralizing effect on primary teeth comparable with 1000 ppm fluoridated toothpaste.

Effectiveness of CPP-ACP and Fluoride Products in Tooth Remineralization

OBJECTIVES

To compare the effectiveness of the casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) in the in situ remineralization of enamel exposed to two different degrees of preformed enamel lesions.

METHODS

One hundred and sixty 3x3x2 mm human enamel slabs were demineralized and divided into two subgroups according to baseline surface hardness (SH=B1≤150 and B2 >150). During each of four 10-day experimental periods, 10 participants wore intraoral removable acrylic palatal expanders with four human enamel slabs with preformed lesions (B1 and B2): CO1 and CO2 - Control: silica dentifrice without fluoride; MP1 and MP2: MI Paste; MPP1 and MPP2: MI Paste Plus; and FD1 and FD2: Fluoride dentifrice. The Knoop hardness test (50/15s Micromet 2001, Buehler, IL, USA) was performed after demineralization (B1 and B2) and after treatment (T1 and T2).

RESULTS

SH was higher in all treatment groups when compared with the controls, except for CO2 (Mann Whitney Wilcoxon Test; p <0.05). %SH was similar between MPP2 and FD2 and between MPP2 and MP2; however, FD2 and MPP2 products were more effective in microhardness recovery. In B1, all treatment groups were similar.

CONCLUSION

MPP and FD are more effective in preventing demineralization in enamel subsurface lesions.

An In Vitro Evaluation of Remineralization Potential of Functionalized Tricalcium Phosphate Paste and CPP-ACPF on Artificial White Spot Lesion in Primary and Permanent Enamel

Aim

Investigation and evaluation of remineralization potential of functionalized tricalcium phosphate paste (fTCP) and casein phosphopeptide-amorphous calcium phosphate (CPP-ACPF) paste on artificially created white spot lesion on human primary and permanent enamel through scanning electron microscopy and microhardness assessment.

Materials and methods

Sixty freshly extracted primary and permanent teeth were selected and artificial white spot lesion were created by using standardized demineralizing solution. Remineralization was carried out using the test pastes. The assessment of demineralization and remineralization was done through a scanning electron microscope and microhardness assessment.

Results

Among the three groups, fTCP shows significantly higher increase in mean microhardness (p < 0.001) through ANOVA and the LSD post hoc test when compared to CPP-ACPF and control group. Also, the unpaired t-test showed that mean change in microhardness in permanent teeth was significantly higher than primary teeth in different time intervals for both experimental groups. Surface morphology was assessed through a scanning electron microscope.

Conclusion

Based on the results of the current study, f-TCP showed comparatively more remineralization potential than CPP-ACP with fluoride.

How to cite this article

Bhadoria N, Gunwal MK, Kukreja R, et al. An In Vitro Evaluation of Remineralization Potential of Functionalized Tricalcium Phosphate Paste and CPP-ACPF on Artificial White Spot Lesion in Primary and Permanent Enamel. Int J Clin Pediatr Dent 2020;13(6):579–584.

Comparative evaluation of remineralizing potential of commercially available agents MI paste, Remin pro, and Clinpro using Scanning Electron Microscope and Energy Dispersive X-ray: An in vitro study

Background:

According to recent approaches, the prevention of initial dental caries is achieved using certain noninvasive methods. One such method is the topical application of remineralizing agents. Various remineralizing products are commercially available, but their efficacy is uncertain.

Aim:

The aim of the study was to evaluate the remineralizing potential of MI, Reminpro, and Clinpro using scanning electron microscope (SEM) and energy dispersive X-ray (EDX).

Methodology:

Forty extracted human premolars were collected. The samples were decoronated and the crown portion was coated with nail varnish leaving behind a 3 mm × 3 mm window on the labial surface. The samples were soaked in demineralizing solution for 4 days to create an artificial lesion, followed by SEM-EDX analysis. The samples were then randomly divided into 4 groups Control, MI, Remin Pro, and Clinpro with ten samples each. The remineralizing agents were applied according to the group and subjected to pH cycling for 21 days which was followed by SEM-EDX analysis. Data obtained were statistically analyzed using SPSS IBM version 23 (ANOVA, post hoc-Tukey, and Paired-t-test).

Results:

Ca and P were increased after remineralization in all groups. Between groups, the increase was more for ReminPro, followed by Clinpro and MI.

Conclusion:

In this study, the remineralizing potential of Remin Pro was effectively more, followed by Clinpro and MI.

In vitro remineralization of primary teeth with a mineralization-promoting peptide containing dental varnish

Mineralization-promoting peptides are attractive candidates for new remineralization systems. In previous studies, peptides have been applied as aqueous solutions, which is not a clinically relevant form.

OBJECTIVE

This study aims to investigate the efficiency of a mineralization-promoting peptide, applied in varnish, on remineralizing artificial caries on primary teeth.

METHODOLOGY

55 primary molars were collected. Specimens were immersed in a demineralizing solution for 7 days and then, divided into 7 groups: Baseline: No-remineralization, Placebo: Blank colophony, F: Colophony 5% fluoride, P: Colophony 10% peptide, P+F: Colophony 5% fluoride and 10% peptide, Embrace: Embrace™ varnish, Durashield: Durashield™ varnish. A mixture of 35% w/v colophony varnishes were prepared in ethanol and applied accordingly. Specimens were immersed in a remineralization solution for 4 weeks and it was evaluated using PLM and SEM. Lesion depth reduction was examined by one-way ANOVA.

RESULTS

There was no significant difference in mean lesion depths between baseline (147.04 ± 10.18 μm) and placebo groups (139.73 ± 14.92 μm), between F (120.95 ± 12.23 μm) and Durashield (113.47 ± 14.36 μm) groups and between P (81.79 ± 23.15 μm) and Embrace (90.26 ± 17.72 μm) groups. Lesion depth for the P+F group (66.95±10.59 μm) was significantly higher compared to all other groups. All groups contained samples with subsurface demineralized regions. Number of subsurface demineralized regions were higher in fluoride-containing groups.

CONCLUSIONS

We conclude that the mineralization-promoting peptide (MPP3) is effective in this in vitro study and the peptide shows benefits over fluoride as it yields less subsurface demineralized regions.

Remineralization and fluoride uptake of white spot lesions under dental varnishes

INTRODUCTION

The aim of this study was to evaluate white spot lesion (WSL) remineralization and fluoride uptake by the application of fluoride varnishes directly onto artificial WSLs in vitro.

METHODS

MI varnish containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and 2.26% fluoride and Duraphat varnish containing 2.26% fluoride (no added calcium) were compared with a placebo varnish (no added calcium or fluoride). Two WSLs were prepared in enamel slabs and varnish applied to cover one of the two lesions. Each slab was immersed in artificial saliva for 14 days at 37°C. Mineral content was determined using transverse microradiography and fluoride uptake using electron probe microanalysis. The data were statistically analysed using a linear mixed model.

RESULTS

Both MI and Duraphat varnishes significantly remineralized the covered and uncovered WSLs when compared with the placebo varnish (P < 0.001). The WSLs covered with varnish showed greater remineralization than those uncovered. MI varnish produced the highest level of remineralization and significantly greater fluoride uptake (0.44 ± 0.08 wt%) compared with Duraphat (0.24 ± 0.03 wt%) and the placebo varnish (0.06 ± 0.05 wt%).

CONCLUSION

Varnish containing fluoride and CPP-ACP was superior to varnish containing fluoride alone in promoting WSL remineralization and fluoride uptake.

Effect of CPP-ACP on remineralization of artificial caries-like lesion: an in situ study

The purpose of this double-blind, randomized, crossover in situ study is to compare remineralization of preformed enamel lesions by casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) and fluoride dentifrice products. During each of four 10-day experimental legs, 10 participants wore intraoral removable palatal acrylic appliances with four human enamel slabs with preformed lesions. A 0.03-mL treatment paste was dripped extraorally onto the enamel blocks once a day for 3 min. The four randomly allocated treatments were as follows: CO- Control: silica dentifrice without fluoride; MP: MI Paste; MPP: MI Paste Plus and FD: Fluoride dentifrice - 1100 ppm F as NaF). Knoop surface hardness (SH) test was performed in three stages (T0 - sound enamel, T1 - after preformed lesion, and T2 - after treatment) and the cross-sectional hardness (CSH) test was performed after treatment using a 50-gram Knoop load for 15 s. Knoop hardness number (KHN) was similar between treatments. %SHr was significantly higher in the MP, FD, and MPP when compared to CO group (Kruskal-Wallis and Mann-Whitney tests, p < 0.05). Harder enamel was found in MP (75 μm) and FD groups at 75 to 175 μm. Treatment with DF, MP, and MPP promoted an increase of 20.27%, 19.24%, and 14.71%, respectively, in Integral Hardness Change (ΔIHC) when compared to CO (p<0.05). Remineralizing agents (MP, MPP, and DF) were able to inhibit demineralization of human enamel subjected to high cariogenic challenge in situ. DF had the greatest preventive potential against the progression of carious lesions.

Morpho-Chemical Observations of Human Deciduous Teeth Enamel in Response to Biomimetic Toothpastes Treatment

Today, biomaterial research on biomimetic mineralization strategies represents a new challenge in the prevention and cure of enamel mineral loss on delicate deciduous teeth. Distinctive assumptions about the origin, the growth, and the functionalization on the biomimetic materials have been recently proposed by scientific research studies in evaluating the different clinical aspects of treating the deciduous tooth. Therefore, appropriate morpho-chemical observations on delivering specific biomaterials to enamel teeth is the most important factor for controlling biomineralization processes. Detailed morpho-chemical investigations of the treated enamel layer using three commercial toothpastes (Biorepair, F1400, and F500) were performed through variable pressure scanning electron microscopy (VP-SEM) and energy dispersive X-ray spectroscopy (EDS) on deciduous teeth in their native state. A new microscopy methodology allowed us to determine the behaviors of silicate, phosphate, and calcium contents from the early stage, as commercially available toothpastes, to the final stage of delivered diffusion, occurring within the enamel layer together with their penetration depth properties. The reported results represent a valuable background towards full comprehension of the role of organic-inorganic biomaterials for developing a controlled biomimetic toothpaste in biofluid media.

Efficacy of remineralizing agents to occlude dentinal tubules in primary teeth subjected to dentin hypersensitivity in vitro: SEM study

Aim:

Comparison of casein phosphopeptides (CPPs) and amorphous calcium phosphate (ACP), tricalcium phosphate, and hydroxyapatite on assessment of dentine tubule occlusion on primary enamel using scanning electron microscope (SEM).

Materials and Methods:

A total of 20 freshly extracted noncarious primary molars were randomly divided into four groups (A to D) with five sections in each group; group A: negative control, group B: CPP-ACP, group C: tricalcium phosphate, and group D: Hydroxyapatite (HA). To assess tubule occlusion, 20 dentin sections of 2 mm thickness were obtained from cervical third of sound primary molars. Each section were processed to simulate the hypersensitive dentin and the test agents were brushed over the sections with an electric toothbrush and observed under SEM for calculation of the percentage of occluded tubules.

Results:

Group B and D showed greater percentage of tubule occlusion than group C. Intergroup comparison of tubule occlusion potential of Group B and D was not significant.

Conclusion:

HA showed significantly higher dentinal tubule occlusion when compared to CPP-ACP and tricalcium phosphate.

Evaluation of the efficacy of casein phosphopeptide-amorphous calcium phosphate on remineralization of white spot lesions in vitro and clinical research: a systematic review and meta-analysis

BACKGROUND

This systematic review with meta-analyses sought to answer whether casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) provided a remineralizing benefit superior to that of nonintervention or placebo.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, Cochrane databases, PubMed, EmBase, and Ovid up to May 20th, 2019, were scanned, only published in English. Study information extraction and methodological quality assessments were accomplished independently by two reviewers. The "Criteria for judging risk of bias in the 'Risk of bias' assessment tool" was used for methodological quality assessment. The continuous data was analyzed by mean difference (MD) or standardized mean difference (SMD) with a 95% confidence interval (CI). Review Manager 5.3 was used for statistical analysis. Outcome variables include quantitative light-induced fluorescence in clinical research, average surface roughness and surface microhardness in vitro.

RESULTS

There were significant differences in the quantitative light-induced fluorescence (SMD = - 0.43, 95% CI: [- 0.79, - 0.07], P = 0.02), average surface roughness (SMD = - 8.21, 95% CI: [- 10.37, - 6.04], P < 0.01), Vickers microhardness (SMD = 1.19, 95% CI: [0.72, 1.66], P < 0.01), and Knoop microhardness (SMD = 3.52, 95% CI: [2.68, 4.36], P < 0.01) between the CPP-ACP and control groups or baseline.

CONCLUSION

Within the limitations of this meta-analysis, CPP-ACP exhibited excellent remineralization effects evaluated in clinical research and in vitro, indicating outstanding restoration of form, aesthetics, and function in treating white spot lesions.

Comparative Analysis of CPP&ndash;ACP, Tricalcium Phosphate, and Hydroxyapatite on Assessment of Dentinal Tubule Occlusion on Primary Enamel Using SEM: An In Vitro Study

Background

Over the last few decades, fluoride in various forms has been proved to reduce caries and dentinal hypersensitivity in both the primary and permanent dentitions. Recently, newer materials containing calcium and phosphate ions, tricalcium phosphate, and hydroxyapatite has received much attention.

Aim

The aim of the study was to compare CPP–ACP, tricalcium phosphate, and hydroxyapatite in relation to the assessment of dentine tubule occlusion on primary enamel using scanning electron microscope (SEM).

Materials and methods

Forty freshly extracted noncarious primary molars were randomly divided into 4 groups (I–IV) with 10 sections in each group—group I: negative control, group II: CPP–ACP, group III: tricalcium phosphate, group IV: hydroxyapatite. To assess tubule occlusion, twenty dentin sections of 2-mm thickness were obtained from the cervical third of sound primary molars. Each section was processed to simulate the hypersensitive dentin and the test agents were brushed over the sections with an electric toothbrush and observed under a SEM for calculation of the percentage of occluded tubules.

Results

Groups II and IV showed a greater percentage of tubule occlusion than group III. An intergroup comparison of tubule occlusion potential of groups II and IV was not significant.

Conclusion

Hydroxyapatite showed significantly higher dentinal tubule occlusion when compared to CPP–ACP and tricalcium phosphate.

How to cite this article

Shah R, Bajaj M. Comparative Analysis of CPP–ACP, Tricalcium Phosphate, and Hydroxyapatite on Assessment of Dentinal Tubule Occlusion on Primary Enamel Using SEM: An In Vitro Study. Int J Clin Pediatr Dent 2019;12(5):371–374.

Effects of Bovine Serum Albumin and High pH Pre-Treatment on the Remineralisation of Enamel Subsurface Lesions in vitro

Accumulated intra-lesion protein such as serum albumin has been speculated to impede remineralisation of carious enamel lesions. The aim of this study was to assess whether intra-lesion bovine serum albumin (BSA) affected subsequent remineralisation of enamel subsurface lesions. Confocal microscopy was used to confirm localisation of BSA in artificial enamel subsurface lesions and its subsequent degradation by a high pH sodium hypochlorite treatment. An in vitro remineralisation experiment tested the effect of intra-lesion BSA, and its degradation by sodium hypochlorite, on remineralisation of subsurface lesions by casein phosphopeptide stabilised amorphous calcium fluoride phosphate. In addition, lesions without BSA were pre-treated with one of 2 high pH solutions (sodium hypochlorite or sodium hydroxide) prior to remineralisation to test whether the high pH pre-treatment influenced remineralisation. Data were obtained on remineralisation using transverse microradiography and were analysed with a one-way ANOVA. Intra-lesion BSA had no significant effect on remineralisation compared with that of control lesions. Pre-treatment of BSA-containing lesions with sodium hypochlorite significantly increased remineralisation. The lesions without BSA that were pre-treated with either sodium hypochlorite or sodium hydroxide also showed the same level of remineralisation as the BSA-containing lesions pre-treated with sodium hypochlorite indicating that the increased remineralisation was pH related. Hence, it was concluded that intra-lesion BSA did not affect remineralisation of artificial enamel subsurface lesions in this model system and that a high pH pre-treatment enhanced remineralisation.

Effects of soy and bovine milk beverages on enamel mineral content in a randomized, double-blind in situ clinical study

Soy beverages are promoted as healthy alternatives to bovine milk even though they can contain added sugar.

OBJECTIVES

To compare enamel mineral content after consumption of bovine milk or a soy beverage in a double-blind, randomized, cross-over in situ clinical study.

MATERIALS AND METHODS

Human enamel slabs with subsurface lesions were prepared and inserted into intra-oral appliances worn by volunteers who consumed 200 ml of either bovine milk or a soy beverage over a 60 s period once a day for 15 days. Enamel lesion depth and mineral content were measured using transverse microradiography. Saliva samples were collected immediately after consuming the beverages and calcium, inorganic phosphate and fluoride levels analysed. Data were statistically analysed using a linear mixed model.

RESULTS

Depth of the enamel subsurface lesions increased by 7.1 ± 2.0 μm and mineral content decreased by 47 ± 22 vol% min.μm after consumption of the soy beverage indicating demineralization. However, after consumption of bovine milk the depth of the lesions decreased by 7.6 ± 3.5 μm and mineral content increased by 202 ± 43 vol% min.μm indicating remineralization. The changes were significantly different (p < 0.001) between the two beverages. Fluoride levels were similar in the saliva samples for both beverages, however the calcium and inorganic phosphate levels for the bovine milk group were significantly higher (p < 0.02) than those for the soy beverage group.

CONCLUSIONS

In this randomized, double-blind in situ clinical trial consumption of a soy beverage demineralized enamel whereas bovine milk produced remineralization.

CLINICAL SIGNIFICANCE

Although soy beverages are promoted as healthy alternatives to bovine milk the added sugar and low calcium bioavailability of the soy drink makes frequent consumption a caries risk. (Trial registration no. ISRCTN19137849).

"Setting the scene in early childhood" - an MID approach for life

This article presents a discussion paper for both consideration and implementation of Minimal Intervention Dentistry (MID) principles by the general dental practitioner. It argues that if these concepts can be adopted in early childhood by both the community and the profession, "Teeth for Life" can become a reality for all. Oral Health promoting behaviours can be nurtured and supported from infancy and developed into everyday living practice for a lifetime thereby maintaining an optimal quality of life. MID techniques have become more refined and supported by scientific research in the recent times and should be considered an essential clinical guideline for the future disease management.

The in vitro remineralizing effect of CPP-ACP and CPP-ACPF after 6 and 12 weeks on initial caries lesion

Objective:

The aim of this in vitro study was to determine the effects of remineralization promoting agents containing casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP), or CPP-ACP in combination with fluoride (CPP-ACPF) on artificial white spot lesions (WSLs) after 6 and 12 weeks.

Methodology:

White spot lesions were created on 123 sectioned premolars (246 specimens) with a demineralization solution during a 96 hours pH-cycling regime. Two experimental groups were created: a CPP-ACP group (Tooth Mousse™), and a CPP-ACPF group (Mi Paste Plus™). Additionally, two control groups were created, one using only a conventional toothpaste (1450 ppm fluoride) and another one without any working agents. All teeth were also daily brushed with the conventional toothpaste except the second control group. Tooth Mousse™ and Mi Paste Plus™ were applied for 180 seconds every day. The volume of demineralization was measured with transverse microradiography. Six lesion characteristics regarding the lesion depth and mineral content of WSLs were also determined.

Results:

The application of CPP-ACP and CPP-ACPF had a significant regenerative effect on the WSLs. Compared to Control group 1 and 2 the volume of demineralization after 6 weeks decreased significantly for CPP-ACP (respectively p<0.001 and p<0.001) and CPP-ACPF (respectively p=0.001 and p=0.003). The same trend was observed after 12 weeks. For the CPP-ACPF group, WSL dimensions decreased significantly between 6 and 12 weeks follow-up (p=0.012). The lesion depth reduced significantly after application of CPP-ACP and CPP-ACPF but increased significantly in the Control groups. Mineral content increased for CPP-ACP and CPP-ACPF after an application period of 12 weeks, but this was only significant for CPP-ACP.

Conclusions:

Long-term use of CPP-ACP and CPP-ACPF in combination with a conventional tooth paste shows beneficial effects in the recovery of in vitro subsurface caries lesions.

Carious lesion remineralizing potential of fluoride- and calcium-containing toothpastes: A laboratory study

BACKGROUND

The authors conducted a laboratory study to determine the carious lesion remineralization and fluoridation potential of fluoride (F)- and calcium-containing toothpastes.

METHODS

The authors created early carious lesions in bovine enamel specimens and assigned them to 7 treatment groups on the basis of their surface Vickers microhardness: Clinpro Tooth Crème (Clinpro) (3M ESPE), CTx4 Gel 1100 (CTx4) (Oral Biotech), Enamelon Fluoride Toothpaste (Enamelon) (Premier Dental), MI Paste ONE (MI-One) (GC America), Crest Cavity Protection Toothpaste (Crest) (Procter & Gamble), and 2 F-dose controls (low F, high F). The authors pH cycled the specimens for 10 days by using an established model, determined changes in surface microhardness, calculated percentage of surface microhardness recovery (%SMHr; primary outcome variable), and measured enamel F uptake (EFU). The authors used a 1-way analysis of variance for data analysis.

RESULTS

Study results showed an F-dose response for both %SMHr (low-F control: mean, 9.8; 95% confidence interval [CI], 5.7 to 13.8); Crest: mean, 26.2; CI, 21.8 to 30.6; high-F control: mean, 33.5; CI, 29.4 to 37.5) and EFU (low-F control: mean, 47; CI, 12 to 83; Crest: mean, 225; CI, 189 to 260; high-F control: mean, 307; CI, 271 to 342; all micrograms of F per cubic centimeter). For %SMHr, Clinpro (mean, 26.5; CI, 22.5 to 30.6) and CTx4 (mean, 27.3; CI, 23.1 to 31.5) were similar to Crest, all being superior to Enamelon (mean, 15.6; CI, 11.6 to 19.7), which was superior to MI-One (mean, 4.3; CI, 0.3 to 8.3). For EFU, there were no differences between Clinpro (mean, 189; CI, 153 to 224), CTx4 (mean, 177; CI, 142 to 213), Enamelon (mean, 196; CI, 161 to 232), and Crest, all being superior to MI-One (mean, 66; CI, 30 to 102).

CONCLUSIONS

This study's results failed to show superior remineralizing efficacy of any of the toothpastes compared with those of a calcium-free F toothpaste, with 2 of the 4 toothpastes being inferior. Clinical testing will be required to establish conclusive evidence.

PRACTICAL IMPLICATIONS

Clinicians should be aware of the remineralizing potential of new anticaries products.

CPP-ACP Promotes SnF2 Efficacy in a Polymicrobial Caries Model

Dental caries is associated with plaque dysbiosis, leading to an increase in the proportions of acidogenic and aciduric bacteria at the expense of alkali-generating commensal species. Stannous fluoride (SnF₂) slows the progression of caries by remineralization of early lesions but has also been suggested to inhibit glycolysis of aciduric bacteria. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) promotes fluoride remineralization by acting as a salivary biomimetic that releases bioavailable calcium and phosphate ions, and the peptide complex has also been suggested to modify plaque composition. We developed a polymicrobial biofilm model of caries using 6 bacterial species representative of supragingival plaque that were cultured on sound human enamel and pulsed with sucrose 4 times a day to produce a high cariogenic challenge. We used this model to explore the mechanisms of action of SnF₂ and CPP-ACP. Bacterial species in the biofilms were enumerated with 16S rRNA gene sequence analyses, and mineral loss and lesion formation were determined in the enamel directly under the polymicrobial biofilms via transverse microradiography. The model tested the twice-daily addition of SnF₂, CPP-ACP, or both. SnF₂ treatment reduced demineralization by 50% and had a slight effect on the composition of the polymicrobial biofilm. CPP-ACP treatment caused a similar inhibition of enamel demineralization (50%), a decrease in Actinomyces naeslundii and Lactobacillus casei abundance, and an increase in Streptococcus sanguinis and Fusobacterium nucleatum abundance in the polymicrobial biofilm. A combination of SnF₂ and CPP-ACP resulted in a greater suppression of the acidogenic and aciduric bacteria and a significant 72% inhibition of enamel demineralization.

State of the Art Enamel Remineralization Systems: The Next Frontier in Caries Management

The principles of minimally invasive dentistry clearly dictate the need for clinically effective measures to remineralize early enamel caries lesions. While fluoride-mediated remineralization is the cornerstone of current caries management philosophies, a number of new remineralization strategies have been commercialized or are under development that claim to promote deeper remineralization of lesions, reduce the potential risks associated with high-fluoride oral care products, and facilitate caries control over a lifetime. These non-fluoride remineralizing systems can be broadly categorized into biomimetic enamel regenerative technologies and the approaches that repair caries lesions by enhancing fluoride efficacy. This paper discusses the rationale for non-fluoride remineralization and the mechanism of action, challenges, and evidence behind some of the most promising advances in enamel remineralization therapies.

Molar incisor hypomineralisation (MIH) - an overview

Recent data indicates that molar-incisor hypomineralisation (MIH) is a frequently - encountered dental condition worldwide. The condition could be associated with dental complications that might affect patients' quality of life as well as create treatment challenges to dentists. The affected teeth are more prone to caries and post-eruptive enamel breakdown, therefore, it is believed that this condition might be responsible for a substantial proportion of childhood caries since the condition has high prevalence. MIH is common, and as such it should be diagnosed and managed in primary care wherever possible. Early diagnosis can lead to more effective and conservative management. This article aims to highlight different aspects related to MIH, from its prevalence to treatment options in young patients.

Evaluating the Mechanical Properties, and Calcium and Fluoride Release of Glass-Ionomer Cement Modified with Chicken Eggshell Powder

The aim of this study was to test the effect of adding chicken eggshell powder (CESP) to conventional glass-ionomer cement (GIC) on its mechanical properties, and fluoride and calcium release. CESP was added with proportions of 3% and 5% by weight to the powder component of conventional glass-ionomer cement. The specimens were categorized into group A: GIC without CESP; group B: GIC with 3% wt. CESP; and group C: GIC with 5% wt. CESP; there were 12 specimens in each group. Groups B and C showed higher compressive strength values compared to group A. However, microhardness scores were higher in group C compared to groups A and B. As for ion-release results, group B displayed the highest values of fluoride release followed by group C at both 7 and 30 days. Group C showed the highest amount of calcium release followed by both groups B and C at 7 days, while at 30 days, groups A and B showed higher calcium release compared to group C. The mechanical properties of conventional glass-ionomer restorative material were enhanced by the addition of CESP. Moreover, fluoride and calcium release were not compromised by adding CESP.

Importance of bioavailable calcium in fluoride dentifrices for enamel remineralization

OBJECTIVES

To compare remineralization of enamel subsurface lesions by fluoride dentifrices with added calcium in a double-blind, randomized, cross-over, in situ study.

METHODS

Human enamel with subsurface lesions were prepared and inserted into intra-oral appliances worn by volunteers. A slurry (1 g toothpaste/4 ml H₂O) was rinsed for 60 s, 4 times per day for 14 days. Seven toothpastes were tested: (i) 1450 ppm F (NaF), (ii) 5000 ppm F (NaF), (iii) 1450 ppm F (MFP) with calcium sodium phosphosilicate (CSP), (iv) 1450 ppm F (MFP) with CaCO₃/Arg, (v) 1150 ppm F (SnF₂) with amorphous calcium phosphate (ACP), (vi) 1100 ppm F (NaF) with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and (vii) 5000 ppm F (NaF) with functionalized tri-calcium phosphate (TCP). Total (acid soluble) and bioavailable (water soluble) calcium, inorganic phosphate and fluoride levels of the dentifrices were measured using ion chromatography (F/MFP) and spectrophotometry (Ca and inorganic phosphate). Enamel lesion mineral content was measured using transverse microradiography. Data were statistically analysed using a linear mixed model.

RESULTS

All calcium and fluoride containing toothpastes released > 90% of bioavailable fluoride and were superior to the respective fluoride alone toothpastes in remineralization of enamel subsurface lesions. The level of remineralization followed the order: CPP-ACP/1l00 ppm F > ACP/1150 ppm F = TCP/5000 ppm F > 5000 ppm F = CaCO₃/Arg/1450 ppm F = CSP/1450 ppm F > 1450 ppm F. Bioavailable calcium levels significantly correlated with enhanced remineralization of enamel subsurface lesions.

CONCLUSIONS

Bioavailable calcium in fluoride dentifrices enhanced remineralization of enamel subsurface lesions.

Overview of Calcium Phosphates used in Biomimetic Oral Care

Background:

The use of biomimetic agents is an emerging field in modern oral care. Promising biomimetic substances for such applications are calcium phosphates, because their chemical composition is very similar to that of the mineral phase in human teeth, especially of natural enamel. Examples for their application include the remineralization of early caries lesions and repair of small enamel defects.

Objective:

This review provides an interdisciplinary view on calcium phosphates and their applications in biomimetic oral care. The aim of this work is to give an overview of in vivo and in situ studies comparing several calcium phosphates in preventive dentistry that can be used as a knowledge base for the development of innovative alternative oral care concepts.

Methods:

Books, reviews, and original research papers with a focus on in vivo and in situ studies were included. The databases PubMed^® and SciFinder^® were used for literature search. Calcium phosphates that are frequently utilized in oral care products are covered in this review and were used as search terms alone and together with the following key words: in vivo, in situ, caries, clinical study, and remineralization. From 13,470 studies found, 35 studies complied with the inclusion criteria and were used for this review.

Results:

Published in vivo and in situ studies demonstrate calcium phosphates’ potential in enamel remineralization. However, more studies are needed to further substantiate existing results and to extend and refine the application of calcium phosphates in modern oral care.

Conclusion:

Calcium phosphates represent an innovative biomimetic approach for daily oral care because of their high similarity to natural enamel that will broaden the range of future treatments in preventive dentistry.

Early Childhood Caries: Epidemiology, Aetiology, and Prevention

Early childhood caries (ECC) is one of the most prevalent diseases in children worldwide. ECC is driven by a dysbiotic state of oral microorganisms mainly caused by a sugar-rich diet. Additionally, poor oral hygiene or insufficient dental plaque removal leads to the rapid progression of ECC. ECC leads not only to dental destruction and pain with children, but also affects the quality of life of the caregivers. Children with extensive ECC are at high risk to develop caries with the permanent dentition or will have other problems with speaking and/or eating. To prevent ECC, several strategies should be taken into account. Children should brush their teeth with toothpastes containing gentle ingredients, such as mild surfactants and agents showing antiadherent properties regarding oral microorganisms. Parents/caregivers have to help their children with brushing the teeth. Furthermore, remineralizing and nontoxic agents should be included into the toothpaste formulation. Two promising biomimetic agents for children's oral care are amorphous calcium phosphate [Ca_x(PO₄)_yn H₂O] and hydroxyapatite [Ca₅(PO₄)₃(OH)].

Effect of dentifrice containing fTCP, CPP-ACP and fluoride in the prevention of enamel demineralization

OBJECTIVE

To evaluate the effect of different fluoride- and calcium- and/or phosphate-containing products on their ability to prevent enamel demineralization under pH cycling conditions.

MATERIAL AND METHODS

Enamel bovine specimens were assigned to the following groups: G1-MPP (MI Paste Plus, 0.2% NaF, Recaldent™, GC Corporation Tokyo, Japan); G2-FD (Crest™ Cavity Protection, 0.243% NaF, Procter & Gamble, USA); G3-CLP (Clinpro™ 5000, 1.1% NaF, 3M ESPE, USA); and G4-CO (Control without fluoride, Silica-based dentifrice; Daudt Ltda, Brazil). The specimens were soaked in demineralizing solution for 6 h and remineralizing solution for 18 h alternatively for 10 days. The toothpaste was prepared with deionized water in a 1:3 ratio (w/v) for three minutes daily. The solutions were renewed every 48 h. After cycling, enamel changes were analysed by percentage change of SMH (%SMH) and energy-dispersive X-ray spectroscopy (EDS). The %SMH value observed for G3-CLP (2.9 ± 39.2) was higher than that found in G4-CO (-13.0 ± 20.7), G1-MPP (-8.9 ± 20.9) and G2-FD (-3.9 ± 27.1). The %SMH was similar for all treatment groups (one-way ANOVA and Tukey's HSD; p < .05). The pH, Ca²⁺ and P_total in the remineralization solutions were not different among all groups (Kruskal-Wallis; p < .05). At 24 h, the Ca²⁺ concentration in the demineralization solution was significantly lower in G1-MPP. Ca²⁺ concentration increased in all groups after 48 h, except for G3-CLP. The EDX quantitative analysis showed that the atomic % of elements is lower level at G4-CO.

CONCLUSIONS

The Clinpro™ 5000 demonstrated having the most protective effect against demineralization; however, the % SMH was similar for all groups.

Effect of fluoride dentifrice and casein phosphopeptide-amorphous calcium phosphate cream with and without fluoride in preventing enamel demineralization in a pH cyclic study

OBJECTIVE

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) complexes are anticariogenic and capable of remineralizing the early stages of enamel lesions. The use of fluoride prevents dental decay and the association of CPP-ACP with fluoride can increase remineralization. To evaluate the effect of CPP-ACP and CPP-ACPF creams associated with a fluoride dentifrice to prevent enamel demineralization in a pH cyclic model.

MATERIAL AND METHODS

Previously selected by surface microhardness (SH) analysis, human enamel blocks (n = 56) were submitted to daily treatment with dentifrice in a pH-cycling model. The enamel blocks were divided into four groups; G1: Crest™ Cavity Protection - Procter & Gamble (1,100 ppmF of NaF); G2: Crest™ +MI Paste (MP) - Recaldent™ GC Corporation Tokyo, Japan); G3: Crest™ + MI Paste Plus (MPP) - Recaldent™ 900 ppm as NaF, GC Corporation Tokyo, Japan), and G4: control, saliva. Specimens were soaked alternatively in a demineralizing solution and in artificial saliva for 5 d. The fluoride dentifrice, with proportion of 1:3 (w/w), was applied three times for 60 s after the remineralization period. The undiluted MP and MPP creams were applied for 3 m/d. After cycling, SH was re-measured and cross section microhardness measurements were taken.

RESULTS

The SH values observed for the groups G3 (257±70), G1 (205±70), and G2 (208±84) differed from the G4 group (98±110) (one-way ANOVA and Tukey's post hoc test). There were no differences between the groups G1xG2, G2xG3, and G1xG3 for demineralization inhibition. The percentage of volume mineral showed that, when applied with fluoride dentifrice, MPP was the most effective in preventing enamel demineralization at 50 µ from the outer enamel surface (Kruskal-Wallis and Mann Whitney p<0.05).

CONCLUSION

Fluoride dentifrice associated with CPP-ACPF inhibited subsurface enamel demineralization.

Influence of biofilm formation on the mechanical properties of enamel after treatment with CPP-ACP crème

The study aimed to investigate the effects of bacterial biofilms on changes in the surface microhardness of enamel treated with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) with and without fluoride. Human enamel blocks with incipient caries-like lesions were divided into four groups of 13: G1: Saliva (Control); G2: fluoride dentifrice (Crest™, 1100 ppm as NaF); G3: CPP-ACP (MI Paste; Recaldent™); and G4: CPP-ACPF (MI Paste Plus; Recaldent™ 900 ppm as NaF). The specimens were soaked in demineralizing solution for 6 h and remineralized in artificial saliva for 18 h alternately for 10 days. The dentifrice was prepared with deionized water in a 1 : 3 ratio (w/w) or applied undiluted in the case of the CPP-ACP group. The surface microhardness (SMH) was evaluated at baseline, after artificial caries, after pH cycling and treatment with dentifrices, and after incubation in media with Streptococcus mutans for biofilm formation. The biofilms were exposed once a day to 2% sucrose and the biofilm viability was measured by MTT reduction. The percentage of change in surface microhardness (%SMHC) was calculated for each block. The data were analyzed by nonparametric test comparisons (α = 0.05). The %SMHC values observed in G2 were different from those of G1, G3, and G4 (p < 0.05). After biofilm formation, %SMHC was positive in G2 and G4 when compared to G1 and G3, but resistance to demineralization after biofilm formation was similar in all groups. In conclusion, the presence of biofilms did not influence the treatment outcomes of anticaries products.

The Effect of MIpaste Plus and Reminpro on Incipient Caries Using DIAGNOdent and SEM: An Invitro Study

BACKGROUND

The remineralization of early caries lesion has an effective role on decreasing caries. For initial remineralization of caries lesion, using Compounds of Casein phosphopeptides (CPP) in different studies has been proposed. REMINPRO including Fluoride, Xylitol and Calcium phosphate has just been offered in the market. This study aims to investigate the efficacy of Reminpro and MI paste plus in terms of remineralization of early enamel lesions.

MATERIALS AND METHODS

In 15 samples of healthy enamels of the maxillary first premolar teeth and 15 samples of Primary Mandibular First Molar under the effect of demineralized gel, artificial caries has been created. The samples have been divided in 3 groups of 20. After performing the cycles of demineralization and remineralization during 5 weeks, the samples were investigated by DIAGNOdent and two samples from each group were compared with SEM. To investigate the remineralization of enamel, two-way ANOVA and to compare the groups in pair, the post hoc tests were used.

RESULTS

The mean of mineralization of teeth in the group using reminpro was 25.2 ± 6.16 and in the group using MI paste plus was 23 ± 5.60, which was significantly high.

CONCLUSIONS

MI paste plus in mineralization of initial enamel caries were more efficient that reminpro pate.

Remineralizing potential of a 60-s in vitro application of Tooth Mousse Plus

BACKGROUND

No published studies exist on the remineralizing potential of Tooth Mousse Plus^® (TMP) when applied for less than 3 min.

AIM

To evaluate (i) the remineralizing potential of TMP on artificial carious lesions, when applied thrice daily for 60 s, and (ii) the benefit of using a fluoridated dentifrice prior to TMP application.

DESIGN

Carious lesions, 120-200 μm deep, were produced by placing molars in demineralizing solution for 96 h, and sections 100-150 μm thick were then randomly assigned to four groups. Specimens were treated thrice daily with a non-fluoridated (Group A), or 1000 ppm F dentifrice (Group B), or TMP (Group C), or a 1000 ppm F dentifrice followed by TMP application (Group D), and then subjected to a 10-day pH cycling model. Lesion evaluation involved polarizing light microscopy and microradiography.

RESULTS

Post-treatment maximum mineral content at the surface zone (V_max ) was significantly increased and lesion depth (LD) significantly decreased in Group C, while only the V_max increased in Group D. Increase in LD was observed in Group B; however, no significant differences were noted in percentage LD changes between groups B, C, and D (P > 0.05).

CONCLUSIONS

TMP applied for 60 s significantly remineralized the artificial carious lesions. No additional benefit was evident when TMP was preceded by treatment with 1000 ppm F dentifrice.

A randomised controlled trial to investigate the remineralising potential of Tooth Mousse™ in orthodontic patients

OBJECTIVE

To investigate the remineralisation of enamel subsurface lesions treated with fluoride toothpaste (1450 ppm) or a combination of fluoride toothpaste in addition to Tooth Mousse™.

DESIGN

An in situ, cross-over, randomised controlled trial.

SETTING

Orthodontic department at Liverpool University Dental Hospital, UK.

PARTICIPANTS

Twelve patients receiving fixed orthodontic treatment.

METHODS

Demineralised subsurface enamel lesions were placed in a carrier and attached onto a fixed orthodontic appliance. Interventions were either standard fluoride toothpaste or CPP-ACP paste (Tooth Mousse™) in addition to the fluoride toothpaste. Participants received both interventions in a randomised order. Transverse microradiography analysis was used to compare lesion mineral content profiles.

RESULTS

Mineral loss was reduced by 15.4 and 24.6% between the fluoride and CPP-ACP groups, respectively (p = 0.023). Lesion depth was reduced by 1.6 and 11.1% between the fluoride and CPP-ACP groups, respectively (p = 0.037). Lesion width was reduced by 4.5 and 15.3% between the fluoride and CPP-ACP groups, respectively (p = 0.015).

CONCLUSIONS

Remineralisation occurred regardless of treatment group allocation. However, the addition of Tooth Mousse™ resulted in a significantly increased remineralisation effect, compared to fluoride alone. Tooth Mousse™ may be beneficial for patients undergoing orthodontic treatment who are at high risk of demineralisation.

TRIAL REGISTRATION

Registered on Current Control Trials http://www.controlled-trials.com/ISRCTN04899524.

Effect of different fluoride varnishes on remineralization of artificial enamel carious lesions

OBJECTIVES

To compare remineralization potential of topical fluoride varnishes with added calcium phosphate-based delivery systems on artificial enamel caries.

METHODS

Human enamel specimens (n = 60) were randomly divided into six groups: Group 0: Control (no varnish), Group 1: Duraphat^® , Group 2: MI Varnish^™ , Group 3: Embrace^™ Varnish, Group 4: Enamel Pro^® Varnish, and Group 5: Clinpro^™ White Varnish. Specimens were immersed in demineralizing solution for 96 h to create artificial caries lesion. Each specimen was then immersed in artificial saliva for 6 h after fluoride varnish application and pH cycling was performed for 8 days. Specimens were evaluated using Knoop surface microhardness (KHN) and transverse microradiography (TMR). One-way anova test was performed to examine the effect of fluoride varnishes on change in percentage of surface hardness recovery (%SHR), change in lesion depth (ΔLD), and change in mineral loss (ΔΔZ) with the significance limit set at 5%.

RESULTS

%SHR of enamel following treatment with Group 1 was significantly higher than Group 3 and Group 4. Conversely, ΔLD and ΔΔZ of Group 1 were significantly higher than Group 2, Group 3, and Group 4. No significant differences in %SHR, ΔLD, and ΔΔZ were found between Group 1 and Group 5.

CONCLUSIONS

Duraphat^® alone achieves significant remineralization of enamel carious lesions. Clinpro^™ White Varnish had similar enamel remineralization effect as Duraphat^® .