Fluoride uptake by dentin surfaces following topical application of TiF4, NaF and fluoride varnishes in vivo

What is the effectiveness of titanium tetrafluoride to prevent or treat dental caries and tooth erosion? A systematic review

OBJECTIVES

Answer the question: What is the effectiveness of titanium tetrafluoride (TiF₄) when compared to other fluorides, placebo solution or a negative control to prevent or treat dental caries and tooth erosion?

MATERIALS AND METHODS

This review is in accordance with PRISMA guidelines. In vivo and in situ studies that used TiF₄ over enamel or dentine were included. Electronic searches were conducted on MEDLINE, Scopus, Embase, WOS, Cochrane Library, VLH, Clinical Trials and OpenGrey. Risk of bias (ROB) assessments used RoB2 and ROBINS-I for randomized and non-randomized controlled trials (RCTs and on-RCTs); Syrcle's ROB tool for animal studies; and a modified tool proposed by Hollanders for in situ studies.

RESULTS

A total of 28 studies met the eligibility criteria. From these, 6 were in humans (3 RCT and 3 Non-RCT); 4 were in animals and 18 were in situ. For in vivo studies, all RCTs have some concerns related to ROB and all of the non-RCT studies were classified as with serious risk. One animal study had a low and three a high ROB. Regarding in situ studies, seven had a low, ten had an average and only one had a high ROB. The certainty of the evidence (GRADE) ranged from moderate to very low.

CONCLUSIONS

Although most of the results suggest a positive effect of TiF4 on the prevention and treatment of caries and dental erosion, it is not possible to have definitive conclusions due to the high studies' methodological heterogeneity, and the low quality of evidence for most outcomes.

REGISTRATION

The protocol of this syste. atic review was registered in the OPEN SCIENCE FRAMEWORK database (osf.io/6dgs9) DOI:10.17605/OSF.IO/KUZA7 on 6 August 2020.

Protective effect of titanium tetrafluoride and silver diamine fluoride on radiation-induced dentin caries in vitro

This in vitro study evaluated the protective effect of titanium tetrafluoride (TiF₄) varnish and silver diamine fluoride (SDF) solution on the radiation-induced dentin caries. Bovine root dentin samples were irradiated (70 Gy) and treated as follows: (6 h): 4% TiF₄ varnish; 5.42% NaF varnish; 30% SDF solution; placebo varnish; or untreated (negative control). Microcosm biofilm was produced from human dental biofilm (from patients with head-neck cancer) mixed with McBain saliva for the first 8 h. After 16 h and from day 2 to day 5, McBain saliva (0.2% sucrose) was replaced daily (37 °C, 5% CO₂) (biological triplicate). Demineralization was quantified by transverse microradiography (TMR), while biofilm was analyzed by using viability, colony-forming units (CFU) counting and lactic acid production assays. The data were statistically analyzed by ANOVA (p < 0.05). TiF₄ and SDF were able to reduce mineral loss compared to placebo and the negative control. TiF₄ and SDF significantly reduced the biofilm viability compared to negative control. TiF₄ significantly reduced the CFU count of total microorganism, while only SDF affected total streptococci and mutans streptococci counts. The varnishes induced a reduction in lactic acid production compared to the negative control. TiF₄ and SDF may be good alternatives to control the development of radiation-induced dentin caries.

Cyclodextrin and TiF4 Nanocomplex on Enamel Demineralization

The aim of this study was to assess the effect of a newly developed nanocomplex formed of hydroxypropyl-b-cyclodextrin and 1% titanium tetrafluoride (TiF4) after distinct complexation periods (12/72 h) on demineralization of bovine enamel in vitro. Enamel blocks (n=60) were allocated in different groups: Mili-Q water, hydroxypropyl-b-cyclodextrin, 1% TiF4, hydroxypropyl-b-cyclodextrin + 1% TiF4 after 12 h of complexation and hydroxypropyl-b-cyclodextrin + 1% TiF4 after 72 h of complexation. The samples were evaluated by surface microhardness, cross-sectional microhardness and micro-CT. Scanning electron microscopy and energy dispersive X-ray spectrometry (SEM/EDX) were also obtained. Hydroxypropyl-b-cyclodextrin + 1% TiF4 after 12 h complexation resulted in lower percentage of surface microhardness loss compared to Mili-Q water, hydroxypropyl-b-cyclodextrin, 1% TiF4 and hydroxypropyl-b-cyclodextrin + 1% TiF4 after 72 h of complexation group, with a large effect size (from 1.307 to 2.943) and high power (84.9 to 99%). All groups resulted in similar integrated mineral loss (ΔZ) obtained by both internal microhardness and micro-CT techniques. Enamel treated with TiF4 and TiF4 + hydroxypropyl-b-cyclodextrin groups showed a TiO2 glaze-layer, while EDX evaluation identified Ti. The solution containing the inclusion complex of hydroxypropyl-b-cyclodextrin + TiF4 with 12 h of complexation period demonstrated a significant ability to reduce surface demineralization of sound enamel under an artificial cariogenic challenge.

Protective Effect of 4% Titanium Tetrafluoride Varnish on Dentin Demineralization Using a Microcosm Biofilm Model

This study evaluated the effect of titanium tetrafluoride (TiF4) varnish on the development of dentin carious lesions. Bovine root dentin samples were treated for 6 h with: (A) 4% TiF4 varnish (2.45% F); (B) 5.42% sodium fluoride (NaF) varnish (2.45% F); (C) 2% chlorhexidine (CHX) gel – positive control; (D) placebo varnish; or (E) untreated – negative control (n = 4 × biological triplicate, n = 12). Treated dentin samples were exposed to human saliva mixed with McBain saliva (1:50) for the first 8 h in 24-well plates. Thereafter, the medium was removed, and McBain saliva containing 0.2% sucrose was applied for 16 h. From days 2 to 5, McBain saliva with sucrose was replaced daily (37°C, 5% CO2). The demineralization was measured using transverse microradiography, while the effect on biofilm was analyzed using viability, extracellular polysaccharide (EPS), and lactic acid production assays. The data were statistically analyzed (p < 0.05). All treatments (fluorides and CHX) significantly reduced the biofilm viability compared to placebo varnish and negative control. However, none of them was able to reduce the colony-forming unit counting for total microorganism, total streptococci, and Streptococcus mutans. NaF significantly reduced the number of Lactobacillus sp. compared to negative control. No effect was seen on lactic acid production neither on EPS synthesis, except that CHX significantly reduced the amount of insoluble EPS. Both fluorides were able to reduce dentin demineralization compared to placebo varnish and negative control; TiF4 had a better effect in reducing mineral loss and lesion depth than NaF. Therefore, TiF4 varnish has the best protective effect on dentin carious lesion formation using this model.

In situ effect of titanium tetrafluoride varnish on enamel demineralization

The effect of a 4% titanium tetrafluoride (TiF 4 ) varnish on enamel demineralization was evaluated. Twelve volunteers participated in this double-blind, randomized crossover study. Six enamel specimens were positioned in intraoral appliances throughout four treatment stages: 4% TiF 4 varnish (experimental varnish), 5% sodium fluoride (NaF) varnish (Duraphat ® ), placebo varnish, and negative control (deionized water). After 24 h, the varnishes were removed and plaques were allowed to accumulate. A 20% sucrose solution was dripped onto enamel blocks (10x/day). Enamel alterations were analyzed by surface microhardness (SMH), percentage of surface loss (%SML), cross-sectional microhardness (CSMH), scanning electron microscopy (SEM), and energy dispersive X-ray spectrometry (EDS). Student's paired t-test was used for SMH analysis and repeated-measures analysis of variance (ANOVA) for %SML and CSMH (∆Z) analyses (p-value=0.05). The TiF 4 varnish group had lower %SML than the placebo and control groups (p=0.044 and p=0.003, respectively), thus showing its capacity to inhibit surface demineralization. TiF 4 and NaF varnishes demonstrated a protective effect against mineral loss on the enamel subsurface. Both were statistically different from the control group when CSMH was analyzed (p=0.000). A titanium dioxide film was observed on enamel surfaces of the TiF 4 group SEM images. EDS confirmed the presence of titanium in all TiF 4 samples. The 4% TiF 4 varnish is a promising compound capable of reacting with enamel to protect it against surface and subsurface demineralization.

Permeability of eroded enamel following application of different fluoride gels and CO2 laser

This study evaluated the combined effect of fluoride compounds and CO(2) laser in controlling the permeability of eroded enamel. Bovine enamel slabs (3 × 2 mm) were cycled twice through an alternating erosion and remineralization regimen. Slabs were immersed in 20 ml of orange juice (pH 3.84) for 5 min under agitation, rinsed with deionized water, and stored in artificial saliva for 4 h to form erosive lesions. Specimens were then divided into four groups (n = 10), which were treated for 1 min with either a control or with one of the following gels: amine fluoride (AmF), titanium tetrafluoride (TiF(4)), or sodium fluoride (NaF). Half of the specimens were irradiated with a CO(2) laser (λ = 10.6 μm; 2.0 W). Specimens were cycled two more times through the aforementioned erosion-remineralization regimen and were subjected to permeability assessment. ANOVA demonstrated a significant interaction between fluoride and laser treatment (p = 0.0152). Tukey's test showed that when fluoride was applied alone, TiF(4) resulted in lower enamel permeability than that observed after application of the placebo gel. Intermediate permeability values were noted after NaF and AmF had been used. A significant reduction in enamel permeability was obtained when fluoride was combined with CO(2) laser treatment, with no difference between fluoride gels. Permeability of eroded enamel may be reduced by combining the application of fluoride gels with CO(2) laser irradiation.

Effect of 4% titanium tetrafluoride application on shear bond strength of composite resin: An in vitro study

AIMS

The objective of thisstudy is to evaluate and compare 4% titanium tetrafluoride with 2% Sodium fluoride, and the bond strength of composite resin with dentin and their effects on the smear layer.

MATERIALS AND METHODS

Fifty freshly extracted non-carious molar and premolar teeth were selected. The occlusal surfaces of the teeth were ground, to prepare flat dentin surfaces at a depth of 2 mm and were randomly grouped with 10 specimens in each. Group I (Etching + Adhesive + Composite resin) was taken as a control group. In Group II, 4% titanium tetrafluoride was applied before etching and in Group III, 4% titanium tetrafluoride was applied after etching. In Group IV, 2% Sodium fluoride was applied before etching and in Group V, 2% Sodium fluoride was applied after etching. Shear bond strength was tested using the Lloyds Universal testing machine and was recorded in MPa.

RESULTS

The results were statistically analyzed using the one-way Anova test. Group III showed the highest bond strength among the experimental groups, but less than the control group.

CONCLUSIONS

Under the conditions of this in vitro study, titanium tetrafluoride did not significantly affect the bond strength of the composite. Sodium fluoride was found to deleteriously affect the bond strength of the composite.

Fluoride varnishes. A review of their clinical use, cariostatic mechanism, efficacy and safety

BACKGROUND

This is a review of the clinical use, cariostatic mechanism, efficacy, safety and toxicity of fluoride varnishes.

TYPES OF STUDIES REVIEWED

The authors reviewed and summarized in vitro, in vivo and in situ studies; clinical trials; demonstration programs; position papers; and editorials published in English in the biomedical literature since 1966.

RESULTS

Extensive laboratory research and clinical trials conducted in Europe and elsewhere show that fluoride varnishes are as efficacious as other caries-preventive agents. Fluoride varnishes are widely used in European caries-preventive programs. The U.S. Food and Drug Administration has cleared these products only as medical devices to be used as cavity liners and for the treatment of hypersensitive teeth. These products have not yet been cleared for marketing in the United States as caries-preventive agents.

CLINICAL IMPLICATIONS

Three fluoride varnishes are currently available in the United States. Semiannual applications are the most proven treatment regimen. Varnishes are safe and easy to apply and set in contact with intraoral moisture.

Permeability changes of dentine treated with titanium tetrafluoride

OBJECTIVES

The aim of this research was to evaluate the effect of titanium tetrafluoride on dentine permeability in comparison with sodium fluoride and acidulated phosphate fluoride to determine their contribution to acid resistance of dentine.

METHODS

Thirty-two dentine discs were prepared from extracted mandibular molars. The hydraulic conductance of all discs was measured before and after the formation of smear layer. The discs were then randomly divided into five experimental and one-control groups. Coronal surfaces of dentine discs were treated with either fluoride solutions of NaF, APF, 1% TiF4, 0.5% TiF4 and 0.1% TiF4 or de-ionised water. Following the measurement of hydraulic conductance, treated surfaces were subjected to 25% citric acid application. Then, final permeability measurements were made. The data were statistically analysed using ANOVA and Tukey's HSD multiple comparisons.

RESULTS

While smear layer formation considerably reduced dentinal permeability of dentine discs, fluoride or de-ionised water application to smeared surfaces did not cause any significant change in hydraulic conductance (p > 0.05). After citric acid application, control and NaF groups showed higher permeability values than 1%, 0.5% and 0.1% TiF4 and APF groups (p < 0.01).

CONCLUSION

Clinical use of acidic solutions of titanium tetrafluoride in dentine cavities may be considered since smeared dentine surfaces are modified to a stabile and acid-resistant state.

The effect of 4% titanium tetrafluoride solution on root canal walls--a preliminary investigation

The aim of the present study was to evaluate the effect of 4% titanium tetrafluoride (TiF4) solution on root canal walls by scanning electron microscopy. Twenty four root canals with or without a smear layer were treated with 4% TiF4 solution. Scanning electron microscopic observation of the smeared canal walls showed that TiF4 solution modified the smear layer and produced a massive structure. In smear-free group, a granular coating was formed on intertubular and intratubular dentin. The stability of this layer was tested further with EDTA and/or NaOCl irrigations on 20 additional specimens. It was observed that none of the solutions was able to remove this modified smear layer. These results may indicate that this extremely stable structure may be advantageous in endodontics, because it can prevent further infection of root canal dentin by sealing off the tubules permanently, and can reduce microleakage by preventing further dissolution and disintegration of the smear layer.

Release of fluoride and metal ions from root surfaces after topical application of TiF4, SnF2, and NaF in vitro

Aqueous solutions of TiF4 cause a rapid uptake and a long-lasting retention of fluoride when applied to dentin. The aim of this study was therefore to investigate the pattern of fluoride release after TiF4 application in vitro, compared with SnF2 and NaF application. TiF4, SnF2, and NaF were applied for 4 min and 1 min to standardized areas of six groups of root surface specimens immersed in distilled water. Untreated specimens were used as controls. The water was changed daily for 30 days, and F concentrations measured by an ion-selective electrode. All test groups showed a rapid decline in F concentration. In the 4-min group F concentration more than double the detection limit of the F electrode could be registered the first 28 days for TiF4, 11 days for SnF2, and 7 days for NaF. In the 1-min group periods of F registration were shorter. Analysis of Sn by atomic absorption spectrophotometry showed decreasing concentrations in the first 12-day samples in the 1-min and 4-min groups. Traces of Ti were found in the first few samples, but no pattern of release could be observed.

Root surface reactions to TiF4 and SnF2 solutions in vitro. An ultrastructural study

Previous studies have indicated that TiF4 and SnF2 differ in their demineralizing effect when applied topically to root surfaces at the same acidity. The aim of this study was to examine in more detail the outermost layer of root surface specimens by transmission electron microscopy (TEM) after short-term exposure to these acidic fluoride solutions. Root surface specimens were exposed for 1 min and 4 min to equimolar (1.1 M F) solutions of a) TiF4, native pH 1.0; b) SnF2, acidified to pH 1.0; and c) SnF2, native pH 2.5. The specimens were then rinsed in saline and processed for TEM. Exposure to TiF4 resulted in a partly demineralized zone 8-10 microns deep after 1 min and 5-27 microns deep after 4 min of application. A 0.1-micron-thick, electron-dense coating was present in all TiF4-treated specimens. Acidified SnF2 resulted in a completely demineralized zone, 4-7 microns deep, when applied for 1 min and 4 min, whereas SnF2 at native pH produced a 0.5- to 1.0-micron-wide partially demineralized zone. Unevenly distributed crystalline deposits were a frequent finding on SnF2-treated surfaces. The results indicate that solutions of TiF4 and SnF2 at native pH will cause only slight demineralization when applied topically to root surfaces.

In vivo uptake and retention of fluoride after a brief application of TiF4 to dentin

The purpose of this study was to examine the long-term retention of F and Ti in dentin after a brief application of 1% TiF4. Six facets of exposed dentin in each of four beagle dogs were treated for 10 sec or 1 min with a 1% solution of TiF4. Four control facets in a fifth dog were left untreated and extracted after 12 weeks. The TiF4-treated teeth were harvested after 4, 8, and 22 weeks and analyzed for F and Ti with an electron microprobe. The F concentrations in dentin surfaces of specimens retained in the mouth for 4, 8, and 22 weeks were after the 10-sec treatment 0.48% +/- 0.24, 0.51% +/- 0.20, and 0.56% +/- 0.20, respectively, and after the 1-min treatment 0.64% +/- 0.20, 0.66% +/- 0.18, and 0.71% +/- 0.19. High concentrations of Ti were found at the specimen surfaces in all groups. None of the control specimens showed F or Ti contents above the detection limits for the method used. The results showed that a very brief application of 1% TiF4 deposited high concentrations of F and Ti which were retained for at least 22 weeks.

Effects of TiF4 solutions on root surfaces in vitro after different application periods

Topical application of aqueous solutions of TiF4 to root surfaces has been shown to result in a rapid uptake of fluoride. The purpose of this study was to assess whether the application period and/or the ionic strength of the TiF4 solution can be reduced without a corresponding reduction in the fluoride uptake. Root halves from human teeth were exposed to (a) 1% TiF4 for 10 sec and 1, 2, and 4 min, and (b) 3.4% TiF4 for the same application periods. Root surface areas protected by nail polish served as controls. Transverse ground sections through the treated root surface areas were then prepared and analyzed for F by electron microprobe analysis. Most treated specimens showed F concentrations in the 0.60-1.94% range, whereas control surfaces contained less than 0.30%. Similar F concentrations were found in the surfaces treated with the two solutions. Reducing the application period resulted in a shallower penetration of F into the hard tissue but only a slight reduction of the F concentration in the surface layer. High concentrations of Ti were found on the surface of all treated specimens. This shows that both the application period and the ionic strength of TiF4 solutions can be considerably reduced and still enable a high uptake of fluoride. The results indicate that TiF4 may be an efficacious agent for F application to root surfaces under clinical conditions.

Electron probe micro-analysis for subsurface demineralization and remineralization of dental enamel

A quantitative study of fluoride distribution profile changes in dental enamel was conducted by means of electron probe micro-analysis (EPMA). Fluoride-deposited hydroxyapatite powders were chosen as fluoride standards, and analytical conditions were optimized. The lower limit of detection for fluoride was estimated to be 270 ppm, with an accelerating voltage of 5 kV, a specimen current of 40 nA, and a counting time of 40 seconds. Fluoride profiles in fluoride-treated dental enamel, which exhibited intact surface layers and subsurface demineralization, were determined. The results were also compared with those of an acid-abrasion method, and reasonable consistency was found between these two methods, although the acid-abrasion procedure yielded a slightly lower fluoride content in the initial layers, followed by a higher content of fluoride in the deeper layers. The precision of fluoride profile data obtained from EPMA permits further studies to be conducted on the kinetics of subsurface demineralization and intact surface layer formation ("white spot" formation) which is observed during the acid challenge of dental enamel.