The effect of silver diammine fluoride on In Vitro Enamel caries lesion remineralization and staining as a function of lesion baseline mineral distribution

OBJECTIVES

to investigate whether baseline mineral distribution modulates the ability of silver diammine fluoride (SDF) to remineralize and stain enamel caries lesions.

METHODS

This laboratory study followed a 3 [treatment: SDF/fluoride varnish (FV)/deionized water (DIW)] ×3 [lesion protocol: methylcellulose (MeC)/hydroxyethylcellulose (HEC)/Carbopol 907 (C907)] factorial design. Lesions were created in bovine enamel specimens (n = 20). Treatments were applied and lesions remineralized in artificial saliva. Digital transverse microradiography (TMR-D) was used to analyze lesions. Lesion color was monitored spectrophotometrically. The effects of lesion protocol and treatment on changes in lesion depth (ΔLD), mineral loss (ΔΔZ), maximum mineral density at the surface zone (ΔSZmax), and color changes related to remineralization (ΔL*remin) were analyzed using two-way ANOVA.

RESULTS

The treatment×lesion protocol interaction was significant for ΔΔZ (p < 0.01) and ΔL*remin (p < 0.01), however not for ΔLD (p = 0.23) or ΔSZmax (p = 0.91). There were no differences in ΔΔZ between treatments in HEC and C907 lesions. However, DIW resulted in more remineralization than both SDF (p < 0.01) and FV (p = 0.01) in MeC lesions. Considering changes from lesion baseline after remineralization in MeC lesions, SDF treatment resulted in the highest mineral gain in the surface zone. However, DIW revealed the highest mineral gain after remineralization in the lesion body. SDF stained lesions with the intensity increasing after remineralization in C907 lesions, whereas staining decreased in MeC and HEC lesions.

CONCLUSION

High fluoride treatments can interfere with continuous remineralization of caries lesions due to partial arrest. Baseline lesion mineral distribution affects SDF's ability to enhance remineralization and the staining caused by SDF.

CLINICAL SIGNIFICANCE

SDF is being used to arrest active caries lesions extending into dentin and to treat dentin hypersensitivity. This study shed light on SDF's effect on an isolated process in dental caries only, remineralization. It achieved this by examining enamel caries lesions with differing mineral distributions and assessing their staining properties.

Red fluorescence intensity as a criterion for assessing remineralization efficacy in early carious lesions

OBJECTIVES

Evaluating early carious lesion activity with an objective and clinically valid approach is crucial for developing effective treatment plans. Therefore, we here assessed the activity of non-cavitated carious lesions using a quantitative light-induced fluorescence-digital (QLF-D) camera and compared the remineralization efficiency after fluoride treatment according to the lesion's activity level.

METHODS

Red fluorescence emission rate (ΔR) and fluorescence loss (ΔF) were evaluated in 44 non-cavitated carious lesions by using a QLF-D camera. Based on the ΔR level, the lesions were classified into 22 active (ΔR ≥37.55) and 22 inactive carious lesions (ΔR <37.55). Each lesion was treated with 1.23 % fluoride gel for 60 s and then immersed into artificial saliva for 7 days. Subsequently, ΔR and ΔF changes in the lesions were measured.

RESULTS

Significant interactions between lesion activity and time were found for both ΔR and ΔF (p < 0.001). ΔR of active lesions declined faster and ΔF increased more steeply than did inactive lesions. Specifically, on day 7 post-fluoride treatment, the ΔR reduction rate was 1.40-times higher in active lesions, and the ΔF recovery rate was 2.50-times higher, indicating that active lesions respond more markedly to fluoride application.

CONCLUSIONS

This study highlighted the significance of ΔR in predicting remineralization efficiency in non-cavitated carious lesions after fluoride application. It underscored the importance of accurately assessing caries activity when formulating effective treatment plans. Lesion activity, as determined by ΔR, not only influences the outcome of remineralization treatments but also provides a more objective measure for tailoring caries management strategies.

Effect of Three Chemical Agents on Stain Removal from Dentin Caries Lesions Treated with Silver Diamine Fluoride

INTRODUCTION

This in vitro study aimed to evaluate the effect of three different chemical agents on stain removal and mineral uptake of artificial dentin caries (ADC) lesions treated with silver diamine fluoride (SDF).

METHODS

Baseline L*a*b* values were determined in polished human permanent dentin blocks, and ADC lesions were induced with an acid gel for 1 week. Samples were assigned to four groups; in three groups, half of each sample received SDF (30% SDF for 3 min), while the other half received SDF followed by a bleaching treatment protocol (garlic extract, bentonite, or 35% hydrogen peroxide). The fourth group had one SDF-treated half and one half without SDF. Color changes (ΔE) were measured by spectrometry, and transversal microradiography was used to quantify integrated mineral loss (ΔZ) 24 h after treatment (SDF or SDF + bleaching). A two-way mixed ANOVA was applied to thirty percent.

RESULTS

SDF application increased mineral uptake by ADC (p = 0.001). The type of chemical agent evaluated (p < 0.0001), time (p = 0.01), and their interaction (p < 0.0001) bleached the ADC treated with SDF. However, 35% hydrogen peroxide was the only compound with a bleaching effect (p < 0.001), without returning to baseline color. None of the compounds altered the mineral uptake effect of SDF (p = 0.30).

CONCLUSION

This in vitro study showed mineral uptake effect in ACD within 24 h after SDF application and the ability of hydrogen peroxide to partially remove (reduction of 24%) the staining caused by SDF without affecting its mineral uptake effect.

Evaluation of an Artificial Mouth for Dental Caries Development

This study validated a microbial caries model (artificial mouth) for dental caries development to determine the optimal time to create early caries suitable for evaluation of the efficacy of caries therapeutic agents. In all, 40 human enamel blocks were placed in an artificial mouth at 37 °C and 5% CO2 and were exposed to brain heart infusion broth inoculated with S. mutans in continuous circulation (0.3 mL/min). The culture medium was replaced three times daily. Samples were exposed to 10% sucrose for 3 min, 3 times daily to promote biofilm growth. Five samples were harvested from the chamber after 3, 4, 5, 6, 7, 14, 21, and 28 days. At the end of experiment, samples were assessed visually by ICDAS criteria, while lesion depth (LD) and mineral loss (ML) were measured using polarizing light microscopy and transverse microradiography. Data were analyzed by Pearson correlation, ANOVA, and Tukey comparison test (p < 0.05). Results showed significant and strong positive correlation (p < 0.01) between all variables and biofilm growth time. LD and ML profiles of 7-day lesions seem to be the most suitable for remineralization studies. In conclusion, using the evaluated artificial mouth, early-stage caries suitable for products’ evaluation studies was produced within 7 days of exposure to microbial biofilm.

Evaluation of Enamel Acid Resistance and Whitening Effect of the CAP System

This study aimed to compare the effectiveness of a novel professional tooth-strengthening system and a conventional caries-prevention method that involved the use of high fluoride concentrations, to determine whether the system has a whitening effect. Bovine tooth-enamel samples were treated with fluoride gel (conventional APF method) or a mixture of citric acid gel, calcium phosphate (α-TCP), and fluoride gel, referred to as the CAP system; these treatments were performed to generate an acid-resistant layer on the enamel surface. For the evaluation of the acid resistance, a cyclic experiment, involving a 1-h remineralization and a 24-h acid treatment, was conducted thrice after the treatments. The height profiles were observed using a 3D-measuring laser microscope and the hardness was evaluated by Vickers hardness test. The morphological changes in the surface and cross-section of the enamel were observed by scanning electron microscopy. To evaluate the whitening effect, the enamel was ground until the color of the underlying dentin was recognizable; the CAP system was applied once, and the color change was measured using a color difference meter. As a result, it was confirmed that an acid-resistant layer was formed on the tooth surfaces treated with the CAP system, and a whitening effect was obtained.

A novel non-destructive technique for qualitative and quantitative measurement of dental erosion in its entirety by porosity and bulk tissue-loss

OBJECTIVE

To explore the potential of combining non-contact profilometry (NCP) and confocal laser scanning microscopy (CLSM) data to measure the entire erosive process non-destructively and to validate findings using inductively coupled plasma-atomic emission spectroscopy (ICP-AES), scanning electron microscopy (SEM) and surface microhardness (SMH) using the same samples throughout.

METHODS

Polished bovine enamel samples (n = 35) were divided into groups (7/group) with similar SMH values. Samples underwent individual erosive challenges (1 % citric acid, pH3.8) for 1, 5, 10, 15 or 30 min under stirring and aliquot extracts were analysed for Ca and P by ICP-AES. SMH was used to measure erosive softening. Profilometry was used to assess bulk volume loss (BVL). Images were captured by SEM. Samples were stained with rhodamine-B (0.1 mM, 24 h) and images captured by CLSM. Image processing was used to determine changes in fluorescent volume for the first 10 μm (ΔFV₁₀) for each enamel sample which were combined with BVL to calculate total lesion volume (TLV). ANOVA, linear regression and Pearson correlation analysis were used where applicable.

RESULTS

Surface softening, [Ca], [P], BVL and ΔFV_10μm increased with acid erosion duration which were significant by 10 min (P < .01). The Ca:P ratio increased to 1.57 then decreased after 5 min erosion suggesting a sub/surface phase change, which was observed by SEM and CLSM showing significant changes to the enamel surface and subsurface morphology with time. Combination of BVL and ΔFV₁₀ as TLV strengthened the significant correlations with [Ca], [P], and SMH (P < .01).

CONCLUSION

This novel combination of CLSM and NCP allows for concurrent non-destructive quantification of the entire erosive process by mineral loss, and qualitatively characterise microstructural changes during dental erosion.

In vitro demineralization prevention by fluoride and silver nanoparticles when applied to sound enamel and enamel caries-like lesions of varying severities

OBJECTIVES

To investigate the effect of fluoride and silver nanoparticles on the prevention of in vitro demineralization of sound enamel and enamel caries-like lesions of varying severities.

METHODS

Caries-like lesions of different severities (1/6/15 days) were created in bovine enamel specimens. One group remained sound. All specimens were demineralized again using a partially saturated acetic acid solution. Mimicking the intra-oral retention of fluoride and silver in vitro, this solution was supplemented with fluoride (0/1/10 ppm) and/or silver nanoparticles (0/10 ppm) in a factorial design. Changes in lesion depth (ΔL) and integrated mineral loss (ΔΔZ) were evaluated by digital transverse microradiography. Data was analyzed using three-way ANOVA.

RESULTS

Lesion severity significantly affected ΔΔZ and ΔL, after no treatment and after the treatment of fluoride and silver independently (p = 0.012 and p = 0.037, respectively). Fluoride and the fluoride × lesion severity interaction were shown to be significant (p < 0.001) on ΔΔZ and ΔL. Silver nanoparticles significantly affected ΔΔZ (p = 0.041), but not ΔL (p = 0.15). The silver nanoparticles × lesion severity interaction was significant for ΔΔZ and ΔL (p = 0.032 and p = 0.024, respectively). No interaction was observed for ΔΔZ and ΔL between fluoride and silver (p = 0.962 and p = 0.971, respectively) as well as lesion severity and the use of fluoride and silver combined (p = 0.722 and p = 0.158, respectively).

CONCLUSION

Fluoride and silver nanoparticles had a significant effect on the prevention of in vitro demineralization of sound enamel and enamel caries-like lesions of varying severities.

CLINICAL SIGNIFICANCE

Fluoride and silver nanoparticles may potentially allow for more tailored caries prevention.

Sorptivity of water in enamel for categorizing caries lesions

OBJECTIVE

The aim of this research was to determine the association between sorptivity of water and the state of mineralization in carious enamel of different stages of severity.

METHODS

As a preliminary work, water droplets of 1.5 μL were placed on the surfaces of hydroxyapatite (HA) discs of different densities. The water droplet profile was dynamically recorded every second over a period of 10 s using a contact angle meter to determine the relationship between sorptivity and density. To measure and calculate sorptivity on enamel surfaces, varnish was painted on the labial surface of 96 extracted caries-free human teeth, leaving two 1.4 ± 0.1 mm diameter circular exposed test sites. The specimens were randomly divided into 6 groups (n = 16) and subjected to 0(G0), 7(G7), 14(G14), 21(G21), 28(G28) and 35(G35) days of pH cycling, respectively. A 0.7 μL water droplet was placed on each exposed site and Optical Coherence Tomography was used to measure its height every 10 seconds for 2 min. Sorptivity was computed by considering sorption equations and Washburn's analysis of capillary kinetics and correction for evaporation was also performed. Micro-Computed Tomography scans of the specimens were obtained and delta Z (ΔZ) is the parameter used to measure mineral loss. ΔZ at 10 μm (ΔZ₁₀) and 50 μm (ΔZ₅₀) from the surface were calculated. One-way ANOVA and Post-hoc Tukey tests were used to compare sorptivity between groups and bivariate correlations were used to analyze the association between sorptivity and ΔZ.

RESULTS

Sorptivity was found to be inversely and linearly correlated with HA density with R² value of 0.95. With enamel, there is a general trend of increase in mean sorptivity from G0 to G35, except for a decrease in G21. The same trends were observed for both ΔZ₁₀ and ΔZ₅₀. The decrease in sorptivity in G21 coincided with the presence of a surface hypermineralized layer in G21 samples. Post-hoc Tukey showed significant differences in mean sorptivity between G0 and G14, G0 and G21 as well as G14 and G21. Post-hoc Dunnett's T3 showed significant differences for ΔZ₁₀ between G0 and G14 as well as G14 and G21. Significant correlation between mean sorptivity and ΔZ₁₀ was detected with Pearson correlation coefficient of 0.461. For ΔZ₅₀, post-hoc Tukey showed significant differences between G0 and G14 but no significant difference was detected between G14 and G21. No correlations were detected between mean sorptivity and ΔZ₅₀.

SIGNIFICANCE

Sorptivity was found to be inversely and linearly correlated with HA density with R² value of 0.95. With enamel, there is a general trend of increase in mean sorptivity from G0 to G35, except for a decrease in G21. The same trends were observed for both ΔZ₁₀ and ΔZ₅₀. The decrease in sorptivity in G21 coincided with the presence of a surface hypermineralized layer in G21 samples.

The effect of theobromine on the in vitro de- and remineralization of enamel carious lesions

OBJECTIVES

This in vitro study investigated the effect of theobromine on the de- and remineralization of enamel carious lesions under plaque fluid-like conditions.

METHODS

Early carious lesions were created in 272 bovine enamel specimens and assigned to sixteen groups (n=17) based on Knoop surface microhardness (SMH). Lesions were demineralized again under plaque fluid-like conditions in the presence of fluoride (0.2 or 1ppm) and theobromine (0; 10; 100 or 200ppm) at different pH values (5.5 or 7.0) in a factorial design. SMH was determined again and percent SMH recovery (%SMHr) calculated. Three-way ANOVA was used for the fixed effects of fluoride, theobromine and pH levels to compare the differences between each level.

RESULTS

The three-way interaction was not significant (p=0.712). The two-way interaction between fluoride and pH was significant (p=0.030), whereas those between fluoride and theobromine as well as that for pH and theobromine were not (p=0.478 and p=0.998, respectively). Theobromine did not affect %SMHr at any of the tested concentrations. There were trends for the higher fluoride concentration and the higher pH resulting in more rehardening with the lesions exposed to 0.2ppm fluoride at pH 5.5 displaying significantly less rehardening than those exposed to 0.2ppm fluoride at pH of 7.0 and lesions exposed to 1ppm fluoride at pH of 5.5.

CONCLUSION

Theobromine, when continuously present in a plaque fluid-like medium at various concentrations and at different pH values, does not affect de- or remineralization of enamel carious lesions under the presently studied conditions.

CLINICAL SIGNIFICANCE

Based on the presently available evidence, theobromine cannot be recommended as an anticaries agent.

Fluoride Dentifrice Overcomes the Lower Resistance of Fluorotic Enamel to Demineralization

We evaluated if the low resistance of fluorotic enamel to demineralization could be overcome by fluoride dentifrice (FD) treatment. Paired enamel slabs of sound and fluorotic enamel (n = 20/group) from human teeth presenting Thylstrup and Fejerskov index (TF) scores from 0 to 4 were obtained. Half of the anatomic surface of the enamel slabs was isolated and used as a control (baseline) regarding enamel mineralization and fluoride concentration. The slabs were submitted to a pH-cycling model simulating a high cariogenic challenge, and 2×/day they were treated with placebo dentifrice (PD) or FD (1,100 µg F/g, as NaF). After 10 days, the slabs were cut into two halves. Enamel demineralization was evaluated by cross-sectional microhardness in one half, and the fluoride formed (FF) concentration was determined in the other half. For statistical analysis, the data on net demineralization area (ΔΔS) and FF (µg F/g) were grouped into TF0, TF1-2, and TF3-4, and analyzed by two-way ANOVA followed by Tukey's test (α = 5%). The factors studied were TF (0, 1-2, and 3-4) and dentifrice treatment (PD or FD). The effect of the factors was statistically significant for ΔΔS and FF (p < 0.05). In the PD group, the following pattern for ΔΔS was observed: TF3-4 > TF1-2 > TF0 (p < 0.05); however, the groups did not differ (p > 0.05) when FD was used. Regarding FF, the groups treated with PD did not differ (p > 0.05), but the greatest (p < 0.05) FF concentration was found in group TF3-4 treated with FD. These findings suggest that the higher susceptibility of fluorotic enamel to demineralization lesions is decreased by the use of FD.

In vitro effect of amorphous calcium phosphate paste applied for extended periods of time on enamel remineralization

Dental applications based on the unique characteristics of amorphous calcium phosphate stabilized by casein phosphopeptides (CPP-ACP) have been proposed, as well as the improvement of its properties.

Effect of Enamel Caries Lesion Baseline Severity on Fluoride Dose-Response

This study aimed to investigate the effect of enamel caries lesion baseline severity on fluoride dose-response under pH cycling conditions. Early caries lesions were created in human enamel specimens at four different severities (8, 16, 24, and 36 h). Lesions were allocated to treatment groups (0, 83, and 367 ppm fluoride as sodium fluoride) based on Vickers surface microhardness (VHN) and pH cycled for 5 d. The cycling model comprised 3 × 1 min fluoride treatments sandwiched between 2 × 60 min demineralization challenges with specimens stored in artificial saliva in between. VHN was measured again and changes versus lesion baseline were calculated (ΔVHN). Data were analyzed using two-way ANOVA (p < 0.05). Increased demineralization times led to increased surface softening. The lesion severity×fluoride concentration interaction was significant (p < 0.001). Fluoride dose-response was observed in all groups. Lesions initially demineralized for 16 and 8 h showed similar overall rehardening (ΔVHN) and more than 24 and 36 h lesions, which were similar. The 8 h lesions showed the greatest fluoride response differential (367 versus 0 ppm F) which diminished with increasing lesion baseline severity. The extent of rehardening as a result of the 0 ppm F treatment increased with increasing lesion baseline severity, whereas it decreased for the fluoride treatments. In conclusion, lesion baseline severity impacts the extent of the fluoride dose-response.

Evidence of an in vitro Coupled Diffusion Mechanism of Lesion Formation within Microcosm Dental Plaque

The purpose of this study was to determine whether or not the dual constant-depth film fermenter (dCDFF) is able to produce caries-like enamel lesions and to ascertain further information regarding the performance of this fully functional biological caries model. Conditions were defined by the continuation (CF) or cessation (FF) of a saliva-type growth medium supply during 50-mM sucrose exposures (8 times daily). Hydroxyapatite (n = 3) and bovine enamel (n = 3) substrata were included within each condition and samples extracted after 2, 4, 8, and 16 days. Community profiles were generated for fastidious anaerobes, Lactobacillus spp., Streptococcus spp., mutans streptococci (MS), and Veillonella spp. using selective culture techniques and enamel demineralisation assessed by transverse microradiography. Results demonstrated that the dCDFF model is able to produce caries-like enamel lesions with a high degree of sensitivity where reduced ionic strength within the FF condition increased surface layer mineral deposition. Between conditions, biofilm communities did not differ significantly, although MS in the biofilms extracted from the FF condition rose to a higher proportion (by 1.5 log10 units), and Veillonella spp. were initially greater within the CF condition (by 2.5 log10 units), indicating an enhanced ability for the clearance of low-pKa acids following exposures to sucrose. However, both conditions retained the ability for caries-like lesion formation.

In situ remineralisation response of different artificial caries-like enamel lesions to home-care and professional fluoride treatments

Background

Artificial lesions produced by different protocols might directly influence the response to different remineralising treatments. This study compared the response of different artificial caries-like enamel lesions to home-care and professional fluoride based-remineralising treatments in situ.

Methods

The tested demineralising protocols were methylcellulose- MC gel, polyacrylic acid - PA gel, tetraethyl methylene diphosphanate - TEMDP solution, and acetate- Buffer solution. The lesions were remineralised using an in situ model, following a crossover and double blind design. Twelve subjects wore intra-oral appliances during 3 phases (3 d each): control (C) (saliva); home-care F⁻ treatment (FD) (1,100 ppm F⁻ dentifrice, 2x1 min/day); and professional (FVD) (22,600 ppm F⁻ varnish) plus FD. The de-remineralisation was measured by transverse microradiography-TMR and hardness (surface hardness/cross-sectional hardness, SH/CSH, respectively).

Results

For SH, lesions produced by PA gel were the only one showing significant differences among the remineralising treatments (C x FD x FVD); while the TEMDP lesion were not responsive to any fluoride treatment (for both SH/CSH). For TMR, there were no differences among the remineralising treatments, regardless of the type of lesion. Generally, the most responsive lesions to fluoride were the less demineralised lesions (considering hardness: PA gel and Buffer).

Conclusions

The type of lesion has influence on the surface remineralisation degree induced by home-care and professional fluoride treatments using this in situ model.

Dentifrice fluoride and abrasivity interplay on artificial caries lesions

Incipient caries lesions on smooth surfaces may be subjected to toothbrushing, potentially leading to remineralization and/or abrasive wear. The interplay of dentifrice abrasivity and fluoride on this process is largely unknown and was investigated on three artificially created lesions with different mineral content/distribution. 120 bovine enamel specimens were randomly allocated to 12 groups (n = 10), resulting from the association of (1) lesion type [methylcellulose acid gel (MeC); carboxymethylcellulose solution (CMC); hydroxyethylcellulose gel (HEC)], (2) slurry abrasive level [low (REA 4/ RDA 69); high (REA 7/RDA 208)], and (3) fluoride concentration [0/275 ppm (14.5 mM) F as NaF]. After lesion creation, specimens were brushed in an automated brushing machine with the test slurries (50 strokes 2×/day). Specimens were kept in artificial saliva in between brushings and overnight. Enamel surface loss (SL) was determined by optical profilometry after lesion creation, 1, 3 and 5 days. Two enamel sections (from baseline and post-brushing areas) were obtained and analyzed microradiographically. Data were analyzed by analysis of variance and Tukey's tests (α = 5%). Brushing with high-abrasive slurry caused more SL than brushing with low-abrasive slurry. For MeC and CMC lesions, fluoride had a protective effect on SL from day 3 on. Furthermore, for MeC and CMC, there was a significant mineral gain in the remaining lesions except when brushed with high-abrasive slurries and 0 ppm F. For HEC, a significant mineral gain took place when low-abrasive slurry was used with fluoride. The tested lesions responded differently to the toothbrushing procedures. Both slurry fluoride content and abrasivity directly impacted SL and mineral gain of enamel caries lesions.

Remineralization Models

During the ICNARA 2 conference, a workshop was held on remineralization models. The group considered the role of remineralization models, whether there was one ideal in situ model design, what essential features should be incorporated into an in situ model, other alternative models, and what new methods for measuring remineralization were on the horizon. This paper summarizes the discussion. In situ and other caries models can be used as a surrogate for caries clinical trials but only when data exist to validate the model. In situ model design should be flexible to allow for investigation of different aspects of the caries process; however, several essential features were identified that should be incorporated into the study design. A range of other caries models was discussed, including the study of non-cavitated lesions, lesions post-orthodontic therapy, plaque retention models to form more standardized lesions, and the study of root caries lesions. Numerous new methods for quantifying remineralization were discussed, but it was considered that these require validation before they can be used in clinical trials.