Efficacy of fluoride varnish and casein phosphopeptide-amorphous calcium phosphate for remineralization of primary teeth: a randomized clinical trial

Professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries: Systematic review

OBJECTIVES

This systematic review aimed to review the safety and effectiveness of professionally applied fluorides for preventing and arresting dental caries in low- and middle-income countries (LMICs).

METHODS

Randomized controlled trials conducted in LMICs, in which professionally applied fluorides were compared with placebo/no treatment/health education only or usual care with a minimum one-year follow-up period, were included. Any topically applied fluoride agents such as sodium fluoride (NaF), acidulated phosphate fluoride, silver diamine fluoride (SDF), and nano silver fluoride (NSF) were included. Five databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were searched in May 2022. Meta-analysis was conducted using a random effect model.

RESULTS

This review included 33 studies for qualitative synthesis, encompassing 16,375 children aged between 1.5 and 14 years. Nevertheless, the meta-analysis focused on only 17 studies, involving 4067 children. Fourteen papers assessed potential adverse events, none of which was reported as major adverse events. SDF and NSF were identified as effective in arresting caries on primary teeth (p < 0.05) compared with a placebo or no treatment. Fluoride varnish and gel were identified as effective in reducing new caries development on primary teeth (p < 0.05) but not on permanent teeth (p > 0.05). The certainty of the generated evidence obtained is low.

CONCLUSION

The review provides valuable insights into the use of professionally applied fluorides in LMICs and contributes to recommendations for their use. However, the limited rigorous evidence suggests the need for further research to strengthen these findings and draw more robust conclusions.

Efficiency of casein phosphopeptide amorphous calcium phosphate versus topical fluorides on remineralizing early enamel carious lesions - A systematic review and meta analysis

Objective

To assess the remineralizing efficiency of caesin phosphopepdide amorphous calcium phosphate (CPP-ACP) versus topical fluorides on early enamel lesions in vivo.

Data sources

PubMed, Web of Science, Scopus, EBSCO were searched based on the PICOS criteria up to December 2022 with English language restriction. All relevant studies were subjected to two separate reviews before being included at the title, abstract, and full text levels.

Study selection

41 studies were reviewed and 11 selected for inclusion in the final sample for the review. All were randomized clinical trials with the follow-up period of the studies ranging from 3 to 12 months. Out of the 11 studies, only two are with low risk of bias on assessment with Cochrane risk of bias assessment tool, while the other nine articles were with the moderate and high risk of bias.

Conclusions

Conflicting evidence exists on the clinical efficacy of CPP-ACP compared to the various fluoride forms tested, and no adverse effect associated with CPP-ACP use was discovered in comparison to fluorides that had certain detrimental health impacts. Although, the review results in favor of both fluorides and CPP-ACP with similar clinical efficiency, when ill effects are considered the CPP-ACP can be a choice of remineralizing early enamel lesions. However, before concrete suggestions can be given, high-quality, well-designed clinical research in this area are still necessary.

Clinical significance

A considerable remineralizing impact has been shown in both in vitro and in vivo experiments, making CPP-ACP/CPP-ACPF a more promising remineralizing agent than fluorides. Therefore, this can be applied clinically to early enamel carious lesion.

Comparative evaluation of four treatments for postorthodontic white spot lesions: a randomized controlled trial

OBJECTIVES

To evaluate the treatment efficacy of fluoride toothpaste alone and those of adjunctive use of resin infiltration, sodium fluoride varnish, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs).

MATERIALS AND METHODS

Seventy-nine patients (356 teeth) with WSLs after orthodontic treatment were randomly allocated into four groups. The WSLs of the participants received resin infiltration only at baseline, and the other groups received fluoride varnish, CPP-ACP mousse, and placebo treatment every 6 months, respectively. A toothpaste containing 1400 ppm fluoride and toothbrushes were distributed to all participants, and oral hygiene instructions were provided. Photos of the teeth with WSL were taken to compare the change between groups which was measured by ImageJ software.

RESULTS

Twelve months later, different degrees of reduction in the area of WSLs were observed in all groups. The percentage of lesion area reduction in WSLs in the resin infiltration group was 46.6%, which was significantly higher than that in fluoride varnish group (26.6%), CPP-ACP group (28.6%), and control group (29.8%), and the differences were statistically significant (p < 0.001).

CONCLUSIONS

This study shows that after 1-year follow-up, the use of fluoride toothpaste, with or without the use of fluoride varnish or CPP-ACP, can reduce the area of WSLs. While resin infiltration can immediately improve dental aesthetics and continuously improved in 12 months, resin infiltration group showed much better results than other groups.

TRIAL REGISTRATION

Clinical Trials Registration Number: ChiCTR2000032516.

CLINICAL SIGNIFICANCE

The use of fluoride toothpaste, with or without adjunctive use of fluoride varnish and CPP-ACP, can reduce the area of WSLs, while resin infiltration treatment has additional effect and can immediately improve dental aesthetics.

Clinical interventions with various agents to prevent early childhood caries: A systematic review with network meta-analysis

BACKGROUND

Dental caries is one of the most prevalent chronic diseases among preschool children globally. Different preventive agents and combinations have been studied. However, the rank of the effectiveness of clinical interventions is equivocal.

AIM

To summarize and rank the effectiveness of clinical interventions using different agents for primary prevention of early childhood caries (ECC).

DESIGN

Two reviewers independently searched PubMed, Embase, and Cochrane Library to identify randomized controlled trials with at least 12-month follow-up. The network meta-analysis (NMA) on different agents was based on a random-effects model and frequentist approach. Standardized mean differences (SMD) with 95% CI of the caries increment were calculated in terms of either dmft or dmfs and used in the NMA. Caries incidences at the child level were compared using odds ratios (ORs) with 95% CI. The effectiveness of the agents was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

After screening 3807 publications and selection, the NMA finally included 33 trials. These trials used either a single or combination of agents such as fluorides, chlorhexidine, casein phosphopeptide-amorphous calcium phosphate, probiotics, xylitol, and triclosan. Compared with control, fluoride foam (FF; SMD -0.69, 95% CI: -1.06, -0.32) and fluoride salt (F salt; SMD -0.66, 95% CI: -1.20, -0.13) were effective in preventing caries increment. Probiotic milk plus low fluoride toothpaste (PMLFTP; OR 0.34, 95% CI: 0.15, 0.77), FF (OR 0.48, 95% CI: 0.37, 0.63), fluoride varnish (FV; OR 0.63, 95% CI: 0.48, 0.81), and fluoride varnish plus high fluoride toothpaste (FVHFTP; OR 0.73, 95% CI: 0.57, 0.93) were effectively preventing caries incidence. According to the SUCRA, FF ranked first in preventing caries increment, whereas PMLFTP ranked first in preventing caries incidence.

CONCLUSION

Fluoride foam, F salt, PMLFTP, FV, and FVHFTP all effectively reduce caries increment or caries incidence in preschool children, but the evidence indicates low degree of certainty. Considering the relatively small number of studies, confidence in the findings, and limitations in the study, clinical practitioners and readers should exercise caution when interpreting the NMA results.

Improving Oral Health with Fluoride-Free Calcium-Phosphate-Based Biomimetic Toothpastes: An Update of the Clinical Evidence

As the demand for clinically effective fluoride-free oral care products for consumers increases, it is important to document which types of toothpastes have been shown in clinical studies to be effective in improving oral health. In this review, we included different indications, i.e., caries prevention, improving periodontal health, reducing dentin hypersensitivity, protecting against dental erosion, and safely improving tooth whitening in defining what constitutes improvement in oral health. While there are several professional and consumer fluoride-containing formulations fortified with calcium-phosphate-based ingredients, this review focuses on fluoride-free toothpastes containing biomimetic calcium-phosphate-based molecules as the primary active ingredients. Several databases were searched, and only clinical trials in human subjects were included; in vitro and animal studies were excluded. There were 62 oral health clinical trials on biomimetic hydroxyapatite (HAP), 57 on casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), 26 on calcium sodium phosphosilicate (CSPS, or so called Bioglass), and 2 on β-tricalcium phosphate (β-TCP). HAP formulations were tested the most in clinical trials for benefits in preventing caries, dentin hypersensitivity, improving periodontal health, and tooth whitening. Based on the current clinical evidence to date, fluoride-free HAP toothpaste formulations are the most versatile of the calcium phosphate active ingredients in toothpastes for improving oral health.

Comparison of therapies of white spot lesions: a systematic review and network meta-analysis

OBJECTIVE

White spot lesions (WSLs), the earliest evidence of enamel demineralization, are considered amenable to intervention to achieve a remineralized or arrested state of caries. The management of WSLs is quite challenging, and there is no definitive cure as yet. We performed a network meta-analysis to assess the efficacy of seven therapies for WSLs and gave a hierarchy of them.

MATERIALS AND METHODS

We systematically searched the PubMed, EMBASE, Cochrane, and Web of Science databases (last search: July 2022) to identify all relevant studies. We limited our search to studies published in English. Randomized controlled designed in vitro/clinical trials related to the efficacy of the seven therapies for WSLs were included. Data extraction was performed independently by two reviewers. The risk of bias (ROB) 2.0 tool from Cochrane and a previous in vitro methodological tool will be used for the quality assessment. Variations in quantitative light-induced fluorescence (QLF), laser fluorescence (LF), and lesions area were the primary outcome measures. Standard mean difference (SMD) was used as the effect size for the Network meta-analysis (NMA). Consistency and inconsistency tests were conducted. The hierarchy of 7 treatment effects was evaluated using surface probabilities under cumulative ranking (SUCRA). Publication bias was evaluated using a bias plot.

RESULTS

Forty-two articles were included in the systematic review. Thirty-one of them, with a total of 1906 participants, were included in the network meta-analysis. The studies owned a low and moderate risk of bias. This analysis does not suffer from significant inconsistency. The difference between 4 groups 'self-assembled peptide (SAP) P11-4', 'P11-4 + Fluoride Varnish (FV)', 'Resin Infiltration (RI)', 'casein phosphor peptides-amorphous calcium fluoride phosphate (CPP-ACFP)' and the 'Control' group was found to be statistically significant. Compared to the 'FV' and 'casein phosphor peptides-amorphous calcium phosphate (CPP-ACP)' groups, the 'P11-4 + FV" group and 'RI" group made a significant difference. The hierarchy was evident in the SUCRA values of 7 therapies. P11-4 + FV and RI were considered effective therapies compared to the control group or the FV group (gold standard group).

CONCLUSIONS

The available evidence suggests that resin infiltration and P11-4 in combination with fluoride varnish had advantages over gold standard (FV). The effect of tricalcium phosphate-based drugs and fluoride is not very noticeable. Overall, drugs based on P11-4 and resin infiltration will be better therapies. Using more than two drugs in combination also would increase efficacy.

Effect of self-assembling peptide and other remineralizing agents on preventing initial enamel lesions around orthodontic brackets: An in vitro comparative study

OBJECTIVE

To investigate and compare the effect of self-assembling peptide SAP (P_11-4), casein phosphopeptide-amorphous calcium phosphate fluoride paste (CPP-ACPF), and fluoride varnish (FV) on preventing enamel demineralization around orthodontic brackets.

MATERIAL AND METHODS

Orthodontic brackets were bonded to the buccal surfaces of 80 freshly extracted human maxillary premolars. Teeth were randomly assigned to four groups (n=20) according to the remineralizing agent used as follows: SAP (P_11-4) group (Curodont™ Protect/Credentis), CPP-ACPF group (MI Paste Plus®/Recaldent™), fluoride varnish group (Profluoride varnish®/VOCO), and control group. All products were applied according to the manufacturer's instructions. Specimens were cycled in daily refreshed demineralizing and remineralizing solutions for 8h and 16h, respectively, for 28 days. The calcium/phosphorus ratio (Ca/P) and surface microhardness (SMH) were evaluated at baseline and at two and four weeks. Two-way ANOVA (analysis of variance), one-way ANOVA and repeated measures ANOVA were used for statistical analysis.

RESULTS

Two-way ANOVA demonstrated significant differences between remineralizing agents and time points. After 4 weeks, the SAP (P_11-4) group had had significantly higher Ca/P ratio and SMH (1.68±0.11 and 346.47±55.38) compared to other groups, followed by CPP-ACPF (1.52±0.19 and 283.53±64.75), FV (1.37±0.14 and 262.80±82.98), and the control group (1.31±0.10 and 213.00±41.95). Significantly higher Ca/P ratio and SMH were observed at 2 weeks in the control group (1.44±0.10 and 269.63±57.37) and FV group (1.52±0.09 and 321.17±55.24) compared to 4 weeks. No significant differences were found regarding Ca/P ratio and SMH at 2 weeks in the CPP-ACPF (1.55±0.15 and 295.14±53.88) and SAP P_11-4 groups (1.64±0.10 and 320.18±58.04) compared to 4 weeks.

CONCLUSION

SAP (P_11-4) had the greatest remineralizing efficacy compared to FV and CPP-ACPF. Moreover, extended period of time improved the preventive efficacy of SAP (P_11-4) compared to the other regimens.

An evaluation of remineralised MIH using CPP-ACP and fluoride varnish: An in-situ and in-vitro study

BACKGROUND

Molar incisor hypomineralization (MIH) affected teeth have enamel with altered mineral content like decreased calcium and phosphorus and increased carbon content leading to porous enamel and subsequent post-eruptive breakdown.

AIM

An in situ study was conducted to evaluate and compare the effects of a Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP)-based cream and fluoride varnish on the remineralization of MIH affected teeth.

METHODS

Enamel slabs were prepared from MIH affected teeth that had been extracted for various reasons and inserted in appliances of 30 participants who were undergoing interceptive orthodontic therapy. They were randomly divided into two groups using block randomization technique: Group A-daily single application of CPP-ACP cream (n = 15); Group B-professional application of fluoride varnishes every 3 months (n = 15). After 6 months of regular wear of the appliance, the enamel slabs were placed under Field Emission Scanning Microscope (FESEM) and Energy-Dispersive Spectroscopy (EDS) for evaluation of ultra structure and mineral content, respectively.

RESULTS

A significant increase in calcium and phosphorus content, and a decrease in carbon content was observed within the 6 months period, suggesting remineralization in both the groups. On comparing the Ca:P and Ca:C ratios, a significant increase in the Ca:C ratio was evident in the two groups. No significant difference was seen in the Ca:P ratio in the CPP-ACP group at six months. The inter-group comparison did not reveal any significant difference between the two groups either at baseline or at 6 months post-intervention.

CONCLUSION

Remineralization can be achieved in MIH affected teeth with the use of remineralizing agents.

Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

A 2014 review for the US Preventive Services Task Force (USPSTF) found that oral fluoride supplementation and topical fluoride use were associated with reduced caries incidence in children younger than 5 years.

OBJECTIVE

To update the 2014 review on dental caries screening and preventive interventions to inform the USPSTF.

DATA SOURCES

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to September 2020); surveillance through July 23, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) on screening, preventive interventions, referral to dental care; cohort studies on screening and referral; studies on diagnostic accuracy of primary care oral examination or risk assessment; and a systematic review on risk of fluorosis included in prior USPSTF reviews.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

RESULTS

Thirty-two studies (19 trials, 9 observational studies, and 4 nonrandomized clinical intervention studies [total 106 694 participants] and 1 systematic review [19 studies]) were included. No study evaluated effects of primary care screening on clinical outcomes. One study (n = 258) found primary care pediatrician examination associated with a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with cavities, and 1 study found a risk assessment tool associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for a child with future caries. No new trials of dietary fluoride supplementation were identified. For prevention, topical fluoride compared with placebo or no topical fluoride was associated with decreased caries burden (13 trials, n = 5733; mean caries increment [difference in decayed, missing, and filled teeth or surfaces], -0.94 [95% CI, -1.74 to -0.34]) and likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; absolute risk difference, -7%) in higher-risk populations or settings, with no increased fluorosis risk. Evidence on other preventive interventions was limited (education, xylitol) or unavailable (silver diamine fluoride), and no study directly evaluated primary care dentistry referral vs no referral.

CONCLUSIONS AND RELEVANCE

There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

Synthetic amorphous calcium phosphates (ACPs): preparation, structure, properties, and biomedical applications

Amorphous calcium phosphates (ACPs) represent a metastable amorphous state of other calcium orthophosphates (abbreviated as CaPO₄) possessing variable compositional but rather identical glass-like physical properties, in which there are neither translational nor orientational long-range orders of the atomic positions. In nature, ACPs of a biological origin are found in the calcified tissues of mammals, some parts of primitive organisms, as well as in the mammalian milk. Manmade ACPs can be synthesized in a laboratory by various methods including wet-chemical precipitation, in which they are the first solid phases, precipitated after a rapid mixing of aqueous solutions containing dissolved ions of Ca²⁺ and PO₄^3- in sufficient amounts. Due to the amorphous nature, all types of synthetic ACPs appear to be thermodynamically unstable and, unless stored in dry conditions or doped by stabilizers, they tend to transform spontaneously to crystalline CaPO₄, mainly to ones with an apatitic structure. This intrinsic metastability of the ACPs is of a great biological relevance. In particular, the initiating role that metastable ACPs play in matrix vesicle biomineralization raises their importance from a mere laboratory curiosity to that of a reasonable key intermediate in skeletal calcifications. In addition, synthetic ACPs appear to be very promising biomaterials both for manufacturing artificial bone grafts and for dental applications. In this review, the current knowledge on the occurrence, structural design, chemical composition, preparation, properties, and biomedical applications of the synthetic ACPs have been summarized.

Tooth mousse containing casein phosphopeptide-amorphous calcium phosphate prevents biofilm formation of Streptococcus mutans

BACKGROUND

Streptococcus mutans is a common cariogenic bacterium in the oral cavity involved in plaque formation. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has been introduced into tooth mousse to encourage remineralization of dental enamel. The aim of this research was to study the effect of tooth mousse containing CPP-ACP (GC Tooth Mousse®) or CPP-ACP with 0.2% fluoride (CPP-ACPF; GC Tooth Mousse Plus®; GCP) on S. mutans planktonic growth and biofilm formation.

METHODS

S. mutans was cultivated in the presence of different dilutions of the tooth mousse containing CPP-ACP or CPP-ACPF, and the planktonic growth was determined by ATP viability assay and counting colony-forming units (CFUs). The resulting biofilms were examined by crystal violet staining, MTT metabolic assay, confocal laser scanning microscopy (CLSM), and scanning electron microscope (SEM).

RESULTS

The CPP-ACP tooth mousse (GC) at a dilution of 5-50 mg/ml (0.5-5%) did not inhibit planktonic growth, and even increased the ATP content and the number of viable bacteria after a 24 h incubation. The same was observed for the CPP-ACPF tooth mousse (GCP), except for the higher concentrations (25 and 50 mg/ml) that led to a drop in the bacterial count. Importantly, both compounds significantly decreased S. mutans biofilm formation at dilutions as low as 1.5-3 mg/ml. 12.5 mg/ml GC and 6.25 mg/ml GCP inhibited biofilm formation by 90% after 4 h. After 24 h, the MBIC90 was 6.25 mg/ml for both. CLSM images confirmed the strong inhibitory effect GC and GCP had on biofilm formation when using 5 mg/ml tooth mousse. SEM images of those bacteria that managed to form biofilm in the presence of 5 mg/ml tooth mousse, showed alterations in the bacterial morphology, where the streptococci appear 25-30% shorter on the average than the control bacteria.

CONCLUSION

Our data show that the tooth mousse containing CPP-ACP reduces biofilm formation of the cariogenic bacterium S. mutans without killing the bacteria. The use of natural substances which inhibit biofilm development without killing the bacteria, has therapeutic benefits, especially in orthodontic pediatric patients.

Evaluation of a community-based early childhood caries (ECC) intervention in Cambodia

OBJECTIVE

To critically evaluate an early childhood caries (ECC) intervention performed by non-dental primary healthcare providers.

METHODS

This mixed-methods investigation includes data from three sources: (a) a pilot non-randomized controlled trial to examine clinical outcomes at four health centres; (b) stakeholder focus group interviews; and (c) a survey of parents whose children were exposed to the intervention. The pilot study involved four Community Health Centres in rural Cambodia whereby mother-child (6-24 months of age)dyads received oral health education (OHE), toothbrushes, fluoride toothpaste and fluoride varnish on up to six occasions as part of the routine vaccination schedule. Outcomes were as follows: presence of ECC; impacts on oral health-related quality of life (OHRQoL); stakeholder perceptions of intervention delivery; and parental perceptions of fluoride varnish.

RESULTS

Participants in the intervention group had six times lower odds of developing ECC than those in the comparison group after controlling for socio-economic status (OR 0.13). Those in the intervention group also had a large reduction OHRQoL scale scores. Key knowledge and practice gaps were identified among stakeholders. Surveyed parents had favourable views of the fluoride varnish placement by medical professionals, and four out of five stated that they would recommend fluoride varnish for other children. Primary healthcare providers, commune council representatives and community health promoters supported oral health interventions being provided in CHCs.

CONCLUSIONS

OHE and fluoride varnish interventions provided by non-dental primary health workers were feasible and acceptable for stakeholders in a Cambodian setting. The intervention group had lower ECC experience and better OHRQoL at 2 years of age.

The Efficacy of Resin Infiltrant and Casein Phosphopeptide-amorphous Calcium Fluoride Phosphate in Treatment of White Spot Lesions (Comparative Study)

Background:

White spot lesions (WSLs) are considered as the first sign of the progression of dental caries that can be reversed. Casein phosphopeptide–amorphous calcium fluoride phosphate (CPP-ACFP) varnish can promote remineralization process of the demineralized tooth structure. Also, WSLs can be managed by using caries infiltrant (ICON), which infiltrates etched enamel surface of the WSLs.

Objectives:

The main aim was to evaluate and compare the efficacy of ICON versus CPP-ACFP varnish to treat WSLs in the same oral environments.

Materials and Methods:

A total of 30 participants aged 20–40 years with at least two WSLs have participated in this trial. Split-mouth technique has been used in this trial where WSLs on the left side have been treated with ICON, whereas WSLs on the right side have been treated with CPP-ACFP varnish. Clinical evaluation using DIAGNOdent was carried out at baseline, 1 week, 1, 3, 6, and 12 months after application to determine the effectiveness of these materials in treating WSLs.

Results:

Significant differences were observed between all follow-up DIAGNOdent scores compared to baseline readings of both ICON and CPP-ACFP (P = 0.000 for all comparisons). Statistically significant differences were observed between DIAGNOdent scores of ICON compared to CPP-ACFP at all follow-up intervals (P = 0.006, 0.008, 0.045, 0.036, and 0.000).

Conclusion:

Both ICON and CPP-ACFP were effective in the treatment of WSLs of smooth surfaces but the efficacy of CPP-ACFP was better than ICON.

In Vitro Comparison of Fluoride, Magnesium, and Calcium Phosphate Materials on Prevention of White Spot Lesions around Orthodontic Brackets

One common negative side effect of orthodontic treatment with fixed appliances is the development of white spot lesions (WSLs) around brackets. This study is aimed at comparing the efficacy of various oral hygiene practices in preventing enamel demineralization around orthodontic brackets under similar in vitro conditions. The study included 90 extracted bovine incisors, which were randomized into six groups: fluoride toothpaste (FT), nonfluoride toothpaste (NFT), fluoride varnish plus fluoride toothpaste (FV+FT), CPP-ACP varnish plus fluoride toothpaste (CPP-ACP+FT), medical minerals gel plus nonfluoride toothpaste (MMG+NFT), and no intervention (control). All groups were subjected to demineralization and remineralization cycles. Visual appraisals were used to evaluate the changes in the enamel surface appearance at the beginning and end of the experiment. The changes in the demineralization degree were evaluated by measuring the Ca⁺² concentration in the demineralization solution at different time points. The majority of teeth in the CPP-ACP+FT group exhibited no shift in appearance, whereas in the other groups, a slight change in enamel translucency was observed. At all the time points, the Ca⁺² concentration in the demineralization solution in the CPP-ACP+FT group was the least among all other groups. At day 5, MMG+NFT's preventive efficacy was significantly higher than FV+FT's, but at days 10, 15, and 19, their efficacy was similar. However, at all the time points, MMG+NFT's efficacy was significantly higher than that of control, whereas FV+FT's efficacy was decreased at days 10, 15, and 19 and was close to the efficacy of control. To fight WSLs, early diagnosis was of great importance and examination of the tooth surface after air-drying for 5 s was recommended.

Effects of different anti-caries procedures on microhardness and micromorphology of irradiated permanent enamel

To explore the effects of infiltration resin, casein phosphate polypeptide-amorphous calcium phosphate (CPP-ACP) and fluoride on microhardness and micromorphology of irradiated enamel. Sixty human permanent teeth were mesiodistally sectioned, yielding 120 enamel samples, which randomly divided into 8 groups: G1: blank control; G2: irradiation control; G3: irradiation+fluoride; G4: irradiation+CPP-ACP; G5: irradiation+CPP-ACP+fluoride; G6: irradiation+infiltration resin; G7: irradiation+infiltration resin+fluoride; G8: irradiation+infiltration resin+CPP-ACP. A progressive improvement was observed on the superficial morphology of enamel treated with different anti-caries procedures. The order of microhardness values after irradiation from the highest to the lowest was as follows: G1>G8~G7>G6>G5>G4~G3>G2. CPP-ACP, infiltration resin and fluoride can effectively restore the direct destruction of enamel caused by irradiation and promote the occurrence of remineralization. Infiltration resin and its combined effects with fluoride or CPP-ACP have the most potential anti-caries agent to resist radiation-caries.

How to Intervene in the Caries Process: Early Childhood Caries – A Systematic Review

For an Organisation for Caries Research/European Federation of Conservative Dentistry consensus, this systematic review is aimed to assess the question of how to manage the caries process in the case of early childhood caries (ECC). Medline via PubMed was searched systematically regarding management of ECC. First priority was existing systematic reviews or randomized clinical trials otherwise cohort studies dealing with management of ECC, primarily with carious anterior teeth. After data extraction, the potential risk of bias was estimated depending on the study types, and the level of evidence was evaluated. Regarding management of ECC, results are presented for silver diamine fluoride (SDF, n = 5), nonoperative caries management (NOCM, n = 10), and restorative approaches (RA, n = 8) separately, as different kinds of studies with different levels of evidence were found for the different aspects in the management of ECC. The 5 systematic reviews on SDF showed a high potential for arrest of ECC on a high level of evidence. In NOCM, a low level of evidence for a moderate effect of fluoride varnish in arresting or remineralizing, especially non-cavitated lesions, was assessed. For RA in carious anterior upper primary teeth, a low level of evidence was found for higher failure rates of glass ionomer cement and composite fillings than composite strip crowns even if placed under general anaesthesia and especially compared to other crowns (stainless steel and zirconia). In conclusions, ECC may be managed successfully with nonoperative (SDF, regular fluoride application) and moderately well with operative approaches, but the decision is affected by many other variables such as pulpal involvement, the child’s cooperation, or a general anaesthesia setting.

Dentin Tubule Occlusion Potential of Novel Dentifrices Having Fluoride Containing Bioactive Glass and Zinc Oxide Nanoparticles

OBJECTIVE

To compare the in vitro potential of dentin tubule occlusion of two novel experimental dentifrices consisting of fluoride containing bioactive glass (BG) with zinc oxide nanoparticles.

MATERIALS AND METHODS

Forty-eight dentin discs (n = 48) were divided into 6 groups (n = 8), based on their brushing dentifrices: Group 1 = artificial saliva (AS; control); Group 2 = fluoride dentifrice (Colgate Palmolive©, UK); Group 3 = experimental nonactive agent dentifrice; Group 4 = experimental dentifrice with 1.5% BG; Group 5 = experimental dentifrice with 4% BG; and Group 6 = BioMinF© dentifrice. Postbrushing, the discs were subjected to acidic challenge with 6% wt citric acid (pH = 4.0) for 1 min. Scanning electron microscope (SEM) and energy-dispersive X-ray (EDX) spectroscopy were performed pre- and post-citric acid challenges, and percentages of tubule occlusion assessed.

RESULTS

SEM micrographs of group 1 (AS) show no tubule occlusion (0%), whereas those of groups 2 and 3 show partial tubule occlusion (25 to <50% of tubules occluded). The SEM micrographs of dentifrices containing fluoride-BG (groups 4, 5, and 6) show that most of the tubules (>50 and <100%) were occluded. For all the groups (excluding group 1), pre- and post-citric acid challenge values are statistically significant (p < 0.05). EDX analysis reveals the presence of zinc in experimental dentifrices only.

CONCLUSION

The results of novel experimental dentifrices are comparable to those of the BioMinF©, in terms of tubule occlusion. Dentifrices containing BG could serve as an alternative in dentin sensitivity management.

Fluoride Varnish and Dental Caries in Preschoolers: A Systematic Review and Meta-Analysis

The aim of this study was to assess the effectiveness of fluoride varnish (FV) in reducing dentine caries at the patient, tooth, and surface levels as well as caries-related hospitalizations in preschoolers. We performed a systematic review of clinical trials of FV, alone or associated with an oral health program, compared with placebo, usual care, or no intervention. Bibliographical search included electronic searches of seven databases, registers of ongoing trials, and meeting abstracts, as well as hand searching. We performed random-effects meta-analyses and calculated confidence and prediction intervals. The search yielded 2,441 records; 20 trials were included in the review and 17 in at least one meta-analysis. Only one study had low risk of bias in all domains. We found no study reporting on caries-related hospitalizations. At the individual level, the pooled relative risk was 0.88 (95% confidence interval [CI] 0.81, 0.95); this means that in a population of preschool children with 50% caries incidence, we need to apply fluoride varnish in 17 children to avoid new caries in one child. At the tooth level, the pooled weighted mean difference was –0.30 (95% CI –0.69, 0.09) and at the surface level –0.77 (95% CI –1.23, –0.31). Considering the prediction intervals, none of the pooled estimates were statistically significant. We conclude that FV showed a modest and uncertain anticaries effect in preschoolers. Cost-effectiveness analyses are needed to assess whether FV should be adopted or abandoned by dental services.

Effects of different anti-caries agents on microhardness and superficial microstructure of irradiated permanent dentin: an in vitro study

BACKGROUND

To compare different anti-caries agents on microhardness and micromorphology of irradiated permanent dentin in vitro, and try to find the most effective agent to prevent radiation-dentin-destruction.

METHODS

A total of 120 dentin samples were prepared from 60 human teeth and randomly divided into 8 groups (n = 15), [ (1)] blank control [2]; irradiation control [3]; irradiation+ fluoride [4]; irradiation+ casein phosphate polypeptide-amorphous calcium phosphate (CPP-ACP) [5]; irradiation+ CPP-ACP+ fluoride [6]; irradiation+ infiltration resin [7]; irradiation+ infiltration resin+ fluoride [8]; irradiation+ infiltration resin+ CPP-ACP. Seven samples of each groups were chosen randomly for microhardness test and eight for scanning electron microscope observation.

RESULTS

A decrease of microhardness (P < 0.05) and an obvious morphological change were presented on dentin surface after radiotherapy. After applications of anti-caries agents, the morphological destructions were effectively restored. The infiltration resin plus fluoride group (56.00 ± 4.02 Kg/mm2), infiltration resin plus CPP-ACP group (56.05 ± 3.69 Kg/mm2), infiltration resin group (54.70 ± 4.42Kg/mm2) and CPP-ACP plus fluoride group (53.84 ± 6.23Kg/mm2) had the highest dentin microhardness value after radiotherapy, and no statistically significant difference were found between them.

CONCLUSIONS

Infiltration resin, CPP-ACP, fluoride and their pairwise combination can effectively prevent radiation-dentin-destruction. Among them, infiltration resin with CPP-ACP, infiltration resin with fluoride, CPP-ACP with fluoride, and infiltration resin have the most protective effects on irradiation-dentin-destructions.

In vitro Comparison of Antimicrobial Activity of Conventional Fluoride Varnishes Containing Xylitol and Casein Phosphopeptide-Amorphous Calcium Phosphate

Objective

Different fluoride varnishes are used for the prevention of dental caries. The aim of this study was to compare the antimicrobial effect of different fluoride varnishes, containing xylitol and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), on Streptococcus mutans.

Materials and Methods

In this in vitro study, the antibacterial effects of four varnishes, namely Polimo and V-varnish (containing xylitol), MI varnish (containing CPP-ACP), and Preventa, were evaluated against S. mutans. The disc diffusion method was used for testing the bacterial sensitivity. The data were analyzed using the Kruskal-Wallis and Mann-Whitney U-tests.

Results

According to the results, Polimo showed the highest antibacterial effects, compared to the other three varnishes (P ≤ 0.05). Growth inhibition zones were not observed in V-varnish and Preventa. The mean diameter of inhibition zone around the MI varnish was significantly higher, compared to those of the V varnish and Preventa (P ≤ 0.05).

Conclusion

As the findings indicated, the fluoride varnish containing xylitol and CPP-ACP could be more effective iAQ1n the prevention of dental caries.

Fluorides and Other Preventive Strategies for Tooth Decay

We focus on scalable public health interventions that prevent and delay the development of caries and enhance resistance to dental caries lesions. These interventions should occur throughout the life cycle, and need to be age appropriate. Mitigating disease transmission and enhancing resistance are achieved through use of various fluorides, sugar substitutes, mechanical barriers such as pit-and-fissure sealants, and antimicrobials. A key aspect is counseling and other behavioral interventions that are designed to promote use of disease transmission-inhibiting and tooth resistance-enhancing agents. Advocacy for public water fluoridation and sugar taxes is an appropriate dental public health activity.

Comparative evaluation of remineralizing efficacy of biomimetic self-assembling peptide on artificially induced enamel lesions: An in vitro study

Background

The biomimetic self-assembling peptide technology is a paradigm for dental hard tissue regeneration.

Aim

To investigate the efficacy of biomimetic self-assembling peptide (P₁₁-4) on enamel remineralization compared to casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF) and fluoride-based delivery systems.

Materials and Methods

Artificial enamel lesions were created on buccal surfaces of 40 extracted human molars. Specimens were randomly assigned to four groups (n = 10) according to the remineralizing agent used: G1 - control: artificial saliva, G2 - fluoride varnish, G3 - CPP-ACPF varnish, G4 - self-assembling peptide agent. All products were applied according to the manufacturer's instructions and the specimens were stored in daily renewed artificial saliva. Surface microhardness (SMH) was assessed at baseline, after demineralization, after 1 week and after 4 weeks storage. SMH values were analyzed using ANOVA and Tukey's post hoc test.

Results

Self-assembling peptide showed the highest statistically significant mean SMH followed by fluoride and CPP-ACPF while the lowest mean SMH was found in artificial saliva. However, no statistically significant difference was found between fluoride and CPP-ACPF. Higher statistically significant mean SMH was found after 4 weeks compared to 1 week remineralization in all groups.

Conclusions

Self-assembling peptide confers the highest remineralizing efficacy compared to fluoride and CPP-ACPF, showing a promising, noninvasive regeneration potential. Furthermore, extended period of time helped attain more benefits from the remineralizing regimens applied.

Primary Fused Teeth and Findings in Permanent Dentition

OBJECTIVE

The aim of this study was to investigate the characteristics of primary fused teeth (PFT) and their effect on permanent dentition in a group of Turkish children.

SUBJECTS AND METHODS

Dental records of 13,450 pediatric patients who attended the Pediatric Dental Clinic in northern Turkey between 2015 and 2017 were reviewed. Forty patients had been diagnosed with PFT and were included in the study. Clinical and radiographic examinations were conducted, and the distribution of PFT was calculated by type, sex, affected jaw, associated dental anomalies, and clinical complications. Data analysis involved descriptive statistics.

RESULTS

A total of 50 PFT were detected in the 40 patients. The mean age of patients was 6.7 ± 0.3 years (range 3-10 years). The most common PFT were the mandibular lateral incisors and canines (34, 68%). The most prevalent type of PFT was type III (20, 40%). Of the 40 patients with PFT, 34 (85%) also ex-hibited other dental anomalies such as tooth aplasia, peg-shaped incisors, talon cusps, ectopic eruption, and delayed eruption in both related and unrelated areas. The most common complications of PFT were fusion-related tooth aplasia (n = 26 [76%]) and caries formation in the affected teeth (24 [48%]).

CONCLUSION

In this study, PFT were frequently observed in the mandibular anterior region. Caries formation and dental anomalies, especially permanent tooth aplasia, were often encountered in areas where PFT were seen. Hence, parents should be informed about possible dental problems associated with PFT and be encouraged to schedule regular follow-up appointments.

[Remineralization effect of casein phosphopeptide-amorphous calcium phosphate for enamel demineralization: a system review]

OBJECTIVE

This study  aims  to  assess  the  remineralization effect of casein phosphopeptide (CPP)-amorphous calcium phosphate (ACP) on enamel demineralization by  performing  system review of  randomized  controlled  trials (RCT)  involving  the  treatment of enamel demineralization with  CPP-ACP.

METHODS

The  study  was  developed  based  on  the 
Cochrane handbook  for  systematic  reviews of  interventions (Version 5.1.0) and included  the  following: search  strategy, selection  criteria, data  extraction, and  risk  of  bias  assessment. We  searched electronic  databases  such  as  PubMed, Embase, Cochrane Library, CNKI, Wanfang and VIP up  to  September  2016. RCT of  treating  enamel demineralization with  CPP-ACP were  included. Data  extraction  and  domain-based  risk  of  bias  assessment  were independently  performed  by  two  reviewers.

RESULTS

Twelve  RCTs  were  included.  Because of the difference of experimental design and evaluation standards, the quantitative analysis can not be carried out.

CONCLUSIONS

There is no strong evidence that CPP-ACP is superior to conventional fluoride formulations in enamel remineralization. However, due  to the limitations of sample size, follow-up time and study design,  more high quality and large-sample RCT are needed to  further  verify  the evidence.

Effect of non-fluoride agents on the prevention of dental caries in primary dentition: A systematic review

Objective

To assess the effect of non-fluoride agents on the prevention of dental caries in primary dentition.

Materials and methods

Medline, Web of Science, Embase, Cochrane Library, CBM and CNKI databases were searched to identify all the relevant articles published prior to 16 December 2016. Grey literature was also searched. Randomized controlled human clinical trials in which non-fluoride agents were delivered by any method were considered.

Results

Of the 1,236 studies screened, 39 full articles were scrutinized and 14 selected for inclusion in the final sample. Five chemical agents, namely arginine, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), chlorhexidine, triclosan and xylitol were investigated in these included studies. The cariostatic effects of non-fluoride agents in vivo were evaluated in comparison with fluoride or placebos in randomized controlled trials. There is evidence that the use of certain doses of xylitol may be effective in arresting dental caries in primary dentition. However, quantitative synthesis could not be carried out because of the clinical and methodological heterogeneity of the included studies.

Conclusions

A study at low risk of bias indicated that daily use of xylitol wipes is a useful adjunct for caries control in young children, however, this conclusion should be interpreted with caution as this study had a very limited sample size. Chlorhexidine and CPP-ACP may be more effective than a placebo in managing caries in primary dentition, but their effectiveness is borderline when compared with fluoride. Arginine-containing mint confection and 0.3% triclosan varnish were found to reduce caries development in primary teeth but the evidence was at high risk of bias. High quality randomized controlled trials are needed in order to make a conclusive recommendation.

Role of fluoride varnish in preventing early childhood caries: A systematic review

Background:

Early childhood caries is a public health problem that continues to affect babies and preschool children worldwide. This untreated caries process results in progressive destruction of the crowns of the teeth, often accompanied by severe pain and suffering, affecting the quality of life. Fluoride varnish which is one of the most important materials to prevent ECC is easy to apply and well tolerated by children. This study aimed to evaluate the scientific evidence regardingthe role of fluoride varnish in preventing early childhood caries.

Materials and Methods:

Records were searched from various databases such as PubMed/Medline, Cochrane, and EMBASE. Articles published over the past 36 years (1979-2015) were identified using the key search terms. A total of 190 records were identified by title/abstracts/full text articles and were retrieved. Potentially relevant reports identified from the reference lists of relevant studies, review articles and chapters were hand-searched, which yielded an additional 10 articles. The main outcome of our investigation was prevention of early childhood caries following application of fluoride varnish and unavoidable fluoride exposure. Out of 190 articles originally identified, 30 records were considered potentially eligible and sought for further assessment. 17 articles met the inclusion criteria and these studies were assessed independently for methodology and performance.

Results:

Analysis of literature revealed that basically two concentrations of fluoride varnishes have been used: 1% and 5%, with a caries preventive fraction ranges of 6.4-30% and 5-63%, respectively.

Conclusion:

The results showed that fluoride varnishes have been used at concentrations of 1% and 5% in the prevention of ECC. The preventive fraction was influenced by the frequency of application, the duration of study and sample size. The evidence level of the studies was of moderate to limited value.

A 12-Week Assessment of the Treatment of White Spot Lesions with CPP-ACP Paste and/or Fluoride Varnish

This 12-week clinical study evaluated the impact of 10% CPP-ACP and 5% sodium fluoride varnish regimes on the regression of nonorthodontic white spot lesions (WSLs). The study included 21 children with 101 WSLs who were randomised into four treatment regimes: weekly clinical applications of fluoride varnish for the first month (FV); twice daily self-applications of CPP-ACP paste (CPP-ACP); weekly applications of fluoride varnish for the first month and twice daily self-applications of CPP-ACP paste (CPP-ACP-FV); and no intervention (control). All groups undertook a standard oral hygiene protocol and weekly consultation. Visual appraisals and laser fluorescence (LF) measurements were made in weeks one and twelve. The majority of WSLs in the control and FV groups exhibited no shift in appearance, whereas, in the CPP-ACP and CPP-ACP-FV groups, the lesions predominantly regressed. The visual and LF assessments indicated that the extent of remineralisation afforded by the treatments was of the following order: control ~ FV < CPP-ACP ~ CPP-ACP-FV. Self-applications of CPP-ACP paste as an adjunct to standard oral hygiene significantly improved the appearance and remineralisation of WSLs. No advantage was observed for the use of fluoride varnish as a supplement to either the standard or CPP-ACP-enhanced oral hygiene regimes.

Comparison of Oral Health Education and Fluoride Varnish to Prevent Early Childhood Caries: A Randomized Clinical Trial

Early childhood caries, a serious health problem among young children, can be prevented with effective intervention. The aim of this study was to evaluate the efficacy of oral health education and a fluoride varnish in the prevention of caries in children under the age of 3 years. For this single-blind randomized parallel group 1-year clinical trial in Shiraz, 300 children aged 12-24 months with sound primary teeth were selected and randomly divided into three groups (n = 100): (1) control: no preventive intervention; (2) oral health counseling, and (3) oral health counseling and fluoride varnish at baseline and 6 months later. At baseline and 4, 8 and 12 months after the intervention, caries risk reduction was recorded as the primary outcome. The mothers' knowledge and performance regarding oral health in children was used as a secondary outcome. A total of 260 children (mean age: 20.49 ± 7.33 months) completed the study. Compared to group 1, caries risk reduction in group 2 was 28% (95% CI: -39.05 to -17.45) and 31% in group 3 (95% CI: -41.88 to -21.73). However, there was no significant difference between groups 2 and 3 (95% CI: -8.58 to 1.47). In all groups, mothers' knowledge and performance at baseline were low; however, they increased significantly in follow-up appointments in groups 2 and 3 (p < 0.001). Oral health education increased mothers' knowledge and performance regarding oral health in children. Oral health counseling alone or associated with the use of fluoride varnish reduced the caries incidence in young children.

Efficacy of calcium- and fluoride-containing materials for the remineralization of primary teeth with early enamel lesion

The aim of the study was to determine the efficacy of different products containing fluoride, calcium and phosphate for enamel remineralization in eroded primary teeth. A total of 90 sound primary canine teeth were randomly divided into 5 groups of 18 teeth each: 1) control (polished enamel), 2) 5% DuraShield sodium fluoride varnish, 3) 500 ppm fluoridated toothpaste, 4) casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) cream, and 5) Clinpro White varnish containing functionalized tri-calcium phosphate (fTCP). Enamel microhardness (EMH) was measured in all samples before and after demineralization and after 28 days of remineralization. Also 8 samples in groups 2 to 5 and four samples of sound and demineralized enamel were examined with atomic force microscopy (AFM). All data were analyzed with one-way ANOVA (p<0.05). Mean microhardness of demineralized enamel was significantly lower than in enamel at baseline (p<0.001). Remineralization significantly increased microharness in groups 2 to 5 compared to the control group (p<0.001). Percent EMH after remineralization with CPP-ACP was significantly higher than after fTCP (p=0.029), toothpaste (p< 0.001) or fluoride varnish (p<0.001); however, there was no significant difference between toothpaste and fluoride varnish (p=0.062). Microhardness increased more after fTCP treatment than after treatment with sodium fluoride varnish (p<0.001) or fluoridated toothpaste (p=0.045). AFM images showed that enamel roughness decreased most after treatment with fTCP, followed by CPP-ACP, toothpaste and fluoride varnish. The efficacy of CPP-ACP cream for remineralizing eroded enamel was greater than fluoride toothpaste, fluoride varnish or fTCP varnish.