Quantitation of enamel demineralization mechanisms. 3. A critical examination of the hydroxyapatite model

Er:YAG laser irradiation to control the progression of enamel erosion: an in situ study

This in situ study evaluated the effect of Er:YAG laser irradiation in controlling the progression of enamel erosion-like lesions. Fifty-six enamel slabs (330 KHN ± 10 %) with one fourth of the surface covered with resin composite (control area) were submitted to initial erosion-like lesion formation with citric acid. The slabs were divided into two groups: irradiated with Er:YAG laser and non-irradiated. Fourteen volunteers used an intraoral palatal appliance containing two slabs, in two phases of 5 days each. During the intraoral phase, in a crossed-over design, half of the volunteers immersed the appliance in citric acid while the other half used deionized water, both for 5 min, three times per day. Enamel wear was determined by an optical 3D profilometer. ANOVA revealed that when deionized water was used as immersion solution during the intraoral phase, lower values of wear were showed when compared with the groups that were eroded with citric acid, whether irradiated or non-irradiated with Er:YAG laser. When erosion with citric acid was performed, Er:YAG laser was not able to reduce enamel wear. Small changes on enamel surface were observed when it was irradiated with Er:YAG laser. It may be concluded that Er:YAG laser irradiation did not reduce the progression of erosive lesions on enamel submitted to in situ erosion with citric acid.

The effects of lasers and fluoride on the acid resistance of decalcified human enamel

OBJECTIVE

In order to preserve the maximum amount of healthy enamel and increase the acid resistance of decalcified enamel, a CO(2) laser, an Nd:YAG laser, and acidulated phosphate fluoride (APF) were used to treat incipient carious lesions, then their effects were compared.

MATERIALS AND METHODS

One hundred and sixty samples of human caries-free premolars were immersed in pH-cycling solution (pH = 5) for 2 d for decalcified lesion formation. Then the tooth samples were randomly divided into eight groups and the lesions were treated using the different modalities: a control group, an APF only group, an APF = Nd:YAG laser group, and APF = CO(2) laser group, an Nd:YAG laser = APF group, a CO(2) laser = APF group, a CO(2) laser only group, and an Nd:YAG laser only group. The energy density setting for the two types of lasers was 83.33 J/cm(2). After treatment the tooth samples were immersed in pH-cycling solution again for 2 d for acid challenge. As for the acid-resistance evaluation, the calcium concentration dissolved from the enamel surface was analyzed by an electrolyte analyzer. Scanning electron microscopy (SEM) was used to assess morphologic changes and polarized light microscopy (PLM) was used to evaluate optical changes in the lesions.

RESULTS

The control group showed a statistically significantly (p < 0.05) higher calcium concentration compared with all the other groups. The APF group also had a statistically significantly higher calcium concentration (p < 0.05) than did the laser groups. However, there was no statistically significant difference in any of the laser groups whether combined with fluoride or not (p > 0.05). Upon SEM analysis, melted surfaces and crater-like holes 1-20 microm in diameter were found in the CO(2) laser and Nd:YAG laser groups. On PLM, positive birefringence and reversal of birefringence after acid challenge of the lased enamel were seen.

CONCLUSIONS

Using lasers and fluoride on decalcified enamel appears to increase the enamel's acid resistance, and the effects of the lasers were better than those of fluoride treatment.

Enamel diffusion modulated by Er:YAG laser

Several studies have demonstrated the caries protective effect of lasers by strengthening enamel crystalline structure. However, the effect of laser on enamel diffusion (ED) remains unclear.

OBJECTIVES

This study aimed to quantify the laser-induced alteration of diffusion coefficients (DC) in enamel using fluorescence recovery after photobleaching (FRAP).

METHODS

Eleven caries-free enamel sections were characterized morphologically using stereomicroscopy, polarized light microscopy and scanning electron microscopy, before and after laser treatment with Er:YAG laser 50 mJ x 5 s x 5 Hz. With 20 microM fluorescein, DCs were measured (n=11) by FRAP coupled with confocal microscopy.

RESULTS

The DCs measured were 2.89+/-0.61 x 10(-7)cm(2)/s and 4.076+/-0.73 x 10(-7)cm(2)/s, at the lased and unlased areas, respectively (p=0.001).

CONCLUSIONS

This study has confirmed the reduction of ED as a potential mechanism involved in laser-induced caries prevention. FRAP was demonstrated to be a promising technique for evaluating diffusion-related phenomenon in enamel.

A new model for nanoscale enamel dissolution

The dissolution kinetics of human tooth enamel surfaces was investigated using nanomolar-sensitive constant composition (CC) and in situ atomic force microscopy (AFM) under simulated caries formation conditions (relative undersaturation with respect to hydroxyapatite = 0.902, pH = 4.5). Scanning electron microscopic (SEM) examination of the resulting etched enamel surfaces showed that deminerzalization, initiated at core/wall interfaces of rods, developed anisotropically along the c-axes. After an initial rapid removal of surface polishing artifacts, the dissolution rate decreased as the reaction proceeded in accordance with our recently proposed crystal dissolution model, resulting in hollow enamel cores and nanosized remaining crystallites, resistant to further dissolution. Generally, dissolution of minerals is regarded as a spontaneous reaction in which all the solid phase can be dissolved in undersaturated solutions. However, the dissolution of some biominerals may be suppressed when the crystallites approach nanometer size. This study shows that CC demineralization of enamel in acidic medium follows this new model that can be used to mimic carious lesion formation. In dissolution studies, nanosized enamel crystallites exhibit a remarkable degree of self-preservation in the fluctuating physiological milieu.

Effect of Er:YAG laser and organic matrix on porosity changes in human enamel

OBJECTIVES

Cariostatic effects of lasers have been well documented in the past few decades; however, the mechanisms remain unclear. Our previous study revealed the statistically significant effect of organic matrix (OM) in the laser-induced caries prevention. The aim of the present study is to further investigate the role of organic matters in the laser-induced porosity changes.

METHODS

Enamel powder from five sound molars was randomly divided into two samples. One sample was treated with approximately 10% NaClO solution to remove OM and the other was left untreated. Both groups were then subjected to irradiation by an Er:YAG laser. The samples were characterized by thermogravimetric analysis (TGA) and N(2) physico-adsorption.

RESULTS

TGA results confirmed that the NaClO treatment had at least partially removed the OM in enamel powder. The surface area and pore volume of normal enamel powder decreased significantly after laser treatment. In contrast, in the NaClO-treated enamel powder, laser treatment did not significantly decrease the surface area and the pore volume remained almost unchanged. The substantial difference between the normal enamel powder and the NaClO-treated enamel powder after laser treatment confirmed the laser-induced blocking of OM in the micro-diffusion pathway in enamel.

CONCLUSION

The findings in this study seemed to substantiate the "organic blocking theory" as one of the mechanisms in the laser-induced caries prevention.

Human enamel dissolution in citric acid as a function of pH in the range 2.30< or =pH< or =6.30--a nanoindentation study

The objective of this study was to investigate the dissolution of human enamel in citric acid solutions over a wide range of pH. The in vitro conditions are considered to be relevant to soft drink-induced enamel erosion. Nanoindentation was used to investigate changes in the nanomechanical properties of polished enamel surfaces after exposure to citric acid solutions. Solutions used had 38.1 mmol l-1 citric acid and pH greater than 2.3 but less than 6.3 (2.30 < or = pH < or = 6.30). Samples were exposed to rapidly stirred, constant composition solutions for 120 s. Statistically significant changes in enamel hardness and reduced elastic modulus were observed after exposure to all solutions. There was an approximately linear dependence of enamel hardness on solution pH for 2.90 < or = pH < or = 6.30. Below pH 2.90, enamel is thought to have reached the lowest possible hardness value. The reduction in enamel dissolution caused by an increase in pH of a soft drink is likely to be small. Product modification to reduce the erosive potential of drinks may require additional methods such as addition of calcium salts.

Effects of low-energy CO2 laser irradiation and the organic matrix on inhibition of enamel demineralization

In the past two decades, accumulated evidence has clearly demonstrated the inhibitory effects of laser irradiation on enamel demineralization, but the exact mechanisms of these effects remain unclear. The purpose of this study was to investigate the effects of low-energy CO2 laser irradiation on demineralization of both normal human enamel and human enamel with its organic matrix removed. Twenty-four human molars were collected, cleaned, and cut into two halves. One half of each tooth was randomly selected and its lipid and protein content extracted. The other half of each tooth was used as the matched control. Each tooth half had two window areas. All the left windows were treated with a low-energy laser irradiation, whereas the right windows served as the non-laser controls. After caries-like lesion formation in a pH-cycling environment, microradiographs of tooth sections were taken for quantification of demineralization. The mean mineral losses (with standard deviation) of the enamel control, the lased enamel, the non-organic enamel control, and the lased non-organic enamel subgroups were 3955 (1191), 52(49), 4565(1311), and 1191 (940), respectively. A factorial ANOVA showed significant effects of laser irradiation (p = 0.0001), organic matrix (p = 0.0125), and the laser-organic matrix interaction (p = 0.0377). The laser irradiation resulted in a greater than 98% reduction in mineral loss, but the laser effect dropped to about 70% when the organic matrix in the enamel was removed. The results suggest that clinically applicable CO2 laser irradiation may cause an almost complete inhibition of enamel demineralization.

Use of Dicalcium Phosphate Dihydrate as a Probe in an Approach for Accurate Calculations of Solution Equilibria in Buffered Calcium Phosphate Systems

Both synthetic and biological carbonated apatites have been shown to possess metastable equilibrium solubility (MES) distributions. Investigation of their MES behavior requires accurate knowledge of the activities of the relevant ions over a range of solution compositions. This in turn requires that the activity coefficients for these ions and the stability constants for the various solution complexes be accurately known. Since the solubility of dicalcium phosphate dihydrate (DCPD) can be easily determined, it can be used as a probe to study the appropriateness of proposed sets of stability constants and activity coefficients. In the present study, the solubility of DCPD was determined in acetate buffer solutions at pHs ranging from 4.5 to 6.5 and this allowed for the determination and evaluation of the stability constants of the NaHPO(-)(4), CaHPO(0)(4), CaH(2)PO(+)(4), and CaAc(+) complexes. The activity coefficients were calculated by a modification of the extended Debye-Hückel method and also by Bockris and Reddy's method, in which the activity of water and the hydration numbers of ions are also considered. The solution conditions were controlled to simulate the dissolution media used for the determination of MES distributions of apatites in our laboratory. Both methods of activity coefficient determination gave very consistent DCPD solubility product (K(DCPD)) values, and values for the stability constants of the relevant complexes determined using the two methods were close to each other. This approach of determining the stability constants under a set of conditions similar to those in apatite dissolution studies offers an effective set of parameters which, though not necessarily always exactly correct in absolute terms, are internally consistent and should allow for the quantitative characterization of the MES behavior of apatites. Copyright 1999 Academic Press.

Surface Reactions of Apatite Dissolution

New experimental data about surface processes of interaction between natural apatite and phosphoric acid solutions were obtained by scanning electron microscopy, Auger electron spectroscopy, and IR reflection spectroscopy. The interaction was found to occur nonstoichiometrically (incongruently) on the very thin surface layer of apatite. The experimental data obtained were compared and extended with results taken from literature. The following sequence of ionic detachment from the surface of apatite to a solution was suggested: first fluorine for fluorapatite or hydroxyl for hydroxyapatite, next calcium, and afterward phosphate. A new chemical mechanism of apatite dissolution was proposed as a result. The mechanism for the first time described the surface irregularity of the dissolution process at the nanolevel. A comparison between this new dissolution mechanism and earlier mechanisms described in the literature was made.

Kinetics of hydroxyapatite dissolution in acetic, lactic, and phosphoric acid solutions

The present study was undertaken in an attempt to relate the kinetics of hydroxyapatite dissolution to solution parameters, under experimental conditions relevant to the dental caries process. Thus, the dissolution of hydroxyapatite was studied in acetic, lactic, and dilute phosphoric acid solutions having initial pH values from 4 to 6. Rates of dissolution and the corresponding degree of saturation with respect to hydroxyapatite were determined at various times throughout the dissolution process. Rates of dissolution of all solutions were found to decrease with increasing degree of solution saturation and were greater in solutions with lower initial values of pH. However, rates of dissolution in partially saturated phosphoric acid solutions (without added organic acid) were at least one order of magnitude lower than those observed in the organic acid buffers with the same initial pH, over the same range of saturation values. The data obtained are consistent with a surface-controlled dissolution model in which the rate of dissolution is dependent upon the degree of saturation and the sum of the activities of the acidic species in solution, i.e., phosphoric and organic acids. These results suggest that in order to assess the cariogenic potential of a given medium (e.g., plaque fluid), one must determine both the degree of saturation with respect to the dissolving mineral and the activities of acidic species in solution.

Kinetics of dissolution of calcium hydroxyapatite powder. III: pH and sample conditioning effects

The kinetics of dissolution of synthetic hydroxyapatite powder (HAP) were studied at 37 degrees C and constant pH in the pH range 3.7-6.9 by continuously recording proton uptake and calcium release. The effect of sample conditioning was carefully investigated. The powder previously equilibrated in saturated solutions shows an initial dissolution rate higher than the one obtained when dry powder directly added to the dissolution solution is used. This effect is interpreted by considering surface state differences. As previously shown, dry powder contains important amounts of calcium and phosphate ions adsorbed onto apatite surface, ions which are desorbed during equilibration. It is assumed that the initial presence of these ions slows the dissolution rate during the first stage of the process by the formation of a permselective layer. Except for these adsorption phenomena which are less important for human enamel powder (HEP) having a lower specific surface area, it is shown that in spite of structural, morphological, and purity differences, the general dissolution behavior of HAP is quite similar to that of HEP, previously studied, and for which a quantitative model has been proposed. The dissolution rates are stirring dependent in a large range of stirring speeds and are proportional to [H+]0.64. Moreover, it is shown that in the whole range of studied pH, a calcium accumulation process occurs at the interface during the first minutes of the acidic attack. It is concluded that in our experimental conditions, the dissolution process is limited by the diffusion of calcium and/or phosphate ions in the interface.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative study of fluoride transport during subsurface dissolution of dental enamel

Previous studies using bovine dental enamel as a model have shown that surface and subsurface dissolution of enamel may be governed by micro-environmental solution conditions. We have now investigated the demineralization phenomenon more rigorously with the primary objective of developing a method for deducing solution species concentration profiles as a function of time from appropriate experimental data. More specifically, in this report, a model-independent method is described for determination of the pore solution fluoride gradients in bovine enamel during subsurface demineralization. Microradiography was used to determine the mineral density profiles, and an electron microprobe technique to determine total fluoride (F) profiles associated with the enamel. In each case, matched sections of bovine enamel were exposed to partially saturated acetate buffers at pH = 4.5 containing 0.5 ppm F for various periods of time (from six to 24 hours). The treated enamel was found to have an intact surface layer and subsurface demineralization. The extent of the demineralization and the depths of the lesions increased with time in all cases. The data were first used to calculate (a) the total F gradients in the enamel at various times, and (b) the local uptake rate of F as a function of time and position. Then, by manipulation of the equations describing the uptake and transport of F, we calculated the pore diffusion rate of F and the micro-environmental solution F concentration in the aqueous pores as a function of time and of distance from the enamel surface. It was also possible to calculate an intrinsic F diffusion coefficient in the pores, which was about 1.0 X 10(-5) cm2/sec, in good agreement with reported values. 14C-sucrose uptake and release experiments with identically prepared demineralized enamel sections were also conducted to provide an independent check on the assumed dependence of porosity on mineral density. The results of this investigation, especially the outcomes relative to this new method for determination of pore solution F gradients during acid attack of the dental enamel, should be valuable in future studies of the mechanism(s) of the action of F in inhibiting dental enamel demineralization.

Hydroxyapatite and carbonated apatite as models for the dissolution behavior of human dental enamel

It is now well-established that kinetic aspects as well as considerations based solely on solubilities and thermodynamic driving forces should be taken into account while one is attempting to understand the mechanism of dental caries. In the present study, kinetic comparisons of the dissolution of hydroxyapatite, carbonated apatite, and ground human dental enamel have been made in order that the appropriateness of these synthetic phases as enamel dissolution models can be assessed. Specific additives used to form intact surface layers in vitro have also been investigated. An interesting phenomenon related to surface-controlled dissolution has been revealed. During Constant Composition experiments, the dissolution rates for all the systems decrease markedly as the reaction proceeds. Further tests with fresh crystals suggest that micro-impurities, in addition to microstructural changes of the dissolving surfaces, may play a role in the case of hydroxyapatite but do not influence the dissolution of carbonated apatite. Kinetic results for ground human enamel indicate the release of dissolution poisons. Nevertheless, the results confirm expectations that carbonated apatite may be a better model for enamel than near-stoichiometric synthetic hydroxyapatite.

Effect of acid type on kinetics and mechanism of dental enamel demineralization

The influence of acid type (pKa effects) of weak organic acid buffers on dissolution kinetics of dental enamel was critically examined for rigorous testing of the behavioral validity of the physical model of Patel et al. (1987). Quantitative evaluation of this model indicated that monitoring initial dissolution rates was a viable approach to critical testing of the model. Initial dissolution rates were determined in 0.1 mol/L acetate (pKa = 4.77), benzoate (pKa = 4.20), and salicylate (pKa = 2.98) buffers (pH = 4.50, mu = 0.50), with ground bovine enamel blocks of known surface area mounted in a rotating disk apparatus. The Levich theory was used to study dependence of dissolution rates on stirring rates in these buffers. The experimental data were analyzed by the physical model which includes pKa effects, complexation of the buffer anion with the other ions, surface kinetics, simultaneous diffusion and equilibrium of all species in enamel pores, diffusion layer thickness, and bulk solution composition. The KIAP (formula: see text) governing the dissolution reaction and the surface resistance factor were deduced from the model. Dissolution kinetics was also followed in these buffers in the presence of calcium or phosphate common ions. In effect, by conducting both the stirring rate studies and common ion experiments, we derived the driving force function independently by these two techniques. The results obtained in this study were consistent with the model, indicating that pKa effects on the dissolution of dental enamel can be accounted for quantitatively by the model, and it was found that weak acids do not influence either the apparent solubility or the surface reaction process of bovine dental enamel.

The kinetics of dissolution of tooth enamel--a constant composition study

The kinetics of dissolution of powdered bovine enamel and of human enamel, both untreated and extracted with either hypochlorite or chloroform, has been studied using a constant solution composition technique in undersaturated solutions of calcium phosphate (total molar calcium concentration, TCa = 0.3 to 13.1 X 10(-3) mol L-1, total molar phosphate, Tp = 0.18 to 7.9 X 10(-3) mol L-1) at an ionic strength of 0.15 mol L-1, and pH = 4.5. The kinetic equations describing the dissolution reactions suggest a surface dislocation mechanism, and the presence of fluoride ion markedly retarded the reaction. For human enamel, a fluoride level of only 0.5 ppm reduced the rate of dissolution ten-fold. In contrast, the dissolution of hydroxyapatite, HAP, is best interpreted in terms of a polynucleation process.

Powder suspension method for critically re-examining the two-site model for hydroxyapatite dissolution kinetics

A powder dissolution method has been developed, and experiments with the hydroxyapatite suspensions confirm earlier conclusions based on dissolution from hydroxyapatite disks. Although a quantitative assessment of the properties of site 1 was not possible from the data obtained in the present study, a rather accurate and independent evaluation of the properties and the behavior of site 2 of the two-site model for hydroxyapatite dissolution was possible, and the results clearly validate the original two-site model. The present work together with the earlier disk studies show that dissolution from site 2 is well described by a first-order expression, rate = kc2 (Cs2-C), where kc2 is a first-order rate constant, Cs2 is the apparent solubility for site 2 (defined by an ion activity product, KHAP, of the form a10Ca2+PO43-a2OH-, and the solution conditions), and C is the microenvironmental solution concentration of hydroxyapatite. For four different precipitated hydroxyapatite preparations, a single KHAP value of 1 X 10(-128) +/- 1 was found to be consistent with experiments using solutions covering wide ranges of partial saturation and calcium-phosphate ratios. The hydroxyapatite powder and pellet methods (including the data evaluation procedures) now offer a powerful combination for investigating the complex kinetics associated with dental enamel dissolution in particular and enamel chemistry in general.

Fluoride uptake and dissolution behavior of a synthetic dental enamel-like substrate

A new ceramic form of hydroxylapatite and enamel were found to behave similarly in regard to their acid dissolution behavior in the presence and absence of topically applied fluoride. Discrepancies between the two materials can be explained by morphological differences between the rough enamel and smooth ceramic particles.

Sex differences in anxiety response and adjustment to dental surgery: effects of general vs. specific preoperative information

Monitored anxiety level by the State-Trait Anxiety Inventory and Corah's (1969a) dental anxiety scale and evaluated adjustment via behavioral ratings, in 32 female and 31 male dental surgery patients who were presented general or specific information prior to surgery. The findings indicated that dental surgery is a stressful procedure that elicits comparably high levels of state anxiety in males and females. For most patients, even those high in dental anxiety, state anxiety level returns to "normal" levels just after the completion of surgery. The dental anxiety scale administered well before surgery is a good predictor of patient anxiety level in the dental situation, especially for males. Females responded to an informational tape received prior to surgery with increased anxiety, and were rated as showing poorer overall adjustment in surgery than males. The general and specific information tapes did not differentially affect adjustment, but informational input and related variables such as patient expectancies and prior level of information are factors that need further investigation in terms of their potential relevance for the reduction of patient anxiety and enhancement of patient adjustment during dental procedures.

Unusual dissolution behavior of tooth enamel and synthetic HAP crystals under high partial saturation conditions

The dissolution behavior of enamel and synthetic hydroxyapatite in acidic media possessing a high degree of partial saturation was found to be neither simple surface dissolution nor linear with time. Instead, a repetitive, stepwise dissolution pattern was observed. To explain this phenomenon, a model based upon a hypothesis that the crystals dissolve in a synchronized fashion was proposed.

Kinetics and mechanism of hydroxyapatite crystal dissolution in weak acid buffers using the rotating disk method

The model given in this report and the rotating disk method provide a useful combination in the study of dental enamel and hydroxyapatite dissolution kinetics. The present approach is a significant improvement over earlier studies, and both the ionic activity product that governs the dissolution reaction and the apparent surface dissolution reaction rate constant may be simultaneously obtained. Thus, these investigations have established the baseline for the dissolution rate studies under sink conditions. Concurrent studies, under conditions where the acidic buffer mediums are partially saturated with respect to hydroxyapatite have shown another dissolution site for hydroxyapatite that operates at a higher ionic activity product but has a much smaller apparent surface reaction rate constant. This has raised the question of whether the presence of this second site may interfere with the proper theoretical analysis of the experimental results obtained under sink conditions. A preliminary analysis of the two-site model has shown that the dissolution kinetics of hydroxyapatite under sink conditions is almost completely governed by the sink condition site (KHAP = 10(-124.5), k' = 174) established in this report. The difference between the predicted dissolution rate for the one-site model and the two-site model are generally of the order of 4 to 5% where the experiments are conducted under sink conditions and over the range of variables covered in the present study.

HPO2-4 content in enamel and artificial carious lesions

The HPO2-4 and CO2-3 content was determined in sound enamel and in material collected from artificially produced carious lesions. The method described shows that the HPO2-4 content can be determined from the 875 cm(-1) infrared absorption band if correction for the CO2-3 contribution are made. The I.R. spectra show that the HPO2-4 content in sound human or bovine enamel is about 5% by weight. In artificially produced carious lesions (pH=4.0), the HPO2-4 content is in the order of 15 wt%. Most likely, the HPO2-4 ions in sound and carious enamel have a different enviroment.

Mechanism for the retardation of the acid dissolution rate of hydroxapatite by strontium

Dissolution rates and apparent solubilities for synthetic hydroxyapatite in acetate buffers containing phosphate and strontium ions in the range of 10-3 to 10-2 M were determined under various pH and buffer conditions. Critical examination of the role of strontium with a physical model suggests that a calcium-strontium apatite surface complex may govern the driving force of the dissolution reaction.

Physical model for plaque action in the tooth-plaque-saliva system

A physical model describing the interrelationships of demineralization, remineralization, plaque thickness, glucose levels, and plaque enzymatic activity was presented. Selection of constants and variations of the parameters were kept in the range of possible in vivo situations. The results of calculations were discussed and correlated with the results of in vivo studies.