Comparative evaluation of remineralization potential of casein phosphopeptide-amorphous calcium phosphate and casein phosphopeptide-amorphous calcium phosphate fluoride on artificial enamel white spot lesion: An in vitro light fluorescence study

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.

Remineralization effects of self-assembling peptide P11 -4 associated with three materials on early enamel carious lesions: An in vitro study

The aim of this study was to assess the remineralization of enamel caries lesions using the self-assembling peptide P11 -4 associated with different materials. Artificial early enamel lesions were prepared on 154 primary teeth. The samples were randomly divided into eight groups: (1) control, (2) P11 -4, (3) fluoridate toothpaste (FT), (4) P11 -4 + FT, (5) casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), (6) P11 -4 + CPP-ACP, (7) fluoridate bioactive glass toothpaste (BT), and (8) P11 -4 + BT. The surface enamel microhardness (EMH) and energy-dispersive X-ray spectroscopy (EDS) of the teeth were then measured at the baseline, after demineralization, and after 28 days of remineralization. The enamel surfaces were assessed by field emission scanning electron microscopy (FESEM) and atomic force microscopy (AFM). The data were analyzed with one-way analysis of variance (ANOVA) (p < .05). EMH after demineralization was significantly lower than the baseline value (p < .001). The interventions led to an enhanced percentage of EMH recovery (%REMH), which was higher in Groups 6 and 7. There was no significant difference between Groups 3 and 4. Groups 1 and 2 had the lowest %REMH. The mean calcium/phosphate weight percentage ratio of P11 -4 was significantly lower than the others (p < .001). The FESEM and AFM images revealed mineral deposition on the eroded enamel and reductions in surface roughness in Groups 5 and 7.

Effectiveness of Self-assembling Peptide P11-4 Compared to Tricalcium Phosphate Fluoride Varnish in Remineralization of White Spot Lesions: A Clinical Randomized Trial

Background

Fluoride varnish with therapeutic tricalcium phosphate formulas such as Clinpro™ varnish has shown greater tendency in treating white spot lesions (WSLs) by inhibiting the progression of initial enamel lesions through the mineral exchange. The self-assembling peptide SAP₁₁-4 (Curodont Repair, CDR) works on a different scale in treating WSLs by mimicking the enamel matrix and aiming to guided enamel regeneration.

Aim

To quantitatively and qualitatively compare the effectiveness of the SAP₁₁-4 vs tricalcium posphate fluoride (TCPF) in remineralization of WSLs in young permanent teeth.

Materials and methods

Nine healthy patients were enrolled in this study. The trial was performed on 40 young permanent teeth in the initial demineralization stage. Teeth were randomly assigned to receive either TCPF (group I) or SAP₁₁-4 (group II). Lesions were assessed at pretreatment, 3, and 6 months posttreatment quantitatively per laser fluorescence DIAGNOdent pen and qualitatively through the International Caries Detection and Assessment System (ICDAS) II.

Results

The result of the current study revealed a significant quantitative and qualitative increase in remineralization of WSLs in both groups and over time intervals. However, the WSL recovery was significantly better in the self-assembling peptide group, reflecting an excellent remineralization potential of the WSLs by the SAP₁₁-4 compared to TCPF varnish.

Conclusion

Both TCPF and SAP₁₁-4 were effective in treating WSLs. However, the success of guided enamel regeneration by the SAP₁₁-4 through the biomineralization has proven superiority of this material compared to TCPF.

Clinical significance

Early detection of WSLs and minimal intervention through remineralizing agents can limit unnecessary tissue loss, further caries progression, and consequently prevent further harm to the patients.

How to cite this article

Kobeissi R, Badr SBY, Osman E. Effectiveness of Self-assembling Peptide P₁₁-4 Compared to Tricalcium Phosphate Fluoride Varnish in remineralization of White Spot Lesions: A Clinical Randomized Trial. Int J Clin Pediatr Dent 2020;13(5):451-456.

The Effect of Remineralizing Agents With/Without CO2 Laser Irradiation on Structural and Mechanical Properties of Enamel and its Shear Bond Strength to Orthodontic Brackets

Introduction: Remineralizing agents may be used for the treatment of white spot lesions (WSLs) prior to bracket bonding. However, some concerns exist regarding their possible interference with the etching and bonding process, negatively affecting the bond strength. This study aimed to assess the effect of two remineralizing agents with/without CO₂ laser irradiation on the mechanical properties and shear bond strength (SBS) of demineralized enamel to the orthodontic bracket. Methods: This study evaluated 60 premolar teeth in 6 groups (n=10) as follows: (I) sound enamel, (II) demineralized enamel, (III) Nupro remineralizing agent (N), (IV) Nupro and CO₂ laser (N/L), (V) Teethmate remineralizing agent (T), and (VI) Teethmate and CO₂ laser (T/L). The remineralizing agents were applied to the enamel surfaces after their immersion in a demineralizing solution for 5 days. In groups IV and VI, the CO₂ laser with a 10.6 μm wavelength, 10 ms pulse duration, a 50 Hz repetition rate, 0.3 mm beam diameter and 0.7 W power was irradiated after applying the remineralizing agents. Brackets were bonded to the enamel surfaces and SBS was measured by a universal testing machine. For the assessment of enamel microhardness, 20 sections of molar teeth were divided into 4 groups (n=5; N, N/L, T, T/L) and their microhardness was measured before demineralization, after demineralization and after remineralization. X-ray diffraction (XRD) analysis, field-emission scanning electron microscopy (FESEM) and energy-dispersive spectrometry (EDS) were carried out to assess the formation of hydroxyapatite. The atomic percentages of the C, O, P, Ca, Na, Si, F and Ca/P ratio were determined by EDS analysis. Results: The SBS significantly decreased in group II (P<0.001). There was no significant difference among the groups I, III, IV, V and VI (P<0.05). This finding was similar to the microhardness results, which showed an increase in microhardness after remineralization (P<0.05), with no difference among the remineralizing agents. The Ca/P ratio was the highest in the Nupro group and the lowest in the demineralized group. Conclusion: Remineralizing agents can significantly improve the microhardness and structural properties of demineralized enamel to a level similar to that of sound enamel with no adverse effect on SBS to orthodontic brackets.

Comparative analysis of the remineralization potential of CPP-ACP with Fluoride, Tri-Calcium Phosphate and Nano Hydroxyapatite using SEM/EDX - An in vitro study

Background

In recent years, the non-invasive management of non cavitated caries lesions using remineralization systems to repair the enamel have received more attention from the scientific community. Aim: To quantitatively evaluate the remineralization potential of Casein phosphopeptide-amorphous calcium phosphate-fluoride(CPP-ACPF), Tri-calcium phosphate(TCP) & Nano-hydroxyapatite(nHAP) using Scanning Electron Microscopy(SEM) and Energy dispersive X-ray Analysis(EDX).

Material and Methods

40 enamel specimens were prepared, and immersed in demineralising solution at a pH of 4.4 for 96 hours at 37°C, to induce artificial carious lesions. Remineralization was carried out for a period of 30 days using CPP-ACPF, TCP, nHAP. The specimens were evaluated for calcium and phosphorus content using SEM-EDX.

Results

The Ca/P mass % after remineralization was significantly higher with CPP-ACP-F and TCP-F followed by nHAP.

Conclusions

CPP-ACP-F and TCP can promote significant remineralization of incipient carious lesions. These are excellent delivery vehicles available in a slow release amorphous form to localize calcium, phosphate and fluoride at the tooth surface.

Key words:Remineralization, in vitro; CPP-ACP fluoride, Nano-hydroxyapatite, Tri-calcium phosphate, SEM/ EDX.

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

Objective:

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

Methodology:

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

Results:

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

Conclusions:

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

Effect of 10% cerium chloride on artificial caries lesions of human enamel evaluated using quantitative light-induced fluorescence: an in vitro study

AIM

To evaluate the effect of 10% cerium chloride intervention on pre-demineralised human enamel subjected to cycles of de- and remineralisation.

METHODS

This was an in vitro, comparative type study of 60 human enamel samples that were randomly divided into control and test groups. The samples were then subjected to a cycle of demineralisation followed by intervention with respective treatment solutions (control group: placebo solution; test: 10% cerium chloride) for 30 s under constant agitation and then to a 2nd cycle of demineralisation followed by remineralisation using artificial saliva. After the first and second cycles of demineralisation (4th and 8th day) and a cycle of remineralisation (22nd day), the samples were evaluated for fluorescence values using a quantitative light-induced fluorescence camera. The data was analysed using paired t test and ANOVA.

RESULTS

Comparing the fluorescence values and mean difference of lesion area between the first cycle of demineralisation to the cycle of remineralisation and the second cycle of demineralisation to the cycle of remineralisation, the test group showed a statistically significant reduction in loss of fluorescence values and lesion area compared to the control group (p < 0.001). Mean fluorescence values and lesion area comparison between cycles of de- and remineralisation for control and test groups (inter-group comparison) showed a statistically significant difference (p < 0.001).

CONCLUSIONS

Cerium chloride alone reduced demineralisation and improved remineralisation of artificial caries lesions in human enamel when subjected to pH cycling in vitro.

In vitro evaluation of remineralization efficacy of different calcium- and fluoride-based delivery systems on artificially demineralized enamel surface

Background:

Caries is the most common dental disease facing the world population. Caries can be prevented by remineralizing early enamel lesions.

Aim:

To evaluate remineralization efficacy of stannous fluoride (SnF₂), casein phosphopeptide-amorphous calcium phosphate with fluoride (CPP-ACPF) and calcium sucrose phosphate (CaSP).

Materials and Methods:

Fifty enamel samples were taken; they were divided into five groups (n = 10). Demineralization was carried out with Groups A, B, C, and E. Remineralization was carried out with Groups A, B, and C for 7 days using SnF₂, CPP-ACPF, and CaSP, respectively. In Group D, no surface treatment was carried out, to mark as positive control whereas Group E was kept as negative control with only surface demineralization of enamel. Enamel microhardness was tested using Vickers's microhardness tester after 7 day remineralization regime.

Statistical Analysis:

One-way analysis of variance and post hoc Tukey tests were performed.

Results:

The mean microhardness values in descending order: Positive control > SnF₂> CaSP > CPP-ACPF > negative control.

Conclusion:

All remineralizing agents showed improved surface remineralization. However, complete remineralization did not occur within 7 days. SnF₂ showed the highest potential for remineralization followed by CaSP and CPP-ACPF.

Assessment of White Spot Lesions and In-Vivo Evaluation of the Effect of CPP-ACP on White Spot Lesions in Permanent Molars of Children

INTRODUCTION

As hindrance of remineralisation process occurs during orthodontic therapy resulting in decalcification of enamel because number of plaque retention sites increases due to banding and bonding of appliances to teeth.

AIM

The present analytic study was undertaken to assess the occurrence of white spot lesions in permanent molars of children with and without orthodontic therapy and to evaluate the effect of Casein PhosphoPeptide-Amorphous Calcium Phosphate (CPP-ACP) on white spot lesions in post-orthodontic patients in a given period of time.

MATERIALS AND METHODS

The study comprised of examination of 679 first permanent molars which were examined to assess the occurrence of smooth surface white spot lesions in children of 8 to 16 years age group. Group I comprised subjects without any orthodontic treatment and Group II comprised of subjects who had undergone orthodontic therapy. The sample size was calculated using the epi-info6 computer package. Treatment group included 20 post-orthodontic patients examined with at least one white spot lesion within the enamel who received remineralizing cream (GC Tooth Mousse, Recaldent, GC Corporation.) i.e., CPP-ACP cream two times a day for 12 consecutive weeks. Computerized image analysis method was taken to evaluate white spot lesions. These frequency and percentages were compared with chi-square test. For comparison of numeric data, paired t-test was used.

RESULTS

Of the total 278 (49.6%) first permanent molars showed occurrence of smooth surface white spot lesions out of 560 in Group I and 107 (89.9%) first permanent molars showed presence of white spot lesions out of 119 debanded first permanent molars of children examined in Group II. CPP-ACP therapy group showed reduction in severity of codes which was found to be highly significant after 12 weeks and eight weeks on gingival-third, p-value (<0.001) and significant after eight weeks and four weeks on middle-third according to ICDAS II criteria and computerized image analysis.

CONCLUSION

CPP-ACP therapy minimum for 12 weeks is highly recommended as post-orthodontic treatment need in management of smooth surface white spot lesions on teeth undergoing fixed orthodontic therapy according to the present study.

An in Vitro Evaluation of Remineralization Potential of Novamin(®) on Artificial Enamel Sub-Surface Lesions Around Orthodontic Brackets Using Energy Dispersive X-Ray Analysis (EDX)

OBJECTIVE

To evaluate and compare the Ca/P ratio of enamel samples around the orthodontic brackets for time periods of 0, 2 and 10 days in two groups (control group and study group).

MATERIALS AND METHODS

Forty extracted teeth were randomly divided into control group and study group. All samples were demineralized and incubated in artificial saliva at 37°C for a period of 10 days after demineralization. During this phase the enamel samples in the study group were treated with remineralizing paste (NuproNusolution containing Novamin®-Dentsply) for 10 days. At the end of the incubation period, Ca/P ratios were analyzed for both the groupsby EDX analysis. Data obtained was subjected to statistical analysis using student t-test for paired samples and Student t- test for individual samples (p ≤ 0.05).

RESULTS

It was found that the mean Ca/P ratio was significantly lower for the control group as compared to the study group (p-value < 0.05) after 10 d of incubation.

CONCLUSION

Novamin(®) containing remineralization toothpaste showed significant remineralizing potential in inhibition of artificial enamel sub-surface lesion around bracket after 10 days of remineralization phase. EDX element analysis was found to be an efficient method to quantify the changes in mineral content of a sample during in vitro caries studies.