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

Evaluation of the effect of self-assembling peptide and fluoride varnish, alone or in combination with laser irradiation, on artificial enamel caries: a SEM/EDS and Micro-CT study

OBJECTIVE

The aim of this study was to investigate the effect of remineralization agents such as fluoride varnish and P11-4, alone and in combination with Er: YAG laser, on in-vitro hard tissue repair in artificial enamel lesions.

MATERIALS AND METHODS

A total of sixty enamel surfaces of 4 × 5 mm in size were created on both the buccal and lingual sides of thirty extracted wisdom teeth. Remineralization agents were applied to the specimens that were grouped as follows: Group 1, control; Group 2, fluoride varnish (FV); Group 3, P11-4; Group 4, laser; Group 5, laser + FV; and Group 6, laser + P11-4. The fluorescence level was determined with DiagnoDent. The enamel mineral density, area and volume, and caries lesion area and volume were determined with micro-computed tomography (µCT), surface features were evaluated using scanning electron microscopy (SEM), and elemental analysis was performed using energy dispersive x-ray spectroscopy (EDS) .

RESULTS

For specimens treated only with self-assembling peptide P11-4, the caries lesion area (mm2) values were 38.19 and 21.62, and the caries lesion volume (mm3) values were 6.27 and 2.99, respectively for pre- and post-treatment. In combination usage of self-assembling peptide P11-4 and laser, the caries lesion area (mm2) values were 38.39 and 16.91, and the caries lesion volume (mm3) values were 11.15 and 3.64, respectively for pre- and post-treatment. In the application of the P11-4 alone and in combination with laser, there was a statistically significant decrease in DiagnoDent values, an increase in enamel volume(mm3),enamel area(mm2) and mineral density(g/cm3) values and a decrease in caries lesion volume(mm3) and area(mm2) obtained by µCT, and an increase in %Ca and %F values obtained by SEM/EDS analysis (p < 0.05). It was discovered that the samples treated with P11-4 had a considerably higher rise in the Ca/P ratio than the samples treated with FV (p < 0.05). The calcium content increased significantly more when P11-4 application was combined with laser irradiation (p < 0.05).

CONCLUSIONS

The combined use of self-assembling peptide P11-4 and laser accelerated the remineralization process and increased the remineralization capacity.

CLINICAL RELEVANCE

FV and P11-4, alone or in combination with laser, can be successfully used as remineralization agents in initial enamel caries.

Evaluation of the remineralization potential of self-assembling peptide P11-4 with fluoride compared to fluoride varnish in the management of incipient carious lesions: a randomized controlled clinical trial

OBJECTIVES

The present trial's aim was to compare the remineralization potential of self-assembling peptide P11-4 combined with fluoride to that of fluoride varnish.

MATERIALS AND METHODS

Twenty-eight participants with 58 incipient carious lesions were enrolled in the present trial. Participants were randomly divided into two groups with 14 participants and 29 incipient lesions in each group. Patients were assigned either to self-assembling peptide combined with fluoride (Curodont Repair Fluoride Plus™) or sodium fluoride varnish (NaF, Bifluorid 10) groups. Both agents were applied according to the manufacturer's instructions on non-cavitated incipient carious lesions. Lesions were assessed by two calibrated and blinded assessors at baseline, and after one-, three- and six-months using a laser fluorescence device (DIAGNOdent).

RESULTS

Although laser fluorescence scores significantly improved in both groups over time (p < 0.05), no notable differences were evident between both groups at one-month (p > 0.05). Yet, at three- and six-months statistically lower laser fluorescence readings were evident in the self-assembling peptide combined with fluoride group in comparison to the fluoride alone group (p < 0.05). There was 60% less risk for caries progression for Curodont Repair Fluoride Plus™ when compared to NaF varnish after six months. Self-assembling peptide combined with fluoride was able to change 65.5% of non-cavitated carious lesions from DIAGNOdent score 3 (11-20) to score 1 (0-4). Fluoride varnish was able to change 13.8% of the lesions from score 3 to score 1 after six months.

CONCLUSIONS

The self-assembling peptide combined with fluoride varnish showed higher remineralization potential than fluoride varnish alone for incipient carious lesions over a six-months follow up.

CLINICAL RELEVANCE

The combination of self-assembling peptide P11-4 and fluoride could offer a new tool in managing incipient carious lesions.

White Spot Lesions in Fixed Orthodontics: A Literature Review on Etiology, Prevention, and Treatment

White spot lesions (WSLs) are a common complication after treatment using fixed orthodontic appliances. Decalcification of enamel surrounding fixed orthodontic appliances, known as WSLs, poses a significant aesthetic difficulty during and after treatment, as the purpose of fixed orthodontic therapy is to improve facial and dental appearance. Modern dentistry utilizes remineralization therapies to non-invasively treat WSLs to prevent the progression of disease and enhance the strength, appearance, and functionality of the affected tooth. This review aims to identify and assess the etiology, formation, and risk factors, as well as current treatment approaches used in achieving WSLs remineralization, induced by fixed orthodontic appliances. An electronic search on the PubMed and ScienceDirect databases was performed using a selected keyword. A total of 172 studies (from 2013 to 2023) were retrieved. Their references were also checked to find other relevant studies. Duplicate copies were excluded. After the abstract and full-text screening, only 39 studies were included. Even though numerous studies address the different treatment modalities for managing post-orthodontic WSLs, such as antiseptics; fluorides such as dentifrices, mouthwash, and varnish, and remineralizing agents such as casein phosphopeptides amorphous calcium phosphate, biomimetic self-assembling peptides, lasers, bleaching, microabrasion, and resin infiltration. There is a lack of evidence-based studies that examine the long-term effects of WSL treatment. Further well-performed controlled clinical trials with long-term follow-up are needed to establish best clinical practice.

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.

Evaluation of the remineralizing effect of biomimetic self-assembling peptides in post-orthodontic white spot lesions compared to fluoride-based delivery systems: randomized controlled trial

OBJECTIVES

To evaluate the clinical performance of self-assembling peptides versus fluoride-based delivery systems in post-orthodontic white spot lesions.

MATERIALS AND METHODS

The participants were randomly assigned into two groups (n = 58) according to the remineralizing agent used, where (A) group represented participants receiving a varnish containing 22.600 fluoride ppm and tricalcium phosphate, while the second group (B) represented participants receiving self-assembling peptide. The remineralizing process of the white spot lesion was assessed using the DIAGNOdent pen and ICDAS scoring system according to the time when the remineralizing agent was used (T), where T0 represented the score taken at baseline. T1 represented the score taken after 3 months of follow-ups and T2 score represented the score taken after 6 months of follow-up. Data were collected and statistically analyzed. The parametric data: two-way ANOVA was used to test the effect of interaction among different variables. The non-parametric data: Mann-Whitney test was used. The significance level was set at p ≤ 0.05.

RESULTS

There was a quantitative statistically significant difference via DIAGNOpen readings between Group A (fluoride material) and Group B (self-assembling peptides). The highest mean value of 10.51 was found in Group A, while the least mean value of 6.45 was found in Group B. Besides, there was a significant difference in each group concerning the time factors T0, T1, and T2 groups where (p < 0.001. As for the qualitative results concerning the ICDAS score, there was no significant difference between the two groups along with the follow-up periods T0, T1, and T2 where the p value is equal to 0.064, 0.087, and 0.277 respectively.

CONCLUSIONS

The visual assessment using ICDAS reveals that the biomimetic remineralization using self-assembling peptides and the fluoride-based varnish material showed a similar effect in masking post-orthodontic white spot lesions. However, the laser fluorescence using DIAGNOpen showed that the self-assembling peptides reveal higher performance in subsurface remineralization than the fluoride-based varnish material. Therefore, self-assembling peptides are considered a promising material for lesion regression in post-orthodontics white spot lesions.

CLINICAL RELEVANCE

Self-assembling peptide SAP-14 is a new approach to reverse and mask off post-orthodontics white spot lesions.

Effect of a Self-Assembly Peptide on Surface Roughness and Hardness of Bleached Enamel

After bleaching, enamel surfaces are damaged, contributing to erosion and tooth sensitivity. Although fluoride is used after bleaching to try and revert alterations, it is not capable of repairing tooth structure. This study compared the effect of a self-assembly peptide (P11-4), with and without fluoride, and sodium fluoride (NaF 2%) on the Knoop microhardness (KHN) and surface roughness (Ra (μm)) of bleached enamel with an in-office bleaching regimen. Enamel blocks of bovine teeth (5 × 5 × 2 mm) with standardized surface hardness were bleached with 35% carbamide peroxide, following the manufacturer’s instructions. The teeth were randomly divided into the following groups (n = 7) according to post-bleaching treatment: no treatment (negative control) (C-); 2% NaF (NaF); Curodont™ Repair (Repair); and Curodont™ Protect (Protect). Specimens were stored in artificial saliva at 37 °C. To evaluate the effect of the post-bleaching treatments, KHN and Ra were measured before bleaching (baseline) and 24 h and 7 days after bleaching. Data were submitted to repeated measures ANOVA and Bonferroni tests (α = 0.05). There were significant interactions between the study factors (p = 0.001). After 7 days, Repair (572.50 ± 79.04) and Protect (583.00 ± 74.76) specimens showed increased surface KHN, with values higher than the NaF (465.50 ± 41.50) and C- (475.22 ± 58.95) baseline values. There was no significant difference in KHN at 24 h among groups (p = 0.587). At 24 h after bleaching, Repair was significantly different from all groups (p < 0.05). Repair showed the lowest Ra (μm) values (0.133 ± 0.035). After seven days, there was no significant difference in Ra values among groups when compared to the baseline. The use of P11-4-based materials after bleaching resulted in the fastest recovery to baseline enamel properties.

Effectiveness of Self-Assembling Peptide (P11-4) in Dental Hard Tissue Conditions: A Comprehensive Review

The limitations on the use of fluoride therapy in dental caries prevention has necessitated the development of newer preventive agents. This review focusses on the recent and significant studies on P11-4 peptide with an emphasis on different applications in dental hard tissue conditions. The self-assembling peptide P11-4 diffuses into the subsurface lesion assembles into aggregates throughout the lesion, supporting the nucleation of de novo hydroxyapatite nanocrystals, resulting in increased mineral density. P11-4 treated teeth shows more remarkable changes in the lesion area between the first and second weeks. The biomimetic remineralisation facilitated in conjunction with fluoride application is an effective and non-invasive treatment for early carious lesions. Despite, some studies have reported that the P11-4 group had the least amount of remineralised enamel microhardness and a significantly lower mean calcium/phosphate weight percentage ratio than the others. In addition, when compared to a low-viscosity resin, self-assembling peptides could neither inhibit nor mask the lesions significantly. Moreover, when it is combined with other agents, better results can be achieved, allowing more effective biomimetic remineralisation. Other applications discussed include treatment of dental erosion, tooth whitening and dentinal caries. However, the evidence on its true clinical potential in varied dental diseases still remains under-explored, which calls for future cohort studies on its in vivo efficacy.