Quantifying the demineralisation of enamel using a hyperspectral camera measuring fluorescence loss

BACKGROUND

The gold standard for quantifying mineral loss of enamel is transverse microradiography (TMR) and is complimented by the non-destructive quantitative light induced fluorescence (QLF) which measures changes in autofluorescence. Fluorescence loss has been shown to correlate with mineral loss. Building upon the established method, the use of hyperspectral fluorescence imaging (HI) allows the capture of a broader range of wavelengths to quantify fluorescence changes more accurately.

METHODS

Bovine Enamel was demineralised within the dual constant depth film fermenter over 14 days and analysed using TMR, QLF and HI. The mineral change values were compared using Pearson's Correlation Coefficient.

RESULTS

The analysis showed a statistically significant correlation that was equal between TMR and HI (r = 0.844) and TMR and QLF (r = 0.844), but weaker between QLF and HI (r = 0.811).

CONCLUSIONS

The correlations indicate that HI is a promising valid non-destructive method for quantifying mineral loss from bovine enamel that is as accurate as QLF and complements TMR.

The cariogenic effect of starch on oral microcosm grown within the dual constant depth film fermenter

Evidence on the link between starch intake and caries incidence is conflicting, therefore the cariogenicity of starch compared with sucrose was explored using a dual Constant Depth Film Fermenter (dCDFF) biotic model system. Bovine enamel discs were used as a substrate and the dCDFF was inoculated using human saliva. CDFF units were supplemented with artificial saliva growth media at a constant rate to mimic resting salivary flow rate over 14 days. The CDFF units were exposed to different conditions, 2% sucrose or 2% starch 8 times daily and either no additional fluoride or 1450 ppm F- twice daily. Bovine enamel discs were removed at intervals (days 3, 7, 10 and 14) for bacterial enumeration and enamel analysis using Quantitative Light Induced Fluorescence (QLF) and Transverse Microradiography (TMR). Results showed that in the absence of fluoride there was generally no difference in mineral loss between enamel exposed to either sucrose or starch when analysed using TMR and QLF (P > 0.05). In the presence of fluoride by day 14 there was significantly more mineral loss under starch than sucrose when analysed with TMR (P < 0.05). It was confirmed that starch and sucrose are similarly cariogenic within the dCDFF in the absence of fluoride. With the aid of salivary amylase, the bacteria utilise starch to produce an acidic environment similar to that of bacteria exposed to sucrose only. In the presence of fluoride, starch was more cariogenic which may be due to the bacteria producing a more hydrophobic intercellular matrix lowering the penetration of fluoride through the biofilm. This is significant as it indicates that the focus on sugars being the primary cause of caries may need re-evaluating and an increase in focus on carbohydrates is needed as they may be similarly cariogenic as sugars if not more so.

Chapter 4: Microelements: Part I: Zn, Sn, Cu, Fe and I

Microelements are essential components of the diet. This chapter describes the effect of several such elements: zinc, copper, iron, tin, and iodine, on oral health. As part of normal diets, these elements have limited associations with specific oral conditions. This is partly because of their presence at relatively low concentrations and partly because they are most often present as mixtures where the effect of any one element is confounded by others. Deficiencies in microelements can cause health problems. Hence supplements, often containing one or more microelements, are prescribed to combat such conditions. All these ions exhibit antibacterial properties. Such effects are invariably small at the concentrations found in conventional foods and drinks. However, at higher concentrations, these ions can inhibit acid production by plaque bacteria involved in dental caries. Of more importance, zinc and tin have potentially significant effects on the de- and remineralisation processes involved in dental caries. Indeed, both elements have been included in oral hygiene products such as toothpastes for many years. Zinc, in particular, has demonstrated not only the ability to reduce dissolution rates of enamel and hydroxyapatite but also to inhibit calculus formation. Tin can also markedly reduce the dissolution rates. Both Cu and Fe have demonstrated anti-caries effects in animal models, whilst Fe-containing drinks have been shown to reduce enamel erosion in situ. The broad spectrum antibacterial properties of iodine have been promoted for its potential use against both early childhood caries and chronic periodontitis. However, more convincing clinical research is required to validate efficacy.

A Novel Kinetic Method to Measure Apparent Solubility Product of Bulk Human Enamel

Introduction: Tooth enamel mineral loss is influenced by its solubility product value, which is fundamental to the understanding of de- and remineralization resulting from a carious or erosive challenge. Published pKsp values for human enamel and hydroxyapatite range from 110 to 126 suggesting a heterogeneous nature of enamel solubility. However, this range of values may also result from the variety of methods used, e.g., some authors reporting values for suspensions of enamel powder and others for bulk enamel. The aim of this study was to develop a method to measure the solubility of bulk human enamel under controlled in vitro conditions simulating demineralization behavior of enamel within the oral environment using scanning microradiography (SMR). SMR was used to monitor real-time changes in enamel demineralization rates at increasing calcium concentrations in a caries simulating demineralization solution until the concentration at which thermodynamic equilibrium between enamel and solution was achieved. Method: 2 mm thick caries free erupted human enamel slabs with the natural buccal surfaces exposed were placed in SMR cells exposed to circulating caries-simulating 2.0 L 0.1 M pH = 4.0 acetic acid, at 25°C. SMR was used to continuously measure in real-time the decrease in mineral mass during the demineralization at 5 different points from on each slab. Demineralization rates were calculated from a linear regression curve of projected mineral mass against demineralization time. Changes in the demineralization rates were monitored following a series of successive increases in calcium (and phosphate at hydroxyapatite stoichiometric ratios of Ca:P 1.67) were added to the demineralizing solution, until demineralization ceased. The pH was maintained constant throughout. Results: Demineralization halted when the calcium concentration was ~30 mM. At higher calcium concentrations, mineral deposition (remineralization) occurred. By comparison with results from speciation software calculations for the calcium phosphate ternary system, this result suggests that the bulk solubility product of enamel (pKsp_BEnamel) under the conditions used is 121. Discussion: The apparent pKsp_BEnamel under these conditions was higher than many previous reported values, and much closer to those previously reported for HAp. However, this is a bulk value, and does not reflect that enamel is a heterogeneous material, nor the influence of ionic inclusions.

Longitudinal correlation of 3D OCT to detect early stage erosion in bovine enamel

Erosive tissue-loss in dental enamel is of significant clinical concern because the net loss of enamel is irreversible, however, initial erosion is reversible. Micro-hardness testing is a standard method for measuring initial erosion, but its invasive nature has led to the investigation of alternative measurement techniques. Optical coherence tomography (OCT) is an attractive alternative because of its ability to non-invasively image three-dimensional volumes. In this study, a four-dimensional OCT system is used to longitudinally measure bovine enamel undergoing a continuous erosive challenge. A new method of analyzing 3D OCT volumes is introduced that compares intensity projections of the specimen surface by calculating the slope of a linear regression line between corresponding pixel intensities and the associated correlation coefficient. The OCT correlation measurements are compared to micro-hardness data and found to exhibit a linear relationship. The results show that this method is a sensitive technique for the investigation of the formation of early stage erosive lesions.

Dose-response effect of fluoride dentifrice on remineralisation and further demineralisation of erosive lesions: A randomised in situ clinical study

OBJECTIVE

The objective was to evaluate the ability of fluoride in a conventional, non-specialised sodium fluoride-silica dentifrice to promote tooth remineralisation and enamel fluoride uptake (EFU), and assess the resistance of the newly formed mineral to attack by dietary acid, across the concentration range used in mass-market dentifrices.

METHODS

Subjects wore a palatal appliance containing eight polished bovine enamel specimens, each including an early erosive lesion. In a randomised full-crossover sequence, 62 healthy subjects were treated with dentifrices containing four different fluoride concentrations: no fluoride; 250ppm, 1150ppm and 1426ppm fluoride. At each treatment visit, under supervision, subjects brushed with 1.5g dentifrice and rinsed once while wearing the appliance; the appliance was removed after a 4-h remineralisation period and effects on the enamel specimens determined. The primary efficacy variable was surface microhardness recovery (SMHR); others included EFU, relative erosion resistance (RER) and comparative erosion resistance.

RESULTS

Highly significant linear and, with the exception of SMHR, quadratic dose-response relationships were observed between all efficacy variables and fluoride concentration. For SMHR, EFU and RER, values for the different fluoride concentrations were statistically resolved from one another, with the exception of the two highest fluoride concentrations. The degree of remineralisation and the acid resistance of enamel after treatment were closely related to EFU.

CONCLUSION

After a single brushing, conventional non-specialised sodium fluoride-silica dentifrices promoted remineralisation of early enamel lesions, and imparted increased acid-resistance to the enamel surface, in a dose-dependent manner at least up to 1500ppm fluoride.

CLINICAL SIGNIFICANCE

Enamel erosive tissue loss is an increasing concern, associated with modern diets. This study demonstrated that sodium fluoride, in a conventional non-specialised dentifrice formulation, can promote repair of the earliest stages of enamel erosion after a single application, in a dose-dependent fashion across the fluoride concentration range used in mass-market dentifrices. This study is registered in the GlaxoSmithKline Study Register (ID RH01299), available at: www.gsk-clinicalstudyregister.com/study/RH01299.

Physical chemical effects of zinc on in vitro enamel demineralization

OBJECTIVES

Zinc salts are formulated into oral health products as antibacterial agents, yet their interaction with enamel is not clearly understood. The aim was to investigate the effect of zinc concentration [Zn(2+)] on the in vitro demineralization of enamel during exposure to caries-simulating conditions. Furthermore, the possible mechanism of zinc's action for reducing demineralization was determined.

METHODS

Enamel blocks and synthetic hydroxyapatite (HAp) were demineralized in a range of zinc-containing acidic solutions (0-3565ppm [Zn(2+)]) at pH 4.0 and 37°C. Inductively coupled-plasma optical emission spectroscopy (ICP-OES) was used to measure ion release into solution. Enamel blocks were analysed by Attenuated Total Reflectance-Fourier Transform Infrared Spectroscopy (ATR-FTIR), and HAp by X-ray diffraction (XRD) and neutron diffraction (ND).

RESULTS

ICP-OES analysis of the acidic solutions showed a decrease in [Ca(2+)] and [PO4(3-)] release with increasing [Zn(2+)]. FTIR revealed a α-hopeite (α-Zn3(PO4)2.4H2O)-like phase on the enamel surfaces at >107ppm [Zn(2+)]. XRD and ND analysis confirmed a zinc-phosphate phase present alongside the HAp.

CONCLUSIONS

This study confirms that zinc reduces enamel demineralization. Under the conditions studied, zinc acts predominantly on enamel surfaces at PO4(3-) sites in the HAp lattice to possibly form an α-hopeite-like phase.

CLINICAL SIGNIFICANCE

These results have a significant implication on the understanding of the fundamental chemistry of zinc in toothpastes and demonstrate its therapeutic potential in preventing tooth mineral loss.

The primary and mixed dentition, post-eruptive enamel maturation and dental caries: a review

The mouth is in flux from the time the primary teeth begin to erupt, in the first year of life, through to the end of the 'mixed dentition' (i.e. the concurrent eruption of the permanent teeth and exfoliation of the primary teeth), at around 12 years of age. Primary teeth facilitate the development of the facial muscles and speech. They act as 'guides' for erupting permanent teeth. If lost prematurely, subsequent misalignment of permanent teeth can make them difficult to clean and possibly more caries-prone. During the mixed dentition phase, teeth are at relatively high risk of caries. Erupting teeth are difficult to clean and cleaning may be avoided because of tender gums and behavioural factors in children. Permanent enamel (and possibly primary enamel) undergoes post-eruptive maturation, accumulating fluoride, becoming harder, less porous and less caries-prone. Overall, primary teeth are more vulnerable to caries than permanent teeth. Widespread use of fluoride toothpaste has effected marked reductions in caries. Some evidence exists that fluoride delivered from toothpastes may be somewhat more effective in reducing caries in primary than in permanent teeth. However, caries remains a public health concern globally. New fluoride toothpaste formulations, optimised using in vivo fluoride delivery and efficacy studies, may improve the caries resistance of mineral deposited during post-eruptive maturation. Behaviour should not be ignored; new formulations will be more effective if used according to professionally endorsed recommendations based on sound science. Establishing good oral hygiene behaviour early in life can lead to lasting anti-caries benefits.

Diet and the microbial aetiology of dental caries: new paradigms

The microbial and dietary factors that drive caries have been studied scientifically for 120 years. Frequent and/or excessive sugar (especially sucrose) consumption has been ascribed a central role in caries causation, while Streptococcus mutans appeared to play the key role in metabolising sucrose to produce lactic acid, which can demineralise enamel. Many authors described caries as a transmissible infectious disease. However, more recent data have shifted these paradigms. Streptococcus mutans does not fulfil Koch's postulates - presence of the organism leading to disease, and absence of the organism precluding disease. Furthermore, molecular microbiological methods have shown that, even with a sugar-rich diet, a much broader spectrum of acidogenic microbes is found in dental plaque. While simple sugars can be cariogenic, cooked starches are also now recognised to be a caries threat, especially because such starches, while not 'sticky in the hand', can be highly retentive in the mouth. Metabolism of starch particles can yield a prolonged acidic challenge, especially at retentive, caries-prone sites. These changes in the paradigms of caries aetiology have important implications for caries control strategies. Preventing the transmission of S. mutans will likely be inadequate to prevent caries if a sufficiently carbohydrate-rich diet continues. Similarly, restriction of sucrose intake, although welcome, would be unlikely to be a panacea for caries, especially if frequent starch intake persisted. Instead, approaches to optimise fluoride delivery, to target plaque acidogenicity or acidogenic microbes, to promote plaque alkali generation, to increase salivary flow or replace fermentable carbohydrates with non-fermentable alternatives may be more promising.

Remineralization agents - new and effective or just marketing hype?

This is a review of the need for better remineralization and of the status of calcium-based remineralizing agents for use in anti-caries toothpastes. Use of fluoride toothpastes has markedly reduced caries. However, the decline may be over or in reverse. There is a limit to what fluoride alone can do; complementary agents are needed. Using plaque as a reservoir for calcium-based agents holds promise. Plaque fluid is already supersaturated with respect to relevant calcium phosphates at neutral pH; extra calcium may lead to surface-blocking and sub-optimal lesion consolidation. However, at cariogenic pH, lesions may be more porous to the ingress of mineral, leading to fuller consolidation, and controlled release of calcium should reduce undersaturation with respect to enamel and accelerate deposition of fluorhydroxyapatite. Clinical data to validate in vitro screening models are scarce. Direct progression to in situ models may often be appropriate. The spectrum of lesion types, from softening to relatively advanced subsurface, and lesion activity should be considered. Far from being 'marketing hype', progress with calcium-based remineralizing agents is both encouraging and scientifically sound. Clinical evidence exists for the efficacy of some agents, but further unequivocal clinical data are needed before these agents might be considered 'effective' when delivered from toothpaste.

Role of gallium and silver from phosphate-based glasses on in vitro dual species oral biofilm models of Porphyromonas gingivalis and Streptococcus gordonii

Phosphate-based glasses (PBGs) are excellent controlled delivery agents for antibacterial ions such as silver and gallium. The aim of this study was to assess the potential utility of novel PBGs combining both gallium and silver for use in periodontal therapy. To this end, an in vitro biofilm model with the putative periodontal pathogen, Porphyromonas gingivalis, and an initial colonizer, Streptococcus gordonii, was established. The effect of increasing calcium content in gallium-silver-doped PBG on the susceptibility of P. gingivalis was examined. A decrease in degradation rates (30.34, 25.19, 21.40 μg mm(-2) h(-1)) with increasing PBG calciumcontent (10, 11, 12 mol.% respectively) was observed, correlating well with gallium and silver ion release and antimicrobial activity against planktonic P. gingivalis (approximately 5.4log(10) colony-forming units (CFU) reduction after 24h by the C10 glass compared with controls) and S. gordonii (total growth inhibition after 32h by C10, C11 and C12 glasses compared with controls). The most potent PBG (C10) was evaluated for its ability to inhibit the biofilm growth of P. gingivalis in a newly established constant-depth film fermentor model. The simultaneous release of silver and gallium from the glass reduced P. gingivalis biofilm growth with a maximum effect (1.92log(10) CFU reduction) after 168 h. Given the emergence of antibiotic-resistant bacteria and dearth of new antibiotics in development, the glasses, especially C10, would offer effective alternatives to antibiotics or may complement current therapies through controlled, localized delivery of gallium and silver ions at infected sites in the oral cavity.

Protection against enamel demineralisation using toothpastes containing o-cymen-5-ol, zinc chloride and sodium fluoride

AIM

To evaluate the ability of two experimental toothpastes containing 0.1%w/w o-cymen-5-ol, 0.6%w/w ZnCl2 and 0.320%w/w NaF to reduce demineralisation of sound human enamel compared with control toothpastes.

METHODS

Study 1: Specimens were treated with toothpaste slurries, followed by alternating periods in demineralising and neutral solutions. Demineralisation was assessed using surface microhardness (SMH). Study 2: Specimens were subjected to a 14 day cycling regime of alternating demineralisation/remineralisation with two toothpaste treatments per day, before and after demineralisation. Demineralisation was assessed by cross-sectional microhardness and mineral loss (ΔZ) was calculated. Test toothpastes were a) 0%w/w or 0.002%w/w NaF placebo, b) 0.055%w/w or 0.149%w/w NaF (dose response), c) 0.320%w/w NaF marketed product, d & e) 0.1%w/w o-cymen-5-ol, 0.6%w/w ZnCl2 and 0.320%w/w NaF (experimental toothpastes).

RESULTS

Study 1: Mean±SE % of baseline hardness values were a) 48.0±2.1a, b) 66.7±1.7b, c) 82.9±1.9c, d) 91.7±1.4d and e) 94.6±2.1d. Study 2: Mean±SE ΔZ values were a) 2114±187a, b) 1206±132b, c) 303±89c, d) 19±73c, and e) -10±55c. Letters represent different statistical groupings (P<0.05).

CONCLUSION

In study 1, both experimental toothpastes were statistically superior to the marketed product and in study 2; they were at least as effective as the marketed product at reducing caries lesion development.

Zinc in the mouth, its interactions with dental enamel and possible effects on caries; a review of the literature

Zinc is an essential trace element. In the mouth, it is present naturally in plaque, saliva and enamel. Zinc is formulated into oral health products to control plaque, reduce malodour and inhibit calculus formation. It has good oral substantivity, and elevated concentrations can persist for many hours in plaque and saliva following delivery from mouthrinses and toothpastes. Although low concentrations of zinc can both reduce enamel demineralisation and modify remineralisation, during caries clinical trials, the addition of zinc to fluoride toothpastes has not affected their ability to reduce caries. Mechanistic studies may help explain this apparent contradiction. Zinc is readily desorbed from hydroxyapatite by calcium, which is plentiful in plaque and saliva. Where crystal-growth sites remain occupied by zinc despite this, they may simply be 'over-grown' by remineralisation initiated at unoccupied sites. Further, under certain conditions, low concentrations of zinc can enhance remineralisation of enamel lesions, by retarding lesion arrestment. Although this may help to explain the apparent lack of an overall zinc effect on caries, it seems unlikely that any negative effects would be countered exactly by positive effects. Further mechanistic studies, complementing well-designed in vitro and in situ caries studies, should lead to further understanding of the zinc-enamel interactions relevant to demineralisation and remineralisation.

Benefits of a silica-based fluoride toothpaste containing o-cymen-5-ol, zinc chloride and sodium fluoride

Fluoride toothpastes in conjunction with tooth brushing are used to clean teeth, control plaque build-up and for anti-caries benefits. Toothpastes are designed with attractive flavours and appearances to encourage regular prolonged use to maximise these benefits. The incorporation of additional ingredients into toothpaste is a convenient way to provide supplementary protection that fits into people's everyday oral care routine. Such ingredients should not compromise the primary health benefits of toothpaste nor discourage its use. o-Cymen-5-ol and zinc chloride have been incorporated into a sodium fluoride (NaF)/silica toothpaste at 0.1%w/w and 0.6%w/w respectively to provide additional benefits. These include improved gingival health maintenance, in terms of the reduction of plaque, gingival index and bleeding, and an immediate and long lasting reduction in volatile sulfur compounds (VSCs) measured on breath. These benefits can be attributed to the antimicrobial and neutralisation actions of the toothpaste. The use of established fluoride models demonstrated no compromise in NaF bioavailability. The toothpaste was formulated without compromising product aesthetics. The combination of o-cymen-5-ol and zinc chloride in toothpaste gave superior maintenance of gingival health and reduction in malodour related VSCs without compromising the primary health benefits of the toothpaste or diminishing attributes preferred for the product's use.

Terahertz pulsed imaging study to assess remineralization of artificial caries lesions

We compare terahertz-pulsed imaging (TPI) with transverse microradiography (TMR) and microindentation to measure remineralization of artificial caries lesions. Lesions are formed in bovine enamel using a solution of 0.1 M lactic acid/0.2% Carbopol C907 and 50% saturated with hydroxyapatite adjusted to pH 5.0. The 20-day experimental protocol consists of four 1 min treatment periods with dentifrices containing 10, 675, 1385, and 2700 ppm fluoride, a 4-h/day acid challenge, and, for the remaining time, specimens are stored in a 50:50 pooled human/artificial saliva mixture. Each specimen is imaged at the focal point of the terahertz beam (data-point spacing = 50 μm). The time-domain data are used to calculate the refractive index volume percent profile throughout the lesion, and the differences in the integrated areas between the baseline and post-treatment profiles are used to calculate ΔΔZ((THz)). In addition, the change from baseline in both the lesion depth and the intensity of the reflected pulse from the air/enamel interface is determined. Statistically significant Pearson correlation coefficients are observed between TPI and TMR/microindentation (P < 0.05). We demonstrate that TPI has potential as a research tool for hard tissue imaging.

A review of the structure of human and bovine dental hard tissues and their physicochemical behaviour in relation to erosive challenge and remineralisation

OBJECTIVES

This review sets out to examine the suitability of bovine hard dental material in lieu of human material when investigating dental erosion, to review the evidence for the major factors popularly attributed to dental erosion: pH, pKa, acid type, erosion duration, temperature and stirring rate as well as examine the case for the use of fluoride in an anti-erosion capacity.

DATA SOURCES

Published works were selected using online search software ICI Web of Knowledge and Pubmed, with key terms such as "enamel", "erosion" and "bovine AND human" and cross referenced with relevant papers cited in the indices.

RESULTS

The growing trend of dental erosion, coupled to legislative changes has precipitated a recent shortage of human enamel and dentine for experimental work. This in turn has resulted in the increasing use of cheap and readily available alternate supplies being sourced. This alternate supply principally originates from beef cattle under 20 months of age, under the assumption that bovine enamel and dentine will behave in a manner similar to human material. Recent experiments attempting to compare the physicochemical properties of these two species have shown that erosion is not simply a matter of bulk tissue loss resulting from acid exposure, but a multi-factorial event encompassing ever increasing and varied complexity of the inter-relationship between solvent and substrate.

CONCLUSIONS

Accurate data from the published literature regarding the comparative properties of human and bovine hard dental tissue remains scarce but consensus appears to accept the continuing use of bovine enamel as a substitute for human enamel. This lack of comparative data is further hampered by the lack of an established, standardised protocol with which to evaluate the two species. In addition, much debate remains regarding the significant principal factors responsible for dental erosion and ways to minimise the pathological manifestation.

Laboratory assessment of the anticaries potential of a new dentifrice

OBJECTIVE

The aim of the present study was to investigate the anticaries potential of a new sodium fluoride dentifrice in comparison to two commercial dentifrices containing different fluoride compounds by determining enamel fluoride uptake (EFU) and early caries lesion remineralization (REM) in an established in vitro caries remineralization/demineralization pH cycling model.

METHODS

Test products were: new dentifrice formulation in a fluoride dose-response (0; 675; 1426 ppm F as sodium fluoride [NaF-0; NaF-675; NaF]); Elmex Kariesschutz (1400 ppm F as amine fluoride [AmF]); and Oral-B Pro-Expert (1450 ppm F-1100 ppm F as stannous fluoride and 350 ppm F as sodium fluoride [SnNaF]). Artificial caries-like lesions were formed in human enamel specimens by immersion in lactic acid buffer (LA). Specimens were then subjected to a daily cycling regime for 20 days comprising four one-minute dentifrice slurry treatments (prepared in pooled human saliva), and one four-hour LA challenge and remineralization in pooled human saliva. After 20 days, REM was evaluated as the change in surface Vickers microhardness from lesion baseline and EFU using the microdrill technique. The data were analyzed using ANOVA.

RESULTS

A good fluoride dose-response was established for EFU and REM, with NaF delivering greater EFU and REM than NaF-675, which was superior to NaF-0 (p < 0.05). The new dentifrice NaF also showed greater EFU and REM than AmF and SnNaF (p < 0.05). In EFU, AmF and SnNaF were as efficacious as NaF-675 and superior to NaF-0 (p < 0.05). AmF and NaF-675 were also comparable in REM, whereas both products exhibited superior REM vs. SnNaF (p < 0.05), which was superior to NaF-0 (p < 0.05).

CONCLUSION

The present study has demonstrated that fluoride dentifrices vary in their capability of enhancing anticaries potential as determined using an established in vitro caries cycling model. The new dentifrice NaF showed superior predicted anticaries potential compared to the two commercial dentifrices AmF and SnNaF in this model, which demonstrates the importance of fluoride compound and formulation excipients on driving anticaries potential in vitro.

A comparison of terahertz pulsed imaging with transmission microradiography for depth measurement of enamel demineralisation in vitro

Terahertz pulsed imaging (TPI) is a relatively new, non-ionising and non-destructive imaging technique for studying hard tissues which does not require tooth section preparation, unlike transmission microradiography (TMR). If TPI can measure the depths of caries/demineralisation lesions accurately the same tooth samples could be reused and remeasured during in vitro and in situ studies on de- and/or re-mineralisation. The aim of this study was to compare TPI and TMR for measuring the depths of a range of artificially induced bovine enamel demineralised lesions in vitro. Bovine slabs with artificial caries, induced to different levels of demineralisation by two different but standard demineralisation techniques ('acid gel' and 'carbopol') were measured by TPI and TMR and the readings compared. The set of TPI/TMR measurements obtained on the gel-demineralised slabs showed an extremely high coefficient of determination (r(2) = 0.995). Detailed analysis of the results and theoretical considerations (involving the relationship between refractive index profiling and mineral loss profile) are used to explain the findings and show that for acid gel lesions TPI is measuring demineralisation in the range of 47% of that of TMR depth plus an intercept of 16 microm, with further calculations allowing the TMR depths to be determined to within 5% using TPI.

Effect of Lesion Characteristics and Mineralising Solution Type on Enamel Remineralisation in vitro

The aim was to study the effect of lesion preparation technique and solution composition on remineralization of artificial lesions in vitro. Lesions were prepared with similar total mineral loss, but different mineral distribution, i.e., low (14.0) or high R (34.8) values. Lesions from both groups were remineralized (10 days, 37 degrees C) in two different solutions, with similar supersaturation with respect to hydroxyapatite (St), but calcium:phosphate ratios representing either hydroxyapatite stoichiometry or plaque fluid (PF). Remineralization was quantified microradiographically, mineral distribution was compared with natural white-spot lesions. Mineral loss and depth decreased significantly, and surface-zone mineral content (Zmax) increased significantly, in all lesions. Overall there was a significant relationship of decreasing remineralization with increasing Zmax, but not within either lesion type. PF was significantly more efficient than St in high-R lesions, with lesions remineralizing almost completely in PF. Remineralization was not significantly different in PF or St for low-R lesions but in high-R lesions, PF was more efficient than St, possibly through differences in relative saturations with respect to different calcium phosphates. Differences in area:solution ratios and baseline Zmax values may also have explained the different response to PF. Low-R lesions were similar to natural white-spot lesions in terms of mineral distribution, whereas high-R were not. Concluding, both lesion and remineralizing solution type had a marked influence on remineralization. It is proposed that use of low-R lesions would be more appropriate where more physiologically relevant mineral distribution is required, whereas high-R lesions would be appropriate for studying inherent remineralizing efficiency.

Decay of photoacoustic signals from biological tissue irradiated by near infrared laser pulses

We describe the phenomenon of a sudden decrease in the amplitude of photoacoustic signals arising from nanosecond laser pulse irradiation of biological samples, measured in vitro. Several dental enamel and chicken/turkey breast samples are examined. Moderate optical energy densities (i.e., about 300 mJ/cm2) are used, typical of those exploited in photoacoustic investigations. Measurements show a rapid decay of photoacoustic signals within the first few laser pulses absorbed by the sample. This phenomenon indicates that laser irradiation interacts with biological samples, causing long-term physical changes that can be attributed to a reduction of optical absorption within the samples.

Effect of Calcium Glycerophosphate on Demineralization in an in vitro Biofilm Model

The aim was to investigate the anti-caries properties of calcium glycerophosphate (CaGP) using an in vitro bacterial flow cell model. Four flow cells, inoculated from a chemostat containing a seven-organism bacterial consortium, were pulsed with sucrose twice daily, to provide an acidic challenge and pH-cycling conditions. Blocks of enamel and dentine were mounted in each flow cell. In a study on the effect of CaGP concentration, CaGP was pulsed into three of the flow cells, at the same time as the sucrose, to give concentrations of 0.10, 0.25 and 0.50%. Water was pulsed into the fourth flow cell with the sucrose. Microradiography revealed a significant dose response of decreasing demineralization as CaGP concentration increased. Reductions at 0.25 and 0.5% were significant when compared to the control. A second study investigated the effect of timing of CaGP pulsing, relative to sucrose, on enamel and dentine demineralization. CaGP (flow cell concentration 0.2%), was pulsed 1 h before, during or 1 h after the sucrose pulse; a water control was employed. In enamel, pulsing CaGP before the sucrose reduced demineralization significantly compared to concurrent pulsing, which in turn gave a significant reduction compared to pulsing after sucrose, which did not reduce demineralization significantly compared to the water control. In dentine, CaGP reduced demineralization significantly only when pulsed before the sucrose. The findings suggest that in vivo, the anti-caries potential of CaGP may be greater if it is applied before a cariogenic challenge.

The Effect of Fluoride at Plaque Fluid Concentrations on Enamel De- and Remineralisation at Low pH

The aim was to study the effect of fluoride, at concentrations typical of plaque fluid, on de- and remineralisation of subsurface lesions at low pH. Artificial lesions in human enamel were microradiographed to quantify mineral loss and placed in acid-gel systems at pH 4.8, 5.0 and 5.2. Calcium and phosphate were added to give initial Ca and Pi concentrations of either 4.1 and 8.0 mM, or 4.7 and 9.7 mM, at each pH value. Further, at each pH and combination of Ca and Pi, fluoride was added to the gels to give initial concentrations of 1, 2 or 5 ppm, with a non-fluoride control group. The lesions were removed after 10 days and change in mineral content quantified. Those in the non-fluoride control groups had demineralised further. Those exposed to fluoride had remineralised, the amount increasing with increasing fluoride concentration, up to a maximum value of approximately 75%. Calcium activity in the gels was reduced significantly, to levels similar to those reported for plaque fluid at low pH. Fluoride activity was also reduced, though to a lesser extent. These findings contrast with those from studies which have simulated conditions on smooth surface sites and which used experimental solutions composed to reflect salivary fluoride concentrations, where net demineralisation was observed at low pH. This reflects the need for further study of de- and remineralisation under plaque-fluid conditions. In conclusion, subsurface lesions were remineralised at low pH by fluoride at concentrations found in plaque fluid during a cariogenic challenge.

The Effect of Lesion Characteristics at Baseline on Subsequent De- and Remineralisation Behaviour

The aim was to study the effect of lesion characteristics at baseline on subsequent de- and remineralisation behaviour. Artificial lesions used during in vitro and intra-oral studies exhibit an increasing tendency toward net remineralisation with increasing integrated mineral loss at baseline (DeltaZ(base)). Proposed explanations include: (i) small lesions may be more vulnerable to demineralisation, and (ii) large lesions may be more difficult to remineralise. To evaluate these hypotheses, subsurface lesions were created in numerous blocks of human and bovine enamel, with a range of depths and DeltaZ(base), measured by microradiography. One group of lesions was further demineralised, a second group remineralised, and subsequently, both groups re-analysed. Under demineralising conditions, there was a marked decrease in further mineral loss with increasing DeltaZ(base). Under remineralising conditions lesions gained mineral in proportion to DeltaZ(base). The decrease in demineralisation of lesions with larger DeltaZ(base) may be partially a result of decreased intrinsic solubility through modified chemical composition, e.g. loss of magnesium, carbonate etc. The results may explain the tendency toward net remineralisation with increasing DeltaZ(base) in pH-cycling regimes.

The Effect of Adjacent Dentine Blocks on the Demineralisation and Remineralisation of Enamel in vitro

The aim was to investigate interactions between enamel and dentine at low pH under conditions simulating those at the enamel-dentine junction. Sound enamel blocks were demineralised in acid-gel systems, at pH 4.6, either in isolation, next to one, or in the middle of two, abutting dentine blocks. The gels were initially infinitely undersaturated with respect to enamel. In a second study, enamel blocks containing pre-formed lesions were placed in acid-gel systems, at pH 5.0, either in isolation or next to dentine blocks. The systems were initially either partially or infinitely undersaturated. In the partially saturated systems, calcium and phosphate concentrations were representative of plaque fluid. In the first study, demineralisation of enamel next to one dentine block was reduced in inverse proportion to the distance from the dentine. Demineralisation of enamel between two dentine blocks was retarded markedly across the whole block. In the second study, in the partially saturated systems, enamel lesions next to dentine blocks remineralised, whereas those in isolation demineralised further. We suggest that diffusion of dissolved dentine mineral over the enamel in the infinitely undersaturated system was sufficient to reduce undersaturation, thus retarding demineralisation, and that in the partially saturated systems, dentine dissolution together with the added calcium phosphate caused remineralisation of enamel lesions. Fluoride released from dissolving dentine may have augmented these effects. Different rates of demineralisation in enamel and dentine, or enamel remineralisation with concurrent dentine demineralisation, enabled by differences in their solubilities, could help explain the progression of so-called 'hidden caries'.

In vitro efficacy of a whitening toothpastecontaining calcium carbonate and perlite

OBJECTIVES

The studies described in this paper aimed to assess the stain removal efficacy, fluoride efficacy and abrasivity to enamel and dentine of a new whitening toothpaste containing calcium carbonate and perlite, using appropriate in vitro models.

METHODS

Stain removal efficacy was assessed using the pellicle cleaning ratio (PCR) method. Fluoride efficacy was assessed using remineralisation, demineralisation and fluoride-uptake methods. Abrasivity was assessed using an enamel and dentine wear method.

RESULTS

The results showed that the new whitening toothpaste was able to remove extrinsic tooth stain more effectively than three commercially available toothpaste formulations. The fluoride efficacy was superior to a non-fluoridated control and was not significantly different to a clinically tested fluoride-containing toothpaste. The abrasivity data showed that the calcium carbonate/perlite toothpaste is no more abrasive to enamel or dentine than two other commercially available whitening toothpastes.

CONCLUSIONS

The studies show that the new whitening toothpaste is effective in extrinsic stain removal, has an efficacious fluoride source and does not have an undue degree of abrasivity to enamel or dentine compared to other relevant commercially available products.

The anti-caries efficacy of calcium carbonate-based fluoride toothpastes

AIM

To summarise clinical support for the anti-caries efficacy of fluoride toothpastes containing sodium monofluorophosphate (SMFP) and to discuss the possible means by which the abrasive particles in calcium carbonate-based SMFP toothpastes might complement and/or enhance fluoride efficacy.

BACKGROUND

The anti-caries efficacy of fluoride has been proven beyond any reasonable doubt, and the efficacy of SMFP, when incorporated into a variety of compatible toothpaste formulations, has been established in numerous clinical trials. Calcium carbonate-based toothpastes may also influence caries by effecting an increase in plaque calcium levels; an inverse relationship between plaque calcium and caries is well-established. It has also been reported that plaque fluoride levels are dependent on plaque calcium levels. Hence elevated plaque calcium resulting from the use of calcium carbonate-based toothpastes has the potential to elevate plaque fluoride, itself linked to reduced caries experience. It has been shown that calcium carbonate particles are retained by plaque and this may also influence caries by neutralising harmful plaque acids and concurrently liberating calcium.

CONCLUSION

Fluoride delivered from calcium carbonate-based SMFP toothpastes is an effective means of reducing caries. Further, calcium carbonate may confer additional benefits through elevation of oral calcium levels and neutralisation of plaque-acids.

Low-levels of fluoride in plaque and saliva and their effects on the demineralisation and remineralisation of enamel; role of fluoride toothpastes

AIM

To summarise support for current consensus on the likely means by which fluoride toothpastes reduce caries and review some relevant studies of the effect of low levels of fluoride on the demineralisation and remineralisation of enamel. The major anti-caries effect of fluoride toothpastes is thought to result from small but protracted elevations in levels of fluoride in plaque and saliva. Fluoride incorporated into enamel systemically does not reduce enamel solubility sufficiently to exert an anti-caries effect. Fluoride has the potential to exert an anti-caries benefit largely through three mechanisms; inhibition of demineralisation, promotion of remineralisation and interference with bacterial growth and metabolism. However, the low levels of fluoride thought to influence caries are insufficient to have a significant effect via the latter mechanism. Thus reductions in caries resulting from the use of fluoride toothpastes can be linked to modification of the demineralisation/remineralisation balance by direct effects on dental mineral exerted topically by low levels of fluoride. Numerous in vitro studies have shown that low levels of fluoride, typical of those found after many hours in resting plaque and saliva, and resulting from the regular use of fluoride toothpastes, can have a profound effect on enamel demineralisation and remineralisation.

Calcium glycerophosphate and caries: a review of the literature

AIM

To review studies in the dental literature regarding the anti-caries mode of action of glycerophosphate with special reference to calcium glycerophosphate. The cariostatic properties of calcium glycerophosphate have been demonstrated during numerous in vivo and in vitro studies. Several mechanisms have been suggested and these include plaque-pH buffering, elevation of plaque calcium and phosphate levels and direct interaction with dental mineral. There is credible evidence that calcium glycerophosphate has the potential to reduce the progression of caries via all of these mechanisms if it is applied frequently and at a sufficiently high concentration. Reduction of plaque mass has also been proposed as a cariostatic mechanism but this seems less likely. Animal studies have shown that the calcium glycerophosphate/sodium monofluorophosphate system can have a greater anti-caries effect than sodium monofluorophosphate alone and this was subsequently confirmed in a caries clinical trial. We conclude that elevation of calcium levels in plaque is the most likely explanation and that any means of enhancing this effect has significant promise as a means to further increase in anti-caries potential of the calcium glycerophosphate/sodium monofluorophosphate system compared to sodium monofluorophosphate alone.