Enhanced Fluoride Bioavailability with Incorporation of Arginine in Child Dentifrices.

OBJECTIVE(S): To: 1) examine the fluoride concentrations in commercial child formula dentifrices (CFD)s; and 2) investigate the effect of arginine incorporation in CFDs on fluoride bioavailability. STUDY DESIGN: Five commercial CFDs were examined for fluoride concentrations. Total, total soluble, and insoluble fluorides in CFDs were determined by the modified Taves acid-diffusion method (TAD). Ionic F and MFP were estimated by modified direct method with standard addition technique. L-arginine (L-Arg)/L-arginine monohydrochloride (L-Arg.HCl) were incorporated at 2% w/w in the commercial CFDs. The pH of the toothpaste slurries, buffer capacity of the added Arg, potentially available fluorides (PAF) and 1-min PAF by TAD were determined. RESULTS: The CFDs had 4 to 32% of insoluble fluorides. Addition of L-Arg/L-Arg.HCl significantly improved the fluoride bioavailability in CFDs (p<0.05). Incorporation of L-Arg significantly increased the pH of toothpaste slurries (p<0.05); while L-Arg.HCl decreased the pH. Principal component analysis showed that L-Arg.HCl decreased the pH of toothpaste slurries due to the presence of Cl in the form of HCl; whereas the inherent elements/molecules (Na/P/Pi/F) remain distinct with unidentified influence on the variables. CONCLUSION(S): The CFDs containing NaF only have higher concentrations of bioavailable fluoride. Incorporating arginine (L-arginine or L-arginine monohydrochloride) at 2% w/w improves fluoride bioavailability of the child formula dentifrices.

European Organization for Caries Research Workshop: Methodology for Determination of Potentially Available Fluoride in Toothpastes.

Toothpastes are the most universally accepted form of fluoride delivery for caries prevention. To provide anti-caries benefits, they must be able to release fluoride during the time of tooth brushing or post brushing into the oral cavity. However, there is no standard accepted procedure to measure how much fluoride in a toothpaste may be (bio) available for release. The European Organization for Caries Research proposed and supported a workshop with experts in fluoride analysis in toothpastes and representatives from industry. The objective of the workshop was to discuss issues surrounding fluoride analysis in toothpaste and reach consensus on terminology and best practices, wherever the available evidence allowed it. Participants received a background paper and heard presentations followed by structured discussion to define the problem. The group also reviewed evidence on the validity, reliability and feasibility of each technique (namely chromatography and fluoride electroanalysis) and discussed their strengths and limitations. Participants were able to reach a consensus on terminology and were also able to identify and summarize the advantages and disadvantages of each technique. However, they agreed that most currently available methods were developed for regulatory agencies several decades ago, utilizing the best available data from clinical trials then, but require to be updated. They also agreed that although significant advances to our understanding of the mechanism of action of fluoride in toothpaste have been achieved over the past 4 decades, this clearly is an extraordinarily complex subject and more work remains to be done.

Insufficient Evidence within a Systematic Review and Meta-Analysis of Powered Toothbrushes over Manual Toothbrushes for Soft Tissue Health During Orthodontic Treatment.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Short-term and long-term effectiveness of powered toothbrushes in promoting periodontal health during orthodontic treatment: A systematic review and meta-analysis. Al Makhmari SA, Kaklamanos EG, Athanasiou AE. Am J Orthod Dentofacial Orthop 2017;152(6):753-66.e7. SOURCE OF FUNDING: None identified TYPE OF STUDY/DESIGN: Systematic review with meta-analysis.

As an Adjunct to Mechanical Oral Hygiene, Essential Oil-containing Mouthwash, Compared to Floss, Cetylpryidinium Chloride, or Placebo may be more Effective in Reduction of Plaque and Gingitivitis.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analysis and meta-regression. Haas AN, Wagner TP, Muniz FWMG, Fiorini T, Cavagni J, Celeste, RK. J Dent 2016;55:7-15. SOURCE OF FUNDING: No specific funding for this systematic review TYPE OF STUDY/DESIGN: Meta-analysis and meta-regression.

Comparison of pain perception during miniscrew placement in orthodontic patients with a visual analog scale survey between compound topical and needle-injected anesthetics: A crossover, prospective, randomized clinical trial.

INTRODUCTION: The use of a compound topical anesthetic (CTA) instead of an injection of a local anesthetic for placing miniscrew implants offers advantages to both the clinician and the patient. The purpose of this crossover, prospective, randomized clinical trial was to compare the clinical effectiveness of a CTA with that of a needle injection of local anesthetic for miniscrew placement. METHODS: Twenty-four orthodontic patients in a university clinic were recruited; they required bilateral buccal miniscrews for orthodontic anchorage. Eligibility criteria included healthy patients with no special needs; over 8 years of age and 25 pounds; not taking sulfonamides, monoamine oxidase inhibitors, tricyclic antidepressants, or phenothiazines; and not allergic to ester-type local anesthetics or any of the other materials used in the study. A computer generated a randomization list. The allocation was randomized by anesthetic protocol and side of the mouth, and was restricted to achieve balance by treatment and side of the mouth. No allocation concealment was applied. Associated with each randomized number was the subjects' assignment into 1 of 4 groups divided by the side of first miniscrew placement and the type of anesthetic. Blinding was done only for data analysis because of clinical limitations. Each patient received a CTA on one side and an injection of anesthetic on the other before miniscrew placement in a crossover study design. The outcome was assessed by measuring pain levels with a 100-mm visual analog scale at 5 time points. Anesthetic failures occurred when the miniscrew could not be fully comfortably placed with a given anesthetic. Data were organized by visual analog scale time points, and descriptive statistics were calculated. A factorial repeated-measures analysis of variance was used to determine any differences. RESULTS: Twenty-seven patients were assessed for eligibility, and 24 agreed to participate in the study. Patients did not distinguish any differences in pain between the application of the CTA and the injection before or during anesthetic placement, but they experienced more pain with the CTA during miniscrew placement. The mean difference for the entire procedure between the 2 anesthesia types was 24.6 units, and the 95% confidence interval was 18.8 to 30.4, a statistically significant finding (P = 0.0002). The CTA was still viewed as more painful 1 month after the procedures. Significantly more anesthetic failures occurred with the CTA (41.6%) than with the injection (0%). No serious harm was observed in any patient; when significant pain was observed with the CTA, a needle injection of local anesthetic was administered. CONCLUSIONS: CTAs provided less predictable, often inadequate, and less comfortable anesthesia than an injection of a local anesthetic for managing patient discomfort during miniscrew placement in buccal sites. REGISTRATION: This trial was not registered. PROTOCOL: The protocol was determined and approved by the research committee and institutional review board before the trial. FUNDING: No external funding was used other than the donation of the miniscrews from Rocky Mountain Orthodontics, and no conflict of interest was declared.

Analysis of 1-Minute Potentially Available Fluoride from Dentifrice.

Previous reports found that some fluoride-containing dentifrices do not release effective concentrations of fluoride during brushing. Failure to release fluoride can be due to dentifrice matrix components that interfere with the solubilization of the fluoride salts during brushing. A new generation of dentifrices has the capability to precipitate beneficial fluoride salts during tooth brushing. Therefore, a method that assesses the potentially available fluoride during the 1-minute brushing is needed. A new filter-paper absorption method to assess the 1-min bioavailable fluoride concentration was developed to meet this need. This method utilizes coiled filter paper that rapidly absorbs the aqueous phase of the dentifrice slurry followed by centrifugation to recover that fluid for fluoride measurement via fluoride ion-selective electrode. The analytical method was used to successfully determine the total fluoride and 1-min bioavailable fluoride in eight dentifrice products containing sodium fluoride (NaF), disodium monofluorophosphate (Na2FPO3, MFP), stannous fluoride (SnF2), or NaF with amorphous calcium phosphate (NaF + ACP). The results showed that some of the dentifrices tested had significantly lower potentially available fluoride than the total fluoride. For a MFP-containing sample, aged seven years past its expiry date, there was significant reduction in the bioavailable fluoride compared to MFP products that were not aged. Other than the aged MFP and the SnF2-containing samples the bioavailable fluoride for all products tested had at least 80 % of the label fluoride concentration. The filter paper absorption method yielded reproducible results for the products tested with MFP samples showing the largest variations.

Tooth whitening: what we now know.

UNLABELLED: Current research about tooth whitening shows that it is safe and effective when manufacturer's protocol is followed, yet there are risks of which the profession and users should be aware. This update provides a summary of current research and assessment of the safety and efficacy of tooth whitening regimens. BACKGROUND: Tooth whitening has become one of the most frequently requested dental procedures by the public. The public has come to demand whiter, more perfect smiles and in response many choices for tooth whitening have been made available. These include home-based products such as toothpastes, gels, and films, as well as in-office based systems where products containing highly concentrated bleaching agents are applied under professional supervision. The profession and public have been aware of certain risks related to tooth whitening such as increased tooth sensitivity and gingival irritation. New research has shown that there are other risks such as tooth surface roughening and softening, increased potential for demineralization, degradation of dental restorations, and unacceptable color change of dental restorations. The new research is also focused on optimizing whitening procedures to reduce tooth sensitivity and to increase the persistence of the whitening. METHODS: Current reports in the literature are reviewed that are related to the use of peroxide based whitening methods. These reports include in vitro studies for method optimization and mechanism as well as clinical studies on effects of various whitening regimens. CONCLUSIONS: When manufacturer's instructions are followed, hydrogen peroxide and carbamide peroxide based tooth whitening is safe and effective. Patients should be informed of the risks associated with tooth whitening and instructed on identification of adverse occurrences so that they may seek professional help as needed.

Focus on fluorides: update on the use of fluoride for the prevention of dental caries.

UNLABELLED: Improving the efficacy of fluoride therapies reduces dental caries and lowers fluoride exposure. BACKGROUND: Fluoride is delivered to the teeth systemically or topically to aid in the prevention of dental caries. Systemic fluoride from ingested sources is in blood serum and can be deposited only in teeth that are forming in children. Topical fluoride is from sources such as community water, processed foods, beverages, toothpastes, mouthrinses, gels, foams, and varnishes. The United States Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) have proposed changes in their long standing recommendations for the amount of fluoride in community drinking water in response to concerns about an increasing incidence of dental fluorosis in children. Current research is focused on the development of strategies to improve fluoride efficacy. The purpose of this update is to inform the reader about new research and policies related to the use of fluoride for the prevention of dental caries. METHODS: Reviews of the current research and recent evidence based systematic reviews on the topics of fluoride are presented. Topics discussed include: updates on community water fluoridation research and policies; available fluoride in dentifrices; fluoride varnish compositions, use, and recommendations; and other fluoride containing dental products. This update provides insights into current research and discusses proposed policy changes for the use of fluoride for the prevention of dental caries. CONCLUSIONS: The dental profession is adjusting their recommendations for fluoride use based on current observations of the halo effect and subsequent outcomes. The research community is focused on improving the efficacy of fluoride therapies thus reducing dental caries and lowering the amount of fluoride required for efficacy.

Remineralization of Early Enamel Lesions with Apatite-Forming Salt.

OBJECTIVES: This study sought to evaluate the remineralization of ex vivo human teeth using commercially available artificial saliva, SalivaMAX®, a supersaturated calcium phosphate rinse (SSCPR). METHODS: early enamel lesions were artificially induced on ex vivo human teeth by chemical means. The teeth were exposed to the SSCPR for two minutes (experimental) or dH2O (control) four times per day for a total of 35 days. At time points of 0, 2.5, 21, and 35 days, micro-CT was utilized to determine the mineral density profile across the lesion and evaluate lesion depth. The relative percent remineralization was calculated from the initial lesion depth (Time 0) at each evaluation time. Student's t-test was used to compare the extent of remineralization between the SSCPR and control groups for statistical significance at each time. To evaluate the changes in percent remineralization over time, a two-way ANOVA was used. RESULTS: At Time 0 and 2.5 days, there was no difference in the percent remineralization between the SSCPR and control groups (p > 0.05). After 21 days, the teeth exposed to the SSCPR remineralized 56.7 ± 3.7%, while the control only remineralized 10.7 ± 11.0% (p < 0.0001). At day 35, the remineralization was 73.7 ± 5.4% and 18.2 ± 10.8% (p < 0.0001) for the SSCPR and control groups, respectively. CONCLUSIONS: A marked increase in remineralization occurred with the use of the SSCPR. Notably, the remineralization of the SSCPR occurred deep within the tooth and progressed toward the surface over time.

Inter-method reliability for determining total and soluble fluorides in child low-fluoride formula dentifrices.

The study aimed to compare three methods for determining total (TF) and total soluble fluorides (TSF) in 5 child formula dentifrices (CFD) using Inter-method reliability (IMR) statistical approach. The methods were direct acid-hydrolysis (DM), the least-time-consuming method; Modified direct acid-hydrolysis with standard-addition method (MDM), ISO 19448:2018 method; and modified Taves acid-HMDS diffusion analysis (TAD), the claimed gold standard method. A significant difference in the mean difference was observed for all methods at all levels (p < 0.001), except DM and TAD for TF (p = 0.622). A proportional bias was discerned in the agreement distribution between DM and TAD for TF (p < 0.001). The ICC analysis identified significant reliability between all measurements, irrespective of the model, measure, and fluoride type (p < 0.001). For TF and TSF, the IMR between DM and TAD was lower than MDM and TAD for consistency/absolute agreement reliability at single/average measures. The reliability measure for DM and MDM was higher than MDM and TAD for TSF, but was lower than MDM and TAD for TF. The ICC measure for DM-TAD was significantly lower than DM-MDM and MDM-TAD (p < 0.05). The ISO 19448:2018 MDM is a reliable test that can be used as an alternative to TAD/DM for determining TF/TSF in CFD.

Synthesis of Polymerizable Cyclodextrin Derivatives for Use in Adhesion-Promoting Monomer Formulations.

The synthesis of the cyclodextrin derivatives reported herein was assisted by extensive literature research together with structure-property relationships derived from three-dimensional molecular modeling. These studies led to the hypothesis that many of the 21 hydroxyl groups on beta-cyclodextrin molecules could be derivatized to form a closely related family of analogous chemical compounds containing both polymerizable groups and hydrophilic ionizable ligand (substrate-binding) groups, each attached via hydrolytically-stable ether-linkages. The vinylbenzylether polymerizable groups should readily homopolymerize and also copolymerize with methacrylates. This could be highly useful for dental applications because substantially all contemporary dental resins and composites are based on methacrylate monomers. Due to hydrophilic ligands and residual hydroxyl groups, these cyclodextrin derivatives should penetrate hydrated layers of dentin and enamel to interact with collagen and tooth mineral. Analyses indicated that the diverse reaction products resulting from the method of synthesis reported herein should comprise a family of copolymerizable molecules that collectively contain about 30 different combinations of vinylbenzyl and hexanoate groups on the various molecules, with up to approximately seven of such groups combined on some of the molecules. Although the hypothesis was supported, and adhesive bonding to dentin is expected to be significantly improved by the use of these polymerizable cyclodextrin derivatives, other efforts are planned for improved synthetic methods to ensure that each of the reaction-product molecules will contain at least one copolymerizable moiety. The long-term objective is to enable stronger and more durable attachments of densely cross-linked polymers to hydrated hydrophilic substrates. Capabilities for bonding of hydrolytically stable polymers to dental and perhaps other hydrous biological tissues could provide widespread benefits.

Adhesive Bonding to Dentin Improved by Polymerizable Cyclodextrin Derivatives.

The objective of this work was to determine bonding characteristics of a hydrophilic monomer formulation containing polymerizable cyclodextrin derivatives. The hypothesis was that a formulation containing hydrophilic cross-linking diluent comonomers and cyclodextrins with functional groups attached by hydrolytically stable ether linkages could form strong adhesive bonds to dentin. The previously synthesized polymerizable cyclodextrin derivatives were formulated with sorbitol dimethacrylate, methacrylic acid and phenylbis(2,4,6-trimethylbenzoyl) phosphine oxide photoinitiator. The same formulation without the polymerizable cyclodextrin derivatives isolated the effects of the polymerizable cyclodextrin derivatives. A commercial self-etching bonding system was tested as a comparative control. Ground mid-coronal dentin was etched with 37 % phosphoric acid (H3PO4) for 15 s and rinsed with distilled water for 10 s. Formulations were applied to the moist dentin and light-cured 10 s. A packable composite was then applied through irises and light-cured 60 s. Teeth were stored in water for 24 h before bonds were tested in a shearing orientation. One-way ANOVA was performed on the data. The average values of shear bond strengths were defined as loads at fracture divided by the 4 mm diameter iris areas. The average value of shear bond strength for the formulation containing the polymerizable cyclodextrin derivatives was higher (p < 0.05), where p is a fraction of the probability distribution) than that of the same monomeric formulation except that the polymerizable cyclodextrin derivatives were not included. This was supporting evidence that the polymerizable cyclodextrin derivatives contributed to improved bonding. The average value of shear bond strength for the formulation containing the polymerizable cyclodextrin derivatives was also higher (p < 0.05) than that of the commercial self-etching bonding system. These preliminary results are in accordance with the hypothesis that formulations containing polymerizable cyclodextrin derivatives can form strong adhesive bonds to hydrated dentin surfaces. Further improvements in bonding to hydrated biological tissues by use of advanced formulations are anticipated.

Effect of irrigants and cementum injury on diffusion of hydroxyl ions through the dentinal tubules.

This study measured hydroxyl ion diffusion through dentinal tubules into a bathing solution. Eighty single-canal, instrumented teeth were divided into 8 groups. Control groups 1 and 3 were irrigated with 10 mL 0.9% saline and 10 mL 6% sodium hypochlorite (NaOCl), respectively. Control groups 5 and 7 were irrigated with 3 mL and 1 mL 17% ethylenediaminetetraacetic acid (EDTA) and then 10 mL 6% NaOCl, respectively. Experimental groups 2, 4, 6, and 8 were irrigated as groups 1, 3, 5, and 7, followed by placement of calcium hydroxide (Ca(OH)2) into canals. Bathing solution pH was recorded for 30 days, a cementum defect was made, and then pH was recorded for another 30 days. With a paired difference test, average pH during steady state was statistically different and higher after the defect (P < .001). With Tukey multiple comparisons, post-defect pH for group 6 was found to be significantly greater (P < .01) than in other groups. This study indicated final canal irrigation with 3 mL 17% EDTA and 10 mL 6% NaOCl before Ca(OH)2 placement allowed the greatest hydroxyl ion diffusion to the root surface.

Dentin Erosion: Method Validation and Efficacy of Fluoride Protection.

The aging population experiences more gingival recession and root exposure which increases the opportunity for dentin erosion. This study tested the use of transverse microradiography (TMR) methods to assess dentin erosion and the interaction between fluoride and citric acid on the amount of erosion in the dentin samples. In a 4 × 3 interaction experimental design, four fluoride concentrations (0.00, 25.0, 50.0, and 100.0 mg/L) and three citric acid concentrations (0.0, 0.25, and 1.00%) were combined to form 12 experimental solutions. Forty-eight dentin samples were placed in the experimental solutions for 1 and 4 h and the amount of surface lost was determined by TMR methods. The resolution of the TMR method was 0.9 µm per pixel with a 0.1% and a 5% confidence interval of ±4.2 µm. Dentin erosion increased with the concentration of citric acid and time, the erosion decreased when concentration of fluoride was increased. Effects due to fluoride and citric acid concentrations individually, and their interaction on the amount of erosion observed was statistically significant (p < 0.0001). This study found that TMR methods are appropriate and that 25.0 mg/L was the optimal fluoride concentration to protect dentin from a 1.00% citric acid challenge.

Medicaid Adult Dental Benefit Impact on Dental Utilization: A University Clinic Setting.

INTRODUCTION: In 2014, the state of Colorado initiated new dental coverage benefits for adults in the Colorado Medicaid program. The goal of this study was to investigate the utilization and impact of this new dental coverage at the University of Colorado School of Dental Medicine. The utilization of dental services delivered and the numbers of patients in this program were compared before and after the implementation of the benefit. MATERIALS AND METHODS: This retrospective study compared the utilization of services provided 2 years prior and 2 years after the Medicaid adult benefit was made available. Through the University of Colorado School of Dental Medicine (CU-SODM) electronic dental record, all adult Medicaid dental patients' (ages 21+) charts were extracted for zip code, CDT dental procedure codes, with a focus on tooth extraction compared to tooth saving procedures. Graphical analysis and Pearson's chi-squared tests were applied to assess the statistical significance of procedure utilization changes over time. RESULTS: After implementation of the Medicaid adult benefit, the number of patients seen at the school under this program increased by a factor of 4.5. The geographic range (zip code) increased with some patients coming from further distances to receive dental care. The number of patients from local zip codes increased by as much as 235%. There was a 51% increase in tooth saving procedures, which was statistically significant (P = 0.0013). Additionally, there was a 22% decrease in extractions, while not statistically significant (P = 0.0992), a downward trend was clear. DISCUSSION: The focus was on the utilization of Medicaid adult benefits at the dental school, which was only a small proportion of the state-wide Medicaid population. Therefore, these data are not generalizable for statewide assessments of the program. However, based on the findings at the school clinics, more adult patients utilized the benefits; and chose to receive more tooth saving procedures and less extractions after implementation of the Medicaid adult benefit. This Medicaid study conducted at the CU-SODM 2 years after the adult dental coverage can be used as a baseline for future studies.

Comparison of Orthodontic Medicaid Funding in the United States 2006 to 2015.

INTRODUCTION: Orthodontic treatment is reimbursed by Medicaid based on orthodontic and financial need with qualifiers determined by individual states. Changes in Medicaid-funded orthodontic treatment following the "Great Recession" in 2007 and the enactment of the Affordable Care Act in 2010 were compared for the 50 United States and the District of Columbia to better understand disparities in access to care. The results from this 2015 survey were compared to data gathered in 2006 (1). MATERIALS AND METHODS: Medicaid officials were contacted by email, telephone, or postal mail regarding the age limit for treatment, practitioner type who can determine eligibility and provide treatment, records required for case review, and rate and frequency of reimbursement. When not attained by direct contact, the information was gleaned from online websites, provider manuals, and state orthodontists. RESULTS: Information gathered from 50 states and the District of Columbia documents that Medicaid program characteristics and expenditures continue to vary by state. Expenditures and reimbursement rates have decreased since 2006 and vary widely by geographic region. Some states have tightened restrictions on qualifiers and increased submission requirements by providers. CONCLUSION: The variation and lack of uniformity that still exists among Medicaid orthodontic programs in different states creates disparities in orthodontic care for US citizens. Barriers to care for Medicaid-funded orthodontic treatment have increased since 2006.

Controlling the fluoride dosage in a patient with compromised salivary function.

BACKGROUND: High-concentration topical fluorides are used commonly to with compromised salivary function due to irradiation and chemotherapy. CASE DESCRIPTION: The authors describe a 50-year-old man with previously treated cancer who was using tray-applied topical fluoride gel. He complained of gastric symptoms, difficulty in swallowing, leg muscle soreness and knee joint soreness. A computed tomographic scan revealed thickening of the esophageal walls. An upper endoscopy revealed abnormal motility. The motility test indicated high-amplitude peristalsis and hypertensive lower esophageal sphincter, and urine testing indicated high levels of systemic fluoride. The patient's fluoride regimen was altered, and within a short period his urinary fluoride levels returned to normal and his symptoms resolved. CLINICAL IMPLICATIONS: Clinicians prescribing home-applied high-concentration fluorides need to be cognizant of the symptoms of fluoride toxicity, carefully monitor the patient's compliance with the treatment regimen, and adjust the dosage or mode of application to control the total ingested dose of fluoride.