Effectiveness of Chewing Gum Containing CPP-ACP for Remineralisation of Demineralised Enamel around Orthodontic Brackets: An in Situ Study

Abstract Objective: To evaluate the effectiveness of chewing gums containing CPP-ACP in remineralisation of demineralised enamel around orthodontic brackets. Material and Methods: Enamel blocks from 120 bovine incisors were used. The blocks were flattened and polished, followed by the development of incipient subsurface caries. The blocks have been subjected to a baseline microhardness analysis. Orthodontic brackets were bonded to the exposed area of the blocks, reserving an area for hardness analysis. An in situ crossover (three-way crossover phases of 21 days with an interval of one week between them), controlled, randomised and blind experimental model was used, with the participation of 12 volunteers divided into groups: G1 - negative control group, without chewing gum; G2 - conventional sugar-free chewing gum, without CPP-ACP (placebo); and G3 - sugar-free chewing gum with CPP-ACP. The following parameters were analysed: superficial linear (Ra), volumetric roughness (Sa), and superficial structural loss, which was indicated by Gap measurement (difference between the healthy and treated area). Statistical tests used were the Friedman, Wilcoxon and Shapiro-Wilk, Kruskal Wallis' nonparametric tests and ANOVA. Results: There was a significant reduction in enamel microhardness after demineralisation in all the groups (p<0.05). This deleterious effect was attenuated in the three groups after the final evaluation, although there were no statistical differences (p<0.05); however, the final values did not return to the baseline values (p<0.05). Conclusion: Chewing gum containing CPP-ACP did not promote in situ remineralisation of demineralised enamel around orthodontic brackets.

Biomateriales que inducen la remineralización del esmalte dental y dentina / Biomaterials that induce remineralization of the dentin and enamel surface

Desde los sesentas, con la invención del vidrio bioactivo, los tratamientos de remineralización se han popularizado entre los cirujanos dentistas y su utilización es cada vez mayor; la remineralización, en conjunto con las adecuadas medidas de higiene preventiva, representa uno de los mejores abordajes mínimamente invasivos y a un costo comparativamente bajo. Este estudio documental tiene por objetivo establecer una mejor comprensión del uso clínico de los biomateriales que inducen la remineralización de la superficie del esmalte dental y dentina. Se realizó una exploración utilizando motores de búsqueda (bases de datos en PubMed, Medigraphic, y Science Direct). El proceso de localización de los estudios relevantes se efectuó introduciendo palabras clave como: silicatos de calcio, fosfopéptidos de caseína-fosfato de calcio amorfo, remineralización, esmalte y dentina, incluyéndose en el procedimiento artículos de antigüedad no superior a siete años, en español e inglés, publicados en revistas científicas aprobadas por pares.Actualmente, no es posible remineralizar del todo la estructura dentaria, por lo cual, en un futuro cercano, los esfuerzos de la odontología de remineralización deben apuntar al desarrollo de agentes biomiméticos inteligentes que restauren al cien por ciento la estructura dental perdida (AU)

Since the sixties, with the invention of bioactive glass, remineralization treatments have become popular among dental surgeons. Their usage is increasing; remineralization, in conjunction with appropriate preventive hygiene measures, represents one of the best minimally invasive treatments at a relatively low cost. This documentary study aims to establish a better understanding of the clinical use of biomaterials that induce remineralization of the surface of teeth enamel and dentin. A search was conducted using search engines (PubMed and Medigraphic databases, and Science Direct). The search process for the relevant studies was carried out by introducing keywords such as calcium silicates, phosphopeptides of amorphous calcium casein-phosphate, remineralization, enamel and dentin, including in the search articles no older than seven years in Spanish and English published in scientific reviewed journals. Currently, it is not possible to completely remineralize the dentary structure so, in the near future, remineralization dentistry efforts should aim to develop (AU)

Tara Gum as a Controlled Delivery System of Fluoride in Toothpaste: In Vitro Enamel Remineralization Study

ABSTRACT Objective: To evaluate the remineralizing potential of a hydrocolloid-based, controlled fluoride-releasing system added to dentifrice formulas. Material and Methods: Sixty-five human enamel blocks were prepared and the surface microhardness (SH0) values were determined. The artificial caries lesions were induced and the demineralization surface microhardness (SH1) was evaluated. The blocks were randomly allocated into five groups (n = 13): (1) 100-TGF (100% NaF with Tara gum added); (2) 50-TGF (50% free NaF + 50% NaF with Tara gum added); (3) 100% TG (100% Tara gum without fluoride); (4) 100% NaF (positive control); and (5) placebo (without Tara gum and NaF). The blocks were submitted to 7 days pH cycling and treated with dentifrice slurries twice a day. Finally, surface hardness (SH2) was assessed and the percentage of surface hardness recovery (%SMHR) was calculated. Analysis of variance (ANOVA) followed by Bonferroni test was used for statistical analysis. Results: A positive %SMHR was found in the 100% NaF (5.07) and 50-TGF (0.64) groups, while the 100-TGF (-1.38), 100% TG (-3.88) and placebo (-0.52) did not undergo remineralization. Statistically significant differences were observed between 100% NaF and all the groups except for 50-TGF (p<0.05). Conclusion: The presence of hydrocolloid (Tara gum) promoted minimal remineralization when associated with NaF. In the applied model, Tara gum may have compromised remineralization, preventing free fluoride from acting effectively in the carious lesion.

ENHANCING REMINERALIZATION OF PRIMARY ENAMEL LESIONS WITH FLUORIDE DENTIFRICE CONTAINING TRICALCIUM PHOSPHATE.

Fluoride dentifrice is effective in preventive dental caries but may cause fluorosis, especially in young children. Reducing the concentration of fluoride from the regular concentration of 1,000 parts per million (ppm) to 500 ppm can reduce the risk for fluorosis but increases the risk of caries. Adding tricalcium phosphate (TCP) to the dentifrices may improve the efficacy of remineralization possibly allowing for a lower concentration of fluoride to reduce the risk of fluorosis. We studied this to inform future caries prevention efforts in children. We immersed 40 sound primary incisors into demineralizing solution (pH=4.4) for 96 hours at 37°C to create demineralized lesions. The 40 teeth were then divided into 4 groups of 10 teeth each. Group A: control (treated with deionized water only); Group B: treated with fluoride dentifrice at a concentration of 1,000 ppm; Group C: treated with fluoride dentifrice at a concentration of 500 ppm and 500 ppm TCP, and Group D: treated with fluoride dentifrice at a concentration of 1,000 ppm and 500 ppm TCP. The teeth were each subjected to 7 days of pH-cycling and the studied dentifrice was applied for one minute, 3 times daily during the 7 day period. After the 7 day period the teeth were each sectioned and examined with polarized light microscopy. The depths of demineralized areas were measured using Image-Pro plus software. A pair t-test was used to compare lesion depths before and after dentifrice treatment. Differences in mean lesion depths within each group were analyzed using the One-way ANOVA and LSD tests; a 95% confidence intervals were calculated. The mean lesion depths in all the groups before dentifrice treatment were not significantly different (p=0.143). The mean demineralized lesion depths after dentifrice treatment were significantly different by group (p=0.00). The mean demineralized lesion depth in Group A significantly deeper than the other groups (p=0.00). Group D had the shallowest depth, significantly shallower than the other groups (p=0.006). There was no significant difference in the mean demineralized lesion depth between Groups B and C (p=0.478). The mean demineralized lesion depth changed significantly after dentifrice treatment in all the groups (p=0.00). Group A was significantly deeper (p=0.00) and groups B, C and D were all significantly shallow. Group D had the greatest reduction in mean demineralized lesion depth (p<0.05). The 1,000 ppm fluoride plus TCP dentifrice gave superior remineralization than the 500 ppm fluoride plus TCP and the 1,000 ppm fluoride dentifrice. The 500 ppm fluoride plus TCP gave the same remineralizing effect as the 1,000 ppm fluoride dentifrice. TCP enhances remineralization on primary enamel when added to fluoride dentifrice. Our results show if TCP is added to fluoride dentifrice a lower concentration of fluoride is needed to provide the same benefit as fluoride dentifrice with a higher concentration of fluoride, reducing the risk of fluorosis in children.

Efecto del blanqueamiento y el remineralizante sobre la microdureza y micromorfología del esmalte dental / Effect of whitening and remineralizing agent on the microhardness and micromorphology of dental enamel

Diversos estudios han demostrado mayor o menor grado de afectacióndel esmalte después del uso de los distintos tratamientos para blanqueamiento dental. Por este motivo, se han propuesto varios métodos ytratamientos remineralizantes que pudieran revertir los efectos negativosde dicho tratamiento. El objetivo del presente trabajo fue evaluar el efecto del Opalescence PF 15 por ciento (peróxido de carbamida al 15%) y delremineralizante Flor-Opal (NaF al 1.1 por ciento), ambos de la casa comercialUltradent, así como de la saliva artifi cial sobre la microdureza y la micromorfología del esmalte humano. Se utilizaron 10 incisivos centrales superiores recién extraídos provenientes de centros de salud del Puerto de Veracruz, México. Réplicas de estos dientes fueron obtenidas en lasdiferentes fases del tratamiento de blanqueamiento para ser posteriormente observadas en el microscopio electrónico de barrido (MEB). Asimismo, se realizaron mediciones de microdureza en la superficie del esmalte de los dientes seleccionados durante las diferentes fases del tratamiento de blanqueamiento. Se observó que la microdureza del esmalte se ve disminuida (aunque no significativamente) después de la aplicación del peróxido de carbamida al 15 por ciento, y vuelve a subir después de la aplicación de los remineralizantes, para posteriormente volver a descender siete días después del uso de los mismos. Los datos de microdureza coincidieron con los de micromorfología obtenidos enel MEB. Se concluye que el peróxido de carbamida al 15 opr ciento sí afecta lamicromorfología de la superficie del esmalte, además de que disminuyela microdureza del mismo. Con el uso del remineralizante Flor-Opal se onsiguieron mayores valores de microdureza y mejores características micromorfológicas comparado con la saliva artificial.

Studies have shown varying degrees of involvement of the enamel following the use of tooth-whitening treatments. Consequently, a range of methods and remineralizing treatments have been proposed to reverse their negative effects. The aim of this study was, therefore, to evaluate the effect of Opalescence PF 15% (carbamide peroxide 15%) and the remineralizing treatment Flor-Opal (1.1% NaF), both produced by Ultradent, as well as artifi cial saliva on the microhard-ness and micromorphology of human enamel. Ten recently-extracted central incisors from health centers in the port of Veracruz, Mexico, were used. Replicas of these teeth were made at the various stages of the whitening treatment in order to observe these under a scanning electron microscope (SEM). Microhardness measurements were also taken on the surface of the enamel of the teeth selected at each of the various stages of the whitening treatment. The microhardness of the enamel was found to decrease (though not signifi cantly) after the ap-plication of carbamide peroxide 15%, then increase again following the application of the remineralizing agents, only to decrease again seven days after these were applied. The microhardness data coincided with that for micromorphology obtained from the SEM. We conclude that carbamide peroxide 15% does affect the micromorphology of the enamel surface and also decreases its microhardness. Flor-Opal produced higher microhardness values and better micromorphological characteristics compared to artifi cial saliva.

Can the Application of Fluoride Iontophoresis Improve Remineralisation of Early Caries Lesions?

PURPOSE: To determine the optimal electric current intensity of fluoride iontophoresis (FI) for remineralisation of early caries lesions in vitro. MATERIALS AND METHODS: Sixty specimens were made from bovine incisors and immersed in a demineralising gel for 96 h. Specimens were divided into control (conventional fluoride application) and experimental (FI) groups. All of the specimens were covered with fluoride for 4 min every day. Different electric current intensities (100, 200, 300 and 400 µA) were applied in the FI groups using the FI device. The concentration of KOH-soluble fluoride was determined to evaluate the amount of CaF2 formed on the tooth surface. The reduction in lesion depth was measured by polarised light microscopy. RESULTS: The concentration of KOH-soluble fluoride was the highest in the specimens of the 300 µA FI group. However, there was no significant difference in the reduction of lesion depth between the experimental groups and the control group. CONCLUSION: Variations in the electric current intensity influenced the amount of CaF2 formed on the enamel surface, with the greatest amount found for 300 µA.

Comparison of the remineralisation effect of a glass ionomer cement versus a resin composite on dentin of primary teeth.

AIM: The aim of this study was to investigate the interaction of a high viscosity glass ionomer cement (GIC) and a composite resin with caries affected dentin and to determine the remineralization levels. MATERIALS AND METHODS: In a split mouth design 24 GIC and composite resin atraumatic restorative treatment restorations were made in vivo and the teeth were collected after 2 years and subsequently sectioned and examined using Vickers microhardness test; the latter was performed starting from the dentin surface adjacent to the restoration. Repeated Measure ANOVA and Bonferroni statistical methods were used for data analysis. RESULTS: The microhardness adjacent to the GIC restorative material resulted to be significantly higher. CONCLUSION: GIC resulted to be a better restorative material for the remineralization of caries affected dentin, though further studies are necessary for the corroboration of this finding. The GIC restored primary molar dentin had a higher level of remineralization and GIC could be the material of choice in pediatric dentistry.

Cariotester, a new device for assessment of dentin lesion remineralization in vitro.

This study aimed to evaluate the potential of a new device (Cariotester) for monitoring of incipient carious lesion remineralization in root dentin by topical fluoride in vitro. Demineralized bovine dentin specimens were treated by fluoride solutions (APF or neutral NaF) and remineralized for 4 weeks. Cariotester was used to measure penetration depth (CTR depth) of the indenter into the de- and remineralized specimen surface. The specimens were assessed by transverse microradiography (TMR) to determine lesion parameters (depth: LD, mineral loss: ΔZ). Pearson's correlation analysis showed an overall significant relationship between CTR depth and both TMR parameters. CTR depth appeared to distinguish the positive effect that topical fluoride application had on the remineralization of the outer zone of dentin lesions. Cariotester had the potential to serve as a quantitative tool for monitoring of incipient carious lesion remineralization in root dentin.

Tratamiento remineralizador de la mancha blanca / White spots remineralizing treatment

Las posibilidades de remineralizar la mancha blanca fueron evaluadas en un estudio clínico que involucró el uso de barnices fluorados y una pasta a base de fosfato de calcio amorfo (FCA), complementada con el uso de una goma de mascar a base de FCA. En una población de niños asistidos en un hospital odontopediátrico, se evaluaron los protocolos establecidos para cada tratamiento comparativo, determinándose la validez del procedimiento con FCA como agente remineralizador.

Strategies for noninvasive demineralized tissue repair.

This article provides a state-of-the-art overview of clinically relevant evidence regarding effective, noninvasive management strategies to prevent, arrest, and remineralize caries lesions. With the rapidly increasing knowledge about oral biofilms and the process of caries in itself, the profession is embarking on new strategies. This is an exciting time, with several promising new agents and novel treatment modalities at the horizon to prevent and manage caries lesions. Some are already available in clinical practice. Studies, however, have yet to show conclusive evidence of clinical efficacy. None have shown to be more effective than fluoride and protection by sealant.

A review of slow-release fluoride devices.

BACKGROUND: Fluoride has been used to combat dental caries using a number of different clinical approaches. An exciting relatively new development is fluoride slow-releasing devices that consistently elevate intra-oral fluoride levels of plaque and saliva for prolonged periods of up to two years. METHODS: The literature on the use of slow-releasing fluoride devices in dentistry were reviewed. A Medline search on key words was carried out. All papers in English were individually reviewed. RESULTS: Slow-releasing fluoride devices have been shown to be effective in elevating salivary fluoride levels in both animals and human studies and to enhance the remineralisation of dental enamel. They have been demonstrated to be safe to use and without the risk of fluoride toxicity. A double blind randomised clinical trial demonstrated 76% fewer new carious surface increment in high caries-risk children after two years. CONCLUSIONS: These devices have a number of potential uses in dentistry and in particular have great potential for caries prevention of non-compliant high caries-risk groups.

Estudio in vitro del efecto de dentífricos fluorurados comercialmente disponibles en Venezuela en el proceso de remineralización de lesiones iniciales de caries dental / An in vitro study of the effect of fluoridated dentifrices commercially available in Venezuela, on the remineralization process of initial dental caries lesions

La técnica de microdureza se ha utilizado para determinar el efecto de dentífricos fluorurados en lesiones artificiales de caries utilizando el modelo in vitro de pH ciclico. Las medidas de microdureza Knoop se realizaron en el esmalte sano, desmineralizado y en el esmalte expuesto al tratamiento in vitro con los diferentes dentífricos. Los resultados demostraron que la exposición a dentífricos que contienen fluoruro produjo un aumento neto en la dureza del esmalte desmineralizado. Se realizaron asociaciones entre los dentífricos que contenían NaF a una concentración de 1100ppm F y la combinación de NaF/MFP a una concentración de 1450 ppm F, encontrándose un incrementos estadísticamente significativo en la medida de microdureza Knoop (p<0.001) cuando se compararon con el dentífrico control. No se observaron diferencias estadísticamente significativas cuando se compararon ambos dentífricos entre sí. También se encontraron diferencias estadísticamente significativas cuando se compararon los dos dentífricos que conteníanla mezcla de NaF/MFP a concentraciones de 1100 y 1450 ppm F, respectivamente. Significación clínica. Este estudio in vitro sugiere que un dentífrico que contiene 1100 ppm F (como NaF solo) tiene el mismo potencial anticariogénico que uno que contiene 1450 ppm F (como una combinación de NaF y MFP). El dentífrico que contenía la combinación de NaF/MFP a una concentración de 1450 F produjo un aumento significativo en la remineralización comparado con el mismo dentífrico pero a una concentración de 1100 ppm F. Los grupos experimentales tratados con NaF, así como los tratados con NaF/MFP a las concentraciones de 1100 y 1450 ppm F, respectivamente, produjeron un aumento significativo (p<0,001) en la remineralización del esmalte humano, al compararlos con el grupo control, el cual no contenía fluoruro, demostrando así el gran potencial anticariogénico de estas formulaciones.

M.E.B. Efecto del grabado ácido aplicado sobre dentina remineralizada con cariostático / S.E.M. Effect of acid etching applied on cariostatic-remineralized dentin

Uno de los agentes cariostáticos más usados en la actualidad en dentición temporaria, es el fluoruro dimaínico de plata. En este estudio realizamos su aplicación sobre caries dentinaria en dientes posteriores de pacientes adultos. Tanto clínica como radiográficamente, pudo observarse la remineralización de la dentina en las 50 piezas dentarias tratadas. Una de las comprobaciones más efectivas de esta remineralización fue llevar 25 de las piezas dentarias que fueron extraídas por otras patologías, al microscopio electrónico de barrido para su estudio. El objetivo de esta observación fue comprobar la obliteración de los conductillos dentinarios y la presencia de retenciones micromecánicas, luego del grabado ácido, en la dentina tratada con el cariostático. Según los resultados obtenidos en la totalidad de las piezas dentarias, la remineralización lograda con el cariostático se conservó en el 100 por ciento de los casos luego de aplicado el ácido grabador y produjo las microrretenciones necesarias para la adhesión de la resina compuesta de fotocurado

Investigation to evaluate and validate the Leeds in situ device for the study of enamel remineralisation in vivo.

OBJECTIVES: Recently, a novel device to generate dental plaque in situ on a removable human enamel surface was described. The device permitted the recovery of plaque intact and undisturbed on its enamel substrate. The aim of this investigation was to determine the utility and robustness of this model for analysis of the effects of therapeutics on both enamel remineralisation and on the overlying biofilm composition. METHODS: Enamel slices were taken from extracted sound human teeth, sterilised and a 'flat' area ground on each slice. An artificial lesion was formed within this area using acidified gel and the hardness of the enamel within the area of the lesion was determined at five sites using a 'Vickers' indenter. A nylon ring was then attached over the area of the lesion with cyanoacrylate and the excess enamel removed to form the completed device. Two devices were attached to the upper molars of 22 volunteers. Each volunteer was randomly assigned to receive either a fluoride containing (1500 ppm) or a fluoride free dentifrice. The devices were retained for a 4 week period whilst undertaking normal oral hygiene. All procedures were conducted according to GCP. After a 2 week break, the volunteers were fitted with two further devices, given dentifrice of the alternate type and the procedure repeated. Plaque from each device was harvested for microbiological analyses and the enamel subject to microhardness measurement. Then for each device the change in microhardness of the enamel within the lesion over the 4 week period was calculated. RESULTS: There were no significant differences in viable counts of total aerobic bacteria, mutans streptococci or lactobacilli, nor in acidic, aciduric or arginolytic populations in plaque from patients using the two different dentifrices. However, devices subjected to the fluoride containing dentifrice demonstrated a significantly greater increase in microhardness of the enamel (P<0.025). CONCLUSIONS: These results suggest that the novel in situ device is capable of measuring the effect of 1500 ppm fluoride on remineralisation of carious enamel over a 4 week period and is also well suited to determining concomitant effects on plaque ecology.

Quantification of formation and remineralization of artificial enamel lesions with a new portable fluorescence device.

Quantitative laser fluorescence has been reported as a useful method for the non-destructive in vitro and in vivo diagnosis of early enamel caries. A portable system for intraoral use has been developed with a new light source and filter system replacing the laser light to facilitate clinical application. This new device was validated with microradiographic and chemical analyses for assessment of mineral changes in enamel during lesion formation and remineralization in vitro and compared with the laser light equipment. A significant correlation was found between fluorescence changes and mineral loss: r = 0.79 (laser system) and r = 0.84 (portable lamp system). The correlation between the two fluorescence methods was r = 0.93. The portable fluorescence device seemed to be a promising new tool for reproducible and sensitive assessment of the severity of incipient enamel lesions.

Dose related remineralization using intraoral fluoride-releasing devices in situ.

Dose-related remineralization of enamel lesions was studied in situ. Enamel specimens with subsurface lesions were mounted on lower molars bilaterally and exposed to five regimens: (A) control with a F-free dentifrice three times daily; (B) NaF dentifrice brushed three times daily; (C) fluoride-releasing device (FRD; 0.07 mg F/day release rate) plus F-free dentifrice; (D) FRD (0.232 mg F/day) plus F-free dentifrice, F/day and (E) FRD (0.232 mg/F/day) plus NaF dentifrice. Resting and stimulated saliva samples were obtained for salivary flow and F content determinations. Twenty-eight subjects participated in this double-blind, random-assignment crossover study. After 50 days the enamel specimens were recovered, sectioned, microradiographed, and scanned with image analysis. Regimens D and E demonstrated approximately 30% additional remineralization as compared with to controls, and regimens B and C showed 13.7 and 10.5% increased remineralization as compared with to controls. The increased remineralization of the regimens generally paralleled the increase in salivary F and clearly demonstrated a dose-related response which was some threefold in relation to release rate, salivary F, and percent remineralization.