Comparative Quantitative Assessments of Salivary Ion Activity Product for Hydroxyapatite and Buffering Capacity in Children with Different Caries Experience.

AIM: If a relation exists between salivary IPHA, buffer capacity and caries experience, then this relationship could be used as screening chair side test for caries risk assessment. STUDY DESIGN: One hundred ninety seven children aged 4 to 6 years were examined. Data was collected by interview and clinical examination. They were divided into low, moderate and high caries experience group of 20 children each. Two ml of each sample was used to measure the pH value with pH meter. Regarding the buffering capacity, freshly prepared hydrochloric acid (HCl) was titrated into saliva and pH was recorded. The collected saliva samples were sent to Laboratory for measurement of calcium and phosphorus. IPHA was calculated and the negative logarithms of IPHA were used to determine the enamel solubility. The correlation between salivary IPHA, buffering capacity and caries experience were evaluated. RESULTS: There was a significant relation between pH, log IPHA and dental caries experience, it could be considered as a predictor of dental caries. CONCLUSION: pH measurement after HCl titration in saliva could be used as chair side screening test for the assessment of caries risk.

The future of fluorides and other protective agents in erosion prevention.

The effectiveness of fluoride in caries prevention has been convincingly proven. In recent years, researchers have investigated the preventive effects of different fluoride formulations on erosive tooth wear with positive results, but their action on caries and erosion prevention must be based on different requirements, because there is no sheltered area in the erosive process as there is in the subsurface carious lesions. Thus, any protective mechanism from fluoride concerning erosion is limited to the surface or the near surface layer of enamel. However, reports on other protective agents show superior preventive results. The mechanism of action of tin-containing products is related to tin deposition onto the tooth surface, as well as the incorporation of tin into the near-surface layer of enamel. These tin-rich deposits are less susceptible to dissolution and may result in enhanced protection of the underlying tooth. Titanium tetrafluoride forms a protective layer on the tooth surface. It is believed that this layer is made up of hydrated hydrogen titanium phosphate. Products containing phosphates and/or proteins may adsorb either to the pellicle, rendering it more protective against demineralization, or directly to the dental hard tissue, probably competing with H(+) at specific sites on the tooth surface. Other substances may further enhance precipitation of calcium phosphates on the enamel surface, protecting it from additional acid impacts. Hence, the future of fluoride alone in erosion prevention looks grim, but the combination of fluoride with protective agents, such as polyvalent metal ions and some polymers, has much brighter prospects.

Understanding the chemistry of dental erosion.

Dental erosion is caused by repeated short episodes of exposure to acids. Dental minerals are calcium-deficient, carbonated hydroxyapatites containing impurity ions such as Na(+), Mg(2+) and Cl(-). The rate of dissolution, which is crucial to the progression of erosion, is influenced by solubility and also by other factors. After outlining principles of solubility and acid dissolution, this chapter describes the factors related to the dental tissues on the one hand and to the erosive solution on the other. The impurities in the dental mineral introduce crystal strain and increase solubility, so dentine mineral is more soluble than enamel mineral and both are more soluble than hydroxyapatite. The considerable differences in structure and porosity between dentine and enamel influence interactions of the tissues with acid solutions, so the relative rates of dissolution do not necessarily reflect the respective solubilities. The rate of dissolution is further influenced strongly by physical factors (temperature, flow rate) and chemical factors (degree of saturation, presence of inhibitors, buffering, pH, fluoride). Temperature and flow rate, as determined by the method of consumption of a product, strongly influence erosion in vivo. The net effect of the solution factors determines the overall erosive potential of different products. Prospects for remineralization of erosive lesions are evaluated.

An in vitro investigation of the erosive potential of smoothies.

INTRODUCTION: Recent health promotion campaigns have encouraged the public to consume at least five portions of fruit and vegetables per day. Many see consuming fruit smoothies as a way of achieving this. OBJECTIVE: To ascertain the potential or otherwise for fruit smoothies to bring about dental erosion. DESIGN: Laboratory study.Method This was an in vitro investigation in which five varieties of shop bought fruit smoothies, including a 'thickie' were investigated, with respect to their initial pH, titratable acidity and effect upon exposure to the surface microhardness and profile of extracted human teeth. In addition their performance was compared to negative (Volvic(™) water) and positive (orange juice) control drinks as well as a homemade smoothie, based upon the recipe of one of the commercially bought drinks, from which ingredient omissions were made. RESULTS: The majority of the drinks investigated had a baseline pH below the critical pH of enamel (5.5) and required comparable volumes of 0.1M NaOH to raise their pH to neutrality as the positive control. Only two drinks (Volvic(™) still mineral water, the negative control, and the yoghurt, vanilla bean and honey 'thickie') displayed a higher pH, though to neutralise the thickie, a lesser quantity of alkali addition was required. The immersion of the tooth samples in the drinks brought about reductions in their surface hardness (expressed as a percentage change of median hardness) but these were only significant (p <0.001) for the cranberry, blueberry and cherry fruit smoothie and homemade strawberry and banana fruit smoothie. There was no reduction in surface hardness in the case of the teeth immersed in the thickie. Omission of certain ingredients from the homemade smoothie affected the magnitude of surface hardness reductions seen. With regard to the loss of surface contour of the tooth samples following immersion in the drinks, as assessed by depth loss, there were significant differences between the drinks (p = 0.0064) with the thickie and negative control not causing depth loss and the kiwi, apple and lime smoothie producing most depth loss (28.26 (5.45) µm). CONCLUSIONS: Within the limitations of this study some fruit smoothies have the potential to bring about dental erosion if consumed irresponsibly. This can be influenced by ingredient variations. In order to minimise the risk of developing dental erosion, without removing the claimed nutritional benefits of their consumption, their consumption should be confined to mealtimes.

Salivary proteins as a biomarker for dental caries--a systematic review.

AIM: To develop a systematic review based on the relation between salivary proteins and dental caries by comparing subjects with and without caries experience and to evaluate whether salivary proteins can be considered biomarkers for dental caries or not. METHODS: An electronic search was performed in the PubMed Medline, Ovid Medline, ISI Web of Science, Medline, Cochrane Library, Lilacs, Scielo, BBO, Paho and Wholis databases applying the following MeSH terms: "dental caries" OR "tooth demineralization" OR "dental caries susceptibility" OR "dental enamel solubility" AND "salivary proteins and peptides" OR "saliva" AND "proteins". To be eligible for the systematic review, the observational controlled studies had to have groups with and without caries experience. Studies with high risk of bias were excluded. RESULTS: From a total of 188 identified studies, only seven were included in this systematic review. Four studies were classified as "low risk of bias" and three as "moderate risk of bias". Three studies reported a relation between salivary proteins and dental caries. CONCLUSION: There was not sufficient evidence to establish salivary proteins as a biomarker for this disease although three of the seven studies showed a relation between salivary proteins and dental caries in terms of protein phenotypes, total protein concentration and protein molecular weight.

Erosive potential of sports beverages.

BACKGROUND: Dental erosion is an increasingly prevalent problem in Australia, with the consumption of sports beverages suggested as a risk factor. The aim of this study was to compare the erosive potential of Australian sports beverages. METHODS: Ten beverages were selected and analysed to determine their pH, titratable acidity and apparent degree of saturation with respect to apatite. The erosive potential of the beverages was measured by human enamel surface loss and surface softening following a 30-minute exposure. A taste testing panel was established to determine the palatability of the sports beverages. RESULTS: All sports beverages except Sukkie and Endura produced substantial surface loss and surface softening. Compared with the other sports beverages, Sukkie and Endura had a higher pH, lower titratable acidity and higher calcium content. However, Sukkie and Endura were deemed to be less palatable than the other more acidic sports beverages. CONCLUSIONS: The majority of the sports beverages tested produced dental erosion in this in vitro model. However, two new products Sukkie and Endura have lower erosive potential but also lower palatability.

Dental erosion--an overview with emphasis on chemical and histopathological aspects.

The quality of dental care and modern achievements in dental science depend strongly on understanding the properties of teeth and the basic principles and mechanisms involved in their interaction with surrounding media. Erosion is a disorder to which such properties as structural features of tooth, physiological properties of saliva, and extrinsic and intrinsic acidic sources and habits contribute, and all must be carefully considered. The degree of saturation in the surrounding solution, which is determined by pH and calcium and phosphate concentrations, is the driving force for dissolution of dental hard tissue. In relation to caries, with the calcium and phosphate concentrations in plaque fluid, the 'critical pH' below which enamel dissolves is about 5.5. For erosion, the critical pH is lower in products (e.g. yoghurt) containing more calcium and phosphate than plaque fluid and higher when the concentrations are lower. Dental erosion starts by initial softening of the enamel surface followed by loss of volume with a softened layer persisting at the surface of the remaining tissue. Dentine erosion is not clearly understood, so further in vivo studies, including histopathological aspects, are needed. Clinical reports show that exposure to acids combined with an insufficient salivary flow rate results in enhanced dissolution. The effects of these and other interactions result in a permanent ion/substance exchange and reorganisation within the tooth material or at its interface, thus altering its strength and structure. The rate and severity of erosion are determined by the susceptibility of the dental tissues towards dissolution. Because enamel contains less soluble mineral than dentine, it tends to erode more slowly. The chemical mechanisms of erosion are also summarised in this review. Special attention is given to the microscopic and macroscopic histopathology of erosion.

Initial erosion models.

Initial dental erosion - the very first tooth surface changes caused by short-term acidic exposures before any tissue loss is observed - has been studied using in vitro and in situ/in vivo protocols. This paper describes the events that should be considered when modelling initial erosion, the available protocols and their strengths and limitations. In vitro initial erosion models can provide relevant information about the erosive outcome. However, the published studies vary considerably regarding the erosive parameters used, and few of these studies have been validated. On the other hand, relevant in situ/in vivo studies are available that have studied the effect of salivary pellicle and preventive treatments on initial erosion, as well as the changes in salivary pH following exposure to acid solutions. Guidelines for good methodology in modelling initial erosion are proposed.

Formation of caries-like lesions in vitro on the root surfaces of human teeth in solutions simulating plaque fluid.

Lesion formation on root surfaces of human posterior teeth was studied in acetate/lactate buffers with a background electrolyte composition based on plaque fluid analyses. Lesion depth after 28 days at 37 degrees C was measured in relation to: the presence or absence of cementum; the concentration of undissociated buffer; the presence or absence of magnesium ions at plaque fluid concentration. Each factor was evaluated at several values of -log(ion activity product for hydroxyapatite): pI(HA). Solutions were formulated to minimize variation in pH, which varied by < or =0.03 for a given comparison (individual pI(HA)) and by 0.42-0.82 over the range of pI(HA) within experiments. Lesions on surfaces from which cementum had been ground were significantly deeper than on intact surfaces, but this is considered to be due to subsurface mechanical damage and not to a solubility difference. Neither the concentration of undissociated buffer nor the presence of magnesium ions significantly affected lesion depth. Lesion depth was strongly influenced by the correlated variations in pI(HA) and pH. At pI(HA) 54 and 55, only extremely shallow lesions formed. From pI(HA) 56, lesion depth increased with increasing pI(HA). The results confirm that the solubility of the mineral of root tissues is higher than that of hydroxyapatite, but indicate that it is probably lower than suggested by Hoppenbrouwers et al. [Arch Oral Biol 1987;32:319-322]. For calcium concentrations of 3-12 mM, the critical pH for root tissue mineral was calculated as 5.22-5.66 assuming solubility equivalent to pI(HA) 54 and 5.08-5.51 assuming pI(HA) 55.

The effects of saliva on the erosive potential of three different wines.

BACKGROUND: The erosive potential of wine on teeth may be modified by the buffering capacity of saliva. This potential effect was studied for three different wines in vitro and in vivo. METHODS: The buffering capacity was studied in vitro by stepwise addition of small volumes of a dry white wine, a medium sweet white wine and a red wine to collected stimulated saliva. In vivo, this was studied by six volunteers vigorously rinsing 5 mL of each wine in their mouth for 15 to 45 seconds. Changes in salivary flow rate and pH were measured during a period of 10 minutes after rinsing with 5 mL wine. RESULTS: pH values < 5.5 were observed in vitro after addition of 0.2 mL dry white wine and medium sweet wine and after 0.3 mL red wine to 1 mL saliva. During rinsing with all wines, the intra-oral pH decreased to below 4 within 15 seconds and remained below this value for at least 45 seconds. After expectoration, the salivary pH remained significantly low for two to six minutes, despite a doubling of the flow rate observed during the first two minutes. CONCLUSIONS: Vigorously rinsing wine induced a decrease in intra-oral pH of significant degree and duration, which increases the risk of developing dental erosion.

Dental erosion and acid reflux disease: an overview.

Dental erosion can be difficult to detect, especially in the early stages when lesions are subtle and can be easily overlooked. Patients often are not aware of erosion until the dentition has sustained severe damage that requires extensive and expensive dental rehabilitation. The pH of stomach acid is much lower than the critical pH of enamel dissolution; therefore, reflux of stomach contents into the oral cavity over an extended period of time can cause severe loss of tooth structure. Dental treatment for reflux-induced erosion should focus not only on appropriate restoration but also on all available preventive measures, such as neutralization of acid and remineralization or strengthening of enamel against acid attack. Dentists must maintain a high degree of suspicion for reflux-induced erosion whenever a patient displays symptoms of acid reflux disease or a pattern of erosion that suggests an intrinsic source of acid exposure.

Acidic beverages increase the risk of in vitro tooth erosion.

Acidic beverages are thought to increase the potential for dental erosion. We report pH and titratable acidities (ie, quantity of base required to bring a solution to neutral pH) of beverages popular in the United States and lesion depths in enamel and root surfaces after beverage exposure, and we describe associations among pH, titratable acidity, and both enamel and root erosive lesion depths. The pH of 100% juices, regular sodas, diet sodas, and sports drinks upon opening and the titratable acidity both upon opening and after 60 minutes of stirring were measured. Enamel and root surfaces of healthy permanent molars and premolars were exposed to individual beverages (4 enamel and 4 root surfaces per beverage) for 25 hours, and erosion was measured. Statistical analyses included 2-sample t tests, analyses of variance with post hoc Tukey studentized range test; and Spearman rank correlation coefficients. All beverages were acidic; the titratable acidity of energy drinks was greater than that of regular and diet sodas that were greater than that of 100% juices and sports drinks (P < .05). Enamel lesion depths after beverage exposures were greatest for Gatorade, followed by those for Red Bull and Coke that were greater than those for Diet Coke and 100% apple juice (P < .05). Root lesion depths were greatest for Gatorade, followed by Red Bull, Coke, 100% apple juice, and Diet Coke (P < .05). Lesion depths were not associated with pH or titratable acidity. Beverages popular in the United States can produce dental erosion.

Erosive tooth wear - a multifactorial condition of growing concern and increasing knowledge.

Dental erosion is often described solely as a surface phenomenon, unlike caries where it has been established that the destructive effects involve both the surface and the subsurface region. However, besides removal and softening of the surface, erosion may show dissolution of mineral underneath the surface. There is some evidence that the presence of this condition is growing steadily. Hence, erosive tooth wear is becoming increasingly significant in the management of the long-term health of the dentition. What is considered as an acceptable amount of wear is dependent on the anticipated lifespan of the dentition and, therefore, is different for deciduous compared to permanent teeth. However, erosive damage to the permanent teeth occurring in childhood may compromise the growing child's dentition for their entire lifetime and may require repeated and increasingly complex and expensive restoration. Therefore, it is important that diagnosis of the tooth wear process in children and adults is made early and adequate preventive measures are undertaken. These measures can only be initiated when the risk factors are known and interactions between them are present. A scheme is proposed which allows the possible risk factors and their relation to each other to be examined.

Solubility properties of human tooth mineral and pathogenesis of dental caries.

Dental research over the last century has advanced our understanding of the etiology and pathogenesis of caries lesions. Increasing knowledge of the dynamic demineralization/remineralization processes has led to the current consensus that bacteria-mediated tooth destruction can be arrested or even to some degree reversed by adopting fluoride and other preventive measures without using restorative materials. Our experimental approach provided new insight into the stoichiometries and solubility properties of human enamel and dentin mineral. The determination of the solubility product constant on the basis of the stoichiometric model (Ca)5.x(Mg)q(Na)u(HPO4)v(CO3)w(PO4)3.y(OH,F)1.z, verifies the difference in their solubility properties, supporting the phase transformation between tooth mineral and calcium phosphates in a wide range of fluid compositions as found in the oral environment. Further refinement of the stoichiometry and solubility parameters is essential to assess quantitatively the driving force for de- and remineralization of enamel and dentin in the oral fluid environment. Prediction of the effects of a combination of inhibitors and accelerator(s) on remineralization kinetics is also required. In order to develop devices efficient for optimizing remineralization in the lesion body, it is a critical question how, and to what extent, fluoride can compensate for the activity of any inhibitors in the mineralizing media.

Demineralization in enamel and hydroxyapatite aggregates at increasing ionic strengths.

Subsurface demineralization of dental enamel is a curious feature of both in vivo and in vitro lesion formation. Numerous explanations have been proposed to explain this. One general hypothesis is that subsurface demineralization in enamel and synthetic hydroxyapatite (HAP) aggregates may result from the phenomenon of coupled diffusion between the inward transport of acid and the outward transport of dissolution products. The aim of this study was to test the validity of this explanation. Inert electrolyte was added to demineralizing solutions in order to reduce electrostatic coupling between the diffusive flows that occur during lesion formation. Scanning microradiography (SMR) was used to examine surface layer formation, and to measure the rate of mineral loss at increasing ionic strengths. It was found that surface layer formation was significantly reduced as the concentration of inert electrolyte was increased. Further, the rate of mineral loss from the developing lesion increased as the concentration of inert electrolyte (and therefore the ionic strength) in the demineralizing solution increased. It is concluded that electrostatic coupling between counter diffusing acid and dissolution products during lesion formation can significantly influence the mineral concentration within the surface layer.

Assessment of enamel erosion and protective effect of salivary pellicle by surface roughness analysis and scanning electron microscopy.

PURPOSE: To assess dental erosion caused by 0.1% and 1.0% citric acid in vitro and to estimate the protective influence of experimentally formed salivary pellicle. MATERIALS AND METHODS: Bovine enamel slabs (n = 80) were polished and embedded in epoxy resin. For the formation of pellicle layer 40 specimens were immersed for 24 h in pooled human saliva. Erosion was caused by immersion in citric acid solution for 1, 5, 10 and 30 min. Erosive alterations on the pellicle-covered and non-covered enamel specimens were scored as a change (delta) of surface roughness parameters Ra, Rt and RzDIN using contact profilometer and observed in scanning electron microscope. RESULTS: Profilometric analysis of eroded enamel specimens emphasized the aggressiveness of even low concentrated citric acid with a short period of challenge. The change of roughness parameters after 1-min immersion in 0.1% citric acid were 16.4, 182.6 and 132.2 nm for deltaRa, deltaRt and deltaRzDIN, respectively, and 54.8, 516.6 and 258.2 nm after 1-min immersion in 1.0% citric acid. Changes of the surface roughness were dependent on the exposure time and concentration of acidic solution. Pellicle layer significantly reduced the extent of erosive destruction, which was additionally documented on SEM-micrographs. Residual pellicle-like structures were detected after 5 min of immersion in 0.1% citric acid. However, there were no significant differences in pellicle-covered and non-covered enamel slabs measured profilometrically for 1.0% citric acid with 10 min and 30 min exposure time. CONCLUSION: The findings confirm the property of pellicle layer to resist against erosive influence of organic acids, which is, however, limited by duration of acidic treatment and concentration of erosive agent.

The effects of the solubility of artificial fissures on plaque pH.

Dissolution of the fissure walls may buffer acids formed in plaque and thus prevent the penetration of acids into the fissure. To test this, five volunteers wore dentin, enamel, and polyacrylate specimens with narrow grooves for 7 days to accumulate plaque. Temporal (pre- and post-glucose) and spatial (0-0.7 mm) pH profiles were recorded in the grooves in a flow-through reactor with pH microsensors. Mineral loss was assessed by transverse microradiography. We observed that resting pH did not differ among substrata. The median pH 1 hr post-glucose at the bottoms of dentin, enamel, and polyacrylate grooves was 6.7, 6.2, and 5.7, respectively (p < 0.01). On subject level, lesions formed in dentin correlated with pH changes in polyacrylate, where no buffering of acids due to mineral dissolution occurred. We conclude that fluoride-deficient tissue at the bottom of a fissure is at increased risk for caries, if acids are not buffered near the entrance to the fissure.