Effect of calcium phosphate addition to fluoride containing dental varnishes on enamel demineralization

Research progress of biomimetic materials in oral medicine

Biomimetic materials are able to mimic the structure and functional properties of native tissues especially natural oral tissues. They have attracted growing attention for their potential to achieve configurable and functional reconstruction in oral medicine. Though tremendous progress has been made regarding biomimetic materials, significant challenges still remain in terms of controversy on the mechanism of tooth tissue regeneration, lack of options for manufacturing such materials and insufficiency of in vivo experimental tests in related fields. In this review, the biomimetic materials used in oral medicine are summarized systematically, including tooth defect, tooth loss, periodontal diseases and maxillofacial bone defect. Various theoretical foundations of biomimetic materials research are reviewed, introducing the current and pertinent results. The benefits and limitations of these materials are summed up at the same time. Finally, challenges and potential of this field are discussed. This review provides the framework and support for further research in addition to giving a generally novel and fundamental basis for the utilization of biomimetic materials in the future.

Remineralization effect of NaF, NaF with TCP, NaF with CPP-ACP and NaF with CXP varnishes on newly erupted first permanent molars: A randomized controlled trial

INTRODUCTION

The aim of this study was to evaluate the remineralization effect of NaF, NaF with TCP, NaF with CPP-ACP and NaF with CXP varnishes on newly erupted first permanent molars using laser fluorescence (LF) method. The study was a randomized, double-blind, controlled trial with four parallel groups.

METHODS

The study was carried out in 48 high caries-risk children (DMFS >8), aged 6-7 years with newly erupted permanent first molars (initial lesion with 13 < LF value<30). A total of 140 teeth were divided randomly into four groups (n = 35): G1.Duraphat Varnish containing 5% NaF, G2. Clinpro™ White Varnish containing 5% NaF with TCP, G3.Embrace™ Varnish containing 5% NaF with CXP, G4. MI Varnish containing 5% NaF with CPP-ACP. All dental treatments of the patients were completed before the varnish application. The varnishes were applied to the targeted teeth at baseline, 1 and 3 months. Patients were called for follow-up appointments at 1, 3 and 6 months, and LF scanning was used to monitor mineralization changes. Data were analysed statistically by Wilcoxon signed-rank and Mann-Whitney U-tests.

RESULTS

In total, 40 children (122 teeth) completed the trial. At the end of 6 months, the amount of reduction in LF values (indicating remineralization) are as follows: NaF with CXP(6.87 ± 4.32) < NaF with TCP(7.36 ± 7.05) < NaF(7.40 ± 7.03) < NaF with CPP-ACP(8.33 ± 4.90). All of the varnishes resulted in significant decrease in LF measurements and there was no significant difference between control (NaF alone) group and other groups. Only MI varnish had a significantly greater remineralization effect than Embrace™ Varnish (p < 0.05).

CONCLUSION

As a non-invasive approach, CPP-ACP, TCP and CXP containing NaF varnishes have the potential to remineralize initial caries lesions on permanent first molars in high caries-risk children.

Analysis of Dental Enamel Remineralization: A Systematic Review of Technique Comparisons

The demineralization process conditions the structure of the enamel and begins with a superficial decalcification procedure that makes the enamel surface porous and gives it a chalky appearance. White spot lesions (WSLs) are the first clinical sign that can be appreciated before caries evolves into cavitated lesions. The years of research have led to the testing of several remineralization techniques. This study's objective is to investigate and assess the various methods for remineralizing enamel. The dental enamel remineralization techniques have been evaluated. A literature search on PubMed, Scopus, and Web of Science was performed. After screening, identification, and eligibility processes 17 papers were selected for the qualitative analysis. This systematic review identified several materials that, whether used singly or in combination, can be effective in the process of remineralizing enamel. All methods have a potential for remineralization when they come into contact with tooth enamel surfaces that have early-stage caries (white spot lesions). From the studies conducted in the test, all of the substances used to which fluoride has been added contribute to remineralization. It is believed that by developing and researching new remineralization techniques, this process might develop even more successfully.

Effect of enamel surface coating on staining capability due to iron containing supplements on primary teeth: An in vitro study

Background

Iron supplements prescribed to anemic children may results in teeth staining. Possible methods for preventing staining of primary teeth following exposure to iron supplements are need of an hour.

Aim

This study was conducted with the aim to assess effect of enamel surface coating on staining capability of iron containing supplements in primary teeth.

Settings and Design

This is an in vitro Experimental study.

Methods

Hundred and forty-four primary incisors with intact crowns were sequentially numbered and randomly divided into four main groups of 36 samples receiving different enamel surface coating such as no surface coating, MI fluoride varnish™, GC G-coat Plus™ and GC-Equia®-forte-coat. Each group was subdivided into two groups, namely A (sound teeth) and B (artificially demineralized teeth). All the samples were immersed in 250 ml artificial saliva containing 10 ml of iron supplement to make the iron concentration 100 mg. The shade of the teeth was measured at baseline and at 90 days, using VITA Easy shade® V digital spectrophotometer. The data was statistically analyzed using the Kruskal-Wallis test and Mann-Whitney U test. Descriptive and inferential statistical analyses was made via SPSS 23.

Results

Overall color change was found to be significantly less at the end of 90th day in sound samples when GC-Equia®-forte-coat was used as an enamel surface coating with pvalue of 0.017. In demineralized samples the overall color change was least at the end of 90th day when MI Varnish™ used as an enamel surface coating with P = 0.042.

Conclusions

GC-Equia®-forte-coat, MI Varnish™ and GC-G-coat-plus™ can be used as a preventive or a precautionary measure to minimizes the staining of teeth. The amount of color change at the end of 90 days with GC-Equia®-forte-coat was least followed by MI varnish™, GC G coat Plus™ and control group.

Comparative evaluation of prevention of demineralization of artificial enamel caries treated with two fluoride varnishes and 38% SDF in primary teeth: an in vitro study

BACKGROUND

This study aimed to compare the effect of Clinpro™ White varnish containing 5% sodium fluoride (NaF) and functionalized tricalcium phosphate, MI varnish containing 5% NaF and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), and 38% Silver diamine fluoride (SDF) in preventing demineralization of treated white spot lesions (WSLs) in enamel of primary teeth.

METHODS

Forty-eight primary molars with artificial WSLs were allocated into four groups as follows: Group 1: Clinpro white varnish, Group 2: MI varnish, Group 3: SDF, and Group 4: control (no treatment). The three surface treatments were applied for 24 h and then enamel specimens were subjected to pH cycling. Thereafter, the mineral content of specimens was evaluated by Energy Dispersive X-ray Spectrometer and the lesion depth was assessed via Polarized Light Microscope. One-way ANOVA followed by Tukey's post hoc test were used at p ≤ 0.05 to identify significant differences.

RESULTS

Insignificant difference in mineral content was observed among treatment groups. Treatment groups exhibited significantly higher mineral content compared to control except for Fluoride (F). MI varnish showed the highest mean calcium (Ca) ion content (66.57 ± 0.63), and Ca/P (2.19 ± 0.11), followed by Clinpro white varnish, and SDF. MI varnish also displayed the highest phosphate (P) ion content (31.46 ± 0.56), followed by SDF (30.93 ± 1.02), and Clinpro white varnish (30.53 ± 2.19). Fluoride content was highest in SDF (0.93 ± 1.18), followed by MI (0.89 ± 0.34) and Clinpro (0.66 ± 0.68) varnishes. Significant difference in lesion depth was observed among all groups (p < 0.001). The lowest mean lesion depth (µm) was found in MI varnish (226.23 ± 44.25) which was significantly lower than Clinpro white varnish (285.43 ± 44.70), SDF (293.32 ± 46.82), and control (576.69 ± 42.66). Insignificant difference in lesion depth was found between SDF and Clinpro varnish.

CONCLUSIONS

In primary teeth, WSLs treated with MI varnish displayed better resistance to demineralization compared to WSLs treated with Clinpro white varnish and SDF.

Fluoride varnish, ozone and octenidine reduce the incidence of white spot lesions and caries during orthodontic treatment: randomized controlled trial

This randomized, parallel, controlled trial assessed the effect of fluoride varnish, ozone and octenidine on white spot lesions (WSLs) and caries during orthodontic treatment. Patients were enrolled between 1st September 2017 and 31st August 2020 at initiation of orthodontic treatment in Department of Interdisciplinary Dentistry Pomeranian Medical University in Szczecin, Poland. All participants were randomly assigned to four study and one control groups using number random generator. However, investigators were not blinded due to the nature of the study. Groups I, II, III, IV had professional cleaning and varnishing (5% NaF) every 4 weeks. Groups II and IV had in-office ozone therapy before varnishing, groups III and IV received domestic octenidine mouthrinse. Group K had no professional hygienic or prophylactic procedures. WSLs were assessed at T0 and then every 4 weeks (T1-T4) and caries-at T0 and T4. The specific objective was to assess the influence of fluoride varnish, ozone and octenidine on the incidence of white spot lesions and caries during orthodontic treatment. The primary outcome of this report was the highest number of WSLs in group K and the lowest percentage of patients with WSLs in group IV. Each group comprised 30 randomized participants; they were all analyzed. No WSLs were found at T0, but they were stated in all groups at T4. The numbers of patients with WSLs significantly increased between T0-T4 in groups I and K. Group IV had the lowest percentage of patients with WSLs in T1-T4. WSLs in group IV were found no earlier than at T2. Group K had the highest percentage of WSLs at T4: 26%. At T0 all the groups had DMFs above 0 with a significant increase at T4. No side effects of the introduced prophylaxis were observed in any group. Caries is an important problem of fixed orthodontic treatment. Even an extremely intensive prophylaxis could not completely prevent WSLs and caries. Simultaneous application of fluoride varnish, ozone gas exposure and octenidine appears to have a beneficial effect in limiting the development of WSLs.Trial registration: NCT04992481.

Effect of Fluoride-based Varnishes with Added Calcium and Phosphate on Microhardness of Esthetic Restorative Materials: An In Vitro Study

Background and objectives

Fluoride varnishes are being used to prevent caries in children. The high concentration of fluoride in varnishes apart from caries prevention may cause changes in surface properties of esthetic restorations. The study aims to evaluate and compare the effect of four commercially available fluoride varnishes with added calcium and phosphate on microhardness of three esthetic materials namely conventional GIC (Fuji II), high viscosity GIC (Fuji IX), and nanocomposite (Filtek Z350).

Materials and methods

A total of 28 pellets were made of each material and stored in distilled water at 37 °C for 48 hours. The microhardness of the pellets was tested which served as a baseline. These were then randomly divided into four subgroups. In one subgroup Profluorid varnish was applied, second subgroup MI varnish was applied, third subgroup Embrace varnish was applied, and in the fourth subgroup Enamel Pro varnish was applied as per protocol. Thereafter, all the pellets were subjected to microhardness testing (load = 100 g for 15 seconds).

Results

The fluoride varnishes increased the microhardness of conventional GIC (Fuji II) whereas in case of high viscosity GIC (Fuji IX) the application of varnishes reduced the microhardness. In case of nanocomposite restorative material (Filtek Z350) only Profluorid varnish increased its microhardness.

Conclusion

Fluoride varnish and calcium-phosphate containing fluoride varnish effect on the microhardness of restorative material is material dependent. So, the choice of fluoride varnish with or without proprietary additives depends on the nature and composition of the restorative material.

How to cite this article

Shetty RS, Bhat SS, HK Sundeep, et al. Effect of Fluoride-based Varnishes with Added Calcium and Phosphate on Microhardness of Esthetic Restorative Materials: An In Vitro Study. Int J Clin Pediatr Dent 2022;15(2):187-193.

The Application of Chitosan Nanostructures in Stomatology

Chitosan (CS) is a natural polymer with a positive charge, a deacetylated derivative of chitin. Chitosan nanostructures (nano-CS) have received increasing interest due to their potential applications and remarkable properties. They offer advantages in stomatology due to their excellent biocompatibility, their antibacterial properties, and their biodegradability. Nano-CSs can be applied as drug carriers for soft tissue diseases, bone tissue engineering and dental hard tissue remineralization; furthermore, they have been used in endodontics due to their antibacterial properties; and, finally, nano-CS can improve the adhesion and mechanical properties of dental-restorative materials due to their physical blend and chemical combinations. In this review, recent developments in the application of nano-CS for stomatology are summarized, with an emphasis on nano-CS’s performance characteristics in different application fields. Moreover, the challenges posed by and the future trends in its application are assessed.

Effects of Fluoride and Calcium Phosphate-Based Varnishes in Children at High Risk of Tooth Decay: A Randomized Clinical Trial

BACKGROUND

The aim of this study was to investigate the effect of the application of two varnishes-MI Varnish (5% sodium fluoride with CPP-ACP) and Clinpro White Varnish (5% sodium fluoride with fTCP)-applied every three months in children with high caries risk for 12 months on plaque indexes, salivary pH, salivary lactic acid and chemical elements concentrations.

METHODS

We included 58 children aged 4-12 years, assigned to control (placebo), Clinpro and MI groups. Baseline and three-month saliva samples were taken. We assessed changes in pH, lactic acid concentrations and chemical elements in saliva.

RESULTS

At 12 months, all groups showed a nonsignificant increase in pH levels and a reduction in lactic acid, which was greatest in the placebo group. There was a significant reduction in ²⁴Mg (p = <0.001), ³¹P (p = 0.033) and ⁶⁶Zn (p = 0.005) levels in the placebo group (p ≤ 0.05), but not in the other elements studied: ²³Na, ²⁷Al, ³⁹K, ⁴⁴Ca, ⁵²Cr, ⁵⁵Mn, ⁵⁷Fe, ⁵⁹Co, ⁶³Cu, ⁷⁵As, ¹¹¹Cd, ¹³⁷Ba, ²⁰⁸Pb and ¹⁹F.

CONCLUSIONS

Neither pH, lactic acid concentrations or most salivary chemical elements were useful in defining patients at high risk of caries or in monitoring the effect of MI Varnish and Clinpro White Varnish after three-month application for 12 months. However, the appearance of new cavities was stopped, and the hygiene index improved, probably due to hygienic and dietary measures and the use of fluoridated toothpaste.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN13681286.

Biomimetic mineralisation systems for in situ enamel restoration inspired by amelogenesis

Caries and dental erosion are common oral diseases. Traditional treatments involve the mechanical removal of decay and filling but these methods are not suitable for cases involving large-scale enamel erosion, such as hypoplasia. To develop a noninvasive treatment, promoting remineralisation in the early stage of caries is of considerable clinical significance. Therefore, biomimetic mineralisation is an ideal approach for restoring enamel. Biomimetic mineralisation forms a new mineral layer that is tightly attached to the surface of the enamel. This review details the state-of-art achievements on the application of amelogenin and non-amelogenin, amorphous calcium phosphate, ions flow and other techniques in the biomimetic mineralisation of enamel. The ultimate goal of this review was to shed light on the requirements for enamel biomineralisation. Hence, herein, we summarise two strategies of biological minimisation systems for in situ enamel restoration inspired by amelogenesis that have been developed in recent years and compare their advantages and disadvantages.

Manifestation and Mechanisms of Abnormal Mineralization in Teeth

Tooth biomineralization is a dynamic and complicated process influenced by local and systemic factors. Abnormal mineralization in teeth occurs when factors related to physiologic mineralization are altered during tooth formation and after tooth maturation, resulting in microscopic and macroscopic manifestations. The present Review provides timely information on the mechanisms and structural alterations of different forms of pathological tooth mineralization. A comprehensive study of these alterations benefits diagnosis and biomimetic treatment of abnormal mineralization in patients.

Application of β-Tricalcium Phosphate in Adhesive Dentin Bonding

The study aimed at synthesizing β-tricalcium phosphate (β-TCP) nanoparticles and comparing the mechanical properties and dentin interaction of two adhesives: experimental adhesive (EA) and EA with 5 wt.% β-TCP nanoparticles (β-TCP-5%). These filler nanoparticles were synthesized and then characterized with scanning electron microscopy (SEM) and micro-Raman spectroscopy. The β-TCP nanoparticles were incorporated in the adhesives to form two groups: gp-1: EA (control) and gp-2: β-TCP-5%. These adhesives were characterized by SEM, energy-dispersive X-ray (EDX) spectroscopy and were also assessed for their micro-tensile bond strength (μTBS) with (TC) and without thermocycling (NTC). Fourier Transform Infrared (FTIR) spectroscopy was performed to evaluate the degree of conversion (DC) of two adhesives. The β-TCP filler was seen as irregularly shaped agglomerates on SEM. The micro-Raman spectra revealed characteristic peaks associated with β-TCP nanoparticles. Both adhesives presented suitable dentin interaction, which was demonstrated by the formation of resin tags of variable depths. The EDX analysis verified the existence of calcium (Ca) and phosphate (P) for the β-TCP-5% group. The greatest μTBS values were shown by β-TCP-5% group samples when they were non-thermocycled (NTC) (β-TCP-5%-NTC: 34.11 ± 3.46) followed by the thermocycled (TC) samples of the same group (β-TCP-5%-TC: 30.38 ± 3.66), compared with the EA group. Although the DC presented by β-TCP-5% group was comparable to the EA group, it was still lower. The addition of β-TCP nanoparticles in the adhesive improved its μTBS and resulted in a suitable dentin interaction, seen in the form of hybrid layer and resin tag formation. Nonetheless, a decreased DC was observed for the β-TCP-5% adhesive. Future studies probing the effect of different filler concentrations on various properties of the adhesive are warranted.

Physicochemical Characteristics of Arginine Enriched NaF Varnish: An In Vitro Study

The in vitro study objectives were to investigate the effect of arginine (Arg) incorporation in a 5% sodium fluoride (NaF) varnish on its physical and chemical properties including F/Arg release. Six experimental formulations were prepared with L-arginine (L-Arg) and L-arginine monohydrochloride at 2%, 4%, and 8% w/v in a 5% NaF varnish, which served as a control. The varnishes were subjected to assessments for adhesion, viscosity, and NaF extraction. Molecular dynamics were simulated to identify post-dynamics total energy for NaF=Arg/Arg>NaF/Arg<NaF concentrations. The Arg/F varnish release profiles were determined in polyacrylic lactate buffer (pH-4.5; 7 days) and artificial saliva (pH-7; 1 h, 24 h, and 12 weeks). Incorporation of L-Arg in NaF varnish significantly influences physical properties ameliorating retention (p < 0.001). L-Arg in NaF varnish institutes the Arg-F complex. Molecular dynamics suggests that NaF>Arg concentration denotes the stabilized environment compared to NaF<Arg (p < 0.001). The 2% Arg-NaF exhibits periodic perennial Arg/F release and shows significantly higher integrated mean F release than NaF (p < 0.001). Incorporating 2% L-arginine in 5% NaF varnish improves its physical properties and renders a stable matrix with enduring higher F/Arg release than control.

Fluoride release and remineralizing potential of varnishes in early caries lesions in primary teeth

This study evaluated the fluoride (F) release and remineralizing potential of varnishes containing sodium fluoride (5% NaF), 5% NaF with CPP-ACP and 5% NaF with TCP in early caries lesions in primary teeth. To determine the F release at 1, 4, 6, 24, 72, and 168 hr, strips were covered with the varnishes and immersed in purified water (n = 7). The varnishes and purified water (negative control) were applied on enamel blocks with early caries lesions (n = 16). Enamel blocks were stored in artificial saliva and submitted to a pH-cycling. The area of enamel hardness loss (ΔS) was analyzed by microhardness, lesion depth by polarized light microscopy (PLM) and the chemical analysis by Energy-dispersive X-ray spectroscopy. Data were submitted to Shapiro-Wilk, two-way and one-way ANOVA, Tukey and paired t-tests (α = 5%). All varnishes released F, but 5% NaF with CPP-ACP had the highest release at 4, 6, 24, and 72 hr (p < .05) followed by 5% NaF with TCP and 5% NaF. No significant difference in ΔS was observed among varnishes (5% NaF = 4,098.4 ± 1,407.9; 5% NaF with CPP-ACP = 4,164.0 ± 1,019.3; 5% NaF with TCP = 4,183.2 ± 1,527.2; p = .999), but all of them differed from the negative control group (6,757.8 ± 2,274.7; p < .001). Lesion depth was lower in varnishes groups compared to negative control (% reduction: 5% NaF = 41.8%, 5% NaF with CPP-ACP = 38.8%, and 5% NaF with TCP = 36.3%; p < .001). Similar Ca, P, and Ca/P ratio percentages among groups and F was not detected after the treatments. All fluoride varnishes showed potential to enhance remineralization of early caries lesions in primary teeth.

Remineralising effects of fluoride varnishes containing calcium phosphate on artificial root caries lesions with adjunctive application of proanthocyanidin

OBJECTIVES

To evaluate the remineralising effects of fluoride (F) varnishes containing bioavailable calcium-phosphate compound (Ca-P) based remineralisation systems and 5000 ppm F toothpaste (FTP) on root caries lesions (RCLs) and the potential effects of proanthocyanidin (PA) for the treatments of RCLs when used as an adjunct to F regimens.

METHODS

Demineralised root dentine and a pH-cycling model were used to mimic RCLs and the oral environment. Remineralising effects of MI Varnish^TM (MIV) containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and Clinpro™ White Varnish (CPWV) containing tri-calcium phosphate (TCP) along with FTP and PA were evaluated regarding the birefringence, elemental composition, mechanical properties and mineral density of remineralised dentine with Duraphat^TM as a comparison.

RESULTS

MIV, CPWV and Duraphat^TM promoted the incorporation of F into RCLs and increased mineral density but did not change microhardness of root dentine significantly. Surface microhardness increased significantly when MIV or CPWV was used with 5000 ppm FTP. Application of PA with F regimens significantly increased subsurface mineral density. When PA was applied with MIV or CPWV along with FTP, the highest ion uptake and relative mineral gain (%ΔZ) was achieved, and significant increase of microhardness was up to 30 μm depth. Generally, MIV was associated with a higher mineral content gain than CPWV.

SIGNIFICANCE

Treatment of carious root surfaces remains challenging due to the complex pathological processes and difficulty in restoring the highly organised structure of root dentine. Treatment strategies targeting both remineralisation and preservation of the dentinal organic matrix have the potential to improve the fluoride-mediated remineralisation approaches.

Clinical Efficacy of Different Dentin Desensitizers

CLINICAL RELEVANCE

Teethmate Desensitizer, Clinpro White Varnish, Shield Force Plus, and Gluma could be recommended for treating dentin hypersensitivity in terms of clinical efficacy.

SUMMARY

Objective: The aim of this study was to evaluate the clinical efficacy of widely used dentindesensitizing agents (DDAs) (Teethmate Desensitizer, Clinpro White Varnish, Shield Force Plus, and Gluma) in the treatment of dentin hypersensitivity (DH) according to different evaluation parameters over a four-week follow-up period.Methods and Materials: This study was a randomized, single-center, controlled, parallel group study involving 144 teeth in 40 subjects. The baseline DH levels of the subjects were determined using different evaluation parameters. Daily life hypersensitivity and evaporative air stimulus hypersensitivity scores were recorded using a visual analog scale (VAS), and tactile hypersensitivity scores were recorded using a Yeaple probe and measured in grams and on the VAS. Subjects who experienced evaporative air stimulus DH (30-80 mm on the VAS) and tactile hypersensitivity (10-50 g with the Yeaple probe) were included in the study. After application of the DDAs, these evaluation parameters were recorded throughout the follow-up period (immediately after application and at one day and two and four weeks post-application).Results: All four DDAs demonstrated clinical dentin-desensitizing effects throughout the follow-up period according to evaporative air hypersensitivity, tactile sensitivity (g-VAS), and daily life hypersensitivity scores (p<0.05). Only Clinpro White Varnish had tactile sensitivity (g) scores that were similar at baseline and the one-day follow-up (p>0.05). A comparison of DH-reducing effects among the DDAs revealed that they yielded different results immediately after application and at the one-day follow-up time point, depending on which evaluation parameter was used. However, all DDAs showed similar DH-reducing effects at the two- and four-week follow-up time points.Conclusions: Teethmate Desensitizer, Clinpro White Varnish, Shield Force Plus, and Gluma DH showed clinical efficacy for four weeks. DDAs may produce inconsistent clinical evaluation scores not only across different evaluation parameters but also between early and later follow-up time points.

Comparative Evaluation of the Remineralizing Efficacy of Fluoride Varnish and its Combination Varnishes on White Spot Lesions in Children with ECC: A Randomized Clinical Trial

Aim

The aim of the study was to assess the remineralizing efficacy of fluoride and its combination varnishes on white spot lesion (WSL) in children with early childhood caries (ECC).

Materials and methods

Sixty children with active WSL on primary maxillary anterior teeth were randomly selected. At baseline, the WSL activity was evaluated using ICDAS II [lesion activity assessment (LAA)] and its dimensions through photographic method. They were allocated to group I (GI) (5% NaF), group II (GII) [5% NaF with amorphous calcium phosphate (ACP)], and group III (GIII) [5% NaF with casein phosphopeptides - amorphous calcium phosphate (CPP -ACP)]. First, oral hygiene instructions and diet counseling were given followed by application of fluoride varnishes in their respective groups. The same parameters were recorded at follow-up of 2, 4, 12, and 24 weeks intervals. Data were collected and subjected to statistical analysis using Friedman Chi-square and Mann-Whitney tests.

Results

Overall, the active WSL changed to inactive over a period of 24 weeks in GI was 90%, GII was 95%, and 100% in GIII. There was a significant reduction in dimension of WSL in GI from 4.119 to 2.525 (p = 0.0001). Likewise, there was a significant reduction in dimension of WSL in GII and GIII from 4.586 to 3.258 and 4.696 to 1.2155, respectively (p = 0.0001, p = 0.0001). Comparatively, group III (MI varnish) showed statistically significant reduction in the dimension of WSL from baseline to 24 weeks (p = 0.002). But the results were statistically insignificant with change of active lesions to its inactivity (p = 0.349).

Conclusion

Fluoride varnish with CPP-ACP was found to be an effective preventive strategy in reversing WSL in children with ECC.

Clinical relevance

These combination varnishes could prove to be a promising preventive measure for pediatric dentists in reversing white spot lesions of ECC.

Clinical trial registry

NCT03360266.

How to cite this article

Radha S, Kayalvizhi G, Adimoulame S, et al. Comparative Evaluation of the Remineralizing Efficacy of Fluoride Varnish and its Combination Varnishes on White Spot Lesions in Children with ECC: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2020;13(4):311-317.

A differentiated approach to the dental caries prevention in children with different levels of caries risk

Relevance. Prevention of caries of the first permanent molars is one of the most relevant problems in pediatricdentistry.

Purpose – to develop an algorithm for prevention of first permanent molars caries in children with differentlevels of caries risk.

Materials and methods. The article presents the results of the implementation of the algorithm for prevention of first permanent molars caries in children with different levels of caries risk. This algorithm includes a comprehensive assessment of the values of indices dmft, DMFT, OHI-S, and the patient's health group is also taken into account. The study involved 253 children aged 6-7 years divided into 4 groups: 3 groups of children depending on the health group and the control group. 3 subgroups were identified in each group – with a low, medium, and high caries risk. We developed preventive measures schemes were for children of each group including training in oral hygiene; controlled and home toothbrushing using fluoride-containing toothpastes; applications of varnishes containing fluoride, calcium, phosphates from 2 to 3 times a year; fissure sealing of the first permanent molars. We carried out these activities were for 24 months, and then evaluated theirs effectiveness. Children in the control group were trained in oral hygiene. The clinical effectiveness of medical prophylaxis was evaluated by changes in the above clinical indicators.

Results. In group of children with medium caries risk the increase in caries was 0.09, and the reduction in caries was 89.65%. In children with a low and high caries risk no increase in caries was observed; the reduction in the intensity of caries was 100%. A significant decrease in OHI-S oral hygiene index values was noted in all groups (p < 0.05). We noted high preventive efficacy of fissures sealing in the first permanent molars. No occlusal surface caries developed in sealed fissures.

Conclusions. The application of the proposed preventive schemes in patients demonstrates high efficacy of fluoride and calcium-containing varnishes and sealing the fissures of the first permanent molars. 

Remineralization and fluoride uptake of white spot lesions under dental varnishes

INTRODUCTION

The aim of this study was to evaluate white spot lesion (WSL) remineralization and fluoride uptake by the application of fluoride varnishes directly onto artificial WSLs in vitro.

METHODS

MI varnish containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and 2.26% fluoride and Duraphat varnish containing 2.26% fluoride (no added calcium) were compared with a placebo varnish (no added calcium or fluoride). Two WSLs were prepared in enamel slabs and varnish applied to cover one of the two lesions. Each slab was immersed in artificial saliva for 14 days at 37°C. Mineral content was determined using transverse microradiography and fluoride uptake using electron probe microanalysis. The data were statistically analysed using a linear mixed model.

RESULTS

Both MI and Duraphat varnishes significantly remineralized the covered and uncovered WSLs when compared with the placebo varnish (P < 0.001). The WSLs covered with varnish showed greater remineralization than those uncovered. MI varnish produced the highest level of remineralization and significantly greater fluoride uptake (0.44 ± 0.08 wt%) compared with Duraphat (0.24 ± 0.03 wt%) and the placebo varnish (0.06 ± 0.05 wt%).

CONCLUSION

Varnish containing fluoride and CPP-ACP was superior to varnish containing fluoride alone in promoting WSL remineralization and fluoride uptake.

In Vitro Comparison of Fluoride, Magnesium, and Calcium Phosphate Materials on Prevention of White Spot Lesions around Orthodontic Brackets

One common negative side effect of orthodontic treatment with fixed appliances is the development of white spot lesions (WSLs) around brackets. This study is aimed at comparing the efficacy of various oral hygiene practices in preventing enamel demineralization around orthodontic brackets under similar in vitro conditions. The study included 90 extracted bovine incisors, which were randomized into six groups: fluoride toothpaste (FT), nonfluoride toothpaste (NFT), fluoride varnish plus fluoride toothpaste (FV+FT), CPP-ACP varnish plus fluoride toothpaste (CPP-ACP+FT), medical minerals gel plus nonfluoride toothpaste (MMG+NFT), and no intervention (control). All groups were subjected to demineralization and remineralization cycles. Visual appraisals were used to evaluate the changes in the enamel surface appearance at the beginning and end of the experiment. The changes in the demineralization degree were evaluated by measuring the Ca⁺² concentration in the demineralization solution at different time points. The majority of teeth in the CPP-ACP+FT group exhibited no shift in appearance, whereas in the other groups, a slight change in enamel translucency was observed. At all the time points, the Ca⁺² concentration in the demineralization solution in the CPP-ACP+FT group was the least among all other groups. At day 5, MMG+NFT's preventive efficacy was significantly higher than FV+FT's, but at days 10, 15, and 19, their efficacy was similar. However, at all the time points, MMG+NFT's efficacy was significantly higher than that of control, whereas FV+FT's efficacy was decreased at days 10, 15, and 19 and was close to the efficacy of control. To fight WSLs, early diagnosis was of great importance and examination of the tooth surface after air-drying for 5 s was recommended.

Comparative Evaluation of Remineralization Potential of Two Varnishes Containing CPP-ACP and Tricalcium Phosphate: An In Vitro Study

Aim

The aim of this study is to evaluate the remineralization potential of Clinpro XT varnish containing tricalcium phosphate (TCP) and MI varnish containing casein phosphopeptide (casein phosphopeptide–amorphous calcium phosphate, CPP–ACP).

Materials and methods

Thirty premolar teeth were taken and divided into three groups. Samples were sliced mesiodistally into buccal and lingual halves using a diamond disk bur. The buccal halves of the teeth were used for the study. Artificial caries like lesions were produced and evaluated with Diagnodent. The samples in each group were treated with the respective remineralizing agent (except for the control group) at every 24 hours for 7 days and the surfaces were assessed using Diagnodent to record the values after the remineralization procedure. The Diagnodent values obtained were tabulated and statistically analyzed using one-way ANOVA and Tukey's multiple comparison tests.

Results

There was a significant difference between the values calculated before and after remineralization in all the three groups.

Conclusion

The study findings showed that MI varnish containing CPP–ACP had the highest release of fluoride as compared to the Clinpro fluoride releasing varnish.

Clinical significance

MI varnish is a 5% NaF varnish containing CPP–ACP to give an exceptional fluoride varnish that releases more bioavailable fluoride, calcium, and phosphate, hence, can be used successfully in remineralization of early carious lesions. CPP–ACP can be used in the clinical practice for reversing or arresting the early carious lesions.

How to cite this article

Varma V, Hegde KS, et al. Comparative Evaluation of Remineralization Potential of Two Varnishes Containing CPP–ACP and Tricalcium Phosphate: An In Vitro Study. Int J Clin Pediatr Dent 2019;12(3):233–236.

A comparative evaluation of ion release characteristics of three different dental varnishes containing fluoride either with CPP-ACP or bioactive glass

OBJECTIVE

To compare ion release characteristics of three different dental varnishes either containing CPP-ACP and fluoride (CPP-ACPF, MI Varnish GC, Japan), bioactive glass and fluoride (BGAF, Dentsply Sirona USA) or fluoride alone (NUPRO White, Dentsply Sirona USA) using fluoride-Ion Selective Electrode (F-ISE), Inductively Coupled Plasma-Optical Emission Spectroscopy (ICP-OES), X-ray diffraction (XRD), Fourier Transform Infrared Spectroscopy (FTIR), ¹⁹F and ³¹P Magic Angle Spinning-Nuclear Magnetic Resonance (MAS-NMR).

METHODS

A thin layer (0.0674±0.0005g) of each varnish (20×25mm in area) was spread on a roughened glass slide (n=7). They were separately immersed in 10ml Tris buffer (0.06M, pH=7.30), and changed after 1, 2, 4, 6, 24 and 48h. Fluoride-ion concentration at each time using the F-ISE, whilst calcium and phosphate release were investigated using ICP-OES. XRD, FTIR. MAS-NMR analyses were also performed before and after immersion.

RESULTS

The cumulative F-ion release was significantly higher in CPP-ACPF (1.113mmol/g)>BGAF(0.638)>F(0.112) (p<0.001). The cumulative calcium and phosphorus were higher in the CPP-ACPF (0.137mmol/g, 0.119) than BGAF (0.067, 0.015) (p<0.001) respectively. The XRD and ¹⁹F MAS-NMR confirmed the presence of NaF peaks in all cases before immersion. There were less prominent signal and appearance of fluorapatite crystals after immersion. ¹⁹F MAS-NMR revealed CaF₂ formation after immersion in both CPP-ACPF and BGAF. ³¹P MAS-NMR showed phosphate signals in both CPP-ACPF and BGAF before immersion. FTIR failed to show any signs of apatite formation.

SIGNIFICANCE

Both CPP-ACP and bioactive glass enhanced ion release without compromising the bioavailability of fluoride. The CPP-ACPF varnish had the most promising ion release.

Effect of three different compositions of topical fluoride varnishes with and without prior oral prophylaxis on Streptococcus mutans count in biofilm samples of children aged 2-8 years: A randomized controlled trial

BACKGROUND

Various strategies for controlling caries focus on disrupting the interaction between risk factors. Of these, fluoride varnish has been shown to reduce the colony-forming (CFU) units and water-insoluble extracellular polysaccharide amount. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol-containing fluoride varnishes have recently gained importance as caries-protective fluoride varnishes.

AIM

This study aims to assess and compare the reduction in Streptococcus mutans count in biofilm samples after topical application of three different fluoride varnishes and to evaluate the effect of oral prophylaxis prior to fluoride varnish application.

MATERIALS AND METHODS

Sixty healthy children with no active caries, in the age group of 2-8 years, were randomly divided into Group A = fluoride varnish containing CPP-ACP; Group B = fluoride varnish containing xylitol; and Group C = fluoride varnish with 0.9% difluorosilane; further, the groups were divided into two subgroups, namely A1, B1, and C1 with prior oral prophylaxis and A2, B2, and C2 without oral prophylaxis. Plaque samples were collected at baseline, 1^st month, and 3^rd month; cultured; and incubated, and CFU/ml was calculated.

RESULTS

Data were compiled, and CFU/ml was analyzed by independent t-test, paired t-test, and one-way ANOVA. There was no statistical difference between the fluoride groups. Furthermore, no statistically significant difference was seen between the subgroups.

CONCLUSION

Fluoride varnish containing CPP-ACP showed higher reduction in S. mutans count followed by xylitol-containing fluoride varnish and Fluor Protector^®. There was no effect of prior oral prophylaxis on the efficacy of fluoride varnish.

Effects of Fluoride and Calcium Phosphate Materials on Remineralization of Mild and Severe White Spot Lesions

Fixed orthodontic treatments often lead to enamel demineralization and cause white spot lesions (WSLs). The aim of this study was to evaluate the mineralization degree of 2 types of WSLs based on ICDAS index and compare the remineralizing efficacy of 3 oral hygiene practices after 1 month and 3 months. 80 mild demineralized and 80 severe demineralized enamel specimens were randomized into three treatments: fluoride toothpaste (FT), fluoride varnish plus fluoride toothpaste (FV+FT), and CPP-ACP plus fluoride toothpaste (CPP-ACP+FT). Microhardness tester, DIAGNODent Pen 2190, and scanning electron microscope were used to evaluate the changes of mineralization degree. Both qualitative and quantitative indicators suggested that the mild and severe white spot lesions were different in the degree of mineralization. Severe WSLs demineralized much more seriously than mild lesions even after 3 months of treatment. Despite the variation in severity, both lesions had the same variation trend after each measure was applied: FT had weak therapeutic effect, FV + FT and CPP-ACP + FT were effective for remineralization. Their remineralizing efficacy was similar after 1 month, and combined use of CPP-ACP plus F toothpaste was more effective after 3 months. In order to fight WSLs, early diagnosis was of great importance, and examination of the tooth surface after air-dry for 5 seconds was recommended. Also, when WSLs were found, added remineralizing treatments were required.

In Vitro Effect of Innovative Desensitizing Agents on Dentin Tubule Occlusion and Erosive Wear

Purpose:

The purpose of this study was to evaluate the effects of four in-office desensitizing products on dentin tubule occlusion and erosive wear.

Methods:

Dentin hypersensitivity was simulated by EDTA application for five minutes. The specimens were randomly allocated into five groups (n=11), according to treatment: No treatment - Control (C), Duraphat (DUR), Desensibilize Nano P (NP), ClinPro XT Varnish (XTV), and ClinPro White Varnish (CWV). They were then submitted to erosive/abrasive cycling for five days. After EDTA, treatment, and cycling, the specimens were analyzed with an environmental scanning electron microscope (ESEM) to verify the number of opened dentin tubules (ODT) which were counted by using ImageJ software, and with a profilometer to determine the surface curvature/loss. ESEM data were analyzed with two-way repeated measure analysis of variance and Tukey tests. For the profilometer, data were analyzed with Kruskal-Wallis, Tukey, and Mann-Whitney tests.

Results:

After treatment, all groups showed lower ODT than the control, without significant differences between them. After cycling, the only group that showed lower ODT than the control was group XTV; however, it did not significantly differ from the other groups. For the profilometric analysis, there were significant differences in SL between the experimental times after treatment and after cycling for all groups (p&lt;0.05). After cycling, no surface loss was detected in groups DUR and XTV, which presented a significantly different curvature than group NP and the control group, but not from group CWV. Surface loss was detected for the control and groups NP and CWV, without difference among them.

Conclusion:

All desensitizing agents tested presented promising results concerning the obliteration of dentin tubules immediately after treatment. XTV was the only desensitizer capable of preventing the reopening of the tubules after the erosive/abrasive challenges. XTV and DUR presented a protective effect against dentin erosive wear.

Comparison of remineralization by fluoride varnishes with and without casein phosphopeptide amorphous calcium phosphate in primary teeth

OBJECTIVE

To compare MI (5% NaF with 2% CPP-ACP) and Prevident (5% NaF) varnishes in remineralizing caries-like lesions in primary teeth regarding calcium and phosphate enamel content and lesion depth.

MATERIAL AND METHODS

Caries-like lesions were created in 48 primary teeth which were divided into 2 halves; one left untreated (control) and the other half treated with MI or Prevident varnishes. Calcium and phosphate content was assessed using energy dispersive X-ray spectrometer and reduction in lesion depth was assessed using polarized light microscopy. Demineralization and remineralization values in each group were compared using paired t test and percentage change between groups was compared using t test and Mann Whitney U test.

RESULTS

A greater percentage increase of calcium was observed in MI than Prevident specimens (median = 8.97 and 2.67, p < .0001), with greater calcium phosphate ratio percentage increase (median = 28.96 and 7.40) and phosphate percentage reduction (median = 15.5 and 4.51). The mean (SD) percentages reduction in lesion depth in the MI varnish was significantly greater than in Prevident varnish (44.41 (7.12) and 22.73 (9.35), p < .0001).

CONCLUSIONS

MI varnish had better remineralization effect in primary teeth than Prevident varnish in terms of higher mineral content and shallower lesion depth.

Comparison of the Efficacy of Different Fluoride Varnishes on Dentin Remineralization During a Critical pH Exposure Using Quantitative X-Ray Microtomography

OBJECTIVES:

The objective of this in vitro study was to quantify the amount of mineral change in demineralized dentin at pH 5.5 after the application of dental varnishes containing fluoride with casein phosphopeptide-amorphous calcium phosphate, fluoride and bioglass, or fluoride alone.

METHODS AND MATERIALS:

A total of 12 extracted human sound mandibular premolar root samples were coated with an acid-resistant varnish, leaving a 2 × 3 mm window at the outer root surface. These root specimens were then randomly divided into four groups and separately subjected to the demineralizing cycle at a pH of 4.8 for five days to create artificial caries-like lesions in dentin. Subsequently, each sample was imaged using quantitative x-ray microtomography (XMT) at a 15-μm voxel size. Each test group then received one of the following treatments: dental varnish containing casein phosphopeptide-amorphous calcium phosphate and fluoride (CPP-ACP, MI varnish, GC Europe), bioglass and fluoride (BGA, Experimental, Dentsply Sirona), or fluoride alone (NUPRO, Dentsply Sirona), as well as a control group, which received no treatment. These samples were kept in deionized water for 12 hours. The thin layer of varnish was then removed. All samples including the nonvarnish group were subjected to the second demineralizing cycle at pH 5.5 for five days. The final XMT imaging was then carried out following the second demineralizing cycle. XMT scan was also carried out to varnish samples at 25 μm voxel size. The change in mineral concentration in the demineralized teeth was assessed using both qualitative and quantitative image analysis.

RESULTS:

There was an increase in radiopacity in the subtracted images of all varnish groups; a significant increase in mineral content, 12% for the CPP-ACP and fluoride ( p≤0.05 and p≤0.001), 25% BGA ( p≤0.001), and 104% fluoride alone varnish ( p≤0.001). There was an increase in the size of radiolucency in the lesion area with a significant decrease in mineral content in the nonvarnish group, 10% ( p≤0.05 and p≤0.001).

CONCLUSIONS:

There was encouraging evidence of a remineralization effect following the application of dental varnish on dentin and also an observed resistance to demineralization during the acidic challenge in all cases. However, a dental varnish containing fluoride alone appeared to have a much greater effect on dentin remineralization when compared with CPP-ACP with fluoride and bioglass with fluoride.

Synthesis of stabilized hydroxyapatite nanosuspensions for enamel caries remineralization

BACKGROUND

The aim of this study was to develop and evaluate a method for synthesizing a stable suspension of hydroxyapatite nanoparticles and to test its efficacy for remineralizing carious enamel lesions.

METHODS

Hydroxyapatite (HA) particles were synthesized using wet chemistry. Synthesized particles were introduced into a high-pressure homogenizer (5-10 homogenization passes at 15 000 psi) in the presence of different stabilizers. Size and distribution of the resultant particles were determined using dynamic light scattering (DLS). The morphology and composition of the nanoparticles were determined using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). Subsequently, artificial lesions were treated with HA nanosuspension plus artificial saliva or a fluoride-containing artificial saliva only. Visual analysis and quantification of the lesion mineral density before and after remineralization were performed using microcomputed tomography.

RESULTS

DLS and SEM results confirmed the formation of nonagglomerated HA nanoparticles (20-40 nm) following high-pressure homogenization treatment. Quantitative evaluation of the lesions showed that remineralization of the lesion with hydroxyapatite nanosuspension led to a significantly higher level of mineral gain compared to the control group (P < 0.05).

CONCLUSION

High-pressure homogenization is an effective method for facile preparation of a stable suspension of hydroxyapatite nanoparticles. Treatment of artificial lesions with nonagglomerated spherical HA nanoparticles improves the remineralization of enamel lesion.

[Rationale for caries prevention in young adults based on caries resistance rates]

The aim of the study was to evaluate the effectiveness of caries prevention in young adults with different caries resistance rates. Sixty-seven patients aged 18-20 with low (n=32) and high (n=35) dmft were enrolled in the study. Caries prevention efficacy was assessed by laboratory tests: enamel resistance test (ERT), clinical enamel remineralization speed test (CERST), estimation of calcium and inorganic phosphorus in oral fluid. Patients with high caries activity in addition to conventional prevention program received prophylaxis procedure with Clinpro White Varnish (3M ESPE). ERT and CERST were significantly higher in high dmft (>13) subgroup. Statistically significant difference in ERT and CERST was observed between subgroups at 3 and 6 months evaluation after prevention program.

Efficacy of fluoride varnishes for preventing enamel demineralization after interproximal enamel reduction. Qualitative and quantitative evaluation

Objectives

To evaluate quantitatively and qualitatively the changes produced to enamel after interproximal reduction and subjected to demineralization cycles, after applying a fluoride varnish (Profluorid) and a fluoride varnish containing tricalcium phosphate modified by fumaric acid (Clinpro White).

Materials and methods

138 interproximal dental surfaces were divided into six groups: 1) Intact enamel; 2) Intact enamel + demineralization cycles (DC); 3) Interproximal Reduction (IR); 4) IR + DC; 5) IR + Profluorid + DC; 6) IR + Clinpro White + DC. IR was performed with a 0.5 mm cylindrical diamond bur. The weight percentage of calcium (Ca), phosphorous (P) and fluoride (F) were quantified by energy-dispersive X-ray spectrometry (EDX). Samples were examined under scanning electron microscopy (SEM).

Results

The weight percentage of Ca was significantly higher (p<0.05) in Groups 1, 2 and 5 than Groups 4 and 6. No significant differences were detected in the weight percentage of Ca between Group 3 and the other groups (p>0.05). The weight percentage of P was similar among all six groups (p>0.05). F was detected on 65% of Group 6 surfaces. SEM images of Groups 4 and 6 showed signs of demineralization, while Group 5 did not.

Conclusions

Profluorid application acts as a barrier against the demineralization of interproximally reduced enamel.