Study of the efficacy of toothpaste containing casein phosphopeptide in the prevention of dental caries: a randomized controlled trial in 12- to 15-year-old high caries risk children in Bangalore, India

Improving Oral Health with Fluoride-Free Calcium-Phosphate-Based Biomimetic Toothpastes: An Update of the Clinical Evidence

As the demand for clinically effective fluoride-free oral care products for consumers increases, it is important to document which types of toothpastes have been shown in clinical studies to be effective in improving oral health. In this review, we included different indications, i.e., caries prevention, improving periodontal health, reducing dentin hypersensitivity, protecting against dental erosion, and safely improving tooth whitening in defining what constitutes improvement in oral health. While there are several professional and consumer fluoride-containing formulations fortified with calcium-phosphate-based ingredients, this review focuses on fluoride-free toothpastes containing biomimetic calcium-phosphate-based molecules as the primary active ingredients. Several databases were searched, and only clinical trials in human subjects were included; in vitro and animal studies were excluded. There were 62 oral health clinical trials on biomimetic hydroxyapatite (HAP), 57 on casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), 26 on calcium sodium phosphosilicate (CSPS, or so called Bioglass), and 2 on β-tricalcium phosphate (β-TCP). HAP formulations were tested the most in clinical trials for benefits in preventing caries, dentin hypersensitivity, improving periodontal health, and tooth whitening. Based on the current clinical evidence to date, fluoride-free HAP toothpaste formulations are the most versatile of the calcium phosphate active ingredients in toothpastes for improving oral health.

Caries-preventing effect of a hydroxyapatite-toothpaste in adults: a 18-month double-blinded randomized clinical trial

Background

Dental caries is a worldwide challenge for public health. The aim of this 18-month double-blinded, randomized, clinical trial was to compare the caries-preventing effect of a fluoride-free, hydroxyapatite toothpaste (test) and a toothpaste with sodium fluoride (1450 ppm fluoride; positive control) in adults.

Methods

The primary endpoint was the percentage of subjects showing no increase in overall Decayed Missing Filled Surfaces (DMFS) index. The study was designed as non-inferiority trial. Non-inferiority was claimed if the upper limit of the exact one-sided 95% confidence interval for the difference of the primary endpoint DMFS between test and control toothpaste was less than the predefined margin of non-inferiority (Δ ≤ 20%).

Results

In total, 189 adults were included in the intention-to-treat (ITT) analysis; 171 subjects finished the study per protocol (PP). According to the PP analysis, no increase in DMFS index was observed in 89.3% of subjects of the hydroxyapatite group and 87.4% of the subjects of the fluoride group. The hydroxyapatite toothpaste was not statistically inferior to a fluoride toothpaste with regard to the primary endpoint.

Conclusion

Hydroxyapatite was proven to be a safe and efficient anticaries agent in oral care.

Clinical trial registration

NCT04756557.

New Technological Approaches for Dental Caries Treatment: From Liquid Crystalline Systems to Nanocarriers

Dental caries is the most common oral disease, with high prevalence rates in adolescents and low-income and lower-middle-income countries. This disease originates from acid production by bacteria, leading to demineralization of the dental enamel and the formation of cavities. The treatment of caries remains a global challenge and the development of effective drug delivery systems is a potential strategy. In this context, different drug delivery systems have been investigated to remove oral biofilms and remineralize dental enamel. For a successful application of these systems, it is necessary that they remain adhered to the surfaces of the teeth to allow enough time for the removal of biofilms and enamel remineralization, thus, the use of mucoadhesive systems is highly encouraged. Among the systems used for this purpose, liquid crystalline systems, polymer-based nanoparticles, lipid-based nanoparticles, and inorganic nanoparticles have demonstrated great potential for preventing and treating dental caries through their own antimicrobial and remineralization properties or through delivering drugs. Therefore, the present review addresses the main drug delivery systems investigated in the treatment and prevention of dental caries.

Comparative Efficacy of Novel Biomimetic Remineralising Technologies

Biomimetic technologies for the remineralisation of enamel subsurface lesions (ESLs) have been developed and include: fluorocalcium phosphosilicate bioglass (BG/F); casein phosphopeptide-amorphous calcium phosphate (CPP−ACP) and with fluoride (CPP−ACFP); and self-assembling oligopeptide P11-4 (SAP). The aim of this study was to compare the remineralisation of ESLs in vitro using these technologies. Human enamel slabs with ESLs were cut into two half-slabs; one half-slab was untreated (control), and the other half was treated by exposure to one of the four technologies with artificial saliva (AS) or AS alone for 14 days at 37 °C. The technologies were applied to the ESL surface according to the manufacturer’s instructions. At the completion of each treatment, the treated half-slabs and their paired control half-slabs were embedded, sectioned and the mineral content was determined using transverse microradiography. The change in mineral content (remineralisation) between treatments was statistically analysed using one-way ANOVA. The order from highest to lowest remineralisation was CPP−ACFP (52.6 ± 2.6%) > CPP−ACP (43.0 ± 4.9%) > BG/F (13.2 ± 2.5%) > SAP (5.8 ± 1.6%) > AS (2.1 ± 0.5%). Only CPP−ACFP and CPP−ACP produced remineralisation throughout the body of the lesions. All four biomimetic technologies had some effect on the remineralisation of ESLs; however, CPP−ACFP with calcium, phosphate and fluoride ions stabilised by CPP was superior in the level and pattern of remineralisation obtained.

Effect of remineralization agents on white spot lesions: A systematic review

Objective:

The goal of this systematic review was to evaluate the therapeutic efficacy of Casein Phosphopeptide Amorphous Calcium Phosphate (CPP-ACP) remineralizing potential to that of other remineralizing treatments and placebo in both naturally occurring and postorthodontic white spot lesions (WSL) in vivo.

Materials and Methods:

From 2005 to 2020, the literature search used electronic databases PubMed, Embase, Science Direct, and Google Scholar to find studies published solely in English and randomized controlled trials (RCTs) employing CPP-ACP as an intervention. All eligible studies were reviewed by two independent reviewers.

Results:

Excluding duplications, 72 articles were identified. Abstracts of 58 articles were reviewed independently, 19 articles were excluded, 36 full text articles were retrieved; finally selecting 14 studies.

Conclusion:

The CPP-ACP was found to have efficacious remineralizing potential on naturally occurring and postorthodontic WSL compared to placebo or other preventive measures. Further well-performed RCTs are needed to determine the therapeutic significance of remineralizing medicines, and long-term follow-ups are required.

Casein phosphopeptide-amorphous calcium phosphate modified glass ionomer cement attenuates demineralization and modulates biofilm composition in dental caries

The study investigated the effects of the modified conventional glass ionomer cement (GIC) incorporated with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on biofilm composition of dental caries. Shear bond strength, durability tests, adhesive remnant index (ARI) and scanning electron microscope were used to measure the physical properties. Microhardness and ions release were determined to evaluate anti-demineralization effects; growth of the biofilm and its composition were assessed using MTT assay and Q-PCR assay. All experimental groups exhibited a significant stimulation of ions release, and reduced attenuation of microhardness. Nearly 39% reduction in the bacterial biofilm was observed with 5% CPP-ACP group. The regulation ability is mainly manifested in the inhibition of S. mutans and promotion of S. gordonii. The modified GICs by exhibiting anti-demineralization effects potentially lead to a reduction in the cariogenicity of plaque and can serve as a putative promising remineralization system with both enhanced antimicrobial and remineralization properties.

Casein phosphopeptide combined with fluoride enhances the inhibitory effect on initial adhesion of Streptococcus mutans to the saliva-coated hydroxyapatite disc

Background

Recent preventive strategies for dental caries focus on targeting the mechanisms underlying biofilm formation, including the inhibition of bacterial adhesion. A promising approach to prevent bacterial adhesion is to modify the composition of acquired salivary pellicle. This in vitro study investigated the effect and possible underlying mechanism of pellicle modification by casein phosphopeptide (CPP) on Streptococcus mutans (S. mutans) initial adhesion, and the impact of fluoride on the efficacy of CPP.

Methods

The salivary pellicle-coated hydroxyapatite (s-HA) discs were treated with phosphate buffered saline (negative control), heat-inactivated 2.5% CPP (heat-inactivated CPP), 2.5% CPP (CPP) or 2.5% CPP supplemented with 900 ppm fluoride (CPP + F). After cultivation of S. mutans for 30 min and 2 h, the adherent bacteria were visualized by scanning electron microscopy (SEM) and quantitatively evaluated using the plate count method. Confocal laser scanning microscopy (CLSM) was used to evaluate the proportions of total and dead S. mutans. The concentrations of total, free, and bound calcium and fluoride in the CPP and fluoride-doped CPP solutions were determined. The water contact angle and zeta potential of s-HA with and without modification were measured. The data were statistically analyzed using one-way ANOVA followed by a Turkey post hoc multiple comparison test.

Results

Compared to the negative control group, the amount of adherent S. mutans significantly reduced in the CPP and CPP + F groups, and was lowest in the CPP + F group. CLSM analysis showed that there was no statistically significant difference in the proportion of dead S. mutans between the four groups. Water contact angle and zeta potential of s-HA surface significantly decreased in the CPP and CPP + F groups as compared to the negative control group, and both were lowest in the CPP + F group.

Conclusions

Pellicle modification by CPP inhibited S. mutans initial adhesion to s-HA, possibly by reducing hydrophobicity and negative charge of the s-HA surface, and incorporating fluoride into CPP further enhanced the anti-adhesion effect.

Nanoparticles as Anti-Microbial, Anti-Inflammatory, and Remineralizing Agents in Oral Care Cosmetics: A Review of the Current Situation

Many investigations have pointed out widespread use of medical nanosystems in various domains of dentistry such as prevention, prognosis, care, tissue regeneration, and restoration. The progress of oral medicine nanosystems for individual prophylaxis is significant for ensuring bacterial symbiosis and high-quality oral health. Nanomaterials in oral cosmetics are used in toothpaste and other mouthwash to improve oral healthcare performance. These processes cover nanoparticles and nanoparticle-based materials, especially domains of application related to biofilm management in cariology and periodontology. Likewise, nanoparticles have been integrated in diverse cosmetic produces for the care of enamel remineralization and dental hypersensitivity. This review summarizes the indications and applications of several widely employed nanoparticles in oral cosmetics, and describes the potential clinical implementation of nanoparticles as anti-microbial, anti-inflammatory, and remineralizing agents in the prevention of dental caries, hypersensitivity, and periodontitis.

Efficacy of erbium-doped yttrium aluminum garnet laser with casein phosphopeptide amorphous calcium phosphate with and without fluoride for remineralization of white spot lesions around orthodontic brackets

Objective

This study aimed to assess the efficacy of erbium-doped yttrium aluminum garnet (Er:YAG) laser, pastes containing casein phosphopeptide amorphous calcium phosphate (CPP-ACP) with and without fluoride and their combination for prevention of white spot lesions in the enamel.

Materials and Methods

This in vitro experimental study was conducted on 90 extracted sound premolars. The teeth were then randomly divided into six groups of 15: (1) Control, (2) laser, (3) CPP-ACP with fluoride (GC MI Paste, Recaldent™ 900 ppm as NaF), (4) CPP-ACP without fluoride (GC Tooth Mousse Recaldent™), (5) laser + CPP-ACP with fluoride, and (6) laser + CPP-ACP without fluoride. In each group, enamel surface was exposed to the remineralizing agent. The teeth were then subjected to pH cycling for 14 days. The teeth were then sectioned, polished, and underwent cross-sectional microhardness testing at 20-160 μ depth quantitatively. Using the Simpson's rule, the amount of mineral loss was calculated in each group. Statistical Analysis Used: ANOVA was used for the comparisons, and Tukey's test was applied for pairwise comparisons.

Results

The highest mean volume percentage of microhardness at 20-60 μ depth belonged to the group laser + CPP-ACP with fluoride and the lowest belonged to the control group (P = 0.001). The differences were not significant at 80-120 μ depth (P > 0.05). These finding are confirmed according to △Z (mineral loss).

Conclusion

Based on these results, Er: YAG laser was able to decrease demineralization and was a potential alternative to preventive dentistry and was more effective when combined with CPP-ACP products.

Fluoride toothpastes of different concentrations for preventing dental caries

BACKGROUND

Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). Regular toothbrushing with fluoride toothpaste is the principal non-professional intervention to prevent caries, but the caries-preventive effect varies according to different concentrations of fluoride in toothpaste, with higher concentrations associated with increased caries control. Toothpastes with higher fluoride concentration increases the risk of fluorosis (enamel defects) in developing teeth. This is an update of the Cochrane Review first published in 2010.

OBJECTIVES

To determine and compare the effects of toothpastes of different fluoride concentrations (parts per million (ppm)) in preventing dental caries in children, adolescents, and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 August 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7) in the Cochrane Library (searched 15 August 2018); MEDLINE Ovid (1946 to 15 August 2018); and Embase Ovid (1980 to 15 August 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 August 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non-fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow-up period of at least 1 year. The primary outcome was caries increment measured by the change from baseline in the decayed, (missing), and filled surfaces or teeth index in all permanent or primary teeth (D(M)FS/T or d(m)fs/t).

DATA COLLECTION AND ANALYSIS

Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. We graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference (MD) or standardised mean difference (SMD) caries increment. Where it was appropriate to pool data, we used random-effects pairwise or network meta-analysis.

MAIN RESULTS

We included 96 studies published between 1955 and 2014 in this updated review. Seven studies with 11,356 randomised participants (7047 evaluated) reported the effects of fluoride toothpaste up to 1500 ppm on the primary dentition; one study with 2500 randomised participants (2008 evaluated) reported the effects of 1450 ppm fluoride toothpaste on the primary and permanent dentition; 85 studies with 48,804 randomised participants (40,066 evaluated) reported the effects of toothpaste up to 2400 ppm on the immature permanent dentition; and three studies with 2675 randomised participants (2162 evaluated) reported the effects of up to 1100 ppm fluoride toothpaste on the mature permanent dentition. Follow-up in most studies was 36 months.In the primary dentition of young children, 1500 ppm fluoride toothpaste reduces caries increment when compared with non-fluoride toothpaste (MD -1.86 dfs, 95% confidence interval (CI) -2.51 to -1.21; 998 participants, one study, moderate-certainty evidence); the caries-preventive effects for the head-to-head comparison of 1055 ppm versus 550 ppm fluoride toothpaste are similar (MD -0.05, dmfs, 95% CI -0.38 to 0.28; 1958 participants, two studies, moderate-certainty evidence), but toothbrushing with 1450 ppm fluoride toothpaste slightly reduces decayed, missing, filled teeth (dmft) increment when compared with 440 ppm fluoride toothpaste (MD -0.34, dmft, 95%CI -0.59 to -0.09; 2362 participants, one study, moderate-certainty evidence). The certainty of the remaining evidence for this comparison was judged to be low.We included 81 studies in the network meta-analysis of D(M)FS increment in the permanent dentition of children and adolescents. The network included 21 different comparisons of seven fluoride concentrations. The certainty of the evidence was judged to be low with the following exceptions: there was high- and moderate-certainty evidence that 1000 to 1250 ppm or 1450 to 1500 ppm fluoride toothpaste reduces caries increments when compared with non-fluoride toothpaste (SMD -0.28, 95% CI -0.32 to -0.25, 55 studies; and SMD -0.36, 95% CI -0.43 to -0.29, four studies); there was moderate-certainty evidence that 1450 to 1500 ppm fluoride toothpaste slightly reduces caries increments when compared to 1000 to 1250 ppm (SMD -0.08, 95% CI -0.14 to -0.01, 10 studies); and moderate-certainty evidence that the caries increments are similar for 1700 to 2200 ppm and 2400 to 2800 ppm fluoride toothpaste when compared to 1450 to 1500 ppm (SMD 0.04, 95% CI -0.07 to 0.15, indirect evidence only; SMD -0.05, 95% CI -0.14 to 0.05, two studies).In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste reduces DMFS increment when compared with non-fluoride toothpaste in adults of all ages (MD -0.53, 95% CI -1.02 to -0.04; 2162 participants, three studies, moderate-certainty evidence). The evidence for DMFT was low certainty.Only a minority of studies assessed adverse effects of toothpaste. When reported, effects such as soft tissue damage and tooth staining were minimal.

AUTHORS' CONCLUSIONS

This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non-fluoride toothpaste. Evidence for the effects of different fluoride concentrations is more limited, but a dose-response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries-preventive effects and our confidence in these effect estimates are uncertain and could be challenged by further research. The choice of fluoride toothpaste concentration for young children should be balanced against the risk of fluorosis.

Clinical Evaluation of Two Different Prevention Programs in Adults Depending on Their Caries Risk Profile: One-year Results

The aim of this study was to investigate the management of incipient caries lesions in adults with two preventive protocols. A total of 44 adult patients with high, moderate and low caries risk with 516 incipient caries took part in the study. These patients were assessed for caries with International Caries Detection and Assessment System (ICDAS) criteria and were then divided into three groups depending on their caries risk profile: a high-risk group (group A), a moderate-risk group (group B), and a low-risk group (group C). Participants in each group were further divided randomly into two subgroups. In subgroups A1, B1, and C1, an intensive preventive protocol was applied, while in subgroups A2, B2, and C2, the protocol consisted only of instructions in oral hygiene. The invasive-intensive protocol included the topical application of fluoride, brushing with 5000-ppm fluoride toothpaste, use of amorphous calcium phosphate-casein phosphopeptide, applications of sealants for occlusal lesions (ICDAS code 2), and minimal resin restorations for occlusal lesions (ICDAS code 3). There was no statistically significant difference in the number of lesions (baseline and after one year) in the high-risk and moderate-risk groups that received the intensive protocol (groups A1 and B1), while the control groups were statistically significant different (groups A2 and B2). In the low-risk group, there was no statistically significant difference in the number of lesions (groups C1 and C2). The two different preventive protocols in the high- and moderate-risk groups presented differences in effectiveness, while in the low-risk group, no significant difference was demonstrated.

State of the Art Enamel Remineralization Systems: The Next Frontier in Caries Management

The principles of minimally invasive dentistry clearly dictate the need for clinically effective measures to remineralize early enamel caries lesions. While fluoride-mediated remineralization is the cornerstone of current caries management philosophies, a number of new remineralization strategies have been commercialized or are under development that claim to promote deeper remineralization of lesions, reduce the potential risks associated with high-fluoride oral care products, and facilitate caries control over a lifetime. These non-fluoride remineralizing systems can be broadly categorized into biomimetic enamel regenerative technologies and the approaches that repair caries lesions by enhancing fluoride efficacy. This paper discusses the rationale for non-fluoride remineralization and the mechanism of action, challenges, and evidence behind some of the most promising advances in enamel remineralization therapies.

Influence of biofilm formation on the mechanical properties of enamel after treatment with CPP-ACP crème

The study aimed to investigate the effects of bacterial biofilms on changes in the surface microhardness of enamel treated with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) with and without fluoride. Human enamel blocks with incipient caries-like lesions were divided into four groups of 13: G1: Saliva (Control); G2: fluoride dentifrice (Crest™, 1100 ppm as NaF); G3: CPP-ACP (MI Paste; Recaldent™); and G4: CPP-ACPF (MI Paste Plus; Recaldent™ 900 ppm as NaF). The specimens were soaked in demineralizing solution for 6 h and remineralized in artificial saliva for 18 h alternately for 10 days. The dentifrice was prepared with deionized water in a 1 : 3 ratio (w/w) or applied undiluted in the case of the CPP-ACP group. The surface microhardness (SMH) was evaluated at baseline, after artificial caries, after pH cycling and treatment with dentifrices, and after incubation in media with Streptococcus mutans for biofilm formation. The biofilms were exposed once a day to 2% sucrose and the biofilm viability was measured by MTT reduction. The percentage of change in surface microhardness (%SMHC) was calculated for each block. The data were analyzed by nonparametric test comparisons (α = 0.05). The %SMHC values observed in G2 were different from those of G1, G3, and G4 (p < 0.05). After biofilm formation, %SMHC was positive in G2 and G4 when compared to G1 and G3, but resistance to demineralization after biofilm formation was similar in all groups. In conclusion, the presence of biofilms did not influence the treatment outcomes of anticaries products.

Effects of tannin-fluoride and milk-fluoride mixture on human enamel erosion from inappropriately chlorinated pool water

This in vitro study aimed to investigate the efficacy of tannin-fluoride and milk-fluoride mixtures on human enamel erosion after exposure to inappropriately chlorinated pool water. Enamel specimens were immersed in swimming pool water (pH 2.7) for 30 min and in each test reagent for 4 min once a day for 60 consecutive days (group I: control, group II: tannin-fluoride, group III: milk-fluoride, group IV: tannin-fluoride before and milk-fluoride after erosive challenge, and group V: milk containing tannin-fluoride before and after erosive exposure). Surface microhardness was assessed on days 0, 30, and 60. Scanning electron microscopy (SEM) and electron probe microanalysis (EPMA) were performed after treatment of samples for 60 days. Surface microhardness of experimental groups was ranked as follows: group III > group IV-group V > group II > group I (P < 0.05). Moreover, SEM images revealed deposition of substances on erosive enamel surface after treatment with tannin-fluoride and milk-fluoride mixtures. Furthermore, EPMA profiles showed decrease of phosphorus and increase of fluoride content in groups II and IV. In conclusion, we demonstrated that treatment with fluoridated milk with or without tannin-fluoride has protective effects against enamel erosion caused by low-pH swimming pool water.

Effect of non-fluoride agents on the prevention of dental caries in primary dentition: A systematic review

Objective

To assess the effect of non-fluoride agents on the prevention of dental caries in primary dentition.

Materials and methods

Medline, Web of Science, Embase, Cochrane Library, CBM and CNKI databases were searched to identify all the relevant articles published prior to 16 December 2016. Grey literature was also searched. Randomized controlled human clinical trials in which non-fluoride agents were delivered by any method were considered.

Results

Of the 1,236 studies screened, 39 full articles were scrutinized and 14 selected for inclusion in the final sample. Five chemical agents, namely arginine, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), chlorhexidine, triclosan and xylitol were investigated in these included studies. The cariostatic effects of non-fluoride agents in vivo were evaluated in comparison with fluoride or placebos in randomized controlled trials. There is evidence that the use of certain doses of xylitol may be effective in arresting dental caries in primary dentition. However, quantitative synthesis could not be carried out because of the clinical and methodological heterogeneity of the included studies.

Conclusions

A study at low risk of bias indicated that daily use of xylitol wipes is a useful adjunct for caries control in young children, however, this conclusion should be interpreted with caution as this study had a very limited sample size. Chlorhexidine and CPP-ACP may be more effective than a placebo in managing caries in primary dentition, but their effectiveness is borderline when compared with fluoride. Arginine-containing mint confection and 0.3% triclosan varnish were found to reduce caries development in primary teeth but the evidence was at high risk of bias. High quality randomized controlled trials are needed in order to make a conclusive recommendation.

Protective effects of a zinc-hydroxyapatite toothpaste on enamel erosion: SEM study

AIM

The aim of the present in vitro study was to evaluate the protective effects of a zinc-hydroxyapatite toothpaste against an erosive challenge produced by a soft drink (Coca-Cola) using Scanning Electron Microscopy (SEM).

METHODS

Forty specimens were assigned to 4 groups of 10 specimens each (group 1: no erosive challenge, no toothpaste treatment, group 2: erosive challenge, no toothpaste treatment, group 3: erosive challenge, fluoride toothpaste treatment, group 4: erosive challenge, zinc-hydroxyapatite toothpaste treatment). The surface of each specimen was imaged by SEM. A visual rating system was used to evaluate the condition of the enamel surface; results were analyzed by nonparametric statistical methods.

RESULTS

Statistically significant differences were found between the samples untreated and those immersed in Coca-Cola (group 1, 2); the highest grade of damage was found in group 2, while the lowest grade was recorded in the samples of group 4. Comparing the groups, the two analyzed toothpaste tended to protect in different extend.

CONCLUSIONS

In this study treatment of erosively challenged enamel with Zn-Hap toothpaste showed a clear protective effect. This was greater than the effect observed for a normal fluoride toothpaste and confirmed the potential benefit the Zn-HAP technology can provide in protecting enamel from erosive acid challenges.

Evaluation of the remineralization capacity of CPP-ACP containing fluoride varnish by different quantitative methods

Objective

The aim of this study was to evaluate the efficacy of CPP-ACP containing fluoride varnish for remineralizing white spot lesions (WSLs) with four different quantitative methods.

Material and Methods

Four windows (3x3 mm) were created on the enamel surfaces of bovine incisor teeth. A control window was covered with nail varnish, and WSLs were created on the other windows (after demineralization, first week and fourth week) in acidified gel system. The test material (MI Varnish) was applied on the demineralized areas, and the treated enamel samples were stored in artificial saliva. At the fourth week, the enamel surfaces were tested by surface microhardness (SMH), quantitative light-induced fluorescence-digital (QLF-D), energy-dispersive spectroscopy (EDS) and laser fluorescence (LF pen). The data were statistically analyzed (α=0.05).

Results

While the LF pen measurements showed significant differences at baseline, after demineralization, and after the one-week remineralization period (p<0.05), the difference between the 1- and 4-week was not significant (p>0.05). With regards to the SMH and QLF-D analyses, statistically significant differences were found among all the phases (p<0.05). After the 1- and 4-week treatment periods, the calcium (Ca) and phosphate (P) concentrations and Ca/P ratio were higher compared to those of the demineralization surfaces (p<0.05).

Conclusion

CPP-ACP containing fluoride varnish provides remineralization of WSLs after a single application and seems suitable for clinical use.

Comparative evaluation of the efficacy of fluoride varnish and casein phosphopeptide - Amorphous calcium phosphate in reducing Streptococcus mutans counts in dental plaque of children: An in vivo study

AIM

To assess the comparative efficacy of fluoride varnish and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) complex visa viz. Streptococcus mutans in plaque, and thereby the role that these two agents could play in the prevention of dental caries.

MATERIALS AND METHODS

A cluster sample of 120 caries inactive individuals belonging to moderate and high caries risk group were selected from 3-5-year-old age group based on the criteria given by Krassee and were randomized to four groups, namely, fluoride varnish - Group I, CPP-ACP complex - Group II, mixture of CPP-ACP complex -Gourp III, and fluoride and routine oral hygiene procedures as control - Group IV. The results thus obtained were analyzed using Statistical Package for the Social Sciences (SPSS) version 16.

RESULTS

A statistically significant difference in the pre and post-application scores of S. mutans (P < 0.01) count was observed in all the groups with CPP-ACP plus fluoride group being the most proficient.

CONCLUSION

Materials such as fluoride varnish, CPP-ACP, and CPP-ACP plus fluoride protects the tooth structure, preserving the integrity of primary dentition, with the most encouraging results being with CPP-ACP plus fluoride.

Remineralizing potential of CPP-ACP creams with and without fluoride in artificial enamel lesions

BACKGROUND

This study evaluated the effect of pastes containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) with and without fluoride on enamel demineralization.

METHODS

Human enamel blocks were used and after incipient caries-like lesions were formed, they were assigned to four groups: G1 - saliva; G2 - MI Paste (Recaldent^TM ); G3 - MI Paste Plus (Recaldent^TM 900 ppm as NaF); and G4 - Crest^™ (1.100 ppm as NaF). The specimens were soaked in demineralizing solution for 6 hours and remineralized in artificial saliva for 18 hours alternatively for 10 days. The dentifrice was prepared with deionized water in a 1:3 proportion (w/w) or applied undiluted in the case of the CPP-ACP formula. Demineralized enamel changes were analysed by surface microhardness (SMH), 3D-profilometry and SEM. Data were analysed by non-parametric Kruskal-Wallis and Mann-Whitney test comparisons and one-way ANOVA and Tukey's HSD post hoc test (α = 0.05).

RESULTS

The SMH values observed in the G2 (47.8 ± 28.5) and G3 (53.6 ± 27.6) groups were different from that of G4 (90.2 ± 17.1), which were significantly higher than that found in G1 (39.4 ± 14.2). The %SMH was significantly lower in G4 when compared to G1 (p < 0.001) and G3 (p < 0.05).

CONCLUSIONS

MI Paste Plus demonstrated a greater protective effect against demineralization than MI Paste and showed smoother surfaces.

Noninvasive Dentistry: A Dream or Reality?

Various caries prevention and repair strategies are reviewed in this article ranging from the use of fluoride to nanohydroxyapatite particles. Several of the strategies which combine fluoride and calcium and phosphate treatments have both in vitro and in vivo data showing them to be efficacious if the surface integrity of the lesion is not breached. Once this has occurred, the rationale for cutting off the nutrient supplies to the pathogenic bacteria without the removal of the infected dentine, a noninvasive restorative technique, is discussed using existing clinical studies as examples. Finally two novel noninvasive restorative techniques using fluorohydroxyapatite crystals are described. The need for clinical data in support of emerging caries-preventive and restorative strategies is emphasized.

Remineralizing efficacy of a CPP-ACP cream on enamel caries lesions in situ

The aim of this double-blind, randomized, cross-over in situ study was to compare the remineralizing effects induced by the application of casein phosphopeptide-stabilized amorphous calcium phosphate complexes (CPP-ACP)-containing cream (without fluoride) after the use of fluoride toothpaste with the prolonged use of fluoride toothpaste on enamel caries lesions in situ. During each of three experimental legs of 4 weeks, 13 participants wore intra-oral mandibular appliances with 8 pre-demineralized bovine enamel specimens in the vestibular flanges mimicking either 'easily cleanable' or 'proximal' surfaces (n = 312). The three randomly allocated treatments were as follows: (1) application of CPP-ACP-containing cream (GC Tooth Mouse, non-fluoride) after the use of fluoride toothpaste (1,400 ppm NaF; TM), (2) prolonged application of fluoride toothpaste (1,400 ppm NaF; positive control, PC) and (3) prolonged application of fluoride-free toothpaste (negative control, NC). Additionally, one of each of the two flanges was brushed twice daily with the respective toothpaste. The differences in integrated mineral loss as assessed by transversal microradiography were calculated between values before and after the in situ period. Changes in mineral loss were analysed for those pairs of subgroups differing in only one of the three factors (intervention, brushing and position). The PC treatment induced a significantly higher mineral gain compared with the TM and NC treatments. No significant differences between TM and NC for both positions were observed. In conclusion, the additional use of a CPP-ACP-containing cream seems to be less efficacious in remineralizing caries lesions than the prolonged application of fluoride toothpaste.

Calcium phosphopeptides -- mechanisms of action and evidence for clinical efficacy

Phosphoproteins/phosphopeptides with clusters of acidic residues are found throughout nature, where they aid in the prevention of unwanted precipitation of solid calcium phosphates. The acidic residues, particularly phosphoserine, interact with calcium and stabilize clusters of calcium and phosphate. Saliva and milk are two examples of biological fluids that contain such phosphoprotein/phosphopeptide-stabilized calcium phosphates, and both share a similar evolutionary pathway. Saliva has been shown to have remineralization potential and is of critical importance in maintaining the mineral content of teeth in the oral environment. Milk can be enzymatically modified to release casein phosphopeptides that contain the clusters of residues that allow milk to stabilize high concentrations of calcium and phosphate. These casein phosphopeptide-stabilized amorphous calcium phosphate nanocomplexes (CPP-ACP) can stabilize even higher concentrations of calcium and phosphate than milk and can be considered a salivary biomimetic, since they share many similarities to statherin. The mechanisms of action and the growing body of scientific evidence that supports the use of CPP-ACP to augment fluoride in inhibiting demineralization and enhancing the remineralization of white-spot lesions are reviewed.

Minimal intervention dentistry for managing dental caries - a review: report of a FDI task group

This publication describes the history of minimal intervention dentistry (MID) for managing dental caries and presents evidence for various carious lesion detection devices, for preventive measures, for restorative and non-restorative therapies as well as for repairing rather than replacing defective restorations. It is a follow-up to the FDI World Dental Federation publication on MID, of 2000. The dental profession currently is faced with an enormous task of how to manage the high burden of consequences of the caries process amongst the world population. If it is to manage carious lesion development and its progression, it should move away from the 'surgical' care approach and fully embrace the MID approach. The chance for MID to be successful is thought to be increased tremendously if dental caries is not considered an infectious but instead a behavioural disease with a bacterial component. Controlling the two main carious lesion development related behaviours, i.e. intake and frequency of fermentable sugars, to not more than five times daily and removing/disturbing dental plaque from all tooth surfaces using an effective fluoridated toothpaste twice daily, are the ingredients for reducing the burden of dental caries in many communities in the world. FDI's policy of reducing the need for restorative therapy by placing an even greater emphasis on caries prevention than is currently done, is therefore, worth pursuing.

Effect of CPP-ACP paste on dental caries in primary teeth: a randomized trial

This clinical trial tested the effect of daily application of 10% w/v calcium phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste for 1 yr when added to regular toothbrushing with fluoridated toothpaste to prevent dental caries in pre-school children. High-caries-risk children aged 2½ to 3½ yrs in a suburban area of central Thailand were assigned to receive either CPP-ACP (n = 150) or a placebo control (n = 146) in addition to fluoridated toothpaste. The International Caries Detection and Assessment System (ICDAS) was recorded at baseline, 6 mos, and 1 yr. At 1 yr, a significant increase in mean numbers of enamel and dentin caries lesions, as well as dmfs, was found in both groups (p < 0.001). No significant difference was observed between groups on these 3 outcome measures (p = 0.23, 0.84, and 0.91, respectively). The odds of enamel caries lesion transitions to a state of regression or stability, compared with progression from baseline, was also not different between groups [OR = 1.00, 95% CI (0.86, 1.17)]. This trial found that daily application of 10% w/v CPP-ACP paste on school days for 1 yr, when added to regular toothbrushing with a fluoride toothpaste, had no significant added effect in preventing caries in the primary dentition of these pre-school children (ClinicalTrials.gov number CT01 604109).

Biofunctional properties of caseinophosphopeptides in the oral cavity

Caseinophosphopeptides (CPPs), bioactive peptides released from caseins, have the ability to enhance bivalent mineral solubility. This is relevant to numerous biological functions in the oral cavity (promotion of tooth enamel remineralisation, prevention of demineralisation and buffering of plaque pH). Therefore, CPPs may play a positive role as prophylactic agents for caries, enamel erosion and regression of white spot lesions. Most in vitro and in situ studies demonstrate strong evidence for the bioactivity of CPPs in the oral cavity. Nevertheless, relatively little is known concerning their use as adjuvants for oral health and more particularly regarding their long-term effects on oral health.

New Approaches to Enhanced Remineralization of Tooth Enamel

Dental caries is a highly prevalent diet-related disease and is a major public health problem. A goal of modern dentistry is to manage non-cavitated caries lesions non-invasively through remineralization in an attempt to prevent disease progression and improve aesthetics, strength, and function. Remineralization is defined as the process whereby calcium and phosphate ions are supplied from a source external to the tooth to promote ion deposition into crystal voids in demineralized enamel, to produce net mineral gain. Recently, a range of novel calcium-phosphate-based remineralization delivery systems has been developed for clinical application. These delivery systems include crystalline, unstabilized amorphous, or stabilized amorphous formulations of calcium phosphate. These systems are reviewed, and the technology with the most scientific evidence to support its clinical use is the remineralizing system utilizing casein phosphopeptides to stabilize and deliver bioavailable calcium, phosphate, and fluoride ions. The recent clinical evidence for this technology is presented and the mechanism of action discussed. Biomimetic approaches to stabilization of bioavailable calcium, phosphate, and fluoride ions and the localization of these ions to non-cavitated caries lesions for controlled remineralization show promise for the non-invasive management of dental caries.

Novel technologies for the prevention and treatment of dental caries: a patent survey

IMPORTANCE OF THE FIELD

Dental caries is one of the most common preventable childhood diseases; people are susceptible to this ailment throughout their lifetime. In the US, 90% of late adolescents and young adults have dental caries, while 94% of all dentate adults had evidence of treated or untreated coronal caries. Dental caries is often not self-limiting and without proper care can progress until the tooth is destroyed.

AREAS COVERED IN THIS REVIEW

In this paper, the etiology of dental caries is briefly introduced. It is followed by a thorough review of patents and literatures on the recent development of various novel technologies for the prevention and treatment of dental caries.

WHAT THE READER WILL GAIN

Recent advances in anti-plaque agents, including chemoprophylactic agents, antimicrobial peptides, vaccines, probiotics/replacement therapy and sugar substitutes, and remineralization agents including fluorides and casein phosphopeptides are analyzed. TAKE HOME MASSAGE: Both the discovery of new anti-caries agents and the development of dentotropic delivery systems will be the future focus of this research field.