The dynamic interplay of dietary acid pH and concentration during early-stage human enamel and dentine erosion

Dental erosion continues to be a significant global health concern affecting nearly 30% of adults world-wide. With increasing soft drink consumption predominantly driving its prevalence, strategies for prevention and control are often implemented when erosion is severe, or rates are high in the populace. While factors affecting dental erosion such as pH on enamel has received much attention, the effect of dietary acid concentration when factored out to a commercially available pH has yet to be determined. Furthermore, understanding these effects on dentine, which is known to be more susceptible to erosion than enamel can unravel structure property relationships between acid characteristics and hard tissue types. This study aimed to develop structure-property relationships between dietary acid concentration, and pH, on the nano-textural and nano-mechanical properties of human enamel and dentine during short-term simulated drinking. To achieve this, a novel sample preparation methodology and analysis approach was developed by applying atomic force microscopy (AFM) in quantitative imaging mode. This enabled simultaneous measurement of enamel and dentine morphology and mechanical properties. Flow-cells were used to simulate drinking, exposing polished and smear layer free human enamel and dentine to 30 s repeated cycles of unbuffered citric acid 6% (pH = 1.88) and 1% (w/v) (pH = 2.55) and commercially available buffered pH = 3.8 states, for up to 180 s. The same 50 µm × 50 µm area of specimen morphology was analysed using in-house developed nanotextural analysis using the bearing area curve (BAC) with a focus on roughness (Ra), normalised peak (PA) and valley areas (VA). Mechanical properties were simultaneously measured for stiffness (N/m) after each 30 s. While all studies agree pH is a major factor in the erosion of enamel, here its dominance over the treatment time varied, with concentration surpassing the importance of pH after initial acid contact. Conversely, dentine erosion showed concentration-dependent changes in morpho-mechanical properties only. These results not only highlight the dynamic process of erosion, but how the interplay between acid characteristics and dental tissue type impact the progression of very early-stage erosion.

Differences in susceptibility of deciduous and permanent teeth to erosion exist, albeit depending on protocol design and method of assessment

Controversial results showing that deciduous teeth are more susceptible to erosion than permanent teeth might be related to study designs. We investigated how different conditions (pH: 3.0, 4.0, 5.0; acid agitation: gentle or vigorous; acid exposure times: 1–5 min) affect the susceptibility of both teeth to erosion. Enamel specimens (90 deciduous, 90 permanent) were distributed into groups (n = 15 permanent, n = 15 deciduous) according to acid pH (pH 5, 4 or 3) and agitation (gentle or vigorous) during erosive challenge. Both milder (less incubation time, gentle agitation, and higher pH) and more severe (longer incubation times, vigorous shaking, and lower pH) conditions were used. Demineralization was measured by relative surface microhardness (rSMH) and calcium released to the acid. Demineralization increased gradually for both teeth with increasing incubation time, agitation (gentle or vigorous), and with decreasing acid pH. The differences between deciduous and permanent teeth depended on the protocol design and assessment method. Under milder conditions, demineralization was better detectable with rSMH. Under more severe conditions, differences were more perceptible with calcium analyses. Differences exist in the susceptibility to erosion between deciduous and permanent teeth, but they are only distinguishable when the appropriate assessment method is used for the specific erosive condition.

Viscosity and mixing properties of artificial saliva and four different mouthwashes

BACKGROUND

Numerous functions of saliva depend on its biophysical properties. Mouth rinses react with saliva and change both their own properties and properties of saliva.

OBJECTIVE

The aim of this study was to define the level of mixing of artificial saliva and mouth rinses, and define their viscosity and its changes at room and body temperature.

METHODS

Artificial saliva, fluoride solutions, chlorhexidine, zinc-hydroxyapatite solution and casein phosphopeptide amorphous calcium phosphate were used. To simulate their mixing, Y-channel PVC chips were used, in two different microfluidics systems. The experiments were recorded with a microscope, then the proportion of mixing was calculated using Matlab. For viscosity measurements rotational viscometer was used.

RESULTS

The results show partial mixing of all solutions with artificial saliva. Measurements with a viscometer indicate different viscosities of all used solutions. Viscosity of a mixture of solution and artificial saliva is always in the range of viscosity of the artificial saliva and the solution separately. Moreover, viscosity of all solutions, as well as mixture with artificial saliva, significantly decreases at higher temperature.

CONCLUSION

Intraoral administration of mouth rinses results in change of biophysical properties of both saliva and mouth rinses. Those changes can affect preventive and therapeutic effect, and therefore oral health.

Application of Mathematical Models and Microfluidics in the Analysis of Saliva Mixing with Antiseptic Solutions

Background/Aim: Human saliva offers many advantages over blood-based biochemical assays, therefore, becomes the biological fluid of interest. Once antiseptic solutions react with saliva, both fluids undergo significant changes of their biophysical properties, consequently, those changes have an impact on their principal function.

Material and Methods: In this study, saliva was collected and mixed with 0,1% chlorhexidine digluconate solution, fluoride mouthwash, zinc-hydroxyapatite solution and CPP-ACP paste. Microfluidic PVC/Green tape chips within the experimental setup were used to simulate solution mixing. The chip had 2 inlets and 1 outlet, and channel was designed in Y shape without any obstacles. The inlet channels were set at a 60° angle. The channel width was 600 µm and the diameter of inlets and outlet was 2 mm. For better visualization, blue food coloring was added to the saliva. The procedure was recorded with digital USB microscope camera and afterwards the percentage of mixing was obtained by MATLAB programming language.

Results: Obtained results show incomplete mixing of all the solutions with saliva. The value of mixed liquid, when mixing 0,1% chlorhexidine digluconate solution with saliva was 51,11%. In case of medium concentration fluoride mouthwash, result was 84,37%. Zinc hydroxyapatite solution obtained result of 85,24%, and the fourth tested solution, CPP-ACP paste, 83,89%.

Conclusions: Analyzed mouthwashes exhibit specific, non uniform behavior during mixing with saliva. Microfluidic setups could be efficiently used in simulating real clinical conditions in laboratory settings. Image processing mathematical models are applicable, accurate and useful in determination of the interaction of saliva with commonly used antiseptic solutions.

A time based objective evaluation of the erosive effects of various beverages on enamel and cementum of deciduous and permanent teeth

Background

Erosion of the teeth is a chronic irreversible process leading to loss of surface enamel and even the dentin, in turn causing sensitivity and pain. Increased consumption of carbonated beverages remains a major cause for dental erosion. However, many of the so called safe beverages that are consumed may also have sufficiently low pH to cause dental erosion. One of the parameters to measure the dental erosion is estimation of hardness and surface roughness. Thus, this study aims to evaluate the difference in hardness and surface roughness of enamel and cementum using three beverages namely (carbonated drink, lime soda, lime juice) in deciduous and permanent teeth.

Material and Methods

Ten permanent and three deciduous teeth samples each were kept in lime juice, lime soda, carbonated beverage and tap water. The VHN using Vickers hardness tester and Ra value using surface profilometer were assessed at baseline, 1 day and 10 days.

Results

At the end of 10 days the decrease in hardness of enamel of permanent teeth was maximum for teeth immersed in carbonated beverage followed by lime soda and lime juice. However, in the deciduous teeth it was observed that the VHN drop was maximum at 1 day in relation to teeth immersed in carbonated beverage followed by lime juice and lime soda. The hardness of cementum decreased significantly at the end of ten days both in deciduous as well as permanent teeth.

Conclusions

The present study shows that many of the most commonly used beverages like lime juice and lime soda have a sufficiently low pH to cause erosion of the enamel surface as well as that of cementum of both deciduous and permanent teeth. Though protective mechanisms do exist in the oral cavity to neutralize the acids present in these beverages, continuous usage of these beverages leads to irreversible damage to the tooth structure.

Key words:Dental erosion, hardness, surface roughness, permanent teeth, deciduous teeth.

Comparison of Profilometric and Microindentation Analyses for Determining the Impact of Saliva on the Abrasion of Initially Eroded Enamel

The aim of this in vitro study was to investigate the impact of saliva on the abrasion of eroded enamel using two measuring methods. A total of 80 bovine enamel specimens from 20 bovine incisors were allocated to four experimental groups (n = 20 specimens per group). After baseline surface microhardness (SMH) measurements and profilometry all specimens were subjected to erosion (2 min, 1% citric acid, pH: 3.6, 37°C). SMH was determined again, and the depths of the Knoop indentations were calculated. Thereafter, specimens were incubated in human saliva (group 1 - no incubation/control, group 2 - 0.5 h, group 3 - 1 h, group 4 - 2 h) before toothbrush abrasion was performed. After final SMH measurements and profilometry, indentations were remeasured, and surface loss was calculated. SMH did not return to baseline values regardless of the length of saliva incubation. Further, an irreversible substance loss was observed for all specimens. With the indentation method, significantly (p < 0.05) more substance loss was found for controls (least square means ± standard error of 198 ± 19 nm) than for groups 2-4 (110 ± 10, 114 ± 11, and 105 ± 14 nm). Profilometric assessment showed significantly more substance loss for controls (122 ± 8 nm) than for group 4 (106 ± 5 nm). Intraclass correlation for interrater reliability between measurement methods was low (0.21, CI: 0.1-0.3), indicating poor agreement. Exposure of eroded enamel to saliva for up to 2 h could not re-establish the original SMH. The amount of measured substance loss depended on the measurement method applied.

Prevention of erosive tooth wear: targeting nutritional and patient-related risks factors

This article provides an overview of the nutritional and patient-related risk factors involved in the aetiology of erosive tooth wear (ETW) and the preventive strategies to counteract them. The first step is to diagnose clinical signs of ETW and to recognise causal factors. Low pH and high buffer capacity of foods/drinks are the major risk factors, while the calcium concentration is the main protective factor. Reduction of frequency of consumption and contact time of erosive foods/drinks with the teeth, use of straws appropriately positioned and consumption of dairy products are advisable. Oral hygiene has a role in the development of ETW, however, postponing toothbrushing is not clinically advisable. In cases of drug abuse, chronic alcoholism, GERD or bulimia, the patient must be referred to a doctor. Immediately after vomiting, patients might be advised to rinse the mouth. Saliva has an important protective role and patients with reduced salivary flow can benefit from the use of chewing gum. Recent studies have focused on improving the protective capacity of the acquired pellicle as well as on the role of protease inhibitors on dentine erosion. However, the degree of evidence for these preventive measures is low. Clinical trials are necessary before these measures can be recommended.

Effects of Erosion Protocol Design on Erosion/Abrasion Study Outcome and on Active Agent (NaF and SnF2) Efficacy

There is no standard for testing anti-erosive/anti-abrasive agents, making the assessment and comparison of study results difficult. Factors which are varied in study designs are amongst others the erosive medium regarding concentration and pH or movement type of acid. The present study therefore investigated the impact of these factors on dimension of tissue loss and on efficacy of active agents used as anti-erosive/anti-abrasive therapeutics. In 8 experiments, consisting of 8 groups each (n = 20 each), resulting in a total of 64 groups, enamel specimens were demineralised (10 days, 6 × 2 min/day) using different acids (1, 0.5 and 0.3% citric acid at native pH 2.3, 2.5 and 2.8, respectively, and 0.3% citric acid adjusted to pH 3.6) with two different movement types (jerky or smooth). Specimens were immersed (2 × 2 min/day) in slurries of 1,450 ppm F- toothpaste (NaF), 1,450 ppm F- and 3,436 ppm Sn2+ toothpaste (NaF/SnF2), 970 ppm F- and 3,000 ppm Sn2+ gel (SnF2) or placebo, or were additionally brushed during immersion (15 s, 200 g). All groups were in between stored in a mineral salt solution. Tissue loss was determined profilometrically. Movement type, pH and concentration of acid had a substantial impact on study outcome. The combination of jerky movement and concentrated acid masked, to some extent, differences between erosive and erosive-abrasive tissue loss. The acid at low concentration (0.3%), independent of pH, was too mild to produce any tissue loss. The model with the best ability to demonstrate effects of abrasive impacts and active agents used the 1% acid concentration combined with smooth acid movements.

Possible ways of reducing dental erosive potential of acidic beverages

Frequent consumption of acidic beverages is related to excessive tooth wear, namely dental erosion. Preventive measures may involve reduction or elimination of acidic drink consumption. However, the success of this approach is difficult to achieve as it is highly dependent on patient compliance. Therefore, a practical way of minimizing the erosive potential of popular acidic drinks may be their chemical modification. The aim of this article was to review the different methods of modification and their shortcomings. The available literature demonstrates that the erosive potential of most acidic beverages could be reduced. To date, the effectiveness of soluble calcium salts supplementation is the best established. However, modification can reduce the sensorial quality of the drink and shorten its shelf-life. There is also a need to evaluate the lowest effective and safe dose of the additive.

Effect of various tooth whitening modalities on microhardness, surface roughness and surface morphology of the enamel

The purpose of this study was to evaluate the effect of four whitening modalities on surface enamel as assessed with microhardness tester, profilometer, and scanning electron microscopy (SEM). Whitening was performed according to manufacturer's directions for over-the-counter (OTC), dentist dispensed for home use (HW) and in-office (OW) whitening. Do-it-yourself (DIY) whitening consisted of a strawberry and baking soda mix. Additionally, negative and positive controls were used. A total of 120 enamel specimens were used for microhardness testing at baseline and post-whitening. Following microhardness testing specimens were prepared for SEM observations. A total of 120 enamel specimens were used for surface roughness testing at baseline and post-whitening (n = 20 per group). Rank-based Analysis of Covariance was performed to compare microhardness and surface roughness changes. Tests of hypotheses were two-sided with α = 0.05. There was a significant difference in Knoop hardness changes (ΔKHN) among the groups (Kruskal-Wallis test, p < 0.0001). Significant hardness reduction was observed in the positive control and DIY group (p < 0.0001). Mean surface roughness changes (ΔRa) were significantly different among the groups (Kruskal-Wallis test, p < 0.0001). Surface roughness increased in the OTC group (p = 0.03) and in the positive control (p < 0.0001). The four whitening modalities-DIY, OTC, HW and OW induced minimal surface morphology changes when observed with SEM. It can be concluded that none of the four whitening modalities adversely affected enamel surface morphology. However, caution should be advised when using a DIY regimen as it may affect enamel microhardness and an OTC product as it has the potential to increase surface roughness.

In Vitro Erosive Effect of Pediatric Medicines on Deciduous Tooth Enamel

This study evaluated, in vitro, the erosive potential of pediatric liquid medicines in primary tooth enamel, depending on the exposure time. Sixty deciduous incisors were randomly assigned to 4 groups (n=15), according to the immersion solutions: guaifenesin; ferrous sulfate; salbutamol sulfate and artificial saliva. The immersion cycles in the medicines were undertaken under a 1-min agitation, which wasperformed three times daily, during 28 days. Surface microhardness was measured at 7,14, 21 and 28 days. The titratable acidity and buffering capacity of the immersion media were determined. Data were analyzed by Analysis of Variance and Tukey's test (α=0.05). Salbutamol sulfate caused a gradual loss in enamel microhardness deciduous, observed at all times (p<0.005). Exposure to guaifenesin or ferrous sulfate resulted in significant decrease of enamel microhardness only after 28 days (p<0.005). In the control group (artificial saliva), microhardness did not changed (p>0.005) at any of the studied times. Scanning Electron Microscopy (SEM) images revealed that after 28 days the surfaces clearly exhibited structural loss, which was unlike those immersed in artificial saliva. Erosion of deciduous enamel was dependent on the type of medicine and exposure time.