An in situ enamel section model for assessment of enamel re/demineralization potential

Demineralization prevention with a new antibacterial restorative composite containing QASi nanoparticles: an in situ study

OBJECTIVES

To investigate whether a newly developed dental composite with quaternary ammonium silica dioxide (QASi) nanoparticles incorporated with other fillers into the restorative material demonstrates antibacterial activity by reducing enamel demineralization in an in situ gap model.

MATERIALS AND METHODS

Twenty subjects wearing a lower removable partial denture (RPD) with acrylic flanges on both sides of the mouth were recruited into the 4-week in situ study. The gap model consisted of an enamel slab placed next to a composite, separated by a 38-μm space. In the split-mouth design on one side of the RPD, the composite was the Nobio Infinix composite (Nobio Ltd., Kadima, Israel), and the contralateral side used a control composite. Each participant received enamel slabs from one tooth. The gap model was recessed into the RPD buccal flange, allowing microbial plaque to accumulate within the gap. After 4 weeks of continuous wearing, decalcification (∆Z mineral loss) of the enamel slabs adjacent to the gap was determined by cross-sectional microhardness testing in the laboratory.

RESULTS

The ∆Z for the antibacterial composite test side was 235±354 (mean±standard deviation [SD]; data reported from 17 participants) and statistically significantly lower compared to ∆Z of the control side (774±556; mean±SD) (paired t-test, P<0.0001; mean of test minus control -539 (SD=392), 95% confidence interval of difference: -741, -338).

CONCLUSIONS

This in situ clinical study showed that composites with QASi antibacterial particles significantly reduced demineralization in enamel adjacent to a 38-μm gap over a 4-week period in comparison to a conventional composite.

CLINICAL RELEVANCE

Composites with QASi nanoparticle technology have the potential to reduce the occurrence of secondary caries.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT04059250.

The Role of Microbiology in Models of Dental Caries: Reaction Paper

Models of the caries process have made significant contributions toward defining the roles of bacteria in caries. Microbiologists use a variety of in vitro systems to model aspects of the caries process. Also, in situ models in humans provide information on the microbiology of caries in vivo. These models do not involve the entire process leading to natural caries; consequently, the results from such studies are used to deduce the roles of bacteria in natural caries. Therefore, they can be described as Inferential Caries Models. In contrast, animal models and some clinical trials in humans involve natural caries and can be described as Complete Caries Models. Furthermore, these models are used in two distinct ways. They can be used as Exploratory Models to explore different aspects of the caries process, or as Test Models to determine the effects of anticaries agents. This dichotomy in approach to the use of caries models results in modification of the models to suit a particular role. For example, if we consider Exploratory Models, the in situ appliance in humans is superior to others for analyzing the microbiology of plaque development and demineralization in vivo. The chemostat and biofilm models are excellent for exploring factors influencing bacterial interactions. Both models can also be used as Test Models. The in situ model has been used to test the effects of fluoride on the microflora and demineralization, while the chemostat and biofilm models allow for the testing of antibacterial agents. Each model has its advantages and disadvantages and role in analysis of the caries process. Selection of the model depends on the scientific question posed and the limitations imposed by the conditions available for the study.

Effect of dentifrices on their remineralizing potential in artificial carious lesions: An in situ study

Background:

The eventual sequel of dental caries is determined by the dynamic equilibrium between pathological factors which lead to demineralization and protective elements, which in turn leads to remineralization. Remineralization is the natural process for noncavitated demineralized lesions and relies on calcium and phosphate ions assisted by fluoride to rebuild a new surface on existing crystal remnants in subsurface lesions remaining after demineralization. Hence, the present study was designed to evaluate the efficacy of fluoride dentifrices in remineralizing artificial caries-like lesions in situ.

Materials and Methods:

A double-blind, randomized study with an initial washout period of 7 days was carried out for 3 weeks. Twenty volunteers were enrolled, who wore the intraoral cariogenicity test appliance having enamel slabs incorporated into them, for 3 weeks. 10 participants were instructed to use Group A dentifrice (fluoride) and the other 10 Group B dentifrice (nonfluoride) for brushing their teeth. The enamel slabs were analyzed by surface microhardness testing and scanning electron microscopy (SEM) at 3 intervals.

Results:

No significant differences was seen in the microhardness values recorded for Group A and Group B at baseline and after demineralization (P > 0.05); however Group B exhibited lesser microhardness compared to Group A, after intra-oral exposure (P < 0.05). In the SEM analysis, the Group A enamel surfaces had more regular and longer crystallites to those of the Group B.

Conclusion:

Fluoride dentifrices avert the decrease in enamel hardness and loss of minerals from the enamel surface to a large extent as compared to the nonfluoride dentifrices.

The effect of various model parameters on enamel caries lesions in a dose-response model in situ

OBJECTIVES

The aim of this exploratory double-blinded, randomized, cross-over, in situ study was to compare the effects of various model parameters ('intervention', 'brushing', 'position') on enamel caries lesions in a dose-response model.

METHODS

In each of four experimental legs of four weeks 16 participants wore intraoral mandibular appliances with four 'plaque-retaining' and four 'easily cleanable' positioned pre-demineralized bovine enamel specimens in the vestibular flanges mimicking proximal and buccal surfaces, respectively (n=512). The four randomly allocated interventions (either application only or brushing) included the following dentifrices: AlF3 1360ppmF(-)+chlorhexidine 0.05% (Lacalut aktiv, LA1360), NaF 1,450ppmF(-)(Blend-a-Med ProExpert), NaF 500ppm F(-) and 0ppm F(-) as negative control (NC) (both experimental, based on Blend-a-Med ProExpert).

RESULTS

Differences in integrated mineral loss (ΔΔZ) and lesion depth (ΔLD) were calculated between values before and after the in situ period using transversal microradiography. Significant differences for ΔΔZ [adjusted mean (95% CI))] were found between NC, NaF500 and LA1360for both 'plaque-retaining' [-1830 (-2371;1289); -986 (-1530;442); -2 (-548;544)vol%×μm] as well as 'easily cleanable' specimens [-399 (-682; -116); -391 (-672; -110); -16 (-302;270)vol%×μm]. Values for NaF1450 revealed a similar dose-response as LA1360.Values for LA1360 and NaF1450 did not differ significantly (p>0.05; ANCOVA).

CONCLUSION/CLINICAL SIGNIFICANCE

The design of the present in situ study was able to reveal a fluoride dose-response to hamper further demineralization of enamel specimens for 'easily cleanable' and 'plaque-retaining' sites being brushed or not. Particularly 'plaque-retaining' sites seem to be recommendable for measuring potential anticaries efficacy in situ.

Appraisal of the remineralizing potential of child formula dentifrices on primary teeth: An in vitro pH cycling model

AIM

To evaluate the remineralizing potential of child formula dentifrices on primary teeth using an in vitro 7 days pH cycling model.

MATERIALS AND METHODS

Twenty-one primary teeth were placed in demineralizing solution for 96 h to produce artificial carious lesions; then cut longitudinally into 100-150 μm thick sections and randomly assigned to three groups. Sections in Group A were treated with dentifrice containing 458 ppm monofluorophosphate (MFP) and sections in Group B with 500 ppm sodium fluoride (NaF). Group C sections were treated with a nonfluoridated dentifrice.

RESULTS

Group A (458 ppm MFP) and Group B (500 ppm NaF) showed significant decrease in lesion depth, whereas Group C (non F) showed a significant increase in depth (P ≤ 0.05, paired t-test).

CONCLUSION

Though dentifrices containing 458 ppm MFP and 500 ppm NaF demonstrated remineralization of carious lesions, it was not complete. Therefore, it is also important to emphasize on other preventive methods in the prevention and/or reversal of carious lesions.

In vitro remineralization of enamel by polymeric amorphous calcium phosphate composite: quantitative microradiographic study

OBJECTIVE

This study explores the efficacy of an experimental orthodontic amorphous calcium phosphate (ACP) composite to remineralize in vitro subsurface enamel lesions microradiographically similar to those seen in early caries.

METHODS

Lesions were artificially created in extracted human molars. Single tooth sections a minimum of 120microm thick were cut and individually placed in holders exposing only the carious enamel surface. The exposed surfaces were either left untreated (control) or coated with a 1mm thick layer of the experimental ACP composite (mass fraction 40% zirconia-hybridized ACP and 60% photo-activated resin), or a commercial fluoride-releasing orthodontic cement. The composite-coated sections were then photo-cured and microradiographic images were taken of all three groups of specimens before the treatment. Specimens were then cyclically immersed in demineralizing and remineralizing solutions for 1 month at 37 degrees C to simulate the pH changes occurring in the oral environment. Microradiographs of all specimens were taken before and after treatment.

RESULTS

Quantitative digital image analysis of matched areas from the contact microradiographs taken before and after treatment indicated higher mineral recovery with ACP composites compared to the commercial orthodontic F-releasing cement (14.4% vs. 4.3%, respectively), while the control specimens showed an average of 55.4% further demineralization.

SIGNIFICANCE

Experimental ACP composite efficiently established mineral ion transfer throughout the body of the lesions and restored the mineral lost due to acid attack. It can be considered a useful adjuvant for the control of caries in orthodontic applications.

The use of in situ models and QLF for the study of coronal caries

OBJECTIVES

The purpose of the paper is to review aspects of the systems available to model the caries process in enamel.

METHODS

The in situ model developed in Liverpool, and the new method of quantifying mineral loss, Quantitative Light-induced Fluorescence (QLF), are described. QLF is a powerful new diagnostic tool which can be used to measure demineralisation and remineralisation in tooth surfaces in vivo; studies to optimise, validate and use QLF in different clinical situations are described.

RESULTS

Examples of the use of in situ models show that they are particularly valuable for monitoring de and remineralisation of artificial lesions in relation to product testing as alternatives to clinical trials, and present significant advances over in vitro methods. Quantification of mineral loss by Transverse Microradiography (TMR) as in the traditional Liverpool model has produced much valuable information, but the destructive nature of the method limits experimental design, and removes the system from the clinical situation. As a possible alternative, QLF has been validated and optimised. Longitudinal measures can be made on the same surface, and examples of its use are for monitoring recurrent caries and demineralisation around orthodontic brackets.

CONCLUSIONS

While current in situ models provide a major advance over earlier caries models, measurement of de and remineralisation by destructive methods such as transverse microradiography limits the design of experimental investigations. QLF offers significant time saving, reduces the cost of clinical studies, and because the measurements can be carried out longitudinally in vivo, can remove the need for intra-oral appliances carrying experimental tissues.

Evaluating the effects of fluoride-releasing dental materials on adjacent interproximal caries

BACKGROUND

The authors examined several restorative materials to evaluate their ability to inhibit demineralization and enhance remineralization of incipient carious lesions on the interproximal enamel of teeth adjacent to those restored with the materials.

METHODS

Twenty-one subjects in need of a crown on a mandibular molar and a Class II inlay on an adjacent tooth took part in this six-phase study. Artificial enamel lesions were created and positioned within the interproximal portion of a crown. Lesions were photographed with polarized light microscopy and characterized before and after 30-day intraoral exposures. Each phase included the placement of a new section in the crown model and a new Class II inlay restorative material in the adjacent tooth.

RESULTS

Results demonstrated that nonfluoridated resin composite, fluoridated resin composite and resin-modified glass ionomer restorative materials, when placed in subjects who brushed with a fluoridated dentifrice, demonstrated significantly (P < .05) less enamel demineralization than the nonfluoridated resin composite control placed in subjects who brushed with a nonfluoridated dentifrice. The resin-modified glass ionomer cement, however, even when brushed with a nonfluoridated dentifrice, exhibited significantly (P < .05) less demineralization than the nonfluoridated resin composite control brushed with a nonfluoridated dentifrice.

CONCLUSIONS

Resin-modified glass ionomer cement appears to significantly inhibit demineralization of interproximal enamel of teeth adjacent to those restored with the material.

CLINICAL IMPLICATIONS

Resin-modified glass ionomer cement restorations can enhance prevention of enamel demineralization on adjacent teeth.

The application of in situ models for evaluation of new fluoride-containing systems

Many in situ models have assessed the anticaries potential of fluoride-containing systems (Stookey et al., 1985; Mellberg et al., 1986, 1992a,b; Corpron et al., 1986; Featherstone and Zero, 1992; Ogaard and Rolla, 1992; Stephen et al., 1992). Several models have reportedly been validated according to guidelines proposed by Proskin et all. (1992). The proposed guidelines cover only dentifrices containing sodium fluoride (NaF) or sodium monofluorophosphate (SMFP) as active ingredients. These compounds are the most widely used sources of fluoride in dentifrices, and dose-response clinical standards are available for both. Other fluoride compounds, such as amine fluoride (AmF) and stannous fluoride (SnF2), have also been proven effective in reducing caries (Muehler et al., 1957, 1958; Marthaler, 1968; Lu et al., 1980; Cahen et al., 1982). Profile standards for these fluorides were not included in the proposed guidelines, primarily due to the lack of clinical data necessary to establish a dose response for these ingredients. Criteria for demonstrating the efficacy of these ingredients, along with methods to assess new fluoride compounds, need to be established. In situ models are used to evaluate the anticaries potential of new compounds added to mouthrinses, gums, slow-release devices, etc. (Creanor et al., 1992; Manning and Edgar, 1992; Lamb et al., 1993; Toumba and Curzon, 1993; Wang et al., 1993). Ingredients are often added to dentifrices previously proven effective against caries in order to provide additional benefits of gum health, tartar control, cleaning, etc. Proposals are made regarding the in situ testing of new dentifrices containing clinically proven fluoride compounds other than NaF and SMFP, as well as alternative delivery systems, in order to assist in their evaluation.

The application of in vitro models to research on demineralization and remineralization of the teeth

Progress in in vivo and in situ experimentation has led many researchers to speculate as to the relevance and importance of in vitro testing protocols in caries research. A Medline/Biosis search for the present review revealed well over 300 citations (since 1989) documenting in vitro tests associated with caries research on mineralization and fluoride reactivity. The present survey documents these recent applications of in vitro test methods in both mechanistic and 'profile' caries research. In mechanistic studies, in vitro protocols over the past five years have made possible detailed studies of dynamics occurring in mineral loss and gain from dental tissues and the reaction dynamics associated with fluoride anticaries activity. Similarly, in profile applications, in vitro protocols make possible the inexpensive and rapid--yet sensitive--assessment of F anticaries efficacy within fluoride-active systems, and these tests represent a key component of product activity confirmation. The ability to carry out single variable experiments under highly controlled conditions remains a key advantage in in vitro experimentation, and will likely drive even further utilization, as advances continue in physical-chemical and analytical techniques for substrate analysis in these protocols. Despite their advantages in vitro testing protocols have significant limitations, most particularly related to their inability to simulate the complex biological processes involved in caries.

In situ caries models

By using in situ models, we have the potential to study both fundamental aspects of the caries process as well as more applied research problems such as the effect of food on dental caries and the role of fluoride in caries prevention in human subjects without actually causing caries in the natural dentition. The key experimental parameters that need to be considered in the development of an in situ model are the characteristics of the subject panel, the physical design of the model, the type of hard tissue substrate and the method of assessing mineral status, and the study design and clinical protocol. Each parameter must be carefully considered in relation to the objectives of the research, study design requirements, ethical considerations, impact on clinical relevance, and impact on the control of variation. The major source of variation associated with in situ models should be of biological and not experimental origin. The design and conduct of proper in situ model studies require a clear understanding of the caries process, sound analytical support, and a knowledge of how to work with research subjects to achieve a high level of compliance. Given the complex nature of caries, a combination of hard tissue substrates--including sound, surface-softened lesions and subsurface lesions--may be necessary to model all aspects of caries progression and prevention successfully. Internal validation of in situ models using fluoride dose-response controls is considered to be necessary for studies evaluating the efficacy of new fluoride dentifrice formulations.

In situ models, physico-chemical aspects

In situ (intra-oral) caries models are used for two purposes. First, they provide information about oral physiological processes. Such information helps to detail our knowledge of the oral ecosystem and to verify conclusions from in vitro experiments. Second, in situ models are utilized to test preventive agents in the phase between laboratory testing and clinical trials. Most investigations involving enamel inserts have been aimed at testing new dentifrices. The experimental designs of such studies usually do not allow one to draw conclusions on physico-chemical processes, e.g., because of single point measurements. Studies of model parameters (lesion type, lesion severity, and de/remineralization in time) constitute only a minority of the research reports. The most striking observation obtained with in situ models has been the significant differences in de/remineralization observed among individuals and, more importantly, within one individual during different time periods and between different sites in the same mouth (for review, see ten Cate et al., 1992). Regardless of this, some general findings can be inferred: During in situ demineralization, up to 62 vol% microns/day may be removed from enamel. For dentin specimens, this value may be as high as 89 vol% microns/day. For remineralization, during fluoride dentifrice treatment, a median deposition rate of 0.7%/day (for lesions with integrated mineral loss values between 2000 and 4000 vol% microns) is found. The rate of deposition seems to be correlated with the extent of the pre-formed lesion. This suggests that the number of sites (crystallite surface) available for calcium phosphate precipitation is an important parameter.(ABSTRACT TRUNCATED AT 250 WORDS)