Application of transverse microradiography for measurement of mineral loss by acid erosion

Characterization of dynamic process of carious and erosive demineralization - an overview

To review the analytical methods for carious and erosive demineralization an initial search of peer-reviewed scientific literature from the digital library database of PubMed/Medline indexed journals published up to early 2022 was carried out based on keywords relevant to the topic criteria including bibliographic citations from the papers to gather the most updated information. This current review aims to provide an updated overview of the advantages, limitations, and potential applications of direct and indirect research methods available for studying various dynamic stages of carious and erosive demineralization in enamel and dentin. This paper categorizes and describes the most suitable, frequently adopted and widely used quantitative and qualitative techniques in in vitro/in vivo research which are well-established, emerging, or comparatively novel techniques that are being explored for their potential validation.

A novel non-destructive technique for qualitative and quantitative measurement of dental erosion in its entirety by porosity and bulk tissue-loss

OBJECTIVE

To explore the potential of combining non-contact profilometry (NCP) and confocal laser scanning microscopy (CLSM) data to measure the entire erosive process non-destructively and to validate findings using inductively coupled plasma-atomic emission spectroscopy (ICP-AES), scanning electron microscopy (SEM) and surface microhardness (SMH) using the same samples throughout.

METHODS

Polished bovine enamel samples (n = 35) were divided into groups (7/group) with similar SMH values. Samples underwent individual erosive challenges (1 % citric acid, pH3.8) for 1, 5, 10, 15 or 30 min under stirring and aliquot extracts were analysed for Ca and P by ICP-AES. SMH was used to measure erosive softening. Profilometry was used to assess bulk volume loss (BVL). Images were captured by SEM. Samples were stained with rhodamine-B (0.1 mM, 24 h) and images captured by CLSM. Image processing was used to determine changes in fluorescent volume for the first 10 μm (ΔFV₁₀) for each enamel sample which were combined with BVL to calculate total lesion volume (TLV). ANOVA, linear regression and Pearson correlation analysis were used where applicable.

RESULTS

Surface softening, [Ca], [P], BVL and ΔFV_10μm increased with acid erosion duration which were significant by 10 min (P < .01). The Ca:P ratio increased to 1.57 then decreased after 5 min erosion suggesting a sub/surface phase change, which was observed by SEM and CLSM showing significant changes to the enamel surface and subsurface morphology with time. Combination of BVL and ΔFV₁₀ as TLV strengthened the significant correlations with [Ca], [P], and SMH (P < .01).

CONCLUSION

This novel combination of CLSM and NCP allows for concurrent non-destructive quantification of the entire erosive process by mineral loss, and qualitatively characterise microstructural changes during dental erosion.

Techniques to Evaluate Dental Erosion: A Systematic Review of Literature

This article reviews different techniques for evaluating dental erosion, weighs the advantages and disadvantages of these techniques, and presents the latest trends in the study of dental erosion. In May 2014, an initial search was carried out in the PubMed/MEDLINE database of indexed journals from 1975 to 2013 using the following keywords: dental erosion; dental erosion In-vitro; and dental erosion in-vivo. Bibliographic citations from the papers found were then used to find other useful sources. The authors categorize the techniques into three classes: in-vitro, in-vivo and in-vitro/in-vivo. The article discusses the instrumentation required to use each of these techniques, as well as their rationale, merits and applications. The emergence of in-vitro/in-vivo techniques offers the potential to accurately quantify tooth wear in clinical situations. Cross-sectional as well as longitudinal studies show that these techniques will improve diagnosis, treatment planning and management of dental erosion.

Early diagnosis of teeth erosion using polarized laser speckle imaging

Dental erosion starts with a chemical attack on dental tissue causing tooth demineralization, altering the tooth structure and making it more sensitive to mechanical erosion. Medical diagnosis of dental erosion is commonly achieved through a visual inspection by the dentist during dental checkups and is therefore highly dependent on the operator's experience. The detection of this disease at preliminary stages is important since, once the damage is done, cares become more complicated. We investigate the difference in light-scattering properties between healthy and eroded teeth. A change in light-scattering properties is observed and a transition from volume to surface backscattering is detected by means of polarized laser speckle imaging as teeth undergo acid etching, suggesting an increase in enamel surface roughness.

The effect of air-abrasion on the susceptibility of sound enamel to acid challenge

OBJECTIVE

To evaluate the effect of air-abrasion using three abrasive powders, on the susceptibility of sound enamel to an acid challenge.

METHODS

40 human enamel samples were flattened, polished and assigned to 4 experimental groups (n=10); a: alumina air-abrasion, b: sodium bicarbonate air-abrasion, c: bioactive glass (BAG) air-abrasion and d: no surface treatment (control). White light confocal profilometry was used to measure the step height enamel loss of the abraded area within each sample at three stages; after sample preparation (baseline), after air-abrasion and finally after exposing the samples to pH-cycling for 10 days. Data was analysed statistically using one-way ANOVA with Tukey's HSD post-hoc tests (p<0.05). Unique prismatic structures generated by abrasion and subsequent pH cycling were imaged using multiphoton excitation microscopy, exploiting strong autofluorescence properties of the enamel without labelling. Z-stacks of treated and equivalent control surfaces were used to generate non-destructively 3-dimensional surface profiles similar to those produced by scanning electron microscopy.

RESULTS

There was no significant difference in the step height enamel loss after initial surface air-abrasion compared to the negative control group. However, a significant increase in the step height enamel loss was observed in the alumina air-abraded samples after pH-cycling compared to the negative control (p<0.05). Sodium bicarbonate as well as BAG air-abrasion exhibited similar enamel surface loss to that detected in the negative control group (p>0.05). Surface profile examination revealed a deposition effect across sodium bicarbonate and BAG-abraded groups.

CONCLUSION

This study demonstrates the importance of powder selection when using air abrasion technology in clinical dentistry. Pre-treating the enamel surface with alumina air-abrasion significantly increased its susceptibility to acid challenge. Therefore, when using alumina air-abrasion clinically, clinicians must be aware that abrading sound enamel excessively renders that surface more susceptible to the effects of acid erosion. BAG and sodium bicarbonate powders were less invasive when compared to the alumina powder, supporting their use for controlled surface stain removal from enamel where indicated clinically.

Comparison of four methods to assess erosive substance loss of dentin

Erosion of dentin results in a complex multi-layered lesion. Several methods have been used to measure erosive substance loss of dentin, but were found to have only limited agreement, in parts because they assess different structural parameters. The present study compared the agreement of four different methods (transversal microradiography [TMR], Confocal Laser Scanning Microscopy [CLSM], Laser Profilometry [LPM] and modified Knoop Hardness measurement [KHM]) to measure erosive substance loss in vitro. Ninety-six dentin specimens were prepared from bovine roots, embedded, ground, polished and covered with nail-varnish except for an experimental window. Erosion was performed for 1 h using citric acid concentrations of 0.00% (control), 0.07%, 0.25% and 1.00% (n = 24/group). Adjacent surfaces served as sound reference. Two examiners independently determined the substance loss. After 1 h erosion with 1% citric acid solution, substance losses (mean±SD) of 12.0±1.3 µm (TMR), 2.9±1.3 µm (LPM), 3.9±1.3 µm (KHM) and 17.0±2.6 µm (CLSM) were detected. ROC curve analysis found all methods to have high accuracy for discriminating different degrees of erosive substance loss (AUC 0.83–1.00). Stepwise discriminatory analysis found TMR and CLSM to have the highest discriminatory power. All methods showed significant relative and proportional bias (p<0.001). The smallest albeit significant disagreement was found between LPM and KHM. No significant inter-rater bias was detected except for KHM. LPM is prone to underestimate erosive loss, possibly due to detection of the organic surface layer. KHM was not found suitable to measure erosive loss in dentin. TMR and CLSM detected the loss of mineralised tissue, showed high reliability, and had the highest discriminatory power. Different methods might be suitable to measure different structural parameters.

Er:YAG laser irradiation to control the progression of enamel erosion: an in situ study

This in situ study evaluated the effect of Er:YAG laser irradiation in controlling the progression of enamel erosion-like lesions. Fifty-six enamel slabs (330 KHN ± 10 %) with one fourth of the surface covered with resin composite (control area) were submitted to initial erosion-like lesion formation with citric acid. The slabs were divided into two groups: irradiated with Er:YAG laser and non-irradiated. Fourteen volunteers used an intraoral palatal appliance containing two slabs, in two phases of 5 days each. During the intraoral phase, in a crossed-over design, half of the volunteers immersed the appliance in citric acid while the other half used deionized water, both for 5 min, three times per day. Enamel wear was determined by an optical 3D profilometer. ANOVA revealed that when deionized water was used as immersion solution during the intraoral phase, lower values of wear were showed when compared with the groups that were eroded with citric acid, whether irradiated or non-irradiated with Er:YAG laser. When erosion with citric acid was performed, Er:YAG laser was not able to reduce enamel wear. Small changes on enamel surface were observed when it was irradiated with Er:YAG laser. It may be concluded that Er:YAG laser irradiation did not reduce the progression of erosive lesions on enamel submitted to in situ erosion with citric acid.

Quantification of incisal tooth wear in upper anterior teeth: conventional vs new method using toolmakers microscope and a three-dimensional measuring technique

OBJECTIVES

This study aimed to quantify tooth wear in upper anterior teeth using a new CAD-CAM Laser scanning machine, tool maker microscope and conventional tooth wear index.

METHODS

Fifty participants (25 males and 25 females, mean age = 25 ± 4 years) were assessed for incisal tooth wear of upper anterior teeth using Smith and Knight clinical tooth wear index (TWI) on two occasions, the study baseline and 1 year later. Stone dies for each tooth were prepared and scanned using the CAD-CAM Laser Cercon System. Scanned images were printed and examined under a toolmaker microscope to quantify tooth wear and then the dies were directly assessed under the microscope to measure tooth wear. The Wilcoxon Signed Ranks Test was used to analyze the data.

RESULTS

TWI scores for incisal edges were 0-3 and were similar at both occasions. Score 4 was not detected. Wear values measured by directly assessing the dies under the toolmaker microscope (range = 113 - 150 μm, mean = 130 ± 20 μm) were significantly more than those measured from Cercon Digital Machine images (range=52-80 μm, mean = 68 ± 23 μm) and both showed significant differences between the two occasions.

CONCLUSIONS

Wear progression in upper anterior teeth was effectively detected by directly measuring the dies or the images of dies under toolmaker microscope. Measuring the dies of worn dentition directly under tool maker microscope enabled detection of wear progression more accurately than measuring die images obtained with Cercon Digital Machine. Conventional method was the least sensitive for tooth wear quantification and was unable to identify wear progression in most cases.

An Automated Digital Microradiography System for Assessing Tooth Demineralization

Digital Transverse microradiography (TMR) offers several advantages over film based methods including real-time image acquisition, excellent linearity with exposure, and it does not require expensive specialized film. The purpose of this work was to demonstrate that a high-resolution digital microradiography system can be used to measure the volume percent mineral loss for sound and demineralized enamel and dentin thin sections from 150-350-μm in thickness. A custom fabricated digital microradiography system with ~ 2-μm spatial resolution consisting of a digital x-ray imaging camera, a computerized high-speed motion control system and a high-intensity copper Kα; x-ray source was used to determine the volume percent mineral content of sound and demineralized tooth sections. The volume percent mineral loss was compared with cross-sectional microhardness measurements on sound extracted human teeth. The correlation between microhardness and microradiography was excellent (Pr=0.99) for section thickness ranging from 59-319-μm (n=13). The attenuation was linear with varying exposure time from 1-10 seconds. Digital TMR is an effective and rapid method for the assessment of the mineral content of enamel and dentin thin sections.

Evaluation of a profilometrical method for monitoring erosive tooth wear

The in vivo monitoring of erosive wear is difficult because lesions mostly progress relatively slowly and reliable reference points are difficult to obtain. To date, only a few methods for clinical monitoring of erosive loss have been described, which either require extensive equipment or do not provide sufficient sensitivity. The aim of the present study was to evaluate, using study models (epoxy resin material), a procedure that permits the reliable and accurate monitoring of erosive substance loss within acceptable observation periods. The method is the profilometric measurement of erosive tissue loss using acid-resistant markers, which represent both a reference area and a structure for the defined retracing of a given erosive lesion surface. The study model magnified values slightly (2.8%; not significant), the precision was < 4 microm, and the repeatability was good (95% limits of repeatability ranging from -4.7 to 5.2 microm). The estimated detection threshold for erosive loss is 15 microm, which appears to be adequate for monitoring. The method is indicated for special dental care in cases of severe dental erosion (e.g. eating disorders) and for clinical studies.

Comparison of Calcium/Phosphorus Analysis, Longitudinal Microradiography and Profilometry for the Quantitative Assessment of Erosive Demineralisation

The study is a comparison of methods for the quantitative measurement of erosive mineral loss including longitudinal microradiography (LMR), profilometry (PM), and analysis of calcium (CA) and phosphorus (PA) in the erosion solution. Polished human enamel samples were taped, covered with nail varnish and the edges of the resulting enamel window marked with drilled holes as a reference. All samples were subjected to baseline LMR. Sixty samples each were eroded with citric acid (0.05 M; pH 2.3; 10 ml per sample) for 30, 60, 90, or 120 min. Erosive loss of each sample was estimated by the four methods. All methods revealed a linear erosive loss over time and showed good linear correlation. Values calculated from PM and LMR were both approximately 20% lower than those from CA and PA. After 30 min erosion, LMR showed no significant correlation with the other three methods. With LMR, erosive loss below 20 microm should be interpreted with care.

The laboratory assessment of enamel erosion: a review

OBJECTIVES

To review the various methods and techniques available to assess enamel erosion in vitro.

DATA

Peer reviewed scientific articles.

SOURCES

Medline and Web of Science searches and manual searching.

STUDY SELECTION

Laboratory based assessments only included.

CONCLUSIONS

A number of macroscopic and microscopic techniques have been used to assess enamel erosion in vitro and in situ. This review examines techniques which are either well established or comparatively novel techniques that are being explored for their potential.

The validation of Quantitative light-induced fluorescence to quantify acid erosion of human enamel

OBJECTIVE

The purpose of this study was to validate the Quantitative light-induced fluorescence (QLF) device against transverse microradiography (TMR) with regard to the quantification of enamel erosion in vitro.

DESIGN

Longitudinal in vitro.

METHODS

Thirty previously extracted, caries free, human premolars were selected and prepared by gentle pumicing and coating in an acid-resistant nail-varnish save for an exposed window on the buccal surface. QLF baseline images were taken and the teeth then exposed to an erosive solution, 0.1% citric acid (pH 2.74). Teeth were removed at 30min intervals, air-dried and QLF images taken. At this time one tooth was randomly selected, removed from solution and sectioned through the lesion at three sites. The polished sample (100microm) was subjected to TMR and analysed for erosive mineral loss using proprietary software, with the DeltaZ values noted. QLF images were analysed by a blinded examiner with DeltaF and DeltaQ values recorded. Data were entered into SPSS and the correlation between the DeltaZ and DeltaF, and DeltaZ and DeltaQ values calculated.

RESULTS

A wide range of erosive lesions was produced, with a steady increase in both DeltaZ and DeltaF over time; DeltaZ (24.0 (S.D. 1.2)-6114.3 (S.D. 1177.57)); DeltaF (1.8-11.2), DeltaQ (2.5-202.6). The results were scatter plotted and a regression line calculated. A positive correlation between DeltaZ and DeltaF of 0.91 was found, and for DeltaZ and DeltaQ; 0.87.

CONCLUSIONS

The ability for QLF to detect and longitudinally monitor in vitro erosion has been shown. The strong positive correlation of DeltaF with DeltaZ suggests that percentage fluorescence loss as measured by QLF could be of great value in the development of a non-destructive, longitudinal tool for use in vitro, in situ and possibly in vivo.

An in vitro assessment using transverse microradiography of the effect on mineral loss of etching enamel for in situ studies

OBJECTIVES

To test the hypothesis that etching enamel with 37% phosphoric acid for 30 s does not lead to detectable mineral loss when measured with transverse microradiography (TMR).

DESIGN

An in vitro laboratory investigation.

EXPERIMENTAL VARIABLE

Forty bovine incisors were used in the experiment. The crowns of the teeth were covered with acid resistant varnish except for a rectangular area on the labial surface approximately 10 x 12 mm. On the exposed labial surface of 20 teeth an enamel lesion similar to that used in the in situ caries model was induced. Twenty teeth were left without a lesion. The exposed area was divided into three areas of equal size. The control area (C) was covered with acid resistant varnish throughout the experiment. The first experimental area (E1) was etched with 37% phosphoric acid for 30 s and a simulated bracket was bonded to the surface with composite resin. The second experimental area (E2) was left exposed for the remainder of the experiment. The teeth were placed in a demineralizing solution for 24, 48, 72 or 96 h to replicate different cariogenic challenges.

OUTCOME MEASURE

Mineral loss as measured with TMR.

RESULTS

There were no significant differences in the mineral loss between etched (E1) and etched (C) areas of enamel. There were significant differences in mineral loss between E1 and E2 for the 48 h (p < 0.001) and 72 h (p = 0.001) exposures without a pre-formed enamel lesion.

CONCLUSION

There is no detectable mineral loss with TMR when enamel has been etched for 37% phosphoric acid for 30 s. The use of in situ enamel specimens with acid etch retained simulated brackets to investigate demineralization during orthodontics will not significantly affect the outcome compared with unetched specimens.

Prevention. Part 3: prevention of tooth wear

Non-carious destruction of teeth has been observed in archaeological material from various parts of the world and clearly pre-dates the first appearance of dental caries. Attrition, abrasion and erosion are also described in the classic text of Pindborg on the pathology of the dental hard tissues. Whilst the dental profession, at least in affluent parts of the world, was engaged in diagnosing, treating and later preventing dental caries these other causes of tooth destruction were largely ignored.

Structured review of enamel erosion literature (1980-1998): a critical appraisal of experimental, clinical and review publications

OBJECTIVE

To attain an objective account of the methods to measure enamel erosion used in 1980-1998 publications, a structured review of the literature was undertaken.

METHODS

Inclusion and exclusion criteria were applied to 731 clinical/experimental research and review reports. Eighty-five included papers were subsequently rated according to 'hierarchy of evidence' guidelines to assess the strength of the report's design and the relevance of the evidence to replicating enamel erosion in vivo in humans. Scores were assigned to rate each aspect in the guidelines.

RESULTS

A total of 16 clinical, 13 review and 56 experimental papers were assessed; 36.4% were published during 1996-1998. Excluding reviews, 16 papers were qualitative and 56 quantitative; 51 used human enamel. Our classification yielded nine groups of methods (five scoring systems and 26 measurement techniques). CTFPHE (Can Med Assoc J 1992; 147: 443) grading of research reports indicated that 2.8% provided evidence grade I; 20.8%, grade IIa; 63.9%, grade III; and 12.5%, grade IV.

CONCLUSIONS

There has been a consistent increase in the body of knowledge. The overall quality of publications has not substantially changed over time. Experimental studies were more often quantitative, and quantitative studies had better research designs. No single group of research methods had obviously superior research designs.

The effect of saliva on enamel and dentine erosion

The present study aims to assess the ability of saliva, both in vitro and in situ, to prevent surface mineral loss from enamel and dentine when exposed to an erosive challenge. Fifteen groups of four varnished thin tooth sections were stored in saliva collected from individuals taking part in the in situ study and a further eight groups, each containing four sections, were stored in deionised water. In vitro, sections were stored in saliva or water for 14 days. In addition, fifteen subjects each wore an appliance with four varnished sections. Appliances with sections were worn for 14 days. All sections were exposed to 25 ml of erosion solution for 5 min twice daily. Microradiography and image analysis of the recovered sections demonstrated significant protection of surface mineral loss from enamel and dentine by saliva in vitro and in situ compared with deionised water (p < 0.05). Significantly less mineral loss (p < 0.05) was observed for enamel and dentine stored in situ compared with storage in saliva in vitro. Generalised linear modelling demonstrated both the subject and protocol had significant effect on mineral loss. A weak positive correlation (r = 0.64) was noted when in situ and in vitro mineral loss from enamel were compared, demonstrating greater reactivity of the in vitro enamel specimens to the erosion challenge. The dentine data did not show any linear correlation. Saliva protected against mineral loss by erosion and, for enamel, in vitro results demonstrated a weak positive correlation with in situ results.