Protective effect of various toothpastes and mouthwashes against erosive and abrasive challenge on eroded dentin: an in vitro study

The study aimed to compare various toothpastes and mouthwashes on permanent tooth dentin after erosive and abrasive challenges. 130 sound premolars dentin were randomly submitted to an initial erosive challenge and a cycle of erosive and abrasive challenges for five days. The five experimental groups (n = 26) were: (1) Control group (artificial saliva), (2) Elmex erosion protection toothpaste and mouthwash, (3) Vitis anticaries biorepair toothpaste and mouthwash, (4) Oral B Pro-expert toothpaste and Oral B Fluorinse mouthwash, and (5) MI Paste ONE toothpaste and Caphosol mouthwash. Microhardness, surface roughness values, and the topographical characteristics of the dentin surface were assessed. The highest percentage of recovered dentin microhardness (%RDMH) value was observed in groups 2 and 4, followed by groups 5 and 3, respectively. The %RDMH values in groups 2 and 4 did not demonstrate a significant difference (p = 0.855). The highest percentage of improvement in surface roughness was recorded in groups 2 and 4, with no significant differences (p = 0.989). The atomic force microscopy (AFM) findings were consistent with the surface roughness data. The best recovery of dentin microhardness and roughness were measured with the Elmex and Oral B toothpaste and mouthwash, followed by MI Paste ONE toothpaste and Caphosol mouthwash and Vitis anticaries biorepair toothpaste and mouthwash.

Combined Casein Phosphopeptide-Amorphous Calcium Phosphate and Fluoride Is Not Superior to Fluoride Alone in Early Carious Lesions: A Meta-Analysis

There is a growing need for effective methods in the management of early stage carious lesions. Therefore, the aim of this study was to evaluate the effect of combined casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and fluoride on white spot lesions (WSLs) compared to fluoride-only interventions. This meta-analysis was performed according to PRISMA guidelines and registered in PROSPERO (CRD42021286245). The Medline, Embase, and Cochrane Central databases were searched until October 17, 2022. Eligible studies were randomized controlled trials. Outcome variables included laser fluorescence (LF), quantitative light-induced fluorescence (QLF), and lesion area scores. The random-effects model was used for analysis, and results were given as standardized mean difference (SMD) and mean difference (MD) with a 95% confidence interval. Risk of bias was assessed using the RoB 2 tool, and the level of evidence with GRADE. Our systematic search yielded 973 records after duplicate removal, 21 studies were included for qualitative synthesis, and 15 studies were eligible for quantitative analysis. No significant difference was found between CPP-ACP and fluoride versus fluoride alone in LF at 1, 3, and 6 months of use: SMD -0.30 (-0.64; 0.04); SMD -0.47 (-1.02; 0.07); SMD -0.49 (-1.13; 0.15), respectively. For QLF, the analysis did not demonstrate significant differences between these two kinds of treatment at 1 and 6 months of use: MD 0.21 (-0.30;0.71); MD 0.60 (-1.70;2.90), but at 3 months, higher QLF values were found in the fluoride-only group compared to the CPP-ACP and fluoride combination was shown regarding the WSLs: MD 0.58 (0.25;0.91). On the contrary, data showed a small but statistically significant decrease in the lesion area in favor of the CPP-ACP plus fluoride versus fluoride alone at 6 months MD -0.38 (-0.72; -0.04). None of these observed changes indicated substantial clinical relevance. The combination of CPP-ACP and fluoride did not overcome the effect of fluoride given alone. Our data suggest that fluoride itself is effective in improving WSLs. However, the certainty of evidence was very low. These results indicate that further studies and future development of more effective products than CPP-ACP are needed in addition to fluoride to achieve robust amelioration of WSLs.

Comparative evaluation of four treatments for postorthodontic white spot lesions: a randomized controlled trial

OBJECTIVES

To evaluate the treatment efficacy of fluoride toothpaste alone and those of adjunctive use of resin infiltration, sodium fluoride varnish, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs).

MATERIALS AND METHODS

Seventy-nine patients (356 teeth) with WSLs after orthodontic treatment were randomly allocated into four groups. The WSLs of the participants received resin infiltration only at baseline, and the other groups received fluoride varnish, CPP-ACP mousse, and placebo treatment every 6 months, respectively. A toothpaste containing 1400 ppm fluoride and toothbrushes were distributed to all participants, and oral hygiene instructions were provided. Photos of the teeth with WSL were taken to compare the change between groups which was measured by ImageJ software.

RESULTS

Twelve months later, different degrees of reduction in the area of WSLs were observed in all groups. The percentage of lesion area reduction in WSLs in the resin infiltration group was 46.6%, which was significantly higher than that in fluoride varnish group (26.6%), CPP-ACP group (28.6%), and control group (29.8%), and the differences were statistically significant (p < 0.001).

CONCLUSIONS

This study shows that after 1-year follow-up, the use of fluoride toothpaste, with or without the use of fluoride varnish or CPP-ACP, can reduce the area of WSLs. While resin infiltration can immediately improve dental aesthetics and continuously improved in 12 months, resin infiltration group showed much better results than other groups.

TRIAL REGISTRATION

Clinical Trials Registration Number: ChiCTR2000032516.

CLINICAL SIGNIFICANCE

The use of fluoride toothpaste, with or without adjunctive use of fluoride varnish and CPP-ACP, can reduce the area of WSLs, while resin infiltration treatment has additional effect and can immediately improve dental aesthetics.

The effect of the Er,Cr:YSGG laser combined casein phosphopeptide amorphous calcium phosphate for enamel remineralisation: a systematic review and meta-analysis of in vitro studies

The purpose of this systematic review and meta-analysis of in vitro studies was to evaluate the effect of the 2780 nm Er,Cr:YSGG laser combined with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) for enamel remineralisation. The electronic PubMed, Cochrane Library, Web of Science, and EMBASE databases were searched, with no language or date restrictions, up to January 2023. Two reviewers independently performed research information extraction and quality assessment. Continuous variables were analysed by standard mean difference (SMD) with a 95% confidence interval (CI). The statistical analyses were conducted using Review Manager (Version 5.4; Rev Man) and Cochrane Collaboration (2020). Finally, four trials were included for meta-analysis. According to the comprehensive results, the effect of the Er,Cr:YSGG laser combined with CPP-ACP on enamel remineralisation was significantly better than that of CPP-ACP alone: surface microhardness (SMD =  - 1.83, 95% CI: [- 2.98, - 0.69], P = 0.002); lesion depth (SMD = 6.63, 95% CI: [4.98, 8.28], P < 0.001). Under the limitations of this meta-analysis, the results show that the Er,Cr:YSGG laser combined with CPP-ACP has a better effect on enamel remineralisation than CPP-ACP alone. The combination of the Er,Cr:YSGG laser and CPP-ACP may be a feasible method to prevent and treat enamel demineralisation.

Evaluation of Iontophoresis as a Tool in Comparison to Topical Remineralization Systems by Transverse Microradiography and Polarized Light Microscopy: An In Vitro Study

Aim

To compare the efficacy of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) (GC Tooth Mousse) and tricalcium phosphate formulation (Clinpro) by topical application and iontophoresis.

Background

Noninvasive treatment of dental caries is a major advance in the clinical management of the disease.

Materials and methods

A total of 20 primary anterior and 20 primary molars were included in the study to be analyzed by transverse microradiography (TMR) and polarized light microscopy (PLM). The samples were coated with acid-resistant varnish, leaving a window on the buccal/lingual surface of enamel and immersed in demineralizing solution for 96 hours. Each sample was coated with varnish on the left half (control), and the right half served as a test. All the samples were divided into four groups. The test windows of specimens in groups I (GC Tooth Mousse) and II (Clinpro) were subjected to remineralization treatments for 10 days. Similarly, groups III and IV were subjected to iontophoresis using GC Tooth Mousse and Clinpro for 7 minutes. The samples were analyzed by TMR and PLM.

Results

There was no significant difference in the mean difference of mineral loss among the four groups. There was a significant difference in the mean difference of lesion depth among the four groups.

Conclusion

Both iontophoresis and topical application were equally efficient, but one remineralization by iontophoresis equals 10 topical applications.

How to cite this article

VC R, Muppa R, Nallanchakrava S, et al. Evaluation of Iontophoresis as a Tool in Comparison to Topical Remineralization Systems by Transverse Microradiography and Polarized Light Microscopy: An In Vitro Study. Int J Clin Pediatr Dent 2023;16(S-1):S85-S90.

Comparative Evaluation of the Remineralizing Potential of Silver Diamine Fluoride, Casein Phosphopeptide-amorphous Calcium Phosphate, and Fluoride Varnish on the Enamel Surface of Primary and Permanent Teeth: An In Vitro Study

Introduction

With the paradigm shift in the management of dental caries, the focus is now laid on remineralization therapies that can arrest the progression of the disease and remineralize the subsurface lesions.

Objectives

The purpose of this study was to determine and compare the remineralizing potential of silver diamine fluoride (SDF), casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), and fluoride varnish (FV) on enamel surfaces in primary and permanent teeth.

Materials and methods

A total of 120 primary anterior teeth and 120 premolars were used to prepare enamel blocks in acrylic resin. The mean baseline surface microhardness (SMH) for each sample was determined using a microvickers hardness testing machine. Thereafter, the samples were randomly and equally distributed into groups and subgroups based on the materials used, that is, SDF, CPP-ACP, FV, and distilled water (control). After subjecting the samples to a pH cycling regime, SMH was determined again and the percentage change in SMH was calculated.

Results

The data were tabulated and subjected to statistical analysis using an independent t-test and one-way analysis of variance (ANOVA). In primary teeth, the least mean percentage reduction in SMH was observed after the application of FV followed by SDF, CPP-ACP, and control. In permanent teeth, both SDF and FV showed the least percentage reduction of enamel SMH followed by CPP-ACP and control.

Conclusion

Silver diamine fluoride (SDF), FV, and CPP-ACP showed remineralizing potential in both primary and permanent teeth.

How to cite this article

Kaur S, Bhola M, Bajaj N, et al. Comparative Evaluation of the Remineralizing Potential of Silver Diamine Fluoride, Casein Phosphopeptide-amorphous Calcium Phosphate, and Fluoride Varnish on the Enamel Surface of Primary and Permanent Teeth: An In Vitro Study. Int J Clin Pediatr Dent 2023;16(S-1):S91-S96.

Shear bond strength of metallic brackets bonded to enamel pretreated with CPP-ACP: a systematic review and meta-analysis of in vitro studies

BACKGROUND

Development of white spot lesions (WSLs) is common among orthodontic patients. Several measures have been introduced to prevent and remineralize the lesions. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) is used for both prevention and remineralization. The effect of its application before bonding is controversial. This systematic review was conducted to investigate the most up to date available literature regarding the effect of CPP-ACP enamel pre-treatment on shear bond strength (SBS) of metallic orthodontic brackets.

METHODS

A search was conducted in electronic databases (MEDLINE (via PubMed), Scopus, Cochrane Library, Web of Science and Google scholar (grey literature)) up to March 29th, 2023. The inclusion criteria included in vitro studies comparing the SBS of metal orthodontic brackets following pre-treatment of enamel using CPP-ACP versus control. The exclusion criteria included study types other than in vitro studies, studies conducted on non-human enamel, or studies using CPP-ACP in combination with another intervention. The included studies were analysed by two reviewers, independently. The risk of bias assessment was done using a modified risk of bias tool. A Meta-analysis was performed. I2 values and Q-test were used for assessment of heterogeneity. Results were displayed in forest plots with a random-effects model. Standardized mean difference, standard error (SE) and 95% confidence intervals were calculated for all studies.

RESULTS

The search resulted in 76 articles. After duplicate removal and assessment for eligibility, 15 studies were included in the review. High statistical heterogeneity was found among the included studies using I2 values and Q-Test (I2 = 95.147%; Q = 288.456; df = 14; P < 0.001). The overall effect of CPP-ACP pre-treatment on the SBS of metal orthodontic brackets was not significant (Mean difference = 1.163 MPa, SE = 0.757, 95% CI = -0.321, 2.648, p value = 0.125). The use of CPP-ACP for prevention of WSLs did not significantly affect the SBS of brackets (Standardized mean difference = 1.009, SE = 0.884, 95% CI = -0.723, 2.740, p value = 0.254). No significant change was found when CPP-ACP was used for remineralization of WSLs (Standardized mean difference = 1.501, SE = 1.087, 95% CI = -0.630, 3.632, p value = 0.167).

CONCLUSIONS

Within the limitations of the study, the evidence suggests that the use of CPP-ACP for either prevention or remineralization of WSLs before bonding does not affect the SBS of metal orthodontic brackets.

Effect of Casein Phosphopeptide-Amorphous Calcium Phosphate Added to Milk, Chewing Gum, and Candy on Dental Caries: A Systematic Review

Casein is one of the most studied proteins with activity against dental caries. In particular, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has shown promising remineralizing properties. In vivo evidence on the anticaries potential of CPP-ACP added to foodstuffs is elusive, nonetheless. Hence, this systematic review aimed at determining whether the use of CPP-ACP added to foodstuffs has a remineralizing or inhibitory action on dental demineralization either in vivo or in situ. The review protocol followed the PRISMA-P criteria and was registered in PROSPERO. PubMed, Scopus, and Web of Science databases were searched using predefined criteria, based on the PICO question: Is there an effect on dental caries upon adding CPP-ACP to milk, chewing gums, or candies? No year or language limits were applied. Article selection and data extraction were carried out independently by 2 investigators. Two hundred ten titles were examined, 23 were selected for full-text review, and 16 studies were included (2 in vivo and 14 in situ). CPP-ACP was added to candy in 2 studies, to milk in 2 studies, and to chewing gum in 12 studies. The main outcomes included enamel remineralization and activity against dental biofilm. The overall quality of the evidence was classified as moderate. The available evidence suggests that CPP-ACP added to milk, chewing gum, or candy has a potential remineralizing activity on tooth enamel, with some additional antibacterial activity on the dental biofilm. Further clinical studies are needed to verify if this effect is clinically significant in reducing the caries lesion incidence or to revert the demineralizing process.

Effect of self-assembling peptide and other remineralizing agents on preventing initial enamel lesions around orthodontic brackets: An in vitro comparative study

OBJECTIVE

To investigate and compare the effect of self-assembling peptide SAP (P_11-4), casein phosphopeptide-amorphous calcium phosphate fluoride paste (CPP-ACPF), and fluoride varnish (FV) on preventing enamel demineralization around orthodontic brackets.

MATERIAL AND METHODS

Orthodontic brackets were bonded to the buccal surfaces of 80 freshly extracted human maxillary premolars. Teeth were randomly assigned to four groups (n=20) according to the remineralizing agent used as follows: SAP (P_11-4) group (Curodont™ Protect/Credentis), CPP-ACPF group (MI Paste Plus®/Recaldent™), fluoride varnish group (Profluoride varnish®/VOCO), and control group. All products were applied according to the manufacturer's instructions. Specimens were cycled in daily refreshed demineralizing and remineralizing solutions for 8h and 16h, respectively, for 28 days. The calcium/phosphorus ratio (Ca/P) and surface microhardness (SMH) were evaluated at baseline and at two and four weeks. Two-way ANOVA (analysis of variance), one-way ANOVA and repeated measures ANOVA were used for statistical analysis.

RESULTS

Two-way ANOVA demonstrated significant differences between remineralizing agents and time points. After 4 weeks, the SAP (P_11-4) group had had significantly higher Ca/P ratio and SMH (1.68±0.11 and 346.47±55.38) compared to other groups, followed by CPP-ACPF (1.52±0.19 and 283.53±64.75), FV (1.37±0.14 and 262.80±82.98), and the control group (1.31±0.10 and 213.00±41.95). Significantly higher Ca/P ratio and SMH were observed at 2 weeks in the control group (1.44±0.10 and 269.63±57.37) and FV group (1.52±0.09 and 321.17±55.24) compared to 4 weeks. No significant differences were found regarding Ca/P ratio and SMH at 2 weeks in the CPP-ACPF (1.55±0.15 and 295.14±53.88) and SAP P_11-4 groups (1.64±0.10 and 320.18±58.04) compared to 4 weeks.

CONCLUSION

SAP (P_11-4) had the greatest remineralizing efficacy compared to FV and CPP-ACPF. Moreover, extended period of time improved the preventive efficacy of SAP (P_11-4) compared to the other regimens.

Qualitative and Quantitative Profiling of Enamel Remineralizing Potential of Fluoride Varnishes Incorporating Bioactive Glass, Dicalcium Phosphate Dihydrate, and Modified MTA: A Raman Spectroscopic Study

Aim

To evaluate and compare for remineralization potential of enamel at three different time intervals using commercially available MI Varnish and Duraflor Halo varnish [5% sodium fluoride (NaF) varnish] incorporating bioactive glass, dicalcium phosphate dihydrate (DCPD), and biomimetically modified mineral trioxide aggregate (MTA).

Materials and methods

For the study, a buccolingual division into equal halves was done for 64 decoronated premolar crowns. Among these 64 crowns, we mounted 32 in acrylic discs to be used for microhardness and induced white spot lesions (WSLs) measuring 5 × 5 mm on the exposed enamel surface. These samples were divided into four groups of 24 each depending upon the varnish used. Varnish application was done, followed by immersion of these samples for 24 hours in artificial saliva, followed by peeling off of varnish. A pH cycling of 28 days was done after the varnish application before assessing the remineralization of the samples. Evaluation of all these samples was done at three different time intervals, baseline, after demineralization, and post remineralization for microhardness on the enamel surface. Raman spectroscopy was utilized for the measurement of phosphate (P) ion release. Sectioning of these samples to a thickness of 100 µm approximately was done to be viewed under a polarized light microscope.

Results

Bioactive glass incorporated varnish showed the highest microhardness values, mineral content levels, and least depth of lesion posttreatment.

Conclusion

All the experimental varnish showed significant remineralizing potential with the best potency seen with bioactive glass incorporated varnish.

Clinical significance

The nonfluoride agents can be appropriately used in 2 wt% amount to augment the benefits of fluoride.

How to cite this article

Hardikar AS, Gaonkar NN, Devendrappa SN, et al. Qualitative and Quantitative Profiling of Enamel Remineralizing Potential of Fluoride Varnishes incorporating Bioactive Glass, Dicalcium Phosphate Dihydrate, and modified MTA: A Raman Spectroscopic Study. Int J Clin Pediatr Dent 2023;16(2):363-370.

Synthesis and characterization of nano bioactive glass for improving enamel remineralization ability of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)

OBJECTIVE

Nanomaterials with superior properties such as high surface area over volume ratio are widely used in dentistry and medicine. This in vitro study was performed to synthesize and characterize nano bioactive glass (nBG) and to evaluate the effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) containing nBG (CPP-ACP@nBG) on enamel remineralization by its application to pH-cycled, synthetically demineralized enamel surfaces.

MATERIALS AND METHODS

nBG particles were prepared by sol-gel method. X-ray diffraction pattern (XRD), Fourier-transform infrared spectroscopy (FTIR) and transmittance electron microscopy (TEM) were used for nBG characterization. Synthetic CPP-ACP paste was prepared and nBG particles were added to it. To evaluate the degree of remineralization, 32 healthy human premolars were selected. The samples were randomly divided into 4 groups as: Group 1: Commercial CPP-ACFP (MI paste plus), Group 2: Synthetic casein phosphopeptide-amorphous calcium phosphate containing fluoride (CPP-ACP@F), Group 3: Synthetic CPP/ACP containing nBG (CPP-ACP@nBG), and Group 4: Control (received no treatment). The pastes were then applied on the tooth surfaces for 28 days. The Vickers microhardness of enamel surfaces was evaluated, and enamel surface morphology was assessed using scanning electron microscopy (SEM).

RESULTS

X-Ray diffraction pattern (XRD) of the synthesized nBG show its crystalline nature with the Larnite crystalline mode. Transmittance electron microscope (TEM) microimage of the synthesized nBG shows its formation as less that 100 nm spherical nanoparticle with partial agglomeration. Fourier transform infrared spectroscopy (FTIR) confirm the success formation of nBG with high purity. The results of this study showed that microhardness of the experimental groups was significantly higher than the control group (p ≥ 0.05). SEM images showed a layer of hydroxyapatite in the CPP-ACP@nBG, synthetic and commercial CPP-ACP@F remineralized groups.

CONCLUSION

The results of this study demonstrated that CPP-ACP@F and CPP-ACP@nBG remineralize the surface of the demineralized enamel. Microhardness of the remineralized enamel in the CPP-ACP@nBG group was higher than synthetic and commercial CPP-ACP@F groups.

Efficacy of casein phosphopeptide-amorphous calcium phosphate varnish in remineralizing white spot lesions: A systematic review and meta-analysis

Background

This systematic review aimed to evaluate the efficacy of casein phosphopeptide-amorphous calcium phosphate (CPP-ACPF) varnish for remineralization of white spot lesions (WSLs) "in vitro" in human teeth.

Materials and Methods

Literature search included three databases, namely Medline (via PubMed), The Cochrane Controlled Clinical Trials Register, and Google Scholar from 2010 to January 2021. The studies assessing WSL depth, calcium, phosphate ion release, and microhardness due to artificial demineralization or remineralization were considered for review. Reference articles were retrieved, and a customized risk assessment tool was used. The Cochrane risk of bias assessment tool was used to generate the risk of bias summary graph. Meta-analysis was performed using RevMan 5.4. Heterogeneity was evaluated by Cochrane's test, and random effects model was used to pool estimate of effect and its 95% confidence intervals (CIs) for surface microhardness.

Results

Eighteen studies were selected for review based on the eligibility criteria. Four studies showed superior remineralizing effect of CPP-ACPF compared to fluoride varnishes. Four studies involving 120 human permanent teeth samples were included in the meta-analysis. Efficacy of CPP-ACPF varnish was equivalent to other fluoride varnishes in improving surface microhardness after remineralization during 7-day period (mean surface microhardness: 3.94, 95% CI [-9.08-1.21], I^2: 75%, P = 0.13). Major risks of bias associated with the studies included in the review were inadequate sample size, improper sample preparation, and unexplained blinding.

Conclusion

CPP-ACPF varnish appears to be equally effective as other fluoride varnishes in remineralizing artificially induced WSLs, but quality of evidence is low.

Role of Chitosan in Remineralization of Enamel and Dentin: A Systematic Review

Aim and objective

The purpose of this research was to analyze the role of chitosan in the remineralization of enamel and dentin.

Materials and methods

An electronic search was done for articles published from January 2009 to January 2020. A manual search was done from bibliographies of selected articles for relevant articles that were unexplored. Only in vitro studies conducted on the application of chitosan for remineralization of enamel and dentin were included in the study.

Results

Of the 162 articles that were searched, only 15 in vitro studies were selected for the study. These studies met the inclusion criteria and were published from January 2009 to January 2020.

Conclusion

The review provides insight into the mechanism of remineralization of enamel and dentin. The properties of chitosan make it an ideal biomaterial that can be employed in the formulation of a novel remineralizing gel. However, more in vivo studies, clinical trials, and research are essential to transform chitosan-based remineralizing gels from research to clinical use.

Clinical significance

This review article opens a new window of opportunities for remineralizing enamel and dentin which have been long considered a challenging job.

How to cite this article

Nimbeni SB, Nimbeni BS, Divakar DD. Role of Chitosan in Remineralization of Enamel and Dentin: A Systematic Review. Int J Clin Pediatr Dent 2021;14(4):562–568.

Effects of Xylitol and CPP-ACP Chewing Gum on Salivary Properties of Children with Molar Incisor Hypomineralization

Aim

To compare the efficacy of chewing gum containing casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and xylitol on salivary characteristics in 8–10 years old children with molar incisor hypomineralization.

Materials and methods

A randomized controlled trial using CPP-ACP chewing gums (group I) and xylitol chewing gums (group II) was conducted among 32 children affected with mild molarincisor hypomineralization (MIH). Salivary flow rate, pH and buffering capacity were measured using saliva check kit (GC America). Data obtained were tabulated and subjected to statistical analysis using SPSS software version 20. Descriptive statistics–mean, standard deviation, 95% confidence interval. Inferential statistics–independent t tests were used.

Results

A significant increase in mean salivary pH, flow rate and buffering action was observed from baseline to immediately after spitting the chewing gum in both the study groups (p 0.05).

Conclusion

Casein phosphopeptide-amorphous calcium phosphate containing chewing gums improve salivary characteristics in MIH-affected children.

Clinical significance

Xylitol and CPP-ACP chewing gums are recommended in MIH children with early demarcated opacities as it improves the salivary properties in those children and prevents further complications.

How to cite this article

Prathima GS, Narmatha M, Selvabalaji A, et al. Effects of Xylitol and CPP-ACP Chewing Gum on Salivary Properties of Children with Molar Incisor Hypomineralization. Int J Clin Pediatr Dent 2021;14(3):412–415.

Comparative Evaluation of Two Remineralizing Agents on Artificial Carious Lesion Using DIAGNOdent

Purpose

The current in vitro study was conducted to assess the remineralization potential of CPP-ACP and a customized dentifrice (tricalcium-phosphate) on artificial carious lesions using DIAGNOdent.

Materials and methods

Fifty-one extracted premolars that satisfied the inclusion criteria were painted using acid-resistant nail varnish. A window of 4 × 4 mm was exposed on the center of the buccal surface of each tooth. After 20 minutes of drying, the baseline reading of enamel specimens was assessed using DIAGNOdent. The teeth were then immersed in a bath of demineralizing solution. An incubation period of 96 hours at 37°C resulted in artificial caries-like lesions on the specimen. Readings of the specimen within the window after demineralization were recorded using DIAGNOdent for all the samples. The specimens were divided into three groups randomly [group I—casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), group II—customized dentifrice, group III—artificial saliva]. Samples were subjected to the daily treatment regimen for a period of 30 days. The samples were evaluated for remineralization by laser fluorescent device (DIAGNOdent) on the 15th and 30th day, respectively.

Results

The statistical analysis was done using the Friedman test, Kruskal–Wallis test, Wilcoxon sign rank test, and Mann–Whitney test. The results showed that both CPP-ACP and customized dentifrice showed almost similar remineralization potential but CPP-ACP showed significant remineralization (p < 0.001).

Conclusion

The DIAGNOdent observation conclusively proves that CPP-ACP and customized dentifrice remineralizes the demineralized tooth samples in vitro with CPP-ACP showing significant remineralization.

How to cite this article

Arjun DS, Bhat SS, Hegde SK, et al. Comparative Evaluation of Two Remineralizing Agents on Artificial Carious Lesion Using DIAGNOdent. Int J Clin Pediatr Dent 2021;14(2):192–195.

Effects of three commercial toothpastes incorporating "chitosan, casein phosphopeptide-amorphous calcium phosphate, sodium monofluorophosphate, and sodium fluoride" on remineralization of incipient enamel caries in the primary dentition: A preliminary in vitro study

BACKGROUND

Given the importance of primary dental caries, assessment of new preventive/therapeutic materials is necessary. In light of the scarcity of such studies on the role of new agents in primary dentition, this study assessed the efficacy of three commercial toothpastes with different ingredients on remineralization of early caries in the primary dentition.

MATERIALS AND METHODS

Thirty-nine intact primary canines were used in this in vitro experimental study. The baseline microhardness of enamel was measured. Particular demineralizer was used for 96 h and then secondary microhardness was measured. Then, samples were divided into three groups treated by toothpastes with sodium fluoride, chitosan, and casein phosphopeptide-amorphous calcium phosphate and sodium monofluorophosphate (CPP-ACP+SMFP). Each group was incubated and pH-cycled. Subsequently, they were demineralized and remineralized using toothpastes. Eventually, tertiary microhardness was measured. Percent of enamel microhardness recovery (EMHR%) and efficacy of toothpastes in remineralization were established. Data were analyzed using paired t-test, repeated-measures test, Kruskal-Wallis, and Mann-Whitney U-test (α = 0.05, 0.017).

RESULTS

Demineralization significantly reduced microhardness from 316.2 to 248.5 Vickers hardness number (VHN) (P = 0.000). All toothpastes succeeded to remineralize the enamel significantly (P = 0.000). The efficacies of toothpastes differed significantly (P < 0.05). Mean EMHR percentages of toothpastes incorporating NaF, chitosan, and CPP-ACP+SMFP were 75.1%, 52.5%, and 55.8%, respectively. The highest increases in enamel microhardness were observed after using NaF-containing toothpaste (~53 VHN) which was significantly superior to other toothpastes (P ≤ 0.001). However, there was no statistically significant difference between EMHR percentages of toothpastes including chitosan and CPP-ACP+SMFP (P = 0.739).

CONCLUSION

Although all three toothpastes could increase the microhardness of primary enamel, NaF toothpaste was superior to others. Toothpastes having chitosan and CPP-ACP+SMFP acted rather similarly.

Quantitative evaluation of remineralizing potential of three agents on artificially demineralized human enamel using scanning electron microscopy imaging and energy-dispersive analytical X-ray element analysis: An in vitro study

BACKGROUND

The aim of this study is to quantitatively evaluate the remineralization potential of three remineralizing systems as follows: fluoride, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), and CPP-ACP with fluoride, under scanning electron microscope with energy-dispersive X-ray analysis.

MATERIALS AND METHODS

In this in vitro study A total of 40 enamel specimens were prepared from the buccal or lingual surfaces of human premolars extracted for orthodontic reason. Specimens were then placed in demineralizing solution for 96 h, to produce artificial caries-like lesion. Calcium and phosphate weight percentage of demineralized specimens was measured. Specimens were divided into four groups as follows: (a) control, (b) CPP-ACP, (c) CPP-ACP with fluoride, and (d) fluoride varnish. Except for the control group, the entire specimens were subjected to remineralization using respective remineralizing agents of their groups. The prepared specimens were assessed for calcium and phosphate weight percentage using scanning electron microscopy-energy dispersive X-ray spectroscopy. One way analysis of variance (ANOVA), followed by Tukey's test, was performed with the help of critical difference (CD) or least significant difference at 5% and 1% level of significance. P ≤ 0.05 was taken to be statistically significant and P < 0.001 as statistically highly significant.

RESULTS

The mean weight percentage of calcium and phosphorus of specimens treated with CPP-amorphous calcium phosphate nanocomplexes plus fluoride (ACPF) was significantly higher than other groups.

CONCLUSION

All the groups showed statistically significant remineralization. However, because of added benefit of fluoride, CPP-ACPF showed statistically significant amount of remineralization than CPP-ACP.

Comparative Efficacy of Resin Infiltrant and Two Remineralizing Agents on Demineralized Enamel: An In Vitro Study

AIM

To compare and evaluate the caries preventive effectiveness of resin infiltrant (ICON), casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) (GC Tooth Mousse), and nanohydroxyapatite (Aclaim) on incipient enamel lesions.

MATERIALS AND METHODS

A total of 60 human maxillary incisors extracted for periodontal reasons were included in this study. The sectioning was done at the middle third region of the crown for the 60 samples with approximate dimensions of 5 × 5 × 5 mm). In order to create the artificial enamel lesions, the samples were demineralized by placing in a beaker containing the prepared demineralizing solution for 14 days. The study samples were then divided into four groups that are resin infiltrant (group I), CPP-ACP (group II), nanohydroxyapatite (group III), and control (group IV) with 15 enamel samples in each group. The caries preventive efficacy of each group was evaluated using a confocal laser scanning microscope.

RESULTS

The mean values after demineralization of enamel samples in demineralizing solution are 245 μm for resin infiltrant (group I), 246 μm for CPP-ACP (group II), 250 μm for nanohydroxyapatite (group III), and 247 μm for control (group IV). After remineralizing the enamel samples for a period of 30 days, the results are group I (resin infiltrant) 158 μm > group II (CPP-ACP) 28.8μm ≥ group III (nanohydroxyapatite) 26.3 μm. After subjecting it to demineralizing solution again for 14 days, the amount of material that was resistant to acid attack was group I (resin infiltrant) 114 μm (72%) > group III (CPP-ACP) 16.4 μm (57%) ≥ group III (nanohydroxyapatite) 13.8 μm (50%). The untreated control group showed increased progression of lesion and least resistance to acid challenge.

CONCLUSION

Based on the results from this in vitro study, it can be concluded that when compared to the two remineralizing agents the resin infiltrant showed better caries preventive effectiveness.

CLINICAL SIGNIFICANCE

Resin infiltrants have a favorable penetration potential in subsurface or incipient enamel lesions.

Evaluation of the efficacy of casein phosphopeptide-amorphous calcium phosphate on remineralization of white spot lesions in vitro and clinical research: a systematic review and meta-analysis

Background

This systematic review with meta-analyses sought to answer whether casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) provided a remineralizing benefit superior to that of nonintervention or placebo.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, Cochrane databases, PubMed, EmBase, and Ovid up to May 20th, 2019, were scanned, only published in English. Study information extraction and methodological quality assessments were accomplished independently by two reviewers. The “Criteria for judging risk of bias in the ‘Risk of bias’ assessment tool” was used for methodological quality assessment. The continuous data was analyzed by mean difference (MD) or standardized mean difference (SMD) with a 95% confidence interval (CI). Review Manager 5.3 was used for statistical analysis. Outcome variables include quantitative light-induced fluorescence in clinical research, average surface roughness and surface microhardness in vitro.

Results

There were significant differences in the quantitative light-induced fluorescence (SMD = − 0.43, 95% CI: [− 0.79, − 0.07], P = 0.02), average surface roughness (SMD = − 8.21, 95% CI: [− 10.37, − 6.04], P < 0.01), Vickers microhardness (SMD = 1.19, 95% CI: [0.72, 1.66], P < 0.01), and Knoop microhardness (SMD = 3.52, 95% CI: [2.68, 4.36], P < 0.01) between the CPP-ACP and control groups or baseline.

Conclusion

Within the limitations of this meta-analysis, CPP-ACP exhibited excellent remineralization effects evaluated in clinical research and in vitro, indicating outstanding restoration of form, aesthetics, and function in treating white spot lesions.

The effects of sodium hexametaphosphate combined with other remineralizing agents on the staining and microhardness of early enamel caries: An in vitro modified pH-cycling model

BACKGROUND

This study was conducted to determine the effects of sodium hexametaphosphate (SHMP) combined with other remineralizing agents on the staining and microhardness of early enamel caries.

MATERIALS AND METHODS

in This in vitro study The enamel buccal surfaces of 70 bovine incisors were classified into seven study groups (n = 10). Remineralizing agents were employed alone and in combination with SHMP in different groups, including: (1) 8% SHMP, (2) 2% sodium fluoride, (3) 2% sodium fluoride + SHMP, (4) Remin Pro®, (5) Remin Pro®+SHMP, (6) MI Paste Plus, and (7) MI Paste Plus + SHMP. A modified pH-cycling technique was used to reconstruct the dynamics of caries. Colorimetric and microhardness analyses were conducted before demineralization (T1), after caries formation (T2), and after the remineralizing treatment (T3). The data were analyzed by the one-way analysis of variance and the repeated measurement analysis (P > 0.05).

RESULTS

After remineralizing cycles, the experimental groups treated with either SHMP alone or in combination with other materials showed less significant changes in the three variables of color (Δa, Δb, and ΔL) and the overall color change (ΔE). The enamel caries treated with Remin Pro® presented the highest color change, while Remin Pro®+ SHMP resulted in the least changes. The mean value of microhardness after remineralization improved significantly in all groups, except in the MI Paste Plus + SHMP group that showed the lowest value. In contrast, the highest microhardness value was recorded for Remin Pro®, being comparable to that of the sound teeth (P > 0.05).

CONCLUSION

SHMP, either alone or combined with remineralizing agents, created the least staining. Remineralizing materials alone showed higher surface hardness, while sodium fluoride alone showed higher surface hardness when combined with SHMP.

Remineralizing Effect of Casein Phosphopeptide-Amorphous Calcium Phosphate and Sodium Fluoride on Artificial Tooth Enamel Erosion: An In Vitro Study

AIM

To compare in vitro the remineralizing effect of toothpastes with casein phosphopeptide-amorphous calcium phosphate (FPC-FCA) and sodium fluoride on the artificial erosion of tooth enamel.

MATERIALS AND METHODS

For the first phase of artificial erosion, group I was considered as the control group without treatment or erosion. For groups II and IV, the drink was used (Coca-Cola®), for groups III and V, the drink (Inca-Kola®), and the four groups were demineralized four times a day (every 3 hours for 2 minutes) for 5 days. In the treatment phase in groups II and III, brushing was performed with sodium fluoride paste (Colgate®), groups IV and V received brushing with FPC-FCA complex (MiPaste®), and for all groups, the same procedure was performed four times a day (every 3 hours for 5 minutes) for 90 days. At the end, the microroughness of the surfaces of all the groups was evaluated by means of a Rugosimeter (Mitutoyo).

RESULTS

It was evidenced that the group of sodium fluoride presented a microroughness of 2.79 μm being the group of least remineralization, but the FPC-FCA complex showed a microroughness of 1.96 μm; however, the control group presented a microroughness of 3.20 μm, and the groups sodium fluoride, FPC-FCA compared to the control group proved to be statistically significant with a p < 0.05.

CONCLUSION

The remineralizing effect of FPC-FCA (MiPaste®) complex proved to be greater than sodium fluoride paste (Colgate®) under artificial enamel erosive conditions.

CLINICAL IMPORTANCE

The results of this research serve as a basis for industries to generate products that have the potential for remineralization against various erosive beverages that are consumed daily. How to cite this article: Pirca K, Balbín-Sedano G, Romero-Tapia P, et al. Remineralizing Effect of Casein Phosphopeptide-Amorphous Calcium Phosphate and Sodium Fluoride on Artificial Tooth Enamel Erosion: An In Vitro Study. J Contemp Dent Pract 2019;20(11):1254-1259.

Casein Phosphopeptide-Amorphous Calcium Phosphate Attenuates Virulence and Modulates Microbial Ecology of Saliva-Derived Polymicrobial Biofilms

BACKGROUND

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) acts as a salivary biomimetic that provides bioavailable calcium and phosphate ions to augment fluoride-mediated remineralisation of early caries lesions. However, there are indications that it may also have beneficial ecological effects on the oral microbiome.

OBJECTIVE

This in vitro study investigated whether CPP-ACP could influence microbial counts, acidogenicity, and the relative abundance of specific caries- and health-associated bacterial -species in polymicrobial biofilms.

METHODS

Saliva-derived polymicrobial biofilms were grown for 96 h in a cariogenic environment and treated every 12 h with 2% CPP-ACP or vehicle control. Colony forming units (CFUs) and acidogenicity were estimated from the treated biofilms. Microbial ecological effects of CPP-ACP were assessed based on the relative abundance of 14 specific caries- and health-associated -bacterial species using a real-time quantitative PCR assay. -Results: CPP-ACP-treated biofilms showed relatively modest, but significant, reductions in microbial CFUs (21% reduction, p = 0.008) and acidogenicity (33% reduction, p < 0.001), compared to the control-treated biofilms. The CPP-ACP treated biofilms also exhibited significantly lower bacterial loads of cariogenic Scardovia wiggsiae (fold change 0.017, p < 0.001) and Prevotella denticola(fold change 0.005, p < 0.001), and higher bacterial loads of commensal Streptococcus sanguinis(fold change 30.22, p < 0.001), S. mitis/oralis(fold change 9.66, p = 0.012), and S. salivarius/thermophilus(fold change 89.35, p < 0.001) than the control-treated biofilms.

CONCLUSIONS

The results indicate that CPP-ACP has virulence-attenuating attributes that can influence a beneficial microbial ecological change in the biofilm.

Remineralizing potential of CPP-ACP in white spot lesions - A systematic review

Objective

The aim of this systematic review was to assess the long term remineralizing potential of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) only in paste form compared with fluoride varnish, and or placebo in both naturally occurring and post-orthodontic white spot lesions in vivo.

Data Sources

The literature search covered the electronic databases: PubMed and Google scholar from 2005-2016. Only articles published in English were included. Randomized control trials in which CPP-ACP delivered by paste form were included. All studies which met inclusion criteria underwent two independent reviews.

Study Selection

Two ninety five articles were identified from the search after excluding duplications. Abstracts of forty one articles were reviewed independently. Twenty nine articles were excluded after reading abstract. Full text articles were retrieved for fifteen relevant studies. After reviewing articles independently, three articles were excluded after full text reading. Finally twelve studies were selected based on the eligibility criteria. The remineralizing effect of CPP-ACP were compared with placebo and fluoridated toothpaste and fluoride varnish in randomized control trial.

Conclusion

A high level evidence of remineralizing potential of CPP-ACP on naturally occurring white spot lesion and WSL post orthodontic treatment was found in comparison with placebo/fluoridated toothpaste and fluoride varnish without any statistically significant difference. Well-designed RCTs are, therefore, required to improve the level of evidence in this area.

In vitro Comparison of Antimicrobial Activity of Conventional Fluoride Varnishes Containing Xylitol and Casein Phosphopeptide-Amorphous Calcium Phosphate

Objective

Different fluoride varnishes are used for the prevention of dental caries. The aim of this study was to compare the antimicrobial effect of different fluoride varnishes, containing xylitol and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), on Streptococcus mutans.

Materials and Methods

In this in vitro study, the antibacterial effects of four varnishes, namely Polimo and V-varnish (containing xylitol), MI varnish (containing CPP-ACP), and Preventa, were evaluated against S. mutans. The disc diffusion method was used for testing the bacterial sensitivity. The data were analyzed using the Kruskal-Wallis and Mann-Whitney U-tests.

Results

According to the results, Polimo showed the highest antibacterial effects, compared to the other three varnishes (P ≤ 0.05). Growth inhibition zones were not observed in V-varnish and Preventa. The mean diameter of inhibition zone around the MI varnish was significantly higher, compared to those of the V varnish and Preventa (P ≤ 0.05).

Conclusion

As the findings indicated, the fluoride varnish containing xylitol and CPP-ACP could be more effective iAQ1n the prevention of dental caries.

[Electronic probe analysis of enamel remineralization effect of casein phosphopeptide-amorphous calcium phosphate promoted by different concentrations of fluorine]

Objective: To evaluate the remineralization effect and mechanism of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) with different concentrations of fluorine on demineralized enamel using electronic probe. Methods: Extracted premolar teeth for orthodontic purpose were immersed into lactic acid gel to prepare artificial white spot lesions (10 teeth in each group). Then the specimens were randomly assigned to three groups: Control group, with 5% of the CPP-ACP+deionized water; Group A with 5% CPP-ACP+500 mg/L F(-) and Group B with 5% CPP-ACP+900 mg/L F(-). The teeth in each group were soaked in different solutions for 4 days and then were measured using electron probe tester. The changes of contents among the three groups were compared. Results: No statistically significant difference in the percentage of fluorine was found in the control group before and after treatment (P=0.06), and the difference in the percentage of fluorine quality in the other two groups was statistically significant (P<0.05). Statistically significant difference was found between calcium oxide and phosphorus peroxide in the three groups before and after mineralization (P<0.05). The percentage change of fluorine mass in group B [(0.107±0.035)%] was significantly greater than that in group A [(0.057±0.038)%] (P<0.05), while fluorine mass in group A was significantly greater than that in control group [(0.013±0.019)%] (P<0.05). In group A and group B, the change in quality of calcium oxide and phosphorus peroxide was significantly greater than that in control group (P<0.05), while no significant difference was found between group A and group B (P>0.05). Conclusions: The addition of fluorine in CPP-ACP increased the transport and penetration of calcium, phosphorus and fluorine on enamel surface.

Comparison of the newer preventive therapies on remineralisation of enamel in vitro

OBJECTIVES

To investigate in vitro the effect of MI Paste, MI Paste Plus and 2800ppm fluoride (F) toothpaste (TP) on the remineralisation of enamel subsurface lesions and to compare these to the effect of 1450ppm and 0ppm F toothpastes.

METHODS

Enamel subsurface lesions were created in bovine enamel slabs (n=120) which were assigned randomly to five groups; (1) 0ppm F TP, (2) 1450ppm F TP, (3) 2800ppm F TP, (4) 1450ppm F TP+MI Paste (Tooth Mousse-TM,10% w/v CPP-ACP) and (5) 1450ppm F TP+MI Paste Plus (Tooth Mousse Plus,10% w/v CPP-ACP, 900ppm F as 0.2% w/w sodium fluoride). The enamel slabs were subjected to a pH cycling regimen for 21days. Quantitative Light-induced Fluorescence (QLF) images were taken and analysed. Data analysis was carried out using one way ANOVA.

RESULTS

In all groups, both ΔF (percentage fluorescence loss) and ΔQ (ΔF times the area) values improved significantly within the same group after the treatment. In addition, the mean difference in ΔF of the non-fluoride control group was significantly lower than all other groups but not for the 2800ppm F^- group. Whereas the mean difference in ΔQ of the non-fluoride control of group was significantly lower when compared with all other groups (p<0.05).

CONCLUSIONS

Both MI Paste and MI Paste Plus when used in conjunction with 1450ppm F did not show a significant increase in efficacy for the remineralisation of bovine enamel subsurface lesions in the model used in this study.

CLINICAL SIGNIFICANCE

Newer preventive agents such as MI paste and MI paste plus are advocated as promoting remineralisation when used in addition to routine oral care. This in vitro study shows that they may have a limited value in promoting remineralisation over and above that of 1450ppm F toothpaste used twice a day.

Effect of Casein Phosphopeptide-Amorphous Calcium Phosphate and Three Calcium Phosphate on Enamel Microhardness

AIM

This study aims to investigate the effect of casein phos-phopeptide-amorphous calcium phosphate and three calcium phosphate (CPP-ACP and TCP) on increasing the microhardness of human enamel after induction of erosion.

MATERIALS AND METHODS

A total of 26 healthy human-impacted third molar teeth were chosen, and their hardness measured using a microhardness testing machine. The samples were immersed in Coca Cola (pH = 4.7) for 8 minutes. Then, micro-hardness was measured again, and these samples were randomly divided into four groups (two control groups and two experimental groups). (1) Negative control group: Artificial saliva was used for 10 minutes, (2) positive control group: Fluoride gel was used for 10 minutes, (3) β-TCP group: TCP was used for 10 minutes, (4) CCP-ACP group: CCP-ACP was used for 10 minutes. The final microhardness of those samples was measured, and the changes in microhardness of teeth within group and between groups were analyzed using the paired and analysis of variance tests respectively. Results were considered statistically significant at a level of p < 0.05.

RESULTS

No significant difference was observed in microhard-ness between CPP-ACP group and TCP group (p = 0.368) during the time microhardness significantly dropped after soaking in soda.

CONCLUSION

Casein phosphopeptide-amorphous calcium phosphate and TCP increased the microhardness of teeth. The increase in hardness in the TCP group was higher than in the CPP-ACP group, but this difference was not significant (p = 0.36).

CLINICAL SIGNIFICANCE

Casein phosphopeptide-amorphous calcium phosphate and TCP can affect the remineralization of erosive lesions.

Quantitative Analysis of Remineralization of Artificial Carious Lesions with Commercially Available Newer Remineralizing Agents Using SEM-EDX- In Vitro Study"

INTRODUCTION

The basic principle of remineralization is by advocating a biological or non-invasive approach rather than the surgical approach for early enamel lesions. There are relatively newer products available for remineralization, latest being the resin-infiltration technique, commercially available as Icon.

AIM

The aim of the study was to evaluate the remineralizing potential of Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP), Vantej and Icon by the quantitative evaluation of mineral gain.

MATERIALS AND METHODS

Seventy eight maxillary premolars were decoronated at Cemento-Enamel Junction (CEJ) and then sectioned mesio-distally using diamond disc into two halves. Mineral content of the sound specimens were recorded using Energy Dispersive X-ray (EDAX) micro-analyser. The samples were then subjected to demineralization by using demineralizing solution. The samples were grouped (n=26) based on the remineralizing agent used, Group 1: Vantej, Group 2: CPP-ACP, Group 3: Icon. After the application of remineralizing agent, the mineral content was measured using EDAX.

RESULTS

After remineralization, there was a significant difference between the groups when calcium and phosphorous ratios (Ca:P) were compared, showing greater potential of remineralization for CPP-ACP followed by Vantej and Icon group.

CONCLUSION

CPP-ACP performed better than Vantej and Icon in remineralizing the demineralized enamel.

Evaluation of Remineralization Potential of Beverages modified with Casein Phosphopeptide-Amorphous Calcium Phosphate on Primary and Permanent Enamel: A Laser Profiler Study

Purpose

To assess the erosive potential of carbonated beverages and the remineralization potential of beverages with added casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste on primary and permanent enamel.

Materials and methods

A total of 32 primary and 32 permanent enamel specimens were immersed for 5, 10, and 30 minutes, respectively, in beverages, i.e., Coke, Sprite, Mirinda, and Mountain Dew, with and without added 0.2% CPP-ACP. Samples were profiled before immersion and after immersion under laser profiler.

Results

Coke was found to be highly erosive at it caused significant enamel erosion at both 10 and 30 minutes of immersion (p < 0.05) for both primary and permanent enamel. The 30-minute immersion caused significant amount of reminerali-zation over primary enamel in all groups, whereas permanent enamel remineralization was significant in Sprite and Mountain Dew at 30 minutes in all the groups (p < 0.05).

Conclusion

This study demonstrated that enamel erosion occurred after immersion in carbonated beverages. Remineralization of enamel was observed after immersion in beverages modified with CPP-ACP paste. Primary enamel was susceptible to remineralization compared with permanent enamel. Within the limitations of this in vitro study, the application of CPP-ACP paste may enhance the remineralization after an erosive challenge and thus offer some protection for patients who are at risk for erosion.

How to cite this article: Rai N, Sandhu M, Sachdev V, Sharma R. Evaluation of Remineralization Potential of Beverages modified with Casein Phosphopeptide-Amorphous Calcium Phosphate on Primary and Permanent Enamel: A Laser Profiler Study. Int J Clin Pediatr Dent 2018;11(1):7-12.

An in vitro Comparative Evaluation of Three Remineralizing Agents using Confocal Microscopy

INTRODUCTION

The caries process has been thought to be irreversible, resulting in the permanent loss of tooth substance and eventually the development of a cavity. Recent approaches focused on application of remineralizing agents to incipient carious lesions, aim at controlling demineralization and promoting remineralization. Remineralizing agents create a supersaturated environment around the lesion; thus, preventing mineral loss and forces calcium and phosphate ions in the vacant areas.

AIM

To compare and evaluate the remineralization potential of Fluoride Varnish, CPP-ACP Paste (Casein Phosphopeptide-Amorphous Calcium Phosphate) and fTCP Paste (functionalized Tricalcium Phosphate) using confocal microscope.

MATERIALS AND METHODS

Two windows of 3X3mm were created on the labial cervical and incisal thirds in 60 permanent maxillary central incisors. The teeth were demineralized to create artificial caries and divided into three groups of 20 each. Group I specimens were coated with Fluoride Varnish once whereas those in CPP-ACP paste group and fTCP group were brushed for 2 minutes, twice daily for 20 and 40 days. The specimens were stored in artificial saliva during the study period and were later sectioned and observed under confocal microscope. Data obtained was statistically analyzed using Fischer's exact test, ANOVA and post-hoc Bonferroni's test.

RESULTS

Fluoride Varnish, CPP-ACP Paste and fTCP Paste showed remineralization of artificial carious lesions at both the time intervals. Fluoride varnish showed the highest remineralization followed by CPP-ACP Paste and fTCP Paste. A statistically significant increase in remineralization potential of CPP-ACP Paste and fTCP Paste was observed at the end of 40 days as compared to 20 days.

CONCLUSION

Fluoride varnish showed the greatest remineralization potential of artificial carious lesions followed by CPP-ACP Paste and fTCP Paste respectively.

Assessment of White Spot Lesions and In-Vivo Evaluation of the Effect of CPP-ACP on White Spot Lesions in Permanent Molars of Children

INTRODUCTION

As hindrance of remineralisation process occurs during orthodontic therapy resulting in decalcification of enamel because number of plaque retention sites increases due to banding and bonding of appliances to teeth.

AIM

The present analytic study was undertaken to assess the occurrence of white spot lesions in permanent molars of children with and without orthodontic therapy and to evaluate the effect of Casein PhosphoPeptide-Amorphous Calcium Phosphate (CPP-ACP) on white spot lesions in post-orthodontic patients in a given period of time.

MATERIALS AND METHODS

The study comprised of examination of 679 first permanent molars which were examined to assess the occurrence of smooth surface white spot lesions in children of 8 to 16 years age group. Group I comprised subjects without any orthodontic treatment and Group II comprised of subjects who had undergone orthodontic therapy. The sample size was calculated using the epi-info6 computer package. Treatment group included 20 post-orthodontic patients examined with at least one white spot lesion within the enamel who received remineralizing cream (GC Tooth Mousse, Recaldent, GC Corporation.) i.e., CPP-ACP cream two times a day for 12 consecutive weeks. Computerized image analysis method was taken to evaluate white spot lesions. These frequency and percentages were compared with chi-square test. For comparison of numeric data, paired t-test was used.

RESULTS

Of the total 278 (49.6%) first permanent molars showed occurrence of smooth surface white spot lesions out of 560 in Group I and 107 (89.9%) first permanent molars showed presence of white spot lesions out of 119 debanded first permanent molars of children examined in Group II. CPP-ACP therapy group showed reduction in severity of codes which was found to be highly significant after 12 weeks and eight weeks on gingival-third, p-value (<0.001) and significant after eight weeks and four weeks on middle-third according to ICDAS II criteria and computerized image analysis.

CONCLUSION

CPP-ACP therapy minimum for 12 weeks is highly recommended as post-orthodontic treatment need in management of smooth surface white spot lesions on teeth undergoing fixed orthodontic therapy according to the present study.

An in vitro evaluation of the demineralization inhibitory effect of F(-) varnish and casein phosphopeptide-amorphous calcium phosphate on enamel in young permanent teeth

Aims and Objectives:

To determine the demineralization inhibitory potential of fluoride varnish and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and to compare and evaluate the additive effect of fluoride varnish + CPP-ACP.

Materials and Methods:

Ten healthy premolar teeth that were extracted for orthodontic purposes were collected, and each tooth was longitudinally sectioned buccolingually and mesiodistally into four sections. The teeth were then assigned to four different treatment groups namely fluoride varnish, CPP-ACP, F⁻ varnish followed by CPP-ACP and control. The prepared enamel samples were suspended in an artificial caries challenge for 10 days. The demineralizing inhibitory effects of the groups were recorded using polarized light microscopy.

Statistical Analysis Used:

Statistical analysis was carried out using analysis of variance and Duncan's multiple range tests.

Results:

The mean lesion depths of all the groups were Group 1 (fluoride varnish): 104.71, Group 2 (CPP-ACP): 127.09, Group 3: (F⁻ varnish + CPP-ACP): 82.34, Group 4 (control): 146.93.

Conclusion:

Demineralization inhibitory potential on the additive use of F⁻ varnish and casein phosphopeptide was superior to fluoride varnish or CPP-ACP applied alone on the enamel of young permanent teeth.

Effect of three different pastes on remineralization of initial enamel lesion: an in vitro study

OBJECTIVE

Dental caries in enamel is unique as enamel is both acellular and avascular. Fluoride is one of the most effective remineralizing agents in caries prevention. The purpose of the study was to assess whether nano-hydroxyapatite and CPP-ACP can be used as an alternative to fluoride for remineralization of early carious lesions.

STUDY DESIGN

Initial artificial carious lesions were prepared in enamel with demineralization solution. The treatment materials used as remineralizing agents were Nano-hydroxyapatite (10%), CPP - ACP (10%), NaF (1000 ppm) and Deionized water (negative control). Surface microhardness (SMH) measurements were performed before/after demineralization and after 3, 6, 9 and 12 days of pH cycling and the percentage surface microhardness recovery (%SMHR) was calculated. The specimens were then examined by scanning electron microscope.

RESULTS

Percentage surface microhardness recovery of nano-hydroxyapatite and fluoride was significantly greater than CPP - ACP and negative control. There was no significant difference of %SMHR between n-HA and fluoride at different time periods in the pH cycling. SEM analysis revealed n-HA particles were deposited on the demineralized enamel surface which formed a new surface layer. When observed under SEM CPP - ACP failed to show any significant surface remineralization while surface globular crystal depositions with multiple discrete porosities were evident with fluoride.

CONCLUSION

It was concluded that nano-hydroxyapatite and fluoride had the potential to remineralize initial enamel lesions. CPP - ACP can be used as an effective adjunct to fluoride therapy but cannot be used as an alternative to fluoride.

Marginal microleakage of a resin-modified glass-ionomer restoration: Interaction effect of delayed light activation and surface pretreatment

BACKGROUND

Despite widespread clinical uses of resin-modified glass-ionomers (RMGIs), their sealing ability is still a concern. This study evaluated the effect of delayed light activation (DLA) of RMGI on marginal sealing in differently pretreated cavities.

MATERIALS AND METHODS

In this in vitro study, two standardized Class V cavities were prepared on the buccal and lingual surfaces of 56 sound maxillary premolars at the cementoenamel junction. The cavities were randomly divided into eight equal groups. In groups 1-4 (immediate light activation [ILA]), no pretreatment (negative control [NC]) and three surface pretreatments were used, respectively as follows: Cavity conditioner, Vitremer primer, cavity conditioner plus and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP). Fuji II LC (GC, Japan) was prepared and placed in the cavities and immediately light-cured according to manufacturer's instructions. In groups 5-8 (DLA), the same pretreatments were applied, respectively. After placing Fuji II LC in the cavities, the restorations were light-cured after a 3-min delay. After finishing the restorations, the specimens were placed in water for 1-week and thermocycled. Microleakage scores were determined using the dye penetration technique. Kruskal-Wallis test and Mann-Whitney U-test were used to analyze the obtained data (α = 0.05).

RESULTS

At the dentin margins, DLA resulted in a lower microleakage for no treatment (NC), cavity conditioner and cavity conditioner plus ACP-CPP pretreatments groups (P ≤ 0.004); however, no difference was observed for Vitremer group (P > 0.05). At the enamel margins, no difference was observed between DLA and ILA for all groups (P > 0.05); only NC group exhibited a lower microleakage in case of DLA (P = 0.007).

CONCLUSION

Delayed light activation of RMGI may lead to different effects on marginal sealing, depending on pretreatment procedures used in the cavity. It might improve dentin sealing when no treatment and conditioner alone or with CCP-ACP is used.

In vitro evaluation of casein phosphopeptide-amorphous calcium phosphate effect on the shear bond strength of dental adhesives to enamel

BACKGROUND

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) is applied for remineralization of early caries lesions or tooth sensitivity conditions and may affect subsequent resin bonding. This in vitro study investigated the effect of CPP-ACP on the shear bond strength of dental adhesives to enamel.

MATERIALS AND METHODS

Sixty extracted human molar teeth were selected and randomly divided into three groups and six subgroups. Buccal or lingual surfaces of teeth were prepared to create a flat enamel surface. Adhesives used were Tetric N-Bond, AdheSE and AdheSE One F. In three subgroups, before applying adhesives, enamel surfaces were treated with Tooth Mousse CPP-ACP for one hour, rinsed and stored in 37°C temperature with 100% humidity. This procedure was repeated for 5 days and then adhesives were applied and Tetric N-Ceram composite was adhered to the enamel. This procedure was also fulfilled for the other three subgroups without CPP-ACP treatment. After 24 hour water storage, samples were tested for shear bond strength test in a universal testing machine. Failure modes were determined by stereomicroscope. Data were analyzed by t-test and one-way analysis of variance with P < 0.05 as the level of significance.

RESULTS

In comparison between applied and non-applied CPP-ACP subgroups, there was no significant decrease in the shear bond strength to enamel only in Tetric N-Bond (P > 0.05). In non-applied CPP-ACP subgroups, there were statistically significant differences among all subgroups. Tetric N-Bond had the highest and AdheSE One F had the lowest shear bond strength.

CONCLUSION

CPP-ACP application reduces the shear bond strength of AdheSE and AdheSE One F to enamel but not Tetric N-Bond.

Effect of erbium, chromium: yttrium, scandium, gallium, garnet laser and casein phosphopeptide-amorphous calcium phosphate on surface micro-hardness of primary tooth enamel

Objective:

The aim was to evaluate the effect of Er, Cr: YSGG laser and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on surface micro-hardness of primary tooth enamel.

Materials and Methods:

A total of 30 freshly extracted caries free primary anterior teeth were cleaned and stored in 1% thymol. Teeth were embedded in acrylic resin such that only their buccal surfaces were exposed and were divided into four groups. Group I: Five intact teeth (negative control). The remaining 25 teeth were immersed for 30 min in 1% citric acid for demineralization. Group II: Five demineralized teeth (positive control), Group III: CPP-ACP (GC tooth mousse-GC International, Itabashi-Ku, Tokyo, Japan) application and Group IV: Etching using Er, Cr: YSGG laser + CPP-ACP application. Groups III and IV were subjected to pH cycling for 5 days. Surface micro-hardness of all the teeth was measured using Brinell hardness tester (Fuel Instruments and Engineers Pvt. Ltd.). Data were analyzed using ANOVA.

Results:

Mean surface micro-hardness of Groups I and II were 177.43 kgf/mm² and 164.86 kgf/mm², respectively. Group IV showed a higher mean surface micro-hardness (230.68 kgf/mm²) compared with that of Group III (190.28 kgf/mm²). In comparison to all other groups, laser etching prior to CPP-ACP application increased surface micro-hardness significantly (P < 0.001).

Conclusion:

Laser irradiation of primary teeth followed by CPP-ACP application increased surface micro-hardness of enamel.

In situ effect of a commercial CPP-ACP chewing gum on the human enamel initial erosion

OBJECTIVE

This study evaluated the in situ rehardening effect of a commercial chewing gum containing casein phosphopeptide - amorphous calcium phosphate (CPP-ACP) on initial erosion lesions.

METHODS

Seventy-two human enamel blocks, after selection (initial surface hardness - SHi) and in vitro short-term acidic exposure (cola drink for 3 min - SHd) were randomly assigned to three groups. The factors under study were treatment (3 levels: GI chewing gum with CPP-ACP, GII chewing gum without CPP-ACP and GIII control group without gum) and intraoral period (2 levels: 2 and 24h). Twelve volunteers wore intraoral palatal devices for 24h in 3 crossover phases. On each phase, after 2h the surface hardness was assessed (SHf1) and the blocks were reinserted and the devices were used for additional 22 h (SHf2). In phases of GI and GII volunteers chewed the respective gum during 30 min, for 4 times with an interval of 4h. Percentage of surface hardness recovery (%SHR) was calculated after 2 and 24 h. The data were analysed by repeated measures ANOVA and Tukey's test.

RESULTS

Chewing gum with CPP-ACP (2h=50.0%<24h=95.9%) showed higher hardness recovery than chewing gum without CPP-ACP (2h=30.0%<24 h=71.1%) and control (2 h=15.7%<24 h=40.9%) (p<0.05).

CONCLUSIONS

The results suggest that saliva increased hardness of softened enamel after the use of conventional chewing gum (GII) and this effect was enhanced by the prolonged intraoral period (24 h) and by the use of CPP-ACP chewing gum (GI).

CLINICAL SIGNIFICANCE

Since chewing gum is an alternative to enhance salivary defenses after erosive challenges, CPP-ACP chewing gum might be a supplementary strategy to potentiate the mineral precipitation of initial erosion lesions.

Influence of casein phosphopeptide-amorphous calcium phosphate application, smear layer removal, and storage time on resin-dentin bonding

The aim of this study is to evaluate the influence of Tooth Mousse (TM) application, smear layer removal, and storage time on resin-dentin microtensile bond strength (µTBS). Dentin specimens were divided into two groups: (1) smear layer covered; (2) smear layer removed using 15% EDTA for 90 s. In each group, half the specimens were treated once with TM for 60 min. After bonding procedures using a two-step self-etching adhesive (Clearfil SE Bond (CSE); Kuraray Medical, Tokyo, Japan), an all-in-one adhesive (G-Bond (GB); GC Corp, Tokyo, Japan), and a total-etch adhesive (Adper Single Bond 2 (SB); 3M ESPE, St. Paul, MN, USA), the specimens were stored for 3 d or 6 months in deionized water at 37 °C, and µTBS was tested and analyzed. With the exception of SB (no TM application) and GB, the μTBS was significantly increased for CSE and SB using EDTA pre-conditioning and 3 d of storage (P≤0.001). Bond strength of GB decreased significantly when using EDTA (3 d storage, P<0.05). TM application only increased the μTBS of GB (no EDTA) and SB (with EDTA) after 3 d (P≤0.02). Comparing the adhesives after 3 d of storage, CSE exhibited the greatest μTBS values followed by GB and SB (P≤0.02). The factors of adhesive, EDTA, and TM did not show any significant impact on μTBS when specimens were stored for 6 months (P>0.05). The additional application of TM and EDTA for cavity preparation seems only to have a short-term effect, and no influence on µTBS of dentin bonds after a period of 6 months.

The effect of casein phosphopeptide-amorphous calcium phosphate paste and sodium fluoride mouthwash on the prevention of dentine erosion: An in vitro study

Aim:

The purpose was to compare the effect of 0.2% sodium fluoride mouthwash and casein phosphopeptide-amorphous calcium phosphate paste on prevention of dentin erosion.

Materials and Methods:

Buccal surfaces of 36 sound premolar teeth were ground flat and polished with abrasive discs. Half the polished surfaces were covered with tape to maintain a reference surface. Samples were randomly allocated into three groups. Group A was pretreated with tooth mousse (TM) 4 times a day for 5 days. Group B was pretreated with 0.2% sodium fluoride mouthwash 4 times a day for 5 days. Group C was considered as the control group with no pretreatment. In the next step, the samples were exposed to Coca-Cola 4 times a day for 3 days. After each erosive cycle, the samples were rinsed with deionized water and stored in artificial saliva. The surface loss was determined using profilometry.

Results:

The erosion in both Groups A and B was less than the control group. The surface loss in mouthwash group was significantly lower than in the control group. Erosion in TM group was more than the mouthwash group and less than the control group.

Conclusion:

Sodium fluoride mouthwash is more effective for prevention of dentin erosion.

Role of casein phosphopeptide amorphous calcium phosphate in remineralization of white spot lesions and inhibition of Streptococcus mutans?

INTRODUCTION

To promote the remineralization by ionic exchange mechanism instead of invasive techniques many remineralizing agents can be used.

OBJECTIVE

To evaluate the remineralization effects of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs) and its inhibitory effect on Streptococcus mutans colonization.

MATERIALS AND METHODS

The study group consisted of 60 subjects exhibiting at least 1-WSL. Subjects were randomly divided into 2 groups: A test group using CPP-ACP cream (GC-Tooth Mousse, Leuven, Belgium) and a control group using only fluoride containing toothpaste for a period of 3-month. Baseline WSLs were scored using DIAGNOdent device (KaVo Germany) and the saliva samples were collected to measure S. mutans counts. After the 3-month period the WSLs were again recorded and the saliva collection was repeated.

RESULT

DIAGNOdent measurements were increased by time (P = 0.002) in the control group and no statistically significant difference (P = 0.217) was found in the test group by the 3-month period. In both groups, the mutans counts were decreased in the 3-month experimental period.

CONCLUSION

These clinical and laboratory results suggested that CPP-ACP containing cream had a slight remineralization effect on the WSL in the 3-month evaluation period however, longer observation is recommended to confirm whether the greater change in WSLs is maintained.

Surface remineralization potential of casein phosphopeptide-amorphous calcium phosphate on enamel eroded by cola-drinks: An in-situ model study

AIM

The aim of this study was to investigate the remineralization potential of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on enamel eroded by cola drinks.

SUBJECTS AND METHODS

A total of 30 healthy subjects were selected from a random sample of 1200 children and divided into two groups of 15 each wherein calcium and phosphorus analyses and scanning electron microscope (SEM) analysis was carried out to investigate the remineralization of enamel surface. A total of 30 non-carious premolar teeth were selected from the human tooth bank (HTB) to prepare the in-situ appliance. Three enamel slabs were prepared from the same. One enamel slab was used to obtain baseline values and the other two were embedded into the upper palatal appliances prepared on the subjects' maxillary working model. The subjects wore the appliance after which 30 ml cola drink exposure was given. After 15 days, the slabs were removed and subjected to respective analysis.

STATISTICAL ANALYSIS USED

Means of all the readings of soluble calcium and phosphorous levels at baseline,post cola-drink exposure and post cpp-acp application were subjected to statistical analysis SPSS11.5 version. Comparison within groups and between groups was carried out using ANOVA and F-values at 1% level of significance.

RESULTS

Decrease in calcium solubility of enamel in the CPP-ACP application group as compared to post-cola drink exposure group (P < 0.05) was seen. Distinctive change in surface topography of enamel in the post-CPP-ACP application group as compared to post-cola drink exposure group was observed.

CONCLUSION

CPP-ACP significantly promoted remineralization of enamel eroded by cola drinks as revealed by significant morphological changes seen in SEM magnification and spectrophotometric analyses.

Comparative evaluation of remineralizing potential of three agents on artificially demineralized human enamel: An in vitro study

INTRODUCTION

Remineralization as a treatment procedure has received much attention from clinicians. The objective of this in vitro study was to find out the efficacy of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), casein phosphopeptide-amorphous calcium phosphate fluoride (CPP-ACPF), and tricalcium phosphate fluoride (TCP-F) in remineralizing enamel surface on which artificial caries lesion had been created. The changes were analyzed using DIAGNOdent(®) (KaVo) and scanning electron microscope (SEM).

MATERIALS AND METHODS

A total of 52 premolars and 24 molars were selected and classified into four groups of 13 premolars and 6 molars in each: I (CPP-ACP), II (CPP-ACPF), III (TCP-F), and IV (artificial saliva). All the samples were assessed using DIAGNOdent at the baseline and after demineralization and remineralization. Ten samples were randomly selected from each group baseline after demineralization and after remineralization for surface evaluation using SEM.

RESULTS

Statistical analysis showed that all the experimental groups had a significantly higher amount of remineralization except for group IV.

CONCLUSION

All the three experimental groups showed a statistically significant amount of remineralization. However, because of the added benefit of fluoride (NaF 0.2%), CPP-ACPF (Tooth Mousse-Plus(®)) and TCP-F showed marginally more amount of remineralization than did CPP-ACP (Tooth Mousse(®)). Remineralization efficacy was TCP-F > CPP-ACPF > CPP-ACP.

Effect of casein phosphopeptide-amorphous calcium phosphate and acidulated phosphate fluoride gel on erosive enamel wear

BACKGROUND

Some studies have shown that casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and acidulated phosphate fluoride (APF) gel can protect teeth against erosion. The aim of this study was to assess whether CPP-ACP and fluoride could reduce enamel wear rates under erosive conditions simulating abrasion and acidic diet regimen.

MATERIALS AND METHODS

Enamel specimens consisted of 3 experimental groups (receiving CPP-ACP, APF or both) and a control group. Specimens were subjected to 5,000 wear cycles at a load of 30 N and a pH of 3 in a tooth wear machine. The amount of wear was determined by stereomicroscope. Data were analyzed using one-way analysis of variance and Tukey post hoc tests (α = 0.05).

RESULTS

Mean wear rate (mean±SD) was 194.6±49.2 micrometers in CPP-ACP group, 197.6±39.5 in APF group, 134.6±44.7 in combination group and 266.2± 22.7 in the control group. Statistical analysis indicated significantly higher wear rate in the control group than the experimental groups and also in the CPP-ACP and APF group than the combination group (P<0.05).

CONCLUSIONS

We concluded that although either CPP-ACP or APF can protect enamel against wear, their combination provides significant enamel wear reduction. These findings would lead to new strategies for the clinical management of tooth wear.