ISSN: 2581-5989

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International Journal of Dental Science and Innovative Research (IJDSIR)

IJDSIR : Dental Publication Service
Available Online at: www.ijdsir.com
Volume – 3, Issue – 6, November - 2020, Page No. : 294 - 304
Comparative evaluation of ability of three different dentifrices to remineralise artificial carious lesions in enamel
1
Dr Anita J Kale,2Dr Ruchi S Rathi, 3Dr Sunanda L Gaddalay, 4Dr Ramchandra S Kabir, 5Dr Amol A Badgire,
6
Dr Praveen F Dhore
1-6
Dept of Conservative dentistry and Endodontics, MIDSR Dental College and Hospital, Latur-413512
Corresponding Author: Dr Ruchi S Rathi, Dept of Conservative dentistry and Endodontics, MIDSR Dental College and
Hospital, Latur-413512
Citation of this Article: Dr Anita J Kale,Dr Ruchi S Rathi, Dr Sunanda L Gaddalay, Dr Ramchandra S Kabir, Dr Amol A
Badgire, Dr Praveen F Dhore, “Comparative evaluation of ability of three different dentifrices to remineralise artificial
carious lesions in enamel” IJDSIR- November - 2020, Vol. – 3, Issue - 6, P. No. 294 – 304.
Copyright: © 2020, Dr Ruchi S Rathi, et al. This is an open access journal and article distributed under the terms of the
creative commons attribution noncommercial License. Which allows others to remix, tweak, and build upon the work non
commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Type of Publication: Original research Article
Conflicts of Interest: Nil
Abstract mousse plus showed the least remineralising ability and
Aim: the aim of this in vitro study was to compare the the difference was statistically significant.
ability of three different dentifrices to remineralise Conclusion: The samples treated with SHY-NM showed
artificial carious lesions in enamel; using a 14 day pH the highest remineralisation followed by ClinPro tooth
cycling model through surface microhardness (SMH) crème and GC Tooth mousse Plus.
analysis. Keywords: Demineralisation, Dentifrice, Minimally
Material and Method: 40 enamel specimens were Invasive Dentistry, Ph Cycling, Remineralisation, White
prepared by flattening the buccal surfaces of freshly Spot Lesions.
extracted human premolars. The samples were randomly Introduction
assigned to experimental and control groups and baseline Shafer identified Dental caries as an infectious disease of
microhardness values were recorded using Vicker’s microbiologic origin but, recent research has led towards
microhardness testing machine. The samples were then identification of this process as a dynamic one, where a
immersed in demineralising solution for lesion formation delicate balance exists between remineralisation and
(1, 2)
followed by surface microhardness evaluation. This was demineralisation. Factors like good oral hygiene,
followed by pH cycling for 14 days and surface balanced diet, saliva buffer, promote remineralization;
microhardness evaluation. The solutions were replenished while increased consumption of dietary sugars,
periodically. colonization by S.mutans or poor oral hygiene result in the
Results: The difference between SHY-NM and ClinPro predominance of demineralisation. (3)
Page 294

tooth creme was statistically non-significant. GC tooth

Corresponding Author: Dr Ruchi S Rathi, ijdsir, Volume – 3 Issue - 6, Page No. 294 - 304
Dr Ruchi S Rathi, et al. International Journal of Dental Science and Innovative Research (IJDSIR)

The overall incidence of dental caries in primary dentition dioxide, flavouring agents, carbomer, potassium
(4, 5)
is 46.6% and its prevalence in adults is 49-84 %. The acesulfame. It is well known for its desensitizing property
traditional treatment involves excavation of carious tooth and its effect in enamel remineralization are promising.
(3, 6)
structure and restoration using a suitable material. The When the glass comes in contact with saliva or any
initial manifestation of dental caries occurs in the form of physiological fluid; it can induce apatite formation in the
an opaque, subsurface demineralisation called a white spot form of hydroxyapatite or fluorapatite. If fluoride is
lesion. These lesions are often undetected owing to an incorporated in the composition, BAG can demonstrate
intact enamel surface; and if detected do not warrant ‘smart properties’ by inducing remineralisation in low pH
traditional treatment. With the advent of minimally environments. Consequently, it has been made a part of
invasive dentistry, the focus has shifted on to the various dentifrices, prophylactic gels or other materials for
prevention of demineralisation and reduction of the the treatment of enamel demineralisation. (11, 12, 13)
incidence of such lesions. (3, 7, 8) CPP-ACP is derived from a milk protein known as casein.
Fluoride is known for its anticariogenic potential. Several In the oral environment, the adhesive property of ACPF
mechanisms have been proposed like formation of component promotes the binding with enamel surface or
fluorapatite crystals, enhancement of subsurface biofilm. It results in delivery of Calcium and Phosphate
remineralisation resulting in reduced caries progression, ions at the local site while creating a reservoir of bio-
(8, 9)
inhibition of bacterial glucose metabolism, etc. available calcium and phosphate ions. The anticariogenic
Despite its beneficial effects in remineralization; property of CPP-ACPF can be attributed to its potential to
detrimental effects to the tooth surface have been noted if enter enamel rods and amend the crystalline apatite
(3)
exposed to increased concentrations. However, fluoride structure. (3, 10, 14, 15, 16) CPP-ACPF is manufactured as GC
is known to have a synergistic effect when used in Tooth Mousse Plus (GC, India) and it consists of Casein
combination with certain compounds. (10) phosphopeptide-amorphous calcium phosphate along with
Bioactive glass (BAG) was developed by Dr. Len 900ppm of fluoride. CPP-ACP acts synergistically with
Litkowski and Dr. Gary Hack at the Department of fluorine and its remineralising potential has been found to
compositions Restorative Dentistry at the University of be superior in comparison with CPP-ACP alone. (15)
Maryland and by Dr. David Greenspan at NovaMin® Tricalcium phosphate helps create a protective barrier
Technologies Inc. It is composed of SiO2, Na2O, CaO, around calcium; which gets dissolved on coming in
P2O5 and the incorporation of fluorine further increases contact with saliva resulting in the release of free Ca,
(16)
its bioactivity. The active ingredient is amorphous calcium phosphate and fluoride ions. ClinPro tooth crème (3M
sodium phosphosilicate. In an aqueous environment, this ESPE, USA) consists of functionalised tri-calcium
compound releases bioavailable calcium, sodium and phosphate or f-TCP along with 950 ppm of fluoride. It acts
phosphate ions; which raise the pH of the solution, thus as a smart system in synergy with fluoride ions to form
contributing to the process of remineralization. SHY-NM acid resistant crystals similar to hydroxyapatite;
(Group Pharmaceuticals, Bengaluru, India) consists of preventing initiation and progression of lesions thereby
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glycerine, PEG 400, silica, calcium, sodium decreasing hypersensitivity. (16, 17, 18)
phosphosilicate, sodium lauryal sulphate, titanium
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The current ‘minimally invasive’ approach is the science Preparation of solutions: Analytical grade chemicals and
of detecting, diagnosing, intercepting and treating dental deionized water were used to prepare the solutions.
caries in such a manner that operative intervention may be Demineralisation: Lactic acid containing 0.2 mmol/L
deferred for as long as possible. Keeping in mind that calcium, 2.0 mmol/L phosphate and 0.075 mol/L acetate
dental caries is an infectious disease; the ‘minimally adjusted at pH=4.3 was used to mimic the conditions
invasive’ approach includes many nonsurgical modalities, during caries process. The samples were immersed in 40
the focus being on maximum conservation of mL of demineralising solution for 6hrs and were stored at
(19)
demineralized, noncavitated enamel and dentin. Till 37ºC temperature in an incubator.
date, no study has compared the enamel remineralising Remineralisation: Artificial saliva contained 1.5 mM of
ability of BAG, CPP-ACPF against f-TCP. Therefore, the Calcium Chloride, 0.9 mM of Sodium Phosphate and 0.15
aim of this in vitro study was to compare the ability of M of Potassium Chloride adjusted at a pH=7 to mimic
three different dentifrices to remineralise artificial carious saliva.
lesions in enamel; using a 14 day pH cycling model Lesion formation: All samples were individually
through surface microhardness analysis. immersed in 40 mL of demineralising solution for 6 hours
Material and Methods to produce lesions approximately 75 µm deep with a
This in-vitro prospective study was conducted in the mineral loss of 10-15%.
Department of Conservative Dentistry and Endodontics. Demineralized SMH: (D-SMH): All samples were
Human premolars extracted for orthodontic reasons were subjected to SMH evaluation using Vicker’s
selected for the study. The teeth were cleaned and stored microhardness testing machine. Three indentations were
in 10% formalin solution until use. made with VMT at the rate of 100g load for 10 seconds.
Inclusion criteria: Teeth with intact enamel surfaces An average value was obtained to avoid discrepancy.
were used for the study. Groups: Forty samples were randomly divided into four
Exclusion criteria: Teeth with any visible or detectable groups of 10 samples each.
caries, stains, restorations, cracks, hypoplastic lesions or Group A: Control – No treatment;
white spot lesions were excluded from the study. Teeth Group B: CPP-ACPF (Tooth Mousse Plus)
having undergone endodontic therapy were also excluded Group C: Bioactive glass (SHY-NM)
from the study. Group D: f-TCP (ClinPro crème)
Samples preparation: The buccal surfaces of teeth were The pH cycling model: To simulate changes occurring in
flattened and polished using abrasive paper. Forty blocks the oral cavity, the following pH cycling model was
were cut out from these teeth of dimensions 4x4mm using adopted. In each 24 hour period, the samples were
a diamond disc. subjected to:
Baseline SMH: (B-SMH): B-SMH was tested using • 6hrs of demineralisation: All samples were immersed
Vicker’s microhardness testing machine for all specimen. in 40mL of demineralising solution and were then
Three indentations were made with VMT at the rate of rinsed by deionized water.
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100g load for 10 seconds. An average value was obtained • minutes of remineralisation: The samples of Group B,
to avoid discrepancy. Group C and Group D were treated with the respective
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remineralising agents for a period of 3 minutes, twice • Remineralized SMH: (R-SMH) All samples were
a day to mimic the daily recommended brushing. They subjected to SMH evaluation using Vicker’s
were rinsed with deionized water. microhardness testing machine. Three indentations
• 17 hours of remineralisation: All the samples were were made with VMT at the rate of 100g load for 10
then immersed in artificial saliva to mimic the action seconds. An average value was obtained to avoid
of saliva in remineralising carious lesions. discrepancy.
The pH cycling was carried out for 14 days. The Statistical analysis: Data obtained was subjected to
remineralising and demineralising solutions were analysis using SPSS software by applying ANOVA,
replenished every 48 hours. paired t-test and post hoc tukey’s test.
Results
Table/fig 1 N Mean Std. Deviation Std. Error Range Minimum Maximum
Baseline 10 275.70 55.08 17.42 140 230 370
Demineralised 10 236.00 6.51 2.06 23 230 253
Tooth mousse
10 257.75 31.52 9.97 82.0 230 312
Plus
ClinPro 10 261.00 35.02 11.08 80.5 230 310.5
SHY NM 10 268.10 36.13 11.43 90 230 320
Table 1: Descriptive statistics of variables with their respective mean values and standard deviations
ANOVA Table 2 N Mean SD F P Inference
Group B 10 249.30 28.91
Group C 10 268.10 36.13 9.88 0.045 (>0.05) Significant
Group D 10 261.00 35.02
Table 2: On applying one way ANOVA, statistically significant differences were obtained between groups.
Table 3 Group D (Clin Pro) Group C (SHY NM)
Group B (Toothmoose Plus) -11.7* -18.8*

Group D (Clin Pro) -7.1

Table 3 - Post hoc tukey’s HSD test was applied for intragroup comparisons where Statistically significant difference was
obtained between Group B and Group C; Group B and Group D; whereas statistically nonsignificant difference was
obtained between Group C and Group D.
297
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The percentage recovery observed for all experimental 2. The chemistry/handling of the adhesive materials used
groups is calculated using the following formula {[(R- to restore the cavity
SMH)-(D-SMH)] X 100}/ [(B-SMH)-(D-SMH)] (Figure 3. Consideration of the practical operative techniques
1). The highest amount of percentage SMH recovery was available to excavate caries minimally. (20)
observed for SHY NM (group C= 53.84%)followed by Consequently, MID helps prevent or reverse caries in its
ClinPro tooth crème (Group D = 64.1%) and Tooth early stages by interrupting the pathogenic process prior to
mousse plus (Group B = 53.84%) respectively. cavitation; thereby fulfilling the treatment objective using
Discussion the least invasive technique. (21)
Miles Markley stated regarding the dentist’s role in the An in vitro study model simulates a phenomenon of
treatment of dental caries; that the loss of even a part of a interest thus allowing investigators to derive information
human tooth should be considered ‘a serious injury’. In about the said phenomenon. Therefore, an in vitro study
relevance to his words, it may be implied that the goal of design was chosen which can mimic the dynamic
dentistry is to preserve healthy and natural tooth structure. variations in mineral saturation involved in the caries
(19)
In order to achieve clinical success using the process. To obtain sufficient quantitative data, a pH
'minimally invasive operative caries management strategy' cycling model was incorporated in the study design. The
(MI OCMS); a thorough understanding of the following pH cycling model was developed by ten Cate and Duijster
critical factors, which constitute 'the golden triangle', is (1982) which was modified by Featherstone JDB et al in
indispensible: 1986. It is rapid, inexpensive and allows the study to be
1. The histology of the dental substrate being treated conducted with a smaller sample size. The pH cycling
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models allow a high scientific control, thereby reducing

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(23)
the variability of outcomes in an in vitro study. The pH light microscopy (PLM). Of these, SMH testing has
cycling protocol used in our study is adopted from the one been the most popular method for measuring hardness of
given by Maia (2003)22, which simulates an in vivo high enamel and dentin. (27) SMH evaluation is simple, fast and
caries risk condition; while simultaneously measuring the a non-invasive method to measure mineral changes. It also
net result of the inhibition of demineralisation and reduces the experimental variations by allowing repeated
enhancement of remineralisation in the in vivo set up. measurements of the specimen over a given period of
(26)
In this model, the samples are immersed in an acidic time. A good correlation (r2 = 0.94) has been
(demineralising) buffer solution followed by established between measurement of net remineralisation
(28)
supersaturated (remineralising) buffer solution to simulate using SMH. In studies with a pre-post experimental
the dynamic cycles of demineralisation and design; measuring the SMH aids comparison between the
remineralisation. Dentifrice use as recommended twice a baseline surface and the modified surface for the same
day is simulated by topical application of agents during indentation load.(29) A slight dissolution of the enamel
the pH cycling. The demineralising solution was an acid surface marks the initiation of the caries process; while
buffer solution of lactic acid adjusted at pH 4.4 and the appearing unaltered owing to continuous regeneration as a
remineralising solution consisted of calcium and result of mineral precipitation. Therefore, the evaluation
phosphate ions at a known degree of saturation, adjusted of changes in this region is relevant and SMH
at pH 7.0 to mimic the effects of saliva. The compositions measurement is a suitable technique for the same. (30)
of the solutions were in accordance with the compositions In our study, the samples were tested prior to lesion
employed by Buzalaf et al.23 formation to obtain baseline SMH values. The mean B-
The primary limitation with pH cycling models is the SMH value obtained was 339.35. After lesion formation,
variability associated with the substrate and test the samples were subjected to SMH and the mean D-SMH
conditions; following which single-section substrates are value obtained was 236.00 after 96 hours of
recommended in order to obtain accurate results. Also, demineralisation. (Table 1) The difference between the
certain mechanistic factors important in predicting two values was statistically significant (p<0.05). These
prevention of caries are better elucidated in a single- values are in accordance with the studies conducted by
section study. Enamel substrates demonstrate mineral loss Gutiérrez-Salazar et al, Vieira AE et al, Soares R et al,
and uptake at similar depths owing to low penetrability by Rao R et al and Neto FCR et al. (3, 26, 28, 31, 32) According to
acids in the interprismatic space. As a result, thin enamel Koulourides and Reed, enamel surfaces exposed to weak
sections of specified dimensions were obtained from acid (pH 5.5) result in calcium loss accompanied by a
freshly extracted human premolar teeth and utilised in our decrease in hardness due to changes of mineral density. (33,
study as substrate. (9, 23, 24, 25) 34)

The physical changes occurring on the surface layer of the Various studies have carried out the pH cycling for
(23)
enamel can be attributed to the interactions between varying number of days. According to Featherstone
(26)
enamel and the oral environment. These changes can and Glena (1990), their 14 day pH-cycling model was
299

be measured quantitatively using hardness profiles and designed to simulate highly susceptible sites in vivo. They
mineral content or qualitatively using SEM or Polarised concluded that, an exponential quantitative relationship
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exists between fluoride concentration and enhancement of hydroxycarbonate apatite (HCA) which chemically similar
remineralization. Therefore, in the present study, the pH to the natural teeth. (11, 35, 36)
cycling was carried out for a period of 14 days. During In the present study, the highest levels of hardness were
this time, the experimental agents were applied topically; demonstrated by SHY-NM containing bioactive glass.
twice daily for two minutes, to simulate the recommended This can be attributed to the compact attachment of BAG
(9, 23)
daily oral prophylaxis. At the end of the pH cycling and precipitation of HCA layer on the surface. The
samples were subjected to SMH analysis (R-SMH) to difference between SHY-NM and ClinPro tooth crème
evaluate the effect of the agents in net remineralisation. was found to be statistically non significant; whereas
Statistically significant results were obtained between the statistically significant difference was found between
experimental groups. (Table 2, 3) SHY-NM and CPP-ACPF. Similar results were obtained
SHY-NM consists of Bioactive Glass. Bioactive glasses in studies conducted by Kamath P et al, Mehta AB et al
are introduced into dentifrices as very fine particles to and Rajan R et al where they observed non-significant
provide calcium and phosphorus at the tooth surface. difference between SHY-NM and ClinPro tooth crème;
According to Wang et al, toothpastes containing bioactive whereas statistically significant difference was observed
glass show significant reduction in dentine permeability between SHY-NM and CPP-ACPF. (7, 36, 37)
and resistance to acid challenge which; owing to its Research has established that the use of ClinPro tooth
remineralising ability, is advantageous for long term crème results in increased surface microhardness. It is a
(35)
treatment of hypersensitivity. In a study, Mehta et al, hybrid material created by high impact grinding of beta-
found that while both bioactive glass and CPP-ACP tricalcium phosphate and sodium lauryl sulfate or fumaric
successfully remineralised early enamel caries; bioactive acid causing fusion of the constituents. This blending
glass remineralised the carious lesion more effectively. creates “functionalized” calcium and “free” phosphate
BAG also demonstrated higher values of hardness owing ions which increase the efficacy of fluoride
(36)
to its ability to attach to the surface more compactly. remineralisation. The Beta-TCP has a similar structure to
Surface reaction of BAG begins immediately in three apatite and possesses calcium environs that are capable of
phases, i.e. leaching and exchange of cations, network reacting with fluoride. The free floating phosphate
dissolution of SiO2 and precipitation of calcium and protects the exposed calcium environs, preventing
phosphate to form an apatite layer. In an aqueous premature interaction between the calcium with fluoride.
environment i.e. presence of saliva in the oral cavity; Therefore, TCP provides high levels of calcium to boost
sodium ions from the BAG particles rapidly exchange fluoride efficacy. On coming in contact with saliva, the
with hydrogen cations, resulting in release of calcium and protective barrier breaks down making the ions available.
phosphate ions at the surface. A localized, transient Subsequently, the fluoride and calcium react with the
increase in pH occurs during the release of sodium ions weakened enamel to provide a seed for enhanced mineral
which help to precipitate additional calcium and growth. Fluoride in combination with β-TCP provides
phosphate ions to form a calcium phosphate layer. As greater recovery of microhardness and increased fluorine
300

these reactions progress, this layer crystallizes into uptake; while decreasing the dose of fluoride required for
the same degree of remineralisation. (37, 38) The statistically
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non-significant difference obtained in our study; between CPP-ACPF. It must be noted that the conclusions drawn
SHY-NM and ClinPro tooth crème, can therefore be from an in vitro study are exclusive of factors which vary
attributed to the above mentioned mechanism. subjectively. Therefore, clinical extrapolations must be
CPP-ACPF is advantageous as it delivers ACP and made accordingly.
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