ORIGINAL Krithikadatta ARTICLE et al
Remineralisation of Occlusal White Spot Lesions with a Combination of 10% CPP-ACP and 0.2% Sodium Fluoride Evaluated Using Diagnodent: A Pilot Study Chain Fredricka/Jogikalmat Krithikadattab/Mohan Abarajithanc/ Deivanayagam Kandaswamyd Purpose: To evaluate the efficacy of 10% casein phosphopeptide amorphous calcium phosphate complex (CPP-ACP) used alone or with fluoride as compared to fluoride mouthrinse for the remineralisation of occlusal white spot lesions in an in vivo pilot study. Materials and Methods: Forty-five subjects with occlusal white spot lesions (WSL) determined by visual examination and confirmed with Diagnodent were randomly divided into 3 groups: group 1: 10% CPP-ACP + 0.2% NaF; group 2: 10% CPPACP; group 3: 0.5% NaF mouthrinse for 30 days. The pre-treatment and post-intervention Diagnodent values were tabulated and subjected to statistical analysis. Results: Among the groups, the remineralising potential of 10% CPP-ACP + 0.2% NaF (group 1) and 10% CPP-ACP (group 2) were similar, however, both groups were superior to 0.5% NaF mouthrinse (group 3). Conclusions: The CCP-ACP technique is highly beneficial for the remineralisation of non-cavitated occlusal white spot lesions when compared to 0.5% NaF mouthrinse. Key words: casein phosphopeptide amorphous calcium phosphate complex (CPP-ACP), diagnodent, fluoride, remineralisation, white spot lesion Oral Health Prev Dent 2013;11:191-196 doi: 10.3290/j.ohpd.a29736
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cientific advances in restorative materials and techniques, as well as in understanding the pathogenesis and prevention of dental caries have led to more effective oral health management (Oshiro et al, 2007). Non-cavitated carious lesions extending up to the dentinoenamel junction can be arrested if the cariogenic challenges of the given micro-environment are sufficiently controlled and/ or if therapeutic agents are applied for tissue healing (Rahiotis and Vougiouklakis, 2007). It is well
a
Postgraduate Student, Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College, Chennai, India.
b
Reader, Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College, Chennai, India.
c
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Ultras Best Dental Sciences College, Madurai, India.
d
Dean, Sri Ramachandra Dental College and Hospitals, Chennai, India.
Correspondence: Dr. J. Krithikadatta, Department of Conservative Dentistry and Endodontics, Meenakshi Ammal Dental College, Alapakkam Main Road, Chennai 600095, India. Tel: +91-44-2378-0177. Email:
[email protected]
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Submitted for publication: 21.10.11; accepted for publication: 08.06.12
established that fluoride in the fluid phase surrounding the tooth structure shifts the equilibrium towards remineralisation. Fluoride enhances remineralisation of early carious lesions by adsorbing onto the partially dissolved crystal lattice, which attracts calcium and phosphate ions and leads to the formation of fluorapatite crystals (Featherstone, 2000). The commonly administered professional fluoride delivery methods for remineralisation are gels, varnishes and fluoride-releasing materials. Casein has been identified as one of the milk fractions responsible for the anticariogenic effect (Lennon et al, 2006). Recently, casein phosphopeptide amorphous calcium phosphate complex (CPP-ACP) has been introduced as a supplemental source of calcium and phosphate ions in the oral environment. Casein phophopeptides bind to calcium and phosphates in nanoparticles, preventing the crystals from growing to critical size and precipitating out of solution. The amorphous calcium phosphate is biologically active and is able to release calcium and phosphate ions to maintain the supersaturat-
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ed state, thus improving the remineralisation process (Tantbirojn et al, 2008). Previous studies have shown CCP-ACP to be effective in the remineralisation of carious lesions (Shen et al, 2001; Reynolds, 2007). Numerous studies have evaluated the remineralisation potential of CPP-ACP in situ; however, scientific knowledge of the same in clinical conditions is negligible (Azarpazhooh and Limeback, 2008). Studies comparing the clinical efficacy of fluoride mouthrinse and CPP-ACP for remineralisation of incipient carious lesions are scarce. Because clinical detection of white spot lesions (WSL) is a challenge, several detection systems based on laser/light fluorescence are currently being used as an adjunct to visual detection. Diagnodent (Kavo; Biberach, Germany) is a caries detection system based on laser-stimulated fluorescence. It has proven to be more sensitive than visual examination and bite-wing radiographs in detecting early non-cavitated occlusal enamel lesions (Lussi et al, 2004). A further advantage is that Diagnodent can quantify the degree of demineralisation by digital readings and these readings are reproducible. Diagnodent is more effective in detecting occlusal caries than proximal caries due to ease of accessibility (Bader and Shugars, 2004). Hence, the purpose of this pilot study was to evaluate the efficacy of 10%CPP-ACP used alone or with 0.2% sodium fluoride (NaF) fluoride as compared to 0.5% NaF fluoride mouthrinse alone for the remineralisation of occlusal WSL in vivo as assessed with Diagnodent.
MATERIALS AND METHODS Study sample The subjects enrolled for the study were healthy first- and second-year dental students belonging to the age group of 17–20 years. All students were residents of the dental college hostel and thus the subjects enrolled had a similar diet served at the cafeteria. The study protocol was approved by the ethics committee of Meenakshi Ammal Academy of Higher Education and Research (MAHER, Chennai, India). The details of the study were explained to a total of 120 students, of whom 97 agreed to participate. They were given an information brochure outlining the study design and the objective to assess the role of newer preventive materials for dental caries. The subjects completed a general health questionnaire and gave informed consent to par-
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ticipate in the study. Based on the completed questionnaires, the subjects were assessed for eligibility to undergo the baseline clinical evaluation. Subjects with good general health and presence of all permanent molars were included in the study. Exclusion criteria were subjects with a history of lactose intolerance, presence of orthodontic treatment, prolonged use of antibiotics or medications which affect the salivary flow, developmental defects, multiple occlusal and proximal restorations and poor oral hygiene as indicated by rampant caries.
Clinical evaluation Oral examination of the subjects was performed under a standard dental operatory light. Professional oral prophylaxis was performed for all subjects using an ultrasonic scaler and prophylaxis paste. The teeth were thoroughly rinsed with water. The fissures were cleaned with a WHO probe to remove any remaining plaque or debris. Occlusal surfaces of teeth were cleaned with an alcohol swab and later dried using air from a three-way syringe for 10 s. Areas of demineralisation were identified based on the demonstration of a white opaque area following re-wetting and drying. The teeth were scored using Ekstrand’s criteria (Ekstrand et al, 1998) (Table 1) for visual scoring of dental caries. Since the depth of demineralisation cannot be determined visually, Ekstrand’s scores of V1 and V2 were further subjected to demineralisation quantification using Diagnodent. The Diagnodent threshold for enamel caries was set between 12 and 30. Of the 97 students screened for occlusal white spot lesions, a total of 45 subjects satisfied the criteria. They were randomly allocated to 3 groups and enrolled in the pilot study. The mean age was 18.2 years for 26 males and 18.6 years for 19 females.
Scoring using Diagnodent The original Diagnodent consists of two probes, A and B, used for occlusal and proximal surfaces, respectively. In this study, probe A was used to record the demineralisation values. The instrument was calibrated on a ceramic mount provided by the manufacturer. The baseline reading for enamel demineralisation was recorded by passing the probe over the entire occlusal surface. Three readings for the same site were taken and the average was record-
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Table 1 Ekstrand’s criteria for visual scoring of dental caries Score
Criterion
V0
No or slight change in enamel translucency after prolonged air drying
V1
Opacity or discolouration hardly visible on wet surface but distinctly visible after air drying
V2
Opacity or discolouration distinctly visible on wet surface without air drying
V3
Localised enamel breakdown in opaque or discoloured enamel and/or grayish discolouration from underlying dentin
V4
Cavitation in opaque or discoloured enamel exposing the dentin
ed. The tooth with the maximum score for enamel demineralisation (D1) was recorded for each subject and the scores were tabulated numerically. The site of the lesion was also recorded on an occlusal pictorial chart for evaluation of the same site after the remineralisation period. Only the worst site was recorded for each subject. All the readings were recorded by a single operator and the operator was blinded to the intervention.
Allocation to groups Subjects identified with enamel demineralisation were randomly allocated to three groups. • Group 1 – 10% CPP-ACP + 0.2% NaF (Tooth Mousse Plus, GC; Tokyo, Japan) • Group 2 – 10% CPP-ACP (Tooth Mousse) • Group 3 – 0.5% NaF mouthrinse (S-flo, Dr Reddy’s Laboratory; Hyderabad, India) The mode of delivery of CPP-ACP with and without fluoride was cream based. The proprietary brand GC Tooth Mousse contains 10% CPP-ACP, and GC Tooth Mousse Plus contains 10% CPP-ACP and 0.2% NaF. Since the remineralising agents were contained in different vehicles (cream and mouthrinse), the subjects were aware of the agents provided and double blinding was not possible. However, the operator performing the clinical and Diagnodent evaluation was not aware of subject allocation into the groups. Hence, this was an openlabelled study with blinded evaluation. The subjects were instructed to use the remineralising agents twice a day (once in the morning after brushing and once in the evening before going to bed). The method of application for the cream-based agent was to smear a peanut-sized dab of cream on all the surfaces of all teeth and not to rinse but swallow the saliva following application. The subjects in
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group 3 were asked to measure 5 ml of solution using the measuring cup (provided with the bottle), rinse for 30 s and then spit it out. The subjects were instructed not to eat or drink anything for 30 min following the application of remineralising agent. The importance of complying with the procedure was explained to the subjects. Every day, progess was monitored by an observer and compliance was recorded by checking the level of the material in remaining in the tube or bottle. All subjects reported 30 days after the usage of the respective remineralising agent for evaluation. They were asked to return the respective tubes/bottles to check compliance. Diagnodent evaluation was performed by the same method described earlier on the tooth surface noted on the chart. The posttreatment values were tabulated and subjected to statistical analysis using SPSS version 15.0 (SPSS; Chicago, IL, USA). Analysis of variance (ANOVA) was used to determine the overall variance. Intragroup comparison to determine extent of remineralisation was done using the paired t-test. In order to perform intergroup comparisons, the difference of means (mean of pre-treatment diagnodent values minus mean of post-treatment diagnodent values) for each group was determined. Intergroup comparisons for this difference of means was done using Tukey’s Honestly Significant Difference test. Significance was set at P < 0.05.
RESULTS All three remineralising agents showed a highly significant (P < 0.0001) remineralising potential at the end of treatment period of 30 days (Table 2). The overall mean differences of the groups were significantly different indicating that the groups were not similar (Table 3).
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Table 2 Mean baseline and post-treatment Diagnodent values with mean differences in the three groups Groups
N
Mean pre-treatment ± SD
Mean post-treatment ± SD
Mean difference (CI)
10% CPP-ACP + 0.2%NaF
15
18.20 ± 1.90
6.87 ± 1.90
10% CPP-ACP
15
18.33 ± 1.40
7.33 ± 1.80
0.5% NaF mouthrinse
15
18.6 ± 0.90
10.47 ± 4.10
SD of difference
t-value
P-value
11.33 (9.99, 12.66)
2.40
18.21
