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ORIGINAL RESEARCH ARTICLE  
Year : 2017  |  Volume : 20  |  Issue : 6  |  Page : 463-466
Comparative evaluation of remineralizing potential of Fluoride using three different remineralizing protocols: An in vitro study


1 Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth Deemed University Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Department of Pharmacology, D.Y.Patil University School of Medicine, Navi Mumbai, Maharashtra, India

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Date of Submission06-Jul-2017
Date of Decision06-Dec-2017
Date of Acceptance06-Dec-2017
Date of Web Publication15-Jan-2018
 

   Abstract 


Background: Remineralization of noncavitated enamel is dependent on the bioavailability of calcium, phosphate, and hydroxyl ions in saliva. However, it is enhanced by the presence of fluoride. This study compared the remineralizing potential of three different topical fluoride agents.
Materials and Methods: Fifteen extracted premolars were selected for the study. The crown of each tooth was longitudinally sectioned buccolingually and mesiodistally using a diamond disc so as to obtain sixty specimens which were embedded in acrylic molds. The specimens were immersed in demineralizing solution for 3 days. The specimens were randomly assigned to four groups, namely Duraphat fluoride varnish, ReminPro paste, ClinPro Tooth Crème, and control group (no surface treatment). A pH cycling includes alternate demineralization and remineralization. Surface mean hardness (SMH) was recorded with 50 g load for 5 s using VHN machine at baseline, after demineralization and pH cycling. The four groups were compared for difference in SMH using one-way ANOVA followed by Tukey–Kramer test. All testing was done with alpha 0.05.
Results: SMH recovery results for ClinPro, Duraphat, and ReminPro were 54.88%, 43.42%, and 26.86%, respectively. The difference in the percentage SMH recovery for ClinPro paste was better than Duraphat and ReminPro, and this difference was statistically significant (P < 0.05).
Conclusions: ClinPro tooth Crème showed the best remineralization potential among the three materials tested followed by Duraphat and ReminPro.

Keywords: ClinPro Tooth Crème; Duraphat; enamel remineralization; ReminPro; topical fluoride

How to cite this article:
Rao R, Jain A, Verma M, Langade D, Patil A. Comparative evaluation of remineralizing potential of Fluoride using three different remineralizing protocols: An in vitro study. J Conserv Dent 2017;20:463-6

How to cite this URL:
Rao R, Jain A, Verma M, Langade D, Patil A. Comparative evaluation of remineralizing potential of Fluoride using three different remineralizing protocols: An in vitro study. J Conserv Dent [serial online] 2017 [cited 2020 Sep 20];20:463-6. Available from: http://www.jcd.org.in/text.asp?2017/20/6/463/223188



   Introduction Top


Remineralization of noncavitated lesions has been reported since the beginning of the twentieth century when demineralized enamel was observed to harden in the presence of saliva.[1] Remineralization of noncavitated enamel is dependent on bioavailability of calcium, phosphate, and hydroxyl ions in saliva. However, it is enhanced by the presence of fluoride. NaF varnish, fluoride pastes containing hydroxyapatite (HA) and xylitol as well as those containing f-TCP molecules have been used. All three remineralizing strategies utilize different ingredients and have different mechanisms of action, yet each one is promising. Hence, it was decided to evaluate and compare the remineralizing potential of commonly available topical fluoride agents.


   Materials and Methods Top


The study protocol and documents were reviewed and approved by the Scientific Review Committee of Bharati Vidyapeeth Dental College and Hospital, Navi Mumbai. Fifteen freshly extracted premolars were taken, and the crowns were longitudinally sectioned buccolingually and mesiodistally using a diamond disc so as to obtain a total of sixty specimens which were embedded in acrylic molds.

The specimens were immersed in demineralizing solution (MP Sai Enterprises, Mumbai) for 3 days at 35° temperature followed by surface mean hardness (SMH) testing. The specimens were randomly assigned to four groups (n = 15) according to the remineralization protocol as follows: Group A: Duraphat fluoride varnish (Colgate), Group B: ReminPro paste (Voco), Group C: ClinPro Tooth Crème (3M), and Group D: Control group (no surface treatment).

A pH cycling regimen including alternate demineralization (3 h in demineralizing solution) and remineralization (21 h in artificial saliva) was undertaken for 5 consecutive days.

Surface microhardness values were recorded with a load of 50 g for 5 s using a VHN machine at baseline and after demineralization and pH cycling. The SMH recovery was calculated the percentage increase in SMH from baseline after pH cycling.

Statistical analysis

Data for SMH were expressed as mean and standard deviation. The four groups were compared for difference in SMH using one-way ANOVA followed by Tukey–Kramer test. All testing was done with alpha 0.05 and P < 0.05 was considered statistically significant.


   Results Top


The mean SMH scores before demineralization, after demineralization, and after remineralization are presented in [Table 1]. The SMH scores were similar in the four groups before demineralization (P = 0.168), whereas the scores are different after demineralization (P < 0.0001) and after remineralization (P < 0.0001).
Table 1: Surface hardness (MPa) in four groups

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The SMH recovery for ClinPro, Duraphat, and ReminPro was 54.88%, 43.42%, and 26.86%, respectively [Figure 1]. The SMH recovery for ClinPro paste was better than Duraphat and ReminPro, the differences being statistically significant (P < 0.05).
Figure 1: Mean change (%) in surface hardness after remineralization

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   Discussion Top


Dental tissues are continuously undergoing cycles of demineralization and remineralization. A drop in pH of the oral cavity results in demineralization, which if continues leads to loss of minerals from the tooth structure resulting in dental caries. A reversal can occur if pH rises resulting in deposition of calcium, phosphate, and fluoride.[2],[3]

Dental caries is a dynamic process which occurs when demineralization exceeds remineralization. However, progression of dental caries is a slow process, and during early stages, non-invasive intervention can convert the lesion to inactive state from an active state.[4]

The best mode for initial caries management is the medical model using remineralizing agents. Early recognition and intervention is essential. At present, fluoride-, calcium-, phosphate-based systems and calcium sodium phosphosilicate, etc., are commercially available.

Even though the initial carious lesions have intact surfaces when compared with sound enamel, they have low mineral content at the surface layer, thus showing a lower hardness value than for sound enamel tissue.[5],[6]

In the present study, the specimen were kept in the demineralizing solution for 72 h at 37 degrees creating a subsurface demineralization of approximately 150-micron width with an intact surface simulating an early enamel lesion.[7] Assessment of in vitro demineralization and remineralization can be done by scanning electron microscopy (SEM)/environmental SEM, Diagnodent method, and surface microhardness test. Microhardness measurement was chosen as it is appropriate for material having fine microstructure, nonhomogeneous and prone to cracking like enamel. In the present study, the microhardness values were measured in three steps, baseline, after demineralization, and remineralization.

The baseline values (VHN) in this study were between 249 and 270 MPa which satisfies the VHN range of normal enamel tissue.[8] Period of demineralization in the pH cycling phase is 3 h to simulate low cariogenic challenge that occurs in the oral cavity.[9]

The test material was applied twice a day to simulate normal recommended daily toothbrushing. The mean SMH recovery percentage of Duraphat was higher than ReminPro but less than ClinPro. Various mechanisms are postulated for role of fluoride in caries resistance and may arise from both systemic and topical application Topical fluoride reagents have the disadvantage of rapid loss of soluble fluoride from surface of teeth. To combat this, waterproof sealant in the form of fluoride varnish was introduced. However, increased levels of topical fluoride lead to rapid mineral precipitation on surface and obliteration of surface enamel pores.[10] Subsurface areas may not be remineralized and white spot lesions may remain indefinitely due to sealing of outer enamel shell. Optimum concentration of fluoride with calcium phosphate may help in addressing both these issues. NaF varnish (Duraphat) and polyurethane-based varnish (Fluoroprotector) are commonly used.

ReminPro contains HA (hydroxyapatite), F (fluoride 1450 ppm), and xylitol (antibacterial agent). It has been recommended for managing hypersensitivity, prevents demineralization, and promotes remineralization of subsurface lesions. In this study, ReminPro yielded the lowest scores. These results are in accordance with the findings of Kamath et al.[11]

ClinPro Crème is a new hybrid material created with a milling technique that fuses beta-tricalcium phosphate and sodium lauryl sulfate or fumaric acid. This blending is hypothesized to create a “functionalized” calcium and a “free” phosphate designed to increase the efficacy of fluoride remineralization.[12],[13]

Beta-TCP is similar in structure to apatite and possesses unique calcium environs capable of reacting with fluoride and enamel. While phosphate floats free, these exposed calcium environs are protected, preventing the calcium from prematurely interacting with fluoride.[14]

Therefore, TCP provides catalytic amounts of calcium to boost fluoride efficacy and can be designed to coexist with fluoride in a mouth rinse or dentifrice. When TCP comes in contact with tooth surface moistened with saliva, the protective barrier breaks down making the calcium, phosphate, and fluoride ions available. The fluoride and calcium then react with weakened enamel to provide a seed for enhanced mineral growth relative to fluoride alone.

F combination with b-TCP not only provides greater remineralization in terms of MH and F uptake but also decreases the dose of F required for the same degree of remineralization.[15] The above may explain the superior performance of ClinPro Crème in this study.


   Conclusions Top


ClinPro Tooth Crème showed the best remineralization potential among the three materials tested followed by Duraphat and ReminPro. Remineralization potential was checked at surface level, and remineralization potential at subsurface level needs to be simulated. Tricalcium phosphate appears to be promising, but most studies have been conducted in vitro, and therefore, more clinical studies are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Head JA. A study of saliva & its actions on tooth enamel in reference to its hardening and softening. J Am Med Assoc 1912;59:2118-22.  Back to cited text no. 1
    
2.
Rao A, Malhotra N. The role of remineralizing agents in dentistry – A review. J Am Dent Assoc 2011;32:26-33.  Back to cited text no. 2
    
3.
Winston AE, Bhaskar SN. Caries prevention in 21st century. J Am Dent Assoc 1989;129:1579-87.  Back to cited text no. 3
    
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Featherstone JD. Dental caries: A dynamic disease process. Aust Dent J 2008;53:286-91.  Back to cited text no. 4
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Koulourides T, Feagin F, Pigman W. Remineralization of dental enamel by saliva in vitro. J Cryst Growth 1965;131:751-7.  Back to cited text no. 5
    
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Arend J, Ten Cate JM. Tooth enamel remineralization. J Cryst Growth 1981;53:135-47.  Back to cited text no. 6
    
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ten Cate JM, Timmer K, Shariati M, Featherstone JD. Effect of timing of fluoride treatment on enamel de- and remineralization in vitro: A pH-cycling study. Caries Res 1988;22:20-6.  Back to cited text no. 7
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Ryge G, Foley DE, Faorhurst CW. Micro-indentation hardness. J Dent Res 1961;40:1116-26.  Back to cited text no. 8
    
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ten Cate JM, Duijsters PP. Alternating demineralization and remineralization of artificial enamel lesions. Caries Res 1982;16:201-10.  Back to cited text no. 9
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García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: The role of dental biofilm, saliva and preventive agents in enamel demineralization and remineralization. J Am Dent Assoc 2008;139 Suppl:25S-34S.  Back to cited text no. 10
    
11.
Kamath U, Sheth H, Mullur D, Soubhagya M. The effect of Remin Pro® on bleached enamel hardness: An in-vitro study. Indian J Dent Res 2013;24:690-3.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Karlinsey RL, Mackey AC. Solid-state preparation and dental application of an organically modified calcium phosphate. J Mater Sci 2009;44:346-9.  Back to cited text no. 12
    
13.
Karlinsey RL, Mackey AC, Walker ER, Frederick KE. Preparation, characterization and in vitro efficacy of an acid-modified beta-TCP material for dental hard-tissue remineralization. Acta Biomater 2010;6:969-78.  Back to cited text no. 13
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14.
Karlinsey RL, Mackey AC, Walker ER, Frederick KE. Surfactant-modified beta-TCP: Structure, properties, and in vitro remineralization of subsurface enamel lesions. J Mater Sci Mater Med 2010;21:2009-20.  Back to cited text no. 14
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15.
Karlinsey RL, Mackey AC, Stookey GK, Pfarrer AM.In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent 2009;22:180-4.  Back to cited text no. 15
[PUBMED]    

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Correspondence Address:
Rahul Rao
Department of Conservative Dentistry and Endodontics, Bharati Vidyapeeth Deemed University Dental College and Hospital, Sector-7, Belpada, Navi Mumbai - 400 614, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCD.JCD_203_17

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