Volume 3, Issue 1 (Journal of Research in Dental & Maxillofacial Sciences winter 2018)                   J Res Dent Maxillofac Sci 2018, 3(1): 6-11 | Back to browse issues page


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Hekmatfar S, Jafari K, Mohammadpour S. An in-vitro Comparison of Calcium Uptake by Intact Enamel after Using two Types of Casein Phosphopeptide-Amorphous Calcium Phosphate Paste. J Res Dent Maxillofac Sci. 2018; 3 (1) :6-11
URL: http://jrdms.dentaliau.ac.ir/article-1-191-en.html
1- Assistant professor, department of pedodontics ,dental faculty, , hekmatfar24@gmail.com
2- Assistant professor department of prorosthodontics, dental faculty
3- Dental student research committeh,dental faculty,
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Abstract

Background and aim: Dental caries is one of the most common childhood diseases worldwide. The implementation of strategies that facilitate the prevention of early dental caries and interrupt its progression has been recently advocated. It has been reported that casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) derived from casein reduces tooth demineralization and enhances the remineralization process. The aim of this in-vitro study was to assess the efficacy of two types of CPP-ACP paste in calcium uptake by enamel surfaces.
Materials and methods: Forty premolars were longitudinally dissected into experimental and control halves, and were coated with nail varnish, except for an enamel window of 4×4 mm. The samples were subjected to cycling in a demineralizing solution and were divided into two groups of GC Tooth Mousse CPP-ACP paste and Misswake CPP-ACP paste. The calcium contents of each half were examined using the acid etch enamel biopsy technique and were measured by atomic absorption. The values were statistically analyzed using Kolmogorov-Smirnov test and one-way analysis of variance (ANOVA).
Results: The enamel surfaces treated with the pastes exhibited higher calcium contents compared to the controls. There was a significant difference between GC Tooth Mousse CPP-ACP paste and Misswake CPP-ACP paste in terms of calcium uptake; a higher calcium uptake was witnessed with GC Tooth Mousse CPP-ACP paste than with Misswake CPP-ACP paste (P<0.05).
Conclusion: Misswake CPP-ACP paste presented some protective potentials; however, the samples treated with GC Tooth Mousse CPP-ACP paste were better able to uptake calcium. These pastes could be considered as effective means for the prevention of dental caries in susceptible patients.
Keywords: Casein phosphopeptide-amorphous calcium phosphate, Tooth Demineralization, Calcium, Dental Enamel
 

Introduction

Dental caries is a common oral health problem affecting a large number of individuals. (1,2) This disease results from an imbalance between the demineralization and remineralization episodes. The reduction of demineralization and development of remineralization are considered as the first approaches for preventing dental caries. (3,4)
Fluoride is the most commonly used remineralizing agent. The effectiveness of topically-applied fluoride products has been well established in caries prevention studies. (5,6)
The inhibition of caries by fluorides is accomplished through the incorporation of fluoride ions into the hydroxyapatite structure of dental enamel in the form of fluorapatite or fluorhydroxyapatite. (7,8)
The only scientifically proven risk of fluoride application is the development of fluorosis in children younger than 8 years old, which may occur with fluoride ingestion during tooth and bone development. (9) Considering this risk in children, different modalities have been proposed for treating carious lesions.
Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) nanocomplexes are novel dental caries preventive materials, and both laboratory and human in-situ studies have proven that these materials have anticariogenic properties. (10-12)
The CPP is derived from milk protein casein combined with calcium and phosphate. It contains a cluster of phosphoseryl residues stabilizing the nanoclusters of ACP in a metastable solution. The CPP binds to plaque, soft tissue, and dentin, creating a reservoir of bioavailable calcium and phosphate in the saliva and on dental surfaces. This eases the limitation of mineral loss during the cariogenic episode and reduces enamel demineralization while promoting the remineralization. (11,13-15) Several studies have demonstrated that the CPP-ACP shows greater remineralization in enamel, in comparison with fluoride, due to more bioavailable calcium and phosphate ions in CPP-ACP agents. (16,17) Moreover, CPP-ACP products are offered to be used for very young children since they can decrease the risk of caries without increasing the risk of fluorosis. (17)
The integration of fluoride into CPP-ACP leads to the co-localization of calcium and phosphate ions with fluoride ions on the tooth surface in the form of CPP-ACPF nanocomplexes. The enhanced concentration of calcium, phosphate, and fluoride ions on the tooth surface results in the diffusion of ions into the enamel and the underlying lesion, which in turn, allows for higher levels of remineralization and fluoride absorption in the mineral phase. (18-21) The present study was conducted to compare the calcium uptake by enamel surface after the application of two types of CPP-ACP paste.
 

Materials and Methods

This experimental study was conducted on 40 caries-free permanent premolars extracted for orthodontic reasons. The exclusion criteria included any visible or detectable caries, hypoplastic lesions, or white spot lesions (WSLs). The teeth were thoroughly cleaned from debris, calculi, and soft tissues. Each tooth was longitudinally sectioned into experimental and control halves which were coated with nail varnish, except for an enamel window of 4×4 mm on the buccal and lingual surfaces of the middle one-third of the crown.
A demineralizing solution was prepared using a combination of 2.2 mM calcium chloride (CaCl2.2H2O), 2.2 mM monosodium phosphate (NaH2PO4.7H2O), and 0.05 M lactic acid (C3H6O3). The final pH was adjusted to 4.5 using 50% potassium hydroxide (KOH). All the samples were then incubated with 50 ml of the demineralizing solution at 37°C for 48 hours. (21) Afterwards, the teeth were washed with deionized water and were then dried. The prepared teeth were randomly assigned into three groups:
1) GC Tooth Mousse CPP-ACP paste (GC Corp., Tokyo, Japan)
2) Misswake CPP-ACP paste (Misswake Co., Switzerland)
3) Control (no treatment)
The samples were rubbed with the respective pastes for 3 minutes, (19,22) were washed with deionized water and were placed in clean glass containers of artificial saliva for 24 hours at 37°C using an incubator (except for the control group). The samples were treated with the pastes every 24 hours for 7 days, were washed with deionized water and were placed in fresh artificial saliva. (21)
After 7 cycles of remineralization, the surfaces of the control and experimental groups were assessed using the acid etch enamel biopsy technique. Subsequently, the samples were immersed in 0.2 M of KOH solution in order to reach an acid-base condition at 2 ml. The level of calcium absorption in each group was evaluated by atomic absorption at the wavelength of 422.7 nm.
Statistical analysis:
Kolmogorov-Smirnov test was applied to check the normality of distribution. Subsequently, one-way analysis of variance (ANOVA) and Tamhane's T2 were performed to compare the data among the three groups.


Results

The mean level of calcium in the treated enamels was higher than that in the control group (P<0.05). The comparison of the two groups revealed that the GC Tooth Mousse samples showed a significantly higher calcium absorption than the Misswake group (P<0.05; Table 1).
Table 1. Mean and standard deviation (SD) of calcium absorption (ppm) in each group


Discussion

Dental fillings or restorations are used as a therapeutic option for the management of childhood caries. (23) Considering the high prevalence of carious lesions among children in most countries, noninvasive interventions have been adopted as a new approach. (24-27) The minimally invasive approaches can arrest caries progression with the aid of therapeutic agents that promote remineralization. (27)
The present study compared the remineralization potential of two CPP-ACP-containing pastes on the enamel surface. MI paste, a water-based, sugar-free cream, is the first product for professional use that contains RECALDENT™ (CPP-ACP). The flavoring of the paste helps to stimulate the salivary flow and provides longevity in the mouth, enhancing the effectiveness of the cream. MI paste has considerable buffering capabilities, resulting in the continual release of calcium phosphate ions for over 3 hours. (27)
Misswake CPP-ACP paste is a new product for younger children, which is claimed to contain calcium and milk protein without any risks during routine applications. There is no published report regarding the remineralizing potential of this paste. Regarding the costs, Misswake is significantly less costly than other CPP-ACP products.
The results of the present study showed a significant difference among the three groups regarding the enrichment of the calcium content of enamel. In this regard, the GC Tooth Mousse group showed the highest calcium content among other groups. Our results were also in accordance with those of the studies performed by Chaudhary et al, (16) Chokshi et al, (28) and Sinfiteli et al. (29) The proposed mechanism of action of CPP-ACP products describes that these products act as a calcium-phosphate reservoir, buffering the activities of free calcium and phosphate ions in the plaque fluid, helping to preserve a state of supersaturation of enamel, inhibiting demineralization and promoting remineralization. (12,16)
Lata et al studied the remineralization potential of fluoride and CPP-ACP in enamel lesions and reported that fluoride was more effective in remineralization although CPP-ACP had the ability to reinforce the enamel. (30)
Rahiotis and Vougiouklakis conducted an in-vitro study on sound human dentin and observed that the presence of CPP-ACP on dentinal surfaces triggered less demineralization in comparison with untreated dentinal surfaces. (31) Tantbirojn et al conducted an in-vitro study in which cola-softened enamel surfaces were examined. (32) In the mentioned study, treatment with CPP-ACP reinforced the surfaces significantly compared to fluoride treatment. (32) The reason for this discrepancy can be due to the use of different methodologies; we evaluated the calcium absorption by enamel surfaces treated with two types of CPP-ACP paste.
Thakkar et al compared the extent of inhibition of demineralization and promotion of remineralization in sound permanent molar enamel with and without the application of CPP-ACP paste, CPP-ACP paste with 900 ppm (part per million) fluoride, and 5% sodium fluoride-containing varnish and observed that CPP-ACPF varnish has the greatest remineralization effect in preventing demineralization and promoting remineralization of enamel. (33) Also, they observed that CPP-ACP in combination with fluoride increases the remineralization potential when compared to CPP-ACP paste alone. (33)
MI paste contains xylitol, which is a non-cariogenic substance that can enhance the benefit of the paste in caries prevention. Xylitol has an antimicrobial effect on Streptococcus mutans (S. mutans), which is dose/frequency-dependent. (33,34) There are several studies investigating the caries-preventive effect of xylitol among children. (34,35)
Misswake bioactive glass-containing paste is a type of mineralizing agent. When bioactive glass comes in contact with saliva or other liquids, its active ingredients (e.g., calcium sodium phosphosilicate) bind to dental surfaces to activate the remineralization process. The bioactive glass reacts with saliva, inducing the dissolution of calcium, phosphate, and silicate ions at the glass surface. The following precipitation of a polycondensed silica-rich layer, which functions as a pattern for the formation of calcium phosphate, crystallizes into hydroxyapatite. (36-38) Consequently, bioactive glass acts as a remineralizing agent in non-cavitated lesions and in high-risk patients.
Narayana et al investigated the efficacy of bioactive glass-containing toothpaste on the remineralization of artificial incipient enamel lesions using the pH cycling method to compare its efficacy with that of fluoride-containing toothpaste, CPP-ACP-containing tooth cream, and CPP-ACPF-containing tooth cream. (38) They concluded that bioactive glass can be considered as an effective remineralizing agent. (38)
One of the limitations of the present in-vitro study was the difficulty in simulating the oral environment; further studies are needed to confirm these results.
 

Conclusion

Although Misswake CPP-ACP paste presented some protective potentials, the samples treated with GC Tooth Mousse CPP-ACP paste were better able to uptake calcium. It can be concluded that these pastes are effective in the prevention of dental caries in susceptible patients.
 
Type of Study: Original article |

References
1. Jamieson LM, Thomson WM, McGee R. Caries prevalence and severity in urban Fijian school children. Int J Paediatr Dent. 2004 Jan;14(1):34-40. [DOI:10.1111/j.1365-263X.2004.00512.x] [PMID]
2. Karlinsey RL, Mackey AC, Walker ER, Amaechi BT, Karthikeyan R, Najibfard K, et al. Remineralization potential of 5,000 ppm fluoride dentifrices evaluated in a pH cycling model. J Dent Oral Hyg. 2010;2(1):1-6.
3. Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot lesions in orthodontic practice: a contemporary review. Aust Dent J. 2006 Dec;51(4):284-9. [DOI:10.1111/j.1834-7819.2006.tb00445.x] [PMID]
4. Pradeep K, Rao PK. Remineralizing agents in the non-invasive treatment of early carious lesions. Int J Dent Case Rep 2011;1:73-84
5. Marinho VC, Worthington HV, Walsh T, Chong LY. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2015 Jun 15;(6):CD002280. [DOI:10.1002/14651858.CD002280.pub2] [PMID]
6. Yimcharoen V, Rirattanapong P, Kiatchallermwong W. The effect of casein phosphopeptide toothpaste versus fluoride toothpaste on remineralization of primary teeth enamel. Southeast Asian J Trop Med Public Health. 2011 Jul;42(4):1032-40.
7. Kapoor A, Indushekar KR, Saraf BG, Sheoran N, Sardana D. Comparative evaluation of remineralizing potential of three pediatric dentifrices. Int J Clin Pediatr Dent. 2016 Jul-Sep;9(3):186-91. [DOI:10.5005/jp-journals-10005-1361] [PMID] [PMCID]
8. Ten Cate JM. Fluorides in caries prevention and control: empiricism or science. Caries Res. 2004 May-Jun;38(3):254-7. [DOI:10.1159/000077763] [PMID]
9. Levy SM, Broffitt B, Marshall TA, Eichenberger-Gilmore JM, Warren JJ. Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood. J Am Dent Assoc. 2010 Oct;141(10):1190-201. [DOI:10.14219/jada.archive.2010.0046] [PMID]
10. Llena C, Leyda AM, Forner L. CPP-ACP and CPP-ACFP versus fluoride varnish in remineralisation of early caries lesions. A prospective study. Eur J Paediatr Dent. 2015 Sep;16(3):181-6.
11. Walker G, Cai F, Shen P, Reynolds C, Ward B, Fone C, et al. Increased remineralization of tooth enamel by milk containing added casein phosphopeptide-amorphous calcium phosphate. J Dairy Res. 2006 Feb;73(1):74-8. [DOI:10.1017/S0022029905001482] [PMID]
12. Hegde MN, Moany A. Remineralization of enamel subsurface lesions with casein phosphopeptide-amorphous calcium phosphate: a quantitative energy dispersive X-ray analysis using scanning electron microscopy: An in vitro study. J Conserv Dent. 2012 Jan;15(1):61-7. [DOI:10.4103/0972-0707.92609] [PMID] [PMCID]
13. Somasundaram P, Vimala N, Mandke LG. Protective potential of casein phosphopeptide amorphous calcium phosphate containing paste on enamel surfaces. J Conserv Dent. 2013 Mar;16(2):152-6. [DOI:10.4103/0972-0707.108199] [PMID] [PMCID]
14. Lennon AM, Pfeffer M, Buchalla W, Becker K, Lennon S, Attin T. Effect of a casein/calcium phosphate-containing tooth cream and fluoride on enamel erosion in vitro. Caries Res. 2006;40(2):154-7. [DOI:10.1159/000091063] [PMID]
15. Bader JD. Casein phosphopeptide-amorphous calcium phosphate shows promise for preventing caries. Evid Based Dent. 2010;11(1):11-2. [DOI:10.1038/sj.ebd.6400701] [PMID]
16. Chaudhary I, M Tripathi A, Yadav G, Saha S. Effect of Casein Phosphopeptide-amorphous Calcium Phosphate and Calcium Sodium Phosphosilicate on Artificial Carious Lesions: An in vitro Study. Int J Clin Pediatr Dent. 2017 Jul-Sep;10(3):261-6. [DOI:10.5005/jp-journals-10005-1447] [PMID] [PMCID]
17. Fahad AH, Al-Weheb AM. Effect of casein phosphopeptide-amorphous calcium phosphate on the microhardness and microscopic features of the sound enamel and initial carieslike lesion of permanent teeth, compared to fluoridated agents. J Bagh College Dentistry. 2012;24(4):114-20.
18. Patil N, Choudhari S, Kulkarni S, Joshi SR. Comparative evaluation of remineralizing potential of three agents on artificially demineralized human enamel: An in vitro study. J Conserv Dent. 2013 Mar;16(2):116-20. [DOI:10.4103/0972-0707.108185] [PMID] [PMCID]
19. Singh S, Singh SP, Goyal A, Utreja AK, Jena AK. Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial. Prog Orthod. 2016 Dec;17:25. [DOI:10.1186/s40510-016-0138-9] [PMID] [PMCID]
20. Yengopal V, Harneker SY, Patel N, Siegfried N. Dental fillings for the treatment of caries in the primary dentition. Cochrane Database Syst Rev. 2009 Apr 15:(2):CD004483. [DOI:10.1002/14651858.CD004483.pub2]
21. Cochrane NJ, Cai F, Huq L, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent Res. 2010 Nov;89(11):1187-97. [DOI:10.1177/0022034510376046] [PMID]
22. Marsh PD, Nyvad B. The oral microflora and biofilms on teeth. In: Fejerskov O, Kidd E, Nyvad B, Baelum V, editors. Dental Caries: The Disease and its Clinical Management. Oxford, UK: Blackwell Munksgaard, 2003:29-47.
23. Evans RW, Dennison PJ. The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for children and adolescents. Aust Dent J. 2009 Dec;54(4):381-9. [DOI:10.1111/j.1834-7819.2009.01165.x] [PMID]
24. Sivapriya E, Sridevi K, Periasamy R, Lakshminarayanan L, Pradeepkumar AR. Remineralization Ability of Sodium Fluoride on the Microhardness of Enamel, Dentin, and Dentinoenamel Junction: An In Vitro Study. J Conserv Dent. 2017 Mar-Apr;20(2):100-4. [DOI:10.4103/JCD.JCD_353_16] [PMID] [PMCID]
25. Jayarajan J, Janardhanam P, Jayakumar P, Deepika. Efficacy of CPP-ACP and CPP-ACPF on enamel remineralization - an in vitro study using scanning electron microscope and DIAGNOdent. Indian J Dent Res. 2011 Jan-Feb;22(1):77-82. [DOI:10.4103/0970-9290.80001] [PMID]
26. Kumar VLN, Itthagarun A, King NM. The effect of casein phosphopeptide-amorphous calcium phosphate on remineralization of artificial caries-like lesions: an in vitro study. Aust Dent J. 2008 Mar;53(1):34-40. [DOI:10.1111/j.1834-7819.2007.00006.x] [PMID]
27. Mehta R, Nandlal B, Prashanth S. Comparative evaluation of remineralization potential of casein phosphopeptide-amorphous calcium phosphate and casein phosphopeptide-amorphous calcium phosphate fluoride on artificial enamel white spot lesion: an in vitro light fluorescence study. Indian J Dent Res. 2013 Nov-Dec;24(6):681-9. [DOI:10.4103/0970-9290.127610] [PMID]
28. Chokshi K, Chokshi A, Konde S, Shetty SR, Chandra KN, Jana S, et al. An in vitro Comparative Evaluation of Three Remineralizing Agents using Confocal Microscopy. J Clin Diagn Res. 2016 Jun;10(6):ZC39-42. [DOI:10.7860/JCDR/2016/18191.7984] [PMID] [PMCID]
29. Sinfiteli PP, Coutinho TCL, Oliveira PRA, Vasques WF, Azevedo LM, Pereira AMB, et al. Effect of fluoride dentifrice and casein phosphopeptide-amorphous calcium phosphate cream with and without fluoride in preventing enamel demineralization in a pH cyclic study. J Appl Oral Sci. 2017 Nov-Dec;25(6):604-11. [DOI:10.1590/1678-7757-2016-0559] [PMID] [PMCID]
30. Lata S, Varghese NO, Varughese JM. Remineralization potential of fluoride and amorphous calcium phosphate-casein phospho peptide on enamel lesions: An in vitro comparative evaluation. J Conserv Dent. 2010 Jan;13(1):42-6. [DOI:10.4103/0972-0707.62634] [PMID] [PMCID]
31. Rahiotis C, Vougiouklakis G. Effect of a CPP-ACP agent on the demineralization and remineralization of dentine in vitro. J Dent. 2007 Aug;35(8):695-8. [DOI:10.1016/j.jdent.2007.05.008] [PMID]
32. Tantbirojn D, Huang A, Ericson MD, Poolthong S. Change in surface hardness of enamel by a cola drink and a CPP-ACP paste. J Dent. 2008 Jan;36(1):74-9. [DOI:10.1016/j.jdent.2007.10.008] [PMID]
33. Thakkar PJ, Badakar CM, Hugar SM, Hallikerimath S, Patel PM, Shah P. An in vitro comparison of casein phosphopeptide-amorphous calcium phosphate paste, casein phosphopeptide-amorphous calcium phosphate paste with fluoride and casein phosphopeptide-amorphous calcium phosphate varnish on the inhibition of demineralization and promotion of remineralization of enamel. J Indian Soc Pedod Prev Dent. 2017 Oct-Dec;35(4):312-8. [DOI:10.4103/JISPPD.JISPPD_308_16] [PMID]
34. Rethman MP, Beltran-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P, et al. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011 Sep;142(9):1065-71. [DOI:10.14219/jada.archive.2011.0329] [PMID]
35. Janakiram C, Deepan Kumar CV, Joseph J. Xylitol in preventing dental caries: A systematic review and meta-analyses. J Nat Sci Biol Med. 2017 Jan-Jun;8(1):16-21. [DOI:10.4103/0976-9668.198344] [PMID] [PMCID]
36. Yli-Urpo H, Närhi M, Närhi T. Compound changes and tooth mineralization effects of glass ionomer cements containing bioactive glass (S53P4), an in vivo study. Biomaterials. 2005 Oct;26(30):5934-41. [DOI:10.1016/j.biomaterials.2005.03.008] [PMID]
37. Saffarpour M, Mohammadi M, Tahriri M, Zakerzadeh A. Efficacy of Modified Bioactive Glass for Dentin Remineralization and Obstruction of Dentinal Tubules. J Dent (Tehran). 2017 Jul;14(4):212-22.
38. Narayana SS, Deepa VK, Ahamed S, Sathish ES, Meyappan R, Satheesh Kumar KS. Remineralization efficiency of bioactive glass on artificially induced carious lesion an in-vitro study. J Indian Soc Pedod Prev Dent. 2014 Jan-Mar;32(1):19-25. [DOI:10.4103/0970-4388.127047] [PMID]

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