Tooth Remineralizing agents in pediatric dentistry

non fluoride modern remineralizing agents

1. G O O D m O R N I N g

2. RECENT BIOMIMETIC ADVANCES IN REBUILDING LOST ENAMEL STRUCTURE Gourismita Acharya , Pratik Agrawal , Gaurav Patri Journal of International Oral Health 2016; 8(4):527-535

3. Introduction Dental caries- a complex disease affects a major portion of the world’s population. Remineralization and Reduce Demineralization

4. Critical ph critical pH of dental enamel as 5.5, The critical pH is the pH at which a solution is just saturated with respect to a particular mineral, such as tooth enamel The concept of critical pH is applicable only to solutions that are in contact with a particular mineral, such as enamel. Saliva and plaque fluid, for instance, are normally supersaturated with respect to tooth enamel because the pH is higher than the critical pH, so our teeth do not dissolve in our saliva or under plaque.

5. Demineralization mechanism Demineralization occurs by disassociation of lactic acid, produced by bacterial carbohydrate metabolism, with tooth mineral. The reaction leads to release of mineral ions into the solution:

6. Remineralization Carious lesion remineralization : supersaturation of saliva with respect to calcium phosphate mineral phases. Remineralization is the process whereby partially demineralized enamel is repaired through the recrystallization of tooth enamel mineral salts. (Silverstone 1977)

7. Remineralization 1) The presence of adequate minerals in saliva. 2) Production of a molecule of carbonic acid 3) Occurrence of above events near the spot to be remineralized . 4) Accessibility of the mineral deficient spot so that the mineral with the correct shape and size can be attracted to the “hole” in the lattice. 5) Dissociation of carbonic acid to carbon dioxide and water.

8. Indications • An adjunct preventive therapy to reduce caries in high‑risk patients • Reduce dental erosion in patients with gastric reflux or other disorders • To reduce decalcification in orthodontic patients • To repair enamel in cases involving white‑ spot lesions • Orthodontic decalcification or fluorosis or before and after teeth whitening and to desensitize sensitive teeth. Zero DT. Dentifrices, mouthwashes, and remineralization caries treatment strategies. BMC Oral Health 2006;6 Suppl 1:S9‑S22.

9. Requirements of a remineralizing agent • Should deliver calcium and phosphate into the sub‑ surface • Should not deliver any excess of calcium • Should not favor calculus formation • Should work at an acidic pH so as to stop demineralization during a carious attack • Should be able to work in xerostomic patients as saliva cannot effectively stop the carious process • Should be able to boost the remineralizing properties of saliva • The novel materials should be able to show some benefits over fluoride.

10. long track record one unit of fluorohydroxyapatite that is formed needs two fluoride ions, ten calcium ions, and six phosphate ions. Thus, the lack of calcium and phosphate ions can be a limiting factor in the formation of fluorohydroxyapatite risk of fluorosis Fluoride as a remineralizing agent

11. Disadvantages The fluorohydroxyapatite is formed on the surface of the lesion, but the loss of hydroxyapatite is from the depth of enamel Effective only in smooth surface caries Doubtful effect on the remineralization of the pit and caries lesions

12. Why to go for non-fluoride strategies? 1. Fluoride is highly effective on smooth-surface caries, but its effect is limited on pit and fissure caries. 2. A high-fluoride strategy cannot be followed 3. Toxicity of fluoride increases with inadequate nutrition. 4. Although fluoride has had a profound effect on the level of caries prevalence, it is far from a complete cure. 5. legal limitations to the use of fluorides.

13. Classification According to the mode of action

14. Proteins which stabilize calcium and phosphate Statherin Acidic- proline rich proteins Histatins Saliva Alpha and beta caseins Milk Ameloblastin Enamelin Osteopontin Bone sialoprotein Dentin sialoprotein Hard tissues

15. Casein phosphor-peptides-amorphous calcium phosphate Casein, a bovine milk phosphor-protein. Discovered by Prof. Reynolds at the School of Dental Science at the University of Melbourne in Australia. -Ser (P)-Ser (P)-Ser (P)- Glu-Glu from casein

16. Mechanism of action

17. CPP Ca Ph Dental plaque Tooth enamel Calcium phosphate At neutral Ph Insoluble Crystalline structure Ca Ph Ca Ca Ph Ph Pool of ca and Ph ions around the tooth structure Remineralization

18. CPP-ACP Ca Ca Ph Ph CPP-ACP incorporated fluoride Amorphous calcium fluoride phosphate ACFP Fluoride+ Calcium + phosphate Fluorohydroxyapatite 1 CPP ACP can bind Ca , Ph and Fl---- 25:15:5

19. Unstabilized ACP ( Enamelon / enamel care tooth pastes) Dentrifice or mouth rinse Produces Two systems – single phase system Two phase system Insoluble calcium phosphate/Ca F No remineralization

20. Single phase system ACP containing chewing gums Dental composites ACP based polymeric composites Drawback : low mechanical strength Glass particles Bases and liners Orthodontic adhesives Endodontic sealers

21. Potassium phosphate Calcium sulphate Ca Ph ACP ACFP Highly unstable Hydroxyapatite / Flurohydroxyapatite 2 PHASE SYSTEM

22. Hybrid ACP fillers, especially Zr -ACP, could be utilized in applications in which it is desired to enhance the performance of composites, sealants, and/or adhesives in preventing demineralization or actively promoting remineralization . Effect of silica and zirconia on the stability of bioactive ACP mineral.

23. Dicalcium phosphate dihydrate DCPD is added to toothpaste DCPD ( brushite ) and octacalcium phosphate- precursors to the formation of apatite. Remineralizing artificial saliva- for dentate patients in management of both dental caries and hyposalivation

24. Inclusion of DCPD in a dentifrice increases the levels of free calcium ions in plaque fluid , and these remain elevated for up to 12 h after brushing , when compared to conventional silica dentifrices. Also, there is enhanced calcium incorporation into Enamel from DCPD, also increased levels are detected in plaque up to 18 h

25. Nano-hydroxyapatite Poorly crystalline HydroxyApatite nanocrystals Excellent biological properties of HA, Nontoxic lack inflammatory and immunizer responses, Bioresorption properties under physiological conditions. 10% nano-hydroxyapatite is considered to be optimal for remineralization of early enamel caries Toothpastes containing n- HAp revealed higher remineralizing effects compared to amine fluoride toothpastes with bovine dentine

26. Bioactive Glass Materials Bioactive glass is made of synthetic mineral containing sodium, calcium, phosphorous and silica. Biomimetic mineralizer , matches the body’s own mineralizing traits, affects cell signals in a way that benefits the restoration of tissue structure and function Bioactive glass formulation is commonly known as 45S5, which has been used extensively in research studies It contains : 45 wt% SiO2, 24.5 wt% Na2O and Ca, O and 6 wt% P2O5

27. To supplement the normal levels found in saliva Mechanism of action Water/ saliva Na Elevates the Ph: 7.5- 8.5 HAP ca Ph This increase in ionic concentration, combined with an increase in pH, causes the ions to precipitate onto the tooth surface calcium hydroxycarbonate apatite (HCA)

28. NovaMin NovaMin - calcium sodium phosphosilicate • Marketed primarily to mange tooth sensitivity. • Reported more effective than potassium nitrate and fluoride dentifrice. (JADA 141:995-999, 2010) • Now in multiple toothpastes (Restore, Renew) 5000ppm F / NovaMin Rx Dentifrice

29. Related studies… Studies have been reported in literature which claim that bioglass dentifrices produce significantly more remineralization than Fluoride dentifrices. Also adding bioglass ( NovaMin ®) to fluoride dentifrices significantly enhanced fluoride uptake into artificial carious lesions in enamel surfaces and provides a synergistic action. Also, bioglass is capable of Tubule occlusion of root dentin as demonstrated by an in-vitro study.

30. Pronamel Despite its name, Pronamel ™ (GlaxoSmithKline, Middlesex,UK ) is not considered a remineralizing agent per se, and it does not contain any calcium compounds. The results of studies conducted show that pronamel reduces enamel erosion from acidic challenges from diet, fruit juices. After treatment with the demineralizing solution followed by Pronamel , both interprismatic and prismatic enamel structures still appear evident.

31. Arginine bicarbonate ( sensistst ) Calcium carbonate carrier ( SensiStat ) developed by Dr. Israel Kleinberg of New York desensitizing Prophy Paste Calcium carbonate Calcium carbonate Calcium carbonate Adhesive property of this mixture paste-like plug that fills the open tubules and adheres to the dentinal tubule walls

32. Cavistat A sugarless mint - CaviStat ® (an arginine bicarbonate calcium carbonate complex) It was evident that mint confections containing CaviStat can inhibit both caries onset and caries progression, also CaviStat mint confection technology is a simple and economical means for reducing prevalent dental diseases in children.

33. Tricalcium phosphate Tricalcium phosphate (TCP) is a new hybrid material created with a milling technique that fuses beta TCP and sodium laurylsulfate or fumaric acid. When TCP comes into contact with the tooth surface and is moistened by saliva, the protective barrier breaks down making calcium, phosphate and fluoride ions available to the tooth. TCP has also been considered as one possible means for enhancing the levels of calcium in plaque and saliva.

34. Clinpro 5000 toothpaste The remineralizing ingredient consists of calcium oxides, calcium phosphate, and free phosphates. Tricalcium phosphate with 950 ppm fluoride paste treatments increases the hardness of the teeth in vitro and also increased the surface microhardness of eroded enamel by chlorinated water in vitro. Also TCP-Si (silica) - Ur (urea) can be combined with fluoride to produce anti-erosion benefits greater than those achieved with fluoride alone. Applied as toothpaste and is not suitable for overnight use because of its high-fluoride concentration.

35. Trimetaphosphate ion The effectiveness of TMP can be attributed to the fact that TMP assists the diffusion of calcium ions to the inner of enamel or reduced their loss to the solutions, Biomimetic remineralization using sodium-TMP is used to remineralize carious lesions particularly in areas devoid of seed crystallites.

36. Calcium Silicate calcium silicate based materials, such as calcium silicate glass, wollastonite , and pseudowollastonite have been used as a template for hydroxyapatite deposition in experimental set ups using stimulated body fluids. Calcium silicate formulation is available as toothpaste and a dual-phase gel for higher enamel remineralization when compared to only fluoride containing pastes.

37. An in vivo study on attached polished enamel blocks showed an increased deposition of hydroxyapatite . Similar studies on stimulated interproximal tooth surfaces also revealed increased remineralization . The toothpaste contains -mono sodium phosphate - trisodium phosphate -along with 1450 ppm fluoride that is added as sodium monofluorophosphate . The dual phase gel consists of Part A: a fluoridated phase containing calcium silicate and sodium phosphate salts Part B: a phase containing sodium fluoride. It is proposed in conjugation with daily use of the toothpaste

38. Advantages of calcium silicate Formation of new hydroxyapatite - protective effect on the enamel. Acts as a buffering agent Calcium silicate can nucleate hydroxyapatite The nucleated hydroxyapatite also forms a protective sacrificial layer to the underlying enamel as well.

39. Biomimetically modified mineral trioxide aggregate The remineralization efficacy of mineral trioxide aggregate (MTA) in phosphate-containing simulated body fluid by incorporating polyacrylic acid and sodium tripolyphosphate as biomimetic analogs of matrix proteins for remineralizing caries like dentin was examined It was concluded that biomimetic analogs in modified MTA provides a potential delivery system for biomimetic remineralization of dentin Because release of biomimetic analogs from set MTA, Inclusion of polyphosphate in the MTA may serve as a supplementary phosphate source when its availability is compromised.

40. Sucrose-free polyol gum The results of various studies and meta-analysis indicate that there is a statistically significant reduction in caries with the use of sucrose-free polyol gums compared with no gum chewing. Similarly there is a lot of evidence suggesting xylitol candy/lozenge/syrup, xylitol dentifrice, triclosan , iodine,topical chlorhexidine products like chlorhexidine varnish, chlorhexidine / thymol varnish, chlorhexidine mouthrinses , chlorhexidine gels and sialogogues have anti-caries effect and are capable of reversal of the carious process

41. Those neutralising bacterial acids Other strategies to combat demineralization include neutralizing bacterial acid using -calcium carbonate as plaque pH buffering effect -and sodium bicarbonate to provide an alkaline oral environment. Alternatively, calcium containing agents like -calcium lactate, -calcium glycerophosphate , and -calcium phytate can be used. They act by increasing plaque calcium and phosphate levels. Also, toothpastes containing chlorophyll, ammoniated toothpaste, and anti-enzyme pastes can be used

42. Recent trends Amelogenins Peptides Enamel matrix derivative (EMD) Dendrimers

43. Amelogenins The arrangement of hydroxyapatite in enamel is regulated by amelogenins . After maturation of the enamel, this protein is lost and so is the capacity of enamel to heal Amelogenins + Fluoride: Form properly arranged bundles of hydroxyapatite crystals. 33microgram/ml of recombinant amelogenin in presence f 1mg/l Fl ions: Organized bundles of hydroxyapatite

44. Hydrogels are better than solution systems Common template -- chitosan

45. Peptides Peptide amphiphiles can self-assemble in the presence of salts. These self-assembled peptides are laid down as nanofibers . repetitive nucleotide sequences of aspartate -serine-serine and has been sequenced from dentin phosphoproteins

46. treatment of early caries using P11‑4 self assembling peptides.

47. aspartate -serine-serine (DSS) 3D template Imbibe Ca and Ph ions from saliva Prevents loss of ions from enamel surface Nano precursors Crystalline hydroxyapatite

48. Enamel matrix derivative (EMD) EMD is extracted from the porcine fetal tooth enamel matrix It consists mainly of amelogenin proteins Mimics the gel like environment Gelatin at physiologic pH it is a sol and hence unsuitable to be used in a biologic set up Agarose

49. Dendrimers Dendrimers are basically artificially synthesized dendritic protein polymers The most commonly synthesized dendrimers are of polyamidoamine (b- alanine subunit) ranging from 1 to 20 nm in diameter. These proteins can be adsorbed onto the etched enamel surface to provide nucleating sites for hydroxyapatite crystallization and growth of uniform nano -rods of hydroxyapatite .

50. Remineralization potential of fluoride and amorphous calcium phosphate-casein phospho peptide on enamel lesions: An  in vitro comparative evaluation S Lata ,  N O Varghese , 1  and  Jolly Mary Varughese J Conserv Dent . 2010 Jan-Mar; 13(1): 42–46 Aim : to evaluate the remineralization potential of fluoride and ACP-CPP and the combination of ACP-CPP and fluoride on early enamel lesions. Fifteen intact carious free human premolars were selected Group 1- Fluoride varnish, Group 2- ACP-CPP cream, Group 3- Fluoride + ACP-CPP & Group 4- Control (No surface treatment). Conclusion: ACP-CPP cream is effective, but to a lesser extent than fluoride in remineralizing early enamel caries at surface level. Combination of fluoride and ACP-CPP does not provide any additive remineralization potential compared to fluoride alone. Fluoride, ACP-CPP and their combination are not effective in remineralizing the early enamel caries at the subsurface level.

51. In vitro hardening of artificial enamel caries lesions using enamel matrix proteins or self-assembling peptides journal of applied oral science 2016;24(1):31-6 Objectives: To assess the re-hardening potential of enamel matrix derivatives (EMD)and self-assembling peptides in vitro Method : Application of enamel-matrix proteins (EMD - lyophilized protein fractions dissolved in acetic acid, Straumann ), (B) self-assembling peptides (SAP, Curodont ), or amine fluorid esolution for 5 min and immersed in artificial saliva for remineralization Conclusion: application of enamel matrix derivatives and self-assembling peptides on artificial carious lesions can improve the rehardening of these lesions, also in deeper layers of the lesion.

52. Evaluation to determine the caries remineralization potential of three dentifrices: An  in vitro  study Arun Balakrishnan ,  R Jonathan ,  P Benin , and  Arvind Kumar Aim : to evaluate the remineralizing potential of three different remineralizing agents (GC tooth Mousse, Clinpro tooth cream and SHY-NM) on demineralized tooth surfaces using micro CT and microhardness . Results: It was observed that all the three remineralizing agents used in the study significantly increased the Linear Attenuation Co-efficient and Vicker's hardness number values of the enamel specimens following 15 days and 30 days application. Conclusion: CPP – ACP showed the better remineralizing potential than the other two agents and there was no statistical significant difference between f-TCP and CSP groups.

53. Efficacy of amelogenin-chitosan hydrogel in biomimetic repair of human enamel in pH-cycling systems Qichao Ruan1, David Liberman1, Journal of Biomedical Engineering and Informatics, 2016, Vol. 2, No. 1 Amelogenin-chitosan (CS-AMEL) hydrogel has shown great potential for the prevention, restoration, and treatment of defective enamel Two pH-cycling systems were designed to simulate the daily cariogenic challenge as well as the nocturnal pH conditions in the oral cavity. After pH cycling and treatment with CS-AMEL hydrogel , a synthetic layer composed of oriented apatite crystals was formed on the eroded enamel surface. CS-AMEL repaired the artificial incipient caries by re-growing oriented crystals and reducing the depth of the lesions by up to 70% in the pH-cycling systems. The results clearly demonstrate that the CS-AMEL hydrogel is effective at –the restoration of erosive and carious lesions under pH-cycling conditions

54. Synthetic Biomimetic Carbonate- Hydroxyapatite Nanocrystals for Enamel Remineralization N. Roveri1,a*, E. Battistella Advanced Materials Research Vols. 47-50 (2008) pp 821-824 chemically, physically and morphologically investigated the enamel surface modifications, in vitro, induced by brushing with toothpastes containing fluoride or CHA. The results highlight that biomimetic nanosized patented CHA produces a persistent coating deposition of carbonate- hydroxyapatite on the enamel surface. This coating is less crystalline than native enamel apatite, and consists of a new apatitic mineral deposition which progressively fills the scratches and pits. On the contrary, the surface remineralisation observed on the specimens treated with fluoride, is mainly based on chemical-physical modifications rather than a formation of a new coating.

55. References 1. Hicks J , Frankiln Garcia –Godoy and Catherine Flaitz.Biological factors in dental caries enamel structure and the caries process in the dynamic process of demineralization and remineralization (Part 1) J.Clin Pediatr Dent. 2005 28(1):119-124 2. Daculsi G, Kerebel B, Kerebel L.M. Mechanisms of acid dissolution of biological and synthetic apatite crystals at the lattice pattern level. Caries Res. 1979. 13: 277-281 3. Featherstone JDB.Continuum of Dental caries. J Dent Res. 2004:75:14-19. 4. Silverstone L.M.Remineralization Phenomena. Caries Res. 1977: 11 ( Suppl 1): 59-84 5. Shu M, Morou -Bermudez E, Suárez-Pérez E, et al. The relationship between dental caries status and dental plaque urease activity. Oral Microbiol Immunol . 2007 Feb;22(1):61-6. 6. Mellberg RJ, Ripa WL, Leske SG. Fluoride in preventive dentistry. Theory and clinical sapects . Quintessence Publishing Co., Inc 1983 7. Agarwal A, Pandey H, Pandey L, Choudhary G. Effect of fluoridated toothpaste on white spot lesions in postorthodontic patients. International Journal of Clinical Pediatric Dentistry, May-August 2013; 6(2): 85-88

56. Conclusion Evidence suggests that initial noncavitated lesions can be remineralized using appropriate technologies, both fluoride and nonfluoride based. Saliva plays an important role in the remineralization . Also, it is important that the control of caries be dealt with biofilm control. With these nontocic alternative remineralization strategies, we would be able to re-establish the health of oral tissues without being under the risk of fluoride toxicity if ingested at high levels, in particular in children.

57. Thank you