pH-cycling models for in vitro evaluation of the efficacy of fluoridated dentifrices for caries control: strengths and limitations

Despite a plethora of in situ studies and clinical trials evaluating the efficacy of fluoridated dentifrices on caries control, in vitro pH cycling models are still broadly used because they mimic the dynamics of mineral loss and gain involved in caries formation. This paper critically reviews the current literature on existing pH-cycling models for the in vitro evaluation of the efficacy of fluoridated dentifrices for caries control, focusing on their strengths and limitations. A search was undertaken in the MEDLINE electronic journal database using the keywords "pH-cycling", "demineralization", "remineralization", "in vitro", "fluoride", "dentifrice". The primary outcome was the decrease of demineralization or the increase of remineralization as measured by different methods (e. g.: transverse microradiography) or tooth fluoride uptake. Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were solved by discussion and consensus or by a third party. One hundred and sixteen studies were included, of which 42 addressed specifically the comparison of dentifrices using different pH-cycling models. The other studies included meta-analysis or reviews, data about the effect of different fluoride sources on de-remineralization, different methods for analysis de-remineralization and chemical variables and characteristics of dental hard tissues that might have influence on de-remineralization processes. Generally, the studies presented ability to detect known results established by clinical trials, to demonstrate dose-related responses in the fluoride content of the dentifrices, and to provide repeatability and reproducibility between tests. In order to accomplish these features satisfactorily, it is mandatory to take into account the type of substrate and baseline artificial lesion, as well as the adequate response variables and statistical approaches to be used. This critical review of literature showed that the currently available pH-cycling models are appropriate to detect dose-response and pH-response of fluoride dentifrices, and to evaluate the impact of new active principles on the effect of fluoridated dentifrices, as well as their association with other anti-caries treatments.

Mechanisms of action of fluoride for caries control

Fluoride was introduced into dentistry over 70 years ago, and it is now recognized as the main factor responsible for the dramatic decline in caries prevalence that has been observed worldwide. However, excessive fluoride intake during the period of tooth development can cause dental fluorosis. In order that the maximum benefits of fluoride for caries control can be achieved with the minimum risk of side effects, it is necessary to have a profound understanding of the mechanisms by which fluoride promotes caries control. In the 1980s, it was established that fluoride controls caries mainly through its topical effect. Fluoride present in low, sustained concentrations (sub-ppm range) in the oral fluids during an acidic challenge is able to absorb to the surface of the apatite crystals, inhibiting demineralization. When the pH is re-established, traces of fluoride in solution will make it highly supersaturated with respect to fluorhydroxyapatite, which will speed up the process of remineralization. The mineral formed under the nucleating action of the partially dissolved minerals will then preferentially include fluoride and exclude carbonate, rendering the enamel more resistant to future acidic challenges. Topical fluoride can also provide antimicrobial action. Fluoride concentrations as found in dental plaque have biological activity on critical virulence factors of S. mutans in vitro, such as acid production and glucan synthesis, but the in vivo implications of this are still not clear. Evidence also supports fluoride's systemic mechanism of caries inhibition in pit and fissure surfaces of permanent first molars when it is incorporated into these teeth pre-eruptively. © 2011 S. Karger AG, Basel.

Topical use of fluorides for caries control

Since the early findings on the protective effects of fluoride present in drinking water upon caries incidence and prevalence, intensive research has been conducted in order to determine the benefits, safety, as well as the cost-effectiveness of other modalities of fluoride delivery. The present chapter reviews the various forms of topical fluoride use - professionally and self-applied - with special emphasis on clinical efficacy and possible side effects. The most widely used forms of fluoride delivery have been subject of several systematic reviews, providing strong evidence supporting the use of dentifrices, gels, varnishes and mouth rinses for the control of caries progression. Dentifrices with fluoride concentrations of 1,000 ppm and above have been shown to be clinically effective in caries prevention when compared to a placebo treatment, but the evidence regarding formulations with 450-550 ppm is still subject of debate. Therefore, the recommendation for low-fluoride dentifrice use must take into account both risks and benefits. The evidence for the combined use of two modalities of fluoride application in comparison to a single modality is still inconsistent, implying that more studies with adequate methodology are needed to determine the real benefits of each method. Considering the currently available evidence and risk-benefit aspects, it seems justifiable to recommend the use of fluoridated dentifrices to individuals of all ages, and additional fluoride therapy should also be targeted towards individuals at high caries risk. © 2011 S. Karger AG, Basel.

Caries resistance of lased human enamel with Er : YAG laser - morphological and ratio Ca/P analysis

Objective: In vitro analysis of caries resistance of dental enamel under caries simulation after irradiation with Er:YAG laser. Background Data: More susceptible to caries development spots at adjacent hard tissues from cavity preparations of dental tissues using burrs or lasers are quite common. Methods: Thirteen caries-free third permanent human molars were distributed as follows: G1: sound control and caries control; G2: Er:YAG 100, 200, 300, or 400 mJ/ 10 Hz/ 3 sec.; G3: the same parameters of G2 followed by artificial caries simulation, through dynamic model of demineralization and remineralization (DE/RE). Caries resistance analysis was evaluated through scanning electron microscopy (SEM) and Ca/P rate (X-Rays spectroscopy - EDX). Results: Photomicrographs showed that the Er:YAG laser created craters with rough aspect which became more evident as the energy per pulse was increased, but without change of regular morphology of enamel prisms. Significant statistical changes among the irradiated and control groups was observed considering the Ca/P ratio. Conclusion: Irradiated groups showed higher caries resistance than control groups. However, it is not possible to affirm that the enamel surface accidental irradiation could be a benefit to caries resistance for other situations can be considered, as biofilm deposit, which could increase the caries susceptibility.

Prevalence of dental fluorosis in Bauru, São Paulo, Brazil

Objective: To evaluate the prevalence of dental fluorosis in scholars aging 12 to 15 years old, residents in the city of Bauru, State of São Paulo, Brazil. Methods: 1318 volunteers were enrolled in this study and examined in 18 public schools of the State of São Paulo. The examinations were performed in the schools' court by three dentists (with a Master's degree in Public Health), after toothbrushing supervised by another dentist. The teeth were dried with cotton pellets and examined under natural light by visual inspection, using an explorer as recommended by the WHO, a plane mirror and a tongue depressor. The Thylstrup-Fejerskov (TF) index was used for rating fluorosis. Intra and inter-examiner reproducibility was calculated and data were submitted to descriptive analysis. Results: Approximately 36% of the children presented dental fluorosis, of which 28% was diagnosed as TF1 while the remaining received scores between TF2 and TF4. Conclusion: The prevalence of dental fluorosis in Bauru is within the expected range, based on previous studies. Although fluoride is an important resource for caries control, its use must be adequate to the needs of each specific population.

Fluoride concentration in public water supply: 72 months of analysis

Known as one of the ten most important advances on Public Health in the 20th century, fluoridation of public water supply is a measure of wide population coverage, which is effective on caries control. The city of Araçatuba, in the Northwest region of the São Paulo state, Brazil, started public water supply fluoridation in 1972 and, based on the average annual highest temperature, has kept the fluoride concentration between 0.6 to 0.8 mgF/L. The purpose of this study was to analyze monthly the fluoride concentration in public water supply in the city of Araçatuba during 72 months. Water samples were collected monthly on weekdays, directly from the water distribution network, on pre-established locations and analyzed in duplicate between November 2004 and October 2010 at the Research Laboratory of the Nucleus for Public Health (NEPESCO) of the Public Health Graduate Program from Araçatuba Dental School/UNESP, Brazil, using an fluoride-specific electrode connected to an ion analyzer. From the total of samples (n=591), 67.2% (n=397) presented fluoride concentration between 0.6 and 0.8 mgF/L; 20.6% (n=122) below 0.6 mgF/L; 11.5% (n=68) between 0.8 and 1.2 mgF/L and 0.7% (n=4) above 1.2 mgF/L. Most samples showed fluoride levels within the recommended parameters. Minimal variation was observed among the analyzed collection locations, showing that the city has been able to control the fluoride levels in the public water supply and reinforcing the importance of surveillance and constant monitoring to assure the quality of the water delivered to the population.

Effect of application time of APF and NaF gels on microhardness and fluoride uptake of in vitro enamel caries

Purpose : To evaluate the effect of time of fluoride application gel, acidulated or neutral, on in vitro enamel resistance to demineralization and fluoride uptake. Materials and Methods: One hundred and ninety-two human enamel blocks were used in this study and 144 were treated with fluoride gel, acidulated or neutral, for I or 4 minutes. Ninety-six blocks treated with fluoride and 24 control blocks were submitted to a high cariogenic challenge. After the pH-cycling, enamel demineralization was assessed by surface and cross-sectional microhardness. Fluoride in the enamel blocks was also determined after removing an enamel layer by etching acid. Results: Acidulated fluoride gel formed more fluoride in enamel than neutral gel (P < 0.05), and it was also more efficient in reducing the demineralization of the enamel blocks submitted to a cariogenic challenge than the neutral one (P < 0.05). It was found that the time of application was significant in terms of fluoride uptake, but it did not render the enamel more resistant to dernineralization.

External control of the public water supply in 29 Brazilian cities

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Protective efficacy of Psidium cattleianum and Myracrodruon urundeuva aqueous extracts against caries development in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Exposed collagen in aged resin-dentin bonds produced on sound and caries-affected dentin in the presence of chlorhexidine

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Artificial methods of dentine caries induction: A hardness and morphological comparative study

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Occlusal caries prevention in high and low risk schoolchildren. A clinical trial

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Caries risk tests and salivary levels of immunoglobulins to Streptococcus mutans and Candida albicans in mouthbreathing syndrome patients

The aim of this study was to compare microbiological and salivary variables possibly related to caries risk in treated and untreated mouthbreathing syndrome (MBS) children and control children. Thirty control children, 30 mouthbreathers and 25 treated mouthbreathers were studied for the numbers of lactobacilli, mutans streptococci and yeasts in their saliva. Snyder's test, salivary flow and buffering capacity were also evaluated. Levels of immunoglobulins to Candida albicans and Streptococcus mutans in the saliva were quantified using ELISA. Considering the results obtained for the microbiological and salivary caries risk tests, no significant differences were observed among the proportions of patients with small/negative and high/moderate caries risk in the studied groups. The level of IgG to S. mutans was significantly higher in the treated MBS group in relation to MBS patients. on the other hand, the median anti-S. mutans IgM level was lower in the treated MBS patients than in the other groups. For the studied anti-Candida immunoglobulins, IgM level was significantly lower in the treated MBS group than in the other groups. No differences were observed for anti-S. mutans and anti-Candida IgA levels among the groups. The findings suggest that mouthbreathing cannot be considered a risk factor for dental caries. Copyright (C) 2003 S. KargerAG, Basel.

Microbiological or Chemical Models of Enamel Secondary Caries Compared by Polarized-Light Microscopy and Energy Dispersive X-ray Spectroscopy

Different secondary caries models may present different results. The purpose of this study was to compare different in vitro secondary caries models, evaluating the obtained results by polarized-light microscopy (PLM), scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS). Standardized human enamel specimens (n = 12) restored with different materials (Z250 conventional composite resin-CRZ, Freedom polyacid-modified composite resin-CRF, Vitremer resin-modified glass-ionomer-GIV, and Fuji IX conventional glass-ionomer cement-GIF) were submitted to microbiological (MM) or chemical caries models (CM). The control group was not submitted to any caries model. For MM, specimens were immersed firstly in sucrose broth inoculated with Streptococcus mutans ATCC 35688, incubated at 37 degrees C/5% CO(2) for 14 days and then in remineralizing solution for 14 days. For CM, specimens were submitted to chemical pH-cycling. Specimens were ground, submitted to PLM and then were dehydrated, gold-sputtered and submitted to SEM and EDS. Results were statistically analyzed by Kruskall-Wallis and Student-Newman-Keuls tests (alpha = 0.05). No differences between in vitro caries models were found. Morphological differences in enamel demineralization were found between composite resin and polyacid-modified composite resin (CRZ and CRF) and between the resin-modified glass-ionomer and the glass-ionomer cement (GIF and GIV). GIF showed higher calcium concentration and less demineralization, differing from the other materials. In conclusion, the glass-ionomer cement showed less caries formation under both in vitro caries models evaluated. (C) 2009 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 90B: 635-640, 2009

Ability of different restorative materials to prevent in situ secondary caries: analysis by polarized light-microscopy and energy-dispersive X-ray

Secondary caries is the main cause of direct restoration replacement. The purpose of this study was to analyze enamel adjacent to different restorative materials after in situ cariogenic challenge using polarized-light microscopy (PLM), scanning electron microscopy (SEM) and energy-dispersive X-ray analysis (EDS). Twelve volunteers, with a low level of dental plaque, a low level of mutans streptococci, and normal salivary flow, wore removable palatal acrylic appliances containing enamel specimens restored with Z250 composite, Freedom composite, Fuji IX glass-ionomer cement, or Vitremer resin-modified glass-ionomer for 14 days. Volunteers dripped one drop of 20% sucrose solution (n = 10) or distilled water (control group) onto each specimen 8 times per day. Specimens were removed from the appliances and submitted to PLM for examination of the lesion area (in mm(2)), followed by dehydration, gold-sputtering, and submission to SEM and EDS. The calcium (Ca) and phosphorus (P) contents were evaluated in weight per cent (%wt). Differences were found between Z250 and Vitremer, and between Z250 and FujiIX, when analyzed using PLM. Energy-dispersive X-ray analysis results showed differences between the studied materials regarding Ca %wt. In conclusion, enamel adjacent to glass-ionomer cement presented a higher Ca %wt, but this material did not completely prevent enamel secondary caries under in situ cariogenic challenge.