Dental erosion--an overview with emphasis on chemical and histopathological aspects

The quality of dental care and modern achievements in dental science depend strongly on understanding the properties of teeth and the basic principles and mechanisms involved in their interaction with surrounding media. Erosion is a disorder to which such properties as structural features of tooth, physiological properties of saliva, and extrinsic and intrinsic acidic sources and habits contribute, and all must be carefully considered. The degree of saturation in the surrounding solution, which is determined by pH and calcium and phosphate concentrations, is the driving force for dissolution of dental hard tissue. In relation to caries, with the calcium and phosphate concentrations in plaque fluid, the 'critical pH' below which enamel dissolves is about 5.5. For erosion, the critical pH is lower in products (e.g. yoghurt) containing more calcium and phosphate than plaque fluid and higher when the concentrations are lower. Dental erosion starts by initial softening of the enamel surface followed by loss of volume with a softened layer persisting at the surface of the remaining tissue. Dentine erosion is not clearly understood, so further in vivo studies, including histopathological aspects, are needed. Clinical reports show that exposure to acids combined with an insufficient salivary flow rate results in enhanced dissolution. The effects of these and other interactions result in a permanent ion/substance exchange and reorganisation within the tooth material or at its interface, thus altering its strength and structure. The rate and severity of erosion are determined by the susceptibility of the dental tissues towards dissolution. Because enamel contains less soluble mineral than dentine, it tends to erode more slowly. The chemical mechanisms of erosion are also summarised in this review. Special attention is given to the microscopic and macroscopic histopathology of erosion.

Computed tomographic and radiographic examination of dental structures in South American camelid specimen of different ages.

BACKGROUND Tooth root problems and periodontal diseases are common in South American camelids (SAC). The objective was to evaluate and optimize the imaging technique for dental radiography in SAC and to describe the radiographic and computed tomographic (CT) anatomy of normal teeth at different ages. In this study, the heads of 20 healthy SAC slaughtered for meat production or euthanized for reasons not related to dental problems included 7 female and 10 male llamas and 3 male alpacas. Using a standardized protocol, radiographs and CT scans of the 20 specimen were performed. RESULTS The most useful radiographic projections for mandibular and maxillary cheek teeth evaluation turned out to be lateral30°ventral-laterodorsal and lateral30°dorsal-lateroventral with slight separation of the dental arcades respectively. Digital radiographic and CT appearance of the mandibular and maxillary teeth were described from the beginning of mineralization till maturity. In addition the normal range of the CT radio density of different cheek teeth and different dental tissues were measured. Hounsfield units of different dental tissues of SAC turned out to be similar to equids. Deviation, shortening and partial destruction of the distal tooth root of mandibular 09's and 10's and of maxillary 09's was observed and the existence of a common pulp chamber in younger teeth was revealed. CONCLUSIONS The present study provides information about the dental imaging morphology in clinically healthy SAC. This basic information provides fundamental knowledge for evaluating images and planning treatments in clinically affected animals.

Understanding the chemistry of dental erosion.

Dental erosion is caused by repeated short episodes of exposure to acids. Dental minerals are calcium-deficient, carbonated hydroxyapatites containing impurity ions such as Na(+), Mg(2+) and Cl(-). The rate of dissolution, which is crucial to the progression of erosion, is influenced by solubility and also by other factors. After outlining principles of solubility and acid dissolution, this chapter describes the factors related to the dental tissues on the one hand and to the erosive solution on the other. The impurities in the dental mineral introduce crystal strain and increase solubility, so dentine mineral is more soluble than enamel mineral and both are more soluble than hydroxyapatite. The considerable differences in structure and porosity between dentine and enamel influence interactions of the tissues with acid solutions, so the relative rates of dissolution do not necessarily reflect the respective solubilities. The rate of dissolution is further influenced strongly by physical factors (temperature, flow rate) and chemical factors (degree of saturation, presence of inhibitors, buffering, pH, fluoride). Temperature and flow rate, as determined by the method of consumption of a product, strongly influence erosion in vivo. The net effect of the solution factors determines the overall erosive potential of different products. Prospects for remineralization of erosive lesions are evaluated.

Significance of primary stability for osseointegration of dental implants

AIM: To investigate the significance of the initial stability of dental implants for the establishment of osseointegration in an experimental capsule model for bone augmentation. MATERIAL AND METHODS: Sixteen male rats were used in the study. In each rat, muscle-periosteal flaps were elevated on the lateral aspect of the mandibular ramus on both sides, resulting in exposure of the bone surface. Small perforations were then produced in the ramus. A rigid, hemispherical Teflon capsule with a diameter of 6 mm and a height of 4 mm and with a hole in its middle portion, prepared to fit the circumference of an ITI HC titanium implant of 2.8 mm in diameter, was fixed to the ramus using 4 mini-screws. On one side of the jaw, the implant was placed through the hole in such a way that its apex did not make contact with the mandibular ramus (test). This placement of the implant did not ensure primary stability. On the other side of the jaw, a similar implant was placed through the hole of the capsule in such a way that contact was made between the implant and the surface of the ramus (control). This provided primary stability of the implant. After placement of the implants, the soft tissues were repositioned over the capsules and sutured. After 1, 3, 6 and 9 months, four animals were sacrificed and subjected to histometric analysis. RESULTS: The mean height of direct bone-to-implant contact of implants with primary stability was 38.8%, 52.9%, 64.6% and 81.3% of the implant length at 1, 3, 6 and 9 months, respectively. Of the bone adjacent to the implant surface, 28.1%, 28.9%, 52.6% and 69.6%, respectively, consisted of mineralized bone. At the test implants, no bone-to-implant contact was observed at any observation time or in any of these non-stabilized specimens. CONCLUSION: The findings of the present study indicate that primary implant stability is a prerequisite for successful osseointegration, and that implant instability results in fibrous encapsulation, thus confirming previously made clinical observations.

Immunodetection of bone-related proteins in microcalcifications of human dental pulp

Objective: Root canal obliterations may pose esthetic and clinical problems or may even be a risk factor for tooth survival. Microcalcifications in the pulp can be so extensive that the entire root canal system becomes obliterated. Since bone sialoprotein (BSP) and osteopontin (OPN) are involved in both physiological and pathological mineralization processes, our hypothesis was that these two bone-related noncollagenous proteins are present in microcalcifications of the pulp. The purpose of this study was, therefore, to characterize the nature of microcalcifications in the pulp of aged human teeth. Methods: From a large collection of human teeth, 10 were found to exhibit pulpal microcalcifications. The teeth were extracted for periodontal reasons from 39-60 year old patients. After fixation in aldehydes and decalcification, teeth were processed for embedding in LR White resin for analysis in the light and transmission electron microscope. For the detection of BSP and OPN, post-embedding high resolution immunocytochemistry was applied. Results: The microcalcifications were round or elongated, occasionally coalescing, and intensely stained with toluidine blue. Collagen fibrils were found in most but not all microcalcifications. All microcalcifications were immunoreactive for both antibodies and showed an identical labeling pattern. Gold particle labeling was extensively found throughout the interfibrillar ground substance of the microcalcifications, whereas the dentin matrix lacked immunolabeling. Conclusion: BSP and OPN appear to be major matrix constituents of pulp microcalcifications and may thus, like in other mineralized tissues, be involved in their mineralization process.

[Casein phosphopeptide--amorphous calcium phosphate (CPP-ACP) and its effect on dental hard tissues]

Dental products with casein phosphopeptide--amorphous calcium phosphate-nanocomplexes (CPP-ACP) are used in several tooth products (toothpastes, chewing gums, mouthrinses) and are as well used in dental filling material. CPP-ACP containing products are supposed to enhance remineralisation of dental hard tissues und thus might play a major role in prevention and therapy of initial caries or erosively dissolved enamel. Furthermore, also in hypersensitive teeth and even cases of hyposalivation, CPP-ACP containig products are supposed to improve the clinical condition. This article aims at three goals: point out the evolvement of CPP-ACP out of milk casein; description of possible biochemical effects of CPP-ACP on dental hard tissues; critical review of the current literature.

The histological features and physical properties of eroded dental hard tissues.

Erosive demineralisation causes characteristic histological features. In enamel, mineral is dissolved from the surface, resulting in a roughened structure similar to an etching pattern. If the acid impact continues, the initial surface mineral loss turns into bulk tissue loss and with time a visible defect can develop. The microhardness of the remaining surface is reduced, increasing the susceptibility to physical wear. The histology of eroded dentine is much more complex because the mineral component of the tissue is dissolved by acids whereas the organic part is remaining. At least in experimental erosion, a distinct zone of demineralised organic material develops, the thickness of which depends on the acid impact. This structure is of importance for many aspects, e.g. the progression rate or the interaction with active agents and physical impacts, and needs to be considered when quantifying mineral loss. The histology of experimental erosion is increasingly well understood, but there is lack of knowledge about the histology of in vivo lesions. For enamel erosion, it is reasonable to assume that the principal features may be similar, but the fate of the demineralised dentine matrix in the oral cavity is unclear. As dentine lesions normally appear hard clinically, it can be assumed that it is degraded by the variety of enzymes present in the oral cavity. Erosive tooth wear may lead to the formation of reactionary or reparative dentine.

Dental Arch Relationships following Palatoplasty for Cleft Lip and Palate Repair

Palatal scarring is assumed to be a primary cause of facial growth derangement in cleft lip and palate. Evidence supporting this hypothesis is confounded by the clinical involvement of various surgeons, and therefore definitive conclusions are not possible. In this study, we investigated the dental arch relationship in two groups, Exposed (47 children; 11.2 yrs) and Unexposed (61 children; 11.2 yrs), with a unilateral cleft lip and palate operated on by the same surgeon. The technique of hard palate repair differed between the two groups. In the Exposed group, palatal bone of the non-cleft side only was left denuded, inducing scar formation. In the Unexposed group, a vomerplasty with tight closure of the soft tissues was applied. Three raters graded the dental arch relationship and palatal morphology using the EUROCRAN Index. The dental arch relationship in the Exposed group was less favorable than in the Unexposed group (p = 0.009). Palatal morphology in both groups was comparable (p = 0.323). This study demonstrates that reduction of denuded bony areas on the palate after palatal repair with a vomer flap had a favorable effect on the dental arch relationship. For palatal morphology, no effect of the type of palatal repair was found.

Bioengineered periodontal tissue formed on titanium dental implants

The ability to use autologous dental progenitor cells (DPCs) to form organized periodontal tissues on titanium implants would be a significant improvement over current implant therapies. Based on prior experimental results, we hypothesized that rat periodontal ligament (PDL)-derived DPCs can be used to bioengineer PDL tissues on titanium implants in a novel, in vivo rat maxillary molar implant model. Analyses of recovered implants revealed organized PDL tissues surrounding titanium implant surfaces in PDL-cell-seeded, and not in unseeded control, implants. Rat PDL DPCs also exhibited differentiative potential characteristic of stem cells. These proof-of-principle findings suggest that PDL DPCs can organize periodontal tissues in the jaw, at the site of previously lost teeth, indicating that this method holds potential as an alternative approach to osseointegrated dental implants. Further refinement of this approach will facilitate the development of clinically relevant methods for autologous PDL regeneration on titanium implants in humans.

Prolyl hydroxylase inhibitors increase the production of vascular endothelial growth factor in dental pulp-derived cells

Introduction: Prolyl hydroxylase (PHD) inhibitors can induce a proangiogenic response that stimulates regeneration in soft and hard tissues. However, the effect of PHD inhibitors on the dental pulp is unclear. The purpose of this study was to evaluate the effects of PHD inhibitors on the proangiogenic capacity of human dental pulp–derived cells. Methods: To test the response of dental pulp–derived cells to PHD inhibitors, the cells were exposed to dimethyloxalylglycine, desferrioxamine, L-mimosine, and cobalt chloride. To assess the response of dental pulp cells to a capping material supplemented with PHD inhibitors, the cells were treated with supernatants from calcium hydroxide. Viability, proliferation, and protein synthesis were assessed by formazan formation, 3[H]thymidine, and 3[H]leucine incorporation assays. The effect on the proangiogenic capacity was measured by immunoassays for vascular endothelial growth factor (VEGF). Results: We found that all 4 PHD inhibitors can reduce viability, proliferation, and protein synthesis at high concentrations. At nontoxic concentrations and in the presence of supernatants from calcium hydroxide, PHD inhibitors stimulated the production of VEGF in dental pulp–derived cells. When calcium hydroxide was supplemented with the PHD inhibitors, the supernatants from these preparations did not significantly elevate VEGF levels. Conclusions: These results show that PHD inhibitors can stimulate VEGF production of dental pulp–derived cells, suggesting a corresponding increase in their proangiogenic capacity. Further studies will be required to understand the impact that this might have on pulp regeneration.

Performance of dental implants after staged sinus floor elevation procedures: 5-year results of a prospective study in partially edentulous patients

OBJECTIVES: The aim of this prospective study was to evaluate the 5-year performance and success rate of titanium screw-type implants with the titanium plasma spray (TPS) or the sand-blasted, large grit, acid-etched (SLA) surface inserted in a two-stage sinus floor elevation (SFE) procedure in the posterior maxilla. MATERIAL AND METHODS: A total of 59 delayed SFEs were performed in 56 patients between January 1997 and December 2001, using a composite graft with autogenous bone chips combined with deproteinized bovine bone mineral (DBBM) or synthetic porous beta-tricalcium phosphate (beta-TCP). After a healing period averaging 7.75 months, 111 dental implants were inserted. After an additional 8-14-week healing period, all implants were functionally loaded with cemented crowns or fixed partial dentures. The patients were recalled at 12 and 60 months for clinical and radiographic examination. RESULTS: One patient developed an acute infection in the right maxillary sinus after SFE and did not undergo implant therapy. Two of the 111 inserted implants had to be removed because of a developing atypical facial pain, and 11 implants were lost to follow-up and were considered drop-outs. The remaining 98 implants showed favorable clinical and radiographic findings at the 5-year examination. The peri-implant soft tissues were stable over time; the mean probing depths and mean attachment levels did not change during the follow-up period. The measurement of the bone crest levels (DIB values) indicated stability as well. Based on strict success criteria, all 98 implants were considered successfully integrated, resulting in a 5-year success rate of 98% (for TPS implants 89%, for SLA implants 100%). CONCLUSION: This prospective study assessing the performance of dental implants inserted after SFE demonstrated that titanium implants can achieve and maintain successful tissue integration with high predictability for at least 5 years of follow-up in carefully selected patients.

Enhancement of titanium implants via bioengineered periodontal tissues

Osseointegration of titanium dental implants into the jaw bone, which is required for maintenance of the implant in the jaw, results in ankylosis. Dental implants are therefore very unlike natural teeth, which exhibit significant movement in response to mechanical forces. The ability to generate periodontal ligament (PDL) tissues onto dental implants would better mimic the functional characteristics of natural teeth, and would likely improve implant duration and function. OBJECTIVES: The objective of this study was to investigate the feasibility of bioengineering PDL tissues onto titanium implant surfaces. METHODS: Bilateral maxillary first and second molars of 8-week old rats were extracted and used to generate single cell suspensions of PDL tissues, which were expanded in culture. Immunohistochemistry and RT-PCR were used to identify putative PDL progenitor/stem cell populations and characterize stem cell properties, including self-renewal, multipotency and stem cell maker expression. Cultured rPDL cells were harvested at third passage, seeded onto Matrigel-coated titanium implants (1.75 mm x 1 mm), and placed into healed M1/M2 extraction sites. Non-cell seeded Matrigel-coated titanium implants served as negative controls. Implants were harvested after 8, 12, or 18 weeks. RESULTS: Cultured rPDL cells expressed the mesenchymal stem-cell marker STRO-1. Under defined culture conditions, PDL cells differentiated into adipogenic, neurogenic and osteogenic lineages. While control implants were largely surrounded by alveolar bone, experimental samples exhibited fibrous PDL-like tissues, and perhaps cementum, on the surface of experimental implants. CONCLUSIONS: PDL contains stem cells that can generate cementum/PDL-like tissue in vivo. Transplantation of these cells might hold promise as a therapeutic approach for the bioengineering of PDL tissues onto titanium implant. Further refinement of this method will likely result in improved dental implant strategies for use of autologous PDL tissue regeneration in humans. This research was supported by CIMIT, and NIH/NIDCR grant DE016132 (PCY), and TEACRS (YL).

In vivo bisphenol-a release from dental pit and fissure sealants: a systematic review

OBJECTIVE To search the literature and assess the short- and long-term release of bisphenol-A (BPA) in human tissues after treatment with dental sealants. DATA Two review authors performed data extraction independently and in duplicate using data collection forms. Disagreements were resolved by discussion with an arbiter. SOURCES Electronic database searches of published and unpublished literature were performed. The following electronic databases with no language and publication date restrictions were searched: MEDLINE (via Ovid and Pubmed), EMBASE (via ovid), Cochrane Trials Register and CENTRAL. The reference lists of all eligible studies were hand-searched. STUDY SELECTION In the absence of RCTs, six interventional and two observational studies, examining in vivo BPA release in human salivary, blood and urinary samples, were included. Due to the heterogeneity in methodology and reporting, the main synthesis of the results was qualitative. The quantitative synthesis based on the weighted Z-test could only include two studies. BPA levels identified in saliva ranged from traces below the method's detection limit to 30 μg/ml. In urine, BPA quantities spanned from 0.17 mg/g to 45.4 mg/g. BPA was not traced in any blood sample at any point of time in the relevant studies. The quantitative analysis showed evidence of BPA release one hour after sealant placement compared to the amount traced before restoration (Stouffer's z trend: <0.001). CONCLUSIONS The available evidence on this topic derived from studies that represent a moderate level of evidence. Nevertheless, the available evidence supports that BPA is released in saliva after sealant placement. CLINICAL SIGNIFICANCE From the qualititative and quantitative synthesis of studies, it is reasonable to conclude that BPA is released after placement of some dental pit and fissure sealants in the oral cavity. The biggest quantities are detected in saliva immediately after or one hour after their placement.

Monoenergetic computed tomography reconstructions reduce beam hardening artifacts from dental restorations

The aim of this study was to assess the potential of monoenergetic computed tomography (CT) images to reduce beam hardening artifacts in comparison to standard CT images of dental restoration on dental post-mortem CT (PMCT). Thirty human decedents (15 male, 58 ± 22 years) with dental restorations were examined using standard single-energy CT (SECT) and dual-energy CT (DECT). DECT data were used to generate monoenergetic CT images, reflecting the X-ray attenuation at energy levels of 64, 69, 88 keV, and at an individually adjusted optimal energy level called OPTkeV. Artifact reduction and image quality of SECT and monoenergetic CT were assessed objectively and subjectively by two blinded readers. Subjectively, beam artifacts decreased visibly in 28/30 cases after monoenergetic CT reconstruction. Inter- and intra-reader agreement was good (k = 0.72, and k = 0.73 respectively). Beam hardening artifacts decreased significantly with increasing monoenergies (repeated-measures ANOVA p < 0.001). Artifact reduction was greatest on monoenergetic CT images at OPTkeV. Mean OPTkeV was 108 ± 17 keV. OPTkeV yielded the lowest difference between CT numbers of streak artifacts and reference tissues (-163 HU). Monoenergetic CT reconstructions significantly reduce beam hardening artifacts from dental restorations and improve image quality of post-mortem dental CT.

Three-dimensional imaging methods for quantitative analysis of facial soft tissues and skeletal morphology in patients with orofacial clefts: a systematic review.

BACKGROUND Current guidelines for evaluating cleft palate treatments are mostly based on two-dimensional (2D) evaluation, but three-dimensional (3D) imaging methods to assess treatment outcome are steadily rising. OBJECTIVE To identify 3D imaging methods for quantitative assessment of soft tissue and skeletal morphology in patients with cleft lip and palate. DATA SOURCES Literature was searched using PubMed (1948-2012), EMBASE (1980-2012), Scopus (2004-2012), Web of Science (1945-2012), and the Cochrane Library. The last search was performed September 30, 2012. Reference lists were hand searched for potentially eligible studies. There was no language restriction. STUDY SELECTION We included publications using 3D imaging techniques to assess facial soft tissue or skeletal morphology in patients older than 5 years with a cleft lip with/or without cleft palate. We reviewed studies involving the facial region when at least 10 subjects in the sample size had at least one cleft type. Only primary publications were included. DATA EXTRACTION Independent extraction of data and quality assessments were performed by two observers. RESULTS Five hundred full text publications were retrieved, 144 met the inclusion criteria, with 63 high quality studies. There were differences in study designs, topics studied, patient characteristics, and success measurements; therefore, only a systematic review could be conducted. Main 3D-techniques that are used in cleft lip and palate patients are CT, CBCT, MRI, stereophotogrammetry, and laser surface scanning. These techniques are mainly used for soft tissue analysis, evaluation of bone grafting, and changes in the craniofacial skeleton. Digital dental casts are used to evaluate treatment and changes over time. CONCLUSION Available evidence implies that 3D imaging methods can be used for documentation of CLP patients. No data are available yet showing that 3D methods are more informative than conventional 2D methods. Further research is warranted to elucidate it.