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November 2007 | MH
Dental hygienists can play key role as prevention specialists, and in helping to rebuild and remineralize enamel.
Caries research has changed its focus. Rather than viewing a carious lesion as an entity that needs to be restored, the focal point is now one of prevention. Caries is being viewed as a process—a bacterial infection—and restoring the cavity does not mean that the disease has been arrested. As well, management of dental caries is now optimal when based upon risk assessment. In the Caries Management by Risk Assessment (CAMBRA) methodology, the clinician identifies the cause of disease by assessing risk factors for each individual patient.1 Specific treatment recommendations include behavioral, chemical, and minimally invasive procedures with the aim of altering the Caries Balance.2 The Caries Balance is a model where pathological factors such as bacteria, absence of healthy saliva, and poor dietary habits (i.e. frequent ingestion of fermentable carbohydrates) battle protective factors (saliva, sealants, antibacterials, fluoride, and an effective diet). With the use of CAMBRA there is evidence that early damage to teeth from dental caries may be reversed and the manifestations of the disease perhaps prevented all together. This paradigm shift in caries management focuses on remineralization of the tooth surface in a minimally invasive manner. This article will focus on the remineralization component of the caries management process. Baseline knowledge Remineralization is defined as a “repair process for dental hard tissues that occurs when the intra-oral pH rises and Ca and P from saliva join together with fluoride in the subsurface area of carious lesion to form a new veneer on existing crystal remnants in the lesion.”3 Minimally invasive therapy suggests chemical repair, using antimicrobials, chlorhexidine, iodine, xylitol, topical fluoride, and calcium and phosphate products.
Part of the Implementation Guidelines for Clinical Practice (to be published in the November 2007 journal of the California Dental Association) states that preventing caries and remineralizing early lesions are cost-effective treatment options and will enhance success.4 Following a caries risk assessment, an evidence-based treatment plan is developed based upon the level of risk—namely low, moderate, high or extreme. Topical fluoride from numerous sources (office and home) should be used to enhance remineralization (e.g. 5% sodium fluoride varnish, 1000-5000 ppm fluoride toothpastes, 0.05% sodium fluoride rinses). Patients not adhering to home-care fluoride recommendations should receive more individual office-based professional topical applications of fluoride, such as fluoride varnish. Fluoride varnishes have the FDA “on label” claim for desensitization and an “off label” claim for caries prevention; significant research in Europe supports use as a caries preventive topical agent. The evidence-based clinical recommendations for professionally applied topical fluoride, as endorsed by ADA Council on Scientific Affairs, can serve as a chairside reference.5 From Science to Practice In addition to fluoride, calcium and phosphate products can be used to replace those minerals missing in patients with reduced salivary function. Other patients with observed surface demineralization (e.g. white spots) may benefit from this therapy, in addition to fluoride treatments. Following are some of the newer remineralizing therapies. ACP. Amorphous calcium phosphate (ACP) is composed of the hydroxyapatite minerals phosphorus, oxygen, and calcium compounds, and is amorphous with no particular crystal form or pattern. It is inorganic and highly soluble, and is created when dissolved calcium ions and phosphate ions react to form a non-crystalline salt. Due to reactivity when combined, the components must be stored separately before applied to the tooth surface. It forms faster intraorally, as saliva contains catalytic elements to activate the Ca and P ions. It is this reacted complex of calcium and phosphate ions that precipitate and grow on tooth surfaces, speeding up the kinetic reaction of natural rebuilding of enamel.6 The chemistry that produces the conductive attraction of Ca and P to the tooth surface is directly influenced by the level of pH in the oral environment. If the pH goes below 5.5 to a highly acidic level, the crystals change. ACP converts to a new coating of hydroxyapatite, releasing essential ions that favor remineralization. Ca and PO4 can bind with other ions (fluoride, protein) and release during acid attacks. Fluoride and hydroxyapatite combined equals fluorapatite crystals; fluorapatite is stronger than original hydroxyapatite enamel.7 CPP-ACP (Recaldent™). Casein phosphopeptides (CPP) stabilize amorphous calcium phosphate (ACP) and may be used to localize ACP in dental plaque, maintaining a state of supersaturation with respect to tooth enamel, reducing demineralization and enhancing remineralization.8 Application of CPP-ACP to plaque may cause a transient rise in plaque fluid free calcium which may assist remineralization. Subsequently, CPP-ACP will form a source of readily available calcium to inhibit demineralization. Hence, CPP-ACP binds well to plaque, providing a large calcium reservoir, which is likely to restrict mineral loss during a cariogenic episode and provide a potential source of calcium for subsequent remineralization. Overall, once in place, CPP-ACP will restrict the caries process. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) nanocomplexes have been shown to prevent demineralization and promote remineralization of enamel subsurface lesions in animal and in situ caries models. The aim of one study was to determine the effect of incorporating CPP-ACP into a self-cured glass-ionomer cement (GIC). The study showed that incorporation of CPP-ACP into the GIC significantly increased microtensile bond strength and compressive strength and significantly enhanced the release of calcium, phosphate, and fluoride ions at neutral and acidic pH. The release of CPP-ACP and fluoride from the CPP-ACP-containing GIC was associated with enhanced protection of the adjacent dentin during acid challenge in vitro.9 NovaMin. NovaMin is a compound made from elements which are naturally critical for bone and tooth mineralization: calcium, phosphorus, silica, and sodium.10 Delivered in their common forms, these elements have limited value in tooth health. Delivered together, in their ionic form, makes them valuable in the process of remineralization. Each microscopic NovaMin particle serves as a delivery system for these ions. When the particle is exposed to water from saliva or water it instantly reacts - releasing billions of mineral ions that become available to the natural remineralization process in your mouth. These ions, along with naturally occurring ions in your saliva, combine to form hydroxyapatite crystals. the future Researchers at NYU College of Dentistry are studying the causes of tooth decay and hope to find out if genetics or environment has the most impact on decay. If research shows it’s in the genes, that could lead to new tests predicting which children are at a higher risk for cavities and treat them more aggressively. In the meantime, try incorporating the CAMBRA protocol and remineralization techniques into your practice.
References available upon request. E-mail mh@advanstar.com.
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