Oral Health and Preventive Dentistry

Purpose: To perform a systematic review of articles related to the clinical efficacy of topical fluoride varnishes/gels, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), and other remineralisation agents of white spot lesions (WSL) in primary teeth. Materials and Methods: Electronic and manual searches were conducted through diverse electronic databases. The search was limited to randomised, clinical, controlled trials, and quasi-experimental papers in full-text version. Suitable individual studies were evaluated through a previously reported quality system, their data extracted and carefully analysed. Results: The search identified 298 citations, and 95 were chosen and reviewed in full text. Nine relevant citations met the eligibility criteria for inclusion in the systematic review. Pair comparisons were made between fluoride varnishes, CPP-ACP, dental lasers, and control interventions. Conclusions: Clinicians are encouraged to discuss more high-quality studies in order to provide sufficient evidence and to confirm the clinical utility of remineralisation agents of WSL in primary teeth. Keywords: primary teeth, remineralisation, systematic review, white spot lesions

Purpose: Sodium bicarbonate (NaHCO3) in toothpaste can enhance the removal of biofilms involved in the development of gingivitis. To examine this over an extended time period, this study compared the efficacy and tolerability of twice-daily brushing for 24 weeks with 67% or 0% NaHCO3-containing toothpastes in subjects with moderate gingivitis. Materials and Methods: 247 adults with bleeding after brushing and ≥ 20 gingival bleeding sites were randomized to twice-daily brushing with a 67% NaHCO3 or 0% NaHCO3 toothpaste. The primary efficacy variables were between-treatment differences in number of bleeding sites and the Modified Gingival Index (MGI) score after 24 weeks' use. Secondary efficacy variables included Bleeding Index (BI) and Turesky modification of Quigley-Hein Plaque Index (TPI) (overall and only interproximal sites). Results: The 67% NaHCO3 toothpaste produced statistically significant improvements compared with the 0% NaHCO3 toothpaste in number of bleeding sites (-17.5; 95% CI -20.32, -14.66; p 0.0001) and MGI score (-0.2; 95% CI -0.24, -0.17; p 0.0001) at week 24. These significant differences were also found at 6 and 12 weeks for these measures and at 6, 12, and 24 weeks for BI and TPI scores (including at only interproximal sites) (all p 0.0001). No treatment-related adverse events were reported. Conclusion: Twice-daily brushing with 67% NaHCO3 toothpaste was generally well tolerated and significantly improved indices of gingival bleeding and plaque compared with 0% NaHCO3 toothpaste in subjects with moderate gingivitis. Keywords: biofilm disruption, dental plaque, periodontal disease, sodium bicarbonate, toothpaste

Purpose: The present study compared the antiplaque effects of two herbal mouthwashes containing Salvadora persica and Azadirachta indica, respectively, with two synthetic mouthwashes containing either chlorhexidine or cetylpyridinium. Materials and Methods: In this triple-blind, randomised controlled trial, 100 patients undergoing orthodontic treatment underwent scaling and polishing at baseline to obtain a plaque score of zero. In the first phase, they were given oral hygiene instructions and were provided with a standard toothpaste to be used twice daily for a period of three weeks. In the second phase, following scaling and polishing, they were randomly allocated to 4 groups according to 4 different types of mouthwash (A: chlorhexidine; B = cetylpyridinium; C = extracts of Salvadora persica miswak; D: extract of Azadirachta indica miswak) along with previously taught toothbrushing protocol for three more weeks. Plaque accumulation was scored three times according to the Modified Bonded Bracket Plaque Index: at the start, after the toothbrush-toothpaste trial, and at the end of mouthwash trial. The paired t-test was used to compare the pre-plaque and post-plaque indices in all groups. Analysis of mean differences of post-plaque indices between and within groups was performed using the post-hoc Tukey test. Qualitative variables were compared by Crosstab. Results: Eighty participants completed the study - 63 females and 17 males. There was a statistically significant decrease in mean plaque scores after using mouthwashes in all four groups at follow-up when compared to the baseline plaque score (p = 0.001). The greatest reduction of plaque score was found in group C (extract of Salvadora persica) when compared with group A, chlorhexidine (p = 0.016). Conclusion: Compared to other mouthwashes, Salvadora persica miswak-based mouthwash showed a maximum reduction in the plaque scores among orthodontic patients. Keywords: Azadirachta indica (neem), cetylpyridinium (CPC), chlorhexidine (CHX), dental plaque, herbal mouthwash, Salvadora persica (peelu)

Purpose: In this study, the protective effects of restorative materials with fluoride content, resin-modified glass-ionomer cement (RMGIC), giomer, and glass carbomer against artificial initial caries lesions in a simulated highly cariogenic oral environment were evaluated. Considering the reported recharging abilities of these restorative materials, fluoridated toothpaste was applied to some groups, in which the anti-demineralising effect was also evaluated. Materials and Methods: Two enamel blocks were produced from each of 60 sound permanent molars. Sixty specimens were used for microhardness analysis, and the rest were used for SEM-EDX analysis. Enamel specimens were randomly assigned to three groups according to the restorative material: A = resin-modified glass-ionomer cement; B = giomer; C = glass carbomer. Artificial initial caries lesions were created using demineralising solutions, after which specimens were exposed to in vitro pH cycling simulating a highly cariogenic oral environment. Microhardness and mineral analyses were performed on the enamel surrounding the restorative materials at three different times during the experiment: at the beginning of the experiment, then after the creation of the artificial early caries lesions, and finally after pH cycling. Results: Microhardness and SEM-EDX results mostly confirmed each other. RMGIC and glass carbomer groups with added fluoride toothpaste showed statitsically significantly better anti-demineralising effects in comparison to other groups. Neither of the giomer groups performed as well as RMGIC or glass carbomer. Conclusion: Because of the similarity between the demineralisation inhibitory activity of glass carbomer and RMGIC, glass carbomer may be preferred as a restorative material in paediatric dentistry. Keywords: fluoride, giomer, glass carbomer, resin-modified glass ionomer, SEM-EDX

Purpose: Radiotherapy causes xerostomia in patients treated for head and neck cancer. This study investigated changes in quality and quantity of saliva after radiotherapy and possible associations between these changes and alterations in oral flora. Materials and Methods: The study was a prospective cohort study of patients receiving radiotherapy for head and neck cancer. Suitable patients were recruited before treatment commenced, and informed consent was obtained. Patients were examined, and provided unstimulated and stimulated saliva samples. Quantity of saliva, buffering capacity and pH were measured. Oral flora was cultured from the saliva samples. Oral clearance of glucose and of lactose was measured. These interventions were repeated at intervals after radiotherapy had been completed. Results: Eighteen patients were recruited. Stimulated and unstimulated saliva flow rates, glucose clearance, salivary pH and buffering capacity were significantly reduced after radiotherapy. Candida albicans counts were significantly increased. These increases were significantly correlated with reductions in stimulated and unstimulated salivary flow rates. Counts of lactobacilli, Streptococcus mutans and Bifidobacteriaceae increased, but not statistically significantly. Conclusions: Therapeutic radiotherapy significantly reduced the quality and quantity of saliva in head and neck cancer patients. These reductions were associated with increased C. albicans counts. Keywords: cancer microflora, quality of life, radiotherapy, saliva, xerostomia

Purpose: To understand the effect of the addition of hydroxyapatite (HA) and bioactive glass (BAG) to compomer restorative materials on the remineralisation capacity of the material. Materials and Methods: 1%, 2%, 3% and 4% w/w HA and BAG particles were added mechanically to the compomers. To examine the resistance to demineralisation, Class V cavities were prepared in extracted teeth and restored with experimental filling materials. Demineralised lesions were created in 72 enamel samples. Vickers microhardness measurements of samples were performed at three different areas including the margin of the restoration, the varnish-protected enamel and the exposed enamel areas. Measurements performed on protected enamel were used as reference enamel values for each group. SEM was used to evaluate the surface texture of the specimens. The statistical analyses were performed by one-way ANOVA, Tukey's HDS and paired-samples t-tests. Results: BAG and HA groups revealed higher microhardness values at the exposed enamel and exposed marginal enamel than did the control group (p = 0.001). 3% and 4% HA and BAG groups produced higher microhardness values than did 1% modified groups on exposed enamel (p = 0.001). 4% HA group revealed the highest microhardness values on marginal exposed enamel (p = 0.001). 2%, 3%, 4% and HA, as well as 3% and 4% BAG groups showed higher microhardness values than did the control group on marginal exposed enamel at 20 µm depth (p = 0.001). SEM images revealed that HA and BAG particles were not distributed homogeneously and the particles seemed to be grouped in the matrix. Conclusions: Within the limits of this study, the addition of the BAG and HA into compomers improved the demineralisation resistance properties of enamel, depending on the amount of additive. Keywords: bioactive glass, compomer, hydroxyapatite

Purpose: To determine in vitro the protection potential against discolouration of two OTC (over-the-counter) desensitising products on enamel and dentin in comparison to a standard toothpaste and water by means of a spectrophotometer. Materials and Methods: A total of 96 samples of bovine enamel-dentin complex and 48 of bovine dentin were alternatively immersed in red wine, tea, coffee or water after having been treated by a sodium monofluorophosphate- and calcium phosphate-based product (Curodont Protect), an amine fluoride-based toothpaste (Elmex Red), a stannous chloride-based toothpaste (Elmex Protection Erosion) or distilled water (negative control). Initial (T0) and final colour (T1, after 4 weeks of immersion in staining solutions) of each specimen were assessed by a spectrophotometer. Statistical analysis was done by means of repeated measures ANOVA followed by Fisher's LSD post-hoc test. Differences between T0 and T1 were considered stastistically significant at p ≤ 0.05. Results: When enamel samples were measured over a black background, ΔE00 values (T0-T1) varied from 2.2 (SD 0.7) for amine fluoride-based product/water to 53.9 (SD 7.6) for amine fluoride-based-product/red wine. When dentin samples were measured over a black background, ΔE00 values (T0-T1) varied from 5.4 (SD 0.9) stannous chloride based product/water to 61.6 (SD 3.7) amine fluoride-based product/red wine. Conclusion: Specifically, the application of the sodium monofluorophosphate was able to statistically significantly (p ≤ 0.05) reduce discolouration induced by the staining solutions tested only on the enamel-dentin complex, while distilled water and the stannous fluoride-based product were able to statistically significantly (p ≤ 0.05) reduce discolouration induced by the staining solutions tested in pure dentin samples. Keywords: ΔE00, discolouration, spectrophotometer

Purpose: Consumption of refined foods and beverages high in sugar make the teeth susceptible to the formation of biofilm and may lead to dental caries. The aim of the present study was to determine the ability of selected probiotics to inhibit growth and biofilm formation by the cariogenic bacterium Streptococcus mutans in vitro. Materials and Methods: Strains of latic acid bacteria (LAB) (n = 120) from the Bioresources Collection and Research Center (BCRC), saliva of healthy adults and infant stool were screened. The antimicrobial activity of LAB in vitro was evaluated by agar spot culture and co-culture of the S. mutans strains. Antagonistic substances in the spent culture suspensions (SCS) of LAB were precipitated by extraction with ammonium sulphate and chloroform to characterise the protein and lipophilic fractions. Results: Results of co-culturing show that the SCS of the three LAB strains (Lactobacillus pentosus 13-1, 13-4 and L. crispatus BCRC 14618) subjected to heat treatment showed statistically significantly higher antimicrobial activity. Substances produced by L. pentosus 13-4 which have the potential to exhibit antimicrobial properties might be lipophilic proteins. Additionally, microtiter plate biofilm assays indicated that in vitro biofilm formation by S. mutans is strongly modulated by L. pentosus 13-4 and L. crispatus BCRC 14618. Conclusion: It can be inferred that the mechanism of reducing biofilm formation by these two LAB strains is associated with sucrose-dependent cell-cell adhesion and the gtfC level of glucosyltransferases in the biofilm. Therefore, it is suggested that L. pentosus 13-4 and L. crispatus BCRC 14618 may contribute to preventing dental caries, as they showed an inhibitory effect on the growth and biofilm formation of the cariogenic bacterium S. mutans in vitro. Keywords: biofilm, dental caries, glucosyltransferases (Gtfs), lactic acid bacteria (LAB), Streptococcus mutans

Purpose: To evaluate the clinical, biochemical, and microbiological reactions to nanocomposite containing amorphous calcium phosphate (ACP) in comparison to a traditional composite restorative material in early childhood caries. Materials and Methods: Eighteen teeth were restored with the test material (ACP-containing resin) and 18 teeth were restored with the control material (traditional composite, TC) in fourteen paediatric patients using a split-mouth design. One caries- and restoration-free intact tooth in each patient was selected as the healthy control. Gingival crevicular fluid (GCF) and supragingival plaque samples were collected at baseline before the treatment and also on days 1, 7, 14 and 30 after treatment. Unstimulated whole saliva samples were obtained from each patient at baseline, and 1 and 6 months after restoration. GCF and saliva samples were assayed for IL-17A, IL-17F IL-17A/F, IL-17E, OPG and RANKL levels by ELISA, and plaque composition was assessed using RT-PCR. Results: Clinical evaluation indicated no statistically significant differences between the two restorative materials according to the FDI criteria surface lustre, material retention and marginal adaptation properties. Pro-inflammatory IL-17 levels decreased statistically significantly at 6 months compared to baseline and 1-month values (p 0.05). The baseline pro-inflammatory IL-17 cytokine levels in GCF samples around the carious teeth were higher than those obtained around the healthy teeth (p 0.05), but similar in GCF from the ACP-test and TC teeth. Microbiological findings were similar in the ACP and T groups. Conclusion: It may be suggested that both ACP-containing and traditional resin composites show similar antimicrobial and biochemical effects in early childhood caries. Keywords: amorphous calcium phosphate, cytokines, early childhood caries, GCF, plaque, saliva

Purpose: To determine the clinical consequences of untreated dental caries among preschool children by using the pufa index (visible pulp, ulceration of the oral mucosa due to root fragments, a fistula or an abscess) and the incorporation of some risk factors. Materials and Methods: Data were collected via structured, pre-tested questionnaires from 729 parents in Turkey's capital, Ankara. Examinations were performed under field conditions by one examiner. The decayed teeth were scored according to the International Caries Detection and Assessment System (ICDAS) II criteria. The filled and missing teeth and surfaces were also recorded as dmft and dmfs, and the pufa index was used for the consequences of untreated caries. The associations were evaluated by univariate analysis and logistic regression. Results: The means age of the study population was 58.8 ± 8.6 months. 45% of the children were female and 55% were male. Mean dmft and dmfs were 4.8 ± 4.7 and 8.3 ± 10.2, respectively. 73.8% of the children had early childhood caries (ECC), while 51.0% had severe cases. Only 58 children (8.0%) had totally healthy primary teeth according to ICDAS II. Of the children with caries (n = 538), 17.5% had at least one pufa tooth. According to the logistic regression analysis, sex, having at least one sibling, extraction experience, and father's educational level were found to be the factors associated with the existence of pufa. Conclusion: Healthcare providers' attention must be drawn to both untreated carious lesions and the high ECC proportion among preschool children. Keywords: Early Childhood Caries, ICDAS II, pufa, preschool, untreated dental caries