Casein Phosphopeptide-stabilized Amorphous Calcium Phosphate Research Articles

EFFICACY OF NOVEL BIOACTIVE GLASS IN THE TREATMENT OF ENAMEL WHITE SPOT LESIONS: A RANDOMIZED CONTROLLED TRIAL✰

to evaluate the efficacy of 2 types of bioactive glass (45S5) compared to casein-phosphopeptide stabilized-amorphous calcium phosphate (CPP-ACP) in the treatment of orthodontically-induced white spot lesions (WSLs). Sixty post-orthodontic WSLs (ICDAS II score 2) were randomly allocated to a double blind randomized controlled trial with 3 parallel arms (n = 20). Test group I (Bio-BAG) received BiominF slurry and toothpaste, and test group II (N-BAG) received Novamin slurry and toothpaste. While the positive control group (CPP-ACP) received Recaldent paste. Products were applied daily in-office during week 1, and boosted by self-administered home application for 4 weeks (week 1-4). Standard oral hygiene care was performed by all participants twice daily during months 2-6. All patients were assessed for change in WSL dimensions using computer assisted analysis based on standardized digital intraoral photographs in addition to laser fluorescence DIAGNOdent assessment before treatment (T0) and at 1 week (T1), 1 month (T2), 3 months (T3,) and 6 months (T4) follow up periods. Kruskal Wallis test was used (P < .05 for all). At T4, a statistically significant (P < .001) regression of WSL was disclosed in all 3 groups compared to baseline, and a highly significant lesion size percent reduction in Bio-BAG group compared to the control group (P < .001). The mean area of the lesions decreased by 64.8%, 32.2%, and 31.6% for groups I, II and III respectively (P = .001). DIAGNOdent findings largely reflected the clinical scores (Mean scores at baseline/T4 for groups I, II, and III respectively; 16.57/3.62, 16.93/7.90, 21.95/19.27). No adverse effects were reported. The combined in-office and home-application of BiominF paste for 4 weeks resulted in greater esthetic improvements of post-orthodontic WSLs compared to Novamin and CPP-ACP. In addition, BiominF showed a significant reduction in fluorescence intensity which indicates potential lesion remineralization. Post-orthodontic WSLs can be diminished using bioactive glass remineralization therapy.

Effectiveness of CPP-ACP and fluoride products in tooth remineralization.

To compare the effectiveness of the casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) in the in situ remineralization of enamel exposed with two different degrees of preformed enamel lesions. One hundred and sixty 3×3×2 mm human enamel slabs were demineralized and divided into two subgroups according to the baseline surface hardness (SH=B1≤150 and B2 >150). During each of four 10-day experimental periods, 10 participants wore intra-oral removable acrylic palatal expanders with four human enamel slabs with preformed lesions (B1 and B2): CO1 and CO2-Control: silica dentifrice without fluoride; MP1 and MP2: MI Paste; MPP1 and MPP2: MI Paste Plus; and FD1 and FD2: Fluoride dentifrice. The Knoop hardness test (50/15s Micromet 2001, Buehler) was performed after demineralization (B1 and B2) and after treatment (T1 and T2). SH was higher in all treatment groups, when compared with the controls, except for CO2 (Mann-Whitney Wilcoxon Test; p<0.05). The %SH was similar between MPP2 and FD2 and between MPP2 and MP2; however, FD2 and MPP2 products were more effective in microhardness recovery. In B1, all treatment groups were similar. MPP and FD are more effective in preventing demineralization in enamel subsurface lesions.

Evaluation of Remineralizing Capacity of P11-4, CPP-ACP, Silver Diamine Fluoride, and NovaMin: An In Vitro Study

To determine and compare remineralizing efficacy of NovaMin, CPP-ACP, silver diamine fluoride (SDF), and P11-4. Sixty permanent premolars were divided into four groups with 15 samples in each group; group I: self-assembling peptide (P11-4), group II: SDF, group III: Casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP), and group IV: NovaMin. Mineral content was assessed using a scanning electron microscope at 7, 14, and 21 days after remineralization with each agent. The mean remineralization in group I at 7 days was 1.73 ± 0.02, at 14 days was 1.79 ± 0.01, and at 21 days was 1.90±0.03. Mean remineralization in group II was 1.61 ± 0.01, 1.64 ± 0.02, and 1.73 ± 0.03 at 7, 14, and 21 days, respectively. Mean remineralization in group III was 1.62 ± 0.01, 1.65 ± 0.02, and 1.74 ± 0.05 at 7, 14, and 21 days, respectively. Mean remineralization in group IV was 1.59 ± 0.02, 1.62 ± 0.07, and 1.70 ± 0.09 at 7, 14, and 21 days, respectively. The maximum value was obtained on day 21. There was a significant difference in mean remineralization values between group I vs group II, group I vs group III, and group I vs group IV (p < 0.05). Self-assembling peptides showed maximum remineralization in tested specimens followed by CPP-ACP, SDF, and NovaMin-containing toothpaste. CPP-ACP, SDF, and NovaMin-containing toothpaste can be indicated for remineralization of initial caries in clinical use.

Effect of CPP-ACP on remineralization of artificial caries-like lesion: an in situ study.

The purpose of this double-blind, randomized, crossover in situ study is to compare remineralization of preformed enamel lesions by casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) and fluoride dentifrice products. During each of four 10-day experimental legs, 10 participants wore intraoral removable palatal acrylic appliances with four human enamel slabs with preformed lesions. A 0.03-mL treatment paste was dripped extraorally onto the enamel blocks once a day for 3 min. The four randomly allocated treatments were as follows: CO- Control: silica dentifrice without fluoride; MP: MI Paste; MPP: MI Paste Plus and FD: Fluoride dentifrice - 1100 ppm F as NaF). Knoop surface hardness (SH) test was performed in three stages (T0 - sound enamel, T1 - after preformed lesion, and T2 - after treatment) and the cross-sectional hardness (CSH) test was performed after treatment using a 50-gram Knoop load for 15 s. Knoop hardness number (KHN) was similar between treatments. %SHr was significantly higher in the MP, FD, and MPP when compared to CO group (Kruskal-Wallis and Mann-Whitney tests, p < 0.05). Harder enamel was found in MP (75 μm) and FD groups at 75 to 175 μm. Treatment with DF, MP, and MPP promoted an increase of 20.27%, 19.24%, and 14.71%, respectively, in Integral Hardness Change (ΔIHC) when compared to CO (p<0.05). Remineralizing agents (MP, MPP, and DF) were able to inhibit demineralization of human enamel subjected to high cariogenic challenge in situ. DF had the greatest preventive potential against the progression of carious lesions.

Self-assembly of dental surface nanofilaments and remineralisation by SnF2 and CPP-ACP nanocomplexes

Dental caries, erosion and hypersensitivity are major public health problems. SnF2 is used widely in oral care products to help prevent/treat these conditions. Casein phosphopeptide-stabilised amorphous calcium phosphate nanocomplexes (CPP-ACP) are a biomimetic nanotechnology of salivary phosphopeptide-ACP complexes that deliver bioavailable calcium and phosphate ions to promote dental remineralisation (repair). We show here using in vitro studies and a double-blind, randomised controlled, cross-over design in situ clinical trial that SnF2 and CPP-ACP interact to form a nanofilament coating on the tooth surface and that together they are superior in their ability to promote dental remineralisation. Sn(II) by cross-linking the CPP-ACP helps to stabilise the complexes which improves delivery to the tooth surface and enhances binding and ion incorporation into tooth mineral. The combination of SnF2 and CPP-ACP in oral care products may significantly improve their efficacy in prevention/treatment of dental caries/erosion and hypersensitivity.

Surface properties of eroded human primary and permanent enamel and the possible remineralization influence of CPP-ACP

It has been widely accepted that the microstructure and composition of human primary enamel differ from those of human permanent enamel. However, the difference of their erosion behaviour has not been fully understood. To extend the understanding of dental erosion, the surface properties of eroded human primary enamel and the possible remineralization influence of CPP-ACP were investigated in vitro by comparing them with those of human permanent enamel in this study. Enamel specimens were prepared from human primary and permanent molar teeth. The enamel specimens were firstly immersed in citric acid solution (pH=3.20) for 0.5, 1, 3, 5, and 10min, respectively, to obtain eroded specimens. After 10min of erosion, remineralization treatment was conducted in vitro by immersing the eroded specimens in 2% w/v casein phosphopeptide-stabilized amorphous calcium phosphate solution (CPP-ACP) for 12h. The surface morphologies of enamel were analyzed by means of various microscope examinations, and its nanomechanical and microtribological properties were examined using nano-indentation/scratch technique. Results showed that the erosion resistance of primary enamel was inferior to that of permanent enamel. An obvious honeycomb-like structure caused by acid attack appeared on the surface of primary enamel only after 3min erosion but appeared on the surface of permanent enamel after 5min erosion. Both the nanomechanical and microtribological properties of the two enamel decreased significantly after erosion treatment. Compared with permanent enamel, the influence of erosion on the nanomechanical properties and microtribological behaviour of primary enamel was more significant. The loss of hardness and Young's modulus and the decrease of wear-resistance of enamel surface by acid erosion were recovered obviously after remineralization treatment. But the recovery of primary enamel was weaker than that of permanent enamel. These results indicated that the primary enamel should be more susceptible to acid-erosion and the remineralization treatment with CPP-ACP could contribute to the repair of its erosion lesions less effectively as compared to permanent enamel.

Interventions for orthodontically induced white spot lesions: a systematic review and meta-analysis.

Although orthodontic white spot lesions (WSLs) are one of the most often and most evident adverse effects of comprehensive fixed appliance treatment, the efficacy of interventions for WSLs has not yet been adequately assessed in an evidence-based manner. Aim of this systematic review was to assess the therapeutic and adverse effects of interventions to treat post-orthodontic WSLs from randomized trials in human patients. An unrestricted electronic search of eight databases from inception to May 2016. Randomized controlled trials assessing any interventions for post-orthodontic WSLs on human patients. After duplicate study selection, data extraction, and risk of bias assessment according to the Cochrane guidelines, random-effects meta-analyses of mean differences (MDs), standardized mean differences (SMDs), and odds ratios (ORs), including their 95% confidence intervals (CIs) were performed, followed by subgroup and sensitivity analyses. A total of 20 unique studies and a total of 942 (42 per cent male and 58% per cent female) patients were included, with an average age of 16.2 years and a mean number of 8.2 WSLs (range 2.2 to 45.4) per patient. These were allocated to adjunct treatment with casein phosphopeptide-stabilized amorphous calcium phosphate creams, external tooth bleaching, low- or high-concentration fluoride films, gels, mouthrinses or varnishes, resin infiltration, miswak chewing sticks, bioactive glass toothpastse, or to no adjunct treatment (i.e. conventional oral hygiene). The monthly use of fluoride varnish was the best supplement to improve WSLs in terms of lesion area (1 trial; MD = -0.80 mm2; 95% CI = -1.10, -0.50 mm2; P < 0.05; high quality) and enamel fluorescence (3 trials; SMD = -0.92; 95% CI = -1.32, -0.52; P < 0.05; high quality), followed by the use of fluoride film. WSL treatment did not provide a considerable improvement in their clinical evaluation (3 trials; OR = 0.97; 95% CI = 0.60, 1.56; P > 0.05; moderate quality), with imprecision due to small sample size being the main limitation of existing evidence. Based on the existing trials, interventions for post-orthodontic WSLs, mainly fluoride varnish, seem to be effective, but further research is needed to elucidate their clinical relevance. PROSPERO (CRD42016037538).

The Interactions of CPP-ACP with Saliva.

The repair of early dental caries lesions has been demonstrated by the application of the remineralisation technology based on casein phosphopeptide-stabilised amorphous calcium phosphate complexes (CPP–ACP). These complexes consist of an amorphous calcium phosphate mineral phase stabilised and encapsulated by the self-assembly of milk-derived phosphopeptides. During topical application of CPP–ACP complexes in the oral cavity, the CPP encounters the enamel pellicle consisting of salivary proteins and peptides. However the interactions of the CPP with the enamel salivary pellicle are not known. The studies presented here reveal that the predominant peptides of CPP–ACP complexes do interact with specific salivary proteins and peptides of the enamel pellicle, and provide a mechanism by which the CPP–ACP complexes are localised at the tooth surface to promote remineralisation.

In situ effect of a CPP-ACP chewing gum on enamel erosion associated or not with abrasion.

The purpose of this study is to analyze the in situ effect of a casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) chewing gum on human enamel erosion lesion associated or not with abrasion. A three-way crossover study of 7days was conducted involving 10 volunteers subjected to the same protocol: (G1) CPP-ACP sugar-free chewing gum, (G2) regular sugar-free chewing gum without CPP-ACP, and (G3) saliva-no chewing gum. An abrasion test was included in each phase. A 3D non-contact profilometry measurement of lesion depth and surface roughness was obtained of sound and eroded surfaces. A salivary calcium concentration was determined for all volunteers. ANOVA followed by Tukey's test were used with a p<0.05. The enamel depth and the enamel surface roughness of the CPP-ACP gum group were significantly lower than the others (ANOVA, p<0.05). No significant differences were observed between the treatments when associated with abrasion (p>0.05). A positive and significant correlation was seen between the lesion depth and enamel surface roughness for GI (r=0.87, p=0.00) and GIII (r=0.79, p=0.00) groups. The estimated total calcium presented in the saliva after the chewed CPP-ACP gum showed no statistical significance between the mean absorbance values at the different time collections (p>0.05). It is demonstrated that the incorporation of the CPP-ACP into a sugar-free gum significantly increased the remineralization/protection of eroded enamel surface. The CPP-ACP added to gum may be a suitable alternative vehicle, to deliver calcium ions to saliva and therefore protecting enamel.

Minimally Invasive Treatment of White Spot Lesions--A Systematic Review.

To evaluate the efficacy of minimally invasive methods for the treatment of white-spot lesions involving fluorides, CPP-ACP (casein phosphopeptide-stabilised amorphous calcium phosphate) and resin infiltration vs a placebo or control. According to predetermined criteria, four databases were searched for eligible studies. References of the selected articles and relevant reviews were searched for any missed publications. Eight randomised controlled trials were selected as eligible studies, and only qualitative analyses were performed because of the diversity of the interventions and outcome measures. Three studies showed significant effects of three different fluoride preparations and used DIAGNOdent and ICDAS to assess the white spot lesions. Both studies comparing resin infiltration to a placebo showed significant effects in treating white spot lesions. One study using CPP-ACP showed a significant improvement in the lesions post treatment. Evidence suggests minimally invasive treatment modalities of white spot lesions produced significant improvement in the appearance and regression of white spot lesions following treatment when compared to a control or placebo.

Remineralizing Efficacy of a CPP-ACP Cream on Enamel Caries Lesions in situ

The aim of this double-blind, randomized, cross-over in situ study was to compare the remineralizing effects induced by the application of casein phosphopeptide-stabilized amorphous calcium phosphate complexes (CPP-ACP)-containing cream (without fluoride) after the use of fluoride toothpaste with the prolonged use of fluoride toothpaste on enamel caries lesions in situ. During each of three experimental legs of 4 weeks, 13 participants wore intra-oral mandibular appliances with 8 pre-demineralized bovine enamel specimens in the vestibular flanges mimicking either ‘easily cleanable' or ‘proximal' surfaces (n = 312). The three randomly allocated treatments were as follows: (1) application of CPP-ACP-containing cream (GC Tooth Mouse, non-fluoride) after the use of fluoride toothpaste (1,400 ppm NaF; TM), (2) prolonged application of fluoride toothpaste (1,400 ppm NaF; positive control, PC) and (3) prolonged application of fluoride-free toothpaste (negative control, NC). Additionally, one of each of the two flanges was brushed twice daily with the respective toothpaste. The differences in integrated mineral loss as assessed by transversal microradiography were calculated between values before and after the in situ period. Changes in mineral loss were analysed for those pairs of subgroups differing in only one of the three factors (intervention, brushing and position). The PC treatment induced a significantly higher mineral gain compared with the TM and NC treatments. No significant differences between TM and NC for both positions were observed. In conclusion, the additional use of a CPP-ACP-containing cream seems to be less efficacious in remineralizing caries lesions than the prolonged application of fluoride toothpaste. © 2014 S. Karger AG, Basel

Effect of CPP-ACP on the remineralization of acid-eroded human tooth enamel: nanomechanical properties and microtribological behaviour study

Casein phosphopeptide-stabilized amorphous calcium phosphate (CPP-ACP) has been used to enhance tooth remineralization in the dental clinic. But the contribution of CPP-ACP to the remineralization of acid-eroded human tooth enamel is of widespread controversy. To confirm the application potential of CPP-ACP in the remineralization repair of tooth erosion caused by acid-attack, the effect of remineralization in vitro in 2% w/v CPP-ACP solution on the acid-eroded human tooth enamel was investigated in this study. The repair of surface morphology and the improvement of nanomechanical and microtribological properties were characterized with laser confocal scanning microscope, scanning electron microscope, nanoindentation tester and nanoscratch tester. Results showed that a layer of uneven mineral deposits, which were mainly amorphous calcium phosphate (ACP) in all probability, was observed on the acid-eroded enamel surface after remineralization. Compared with the acid-eroded enamel surface, the nanoindentation hardness and Young's modulus of the remineralized enamel surface obviously increased. Both the friction coefficient and wear volume of the acid-eroded enamel surface decreased after remineralization. However, both the nanomechanical and the anti-wear properties of the remineralized enamel surface were still inferior to those of original enamel surface. In summary, tooth damage caused by acid erosion could be repaired by remineralization in CPP-ACP solution, but the repair effect, especially on the nanomechanical and anti-wear properties of the acid-eroded enamel, was limited. These results would contribute to a further exploration of the remineralization potential of CPP-ACP and a better understanding of the remineralization repair mechanism for acid-eroded human tooth enamel.

Calcium Phosphopeptides — Mechanisms of Action and Evidence for Clinical Efficacy

Phosphoproteins/phosphopeptides with clusters of acidic residues are found throughout nature, where they aid in the prevention of unwanted precipitation of solid calcium phosphates. The acidic residues, particularly phosphoserine, interact with calcium and stabilize clusters of calcium and phosphate. Saliva and milk are two examples of biological fluids that contain such phosphoprotein/phosphopeptide-stabilized calcium phosphates, and both share a similar evolutionary pathway. Saliva has been shown to have remineralization potential and is of critical importance in maintaining the mineral content of teeth in the oral environment. Milk can be enzymatically modified to release casein phosphopeptides that contain the clusters of residues that allow milk to stabilize high concentrations of calcium and phosphate. These casein phosphopeptide-stabilized amorphous calcium phosphate nanocomplexes (CPP-ACP) can stabilize even higher concentrations of calcium and phosphate than milk and can be considered a salivary biomimetic, since they share many similarities to statherin. The mechanisms of action and the growing body of scientific evidence that supports the use of CPP-ACP to augment fluoride in inhibiting demineralization and enhancing the remineralization of white-spot lesions are reviewed.

Topical preventive measures to avoid or reverse white spot lesions in orthodontic patients

Data sourcesMedline/PubMed and the Cochrane Library.Study selectionOnly human controlled in vivo studies of topical technologies with white spot lesions incidence/reversals or other relevant surrogate endpoints in the English language were accepted.Data extraction and synthesisData on design, performance and outcome were extracted independently but no formal quality grading was conducted. The prevented WSL fraction was calculated as the difference in mean WSL increment between the intervention and control groups, expressed as percentage of the increment in the control group. For WSL reversals, the absolute risk reduction (ARR%) was calculated when possible.ResultsTwenty-five studies were included; nine considered primary prevention, eight WSL reversals while six utilised surrogate measures such as bacterial counts, plaque amount or pH-values. Fluoride use was the most common intervention (nine papers), followed by antibacterial agents (five papers), use of casein phosphopeptide-stabilised amorphous calcium phosphate (CPP-ACP) for remineralisation (five papers) and various other methods (six papers). The mean prevented fraction based on six topical fluoride trials was 42.5% with a range from −4% to 73%.ConclusionsThe recent papers provided the strongest support for regular professional applications of fluoride varnish around the bracket base during the course of orthodontic treatment. For the treatment of post-orthodontic WSL, home-care applications of a remineralising cream, based on CPP-ACP, as adjunct to fluoride toothpaste could be beneficial but the findings were equivocal. Only studies with surrogate endpoints are available for technologies such as sugar alcohols and probiotics. Further well-designed studies with standardised regimes and endpoints are needed before guidelines on the non-fluoride technologies can be recommended.

A Review on Prevention and Treatment of Post-Orthodontic White Spot Lesions - Evidence-Based Methods and Emerging Technologies

Objective:The aim of this paper was to update the evidence for primary and secondary prevention (treatment) of white spot lesions (WSL) adjacent to fixed orthodontic appliances. Material and methods:A search for relevant human clinical trials published in English between 2004 and March 2011 retrieved 25 publications that fulfilled the inclusion criteria. The papers were assessed for prevented fraction and/or absolute risk reduction when possible.Results and conclusions:The findings consolidated the use of topical fluorides in addition to fluoride toothpaste as the best evidence-based way to avoid WSL. The mean prevented fraction based on 6 trials was 42.5% with a range from -4% to 73%. The recent papers provided the strongest support for regular professional applications of fluoride varnish around the bracket base during the course of orthodontic treatment. For the treatment of post-orthodontic WSL, home-care applications of a remineralizing cream, based on casein phosphopeptide-stabilized amorphous calcium phosphate, as adjunct to fluoride toothpaste could be beneficial but the findings were equivocal. For emerging technologies such as sugar alcohols and probiotics, still only studies with surrogate endpoints are available. Thus, further well-designed studies with standardized regimes and endpoints are needed before guidelines on the non-fluoride technologies can be recommended.

Treatment of post-orthodontic white spot lesions with casein phosphopeptide-stabilised amorphous calcium phosphate

This study aims to investigate the effect of topical applications of 10% casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSL) detected after treatment with fixed orthodontic appliances. Sixty healthy adolescents with ≥1 clinically visible WSL at debonding were recruited and randomly allocated to a randomised controlled trial with two parallel groups. The intervention group was instructed to topically apply a CPP-ACP -containing agent (Tooth Mousse, GC Europe) once daily and the subjects of the control group brushed their teeth with standard fluoride toothpaste. The intervention period was 4weeks and the endpoints were quantitative light-induced fluorescence (QLF) on buccal surfaces of the upper incisors, cuspids and first premolars and visual scoring from digital photos. The attrition rate was 15%, mostly due to technical errors, and 327 lesions were included in the final evaluation. A statistically significant (p < 0.05) regression of the WSL was disclosed in both study groups compared to baseline, but there was no difference between the groups. The mean area of the lesions decreased by 58% in the CPP-ACP group and 26% in the fluoride group (p = 0.06). The QLF findings were largely reflected by the clinical scores. No side effects were reported. Topical treatment of white spot lesions after debonding of orthodontic appliances with a casein phosphopeptide-stabilised amorphous calcium phosphate agent resulted in significantly reduced fluorescence and a reduced area of the lesions after 4weeks as assessed by QLF. The improvement was however not superior to the "natural" regression following daily use of fluoride toothpaste.

Enamel Subsurface Lesion Remineralisation with Casein Phosphopeptide Stabilised Solutions of Calcium, Phosphate and Fluoride

Casein phosphopeptide stabilised amorphous calcium phosphate (CPP-ACP) and amorphous calcium fluoride phosphate (CPP-ACFP) solutions have been shown to remineralise enamel subsurface lesions. The aim of this study was to determine the effect of ion composition of CPP-ACP and CPP-ACFP solutions on enamel subsurface lesion remineralisation in vitro. CPP-bound and free calcium, phosphate and fluoride ion concentrations in the solutions were determined after ultrafiltration. The ion activities of the free ion species present were calculated using an iterative computational program. The mineral deposited in the subsurface lesions was analysed using transverse microradiography and electron microprobe. CPP was found to stabilise high concentrations of calcium, phosphate and fluoride ions at all pH values (7.0–4.5). Remineralisation of the subsurface lesions was observed at all pH values tested with a maximum at pH 5.5. The CPP-ACFP solutions produced greater remineralisation than the CPP-ACP solutions at pH 5.5 and below. The mineral formed in the subsurface lesions was consistent with hydroxyapatite and fluorapatite for remineralisation with CPP-ACP and CPP-ACFP, respectively. The activity gradient of the neutral ion pair CaHPO₄⁰ into the lesion was significantly correlated with remineralisation and together with HF⁰ were identified as important species for diffusion.