Incipient Carious Lesions Research Articles

A Scanning Electron Microscopic Study of Enamel Surfaces of Incipient Caries

The surface changes of natural incipient caries in human teeth were examined by scanning electron microscopy. Numerous small round depressions due to dissolved prism ends are observed. The prism sheaths seem to be preferentially demineralized, followed by demineralization of prism cores. Perikymata are well-pronounced. Focal holes and relatively large dissolution areas can be present. A new prismatic pattern of destruction with an appearance of fish scales is found. Evidence of remineralization of the incipient carious lesions is seen on the surfaces of the lesions. This study disagrees with the concept of an intact enamel surface layer.

Incipient caries: an early intervention approach

Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitation (Shafer-1993). Organic acids produced as a by-product of fermentable carbohydrate metabolism plays a key role in the disease. The caries process is a continuous, involving various cycles of demineralization and remineralization. Demineralization begins at the atomic level on the crystal surface in enamel or dentine and can continue to cavitation. However currently there are many treatment modalities to intervene this continuing process, to arrest or reverse the progress of the lesion. Remineralization is the natural repair process for non-cavitated or incipient carious lesion.

Terapia remineralizadora alternativa en la práctica odontológica

A very important field in dentistry has been open for a long time in the treatment of incipient caries lesions as well as in the prevention of caries. Evidence shows the action of agents that promote remineralization of dental tissues from early stages. The non-invasive treatment of incipient lesions by remineralization constitutes a great achievement in the management of the disease and it can be possible with a variety of available agents, being fluoride the most commonly used agent so far. Research has been done on the topical application of other minerals that can also be used as remineralizers (calcium and phosphate) that can easily diffuse through the enamel pores to remineralize incipient enamel lesions and on the commercial products on the market that contain them.   Received for review: May 2015 Accepted for publication: June 2015 Correspondence: Benito Blanco 837/102 C.P. 11300 Montevideo, Uruguay. Tel. 099099032.Contact e-mail: ocao_1972@hotmail.com

The effect of ER: YAG laser on enamel resistance to caries during orthodontic treatment: An in vitro study

Background: One common undesirable side effect of orthodontic treatment with fixed appliances is the development of incipient caries lesions around brackets, particularly in patients with poor oral hygiene. Different methods have been used to prevent demineralization; the recent effort to improve the resistance against the demineralization is by the application of lasers. Materials and method: Thirty human premolars extracted for orthodontic purposes were used to test the effect of two energy level of ER-YAG laser on enamel resistance to demineralization. The brackets were bonded on the teeth and all the labial surface excluding 2 mm area gingival to the brackets were painted with acid resistance varnish. Three groups were generated. The first group was the control group (A), with no treatment was performed. In group II (B)and groups III (C); teeth were irradiated by ER-YAG laser of 200, 60 mj energy respectively. All the teeth were individually subjected to acid challenge cycle for 30 days. After debonding longitudinal sections were taken and examined under stereomicroscope. The enamel demineralization evaluation was done by taking the average of three depths at the centre of the artificial lesion. Also the enamel surface was classified by an experienced investigator according to acid etch pattern. Comparisons of the average depth values of the groups were performed with ANOVA and LSD tests. The statistical significance level was set at p ≤ 0.05. Results: The results revealed that average lesion depth was significantly deeper at the control group than the laser groups, and its significantly deeper in group (B) 200 mj than in group (C) 60 mj, enamel surfaces showed deeper pits and craters than in control group. Conclusions: the decrease in artificial caries lesion depth associated with use of the two laser energy level support the ER-YAG laser as a tool to increase enamel resistance to demineralization and white spot lesion prevention. Key words: Demineralization, ER-YAG, laser.

Incipient caries lesions: from concept to actual treatment approaches

The concepts introduced by the Minimally Invasive Dentistry (MID) allowed the rising of new conservative treatment and assessment system for caries lesions’ classification. In this context, the approaches of the incipient caries lesions surpass the use of only traditional restorative techniques. The aim of this study was to review the new caries classifications criteria (ICDAS and CAST), the importance of the early diagnosis of caries lesions and the clinical procedures for treatment in MID.

Dentifrice Fluoride and Abrasivity Interplay on Artificial Caries Lesions

Incipient caries lesions on smooth surfaces may be subjected to toothbrushing, potentially leading to remineralization and/or abrasive wear. The interplay of dentifrice abrasivity and fluoride on this process is largely unknown and was investigated on three artificially created lesions with different mineral content/distribution. 120 bovine enamel specimens were randomly allocated to 12 groups (n = 10), resulting from the association of (1) lesion type [methylcellulose acid gel (MeC); carboxymethylcellulose solution (CMC); hydroxyethylcellulose gel (HEC)], (2) slurry abrasive level [low (REA 4/ RDA 69); high (REA 7/RDA 208)], and (3) fluoride concentration [0/275 ppm (14.5 m<smlcap>M</smlcap>) F as NaF]. After lesion creation, specimens were brushed in an automated brushing machine with the test slurries (50 strokes 2×/day). Specimens were kept in artificial saliva in between brushings and overnight. Enamel surface loss (SL) was determined by optical profilometry after lesion creation, 1, 3 and 5 days. Two enamel sections (from baseline and post-brushing areas) were obtained and analyzed microradiographically. Data were analyzed by analysis of variance and Tukey's tests (α = 5%). Brushing with high-abrasive slurry caused more SL than brushing with low-abrasive slurry. For MeC and CMC lesions, fluoride had a protective effect on SL from day 3 on. Furthermore, for MeC and CMC, there was a significant mineral gain in the remaining lesions except when brushed with high-abrasive slurries and 0 ppm F. For HEC, a significant mineral gain took place when low-abrasive slurry was used with fluoride. The tested lesions responded differently to the toothbrushing procedures. Both slurry fluoride content and abrasivity directly impacted SL and mineral gain of enamel caries lesions.

Sodium fluoride mouthrinse used twice daily increased incipient caries lesion remineralization in an in situ model

ObjectivesTo investigate the remineralizing effects of fluoride mouthrinses used at different times and frequency in addition to fluoride toothpaste. MethodsA randomized crossover single blinded study comprised 4 experimental phases of 21 days each. Twelve orthodontic volunteers were fixed with an orthodontic bracket containing an artificial carious enamel slab, which was from the same tooth in all 4 phases, and were randomly assigned to the following groups: (1) brushing with F toothpaste 2× per day (F- brush), (2) F- brush+rinsing with 0.05% NaF (F- rinse) after lunch, (3) F- brush+F-rinse before bedtime, and (4) F- brush+F- rinse 2× per day. Mean mineral gain after each phase was determined from mineral density profiles obtained using Micro-CT. ResultsThe mean mineral gain in all treatments with F- brush and F-rinse were significantly greater than those in F- brush (p<0.05). Moreover F- rinse 2× per day increased lesion remineralization more than F- rinse once a day. ConclusionsThe twice-daily use of 0.05% NaF mouthrinse combined with twice-daily regular use of fluoride toothpaste resulted in the greatest remineralization of incipient caries. These data indicate that rinsing frequency is a factor affecting the effectiveness of fluoride mouthrinse. Clinical significanceThe rinsing frequency of NaF mouthrinse, when used with fluoride toothpaste, also affects the remineralization. This finding, if confirmed by a clinical study, would lead to a new recommendation for fluoride mouthrinse used in high caries risk patients who could benefit from using it twice a day.

An in vitro evaluation of the efficacy of a novel iontophoresis fluoride tray on remineralization.

Objectives: The aim of this study is to determine the effects on remineralization of a novel iontophoresis device called ‘Fluorinex’, conventional (acidulated phosphat fluoride) APF gel treatment, and conventional ionthophoresis device comparatively by laser fluorescence measurements. Study Design: Artificial incipient carious lesions were created on immature, 60 intact premolar and molar teeth with no defects. The specimens were randomly allocated to four groups. In the first group 1.23% APF gel was applied to specimens by conventional method for 4 minutes and in the second group 2% (sodium fluoride) NaF solution applied by conventional iontophoresis device for 4 minutes. In Fluorinex group specimens were pretreated with (copper chloride) CuCl2 for 1 minute and then treated for 4 minutes with 1.23% APF gel in a Fluoritray. Control group was placed in distilled water for 4 minutes. After these applications all specimens were included to a pH cycling. DIAGNOdent pen measurement were obtained in three different time intervals; after incipient carious lesions, after fluoride treatments and after pH cycling. Specimens were studied by SEM(scanning electron microscopy) after artificial caries lesions and fluoride treatments. Results: Alterations on DIAGNOdent pen measurements before and after treatment, the Fluorinex group was statistically different from conventional APF gel (p=0.011), conventional NaF iontophoresis (p<0.001) and control group (p<0.001). As the DIAGNOdent pen measurements before treatment and after pH cycling were compared, differences were statistically significant in Fluorinex and conventional APF gel groups (p<0.001). Conclusions: The results of this in vitro study has shown that fluoride application by Fluorinex was superior to the conventional APF gel application and NaF iontophoresis on incipient carious lesions. Key words:Fluoride, iontophoresis, remineralization.

Remineralization efficiency of bioactive glass on artificially induced carious lesion an in-vitro study

The objective of this study is to investigate the efficacy of bioactive glass containing product on remineralization of artificial induced carious enamel lesion and to compare its efficiency with other remineralization products using an in-vitro pH cycling method. The null hypothesis tested was bioactive glass has no effect on enamel remineralization. A total of 20 enamel samples of human molar teeth were subjected to artificial caries lesion formation using pH cycling method and was verified using high resolution scanning electron microscope (HRSEM). Each demineralized sample was then divided into five test groups each containing twenty. Group A - Bioactive glass (SHY-NM), Group B - Fluoride tooth paste (Amflor), Group C - CPP-ACP (Tooth mousse), Group D - CPP-ACPF (Tooth mousse plus), Group E - control. All the test groups were exposed to the pH cycling regime, the remineralizing agents were applied for 10 min except control. After 10 days period, the entire test groups were evaluated with HRSEM and quantitative assessment by energy dispersive X-ray spectroscopy. The obtained data was analyzed statistically using one-way ANOVA, Student's t-test and Tukey's multiple comparison tests. P ≤ 0.05 was considered to be significant. Rejection of the null hypothesis and highlights the concept of biomimetic bioactive glass as an effective remineralizing agent. To focus on the importance of minimal invasive treatment on incipient carious lesion by remineralization.

Chemical alteration by tooth bleaching of human salivary proteins that infiltrated subsurface enamel lesions--experimental study with bovine lesion model systems.

Salivary macromolecules infiltrate white and brown spot enamel lesions and adsorb onto hydroxyapatite. Calcium-binding salivary proteins such as statherin hinder remineralization of these lesions. We assessed whether bleaching agents can remove salivary components that have infiltrated and bound to experimental subsurface lesions in bovine enamel prepared by immersing specimens in acid and then human saliva. Transversal microradiography showed that such demineralized lesions mimicked incipient carious lesions. Bound proteins to the experimental and untreated control specimens were eluted in a stepwise manner with phosphatebuffered saline, 0.4 M phosphate buffer, and 1 M HCl. SDS-PAGE of dialyzed extracts showed that specific salivary proteins bound to the lesions, while virtually no protein bands were detected if the specimens were bleached. Western blotting showed that even statherin, which was more firmly bound than other proteins, was removed. In-office bleaching agent may be useful in treating enamel lesions for removing proteins bound to these lesions.

Diagnosis of incipient caries lesions. A review of the literature

Diagnosis of incipient caries lesions. A review of the literature

In vivo effectiveness of enamel sealants around orthodontic brackets

In this randomized study, the caries-protective effect on vestibular enamel of two fluoride-containing sealants (Protecto® and Light Bond®) during multibracket treatment was investigated. In all, 40 orthodontic patients about to receive a multibracket appliance with the brackets bonded to the vestibular tooth surfaces were randomly included in this study. Each one was randomly assigned to one of four groups. A crossover design was selected in which a sealed quadrant was contralateral to an unsealed quadrant, then choosing the reverse configuration in the opposite jaw. Two sealants were, thus, tested on vestibular enamel on left and right anterior teeth and premolars in both jaws of each patient over 6 months of multibracket treatment. A DIAGNOdent® pen measuring laser fluorescence was used to analyze the relevant enamel surfaces both at baseline and after 6 months. Neither the incidence nor the characteristics of the demineralization we observed during the study differed between the 4 groups. Single application of smooth-surface sealants did not protect enamel around brackets from incipient carious lesions during the first 6 months of multibracket treatment.

Influence of CO2 (10.6 μm) and Nd:YAG laser irradiation on the prevention of enamel caries around orthodontic brackets

One possible undesirable consequence of orthodontic therapy is the development of incipient caries lesions of enamel around brackets. The aim of this study was to compare the effects of CO2 (λ = 10.6 μm) and Nd:YAG (λ = 1,064 nm) lasers associated or not with topical fluoride application on the prevention of caries lesions around brackets. Brackets were bonded to the enamel of 65 premolars. The experimental groups (n = 13) were: G1--application of 1.23% acidulated fluoride phosphate gel (AFP, control); G2--Nd:YAG laser irradiation (0.6 W, 84.9 J/cm(2), 10 Hz, 110 μs, contact mode); G3--Nd:YAG laser irradiation associated with AFP; G4--CO2 laser irradiation (0.5 W, 28.6 J/cm(2), 50 Hz, 5 μs, and 10 mm focal distance); and G5--CO2 laser irradiation associated with AFP. Quantitative light-induced fluorescence was used to assess enamel demineralization. The data were statistically compared (α = 5%). The highest demineralization occurred in the Nd:YAG laser group (G2, 26.15% ± 1.94). The demineralization of all other groups was similar to that of the control group. In conclusion, CO2 laser alone was able to control enamel demineralization around brackets at the same level as that obtained with topical fluoride application.

Laser application in prevention of demineralization in orthodontic treatment.

One common negative side effect of orthodontic treatment with fixed appliances is the development of incipient caries lesions around brackets, particularly in patients with poor oral hygiene. Different methods have been used to prevent demineralization such as fluoride therapy and application of sealant to prevent caries. The recent effort to improve the resistance against the demineralization is by the application of different types of lasers. The purpose of this review article is discussing the effects of laser in prevention of demineralization in orthodontic patients.

Efficacy of 1.23% APF gel applications on incipient carious lesions: a double-blind randomized clinical trial

The aim of this double-blind randomized clinical trial was to evaluate the efficacy of 1.23% APF gel application on the arrest of active incipient carious lesions in children. Sixty 7- to 12-year-old children, with active incipient lesions were included in the study. Children were divided randomly into 2 groups: 1.23% APF gel and placebo gel applications. Each group received 8 weekly applications of treatment. The lesions were re-evaluated at the 4th and 8th appointments. Poisson regression analysis was used to estimate relative risks of the presence of active white spot lesions. Groups showed similar results (PR = 1.67; CI 95% 0.69-3.98). The persistence of at least 1 active lesion was associated with a higher number of lesions in the baseline (PR = 2.67; CI 95% 1.19-6.03), but not with sugar intake (PR = 1.06; CI 95% 0.56-2.86) and previous exposure to fluoride dentifrice (PR = 1.26; CI 95% 0.49-2.29). The trial demonstrates the equivalence of the treatments. The use of the APF gel showed no additional benefits in this sample of children exposed to fluoridated water and dentifrice. The professional dental plaque removal in both groups may also account for the resulting equivalence of the treatments.

Caries diagnosis using light fluorescence devices: VistaProof and DIAGNOdent

The modern concept of minimally invasive dentistry encompasses early detection of incipient carious lesions and their treatment. Due to the low sensitivity of visual inspection and radiography in the detection of occlusal hidden carious lesions under a macroscopically sound surface, several devices have been developed to increase detection accuracy. DIAGNOdent is one of the tools used for that purpose and VistaProof is a new device recently introduced into the market. They both use light fluorescence to detect incipient carious lesions. DIAGNOdent is based on the fact that carious lesions show higher level of fluorescence than sound tissues when excited by light at specific wavelength. Vistaproof is based on the same principle, but it uses a different wavelength of excitation than DIAGNOdent and a video camera for the detection of fluorescence. The aim of this article was to compare these two devices and present their clinical use.

In vitro remineralization of enamel subsurface lesions and assessment of dentine tubule occlusion from NaF dentifrices with and without calcium

Currently, fluoride is the most effective preventive treatment for remineralization of incipient carious lesions and dentinal hypersensitivity due to wasting disorders. The products containing fluoride, calcium and phosphate are also claim to remineralize early, non-cavitated enamel demineralization. The aim of this study was to investigate and compare the efficacy of two such products, Tooth Mousse and Clinpro tooth crème on remineralization and tubule occluding ability with 5000ppm fluoride-containing toothpaste. Thirty third molar teeth were placed in demineralizing solution for 5 days such that only a window of 1mm x 5mm was exposed to the environment to produce artificial caries-like lesions and randomly assigned to three groups: Group I, 5000ppm sodium fluoride; Group II, GC MI paste plus and Group III, Clinpro tooth crème. Axial longitudinal sections of 140-160 μm of each tooth which included the artificial carious lesion taken and were photographed under polarized light microscope. The demineralized areas were then quantified with a computerized imaging system. The experimental materials were applied onto the tooth sections as a topical coating and subjected to pH-cycling for 28 days. To evaluate tubule occlusion ability, thirty dentin specimens of 2mm thickness were obtained from cervical third of sound third molars. Specimens were ultrasonicated and etched with 6% citric acid for 2 minutes to simulate the hypersensitive dentin. Specimens were randomly divided into above mentioned three groups (n=10). The test agents were brushed over the specimens with an electric toothbrush, prepared and observed under Scanning Electron Microscope for calculation of the percentage of occluded tubules. Group I showed a significantly greater percentage of remineralization than Group III and Group II. Comparison of the remineralization potential between group II and group III were not significant.In case of dentine hypersensitivity, Group I and group III showed greater percentage of tubule occlusion ability than Group II. Intergroup comparison of the tubule occlusion potential of group I and group III were not significant. Within the limitations of our study, sodium fluoride showed relatively greatest remineralizing and dentinal tubule occlusion property when compared with GC MI paste plus and Clinpro tooth crème.

Capability of an Ultrasonic System to Detect Very Early Caries Lesions on Human Enamel

The purpose of this investigation was to determine if changes in dental enamel with 20 micron depth incipient carious lesion could be detected by an ultrasonic system (US). Natural (unground, unpolished) lesions were produced on human enamel by using a microbial caries model. Specimens with lesions were analyzed using Ultrasonic system (US) as test method, Quantitative-Light Induced Fluorescence (QLF) and Confocal Laser Scanning Microscopy (CLSM) as gold standards. It was found that both ultrasound and QLF could not detect these very early lesions (mean lesion depth: 18.89 µm) created in vitro in the microbial caries model.

Cariotester, a new device for assessment of dentin lesion remineralization in vitro

This study aimed to evaluate the potential of a new device (Cariotester) for monitoring of incipient carious lesion remineralization in root dentin by topical fluoride in vitro. Demineralized bovine dentin specimens were treated by fluoride solutions (APF or neutral NaF) and remineralized for 4 weeks. Cariotester was used to measure penetration depth (CTR depth) of the indenter into the de- and remineralized specimen surface. The specimens were assessed by transverse microradiography (TMR) to determine lesion parameters (depth: LD, mineral loss: ΔZ). Pearson's correlation analysis showed an overall significant relationship between CTR depth and both TMR parameters. CTR depth appeared to distinguish the positive effect that topical fluoride application had on the remineralization of the outer zone of dentin lesions. Cariotester had the potential to serve as a quantitative tool for monitoring of incipient carious lesion remineralization in root dentin.

Characterizing and Identifying Incipient Carious Lesions in Dental Enamel Using Micro-Raman Spectroscopy

Early detection of dental caries is vital if improved patient outcomes are to be achieved by reversal of the demineralization process. Current techniques used by dentists for identifying carious lesions are effective in identifying more advanced lesions, but do not have sufficient sensitivity and specificity to detect them at the earliest stages. This study focused on characterizing the growth of incipient carious lesions in vitro using micro-Raman spectroscopy. The incipient carious lesions were grown on the buccal faces of human molars by controlled exposure to lactic acid. Lesions were cross-sectioned to expose the subsurface body of the lesion and then examined using micro-Raman spectroscopy. The intensity of the phosphate peaks in the Raman spectra was found to differ significantly between healthy enamel and the demineralized region of the lesions. The sensitivity of the phosphate peaks to the degree of demineralization was observed by taking a series of spectra over the cross section of the lesions. This revealed that the body of the lesion is highly demineralized, but in a narrow surface region (up to 10 µm) there is little demineralization. All the phosphate peaks were found to be sensitive to the degree of demineralization; however, changes in the intensity of the pronounced phosphate peak at 961 cm^–1 offer the most promise for identifying lesions. The results indicate that micro-Raman spectroscopy has both the sensitivity and selectivity to identify incipient carious lesions, but the presence of a surface layer with a relatively high mineral content could complicate the analysis.