remineralization with cpp-acpdibateb.com/wp-content/uploads/2018/02/mid3.pdf · understand that...

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Remineralization with CPP-ACP: the evidence Remineralisation with CPP-ACP’ to MIH:

the treatment protocol

Hands on, drills off

Remineralisation with CPP-ACP

MID resources

minimum intervention, maximum return Issue 3

GC EUROPE N.V.Head Office Tel. [email protected] www.gceurope.com GC UNITED KINGDOM Ltd. Tel. [email protected] www.uk.gceurope.com

Identify plaque cariogenicity and age within 5 minutes

Prevention starts with

risks identification

and personal motivationPlaque Indicator Kit from GC.

Plaque formation is a normal occurrence for most of the population. To determine the potential damage plaque can cause

and discover exactly which plaque sites are more

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Plaque Indicator Kit is a simple and inexpensive test that quickly identifies and visually communicates the problem to motivate and educate patients.

Minimum Intervention

8. Practice perspectives• Hands on, drills off

10. Clinical corner• MIH: the evidence and treatment protocol• White spot reversal protocol• Topical CPP-ACP crème (Tooth Mousse): more evidence that demands a verdict

26. Evidence• A closer look at remineralisation and CPP-ACP

30. MI toolkit• Tooth Mousse: All you need to know

Thanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate bene� t of the patient community.

4. MID Worldwide

Issue 3

minimum intervention, maximum return

mid

mi.gceurope.com

6. Q&A

7. Resources

Dr Graham Mount answers a question about what he has found to be the most e� ective way to apply CPP-ACP

Networks, websites, books, events and journal articles relating to advances in MID

What’s insideWhat’s insideWhat’s insideMID 3 videoMID 3 videoMID 3 video

https://www.youtube.com/watch?v=hucktLMD044

4 mi.gceurope.commid worldwide

MID WorldwideThanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate bene� t of the patient community.

Dr Matteo BassoAs a student, I did my internship in the Department of Periodontology at the University of Milan, directed by Professor Roberto Weinstein. In that department, the concepts of minimal-ly invasive dentistry had been � rmly

ingrained for many years and advanced periodontal procedures were envied and admired nationally and internationally. Here I learnt the importance of the preservation of healthy tissue as a fundamental condi-tion for the success of treatment, both functionally and aesthetically. After graduation and obtaining a PhD, I became the head of restorative dentistry at the univer-sity dental clinic, IRCCS Galeazzi Orthopaedic Institute in Milan (Italy). There, I realized it was a good approach to change concepts of minimally invasive therapy,

possible only when a disease is already established, towards the concept of ‘minimum intervention’, in other words to intervene when the disease has not yet had an irreversible e� ect on the teeth and gums.

The literature helped us to comprehend what ‘mini-mum intervention’ actually is. And so, the traditional department of restorative dentistry quickly evolved into a new department, built on these ideas, called the Center of Aesthetic and Mininvasive Oral Rehabilitation (CROME). The goal of this centre is to intervene early in carious disease, seeking not only to treat cavities, how-ever necessary, but also to understand why the carious lesions manifested themselves in the � rst place. One of our challenges is to see if you can change the suscepti-bility of patients in order to protect their teeth and mas-ticatory ability. It was not so easy to explain to patients all the reasons and the importance of this approach,

Italy

MIDworldwide

5mid worldwide

Dr Zhouqun Yan, GC ChinaThere is an increasing awareness of MI among the Chinese dental profession. This is due to information in international journals and returning overseas dentists who have studied abroad for postgraduate degrees or special research projects. However, due to the requirement of an import license for any item regarded as a dental device, most ‘state of the art’ items

including MI products are not available for Chinese dentists at the same time as other countries. Some successful items take years to satisfy the strict governmen-tal requirements. To emphasise this, Tooth Mousse was only launched in China at the end of 2009. At present, most of the products available in China � t into the repair category of the MI concept and products like GC Fuji IX GP are popular in government dental clinics. It is di� cult to embrace the complete MI concept in the majority of government clinics at this stage but private dentists have already realized the MI concept of diagnosis, prevention and repair is the future.

In the large cities like Beijing and Shanghai, it is possible to run a successful dental practice based on MI principles. However, more information and educa-tion about MI is the key to boost the concept in these cities.

GC Fuji IX GP is the bestselling MI product in China and complies with the ‘easier, faster and better’ concept of Dr Gordon Christensen and other leading clinicians around the world. Economic reasons dictate that only the hand-mix version of Fuji IX GP is popular here. This special high strength glass ionomer has changed the way dentists work throughout China. It is also important to understand that China is a developing country and the ART technique is very important in remote areas. GC is working together with local KOLs and govern-ment departments to boost the availability of ART there. Fuji IX GP is the key to the success in these areas and overall sales have doubled over the past 2 years.

MI dentistry is the future. It is not only a GC story but the future for the dental profession everywhere in the world. It is not something that costs extra money but can help dentists earn more. MI will eventually reduce costs for patients if they are also educated in proper oral care and embrace the principles as there will be less invasive treatment necessary. One of the exciting long term projects will be to work with policymakers to train dental professionals to identify and heal early lesions rather than watch and wait for them to progress to cavitation. MI will mean that dentists and nurses will be busier than ever but with many new and di� erent roles in the practice.

Chin

a

but after several years, we can say that the programme is a big success in tooth preservation. To create a form of restorative dentistry that can prevent the intervention of the periodontist, the prosthodontist or implantologist for as long as possible is the main goal for me and my sta� .

The adoption of the MID, once understood, is very simple. However, we cannot hide that the � rst and biggest challenge is the identi� cation of clear guidelines for the correct application of MID into the clinical reality of each dentist. Still too many dentists observe the magni� cent results of some colleagues who publish books and magazines on MID, but still wonder how they can integrate it into their own situations. Some are even afraid to make the patients pay for preventive diagnostic procedures, and therefore they prefer not to perform diagnosis and tests, intervening when there is already an established disease or, even worse, when the disease can be only treated

conservatively with the ‘drill, � ll and bill’ option. Sometimes dentists are not helped by di� erent

situations in European countries: for example, in some countries there is no profession of the dental hygienist, a role in other countries which is championing the MID drive. The MID principles are certainly not so easy to introduce immediately into clinical daily practice, be-cause it requires dentists to evaluate their own resources (sta� , hygienist, number of dental chairs, availability of patients) and sometimes to signi� cantly change their habits of diagnosis and treatments.

Minimum intervention dentistry is a � eld that is in continuous expansion. Its potential results, in terms of successful treatment with aesthetic success and conser-vation of the masticatory function, are huge compared to its di� usion, which is unfortunately still small within the national territory.

6 mi.gceurope.comq&a

Q&AThe question below was sent to Dr Graham Mount in response to his article in MID 2

Answer – Dr Graham Mount Dear Jack Stellpflug,The material CCP-ACP, developed in Melbourne, came from a desire to be able to remineralise a demineralised enamel or dentine lesion in depth. As you are aware the application of fluoride in one form or another will tend to remineralise the surface first and will tend to prevent the further penetration of ions in to the depths of the lesion. This may well minimize the further demineralisation of the area but it will not overcome the level of porosity of the tooth structure in depth. In other words a ‘white spot lesion’ may well remain visible to the naked eye even though the lesion is sealed from further loss of ions in the short term.

On the other hand the CPP-ACP will penetrate to the full depth of the demineralisation and will successfully deposit both calcium and phosphate ions to the full depth of the lesion thus overcoming the ‘white spot’ entirely. Add the fluoride ion to it and the resistance to further demineralisation will be further enhanced – that is, use Tooth Mousse Plus.

This means that the preferred timing and method of application will be to apply when the disease is first diagnosed and before any other fluoride therapy has been introduced. The most effective way is to make a personal plastic ‘pull-down’ specifically for the patient. Apply daily, carry out normal hygiene then apply pull-down loaded with CPP-ACP paste and leave in place for say 15 minutes on each occasion. Treatment may need to last for 2 weeks or thereabouts, longer if desired.

As part of an overall anti-caries discipline for the high risk patient or one with cervical sensitivity it can also be applied with the finger after cleaning any time and leave it on the teeth for as long as you like. It will wash away quite quickly of course but in the meantime will have transferred a reasonable dose of ions to the dentine beneath assisting in closing over the tubules.

Yours sincerely, Graham Mount

Melbourne, Australia

Name: Jack StellpflugCountry: USAQuestion: Can Dr Mount comment on the most effective way he has found to apply CCP-ACP?

MID resourcesThis is a collection of online resources on MID for dental professionals and patients

OnlineProfessor Brian Nový articlesProfessor Nový is featured in the USA version of the MID ezine, compiled by GC America – click here to read the issue

He is a renowned MID advocate and here is a list of some of his most recent publications:

The Material Science of Minimally Invasive Restorations. Compendium of Continuing Education in Dentistry, July 2008.

Salivary Diagnostics: Practical Applications. AGD Impact. September 2009.

Glass ionomers: Invaluable materials in today’s dental operatory. National Network for Oral Health Access Quarterly Newsletter. Winter 2009: 2(1).

Profi le in Oral Health: Treating the Caries Disease, an interview with Dr. Brian B. Nový. Dental Town Magazine. April 2009 10(4): 90-94.

Dental Caries: A pH mediated disease. Journal of the California Dental Hygienist’s Association, Winter 2010: 25(1).

Dental VillageDentalvillage is an online resource developed my two dental hygienists, Dave Bridges and Tim Ives who are passionate about raising the profi le of MID among the public and healthcare professions. The site has up to date information on this fresh approach to preventing dental decay and periodontal (gum) diseases.

Excerpt: The focus is on maximum conservation of demineralised, non-cavitated enamel and dentine. Once control of the infection is achieved, the patient’s caries risk status and evidence of lesion demineralisation can be monitored over extended periods. These principles can also be applied to the treatment and management of periodontal disease. Minimally Invasive Periodontal Management relies heavily on patient involvement, ownership and management of their own disease. The patient reduces their own infl ammation under guidance of the clinician and operative treatment is kept as minimal as possible.

Click here: dentalvillage.co.uk

Dental Caries Classi� cation GridAn online resource run by Graham Mount, Wyatt Rory Hume and Brian Monteith has an interactive dental caries classifi cation grid based on MID principles that introduces an alternative to the GV Black classifi cation system.

Excerpt: A revised understanding of the caries lesion

In recent times the term “Minimal Intervention Dentistry” has been coined to describe a new approach to the treatment of early carious lesions. It is now clearly acknowledged that caries is a bacterial disease and treatment should therefore revolve primarily around overcoming the infection.

Click here: http://www.midentistry.org/grid.html

California Dental Association Journal Back IssuesThe California Dental Association has made the back issues of its journal available for download online through its website.

Excerpt: The Journal of the California Dental Association is an award-winning monthly peer-reviewed scientifi c publication keeps dentists up-to-date about scientifi c advances, business management strategies and new products. It also features thought-provoking editorials, comprehensive statewide continuing education listings, California practices for sale, and dentistry’s favourite humour columnist - Dr Bob, Robert E. Horseman, DDS.

Click here: http://www.cda.org/publications/journal_of_the_california_dental_association

MID patient factsheetAcademy of General Dentistry has compiled a useful document that explains the principles of MID to patients

Click here: http://www.midentistry.com/AGD-MI.pdf

Social mediaHere is an overview of MID related resources that you can follow through social media

Facebook MI Paste (Tooth Mousse) fanpageClick here: http://www.facebook.com/#!/mi.paste?ref=ts

TwitterMI Paste (Tooth Mousse)Click here: http://twitter.com/mipaste

CarifreeClick here: http://twitter.com/CariFree

7resources

8 mi.gceurope.compractice perspectives

Hands on, drills off

MID: What goes into achieving the title of Preventive Practice of the Year? Dr Kirk Young: According to the judges of this award, our dedication to improving patient care, passion and enthusiasm for MID in our practice is evident. In our practice we also have a physiotherapy and sports injury clinic and this all contributes to us being an overall preventive practice. An essential part of our success is excellent teamwork: from the reception staff, the nurses to the hygienists and dentists.

The MI systems, materials and techniques that we have put in place at the practice have taken us many years to implement fully and we have spent a great deal of time and consideration on each. It certainly didn’t happen overnight!

Years ago I was looking for a mentor in dentistry to inspire me. I met Hien Ngo at a conference and heard him speak quite a few times and his ideas influenced me tremendously. I always preferred doing prevention rather than extractions anyway.

Another move in the right direction came when we stopped being an NHS practice four years ago. When the new NHS contract was announced I realised that the prevention component was not included. I felt we couldn’t give patients adequate care in prevention on the NHS so we became a private practice.

We told the patients what was happening and why we were changing and they had already become used to our way of

performing preventive dentistry. We always try to keep the patients involved – our website has many resources on MID and prevention for them.

Winning the award has been a great recognition for the whole team and confirmed to us that what we are doing with MID and prevention is the way forward.

MID: What techniques and strategies have you found to work best for doing preventive dentistry?Dr Kirk Young: Keeping patients informed is crucial. We have to show them what we have to offer and we do this through our newsletter, which every patient receives at a recall appointment. In it we publish content about the benefits of MID and prevention, and we highlight the equipment that helps us to practice preventively, such as Cariescan, The Wand, Healozone and Velopex.

Using an intraoral camera is another excellent way get the patient involved in the problem. You don’t just tell them they have a disease, but you also show them where it is, how it looks and what it is doing. One of the cornerstones of MID is that it’s not a one way partnership between the patient and dentist. You need increased patient involvement to make this work.

Education the team is another important facet and we have spent a great deal of time training together with the whole team. When the team members fully understand the

Dr Kirk Young is the practice principal and owner of Young’s Dental Practice, which was awarded the 2009 Preventive Practice of the Year award. MID recently spoke to him about his practice and what motivates him to pursue MID.

“I always preferred doing prevention rather than extractions anyway”

9practice perspectives

benefits of MID they can explain it better to the patients and communicate the benefits more effectively to them.

We also make use of questionnaires and work through these with the patients, in order to assess their caries risk. Our staff members are fully trained to undertake this because we find that sometimes the patients feel more comfortable to share this kind of information with the staff members. Everyone is focused on the practice having healthy and happy patients.

MID: To what extent do you conduct practice based research in MID topics?Dr Kirk Young: Everything is recorded in our practice. Every patient fills out a comprehensive MID questionnaire, which is evaluated at every recall to see what treatment has worked or to monitor the progress. Our practice management software allows us to record all this data so we can chart the patient’s progress at each recall. At every appointment we measure the caries risk using the ‘traffic light system’ which is determined by using the intra-oral camera and questionnaires. All the oral hygiene and dietary advice given to each patient is also recorded to we can track their behaviour.

Last year my practice data was used by Dr Avijit Banerjee at a conference presentation. I think it’s important to not only practice MID but to record and capture how we are treating patients so we can build the evidence base.

MID: What advice would you give dentists who are considering moving over to an MID-centered practice model?Dr Kirk Young: •Investinteambuildingandtraining.•Teachpatientstoself-preventtoothdecay

proactively, rather than treating it reactively•Buildyourpracticesystemsupgradually•Gototalks,attendcourseswithyourteam,

join study groups; try to get as much information about MID as you can.

•Investindentalcariesdetectionsystemssuch as Diagnodent, Cariescan, SapproLife and use them every day

•Makeuseofremineralisationproducts–theyhave a huge body of evidence behind them that support their efficacy

•Keepontopofnewdevelopments:Airabrasion is another emerging aspect to MID - new research shows that bioactiveglass material can cut through enamel very quickly and can kickstart the reminerlisation process in the teeth

I am still surprised to see how few dentists have intraoral cameras in their practices. In some countries this is second nature. I hope to see this change in the UK. MID is the buzzword in dentistry at the moment, it is no longer a marginal activity, everyone is talking about it. It is the way forward for dentistry

For more information about the practice visit www.youngsdentalpractice.co.uk

A day in the life at Young’s Dental PracticeSally Wright, practice manager

I enjoy most being part of a team who are all working towards the same goal - for all clients to be dentally fit etc. I also enjoy organising Kirk’s lectures and taking part in them and co-ordinating with the dental companies supporting MID. I probably gain most enjoyment from patient interaction especially when involving them in their care which includes oral health, diet and grinding advice.

My specific roles include educating patients by oral hygiene instruction and diet advice, grinding appliance demonstration and advice. I also give patients information on the techniques

and equipment we use such as air abrasion for MID. I am responsible for doing MID marketing by creating leaflets, websiteupdatesandbrochures.IhelpwithMIDlecturesanddiscussionswithGDPs/VDPsandIadvisepatientsondifferent most up to date products to assist them at home in prevention.

I think we have been so successful as a team because we are all big believers in MID. We also spend a large amount of time with our patients implementing MID and great part of it is education. We also use intra-oral cameras routinely for examinations and patients are offered separate time with a DCP for any advice.

10 mi.gceurope.comclinical corner

MIH: the evidence and treatment protocols By Dr Felicity Crombie and Dr David Manton

While developmental defects have long been identified in human enamel, recently a new condition has been described: molar incisor hypomineralisation (MIH). First suggested as a distinct diagnosis by Weerheijm et al in 2001 it is defined as demarcated, qualitative defects of enamel (hypomineralisation) of systemic origin of one to four permanent first molars, frequently associated with affected incisors1. Given the propensity of affected molars to break down rapidly and/or develop caries there is some debate as to whether this condition constitutes a new entity or has simply become more apparent as caries rates decrease and accurate diagnosis improves, both in regards to differentiating between true hypoplasia and post-eruptive breakdown (PEB) and recognition of abnormal caries patterns/presentation. The distribution of the condition is often asymmetric, with marked variation in severity common within an individual. The likelihood that incisors are affected has been reported to increase as the number and severity of molar lesions increases2.Affected teeth present patients and clinicians alike with many challenges with aesthetic issues, hypersensitivity, difficulty achieving adequate local analgesia and difficulty providing adequate and enduring restorations all reported in association with MIH1,3. Children with teeth affected by MIH undergo up to ten times the treatment of unaffected children by the age of 8 years and have significantly higher

levels of dental anxiety and phobia4,5. These

factors combined with the

fact that extraction is often the most appropriate definitive treatment option means general anaesthetic management, with its attendant increase in risk and cost, is often required 6-8.

PrevalencePrevalence studies are increasingly investigating MIH specifically and using newly developed indices tailored for this purpose 9,10; however the majority of published studies have used either non-standard indices or the Developmental Defects of Enamel (DDE) Index. Caution must therefore be applied when interpreting prevalence data as the DDE Index has the potential to both over- and under- estimate the true prevalence of MIH since: MIH is not the only cause of demarcated enamel defects; caries, PEB, restoration and extraction are not accounted for by the DDE Index and PEB may be classified incorrectly as hypoplasia. A recent review of MIH prevalence data found that the prevalence varied widely with values from 2.4% to 40.2% reported11. The majority of studies were performed using European populations and ranged from 2.4% in Germany and Bulgaria to 37.5% in Denmark. Worldwide a low prevalence has been reported in Hong Kong (2.8%) and Libya (2.9%) increasing to 13.7% in Kenya, 22% in Australia and up to 40.2% in Brazil. The lack of standardized examination protocols as well as the aforementioned index limitations must be considered when comparing these results. Although difficult to establish given the lack of reliable, comparable prevalence data worryingly many clinicians feel the prevalence of MIH is increasing3, 12.

Aetiological factorsThe limitations of experimental design and study comparability identified for prevalence data also apply to a review of MIH aetiology. Bearing this in

mind a critical literature review found: very little evidence to support a relationship between

breast-feeding or fluoride exposure and demarcated enamel defects; moderate

evidence that exposure to PCB/dioxins may be associated with an increased prevalence of these lesions; maternal factors, birth

complications, nutritional status, childhood illness and medical conditions appear to

exert some influence on the prevalence of enamel defects generally, but the type of defect and the specific aetiological factors

are not yet clear13. It is also likely that, in addition to the environmental exposures so far identified, genetic susceptibility may

11treatment plan

the disease itself, the associated fever, the treatment administered or a combination which is responsible14.

Tooth propertiesAs with the clinical presentation of MIH, lesions studied in vitro are often highly variable, however some significant findings for enamel affected by MIH include: increased porosity; decreased hardness; decreased mineral content; increased carbonate content; increased protein content and abnormal ultrastructure, etching patterns and bonding properties. Discrete areas of >25% porosity have been observed, though the bulk of lesions are less than 10%. Both microhardness and nanohardness is significantly reduced (up to a 70% reduction) as is mineral content (> 45% decrease) compared to normal enamel15-17. For both hardness and mineral content the gradient is abnormal with harder and more mineralised enamel found toward the dentino-enamel junction16,17. For each of these properties the most severe areas are almost always in the outer half of enamel and a surface layer of reduced porosity and increased hardness and mineral content is observed, even in areas with PEB, while cervical regions appear unaffected. Higher carbon levels have been reported using secondary ion mass spectrometry which can reflect either a higher proportion of carbonated apatite or increased organic component18: in fact it appears to be a combination, with MIH lesions containing 3-15 times the protein (primarily exogenous) and 1.6 times the carbonate content of normal enamel14,19.The ultrastructure of the enamel, observed under scanning electron microscopy (SEM) is also affected with increased disorganisation, abnormal prism core and inter-prismatic appearance and abnormal etching patterns reported20,21. The enamel-adhesive interface is markedly different and associated with reduced bond strengths to resin composite, however in the majority of cases failure was cohesive within the enamel22. Bacterial invasion of dentine tubules, and associated inflammatory change (secondary

dentine formation), under apparently intact hypomineralised enamel has also been demonstrated using SEM techniques23. Other investigations of the pulp status of MIH affected teeth have reported increased expression of an inflammatory mediator implicated in pain development, an increase in immune cells and increased innervation and vascularisation, providing a reason for the increased sensitivity and refractory nature with anaesthesia of these teeth24,25.

ManagementUnfortunately it is, as yet, impossible to use evidence based dentistry in the treatment of MIH as, while recommendations are supported theoretically by research evidence, only very limited clinical data is available. Generally it is advised clinicians utilize the apparently sound cervical enamel for bonding of ‘permanent’ restorations as marginal breakdown is otherwise commonly observed, however this strategy does involve the sacrifice of a great amount of enamel26-28. Glass ionomer cements are often recommended, especially for early protection of the enamel, but currently there is no evidence beyond anecdotal for using this material either in vitro or in vivo26, 27. Despite this a recent European Academy of Paediatric Dentistry policy document for MIH management included GIC restorations in its recommendations29. Also suggested was the use of preformed crowns which have been found to perform well and do not

“Children with teeth affected by MIH undergo up to ten times the treatment of unaffected children

by the age of 8 years and have significantly higher levels of dental

anxiety and phobia”

1: Hypomineralised tooth demonstrating both severe (post-eruptive breakdown on distal cusps) and mild (white demarcated opacity on mesio-buccal cusp tip) lesions. 2: Polished hypomineralised lesion demonstrating demarcated defect edge. 3: Polarised light image (water imbibition) demonstrating surface layer of improved physical properties in area of post-eruptive breakdown (blue layer). 4: Clinical images of hypomineralised teeth demonstrating demarcated opacities, post-eruptive breakdown and cavitation even before complete eruption.

12 mi.gceurope.comclinical corner

vitro or in vivo26, 27. Despite this a recent European Academy of Paediatric Dentistry policy document for MIH management included GIC restorations in its recommendations29. Also suggested was the use of preformed crowns which have been found to perform well and do not need extensive tooth preparation thus conserving maximum tooth structure, and therefore options, for future treatments as these restorations cannot really be considered a permanent solution29,30. Given the eventual outcome the restoration cycle, the rapidity with which MIH teeth can pass through this cycle and the costs associated with treatment (potentially endodontic treatment, fixed prosthodontics and eventual replacement with an implant at a relatively young age as other options are exhausted) it is recommended that extraction, ideally with consultation and co-ordination with orthodontic advice, be considered for severely affected teeth. Acceptable outcomes, even without (but preferably with) orthodontic intervention, can be achieved and cases should be assessed as to whether this option is more appropriate if extensive treatment seems otherwise inevitable 6,7,29. It is commonly requested that extractions be delayed until the most orthodontically favourable time in which case interim restorations or preventive strategies may be needed in the interim. Preventive advice is based on the early caries/remineralisation model utilizing CPP-ACP, fluoride products and fissure sealants, however again the efficacy of such treatments is anecdotal only29.

1. Weerheijm, K.L., B. Jalevik, and S. Alaluusua, Molar-incisor hypomineralisation. Caries Research, 2001. 35(5): p. 390-1.

2. Weerheijm, K.L., et al., Prevalence of cheese molars in eleven-year-old Dutch children. Journal of Dentistry for Children, 2001. 68(4): p. 259-62.

3. Crombie, F.A., et al., Molar incisor hypomineralization: a sur-vey of members of the Australian and New Zealand Society of Paediatric Dentistry. Aust Dent J, 2008. 53(2): p. 160-6.

4. Leppaniemi, A., P.L. Lukinmaa, and S. Alaluusua, Nonfluo-ride hypomineralizations in the permanent first molars and their impact on the treatment need. Caries Research, 2001. 35(1): p. 36-40.

5. Jalevik, B. and G.A. Klingberg, Dental treatment, dental fear and behaviour management problems in children with severe enamel hypomineralization of their permanent first molars. International Journal of Paediatric Dentistry, 2002. 12(1): p. 24-32.

6. Williams, J.K. and A.J. Gowans, Hypomineralised first permanent molars and the orthodontist. European Journal of Paediatric Dentistry, 2003. 4(3): p. 129-32.

7. Mejare, I., E. Bergman, and M. Grindefjord, Hypomineral-ized molars and incisors of unknown origin: treatment out-come at age 18 years. International Journal of Paediatric Dentistry, 2005. 15(1): p. 20-8.

8. Crabb, J.J. and W.P. Rock, Treatment planning in relation to the first permanent molar. British Dental Journal, 1971. 131(9): p. 396-401.

9. Jalevik, B., et al., The prevalence of demarcated opacities in permanent first molars in a group of Swedish children. Acta Odontologica Scandinavica, 2001. 59(5): p. 255-60.

10. Jasulaityte, L., J.S. Veerkamp, and K.L. Weerheijm, Molar incisor hypomineralization: review and prevalence data from the study of primary school children in Kaunas/Lithu-ania. European Archives of Paediatric Dentistry: Official Journal of the European Academy of Paediatric Dentistry, 2007. 8(2): p. 87-94.

11. Jalevik, B., Prevalence and Diagnosis of Molar-Incisor- Hypomineralisation (MIH): A systematic review. Eur Arch Paediatr Dent. 11(2): p. 59-64.

12. Weerheijm, K.L. and I. Mejare, Molar incisor hypominer-alization: a questionnaire inventory of its occurrence in member countries of the European Academy of Paediatric Dentistry (EAPD). International Journal of Paediatric Den-tistry, 2003. 13(6): p. 411-6.

13. Crombie, F., D. Manton, and N. Kilpatrick, Aetiology of molar-incisor hypomineralization: a critical review. Int J Paediatr Dent, 2009. 19(2): p. 73-83.

14. 57th Annual ORCA Congress July 7-10, 2010, Montpellier, France Abstracts. Caries Research. 44(3): p. 172-244.

15. Mahoney, E., et al., Mechanical properties across hypomin-eralized/hypoplastic enamel of first permanent molar teeth. European Journal of Oral Sciences, 2004. 112(6): p. 497-502.

16. Fearne, J., P. Anderson, and G.R. Davis, 3D X-ray microscop-ic study of the extent of variations in enamel density in first permanent molars with idiopathic enamel hypominer-alisation. British Dental Journal, 2004. 196(10): p. 634-8; discussion 625.

17. Anonymous, 56th Congress of the European-Organisa-tion-for-Caries-Research (ORCA), Budapest, HUNGARY, July 01 -04, 2009. Caries Research, 2009. 43(3): p. 179-241.

18. Jalevik, B., et al., Secondary ion mass spectrometry and X-ray microanalysis of hypomineralized enamel in human permanent first molars. Archives of Oral Biology, 2001. 46(3): p. 239-47.

19. Mangum, J.E., et al., Surface integrity governs the proteome of hypomineralised enamel. Journal of Dental Research, Accepted for publication, April 2010.

20. Mahoney, E.K., et al., Mechanical properties and micro-structure of hypomineralised enamel of permanent teeth. Biomaterials, 2004. 25(20): p. 5091-100.

21. Jalevik, B., W. Dietz, and J.G. Noren, Scanning electron micrograph analysis of hypomineralized enamel in

permanent first molars. International Journal of Paediatric Dentistry, 2005. 15(4): p. 233-240.

22. William, V., et al., Microshear bond strength of resin composite to teeth affected by molar hypomineralization using 2 adhesive systems. Pediatric Dentistry, 2006. 28(3): p. 233-41.

23. Fagrell, T.G., et al., Bacterial invasion of dentinal tubules beneath apparently intact but hypomineralized enamel in molar teeth with molar incisor hypomineralization. International Journal of Paediatric Dentistry, 2008. 18(5): p. 333-340.

24. Rodd, H.D., et al., Pulpal status of hypomineralized perma-nent molars. Pediatric Dentistry, 2007. 29(6): p. 514-20.

25. Rodd, H.D., et al., Pulpal expression of TRPV1 in molar inci-sor hypomineralisation. European Archives of Paediatric Dentistry: Official Journal of the European Academy of Paediatric Dentistry, 2007. 8(4): p. 184-8.

26. William, V., L.B. Messer, and M.F. Burrow, Molar incisor hy-pomineralization: review and recommendations for clinical management. Pediatric Dentistry, 2006. 28(3): p. 224-32.

27. Mathu-Muju, K. and J.T. Wright, Diagnosis and treatment of molar incisor hypomineralization. Compendium of Continuing Education in Dentistry, 2006. 27(11): p. 604-10; quiz 611.

28. Lygidakis, N.A., A. Chaliasou, and G. Siounas, Evaluation of composite restorations in hypomineralised permanent molars: a four year clinical study. European Journal of Paediatric Dentistry, 2003. 4(3): p. 143-8.

29. Lygidakis, N.A., et al., Best Clinical Practice Guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH) An EAPD Policy Docu-ment. Eur Arch Paediatr Dent, 2010. 11(2): p. 75-82.

30. Zagdwon, A.M., S.A. Fayle, and M.A. Pollard, A prospective clinical trial comparing preformed metal crowns and cast restorations for defective first permanent molars. European Journal of Paediatric Dentistry, 2003. 4(3): p. 138-42.

References

Affected anterior teeth tend to present aesthetic problems only, rather than the breakdown, sensitivity and increased caries risk found when molars are involved. Management is therefore usually more straightforward and options include: microabrasion, bleaching and sealant and direct or eventually indirect restorations to improve the appearance29.

In conclusion, the apparent increasing prevalence of MIH creates the need for greater practitioner knowledge regarding the diagnosis of the condition and also the treatment options possible.

About the authorsDr Felicity Crombie completed her BDSc with Honours at the University of Melbourne and works in private practice as well as teaching undergraduates. In 2007 Dr Crombie started her PhD studies investigating the properties of molars affected by enamel hypomineralisation and subsequently has published and presented on the

topic of molar hypomineralisation locally and internationally.

David John Manton [BDSc MDSc PhD FRACDS FICD] is the convener of Paediatric Dentistry at the Cooperative Centre for Oral Health Science, Melbourne Dental School, University of Melbourne.

White spot reversal protocolThe following protocols were developed by clinicians in their own dental practices in the USA, and published by GC America.

Steps to white spot reversal• Takephotosofthewhitespotlesionpriortothe

start.• Itisimportantduringmicroabrasionforthe

clinician not to over abrade the tooth surface, careful attention needs to be paid to the etching materials, their concentrations and application time.

• Apply37%phosphoricacidgeltowhitespotlesions, (10/15 sec. To 2 min. – suggested to be conservative), Rinse.

• Gentlypumicefor10-20sec.,(withnonfluoridated,nonglycerinepumice-suggestflourofpumice), Rinse.

• Reviewtheeffectsometimesmayhavetoetchasecond time.

• Somedentistsprefertopumicefirst,thenetch.• ApplythicklayerofMIPastetotheetchedteethfor

5 minutes.• InstructpatienttouseMIPaste2Xdailyfor5

minutes.• Customtrayisoptional.• Havepatientreturnforevaluationin7-10days.• Repeatprocedureifnecessary.

Successful casesClinician: Dr Scott Munro-Racine,WI,USA

Before

After

Treatment protocol followed:09/18/073MinuteEtch,5MinuteMIPasteTreatment09/24/073MinuteEtch,5MinuteMIPasteTreatment10/04/073MinuteEtch,5MinuteMIPasteTreatment10/15/073MinuteEtch,5MinuteMIPasteTreatment-Bleach15%Opalescence

10/18/073MinuteEtch,5MinuteMIPasteTreatment-Bleach15%Opalescence

11/01/073MinuteEtch,5MinuteMIPasteTreatment11/29/073MinuteEtch,5MinuteMIPasteTreatment

Notes• Norestorativeworkwasdoneonpatient• MIPastewasusedandsomelightmicroabrasion

was done on cusp tips. #9 wasn’t bleached internally,butwaswhitenedwithZOOMinoffice.Patientworetraysfor5minutes,twicedaily.

13clinical corner

mi.gceurope.comclinical corner14

Clinician: Dr Stephanie Benton - Grand Rapids, MI, USA

Before

Treatment protocol followed:• Teethwereetchedtwice,for20secondintervals.• Nopumicewasused.• MIPastewasplacedimmediatelyonteethfollowingetchingandworetraysatnighttimeonly.• Immediateresultswereseenoverthefirstweekend.• Patientcontinuedtowearthetraysfor2-3weeksatnighttime.

Clinician: Dr Brett Kessler - Denver, CO, USA

Before

Before close-up

Treatment protocol followed:• Etched#8&9for3minutes• GaveMIPastewithtraysto15minutesbeforebed,

after 3 days• PatientusedMIPasteforthespotsweregone.

• Theafterphotosare2weeksaftertheonetimeetching and daily use.

• Thepatientusedapproximately1/2ofthetubeofMI Paste to achieve these results.

After

After

After close-up

15clinical corner

Clinician: Dr Ivan A. Serdar - San Francisco, CA, USA

Before

After

Treatment protocol followed:12/02/08 - Pumice, rinse, 1 minute etch with 37%

Phosphoric acid, rinse, blot, 5 minutes MI Paste.01/07/09 - Pumice, rinse, 1 minute etch with 37%

Phosphoric acid, rinse, blot, 5 minutes MI Paste.01/26/09 - Pumice, rinse, minute etch with

Phosphoric acid, rinse, blot, minutes Paste.02/25/09 - Pumice, rinse, 1 minute etch with 37%



Phosphoric acid, rinse, blot, 5 minutes MI Paste.

NotesPatient used trays at home for the duration of this treatment and placed MI Paste in her trays for 5 minutes, twice a day. Patient also used regular strength Whitestrips at home for three weeks.

Clinician: Dr Rubin and Dr Pong - Cincinnati, OH, USA

Before

After

Treatment protocol followed:• 2Minuteetchwith37%phosphoricacid(bluegel)• Heavypumice• DispensetubeofMIPasteorMIPastePlus.Patient

apply/rub• MIPastewithfingertoaffectedareasfor10

seconds, daily at bedtime. Re-evaluate in 2 weeks• Repeatsequenceasneededfordesiredresult.• Treatmentwasoverthecourseof1month

9/3/2008-9/29/2008.

16 www.gceurope.comClinical corner

Topical CPP-ACP crème (Tooth Mousse): more evidence that demands a verdictBy Laurence J Walsh

journal papers and presentations at international and regional meetings of the International Association for Dental Research (IADR), the peak international body for dental research, over the period from January 2002 to August 2010.

Bio-availability of calcium and phosphate ionsIn most preventive protocols, TM is applied daily in a pea-size amount using a finger to the labial surfaces of the teeth immediately before bed. By dissolving slowly, the material contributes bio-available calcium and phosphates to the saliva, and is able to promote remineralization at a time when salivary defenses are at their lowest point. TM can be used in patients of all ages as the material is classified as safe to ingest.

The release of ions from TM has been examined in considerable detail. The release of ions at neutral pH was reported by Paterson et al. (2008) who dissolved TM directly into deionized water and then used a calcium ion-selective electrode to measure calcium ion release. The free calcium ion concentration in the solution increased with time in a saturating exponential manner, with approximately 95 % release after only 15 minutes. This rapid release means that when the crème is applied to tooth surfaces there will be a rapid increase in calcium ion concentration in the plaque fluid and saliva. Their supersaturation for calcium with respect to tooth enamel drives remineralization and prevents mineral loss.

Comparative studies with a broad range of toothpastes, gels, liquids claimed to have remineralizing or desensitizing actions (including NovaMin®,ClinPro®ToothCreme,ClinPro5000,andReminPro®)revealthatcalciumcontainedinthese products has low water solubility and poor bio-availability, unlike the situation for TM and TMP. The level of water soluble calcium per gram of crème in TM or TMP (321.8 ± 2.6 µmol/g) is some 14 times or greater than any of these other products (Cai et al. 2009; Yasuda et al. 2010). Tooth Mousse Plus also has been shown to contain the highest amount of water soluble phosphate (245.7 ± 2.7 µmol/g) of any currently available products. The rapid release of calcium ions (within 1 hour) has been confirmed in other studies of TM, including those conducted by commercial competitors (Burwell et al. 2009).

The high water solubility and bioavailability of the calcium, phosphate and fluoride in TM and TMP is due to this being a protein technology (containing casein phosphopeptides), whereas all other marketed

Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) is a unique naturally derived protein-based remineralizing technology which is now used globally in chewing gums and topical crèmes. The unique phosphopeptides are derived from milk caseins, and are complexed with amorphous calcium phosphate, to form stable complexes which are nanoparticles of some 2 nm in diameter with a large surface area for mineral exchange Cross et al. 2006). The configuration of the ACP in the CPP-ACP complex differs completely from that found in macromolecular aggregates of ACP, as has been included in some current prophylaxis pastes and bleaching gels.

CPP-ACP nanocomplexes act as biological calcium phosphate delivery vehicles, and are able to boost levels of bio-available calcium and phosphate in saliva and plaque fluid without causing indiscriminate precipitation of calcium salts. This makes this material particularly effective in the remineralization of early enamel lesions, and in the treatment of other types of enamel opacities. The efficacy of these nanocomplexes as anti-cariogenic agents has been demonstrated in numerous animal and in situ human caries studies (Reynolds 1997, 1998, 2008, 2009; Cross et al. 2007), as well as in clinical trials. Over the past decade, the use of products containing CPP-ACP nanocomplexes has become a well established part of clinical practice across the globe. The clinical use of this technology is supported by a large body of refereed papers and conference presentations as well as by systematic reviews, the highest form of evidence in the pyramid of evidence-base practice. For example, a 2006 systematic review focused on chewing gums andlozengesenrichedwithCPP-ACP(Yengopal&Mickenautsch,2006&2009),identifiedover120journal articles on CPP-ACP technology, which included laboratory trials and animal studies as well as clinical trials and numerous in situ clinical studies.

In Australia and in many other parts of the world, the most commonly used CPP-ACP product is the topical crème which contains 10% CPP-ACP. This product, which is known alternatively as Tooth Mousse or MI Paste, is intended for both in-office and at-home use. The purpose of this article is to summarize the global research effort which underpins the current clinical applications of Tooth Mousse (TM) and its related fluoride-containing counterpart, Tooth Mousse Plus (TMP). The article draws on the refereed literature, including both

17clinical corner

products are inorganic in nature and lack the ability to stabilize the calcium and phosphate ions.

Prevention of mineral loss in caries modelsTopical application of TM immediately before a cariogenic challenge has been shown to prevent

demineralization of enamel during subsequent challenge, and also to reduce the pH reduction caused by S. mutans fermentation (Sato et al. 2003). This capacity to buffer acids produced by cariogenic bacteria adds to other ecological effects of TM on dental plaque. TM has benefits in preventing root

Author Year Location Design Outcomes

Enamel caries

Sato 2003 Tokyo Enamel slabs with demin gel TM buffered acids produced (microhardness) by S. mutans TM reduced enamel demin from acidic gel and S. mutans fermentation.

Takamizawa 2005 Tokyo Enamel slabs with demin gel TM preserved the inorganic component (ultrasound) of enamel by preventing demin.

Sakaguchi 2005 Tokyo Enamel slabs with demin gel TM preserved the inorganic component (QLF) of enamel by preventing demin.

Sudjalimi 2006 Melbourne Extracted teeth in demin gel TM reduced mineral loss around (QLF) orthodontic brackets.

Manton 2007 Melbourne Enamel slabs with white TM caused more remin of white spot spot lesions lesions than human saliva.

Lovel 2007 Liverpool Enamel slabs with white TM was more effective than 1000 ppm spot lesions (QLF) F toothpaste in promoting remin of WSL

Kim 2007 South Korea Enamel slabs with WSL TM was more effective than 3000 ppm (microhardness) F solution in preventing demin.

Kumar 2008 Hong Kong Enamel slabs with WSL TM remineralized WSL and showed a higher remineralizing potential when applied after the use of a fluoride toothpaste.

Adebayo 2008 Melbourne Enamel slabs TM treatment of intact enamel improves resistance to phosphoric acid etching

Kao 2008 West Virginia Enamel slabs TM treatment increases acid resistance of enamel when exposed to a demin gel.

Setien 2008 Dallas Enamel slabs with WSL TM treatment increased the (microhardness) microhardness of demineralized enamel.

Theerapiboon 2008 Bangkok Enamel slabs with WSL (PLM) TM treatment reduced lesion volume and caused remin in WSL in both permanent and deciduous enamel.

Huang 2008 Minneapolis Enamel slabs eroded TM treatment improved enamel withCoke® hardnessmorethanartificialsaliva.

Kallayahi 2008 Bangkok Enamel slabs TM treatment protected enamel from (microhardness) softening from cola drink exposure.

Behnan 2009 Ann Arbor Enamel slabs TM prevented enamel demineralization (QLF) around orthodontic brackets during an in-vitro acid challenge.

Elsayad 2009 Cairo Molar teeth with demin TM caused remin, which was enhanced when F was added simultaneously.

Chapman 2010 Bristol Enamel slabs (profilometry) TMP and TMP reduced enamel surface loss from citric acid challenge.

Table 1. Prevention and treatment of enamel caries using Tooth Mousse in laboratory models

F = fluoride, QLF = Quantitative light fluorescence; PLM = polarizing light microscopy, WSL = white spot lesions.


surface caries as well as enamel caries (Tables 1-3). NumerouslaboratorystudieshavedocumentedthatTM is more effective than saliva for remineralization after caries- and erosion-like assaults to the enamel (Table 1). This holds true regardless of the methods which are used to assess the integrity of the enamel. Preventive benefits of TM and TMP are now recognized to extend to root surfaces as well as enamel (Table 2), and evidence of arrest and reversal of root surface caries has also been presented (Vlacic et al. 2007).

As well as effects mediated through promoting remineralization and inhibiting demineralization, it is now recognized that TM can exert ecological effects on the dental plaque biofilm. A recent large scale clinical trial reported that daily use of TM in infants from the time of first tooth eruption had similar effects on plaque acid production as daily use of 0.12% chlorhexidine gel (Plonka et al. 2010).

Visible reversal of white spot carious lesionsEarly case reports of visible reversal of enamel white spot lesions (WSL) in young adult patients in Australia

(Walsh 2004; Walsh 2007) and later in Japan (from 2002) (Reynolds&Walsh,2005),Europe(Arduetal.2007)andNorthAmerica(Milnar,2007)havebeenfollowedbyinsitu studies of laboratory-created WSL (Manton et al. 2007) and full scale randomized controlled clinical trials in patients with naturally occurring WSL (Andersson et al. 2006; Kitasako et al. 2009; Bailey et al. 2009; Zhou et al. 2009; Yazicioglu et al. 2010). Cases of reversal of moderate fluorosis have also been presented (Walsh 2003;Walsh2004;Reynolds&Walsh2005;Walsh2007;Ng&Manton2007).

Recent reviews have concluded that predictable remineralization of enamel white spot lesions (WSL) can be achieved clinically by using frequent applications of TM as a self-administered topical therapy (Ilena et al. 2009; Reynolds 2009). This significant body of work (summarized in Table 3) demonstrates that dramatic cosmetic changes occur in enamel as WSL undergo reversal during treatment with TM on a daily basis. A particular risk group where TM is useful for gaining regression of white spot lesions is patients who are undergoing orthodontic treatment (Table 4).


Root caries

Hicks 2005 Houston Root segments with demin gel TM enhanced the resistance of root (PLM) surfaces to artificial caries formation, when compared with fluoride rinse (0.05%NaF).

Rahiotis 2007 Athens Dentine slabs with demin gel TM treatment reduced demin and enhanced remin of dentine.

Xie 2007 Chicago Root segments with demin gel TM treatment increased the hardness (microhardness) of dentine.

Trajtenberg 2007 Houston Root segments with demin gel TM treatment improved caries (PLM) resistance of root surfaces.

Garcia-Godoyi 2009 Fort Lauderdale Root segments with demin gel TM and TMP protected root surfaces (PLM) from an artificial caries challenge.

Other applications

Wong 2010 Melbourne Teeth undergoing bleaching A 2 week application of TM prior to the use of an in-office bleaching gel did not adversely affect the bleaching effectiveness, but reduced the levels of hydrogen peroxide entering the pulp chamber.

Augustson 2010 Minneapolis Enamel eroded with HCl After HCL erosion, 60 minutes exposure (microhardness) to TMP or TM (but not 3000 ppm F rinse) increased the enamel hardness. Greater recovery seen with TMP than with TM.

Gomes 2010 San Paulo De-proteinated enamel TM applied after in-office bleaching helped to restore the glossy nature of the enamel surface.

Table 2. Other Laboratory Studies of Tooth Mousse

19clinical corner

While it is now well established that TM can cause reversal of WSL, it is remarkable that there are as yet no clinical trials or case reports in the literature showing visual reversal of enamel WSL for other agentssuchasNovaMinorClinProToothCrèmewhich claim to have remineralizing actions.

TMP is a potent agent for promoting regression and reversal of WSL. Mixtures of CPP-ACP with fluoride (TMP) and CPP-ACFP solutions have been shown to remineralize enamel subsurface lesions in vitro by depositing fluorapatite. This remineralization is accompanied by improved translucency and reduced opacity of the white spot lesions, as reversal occurs and mineral content increases (Cochrane et al. 2006).

Treatment of cervical dentinal hypersensitivity (CDH)There is a significant literature regarding the strong interactions which occur between TM and dentine (Adebayoetal.2008A&B,2009,2010).Oneofthefirstclinical trials using TM to treat CDH was undertaken in Belgium in 2004. The study involved 11 private practitioners, whose patients with CDH were instructed to apply TM for 21 days, immediately after the evening brushing, leaving the material for 3 minutes, and spreading it across the mouth, and then leaving it in place during sleep. The patient cohort reported a reduction in sensitivity, particularly to stimulation with air as opposed to tactile stimuli. Daily diaries which recorded symptoms of CDH showed a progressive


Chewing Gums

Cai 2003 Melbourne RCT,insitumodel,N=10, IncorporationofCPP-ACPintoalozenge over 14 days increased enamel subsurface lesion remineralization relative to a control sugar-free lozenge.

Manton 2005 Melbourne RCT,insitumodel,N=10, CPP-ACPgumproduced75-107%more over 14 days remineralization than sugar-free gums.

Cai 2006 Melbourne RCT,insitumodel,N=10, CPP-ACPgumproducedmore over 14 days remineralization than chewing with placebo gum. Extended acid challenge of the remineralized lesions showed that the mineral formed was more acid resistant.

Iijima 2006 Nagasaki RCT,insitumodel,N=20, CPP-ACPgumproducedreminof over 14 days subsurface enamel with mineral of higher crystallinity and greater acid resistance than when remin occurs with saliva.

Morgan 2008B Melbourne RCT,N=2720children, CPP-ACPsugar-freegumslowed over 2 years progression and enhanced regression of approximal caries relative to a control sugar-free gum.

Toothpaste

Reynolds 2006 Melbourne RCT,insitumodel,N=10, Toothpastewith2%CPP-ACPproduced over 14 days remin similar to 2800 ppm F toothpaste.

Rao 2009 Manipal RCT,N=150children, Toothpastewith2%CPPcauseda over 2 years significant reduction in caries increment versus placebo, and was equally as effective as a toothpaste containing 1190 ppm F.

Mouthrinse

Shen 2006 Melbourne RCT,insitumodel,N=10, Mouthrinsecontaining0.5%CPP-ACP over 10 days at pH 5.5 produced greater remin of enamel subsurface lesions than the same rinse at pH of 7.0.

Table 3. Selected clinical studies of CPP-ACP products

RCT = randomized controlled clinical trial.


reduction from the first day of treatment over the following 3 weeks. Half of the treated patients reported that the general reduction in CDH symptoms was sufficiently great that they wished to repeat the treatment if symptoms of sensitivity recurred (Poitevin et al. 2004). A later series of randomized controlled clinical trials conducted in Brisbane showed that TM reduced sensitivity to air, osmotic, thermal and tactile stimuli, with equal effectiveness to potassium nitrate toothpaste (Walsh et al. 2006; Vlacic 2007, Walsh 2010). This finding has been confirmed by more recent studies (Duan et al. 2009). This aligns with studies which show that a single application of TM can coat and partially occlude dentine tubules, and resist thermocycling (Hiller et al. 2008), but is insufficient to give permanent resolution of sensitivity symptoms (Table 5).

Tooth Mousse Plus CPP is able to stabilize amorphous calcium fluoride phosphate (CPP-ACFP), which allows additive effects on remineralization compared with the fluoride or

CPP-ACP alone (Cochrane et al. 2006; Sakaguchi et al. 2006). Moreover, CPP-ACP promotes the incorporation of fluoride into plaque and sub-surface enamel, producing effects superior to those which can be achieved using fluoride alone (Reynolds et al. 2006) (Table 5). Early studies showed that addition of 900 ppm fluoride to TM increased the acid resistance of the product formed when enamel lesions were remineralized, compared with using TM alone (Kariya et al. 2004). This level of fluoride was designed to provide the correct ionic ratio of components for remineralization. The inclusion of fluoride in TM to create TMP has been shown to enhance the resistance of enamel surfaces to in vitro caries formation, compared with TM or fluoride alone (Hicks 2006). A range of studies support the greater potential of TMP as a treatment agent over and above TM (Table 6).

Direct comparisons of TMP with TM show the superior remineralizing capabilities of Tooth Mousse Plus, however, because of its fluoride content (900


Reversal of white spot lesions

Manton 2006 Melbourne RCT,insitumodel,N=6, TMproduced551%morereminof over 10 days enamel WSL than the placebo crème.

Sakaguchi 2006 Tokyo Insitustudy,N=5subjects, TMgavegreaterreminthan950ppm 7 days fluoride toothpaste, and even greater remin occurred with TMP, indicating synergy of fluoride with CPP-ACP.

Vlacic 2007 Brisbane RCT,N=16,over12months TMinpatientswithsalivarydysfunction arrested cervical lesions, and improved the stimulated salivary flow rate and pH over time.

Andresson 2007 Halmstad Cohortstudy,N=26, TMcausedareductioninpost- over 12 months orthodontic WSL over time, and was better than F mouthwash combined with F toothpaste.

Morgan 2008A Melbourne RCT,N=45subjects,12weeks TMproducedmoreregressionofWSL remaining after orthodontics than the placebo control at 12 weeks.

Kitasako 2009 Tokyo Cohortstudy,N=7subjects, TMproducedremineralizationofWSL 6 months over 6 months, and increased the surface pH of the lesions (using a micro sensor).

Zhou 2009 Changchun Cohortstudy,N=10subjects, TMPreducedvisibleenamel 2 months demineralization and improved the appearance of long-standing post- orthodontic WSL.

Reynolds 2010 Melbourne RCT,insitumodel,N=6, TMandTMP(butnotClinPro)increased over 10 days salivary calcium and phosphate levels, and caused remin of enamel WSL.

Yazicioglu 2010 Istanbul Cohortstudy,N=26, TMPcausedremineralizationofWSLon over 28 days both smooth and occlusal surfaces.

Table 4. Clinical trials showing reversal of WSL by Tooth Mousse

21clinical corner

ppm), TMP is not suitable for use in children aged less than 7 years, because of concerns regarding ingestion of fluoride.

CPP-ACP inclusion in chewing gumsThe inclusion of CPP-ACP in chewing gums (such as Recaldent ™) is a well established caries preventive measure (Table 3). Early studies of this approach used in situ studies (Cai et al. 2003) and then progressed to randomized, double blind cross-over designs to compare CPP-ACP containing gums with several commercial sugar-free gums. Subjects in these studies chewed the various gums for a 20 minute period 4 times per day for 14 days. By using paired

enamel half slabs, precise determinations of mineral levels could be made. These studies showed that CPP-ACP gum produced 75-107% more remineralization than sugar-free gums (Manton 2005). It is well known that xylitol-based gums reduces the caries increment, but have little or no effect on approximal caries (Antonio et al. 2009). In contrast, gums containing CPP-ACP are highly effective at remineralizing WSL, and have been shown to arrest and reverse approximal lesions in a large scale clinical trial (Morganetal.2008A&B).

Recaldent gum is ideally suited to both child and adult patients where a lifestyle activity is linked to sub-clinical dehydration, and the patient suffers the


Cervical dentinal hypersenitivity

Poitevin 2004 Leuvin Cohortstudy,N=61subjects, TMreducedsensitivityairandtactile over 21 days stimuli.

Kowalczyk 2006 Poland Cohortstudy,N=13subjects, AsingleapplicationofTMgave over 4 weeks immediate benefit on response to air stimulation. There was no further treatment so relapse occurred.

Walsh 2006 Brisbane RCT,N=36subjects, TMreducedsensitivitytoair,osmotic, over 56 days, versus thermal and tactile stimuli, with equal potassium nitrate toothpaste effectiveness to potassium nitrate toothpaste.

Vlacic 2007 Brisbane RCT,N=12,over12months TMcausedaprogressivereductionin sensitivity to air stimulation, and also improved stimulated salivary flow and pH.

Duan 2009 Wuhan RCT,N=30subjects,14days TMreducedsensitivitywithequal effectiveness to potassium nitrate gel.

Other applications

Aytepe 2008 Istanbul Cohortstudy,N=15children, TMelevatedsalivabufferingcapacity 56 days and plaque pH over 8 weeks in children with cerebral palsy.

Caruana 2009 London RCT,N=15subjects TMappliedimmediatelybeforeasucrose challenge reduced plaque acid production.

Rahiotis 2009 Athens Cohortstudy,N=6subjects, AsingleapplicationofTMformsa 8 hours. surface coating which attaches to metal surfaces, making these smoother. These surface films retain calcium phosphates.

Amornpipithkul 2009 Bangkok Cohortstudy,N=21children, DailyapplicationofTMincreasedplaque 14 days calcium and inorganic phosphate levels in a time-dependent manner.

Baroni 2010 Bologna Cohortstudy,n=30children, TMimprovedthemorphologyand 3 years microstructure of the enamel in teeth affected by molar incisor hypoplasia.

Plonka 2010 Brisbane RCT,N=345infants,2years TMsuppressedtheemergenceofS. mutans in the oral microflora, and lowered dental plaque acid production.

Table 5. Selected clinical studies of Tooth Mousse


problems from depressed salivary pH and flow under resting conditions. Because gum can be incorporated into a range of outdoor and exerting activities, the introduction of Recaldent gum should be considered for patients who undertake strenuous activity, for example, through outdoor exercise, outdoor work, or

gym training sessions. The timing is important since the stimulation of salivary flow achieved by the gum will occur at a time when otherwise resting flow and pH would be depressed. Recaldent gum provides an excellent preventive effect, and is easily incorporated into a busy modern lifestyle.


Kariya 2004 Tokyo In vitro, enamel slabs with TMP reduced enamel mineral loss demin gel compared with TM. Acid resistance of remineralized lesions was greater for TMP compared with TM.

Hicks 2006 Houston In vitro, enamel slabs with TMP enhanced the resistance of enamel demin gel surfaces to in vitro caries formation compared with TM or fluoride alone.

Itthagarun 2006 Gold Coast In vitro, enamel slabs with TM remineralized initial enamel lesions, demin gel and gave more remineralization when applied as a topical coating after the use of fluoride toothpaste.

Sudjalimi 2006 Melbourne In vitro, extracted teeth in TMP was better at reduced mineral loss demin gel (QLF) around orthodontic brackets than TM or fluoride alone.

Reynolds 2006 Melbourne RCT,insitumodel,N=10, Toothpastecontaining2%CPP-ACP over 14 days plus 1100 ppm F was superior to paste with CPP-ACP alone and to 2800 ppm F toothpaste. Remineralized lesions were relatively acid resistant.

Reynolds 2006 Melbourne RCT,N=10,over14days Mouthrinsescontaining2%CPP-ACP plus 450 ppm F increased the incorporation of fluoride ions into plaque to achieve over double that obtained with 450 ppm F rinse alone.

Sakaguchi 2006 Tokyo Insitustudy,N=5subjects, TMPgavegreaterreminthaneitherTM 7 days or 950 ppm fluoride toothpaste.

Kim 2007 Sth Korea In vitro, enamel slabs with TMP was more effective than TM alone WSL (microhardness) or 3000 ppm F solution in preventing demin.

Turssi 2008 San Paulo In vitro, enamel slabs with Treatment of eroded enamel with TMP erosion lesions (microhardness) reduced progression of erosion compared with the untreated control.

Cochrane 2008 Melbourne In vitro, enamel slabs with WSL CPP-ACP and CPP-ACFP solutions promoted high levels of remineralization throughout the body of enamel WSL.

Hamba 2010 Tokyo In vitro, enamel slabs with TMP prevented demineralization more demin gel (micro CT) effectively than TM without F, and F alone.

Hicks 2010 Houston In vitro, enamel slabs with TMP reduced lesion depths as effectively demin gel (PLM) as a 5000 ppm F toothpaste despite having a fluoride content of only 900 ppm F.

Cochrane 2010 Melbourne In vitro, enamel slabs with TMP produced high percentages of WSL and orthodontic brackets remineralization of WSL, which reduced the extent of enamel damage caused by bracket removal subsequently.

Table 6. Studies of CPP-ACP with fluoride (Tooth Mousse Plus)

RCT = randomized controlled clinical trial.

23clinical corner

Extending the range of clinical applications The addition of CPP-ACP to existing foods has been shown to enhance their dental health benefits. Addition of CPP-ACP to cheese and milk at concentrations from 0.2-0.5% has been shown in laboratory studies to reduce mineral loss in enamel cased by acid exposure, and to enhance remineralization (Minami et al. 2004; Walker et al. 2009).

Likewise, TM has been shown to increase the hardness of enamel which has been eroded by repeated contact with acidic drinks such as colas, improving mineral uptake beyond that possible withsalivaalone(Sukasaemetal.2006;Huang&Tantbironj 2008). Topical application of TM reduces the extent of softening and mineral loss caused by subsequent exposure to erosive beverages (Kallayathi et al. 2008).

CPP-ACP has potential as an additive to acidic drinks to prevent dental erosion. A key factor in such an approach is to estimate the lowest concentration of CPP-ACP which can be added to erosive drinks to eliminate the risk of erosion to enamel. Past research work on this topic has explored this issue using Powerade™, to which was added varying amounts of CPP-ACP from 0.063% up to 0.25%. Analysis of the surface characteristics of enamel slabs in the laboratory setting using stereomicroscopy, scanning electron microscopy and surface profilometry demonstrated that adding CPP-ACP at 0.25% raised the pH from 2.70 to 3.90, and lowered the titratable acidity from 1.83 to 1.36). Enamel loss from etching reduced from 3.87µm to 0.19µm, which was identical to enamel samples kept in distilled water (0.25µm). A reduction in the erosive step defect occurred at concentrations down to 0.09%. Overall, the erosive potential of Powerade™ was attenuated or eliminated completely by the addition of low concentrations of CPP-ACP(Ramalinghametal.2002&2005).

There is also interest in including CPP-ACP in dental materials, such as glass ionomer cements (Mazzaoui et al. 2003) and zinc oxide non-eugenol temporary

cements used in crown and bridgework. Both lines of investigation have been followed, with the logic being to provide greater resistance to mineral loss at restoration margins, and reduced permeability of cut dentine beneath temporary crowns, respectively. Addition of up to 8.0% CPP-ACP into zinc oxide cements appears to be viable in terms of the compressive strength and film thickness achieved (Wong et al. 2006).

A particularly interesting application of TM is the management of pathological tooth wear from acid regurgitation or severe bruxism (Meyers 2008). As well as prevebting dental erosion, laboratory studies suggest that frequent application of TM reduces enamel wear under conditions simulating bruxism and acid regurgitation, probably due to its lubrication properties (Ranjitkar et al. 2006, 2007, 2008,2009A&B).TMisabletoreduceabrasiveandacid-accelerateddentinewear(Narayanaetal.2006),supporting the use for TMP in patients with severe tooth wear from these differing causal pathways. Benefit has also been suggested for prevention of erosion from frequent consumption of wine (Piekarz et al. 2008).

About the author:ProfessorLAURENCEWALSHBDScPhD DDSc GCEd FFOP(RCPA) FICD FPFA Laurence Walsh is Professor of Dental Science and Head of the School of Dentistry at the University of Queensland. He is a dental specialist in special needs dentistry and maintains a part time clinical practice in that field. Laurence is actively involved in the dental profession at a range of levels both nationally and internationally and has been involved in the development and assessment of chair-side diagnostic tools which use saliva and dental plaque. He is currently involved in studies of novel approaches for remineralisation of enamel and caries prevention.

O. ADEBAYO, M. BURROW, and M. TYAS. SEM evaluation of casein phosphopeptide-amorphous calcium phosphate-treated and conditioned enamel. J Dent Res 87(Spec Iss C):1, 2008A.

O.A. ADEBAYO, M.F. BURROW, and M.J. TYAS. Dentine bonding after CPP-ACP paste treatment with and without conditioning. J Dent 36(12):1013-1024, 2008B.

O.A. ADEBAYO, M.F. BURROW, and M.J. TYAS. An SEM evaluation of conditioned and bonded enamel following carbamide peroxide bleaching and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) treatment. J Dent 37(4):297-306, 2009.

O.A. ADEBAYO, M.F. BURROW, and M.J. TYAS. Resin-dentine interfacial morphology following CPP-ACP treatment. J Dent 38(2):96-105, 2010.

C. AMORNPIPITHKUL, S. SANGUANSIN, and P. LEELATAWEEWUD. The Effects of Casein-Phosphopeptide-Amorphous-Calcium-Phosphate Paste on Plaque Calcium and Phosphate. J Dent Res 88(Spec Iss C):190, 2009.

A. ANDERSSON, S. TWETMAN, K. SKÖLD-LARSSON, and L.G. PETERSSON. Lesion regression with CPP/ACP-containing cream assessed by laser fluorescence. J Dent Res 85(Spec Iss B):2539, 2006.

A. ANDERSSON, K. SKÖLD-LARSSON,

A. HALLGREN, L.G. PETERSSON and S. TWETMAN. Effect of a dental cream containing amorphous cream phosphate complexes on white spot lesion regression assessed by laser fluorescence. Oral Health Prev Dent 7;5(3):229-233, 2007.

A.G. ANTONIO, V. PIERRO, and L.C. MAIA. Xylitol-based candies/lozenges: What is the evidence for caries-preventive effects? J Dent Res 88(Spec Iss A):2528, 2009.

S. ARDU, N.V. CASTIONI, N. BENBACHIR, and I. KREJCI. Minimally invasive treatment of white spot enamel lesions. Quintessence Int 38(8):633-636, 2007.

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26 mi.gceurope.comevidence

A closer look at remineralisation and CPP-ACP

Systematic ReviewTitle: Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis

Objective. This systematic review with meta-analyses sought to answer the following question: ‘‘Does CPP-ACP [casein phosphopeptide-amorphous calcium phosphate], when introduced into the oral environment, provide any caries-preventive benefit superior to that of any other intervention or placebo?’’

Material and methods. Seven electronic databases were searched for trials relevant to the review question. Twelve articles were accepted after application of inclusion and exclusion criteria.

Results. Of the accepted articles, five in situ randomized control trials (RCT) could be pooled for meta-analyses. During the short-term (7_21 days) in situ trials, participants wore appliances containing enamel slabs that were analyzed in the laboratory after exposure to CPP-ACP. The pooled in situ results showed a weighted mean difference (WMD) of the percentage remineralization scores in favor of chewing gum with 18.8 mg CPP-ACP as compared to chewing gum without CPP-ACP (WMD _8.01; 95% CI: _10.54 to _5.48; p_0.00001), as well as compared to no intervention (WMD_13.56; 95% CI: _16.49 to _10.62; p_0.00001). A significant higher remineralization effect was also observed after exposure to 10.0 mg CPP-ACP (_7.75; 95% CI: _9.84 to _5.66; p_0.00001). One long-term in vivo RCT (24 months) with a large sample size (n_2720) found that the odds of a tooth surface’s progressing to caries was 18% less in subjects who chewed sugar-free gum containing 54 mg CPP-ACP than in control subjects who chewed gum without CPP-ACP (p_ 0.03).

Conclusion. Within the limitations of this systematic review with meta-analysis, the results of the clinical in situ trials indicate a short-term remineralization effect of CPP-ACP. Additionally, the promising in vivo RCT results suggest a caries preventing effect for long-term clinical CPP-ACP use. Further randomized control trials are needed in order to confirm these initial results in vivo.

Article details :Yengopal V, Mickenautsch S. Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. Acta Odontol Scand 2009; 67: 321-32.

The academic explanationDr Steffen Mickenautsch, academic researcher in Johannesburg, South Africa

MID: Of all the studies available on this subject, why were you only able to use 5 for your meta analysis? Steffen Mickenautsch: Firstly, we

had to exclude other studies because they were either: conducted in the laboratory and not in the clinic; done on animal and not on human tissue or did not compare CPP-ACP against anything else.

The problem with studies from the laboratory is that one really cannot be sure that the results would be the same in the ‘real’ world. The same is valid when studying the effect of treatments on animal tissue. The results of either are important to justify whether studies should be conducted on patients or not, because it is not ethical to study new treatments on humans if laboratory and/or animal studies show that these are not successful. Therefore, laboratory and/or animal studies are important first steps for testing new drugs or treatments before they can be allowed to be tested on humans. However, in our systematic review we wanted to know whether CPP-ACP is beneficial for clinical use on patients and neither, laboratory nor animal studies, can answer this question. That is why we had to exclude them.

Clinical studies that fail to compare a new type of treatment against another, (preferably the type of standard treatment commonly used to date) are unable to answer the question whether the new treatment is better, the same or worse. But this was exactly what we were trying to find out, thus we could not include these types of studies either.

After all these considerations we had 11 studies available to work with. From these, 5 were similar enough to be combined in a meta-analysis. A meta-analysis is a statistical method by which the separate results of several studies are combined to one average result. However, in order to be able to do this the studies need to be similar, e.g. in their methods and outcomes, before they can be combined. Otherwise the meta-analysis would produce meaningless results.

As a publication, MID believes in the importance of informing dentists about the evidence available on MI topics so they can make scientifically sound choices in the treatment of their patients. In the research-clinical application jigsaw puzzle, it is essential to make all the pieces fit in order to see the whole picture.

This process is outlined in the flow diagram below

Systematic review -> academic explanation -> clinical application

27 evidence

We reviewed the other 6 studies separately in our systematic review without including them in the meta-analysis.

MID: What criteria did the 5 that you selected meet and why is this important?Steffen Mickenautsch: These 5 studies compared CPP-ACP against other types of treatments. They provided information on how well each, the CPP-ACP and the other treatment worked on patients and then compared both results to find out which one was better. This was exactly what we needed to know. In addition, they all fulfilled the requirements for meta-analysis; they all used CPP-ACP in dental chewing gum; they included the same CPP-ACP concentration; study length and used the same type of other treatment for comparison.

MID: Please explain your introduction: “The advantages of meta-analysis over qualitative synthesis is that it provides the opportunity to identify a treatment effect as statistically significant (p<0.05) and to improve estimation of the effect by quantifying its outcome, thus making its estimation more precise”

Steffen Mickenautsch: Statements that are based on qualitative synthesis are like saying: “The water is cold” But that does not answer the question: “How cold is it?” Some of us jump happily into the water at 17ºC without even developing goose bumps. They would do so and subsequently declare “It’s not cold!” while I would beg to differ as my definition of cold water is anything below 25 oC! So, is the water now cold or not? Qualitative synthesis always remains subjective. In contrast, a quantitative synthesis would be: “The water is 10º C”. Now we know what we are talking about, because we have measured something, expressed it in numbers and that gives a much clearer, objective picture. That’s also exactly what we did in our systematic review through meta-analysis. Once we have such result we are then able to judge whether it is ‘statistically significant’.

A ‘statistically significant’ difference simply means that the difference is very unlikely to be a coincident. Statisticians use a p-value below 0.05 to say that any difference, e.g. between 2 treatments, has a probability below 5% that such difference is a coincident and not due to the fact that one treatment is better than the other (under the condition, of course, that the patients only differ in the type of treatment they received and otherwise are the same). If we find after meta-analysis that chewing

gum with 18.8 mg of CPP-ACP has a higher remineralising effect than chewing gum without and the calculated p-value is 0.00001 then we provided evidence that the higher remineralising effect was very, very unlikely to have happened due to chance or coincidence.

Qualitative synthesis is unable to provide such information.

MID: Of the studies you looked at that investigated the short term effects of CPP-ACP, what were the emerging trends and why are these significant?Steffen Mickenautsch: The emerging trend is that CPP-ACP is also effective on long-term basis. We will show that in a forthcoming update of our systematic review. In the short-term we found that the observed caries-preventive effect of CPP-ACP is unlikely to be a coincident but more likely because CPP-ACP actually supports remineralisation. The statistical significant effect of CPP-ACP is caused simply by its comparatively higher ability to replenish minerals in demineralised teeth. This ability has been measured in the 11 studies that we included in our systematic review for both CPP-ACP and the comparison treatments. The measured quantities were so much higher for CPP-ACP that the calculated p-values remained below 0.05 and that shows that this higher remineralising effect was very unlikely a coincident.

“The statistical significant effect of CPP-ACP is caused simply by its comparatively higher

ability to replenish minerals in demineralised teeth.”

Steffen Mickenautsch

28 mi.gceurope.comevidence

MID: In your conclusion it states that this meta analysis shows that CPP-ACP does have a short term remineralising effect – what should a practising dentist who reads this understand about this statement?Steffen Mickenautsch: If a patient is identified to have a high caries activity or a high risk to develop cavities in the near future, the established short-term effect promises that CPP-ACP is able to stop the further progression of (non-cavitated) carious lesions and is able to prevent the development of such. Therefore, CPP-ACP may be used as one immediate intervention in the treatment of such patients.

MID: You also looked at one study that examined the long-term effect of CPP-ACP – what were the important elements of this particular study?Steffen Mickenautsch: In that study, patients were given CPP-ACP containing chewing gum over the period of 2 years and were compared to similar patients that chewed sugar-free chewing gum without CPP-ACP. The result showed that patients using the CPP-ACP containing gum had 18% lesser likelihood of caries progression. This result was statistically significant, thus very unlikely to be a coincident. All patients had active caries and the CPP-ACP gum showed to be more effective to stop further progress of the existing carious lesions. In that regard one has to remember that sugar-free chewing gum is considered to be effective against caries too. That means, that the group of patients without the CPP-ACP would have also experienced an anticaries effect. Only, this effect was observed to be larger in the CPP-ACP group.

MID: Is this systematic review conclusive or is more research needed?Steffen Mickenautsch: From an academic point of view, the current knowledge about CPP-ACP allows us to be optimistic about the claim that CPP-ACP is effective against caries. The currently available studies provide evidence that this claim is not only plausible but also tends to prove it to be correct rather than disproving it. To have more high quality research will be of advantage to validate and strengthen this claim even further.

The clinical applicationDr Andrew Brostek, private dentist in Perth, Australia

MID: For how many years have you been using Tooth Mousse/MI Paste in your practice?Andrew Brostek: I began soon after it was first made available in Australia, but have used it more intensively in the last three years.

MID: What factors made you decide to start using it in your practice and recommend it to your patients in the first place?Andrew Brostek: After being exposed to the information about CPP-ACP presented at several Continuing Education courses, and then reading some of the early studies published by Professor Eric Reynolds and his University of Melbourne research group, I realised that using the products containing CPP-ACP (GC Tooth Mousse / Mi Paste, Tooth Mousse Plus (CPP-ACFP) and the GC Recaldent chewing gum) had great potential to benefit my patients.

MID: After reading the abstract of the meta-analysis on the remineralising effect of CPP-ACP, how will this affect the way in which you use and prescribe Tooth Mousse/MI Paste in your practice, if at all?Andrew Brostek: The publication of this meta-analysis review reinforces my own belief in the effectiveness of CPP-ACP, based on my own clinical experiences with compliant patients. Evidence based dentistry is essential to guide clinicians in improving treatment protocols, and I await further data from in vivo trials to confirm these results. In terms of prescribing, I use the fluoride versions CPP-ACFP i.e. Tooth Mousse Plus/ Mi Paste Plus for high risk patients over the age of 7 years, as study results show an increased lesion preventive effect with the fluoride combination. I usually prescribe nightly application of a pea-sized amount of the Tooth Mousse Plus / Mi paste Plus (immediately before bed), but in very high caries rate patients, I prescribe both a morning and nightly application, with concomitant use of Recaldent gum at least twice per day (10 minutes per application). As evidenced by studies, chewing the CPP-ACP gum, three times per day was very effective in caries-rate reduction.

MID: Do you find this meta-analysis easy to interpret, in terms of applying this to your daily practice?Andrew Brostek: My understanding of the value of meta-analysis is to provide a more objective assessment of the available statistically significant literature. So yes, it does have value to me in suggesting improved protocols. Again

“In my practice the compliance rate and re-purchase of the Tooth Mousse / Mi paste has been very high, and this indicates to me that the patients are happy with the results, and

find value in the products.” Andrew Brostek

29evidence

speaking as a full-time clinician, I am very interested in any improvement in caries-preventive benefit and particularly in achieving enamel remineralisation.

My daily practice protocols vary depending on the patient lesion presentation. For poor compliance patients with rampant caries, I mainly rely on prescribing twice-daily brushing with a high-dose fluoride (5000 ppm) toothpaste, and clinician-applied fluoride varnish at recall. The prevention of demineralisation by the use of high concentrations of fluoride is of critical importance in our anti-caries chemical armentarium.

But for compliant high-risk patients with multiple early lesions (white-spot lesions) I use a slightly different protocol emphasising the use of CPP-ACP. To achieve increased remineralisation of these white spot lesions, especially in younger people with unaesthetic anterior lesions, I prescribe daily CPP-ACP (or CPP-ACFP) Tooth Mousse / Mi Paste application, in combination with twice-daily tooth brushing with a lower fluoride concentration (1000 ppm) toothpaste. This allows greater sub-surface remineralisation of non-cavitated lesions, evidenced over time by the reversal of the white-spot appearance. Unfortunately utilising a higher 5000 ppm fluoride toothpaste will seal off the unaesthetic surface scar rapidly, not allowing the deeper subsurface remineralisation to occur. Of course, regular effective plaque removal, diet and lifestyle modification, normal saliva quality and quantity, are all important factors in modifying the disease risk and aiding in tooth remineralisation.

MID: As a busy clinician, how do you keep yourself updated on developments in clinical evidence in dentistry, particularly in MID?Andrew Brostek: That’s a tough question, as most of us are fairly busy in our own dental practices. The role of Continuing Education courses is important and attendance is compulsory in Australia. Belonging to various professional dental bodies helps, as it entitles you to some dental journal subscriptions, and staying current is important. I think that allows most of us to entertain our own specific dental interests.

MID: Some dental academics say that clinicians and the practice-based evidence they record is very important in filling the gaps left by academic research studies. Have you captured and recorded any interesting data on remineralisation with Tooth Mousse/MI Paste since you’ve started using it? If so, what are some of the most interesting trends that you’ve noticed?Andrew Brostek: I find recording practice-based evidence hard to do in a typical busy day. Many of you may identify with my daily problems, where some patients come late to appointments, or extra ‘pain’ patients are over-booked into an already busy schedule. My main contribution is to have my dental camera handy to document any interesting dental issues quickly.

My belief in CPP-ACP has been reinforced by observing non-cavitated white-spot lesions becoming remineralised over periods of between six weeks and 3 months with regular daily use of the Tooth Mousse / Mi paste by the patient. Progress is easy to observe, as the lesions change from the surface white scar to a relatively normal tooth appearance. The clinical protocol I use to achieve this is quite simple: The enamel lesion is etched with phosphoric acid for 10 seconds and then Tooth Mousse / Mi Paste is immediately applied. The patient then applies the Tooth Mousse nightly until lesion reversal occurs. In difficult cases, I might re-etch at one-month recall, or even additionally at the two-month recall, to aid CPP-ACP penetration by removing surface protein from the enamel.

In my practice the compliance rate and re-purchase of the Tooth Mousse / Mi paste has been very high, and this indicates to me that the patients are happy with the results, and find value in the products. Many of the mothers are also using the CPP-ACP products on their younger children’s teeth for caries prevention.

In conjunction with our individual patient caries risk assessment protocols (diet /lifestyle analyses, and the use of saliva and plaque testing on select patients) and then specific treatment targeting (such as the use of CPP-ACP), my dental hygienists and I believe we are benefitting our patients, and practising modern 21st century dentistry.

Patient with extensive white spot lesions After two months, showing partial remineralisation after twice daily application of CPP-ACP

30 mi.gceurope.commi toolkit

MI toolkit

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31mi toolkit

What’s inside the tube?

Click on the numbers to learn more1. GC Tooth Mousse offers Three-in-One solution

2. Uses for Tooth Mousse/MI Paste

3. Contraindications

4. Application methods

5. Packaging

6. Additional instructions5

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Tooth Mousse, also known as MI Paste in some regions of the world, is considered the number one remineralizing paste that is backed by sound scientific evidence.

For low to medium risk patients, MI Paste or Tooth Mousse is recommended. However,

for patients with high risk, MI Paste Plus/Tooth Mousse Plus contains

additional 900ppm Flouride and is therefore better suited to their oral health requirements.

Studies that prove the clinical superiority of GC Tooth Mousse/MI Paste are:z The only remineralizing cream with proven a scientific

record with more then 200 scientific references and having sold material for more than 160 million applications worldwide since the original Australasian introduction in 2002Abstract 3645 - IADR 2010, Barcelona, Spain. Comparison of Tooth Mousse (MI Paste) with Clinpro in situ. E Reynolds, F Cai, P. Shen, G Walker, Y Yuan, N Cochrane, D Manton, C Reynolds. Oral Health CRC, Melbourne Dental School, University of Melbourne, Australia

z Searching from 7 databases and about 3500 articles, it has been concluded that Tooth Mousse/MI Paste Plus does Remineralization and has Caries protection effect.V. YENGOPAL & S. MICKENAUTSCH. University of the Witwatersrand, South Africa. Acta Odontologica Scandinavica 2009

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The Science behind ReminThe only Reminaralizing cream with proven a Scientific record with more then 200 scientific references and having sold material for more than 160 million applications worldwide since the original Australasian introduction in 2002*

Searching from 7 databases and about 3500 articles, it has been concluded that Tooth Mousse/MI Paste Plus does Remineralization and has Caries protection effect.**V. YENGOPAL & S. MICKENAUTSCH. University of the Witwatersrand, South Africa. Acta Odontologica Scandinavica 2009

Articles identified through keyword search in databases (n=3459)

Articles included for more detailed review (n=35)

Articles accepted (n=12)

Randomized control trials (n=11)

Randomized control trials included in meta-analysis (n=5)

Articles without relevance to review questions excluded (n=3424)

Articles excluded due to non-compliance with exclusion criteria (n=3424)

Systematic review (n=1)

Randomized control trials not included in meta-analysis (n=6)

33mi toolkit

The Science behind Remin Notice no change in the demineralised White Spot Lesion after the use of a Placebo Paste

Notice the hard hypermineralised layer formed due to the very high fluoride ppm, this acts like a hard shell preventing the Remineralization of the underlying White Spot Lesion lesion. Concluding that Ca and PO4 are the most crucial elements for Remineralization and Fluoride only acts as a catalyst.

*Abstract 3645 - IADR 2010, Barcelona, Spain. Comparison of Tooth Mousse (MI Paste) with Clinpro in situ. E Reynolds, F Cai, P. Shen, G Walker, Y Yuan, N Cochrane, D Manton, C Reynolds. Oral Health CRC, Melbourne Dental School, University of Melbourne, Australia

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PLACEBO PASTE

1000PPM F PASTE

5000PPM F PASTE

TOOTH MOUSSE

MI PASTE PLUS

CLINPRO

Notice no Hard impervious layer as compared to High Fluoride containing products.Tooth Mousse and MI Paste Plus show a uniform Remineralization of the Enamel and Dentine structures. However, MI Paste Plus shows higher Remineralization due to the fact that Fluoride acts as a catalyst to encourage Calcium and Phosphate to enter inside the Tooth structure

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minimum intervention, maximum return Issue 3

remineralization with cpp-acpdibateb.com/wp-content/uploads/2018/02/mid3.pdf · understand that...

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