The effect of different fluoride application methods on the remineralization of initial carious lesions

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1 Reserh rtile ISSN (print) / ISSN (online) The effet of ifferent fluorie pplition methos on the reminerliztion of initil rious lesions Seon Mi Byeon, Min Ho Lee, Te Sung Be* Deprtment of Dentl Biomterils n Institute of Bioegrle Mteril, Institute of Orl Biosiene n BK21 plus projet, Shool of Dentistry, Chonuk Ntionl University, Jeonju, Kore Ojetives: The purpose of this stuy ws to ssess the effet of single n omine pplitions of fluorie on the mount of fluorie relese, n the reminerliztion n physil properties of enmel. Mterils n Methos: Eh of four fluorie vrnish n gel prouts (Fluor Protetor, FP, Ivolr Vivent; Tooth Mousse Plus, TM, GC; 6 Seon Gel, A, Germiphene; CvityShiel, CS, 3M ESPE) n two fluorie solutions (2% soium fluorie, N; 8% tin(ii) fluorie, S) were pplie on ovine teeth using single n omine methos (1 per group), n then the mount of fluorie relese ws mesure for 4 wk. The eletron proe mironlysis n the Vikers mirohrness mesurements were onute to ssess the effet of fluorie pplition on the surfe properties of ovine teeth. Results: The mount of fluorie relese ws higher in omine pplitions thn in single pplition (p <.5). Mirohrness vlues were higher fter omine pplitions of N with FP, TM, n CS thn single pplition of them, n these vlues were lso higher fter omine pplitions of S thn single pplition of A (p <.5). C n P vlues were higher in omine pplitions of N with TM n CS thn single pplition of them (p <.5). They were lso inrese fter omine pplitions of the S with A thn fter single pplition (p <.5). Conlusions: Comine pplitions of fluorie oul e use s sis to esign more effetive methos of fluorie pplition to provie enhne reminerliztion. (Restor Dent Eno 216;41(2): ) Key wors: Dentl Cries; Eletron proe mironlysis; Fluories; Reminerliztion; Vikers hrness Reeive Novemer 1, 215; Aepte April 14, 216. Byeon SM, Lee MH, Be TS *Corresponene to Te Sung Be, PhD. Professor, Deprtment of Dentl Biomterils n Institute of Bioegrle Mteril, Institute of Orl Biosiene n BK21 plus projet, Shool of Dentistry, Chonuk Ntionl University, 567, Bekje-ero, Deokjin-gu, Jeonju, Kore TEL, ; FAX, ; E-mil, ts@jnu..kr Introution Generlly, preventive mesures suh s the use of fluorie to prevent entl ries re more effiient thn the entl tretment. Therefore, stuies hve een onute on ifferent types of fluorie n their pplition methos in orer to ssess the effets of fluorie. 1-3 When fluorie prouts re pplie to enmel surfe of the teeth, the fluorie ions reple the hyroxie ions in the hyroxyptite rystl struture of the teeth. 4 The lower soluility of fluorptite ompre to tht of hyroxyptite results in higher i resistne of the enmel. Lrger ining fores etween the fluorie n ptite rystls inrese the hrness of the teeth. 5-8 When fluorie onentrtion in enmel is inrese y topil fluorie pplition, this les to the formtion of fluorie film on the enmel surfe, thus reuing the penetrtion of i y teri n enhning reminerliztion. 5 Therefore, This is n Open Aess rtile istriute uner the terms of the Cretive Commons Attriution -Commeril Liense ( y-n/3.) whih permits unrestrite non-ommeril use, istriution, n reproution in ny meium, provie the originl work is properly ite. Copyrights 216. The Koren Aemy of Conservtive Dentistry. 121

2 Byeon SM et l. topil fluorie pplition is use for iniviuls with high ries risk, orthoonti ptients, n ptients with erese slivry flow. 9 Topil fluorie pplition n e lssifie into personl n professionl pplitions. Soium fluorie (NF) solution n e pplie to the teeth with otton pplitor or y using iontophoresis. The preventive effets of 2% NF solution ginst initil entl ries hve een reporte. 1-3 It hs lso een reporte tht tin(ii) fluorie (SnF 2 ) solution hs ntiteril effets, 1,11 ut it n use isolortion of enmel surfe n gingivl irrittion. 12 In ition, fluorie gels n vrnishes enhne reminerliztion of initil rious lesions n resist enmel eminerliztion. It ws reporte tht the iniene of entl ries erese when Fluor Protetor ws pplie to enmel surfe of ovine teeth n the teeth were expose to riogeni everges. 13 Reently, some reports ttrte ttention euse they showe tht Tooth Mousse Plus whih ontins sein phosphopeptie-morphous lium phosphte fluorie (CPP-ACPF) inrese the reminerliztion of initil entl ries y supplementing iniviul slivry uffering pity. 6,14 Also, CvityShiel ontins olophony omponent to tth on enmel surfe for longer perio n mintins 5% NF ontent onsistently ue to its visous omponent. It enhne the fluorie onetrtion in enmel. 15 Fluorie vrnish hs een wiely use in Cn n Europen ountries sine the 197s. Due to the pplition of these prouts, smll mount of high ensity fluories remin in ontt with the teeth for long urtion, n then penetrte the tooth struture to form ons. 16 However, prouts suh s fluorie solutions, gels, or foms remin in ontt with teeth for shorter urtion thn vrnishes, thus resulting in the formtion of ons in more superfiil portion of the enmel. 9,17 To enhne the effets of fluorie pplition, ontt time etween teeth n fluorie shoul e extene, n oringly, ontinuing stuies on this topi hve een performe wiely, whih hs le to new finings n methos. 9,16,17 The uptke of fluorie y enmel is proportionl to the mount of ontt time. 18 It ws reporte tht the pplition of iulte phosphte fluorie (APF) gel on enmel surfe initilly resulte in high onentrtion of fluorie on enmel surfe. Therefore, the omine pplition of APF-SnF 2 ws introue s new metho. 17,19 In this stuy, single or omine pplitions of fluorie were suggeste to protet ginst entl ries y inresing the effets of fluorie pplition. The null hypothesis of this stuy ws tht single n omine pplitions of ifferent topil fluorie prouts exert the sme reminerliztion effets on enmel. Mterils n Methos Preprtion of speimens n formtion of rtifiil ries Thirty fresh ovine mniles were otine from lol slughterhouse (Chuklim, Iksn, Kore) n were ryopreserve in orer to mintin the physil properties of the ovine teeth. Eight inisors were extrte from eh mnile. From these, flt, smooth, soun (nonrious) teeth were ollete for use in this stuy. The ovine teeth were ut into lok-shpe speimens of 8 8 mm 2 size (n = 24) to otin the wiest n fltest res on the lil surfes. The speimens were polishe to gloss using # 4-1,2 grit silion rie ppers (Deerfos, Inheon, Kore) n.5 μm lumin oxie suspension (Buehler, Lke Bluff, IL, USA). Polishe smples were immerse in eminerliztion solution (ph 5.) ontining.2% ropol (BF Goorih, Cleveln, OH, USA) n.1% lti i (Sigm-Alrih Chemil, St. Louis, MO, USA) sturte with lium phosphte trisi for 72 hours. Deminerlize speimens with Vikers hrness numer (VHN) of 96 ±.4 were selete for stnriztion (n = 13). Mesurement of Vikers mirohrness Vikers mirohrness of the eminerlize speimens n the fluorie trete speimens ws mesure using igitl mirohrness tester (HM-124, Mitutoyo, Kngw, Jpn) with lo of 2 g for 1 seons in four res (4 per group). Topil fluorie pplition In the ontrol group, no tretments were one on enmel surfes of speimens, n in the experimentl groups, four prouts inluing Fluor Protetor (FP, Ivolr Vivent, Shn, Liehtenstein), Tooth Mousse Plus (TM, GC, Tokyo, Jpn), 6 Seon Gel (A, Germiphene, Brntfor, Cn), CvityShiel (CS, 3M ESPE, St. Pul, MN, USA) were use for single pplition of fluorie (Tle 1). For omine pplitions of fluorie, 2% soium fluorie (N, Junsei, Tokyo, Jpn), 8% tin(ii) fluorie (S, Sigm-Alrih Chemil, St. Louis, MO, USA) solutions were prepre, n fter pplition of the 4 fluorie prouts, the speimens were immerse in eh solution for 1 minute (Tle 2). In se of single pplition of fluorie, the speimens were wshe with istille wter n rie. The remining surfes of the speimens, other thn enmel surfes on whih fluorie ws pplie, were overe with nil vrnish. The prepre speimens were ple in tightly ppe ontiner fille with 5 ml of istille wter n store in n inutor t

3 Reminerliztion effet of new fluorie pplition methos Tle 1. Fluorie prouts use in this stuy Prout Coe Mnufturer Ingreient Fluor Protetor FP Ivolr Vivent, Shn, Liehtenstein (Bis{4-[2-(ifluorhyroxysilyl)ethyl] 2 methoxyylohexyl} [N,N-(trimethylhexne 1,6 iyl)irmte]) Tooth Mousse Plus TM GC, Tokyo, Jpn Csein Phosphopeptie-Amorphous Clium Phosphte Fluorie 6 Seon Gel A Germiphene, Brntfor, Cn 1.23% Aiulte phosphte fluorie CvityShiel CS 3M ESPE, St. Pul, MN, USA 5% Soium fluorie Soium Fluorie N JUNSEI, Tokyo, Jpn Soium fluorie Tin(II) Fluorie S Sigm-Alrih Chemil, St. Louis, MN, USA Stnnous fluorie Tle 2. Fluorie pplition methos on speimens followe in this stuy (n = 1) Group Fluorie pplition metho (pplition time) Untrete FP Fluor Protetor (1 min) FPN Fluor Protetor (1 min) + Immersion in 2% Soium Fluorie (1 min) FPS Fluor Protetor (1 min) + Immersion in 8% Tin(II) Fluorie (1 min) TM Tooth Mousse Plus (3 min) TMN Tooth Mousse Plus (3 min) + Immersion in 2% Soium Fluorie (1 min) TMS Tooth Mousse Plus (3 min) + Immersion in 8% Tin(II) Fluorie (1 min) A 6 Seon Gel (1 min) AN 6 Seon Gel (1 min) + Immersion in 2% Soium Fluorie (1 min) AS 6 Seon Gel (1 min) + Immersion in 8% Tin(II) Fluorie (1 min) CS CvityShiel (4 hr) CSN CvityShiel (4 hr) + Immersion in 2% Soium Fluorie (1 min) CSS CvityShiel (4 hr) + Immersion in 8% Tin(II) Fluorie (1 min) Mesurement of fluorie relese The mount of fluorie relese ws mesure on ys 1, 2, 3, 4, 7, 14, 21, n 28 (5 per group). Distille wter ws hnge everyy throughout the experiment. Five milliliters of the solution tht ontine the speimen ws mixe with the sme mount (5 ml) of TISAB III (Totl Ioni Strength Ajustment Buffer, Thermo Sientifi Orion, Beverly, MA, USA). This solution (totl volume = 1 ml) ws mesure on fluorie eletroe (Orion 96-9BN, Thermo Sientifi Orion) with millivolt meter (Orion72A plus, Thermo Eletron, Sn Jose, CA, USA). TISAB III solution ws e to mintin its ph in the rnge of euse the fluorie eletroe is sensitive to hnges in ph. To mesure the mount of fluorie relese,.1, 1, 1, n 1 ppm of stnr fluorie solutions (Fluorie stnr, Thermo Sientifi Orion) were use to stnrize the mesurements. Eletron proe miro nlysis Chnges in the onstituents of enmel surfe use y fluorie uptke ue to fluorie tretment were nlyze on ys 7, 14, 21, n 28 y onuting quntittive nlysis of prinipl omponents of teeth (C n P) using eletron proe mironlysis (EPMA, EPMA-16, Shimzu, Kyoto, Jpn) (1 per group). In the EPMA, 1 μm em size, 15 kv elertion voltge, n 2 na eletron em urrent were pplie, n the quntittive nlysis ws onute t four points

4 Byeon SM et l. Sttistil nlysis All the t ws nlyze using SPSS 12. (SPSS, Chigo, IL, USA). To ompre the reminerliztion effets of single n omine pplitions of fluorie, two-wy repete mesure ANOVA tests were onute, n vriles showing signifint ifferenes were teste susequently y Tukey s omine omprison tests. A p vlue of.5 ws onsiere sttistilly signifint. Results Mesurements of Vikers mirohrness of the speimen surfes re presente in Figure 1. Among the groups in whih FP ws pplie, the FPN group showe the highest vlues in surfe mirohrness fter 4 weeks (p <.5). The TMN n CSN groups lso showe signifintly higher vlues fter 4 weeks thn TMS n CSS groups (p <.5). However, mong the groups in whih A ws pplie, the AS group showe signifint inrese in surfe mirohrness fter 3 n 4 weeks ompre to the AN group (p <.5). Surfe mirohrness (HV.2 ) y 14 y 21 y 28 y Surfe mirohrness (HV.2 ) y 14 y 21 y 28 y 2 2 FP FPN FPS TM TMN TMS Surfe mirohrness (HV.2 ) y 14 y 21 y 28 y Surfe mirohrness (HV.2 ) y 14 y 21 y 28 y 2 2 A AN AS CS CSN CSS Figure 1. Men Vikers mirohrness of speimen surfe fter fluorie pplitions (n = 4). Brs inite stnr evitions., Untrete; FP, Fluor Protetor; FPN, Fluor Protetor + 2% soium fluorie (NF); FPS, Fluor Protetor + 8% tin(ii) fluorie (SnF 2 ); TM, Tooth Mousse Plus; TMN, Tooth Mousse Plus + 2% NF; TMS, Tooth Mousse Plus + 8% SnF 2 ; A, 6 Seon Gel; AN, 6 Seon Gel + 2% NF; AS, 6 Seon Gel + 8% SnF 2 ; CS, CvityShiel; CSN, CvityShiel + 2% NF; CSS, CvityShiel + 8% SnF 2. -, Groups with ifferent letters were signifintly ifferent (p <.5). HV.2, Hrness vlues were etermine using igitl mirohrness tester with lo of.2 kg

5 Reminerliztion effet of new fluorie pplition methos Chnges in fluorie relese t eh time point re illustrte in Figure 2. Compre with the non-tretment group, fluorie relese ws signifintly higher on the first y in ll of the trete groups (p <.5), ut erese rpily fter the first y, n then ontinue to erese rther slowly. It is ler tht mong the groups in whih FP, TM, n CS were pplie, tht fluorie relese ws signifintly higher in the groups trete with omine pplition of N n S. In prtiulr, lrge fluorie relese ws oserve in the FPN, TMN, n CSN groups. However, mong the groups in whih A ws pplie, the fluorie relese ws signifintly higher in the AS group thn AN group (p <.5). Chnges in the prinipl omponents of the teeth were oserve y mesurements of C n P fter fluorie pplition (Figures 3 n 4). The mesure vlues of C n P were greter in the FPN, TMN, AS, n CSN groups thn those in the FPS, TMS, AN, n CSS groups (p <.5). Fluorie relese (µg/m 2 ) Fluorie relese (µg/m 2 ) FP FPN FPS Time (y) A AN AS Fluorie relese (µg/m 2 ) Fluorie relese (µg/m 2 ) TM TMN TMS Time (y) CS CSN CSS Time (y) Time (y) Figure 2. Fluorie relese fter fluorie pplitions (n = 5). Brs inite stnr evitions., Untrete; FP, Fluor Protetor; FPN, Fluor Protetor + 2% soium fluorie (NF); FPS, Fluor Protetor + 8% tin(ii) fluorie (SnF 2 ); TM, Tooth Mousse Plus; TMN, Tooth Mousse Plus + 2% NF; TMS, Tooth Mousse Plus + 8% SnF 2 ; A, 6 Seon Gel; AN, 6 Seon Gel + 2% NF; AS, 6 Seon Gel + 8% SnF 2 ; CS, CvityShiel; CSN, CvityShiel + 2% NF; CSS, CvityShiel + 8% SnF

6 Byeon SM et l. C weight % y 14 y 21 y 28 y C weight % y 14 y 21 y 28 y 3 3 FP FPN FPS TM TMN TMS C weight % y 14 y 21 y 28 y 45 7 y 14 y 21 y 4 28 y C weight % 35 3 A AN AS CS CSN CSS 3 Figure 3. Clium ontent of speimens fter fluorie pplitions y EPMA nlysis. Brs inite stnr evitions., Untrete; FP, Fluor Protetor; FPN, Fluor Protetor + 2% soium fluorie (NF); FPS, Fluor Protetor + 8% tin(ii) fluorie (SnF 2 ); TM, Tooth Mousse Plus; TMN, Tooth Mousse Plus + 2% NF; TMS, Tooth Mousse Plus + 8% SnF 2 ; A, 6 Seon Gel; AN, 6 Seon Gel + 2% NF; AS, 6 Seon Gel + 8% SnF 2 ; CS, CvityShiel; CSN, CvityShiel + 2% NF; CSS, CvityShiel + 8% SnF 2. -, Groups with ifferent letters were signifintly ifferent (p <.5). Disussion To ientify the effets of topil fluorie pplition n omine pplitions with fluorie solution on teeth, stuies ssessing mount of fluorie relese, hnges in surfe mirohrness, n hnges in the C n P omponents of tooth enmel using the EPMA hve een onute. 6,7,18,2-24 Crll et l. reporte tht preventive effets ginst entl ries inrese long with n inrese in the mount of fluorie relese fter omine pplition of SnF 2 following the pplition of APF. 19 In ition, Reynols et l. reporte tht the reminerliztion rte ws higher fter the omine pplition of NF solution thn the in situ single pplition of CPP-ACP fluorie prouts, n it ws ompnie with erese in the rte of entl ries. 25 In this stuy, fluorie relese ws mesure ontinuously from the first y fter fluorie pplition. Speifilly, lrge mount of fluorie ws relese in the FPN, TMN, n CSN groups trete with omine pplition of N ompre to the FP, TM, n CS groups (p <.5). Also, the mount of fluorie ws signifintly higher in the AS group fter omine pplition of S, ompre to the A group (p <.5). Fluorie relese

7 Reminerliztion effet of new fluorie pplition methos P weight % y 14 y 21 y 28 y P weight % y 14 y 21 y 28 y FP FPN FPS TM TMN TMS P weight % y 14 y 21 y 28 y P weight % y 14 y 21 y 28 y A AN AS CS CSN CSS Figure 4. Phosphorus ontent of speimens fter fluorie pplitions y EPMA nlysis. Brs inite stnr evitions., Untrete; FP, Fluor Protetor; FPN, Fluor Protetor + 2% soium fluorie (NF); FPS, Fluor Protetor + 8% tin(ii) fluorie (SnF 2 ); TM, Tooth Mousse Plus; TMN, Tooth Mousse Plus + 2% NF; TMS, Tooth Mousse Plus + 8% SnF 2 ; A, 6 Seon Gel; AN, 6 Seon Gel + 2% NF; AS, 6 Seon Gel + 8% SnF 2 ; CS, CvityShiel; CSN, CvityShiel + 2% NF; CSS, CvityShiel + 8% SnF 2. -, Groups with ifferent letters were signifintly ifferent (p <.5). t eh time point fter fluorie pplition showe rpi erese from the first y to the next y. The initil urst of fluorie ion relese fter topil fluorie pplition hs een expline y iffusion from enmel surfe of high fluorie ontent. As ssume in the stuies y Lee et l., 7 the mount of fluorie relese woul epen on the ifferenes in soluility n relese of fluorie oring to the fluorie prouts. An inrese in fluorie relese on enmel ws oserve in ses with omine pplitions of fluorie suh s A with S, n N with FP, TM, n CS ompre to ses with single pplition of fluorie. Densifie enmel ue to inrese fluorie ontent through fluorie pplition inreses the strength of the tooth struture, n suh inreses hve een oserve in the hnges in mirohrness of enmel surfe for 4 weeks fter topil fluorie pplition in mny stuies. 6,7,17,18,2 Kok et l. reporte tht there existe lose reltionship etween minerl ontents n the mirohrness of enmel of soun tooth, 22 n Fegin et l. note tht the inrese in the C n P onentrtions inrese the strength of tooth struture with n elerte reminerliztion rte. 24 Among vrious minerl ontents tht onstitute tooth enmel, C n P form the

8 Byeon SM et l. ptite through eposition proess lle lifition or minerliztion. 26 As the reminerliztion filitte through fluorie pplition is expete to use hnges in the C n P ontents n the EPMA is known to e ple of mesuring hnges in these onstituents rther urtely. 21,27 In this stuy, tooth hrness oserve through hnges in the mirohrness fter single n omine pplitions of fluorie ws inrese in the groups trete with omine pplitions of fluorie with N (FPN, TMN, n CSN groups) ompre to the groups trete with single pplitions of FP, TM, n CS. Also, the group trete with omine pplition of fluorie with S (AS group) showe signifintly inrese mirohrness ompre to the A group (p <.5). This my suggest tht tooth hrness ws gretly enhne in ses in whih omine pplitions of fluorie using A with S n FP, TM, n CS with N. Also, the EPMA results showe the signifint inrese in C n P ontents, whih llowe signifint enhnement of tooth hrness in the ses with omine pplitions (FPN, TMN, CSN, n AS groups) ompre to single pplitions (FP, TM, CS, n A groups) (p <.5). To summrize the results, the time require for ining fluories to tooth struture ws inrese y omine pplitions of fluorie using S with A n N with FP, TM, n CS. This resulte in n inrese in fluorie ontents on the surfe n insie the teeth. Also, the inrese in the fluorie ontent of enmel surfe improve the hrness of the tooth struture. These results orrespone prtilly with the results reporte y Crll et l., whih emonstrte tht the omine pplition of A n S resulte in exellent preventive effets ginst initil entl ries ompre to ses trete with single pplition of fluorie with APF. 28 Sine most of the urrent professionl fluorie pplitions inlue single fluorie prouts, we ime to hieve n inrese uptke of fluorie y pplying fluories for longer time through omine pplitions of fluorie. The omine pplitions of fluorie opte in this stuy oul e use s sis for esigning new methos of fluorie pplition for prevention ginst entl ries. However, there oul e ifferenes etween the rel orl environment n experimentl onitions, n there were lso time limittion of 4 weeks for eh mesurements. Therefore, more omprehensive n in-epth stuies on the long-term reminerliztion effets in situ or linil tests re neee. Conlusions Comine topil pplitions of fluorie use in this stuy showe improve reminerliztion effets n strengthening enmel. It ws lso ssume tht the omine pplitions of fluorie prouts n solutions oul e use s the sis for esigning more effetive methos of fluorie pplition to protet ginst entl ries. Aknowlegement This work ws supporte y the Ntionl Reserh Fountion of Kore (NRF) grnt fune y the Kore government (MEST, No , 214R1A4A1539). Ori numer Seon Mi Byeon, Min Ho Lee, Te Sung Be, Conflit of Interest: No potentil onflit of interest relevnt to this rtile ws reporte. Referenes 1. Mühlemnn HR, Ruolf ER. Fluorie retention fter rinsing with soium fluorie n mine fluorie. Helv Oontol At 1975;19: Glgn DJ, Knutson JW. The effet of topilly pplie fluories on entl ries experiene; report of finings with two, four n six pplitions of soium fluorie n of le fluorie. Puli Helth Rep 1947;62: Knutson JW, Armstrong WD. The effet of topilly pplie soium fluorie on entl ries experiene. Puli Helth Rep 1943;58: Cury JA, Tenut LM. How to mintin riostti fluorie onentrtion in the orl environment. Av Dent Res 28;2: Tenut LM, Cury JA. Fluorie: its role in entistry. Brz Orl Res 21;24: Lt S, Vrghese NO, Vrughese JM. Reminerliztion potentil of fluorie n morphous lium phosphtesein phospho peptie on enmel lesions: n in vitro omprtive evlution. J Conserv Dent 21;13: Lee YE, Bek HJ, Choi YH, Jeong SH, Prk YD, Song KB. Comprison of reminerliztion effet of three topil fluorie regimens on enmel initil rious lesions. J Dent 21;38: ten Cte JM, Jongeloe WL, Arens J. Reminerliztion of rtifiil enmel lesions in vitro. IV. Influene of fluories n iphosphontes on short- n long-term reiminerliztion. Cries Res 1981;15: Amerin Dentl Assoition Counil on Sientifi Affirs. Professionlly pplie topil fluorie: eviene-se linil reommentions. J Dent Eu 27;71: Ostel I, Krhuvr L, Tenovuo J. Comprtive ntiteril effets of hlorhexiine n stnnous

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