An Update On Tooth Remineralization

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1 REVIEW ARTICLE An Update On Tooth Remineralization Nisha Garg, MDS; Amit Garg, MDS; Saru Kumar Manchanda, MDS; Navjot S. Khurana * Department of Conservative Dentistry and Endodontics, Sri Sukhmani Dental College and Hospital, Derra Bassi,Mohali. ** Department of Oral and maxillofacial surgery, Sri Sukhmani Dental College and Hospital, Derra Bassi,Mohali. *** Consultant endodontist, Faridabad. # Department of Conservative Dentistry and Endodontics, Govt. Dental College, Patiala. Address for correspondence: : Dr. Nisha Garg, house no. 2347, Sec 23 C, Chandigarh, India. Pin code: Mob: drnishagarhg1@gmail.com Abstract : MID is of utmost importance in today's dental practice as it focuses on least invasive treatment options possible in order to minimize the tissue loss and patient discomfort. So MID is the key principle in remineralization of early carious lesions non invasively by advocating a therapeutic or biological approach rather than traditional surgical approach for early surface lesions. The aim of this paper is to review contemporary and new remineralizing systems for remineralization therapy and their implementation into the clinical practice. Clinical relevance:-remineralization helps in management of hypocalcified areas, desensetization of exposed dentin by dental erosion and after debonding of brackets in liew of completion of orthodontic treatment. Keywords: casein derivatives, remineralizing agents, remineralization-demineralization. cavity. Oral bacteria excrete acid after consuming Scan this QR code to access article. sugar, leading to demineralization.3 Upon this acid challenge, the hydroxyapatite crystals are dissolved from the subsurface. Introdution Dental caries is a multifactorial disease caused by the interaction of dietary sugars, dental biofilm and the host s dental tissue within the oral environment.1 The process of caries formation is a cycle of remineralization and demineralization with various stages being either reversible or irreversible.2 A break in the equilibrium causes the tooth to remineralize or demineralize depending upon the concentration of the mineral saturation in the oral In a neutral environment, the hydroxyapatite of the enamel is in equilibrium with saliva which is saturated with calcium and phosphate ions.4 At or below ph 5.5, H + ions produced by the bacterial metabolites react preferentially with the phosphate group of the enamel crystals, converting PO4 2- ion to (HPO4) 2- ion which, once formed, can no more form the crystal lattice; at the same time H+ ions are buffered. This leads to enamel dissolution, termed as demineralization, which marks the beginning of early enamel caries.5,6 Downloaded from

2 Remineralization is the natural repair process for noncavitated lesions. Remineralization is defined as the process whereby calcium and phosphate ions are supplied from a source external to the tooth to promote ion deposition into crystal voids in demineralized enamel to produce net mineral gain.7 In other words, remineralization would be best defined as the redeposition of minerals lost by enamel, and this term has been used as a synonymous of enamel repair or rehardening.8 The requirements of an ideal remineralization material are as follows:11,13 Should diffuse into the subsurface or deliver calcium and phosphate into the subsurface Should be able to work at an acidic ph Should work in xerostomic patients Should not deliver an excess of calcium Should not favor calculus formation Boosts the remineralizing properties of saliva Any "remineralizing therapy" should follow two Mineral loss (demineralization) or gain fundamental principles:8 (remineralization) by enamel is a dynamic 1. Dental biofilm, the necessary factor responsible for physicochemical process occurring when oral bacteria form a biofilm on the enamel surface and this caries lesions, should be controlled by toothbrushing. 2 Fluoride should be used either to arrest existing biofilm is exposed to fermentable dietary lesions or to reduce the progression of new ones. carbohydrates, sucrose being the most cariogenic of them.9 One of the key elements of a biological approach is the usage and application of a remineralizing agents to tooth surface. These agents are part of a new era of dentistry aimed at controlling the demineralization Fluoride It has been known since the 1980s that fluoride controls caries predominantly through its topical, not systemic, effect.1 Arnold, in 1957, was the first author to mention the post-eruptive effect of fluoride in the drinking water and the ability of topical remineralization cycle, depending upon the fluoride to reduce the incidence of caries. microenvironment around the tooth.10 This article details the various agents that enhance and promote Four mechanisms are involved by which fluoride increases caries resistance viz; increased enamel remineralization and their clinical implications. resistance, increased rate of maturation, Indications of tooth remineralization11 An adjunct preventive therapy to reduce caries in high-risk patients To repair enamel in cases involving white-spot lesions Reduce dental erosion in patients with gastric reflux or other disorders To reduce decalcification in orthodontic patients Before and after teeth whitening Desensitize sensitive teeth.12 remineralization of incipient caries, interference with micro-organisms and improved tooth morphology.14 Enamel is dissolved by lowering of ph in dental plaque due to acid production every time sugar is ingested. However, if F - is present in the biofilm fluid, and the ph is not lower than the critical ph, hydroxyapatite (HA) is dissolved and at the same time fluorapatite is formed. This indirect effect of fluoride in reducing enamel demineralization when the ph drops is complemented by its natural effect on remineralization.15this fluoride comes from topical Downloaded from

3 sources such as drinking water, and fluoride products All these limitations have prompted researchers to like toothpastes and varnishes. look for non-fluoridated alternatives for When the ph returns to ph 5.5 or above, saliva which is supersaturated with calcium and phosphate, forces mineral back into the tooth. Fluoride adsorbs to the surface of the partially demineralized crystals and attracts calcium ions. Fluoride speeds up the growth of the new surface by bringing calcium and phosphate ions together which are preferably incorporated into the remineralized surface. This produces a surface which is now more acid resistant.16 remineralization. CPP-ACP (Recaldent) In 1946, studies showed that that the anticariogenic properties of milk were due to casein, calcium and phosphate. Further investigation by the University of Melbourne in Australia showed that a particular part of the casein protein, casein phosphopeptides (CPP), was responsible for the tooth-protective activity. This technology was developed by Eric Reynolds.21They Fluorides inhibit bacterial activity. In acid showed that peptides containing the cluster sequence environment, fluoride combines with hydrogen to form HF which diffuses into the bacterial cell. Inside the cell HF breaks up and releases fluoride ions that interfere with the essential enzyme activity of the bacteria. Moreover, fluoride acts as reservoir after application of a fluoride treatment such as toothpaste, varnish or restorative material and is then released into the saliva over time.17,18 Fluoride can be used in combination with sodium, tin and titanium. The newly introduced titanium fluoride (TiF) exhibits enhanced uptake of calcium, and TiF pretreated enamel also shows loss of calcium during demineralization.19 Reasons to seek alternatives to fluoride: 1. Fluoride is highly effective on smooth-surface caries; its effect would seem to be more limited on pit and fissure caries. 2. A high-fluoride strategy cannot be followed to avoid the potential for adverse effects (e.g., fluorosis) due to overexposure to fluoride. of amino acids -Ser(P)-Ser(P)-Ser(P)-Glu-Glu have a remarkable ability to stabilise calcium and phosphate and keep them in a soluble, amorphous state. In general, combining calcium and phosphate ions results in formation of insoluble calcium phosphate crystals. But in the presence of CPP, the calcium and phosphate remain in an ionic form that can diffuse into the tooth enamel and repair areas for remineralization.22 CPP-ACP is the acronym for a complex of casein phosphopeptides (CPPs) and amorphous calcium phosphate (ACP). Caseins are a heterogeneous family of proteins predominated by alpha 1 and 2 and b- caseins. CPPs are phosphorylated casein-derived peptides produced by tryptic digestion of casein.12 The proposed mechanism of anticariogenicity for the CPP-ACP is that it localizes ACP in dental plaque, which buffers the free calcium and phosphate ion activities, thereby helping to maintain a state of supersaturation with respect to tooth enamel 3. Although fluoride presents no problems when used depressing demineralization and enhancing properly, among certain parts of the world, there has been the suggestion that fluoride exposure should be limited.20 remineralization. 13Adding CPP-ACP to soft drinks and sports drinks reduced their erosive potential on enamel when compared to those without.23,24 CPP Downloaded from

4 inhibits adherence of oral bacteria to saliva-coated hydroxyapatite beads (S-HA). It can be incorporated into the pellicle in exchange for albumin, and thus inhibits the adherence of Streptrococcus mutans and Streptococcus sobrinus, causing both neutralization and enhancement of remineralization.25 arrested white spot lesions should have a surface etching treatment before remineralization with Recaldent products, unlike fluoride treatments with conventional dentifrices (1000 ppm) that deposit surface mineral but do not eliminate a white-spot lesion. Thus, it is evident that other than for fluoride, RECALDENT is an ingredient derived from casein, the strongest level of clinical evidence for part of the protein found in cow's milk. More recently, remineralization is for the CPP-based Recaldent a sugar-free, water-based cream containing technology, with both long-term large-scale clinical RECALDENT (CPP-ACP) (GC Tooth trials and randomized controlled clinical trials to Mousse/Prospec MI Paste) has been made available to dental professionals.26 Recaldent is available in solutions, gums, lozenges support its efficacy. Bioactive glass (calcium sodium phosphosilicate) Bioactive glass (Bioglass) was invented by Dr. Larry and creams form.chewing a sugarless gum Hench in1960s.28 Bioglass in an aqueous containing RECALDENT (CPP-ACP), or applying GC Tooth Mousse27 immediately after brushing with a fluoride toothpaste, or even after administration of environment immediately begins surface reaction in three phases, leaching and exchange of cations, network dissolution of SiO 2 and precipitation of fluoride by a dental professional, enhances the calcium and phosphate to form an apatite layer. It has remineralization activity of the fluoride. It is ph responsive, i.e. with increasing ph, the level of bound ACP increases, stabilizing free calcium and phosphate and thus providing an anti-calculus been demonstrated that fine particulate bioactive glasses (<90 μm) incorporated into an aqueous dentifrice have the ability to clinically reduce the tooth hypersensitivity through the occlusion of action.21 The anti-caries action influences the dentinal tubules by the formation of the CAP layer. properties and behavior of dental plaque through (1) 29 Novamin, a trade name for bioactive glass, is binding with adhesion molecules on mutans manufactured by Novamin Technologies Streptococci, impairing their incorporation into Inc.(Alachua, FL, USA). It is technically described plaque, (2) elevating plaque calcium ion levels to as an inorganic amorphous calcium sodium inhibit plaque fermentation and (3) providing protein and phosphate buffering of plaque fluid ph to suppress overgrowth of aciduric species when phosphosilicate (CSPS). The NovaMin Technology was developed by Dr. Len Litkowski and Dr. Gary Hack. Currently available products in the market are fermentable carbohydrate is in excess. NovaMin: SootheRx, DenShield, NuCare-Root Tooth crèmes using CPP-ACP (Recaldent Conditioner with NovaMin, NuCare-Prophylaxis technology) such as MIPaste and ToothMousse 27recognize the importance of the neutral ion species, gaining access to the sub-surface lesion through a porous enamel surface. This is the reason why Paste with NovaMin, and Oravive.30,31 In the presence of water or saliva, NovaMin rapidly releases sodium ions. This increases the local ph and initiates the release of calcium and phosphate. Downloaded from

5 NovaMin particles act as reservoirs and continuously release calcium and phosphate ions into the local environment. This may continue over many days.32 remineralization. 39,40 When it is used in toothpaste formulations, a protective barrier is created around the calcium, allowing it to coexist with the fluoride Calcium-phosphate complexes crystallize into ions. When TCP comes into contact with saliva, the hydroxycarbonate apatite. Chemically and protective barrier breaks down, making the calcium, structurally, this apatite is nearly identical to bone and tooth mineral.33,34 NovaMin has been incorporated into toothpastes, gels and prophy pastes. A novel delivery system for NovaMin is through an air polishing unit. This system provides the benefits of both tooth desensitization and smoothing of surface roughness, promoting a smoother, less plaque and stain retentive surface. 35,36 Caries can also result from inadequate saliva, without which fluoride is of limited value. 37 Thus, phosphate and fluoride ions available to the teeth. The fluoride and calcium then react with weakened enamel to provide a seed for enhanced mineral growth relative to fluoride alone. Studies have shown that TCP provides superior remineralization when compared to a 5000 ppm fluoride and CPP-ACP.41 ACP technology {enamelon, enamel care} The ACP technology requires a two-phase delivery system to keep the calcium and phosphorous components from reacting with each other before use. individuals who experience reduced calcium, The current sources of calcium and phosphorous are phosphate and fluoride ions caused by hyposalivation can benefit from the use of bioactive glass. Also, women are at increased caries risk due to inadequate salivary calcium levels at different points in their two salts, calcium sulfate and dipotassium phosphate. When the two salts are mixed, they rapidly form ACP that can precipitate on to the tooth surface. This precipitated ACP can then readily dissolve into the lives, including ovulation, pregnancy and postmenopause, saliva and can be available for tooth resulting in the same net effect as reduced saliva fluoride efficacy. Thus, the use of remineralization.42 It can be considered a useful adjuvant for the control of caries in orthodontic bioactive glass (Novamin Technology) in applications. remineralization of enamel is quite promising, especially in patients with systemic problems, but further research needs to be undertaken to prove its efficacy.11 Tri-calcium phosphate (TCP) (Clinpro Tooth Crème) TCP is a bioactive formulation of tri-calcium phosphate and simple organic ingredients.38,39tcp is a new hybrid material created with a milling technique that fuses beta tricalcium phosphate and sodium lauryl sulfate or fumaric acid. This results in a "functionalized" calcium and a "free" phosphate, so The ACP technology was developed by Dr. Ming S. Tung. In 1999, ACP was incorporated into toothpaste called Enamelon and later reintroduced in 2004 in Enamel Care toothpaste by Church and Dwight. It is also available as Discus Dental's Nite White Bleaching Gel and Premier Dental's Enamel Pro Polishing Paste. It is also used in the Aegis product line, such as Aegis Pit and Fissure Sealant, produced by Bosworth.43 Sugar substitutes Xylitol as to increase the efficacy of fluoride Downloaded from

6 It is a sugar alcohol that has been shown to have noncariogenic as well as cariostatic effects.44 Its sources are fruits, berries, mushrooms, lettuce, hardwoods and corn on the cob. Xylitol results in11:- Reduction of dental plaque formation Neutralization of plaque acids by decreasing the production of lactic acid. Reduction of levels of S.mutans Reduction of cavities by up to 80% Remineralization of tooth enamel Xylitol interfers with the metabolism of S.mutans. When S. mutans is transported into a cell, xylitol makes it to bind to proteins. Due to this bond, transport protein is unable to go out of the cell and bring more glucose into the cell, thereby, bacteria are calcium and phosphate in combination with xylitol has been developed using a NaF varnish. This varnish contains calcium and phosphate salts that have been nano-coated with xylitol. Xylitol coating produces a sustained release of the remineralizing ions. Saliva exposure dissolves the xylitol and frees the calcium and phosphate ions which further react with the fluoride in the varnish to form protective fluorapatite on the teeth.53,7 Sorbitol is another sugar substitute that is used as an artificial sweetner. The abilities of xylitol and sorbitol to remineralize early enamel caries seem to be almost similar.54 Isomalt ia a noncariogenic sweetner that is widely used as a sugar substitute. Adding isomalt to a unable to produce the sticky extracellular demineralizing solution has shown to significantly polysaccharides that bind bacteria together.45this decreases caries incidence and promotes colonization of less virulent strains of bacteria that can ferment xylitol. It has also been shown that a combination of fluoride reduce tooth mineral loss.55 Grape seed extract When caries reach the dentin, the demineralized dentin matrix is further degraded, allowing bacteria to infiltrate the intertubular area.56 Thus, stability of and xylitol is more effective than fluoride dentin collagen is essential during the alone.46,47,48,49 Best time to use xylitol is immediately after eating and clearing the mouth by swishing with water. Also it does not raise blood pressure or blood glucose levels as most sugar substitutes do. Studies have shown that the habitual chewing of xylitol gum by mothers can decrease the caries incidence in their children by preventing the remineralization process, because it acts as a scaffold for mineral deposition. Polyphenols (plant-derived substances) have antioxidant and anti-inflammatory properties 57,58,59 by interacting with microbial membrane proteins, enzymes and lipids. This changes the cell permeability and allows loss of proteins, ions and macromolecules. One such transmission of S. mutans.50 Besides fluoride, polyphenol is proanthocyanidin (PA), which calcium lactate also enhances remineralization when added to xylitol.51 The recommended dose for maximum prevention of dental caries is minimum of 5-6 grams and three exposures per day (from chewing gum and/or accelerates the conversion of soluble collagen to insoluble collagen during development and increases collagen synthesis.57 Grape seed extract (GSE) has high PA content. PA-treated collagen matrices are non-toxic and inhibit the enzymatic activity of candies).52 The A novel method of transporting glucosyl transferase, F-ATPase and amylase. Downloaded from

7 Inhibition of glucosyl transferases by PA in turn inhibits caries.58,60,61 GSE can act as a potential adjunct or alternative to fluoride in the treatment of root caries during minimally invasive therapy. Calcium carbonate carrier sensi stat The SensiStat Technology was developed by Dr. Israel Kleinberg of New York. The technology was first incorporated into Ortek's Proclude desensitizing remineralizing agents, we can create a more favorable relationship in which remineralization can occur.11 Mostly published studies supporting these materials have been in vitro studies. The potential of remineralising agents is promising, but more studies are needed, including clinical trials supporting its efficacy in boosting remineralization. References prophy paste and later in Denclude SensiStat 1. Buzalaf MAR, Fluoride and the Oral technology is made of arginine bicarbonate, an amino acid complex, and calcium carbonate. Arginine Environment, Monogr Oral Sci, Basel, Karger, 2011, vol 22, p complex is responsible for holding the calcium 2. Vashist R, Indira R, Ramachandran S, Kumar carbonate particles to the tooth surface and allows the calcium carbonate to slowly dissolve and release calcium which is then available to remineralize the tooth surface.63 A, Srinivasan MR. Role of casein phosphopeptide amorphous calcium phosphate in remineralization of white spot lesions and inhibition of Streptococcus mutans. Ozone 3. Fejerskow O, Kidd, EA, Nyvad B, Baclum V, Ozone is a chemical compound consisting of three oxygen atoms (O3, triatomic oxygen). Ozone therapy is also proposed to stimulate remineralization of incipient caries following treatment for a period of Defining the disease: an introduction: in Fejerskov O, KiddE (eds): Dental Caries- The Disease and its Clinical Magement, ed 2, Oxford, Blackwell Munksgaard, 2008, p 3-6. about 6-8 weeks.64,65 4. Silverstone LM, Hicks MJ, MJ Featerstone. Conclusion Due to recent innovations and more inclination towards preventive care, the multifactorial disease process of demineralization and caries can be slowed Dynamic factors affecting lesion initiation and progression in human dental enamel, 2 Surface morphology of sound enamel and caries like lesions of enamel. Quintessence Int 1988;19: down before more extensive treatment becomes 5. Marsh PD. The oral microflora and biofilm on necessary. Therefore the goal of modern dentistry is the non-invasive management of non-cavitated caries lesions involving remineralization systems to repair the enamel with fluorapatite or fluorhydroxyapatite. the teeth. In: Fejerskov O, Kidd E, editors. Dental caries: The disease and its clinical management. Oxford (UK): Blackwell and Munksgaard; p Incidence of caries has shown to be reduced because 6. Larsen MJ. Dissolution of enamel. Scand J of simple remineralization tools, techniques and Dental Research1973;81: products that have been found effective in reversing 7. Cochrane NJ, Cai F, Huq NL, Burrow MF, and controlling the caries process. With a clearer understanding of the implementation of these Reynolds EC. New approach to enhance Downloaded from

8 remineralization o tooth enamel. J Dent Res 18. Van Louveren C, the antimicrobial action of 2010;89: fluoride and its role in caries inhibition, J Dent 8. Cury JA, Tenuta LMA. Enamel Res1990:69: remineralization: controlling the caries disease or 19. Exterkate RA, Tencate JM. Effects of a new treating early caries lesions? titanium fluoride derivative on enamel de and 9. Dawes C. What is the critical ph and why remineralization. Eur J Oral Sci. 2007;115(2): does a tooth dissolve in acid? J Can Dent Assoc. 20. Brown WE. Physicochemical mechanisms in 2003;69: dental caries. J Dent Res 1974;53: Rao A, Malhotra N. The role of 21. Reynolds EC. Anticariogenic complexes of remineralizing agents in dentistry: a review. amorphous calcium phosphate stabilized by casein Continuing Education 2, compendium phosphopeptides: A review. Spec Care Dentist 2011;32(6): ;18: Tyagi SP, Garg P, Sinha DJ, Singh P. an 22. Azarpazhooh A, Limeback H. Clinical update on remineralizing agents. 2013;3(3):151-8 efficacy of casein derivatives. A systematic review of 12. Zero DT. Dentifrices, mouthwashes, and the literature. J Am Dent Assoc 2008;139: remineralization caries treatment strategies. BMC 23. Manton DJ, Cai F, Yuan Y, Walker GD, Oral Health 2006;6 Suppl 1:S9-S22. Cochrane NJ, Reynolds C, et al. Effect of casein 13. Walsh LJ. The current status of tooth crèmes phospeptide -amorphous calcium phosphate added to for enamel remineralization. Dental Inc. acidic beverages on enamel erosion in vitro. Aust 2009;2(6):38-42 Dent J 2010;55: Mellberg RJ, Ripa WL, Leske SG. Fluoride in 24. Ramalingam L, Messer LB, Reynolds EC. preventive dentistry-theory and clinical applications. Chicago: Quintessence Publishing Co., Inc; Adding caseinphosphopeptide- amorphous calcium phosphate to sports drinks to eliminate in vitro 15. Cury JA, Tenuta LM. Enamel erosion. Pediatr Dent 2005;27:67-7 remineralization: Controlling the caries disease or 25. Schupbach P, Neeser JR, Golliard M, Rouvet treating the early caries lesions? Braz Oral Res M, Guggenheim B. incorporation of 2009;23 Suppl 1: caseinoglycomacropeptide and 16. Ten Cate JM, feathersone JDB, Mechaanistic caseinophosphopeptide into the salivary pellicle aspects of the interactions between fluoride and dental enamel, Crit Rev Oral Biol 1991, 2: inhibits adherence of mutans streptococci. J Dent Res 1996;75: Hamilton IR, Bowden GHW, Fluoride effects 26. Llena C, Fomer L, Baca P. Anticariogenicity on oral bacteria, In Fejerskov O Ekstrand J, Burt BA of casein phosphopeptides-amorphous calcium (eds) Fluoride in Dentistry, Copenhagen, phosphate: A review of the literature. J Contemp Dent Munksgaard, 1996 p Pract 2009;10: Walsh LJ. Tooth Mouse: Anthology of applications. Singapore: GC Asia Pte Ltd; Downloaded from

9 28. Reynolds EC. Calcium phosphate-based 37. Leone CW, Oppenheim FG. Physical and remineralization systems: Scientific evidence? Aus Dent2008;53: chemical aspects of saliva as indicators of risk for dental caries in humans. J Dent Educ 2001;65: Litkowski LJ, Hack GD, Sheaffer HB, 38. Karlinsey RL, Mackey AC, Walker ER, Greenspan DC. Occlusion of dentin tubules by 45S5 Bioglass.Bioceramics 1997; p. 10. Frederick KE, Enhancing Remineralization of Subsurface Enamel Lesions with Functionalized 30. Tai BJ, Bian Z, Jiang H. Anti-gingivitis effect ftcp, In Biomaterials Developments and of a dentifrice containing bioactive glass (NovaMin) Applications, 2010, EDS H Bourg, A Lisle: particulate. J Clin Periodontol 2006;33: Karlinsey RL, Mackey AC, Solid-State 31. Iijima Y, Cai F, Shen P, Walker G, Reynolds Preparation and Dental Application of an Organically C, Reynolds EC. Acid resistance of enamel sub Modified Calcium Phosphate, J Mater Sci, surface lesions remineralized by a sugar free chewing 2009:44: gum containing amorphous calcium phosphate. 40. Karlinsey RL, Mackey AC, Walker ER, Caries Res 2004;38: Frederick KE. Surfactant-modified ß-TCP: Structure, 32. Damen JJ, ten Cate JM, Silica-induced properties, and in vitro remineralization of subsurface precipitation of calcium phosphate in the presence of enamel lesions. J Mater Sci 2010;21: inhibitors of of hydroxyapatite formation, J Dent Res, 41. Karlinsey RL, Mackey AC, Walker ER, 1992: 71: Amaechi BT, Karthikeyan R, Najibfard K. et al. 33. Gandolfi MG, Silvia F, H PD, Gasparrotto G, Remineralization potential of 5000 ppm fluoride Carolo P, Calcium silicate coating derived from Portland cement as a treatment for hypersensitive dentifrices evaluated in a ph cycling model. J Dent Oral Hyg 2010;2:1-6. dentine, Journal of Dentistry, 2008,36(8), Tung MS, Eichmiller FC. Dental applications 34. Anderson OH, Kangasniemi I, Calcium of amorphous calcium phosphates. J Clin Dent 2003; phosphate formation at the surface of bioactive glass 10:1-6. in vitro, Journal of Biomedical Materials Research, 43. Sullivan RJ, Charig A, Haskins JP, Zhang YP, 1991, 25(8), Miller SM, Strannick M, et al. In vivo detection of 35. Sauro, S, Watson T, Thompson I, calcium from dicalcium phosphate dehydrate Ultramorphology and dentine permeability changes induced by phophylactic procedures on exposed dentrifrice in demineralized human enamel and plaque. Adv Dent Res 1997;11: dentinal tubules in middle dentine, Med Oral Patol 44. Maguire A, Rugg-Gunn AJ, Xylitol and caries Oral Cir Buccal, Biomaterials and bioengineering in dentistry, prevention is it a magic bullet?, British Dental Journal, 2003:194: Wang Z, et al, Dentine remineralization 45. Makinen KK. Can the pentitol-hexitol theory induced by two bioactive glasses developed for air abrasion purposes, Journal of Dentistry, 2011, explain the clinical observations made with xylitol? Med Hypotheses 2000;54: doi: /j.dent Downloaded from

10 46. Smits MT, Arends J. Influence of human enamel lesions in situ. Caries Res. xylitoland/orfluoride-containing toothpastes on the 1992;26(2):104-9 remineralization of surface softened enamel defects 55. Takatsuka T, Exterkate RA, Tencate JM. in vivo. Caries Res 1985;19: Effects of isomalt on enamel de and remineralization, 47. Gaffar A, Blake-Haskins JC, Sullivan R, a combined in vitro Ph cycling model and in situ Simone A, Schmidt R, Saunders F. Cariostatic effects study. Clin Oral Investig.2008;12(2): of a xylitol/naf dentifrice in vivo. Int Dent J 56. Ten Cate AR. In: Oral histology: 1998;48:32-9. Development, structure, and function. 5 th ed. St. 48. Amaechi BT, Higham SM, Edgar WM. The Louis: Mosby; p influence of xylitol and fluoride on dental erosion in 57. Mount GJ, Ngo H. Minimal intervention: A vitro. Arch Oral Biol 1998;43: new concept for operative dentistry. Quintessence Int 49. Maehara H, Iwami Y, Mayanagi H, Takahashi 2000;31: N. Synergistic inhibition by combination of fluoride 58. Xie Q, Bedran-Russo AK, Wu CD. In vitro and xylitol on glycolysis by mutans streptococci and its biochemical mechanism. Caries Res 2005;39:521- remineralisation effects of grape seed extract on artificial root caries. J Dent 2008;36: Ferrazzano GF, Amato I, Ingenito A, Zarrelli 50. Isokangas P, Soderling E, Pienihakkinen K, A, Pinto G, Pollio A. Plant polyphenols and their anticariogenic Alanen P, Occurance of Dental Decay in Children properties: A review. Molecules after Maternal Consumption of Xylitol Chewing 2011;16: gum, a Follow up from 0 to 5 Years of Age, Journal 60. Wu CD. Grape products and oral health. J of dental Research, 2000,79,1885. Nutr 2009;139 Suppl:1818S-23S. 51. Suda R, Suzuki T, Takiguchi R et al. the effect 61. Hattori M, Kusumoto IT, Namba T, Ishigami of adding calcium lactate to xylitol chewing gum on remineralization of enamel lesions. Caries Res. 2006;40(1):43-6. T, Hara Y. Effect of tea polyphenols on glucan synthesis by glucosyltransferases from Streptococcus mutans. Chem Pharm Bull 1990;38: Milgrom P, Ly KA, Rothen M, Xylitol and Its 62. McClure MJ. Further studies on the cariostatic Vehicles for Public Health needs, Advances in Dental Research, 2009, doi / effect of organic and inorganic phosphates. J Dent Res 1963;42: Cochrane NJ, Cai F, Huq NL, Burrow MF, 63. Nizel AE, Harris RS. The Effects of Reynolds EC. New approach to enhance Phosphates on Experimental Dental Caries: A remineralization o tooth enamel. J Dent Res Literature Review. J Dent Res 1964;43: ;89: Nogales CG, Ferrari PH, Kantorovich EO, 54. Manniung RH, Edgar WM, Agalamanyi EA. Lage-Marques JL. Ozone therapy in medicine and Effects of chewing gum sweetened with sorbitolor a dentistry. J Contemp Dent Pract. 2008;9(4):75-84 sorbitol/xylitol mixture on the remineralization of 65. Huth KC, Paschos E, Brand K, Hickel R. effect of ozone on non cavitated fissure carious Downloaded from

11 lesions in permanent molars. A controlled prospective clinical study. Am J Dent. 2005;18(4): How to cite this article: Garg N, Garg A, Manchanda SK, Khurana NS. An Update On Tooth Remineralization. IJRD 2015;4(2): Downloaded from