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Remineralization!Strategies:!! Advancements!in!Fluoride,!Calcium!&!Phosphate!Technologies!!

Kristy!Menage!Bernie,!RDH,!BS,[email protected]!! On

Our Opportunities... · Understand how calcium, phosphate & fluoride work synergistically to provide optimal caries & sensitivity prevention. · Discuss the 4 types of calcium phosphate systems available on the market today & identify products with these systems. · Provide the rationale for use of CP systems in combination with fluoride. Why? Who? What? Where? When? ! Caries Management by Risk Assessment (CAMBRA) ! Remineralization is a LIFE LONG benefit ! Treatment/prevention based on RISK vs. disease activity or lack thereof... ! Legal implications? Fluoride: Mechanism of Action 1. Inhibits demineralization at the time of acid challenge. 2. Enhances remineralization when present by accelerating the formation of new mineral, combining calcium, phosphate, and fluoride forming a low soluble veneer. The resulting mineral is much less soluble then the original tooth mineral. 3. Generates antibacterial action through the formation of hydrogen fluoride (HF), which is a result of acid produced by bacteria combining with fluoride. HF diffuses through cell walls and interferes with enzyme pathways slowing down and even killing bacteria. Fluoride Options ! Neutral Sodium Fluoride (NaF) ! Acidulated Phosphate Fluoride (APF) ­ `Minute' products ! Stannous Fluoride (SnF) Professionally Applied Fluoride Options ! Professionally applied o Tray systems ­ 2% NaF and 1.23% APF o Varnish ­ 5% NaF o Rinses ­ 2% NaF and APF/SnF combination ! In-Office Candidates (Wilkins) o Primary teeth o Posteruptive period o Active caries o Secondary/ recurrent caries o Wearing orthodontic appliance, bands, bonded brackets o Compromised salivary flow o Teeth supporting an overdenture o Exposed root surfaces following periodontal recession o Lack of compliance and conscientious efforts for daily dental biofilm removal o Low or no fluoride in drinking water o Early carious lesions

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ADA Resolution 37B - Fluoride Varnish Resolved, that the ADA supports the use of fluoride varnishes as safe & efficacious within a caries prevention program that includes caries diagnosis, risk assessment, and regular dental care, and be it further Resolved, that the ADA encourage the FDA to consider approving professional applied fluoride varnish for reducing dental caries, based on substantial amount of available data supporting the safety and effectiveness of this indication. ADA Topical Fluoride Recommendations ­ 2006 ­ Summary Fluoride gel is effective in preventing caries in school-age children Patients whose caries risk is low may not receive additional benefit from professional topical fluoride application There are considerable data on caries reduction for professionally applied topical fluoride gel treatments of 4 minutes or more Fluoride varnish applied every 6 months is effective in preventing caries in primary and permanent dentition of children and adolescents 2 or more applications of fluoride varnish per year are effective in preventing caries in high risk populations Fluoride varnish applications take less time, create less patient discomfort and achieve greater patient acceptability than fluoride gel especially in preschool children 4-minute fluoride foam applications, every 6 months are effective in caries prevention in the primary dentition & newly erupted permanent first molars There is insufficient evidence to address whether or not there is a difference in the efficacy of NaF versus APF gels Full guideline document online at: Take Home Fluoride Options ! NaF, APF, SnF toothpastes, gels & rinses ! Rx ! 5,000 ppm or Over-the-counter ! 250 (rinses) ­ 1,500 ppm (toothpastes) Calcium & Phosphate (CP) ­ How do they work? ! Building blocks for HAP ! Desensitization ! Remineralization Effective CP Systems must: ! Be soluble to release Ca and phosphate ions ! Not remove fluoride from the oral cavity ! ! Improved surface appearance/ luster Enhance fluoride `uptake'

! !

Not produce calculus Not prevent remineralization

Remineralization Requirements & Calcium Phosphate Systems ! A source of calcium ! A substrate on which to precipitate ! A source of phosphate ! Time ! The proper pH to react

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Calcium Phosphate Systems ! Tri-Calcium Phosphate (TCP): During the manufacturing process, a protective barrier is created around the calcium allowing it to coexist with the fluoride ions. As the toothpaste comes in contact with saliva during brushing, the barrier breaks down and makes the calcium, phosphate and fluoride readily available. ! Casein Phosphopeptide Amorphous Calcium Phosphate (CPP-ACP): Recaldent" - casein (milk protein) enclosed system that binds to oral tissues, plaque, etc. and then releases ACP at an acidic pH. ! Calcium Sodium Phosphosilicate (CSP): Novamin® - bioactive glass assists in sustained release of calcium & phosphate while neutralizing the pH. ! Amorphous Calcium Phosphate (ACP): ADA Foundation Technology - typically combined at point of use via dual chamber/ dual barrel/ mixing systems. Immediate release of CP upon contact with oral cavity. ! Other: o Arginine Bicarbonate & Calcium Carbonate (Sensistat products) o Sodium Phosphate, Disodium Phosphate & Calcium Disodium (ACT Restoring MR) Casein Phosphopeptide Amorphous Calcium Phosphate (CPP ­ ACP/ Recaldent) ! From milk protein casein ! Can be added to foods and dental products ! Releases calcium & phosphate at an acidic pH of 5.5 or below ­ `sticky' substance lends to retention & release kinetics ! Majority of studies focus on natural function of dairy and additives to food ! Contraindicated for those with true milk protein allergy ­ OK for lactose intolerant ! Recaldent: Trident Chewing Gum, MI Paste & MI Paste Plus ­ 950 ppm Fl (GC America) ! General Use Recommendations o 3 - 5 minute contact time recommended for professional and daily application 2 x a day o Application with finger or toothbrush o Pre & post whitening use indicated to relieve sensitivity o Chewing gum: 2 ­ 4 times a day Calcium Sodium Phosphosilicate (CSP/ Novamin) ! Solid bioactive glass that releases calcium, phosphate and silicate ! 15-year history as a bone regenerations system ! Found in various dental products ! May have anti-microbial properties, mechanism of action not understood ! Novamin: Oravive, SoothRx (3M ESPE), Nupro Prophy Paste,Nupro NuSolutions 5,000 ppm toothpaste (Dentsply), Sylc (Osspray), air polishing powder and Topex ReNew Toothpaste, (Sultan Healthcare). ! Pre & post whitening use indicated to relieve sensitivity ! General Use Recommendations ~ see individual product lines, varies o Contact time 2 - 3 minutes, no rinsing for 30 minutes o No specific recommendations for use with fluoride products Other CP Systems? ! Sensistat products: Proclude (prophy paste) & Denclude (take home) o Recommended for use in whitening desensitization treatment and prevention ! Reach ACT Restoring Mouthrinse ! Tri-Calcium Phosphate (TCP): 3M ESPE Clinpro 5,000 (5,000 ppm NaF with TCP) & Vanish XT

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Amorphous Calcium Phosphate (ACP) ! ADA Foundation system; Dual chamber systems that combine calcium & phosphate at point of use creating immediate release (under 1 minute) to generate bio-available calcium and phosphate in the oral cavity ! Very high solubility in saliva and rapidly transforms into stable apatite ! Can be delivered in many different forms and methods with or without fluoride ! ACP: Nite White ACP, Day White ACP, Turbo ACP, (Discus Dental) Enamel Care with Liquid Calcium toothpaste (Arm & Hammer), Aegis Pit & Fissure Sealant, Enamel Pro Prophy Paste, Enamel Pro Varnish, Enamel Pro APF Fluoride Gel (Premier), Quell Desensitizer, Aegis Crown & Bridge Cement, Aegis ORTHO Adhesive, and Relief ACP Oral Care Gel (Discus Dental) for home use (dual barrel syringe delivery with fluoride, KNO3 and ACP) ! Only system with research on use in take-home professionally dispensed whitening products to avoid sensitivity and enhance whitening result; various products can also be used pre & post whitening for sensitivity and to improve surface luster ! General Use Recommendations ~ see individual product lines, varies o Contact time 2 - 3 minutes, no rinsing for 30 minutes (when using toothpaste, mouthrinse, gel in tray, etc. type formulations) o Use prior to fluoride application in office or daily

Making the Most of Both: Calcium, phosphate and fluoride are more effective working together ! Consider utilizing systems to maximize remineralization and beyond! ! Apply calcium/phosphate systems prior to fluoride...we think!

Additional Agents for Caries Treatment/Prevention: ! Currently available and recommended: Chlorhexidine gluconate & Xylitol ! Emerging Therapies: o Natural Products: ! Propolis - Antibacterial against S. mutans ! Licorice root - Inhibits S. mutans ! Green and Black tea - Bactericidal against S. mutans ! Cranberry extract - Inhibit acid production, attachment, & biofilm formation by S. mutans o Probiotics ! Strain specific ! Works as long as probiotic is consumed ! Lozenge, yogurt, cheese and milk products o Caries Vaccine ! Passive administration of antibody ! Mucosal immunization with antigen ! Several challenges must be overcome before this is a reality

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Resources ­ visit sites below of archived issues, articles, etc.! Dimensions of Dental Hygiene ~ FREE ~ The Journal of Practical Hygiene ~ FREE ~ Journal of Periodontology ! 312-787-5518 ! $ 90.00 per year ! Modern Hygienist ~ FREE ~ PERIO Reports ~ FREE with HygieneTown ~ or RDH Magazine ~ FREE ~ ACCESS FREE with Membership Journal of Dental Hygiene FREE with Membership THE AMERICAN DENTAL HYGIENISTS' ASSOCIATION Online National Dental Hygiene List Serves/ Groups: ­ Electronic hygiene newsletter, product comparison site and more! ­ Click on purple ribbon to join as a RDH "lister" [email protected] ­ moderated by ADHA go to to join ­ A `MySpace' with `teeth'! Check out related feature article on Calcium & Phosphate at: and compare CP systems at: Check out related feature article on Orthodontic Dental Hygiene Care Plan at: Check out related feature article on FMD/Accelerated Periodontal Instrumentation at: Check out CAMBRA articles with charts at: and ADA Topical Fluoride Recommendations: ADA Caries Risk Assessment Forms: American Association of Orthodontists: Home Study CE Course: Clinical Considerations for the Dental Hygienist in Orthodontic Therapy Hosted by the California Dental Hygienists' Association · 2 hours CE credit · Download at:

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