Jonathan E. Creeth

Interplay between fluoride and abrasivity of dentifrices on dental erosion–abrasion

OBJECTIVES Eroded teeth are more susceptible to toothbrushing wear than sound teeth. We tested the hypothesis that fluoride and abrasivity of dentifrices can interact, modulating the development of erosive-abrasive lesions. METHODS Human enamel and root dentin specimens were submitted to cycles of demineralization, remineralization and toothbrushing using six dentifrices formulated with three different abrasivity levels: low (L), medium (M) and high (H); with (+F) and without (-F) fluoride. Surface loss was quantified by optical profilometry and compared among groups (alpha=0.05). RESULTS In dentin, it was ranked: L<M<H, for both +F and -F dentifrices. In enamel, +F dentifrices had similar results; however for -F formulations, M and H did not differ. Fluoride reduced surface loss in enamel, at all abrasive levels. In dentin, the same fluoride effect was observed but only for the low abrasive formulation. CONCLUSIONS Both fluoride and abrasivity were important modulators of enamel surface loss, while abrasivity had a higher impact than fluoride on dentin.

The effect of human saliva substitutes in an erosion–abrasion cycling model

Saliva may affect dental erosion-abrasion by reducing demineralization, enhancing remineralization, and acting as lubricant. This study tested the effect of human saliva substitutes in an erosion-abrasion cycling model designed for enamel and root dentin. Specimens were randomly assigned into the following groups (n = 8): artificial saliva (AS), artificial saliva + mucin (AS+M), deionized water (DIW, negative control), and pooled human saliva (HS, clinical reference). Each group was submitted to a cycle of 5 min in 1% citric acid (pH 3.75), 30 min in the testing solutions, and toothbrushing (enamel, 500 strokes; dentin, 150 strokes, approximately 200 g load) in fluoridated dentifrice (1,100 p.p.m. NaF) slurry. Specimens were rinsed and dried after each procedure. This cycle was repeated three times each day, for 3 d. Substrate loss was measured daily using optical profilometry. Analysis of variance (anova) and Tukey tests (alpha=0.05) showed a significant increase in enamel and dentin wear throughout the experiment for all groups. At the end of the experiment, enamel wear for each group was ranked as: (AS)<(AS+M) and (HS)<(DIW), with AS+M not differing from HS. For dentin, groups AS and AS+M did not differ from each other or from DIW, but showed significantly higher wear than HS. The artificial saliva with mucin showed promise as a potential substitute for human saliva in the enamel erosion-abrasion cycling model. For dentin, none of the artificial salivas performed similarly to human saliva.

The effect of brushing time and dentifrice quantity on fluoride delivery in vivo and enamel surface microhardness in situ

While the clinical anticaries efficacy of fluoride toothpaste is now without question, our understanding of the relation of fluoride efficacy to brushing time and dentifrice quantity is limited. The aim of this in situ study was to determine how differences in brushing time and dentifrice quantity influence (i) fluoride distribution immediately after brushing, (ii) clearance of fluoride in saliva, (iii) enamel fluoride uptake (EFU) and (iv) enamel strengthening, via the increase in surface microhardness. The study compared brushing times of 30, 45, 60, 120 and 180 s with 1.5 g of dentifrice containing 1,100 µg/g fluoride as sodium fluoride. In addition, 60 s of brushing with 0.5 g dentifrice was evaluated. A longer brushing time progressively reduced retention of dentifrice in the brush, thereby increasing the amount delivered into the mouth. A longer brushing time also increased fluoride concentrations in saliva for at least 2 h after the conclusion of brushing, showing that increased contact time promoted fluoride retention in the oral cavity. There was a statistically significant positive linear relationship between brushing time and both enamel strengthening and EFU. Compared to 0.5 g dentifrice, brushing with 1.5 g dentifrice more than doubled the fluoride recovered in saliva after brushing and increased EFU. In conclusion, the results of this preliminary, short-term usage study suggest for the first time that both brushing time and dentifrice quantity may be important determinants both of fluoride retention in the oral cavity and consequent enamel remineralization.

The effect of dentifrice quantity and toothbrushing behaviour on oral delivery and retention of fluoride in vivo

While toothpaste F(-) concentration and rinsing regimen have well-characterised impacts on fluorides effectiveness, other aspects of brushing regimen have much less well-established effects, in particular, dentifrice quantity and brushing duration. An in vivo study (n = 42) of oral fluoride delivery (i.e. oral disposition post-brushing), and retention (i.e. concentration of F(-) in saliva post-brushing, a known efficacy predictor), was performed to compare effects observed with those of dentifrice F(-) concentration and rinsing regimen. Subjects brushed with a NaF-silica dentifrice (Aquafresh Advanced, 1,150 ppm F(-) ) or a control dentifrice (250 ppm F(-) , same base), for 45, 60, 120 or 180 seconds with 0.5 or 1.5 g dentifrice, and rinsed with 15 ml water once or three times in a cross-over design. The F(-) concentration was measured in post-brushing expectorate, rinse and toothbrush washing samples, and in saliva between 5-120 minutes after brushing. Using 1.5 g versus 0.5 g dentifrice increased F(-) in all samples: oral retention of F(-) was almost doubled by this increase. Increasing duration of brushing had more complex effects. The amount of F(-) in the expectorate increased but decreased in both rinse and toothbrush washing samples. Oral F(-) retention increased, but only in the period 30-120 minutes after brushing. Over the ranges investigated, the order of importance on oral F(-) retention was: dentifrice F(-) concentration > quantity > rinsing regimen > brushing duration. Hence, increasing dentifrice quantity and, to a lesser extent, the duration of brushing, can elevate oral fluoride post-brushing. Evidence is accumulating that the importance of these variables to fluoride efficacy may have been underestimated.

Dose–response effect of fluoride dentifrice on remineralisation and further demineralisation of erosive lesions: A randomised in situ clinical study

OBJECTIVE The objective was to evaluate the ability of fluoride in a conventional, non-specialised sodium fluoride-silica dentifrice to promote tooth remineralisation and enamel fluoride uptake (EFU), and assess the resistance of the newly formed mineral to attack by dietary acid, across the concentration range used in mass-market dentifrices. METHODS Subjects wore a palatal appliance containing eight polished bovine enamel specimens, each including an early erosive lesion. In a randomised full-crossover sequence, 62 healthy subjects were treated with dentifrices containing four different fluoride concentrations: no fluoride; 250ppm, 1150ppm and 1426ppm fluoride. At each treatment visit, under supervision, subjects brushed with 1.5g dentifrice and rinsed once while wearing the appliance; the appliance was removed after a 4-h remineralisation period and effects on the enamel specimens determined. The primary efficacy variable was surface microhardness recovery (SMHR); others included EFU, relative erosion resistance (RER) and comparative erosion resistance. RESULTS Highly significant linear and, with the exception of SMHR, quadratic dose-response relationships were observed between all efficacy variables and fluoride concentration. For SMHR, EFU and RER, values for the different fluoride concentrations were statistically resolved from one another, with the exception of the two highest fluoride concentrations. The degree of remineralisation and the acid resistance of enamel after treatment were closely related to EFU. CONCLUSION After a single brushing, conventional non-specialised sodium fluoride-silica dentifrices promoted remineralisation of early enamel lesions, and imparted increased acid-resistance to the enamel surface, in a dose-dependent manner at least up to 1500ppm fluoride. CLINICAL SIGNIFICANCE Enamel erosive tissue loss is an increasing concern, associated with modern diets. This study demonstrated that sodium fluoride, in a conventional non-specialised dentifrice formulation, can promote repair of the earliest stages of enamel erosion after a single application, in a dose-dependent fashion across the fluoride concentration range used in mass-market dentifrices. This study is registered in the GlaxoSmithKline Study Register (ID RH01299), available at: www.gsk-clinicalstudyregister.com/study/RH01299.

Effect of toothbrushing duration and dentifrice quantity on enamel remineralisation: An in situ randomized clinical trial

OBJECTIVES The influence of toothbrushing duration and dentifrice quantity on fluoride efficacy against dental caries is poorly understood. This study investigated effects of these two oral hygiene factors on enamel remineralisation (measured as surface microhardness recovery [SMHR]), enamel fluoride uptake (EFU), and net acid resistance (NAR) post-remineralisation in a randomized clinical study using an in situ caries model. METHODS Subjects (n=63) wore their partial dentures holding partially demineralised human enamel specimens and brushed twice-daily for two weeks, following each of five regimens: brushing for 120 or 45s with 1.5g of 1150ppm F (as NaF) dentifrice; for 120 or 45s with 0.5g of this dentifrice; and for 120s with 1.5g of 250ppm F (NaF) dentifrice. RESULTS Comparing brushing for 120s against brushing for 45s, SMHR and EFU increased by 20.0% and 26.9% respectively when 1.5g dentifrice was used; and by 22.8% and 19.9% respectively when 0.5g dentifrice was used. Comparing brushing with 1.5g against brushing with 0.5g dentifrice, SMHR and EFU increased by 35.3% and 51.3% respectively when brushing for 120s, and by 38.4% and 43.0% respectively when brushing for 45s. Increasing brushing duration and dentifrice quantity also increased the NAR value. The effects of these two oral hygiene factors on SMHR, EFU, and NAR were statistically significant (p<0.05 in all cases). CONCLUSION Brushing duration and dentifrice quantity have the potential to influence the anti-caries effectiveness of fluoride dentifrices. Study NCT01563172 on ClinicalTrials.gov. CLINICAL SIGNIFICANCE The effect of two key oral hygiene regimen factors - toothbrushing duration and dentifrice quantity - on fluorides anticaries effectiveness is unclear. This 2-week home-use in situ remineralisation clinical study showed both these factors can influence fluoride bioactivity, and so can potentially affect fluorides ability to protect against caries.

In situ anticaries efficacy of dentifrices with different formulations – A pooled analysis of results from three randomized clinical trials

OBJECTIVES Data generated from three similar in situ caries crossover studies presented the opportunity to conduct a pooled analysis to investigate how dentifrice formulations with different fluoride salts and combinations at concentrations of 1400-1450 ppm F, different abrasive systems and in some cases, carbomer (Carb), affect enamel caries lesion remineralization and fluoridation. METHODS Subjects continuously wore modified partial dentures holding two gauze-covered partially-demineralized human enamel specimens for 14 days and brushed 2×/day with their assigned dentifrice: Study 1: sodium fluoride (NaF)/Carb/silica, NaF/silica, NaF + monofluorophosphate (MFP)/chalk; Study 2: NaF/Carb/silica, NaF + MFP/dical, amine fluoride (AmF)/silica; Study 3: NaF/Carb/silica, NaF + stannous fluoride (SnF2)/silica/hexametaphosphate (HMP). All studies included Placebo (0 ppm F) and/or dose-response controls (675 ppm F as NaF [675F-NaF]) ±Carb. Specimens were evaluated for percentage surface microhardness recovery (SMHR) and enamel fluoride uptake (EFU). RESULTS All 1400-1450 ppm F dentifrices except NaF + SnF2/silica/HMP provided significantly greater lesion remineralization than Placebo (p < 0.0001): differences in SMHR ranged from 17.46% (NaF + MFP/dical) to 26.66% (AmF/silica). For EFU (back-transformed log EFU), all 1400-1450 ppm F dentifrices gave significant fluoride uptake compared to Placebo (p < 0.0001): increases in EFU ranged from 4.95 μg F/cm2 (NaF + SnF2/silica/HMP) to 16.32 μg F/cm2 (NaF/carb/silica). Dentifrices containing NaF or AmF as sole fluoride source provided the greatest remineralization and fluoridation; Carb addition did not alter fluoride efficacy; some excipients appeared to interfere with the cariostatic action of fluoride. Treatments were generally well-tolerated with ≤4 treatment-related adverse events per study. CONCLUSION Commercially available fluoride dentifrices varied greatly in their ability to remineralize and fluoridate early caries lesions. CLINICAL SIGNIFICANCE Fluoride dentifrices are the most impactful anticaries modality worldwide. While clinical caries trials have not consistently shown the superiority of one formulation over another, these findings using a sensitive in situ caries model indicated that dentifrices containing NaF or AmF as the sole fluoride source provided the greatest remineralization and fluoridation benefits.