Rupert Austin

Surface texture measurement for dental wear applications

The application of surface topography measurement and characterization within dental materials science is highly active and rapidly developing, in line with many modern industries. Surface measurement and structuring is used extensively within oral and dental science to optimize the optical, tribological and biological performance of natural and biomimetic dental materials. Although there has historically been little standardization in the use and reporting of surface metrology instrumentation and software, the dental industry is beginning to adopt modern areal measurement and characterization techniques, especially as the dental industry is increasingly adopting digital impressioning techniques in order to leverage CAD/CAM technologies for the design and construction of dental restorations. As dental treatment becomes increasingly digitized and reliant on advanced technologies such as dental implants, wider adoption of standardized surface topography and characterization techniques will become evermore essential. The dental research community welcomes the advances that are being made in surface topography measurement science towards realizing this ultimate goal.

An in situ study investigating dentine tubule occlusion of dentifrices following acid challenge

OBJECTIVES To investigate the dentine occlusion and acid resistance of dentifrices developed to treat dentine hypersensitivity. METHODS This was a single centre, single blind, randomised, split mouth, four treatments, two period crossover, in situ study in healthy subjects. Subjects wore buccal intra-oral appliances each fitted with four dentine samples over four consecutive days with one study product applied per appliance; 8% strontium acetate in silica base, 1040 ppm sodium fluoride (Sensodyne(®) Rapid Relief), 8% arginine, calcium carbonate, 1450 ppm sodium monofluorophosphate (Colgate Sensitive Pro-Relief(®)), 1450 ppm sodium fluoride (control paste) and water. On days 3 and 4, two agitated grapefruit juice challenges (ex vivo) occurred for 1 min. At the end of each treatment day 1 dentine sample was removed from each appliance for scanning electron microscopy (SEM). The extent of tubule occlusion was measured using an examiner-based visual scoring index (three trained examiners). RESULTS In total, 28 subjects ((12 males and 16 females with a mean age of 34.7 years (SD 8.41 years)) completed the study. On day 2, both test dentifrices demonstrated significantly better dentine tubule occlusion than water (p < 0.0001) and control paste (8% strontium p = 0.0003 and 8% arginine p = 0.0019). After 3 and 4 days of twice daily brushing with acid challenges on days 3 and 4 the strontium-based dentifrice demonstrated significantly better dentine occlusion than all other treatments (p < 0.0001). CONCLUSIONS Strontium acetate and arginine-based dentifrice result in statistically significant dentine tubular occlusion compared to controls, but the arginine-based dentifrice is more susceptible to acid challenge. CLINICAL SIGNIFICANCE Erosive beverages are an important aetiology in DH by exposing dentine tubules. Their consumption has increased significantly over the past decade in the UK. This 4-day in situ study investigated the properties of commercially available dentifrices designed to occlude dentine tubules and their resistance to an agitated acid challenge.

The effect of increasing sodium fluoride concentrations on erosion and attrition of enamel and dentine in vitro

OBJECTIVES To investigate the effect of an aqueous sodium fluoride solution of increasing concentration on erosion and attrition of enamel and dentine in vitro. METHODS Enamel and dentine sections from caries-free human third molars were polished flat and taped (exposing a 3 mm x 3 mm area) before being randomly allocated to 1 of 5 groups per substrate (n=10/gp): G1 (distilled water control); G2 (225 ppm NaF); G3 (1450 ppm NaF); G4 (5000 ppm NaF); G5 (19,000 ppm NaF). All specimens were subjected to 5, 10 and 15 cycles of experimental wear [1 cycle=artificial saliva (2h, pH 7.0)+erosion (0.3% citric acid, pH 3.2, 5 min)+fluoride/control (5 min)+attrition (60 linear strokes in artificial saliva from enamel antagonists loaded to 300 g)]. Following tape removal, step height (SH) in mum was measured using optical profilometry. RESULTS When the number of cycles increased the amount of tooth surface loss increased significantly in enamel and dentine after attrition and erosion and for dentine after attrition. Attrition and erosion resulted in greater surface loss than attrition alone after 15 cycles of experimental wear of enamel. 5000 ppm and 19,000 ppm sodium fluoride solutions had a protective effect on erosive and attritional enamel tooth wear in vitro, however no other groups showed significant differences. CONCLUSIONS The more intensive the fluoride regime the more protection was afforded to enamel from attrition and erosion. However, in this study no such protective effect was demonstrated for dentine.

In vivo measurements of tooth wear over 12 months.

The aim of this study was to measure the progression of tooth wear in a cohort of 63 patients, 43 males and 20 females with a mean age of 39.1 years. Recruitment followed referral from general practice to Guy’s Hospital for advice/management of tooth wear. Addition silicone impressions were taken at 6-month intervals for a total of 12 months; impressions were subsequently poured in type IV gypsum. Casts were scanned using a non-contacting laser profilometer and then superimposed using Geomagic® Qualify 11. Wear was measured in µm by tooth per time interval. A questionnaire highlighting dietary, parafunctional and gastric risk factors was obtained from each participant. Clustered multiple regression analysis was used to determine the relationship between tooth wear progression and risk factors. Maximum follow-up times were 6 months for 63 participants and 12 months for 30 participants. The measurement error was 15 µm. At the tooth level, 72.2% of 1,078 teeth wore <15 µm over a 6-month period. At the subject level, 77.7% of 63 participants showed median wear <15 µm over a 6-month period. There was a statistical trend towards tooth wear progression being associated with gastric risk factors (p < 0.05). The lower molars and the upper anterior teeth were the most commonly affected teeth; the lower molars and the upper central incisors were the most severely affected teeth. Tooth wear progression was slow in this cohort, suggesting that tooth wear may be cyclical and inactive in the majority of participants.

A qualitative and quantitative investigation into the effect of fluoride formulations on enamel erosion and erosion–abrasion in vitro

OBJECTIVES To investigate the effect of a single application of highly concentrated SnF(2) and NaF solutions and a NaF/CaF(2) varnish on human enamel subjected to hydrochloric acid erosion and tooth brush abrasion. METHODS Forty enamel samples were prepared from human third molars and NaF (9500ppm, pH 8.0), SnF(2) (9500ppm, pH 2.6) solutions; Bifluorid10(®) varnish (42,500ppm, NaF 5%, CaF(2) 5%) and deionized water (control) was applied to the enamel. Following this three, six and nine cycles of erosion [1 cycle=erosion (0.01M HCl, pH 2.2, 2min)+artificial saliva (1h, pH 7.0)] and erosion-abrasion [1 cycle=erosion (0.01M HCl, pH 2.2, 2min)+artificial saliva (1h, pH 7.0)+abrasion (120 linear strokes in artificial saliva from Tepe medium soft brushes 200g loading)] were carried out. The fluoride treated enamel was analysed using Knoop microhardness, scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). RESULTS For erosion alone, there was significantly less microhardness reduction in the Bifluorid10(®) group after three and six cycles of erosion (P<0.05), however no other groups showed statistically different hardness (P>0.05). The EDS analysis showed that only the Bifluorid10(®) group had any detectable fluorine following erosion and erosion-abrasion (0.1wt.% and 0.2wt.% fluorine respectively). The surface fluorine was found to have been removed after erosion and erosion-abrasion for all other surface treatments. Although precipitates were observed after application of the surface treatments, following erosion-abrasion, no visible surface effects from any fluoride preparation remained. CONCLUSIONS Enamel surface precipitates from application NaF, SnF(2) solutions appear to not be able to provide protection against gastric erosion and tooth brush abrasion. The NaF/CaF(2) varnish provided limited protection against erosion but the role for such varnishes in gastric erosion and tooth brush abrasion remains uncertain.

Composition of Enamel Pellicle from Dental Erosion Patients

Oral health is dependent upon a thin mobile film of saliva on soft and hard tissues. Salivary proteins adhere to teeth to form the acquired enamel pellicle which is believed to protect teeth from acid erosion. This study investigated whether patients suffering diet-induced dental erosion had altered enamel pellicles. Thirty patients suffering erosion were compared to healthy age-matched controls. Subjects wore a maxillary splint holding hydroxyapatite and human enamel blocks for 1 h. The acquired enamel pellicle was removed from the blocks and compared to the natural incisor pellicle. Basic Erosive Wear Examination scores confirmed that dental erosion was present in erosion patients and absent from healthy age-matched controls. Erosion patients had half the amount of proteins (BCA assay) within the acquired pellicle forming on splint blocks compared to normal controls (p < 0.05). In particular, statherin, a calcium-binding protein, was 35% less abundant (p < 0.05). Calcium concentration within the acquired pellicle was also reduced by 50% in erosion patients (p < 0.001). In contrast, the natural pellicle on the incisor had similar amounts of total protein in erosion patients and healthy controls. In summary, the formation of new acquired pellicles on surfaces was reduced in erosion patients, which may explain their greater susceptibility to acid erosion of teeth.

Comparison of the Possible Protective Effect of the Salivary Pellicle of Individuals with and without Erosion

The acquired pellicle adheres to tooth surfaces and has been suggested to provide differing degrees of protection against acidic erosion. This study investigated whether pellicle formed on enamel blocks in patients suffering dietary dental erosion modified the effect of an in vitro simulated dietary challenge, in comparison with pellicle formed on enamel blocks in healthy subjects and to no-pellicle enamel samples. Sixty subjects recruited from dental erosion clinics were compared to healthy age-matched controls. Subjects wore a custom-made maxillary splint holding human enamel blocks for 1 h during which the acquired enamel pellicle was formed. Enamel blocks were removed from the splints and a simulated dietary erosive challenge of 10 min was performed. In addition the challenge was performed on 30 enamel samples without pellicle. Profilometry showed no statistical difference between samples from the erosion subjects with a mean step height of 1.74 µm (SD 0.88) and median roughness (Sa) of 0.39 µm (interquartile range, IQR 0.3-0.56) and the controls with 1.34 µm (SD 0.66) and 0.33 µm (IQR 0.27-0.38), respectively. The control samples without pellicle had Sa of 0.44 µm (IQR 0.36-0.69) and these differences were statistically significant compared to those from the healthy subjects (p = 0.002). Mean (SD) microhardness reduction with a 100-gram load for the erosion group was 113.5 (10) KHN, for healthy subjects was 93 (15.4) KHN and for the enamel samples without pellicle 139.6 (21.8) KHN and all groups were statistically different. The microhardness and roughness data suggested the pellicle influenced erosion under these study conditions.

Confocal laser scanning microscopy and area-scale analysis used to quantify enamel surface textural changes from citric acid demineralization and salivary remineralization in vitro

OBJECTIVES This paper investigates the application of confocal laser scanning microscopy to determine the effect of acid-mediated erosive enamel wear on the micro-texture of polished human enamel in vitro. METHODS Twenty polished enamel samples were prepared and subjected to a citric acid erosion and pooled human saliva remineralization model. Enamel surface microhardness was measured using a Knoop hardness tester, which confirmed that an early enamel erosion lesion was formed which was then subsequently completely remineralized. A confocal laser scanning microscope was used to capture high-resolution images of the enamel surfaces undergoing demineralization and remineralization. Area-scale analysis was used to identify the optimal feature size following which the surface texture was determined using the 3D (areal) texture parameter Sa. RESULTS The Sa successfully characterized the enamel erosion and remineralization for the polished enamel samples (P<0.001). SIGNIFICANCE Areal surface texture characterization of the surface events occurring during enamel demineralization and remineralization requires optical imaging instrumentation with lateral resolution <2.5 μm, applied in combination with appropriate filtering in order to remove unwanted waviness and roughness. These techniques will facilitate the development of novel methods for measuring early enamel erosion lesions in natural enamel surfaces in vivo.

Biologically Based Restorative Management of Tooth Wear

The prevalence and severity of tooth wear is increasing in industrialised nations. Yet, there is no high-level evidence to support or refute any therapeutic intervention. In the absence of such evidence, many currently prevailing management strategies for tooth wear may be failing in their duty of care to first and foremost improve the oral health of patients with this disease. This paper promotes biologically sound approaches to the management of tooth wear on the basis of current best evidence of the aetiology and clinical features of this disease. The relative risks and benefits of the varying approaches to managing tooth wear are discussed with reference to long-term follow-up studies. Using reference to ethical standards such as “The Daughter Test”, this paper presents case reports of patients with moderate-to-severe levels of tooth wear managed in line with these biologically sound principles.

The influence of varnish and high fluoride on erosion and abrasion in a laboratory investigation.

BACKGROUND The aim of this study was to investigate the potential of concentrated fluoride varnishes to reduce enamel loss from repeated cycles of citric acid erosion and toothbrush abrasion in vitro. METHODS Polished human enamel samples were exposed to fluoride varnishes: Bifluorid10® (NaF&CaF2- 45,200 ppmF), Duraphat® (NaF 22,600 ppmF), Fluor-Protector® (difluorsilane 1000 ppmF) and a control coating of copal ether varnish (0 ppmF) group and a deionized water group. For each group of 16 samples, nine cycles of erosion and nine cycles of erosion-abrasion [1 cycle=erosion (0.3% citric acid, pH 3.2, 5 min)+artificial saliva (1 h, pH 7.0)+abrasion (120 linear strokes in artificial saliva from Oral B medium soft brushes 300 g loading]. The change in the enamel surface was evaluated using optical profilometry. RESULTS Duraphat® and Bifluorid10® applications had a median (IQR) step height of 4.21 um (1.59) and 5.01 um (1.02). This was statistically significantly less than Fluor-Protector® 6.83 um (1.25), copal ether 7.22 um (1.97) and water 7.39 um (1.96) (p<0.001). For erosion-abrasion, both Duraphat® and Bifluorid® had statistically lower step heights than the other products (p<0.01). CONCLUSIONS The action of fluoride in a range of single-application topical varnishes was effective in reducing enamel wear from erosion and erosion-abrasion in this laboratory study.