Enhanced Remineralisation of Tooth Enamel Using Casein Phosphopeptide-Amorphous Calcium Phosphate Complex: a Review

Home , Calcium phosphate, Fluorapatite

Review Article Int J Clin Prev Dent 2018;14(1):1-10ㆍhttps://doi.org/10.15236/ijcpd.2018.14.1.1 ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197

Enhanced Remineralisation of Tooth Enamel Using Casein Phosphopeptide-Amorphous Calcium Phosphate Complex: A Review

Nidhi Chhabra, Anuj Chhabra

Department of Dental Surgery, North DMC Medical College and Hindu Rao Hospital, Delhi, India

The protective effects of milk and milk products against dental caries, due to micellar casein or caseinopeptide derivatives, have been demonstrated in various animal and human in situ studies. Among all the remineralising agents, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) technology has shown the most promising scientific evidence to support its use in prevention and reversal of carious lesions. CPP-ACP complex acts as a calcium phosphate reservoir and buffer the activities of free calcium and phosphate ions in the plaque. Calcium phosphate stabilized by CPP produces a metastable solution supersaturated with respect to the amorphous and crystalline calcium phosphate phases, thereby depressing enamel demineralisation and enhancing mineralisation. CPP-ACP provides new avenue for the remineralisation of noncavitated caries lesions. The objective of this article was to review the clinical trials of CPP-ACP complex and highlight its evidence based applications in dentistry.

Keywords: remineralisation, casein derivatives, casein phospho peptide-amorphous calcium phosphate

Introduction from an imbalance in the physiological process of remineralisation/demineralisation of the tooth structure and results in the Recent scientific advances in restorative materials, techni- formation of a subsurface lesion [1]. At an early stage, the caries ques and better understanding of the etiology, pathogenicity and lesion is reversible via remineralisation process involving the prevention of caries, have led to more efficient management of diffusion of calcium and phosphate ions into the subsurface le- oral health. Dental caries is a pathological condition arising sion, to restore the lost tooth structure. Due to the presence of calcium and phosphate ions in supersaturated state, the whole human saliva has the potential to remineralise demineralised Corresponding author Nidhi Chhabra crystals of tooth structure, while preventing surface deposition Department of Dental Surgery, North DMC Medical College in the form of calculus [2]. However, net remineralisation pro- and Hindu Rao Hospital, DR. J.S. Kkaranwal Memorial duced by saliva is small and a slow process, with a tendency for Road, Near Malka Ganj, Sabji Mandi, Malka Ganj, New the mineral gain to be in the surface layer of the lesion due to Delhi, Delhi 110007, India. Tel: +91-1127471245, Fax: the low ion concentration gradient from saliva into the lesion +91-1127471245, E-mail: [email protected] [3]. Thus, if the pH challenge overcome the physiological re- https://orcid.org/0000-0002-0277-8938 mineralisation process, a therapeutic approach using the new Received February 28, 2018, Revised March 5, 2018, remineralisation system is necessary to achieve effective lesion Accepted March 9, 2018 regression.

Copyright ⓒ 2018. Korean Academy of Preventive Dentistry. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Enamel Remineralising Systems ally would sequester available fluoride ions, thereby reducing their ability to promote remineralisation of subsurface enamel Fluoride has been known as a remineralising agent that inter- lesions [18,19]. acts with the oral fluids on the interface of enamel and subsur- Recent developments in the area of remineralisation include face regions of teeth, and combines with the calcium and phos- casein phosphopeptide (CPP)-ACP nanocomplexes, which are phate ions to form fluorapatite crystals [4]. Fluoride is the cor- derived from bovine milk protein, casein, calcium, and nerstone of the non-invasive management of non-cavitated ca- phosphate. ries lesions, but its ability to promote net remineralisation is limited by the availability of calcium and phosphate ions in the sali- CPP-ACP va or dental plaque [5]. Various studies have shown that enamel remineralisation in situ and the retention of fluoride in plaque In the late 1950s, milk and dairy products were shown to be are dependent on the availability of calcium ions [5-8]. Hence, effective in preventing caries without any side effects on the on topical application of fluoride ions, the availability of cal- teeth [20-30]. Casein is the predominant phosphoprotein in bo- cium and phosphate ions can be the limiting factor for fluoride vine milk and accounts for almost 80% of its total protein, pri- retention and net enamel remineralisation to occur, and this is marily as calcium phosphate stabilized micellular complexes highly exacerbated under hypo-salivation conditions [5]. that can be released as small peptides (CPPs) by partial enzy- Moreover, the topical fluoride applications (particularly matic digestion. This has led to the development of a reminerali- high concentrations) promote mainly the surface remineralisa- sation technology based on CPP-stabilized ACP complexes tion of enamel [9-12]. However, remineralising agents should (CPP-ACP) (RecaldentR CASRN691364-49-5) [31,32] and supply stabilized bioavailable calcium, phosphate and fluoride CPP stabilized ACFP complexes (CPP-ACFP) [5,33,34]. The ions that favor the subsurface remineralisation rather than CPPs are approximately 10% (w/w) of the protein casein [35]. merely promoting the surface remineralisation. Also, this ele- They can be easily purified from a tryptic digest of casein by ment can cause fluorosis, and is toxic if administered in high selective precipitation, iron exchange, or ultrafiltration [36]. dosages [13,14]. Moreover, CPP does not have the limitations that are associated With the increasing focus on early detection and non-in- with the use of casein like the adverse organoleptic properties vasive management of caries, researchers have been testing and large amount required for its efficacy. The potential for a new methods to enhance the remineralisation of enamel. The specific anticariogenic activity is at least 10 times greater on a problem with applying crystalline calcium phosphate reminer- weight basis for CPP than it is for casein [37]. alising materials to promote enamel remineralisation in the oral The concept of CPP-ACP as a remineralising agent was first cavity is the poor solubility of the calcium phosphate phases, postulated in 1998 [37]. The CPP-ACP complex was patented such that the calcium and phosphate ions are unavailable for re- by the University of Melbourne, Australia, and the Victorian mineralisation at normal pH range of saliva [15]. Furthermore, Dairy Industry Authority, Abbotsford, Australia. Bonlac Foods localization of significant quantities of solid calcium phosphate Limited (an Australian company owned by 2,300 dairy farmers phases at the tooth surface is problematic [16]. in Victoria and Tasmania) has retained exclusive manufactur- The unstabilized amorphous calcium phosphate (ACP) sys- ing and marketing rights for CPP-ACP and is the owner of the tems deliver calcium ions with phosphate ions that result in im- trademark RecaldentTM [38]. The protective anticariogenic ef- mediate precipitation of ACP or, in the presence of fluoride ions, fects of CPP-calcium phosphate complexes have been shown amorphous calcium fluoride phosphate (ACFP). In the intra-or- in various laboratory, animal and human in situ studies [39-48]. al environment, these phases (ACP and ACFP) are potentially CPP-ACP complexes have been incorporated into commer- very unstable and may rapidly transform into a more thermody- cially available sugar-free chewing gum (RecaldentTM; GC namically stable, crystalline phase (e.g., hydroxyapatite [HA] Corp, Tokyo, Japan and Trident WhiteⓇ; Cadbury Adams USA, and fluorhydroxyapatite) [17]. Although some of the published Parsippany, NJ, USA), mints (Recaldent MintsTM; Cadbury papers suggest that the unstabilized ACP/ACFP technology Japan Ltd, Tokyo, Japan), topical gels (Tooth Mousse, Tooth may have efficacy in preventing caries progression, some au- Mousse Plus; GC Corp, and MI Paste and MI Paste Plus; GC thors have expressed concern with the unstabilized nature of the America, Alsip, IL, USA) and experimentally tested sports product that forms intra-orally with this technology. The un- drinks and glass ionomer cements (Figure 1) [16,45,46,49]. stabilized ACP/ACFP may transform to poorly soluble phases One of the advantages of CPP-ACP products over fluoride in the mouth, and, in so doing, may act to promote dental products is that they do not cause fluorosis of the enamel and calculus. The formation of fluoride-containing apatite intra-or- are ingestible in contrast to the topical fluoride products that

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CPP-ACP release the weakly bound calcium and phosphate ions [32,52,53] which would then deposit into crystal voids. Hence, the CPPs have a role in regulating the anisotropic crystal growth and also inhibiting crystal demineralisation in the enamel subsurface lesions [54]. In addition to it, the increased calcium phosphate in the plaque buffers free calcium and phosphate ion activities and maintains a state of super-saturation of the ions in close approximation with the tooth, thus enhancing the enamel remineralisation [37]. Numerous in vitro studies have highlighted that CPP has the potential to stabilize calcium phosphate in solution by forming colloidal CPP ACP complexes [32,43]. The CPP contains a cluster of phosphoseryl residues –Ser(P)–Ser(P)–Ser(P)-Glu- Glu, which stabilize calcium and phosphate ions under neutral and alkaline conditions forming metastable solutions, thereby preventing their growth to the critical size required for nuclea- tion and precipitation [43]. 2. Inhibition of streptococci adhesion to tooth Figure 1. Commercially available forms of casein phosphopeptide- surface amorphous calcium phosphate (CPP-ACP). Schüpbach et al. [19] proposed that the CPP-ACP inhibits the adhesion of cariogenic streptococci to tooth surface, resulting pose a risk if the patient ingests a significant amount of fluoride in the formation of a less cariogenic plaque. The CPP-ACP [50]. nano-complexes have also been demonstrated to bind on to the adsorbed macromolecules on the tooth surface, components of Mechanism of Action of CCP-ACP the intercellular plaque matrix and the surface of bacterial cells [14]. The method of binding CPP-ACP into plaque has been hy- pothesized to be due to calcium cross-linking [14,16,55] and/or 1. Buffering action by the calcium phosphate hydrophobic and hydrogen-bond-mediated interactions [16]. reservoir Rose [14] demonstrated that CPP-ACP competes with calcium Reynolds [44] suggested that the mechanism of anticario- for plaque calcium binding sites and thus reduce the degree of genicity for CPP-ACP is that it substantially localizes the cal- calcium binding between the pellicle and adhering cells and be- cium and phosphate ions in the plaque, which provides a reser- tween the cells themselves. CPP-ACP incorporates into the pel- voir of soluble calcium phosphate ions on the tooth surface. licle and plaque and results in an ecological alteration of the bac- When the acidogenic bacteria present in the dental biofilm me- terial population, which, together with the remineralising ca- tabolize dietary sucrose, the pH rapidly decreases below the pacity of the CPP-ACP, modifies the plaque’s cariogenic poten- resting pH of 7.0. Once this acid decreases the pH surrounding tial, leading to the formation of a less cariogenic plaque. Rose the teeth past a critical level (pH=5.5), it has the potential to dif- [14] also proposed that CPP-ACP could have a bactericidal or fuse into enamel and dissolve calcium phosphate mineral [51]. bacteriostatic effect by maintenance of high extracellular free Under these acidic conditions, the CPP-bound ACP break- calcium concentrations. downs and dissociate to release calcium and phosphate ions. In a study by Nyvad and Fejerskov [56], basing their study This mechanism is ideal for the prevention of enamel de- on earlier work by Weiss and Bibby [24] and Pearce and Bibby mineralization as there appears to be an inverse association be- [23], used transmission and scanning electron microscopy to tween plaque calcium and phosphate levels and measured ca- show that milk of various fat contents could substantially mod- ries experience [43,45,49]. ify the structure of the pellicle formed in vivo. The pellicle Recently, it has been shown, with confocal laser microscopy formed was not a uniform protein layer, but rather had a distinct and fluorescently labeled anti-CPP antibodies, that CPP was globular structure. They suggested that caseinglycomacropeptide present inside a CPP-ACP remineralised enamel subsurface le- and CPP adsorb to the surface of the pellicle and mask receptors sion [18]. Once present in the enamel subsurface lesion, the on salivary molecules for these streptococci [56]. Rahiotis et al.

www.ijcpd.org 3 International Journal of Clinical Preventive Dentistry

[57] observed that the presence of CPP-ACP agent (Tooth mineral that was more resistant to acid challenge [5]. The Mousse) delays the biofilm formation and favoured the nuclea- CPP-ACP nanocomplexes-plus-fluoride dentifrices resulted in tion and crystallization of calcium phosphates, possibly in apa- significantly greater incorporation of fluoride into the subsur- titic form, in matured biofilm. face enamel as fluorapatite. In a randomized controlled mouth rinse trial, a rinse containing 2.0% CPP-ACP nanocomplexes Synergistic Effects of Fluoride and plus 450 ppm fluoride significantly increased supra gingival CPP-ACP plaque fluoride ion content to 33.0±17.6 nmol F/mg dry weight (wt) of plaque when compared with 14.4±6.7 nmol F/mg dry The additive anticariogenic effect of CPP-ACP and fluoride wt of plaque attained by the use of a rinse containing the equiv- may be due to the localization of ACFP at the tooth surface alent concentration of fluoride ions [5]. which, in effect, would co-localize calcium, phosphate, and flu- In a study conducted by Papas et al. [60], to test the efficacy oride ions [43]. Electron microprobe analysis has shown that of ACFP-forming dentifrice in high-caries-risk patients, who the mineral formed in the enamel lesion is consistent with HA, underwent head and neck irradiation, the dentifrice forming when CPP-ACP is provided with a low background of fluoride, ACFP was found to be superior in lowering the root caries in- and when fluoride is present, the mineral is consistent with fluo- cidence compared to the dentifrice having only fluoride. rapatite or fluorhydroxyapatite [34]. The use of CPP-ACP alone, or in conjunction with fluoride, also reduces the amount Scientific Evidence for the of fluoride needed and thus reduces the amount of fluorosis [43]. Remineralisation Potential of CPP-ACP In a study by Cochrane et al. [34], concluded that remineralisation of the subsurface lesions was observed at all pH values There are numerous scientific studies highlighting the pro- tested, with a maximum at pH 5.5. This study showed that CPP motion of remineralisation of enamel subsurface lesions by stabilizes high concentrations of calcium, phosphate and fluo- CPP-ACP and CPP-ACFP. The mineral gained by the enamel ride ions at all pH values (7.0-4.5). CPP-ACFP solutions pro- subsurface lesions during in situ treatment with CPP-ACP has duced greater remineralisation than the CPP-ACP solutions at been acid-challenged to determine its relative solubility pH 5.5 and below. The mineral formed in the subsurface lesions [5,61,62]. These results of these studies highlighted that the was consistent with HA and fluorapatite for remineralisation CPP-ACP produced mineral was more acid-resistant than the with CPP-ACP and CPP-ACFP, respectively. non-CPP-ACP-treated lesions. This is due to the production of The other reason for the additive effect of CPP-ACP and fluo- a more stable mineral phase (e.g., HA or fluorapatite, as shown ride is that the plaque enzymes, such as phosphatases and pepti- by electron microprobe analysis) that has a lower solubility than dases partially degrade CPP-based products, consequently in- a calcium-deficient carbonated apatite of normal tooth enamel creasing pH due to the production of ammonia. Adding fluoride [62]. to CPP limits phosphatase action by extending the action of mo- In a study by Morgan et al. [48], conducted a randomized, lecular complexes [58]. controlled caries clinical trial in 2,720 schoolchildren for a peri- In a clinical trial, the animals receiving 0.5% CPP-ACP plus od of 24-month, to assess the impact of CPP-ACP in sugar-free 500 ppm fluoride had significantly lower caries activity than gum relative to a control sugar-free gum. Participants were in- those animals receiving either CPP-ACP or fluoride alone [31]. structed to chew their assigned gum for 10 min three times per Sakaguchi et al. [59] described a synergistic effect of CPP-ACP day. Standardized digital radiographs were taken at baseline and fluoride, as found in Tooth Mousse PlusTM (MI Paste and at the completion of the trial. The results showed that the PlusTM), in remineralising subsurface enamel lesions in bovine CPP-ACP gum significantly slowed caries progression up to teeth. Tooth Mousse PlusTM was compared with Tooth MousseTM, 18% and enhanced regression of baseline carious lesions up to a placebo containing no CPP-ACP or fluoride, and a paste con- 53% compared with the control sugar-free gum. Caruana et al. taining 950 ppm fluoride. The remineralisation potential of [63] performed a crossover study in which the plaque pH was Tooth Mousse PlusTM (Tooth MousseTM with 900 ppm fluoride) measured on 15 subjects with and without prior application of was greater than the additive effect of the Tooth MousseTM and the paste and it was observed that prior application of a CPP- the 950 ppm fluoridated paste groups. ACP containing paste reduced the fall in plaque pH following A dentifrice formulation containing 2% CPP-ACP nano- a sucrose challenge. complexes plus 1,100 ppm F (CPP-ACPF) has been shown to The reduction of caries activity by CPP-ACP is dose-depend- be superior (2.6 times) to a dentifrice containing only 1,100 ppm ent [31,45,49,62]. Reynolds et al. [31] conducted a study in the F in remineralisation of enamel subsurface lesions in situ with specific-pathogen-free rats that were orally infected with

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Streptococcus sobrinus bacterium. CPP-ACP solutions applied and in patients suffering from erosion, caries, dentin hyper- twice daily, showed significant reduced caries activity, with sensitivity and conditions arising from xerostomia. 0.1% weight/volume (w/v) CPP-ACP producing a 14% reduc- 1. Prevention of erosive/abrasive wear tion, and 1.0% w/v CPP-ACP producing a 55% reduction on smooth surfaces and 0.1% and 1.0% w/v CPP-ACP, re- Erosive tooth wear has become a focus of attention for the spectively, produced a 15% and 46% reduction in fissure caries dental researchers and practitioners. During the last decade, the activity relative to the distilled water control. use of CPP-ACP to enhance the remineralisation of carious le- Shen et al. [45] evaluated the effect of incorporating CPP-ACP sions and reduce the erosive potential of acidic drinks has been into sugar-free gum on enamel remineralisation. The addition reported [45,46]. Ramalingam et al. [46] immersed human en- of CPP-ACP to either the sorbitol or xylitol-based gums at 10.0, amel specimens in an erosive sports drink (Powerade [World 18.8, or 56.4 mg produced a significant increase in enamel re- of Coca-Cola, Atlanta, GA, USA] alone [0.063%, 0.09%, mineralisation, with a 63%, 102%, and 152% average increase, 0.125%, and 0.25%] and double deionized water as the place- respectively, relative to the sugar-free gum not containing bo). Scanning electron microscopic examination of the speci- CPP-ACP. Cai et al. [49] found that the used of sugar-free loz- mens showed that the erosive lesions that developed in speci- enges containing CPP-ACP significantly increased reminerali- mens immersed in Powerade, were eliminated with the addition sation of enamel subsurface lesions in situ, with 18.8 and 56.4 of CPP-ACP at all concentrations except 0.063%. It was con- mg of CPP-ACP increasing remineralisation by 78 and 176% cluded that adding CPP-ACP to the sports drinks, soft drinks respectively. Manton et al. [64] observed significant greater re- and other frequently consumed acid products significantly remineralisation with the gum containing CPP (Trident White duce the beverages erosivity without affecting the product’s [18.4%]) than gum without CPP (Orbit [8.9%] and Orbit taste. Professional [10.5%]). It has been suggested that the erosion inhibiting potential of The CPP-stabilised calcium phosphate solutions can re- CPP-ACP probably involves remineralisation by deposition of mineralise enamel subsurface lesions at rates of 1.5 to 3.9×10-8 mineral into the porous zone of the eroded enamel [67-70]. mol HA m-2 s-1 [43]. The CCP can stabilize over 100 times more Furthermore, studies by Ranjitkar et al. [68-70] showed statisti- calcium phosphate than is normally possible in aqueous sol- cally significant protective effects of CPP-ACP containing ution at neutral and alkaline pH before spontaneous precip- cream against erosive/abrasive tooth wear. This effect, how- itation [65]. ACP, crystalline phases dicalcium phosphate dehy- ever, was not shown in other studies dealing with CPP-ACP drate, and octacalcium phosphate have been suggested as the containing products [71,72]. Their studies elicited erosion us- intermediate structures in the formation of HA, depending on ing solutions with pH-values below the pH measured in the oral pH and degree of saturation. Assuming the deposited mineral cavity during reflux events. During reflux events, intra-oral pH in the remineralised lesions to be predominantly HA, the max- remains above 5.5 most of the time. Thus information is lacking imal average rate of remineralisation was 3.9±0.8×10-8 moles as to whether the use of CPP-ACP is able to minimize erosively HA/m2 for the ten-day period. This value is equivalent to the induced hard tissue loss in patients suffering from gastro-oeso- maximal rate of remineralisation of enamel subsurface lesions phageal reflux disease. obtained by de Rooij and Nancollas [66] using a constant-com- 2. Prevention and reversion of white spot lesions position procedure. Another in vitro study demonstrated that after a ten-day period, 1.0% CPP-calcium phosphate (pH 7.0) sol- Many a times, the orthodontic treatment is tarnished by the ution promoted a 63.9%+20.1% of remineralisation of enamel appearance of white spot lesions on the facial surface of teeth, subsurface lesion when compared to solutions with lower con- after removing the fixed appliances. White spot lesion is an area centrations of CPP-stabilized free calcium and phosphate ions of demineralised enamel that usually develops because of pro- [43]. longed plaque accumulation. If these early lesions are left un- treated, further decalcification may lead to development of cav- CPP-ACP Complex-Evidence Based itations, requiring tooth reduction or permanent restoration Clinical Applications [73]. Prevention of the white, opaque areas throughout orthodontic treatment is essential to providing the patient with the The various recommended professional applications of most esthetic outcome. Reynolds et al. [5,16] concluded that CCP-ACP complex are white spot lesions prevention/re- CPP-ACP promotes remineralisation of enamel subsurface le- gression, topical use following professional tooth cleaning and sion, restoring the white opaque appearance of the lesions to root smoothing, after application of topical fluoride, bleaching translucency, even in the presence of fluoride.

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Andersson et al. [74] conducted a randomized, controlled amel remineralisation after interdental stripping. clinical trials on 26 individuals who developed 152 visible The reduction in postoperative dentin sensitivity is due to the white-spot lesions on 60 incisors and canines immediately after fact that mineralisation of the dentinal tubule openings recloses the orthodontic debonding. After bracket removal, professional the tubules and rapidly reduces the dentine hypersensitivity. tooth cleaning and drying, visual scoring (0-4) and laser fluo- 4. Treating dry mouth rescence assessment were performed. The participants were randomly assigned to two different treatment protocols with the Clinical trials with CCP-ACP preparations have revealed aim of remineralising the lesions. One treatment modality was positive results in terms of caries prevention [81] and mouth the daily topical application of a dental cream containing moistening [81,82], in patients with severe xerostomia. Hay and CPP-ACP for 3 months, followed by a 3-month period of daily Morton [82] administered a self evaluation survey to 38 patients tooth brushing with a fluoride dentifrice. The other treatment in the original sample. They were asked to compare the casein protocol was daily topical application of a 0.05% sodium fluo- derivatives coupled with calcium phosphate (CD-CP) mouth ride mouthwash combined with the use of a fluoride dentifrice rinse with their usual mouth moistening strategies (for e.g., sip- for 6 months. Follow up clinical examinations were repeated ping water, chewing gum, and using artificial saliva). The au- after 1, 3, 6, and 12 months, and data were compared with base- thors concluded that the CD-CP mouth rinse, when used as an line measurements. The study showed that 63% of white spots atomized spray in the mouth, provide good moistening and regressed in the CPP-ACP group compared with 25% in the flu- lubrication. oride group, which was significantly different (p<0.01). The CCP-ACP preparations have a clear advantage over the In a study by Ardu et al. [75], concluded that enamel micro- fluoride based preparations because it could be swallowed in- abrasion together with prolonged use of a CPP-ACP based paste stead of spat out as CCP-ACP formulations are nontoxic. is useful for treating white spot enamel lesions. Kumar et al. [76] However, the potential side effects from ingestion of casein de- observed the effect of CPP-ACP on remineralisation of artifi- rivative protein in people with immunoglobulin E allergies to cial caries-like lesions. They found that the CCP-ACP contain- milk proteins should be considered before administration. ing Tooth Mousse remineralised initial enamel lesions and has 5. Transport medium for the avulsed teeth a higher remineralising potential when applied as a topical coat- ing after the use of a fluoridated tooth paste, as compared to ei- Cehreli et al. [83] suggested that highly diluted CPP-ACP ther of them alone. preparation may be used as a transport medium for the avulsed In another study conducted by Bailey et al. [77] in a post-or- teeth, as it preserves L929 cell viability in the short term without thodontic population of 45 individuals, with 408 white-spot le- inducing apoptosis. sions, results revealed that 92% of white spot lesions regressed 6. Improve the properties of other dental materials or stabilized after using a remineralising cream (Tooth MousseTM) containing 10% w/v CPP-ACP. Over 12 weeks, sig- A study by Mazzaoui et al. [84] used 1.56% w/w CPP-ACP nificantly more post-orthodontic white spot lesions (31%) re- in glass-ionomer cement (GIC). The in vitro study found that gressed with the remineralising cream compared with an identi- the new cement has higher compressive strength (23%) and cal cream not containing CPP-ACP. Zhou et al. [78] showed that higher microtensile bond strength (33%). This is due to in- the mean reduction in demineralised enamel white spot lesions corporation of the CPP-ACP nanoparticles into the cross linked size after treatment was 4.89% for one month, and 8.36% for matrix of the GIC. The investigators also noted significant and two months. They concluded that CPP-ACP can effectively re- enhanced release of fluoride from the cement with CPP-ACP. mineralise the long-standing post-orthodontic demineralised Matsuya et al. [85] suggested that the CPP-ACP nano- enamel white lesion. particles become physically encapsulated into the set GIC and are released as the acid erode the cement during the acid chal- 3. Decrease postoperative dentin sensitivity lenge, causing protection of the adjacent dentin. CPP-ACP may enhance remineralisation and decrease post- In a study by Vanthana et al. [86], proposed that CPP-ACP operative sensitivity following tooth whitening and micro- complex may be beneficial to the dentine bonding of self-etch- abrasion procedures in hypomineralised teeth [79]. Manton et ing adhesive systems, as the chemical interactions between cal- al. [64] concluded that Tooth Mousse may be applied con- cium and functional monomers of the adhesives might be en- currently with the bleach without reducing bleaching effec- hanced to some degree. tiveness. In a study by Giulio et al. [80], proposed that the topical applications of CPP-ACP could be effective in promoting en-

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Conclusion phosphonates on short- and long-term reimineralization. Caries Res 1981;15:60-9. Concept of minimal intervention dentistry has evolved as a 11. Ogaard B, Rølla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralisation. Part 2. Prevention and treat- consequence of increased understanding of the carious process ment of lesions. Am J Orthod Dentofacial Orthop 1988;94: and the advances in dental materials and techniques. The ulti- 123-8. mate goal of the modern dentistry is the non-invasive manage- 12. Willmot DR. White lesions after orthodontic treatment: does low ment of non-cavitated carious lesions through remineralisation fluoride make a difference? J Orthod 2004;31:235-42; dis- in an attempt to prevent caries progression and improve aes- cussion 202. thetics, strength, and function. Steps should be taken to prevent 13. Dean HT, McKay FS, Elvove E. Mottled enamel survey of baux- the onset of caries in individuals who are at high risk, and the ite, ark., 10 years after a change in the common water supply. Publ initial carious lesions should be treated non-invasively by re- Health Rep 1938;53:1736-48. 14. Rose RK. Binding characteristics of Streptococcus mutans for mineralisation agents, in those in whom disease is already evi- calcium and casein phosphopeptide. Caries Res 2000;34:427- dent, The ability to stabilize calcium phosphate and promote 31. mineral solubility and bioavailability confers upon the 15. Larsen MJ, Pearce EI. Saturation of human saliva with respect CPP-ACP the potential to be biological delivery vehicles for to calcium salts. Arch Oral Biol 2003;48:317-22. calcium and phosphate. Of the various remineralisation tech- 16. Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and nologies currently available in the market, the CPP-ACP and remineralization of enamel lesions by various forms of calcium CPP-ACFP technology has the most promising evidence to in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82: 206-11. support its use in caries prevention and lesion reversal. Further 17. Tung MS, Eichmiller FC. Amorphous calcium phosphates for scientific research and long term studies are necessary to pro- tooth mineralization. Compend Contin Educ Dent 2004;25(9 vide definite and evidence based clinical recommendations of Suppl 1):9-13. novel remineralisation treatment. 18. Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent References Res 2010;89:1187-97. 19. Schüpbach P, Neeser JR, Golliard M, Rouvet M, Guggenheim 1. Featherstone JD. Caries prevention and reversal based on the ca- B. Incorporation of caseinoglycomacropeptide and casein- ries balance. 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8 Vol. 14, No. 1, March 2018 Nidhi Chhabra and Anuj Chhabra：Enhanced Remineralisation of Tooth Enamel Using CPP-ACP Complex

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