Earn 4 CE credits This course was written for dentists, dental hygienists, and assistants.

Treatment Options for Discoloration and Remineralization A Peer-Reviewed Publication Written by Dr. Fiona M. Collins, MBA, MA

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Go Green, Go Online to take your course This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives teeth normal enamel reflects and refracts light, resulting in Overall goal: The purpose of this article is to provide dental a lustrous and glossy appearance.2 As enamel ages, it loses professionals with information on the etiology and treatment its initial surface texture. This causes a reduction in light of tooth discoloration and loss of tooth structure. refraction and reflection and results in the light penetrating deeper into the tooth. As a consequence, the tooth appears Upon completion of this course, the clinician will be able to less lustrous and shade differences become more obvious, do the following: leading to the appearance of a darker tooth. In addition, the 1. List the etiologies for tooth discoloration. translucent incisal edge increases in area.3,4 2. List traditional therapies available for the treatment of tooth discoloration and describe and Tooth Discoloration and Staining technology and the clinical application of this technology Changes in the coloration of teeth occur due to extrinsic in treating and preventing discoloration of teeth. and intrinsic staining in addition to the aging changes 3. List the etiologies for tooth demineralization. described above. 4. List traditional and new therapies available for the preven- tion of demineralization and for remineralization, and Table 1. Factors in Tooth Discoloration and Staining describe how these work. Intrinsic Extrinsic Aging Aging changes of tooth Abstract Fully developed teeth have a finite quantity of enamel and Trauma Surface changes (defects) , and internally consist of and . Over Specific medications Red wine time, patients may experience loss of tooth structure due Thickness of Tobacco to caries, erosion, or . Patients also expe- Structure of hard tissue Coffee and tea rience tooth discoloration due to aging changes as well as extrinsic and intrinsic staining. The prevention and treat- Enamel cracks Foods rich in polyphones ment of these conditions is clinically and esthetically de- Specific medications gluconate rinse sirable. Traditional treatment and prevention options have Metabolic diseases Level of oral hygiene included fluoride and chemotherapeutics to help prevent Systemic conditions tooth structure loss, and abrasives and hydrogen peroxide to treat tooth discoloration and staining. Recently intro- duced calcium and phosphate technologies have increased Intrinsic Staining the treatment options available. Intrinsic staining starts from inside the tooth or results from stain penetrating into the dentin from the surface Introduction of the tooth. The use of certain medications such as tet- Fully developed newly-erupted teeth have a finite quan- racycline during tooth development also causes intrinsic tity and depth of enamel and cementum that overlie den- staining. Genetics plays a role, and some metabolic disease tin, and internally have large pulp chambers. The enamel and systemic conditions result in tooth discoloration dur- structure comprises approximately 97% ing development.5 Finally, trauma to teeth can result in containing calcium and phosphate (as nonvitality and a gradual graying and blackening of the well as traces of other minerals and organic material). crown of the tooth. Dentin and cementum contain a higher proportion of organic material compared to inorganic material ( Treating Intrinsic Tooth Discoloration content). Over a period of many years, the pulp chamber While extrinsic discoloration and staining has the potential contracts while secondary dentin is simultaneously laid to be treated chemically and/or mechanically, mechanical down internally in areas that were originally occupied by treatment will not treat intrinsic staining. the outer region of the pulpal tissue.1 Dental disease and Intrinsic tooth discoloration can be treated using carb- conditions resulting in the loss of tooth structure post- amide peroxide (which breaks down to hydrogen peroxide eruption include caries, erosion, abrasion and attrition. and urea) or hydrogen peroxide compounds in either an in-office or at-home procedure. In-office treatments will Aging Changes typically use a higher concentration of whitening agent, The surface morphology of teeth influences both the per- usually hydrogen peroxide in concentrations of up to 35%. ception of and the amount of extrinsic stain that accu- Irrespective of the selected method, the mechanism of action mulates – smooth surfaces with few or no crevices or cracks is the same – hydrogen peroxide degrades into free radicals are less likely to develop extrinsic stain (or, via cracks, that break double bonds in the stain, thereby lightening and intrinsic stain) than are rough surfaces. In newly erupted removing the color from the stained material. In the case of

2 www.ineedce.com nonvital teeth, discoloration can be removed by bleaching in dentifrices to help remove stain and prevent stain buildup from the internal aspect of the crown of the tooth (provided on a daily basis. Recent studies have shown not only that root canal obturation was adequate). This method has been dentifrices containing no abrasive result in stain accumula- found to be effective and, where sufficient tooth structure tion, but that patients are unwilling to comply with regular remains, can conservatively provide an esthetic result with- home care using a nonabrasive even under study out requiring fabrication of a crown.6 conditions.10,11,12 This would result not only in the accumu- lation of stain, but also the accumulation and maturation of biofilm since patients do not perform good home care Figure 1a. Intrinsic staining under these conditions. Therefore, for good oral hygiene and patient compliance it is important to be able to achieve cleaning and stain prevention and removal, while preserving tooth structure. A dentifrice should ideally contain sufficient cleaning power to remove and help prevent staining without being so abrasive that it results in loss of tooth structure.13,14

Dentifrice Use for Stain Removal and Prevention Increasingly, abrasives with fine, rounded particles have been used in modern-day dentifrices, to gently remove Image courtesy of Howard E. Strassler, DMD stain and simultaneously help impart a polish that gives the appearance of whiter teeth. Typical agents include , calcium carbonate and sodium bicarbonate. Figure 1b. Removal of intrinsic staining by toothwhitening The Radioactive Dentin Abrasion (RDA) measures how abrasive a toothpaste is. The cleaning ability of a dentifrice depends on both its cleaning power and its abrasivity – a dentifrice with high cleaning power and low abrasivity will minimize the risk of abrasion while maximizing cleaning efficacy. A European study in 1997 found that most of the cleaning obtained from a dentifrice was through abrasion.15 An exception is dentifrice containing sodium bicarbonate (baking soda), which has been used in dentifrices for almost 30 years. Image courtesy of Howard E. Strassler, DMD Sodium Bicarbonate Sodium bicarbonate (baking soda) functions as both a Extrinsic Staining mechanical and a chemical cleaning agent. Mechanical Smoking can result in severe and stubborn staining, while cleaning relies on abrasives. The RDA of sodium bicar- tea, coffee and red wine are common culprits associated bonate ranges from 30-40, compared to an RDA of 70-110 with surface staining.7 Eating specific types of food results in typical dentifrices. Studies show that while it has low in surface staining of teeth. Good oral hygiene helps reduce abrasivity, baking soda has excellent cleaning ability even and prevent staining, and conversely the propensity to stain when compared to higher RDA agents. Controlled-con- is increased if oral hygiene is poor. Medium- to long-term dition laboratory studies using several grades of sodium use of chlorhexidine gluconate rinse is known to result in bicarbonate differing in particle size, with water and glyc- tooth staining, as is use of other specific therapeutics.8 erin to simulate dentifrice and tooth brushing, determined that the mean ratio of abrasion to cleaning power was 10.2, Treating Extrinsic Stain/Tooth Discoloration compared to 1.7 for calcium (which is used Chemically, hydrogen peroxide is effective for treating as a reference material for abrasiveness studies).16 Little extrinsic stain.9 In addition, surfactants contained in den- difference was found in the results across the various par- tifrices and rinses, such as sodium lauryl sulphate, help ticle sizes used for the sodium bicarbonate. The results lift and remove stain from the tooth surface. were more impressive considering that the comparative Physical removal of extrinsic stain can be achieved with agent, sodium pyrophosphate, has a higher RDA and, ad- abrasives. These are routinely used in prophylactic pastes ditionally, prevents stain buildup by means of chelation as during dental prophylaxis where they have the ability to well as abrasion.17,18,19 Zambon et al. found that use of 52% remove stubborn stain due to their abrasivity, that regular and 65% sodium bicarbonate for 6 months resulted in a dentifrices would not remove. Abrasives are also contained positive shift in the composition of the intraoral microbial www.ineedce.com 3 flora and reduced plaque, and stain compared Foundation. It is contained in dentifrice (ARM & HAM- to baseline.20 MER® Age Defying, Church & Dwight) as well as in-office It is believed that cleaning power rather than abrasivity is preventives and prophy pastes (Enamel ProTM and Enamel an important factor in the effectiveness of sodium bicarbon- ProTM Varnish, Premier Dental), tooth-whitening agents ate as a stain remover and in preventing stain buildup, and (Zoom® 2 Day White and Nite White® with ACP, Discus that bicarbonate cleans through both physical and chemical Dental), and other products. action. The sodium bicarbonate helps lift stain from the surface of the tooth. Figure 3. SEM of ACP Figure 2. Extrinsic staining and abrasion

Image courtesy of the American Dental Association Foundation Image courtesy of Salim Nathoo, DDS, PhD

Recently, the introduction of calcium and phosphate The role of ACP in dentifrices technology - amorphous calcium phosphate (ACP) - has ACP offers preventive and cosmetic benefits. Calcium and offered the potential for esthetic and preventive benefits phosphate are deposited onto the surface of the tooth from dentifrices and other products, as well as from tradi- with ACP-delivering dentifrice use, precipitating ACP tional therapies. globules. If scratches and surface defects are present on a Two other calcium and phosphate technologies avail- tooth, light is dispersed in such a way that the tooth can able include Novamin® and casein phosphopeptide –amor- appear dull and darker than it otherwise would. Filling in phous calcium phosphate (CPP-ACP). The casein in CPP surface defects changes the light dispersion, thereby im- is obtained from cow’s milk and forms a complex with ACP. proving esthetics.25,26 The light becomes scattered, giving CPP-ACP (Recaldent®) is bioavailable and releases cal- the appearance of a surface gloss and luster. In situ testing cium and phosphate for remineralization.21 It is contained has found that ACP precipitates and lodges in defects such in MI PasteTM (GC America) and chewing gum (Trident, as crevices and pits; it is believed this converts to min- Cadbury Adams) as well as in glass ionomer cements and eral hydroxyapatite.27 While hydrogen peroxide and other other products. CPP-ACP has been shown to remineralize chemical cleaning agents will remove stain, they cannot subsurface lesions in in vitro testing.22 Novamin contains repair surface defects that alter the dispersion of light and calcium, , silica and sodium. The Novamin re- therefore the appearance of the (nonstained) tooth. leases these ions upon exposure to saliva or water, aiding in One single-center, double-blind randomized trial as- remineralization and helping to prevent demineralization. sessed twice-daily use of a fluoride dentifrice with ACP Studies of Novamin-containing dentifrice have found it to technology for its effect on surface gloss and surface have a whitening effect.23 A Novamin-containing dentifrice roughness. Surface gloss was measured using the enamel that also includes fluoride has been found to remineralize gloss standard test. The subjective improvement using the surface lesions in vitro by 41.9% compared to 24.9% for a test dentifrice was found to be 73.8% compared to 17.6% control fluoride-containing dentifrice.24 CPP-ACP and No- for the control dentifrice, with between 76% and 83% of vamin are not available in sodium bicarbonate dentifrices; teeth showing improvement. Surface roughness was mea- they are however available in other dentifrices. sured using a profilometer at the start of the study and one and three months after use of either the test or control Amorphous Calcium Phosphate dentifrice. Surface roughness was reduced significantly us- Amorphous calcium phosphate (ACP) consists of an un- ing the test dentifrice, but did not decrease with use of the structured form of calcium phosphate molecules (Figure 3) control dentifrice.28 ACP will precipitate onto the tooth as and was developed by the American Dental Association globules as shown by scanning electron microscopy. Im-

4 www.ineedce.com provements in luster and deposition of ACP into surface of children between the ages of 2 and 5 have experienced defects have also been found to occur using prophy paste decay.33 By age 19, 68% of adolescents have experienced delivering ACP.29 caries in the permanent dentition.34 The patient’s level of plaque control (bacterial load), salivary flow and composi- Figure 4. ACP precipitation onto dentin in in vitro study tion, diet (amount and frequency of intake of fermentable carbohydrates), tooth structure, and use of home care products and therapeutics determine whether demineral- ization occurs. These factors also determine whether this process progresses to subsurface demineralization and, eventually if unhindered, frank cavitation. Hydroxyapatite crystals are stable at a pH of 7 (neutral). When acid attacks occur, dissolution of the hydroxyapatite crystals starts when the pH has decreased to around 5.5. Demineralization results in the loss of calcium, phosphate and hydroxyl ions from the hydroxyapatite crystals. Fol- lowing this acid attack, the pH rebounds. Normalization of the pH takes longer if salivary flow is reduced, increasing the time during which demineralization can occur. Addi-

Image courtesy of American Dental Association Foundation tionally, a reduced salivary flow results in fewer minerals being available from saliva that would aid remineraliza- tion – namely calcium and phosphate. Natural saliva is Intraorally, ACP has the fastest rate of formation and dis- supersaturated with calcium and phosphate that over time solution of the calcium phosphate compounds.30 As pH help repair defects, including in the absence of fluoride.35 increases, ACP precipitates onto the tooth surface. The in- Salivary flow is an important determinant of remineraliza- clusion of carbonate results in a more rapid increase in pH. tion, and this helps explain the rampant caries seen in xe- Carbonates have been shown to control the precipitation of rostomic patients.36 An increased concentration of calcium ACP onto tooth surfaces.31,32 Thus, the combination of bi- and phosphate at the tooth surface would strengthen the carbonate and ACP delivery in dentifrice has been found to repair of the enamel surface. help the presence of ACP at the site and the supersaturation of calcium and phosphate ions. Figure 6. Dynamics of demineralization and remineralization

Figure 5. Bicarbonate, ACP and dentifrice activity

Intact enamel is the hardest substance in the body. Dentin is considerably softer; the softest and thinnest layer of den- tal hard tissue is the cementum. Studies have found that enamel is approximately 4 to 10 times harder than dentin, depending on the locations of the samples of the enamel Loss of Tooth Structure and the dentin within the tooth.37 As enamel is lost and Loss of tooth structure over time can occur as a result of dentin exposed, there results increased susceptibility to the caries process, abrasion, erosion or attrition. loss of dental hard tissue. Dental caries is a chronic disease experienced by the The presence of erosion complicates the clinical picture. majority of the population. Most children are infected with Tooth erosion occurs when acids of nonbacterial origin cariogenic bacteria before the age of 2, and around 28% (i.e., not produced by cariogenic bacteria)38 demineralize www.ineedce.com 5 the exposed surface of the tooth. These acids may be the Fluoride result of regurgitation of stomach acid such as occurs due The first use of fluoride as a caries preventive occurred to gastro-esophageal reflux disease (GERD) or due to the more than a hundred years ago in Europe. Fluoridens was frequent vomiting associated with bulimia.39,40 External a fluoride-containing powder used in the late 1800s. Dur- sources of acids causing erosion of dental hard tissues in- ing the 1950s and 1960s, acidulated phosphate fluoride, clude soda pop, which currently accounts for around 28% neutral sodium fluoride, amine fluoride and stannous fluo- of all beverages consumed, as well as other dietary habits ride were investigated and introduced as in-office topical and environmental hazards.41,42,43 Erosion results in surface agents and home-use products. The frequency of in-office loss, removes surface minerals and results in the tooth fluoride treatments differs with each patient’s level of risk losing its luster and glossy appearance;44 it also softens (typically from zero up to four times per year). mineralized tissue, increasing susceptibility to (further) demineralization, abrasion and attrition.45,46 Figure 7. Timeline of preventive measures Abrasion physically wears away the surface layer of the tooth and in the long term results in the intraoral exposure 1940s Late 1800s of the softer dentin. Attrition also results over time in the Water exposure of dentin, and can occur due to or mas- Fluoridens tication of rough high-fiber foods over the long term. As fluoridation abrasion proceeds, the perception of tooth color changes – abrasion results in less enamel being present and dentin 1990s, 2000s shining through the thinner layer of enamel or being ex- 1950s and 60s Calcium and posed, or only dentin being present. Topical fluorides phosphate technologies

Table 2. Tooth structure loss Caries Surface and subsurface loss Dentifrices provide patients with a regular daily supply Abrasion Surface loss of fluoride, and it has been stated that fluoride-containing Attrition Surface loss dentifrices and rinses have contributed more to the re- Erosion Surface loss; contributes to other causes duction of caries in the general population than other measures.50 The investigation recently of calcium and phosphate technology has shown the ability to enhance prevention as well as esthetics. Use of fluoride-containing Remineralization and the Prevention dentifrices that include calcium and phosphate and deliver of Demineralizaton ACP helps the supply of calcium and phosphate ions for Demineralization can be counteracted and reversed through the strengthening of enamel. A risk assessment is required remineralization at the time of acid attacks as well as in the to determine the appropriate preventive measures for indi- early stages of hard tissue demineralization. Conditions that vidual patients. discourage demineralization and favor remineralization include a reduced load of cariogenic bacteria, good salivary The Role of Calcium and Phosphate in the flow, the presence of calcium, phosphate and fluoride, as Demineralization-Remineralization Balance well as the use of chemotherapeutic agents. Antibacterial Normal saliva is supersaturated with calcium and phos- agents have been used to prevent demineralization. Chlo- phate ions that help prevent dissolution of hydroxyapatite rhexidine gluconate rinse and povidone iodine reduce the crystals. Calcium from milk and cheese has been found load of cariogenic (and periodontopathic) bacteria present, to mitigate the effects of erosion.51 Using calcium and and have been found to help prevent caries in high-risk phosphate solutions, testing has shown that using these children and in high-risk adults with severe xerostomia.47,48 sequentially (first calcium, then phosphate) results in the Xylitol occurs naturally and is known to be antimicrobial rapid deposition of amorphous calcium phosphate and its and a caries preventive. A three-year study of a dentifrice conversion to hydroxyapatite.52 containing 10% xylitol and fluoride found a 12% reduction The use of calcium and phosphate and ACP delivery in decayed and filled surfaces after accounting for fluoride in has been studied in dentifrices in vitro and in vivo. High the control dentifrice.49 Xylitol is used in chewing and concentrations of calcium and phosphate can exist at low mints, and as a sweetener in a number of oral care products pH, and as the pH increases, the calcium and phosphate in the United States. The single greatest advancement in the precipitate. Supersaturation of calcium and phosphate last century for caries prevention was the use of fluoride. adjacent to the tooth at low pH helps prevent dissolution

6 www.ineedce.com of crystals. This is a concentration gradient effect. As the Clinical Application – In-office and Home Use pH increases, the balance changes and ACP and fluoride Demineralization and discoloration of teeth can be treated are incorporated on the surface of the tooth. ACP can then and/or prevented using suitable in-office and home-care convert to hydroxyapatite, which is less soluble than ACP. therapies that effectively and safely prevent and treat these This can help prevent demineralization, since, at a given conditions. In the case of home care, an ideal would be for the pH, ACP is more soluble than hydroxyapatite crystals, same care to prevent demineralization, aid remineralization, with the result that the ACP would dissolve first and super- prevent tooth discoloration and remove any discoloration saturate the area with calcium and phosphate ions, helping present. One option that utilizes over-the-counter dentifrice to prevent dissolution of the hydroxyapatite crystals. without an additional steps being required by the patient, The amorphous structure of ACP also enables fluoride would be the use of products containing fluoride and delivering and other ions to be incorporated into it. In vitro testing ACP. Based on in vitro studies, in-office use of prophylactic has found that the presence of ACP can increase fluoride paste delivering ACP increases fluoride availability where bioavailability and uptake in ACP-delivering products.53,54 prophylaxis is indicated and has also been shown to result in Dentifrice containing calcium and phosphate ions has been the filling in of surface defects and an improvement in lus- found to increase the bioavailability of fluoride, resulting ter, which would enhance esthetics since the light would be in increased uptake of fluoride in in vitro studies using dispersed over a smoother surface. Home use of dentifrice enamel cores. An uptake of more than 5000 ppm compared delivering ACP to the tooth (ARM & HAMMER® Age to just over 1900 ppm for a control dentifrice was found, Defying) has been shown in in vivo and in vitro studies to and the solubility of enamel was reduced.55 improve appearance and surface luster by this mechanism and, based on in vitro studies, also results in supersaturation of the area with calcium and phosphate. Table 3. Fluoride uptake and solubility of enamel Clinically, a combined in-office and home care regimen is suitable for patients presenting with extrinsic staining, 6000 5031 loss of surface luster and hard tissue, and patients at risk for 5000 demineralization. Depending on caries risk, increased levels 4000 of topical fluoride, frequency of in-office fluoride, and use of

3000 antimicrobials may also be indicated. 1915 2000 1000 Table 4. Indications for patients for in-office and home use regimen Fluoride Uptake (ppm) 0 • Extrinsic staining -3.1 Liquid Calcium • Loss of surface area -1000 Non-Fluoride Fluoride and Fluoride • Loss of enamel luster Dentifrice Type • Risk of demineralization

In separate in vitro studies, eroded enamel discs were ex- Summary posed to a test dentifrice containing liquid calcium, phos- Loss of tooth structure occurs as a result of dental disease phate and fluoride, and it was found that the test dentifrice and conditions that include caries, erosion, abrasion and increased hardness more than the fluoride-containing den- attrition. Tooth discoloration and staining is prevalent, tifrice. In addition, after pretreatment with soda pop, the and varies with age and habits and by individual patient. test dentifrice increased hardness of the enamel discs by The treatment of tooth discoloration and the prevention 12% compared to 7% for the control dentifrice, indicative and treatment of caries have been central in for a of a greater remineralizing effect.56 number of decades. Fluoride was first routinely used more than half a century ago, and has become a routine procedure. Extrinsic stain can be treated chemi- Figure 8. In vitro surface hardness using liquid calcium-containing cally and mechanically. In addition to stain removal, the dentifrice filling in of surface defects has been found to alter light diffraction and dispersion, altering the perception of tooth color and improving surface luster. Recent innovations have resulted in products containing calcium and phos- phate technology as well as fluoride. These offer cosmetic benefits and increase the availability of calcium, phosphate and fluoride for the strengthening of enamel. www.ineedce.com 7 References 18 Smith J, Ersen E, Coffman L, Berg ML, Hefferren J. 1 Kvaal SI, Kolltveit KM, Thomsen IO, Solheim T. Age Cyclic laboratory model to measure the chemical cleaning estimation of adults from dental radiographs. Forensic Sci powder of seven grades of sodium bicarbonate. J Dent Int. 1995;74(3):175-85. Res. 2003;82:A #384. 2 Ten Bosch JJ, Coops CC. Tooth color and reflectance as 19 Stookey GK, Burkhard TA, Schemehorn BR. In related to light scattering and enamel hardness. J Dent Res. vitro removal of stain with dentifrices. J Dent Res. 1995;74:374-80. 1982;61:1236-9. 3 Shimada K, Kakehashi Y, Matsumura H, et al. In vivo 20 Zambon JJ, Mather ML, Gonzales Y. A microbiological quantitative evaluation of tooth color with hand-held and clinical study of the safety and efficacy of baking soda colorimeter and custom template. J Prosthet Dent. dentifrices. Comp Cont Ed Dent. 1997;18(21):S39-44. 2004;1991:389-91. 21 Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. 4 Nathoo SA, Chmielewski MB, Rustogi KN. Clinical Remineralization of enamel subsurface lesions by sugar- evaluation of Colgate Platinum Professional Toothwhitening free chewing gum containing casein phosphopeptide- System and Rembrandt Lighten Bleaching Gel. Compend amorphous calcium phosphate. J Dent Res. 2001 Contin Educ Dent. 1994;15(S17):S640-45. Dec;80(12): 5 Pindborg JJ. 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Available at: http://novamin.com/pdf/ use: results from the Department of Veterans Affairs Dental Evaluation_of_NovaMin_As_An_Adjunct_to_Fluoride. Diabetes Study. J Am Dent Assoc. 2008;139(2):178-83. pdf. Accessed April, 2008. 9 Joiner A, Thakker G. In vitro evaluation of a novel 6% 25 Tung MS, Eichmiller FC. Dental applications of amorphous hydrogen peroxide tooth whitening product. J Dent. calcium . J Clin Dent. 1999;10(1 spec no):1-6. 2004;32 Suppl 1:19-25. 26 Schemehorn BR, Orban JC, Wodd GD, et al. 10 Hefferren J, and Dentifrice Function Committee. Clinical Remineralization by fluoride enhanced with calcium studies to determine clinical response to nonabrasive and phosphate ingredients. J Clin Dent. 1999;10(1 spec dentifrice use. J Dent Res. 1996;75:45. no):13-6. 11 Cooley WE, Sturzenberger P, Hefferren J. and Dentifrice 27 Tung MS, Eichmiller FC. Amorphous calcium phosphates Function Committee. Clinical response of non-abrasive for tooth mineralization. Comp Cont Educ Dent. dentifrice use in adults. J Dent Res. 1996;75:87. 2004;25(9, Suppl. 1);9-13. 12 Lobene R, Hefferren J, and Dentifrice Function Committee. 28 Muñoz CA, Stephens JA, Proskin HM, Ghassemi Clinical response of non-abrasive dentifrice use in dental A. Clinical efficacy evaluation of a fluoride dentifrice hygienists. J Dent Res.1996;75:88. containing calcium, phosphate, and sodium bicarbonate 13 Wülknitz P. Cleaning power and abrasivity of European on surface-enamel smoothness and gloss. Comp Cont Ed . Adv. Dent Res. 1997;11:576-579. Dent. 2004;25(9)(Suppl. 1):32-43. 14 Miller WD. Experiments and observations on the wasting 29 Tung MS, Eichmiller FC. Amorphous calcium phosphates of tooth tissue variously described as erosion, abrasion, for tooth mineralization. Comp Cont Educ Dent. chemical abrasion, denudation, etc. Dent Cosmos. 2004;25(9, Suppl. 1);9-13. 1907;49:1–23, 109–124, 225–247. 30 Eanes ED. Amorphous calcium phosphate thermodynamic 15 Wülknitz P. Cleaning power and abrasivity of European and kinetic considerations. In: Amjad Z, ed. Calcium, toothpastes. Adv. Dent Res 1997;11:576-579. phosphates in biological and industrial sciences. Boston, 16 International Standards Organization ISO 11609, 1995 Mass:Kluwer academic publishers;1997:21-39. Dentistry—toothpaste—requirements, test methods and 31 Munoz CA, Stephens J, Wilson A, et al. Tooth surface marking. restoration with a bicarbonate-dentifrice containing calcium 17 Berg ML, Ersen E, Smith J, Coffman L, Hefferren and phosphate (Abstract). J Dent Res. 2004;83(spec iss). J. Clinical functionality of seven grades of sodium Abstract 2115. bicarbonate in the same toothpaste formulation. J Dent 32 Muñoz CA, Dahlke H, Charig A, et al. Surface Res. 2003;82:A #386. mineralization by a two-phase baking soda toothpaste

8 www.ineedce.com containing calcium. J Dent Res. 2004;83(spec iss). 50 Harinho VCC, Higgins JPT, Logan S, et al. Fluoride Abstract 2117. toothpastes for preventing dental caries in children and 33 Centers for Disease Control. http://www.cdc.gov/ adolescents (Cochrane Review); the Cochrane Library, OralHealth/topics/child.htm. Accessed May 2008. Issue 2. New York:John Wiley and Sons;2004. 34 Ibid. 51 Gedalia I, Ionat-Bendat D, Ben-Mosheh S, et al. Tooth 35 Ogaard B, ten Bosch JJ. Regression of white spot enamel enamel softening with a cola type drink and rehardening lesions: A new optical method for quantitative longitudinal with hard cheese or stimulated saliva in situ. J Oral Rehab. evaluation in vitro. Am J Orthod Dentofacial Orthop. 1991;18:501-6. 1994;106:238-42. 52 Tung MS, Eichmiller FC. Amorphous calcium phosphates 36 Dreizen S, Brown LR, Daly TE, Drane JB. Prevention for tooth mineralization. Comp Contin Ed Dent. of xerostomia-related dental caries in irradiated cancer 2004;25(9S1):9-13. patients. J Dent Res. 1977;56: 99-104. 53 Tung MS, Hwang J, Malerman R, McHale WA. Reactivity 37 Cirano FR, Romito GA, Todescan JH. Determination of of varnish containing calcium, phosphate and fluoride enamel and coronal dentin microhardness. Braz J Oral Sci. salts. J Dent Res. 2007; 86(spec iss)A0:1078. 2003;2(6):258-63. 54 Final Report: Sound enamel fluoride uptake study. 38 Moss SJ. Dental erosion. Int Dent J. 1998;48:529-39. 2007;Study 07-107. Dental Products Testing, Indiana 39 Rytomaa I, Jarvinen V, Kanerva R, et al. Bulimia and tooth University Emerging Technologies Center. erosion. Acta Odontol Scand. 1998;56:36-40. 55 Schemehorn BR, Wood GD, Winston AE. Laboratory 40 Lackey MA, Barth J. Gastroesophageal reflux disease: a enamel solubility reduction and fluoride uptake from dental concern. Gen Dent. 2003;51(3):250-4. enamel on dentifrice. J Clin Dent. 1999;10(1 Spec 41 National Soft Drink Association. Soft drink facts. NSDA No):9-12. Web site. Available at: http://www.ameribev.org/all- 56 Muñoz CA, Feller R, Haglund A, Triol CW, Winston about-beverage-products-manufacturing-marketing-- AE. Strengthening of by a remineralizing consumption/what-america-drinks/index.aspx. Accessed toothpaste after exposure to an acidic soft drink. J Clin May 10, 2008. Dent. 1999;10(1 Spec No):17-21. 42 Millward A, Shaw L, Smith AJ, et al. The distribution and severity of and the relationship between Author Profile erosion and dietary constituents in a group of children. Int. J. Paediatr. Dent. 1994;4:151-7. Dr. Fiona M. Collins, MBA, MA 43 Phelan J. The erosive potential of some herbal teas. J Dent. Dr. Fiona M. Collins has 13 years of clinical 2003;31:241-6. experience as a general dentist, and has held 44 Muñoz CA, Feller R, Hagland A, et al. Strengthening positions in professional marketing, educa- of tooth enamel by a remineralizing toothpaste after tion and training, and professional relations. exposure to an acidic soft drink. J Clin Dent. 1999;10(1 She has authored and given CE courses to spec. no.):17-21. dental professionals and students in the US 45 Hooper S, West NX, Pickles MJ, et al. Investigation of and Canada, and consulted on market research and oppor- erosion and abrasion on enamel and dentine: a model tunity assessment projects. in situ using toothpastes of different abrasivity. J Clin Dr. Collins is a past-member of the Academy of Gen- Periodontol. 2003;30(9):802-808. eral Dentistry Foundation Strategy Board and has been 46 Hunter ML, Addy M, Pickles MJ, et al. The role of a member of the British Dental Association, the Dutch toothpastes and toothbrushes in the aetiology of tooth Dental Association, the American Dental Association and wear. Int. Dent. J. 52: 399-405, 2002. the International Association of Dental Research. Dr. Col- 47 Joyston-Bechal S, Hayes K, Davenport ES, Hardie JM. lins holds a dental degree from Glasgow University and an Caries incidence, mutans streptococci and lactobacilli MBA and MA from Boston University. in irradiated patients during a 12-month preventive programme using chlorhexidine and fluoride. Caries Res. Disclaimer 1992;26(5):384-90. The author(s) of this course has/have no commercial ties with 48 Katz S. The use of fluoride and chlorhexidine for the sponsors or the providers of the unrestricted educational the prevention of radiation caries. J Am Dent Assoc. grant for this course. 1982;104(2):164-70. 49 Sintes JL, Escalante C, Stewart B, McCool JJ, Garcia L, Reader Feedback Volpe AR, Triol C. Enhanced anticaries efficacy of a We encourage your comments on this or any PennWell course. 0.243% sodium fluoride/10% xylitol/silica dentifrice: For your convenience, an online feedback form is available at 3-year clinical results. Am J Dent. 1995;8(5):231-5. www.ineedce.com. www.ineedce.com 9 Questions

1. Fully developed teeth have a finite 11. The cleaning ability of sodium 21. Hydroxyapatite crystals are stable quantity and depth of enamel and bicarbonate dentifrices is less than other at ______. cementum. dentifrices due to its low abrasivity. a. a pH of 3 a. True a. True b. a pH of 4 b. False b. False c. a pH of 5 d. a pH of 7 2. As enamel loses its initial surface 12. Sodium bicarbonate ______. texture, this can cause ______. a. helps lift stain from the surface of the tooth 22. Erosion results in ______. a. reduction in light refraction b. cleans through both physical and chemical action a. surface loss b. reduction in light reflection c. has been shown to reduce stain in studies b. the tooth losing­ its luster and glossy appearance c. the tooth to appear darker d. all of the above c. increased susceptibility to demineralization and d. all of the above abrasion 13. Available calcium and phosphate d. all of the above 3. Intrinsic staining ______. technologies include ______. 23. ______has been used therapeuti­ a. is stain present inside the tooth a. ACP b. only affects the outside of the tooth b. Novamin cally to help prevent caries. c. can result from stain penetrating into the dentin a. Fluoride c. CPP-ACP d. a and c b. Chlorhexidine gluconate d. all of the above c. Xylitol 4. Intrinsic discoloration and staining has 14. CPP-ACP (Recaldent) is ______. d. all of the above the potential to be treated chemically a. bioavailable 24. Supersaturation of calcium and phos­ and/or mechanically. b. derived from sheep’s milk phate adjacent to the tooth at low pH a. True c. releases calcium and phosphate for remin­ b. False helps prevent dissolution of crystals. eralization a. True 5. Extrinsic stain can be removed and/or d. a and c b. False lifted using ______. 15. ACP consists of ______. a. hydrogen peroxide 25. In vitro testing has found that the a. an unstructured­ form of calcium phosphate b. abrasion presence of ACP can increase fluoride molecules c. chelation bioavailability­ and uptake in products b. an unstructured­ form of calcium polysorbate d. all of the above delivering ACP. molecules a. True 6. Dentifrices containing no abrasive have c. an unstructured­ form of carbinic phosphate b. False been found to result in ______. molecules a. stain accumulation d. none of the above 26. At a given pH, ACP ______. b. more abrasion a. is more soluble than hydroxyapatite crystals 16. Filling in surface defects changes the c. patient noncompliance with oral hygiene b. will supersaturate the area with calcium and light dispersion, which can improve d. a and c phosphate ions esthetics. 7. ______have been used to gently c. will supersaturate the area with calcium and a. True remove stain and simultaneously help silicate ions b. False impart a polish that gives the appear­ d. a and b ance of whiter teeth. 17. A double-blind randomized trial 27.Conditions­ that discourage demin­ a. Dentifrice abrasives with large, rounded particles assessing twice-daily use of a fluoride eralization and favor remineralization­ b. Dentifrice abrasives with fine, rounded particles dentifrice with ACP found include______. c. Dentifrice abrasives with fine, octagonal particles that ______. a. a reduced load of cariogenic bacteria d. none of the above a. its use improved enamel gloss b. the presence of calcium, phosphate and fluoride 8. The discoloration of nonvital teeth can b. its use decreased surface roughness c. the use of chemotherapeutic agents c. its use gave identical results to the control only be treated by prosthetic options d. all of the above dentifrice (crowns or veneers). 28. Clinically, products containing ACP d. a and b a. True can be used in-office followed by at- b. False 18. Novamin-containing dentifrice have home use as an oral care regimen. found it to have a whitening effect. 9. A dentifrice with high cleaning power a. True a. True and low abrasivity will minimize the b. False b. False risk of abrasion while maximizing 29. ACP can precipitate onto the tooth as cleaning efficacy. 19. Carbonates have been shown to globules as shown by scanning electron a. True control the precipitation­ of ACP onto microscopy.­ b. False tooth surfaces. a. True 10. The RDA of sodium bicarbonate­ a. True b. False b. False ranges from ______compared 30. Calcium and phosphate-containing to an RDA of ______in typical 20. ______causes of loss of tooth dentifrice ______. dentifrices. structure over time. a. is available over-the-counter a. 20-30, 60-80 a. Abrasion b. does not require the patient to perform an extra b. 30-40, 70-110 b. Erosion step in home care c. 35-50, 80-200 c. Caries c. helps esthetics and prevention d. 50-60, 90-150 d. all of the above d. all of the above

10 www.ineedce.com ANSWER SHEET Treatment Options for Tooth Discoloration and Remineralization

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to Educational Objectives Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 1. List the etiologies for tooth discoloration. P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447 2. List traditional therapies available for the treatment of tooth discoloration and describe calcium and phosphate technology and the clinical applications of this technology in treating and preventing discoloration of teeth. For immediate results, go to www.ineedce.com 3. List the etiologies for tooth demineralization. and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to 4. List traditional and new therapies available for the prevention of demineralization and for remineralization, and describe (440) 845-3447, (216) 398-7922, or (216) 255-6619. how these work. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Course Evaluation If paying by credit card, please complete the following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No Exp. Date: ______Objective #2: Yes No Objective #4: Yes No Charges on your statement will show up as PennWell 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them. ______

11. Was there any subject matter you found confusing? Please describe. ______

12. What additional continuing dental education topics would you like to see? ______AGD Code 258, 780

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING The author(s) of this course has/have no commercial ties with the sponsors or the providers of All questions should have only one answer. Grading of this examination is done All participants scoring at least 70% (answering 21 or more questions correctly) on the PennWell maintains records of your successful completion of any exam. Please contact our the unrestricted educational grant for this course. manually. Participants will receive confirmation of passing by receipt of a verification examination will receive a verification form verifying 4 CE credits. The formal continuing offices for a copy of your continuing education credits report. This report, which will list form. Verification forms will be mailed within two weeks after taking an examination. education program of this sponsor is accepted by the AGD for Fellowship/Mastership all credits earned to date, will be generated and mailed to you within five business days SPONSOR/PROVIDER credit. Please contact PennWell for current term of acceptance. Participants are urged to of receipt. This course was made possible through an unrestricted educational grant from EDUCATIONAL DISCLAIMER contact their state dental boards for continuing education requirements. PennWell is a Church & Dwight Co., Inc. No manufacturer or third party has had any input into the The opinions of efficacy or perceived value of any products or companies mentioned California Provider. The California Provider number is 3274. The cost for courses ranges CANCELLATION/REFUND POLICY development of course content. All content has been derived from references listed, in this course and expressed herein are those of the author(s) of the course and do not from $49.00 to $110.00. Any participant who is not 100% satisfied with this course can request a full refund by and or the opinions of clinicians. Please direct all questions pertaining to PennWell or necessarily reflect those of PennWell. contacting PennWell in writing. the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK Many PennWell self-study courses have been approved by the Dental Assisting National 74112 or [email protected]. Completing a single continuing education course does not provide enough information Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet © 2008 by the Academy of Dental Therapeutics and Stomatology, a division to give the participant the feeling that s/he is an expert in the field related to the course DANB’s annual continuing education requirements. To find out if this course or any other of PennWell COURSE EVALUATION and PARTICIPANT FEEDBACK topic. It is a combination of many educational courses and clinical experience that PennWell course has been approved by DANB, please contact DANB’s Recertification We encourage participant feedback pertaining to all courses. Please be sure to complete the allows the participant to develop skills and expertise. Department at 1-800-FOR-DANB, ext. 445. REMIN0806RDH survey included with the course. Please e-mail all questions to: [email protected]. www.ineedce.com 11 ACP: the next big thing. Trim: 7.5”x10.5” Bleed: 7.75”x 10.75” Live area: 7”x10” FL (DS) OP5107 - Oral Care Professional Ad - RDH CE I nsert June 2008 Full page

e word on ACP is out. And, only one toothpaste combines it with fluoride.

When you see all the facts, you’ll understand why we call this toothpaste ARM & HAMMER® Age Defying: • The only toothpaste delivering fluoride, ACP (amorphous calcium phosphate), and all the benefits of Baking Soda. • A highly effective way to strengthen and rebuild enamel daily and bring

superior cleaning to patients. SGP • Baking Soda and ACP formula maximizes whitening. – Our Baking Soda dissolves, penetrates and lifts stains from places other toothpastes can’t reach. – ACP restores enamel luster by filling in the tooth surface with minerals for a younger, brighter smile.

Make it your recommendation today! For more information visit www.oralcarepro.com.

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