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 Table of Contents  
ORIGINAL RESEARCH
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 377-381

Efficacy of domestically manufactured remineralizing agent on artificially created surface lesions: A comparative ex-vivo study


1 Department of Conservative Dentistry and Endodontics, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontics, Sri Ramakrishna Dental College, Coimbatore, Tamil Nadu, India
3 Consultant Endodontist, Iyyapanthangal, Chennai, Tamil Nadu, India
4 Department of Conservative Dentistry and Endodontics, Sri Venkateshwaraa Dental College, Ariyur, Puducherry, India

Date of Submission12-Jan-2022
Date of Decision25-Jul-2022
Date of Acceptance25-Jul-2022
Date of Web Publication29-Aug-2022

Correspondence Address:
Dr. Chakravarthy S Vineetha
Department of Conservative Dentistry and Endodontics, Sri Ramakrishna Dental College, Coimbatore 641006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_14_22

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  Abstract 

Aim: To compare and evaluate the efficacy of domestically manufactured remineralizing agents on artificially created carious lesions. Materials and Methods: Freshly extracted 60 human maxillary first premolars were used for our in-vitro comparative study. The samples were embedded in acrylic resin such that the surface of enamel is visible for study. These samples were stored in deionized water for 1 month. The surfaces were demineralized to create a subsurface lesion. Samples were then divided using random sampling method into four groups. Each group had a sample size of 15, according to the remineralizing agent used. Group 1—tri-calcium phosphate (β-TCP), Group 2—domestically manufactured nano hydroxyapatite (NHA), Group 3—bioactive glass (BAG), and Group 4—artificial saliva (control). These remineralizing agents were applied on the samples of respective groups for 4 min, at every 24th hour for a duration of 7 days. After which, incubation of the samples was carried out by placing them in artificial saliva. This was done at a temperature of 37°C between every cycle. After completion of seven cycles, Vickers microhardness test was used to measure the surface microhardness. Data were collected and HV values among the groups were compared using one-way analysis of variance. Multiple pairwise comparisons were analyzed using Tukey’s honestly significant difference post hoc tests. Results: Improved surface remineralization was observed in all the three groups. Nano-hydroxyapatite showed highest remineralization. TCP showed better remineralization compared to BAG. Conclusion: Remineralizing efficacy of NHA toothpaste was higher when compared with BAG and β-TCP.

Keywords: Bioactive Glass, Nano Hydroxyapatite, Remineralization, Tricalcium Phosphate


How to cite this article:
Tamil S, Vineetha CS, Prasad R, Jayakumar S, John BM, Varghese R. Efficacy of domestically manufactured remineralizing agent on artificially created surface lesions: A comparative ex-vivo study. J Int Oral Health 2022;14:377-81

How to cite this URL:
Tamil S, Vineetha CS, Prasad R, Jayakumar S, John BM, Varghese R. Efficacy of domestically manufactured remineralizing agent on artificially created surface lesions: A comparative ex-vivo study. J Int Oral Health [serial online] 2022 [cited 2022 Oct 5];14:377-81. Available from: https://www.jioh.org/text.asp?2022/14/4/377/355012


  Introduction Top


Alternating episodes of demineralization and remineralization caused dental caries.[1] When the oral pH decreases below the critical pH of 5.5, it leads to demineralization.[2] This is prevented when there is a favorable environment for remineralization.[3] Early enamel lesions can be remineralized by further increasing the mineral content of the tooth, thereby increasing resistance to the acids, using remineralizing treatments.[4]

Fluoride is considered to be one of the highly effective remineralizing agents in the prevention of caries. Several alternatives to fluorides have been proposed in recent years because of their high anticariogenic characteristics.[5],[6]

N-Hap has smaller particle size that is similar to hydroxyapatite structure present in the enamel. It is a bioactive material and has a high affinity to the enamel surface.[7],[8] Since it has a unique potential for remineralization, it is widely used as an effective anti-cariogenic agent.[9],[10]

Bioactive glass (BAG) (Novamin) is another novel remineralizing agent in which the calcium sodium phosphosilicate disintegrates and leads to the release of minerals like calcium and phosphate which increases the mineralized content of the tooth structure.[11],[12],[13]

In recent days, biomimetic material has gained attention as it prevents the need for invasive treatment. Several studies have used various remineralizing agents and methods for early tooth structure loss,[14] but not many studies have compared the efficacy of these agents on artificially created surface carious lesion.

Hydroxyapatite is the major hard tissue component of teeth and bones. Nanosized hydroxyapatite has various medical and dental applications. The commercially available remineralizing agents are expensive and hence in this study, we have compared the domestically manufactured nanohydroxyapatite with commercially available tricalcium phosphate (TCP) and BAG.

The null hypothesis for the current study is that there is no difference in remineralizing efficacy of the three remineralizing agents. The outcome of this study will aid in selecting the appropriate remineralizing agent for the treatment of early enamel caries.


  Materials and Methods Top


Ethical clearance was obtained (VDCW/IEC/2016) from the Institution’s Ethics Board for an ex-vivo study with a study duration of 6 months. Caries-free teeth, extracted for orthodontic or periodontal reasons, were set as the inclusion criteria and teeth with evidence of caries, hypoplasia, or fracture were not included in the study. The samples were grouped based on random sampling method. Double blinding method was followed to avoid bias. Sample size was calculated using Cochran’s formula. Sixty freshly extracted maxillary first premolars were selected following inclusion and exclusion criteria. The samples were cleaned from external debris and mounted in self-cure acrylic such that the buccal aspect of the enamel was visible outside. The samples were immersed in 50 mL of demineralizing solution for 48 h and incubated at 37°C to create a subsurface lesion.[15] Then, the demineralized samples were rinsed with deionized water, dried, and were then segregated as n = 15 based on the remineralizing agent used:

  • Group 1—β-tri-calcium phosphate (β-TCP)


  • Group 2—domestically manufactured nanohydroxyapatite


  • Group 3—BAG


  • Group 4—control (only artificial saliva)


Preparation of nanohydroxyapatite

Hydroxyapatite nano powders (20–60 nm) were synthesized in the Chemistry Department Laboratory, Vivekanandha Dental College for Women, with a sol–gel route using calcium nitrate and phosphoric acid. Double distilled water was used as a diluting medium for HA sol preparation and ammonia was used to adjust the pH.[16]

Sample preparation

After treating the samples with the specific remineralizing agent for 4 min using polishing cup, they were stored in artificial saliva. This process was carried out at every 24th hour for 7 days. The samples in the control group were immersed only in artificial saliva with no other remineralizing agent.

A universal incubator was used to incubate the samples at 37°C between each remineralizing cycle. Vickers microhardness test was carried out to assess the surface micro hardness after seven remineralization cycles [Figure 1].
Figure 1: Vickers microhardness test on the mounted sample

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The values were tabulated and analyzed using SPSS [IBM Version 23.0, Armonk]. Level of significance was set as α = 0.05. Shapiro–Wilks tests and normality tests showed normal distribution of the variable.


  Results Top


Based on the mean values, the control group showed 54.02 ± 2.582 MPa, which was the lowest. In the experimental group, the highest mean of 181.05 ± 2.963 MPa was noted in the nano hydroxyapatite (NHA) group, TCP had a mean value of 143.05 ± 3.295 MPa, and the lowest mean value was seen in the BAG group which was 92.23 ± 2.067 MPa [Table 1].
Table 1: One-way ANOVA to compare mean HV values between groups

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F-statistic of 6123.315 was arrived using one-way analysis of variance (ANOVA), which showed that the mean microhardness among all the groups was significantly different. After this, pairwise comparison was performed [Table 2]. One-way ANOVA and Tukey’s honestly significant difference (HSD) post hoc tests were carried out for multiple pairwise comparisons [Table 3].
Table 2: ANOVA test

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Table 3: Tukey HSD post hoc tests for multiple pairwise comparisons

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The mean value of NHA showed that it had the highest microhardness than other two groups. There was a statistically significant difference from each other in the mean values of all the three groups.


  Discussion Top


Salivary calcium and phosphate ions play a major role in compensating demineralization.[17] The current study focusses on analyzing the efficacy of BAG, β-TCP, and domestically manufactured-NHA, which would aid in selecting an effective remineralizing agent for clinical use. As BAG and TCP were extensively used in several studies and not many evidence is available on nanohydroxyapatite as remineralizing agent, the efficacy of nanohydroxyapatite in comparison with the other two agents was evaluated in this study.

BAG[18] has a remarkable capacity in the formation of hydroxycarbonate apatite.[19],[20] Blending of β-TCP, sodium laurylsulfate, and fumaric acid increases the fluoride remineralization.[21],[22] NHA has gained attention in the field of medicine and dentistry.[23] The use of hydroxyapatite has also been mentioned as biomimetic[24] advancement in rebuilding the lost enamel structure in a recent published study by Acharya et al.[25]

A recent study by Juntavee et al.[26] showed a potential lesion depth reduction and forming a new enamel layer using nanohydroxyapatite compared with TCP, which was similar to the results of the current study.

After remineralization, there was a gradual increase in microhardness values in enamel to 251.08 VHN at the 28th day which was similar to the control values (268.38 VHN). This was also similar to the results of a study by Rana et al.,[27] which showed the penetration depth and improved surface microhardness with the use of Novamin on enamel demineralization.

From the results of the present study, it can be seen that the microhardness of tooth was significantly increased in all the three experimented remineralizing agents. A study by Amaechi et al.[28] showed a similar remineralizing efficacy for fluoridated toothpaste and nanohydroxyapatite, but in our study, NHA toothpaste had higher remineralizing ability than that of fluoride toothpaste. This may be due to the use of artificial saliva in our study which better simulates the oral environment.

Currently, the cost of all the above-mentioned remineralizing agents in the form of toothpastes would take a toll on patients from the economically weaker sector. Thus, evaluation of the efficacy of a domestically made toothpaste containing NHA is more affordable than similar foreign products. Thus, it would help patients opt for an indigenous tooth paste. Hence, in our study, we manufactured nanohydroxyapatite which costed nearly one-third of the expense of a commercially available remineralizing agent.

Since this is an in vitro study, it cannot completely simulate oral environment. Thus, in-vivo studies using variable concentrations and duration need to be carried out to further enhance the conclusion drawn from the present study. The scope of the current study can also be expanded by comparing various other remineralizing agents and using different modes of application.

Manufacture of other remineralizing agents domestically could also play a major role in decreasing the cost factor. Comparison of commercial and domestically manufactured remineralizing agents has a wider scope for further research.


  Conclusion Top


Within the limitations of this study, the null hypothesis was rejected. Remineralization was evident in all the three experimental groups. However, there was no complete remineralization within a period of 7 days. This study showed that domestically manufactured NHA paste had better ability to remineralize the surface than the other two experimental groups. Thus, traditional invasive dental treatment can be avoided with early diagnosis and the use of newer and indigenous remineralizing toothpaste.

Acknowledgement

Not applicable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

Not applicable.

Ethical policy and Institutional Review Board statement

Ethical clearance was obtained (VDCW/IEC/2016) fromthe Institution’s Ethics Board for an ex-vivo study

Patient declaration of consent

Not applicable.

Data availability statement

Data is available on reasonable request to corresponding author mail.

 
  References Top

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Narayana SS, Deepa VK, Ahamed S, Sathish ES, Meyappan R, Satheesh Kumar KS Remineralization efficiency of bioactive glass on artificially induced carious lesion: An in-vitro study. J Indian Soc Pedod Prev Dent 2014;32:19-25.  Back to cited text no. 17
    
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Suryani H, Gehlot PM, Manjunath MK Evaluation of the remineralisation potential of bioactive glass, nanohydroxyapatite and casein phosphopeptide-amorphous calcium phosphate fluoride-based toothpastes on enamel erosion lesion—An ex vivo study. Indian J Dent Res 2020;31:670-7.  Back to cited text no. 19
    
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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