|Year : 2023 | Volume
| Issue : 2 | Page : 127-133
In vitro remineralization effectiveness of grape seed extract on primary tooth: A systematic review and meta-analysis
RajaKumar Sekar1, MP Revanth2, Russia Marimuthu3, Sibyl Siluvai4, Saravanan Vadivelu5, Divya Raghunathan6
1 Department of Pediatric and Preventive Dentistry, SRM Kattankulathur Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Public Health Dentistry, KIDS, Chennai, Tamil Nadu, India
3 Department of Prosthodontics, SRM Kattankulathur Dental College and Hospital, Chennai, Tamil Nadu, India
4 Department of Public Health Dentistry, SRM Kattankulathur Dental College and Hospital, Chennai, Tamil Nadu, India
5 Department of Periodontics, SRM Kattankulathur Dental College and Hospital, Chennai, Tamil Nadu, India
6 Department of Public Health Dentistry, MAHER, Chennai, Tamil Nadu, India
|Date of Submission||17-Jun-2022|
|Date of Decision||18-Nov-2022|
|Date of Acceptance||27-Nov-2022|
|Date of Web Publication||28-Apr-2023|
Dr, RajaKumar Sekar
Department of Pediatric and Preventive Dentistry, SRM Kattankulathur Dental College, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: Grape seed extract (GSE) is considered a herbal alternative and has been noted for its remineralization potential. Thus, this systematic review is to analyze the in-vitro remineralization effectiveness of the natural remineralizing agent, GSE, helping to reinstate new investigative possibilities in the field of restorative dentistry. Materials and Methods: This systematic review was undertaken using objectives and transparent methods as per the PRISMA guideline and was registered with PROSPERO (CRD42021269585). Studies that had assessed the remineralizing efficacy of GSE on human primary teeth for the past 20 years published in English language were included. Electronic and manual searches were conducted to identify suitable citations, and electronic search was performed using various databases such as PubMed, Trip Database, Google Scholar, EBSCOhost Database, Scopus, and Web of Science. Those articles that were written in English and those that had full text available were considered because of its use in dentistry, whereas unpublished data and literature written in other languages and articles with only abstracts were excluded. The search was focussed on the effect of GSEs on primary teeth. Results: The search identified 446 citations, and 12 articles were chosen and reviewed in full texts, among which 2 relevant citations met the eligibility criteria for the final inclusion in the systematic review. The studies were of good quality and meta-analyses showed inconsistent evidence on the remineralization potential of GSE when compared with fluoride [mean difference: 16.63 (95% confidence interval: -62.48, 95.73); P = 0.004]. Conclusion: Within the limitations of the present study, the findings of this systematic review suggest that GSE has a remineralizing effect on primary teeth but strong literature-based clinical evidence in favor of GSE is lacking and also the remineralizing effectiveness is lesser when compared with fluoride. This reinforces the need for further in-vivo, in-vitro, and comparative clinical studies.
Keywords: Dental Caries, Fluoride Toxicity, Grape Seed Extract, Proanthocyanidins, Remineralization
|How to cite this article:|
Sekar R, Revanth M, Marimuthu R, Siluvai S, Vadivelu S, Raghunathan D. In vitro remineralization effectiveness of grape seed extract on primary tooth: A systematic review and meta-analysis. J Int Oral Health 2023;15:127-33
|How to cite this URL:|
Sekar R, Revanth M, Marimuthu R, Siluvai S, Vadivelu S, Raghunathan D. In vitro remineralization effectiveness of grape seed extract on primary tooth: A systematic review and meta-analysis. J Int Oral Health [serial online] 2023 [cited 2023 Jun 4];15:127-33. Available from: https://www.jioh.org/text.asp?2023/15/2/127/375360
| Introduction|| |
Dental caries is preventable yet highly prevailing and often cited as the most common chronic dental disease in both children and adults worldwide. Globally, it is estimated that three billion people have dental caries, and nearly 70% to almost all of the children suffer from caries once in their lifetime. Development of dental caries is considered to require a tetrad of indispensable factors such as the tooth in the oral environment, a host, aciduric bacteria, and a dietary substrate. Over the period of time, the constant presence of the substrate serves as a nutrient for the microbial growth and thus causes the production of acids by the bacteria, which leads to demineralization of the tooth in contact. Dental caries is defined by the process of destruction of hard tooth surfaces, initiated by thin bacterial biofilms adhered to the body of tooth surfaces. The enamel and dentinal mineral loss are due to the acid attacks produced by the bacterial metabolism of carbohydrates and sugars. Fortunately, dental caries is reversible early in the disease state, and stagnation of enamel and dentin demineralization is possible with inhibition of biofilm formation and salivary protective factors.
The literature search, has revealed that a plethora of materials, namely, fluorides, calcium glycerophosphate, and xylitol, have been used to promote successful remineralization of demineralized enamel and dentin. Many investigators have studied the demineralization and remineralization of enamel lesions in permanent teeth by using conventional fluoridated and non-fluoridated dentifrices. However, despite its benefits, excess fluoride can be toxic causing dental and skeletal fluorosis, hypersensitivity reactions, hypersalivation, dyspepsia, gastric irritation, muscular spasm, and birth defects. Hence, to avoid the toxic effect of fluoride, its usage is restricted in children below the age of 6 years, and alternative remineralizing agents were searched. Therefore, an extraordinary measure of enamel and dentin remineralization management has centered on looking for replacing treatment options which are natural, effective, and non-fluoride-based., Understanding the significance of alternative biomaterials and minimally invasive approaches, such as non-fluoride remineralization therapies, are important to reduce the caries burden and risk of toxicity in pediatric population. Interestingly, grape seed extract (GSE) is one such readily available over-the-counter (OTC) biomaterial and has been noted for its potential use in dental restorative for the lost enamel surface due to acids attacks and caries preventative nature, with potent antioxidant properties. There are multiple bioactive properties in GSE, but its rich content of proanthocyanidins (PAs) and gallic acid (GA) plays a beneficial role in the prevention of caries and remineralization. As described by Jassy et al., the large molecular structure of PA, called as bioflavonoid, consists of flavin, which has been found to prevent acid production by Streptococcus mutans as well as increased collagen synthesis by preventing conversion of soluble-to-insoluble collagen, thus promoting remineralization. A systematic review conducted by Delimont and Carlson on remineralizing efficacy of GSE was found to be beneficial in remineralizing the enamel of permanent tooth. But, its remineralizing efficacy on primary tooth remains unclear and no value reviews were done so far. Hence, this systematic review was done to evaluate the remineralizing efficacy of GSE on primary tooth.
| Materials and Methods|| |
This systematic review was undertaken using objectives and transparent methods as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, to identify, evaluate, and summarize all relevant research findings. The protocol for systematic review was registered with PROSPERO (International Prospective Register of Systematic Review) with registration number CRD42021269585.
The PICO analysis of the articles searched was set as shown below:
Artificial caries lesion/dental caries in primary teeth
Other remineralizing agents
Inclusion and exclusion criteria
- Studies that had assessed the remineralizing efficacy of GSE on human primary teeth.
- In-vitro studies and cross-sectional, cohort, and comparative studies were only included.
- Studies done in the past 20 years were included.
- Studies that were written in English language were only included.
- Studies that included other than human primary teeth.
- Qualitative studies, reviews, expert opinion, systematic reviews, meta-analysis, and case studies/series.
- Studies that required translation to English language.
Data collection and selection techniques
Titles and abstracts that could potentially be included were selected initially by all calibrated reviewers. All titles and abstracts selected by the reviewer were discussed together for the possibility of inclusion in the full-text reading. If the title and abstract did not provide sufficient information, the reviewer would read the article in full. If an article was found with questionable content by one reviewer, the reviewer could discuss it with other reviewers to decide whether the article could be included in inclusion or not.
Search strategy and preferences
A broad search of the literature was done in PubMed, Trip Database, Google Scholar, EBSCOhost Database, Scopus, and Web of Science, which was performed from the year January 2001 to June 2021 using MeSH terms and keywords such as dental caries, grape seed extract, proanthocynadine, primary tooth, and remineralization. The search strategy included the combination of the following terms: grape seed extract, remineralization and primary teeth, grape seed extract and primary teeth, remineralization and grape seed extract, dental caries and remineralization. Hand searches of the articles were also conducted to ensure additional relevant references, but no relevant articles had been found. The references of all the full-text articles were searched to select the relevant articles.
The remaining studies were sorted out on the basis of their title and abstract. Finally, those studies in which the abstract fulfilled all the inclusion criteria were selected for further full-text reading. In those cases, in which a study met the eligibility criteria, but the information in the abstract was insufficient, full texts of the articles were also obtained. Further literature search was also performed on the basis of the references of the selected articles.
After identification of the eligible studies, the data extraction (characteristics of the studies) was done using a data extraction form by an independent author (R.K.S). Missing or unclear information was requested by the trials’ authors. The data extraction form included the first author’s name, year of publication of the article, study design, aim of the study, study summary, and outcome [Table 1].
A meta-analysis was performed for outcomes that were reported in two different studies based on Review Manager (RevMan) version 5. 4. The comparable data were extracted, and for descriptive analysis purposes, means and standard deviations were calculated. A confidence interval (CI) of 95% and P-value of less than 0.05 were considered statistically significant. The study heterogeneity was assessed by the I2 statistic test, in which values <25%, 25–50%, and >50% were considered as low, moderate, and high degree of heterogeneity, respectively. With respect to insufficient observations, the regression-based Egger’s test and Begg’s rank test could not be used to quantify publication bias. In the meanwhile, non-parametric trim-and-fill analysis was done to estimate the number of studies missing from the meta-analysis. Risk of bias was assessed using the Cochrane Collaboration’s tool.
Assessment of heterogeneity
A meta-analysis was performed using RevMan software version 5.4.1. The assessment of heterogeneity was done by inspecting the forest plot visually to determine closeness of point estimates with each other and overlap of CIs.
In this present review, though only limited studies were included with difference in sample size and varying follow-up period, we still performed a meta-analysis for this review. A meta-analysis can yield a more precise overall estimate of the treatment effect.
| Results|| |
The search generated a total of 446 articles from six different electronic databases and manual searches. Finally, on the basis of inclusion and exclusion criteria, two articles were selected for the review using PRISMA flowchart [Figure 1]. The inter-examiner bias was eliminated. The first two authors analyzed the studies. The discrepancies between the studies were resolved by the consensus from the third author. Good inter-examiner reliability (kappa value = 0.82) was obtained.
Risk of bias and meta-analysis outcome
The quality of the studies was represented in [Figure 2](A), and it was found to be moderate risk of bias. Results of meta-analysis showed 88% (I2) of heterogenicity (tauz=2910.72) between the two studies and showed significant evidence on the remineralization potential of fluoride when compared with GSE [mean difference: 16.63 (95% CI: -62.48, 95.73); P = 0.004] [Figure 2](B).
|Figure 2: (A) Risk of bias assessment. Risk of bias assessment using Cochrane risk of bias tool. Top panel—risk of bias summary showing review author’s judgment about each risk of bias item for each included study. Bottom panel—risk of bias graph showing review author’s judgment about each risk of bias item presented as percentages across all included studies. (B) Forest plot of meta-analysis|
Click here to view
[Figure 3] represents the funnel plot with the missing studies imputed by non-parametric trim-and-fill method. One missing study was filled in the plot and the overall mean difference becomes -19.2 with 95% CI (-107.13, 68.73).
The studies included in the review were focused on remineralizing efficacy of GSE on human primary teeth compared with other remineralizing agents.
Studies done by Mirkarimi et al. (2013) and Amin et al. (2019) showed that GSE has significant remineralizing efficacy on primary teeth.
| Discussion|| |
A process of remineralization is the deposition of ion into crystal voids in demineralized enamel, producing net mineral gain, wherein the calcium and phosphate ions are supplied from an external source such as saliva to the tooth. Remineralization of enamel carious lesions is possible with various remineralizing agents such as fluoride, bioactive glass CPP-ACP, and tricalcium phosphate self-assembling peptide., Fluorides are the agents that promote remineralization and also inhibit demineralization process. Application of fluoride agents to the enamel surface replaces the hydroxide ions by fluoride ion in the hydroxyapatite crystal structure of the teeth and forms fluorapatite. One of the major drawbacks of fluoride is it might be efficient on smooth surface caries, but its effect is limited on pit and fissure caries. Its overexposure can also lead to fluorosis.
In recent times, natural products gained attention and have been the focus of much researchers as an alternative and as a new therapeutic agent to overcome the potential risk of toxicity on the usage of synthetic agents. More recently, various naturally occurring fruits, food supplements, and plant extracts have shown to promote general health and is now suggested that antimicrobial compounds of these plant origin can be considered alternative to the commonly used synthetic agents for controlling various dental diseases. One such natural product is the GSE.
GSE is the richest source of PA, which by increased collagen cross-linkages strengthens the collagen-based tissues, namely, human enamel. PA is a naturally occurring plant metabolite widely available in nuts, seeds, flowers, and bark. GSE is advocated for its beneficial remineralization, antioxidant, antibacterial, and free radical scavenging properties.
Generally, S. mutans produced glucosyltransferase, which polymerizes the glucosyl moiety into glucans by the presence of sucrose and starch carbohydrates. This constitutes the sucrose-dependent pathway for S. mutans, making it a prime importance in the formation of plaque and development of dental caries. The adherent glucans to the tooth surface in turn contribute to the formation of dental plaque, leading to the accumulation of acids and forming localized decalcification surfaces on the enamel. Hence, inhibition of glucosyltransferases by PA, in turn, inhibits caries; thus the PA-treated collagen matrices are non-toxic and inhibit enzymatic activity of F-ATPase, glucosyltransferase, and amylase, making GSEs an efficient antibacterial agent along with remineralizing capacity.
Xie et al. suggested that GSE could not only contribute to the deposition of mineral on the superficial layer of the lesion but also interact with the organic portion of enamel and dentin through PA–collagen interaction, thus stabilizing the exposed collagen matrix. Another study by Reis et al. also have reported that GSE treatment significantly increased the tensile strength of demineralized dentin, indicating the potential of GSE to induce cross-links in the dentin collagen, thereby improving the remineralization potential.
According to Abdel-Azem et al., GA, one of the major constituents of GSE and Galla chinensis, facilitates mineral deposition, predominately on the superficial layer. Proline-rich proteins such as collagen have an extremely high affinity for PA-based components, forming a proline–PA complex. As described by Nagi et al., enamel is one such structure that contains type 1 collagen
In evaluating the compiled literature, GSE showed a promising source of remineralization on dental caries and artificial enamel carious lesion. But in this systematic review, the two included studies were found to be controversial in estimating the level of remineralization potential of GSE on primary tooth: one paper (Mirkarimi et al.) had focussed on the evaluation of remineralization potential of the GSE with distilled water and found that GSE enhanced the remineralization process of artificial enamel lesions of primary teeth, whereas the other (Amin et al.) compared GSE with sodium fluoride showing remineralization potential of GSE but comparatively lesser than the fluoride. Due to this difference in the combination groups, the meta-analysis result showed 88% (I2) of heterogenicity (tauz=2910.72) between the two studies and also showed an insignificant evidence on the remineralization potential of GSE when compared with fluoride. But in both the studies, GSE showed remineralizing efficacy.
The limitation of this systematic review is that the GSE has remineralizing potential on primary tooth, but no associated clinical or in-vivo trials or no comparable studies were done using GSE, to prove its effectiveness over other agents. This reduces the evidence for the potential use of GSE over other synthetic remineralizing agents. This article emphasizes the need for further research on GSE as an alternative for the cytotoxic synthetic and fluoride remineralizing agents.
| Conclusion|| |
In conclusion, two studies that have been included in this review have showed that GSE had a remineralization effect on primary enamel carious lesion, but the efficacy of the remineralization when compared with fluoride was lesser. With this limited study results, the conclusion cannot be arrived favoring remineralizing efficacy of GSE on primary tooth. Hence, further in-vitro and in-vivo clinical studies are needed to evaluate the remineralizing efficacy of GSE on primary teeth for the arrival of the concrete conclusion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
RKS and RMP contributed in study conception, design, intellectual content, data acquisition and analysis, data interpretation, and manuscript writing and review. RM, SS, S, DR contributed to the literature search, date acquisition, data analysis and manuscript revision. All the authors approved the manuscript for final submission.
Ethical policy and Institutional Review Board statement
Registered with PROSPERO (CRD42021269585).
Patient declaration of consent
Data availability statement
Available on request (Dr.Rajakumar S, [email protected]).
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[Figure 1], [Figure 2], [Figure 3]