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Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial
p e d i a t r i c d e n t a l j o u r n a l x x x ( 2 0 1 6 ) 1 e6
Available online at www.sciencedirect.com
Pediatric Dental Journal journal homepage: www.elsevier.com/locate/pdj
Original Article
Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial Salwa A. Hegazy*, Rabab I. Salama Dental Public Health and Preventive Dentistry, Faculty of Dentistry, Mansoura University, Egypt
article info
abstract
Article history:
Objectives: The aim of this study was to compare the effectiveness of Biorepair, fluoride and
Received 25 January 2016
chlorhexidine mouthwashes in controlling plaque accumulation and gingivitis, in addition
Received in revised form
to their remineralizing effect on the initial carious lesions.
27 May 2016
Methods: about 81 children aged 7e12 years were participated in this study. They were
Accepted 31 May 2016
randomly allocated in 3 groups according to the type of the used mouthwash. At baseline,
Available online xxx
each child was examined for plaque and gingival indices. DIAGNOdent was used to determine the mineral content in the incipient lesions. Children were instructed to use
Keywords:
their specific mouthwash twice daily for 2 weeks, then they were recalled after 1, 2, 4, and 6
Antiplaque
weeks for recording the same parameters.
Antigingival
Results: All the three types of mouthwashes showed significant reduction in plaque accu-
Biorepair
mulation and gingivitis compared to the baseline. However, Biorepair and fluoride
Remineralization
mouthwashes only showed significant remineralization of early carious lesions.
Mouthwash
Conclusion: Biorepair mouthwash can serve as a better alternative to different mouth-
Nanocrystals
washes including both fluoride and chloehexidine. This single mouthwash can serve as a multi-purpose mouthwash. © 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Modern dentistry aims to reduce the loss of tooth structure, so it focused on prevention and early management of carious lesions. Management of the plaque film through brushing and flossing alone is not enough to achieve this aim, however, new technologies are required. The inhibition of demineralization and enhancing remineralization is essential for such purposes. Many agents as fluoride agents, silica compounds and casein products have been proved beneficial in this regard [1e5]. In addition to reducing demineralization and enhancing remineralization, the incorporation of fluoride into enamel
crystals leads to the formation of fluorohydroxyapatite crystals. These crystals are responsible for reducing the enamel solubility, which in turn reduce enamel demineralization [6,7]. In addition to, these fluorohydroxyapatite crystals limit the incorporation of the calcium and phosphorus ions that are needed to reconstruct subsurface lesions [8]. With the nanotechnology revolution, the hydroxyapatite nanocrystals were developed. It was found to form a layer that protects the underlying enamel structure in vitro [9]. Tschoppe et al. [10] reported that the incorporation of nanocrystals in toothpaste provided long term anticaries effect. It was found that the ions have the ability to be retained in saliva and dental plaque for a long time. The same results were also
* Corresponding author. Faculty of Dentistry, Mansoura University, El Gomhoria Street, 35516, El Mansoura, Egypt. E-mail address: [email protected] (S.A. Hegazy). http://dx.doi.org/10.1016/j.pdj.2016.05.002 0917-2394/© 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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reported by Palmieri et al. [11] it was reported to increase remineralization, inhibit demineralization, and reduce the plaque bacteria [12e14]. In spite of many in vitro studies, there is a lack in the in vivo studies concerning the effect of hydroxyapatite nanocrystals. Hence, this study aimed to evaluate the in vivo effect of mouthwash containing hydroxyapatite nanocrystals regarding dental plaque, gingivitis, and enamel remineralization, in comparison with fluoride and chloehexidine mouthwashes.
2.
Materials and methods
2.1.
This study was a randomized controlled clinical trial
2.1.1.
Study sample
After applying the inclusion and exclusion criteria, total of 81 children (36 males and 45 females) aged between 7 and 12 years old participated in the study. They were selected from outpatients of the Pediatric Dental Clinic, Faculty of Dentistry, Mansoura University. The children aged from 7 to 12 years attended the clinic examined over one month period. The inclusion criteria were children free from systemic diseases, take no medication, signed the informed consent to participate in the study, brush their teeth once before bed time, and had at least one permanent molar with discolored fissures without any signs of undermined enamel or softness at the base of fissures that scored between 12 and 25 by DIAGNOdent (indicating initial carious lesion). Teeth with cavitation, large or defective restorations on any other surface, or those having scores less than 12 by DIAGNOdent were excluded from this study. This study was approved by the Ethical Committee at the Faculty of Dentistry, Mansoura University. The purpose of the study was explained to the participants and their parents before starting the study. Written consents were taken.
2.1.2.
Study materials
Three mouthwashes were used in this study: Biorepair (hydroxyapatite nanocrystals mouthwash) (Coswell, SPA40050 FUNO e ITALY), Listerine (fluoride mouthwash) (Johnson & Johnson Middle East FZ e LLC), and Peridex (chlorhexidine mouthwash) (3M, United States). Their active ingredients are illustrated in Table 1.
2.1.3.
Inter- and intra-examiner reproducibility
Five children were assessed by two investigators twice in one visit, using the study diagnostic parameters, over one hour interval, for the clinical parameters used in this study. The second assessment was carried out blindly to the first one. Reproducibility of the data was determined. (Weighted Kappa values for intra- and inter-examiner reproducibility were 0.87 and 0.89 respectively).
2.1.4.
Study procedures
The children were randomly assigned into three groups according to the type of mouthwashes, each group contained 27
children. Group I composed children who used Biorepair mouthwash, group II children used Listerine mouthwash, and group III used Peridex mouthwash. The randomization process was made externally by the statistician using a computer-generated random table, and the investigators were neither involved in the randomization process nor were aware of the assigned group in all outcome evaluations. Randomly assigned identification codes for each child were printed on the bottles that contained the mouthwashes, each child had to use only the bottle having his/her assigned number during the follow-up. The mouthwashes were packed in similar bottles. Although the mouthwashes color had a slightly different tonality of blue, no subject could reasonably guess the assigned mouthwash. Each child was supplied with a bottle containing 70 ml of mouthwash (enough to use for one week) according to the group he/she was assigned in. Each one was instructed to use the supplied graduated cup and return the bottle at the follow up appointments to assure compliance to the treatment. All children were instructed to rinse with 5 ml of their specific mouthwash for (30e60sec) twice daily once after breakfast, and once after dinner before bedtime for two weeks under parental supervision. Printed checklist was distributed to each child and filled by one of their parents to ensure using the proper mouthwash at the correct time and dose. It also helped in recording any medication and the time the child had. The checklists were reviewed weekly. All the children were instructed to keep their normal diet and hygiene habits. Any dental complaints during the research period were dealt with through the researches. At baseline, each child was examined for the plaque € e index) [15], and the accumulation using (Silness and lo € e and Silness index) [16]. In addigingival condition using (lo tion, the visual diagnosis of the initial occlusal carious lesions on the first permanent molars was confirmed by the DIAGNOdent, to determine the mineral content of enamel (to indicate the degree of remineralization). No other oral hygiene methods were used during the study period. They were recalled after 1, 2, 4, and 6 weeks for recording the same parameters.
2.1.5.
Sample size estimation
The main outcome was the difference across groups between the mean changes from baseline to the end of the follow-up. The expected percentages at the end of the follow-up was 90% in the experimental group 50% in the control group, and (from baseline to the end), respectively, of 50% and 90%. Assuming an error 0.05 and an expected withdrawal/dropout rate of 10%, a minimum of 23 subjects per group were requested to achieve an 90% statistical power.
2.1.6.
Statistical analysis
Data were collected, tabulated and statistically analyzed using SPSS statistical software package for windows version17. Means and standard deviation (SD) values were used for data presentation. Student paired “t” test was used for intragroup comparison, and one way ANOVA and post hoc Turkey's test were used for inter group comparisons. The significance level was set at P 0.05.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 1 e Active ingredients of the mouthwashes used in this study. 1. Biorepair (mouth wash with microrepair)
Aqua, Sorbitol, Glycerin, Xylitol, Cellulose Gum, Zinc PCA, Zinc Hydroxyapatite, Aroma, Sodium Lauryl Sulfate, Silica, Ricinus Communis Seed Oil, Ammonium Acryloyldimethyltaurate/VP Copolymer, Mentha Arvensis Leaf Oil, Sodium Myristoyl Sarcosinate, Sodium Methyl Cocoyl Taurate, Sodium Saccharin, Tromethamine, Sodium Benzoate, Benzyl Alcohol, Phenoxyethanol, Limonene. * microRepair® Sodium fluoride 0.02% (0.01% w/v fluoride ion Water) Aqua, sorbitol, alcohol (21.6%),flavors, poloxamer 407, sodium lauryl sulfate, eucalyptol, methyl salicylate, thymol, phosphoric acid, sucralose, menthol, disodium phosphate, FD&C Blue No. 1 0.12% chlorhexidine gluconate. Nonmedicinal ingredients: water, alcohol, glycerine, PEG-40 sorbitan diisostearate, flavor, saccharin sodium, and FD&C Blue No. 1 Dye
2. Listerine (fluoride mouthwash)
3. Peridex (chlorohexidine mouthwash)
Table 2 e Demographic characters of the study sample. Variable Mean age Number of children Male Female Total Number of teeth with incipient lesions Male Female Total Mean DMFT components DT MT FT Total DMFT Mean dft components Dt Ft Total dft Mean number of dental visits per year
3.
Group I
Group II
8.93 ± 2.35
9.01 ± 2.43
8.99 ± 2.36
0.8
12 (46.2%) 14 (53.8%) 26 (34.2%)
11 (42.2%) 15 (57.7%) 26 (34.2%)
10 (41.7%) 14 (58.3%) 24 (31.6%)
0.7
34 (45.3%) 41 (54.7%) 75 (35.7%)
31 (45.6%) 37 (54.4%) 68 (32.4%)
32 (47.8%) 34 (50.7%) 67 (31.9%)
0.5
0.382 ± 0.231 ± 0.115 ± 0.244 ±
0.361 ± 0.210 ± 0.107 ± 0.226 ±
0.358 0.275 0.108 0.242
0.041 0.042 0.016 0.027
0.076 ± 0.006 0.039 ± 0.004 0.057 ± 0.005 2.12 ± 0.152
Results
This study started with (81) children (36 male and 45 females) divided as 12 male and 15 female in each group. Five children were excluded due to the incompliance to the study guidelines, or taking a course of antibiotics during the study period. A total of (76) children having (210) teeth fulfilled the inclusion guidelines, completed the study, were included in the statistical analysis. Their demographic data is presented in (Table 2). The mean scores of plaque index at different follow up periods are presented in Table 2. In group (I), significant reduction in the mean index scores was evident at the end of the following period (6 weeks) in comparison with the base line scores. On the other hand, groups (II and III) showed significant reduction after two weeks of using the mouthwash. By comparing the three groups, group (III) showed significantly higher reduction of plaque scores than the other two groups, while there was no significant difference between groups (I and II). As for gingival condition, the three groups showed improvement in the gingival index scores. However, in groups (I and III) significant difference from the base line appeared only after the 4th and 6th weeks of using the mouthwash,
0.052 0.431 0.018 0.014
0.038 ± 0.001 0.032 ± 0.001 0.034 ± 0.002 2.11 ± 0.162
Group III
± 0.047 ± 0.041 ± 0.013 ± 0.021
0.041 ± 0.002 0.083 ± 0.006 0.062 ± 0.005 2.17 ± 0.167
P value
0.09
0.000 0.2
while in group (II), the significant difference appeared only after six weeks. In addition, group III showed significantly higher reduction of the mean gingival index scores than the other two groups after four and six weeks (Table 3). In Table 4, the mean DIAGNOdent scores of group (I) revealed significant reduction of the mean scores starting one week after using the mouthwash. In group (II), the significant reduction was detected after two weeks, while group (III) showed no significant difference at all the follow up periods. Groups (I and II) showed significant improvement in the scores in comparison with group (III). There was no significant difference between groups (I and II) (see Table 5).
4.
Discussion
A thorough exploration of the available literature revealed few studies in which different Biorepair mouthwashes were compared with chlorhexidine or fluoride mouthwashes. For this reason, the present study aimed to evaluate the effect of hydroxyapatite nanocrystals mouthwash (Biorepair) on reducing plaque formation and gingivitis, in addition to its enhancement of the remineralization of the incipient enamel lesions.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 3 e The mean and standard deviation plaque index scores of the children in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth washes usage. Groups
Group I N ¼ 26 n ¼ 75 Group II N ¼ 26 n ¼ 68 Group III N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
One way ANOVA (P value)
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
2.41 ± 1.94a
2.11 ± 1.22*
1.99 ± 1.13*
1.75 ± 1.06*
1.40 ± 0.77*a
4.932 (0.05)
2.76 ± 1.38bcd
2.52 ± 1.37#
2.01 ± 1.25#b
1.78 ± 0.79#c
1.51 ± 0.69#d
4.285 (0.05)
2.11 ± 1.26efg
1.97 ± 1.15
1.32 ± 0.98e
1.12 ± 0.65f
0.91 ± 0.42g
6.974 (0.02)
1.673 (0.244)
3.559 (0.03)
8.162 (0.000)
13.166 (0.000)
16.890 (0.000)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesions in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicates significant difference than the baseline scores within the same group.
Table 4 e The mean and standard deviation gingival index scores of the children in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth washes usage. Groups
Group I N ¼ 26 n ¼ 75 Group II N ¼ 26 n ¼ 68 Group III N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
One way ANOVA (P value)
2.35 ± 1.43ab
2.09 ± 1.41
1.69 ± 1.13
1.31 ± 0.87*a
1.12 ± 0.72*b
4.825 (0.05)
2.17 ± 1.81c
2.11 ± 1.55
1.76 ± 1.52
1.47 ± 0.95#
1.24 ± 0.66#c
5.194 (0.05)
2.07 ± 1.77de
1.96 ± 1.39
1.49 ± 0.88
1.01 ± 0.49d
0.86 ± 0.42e
7.724 (0.000)
0.318 (0.437)
0.212 (0.809)
2.238 (0.147)
5.819 (0.003)
6.914 (0.001)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesion in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicate significant difference than base line within the same group.
This study was designed as randomized clinical trial, controlling confounding factors such as mineral containing medications or usage of other daily oral care was stopped and if any was reported in the weekly checklist was performed. Compliance of the participant to the treatment was controlled by two ways the parent's weekly checklist and the weekly returned mouth wash excess. Double blinded technique was used to ensure data validity. The study period was designed to last for 6 weeks only, to avoid any possible side effect of chlorhexidine as staining of the teeth surfaces, and enhancing the calculus formation as reported by Zanatta et al. [17]. In addition, this period ensures the deposition of minerals on initial carious lesions and allows the antimicrobial action of the mouthwashes [6e8,10]. In the present study, DIAGNOdent was used for diagnosing the incipient enamel lesions as it is a simple and quick device to use that doesn't need a lot of cooperation from the child, additionally the numbers obtained determine the condition of
the caries [18]. The repetitive use of this device has no harm for the child. Sridhar et al. [19] showed that DIAGNOdent can diagnose occlusal surface caries better than visual method and radiography. Considering the reported sensitivity and specificity in different studies [19e21], it seems that DIAGNOdent is a suitable device for detection of caries. After 6 weeks of follow-up, no adverse events were reported by children of all groups. The use of 0.12% chlorhexidine mouthwash was recommended in the present study as Kaur et al. [22] revealed that the use of 0.12% chlorhexidine mouthwash reported no side effects compared with 0.2% chlorhexidine concentration. The results of this study revealed that Biorepair mouthwash reduced plaque formation from the first week of use compared to the baseline data; however, this reduction was significant only after the 6th week. It also reduced the degree of present gingivitis since the first week; the difference from the baseline data was significant at the 4th and 6th weeks.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 5 e the mean and standard deviation DIAGNOdent scores of the children's teeth in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth wash usage. Groups
Group I N ¼ 26 n ¼ 75 GroupII N ¼ 26 n ¼ 68 GroupIII N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
One way ANOVA (P value)
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
23.72 ± 14.93abcd
17.01 ± 9.31*a
15.37 ± 7.59*b
14.86 ± 7.44*c
13.95 ± 7.23d
11.153 (0.000)
23.07 ± 15.21efg
18.43 ± 8.19#
15.55 ± 6.82#e
15.46 ± 6.35#f
14.91 ± 6.26g
6.931 (0.02)
22.99 ± 17.75
21.64 ± 11.34
20.99 ± 11.19
21.17 ± 10.21
20.76 ± 10.13
2.173 (0.619)
1.782 (0.684)
3.189 (0.02)
11.064 (0.000)
11.435 (0.000)
14.478 (0.000)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesions in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicate significant difference than base line within the same group.
These results coincide with the results of Hanning et al. [14] who reported that mouthwash containing hydroxyapatite microclusters has an antiplaque adherent effect in addition to affecting the antibacterial properties. They concluded that the antiadhesive effect is exerted by the hydroxyapatite microclusters, while xylitol and the other components are responsible for the antibacterial effect. The results of this study also showed that Biorepair mouthwash exhibited a similar effect to Listerine (fluoride mouthwash). There was no significant difference between them in reducing plaque and gingivitis. The antiplaque and antibacterial properties of Listerine mouthwash was proved in previous studies [23,24]. It could be thus concluded that Biorepair mouthwash that contains the hydroxyapatite nanocrystals is beneficial as fluoride containing mouthwashes. Comparing the effect of Biorepair with chlorhexidine, it was found that both mouthwashes exhibited significantly lower reducing effects on plaque and gingivitis. This could be explained by the fact that mouthwashes with antimicrobial effects perform their actions using three methods, which include apoptosis, inhibition of bacterial growth and/or cell metabolic inhibition [25]. However no backings with similar results are evident in the dental literature since there were no previous attempts comparing Biorepair and chlorhexidine mouthwashes. Regarding the mineral contents in the incipient enamel lesions as measured by DIAGNOdent, fluoride and nanocrystals containing mouthwashes provided better remineralization than chlorhexidine containing mouthwash. However, hydroxyapatite containing mouthwash showed a superior effect over that containing fluoride. This could be evident by the significant increase of the lesion's mineral content that appeared one week after using of Biorepair mouthwash. However Listerine (fluoride mouthwashes) showed the significant increase in the minerals content after two weeks. These results were previously reported in other studies [26e28]. It was reported that the presence of hydroxyapatite crystals during remineralization induce the minerals into the depth of the lesion, while fluoride forms a layer on the surface preventing the diffusion of the minerals into the depth of lesion [27,28].
However this study have some limitations, it was applied on a relatively small sample, so there is a need to perform the study on a larger sample. However, the inclusion criteria were precise, which helped to reduce the bias together with the blindness and the randomization techniques used in this study. Nevertheless, other confounding variables may cause sample bias (as the mineral content in the diet).
5.
Conclusion
The efficacies of biorepair and fluoride mouthwashes were equally effective in reducing plaque and gingivitis as compared to chlorhexidine mouthwash. In addition to the antiplaque and anti-gingival action of Biorepair mouthwash, the remineralizing effects on early signs of initial caries were evident. The findings of the present study suggest that Biorepair mouthwash can be used as an alternative for both fluoride and chlorhexidine. This single mouthwash could act as a multipurpose mouthwash.
The present study showed significant importance for pediatric oral health Provide significance results for early remineralization of initial carious lesions which are common among children. Mouthwash is considered more easily and effective methods used among children for control plaque and gingivitis which are proven in this study. New material with its valuable results on dental caries reduction which can be used easily among children.
Conflict of interest No conflict of interest.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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references
[1] Frencken JE, Holmgren CJ. ART: a minimal intervention approach to manage dental caries. Dent Update 2004;31:295e301. [2] Marsh PD. Dental plaque as a microbial biofilm. Caries Res 2004;38:204e11. [3] Hassanein OE, El Borolossy TA. An investigation about the remineralization potential of bioactive glass on artificially carious enamel and dentin using Raman spectroscopy. Egypt J Solids 2006;29:1. [4] Cross KJ, Huq NL, Reynolds EC. Casein phosphopeptides in oral healthdchemistry and clinical applications. Curr Pharm Des 2007;13:793e800. [5] Hannig M, Hannig C. Nanomaterials in preventive dentistry. Nat Nanotechnol 2010;5:565e9. [6] Hamdan AM, Maxfield BJ, Tu¨fekc¸i E, Shroff B, Lindauer SJ. Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists. J Am Dent Assoc 2012;143:777e83. [7] Zanarini M, Pazzi E, Bonetti S, et al. In vitro evaluation of the effects of a fluoride-releasing composite on enamel demineralization around brackets. Prog Orthod 2012;13:10e6. [8] Late S, Varghese NO, Varughese JM. Remineralization potential of fluoride and amorphous calcium phosphatecasein phosphopeptide on enamel lesions: an in vitro comparative evaluation. J Conserv Dent 2010;13:42e6. [9] Roveri N, Battistella E, Foltran I. Synthetic biomimetic carbonate-hydroxyapatite nanocrystals for enamel remineralization. Mater Sci Forum 2008;47e50:821e4. [10] Tschoppe P, Zandim DL, Martus P, Kielbassa AM. Enamel and dentine remineralization by nano hydroxyapatite toothpastes. J Dent 2011;39:430e7. [11] Palmieri C, Magi G, Orsini G, Putignano A, Facinelli B. Antibiofilm activity of zinc-carbonate hydroxyapatite nanocrystals against Streptococcus mutans and Mitis Group Streptococci. Curr Microbiol 2013;67:679e81. [12] Poggio C, Lombardini M, Colombo M, et al. Impact of two toothpastes on repairing enamel erosion produced by a soft drink: an AFM in vitro study. J Dent 2010;38:868e74. [13] Roveri N, Palazzo B, Iafisco M. The role of biomimetism in developing nanostructured inorganic matrices for drug delivery. Expert Opin Drug Deliv 2008;5:861e77. [14] Hannig C, Basche S, Burghardt T, Al-Ahmad A, Hannig M. Influence of a mouthwash containing hydroxyapatite microclusters on bacterial adherence in situ. Clin Oral Invest 2013;17:805e14. € e H. Periodontal disease in pregnancy. II. [15] Silness J, Lo Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121e35.
€ e H, Silness J. Periodontal disease in pregnancy. I. [16] Lo Prevalance and severity. Acta Odontol Scand 1963;21:533e51. [17] Zanatta F, Antoniazzi R, Rosing C. Staining and calculus formation 0.12% chlorhexidine rinse in plaque-free and plaque covered surfaces: a randomized trial. J Appl Oral Sci 2010;18:515e21. [18] Nokhbatolfoghahaie H, Alikhasi M, Chiniforush N, Khoei F, Safavi N, Zadeh B. Evaluation of the accuracy of DIAGNOdent in diagnosis of primary and secondary caries in comparison to conventional methods. J Lasers Med Sci 2013;4(4):159e67. [19] Sridhar N, Tandon S, Rao N. A comparative evaluation of DIAGNOdent with visual and radiography for detection of occlusal caries: an in vitro study. Indian J Dent Res 2009;20(3):326e31. [20] Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33:261e6. [21] Chu CH, Lo EC, You DS. Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques. Lasers Med Sci 2010;25(3):355e62. [22] Kaur P, Singh H, Khatri A, Aulakh KS. Evaluation and comparison of short term side effects of 0.2% and 0.12% chlorhexidine mouthwash. J Adv Med Dent Scie Res 2015;3(3):26e8. [23] TenCate J, Zaura E. The numerous microbial species in oral biofilms: how could antibacterial therapy be effective? Adv Den Res 2012;24:108e11. [24] Sun F, Engelman E, McGuire J, et al. Impact of an anticaries mouthrinse on In vitro remineralization and microbial control. Int J Dent 2014:11. http://dx.doi.org/10.1155/2014/ 982071. Article ID 982071. [25] Yousefimanesh H, Amin M, Robati M, Goodarzi H, Otoufi M. Comparison of the antibacterial properties of three mouthwashes containing chlorhexidine against oral microbial plaques: an in vitro study. Jundishapur J Microbiol 2015 February;8(2):e17341. [26] Orsini G, Procaccini M, Manzoli L, Giuliodori F, Lorenzini A, Putignano A. A double- blined randomized-controlled trial controlling the desensitizing efficacy of a new dentifrice containing carbonate/hydroxyapatite nanocrystals and a sodium fluoride/potassium nitratedentifrice. J Clin Periodontol 2010;37:510e7. [27] Roveri N, Battistella E, Flotran I, et al. Synthetic biomimetic carbonate-hydroxyapatite nanocrystals for enamel remineralization. Adv Mat Res 2008;47:821e4. [28] Roveri N, Battistella E, Bianchi C, et al. Surface enamel remineralization: biomimetic aptite nanocrystals and fluoride ion different effects. J Nanomater 2008;10:14e25.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
Available online at www.sciencedirect.com
Pediatric Dental Journal journal homepage: www.elsevier.com/locate/pdj
Original Article
Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial Salwa A. Hegazy*, Rabab I. Salama Dental Public Health and Preventive Dentistry, Faculty of Dentistry, Mansoura University, Egypt
article info
abstract
Article history:
Objectives: The aim of this study was to compare the effectiveness of Biorepair, fluoride and
Received 25 January 2016
chlorhexidine mouthwashes in controlling plaque accumulation and gingivitis, in addition
Received in revised form
to their remineralizing effect on the initial carious lesions.
27 May 2016
Methods: about 81 children aged 7e12 years were participated in this study. They were
Accepted 31 May 2016
randomly allocated in 3 groups according to the type of the used mouthwash. At baseline,
Available online xxx
each child was examined for plaque and gingival indices. DIAGNOdent was used to determine the mineral content in the incipient lesions. Children were instructed to use
Keywords:
their specific mouthwash twice daily for 2 weeks, then they were recalled after 1, 2, 4, and 6
Antiplaque
weeks for recording the same parameters.
Antigingival
Results: All the three types of mouthwashes showed significant reduction in plaque accu-
Biorepair
mulation and gingivitis compared to the baseline. However, Biorepair and fluoride
Remineralization
mouthwashes only showed significant remineralization of early carious lesions.
Mouthwash
Conclusion: Biorepair mouthwash can serve as a better alternative to different mouth-
Nanocrystals
washes including both fluoride and chloehexidine. This single mouthwash can serve as a multi-purpose mouthwash. © 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
Modern dentistry aims to reduce the loss of tooth structure, so it focused on prevention and early management of carious lesions. Management of the plaque film through brushing and flossing alone is not enough to achieve this aim, however, new technologies are required. The inhibition of demineralization and enhancing remineralization is essential for such purposes. Many agents as fluoride agents, silica compounds and casein products have been proved beneficial in this regard [1e5]. In addition to reducing demineralization and enhancing remineralization, the incorporation of fluoride into enamel
crystals leads to the formation of fluorohydroxyapatite crystals. These crystals are responsible for reducing the enamel solubility, which in turn reduce enamel demineralization [6,7]. In addition to, these fluorohydroxyapatite crystals limit the incorporation of the calcium and phosphorus ions that are needed to reconstruct subsurface lesions [8]. With the nanotechnology revolution, the hydroxyapatite nanocrystals were developed. It was found to form a layer that protects the underlying enamel structure in vitro [9]. Tschoppe et al. [10] reported that the incorporation of nanocrystals in toothpaste provided long term anticaries effect. It was found that the ions have the ability to be retained in saliva and dental plaque for a long time. The same results were also
* Corresponding author. Faculty of Dentistry, Mansoura University, El Gomhoria Street, 35516, El Mansoura, Egypt. E-mail address: [email protected] (S.A. Hegazy). http://dx.doi.org/10.1016/j.pdj.2016.05.002 0917-2394/© 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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reported by Palmieri et al. [11] it was reported to increase remineralization, inhibit demineralization, and reduce the plaque bacteria [12e14]. In spite of many in vitro studies, there is a lack in the in vivo studies concerning the effect of hydroxyapatite nanocrystals. Hence, this study aimed to evaluate the in vivo effect of mouthwash containing hydroxyapatite nanocrystals regarding dental plaque, gingivitis, and enamel remineralization, in comparison with fluoride and chloehexidine mouthwashes.
2.
Materials and methods
2.1.
This study was a randomized controlled clinical trial
2.1.1.
Study sample
After applying the inclusion and exclusion criteria, total of 81 children (36 males and 45 females) aged between 7 and 12 years old participated in the study. They were selected from outpatients of the Pediatric Dental Clinic, Faculty of Dentistry, Mansoura University. The children aged from 7 to 12 years attended the clinic examined over one month period. The inclusion criteria were children free from systemic diseases, take no medication, signed the informed consent to participate in the study, brush their teeth once before bed time, and had at least one permanent molar with discolored fissures without any signs of undermined enamel or softness at the base of fissures that scored between 12 and 25 by DIAGNOdent (indicating initial carious lesion). Teeth with cavitation, large or defective restorations on any other surface, or those having scores less than 12 by DIAGNOdent were excluded from this study. This study was approved by the Ethical Committee at the Faculty of Dentistry, Mansoura University. The purpose of the study was explained to the participants and their parents before starting the study. Written consents were taken.
2.1.2.
Study materials
Three mouthwashes were used in this study: Biorepair (hydroxyapatite nanocrystals mouthwash) (Coswell, SPA40050 FUNO e ITALY), Listerine (fluoride mouthwash) (Johnson & Johnson Middle East FZ e LLC), and Peridex (chlorhexidine mouthwash) (3M, United States). Their active ingredients are illustrated in Table 1.
2.1.3.
Inter- and intra-examiner reproducibility
Five children were assessed by two investigators twice in one visit, using the study diagnostic parameters, over one hour interval, for the clinical parameters used in this study. The second assessment was carried out blindly to the first one. Reproducibility of the data was determined. (Weighted Kappa values for intra- and inter-examiner reproducibility were 0.87 and 0.89 respectively).
2.1.4.
Study procedures
The children were randomly assigned into three groups according to the type of mouthwashes, each group contained 27
children. Group I composed children who used Biorepair mouthwash, group II children used Listerine mouthwash, and group III used Peridex mouthwash. The randomization process was made externally by the statistician using a computer-generated random table, and the investigators were neither involved in the randomization process nor were aware of the assigned group in all outcome evaluations. Randomly assigned identification codes for each child were printed on the bottles that contained the mouthwashes, each child had to use only the bottle having his/her assigned number during the follow-up. The mouthwashes were packed in similar bottles. Although the mouthwashes color had a slightly different tonality of blue, no subject could reasonably guess the assigned mouthwash. Each child was supplied with a bottle containing 70 ml of mouthwash (enough to use for one week) according to the group he/she was assigned in. Each one was instructed to use the supplied graduated cup and return the bottle at the follow up appointments to assure compliance to the treatment. All children were instructed to rinse with 5 ml of their specific mouthwash for (30e60sec) twice daily once after breakfast, and once after dinner before bedtime for two weeks under parental supervision. Printed checklist was distributed to each child and filled by one of their parents to ensure using the proper mouthwash at the correct time and dose. It also helped in recording any medication and the time the child had. The checklists were reviewed weekly. All the children were instructed to keep their normal diet and hygiene habits. Any dental complaints during the research period were dealt with through the researches. At baseline, each child was examined for the plaque € e index) [15], and the accumulation using (Silness and lo € e and Silness index) [16]. In addigingival condition using (lo tion, the visual diagnosis of the initial occlusal carious lesions on the first permanent molars was confirmed by the DIAGNOdent, to determine the mineral content of enamel (to indicate the degree of remineralization). No other oral hygiene methods were used during the study period. They were recalled after 1, 2, 4, and 6 weeks for recording the same parameters.
2.1.5.
Sample size estimation
The main outcome was the difference across groups between the mean changes from baseline to the end of the follow-up. The expected percentages at the end of the follow-up was 90% in the experimental group 50% in the control group, and (from baseline to the end), respectively, of 50% and 90%. Assuming an error 0.05 and an expected withdrawal/dropout rate of 10%, a minimum of 23 subjects per group were requested to achieve an 90% statistical power.
2.1.6.
Statistical analysis
Data were collected, tabulated and statistically analyzed using SPSS statistical software package for windows version17. Means and standard deviation (SD) values were used for data presentation. Student paired “t” test was used for intragroup comparison, and one way ANOVA and post hoc Turkey's test were used for inter group comparisons. The significance level was set at P 0.05.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 1 e Active ingredients of the mouthwashes used in this study. 1. Biorepair (mouth wash with microrepair)
Aqua, Sorbitol, Glycerin, Xylitol, Cellulose Gum, Zinc PCA, Zinc Hydroxyapatite, Aroma, Sodium Lauryl Sulfate, Silica, Ricinus Communis Seed Oil, Ammonium Acryloyldimethyltaurate/VP Copolymer, Mentha Arvensis Leaf Oil, Sodium Myristoyl Sarcosinate, Sodium Methyl Cocoyl Taurate, Sodium Saccharin, Tromethamine, Sodium Benzoate, Benzyl Alcohol, Phenoxyethanol, Limonene. * microRepair® Sodium fluoride 0.02% (0.01% w/v fluoride ion Water) Aqua, sorbitol, alcohol (21.6%),flavors, poloxamer 407, sodium lauryl sulfate, eucalyptol, methyl salicylate, thymol, phosphoric acid, sucralose, menthol, disodium phosphate, FD&C Blue No. 1 0.12% chlorhexidine gluconate. Nonmedicinal ingredients: water, alcohol, glycerine, PEG-40 sorbitan diisostearate, flavor, saccharin sodium, and FD&C Blue No. 1 Dye
2. Listerine (fluoride mouthwash)
3. Peridex (chlorohexidine mouthwash)
Table 2 e Demographic characters of the study sample. Variable Mean age Number of children Male Female Total Number of teeth with incipient lesions Male Female Total Mean DMFT components DT MT FT Total DMFT Mean dft components Dt Ft Total dft Mean number of dental visits per year
3.
Group I
Group II
8.93 ± 2.35
9.01 ± 2.43
8.99 ± 2.36
0.8
12 (46.2%) 14 (53.8%) 26 (34.2%)
11 (42.2%) 15 (57.7%) 26 (34.2%)
10 (41.7%) 14 (58.3%) 24 (31.6%)
0.7
34 (45.3%) 41 (54.7%) 75 (35.7%)
31 (45.6%) 37 (54.4%) 68 (32.4%)
32 (47.8%) 34 (50.7%) 67 (31.9%)
0.5
0.382 ± 0.231 ± 0.115 ± 0.244 ±
0.361 ± 0.210 ± 0.107 ± 0.226 ±
0.358 0.275 0.108 0.242
0.041 0.042 0.016 0.027
0.076 ± 0.006 0.039 ± 0.004 0.057 ± 0.005 2.12 ± 0.152
Results
This study started with (81) children (36 male and 45 females) divided as 12 male and 15 female in each group. Five children were excluded due to the incompliance to the study guidelines, or taking a course of antibiotics during the study period. A total of (76) children having (210) teeth fulfilled the inclusion guidelines, completed the study, were included in the statistical analysis. Their demographic data is presented in (Table 2). The mean scores of plaque index at different follow up periods are presented in Table 2. In group (I), significant reduction in the mean index scores was evident at the end of the following period (6 weeks) in comparison with the base line scores. On the other hand, groups (II and III) showed significant reduction after two weeks of using the mouthwash. By comparing the three groups, group (III) showed significantly higher reduction of plaque scores than the other two groups, while there was no significant difference between groups (I and II). As for gingival condition, the three groups showed improvement in the gingival index scores. However, in groups (I and III) significant difference from the base line appeared only after the 4th and 6th weeks of using the mouthwash,
0.052 0.431 0.018 0.014
0.038 ± 0.001 0.032 ± 0.001 0.034 ± 0.002 2.11 ± 0.162
Group III
± 0.047 ± 0.041 ± 0.013 ± 0.021
0.041 ± 0.002 0.083 ± 0.006 0.062 ± 0.005 2.17 ± 0.167
P value
0.09
0.000 0.2
while in group (II), the significant difference appeared only after six weeks. In addition, group III showed significantly higher reduction of the mean gingival index scores than the other two groups after four and six weeks (Table 3). In Table 4, the mean DIAGNOdent scores of group (I) revealed significant reduction of the mean scores starting one week after using the mouthwash. In group (II), the significant reduction was detected after two weeks, while group (III) showed no significant difference at all the follow up periods. Groups (I and II) showed significant improvement in the scores in comparison with group (III). There was no significant difference between groups (I and II) (see Table 5).
4.
Discussion
A thorough exploration of the available literature revealed few studies in which different Biorepair mouthwashes were compared with chlorhexidine or fluoride mouthwashes. For this reason, the present study aimed to evaluate the effect of hydroxyapatite nanocrystals mouthwash (Biorepair) on reducing plaque formation and gingivitis, in addition to its enhancement of the remineralization of the incipient enamel lesions.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 3 e The mean and standard deviation plaque index scores of the children in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth washes usage. Groups
Group I N ¼ 26 n ¼ 75 Group II N ¼ 26 n ¼ 68 Group III N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
One way ANOVA (P value)
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
2.41 ± 1.94a
2.11 ± 1.22*
1.99 ± 1.13*
1.75 ± 1.06*
1.40 ± 0.77*a
4.932 (0.05)
2.76 ± 1.38bcd
2.52 ± 1.37#
2.01 ± 1.25#b
1.78 ± 0.79#c
1.51 ± 0.69#d
4.285 (0.05)
2.11 ± 1.26efg
1.97 ± 1.15
1.32 ± 0.98e
1.12 ± 0.65f
0.91 ± 0.42g
6.974 (0.02)
1.673 (0.244)
3.559 (0.03)
8.162 (0.000)
13.166 (0.000)
16.890 (0.000)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesions in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicates significant difference than the baseline scores within the same group.
Table 4 e The mean and standard deviation gingival index scores of the children in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth washes usage. Groups
Group I N ¼ 26 n ¼ 75 Group II N ¼ 26 n ¼ 68 Group III N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
One way ANOVA (P value)
2.35 ± 1.43ab
2.09 ± 1.41
1.69 ± 1.13
1.31 ± 0.87*a
1.12 ± 0.72*b
4.825 (0.05)
2.17 ± 1.81c
2.11 ± 1.55
1.76 ± 1.52
1.47 ± 0.95#
1.24 ± 0.66#c
5.194 (0.05)
2.07 ± 1.77de
1.96 ± 1.39
1.49 ± 0.88
1.01 ± 0.49d
0.86 ± 0.42e
7.724 (0.000)
0.318 (0.437)
0.212 (0.809)
2.238 (0.147)
5.819 (0.003)
6.914 (0.001)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesion in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicate significant difference than base line within the same group.
This study was designed as randomized clinical trial, controlling confounding factors such as mineral containing medications or usage of other daily oral care was stopped and if any was reported in the weekly checklist was performed. Compliance of the participant to the treatment was controlled by two ways the parent's weekly checklist and the weekly returned mouth wash excess. Double blinded technique was used to ensure data validity. The study period was designed to last for 6 weeks only, to avoid any possible side effect of chlorhexidine as staining of the teeth surfaces, and enhancing the calculus formation as reported by Zanatta et al. [17]. In addition, this period ensures the deposition of minerals on initial carious lesions and allows the antimicrobial action of the mouthwashes [6e8,10]. In the present study, DIAGNOdent was used for diagnosing the incipient enamel lesions as it is a simple and quick device to use that doesn't need a lot of cooperation from the child, additionally the numbers obtained determine the condition of
the caries [18]. The repetitive use of this device has no harm for the child. Sridhar et al. [19] showed that DIAGNOdent can diagnose occlusal surface caries better than visual method and radiography. Considering the reported sensitivity and specificity in different studies [19e21], it seems that DIAGNOdent is a suitable device for detection of caries. After 6 weeks of follow-up, no adverse events were reported by children of all groups. The use of 0.12% chlorhexidine mouthwash was recommended in the present study as Kaur et al. [22] revealed that the use of 0.12% chlorhexidine mouthwash reported no side effects compared with 0.2% chlorhexidine concentration. The results of this study revealed that Biorepair mouthwash reduced plaque formation from the first week of use compared to the baseline data; however, this reduction was significant only after the 6th week. It also reduced the degree of present gingivitis since the first week; the difference from the baseline data was significant at the 4th and 6th weeks.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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Table 5 e the mean and standard deviation DIAGNOdent scores of the children's teeth in the three groups at the baseline and after 1, 2, 4 and 6 weeks of the mouth wash usage. Groups
Group I N ¼ 26 n ¼ 75 GroupII N ¼ 26 n ¼ 68 GroupIII N ¼ 24 n ¼ 68 One way ANOVA (P value)
Baseline
1 week
2 weeks
4 weeks
6 weeks
One way ANOVA (P value)
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
23.72 ± 14.93abcd
17.01 ± 9.31*a
15.37 ± 7.59*b
14.86 ± 7.44*c
13.95 ± 7.23d
11.153 (0.000)
23.07 ± 15.21efg
18.43 ± 8.19#
15.55 ± 6.82#e
15.46 ± 6.35#f
14.91 ± 6.26g
6.931 (0.02)
22.99 ± 17.75
21.64 ± 11.34
20.99 ± 11.19
21.17 ± 10.21
20.76 ± 10.13
2.173 (0.619)
1.782 (0.684)
3.189 (0.02)
11.064 (0.000)
11.435 (0.000)
14.478 (0.000)
N ¼ number of children within the group. n ¼ number of permanent teeth with incipient lesions in each group. *Significant difference between group I and III at P < 0.05. #Significant difference between group II and III at P < 0.05. Similar letters indicate significant difference than base line within the same group.
These results coincide with the results of Hanning et al. [14] who reported that mouthwash containing hydroxyapatite microclusters has an antiplaque adherent effect in addition to affecting the antibacterial properties. They concluded that the antiadhesive effect is exerted by the hydroxyapatite microclusters, while xylitol and the other components are responsible for the antibacterial effect. The results of this study also showed that Biorepair mouthwash exhibited a similar effect to Listerine (fluoride mouthwash). There was no significant difference between them in reducing plaque and gingivitis. The antiplaque and antibacterial properties of Listerine mouthwash was proved in previous studies [23,24]. It could be thus concluded that Biorepair mouthwash that contains the hydroxyapatite nanocrystals is beneficial as fluoride containing mouthwashes. Comparing the effect of Biorepair with chlorhexidine, it was found that both mouthwashes exhibited significantly lower reducing effects on plaque and gingivitis. This could be explained by the fact that mouthwashes with antimicrobial effects perform their actions using three methods, which include apoptosis, inhibition of bacterial growth and/or cell metabolic inhibition [25]. However no backings with similar results are evident in the dental literature since there were no previous attempts comparing Biorepair and chlorhexidine mouthwashes. Regarding the mineral contents in the incipient enamel lesions as measured by DIAGNOdent, fluoride and nanocrystals containing mouthwashes provided better remineralization than chlorhexidine containing mouthwash. However, hydroxyapatite containing mouthwash showed a superior effect over that containing fluoride. This could be evident by the significant increase of the lesion's mineral content that appeared one week after using of Biorepair mouthwash. However Listerine (fluoride mouthwashes) showed the significant increase in the minerals content after two weeks. These results were previously reported in other studies [26e28]. It was reported that the presence of hydroxyapatite crystals during remineralization induce the minerals into the depth of the lesion, while fluoride forms a layer on the surface preventing the diffusion of the minerals into the depth of lesion [27,28].
However this study have some limitations, it was applied on a relatively small sample, so there is a need to perform the study on a larger sample. However, the inclusion criteria were precise, which helped to reduce the bias together with the blindness and the randomization techniques used in this study. Nevertheless, other confounding variables may cause sample bias (as the mineral content in the diet).
5.
Conclusion
The efficacies of biorepair and fluoride mouthwashes were equally effective in reducing plaque and gingivitis as compared to chlorhexidine mouthwash. In addition to the antiplaque and anti-gingival action of Biorepair mouthwash, the remineralizing effects on early signs of initial caries were evident. The findings of the present study suggest that Biorepair mouthwash can be used as an alternative for both fluoride and chlorhexidine. This single mouthwash could act as a multipurpose mouthwash.
The present study showed significant importance for pediatric oral health Provide significance results for early remineralization of initial carious lesions which are common among children. Mouthwash is considered more easily and effective methods used among children for control plaque and gingivitis which are proven in this study. New material with its valuable results on dental caries reduction which can be used easily among children.
Conflict of interest No conflict of interest.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002
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references
[1] Frencken JE, Holmgren CJ. ART: a minimal intervention approach to manage dental caries. Dent Update 2004;31:295e301. [2] Marsh PD. Dental plaque as a microbial biofilm. Caries Res 2004;38:204e11. [3] Hassanein OE, El Borolossy TA. An investigation about the remineralization potential of bioactive glass on artificially carious enamel and dentin using Raman spectroscopy. Egypt J Solids 2006;29:1. [4] Cross KJ, Huq NL, Reynolds EC. Casein phosphopeptides in oral healthdchemistry and clinical applications. Curr Pharm Des 2007;13:793e800. [5] Hannig M, Hannig C. Nanomaterials in preventive dentistry. Nat Nanotechnol 2010;5:565e9. [6] Hamdan AM, Maxfield BJ, Tu¨fekc¸i E, Shroff B, Lindauer SJ. Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists. J Am Dent Assoc 2012;143:777e83. [7] Zanarini M, Pazzi E, Bonetti S, et al. In vitro evaluation of the effects of a fluoride-releasing composite on enamel demineralization around brackets. Prog Orthod 2012;13:10e6. [8] Late S, Varghese NO, Varughese JM. Remineralization potential of fluoride and amorphous calcium phosphatecasein phosphopeptide on enamel lesions: an in vitro comparative evaluation. J Conserv Dent 2010;13:42e6. [9] Roveri N, Battistella E, Foltran I. Synthetic biomimetic carbonate-hydroxyapatite nanocrystals for enamel remineralization. Mater Sci Forum 2008;47e50:821e4. [10] Tschoppe P, Zandim DL, Martus P, Kielbassa AM. Enamel and dentine remineralization by nano hydroxyapatite toothpastes. J Dent 2011;39:430e7. [11] Palmieri C, Magi G, Orsini G, Putignano A, Facinelli B. Antibiofilm activity of zinc-carbonate hydroxyapatite nanocrystals against Streptococcus mutans and Mitis Group Streptococci. Curr Microbiol 2013;67:679e81. [12] Poggio C, Lombardini M, Colombo M, et al. Impact of two toothpastes on repairing enamel erosion produced by a soft drink: an AFM in vitro study. J Dent 2010;38:868e74. [13] Roveri N, Palazzo B, Iafisco M. The role of biomimetism in developing nanostructured inorganic matrices for drug delivery. Expert Opin Drug Deliv 2008;5:861e77. [14] Hannig C, Basche S, Burghardt T, Al-Ahmad A, Hannig M. Influence of a mouthwash containing hydroxyapatite microclusters on bacterial adherence in situ. Clin Oral Invest 2013;17:805e14. € e H. Periodontal disease in pregnancy. II. [15] Silness J, Lo Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121e35.
€ e H, Silness J. Periodontal disease in pregnancy. I. [16] Lo Prevalance and severity. Acta Odontol Scand 1963;21:533e51. [17] Zanatta F, Antoniazzi R, Rosing C. Staining and calculus formation 0.12% chlorhexidine rinse in plaque-free and plaque covered surfaces: a randomized trial. J Appl Oral Sci 2010;18:515e21. [18] Nokhbatolfoghahaie H, Alikhasi M, Chiniforush N, Khoei F, Safavi N, Zadeh B. Evaluation of the accuracy of DIAGNOdent in diagnosis of primary and secondary caries in comparison to conventional methods. J Lasers Med Sci 2013;4(4):159e67. [19] Sridhar N, Tandon S, Rao N. A comparative evaluation of DIAGNOdent with visual and radiography for detection of occlusal caries: an in vitro study. Indian J Dent Res 2009;20(3):326e31. [20] Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33:261e6. [21] Chu CH, Lo EC, You DS. Clinical diagnosis of fissure caries with conventional and laser-induced fluorescence techniques. Lasers Med Sci 2010;25(3):355e62. [22] Kaur P, Singh H, Khatri A, Aulakh KS. Evaluation and comparison of short term side effects of 0.2% and 0.12% chlorhexidine mouthwash. J Adv Med Dent Scie Res 2015;3(3):26e8. [23] TenCate J, Zaura E. The numerous microbial species in oral biofilms: how could antibacterial therapy be effective? Adv Den Res 2012;24:108e11. [24] Sun F, Engelman E, McGuire J, et al. Impact of an anticaries mouthrinse on In vitro remineralization and microbial control. Int J Dent 2014:11. http://dx.doi.org/10.1155/2014/ 982071. Article ID 982071. [25] Yousefimanesh H, Amin M, Robati M, Goodarzi H, Otoufi M. Comparison of the antibacterial properties of three mouthwashes containing chlorhexidine against oral microbial plaques: an in vitro study. Jundishapur J Microbiol 2015 February;8(2):e17341. [26] Orsini G, Procaccini M, Manzoli L, Giuliodori F, Lorenzini A, Putignano A. A double- blined randomized-controlled trial controlling the desensitizing efficacy of a new dentifrice containing carbonate/hydroxyapatite nanocrystals and a sodium fluoride/potassium nitratedentifrice. J Clin Periodontol 2010;37:510e7. [27] Roveri N, Battistella E, Flotran I, et al. Synthetic biomimetic carbonate-hydroxyapatite nanocrystals for enamel remineralization. Adv Mat Res 2008;47:821e4. [28] Roveri N, Battistella E, Bianchi C, et al. Surface enamel remineralization: biomimetic aptite nanocrystals and fluoride ion different effects. J Nanomater 2008;10:14e25.
Please cite this article in press as: Hegazy SA, Salama RI, Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial, Pediatric Dental Journal (2016), http://dx.doi.org/10.1016/j.pdj.2016.05.002