Download Full Text PDF - Jaypee Journals

JIOS
10.5005/jp-journals-10021-1267
Comparative Evaluation of Two Remineralizing Agents on Enamel around Orthodontic
Brackets: An in vitro Study
Original article
Comparative Evaluation of Two Remineralizing Agents on
Enamel around Orthodontic Brackets: An in vitro Study
1
Soumya kM, 2Nikhilanand Hegde, 3Vinay P Reddy, 4 BS Chandrashekar, 5Harish Koushik SR, 6Aravind S Raju
ABSTRACT
Objective: This study was designed to compare the relative
efficiency of GC, Tooth Mousse, which contains 10% ACP-CPP
and GC Tooth Mousse Plus which contains amorphous calcium
phosphate casein phosphopeptide (ACP-CPP) with sodium
fluoride 0.2% w/w (900 ppm) to inhibit enamel demineralization
adjacent to orthodontic brackets in vitro.
Materials and methods: Forty-five non-carious, human maxil­
lary premolars with no visible enamel defects were collected
and bonded with stainless pre-adjusted stainless steel premolar
brackets with light-cure composite resin. The teeth were ran­
domly assigned into three groups of 15 teeth and each group
coded with unique colored nail varnish leaving a rectangular
window extending occlusally. The teeth in each group were
immer­sed separately in an artificial saliva solution for 11 hours
and an acid solution for 1 hour maintained at room temperature.
Group I, control group did not receive any application, as Groups
II and III received GC Tooth Mousse and GC Tooth Mousse Plus
respectively. The teeth were immersed alternately in the saliva
and acid solution for 31 days. Two sections, each approximately
0.5 mm thick were obtained from each specimen. The sections
were photographed with a polarized light microscope at 4×
magnification. The depths of demineralized enamel in each
section were measured at three sites.
Results: The results of this study showed that GC Tooth Mousse
Plus on daily application will provide maximum protection
against the enamel demineralization in orthodontic patients, by
reducing the lesion formation and simultaneously remineralizing
the demineralized area by providing calcium phosphate ions
and fluoride ions constantly.
Conclusion: GC Tooth Mousse Plus (ACP-CPPF) showed
better efficiency in reducing the demineralization and enhancing
the remineralization around the orthodontic brackets and have
maximum benefit compared to GC Tooth Mousse with good
patient compliance.
Keywords: Tooth Mousse, Tooth Mousse Plus, Remineralization,
Demineralization.
1,5,6
Senior Lecturer, 2-4Professor
1
Department of Orthodontics, Al-Azhar Dental College
Thodupuzha, Kerala, India
2-5
Department of Orthodontics, Krishnadevaraya College of
Dental Sciences and Hospital, Bengaluru, Karnataka, India
6
Department of Orthodontics, St Gregorios Dental College
Chelad, Ernakulam, Kerala, India
Corresponding Author: Soumya KM, Senior Lecturer
Department of Orthodontics, Al-Azhar Dental College
Thodupuzha, Kerala, India, Phone: +918281422210, e-mail:
[email protected]
How to cite this article: Soumya KM, Hegde N, Reddy VP,
Chandrashekar BS, Koushik HSR, Aravind SR. Comparative
Evaluation of Two Remineralizing Agents on Enamel around
Orthodontic Brackets: An in vitro Study. J Ind Orthod Soc
2014;48(4):313-318.
Source of support: Nil
Conflict of interest: None
Received on: 17/5/13
Accepted after Revision: 27/8/13
INTRODUCTION
As the saying goes, Beauty is power; a smile is its sword.
In any social interaction, one’s attention is mainly drawn
toward the mouth and eyes of the speaker’s face. As speech
are the main form of communication, a smile plays an
impor­tant role in facial expression and appearance. Within
the field of orthodontics there is long-standing recognition
that malocclusion and dentofacial anomalies can produce
immense physical, social, and psychological upset.
While using fixed appliances for orthodontic treatments,
the formation of incipient caries, commonly called white
spot lesions is an unesthetic and common side effect. Bands
and brackets increase the retention of plaque and food on
smooth tooth surfaces that would otherwise tend to have
a low prevalence of caries.1 The white spot lesions can be
defined as ‘subsurface enamel porosity from carious demine­
ralization’ that presents itself as a milky white opacity when
located on smooth surfaces.2 Clinically, formation of white
spots around orthodontic attachments can occur as early as
4 weeks into treatment, the maxillary lateral incisors were
the most frequently and severely affected teeth by white
spot lesions, followed by the maxillary canine, premolar
and central incisor respectively.3
Reynolds in 1980 reported that amorphous calcium
phosphate-casein phosphopeptide (ACP-CPP), which is a
product derived from milk casein, was capable of being
absorbed through the enamel surface and could affect the
carious process. ACP-CPP is a delivering system that allows
freely available calcium and phosphate ions to attach to
the enamel and reform into calcium phosphate crystals. A
number of different mediums have been produced to deliver
the ACP-CPP, including a water based mousse, a topical
cream, chewing gum, mouth rinses and sugar free lozenges.4
The Journal of Indian Orthodontic Society, October-December 2014;48(4):313-318
313
Soumya KM et al
At the present state of knowledge, it was found that
ACP-CPP can prevent enamel demineralization and pro­
mote remineralization of enamel subsurface lesions.
Recently, ACP-CPP has been shown to interact with
fluo­ride ions to produce an additive anticariogenic effect
through the formation of stabilized amorphous calcium
fluoride phosphate phase.5 The objective of this study was
to compare the relative efficiency of GC—Tooth Mousse,
which contains 10% ACP-CPP and GC Tooth Mousse Plus
which contains ACP-CPP with sodium fluoride 0.2% w/w
(900 ppm) to inhibit enamel demineralization adjacent to
orthodontic brackets in vitro.
the long axis of the tooth. The excess bonding agent was
removed with a explorer and the brackets were light cured
for 20 seconds.
Masking tape was used to cover the occlusal 1/3rd on
buccal surface area (4 × 1 mm) adjacent to brackets and acid
resistant varnish (nail varnish) was used to paint the rest of
the tooth surfaces. The teeth were randomly assigned into
three groups of 15 teeth each. Each group coded with unique
colored nail varnish.
Assignment of three different groups with color coding
(Fig. 1) as follows:
Groups
Material applied
Color
MATERIALS and METHODS
I
Control
Pink
Patients ranging from (12-25 years) participated in this
investigation. Selection criteria were based on the patients
requiring orthodontic treatment, including extraction of
four premolars and fixed appliances. An informed consent
was signed by the patient/ parent before the investigation.
The premolars were extracted after taking the consent from
the patients. A total of 45 non-carious human maxillary
premolars with no visible enamel defects extracted for
ortho­dontic purposes were divided into three groups—
group I, group II, group III. Each group consists of 15
samples. The extracted teeth were cleaned using scalars and
stored in deionized water till they were used for the study.
Exclusion criteria were decayed, restored and attrited teeth
were excluded.
• Group I: Control group did not receive any application.
• Group II: Tooth mousse was applied to the exposed
enamel windows using applicator brush, and allowed to
dry for 3 minutes before teeth were immersed in artificial
saliva solution.
• Group III: Tooth Mousse Plus was applied to the exposed
enamel windows, using applicator brush, and allowed to
dry for 3 minutes before teeth were immersed.
For all 45 samples, pre adjusted edge wise stain­less steel
premolar brackets were bonded on the teeth with light cure
composite resin, Transbond XT (3M Unitek)with a curing
light (XL2500 3M Unitek). The enamel was conditioned
with the etchant (3M ESPE) containing 37% phosphoric
acid, for 30 seconds. The teeth were then washed and air
dried with moisture and oil free air spray for 15 seconds.
The enamel surface exhibited a dull frosty white appearance
indicating a successful etch. A thin layer of Transbond XT
light cure adhesive primer was painted over the etched
enamel surface with a brush tip and was light cured for
20 seconds. Transbond XT adhesive paste (3M Unitek) was
applied to the bracket base and the brackets were positioned
on the buccal surface at the height of contour mesiodistally,
in the middle one third occlusogingivally and parallel to
II
TM
Yellow
III
TM Plus
Silver gray
314
Specimen Preparation
Masking tape was removed from the occlusal 1/3rd on buccal
surface area adjacent to brackets, and the exposed enamel
of each tooth was treated with application of respective
materials. The teeth in each group were immersed separately
in an artificial saliva solution (neutral pH and containing
20 mmol/l KHCO3, 3 mmol/l KH2PO4 and 1 mmol/l CaCl2)
for 11 hours and acid solution (2.2 mmol/l PO4–, 2.2 mmol/l
Ca+, 50 mmol/l acetic acid at 4.4 pH) for 1 hour for 31 days.
Both solutions were agitated constantly and maintained at
room temperature. This was performed by immersing the
teeth in artificial saliva solution for 11 hours, removed and
immersed in the acid solution for 1 hour. After each acid
challenge, the surface layers in exposed enamel windows in
all the three groups were removed by brushing the teeth for 5
seconds with a soft tooth brush. The solutions were changed
twice a week and pH of each solution was monitored.
Fig. 1: Assignment of three different groups with color coding
with pink—Group I, yellow—Group II, silver gray—Group III
JIOS
Comparative Evaluation of Two Remineralizing Agents on Enamel around Orthodontic Brackets: An in vitro Study
Fig. 2: Demineralized area—Control group
Fig. 3: Demineralized area—Tooth Mousse
are presented on mean ± SD (min-max) and results on
categorical measurements are presented in number (%).
Significance is assessed at 5% level of significance. Analysis
of variance (ANOVA) has been used to find the significance
of study parameters between three or more groups of
patients. Post hoc Tukey test has been used to find the
pairwise significance.
RESULTS
Comparison of Depth (in micrometers)
Fig. 4: Demineralized area—Tooth Mousse Plus
After 31 days the brackets were removed and the teeth
were mounted in acrylic cylindrical blocks (2.5 cm diameter
and 2 cm height). The teeth were sectioned longitudinally
through the buccal windows with a hard tissue microtome
(Leica SP 1600). A specimen of 0.5 mm thickness was
obtained by sectioning through the middle of teeth.
The acrylic surrounding the thin specimens was removed
and mounted on the glass slide using water. The sections
were evaluated with polarized light microscopy (Olympus
VX 52) microphotographs of the occlusal half of the buccal
surface were taken with fixed magnification of 20 times
(Figs 2 to 4). The depth of demineralized lesions was
measured using Progres C3 2.5 image analysis software.
The depths of the demineralized enamel in each section
were measured at three sites. The first site at D1 which
was near the gingival margin and close to the bracket, the
second site D2 at middle 3rd and the third site D3 at near
the occlusal margin.
STATISTICAL ANALYSIS
Descriptive statistical analysis has been carried out in
the present study. Results on continuous measurements
In this experiment, we have two factors influencing the depth,
i.e. group and site. Groups are of three types—Control, Tooth
Mousse (TM) and Tooth Mousse Plus (TM+), and site is of
three types—occlusal third, middle third and gingival third.
The factors and their levels are tabulated in Table 1.
Test Procedure
Null Hypotheses
• H0(a):There is no significant difference between the test
groups.
• H0(b):There is no significant difference between the test
sites.
• H0(c):The interaction (joint effect) of various factors is
not significant.
Alternate Hypotheses
• H1(a):There is a significant difference between the test
groups.
• H1(b):There is a significant difference between the test
sites.
• H1(c):The interaction (joint effect) of various factors is
significant.
The Journal of Indian Orthodontic Society, October-December 2014;48(4):313-318
315
Soumya KM et al
Table 1: Comparison of depth of demineralized enamel in three groups of teeth studied
Depth of demineralized of enamel
D1—near the gingival margin
D2—in the middle third
D3—near the occlusal margin
Mean of D1, D2 and D3
*Significant
Group I (µm)
47.83 ± 14.18
44.21 ± 12.45
38.62 ± 8.30
43.55 ± 11.08
Group II (µm)
28.66 ± 10.85
29.77 ± 10.80
27.53 ± 10.44
28.78 ± 10.24
The results of the two factors ‘group’ and ‘site’ can be
categorised as follows:
The mean depth recorded among different groups and
their sites, and the mean depth recorded at different sites of
each group is tabulated in Table 1.
The ANOVA test (Table 1) has shown that the Group is a
significant factor in influencing the depth of demineralization
and the difference in mean depth recorded among the
different groups are found to be statistically significant
(p < 0.001). It was observed, that Control Group recorded
higher mean depth of enamel loss of 43.55 ± 11.08 (maximum
depth of 74.49373 µm and minimum of 24.41 µm) compared
to the other groups. The second highest mean depth was
recorded in TM group (28.78 ± 10.24 µm). The lowest mean
depth was recorded in TM+ group (25.34 ± 6.93).
Among the different sites examined, gingival third
recorded higher mean depth (47.83 ± 14.18 µm) followed
by middle third (44.21 ± 12.45 µm). Lowest mean depth
(38.62 ± 8.30 µm) was recorded in occlusal third which was
found to be statistically significant (p < 0.001).
Post-hoc test was carried out to find the pairwise
significance and the results are given in Table 2.
There was difference in mean depth between Control
Group and TM group and between the Control and TM+
Group which was statistically significant (P < 0.001).
However, the difference in mean depth recorded between
TM and TM+ is not statistically significant (p > 0.05).
The difference in mean depth recorded at gingival third
and occlusal third was statistically significant (p < 0.001).
The difference in mean depth recorded at gingival third
and middle third and the difference in mean depth recorded
at middle third and occlusal third was also statistically
significant (p < 0.01). TM+ group recorded the lowest mean
depth (25.34 ± 6.93) to all the other groups at all the sites.
When pairwise comparison was done between control and
TM/TM+ groups for depth of demineralization, it was found
that mean depth of demineralization is statistically signi­ficant
in control group. However, within TM and TM+ group, the
mean depth of demineralization is not statistically significant.
DISCUSSION
Fixed appliances are an inseparable part of contemporary ortho­
dontic treatment. But, a major disadvantage of fixed mechano­
316
Group III (µm)
27.29 ± 9.16
24.61 ± 7.02
24.13 ± 7.59
25.34 ± 6.93
F-value
14.727
14.488
10.966
15.271
p-value
< 0.001*
< 0.001*
< 0.001*
< 0.001*
Table 2: Pairwise comparison of depth of demineralized
enamel in three groups of teeth studied: post-hoc ANOVA results
Depth of demineralized
of enamel
Difference
D1—near the gingival
margin
D2—in the middle third
D3—near the occlusal
margin
Mean of D1, D2 and D3
p-value
D1—near the gingival
margin
D2—in the middle third
D3—near the occlusal
margin
Mean of D1, D2 and D3
*Significant
Groups
I vs II
Groups
I vs III
Groups
II vs III
19.16
20.54
1.37
14.45
19.66
5.15
11.09
14.49
3.39
14.78
18.21
3.44
<0.001*
<0.001*
0.944
0.001*
<0.001*
0.368
0.004*
<0.001*
0.551
<0.001*
<0.001*
0.592
therapy is significant amount of enamel demineralization that
might occur adjacent to orthodontic bracket even within one
month of bonding. Decalcification of the enamel surface
adjacent to fixed orthodontic appliance is an important and
prevalent iatrogenic effect of orthodontic therapy. As enamel
translucency is directly related to the degree of mineralization, initial enamel demineralization usually manifest itself
clinically as a white spot lesion. Such a lesion has been
clinically induced within a span of 4 weeks, which is typically within the time period between the one orthodontic
appointment to the next.6-8
In highly cariogenic environment, these lesions can
rapidly progress. If left untreated, they may produce carious
cavitations that may need an appropriate restoration. Thus,
prevention, diagnosis, and treatment of white spot lesions
(WSL) are crucial to prevent tooth decay as well as minimize
tooth discoloration that could compromise the esthetics of
the smile.9,10
Amorphous calcium phosphate-Casein phosphopeptide
product derived from milk casein was intro­d uced by
Reynolds EC.11 It has been reported to have topical anticario­genic effect. The proposed mechanism of action of
ACP-CPP is related to its localization at the tooth surface,
where it buffers free calcium and phosphate ion activities,
maintaining a state of super saturation with respect to tooth
JIOS
Comparative Evaluation of Two Remineralizing Agents on Enamel around Orthodontic Brackets: An in vitro Study
enamel, thereby preventing demineralization and facilitating
remineralization. It acts as Ca+ and PO4 reservoir which
increases the level of plaque calcium and phosphate ions,
thereby limiting enamel demineralization and enhancing
remi­ne­ralization. The remineralized enamel was generally
more resistant to decalcification than untreated enamel. Incor­
poration of ACP-CPP into a sugar free lozenge or chewing
gums significantly decreased enamel sub surface lesions.12-14
ACP-CPP decreases lesion depth irrespective of whether
or not it was used as a toothpaste or topical coating. Immuno­
localization studies have shown that ACP-CPP leads to the
formation of a less-cariogenic plaque. In addition, ACPCPP could be incorporated into the pellicle in exchange
for albumin. It also inhibits the adherence of S. mutans and
S. sobrinus.15
ACP-CPP (Tooth Mousse) has a greater capacity to
neutra­lize acids than fluoride toothpaste. The acid resistance
of enamel exposed to ACP-CPP was increased by the
addition of fluoride. This was probably due to the ability
of ACP-CPP to interact with fluoride ions to produce an
addi­tive anticariogenic effect through the formation of a
stabi­lized amorphous calcium fluoride phosphate phase.
ACP-CPP showed higher remineralizing potential when used
in combination with fluoridated toothpaste than when used
alone.16,17
Using the knowledge of both fluoride and ACP-CPP,
a new product has been developed where 900 ppm of fluoride
is combined with ACP-CPP (Tooth Mousse plus). This
in vitro study aims at comparing the effect of tooth mousse
ACP-CPP and Tooth Mousse plus in reducing the demine­
ralization adjacent to orthodontic brackets (ACP-CPP
+900 ppm fluoride 0.2% w/w).
In this study, nonfluoridated composite resin was used
as an adhesive to eliminate the influence of fluoride on results
providing fluoride protection of enamel despite patient
noncompliance and delivering the fluoride in a sustained
manner over a longer period of time. GC Tooth Mousse
(TM) and GC Tooth Mousse Plus (TM+) are water-based
creams containing 1% casein phosphopeptide-amorphous
calcium phosphate. In CPP-ACPF, the level of fluoride is
0.2% w/w (900 ppm), which approximates that of adult
strength toothpastes.
The results of this study were in accordance with the
study conducted by Theresia Rini Sudjalim et al. in which
they found that the application of TM, NaF, or TM/NaF can
significantly reduce the demineralization, but better results
were seen with combined application of TM and NaF15.
Nasab NK et al have shown that there was a 50% reduction
in the enamel demineralization when ACP-CPP preparation
was used alone.18
The results of present study showed that TM+ Group
had the maximum effect on inhibition of demineralization
of enamel adjacent to orthodontic brackets followed by TM
group which is similar to the results found by VLN Kumar
et al. They used topical coating of ACP-CPP after the use
of a fluoridated tooth paste. The results were better when
TM was used than NaF used alone. The results were further
improved when TM/NaF was used and similar results were
found with TM+ group. This suggests the synergistic action
of fluoride with ACP-CPP.10,18
Among the different Sites examined, gingival third recor­
ded higher mean depth followed by middle third. Lowest mean
depth was recorded in occlusal third which is in accordance
with the study done by Bishara SE et al.2 This may be due to
morphological differences in the enamel or due to the different
environmental conditions in our in vitro model.
TM group recorded a lower mean depth compared
to control in the middle and occlusal third which was in
accor­­dance with findings of Nasab NK et al who found a
signi­ficant difference between control and ACP-CPP group.
Deeper demineralization was found in gingival third.18 TM+
group recorded the lowest mean depth compared to all the
other groups at all the sites. This result supports the ability
of ACP-CCP to interact with fluoride ions to produce an
additive anticariogenic effect through the formation of a
stabilized amorphous calcium fluoride phosphate phase
and also the synergistic effect as reported by studies.5,10,19
The results of this study showed that ACP-CPPF on
daily application will provide maximum protection against
the enamel demineralization in orthodontic patients, by
reducing the lesion formation and simultaneously remine­
ralizing the demineralized area through providing calcium
phosphate ions and fluoride ions constantly.20 For high
caries, risk and poor oral hygiene patients ACP-CPPF
have maximum benefit compare to ACP-CPP with good
compliance. The efficacy of ACP-CPP and ACP-CPPF
application in preventing demineralization in vitro has been
demonstrated in the present study. In orthodontic practice
further clinical trials are required to assess the effectiveness
of ACP-CPP and ACP-CPPF application. However, since
TM and TM+ contain casein, it is contraindicated in patients
allergic to milk and milk products.
CONCLUSION
• ACP-CPP and ACP-CPPF when applied alone has a
definite benefit in preventing the enamel demineralization
adjacent to orthodontic brackets over the controls.
• Addition of fluoride to ACP-CPP will enhance the
prevention of demineralization by two to three times.
The Journal of Indian Orthodontic Society, October-December 2014;48(4):313-318
317
Soumya KM et al
• ACP-CPPF showed better reducing efficiency of demine­
ralization compared to ACP-CPP, suggesting the
probable synergistic action of ACP-CPP with fluoride
in reducing the demineralization and enhancing the
remine­ralization around the orthodontic bracket with
good patient compliance.
References
1.Chapman JA, Roberts WE, Eckert GJ, Kula KS, GonzalezCabezas C. Risk factors for incidence and severity of white spot
lesions during treatment with fixed orthodontic appliances. Am
J Orthod Dentofac orthop 2010;138(2):188-194.
2. Bishara SE, Ostby AW. White spot lesions: formation,
prevention, and treatment. Semin Orthod 2008;14(3):174-182.
3. Oggard B. White spot lesions during orthodontic treatment:
Mechanisms and fluoride preventive aspects. Seminars in
orthodontics 2008;14(3):183-193.
4. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot for­
ma­tion after bonding and banding. Am J Orthod 1982;81(2):93-97.
5. Qgaard B, Odont. Prevalence of white spot lesions in 19-yearlyold: a study on untreated and orthodontically treated persons
5 year after treatment. Am J Orthod Dentofac Orthop 1989;
96(5):423-427.
6. Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The
effectiveness of a fluoride varnish in preventing the development
of white spot lesions. World J Orthod 2006;7(2):138-144.
7. Chadwick BL, Roy J, Knox J, Tressure ET. The effects of topical
fluoride on decalcification in patients with fixed orthodontic
appliances: a systemic review. Am J Orthod Dentofac Orthop
2005;128(5):601-606.
8. Itthagarun A, Shy W, Wefel JS. The effect of different commercial
dentifrices on enamel lesion progression: an in vitro pH cycling
study. Int Dent J 2000;50(1):21-28.
9. Ogaard B, Rolla G, Arends J. Orthodontic appliances and enamel
demineralization. Part 1. Lesion development. Am J Orthod
Dentofac Orthop 1988;94(1):68-73.
10. Ogaard B, Rolla G, Ten Gate AJM. Orthodontic appliances and
enamel demineralization. Part 2. Prevention and treatment of
lesions. Am J Orthod Dentofac Orthop 1988;94(2):123-128.
318
11. Reynolds EC, Cain CJ, Webber FL, Black CL, Riley PE,
Johnson IH, Perich JW. Anticariogenicity of calcium phosphate
complexes of tryptic casein phosphopeptides in the rat. J Dent
Res 1995;74(6):1272-1279.
12. Schupbach P, Neeser JR, Golliard M, Rouvet M, Guggenheiml B.
Incorporation of caseinoglycomacropeptide and casein
phosphopeptide into the salivary pellicle inhibits adherence of
mutans streptococci. J Dent Res 1996 Oct;75(10):1779-1788.
13. Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Remine­
ralization of enamel subsurface lesions in situ using sugar free
lozenges containing casein phosphopeptide-amorphous calcium
phosphate. Aust Dent J 2003;48(4):240-243.
14. Lijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC.
Acid resistance of enamel subsurface lesions by a sugar-free
chewing gum containing casein phosphopeptide amorphous
calcium phosphate. Caries Research 2004;38(6):551-556.
15. Shen, Cai1 F, Nowicki A, Vincent J, Reynolds EC. Remine­
ralization of enamel subsurface lesions by sugar-free chewing
gum containing casein phosphopeptide-amorphous calcium
phosphate. J Dent Res 2001;80(12):2066-2070.
16. Nasab NK, Kajan ZD, Balalaie A. Effect of topacal C5 on enamel
adjacent to orthodontic brackets: an in vitro study. Aust Orthod
J 2007;23(1):46-49.
17. Kumar VLN, Itthagarun A, King NM. The effect of
casein phosphopeptide-amorphous calcium phosphate on
remineralization of artificial caries-like lesions: an in vitro study.
Aust Dent J 2008;53(1):34-40.
18. Kecika D, Sevi Burcak C, Unverd B. Effect of acidulated
phosphate fluoride and casein phosphopeptide-amorphous
calcium phosphate application on shear bond strength of
orthodontic brackets. Angle Orthodontist 2008;78(1):36-42.
19. Roslyn J, Nathan JM, Michael CFG, Eric WC. Reynolds
in vitro study of the effect of casein phosphopeptide-amorphous
calcium fluoride phosphate on iatrogenic damage to enamel
during orthodontic adhesive removal. Am J Orthod Dentofac
Orthop 2011;139(6):543-551.
20. Guotao Wu, Xinqiang Liu, Yong fu Hou. Analysis of the effect of
CPP-ACP tooth mousse on enamel remineralization by circularly
polarized images. Angle Orthod 2010;80(5):267-272.