Download Treatment Options for Tooth Discoloration and Remineralization

Earn
4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Treatment Options for
Tooth Discoloration and
Remineralization
A Peer-Reviewed Publication
Written by Dr. Fiona M. Collins, MBA, MA
PennWell is an ADA CERP recognized provider
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual
courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
PennWell is an ADA CERP Recognized Provider
Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at
www.ada.org/goto/cerp.
PennWell is an ADA CERP Recognized Provider
1-888-INEEDCE
Go Green, Go Online to take your course
This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Educational Objectives
Overall goal: The purpose of this article is to provide dental
professionals with information on the etiology and treatment
of tooth discoloration and loss of tooth structure.
Upon completion of this course, the clinician will be able to
do the following:
1. List the etiologies for tooth discoloration.
2. List traditional therapies available for the treatment of
tooth discoloration and describe calcium and phosphate
technology and the clinical application of this technology
in treating and preventing discoloration of teeth.
3. List the etiologies for tooth demineralization.
4. List traditional and new therapies available for the prevention of demineralization and for remineralization, and
describe how these work.
Abstract
Fully developed teeth have a finite quantity of enamel and
cementum, and internally consist of dentin and pulp. Over
time, patients may experience loss of tooth structure due
to caries, erosion, abrasion or attrition. Patients also experience tooth discoloration due to aging changes as well as
extrinsic and intrinsic staining. The prevention and treatment of these conditions is clinically and esthetically desirable. Traditional treatment and prevention options have
included fluoride and chemotherapeutics to help prevent
tooth structure loss, and abrasives and hydrogen peroxide
to treat tooth discoloration and staining. Recently introduced calcium and phosphate technologies have increased
the treatment options available.
Introduction
Fully developed newly-erupted teeth have a finite quantity and depth of enamel and cementum that overlie dentin, and internally have large pulp chambers. The enamel
structure comprises approximately 97% hydroxyapatite
crystals containing calcium and phosphate minerals (as
well as traces of other minerals and organic material).
Dentin and cementum contain a higher proportion of
organic material compared to inorganic material (mineral
content). Over a period of many years, the pulp chamber
contracts while secondary dentin is simultaneously laid
down internally in areas that were originally occupied by
the outer region of the pulpal tissue.1 Dental disease and
conditions resulting in the loss of tooth structure posteruption include caries, erosion, abrasion and attrition.
Aging Changes
The surface morphology of teeth influences both the perception of color and the amount of extrinsic stain that accumulates – smooth surfaces with few or no crevices or cracks
are less likely to develop extrinsic stain (or, via cracks,
intrinsic stain) than are rough surfaces. In newly erupted
2
teeth normal enamel reflects and refracts light, resulting in
a lustrous and glossy appearance.2 As enamel ages, it loses
its initial surface texture. This causes a reduction in light
refraction and reflection and results in the light penetrating
deeper into the tooth. As a consequence, the tooth appears
less lustrous and shade differences become more obvious,
leading to the appearance of a darker tooth. In addition, the
translucent incisal edge increases in area.3,4
Tooth Discoloration and Staining
Changes in the coloration of teeth occur due to extrinsic
and intrinsic staining in addition to the aging changes
described above.
Table 1. Factors in Tooth Discoloration and Staining
Intrinsic
Extrinsic
Aging
Aging changes of tooth
Trauma
Surface changes (defects)
Specific medications
Red wine
Thickness of hard tissue
Tobacco
Structure of hard tissue
Coffee and tea
Enamel cracks
Foods rich in polyphones
Specific medications
Chlorhexidine gluconate rinse
Metabolic diseases
Level of oral hygiene
Systemic conditions
Intrinsic Staining
Intrinsic staining starts from inside the tooth or results
from stain penetrating into the dentin from the surface
of the tooth. The use of certain medications such as tetracycline during tooth development also causes intrinsic
staining. Genetics plays a role, and some metabolic disease
and systemic conditions result in tooth discoloration during development.5 Finally, trauma to teeth can result in
nonvitality and a gradual graying and blackening of the
crown of the tooth.
Treating Intrinsic Tooth Discoloration
While extrinsic discoloration and staining has the potential
to be treated chemically and/or mechanically, mechanical
treatment will not treat intrinsic staining.
Intrinsic tooth discoloration can be treated using carbamide peroxide (which breaks down to hydrogen peroxide
and urea) or hydrogen peroxide compounds in either an
in-office or at-home procedure. In-office treatments will
typically use a higher concentration of whitening agent,
usually hydrogen peroxide in concentrations of up to 35%.
Irrespective of the selected method, the mechanism of action
is the same – hydrogen peroxide degrades into free radicals
that break double bonds in the stain, thereby lightening and
removing the color from the stained material. In the case of
www.ineedce.com
nonvital teeth, discoloration can be removed by bleaching
from the internal aspect of the crown of the tooth (provided
root canal obturation was adequate). This method has been
found to be effective and, where sufficient tooth structure
remains, can conservatively provide an esthetic result without requiring fabrication of a crown.6
Figure 1a. Intrinsic staining
in dentifrices to help remove stain and prevent stain buildup
on a daily basis. Recent studies have shown not only that
dentifrices containing no abrasive result in stain accumulation, but that patients are unwilling to comply with regular
home care using a nonabrasive toothpaste even under study
conditions.10,11,12 This would result not only in the accumulation of stain, but also the accumulation and maturation
of biofilm since patients do not perform good home care
under these conditions. Therefore, for good oral hygiene
and patient compliance it is important to be able to achieve
cleaning and stain prevention and removal, while preserving
tooth structure. A dentifrice should ideally contain sufficient
cleaning power to remove and help prevent staining without
being so abrasive that it results in loss of tooth structure.13,14
Dentifrice Use for Stain Removal and Prevention
Image courtesy of Howard E. Strassler, DMD
Figure 1b. Removal of intrinsic staining by toothwhitening
Image courtesy of Howard E. Strassler, DMD
Increasingly, abrasives with fine, rounded particles have
been used in modern-day dentifrices, to gently remove
stain and simultaneously help impart a polish that gives the
appearance of whiter teeth. Typical agents include calcium
phosphate, calcium carbonate and sodium bicarbonate.
The Radioactive Dentin Abrasion (RDA) measures how
abrasive a toothpaste is.
The cleaning ability of a dentifrice depends on both its
cleaning power and its abrasivity – a dentifrice with high
cleaning power and low abrasivity will minimize the risk of
abrasion while maximizing cleaning efficacy. A European
study in 1997 found that most of the cleaning obtained
from a dentifrice was through abrasion.15 An exception is
dentifrice containing sodium bicarbonate (baking soda),
which has been used in dentifrices for almost 30 years.
Sodium Bicarbonate
Extrinsic Staining
Smoking can result in severe and stubborn staining, while
tea, coffee and red wine are common culprits associated
with surface staining.7 Eating specific types of food results
in surface staining of teeth. Good oral hygiene helps reduce
and prevent staining, and conversely the propensity to stain
is increased if oral hygiene is poor. Medium- to long-term
use of chlorhexidine gluconate rinse is known to result in
tooth staining, as is use of other specific therapeutics.8
Treating Extrinsic Stain/Tooth Discoloration
Chemically, hydrogen peroxide is effective for treating
extrinsic stain.9 In addition, surfactants contained in dentifrices and rinses, such as sodium lauryl sulphate, help
lift and remove stain from the tooth surface.
Physical removal of extrinsic stain can be achieved with
abrasives. These are routinely used in prophylactic pastes
during dental prophylaxis where they have the ability to
remove stubborn stain due to their abrasivity, that regular
dentifrices would not remove. Abrasives are also contained
www.ineedce.com
Sodium bicarbonate (baking soda) functions as both a
mechanical and a chemical cleaning agent. Mechanical
cleaning relies on abrasives. The RDA of sodium bicarbonate ranges from 30-40, compared to an RDA of 70-110
in typical dentifrices. Studies show that while it has low
abrasivity, baking soda has excellent cleaning ability even
when compared to higher RDA agents. Controlled-condition laboratory studies using several grades of sodium
bicarbonate differing in particle size, with water and glycerin to simulate dentifrice and tooth brushing, determined
that the mean ratio of abrasion to cleaning power was 10.2,
compared to 1.7 for calcium pyrophosphate (which is used
as a reference material for abrasiveness studies).16 Little
difference was found in the results across the various particle sizes used for the sodium bicarbonate. The results
were more impressive considering that the comparative
agent, sodium pyrophosphate, has a higher RDA and, additionally, prevents stain buildup by means of chelation as
well as abrasion.17,18,19 Zambon et al. found that use of 52%
and 65% sodium bicarbonate for 6 months resulted in a
positive shift in the composition of the intraoral microbial
3
flora and reduced plaque, gingivitis and stain compared
to baseline.20
It is believed that cleaning power rather than abrasivity is
an important factor in the effectiveness of sodium bicarbonate as a stain remover and in preventing stain buildup, and
that bicarbonate cleans through both physical and chemical
action. The sodium bicarbonate helps lift stain from the
surface of the tooth.
Foundation. It is contained in dentifrice (ARM & HAMMER® Age Defying, Church & Dwight) as well as in-office
preventives and prophy pastes (Enamel ProTM and Enamel
ProTM Varnish, Premier Dental), tooth-whitening agents
(Zoom® 2 Day White and Nite White® with ACP, Discus
Dental), and other products.
Figure 3. SEM of ACP
Figure 2. Extrinsic staining and abrasion
Image courtesy of Salim Nathoo, DDS, PhD
Recently, the introduction of calcium and phosphate
technology - amorphous calcium phosphate (ACP) - has
offered the potential for esthetic and preventive benefits
from dentifrices and other products, as well as from traditional therapies.
Two other calcium and phosphate technologies available include Novamin® and casein phosphopeptide –amorphous calcium phosphate (CPP-ACP). The casein in CPP
is obtained from cow’s milk and forms a complex with ACP.
CPP-ACP (Recaldent®) is bioavailable and releases calcium and phosphate for remineralization.21 It is contained
in MI PasteTM (GC America) and chewing gum (Trident,
Cadbury Adams) as well as in glass ionomer cements and
other products. CPP-ACP has been shown to remineralize
subsurface lesions in in vitro testing.22 Novamin contains
calcium, phosphorus, silica and sodium. The Novamin releases these ions upon exposure to saliva or water, aiding in
remineralization and helping to prevent demineralization.
Studies of Novamin-containing dentifrice have found it to
have a whitening effect.23 A Novamin-containing dentifrice
that also includes fluoride has been found to remineralize
surface lesions in vitro by 41.9% compared to 24.9% for a
control fluoride-containing dentifrice.24 CPP-ACP and Novamin are not available in sodium bicarbonate dentifrices;
they are however available in other dentifrices.
Amorphous Calcium Phosphate
Amorphous calcium phosphate (ACP) consists of an unstructured form of calcium phosphate molecules (Figure 3)
and was developed by the American Dental Association
4
Image courtesy of the American Dental Association Foundation
The role of ACP in dentifrices
ACP offers preventive and cosmetic benefits. Calcium and
phosphate ions are deposited onto the surface of the tooth
with ACP-delivering dentifrice use, precipitating ACP
globules. If scratches and surface defects are present on a
tooth, light is dispersed in such a way that the tooth can
appear dull and darker than it otherwise would. Filling in
surface defects changes the light dispersion, thereby improving esthetics.25,26 The light becomes scattered, giving
the appearance of a surface gloss and luster. In situ testing
has found that ACP precipitates and lodges in defects such
as crevices and pits; it is believed this converts to mineral hydroxyapatite.27 While hydrogen peroxide and other
chemical cleaning agents will remove stain, they cannot
repair surface defects that alter the dispersion of light and
therefore the appearance of the (nonstained) tooth.
One single-center, double-blind randomized trial assessed twice-daily use of a fluoride dentifrice with ACP
technology for its effect on surface gloss and surface
roughness. Surface gloss was measured using the enamel
gloss standard test. The subjective improvement using the
test dentifrice was found to be 73.8% compared to 17.6%
for the control dentifrice, with between 76% and 83% of
teeth showing improvement. Surface roughness was measured using a profilometer at the start of the study and
one and three months after use of either the test or control
dentifrice. Surface roughness was reduced significantly using the test dentifrice, but did not decrease with use of the
control dentifrice.28 ACP will precipitate onto the tooth as
globules as shown by scanning electron microscopy. Imwww.ineedce.com
provements in luster and deposition of ACP into surface
defects have also been found to occur using prophy paste
delivering ACP.29
Figure 4. ACP precipitation onto dentin in in vitro study
Image courtesy of American Dental Association Foundation
Intraorally, ACP has the fastest rate of formation and dissolution of the calcium phosphate compounds.30 As pH
increases, ACP precipitates onto the tooth surface. The inclusion of carbonate results in a more rapid increase in pH.
Carbonates have been shown to control the precipitation of
ACP onto tooth surfaces.31,32 Thus, the combination of bicarbonate and ACP delivery in dentifrice has been found to
help the presence of ACP at the site and the supersaturation
of calcium and phosphate ions.
of children between the ages of 2 and 5 have experienced
decay.33 By age 19, 68% of adolescents have experienced
caries in the permanent dentition.34 The patient’s level of
plaque control (bacterial load), salivary flow and composition, diet (amount and frequency of intake of fermentable
carbohydrates), tooth structure, and use of home care
products and therapeutics determine whether demineralization occurs. These factors also determine whether this
process progresses to subsurface demineralization and,
eventually if unhindered, frank cavitation.
Hydroxyapatite crystals are stable at a pH of 7 (neutral).
When acid attacks occur, dissolution of the hydroxyapatite
crystals starts when the pH has decreased to around 5.5.
Demineralization results in the loss of calcium, phosphate
and hydroxyl ions from the hydroxyapatite crystals. Following this acid attack, the pH rebounds. Normalization of
the pH takes longer if salivary flow is reduced, increasing
the time during which demineralization can occur. Additionally, a reduced salivary flow results in fewer minerals
being available from saliva that would aid remineralization – namely calcium and phosphate. Natural saliva is
supersaturated with calcium and phosphate that over time
help repair defects, including in the absence of fluoride.35
Salivary flow is an important determinant of remineralization, and this helps explain the rampant caries seen in xerostomic patients.36 An increased concentration of calcium
and phosphate at the tooth surface would strengthen the
repair of the enamel surface.
Figure 6. Dynamics of demineralization and remineralization
Figure 5. Bicarbonate, ACP and dentifrice activity
Loss of Tooth Structure
Loss of tooth structure over time can occur as a result of
the caries process, abrasion, erosion or attrition.
Dental caries is a chronic disease experienced by the
majority of the population. Most children are infected with
cariogenic bacteria before the age of 2, and around 28%
www.ineedce.com
Intact enamel is the hardest substance in the body. Dentin
is considerably softer; the softest and thinnest layer of dental hard tissue is the cementum. Studies have found that
enamel is approximately 4 to 10 times harder than dentin,
depending on the locations of the samples of the enamel
and the dentin within the tooth.37 As enamel is lost and
dentin exposed, there results increased susceptibility to
loss of dental hard tissue.
The presence of erosion complicates the clinical picture.
Tooth erosion occurs when acids of nonbacterial origin
(i.e., not produced by cariogenic bacteria)38 demineralize
5
the exposed surface of the tooth. These acids may be the
result of regurgitation of stomach acid such as occurs due
to gastro-esophageal reflux disease (GERD) or due to the
frequent vomiting associated with bulimia.39,40 External
sources of acids causing erosion of dental hard tissues include soda pop, which currently accounts for around 28%
of all beverages consumed, as well as other dietary habits
and environmental hazards.41,42,43 Erosion results in surface
loss, removes surface minerals and results in the tooth
losing its luster and glossy appearance;44 it also softens
mineralized tissue, increasing susceptibility to (further)
demineralization, abrasion and attrition.45,46
Abrasion physically wears away the surface layer of the
tooth and in the long term results in the intraoral exposure
of the softer dentin. Attrition also results over time in the
exposure of dentin, and can occur due to bruxism or mastication of rough high-fiber foods over the long term. As
abrasion proceeds, the perception of tooth color changes
– abrasion results in less enamel being present and dentin
shining through the thinner layer of enamel or being exposed, or only dentin being present.
Fluoride
The first use of fluoride as a caries preventive occurred
more than a hundred years ago in Europe. Fluoridens was
a fluoride-containing powder used in the late 1800s. During the 1950s and 1960s, acidulated phosphate fluoride,
neutral sodium fluoride, amine fluoride and stannous fluoride were investigated and introduced as in-office topical
agents and home-use products. The frequency of in-office
fluoride treatments differs with each patient’s level of risk
(typically from zero up to four times per year).
Figure 7. Timeline of preventive measures
Late 1800s
Fluoridens
1950s and 60s
Topical fluorides
1940s
Water
fluoridation
1990s, 2000s
Calcium and
phosphate technologies
Table 2. Tooth structure loss
Caries
Surface and subsurface loss
Abrasion
Surface loss
Attrition
Surface loss
Erosion
Surface loss; contributes to other causes
Remineralization and the Prevention
of Demineralizaton
Demineralization can be counteracted and reversed through
remineralization at the time of acid attacks as well as in the
early stages of hard tissue demineralization. Conditions that
discourage demineralization and favor remineralization
include a reduced load of cariogenic bacteria, good salivary
flow, the presence of calcium, phosphate and fluoride, as
well as the use of chemotherapeutic agents. Antibacterial
agents have been used to prevent demineralization. Chlorhexidine gluconate rinse and povidone iodine reduce the
load of cariogenic (and periodontopathic) bacteria present,
and have been found to help prevent caries in high-risk
children and in high-risk adults with severe xerostomia.47,48
Xylitol occurs naturally and is known to be antimicrobial
and a caries preventive. A three-year study of a dentifrice
containing 10% xylitol and fluoride found a 12% reduction
in decayed and filled surfaces after accounting for fluoride in
the control dentifrice.49 Xylitol is used in chewing gums and
mints, and as a sweetener in a number of oral care products
in the United States. The single greatest advancement in the
last century for caries prevention was the use of fluoride.
6
Dentifrices provide patients with a regular daily supply
of fluoride, and it has been stated that fluoride-containing
dentifrices and rinses have contributed more to the reduction of caries in the general population than other
measures.50 The investigation recently of calcium and
phosphate technology has shown the ability to enhance
prevention as well as esthetics. Use of fluoride-containing
dentifrices that include calcium and phosphate and deliver
ACP helps the supply of calcium and phosphate ions for
the strengthening of enamel. A risk assessment is required
to determine the appropriate preventive measures for individual patients.
The Role of Calcium and Phosphate in the
Demineralization-Remineralization Balance
Normal saliva is supersaturated with calcium and phosphate ions that help prevent dissolution of hydroxyapatite
crystals. Calcium from milk and cheese has been found
to mitigate the effects of erosion.51 Using calcium and
phosphate solutions, testing has shown that using these
sequentially (first calcium, then phosphate) results in the
rapid deposition of amorphous calcium phosphate and its
conversion to hydroxyapatite.52
The use of calcium and phosphate and ACP delivery
has been studied in dentifrices in vitro and in vivo. High
concentrations of calcium and phosphate can exist at low
pH, and as the pH increases, the calcium and phosphate
precipitate. Supersaturation of calcium and phosphate
adjacent to the tooth at low pH helps prevent dissolution
www.ineedce.com
of crystals. This is a concentration gradient effect. As the
pH increases, the balance changes and ACP and fluoride
are incorporated on the surface of the tooth. ACP can then
convert to hydroxyapatite, which is less soluble than ACP.
This can help prevent demineralization, since, at a given
pH, ACP is more soluble than hydroxyapatite crystals,
with the result that the ACP would dissolve first and supersaturate the area with calcium and phosphate ions, helping
to prevent dissolution of the hydroxyapatite crystals.
The amorphous structure of ACP also enables fluoride
and other ions to be incorporated into it. In vitro testing
has found that the presence of ACP can increase fluoride
bioavailability and uptake in ACP-delivering products.53,54
Dentifrice containing calcium and phosphate ions has been
found to increase the bioavailability of fluoride, resulting
in increased uptake of fluoride in in vitro studies using
enamel cores. An uptake of more than 5000 ppm compared
to just over 1900 ppm for a control dentifrice was found,
and the solubility of enamel was reduced.55
Table 3. Fluoride uptake and solubility of enamel
Fluoride Uptake (ppm)
6000
5031
5000
4000
3000
1915
2000
1000
0
-1000
-3.1
Non-Fluoride
Fluoride
Liquid Calcium
and Fluoride
Dentifrice Type
In separate in vitro studies, eroded enamel discs were exposed to a test dentifrice containing liquid calcium, phosphate and fluoride, and it was found that the test dentifrice
increased hardness more than the fluoride-containing dentifrice. In addition, after pretreatment with soda pop, the
test dentifrice increased hardness of the enamel discs by
12% compared to 7% for the control dentifrice, indicative
of a greater remineralizing effect.56
Figure 8. In vitro surface hardness using liquid calcium-containing
dentifrice
www.ineedce.com
Clinical Application – In-office and Home Use
Demineralization and discoloration of teeth can be treated
and/or prevented using suitable in-office and home-care
therapies that effectively and safely prevent and treat these
conditions. In the case of home care, an ideal would be for the
same care to prevent demineralization, aid remineralization,
prevent tooth discoloration and remove any discoloration
present. One option that utilizes over-the-counter dentifrice
without an additional steps being required by the patient,
would be the use of products containing fluoride and delivering
ACP. Based on in vitro studies, in-office use of prophylactic
paste delivering ACP increases fluoride availability where
prophylaxis is indicated and has also been shown to result in
the filling in of surface defects and an improvement in luster, which would enhance esthetics since the light would be
dispersed over a smoother surface. Home use of dentifrice
delivering ACP to the tooth (ARM & HAMMER® Age
Defying) has been shown in in vivo and in vitro studies to
improve appearance and surface luster by this mechanism
and, based on in vitro studies, also results in supersaturation
of the area with calcium and phosphate.
Clinically, a combined in-office and home care regimen
is suitable for patients presenting with extrinsic staining,
loss of surface luster and hard tissue, and patients at risk for
demineralization. Depending on caries risk, increased levels
of topical fluoride, frequency of in-office fluoride, and use of
antimicrobials may also be indicated.
Table 4. Indications for patients for in-office and home use regimen
• Extrinsic staining
• Loss of surface area
• Loss of enamel luster
• Risk of demineralization
Summary
Loss of tooth structure occurs as a result of dental disease
and conditions that include caries, erosion, abrasion and
attrition. Tooth discoloration and staining is prevalent,
and varies with age and habits and by individual patient.
The treatment of tooth discoloration and the prevention
and treatment of caries have been central in dentistry for a
number of decades. Fluoride was first routinely used more
than half a century ago, and tooth whitening has become
a routine procedure. Extrinsic stain can be treated chemically and mechanically. In addition to stain removal, the
filling in of surface defects has been found to alter light
diffraction and dispersion, altering the perception of tooth
color and improving surface luster. Recent innovations
have resulted in products containing calcium and phosphate technology as well as fluoride. These offer cosmetic
benefits and increase the availability of calcium, phosphate
and fluoride for the strengthening of enamel.
7
References
1 Kvaal SI, Kolltveit KM, Thomsen IO, Solheim T. Age
estimation of adults from dental radiographs. Forensic Sci
Int. 1995;74(3):175-85.
2 Ten Bosch JJ, Coops CC. Tooth color and reflectance as
related to light scattering and enamel hardness. J Dent Res.
1995;74:374-80.
3 Shimada K, Kakehashi Y, Matsumura H, et al. In vivo
quantitative evaluation of tooth color with hand-held
colorimeter and custom template. J Prosthet Dent.
2004;1991:389-91.
4 Nathoo SA, Chmielewski MB, Rustogi KN. Clinical
evaluation of Colgate Platinum Professional Toothwhitening
5
6
7
8
System and Rembrandt Lighten Bleaching Gel. Compend
Contin Educ Dent. 1994;15(S17):S640-45.
Pindborg JJ. Pathology of the dental hard tissues.
Copenhagen:Munksgaard, 1970. p221.
Amato M, Scaravilli MS, Farella M, Riccitiello F. Bleaching
teeth treated endodontically: long-term evaluation of a
case series. J Endod. 2006;32(4):376-8.
Nathoo SA. The chemistry and mechanisms of
extrinsic and intrinsic discoloration. J Am Dent Assoc.
1997;128:6S–10S.
McCoy LC, Wehler CJ, Rich SE, Garcia RI, Miller DR,
Jones JA. Adverse events associated with chlorhexidine
use: results from the Department of Veterans Affairs Dental
Diabetes Study. J Am Dent Assoc. 2008;139(2):178-83.
9 Joiner A, Thakker G. In vitro evaluation of a novel 6%
hydrogen peroxide tooth whitening product. J Dent.
2004;32 Suppl 1:19-25.
10 Hefferren J, and Dentifrice Function Committee. Clinical
studies to determine clinical response to nonabrasive
dentifrice use. J Dent Res. 1996;75:45.
11 Cooley WE, Sturzenberger P, Hefferren J. and Dentifrice
Function Committee. Clinical response of non-abrasive
dentifrice use in adults. J Dent Res. 1996;75:87.
12 Lobene R, Hefferren J, and Dentifrice Function Committee.
Clinical response of non-abrasive dentifrice use in dental
hygienists. J Dent Res.1996;75:88.
13 Wülknitz P. Cleaning power and abrasivity of European
toothpastes. Adv. Dent Res. 1997;11:576-579.
14 Miller WD. Experiments and observations on the wasting
of tooth tissue variously described as erosion, abrasion,
chemical abrasion, denudation, etc. Dent Cosmos.
1907;49:1–23, 109–124, 225–247.
15 Wülknitz P. Cleaning power and abrasivity of European
toothpastes. Adv. Dent Res 1997;11:576-579.
16 International Standards Organization ISO 11609, 1995
Dentistry—toothpaste—requirements, test methods and
marking.
17 Berg ML, Ersen E, Smith J, Coffman L, Hefferren
J. Clinical functionality of seven grades of sodium
bicarbonate in the same toothpaste formulation. J Dent
Res. 2003;82:A #386.
8
18 Smith J, Ersen E, Coffman L, Berg ML, Hefferren J.
Cyclic laboratory model to measure the chemical cleaning
powder of seven grades of sodium bicarbonate. J Dent
Res. 2003;82:A #384.
19 Stookey GK, Burkhard TA, Schemehorn BR. In
vitro removal of stain with dentifrices. J Dent Res.
1982;61:1236-9.
20 Zambon JJ, Mather ML, Gonzales Y. A microbiological
and clinical study of the safety and efficacy of baking soda
dentifrices. Comp Cont Ed Dent. 1997;18(21):S39-44.
21 Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC.
Remineralization of enamel subsurface lesions by sugarfree chewing gum containing casein phosphopeptideamorphous calcium phosphate. J Dent Res. 2001
Dec;80(12):
22 Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds
EC. Enamel subsurface lesion remineralisation with
casein phosphopeptide stabilised solutions of calcium,
phosphate and fluoride. Caries Res. 2008;42(2):88-97.
Epub 2008 Jan 15.
23 Clinical Evaluation for Tooth Whitening of a Bioglass®
(NovaMin) Containing Dentifrice.
24 Alaudin SS, Fontana M. Evaluation of NovaMin® as an
adjunct to fluoride for caries remineralization. Novqamin
Research Report. Available at: http://novamin.com/pdf/
Evaluation_of_NovaMin_As_An_Adjunct_to_Fluoride.
pdf. Accessed April, 2008.
25 Tung MS, Eichmiller FC. Dental applications of amorphous
calcium phosphates. J Clin Dent. 1999;10(1 spec no):1-6.
26 Schemehorn BR, Orban JC, Wodd GD, et al.
Remineralization by fluoride enhanced with calcium
and phosphate ingredients. J Clin Dent. 1999;10(1 spec
no):13-6.
27 Tung MS, Eichmiller FC. Amorphous calcium phosphates
for tooth mineralization. Comp Cont Educ Dent.
2004;25(9, Suppl. 1);9-13.
28 Muñoz CA, Stephens JA, Proskin HM, Ghassemi
A. Clinical efficacy evaluation of a fluoride dentifrice
containing calcium, phosphate, and sodium bicarbonate
on surface-enamel smoothness and gloss. Comp Cont Ed
Dent. 2004;25(9)(Suppl. 1):32-43.
29 Tung MS, Eichmiller FC. Amorphous calcium phosphates
for tooth mineralization. Comp Cont Educ Dent.
2004;25(9, Suppl. 1);9-13.
30 Eanes ED. Amorphous calcium phosphate thermodynamic
and kinetic considerations. In: Amjad Z, ed. Calcium,
phosphates in biological and industrial sciences. Boston,
Mass:Kluwer academic publishers;1997:21-39.
31 Munoz CA, Stephens J, Wilson A, et al. Tooth surface
restoration with a bicarbonate-dentifrice containing calcium
and phosphate (Abstract). J Dent Res. 2004;83(spec iss).
Abstract 2115.
32 Muñoz CA, Dahlke H, Charig A, et al. Surface
mineralization by a two-phase baking soda toothpaste
www.ineedce.com
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
containing calcium. J Dent Res. 2004;83(spec iss).
Abstract 2117.
Centers for Disease Control. http://www.cdc.gov/
OralHealth/topics/child.htm. Accessed May 2008.
Ibid.
Ogaard B, ten Bosch JJ. Regression of white spot enamel
lesions: A new optical method for quantitative longitudinal
evaluation in vitro. Am J Orthod Dentofacial Orthop.
1994;106:238-42.
Dreizen S, Brown LR, Daly TE, Drane JB. Prevention
of xerostomia-related dental caries in irradiated cancer
patients. J Dent Res. 1977;56: 99-104.
Cirano FR, Romito GA, Todescan JH. Determination of
enamel and coronal dentin microhardness. Braz J Oral Sci.
2003;2(6):258-63.
Moss SJ. Dental erosion. Int Dent J. 1998;48:529-39.
Rytomaa I, Jarvinen V, Kanerva R, et al. Bulimia and tooth
erosion. Acta Odontol Scand. 1998;56:36-40.
Lackey MA, Barth J. Gastroesophageal reflux disease: a
dental concern. Gen Dent. 2003;51(3):250-4.
National Soft Drink Association. Soft drink facts. NSDA
Web site. Available at: http://www.ameribev.org/allabout-beverage-products-manufacturing-marketing-consumption/what-america-drinks/index.aspx. Accessed
May 10, 2008.
Millward A, Shaw L, Smith AJ, et al. The distribution
and severity of tooth wear and the relationship between
erosion and dietary constituents in a group of children. Int.
J. Paediatr. Dent. 1994;4:151-7.
Phelan J. The erosive potential of some herbal teas. J Dent.
2003;31:241-6.
Muñoz CA, Feller R, Hagland A, et al. Strengthening
of tooth enamel by a remineralizing toothpaste after
exposure to an acidic soft drink. J Clin Dent. 1999;10(1
spec. no.):17-21.
Hooper S, West NX, Pickles MJ, et al. Investigation of
erosion and abrasion on enamel and dentine: a model
in situ using toothpastes of different abrasivity. J Clin
Periodontol. 2003;30(9):802-808.
Hunter ML, Addy M, Pickles MJ, et al. The role of
toothpastes and toothbrushes in the aetiology of tooth
wear. Int. Dent. J. 52: 399-405, 2002.
Joyston-Bechal S, Hayes K, Davenport ES, Hardie JM.
Caries incidence, mutans streptococci and lactobacilli
in irradiated patients during a 12-month preventive
programme using chlorhexidine and fluoride. Caries Res.
1992;26(5):384-90.
Katz S. The use of fluoride and chlorhexidine for
the prevention of radiation caries. J Am Dent Assoc.
1982;104(2):164-70.
Sintes JL, Escalante C, Stewart B, McCool JJ, Garcia L,
Volpe AR, Triol C. Enhanced anticaries efficacy of a
0.243% sodium fluoride/10% xylitol/silica dentifrice:
3-year clinical results. Am J Dent. 1995;8(5):231-5.
www.ineedce.com
50 Harinho VCC, Higgins JPT, Logan S, et al. Fluoride
toothpastes for preventing dental caries in children and
adolescents (Cochrane Review); the Cochrane Library,
Issue 2. New York:John Wiley and Sons;2004.
51 Gedalia I, Ionat-Bendat D, Ben-Mosheh S, et al. Tooth
enamel softening with a cola type drink and rehardening
with hard cheese or stimulated saliva in situ. J Oral Rehab.
1991;18:501-6.
52 Tung MS, Eichmiller FC. Amorphous calcium phosphates
for tooth mineralization. Comp Contin Ed Dent.
2004;25(9S1):9-13.
53 Tung MS, Hwang J, Malerman R, McHale WA. Reactivity
of varnish containing calcium, phosphate and fluoride
salts. J Dent Res. 2007; 86(spec iss)A0:1078.
54 Final Report: Sound enamel fluoride uptake study.
2007;Study 07-107. Dental Products Testing, Indiana
University Emerging Technologies Center.
55 Schemehorn BR, Wood GD, Winston AE. Laboratory
enamel solubility reduction and fluoride uptake from
enamel on dentifrice. J Clin Dent. 1999;10(1 Spec
No):9-12.
56 Muñoz CA, Feller R, Haglund A, Triol CW, Winston
AE. Strengthening of tooth enamel by a remineralizing
toothpaste after exposure to an acidic soft drink. J Clin
Dent. 1999;10(1 Spec No):17-21.
Author Profile
Dr. Fiona M. Collins, MBA, MA
Dr. Fiona M. Collins has 13 years of clinical
experience as a general dentist, and has held
positions in professional marketing, education and training, and professional relations.
She has authored and given CE courses to
dental professionals and students in the US
and Canada, and consulted on market research and opportunity assessment projects.
Dr. Collins is a past-member of the Academy of General Dentistry Foundation Strategy Board and has been
a member of the British Dental Association, the Dutch
Dental Association, the American Dental Association and
the International Association of Dental Research. Dr. Collins holds a dental degree from Glasgow University and an
MBA and MA from Boston University.
Disclaimer
The author(s) of this course has/have no commercial ties with
the sponsors or the providers of the unrestricted educational
grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.
9
Questions
1.Fully developed teeth have a finite
quantity and depth of enamel and
cementum.
11. The cleaning ability of sodium
bicarbonate dentifrices is less than other
dentifrices due to its low abrasivity.
2.As enamel loses its initial surface
texture, this can cause _________.
12. Sodium bicarbonate _________.
a. True
b. False
a. reduction in light refraction
b. reduction in light reflection
c. the tooth to appear darker
d. all of the above
3.Intrinsic staining _________.
a. is stain present inside the tooth
b. only affects the outside of the tooth
c. can result from stain penetrating into the dentin
d. a and c
4.Intrinsic discoloration and staining has
the potential to be treated chemically
and/or mechanically.
a. True
b. False
5. Extrinsic stain can be removed and/or
lifted using _________.
a. hydrogen peroxide
b. abrasion
c. chelation
d. all of the above
6.Dentifrices containing no abrasive have
been found to result in _________.
a. stain accumulation
b. more abrasion
c. patient noncompliance with oral hygiene
d. a and c
7._________ have been used to gently
remove stain and simultaneously help
impart a polish that gives the appear­
ance of whiter teeth.
a. Dentifrice abrasives with large, rounded particles
b. Dentifrice abrasives with fine, rounded particles
c. Dentifrice abrasives with fine, octagonal particles
d. none of the above
8.The discoloration of nonvital teeth can
only be treated by prosthetic options
(crowns or veneers).
a. True
b. False
9.A dentifrice with high cleaning power
and low abrasivity will minimize the
risk of abrasion while maximizing
cleaning efficacy.
a. True
b. False
10. The RDA of sodium bicar­bonate
ranges from _________ compared
to an RDA of _________ in typical
dentifrices.
a. 20-30, 60-80
b. 30-40, 70-110
c. 35-50, 80-200
d. 50-60, 90-150
10
a. True
b. False
a. helps lift stain from the surface of the tooth
b. cleans through both physical and chemical action
c. has been shown to reduce stain in studies
d. all of the above
13. Available calcium and phosphate
technologies include _________.
a. ACP
b. Novamin
c. CPP-ACP
d. all of the above
14. CPP-ACP (Recaldent) is _________.
a. bioavailable
b. derived from sheep’s milk
c. releases calcium and phosphate for remin­
eralization
d. a and c
15. ACP consists of _________.
a. an unstruc­tured form of calcium phosphate
molecules
b. an unstruc­tured form of calcium polysorbate
molecules
c. an unstruc­tured form of carbinic phosphate
molecules
d. none of the above
16. Filling in surface defects changes the
light dispersion, which can improve
esthetics.
a. True
b. False
17. A double-blind randomized trial
assessing twice-daily use of a fluoride
dentifrice with ACP found
that _________.
a. its use improved enamel gloss
b. its use decreased surface roughness
c. its use gave identical results to the control
dentifrice
d. a and b
18. Novamin-containing dentifrice have
found it to have a whitening effect.
a. True
b. False
19. Carbonates have been shown to
control the precipita­tion of ACP onto
tooth surfaces.
a. True
b. False
20. _________ causes of loss of tooth
structure over time.
a. Abrasion
b. Erosion
c. Caries
d. all of the above
21. Hydroxyapatite crystals are stable
at _________ .
a. a pH of 3
b. a pH of 4
c. a pH of 5
d. a pH of 7
22. Erosion results in _________.
a. surface loss
b. the tooth los­ing its luster and glossy appearance
c. increased susceptibility to demineralization and
abrasion
d. all of the above
23. _________ has been used therapeuti­
cally to help prevent caries.
a. Fluoride
b. Chlorhexidine gluconate
c. Xylitol
d. all of the above
24. Supersaturation of calcium and phos­
phate adjacent to the tooth at low pH
helps prevent dissolution of crystals.
a. True
b. False
25. In vitro testing has found that the
presence of ACP can increase fluoride
bio­availability and uptake in products
delivering ACP.
a. True
b. False
26. At a given pH, ACP _________.
a. is more soluble than hydroxyapatite crystals
b. will supersaturate the area with calcium and
phosphate ions
c. will supersaturate the area with calcium and
silicate ions
d. a and b
27.Con­ditions that discourage demin­
eralization and favor remin­eralization
include_________.
a. a reduced load of cariogenic bacteria
b. the presence of calcium, phosphate and fluoride
c. the use of chemotherapeutic agents
d. all of the above
28. Clinically, products containing ACP
can be used in-office followed by athome use as an oral care regimen.
a. True
b. False
29. ACP can precipitate onto the tooth as
globules as shown by scanning electron
micros­copy.
a. True
b. False
30. Calcium and phosphate-containing
dentifrice _________.
a. is available over-the-counter
b. does not require the patient to perform an extra
step in home care
c. helps esthetics and prevention
d. all of the above
www.ineedce.com
ANSWER SHEET
Treatment Options for Tooth Discoloration and Remineralization
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
1. List the etiologies for tooth discoloration.
2. List traditional therapies available for the treatment of tooth discoloration and describe calcium and phosphate technology
and the clinical applications of this technology in treating and preventing discoloration of teeth.
3. List the etiologies for tooth demineralization.
4. List traditional and new therapies available for the prevention of demineralization and for remineralization, and describe
how these work.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
If paying by credit card, please complete the
following:
MC
Visa
AmEx
Discover
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met?Objective #1: Yes No
Objective #3: Yes No
Objective #2: Yes No
Objective #4: Yes No
Acct. Number: _______________________________
Exp. Date: _____________________
Charges on your statement will show up as PennWell
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives.
5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic?
5
4
3
2
1
0
6. Please rate the instructor’s effectiveness.
5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Do you feel that the references were adequate?
Yes
No
9. Would you participate in a similar program on a different topic?
Yes
No
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
AGD Code 258, 780
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The author(s) of this course has/have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant from
Church & Dwight Co., Inc. No manufacturer or third party has had any input into the
development of course content. All content has been derived from references listed,
and or the opinions of clinicians. Please direct all questions pertaining to PennWell or
the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK
74112 or [email protected].
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: [email protected].
www.ineedce.com
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 3274. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
REMIN0806RDH
11
ACP: the next big thing.
The word on ACP is out. And, only one
toothpaste combines it with fluoride.
When you see all the facts, you’ll understand why we call this toothpaste
ARM & HAMMER® Age Defying:
• The only toothpaste delivering fluoride, ACP (amorphous calcium phosphate),
and all the benefits of Baking Soda.
• A highly effective way to strengthen and rebuild enamel daily and bring
superior cleaning to patients.
• Baking Soda and ACP formula maximizes whitening.
– Our Baking Soda dissolves, penetrates and lifts stains from places other
toothpastes can’t reach.
– ACP restores enamel luster by filling in the tooth surface with minerals for a
younger, brighter smile.
Make it your recommendation today! For more information visit www.oralcarepro.com.