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Title Remineralizing White Spot Lesions With Fluoride Alone Or Fluoride And Casein Phosphopeptide-Amorphous Calcium Phosphate
Clinical Question When there are white spot lesions present of enamel, does using fluoride alone or casein phosphopeptide-amorphous calcium phosphate in conjunction with fluoride increase enamel remineralization?
Clinical Bottom Line Casein phosphopeptide-amorphous calcium phosphate aids in fluoride uptake by enamel which accounts for more remineralization than just using fluoride alone. (See Comments on the CAT below)
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 18362316Reynolds/200814 healthy participantsRandomized comparative study
Key resultsFluoride produced dose-related remineralization at higher ppm (2800ppm) of fluoride replacing significantly more mineral compared to a lower ppm (1100 ppm) of fluoride. CPP-ACP increased the incorporation of fluoride into plaque and promoted the remineralization of enamel in situ; CPP-ACP alone had the same remineralization effect as 2800 ppm of fluoride alone. Fluoride by itself promoted remineralization of only the surface layer of enamel while CPP-ACP promoted remineralization throughout the body of the lesion even in the absence of fluoride. 2% CPP-ACP in addition to 1100ppm F contained on a dentrifice ended up being the best compared to all other formulations.
#2) 19864905Rao/200912-15 year old high caries risk children in Bangalore, IndiaRandomized Controlled Clinical Trial
Key resultsCPP can be incorporated into calcium carbonate-based toothpaste effectively, and toothpaste that contains CPP is shown to prevent caries. The toothpaste that contained 2% CPP appeared to have about the same efficacy to paste that contained 1,190 mg/kg sodium monofluorophosphate in the prevention of caries.
#3) 18304239Kumar/2008In vitro In vitro Randomized controlled study
Key resultsThe fluoridated toothpaste group (1100 ppm) decreased the 200 um caries-like lesion by 7%. In the Tooth Mousse containing CPP-ACP in toothpaste and topical coating group the lesion was decreased by 10.1% and in the topical CPP-ACP coating after treating the sections with the same fluoridated toothpaste as used before group, the depth of the lesion was decreased 13.1%. In the non-fluoridated toothpaste group the depth of the lesion was increased by 23%.
Evidence Search Limits: Meta-Analysis, Randomized Controlled Trial, Search "Caseins"[Mesh] Search "Fluorides"[Mesh]
Comments on
The Evidence
In the Reynolds study the plaque fluoride study was double-blind. In this article there was a small number of people participating in this study (14 people) so there is not a good representation of the general public. This article did not mention the completion rate but it is assumed that all fourteen people completed the study and it is assumed that the groups were similar at the start but it is not directly stated in the article.In the Rao article, the study was triple-blind instead of double-blind like the article mentioned above. Compliance was adequate and there was an over ninety percent completion rate. The 150 participants were split into three groups that all were similar at the start and treated the same with the only difference being the ingredient in the toothpaste (CPP, Fluoride, or placebo). This was more valid than the other article because it directly stated validity claims that were not clear in the other article. The Kumar article was an in vitro study that utilizes a t-test, standard deviations, and other forms of analysis to validate the conclusion that CPP-ACP should be used in conjunction with fluoride in order to have higher remineralization of high caries risk individuals.
Applicability The subjects in the studies were representative of patients with white spot lesions or patients at high caries risk. The articles suggest that CPP-ACP should be used along with fluoride in order to promote the incorporation of more fluoride into the enamel causing better remineralization. Patients would benefit from using a topical containing CPP-ACP after brushing with fluoridated toothpaste.
Specialty/Discipline (Public Health) (Oral Medicine/Pathology/Radiology) (General Dentistry) (Pediatric Dentistry) (Restorative Dentistry) (Dental Hygiene)
Keywords Casein phosphopeptide, children, clinical trial, dental caries, dentrifices, fluoride, prevention, randomized controlled trial, demineralization, caries, pH-cycling, CPP-ACP, remineralization
ID# 572
Date of submission: 03/31/2010spacer
E-mail penacl@uthscsa.edu
Author Christina Pena
Co-author(s) e-mail
Faculty mentor/Co-author Irene Bober-Moken, DMD, MPH
Faculty mentor/Co-author e-mail bobermoken@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
Comments and Evidence-Based Updates on the CAT
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by Lauren Roper, Supriya Patel & Alicia Casarez-Quintana (San Antonio, TX) on 01/07/2013
The CAT included research with limited subjects and dated research, therefore the answer should be reevaluated. Based on more recent research (PMID 22805294 ), a randomized trial of 296 subjects, the use of CPP-ACP paste in conjunction with fluoride treatment for preventing caries does not have a significant added effect over using fluoride alone. Another recent randomized controlled trial (PMID: 21250566) has a limited number of subjects, n=32, but the trial was in-vivo and the results support those that were found by this CAT.

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