by Renée Marchant-Turner, RDH
Last month (see article from December RDH), we learned about the many remineralization products on the market, looking at each product by its composition and what it does. This article will advise when and how to use each of these products.
Remineralization products can prevent tooth breakdown, also known as demineralization. Remineralization products repair early demineralization, reduce or eliminate tactile and temperature sensitivity, and reduce the appearance of white spot lesions.
Demineralization occurs when the oral environment has low pH, inadequate available mineral ions, and/or bacteria in the presence of carbohydrates. Some causes of demineralization are: low saliva quantity, poor saliva quality, systemic diseases such as Sjogren's syndrome, head and neck radiation, prescription medications that cause xerostomia, poor oral hygiene, high carbohydrate diet, orthodontic appliances, dental restorations that retain bacterial biofilms, clenching and grinding resulting in abfractions, and the list goes on …
Below is a list of conditions that would benefit from using remineralizing products with an explanation of when and how to use each. Clinicians can use one or more products depending on severity or needs in each case and the willingness of the patient to use products at home.
High caries risk
High caries risk due to high carbohydrate diet, poor oral hygiene, poor quality saliva lacking in buffering ions (calcium and phosphorus), medical treatments that cause nausea, acid reflux, bulimia, and exposed root surfaces:
1) NovaMin (calcium sodium phosphosilicate-containing toothpastes with or without 5,000 ppm 1.1% sodium fluoride). Products: Sultan Topex ReNew toothpaste with 5,000 ppm fluoride, Dentsply Nupro Nusolutions 5,000 ppm Fluoride Remineralizing and Desensitizing Toothpaste and Oravive Tooth Revitalizing Toothpaste (contains no fluoride).
Note: Studies show adding fluoride to NovaMin enhances mineral penetration into the tooth surface.
Directions:Brush two times per day; avoid rinsing and eating for 30 minutes after use.
NovaMin products are available from dental distributors. Oravive Tooth Revitalizing Toothpaste is over-the-counter and available from www.cvs.com or www.oravive.com.
2) CPP-ACP, Recaldent (casein phosphopeptide-amorphous calcium phosphate). Products: MI Paste and MI Paste Plus 900 ppm 2% sodium fluoride.
Directions:Apply pea-size amount to teeth with finger. Do not rinse. Allow to slowly dissolve overnight. CPP-ACP is released during an acid challenge. When the mouth is dry, the pH is lower so CPP-ACP will be released for deposition into the tooth.
Recaldent is not to be used on patients allergic to milk protein or benzoate preservatives.
Note: Studies show adding fluoride to MI Paste enhances mineral penetration into the tooth surface.
MI Paste is available from dental distributors.
3) Recaldent gum. Product: Cadbury's Trident Extra Care Gum.
Directions:Patients chew CPP-ACP gum for 10 minutes three times per day. Since CPP-ACP needs an acid challenge to be released, timing of chewing is important. For example, when the mouth is dry, the pH is lower. Chewing this gum at this time would raise the pH so the CPP-ACP will be released for deposition into the tooth.
Trident Extra Care Gum is available over-the-counter.
4) ACP (amorphous calcium phosphate). Products: Age Defying Toothpaste by Arm and Hammer.
Directions:Use twice daily in place of current dentifrice. Age Defying Toothpaste is available over-the-counter.
Enamel Pro Gel and Enamel Pro Fluoride Varnish. The addition of ACP increases the availability of fluoride to the tooth.
Directions:Professional application per package directions every three to six months.
5) Fluoride foams, gels, and varnish. Products are prescription strength and available from numerous companies.
Directions:Apply every three to six months per package directions. Varnishes are the preferred option with enhanced uptake due to increased time the product stays on the tooth surface as compared to foams or gels.
Note: Studies show the addition of fluoride to NovaMin and Recaldent products penetrates deeper than the same product without fluoride.
High-strength fluoride products are prescription only and available through dental distributors.
Xerostomia
Xerostomia is caused by medications, diseases such as Parkinson's and Sjogren's, and head and neck radiation:
1) NovaMin toothpaste with or without 5,000 ppm fluoride. Products: Sultan Topex ReNew toothpaste with 5,000 ppm fluoride, Dentsply Nupro Nusolutions 5,000 ppm Remineralizing and Desensitizing Toothpaste, and Oravive Tooth Revitalizing Toothpaste.
Directions:Brush two times per day; avoid rinsing and eating for 30 minutes after use.
2) CPP-ACP, Recaldent. Products: MI Paste and MI Paste Plus 900 ppm 2% sodium fluoride.
Directions:Apply twice or more per day. Apply small amount with finger to teeth. Do not rinse. Allow to slowly dissolve. MI Paste and MI Paste Plus have a slippery texture that sticks to oral mucosa. Xerostomia patients may find applying a small amount throughout the day and night helpful as a lubricant in addition to its remineralizing properties.
3) ACP (amorphous calcium phosphate). Products: Age Defying Toothpaste by Arm and Hammer.
Directions:Use twice daily in place of current dentifrice.
4) Recaldent gum. Product: Cadbury's Trident Extra Care Gum.
Directions:Chew as necessary to stimulate saliva.
5) Fluoride foam, gel, and varnish.
Directions:Apply every three to six months per package directions. Varnishes are the preferred option with enhanced uptake due to increased time the product stays on the tooth surface. Severe xerostomia patients may not tolerate the sticky consistency of varnishes because the oral mucosa may adhere to the varnish coating. Varnishes should be used sparingly, especially in these patients. Using saliva substitutes immediately after applying varnish may be helpful for lubrication if the mucosa sticks to the varnished teeth.
Orthodontic and other fixed appliances
Orthodontic and other fixed appliances add to plaque retention, increasing risk of demineralization and/or decay.
1) NovaMin toothpaste with or without 5,000 ppm fluoride. Products: Sultan Topex ReNew toothpaste with 5,000 ppm fluoride, Dentsply Nupro Nusolutions 5,000 ppm Remineralizing and Desensitizing Toothpaste, and Oravive Tooth Revitalizing Toothpaste.
Directions:Brush two times per day; avoid rinsing and eating for 30 minutes after use.
2) CPP-ACP, Recaldent. Products: MI Paste and MI Paste Plus 900 ppm 2% sodium fluoride. Avoid eating and drinking for 30 minutes after application.
Directions:Apply small amount with finger to teeth. Do not rinse. Allow to slowly dissolve overnight.
3) ACP (amorphous calcium phosphate). Products: Age Defying Toothpaste by Arm and Hammer.
Directions:Use twice daily in place of current dentifrice.
Enamel Pro Gel and Enamel Pro Fluoride Varnish. The addition of ACP increases the availability of fluoride to the tooth.
Directions:Professional application per package directions.
4) Fluoride foams, gels, and varnish. Products are prescription strength and available from numerous companies.
Directions:Apply every three to six months per package directions. Varnishes are the preferred option with enhanced uptake due to substantivity.
Sensitivity
Sensitivity, either thermal, pH, or tactile, can be from many sources including acidic diets, erosion, abfractions, recession, restoration margins, and occlusal trauma. Sensitivity can be significantly reduced or eliminated by using remineralizing products.
1) NovaMin makes two products specifically for sensitivity:
Sultan VitalMin Tooth Root Desensitizer with NovaMin for Periodontal Therapy is an in-office prescription treatment. It is a two-part syringe system that is mixed and applied to a slightly moist tooth surface for one to two minutes. VitalMin is then lightly rinsed and suctioned off the tooth surface at the end of periodontal treatment. No eating for one hour after treatment.
3M ESPE makes Omni SootheRx Therapy for Sensitive Teeth. This prescription treatment comes with two 1.5 oz. tubes of paste in the packaging. The patient brushes it on twice per day in place of regular toothpaste for two weeks. Then use once per week for 24 weeks. Use a wet soft toothbrush and brush for two minutes. Do not rinse after brushing. Do not eat or drink for 30 minutes. These products are available from dental distributors.
The previously mentioned NovaMin products will also reduce or eliminate sensitivity: Sultan Topex ReNew toothpaste with 5,000 ppm fluoride, Dentsply's Nupro Nusolutions prophy paste and 5,000 ppm Remineralizing and Desensitizing Toothpaste and Oravive Tooth Revitalizing Toothpaste.
Directions:Brush two times per day; avoid rinsing and eating for 30 minutes after use.
2) CPP-ACP, Recaldent. Products: MI Paste and MI Paste Plus 900 ppm 2% sodium fluoride.
Directions:Apply small amount with finger to teeth. Do not rinse. Allow to slowly dissolve overnight. Can be used twice or more per day to maximize effect.
3) ACP (amorphous calcium phosphate). Product: Discus Dental Relief ACP Oral Care Gel.
Directions:Apply to bleach-type tray where sensitivity is felt. Wear tray for 30 minutes; then brush or rinse gel off. Alternative method is to brush it on for three minutes. Do not eat or rinse for 30 minutes after application. Use twice daily until symptoms are gone.
Dental Relief ACP Oral Care Gel is available from dental distributors.
Product: Enamel Pro prophy paste from Premier.
Directions:Polish before scaling.
Product: ACP (amorphous calcium phosphate). Products: Age Defying Toothpaste by Arm and Hammer.
Directions:Use twice daily in place of current dentifrice.
Enamel Pro Gel and Enamel Pro Fluoride Varnish. The addition of ACP increases the availability of fluoride to the tooth.
Directions:Professional application per package directions every three to six months.
4) Fluoride foams, gels, and varnish. Products are prescription strength and available from numerous companies.
Directions:Apply every three to six months per package directions.
White spot lesions
White spot lesions are caused by bacterial plaque retention over time. Orthodontic appliances, fluorosis, and cervical areas are typically the site of such lesions due to difficulty in keeping these areas plaque-free. Incipient decay can be treated similarly to white spot lesions.
1) CPP-ACP Recaldent. Products: MI Paste and MI Paste Plus 900 ppm 2% sodium fluoride.
Directions:For existing white spot lesions, do not apply acid etch before applying MI Paste. With arrested lesions, it is recommended to etch for 15 seconds with orthophosphoric acid to make the tooth surface permeable. Microabrasion is sometimes needed in addition to acid etch followed by five-minute applications twice daily of MI Paste for 12 weeks. Trays may be used for MI Paste application to keep the paste in contact with the etched areas. The in-office acid etch may need to be repeated numerous times for the best results.
2) NovaMin products are showing promise in this area. The company is currently conducting case studies. All NovaMin products will have a positive effect on reducing white spot lesions when used as described in the sensitivity treatment section above.
Summary
Using remineralization therapies can significantly affect the health of our patients. As primary health providers, dental hygienists are in a position to impact the future of our patients. We have the responsibility to provide the latest remineralization products and services to our patients. Remineralization therapy is a fairly simple and inexpensive way to promote tooth structure preservation.
About the Author
Renee Marchant-Turner, RDH, has been in private practice since 1980. She teaches hands-on micro-ultrasonic continuing education courses to hygienists and dentists. She can be contacted at [email protected].
