|Year : 2020 | Volume
| Issue : 4 | Page : 305-312
Effect of calcium sodium phosphosilicate–containing compared to nanohydroxyapatite-containing toothpastes on dentinal tubule occlusion: A randomized clinical in situ study
Heba H Alsherbiney1, Heba A El-Deeb1, Ahmed H Alsherbiney2, Ahmed A Abdou3, Enas H Mobarak1, Omaima S Hamza1
1 Department of Conservative Dentistry, Faculty of Dentistry, Cairo University, Cairo, Egypt
2 Department of Orthodontic, National Research Centre, Cairo, Egypt
3 Biomaterials Department, Faculty of Oral and Dental Medicine, Modern University for Technology and Information, Cairo, Egypt; Department of Cariology and Operative Dentistry, Division of Oral Health Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
|Date of Submission||06-Jan-2020|
|Date of Decision||28-Jan-2020|
|Date of Acceptance||28-Jan-2020|
|Date of Web Publication||20-Aug-2020|
Dr. Heba H Alsherbiney
Misr Helwan Agriculture Road, Maadi, Cairo.
Source of Support: None, Conflict of Interest: None
Aim: Treatment of dentin hypersensitivity is a challenging procedure; the evolution of many materials dictates the necessity of comparing them to choose the one with rapid and sustained effect.The aim of this study was to compare between calcium sodium phosphosilicate (Ca-Na-P) containing toothpaste and nanohydroxyapatite (n-HA) containing toothpaste in treatment of dentin hypersensitivity by occlusion of dentinal tubules using a novel intraoral appliance in situ. Materials and Methods: A total number of 42 patients were assigned randomly to receive intraoral appliances holding sterilized dentin specimens on the upper first molars to one of the two groups:; either calcium sodium phosphosilicate-containing or n-HAnanohydroxyapatite-containing toothpastes. A total of 63 lower premolars were used to obtain dentin specimens. Dentin specimens were examined under scanning electron microscope. Dentinal tubules were counted visually to determine the percentages of their occlusion:; pretreatment and after 24 hours, six weeks, and eight weeks of toothpastes’ application. Data wereas collected and analyzed using Kruskall-Wallis test and Mann-Whitney test. Results: There was a significant increase in dentinal occlusion scores for both materials at a P value of ≤0.001. n-HA showed significant higher scores compared to Ca-Na-P at all follow-up periods (P ≤ 0.001). Conclusion: Biomimetic zinc n-HAcontaining toothpaste proved immediate dentinal tubule occlusion; moreover, both toothpastes provided long-term tubules occlusion.
Keywords: Calcium Sodium Phosphosilicate, Hydroxyapatite, Hypersensitivity, NovaMin, Toothpaste, Tubules Occlusion
|How to cite this article:|
Alsherbiney HH, El-Deeb HA, Alsherbiney AH, Abdou AA, Mobarak EH, Hamza OS. Effect of calcium sodium phosphosilicate–containing compared to nanohydroxyapatite-containing toothpastes on dentinal tubule occlusion: A randomized clinical in situ study. J Int Oral Health 2020;12:305-12
|How to cite this URL:|
Alsherbiney HH, El-Deeb HA, Alsherbiney AH, Abdou AA, Mobarak EH, Hamza OS. Effect of calcium sodium phosphosilicate–containing compared to nanohydroxyapatite-containing toothpastes on dentinal tubule occlusion: A randomized clinical in situ study. J Int Oral Health [serial online] 2020 [cited 2020 Oct 23];12:305-12. Available from: https://www.jioh.org/text.asp?2020/12/4/305/292764
| Introduction|| |
Dentin hypersensitivity is an enigma being usually encountered but hardly understood. It is characterized by short, sharp pain resulting from exposed dentin responding to thermal, evaporative, tactile, chemical, or osmotic stimuli. Severity of dentin hypersensitivity is related to increase in the number and width of patent dentinal tubules. Management of hypersensitivity includes agents that either chemically modify or suppress the nerve impulses by direct neurological interaction, or mechanically occlude the dentinal tubules to prevent fluid movement or decrease dentin permeability, thereby, reducing pain and discomfort. Nevertheless, chemicals modifying the nerve excitation have transient and reversible effect. Consequently, several physical and chemical agents were used to treat dentin hypersensitivity by dentinal tubule occlusion.,
Many agents had been used for this purpose, however, there is still no gold standard in dentin hypersensitivity treatment. Most of these products either form small crystals easily removed by daily brushing or are prone to dissolve or degrade in the oral environment. This raised the need in the dental field for a material that can chemically react with dentin surface; intimately adhere to the tooth structure, thus reducing the possibility of reopening of the dentinal tubules; and provide immediate and long-term relief from hypersensitivity.
Recently, toothpaste containing calcium sodium phosphosilicate (Ca-Na-P) was found to be a bioactive material effective in occlusion of the dentinal tubules. It releases sodium, calcium, and phosphate ions, which interact with saliva resulting in hydroxycarbonate deposition over the exposed dentin and within the dentinal tubules.
Moreover, with the breakthrough of nanotechnology, nano-sized biomimetic apatite–containing toothpaste is a relative newcomer in the dental field.
Few studies were published to investigate the effectiveness of hydroxyapatite-containing toothpaste in the treatment of dentin hypersensitivity. They were also of short duration.
To the best of our knowledge, there is no available published clinical data concerning the short-term and relatively long-term maintenance of dentinal tubule occlusion ability of these novel technologies of toothpastes. Therefore, the null hypotheses were that there was no difference in percentages of dentinal tubule occlusion after application of either Ca-Na-P-containing or nanohydroxyapatite-containing toothpaste, and that there was no difference in percentages of dentinal tubule occlusion after 24h, 6 weeks, and 8 weeks of application of both toothpastes.
| Materials and Methods|| |
Setting and design
This study is a randomized, controlled, triple-blinded (participant, outcome assessor, and statistician), unicenter, parallel, two-arm trial with 1:1 allocation ratio. The trial was designed following SPIRIT 2013 Statement (Standard Protocol Items. Appliances were planned to be removed when there were any signs of discomfort or pain. For sample size calculation, the Student t test was performed based on a previous study. A large effect size of approximately 0.8 was expected. A total sample size of 42 (21 per group) will be sufficient to detect an effect size of 0.8, a power of 80%, and a significance level of 5%. Sample size was calculated using G*Power program (University of Düsseldorf, Düsseldorf, Germany).
Grouping and recruitment of participants
Adult outpatients of the Conservative Dentistry Clinic were asked to participate in this trial. The patients were both men and women of age range 18–40 years. The participants were chosen according to the following eligibility criteria.
- Patients with age range 18–40 years.
- Patients with good general and oral health.
- Patients with low plaque index (score 0 or 1) measured by Löe index.
- Patients with low-to-moderate caries risk calculated using DMF (Decayed Missing Filled Surfaces/Teeth) index.
- Patients without known allergy to any commercial dental product.
- Patients with at least 18 healthy teeth exposed to the oral environment.
- Patients with sound, unrestored buccal surface of maxillary first molars.
- Patients with normal salivary function not taking any antibiotics or medications affecting salivary flow rate (unstimulated salivary flow of 0.1–0.3mL/min and simulated salivary flow of maximum 7mL/min) and salivary pH equal to 7.
- No evidence of significant oral soft tissue pathology.
- Patients with periodontal disease requiring aggressive treatment.
- Lactating and pregnant women.
- Medically compromised patients.
- Patients with neuromuscular disabilities.
The researcher explained verbally all aspects of the trial, including every step and its advantage and disadvantage to all participants. Additionally, eligible participant had to sign a written informed consent to be recruited in the study. A total of 42 participants gave consent for participation and fulfilled the eligibility criteria.
Blinding, randomization, allocation concealment, and implementation
The study was triple blinded (participants, outcome assessors, and statistician). Participants were randomly assigned to either intervention or control group with 1:1 allocation using computer-generated randomization (www.random.org).,, Numbers were placed in an opaque, sealed envelope. Each participant pulled a number from the opaque, sealed envelope to be allocated. The allocation sequence was generated by one contributor other than the outcome assessors. The participants were blinded by wrapping both toothpastes with the same opaque wrapper and coded either A or B to hide their identity.
The outcome assessors were neither involved in the randomization process nor were aware of the assigned group in the outcome assessment.
The participants were divided into two groups (n = 21) according to the toothpaste utilized: either Sensodyne Repair and Protect (Ca-Na-P-containing toothpaste) or Biorepair (zinc hydroxyapatite–containing toothpaste) (n-HA). Tested toothpastes’ brand names, specifications as well as their manufacturers, compositions, and lot numbers are represented in [Table 1].
|Table 1: Materials’ brand names, specifications, lot numbers, manufacturer names, and composition|
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Preparation of dentin specimens
A total of 63 lower single-rooted premolars, extracted from patients of average age 18–40 years for orthodontic reasons, were used. Teeth were checked to be of average dimensions (length, 14mm; width, 7mm; and thickness, 5mm) (± 0.02mm), and free from cracks, caries, fracture, or any pathological abnormality using magnifying ×6 lens. The teeth were stored in Sorensen’s phosphate buffer solution containing sodium azide at 4oC until being used within 1 month. For all teeth, the crown was separated from root at cementoenamel junction using diamond disc (Dental Burs USA, Chicago, IL). Sectioned roots, except 2mm from the cervical portion of each root, were centrally embedded in squared rubber base molds containing fast-setting cyanoacrylate transparent cold cure denture base material (Acrostone, Cairo, Egypt) mixed according to manufacturer’s instructions.
After setting of the acrylic, the embedded root was removed from the mold and prepared to be sectioned. Embedded root was then fixed vertically to microtome cutting machine (Techno Motori, Italy) with a double-sided abrasive disc of thickness 0.5mm (Aoke, Dongguan, China) rotating at low speed with copious water coolant. The microtome cutting machine was used for sectioning the root and obtaining the dentin specimens. From each root, two rectangular-shaped dentin specimens were obtained from the middle part of the root (6mm length, 4mm width, and 1 ± 0.05mm thickness) measured with a digital caliber (Silverline Tools, UK). A total of 126 specimens were used in this study. Each dentin specimen was sterilized at 121°C for 20min.
To obtain uniform smear layer, dentin specimens were finished using wet 600-grit silicon carbide (SiC) paper in figure eight movement for 20s. The specimens were then treated with 6% citric acid for 2min and rinsed thoroughly with water, thus, to obtain open patent dentinal tubules resembling hypersensitive dentin. A rectangle was drawn by permanent marker in the center of each specimen to ensure the standardization that the same area was assessed under scanning electron microscope before and after treatment. Each dentin specimen served as its own control.
Then, each specimen was scanned using environmental scanning electron microscope (Scanning Electron Microscope 515; Philips, Eindhoven, the Netherlands) at magnification ×2500 to obtain photomicrograph before toothpaste application. After pretreatment, each dentin specimen was replaced in its sterilization bag.
For each participant, three dentin specimens were placed intraorally in a customized intraoral appliance. Specimens were subdivided into three groups (n = 21) according to the testing periods, that is, 24h, 6 weeks, and 8 weeks. All dentin specimens were examined and photographed using environmental scanning electron microscope after the assigned treatment period. All specimens’ photomicrographs were evaluated using visual counting and scoring method to calculate the dentinal tubule numbers and their diameters (percentages of occlusion). Before and after treatment, 126 photomicrographs were assessed and evaluated, ending up with 252 specimens’ photomicrographs evaluation.
Customized intraoral appliance fabrication
A suitable size of orthodontic band (Ortho Pro, Miami, FL) was selected to fit the contour of the upper first molars on the cast. To produce an auxiliary carrying portion for the dentin specimen, an orthodontic band sheet (Dentaurum, Ispringen, Germany) material was used. The two ends of the band sheet were bent thus serving as a drawer carrying the dentin specimen [Figure 1]. The bent orthodontic sheet was welded to the buccal surface of the orthodontic band. A nonfluoride-containing cement, zinc phosphate luting cement (TG, London, UK), was used to cement the customized intraoral appliance.
|Figure 1: Appliance carrying dentin sample (A) on cast and (B) intraorally|
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Participants were instructed to brush their teeth twice daily in the morning and in the evening with one of the tested toothpastes using modified Stillman’s method for toothbrushing. At the baseline, the participants’ first brushing was carried out under supervision of the operator.
Safety and compliance
Spontaneously reported adverse effects and any abnormalities were recorded from the first supervised brushing with the administrated toothpastes at the screening visit and till the last administration. The investigator assessed the relationship between the toothpastes and the occurrence of any adverse effects, and graded the intensity as mild, moderate, or severe. The participants were provided with a diary to keep record of the number of times brushed per day. The use of other oral hygiene products such as mouthwash was prohibited., All the participants received dental treatment during follow-up periods, and they were instructed to contact operator in case of any complaint.
Assessment of the dentinal tubule occlusion
Visual counting and scoring
Two examiners who were blinded to the treatment used counted the dentinal tubules in each photomicrograph before and after treatment for each follow-up periods, and the mean score of the dentinal tubule occlusion was taken and used for analysis. They were also asked to score the degree of dentinal tubule occlusion as follows:
Score 1: 0% dentinal tubule occlusion.
Score 2: 25% dentinal tubule occlusion.
Score 3: 50% dentinal tubule occlusion.
Score 4: 75% dentinal tubule occlusion.
Score 5: 100% dentinal tubule occlusion.
Data were presented with median and 95% confidence interval (CI). Nominal logistic regression was used to evaluate whether there was a significant association between the dentinal tubule occlusion score data, different toothpastes, and follow-up periods by likelihood-ratio chi-square test. For interaction, Kruskal–Wallis test was used to compare follow-up periods, followed by multiple comparison with Dunn–Bonferroni test. The Mann–Whitney test was used to compare tested toothpaste within each follow-up. Statistical analysis was performed with Statistical Package of Social Science software (SPSS Inc., IBM Corporation, NY) Statistics, version 25, for Windows.
| Results|| |
[Table 2] shows median and 95% CI of dentinal tubule occlusion score data. Distribution of dentinal tubule occlusion scores are presented in [Figure 2]. Kruskall–Wallis test showed a significant increase in dentinal occlusion scores for both materials at P value of ≤0.001. n-HA showed a significant higher dentinal tubule blockage scores compared to Ca-Na-P for all follow-up periods at P value of ≤0.001. Nominal logistic regression model showed that different toothpastes and follow-up periods had a significant effect on dentinal tubule occlusion score at P value of <0001 [Table 3]. [Figure 3] shows SEM photomicrograph of dentin specimens of both toothpastes at different observation time points.,
|Figure 2: Box plot showing the distribution of the dentinal tubule blockage scores. Different superscript lowercase letters indicate significant difference between follow-up periods within each group. Different superscript uppercase letters indicate significant difference between different groups within each time|
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|Table 3: Nominal logistic regression analysis for the dentinal tubule occlusion score data, different toothpastes, and follow-up periods|
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|Figure 3: SEM photomicrograph of dentin specimens of both toothpastes at different observation time points: (A) before treatment with Sensodyne Repair and Protect toothpaste; (B) Sensodyne Repair and Protect toothpaste after 24h; (C) Sensodyne Repair and Protect toothpaste after 6 weeks; (D) Sensodyne Repair and Protect toothpaste after 8 weeks; (E) before treatment with Biorepair toothpaste; (F) Biorepair toothpaste after 24h; (G) Biorepair toothpaste after 6 weeks; and (H) Biorepair toothpaste after 8 weeks|
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| Discussion|| |
In situ studies are considered as a bridge for the gap found between the in vitro and the clinical trials. It allows the control of experimental variables and a flexibility of experimental design that is impossible to be achieved in clinical trials. The appliance used in in situ studies must be appropriate for patients’ comfort and safety with specimens securely fit. Previous in situ studies used removable intraoral appliances. The drawbacks with these kinds of appliances are as follows: they might not be used by the patient the whole day; additionally, the possibility that the patient skips brushing the specimens could be high and the discomfort caused by the bulk of these appliances could not be neglected. Thus, the novelty of the intraoral appliance used in this study is that it is fixed intraorally, ensuring that the patient brushes the specimens daily and that the specimens were subjected to the oral environment all the time. The fixed intraoral appliance was cemented on the upper first molar so it was easily reachable for brushing, and at the same time, it did not affect the occlusion and the esthetics.
The results of this study confirmed the rejection of the two suggested null hypotheses: where there was a statistical significant difference between the percentages of dentinal tubule occlusion of the Ca-Na-P-containing toothpaste (Sensodyne repair and protect) and zinc hydroxyapatite–containing toothpaste (Biorepair) and there was a statistically significant difference between the percentages of dentinal tubule occlusion after 24h, 6 weeks, and 8 weeks of application of Ca-Na-P- and nanohydroxyapatite-containing toothpastes.
The results were in favor of the hydroxyapatite-containing toothpaste (Biorepair) regardless of the tested follow-up periods. These results were confirmed by other researchers either clinically or in vitro. These results could be properly explained by studying the mechanism of action of both types of toothpastes.
Sensodyne Repair and Protect (Ca-Na-P-containing toothpaste) is a bioactive material and forms a part of a larger class of inorganic synthetic biomaterials known as bioactive ceramics. When exposed to body fluids, it becomes reactive and deposits hydroxycarbonate apatite, a mineral similar chemically to dentin. These particles physically occlude the open dentinal tubules following its initial application and then it promotes surface reaction on the particle to promote formation of a protective hydroxyapatite similar to tooth mineral.
On the contrary, Biorepair (zinc hydroxyapatite–containing toothpaste) is a biomimetic oral health product. It is formed of synthetic hydroxyapatite of the same physical and chemical properties of the apatite structure of the tooth. This similarity increases the affinity of these nanoparticles to be adsorbed onto the tooth surface. They obliterated the open dentinal tubules and blended to them forming a thin coat or artificial smear layer on the exposed dentin surface.
The possible reason that the results of the dentin specimens treated with Biorepair surpassed those of Sensodyne Repair and Protect could be due to small particles of nanohydroxyapatite that could be easily penetrated and accumulated into the dentinal tubules than the large Ca-Na-P broken particles that are only physically bounded till the beginning of the bioactive reaction of these particles.
In comparing the precipitate layer deposition of hydroxyapatite- and Ca-Na-P-containing toothpaste, the precipitate deposit was thicker for the hydroxyapatite-containing toothpaste, suggesting its rapid action. On the contrary, the delayed action of Ca-Na-P-containing toothpaste can be explained by the glass particle protection of the released calcium and phosphate ions. These glass particles need to be trapped into the Ca-Na-P broken particles so that the calcium and phosphate ions can be localized in place.,
Studying separately and in detail the sequence of the reaction of each toothpaste will further clarify their behavior throughout the follow-up periods. The sequential reaction of Ca-Na-P (NovaMin) during its application in the oral cavity occurs as it is subjected to aqueous environment, sodium ions begin to exchange with hydrogen cations (H+ or
). This rapid release allows calcium and phosphate ions to be released from the material. This initial series of reaction occurs within seconds and the release of calcium and phosphate ions continues as long as particles are exposed to an aqueous environment. During the initial exposure of the material and release of sodium ions, there is a localized and transient increase in pH, helping in precipitation of calcium and phosphate ions from NovaMin particles along with calcium and phosphorus in saliva forming a calcium phosphate layer. As the deposition continues, this layer crystallizes into hydroxycarbonate apatite, which is chemically and structurally similar to the biological apatite. The combination of NovaMin particles and hydroxyapatite layer results in physically occluding the dentinal tubules, relieving the dentin hypersensitivity.
Additionally, there was a loss of soluble silica as Si(OH)4 by breaking of Si–O–Si bridges and the subsequent formation of surface silanol groups creating a three-member SiO2 chains. These chains were condensed together and repolymerized to form SiO2-rich layer. This charged layer attracts and allows migration of Ca2+ ions and
onto its surface and the formation of a porous CaP-rich layer. The later layer promoted the incorporation of OH‒ and
from the surrounding solution and subsequently the crystallization of the CaP layer to form hydroxyapatite-like layer. Studies clarified that the formed amorphous Ca-Na-P are physically attracted to Type I collagen present in dentin. This could be another reason for its occluding effect by time.
Also, its delayed dentinal tubule occlusion might be related to the release of the Na+ ions, which were relatively small in size and its function was to raise the pH of the surrounding. Also, the formation of the porous and amorphous layer that might not be enough or weaker to completely block dentinal tubules at the first days or may be weeks of its application.
By time, the percentage of dentinal tubule blockage increased because of the formation of the hydroxyapatite-like layer that succeeded to block the dentinal tubules. Additionally, the increase in pH and the increase in number of available NovaMin particles allowed the surface layer to act as mineral reservoir and nucleation sites that promoted further crystals growth. It should be mentioned that the presence of silica was very important in the ingredient of this product as it increased the rate of mineral precipitation. Generally, minimal abrasive components in toothpastes play a role in dentinal tubule occlusion. The effect of silica played an important role in occluding the dentinal tubules, where they found that when NovaMin was used in toothpaste without abrasives, the dentinal tubule penetration was less compared to NovaMin toothpaste containing abrasives.
Regarding the nanohydroxyapatite-containing toothpaste (Biorepair), zinc hydroxyapatite–containing toothpaste, unlike Ca-Na-P technology, is a biomimetic material. It has the potential for crystal precipitation and the formation of amorphous calcium phosphate, which is rapidly converted to apatite. This rapid reaction leads to not only the progressive closure of dentinal tubules opening with plugs in few minutes but also the regeneration of a mineralized layer within hours.,
Additionally, the nanohydroxyapatite clusters act as a calcium and phosphate reservoir, helping to maintain a supersaturation of these ions causing their deposition on the tooth surface, and elevates the calcium concentration in the saliva, thus promoting crystal integrity and growth.
The innovation in this product is its zinc contents. A deposition of zinc carbonate hydroxyapatite was described by dentin surface sealing the dentinal tubules. The zinc carbonate hydroxyapatite particles had higher density than any other formed particles. Previous studies interpreted its higher adhering potential because of its high surface energy and greater affinity to be deposited in irregular spaces. Furthermore, zinc hydroxyapatite particles complexed with pyrrolidone carboxylic acid content (ZnPCA) enhanced the accumulation of nano-sized hydroxyapatite crystallites and the hydroxyapatite microclusters. The formation of these crystallites and microclusters maintained the blockage of dentinal tubules along their length overtime.
Finally, findings of this study encourage the application of nanotechnology, biomimetic, and bioactive materials in the toothpastes as potential treatment modality for dentin hypersensitivity. These novel technologies when incorporated in home-applied products could provide low cost, ease of use, and long-lasting effect not only for treatment of dentin hypersensitivity but also for the total oral health care.
Biomimetic zinc nanohydroxyapatite–containing toothpaste proved immediate dentinal tubule occlusion; moreover, both toothpastes provided long-term tubule occlusion. Thus, both types of toothpastes could have the potential to treat dentin hypersensitivity.
Biomimetic zinc hydroxyapatite–containing toothpaste could provide rapid treatment of dentin hypersensitivity by occluding of the dentinal tubules.
Financial support and sponsorship
Conflicts of interest
The authors declare that there is are no conflict of interest.
Ethical policy and Institutional Review board statement
The ethical issues of this trial were reviewed and approved by the Research Ethics Committee (REC), Faculty of Dentistry, Cairo University (Ref. 15721). Informed consent was obtained from all participants. Participants were given freedom to withdraw from the trial at any point. Appliances were planned to be removed when there were any signs of discomfort or pain.
Patient declaration of consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
The data that support the findings of this study are available from the corresponding author, upon reasonable request.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]