CE Questions The answer sheet and further instructions are located on the tear-out card that appears on page 37, or take the test online at dimensionsofdentalhygiene.com. 1. In the ensuing years after 1945, what percentage of the United States population gained access to publicly fluoridated water? A. 65% B. 71% C. 74% D. 82% 2. In recent years, a complementary approach has taken root that focuses on the treatment of caries as a disease process, not just as the end point of a disease. True False 3. Fill in the blank: A key tenet of caries management relies on healing enamel and dentin at a stage where mechanical repair is not yet necessary; this involves the concept of _______. A. Calcification B. Remineralization C. Demineralization D. Obturation 4. Enamel structure is composed of approximately what percentage of inorganic material? A. 1% B. 3% C. 69% D. 96% 5. A caries lesion develops when the demineralization/remineralization cycle shifts toward demineralization, which is a natural destructive process of which type of crystal? A. Alkasite B. Hydroxyapatite C. Enamel pellicle D. A and C 6. At which critical pH initiation level will enamel start to demineralize? A. 6.0 B. 5.8 C. 5.5 D. 5.1 7. Dentin begins to demineralize when oral pH reaches what levels? A. 5.1 to 5.9 B. 5.7 to 5.8 C. 6. 1 to 6.3 D. 6.2 to 6.4 8. Which of the following materials was developed as a bulk-fill bioactive restorative capable of releasing fluoride, calcium and hydroxyl ions to support remineralization? A. Alkasite B. Lithium disilicate C. Amalgam D. Zirconia 9. A systematic review concluded that sodium fluoride has a proven track record in remineralizing enamel caries, and silver diamine fluoride effectively arrests dentinal caries. True False 10. Through the process of biomimetic remineralization, which proteins are being studied to not just repair enamel, but also regenerate lost tooth structure? A. Dentin phosphoprotein peptides B. Amelogenin C. Poly(amidoamine) dendrimers D. All of the above SECTION 1 SECTION 2 SECTION 3 Future Trends One promising area of remineralization research involves the use of proteins to not just repair enamel, but also regenerate lost tooth structure. These materials work through the process termed biomimetic remineralization, and include dentin phosphoprotein peptides, self- assembling P11-4 peptides, amelogenin, and poly(amidoamine) dendrimers.11 They are included in toothpastes, gels, and rinses. These agents demonstrate some ability to regenerate enamel in vitro, but more research is needed to prove their clinical efficacy. Synthetic nanohy- droxyapatite (nHa) is a biocompatible and bioactive material that has been used since the 1980s in toothpastes and rinses. Experiments using this compound show comparable and sometimes superior results to fluoride therapy as far as remineralization. Some researchers pro- pose that nHa promotes remineralization through deposition of new enamel, while others suggest remineralization is due to the presence of a supersaturated solution of calcium and phosphate. More clinical evidence is needed to prove the superior efficacy of nHa to fluoride. An additional area of research focuses on fluoride boosters. These solutions are based on varying compositions of calcium and phosphate and are included in toothpastes and chewing gum. This class of products includes CPP-ACP, functionalized beta-tricalcium phosphate, calcium sodium phosphosilicate, and ACP. Some have been used for years, but evidence of clinical effec- tiveness varies widely.12 Evidence that supports other calcium phosphate solutions is also either weak or demonstrates limited clinical applicability.11 Clearly, further research is indicated. Sodium trimetaphosphate (STMP) is an additional phosphate solution under investigation. This solution has been added to dentifrices to partly replace fluoride. Recent research demonstrates that a dentifrice and varnish containing STMP and fluoride were superior to a standard fluoride dentifrice and varnish in reducing caries activity.13,14 Again, more research is needed to demon- strate efficacy in the remineralization of early lesions.11 Summary The gold standard for effective remineralization continues to be agents designed to increase the availability of calcium, phosphate and fluoride at the right time and at the right pH. Products contain- ing these compounds have been proven to work clinically, but, like so much in dentistry, they are dependent on several factors to work effectively — most importantly, patient cooperation. The science of dentistry is clear: remineralization works. Regenerative therapy may be the Holy Grail of preventive dentistry, however, there is much work to be done to bring useful and proven products to market. The Global Burden of Disease Study (1990–2010) reported that “oral diseases affect 3.9 billion people worldwide and untreated tooth decay affects almost half of the world’s population (44%), making it the most prevalent of the 291 conditions included in this study.”15 Many of these lesions are beyond the scope of remineralization as described in this paper. However, this does not limit the effectives of remineralization therapy. There is a subset of this population that presents with smooth surface lesions at various stages of development. Practitioners must identify patients who can benefit from this therapy, and initiate treatment as early as possible. When used properly in the younger patient, this can lead to a lifetime of improved oral health and help break the cycle of rerestoration. Dental professionals have always promoted the value of prevention. And while great strides have been made in caries restoration techniques, researchers need to accelerate efforts to understand the mechanisms of the disease process and search for novel techniques and materials that enhance remineralization — and, if possible, regeneration. Clinicians must also utilize the materials currently available to treat the disease and not just its symptoms. That said, the use of any clinical approach must be based in a fundamental understand- ing of the cause of the underlying condition — and the science that dictates how the disease process might best be alleviated. The references that accompany this article appear with the web version at dimensionsofdentalhygiene.com. D SECTION 3 dimensionsofdentalhygiene.com January/February 2024 • Dimensions OF DENTAL HYGIENE 45
