COMPARATIVE EVALUATION OF EFFICACY OF FOUR DIFFERENT ...
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COMPARATIVE EVALUATION OF EFFICACY OF
FOUR DIFFERENT INTERVENTIONAL METHODS
ON SALIVARY pH AFTER AN ACIDIC SURGE
Dissertation Submitted to
THE TAMILNADU Dr. M.G.R. MEDICAL
UNIVERSITY
In Partial Fulfillment for the Degree of
MASTER OF DENTAL SURGERY
BRANCH VIII
PAEDODONTICS AND PREVENTIVE DENTISTRY
APRIL 2016
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ACKNOWLEDGMENT
The very first person, I would like to thank is my dedicated, eminent,
guide and mentor, Prof and H.O.D.,Dr.M.JAYANTHI, MDS.,whose guidance
filled me with wisdom and passion over dentistry, her down to earth
personality and simplicity is a very rare holding. Her brassbound as well as
liberal poise towards training us has changed us in many ways; has made us
to check the depth of our inventiveness and originality and she has always
been an immense support for our fascination over clinical, theoretical and
research oriented progress. My education would not be comprehensively
intact without her invaluable erudition and sound judgment. My deepest and
sincere thanks will not be adequately sufficient for all the righteousness and
virtue she has instilled in me.
I also profoundly express my sincere thanks to Dr.NILAYA
REDDY,MDS., DNB., an eminent, enlightened Professor, for her
extraordinary support and consistent encouragement throughout the course of
study and mainly for acquiring self-confidence and excellency in clinical
work, during my post-graduation. Her ultra-practicable mode of tutelage has
helped me greatly in thinking out of the box.
Special thanks to Dr.S.RAMACHANDRAN,MDS., Principal and
DR.AZHAGARASEN, MDS., Vice principal, for providing me with an
opportunity to utilize the facilities in their reputed and esteemed institution.
I would also like to express my heartfelt gratitude to Dr.Vijayaprabha,
MDS.,Dr. Sakthivel, MDS.,Dr. Poornima, MDS.,, Readers, Dr. Arun
Elangovan MDS, senior lecturer for their steadfast encouragement/guidance
during my post-graduation and teaching me the importance of patience and
love and care towards patients.
I am also thankful to former faculty memberDr. Girija, MDS.,for her
help and support during the first half of my post-graduation program.
I am thankful for my co-P.G. Dr.R.P.Ramadevi, who was such a large
part of my P.G. life. Her support and friendship was constant during these last
years, and I deeply appreciate it.
I would like to express my sincere thanks to my fellow postgraduate
colleagues, Dr.Porselvi, Dr.Madhan, Dr.Deebiga, Dr.Keerthi, Dr.Devi
Chandrikafortheir encouragement throughout my studies and postgraduate
course. Special thanks to Dr.Bhuvanesswari, for being a friend more than a
colleague and helping me out whenever I was down and confused.
My Dad MR.KARTHIGEYAN, MomMRS.GEETHALAKSHMI and
my family members have stood unwaveringly behind me at all times. I
wouldn’t be here if they were not supportive in part and parcel of my post
graduation. There were times when I needed them most and they were there as
stanchions helping me with the herculean job. I take this opportunity to
acknowledge them for their unconditional love and support. Words really do
not express gratitude. I would like to dedicate my work to my family who never
gave a second thought in allowing me pursue my dreams.
I would like to mention a special thanks to the non-teaching staffs, who
helped me on clinical side to provide good treatment for patients. My post
graduation wouldn’t be complete if I don’t thank my patients who helped me
gain knowledge and showed me the newer perspectives of my life.
Above all, my greatest thanks belong to God, for sheltering and
standing by me despite everything and making my life joyful and complete. I
owe everything to the Almighty.
“CARPE DIEM”
CONTENTS
S.NO. TITLE PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 5
3. REVIEW OF LITERATURE 6
4. MATERIALS AND METHODS 35
5. RESULTS 40
6. DISCUSSION 43
7. CONCLUSION 49
8. SUMMARY 51
9. BIBLIOGRAPHY 53
10. ANNEXURES
LIST OF TABLES
TABLE
NO.
TITLE PAGE NO.
1.
MEAN VALUES OF THE pH CHANGES IN SALIVA AFTER
SUGAR EXPOSURE AND AFTER VARIOUS
INTERVENTIONAL METHODS
2.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA
AFTER SUGAR EXPOSURE AND AFTER WATER RINSING
AND BRUSHING WITH WATER
3.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA
AFTER SUGAR EXPOSURE WITH BRUSHING WITH WATER
AND BRUSHING WITH NON-FLUORIDATED DENTIFRICE
4.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA
AFTER SUGAR EXPOSURE WITH WATER RINSING
BRUSHING WITH FLUORIDATED DENTIFRICE AND
BRUSHING WITH NON-FLUORIDATED DENTIFRICE
5.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA
AFTER SUGAR EXPOSURE AND BRUSHING WITH NON-
FLUORIDATED AND BRUSHING WITH FLUORIDATED
DENTIFRICE
LIST OF GRAPHS
GRAPH
NO. TITLE PAGE NO.
1. GRAPH DEPICTING MEAN VALUES OF THE PH
CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND
AFTER VARIOUS INTERVENTIONAL METHODS
2. GRAPH DEPICTING MEAN VALUES OF THE PH
CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND
AFTER WATER RINSING
3. GRAPH DEPICTING MEAN VALUES OF THE PH
CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND
AFTER BRUSHING WITH WATER
4. GRAPH DEPICTING MEAN VALUES OF THE PH
CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND
AFTER BRUSHING WITH NON-FLUORIDATED
DENTIFRICE
5. GRAPH DEPICTING MEAN VALUES OF THE PH
CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND
AFTER BRUSHING WITH FLUORIDATED DENTIFRICE
LIST OF FIGURES
FIGURE
NO. TITLE PAGE NO.
1. ARMAMENTARIUM (FOR SCREENING)
2. ARMAMENTARIUM (FOR EXPERIMENTAL PART)
3. SCREENING PATIENTS BASED ON INLCUSION
CRITERIA
4. CHILDREN GIVEN APPLE JUICE TO RECORD FALL
IN THE SALIVARY pH
5. CHILDREN ASKED TO FOLLOW INTERVENTIONAL
METHOD
6. COLLECTION OF SALIVA AFTER INTERVENTIONAL
METHOD
7. MEASURING PH USING COLOUR CODED PH STRIPS
LIST OF ANNEXURES
S.NO. TITLE
I SCREENING FORM
II MASTER SHEET
III CONSENT FORM- ENGLISH
IV CONSENT FORM – TAMIL
V INSTITUTIONAL REVIEW BOARD APPROVAL CERTIFICATE
Introduction
Introduction
1
INTRODUCTION
Dental caries is a significant public dental health problem affecting 60-
90% of school children in developed countries1 (WHO, 2003). The changing
dietary habits with modernization haveleadto an increase in consumption of
sugared items in diet which is directly responsible for the increased prevalence
of dental caries.
The extensive study material available on dental caries has made clear
that it is a multifactorial disease and the interface between the saliva and oral
tissues is the site of many dynamic reactions which affects both the soft tissues
and hard tissues of the mouth. Saliva provides this physiologic environment
where the complex interactions between the agents, host and the environment
occurs. The salivary parameters which affect the enamel stability in the oral
environment are pH of saliva, salivary flow rate, oral clearance, concentrations
of calcium, phosphate & fluoride and salivary levels of microorganisms.The
research work by Stephan in 1940’s showed that the pH decrease was
inversely and clearly related to dental caries activity. The more basic the pH of
the saliva more is the reminerlization of tooth surface by precipitation of
bicarbonate ions. The pH at which the saliva ceases to be saturated is referred
to as “critical pH” (5.0 to 5.5) and below this value, the inorganic components
of the teeth may dissolve in it. As the demineralization progresses so will the
carious lesion leading to the loss of tooth structure2. The study by Anderson et
al proved that the decreased concentration of calcium and phosphate ions in
Introduction
2
primary teeth enamel predisposes them for faster demineralization and also at
a higher salivary pH.3
The continuous failure of attempts to quit dietary sugar intake in
children had lead to the reconsideration of the key role of the buffering action
of salivary pH against the caries and the changing paradigms of caries
intervention. Some of the interventional methods act locally whereas others
act systemically. The salivary pH being an important biomarker for dental
caries, the ideal intervention should be targeted towards the maintenance of
salivarypH. Preventive strategies are considered as top priority in dental health
program for the high-risk individuals. Some of the most commonly practiced
preventive strategies are water rinsing, brushing, tooth powder, fluoridated and
non-fluoridated tooth pastes, mouth washes,sugar free chewing gums,
systemic water fluoridation, pit and fissure sealants and professionally applied
topical fluoride formulations. Among all the methods, the most childfriendly
and daily applicable method is brushing with a dentifrice.
Water rinsing after meals has been advised universally as it has
property of reducing salivary pH after a pH challenge4(Elen De Souza
Tolentino) but on the contrary study by Mirjalili has proved that it is no
superior to brushing and chewing sugar free gums5.
Tooth brushing alone without dentifrice was found to be beneficial to
the teeth by increasing both salivary ph and salivary flow rate6 (A J M
Ligtenberg). On the contrary a study conducted by Mirjalili et al concluded
Introduction
3
that brushing without dentifrice was not so effective in bringing about the
desired positive change in pH following a sugar exposure5. Studies have
shown that maintenance of oral hygiene with brushing is influenced by
multiple variables, as shown in different studies: no. of bristles, thickness of
bristles, brushing technique, etc.
On the other hand use of dentifrices along with brushing was seen to
be beneficial in increasing the salivary pH7 (Chand et al), and in decreasing
the microbiological load in plaque8,9,10,11,12
(JOkpalugo, Surdacka, Sudhapatil,
Rahul Deshpande, Wafa K.M. Talha). But in areview by Burt, it was noted
that the suggested upper limit of fluoride intake is being reached in many
children by ingestion of fluoride from dentifrices13
. The alkaline pH of
toothpastes helps neutralize the salivary acids which cause tooth decay;
whereas very little documentary evidence supporting this fact is available.
School environment mandates short break times and quick
meals and since children spend most of the time at schools, the possibility of
brushing after every meal or snack may not be practically feasible. Since water
rinsing can wash large food particles and dilute oral contents, it appears to be a
logical emergency substitute for brushing teeth. Although not based on any
reliable data, most clinicians encourage patients to swish and swift with water
whenever tooth brushing is not possible. Hence the present study was
undertaken to compare the efficacy of water rinsing, brushing without
Introduction
4
dentifrice, brushing with non-fluoridated dentifrice and brushing with
fluoridated dentifrice in maintaining the salivary pH following an acidic surge.
Aims and objectives
Aims and Objectives
5
AIMS AND OBJECTIVES
1. To evaluate the efficacy of water rinsing as an interventional method
on the salivary pH after an acidic surge
2. To evaluate the efficacy of brushing with water as an interventional
method on the salivary pH after an acidic surge
3. To evaluate the efficacy of brushing with non-fluoridated dentifrice as
an interventional method on the salivary pH after an acidic surge
4. To evaluate the efficacy of brushing with fluoridated dentifrice as an
interventional method on the salivary pH after an acidic surge
5. To evaluate and compare the efficacy of four interventional methods
(water rinsing, brushing with water, brushing with non-fluoridated
dentifrice and brushing with fluoridated dentifrice) on the salivary pH
after an acidic surge.
Review of Literature
Review of Literature
6
REVIEW OF LITERATURE
Zimmer S, Didner B, Roulet J.F conducted a study to evaluate the
efficacy of triple headed tooth brush on plaque removal. Thirty healthy
volunteers, aged 6–60 years, participated in this single blind cross-over study.
They were randomly assigned to 3 groups (A, B, C) with 12 participants each.
To obtain a plaque-free condition at the baseline, professional tooth cleaning
was performed in each participant. After instructions on how to use the
toothbrushes, each group started the experiment with a different type of
toothbrush. After 1 week of application, the Quigley-Hein plaque index (QHI)
and the proximal plaque index (API) were used to assess the oral hygiene
status of each participant. This was followed by 1 week of recess before each
group switched to the next type of toothbrush. The duration of the study was 5
weeks. All examinations were performed by a single examiner. Compared to
the 2 other brushes, the Superbrush was more effective in removing plaque
(medians of QHI: 0.84 versus 1.56 (Elmex) and 1.56 (Braun); p<0.001;
medians of API: 0.69 versus 0.94 (Elmex) and 0.87 (Braun); p<0.001). The
study indicated that the triple headed design of toothbrush may be an effective
alternative to commonly used toothbrushes.14
Davies, Worthington et al (2002) conducted a study to check the
efficiency of fluoride dentifrice on reducing dental caries in 5-6 yr old
children. 7,422 children were randomly assigned to one of the 2 groups:
group1 (dentifrice containing 440ppm of fluoride; Colgate gel 0-6 years)
Review of Literature
7
group2 (dentifrice containing 1450ppm fluoride, Colgate regular). Free
toothpastes were given to children of age 12 months based on the group and
were reviewed at three monthly intervals and were asked to use the dentifrice
up to the age of 5-6years. At the end of the study 3731 children remained as
the study population and the efficacy was measured based on the dmft index.
Thus there was 16% reduction of caries experience in high fluoride group
(1450ppm fluoride) (p<0.05). The study concluded that the use of high
fluoride dentifrice reduces caries in kids residing in fluoride deprived areas.15
McCracken GI, Janssen J, Swan M, Steen N, de Jager M,
Heasman PA. et al (2003) conducted a randomised, single-blind, 16-cell,
cross-over trial to compare the efficacy of plaque removal capacity of a
powered toothbrush (PTB) used with four brushing forces (75, 150, 225 and
300 g) and over four brushing times (30, 60,120 and 180 s). Twelve volunteers
(18–30 years) were recruited and trained to use the powered tooth brush. Each
subject was asked to abstain from all oral hygiene procedures for 24 hrs prior
to each brushing event, to allow plaque accumulation. Plaque was recorded
using a modified Quigley & Hein index (PI) at six points per tooth before and
after each episode of brushing, and the differences in the means (pre- to post-
brushing) were compared. Three-way ANOVA was undertaken to compare
differences between plaque-removing efficacy for the 16 combinations of
force and time. All 12 subjects participating completed the 16 combinations of
force and time over which plaque removal was assessed. Subjects, brushing
Review of Literature
8
time and brushing force were used as fixed effects within the analysis. The
study results showed statistically significant differences in PI reductions were
found between different brushing times and forces over all tooth surfaces
(p<0.001). The interaction of varying brushing force and brushing time was
significant for full mouth (FM) and interproximal (IP) sites (p=0.03). No
statistical significance was demonstrated for smooth surface (SS) sites, nor
was it detected for the interaction of subjects with brushing force or subjects
with brushing time (p=0.05). The study concluded that brushing time and
brushing force have significant effects upon the level of plaque removal by a
PTB, and at 120 s brushing time the improvement in plaque removal with
forces in excess of 150 g was negligible.16
Sirosiri Taweboon, Boonyarit Thaweboon et al (2004) conducted a
study to determine the levels of secretory IgA (sIgA), salivary pH, salivary
flow and mutans streptococci and candida levels in saliva of children with
rampant caries compared to those who were caries free. Thirty children, aged
62 to 123 months were selected for this study and were classified under 2
groups caries free and rampant caries group (children with >5 cavities (or) >10
surfaces involved). Children with cooperative ability, normal growth and
development absence of congenital or systemic diseases, absence of any dental
abscesses, absence of any medication therapy, no infection 3 months prior to
experiment were included in this study. Each child was instructed not to eat or
drink anything for 2 hours before appointment. Whole saliva was stimulated
and collected for 5 minutes. Salivary pH was determined using microelectrode
Review of Literature
9
pH meter. The results of the study concluded that there was increased sIgA
concentration in rampant caries group when compared to non- carious group.
Children with rampant caries had salivary pH of 6.59±0.32 whereas children
without caries had a mean value of 7.08±0.13. Salivary flow rates were similar
in both the groups. There was significant increase in the MS levels in rampant
caries group when compared to that of non carious group (p<0.05). The study
concluded that rampant caries was attributed to the increased MS count and
candida counts and also because of increased salivary pH whereas salivary
flow rate did not have any influence on the presence of caries.17
Stookey, Man et al (2004) conducted a study to compare and evaluate
the anticaries effectiveness of three fluoride containing dentifrices. The three
different toothpastes used for this study were low-dose fluoride (500ppm F,
low NaF group), high dose (2800 ppm F, high NaF group) and an
experimental 0.454% stabilized stannous fluoride (1100 ppm F) with sodium
hexametaphosphate (SnF2 – HMP group) and each was compared to relatively
normal sodium fluoride dentifrice (positive control). 955 individuals of mean
age 10.6 years (9-12 years) were randomly assigned to one of the four groups.
Two calibrated examiners were asked to check for the baseline status by visual
and tactile observation of caries as DMFS which was also supplemented by
radiographs at the baseline, 12 months and 24 months for each subject. At the
end of the two year period, considering that all individuals at least attended
60% of supervised brushing sessions, the study results showed that
Review of Literature
10
significantly less caries was observed in high- NaF group compared to that of
control group. The study concluded that there was no increase in caries in all
these groups but the caries experience significantly decreased in SnF2-HMP
than the control group.18
Surdacka A, Stopa J (2005) conducted a study to evaluate the effect
of xylitol on oral cavity environment. The tests were carried out on 34 students
who were divided into 2 groups: A and B with 17 students in each group. The
initial clinical examination was carried out after 2 and 4 months of brushing
teeth with fluoride toothpaste with xylitol (group A) and fluoride toothpaste
without xylitol (group B). Clinical examination related to the evaluation of the
hygienic condition of the mouth, plaque index (PLI) and hygiene index (HI),
gingival index (GI), and gingival bleeding index (GBI) and Decayed Missing
Filled Teeth (DMF-t) and Decayed Missing Filled Surfaces (DMF-s) was
performed. 10 people from each group underwent a test on saliva secretion
focusing on the number of S.mutans (SM) and L.acidophilus (LB). The
parameters that were checked were salivary pH, as well as the amount of
saliva and the level of fluoride in saliva. No significant differences in the
tested parameters were observed between the two groups. The results of the
tests after 2 and 4 months of using both toothpastes pointed out the
improvement of the hygienic condition of the mouth and gums. The study
concluded that tooth paste with xylitol had influence on the decrease of the
number of S.mutans in saliva, the amount of secreted saliva and the increase
Review of Literature
11
of pH value. The use of toothpaste with xylitol as well as without xylitol
caused the increase of mean values of fluoride in saliva. Xylitol added to the
toothpastes has a positive influence on the quality of the oral environment.9
Arnold W, Andreas Dorow et al (2006) conducted a study to check
the efficacy of four fluoride tooth pastes on enamel demineralization. Ninety
human premolars were demineralized in a pH of 4.8 (3x3mm window was
created). The teeth were divided into 6 groups and the lower half of the
window was covered with varnish serving as control. The teeth were
immersed in a tooth paste slurry containing the tooth paste based on the group;
Group 1 (placebo tooth paste), Group 2 (Remineralisation solution), Group 3
(Elemen Anti caries tooth paste), Group 4 (Elemen sensitive), Group 5 (Blend
– a med complete), Group 6 (colgate GRF). Ten teeth of each group were used
for the determination of F content in the superficial enamel layer and acid
solubility. Six teeth of each group were evaluated under polarised light
microscopy. The results of the study showed remineralisation of enamel. The
superficial fluoride levels were increased significantly in Elemen groups and
Blend –a – med group (p<0.001).The study concluded that, tooth pastes with
amine also caused remineralistion followed by sodium fluoride and sodium
monoflurophosphate formulations.19
AJM Ligtenberg, HS Brand (2006) conducted a study to evaluate the
change in salivary pH before and after brushing with and without toothpaste.
Review of Literature
12
Eighty healthy volunteers participated in this study; subjects were randomly
distributed with regard to age, history of smoking, and the use of oral
contraceptives and other medication. All subjects were instructed to refrain
from smoking, eating, drinking caffeine-containing beverages and tooth
brushing at least 1 hour prior to the experiment, which took place between
13.00 and 15.00 hours. Unstimulated whole saliva was collected in pre-
weighed tubes for 2 min. Next, the volunteers brushed their teeth according to
the Bass method for 2 min, using a new Lactona IQ soft tip with either water
(22 persons), Elmex mentholfree toothpaste (29 persons), Elmex, anti-caries
toothpaste (13 persons) or Parodontax (16 persons). Immediately after tooth
brushing, toothpaste with residual saliva was expectorated. Thereafter,
collection of saliva was started. Saliva was collected without stimulation for 2
min at 0, 10, 30 and 60 min after tooth brushing. The secretion rates were
determined gravimetrically (1 g ¼ 1 ml) and expressed as mg ml). Salivary pH
was measured with pH indicator strips (4.0–7.0 and 6.5–10.0, Merck,
Darmstadt, Germany). Subsequently, equal volumes of 5 mL HCl and saliva
were mixed and the final pH of this solution was used as an indication of the
buffer capacity (titrated pH). For statistical analysis, repeated measures multi-
analysis of variance was used followed by paired t-tests or independent
samples t-tests where appropriate (SPSS version 10.0: SPSS Inc, Chicago, IL,
USA). Tooth brushing induced transient changes in the salivary flow rate, pH
and buffering capacity. After brushing with water, the salivary secretion rate
increased significantly for 60 min suggesting tooth brushing mechanically
Review of Literature
13
stimulates saliva secretion. When compared with brushing with water, the
secretion rates enhanced significantly after brushing with toothpaste. The
study concluded that one of the beneficial side effects of tooth brushing is an
enhancement of the salivary flow rate what may result in increased oral
clearance. This effect is independent of the gustatory stimulus of the
toothpaste, as tooth brushing with water already results in a significant
increase.6
Hiroshi Sano, Syozinakashima et al 2007 conducted an in vitro
experiment study to evaluate the remineralization effect of a xylitol and
fluoride containing tooth paste on human enamel using four kinds of the
toothpastes formulations were used 1) without sodium fluoride and xylitol
2)with 500ppm of sodium fluoride 3) with 500ppm of sodium fluoride with
xylitol 4) a silica based tooth paste with 500 ppm of sodium .Where artificial
subsurface lesion by deminerlization. The sectioned teeth were randomly
divided into one of 4 groups. The remineralization was done by applying 1.5
ml of tooth paste slurry for 3 min twice a day at 25 degree celcius for 4 hours
daily. The enamel were assessed for degree of remineralization using QLF
acquisition. The results showed no significant difference among the four
treatment groups with respect to their baseline values. The study concluded
that tooth paste containing 500ppm of sodium fluoride and 5 % xylitol
enhances the reminerlization of early caries lesion for 14 days treatment
Review of Literature
14
period compared to tooth paste containing only 500ppm of sodium fluoride
and the other 2 groups.20
Ravi V Shirahatti, Anil V Ankola, L Nagesh (2007) conducted a
study to know the effect of chewing fennel seeds on plaque pH and salivary
pH. Twenty subjects were recruited based on eligibility criteria and were
informed not to use any oral hygiene measures 24 hours prior to appointment.
The resting plaque and salivary pH was measured to record the baseline data.
For measurement of salivary pH 2 ml. of stimulated saliva was taken. The
measurement of the plaque pH was done as follows. The plaque was collected
from buccal surfaces of the designated posterior teeth and pH measured by
pooling the plaque. The collected pooled plaque was thoroughly mixed with
10 milliliters of distilled water and pH determined using a previously
calibrated glass combination electrode. After the subjects chewed seeds for
five minutes resultant plaque and salivary pH were measured again. A third
saliva sample was taken and pH measured five minutes later. The Results
showed a very transient drop in salivary pH on chewing the seeds was
observed (0.56 + 0.46). However plaque pH did not show any significant
change. The study concluded that the drop in pH is not sustained and is
returning to normal limits within five minutes after chewing the seeds
suggesting that the seeds have very little Cariogenic potential.21
Review of Literature
15
Sudha Patil, Karthik Venkataraghavan (2007) conducted a study to
assess the anti-microbial effect of two commercially available toothpastes and
to compare and evaluate the effect of the two toothpastes on Streptococcus
mutans count level. One hundred student participants in the age group of 4-6
years with dmf = 0 were selected. A Baseline saliva sample was taken and
cultured for mutans streptococci, the colonies counted and noted. The 100
participants were randomly divided into two groups with 50 participants in
each group. Group I was provided with Himalaya Herbals Dental cream
containing Neem, Group II was provided with 458 ppm containing fluoride
toothpaste Cheerio gel. The toothpastes and toothbrush were provided over a
period of 5 months for home care use. Instructions were given to the parents
on brushing technique, amount of paste to be used and twice daily brushing
with the pastes, with specific instructions that the child should not use other
toothpastes during these 5 months. The saliva sample was then collected and
streptococcus mutans estimated in 4 phases, 1) 15 days 2) 30 days 3) 90 days
4) 150 days. The results showed that there was a steady decrease in the
bacterial count over a period of 5 months; the overall percentage decrease in
Group I being 90.69% and Group II being 89.69%. However, between the
toothpastes there was no statistically significant difference in the bacterial
count and both the toothpastes were efficacious in reducing the bacterial
count. Hence it was concluded that both Herbal toothpaste containing Neem
and Fluoridated toothpastes are efficacious in combating caries and both can
be used as a regular home care preventive measure in combating caries in
Review of Literature
16
children. The study concluded that both the toothpastes have a good
antimicrobial effect on caries producing salivary streptococcus mutans
bacteria. Toothpastes containing Neem as well as fluoridated toothpaste are
equally efficacious against caries producing bacteria.10
Wafa K. M. Talha , Manal E said in (2008) conducted a study to
compare the effect of Meswak and fluoride and fluoride tooth pastes on the S.
mutans and Lactobacilli count in dental plaque and to compare the effect of
both types of tooth pastes on plaque and salivary pH. Forty children of both
sexes ranging in age 7-9 years with completely erupted first permanent molars
and permanent upper incisors, apparently healthy with no history of systemic
diseases, none of them were under anti microbial agents who had DMF
ranging from 4-8 were included in the study. All patients were instructed to
brush twice daily, refrain from any other oral hygiene procedures and continue
their dietary routine throughout the study. Pooled plaque samples were
collected from buccal surface of incisors and the salivary collection was done
by asking the patient to expectorate unstimulated (resting) saliva over 10
minutes. A portable pH meter was used to analyze the salivary pH. There was
significant pH change in the Meswak group whereas the fluoride group did not
show any change (significant) (p=0.033) (0.063). There was no difference in
salivary pH in both Meswak and fluoride group (p-0.688 and p-0.834). There
was significant decrease in S.mutans CFU in fluoridated group (p-0.026). The
study concluded that both tooth pastes have good antimicrobial effect but
Review of Literature
17
fluoridated group had a higher decrease in CFU. Whereas Meswak toothpaste
raised plaque pH suggesting a positive role in the reduction and prevention of
dental caries.12
M.T. Kato, M.Lancia et al (2009) conducted an in-vitro study to
evaluate the preventive effect of commercial desensitising tooth paste on
Bovine enamel against erosions. One hundred Bovine teeth were prepared as
blocks which were randomly allocated into 5 groups (20 in each group).
Group 1; Sensodyne pro enamel (1,425 ppm fluoride and 5% KNO3), Group
2; Sensodyne original (no fluoride 10% Srcl2), colgate sensitive (1,450 ppm
sodium monofluoride phosphate, 5%KNO3) crest (fluoride only tooth paste
(1,100 ppm of NaF) and water (Negative control). All the experimental teeth
blocks were exposed to four cycles of alternating demineralisation (cola, 10
min) and mineralisation (artificial saliva 1 hr). Before and between the cycles
of demineralisation and remineralisation the teeth were treated with tooth
paste slurries or negative control (water) for 1 min duration. The erosive tissue
loss was analyzed by profilometry. The results showed that the mean erosive
depth was significantly less for colgate sensitive (0.04+-0.00) followed by
sensodyne original (0.06+_0.01) and crest (0.07+_0.01) than that of sensodyne
proenamel (2.36+_0.25) or water (2.92+_0.24). The study concluded that the
tooth pastes that contained both fluoride and desensitising agents reduced
enamel erosion but they did not have an additive effect. In addition the study
concluded that, combination of KNO3 and F did not reduce the erosion.22
Review of Literature
18
J.Okpalugo, k Ibrahim et al (2009) conducted a study to evaluate the
effectiveness of seven branded tooth paste formulations in reducing oral flora.
seven brands of tooth pastes were selected for the study .two contained
triclosan too4 and too6, four contained fluoride, too1, too2, too5 and too7 and
one tooth paste and herbal too3, all the tooth paste brands were assessed for
their microbial load after which each individual used the tooth paste 12 hourly
on three consecutive occasion as the only oral hygiene measure . After the
procedure the saliva was collected and were cultured on agar plate using pour
technique analysis of microbial load showed that tooth paste containing two
antibacterials (sodium fluoride+ triclosan) had more reduction in antibacterial
load than non – triclosan containing tooth paste (P=0.009).8
Preethi BP, Maitreyee D.S, Dodawood R (2010) conducted a study
to estimate the endogenous pH and titrable acidity of fruit juices and assessed
their effect on the pH of the plaque in carious and non-carious groups. Twenty
four volunteers aged 20-30 years were divided into carious groups (DMFT<3)
NM carious group(DMFT=0) and were randomly allocated in one of the four
fruit juices group (freshly prepared apple juice, freshly prepared sweet lime
juice, ready to drink frooti, ready to drink pulpy orange group). Plaque pH was
collected at baseline and at 1, 5, 10, 15, 30 mm after consumption of fruit
juices and was assessed using PH meter. The results of the study showed that
the PH of frooti, apple, pulpy orange and sweet lime was found to be 3.43,
4.52, 2.31 and 3.76 respectively. The study concluded that ready to drink fruit
Review of Literature
19
juices have more acidic nature when compared to that of freshly prepared fruit
juices which has more cariogenic potential especially for the caries active
group.23
M. Ribelles Llop, F. Guinot Jimeno (2010) conducted a study to
compare variations in salivary flow rate, pH, buffering capacity and levels of
Streptococcus mutans in baseline conditions and after chewing paraffin pellets
or xylitol chewing gum in children between the ages of 6 and 12 years who eat
lunch in a school canteen. The study sample consisted of 90 children divided
into 2 study groups, and a control group. The baseline data was recorded in the
first phase soon after the lunch and were compared with the data recorded in
the second phase, after 15 minutes of chewing xylitol-sweetened chewing
gums or paraffin pellets, depending on the study group. Salivary flow rate was
measured by collecting the stimulated saliva in a graduated beaker. Levels of
pH were measured using a Cyberscan pH 110 pH meter (Eutech
Instruments®). Buffer strips and the CRT bacteria test (Ivoclar-Vivadent) was
used to measure buffering capacity and levels of S. mutans, respectively. The
data obtained after sample collection were compared by means of a 1-way
analysis of variance using the StatGraphics Plus statistical software package,
version 5.0. Statistically significant differences were found (p <.05) when pH,
buffering capacity and levels of S. mutans were compared between the 3
groups. Comparison of salivary flow rates revealed no statistically significant
differences (p >.05), though salivary flow rates were higher in the groups
Review of Literature
20
where gum was chewed. The study concluded that the effect of chewing is
essential to the stimulation of salivary flow and the resulting recovery of pH
levels and reduction of levels of S.mutans in saliva.24
Updesh Masih, Manisha Prabhakar, et al (2010) conducted a study
to compare the human plaque pH changes after consumption of milk and
infant milk formulae. Thirty school going children of age group 8 – 12 years
with dmft/DMFT<3 who were free of any dental or systemic problems. All the
children were given oral prophylaxis followed by which they were abstained
from oral hygiene measures for to ensure uniform plaque accumulation.
Baseline plaque samples were collected followed by which they were told to
swish for 40 sec and either spit or swallow the milk formulae based on their
convenience. Plaque samples were taken from teeth no 46, 44/84, 36, 34/74
at 5, 10, 20 and 30 min interval respectively. The children were again asked to
report after 5 days and the entire experiment was repeated except for the milk
formulae that were changed. The study confirmed that all milk formulae can
be recommended for diet counseling but lactodex 2 gave better result pH -
6.487 ±0.142 than lactogen – 6.323±0.131 and amul spray pH – 6.o24
±0.3130.25
Apiwan Smutkeeree, Norawan Rojlakkanawong & Veeritta
Yimcharoen (2011) conducted a study to compare the efficacy between the
horizontal scrub and modified Bass methods in visually impaired students.
Review of Literature
21
Sixty visually impaired students, aged 10–12 years, were recruited to a
randomized controlled clinical trial. At baseline, plaque index (PI) and
gingival index (GI) were assessed, and then subjects were randomly divided
into the horizontal Scrub and modified Bass groups. Subjects received verbal
and tactile tooth brushing instruction and used their assigned methods twice
daily. They were recalled at 1 and 6 months for clinical measurement and
reinforce of instruction. Significance of plaque index and gingival index over
time was compared using the paired t-test and between brushing group at each
time point using the t-test. The study results showed that over the 6-month
period, there were significant reductions from baseline for the mean PI and GI
in both groups (P < 0.001). There were no significant differences between two
methods at each time point (P > 0.05).the study concluded that both the
horizontal Scrub and modified Bass methods can be effectively reduced
plaque index and gingival index in visually impaired students. The efficacy of
both methods was not different.26
Elen de Souza Tolentino, Luiz Eduardo Montenegro Chinellato
(2011) conducted a study to evaluate saliva and tongue coating pH before and
after use of different oral mouthrinses. Fifty patients aged 18 years of both
sexes allocated in 5 groups whose Saliva and tongue coating pH of measured
respectively by a digital pH meter and color pH indicators, Each patient
underwent three collections of saliva samples: at the beginning of the
consultation,30 min after rising (phases before, after, and 30 min, respectively.
Review of Literature
22
The volunteers were randomly divided into 5 different mouthrinses (10
persons in each group): cetilpiridine chloride associated with sodium chloride,
triclosan, enzymatic solution, essential oil and distilled water. Only triclosan
and essential oil increased salivary pH immediately after rising. The difference
in the salivary pH between the groups before and 30 min phases was
significant (p>0.05). The enzymatic solution decreased salivary and tongue
coating pH immediately after rinsing. According to the methodology applied
in this study, it may be concluded that: In a situation of physiological halitosis,
salivary pH tended to be acidic while tongue coating pH tended to be alkaline,
even after the use of mouthrinses; Only triclosan and essential oil mouthrinses
increased salivary pH immediately after rising; The enzymatic solution was
able to decrease saliva and tongue coating pH immediately after rising.4
Sabyachi Saha, Gerdamariahelly Venkatarayappa (2011) checked
the effect of commonly consumed fresh fruit juices and commercially
available fruit juice on pH of saliva at various time intervals. The double –
blinded study was done in 40 volunteers of age group 18 – 20 years , 17 males
– 23 females with DMFT<3. Baseline salivary pH was estimated using digital
pH meter. Volunteers were asked to drink the juices and the salivary pH was
estimated at 1min., 5 min, and 15 min, 30 min after drinking juice. The result
of this study concluded that all the juice causes a fall in salivary pH. Drop in
pH was significant in commercially available juice than freshly prepared juice
p=0.001 after 1 min and p = 0.005 after 5 minutes.27
Review of Literature
23
Kristina Peros et al (2012) conducted a study to evaluate the
antimicrobial effect of different frequencies of brushing with fluoride
dentifrice on the streptococcus mutans and lactobacilli in children undergoing
orthodontic treatment. Twenty two patients scheduled for fixed orthodontic
treatment were divided into two groups with different hygiene regimes.
Group1 (brushed four times daily) and Group2 (brushed twice daily).
Unstipulated saliva was obtained at before placement of appliance and 6, 12
and 18 weeks after placement (i.e during therapy). The results showed that the
salivary streptococcus mutans were significantly reduced throughout the
experimental period in the group that brushed four times a day (p<0.05).
However they had little effect on lactobacillus population. The study
concluded that brushing with 0.32% NaF decreased the salivary mutans
streptococci significantly.28
Malgorzata Klukowska, Juliem Grender, Hans Timm (2012)
conducted a study to determine the effectiveness of a new multi-directional
power toothbrush in reducing plaque when compared to a standard manual
toothbrush control in a single brushing design. The study was a randomized,
replicate use, single-brushing, two-treatment, four-period, examiner-blinded
crossover clinical trial at a single center. Qualified subjects entered an
acclimation phase, after which they were randomly assigned to one of four
treatment sequences specifying the order of use of the two test toothbrushes: a
Review of Literature
24
novel multi-directional power toothbrush with a 2-D drive and an American
Dental Association (ADA) reference soft manual brush. Subjects used each
brush twice over the course of the trial. At each of the four period visits, after
abstaining from oral hygiene for 24 hours, participants received a baseline
(pre-brushing) Turesky Modification of the Quigley-Hein Plaque Index
(TMQHPI) examination. They then brushed under supervision with the brush
assigned for that period for 2 minutes (multi-directional power brush) or as
customary (manual brush control). Subjects were then re-examined for
TMQHPI post-brushing to determine the plaque removal efficacy of the
respective brushes. A washout phase of 2-5 days separated treatment periods.
TMQHPI scores were averaged on a per-subject basis, and analyzed using a
mixed model analysis of covariance for a crossover design. The study results
showed that both the multi-directional power and manual control brushes
produced statistically significant mean whole mouth TMQHPI plaque
reductions compared to baseline (P< 0.001). Comparing the brushes, the
power brush provided a 7.9% significantly superior mean whole mouth plaque
reduction relative to the manual brush control (P= 0.003). The study
concluded that both the brushes performed well in plaque removal capacity
but the powered brush was superior when compared to that of manual brush.29
Chand S, Gulati P, Dhingra S conducted a study to estimate the pH
of commercially available dentifrices and evaluating its effect on salivary pH
after brushing. 60 study subjects were selected and were divided into 12
Review of Literature
25
groups (each group comprises of 5 subjects). The salivary pH was directly
estimated using the digital pH meter calibrated using buffers of pH 4, 7 and 9.
Paired t test was used to compare the changes in the mean salivary pH after
brushing in each group. One way ANOVA and Tukey’s test was used to
compare the changes in mean salivary pH after brushing between different
groups. The results showed that the pH of different types of commercially
available dentifrices which were used in the study was found to be 8.4, 7.9,
7.9, 6.7, 7.2, 8.3, 8.4, 7.1, 6.5, 5.6, 8.2 and 6.5 respectively. Difference in
mean salivary pH after brushing was found to be statistically significant for
Colgate, Neem active group, Vicco, Triguard, Colgate active salt, Dabur,
Meswak, Dabur Babool, Close-up active gel, RA Thermoseal, Daburlal
Dantmanjan, Colgate powder groups. Mean salivary pH (before and after
brushing) between study groups showed a statistically significant difference.
The study found a statistically significant affect of pH of these dentifrices on
the salivary pH as it was found that there was significant increase in mean
salivary pH of study subjects after brushing with various dentifrices (P<0.05)
except for MDH Dantmanjan dentifrice(P>0.05). The study concluded that the
pH of saliva increases after brushing in each commercially available dentifrice
group.7
Isha Goel, S. Nawit et al (2013) conducted a study to assess the effect
of carbonated drink and fruit juice on salivary pH in children. Thirty nine
children of age group 8-12 years were included in this study who were free of
Review of Literature
26
any systemic diseases and whose dmft/ DMFT index was <2. The base line
salivary pH was determined from unstimulated saliva, followed by which the
children were asked to take carbonated soft drink (Mirinda) on the first day
and fruit juice (Tropicana) on day 2. The base line saliva was taken followed
by salivary samples collected at 5, 10 15 and 30 min. The salivary pH was
determined using a digital pH meter. There was significant fall in pH after
intake of carbonated drink when compared to fruit juice group (0.579+0.136
mean difference; p<0.001). The study concluded that the regular use of such
drinks should be discouraged as it may cause dental erosions and also caries in
children.30
P. Moeiny, N. Shafizadeh, SH. Biabani, F. Raofie, MJ. Kharazifard
conducted a study to evaluate the efficacy of three fruit juices on plaque pH.
In this randomized clinical trial, 10 healthy dental students were selected
based on the inclusion criteria namely the amount of streptococcus mutans and
lactobacillus in the saliva, salivary secretion rate, buffering capacity of saliva,
absence of active dental caries, absence of systemic disease and etc. Dental
plaque pH in certain areas of the 4 mouth quadrants was measured by 5
MetroHM microelectrode and digital pH meter before and 2 to 60 minutes
after the consumption of Children orange juice, orange nectar with pulp,
pineapple nectar and 10% sucrose solution. The pH curve at different time
points was then drawn for each product. Data were analyzed statistically by
repeated measures ANOVA (P<0.05).The maximum drop in plaque pH
Review of Literature
27
occurred 2 minutes after consumption. The time spent below the critical pH
was the longest for orange nectar with pulp (10.75 ±2.24) and shortest for
pineapple nectar (3.46 ± 1.14) .At sixty minutes of study, plaque pH returned
to its baseline value after consumption of all fruit juices except for orange
nectar with pulp).The study concluded that after consumption of orange nectar
with pulp, the mean plaque pH was significantly lower in comparison to other
juices and the time spent under the critical plaque pH was the longest and the
orange nectar had an increase risk of causing enamel demineralization.31
Priya Subramaniam, Krishna kumar et al (2013) conducted a study
to evaluate the change in salivary pH following use of commonly prescribed
homeopathic medicines in children. Forty five normal and healthy children
were divided into 3 Groups of 15 children each. Group 1 was given a placebo,
Group 2 was given chamomilla and Group 3 was given arsenicum. Each child
was given 2 pellets to be placed under their tongue and allowed to dissolve
completely. Unstimulated salivary samples were collected baseline and
following 5, 15, 30 and 60 minutes of administration. There was significant
reduction in salivary pH at 5, 15 and 30 minutes in chamomilla and arsenicum
Group. (pH- 5.40, 5.16 respectively) (p-0.000). In all groups, salivary pH did
not return to baseline values even after I hr of administration of the
homeopathic pellets. The study concludes that when homeopathic medicines
are given on long duration, they might act as carious acting agents.32
Review of Literature
28
Rokaya D, Manipal S, Bajracharya M (2013) conducted a study to
see the effect of two chewing gums on pH of saliva. Four hundred and forty
five school children of both sexes in Kathmandu were divided into two
groups; sugar-free group (n=222) and sugar-based group (n=223). The pH was
measured with Universal pH indicator at different time intervals; 5 minutes
before meal & 10 minutes after meal. Then 15 minutes after meal each group
were given two different types of chewing gums; sugar-free and sugar-based.
Then the students were allowed to chew for 5 minutes and the pH was
measured, i.e. 20 minutes after meal. In sugar-based group, the mean pH 5
minutes before meal was 6.9484 and the mean pH 10 minutes after meal was
4.8161. In sugar-free group, the mean pH 5 minutes before meal was 6.927
and the mean pH 10 minutes after meal was 4.7927. The mean pH after 20
minutes after meal in sugar-based chewing gum was 8.977 whereas in sugar
free, pH was 9.240. The differences between sugar-free gum and sugar-based
gum groups were analyzed by Student’s T-test at the 5% level of significance.
It shows that, though after using chewing-gums, the pH of saliva raised but
statistically, there was no significant difference between sugar-free and sugar-
based chewing gum groups. The study concluded that the chewing gum
stimulates the pH of saliva which demonstrates the beneficial effects on the
oral health. In this study, there is no significant difference between sugar-free
and sugar-free chewing gum.33
Review of Literature
29
Shikhar Kumar, Suma Sogi H. P., Indushekar K. R. (2013)
conducted a study to evaluate the salivary and dental plaque pH changes after
consumption of sugared and sugar-free (xylitol) chewing gums in children. A
total of thirty school children were selected for this study and were divided
into two equal groups and given both chewing gums for the experiment.
Group A children were subjected to sugared chewing gum (Happydent White
Chewing Gum) and Group B children were subjected to sugar-free chewing
gum (Happydent White Xylit Chewing Gum). The plaque samples were
collected from buccal and palatal surfaces of the maxillary teeth; and buccal
and lingual surfaces of the mandibular teeth with the help of a sterile spoon
excavator. These plaque samples were then dispersed in a test tube containing
double de-ionized distilled water. The dental plaque samples that were
obtained were then subjected to pH measurements. The values displayed
digitally were taken as control values. Then the children were given 1 pellet of
sugared chewing gum to chew for 10 min. After 10 min the chewing gum was
discarded. The saliva and the dental plaque samples were then collected
immediately by the same procedure as mentioned earlier and up to 1 h at a
time interval of 15, 30 and 60 min. Following this, the collected saliva and the
dental plaque samples were subjected to pH measurements. The values
displayed digitally were taken as experimental values. After this, a thorough
oral prophylaxis was done for all the children of Group A. The children were
then given proper oral hygiene instructions and oral hygiene measures were
reinforced in them. Similarly, the above mentioned entire procedure was
Review of Literature
30
carried out in all the selected 15 children of Group B (all the children were
given 1 pellet of sugar-free chewing gum instead of sugared chewing gum).
The pH values were assessed with the help of a pH meter. The results showed
that children consuming the sugar-free (xylitol) chewing gum showed a
marked increase in the pH of saliva and plaque when compared to their
counterpart. All these values had a significant difference of P ≤ 0.0001. The
study concluded that xylitol is a safe all natural sweetener which helps to
reduce tooth decay. It plays a unique role in preventive strategies for better
health.34
Ali Nozari, Faezel Ghaderi, Saced Madadelhi (2014), Conducted a
study to assess the ph change in plaque saliva solutions with four customary
used infants with formulas. Plaque saliva samples were collected from twenty
five children. Infant milk formulas including bebalac 1, nan 1, nan 2, and
aptamil 1 were prepared and added to 4 respective tubes of saliva – plaque
solution , the pH samples were measured at 10 min interval (10 -60 min) at
37 ˚c . All the infant milk formulas caused significant pH drop in all the
samples. The study concluded that Nan 1 and Nan 2 caused decreased fall in
pH when compared to Bebelac and Aptamil as all the other ingredients were
same in all 4 milk formulae.35
Narges Mirgalili, Mohammad Harsan, JafarFarahman (2014)
conducted a study to investigate the effect of tap water rinsing compared to
Review of Literature
31
tooth brushing and chewing gums on salivary pH after consumption of sugar
solution. Salivary samples were collected from 60 participants of age group
20-25 years of age including both sexes who were of any dental (or)
periondontal diseases with normal oral pH of 6.2-7.4. In the first attempt
unstimulated salivary pH was obtained followed by which all participants
were asked to swish with 50% sugar solution for one minute. A minute later,
salivary pH was obtained. The final sample was taken 1minute after they were
asked to rinse their mouth with water. On the second day similar procedure
was done except that the water was replaced with brushing without dentrifice
and on the third day the intervention was changed to xylitol containing
chewing gum xylitol. The data was analyzed using ANOVA and paired T-
Test. This study concludes that, sugar free gum is a beneficial inter rim oral
hygiene whereas water on the contrary is neither beneficial as inter rim oral
hygiene measure nor as an anti-caries adjunct to tooth brushing.5
Paola A. Belardinelli, Rosana A. Morelatto, Tomás E. Benavidez,
Ana M. Baruzzi, Silvia A. López de Blanc (2014) conducted a study to
evaluate the effect of two commercially available mouthwashes on salivary pH
and correlate it with age, buffer capacity and saliva flow rate in healthy
volunteers. A crossover phase IV clinical study involving three age-based
groups was designed. Two commercial mouthwashes (MW), Cool Mint
Listerine® (MWa) and Periobacter® (MWb) were used. The unstimulated
saliva of each individual was first characterized by measuring flow rate, pH,
Review of Literature
32
and buffer capacity. Salivary pH was evaluated before rinsing with a given
MW, immediately after rinsing, 5 minutes later, and then every 10 min (at 15,
25, 35 min) until the baseline pH was recovered. Paired t-test, ANOVA with a
randomized block design, and Pearson correlation tests were used. Averages
were 0.63 mL/min, 7.06, and 0.87 for flow rate, pH, and buffer capacity,
respectively. An immediate significant increase in salivary pH was observed
after rinsing, reaching average values of 7.24 (MWb) and 7.30 (MWa), which
declined to an almost stable value 15 minutes. It was evident that pH of the
external agent alone is not a good indicator for its erosive potential because
biological systems tend to neutralize it. The study concluded that that the pH
of the external agent alone is not a good indicator for its erosive potential
because biological systems tend to neutralize sudden changes in pH generated
by these agents.36
Rahul R. Deshpande, Priyankakachare, et al (2014) conducted a
study to compare the antimicrobial efficacy of two commercially used tooth
pastes. Patients of age group 6-12 years in mixed dentition period with high
caries experience were included this study. The subjects were told to rinse
with water and salivary samples were collected from the floor of their mouth.
The toothpastes were diluted at 25%, 50% and 100% concentrations. The
salivary samples were cultivated in nutrient agar plates in which dentrifice
concentrations were introduced in each well. The antimicrobial activity was
evaluated by measuring the diameter of zones of inhibition. The fluoridated
Review of Literature
33
tooth paste showed increased antimicrobial efficacy on all concentrations
compared to that of herbal tooth paste (p<0.05).This study has proved that
fluoridated tooth paste remains as a gold standard as far as antimicrobial
efficacy is concerned.11
Sanjyot Mulay, Hansa Jain (2014) conducted a study to evaluate &
compare change in salivary flow rate & pH after chewing xylitol & sorbitol
containing chewing gums. It was a randomized controlled study was
conducted on 60 healthy males between the age group of 20-40 years, who
were non-smoker, non tobacco chewer, having OHI index <3 and carious
lesions between 2-5. The selected patients were equally segregated into two
groups, Group X - Xylitol & Group S - Sorbitol [n=30]. Patients were first
asked to chew paraffin wax [control] for five minutes. After a rest time of 5
minutes the medicated gum was chewed for the same time period. They were
asked to spit the hoarded saliva in a calibrated saliva collection cup. The
collected saliva was measured and the pH was noted using pH strips. The
study results showed that both the chewing gums caused increase in salivation
but xylitol comprising chewing gum showed marked increase in comparison to
sorbitol gum, although the result was not statistically significant. Though
clinically rise in pH was just 1.33 and 1.10, but statistically it was found
significant, i.e. the ‘p’ value 0.002. It was concluded in the study that chewing
gums containing xylitol are more effective in increasing the salivary flow rate,
Review of Literature
34
this can be used in patients suffering from severe caries and disease leading to
hypoptyalism and xerostomia.37
Srinivasan, Schimmel et al (2014) conducted a study to evaluate the
effectiveness of the application of a high fluoride tooth paste on root caries. A
total of 130 participants with diagnosed root caries were taken up for this
study and were divided into two groups: Group 1 (Test group with
intervention of 5000 ppm F containing high fluoride dentrifice) and Group 2
(control Group- intervention with regular fluoride containing tooth paste with
1350 ppm of fluoride). Clinical examinations and surface hardness scoring of
the carious lesions were performed for each subject at specified time intervals
(To- at base line, T1 at 3 months, T3 at 6 months after intervention). Two way
ANOVA was done. The results revealed that the hardness was significantly
higher in high fluoride group compared to the control (p<0.0001). The study
concluded that use of high fluoride tooth pastes significantly improves the
surface hardness of untreated root caries compared to that of normal tooth
pastes.38
Materials and Methods
Materials and Methods
35
MATERIALS AND METHODS
Forty three school going children aged 4-6 years of both the sexes who
were willing to participate with informed written consent signed by their
parent/guardian/teacher participated in the present study to test the efficacy of
four different interventional methods i.e. water rinsing, brushing without
dentifrice, brushing with non-fluoridated dentifrice and brushing with
fluoridated dentifrice on salivary pH during the experimental period.
Armamentarium:
Mouth mirror
Explorer
Cotton
Tweezers
Sterile container
pH strips
De-Ionized(distilled) water
Kids toothbrush
Fluoridated dentifrice
Non-fluoridated dentifrice
Stop watch
Freshly prepared apple juice
Materials and Methods
36
Criteria for inclusion:
1. Children with overall good general/oral health ( with no systemic
illness or oral disorders)
2. Children with minimal or no caries ( dmft = 0-3)
3. No antibiotic coverage for past one month
4. With no acute intra-oral or extra-oral lesions (soft tissue swelling, pus
discharge, sinus or fistula opening)
5. Child with co-operative ability.
Criteria for exclusion:
1. Children with active dental or periodontal diseases
2. Children with debilitating systemic diseases
3. Children with extensive caries (dmft>3)
4. Children who wore orthodontic appliances and crowns.
5. Children whose parents were not acceptable for the study
6. Children lacking co-operative ability.
Clinical and sampling procedure:
Forty three school going children of both sexes aged 4-6 years were
selected from a residential school for the present study following the inclusion
criteria and an informed written consent was obtained from the parents of the
children. The children and parents were explained about the study. The study
Materials and Methods
37
was carried out between 9 a.m to 12 p.m. There were no restrictions placed on
the diet and usual oral hygiene measures of the participants.
The experimental trial was divided to four consecutive days of intervention.
Day 1: rinsing with water
Day 2: brushing without dentifrice
Day 3: brushing with non-fluoridated dentifrice
Day4: brushing with fluoridated dentifrice
Saliva collection:
For the collection of unstimulated saliva, the children were asked to sit
comfortably; the baseline saliva collection was done within a period of 30-60
seconds by Dawe’smethod.39
The children were asked to pool unstimulated
saliva in the floor of the mouth followed by which they were asked to
expectorate inside the sterile container.
Total sample
(n=53)
Day 1
(Water rinsing)
Day 2
(Brushing)
Day 3
(Brushing with non-fluoridated
dentifrice)
Day 4
(brushing with fluoridated dentifrice)
Materials and Methods
38
Preparation of apple juice:
Freshly prepared apple juice was used for this study. An average sized
apple was blended along with two tablespoons of sugar. The blended mixture
was then filtered and used for the study.
Experimental methodology:
On the first day, after taking unstimulated baseline saliva samples, then
the subjects were asked to drink 50 ml of freshly prepared apple juice in one
minute and to swish and drink carefully in order to maintain a uniform method
in drinking. A minute later, a saliva sample was obtained from each
participant. Immediately, they rinsed their mouth with tap water for 1 min. A
third saliva sample was taken after another 1 min. On the second day, the
subjects repeated the first two steps (i.e. saliva collection before and after juice
consumption). Then they were asked to brush their teeth instead of rinsing
their mouth with tap water. The third sample was collected 1 min after
brushing. On the third day of experiment the children were asked to follow the
same steps except for the intervention method which was brushing with non-
fluoridated toothpaste. On the final day of experiment, the participants brushed
with fluoridated toothpaste as the intervention method after the initial steps of
saliva collection before and after fruit juice consumption.
Materials and Methods
39
Measurement of pH:
The collected salivary samples were pooled with 10 ml of distilled
water and the acidities were checked using pH strips twice. The pH test strip
was dipped in the salivary sample for 30 seconds to record optimal color
change; after which it was removed and the change of color was compared
with the color coded chart that was given along with the pH strip pack. Based
on the calorimetric change of the strip; the pH of the saliva was recorded.
Statistical analysis:
The changes in the pH measurements were tabulated and analyzed with
SPSS software (version 17.0 for Windows) by analysis of variance (ANOVA)
and Paired T-test.
Figures
Figures
FIGURE 1: ARMAMENTARIUM (FOR SCREENING)
FIGURE 2: ARMAMENTARIUM (FOR EXPERIMENTAL PART)
Figures
FIGURE 3: SCREENING PATIENTS
FIGURE 4: CHILDREN GIVEN APPLE JUICE TO RECORD FALL IN
THE SALIVARY pH
Figures
FIGURE 5: CHILDREN ASKED TO FOLLOW INTERVENTIONAL
METHOD
FIGURE 5: CHILDREN ASKED TO FOLLOW INTERVENTIONAL
METHOD
Figures
FIGURE 6: COLLECTION OF SALIVA AFTER INTERVENTIONAL
METHOD
FIGURE 7: MEASURING pH USING COLOUR CODED pH STRIPS
Results
Results
RESULTS
Salivary sample of forty three children were analyzed for pH changes
on four consecutive days of experiment to assess the effect of various
interventional measures after sugar exposure. The results were analyzed using
the one way ANOVA (SPSS software version 17.0)
The mean pH on day 1 at baseline was 7.384±0.37 and after sugar
exposure it fell significantly to 4.895±0.72. The salivary pH increased
significantly to 6.337±0.69 after water rinsing (p=0.00). The fall in the
salivary pH increased significantly after rinsing with water but did not reach
the baseline salivary pH.(Table 1 and Graph 2)
The mean pH on day 2 was 7.430±0.39 at baseline and after sugar
exposure decreased significantly to 4.779±0.74. After brushing without
dentifrice the salivary pH increased to 6.733±0.45 (p=0.00).The fall in the
salivary pH increased significantly after brushing but failed to reach the
baseline salivary pH.(Table 1 and Graph 3)
The mean pH on day 3 was 7.302±0.60 at baseline and decreased
significantly to 4.372±0.57 after the sugar challenge. After brushing with non-
fluoridated tooth paste there was significant increase in salivary pH to
8.291±0.47.(p=0.00)(Table 1 and Graph 4)
The mean pH on day 4 at baseline was 7.465±0.33 and decreased to
4.395±0.62 after the sugar intake. After brushing with fluoridated tooth paste
Results
the salivary pH increased to 8.407±0.29 and the increase was highly
significant with p=0.00.(Table 1 and Graph 1)
On comparing between various groups, there is no significant
difference in the salivary pH of baseline (p=0.251) as well as after sugar
challenge (p=0.368).(Table 1 and Graph 1)
But a significant increase was seen in the salivary pH, when brushing
was performed using fluoridated and non-fluoridated tooth paste (p=0.00)
(Table 1 and Graph 1) compared to that of brushing without dentifrice and
water rinsing groups. When water rinsing and brushing without dentifrice was
compared, brushing without dentifrice was proved to be superior when
compared to water rinsing (p=0.002) (Table 1 and Graph 1)
There was no significant difference among brushing with fluoridated
and non-fluoridated toothpaste groups in increasing the salivary pH after sugar
exposure(p=1.00) (Table 1 and Graph 5).
Tables and Graphs
Tables and Graphs
Table 1: Mean values of the pH changes in saliva after sugar exposure and after various interventional methods
Day of
experiment
Salivary pH at
Baseline ±
std.deviation
Baseline
salivary pH
Std.error
Salivary pH
after sugar
exposure±
std.deviation
Salivary
pH after
sugar
exposure
Std.error
Salivary pH
after
intervention±
Std.deviation
After
intervention
Std.error
P value
Day 1 7.384±0.37 .0703 4.895±0.72 .1098 6.337±0.69 .1062 0.000
Day 2 7.430±0.39 .0566 4.779±0.74 .1132 6.733±0.45 .0693 0.000
Day 3 7.302±0.60 .0603 4.372±0.57 .0882 8.291±0.47 .0730 0.000
Day 4 7.465±0.33 .0510 4.395±0.62 .0949 8.407±0.29 .0448 0.000
P value 0.251 0.368 0.000
pvalue : p values at 95% confidence level
Inter group comparison:
Baseline salivary pH: 0.251 N.S; Salivary pH after sugar exposure: 0.368 N.S;
Salivary pH after intervention: 0.000 *
Salivary pH after intervention – water rinsing Vs brushing without dentifrice: 0.002*
Salivary pH after intervention –brushing without dentifrice Vs brushing with fluoridated or non-fluoridated
dentifrice:: 0.000*
Salivary pH after intervention –brushing with fluoridated dentifrice Vs non-fluoridated dentifrice: 1.000 N.S
*- significant N.S- non-significant
Tables and Graphs
Graph 1: Mean values of the pH changes in saliva after sugar
exposure and after various interventional methods
0
1
2
3
4
5
6
7
8
9
Day 1 Day 2 Day 3 Day 4
Baseline
After sugar
exposure
After
intervention
X- axis: Days of Experiment
Y- axis: Salivary pH
Tables and Graphs
Graph 2: Mean values of the pH changes in saliva after sugar
exposure and after water rinsing
7,384
4,895
6,337
0
1
2
3
4
5
6
7
8
Baseline After sugar
exposure
After water
rinsing
X- axis: Salivary Samples
Y- axis: Salivary pH
Tables and Graphs
Graph 3: Mean values of the pH changes in saliva after sugar
exposure and after brushing with water
7,43
4,779
6,733
0
1
2
3
4
5
6
7
8
Baseline After sugar
exposure
After brushing with
water
X- axis: Salivary Samples
Y- axis: Salivary pH
Tables and Graphs
Graph 4: Mean values of the pH changes in saliva after sugar
exposure and after brushing with non-fluoridated dentifrice
7,302
4,372
8,291
0
1
2
3
4
5
6
7
8
9
Baseline After sugar
exposure
After brushing
with non-
fluoridated
dentifrice
X- axis: Salivary Samples
Y- axis: Salivary pH
Tables and Graphs
Graph 5: Mean values of the pH changes in saliva after sugar
exposure and after brushing with Fluoridated dentifrice
7,465
4,395
8,407
0
1
2
3
4
5
6
7
8
9
Baseline After sugar exposure After brushing with
fluoridated dentifrice
X- axis: Salivary Samples
Y- axis: Salivary pH
Discussion
Discussion
43
DISCUSSION
Research on caries shows its rise in children especially the very young
and poor is related to the consumption of increasingly available inexpensive
foods containing excess sugars and ubiquitous habit of snacking and drinking
sweetened drinks. However not all children are equally affected due to the
variation in the factors that are responsible for caries.
The initiation of demineralization and reminerlization takes place at
the saliva-tooth interface with biofilm formation, which is a natural process
and the dynamic reactions taking place in the biofilm affects the hard tissues
leading to formation of caries. These dynamic changes are pH dependent. The
critical pH is one at which the solution (saliva) is saturated with a particular
mineral such as enamel (calcium, phosphate, hydroxyl ions). At the critical pH
the rate of forward reaction (mineral dissolution) is equal to that of backward
reaction (mineral precipitation). When there is imbalance between the
solubility product and ionic product, reminerlization or demineralization takes
place. The enamel solubility is influenced by impurities present in
hydroxyappatite (fluoride and carbonate) which differs from person to person.
If there is lesser concentration of calcium and phosphate ions in the saliva then
the critical pH will be high and vice versa. The calcium and the phosphate ions
in the saliva act as a driving force for the hydroxyappatite crystals to
precipitate. When normal oral pH is achieved after an acidic challenge
reminerlization is favored by positive thermodynamic condition3, 40, 41, 42,
Discussion
44
43(Anderson, Bradshaw and Lynch, 2013; Davies and Blinkhorn, 2013;
Elkassas and Arafa, 2014; Shetty et al., 2014).
The salivary pH is lower and is more acidic in the rampant caries
group when compared to that of caries resistant group23, 44, 45
(B.P.Preethi et al
and Kuriakose et al, Sissons et al, Ahmadi-Motamayel et al). The end result of
all these contributing factors is demineralization of teeth.
According to Cawfield the main dietary changes takes place in the
kindergarten age group after the eruption of all the primary molars46
. In
children, lower salivary calcium ions concentration means a higher critical pH
and a lower driving force for reminerlization compared to adults (Anderson)3.
So it is important to implement the preventive strategies targeting the salivary
ph and biofilm formation to control caries. Dentifrices and tooth brushes are
not readily available in the school environment for fighting against the acid
surge which usually follows any snacking. Whereas availability of water is
profound and is easy for children to swish and swirl which might have a
positive effect in the salivary pH. Hence this study was done in children of 4-5
years without gender variation who are more susceptible to caries when
compared to that of adults with an aim to detect the efficacy of water rinsing,
tooth brushing without dentifrice and brushing with fluoridated and non-
fluoridated toothpastes in reducing the salivary pH following an acid attack.
“Home-care” means the sum effect of motivation, knowledge, oral
hygiene aids and motor skill. The use of fluoride has been cornerstone of
Discussion
45
caries prevention programmes and the use of fluoridated toothpaste is by far
the most common form of caries control in use today. The caries preventive
effect of low fluoride dentifrices for kids may be less than that of adult
dentifrices but considering the fact that most of the children swallow
toothpaste while brushing which may result in an unfavorable effect causing
enamel hypo mineralization by fluorosis, so the use of non-fluoridated
toothpaste under 6 yrs of age seems warranted. While many non-fluoridated
dentifrices claim to have antimicrobial properties and have caries preventive
action, very little research has been conducted to validate the immediate action
of fluoride on salivary pH.
In our study whole saliva was collected using Dawe’s method39; whole
saliva was collected for a 5 min time span. The subject was seated at a low
table and asked to swallow residual saliva present in the mouth before the
beginning of collection and then, with the head down and mouth slightly open,
saliva was allowed to drip from the lower lip into a small sterile container.
pH strips were used in determining the salivary pH in this study as it
was available chair side, user friendly, gave immediate results and it could
also be used for patient education.
In the present study results, water was found to cause a significant rise
in pH although it did not reach the baseline value. Water has a positive effect
in dislodging the loosely stuck food debris from the teeth, also the pH of water
being neutral will help in increasing the pH of saliva and plaque, thereby
Discussion
46
increasing the calcium and phosphate ions in them47
(Tenuta et al). However it
was found to have the least effect in altering the salivary pH when compared
with other groups (p<0.001) after a sugar exposure owing to the fact that it
dilutes the oral fluids and has almost no documented cleansing effect on dental
plaque and water attenuates the original buffering capacity of the saliva by
diluting it which seems to explain why tap water did not enhance oral pH
when compared to that of other groups in this trial; which was similar to the
studies conducted by Mirjalili et al5 and Tolentino et al
4.
Brushing is potent in removing the plaque and debris because of its
mechanical action stimulating the salivary flow rate; even though brushing
with dentifrice is considered as a gold standard. There was a significant
difference in the salivary pH between the brushing without dentifrice group
and brushing with dentifrice groups (p=0.000), which is contradictory to a
study conducted by Ligtenberg6 in which brushing without dentifrice did not
make much of a difference in increasing the salivary pH compared to that of
brushing with dentifrice, which was attributed to the fact that even though
brushing had a mechanical effect increasing the salivary pH, the gustatory
stimulus provided by the dentifrices had an increased effect along with
brushing in increasing the salivary pH.
There was significant increase in the salivary pH after brushing with
fluoridated tooth paste. The fact that salivary pH increased significantly after
brushing with dentifrice was because of the combination of mechanical and
Discussion
47
chemical stimulations on the saliva. Fluoride dentifrices provide a substantial
protective effect against lesion formation and lesion progression. Twice a day
application of fluoridated dentifrice substantially reduced the dissolution of
sound enamel, as well as enamel with lesions produced by subsequent acid
challenge21
(Ravi Shiratti). However in the present study not much difference
was present between the fluoridated and non-fluoridated groups in increasing
the salivary pH (p=1.00); which was because the efficacy of fluoridated and
non-fluoridated toothpastes differ mainly by their ant-microbial efficacy on
prolonged use and as intermediate cleansing agents, both did not make much
of difference.
The study concluded that tooth brushing with dentifrice regardless of
its fluoride content is the best method of intervention to retaliate an acidic
surge whereas water and brushing without dentifrice can be used as an
intermediate intervention to partially attenuate the fall in the salivary pH
following an acid attack.
This study was done in caries free and minimal caries group, the fall in
pH takes more time to reach to the baseline level in the high caries children48
(Widowati); so further studies should be performed on high carious children to
know the outcome in high carious group. The interventional methods used in
this study are use of water rinsing, brushing without dentifrice, brushing with
non-fluoridated and fluoridated tooth pastes further studies should be done to
evaluate the efficacy of other interventional methods like use of mouthwashes,
Discussion
48
chewing gums and flossing. The effect of the interventional methods on
salivary pH was the preliminary concern of this experimental study future
research of efficacy of the interventional methods on the plaque biofilm will
give a detail of the supremacy of the interventional methods against the
demineralization process.
Conclusion
Conclusion
48
CONCLUSION
1. There was no significant difference in the baseline salivary pH on all
four experimental days (p=0.251)
2. No significant difference was present in the fall in salivary pH after
sugar exposure during the four days of experiment (p=0.368)
3. Water rinsing caused the salivary pH to rise after sugar exposure
(p<0.01) but less than that of the baseline.
4. Tooth brushing with water also caused a rise in salivary pH after sugar
exposure slightly below the level of the baseline pH (p<0.01).
5. Tooth brushing with non-fluoridated dentifrice was potent in
increasing the salivary pH above the baseline value after sugar
exposure (p<0.01).
6. Tooth brushing with fluoridated tooth paste caused an increase in the
salivary pH beyond the baseline salivary pH after an acidic surge
(p<0.01).
7. Water rinsing was the least effective when compared to brushing
without dentifrice (p=0.002), brushing with fluoridated dentifrice
(p<0.001) and non-fluoridated dentifrice (p<0.001).
8. Tooth brushing with water was better than water rinsing in increasing
the salivary pH after the sugar exposure (p=0.02) but less effective
when compared to brushing with non-fluoridated dentifrice (p<0.01)
and fluoridated dentifrice (p<0.001).
Conclusion
49
9. Among all the interventional methods, tooth brushing with fluoridated
and non-fluoridated dentifrice was better in increasing the salivary ph
to an alkaline limit (p<0.01).
10. No significant difference was seen between the efficacy of brushing
with non-fluoridated and fluoridated dentifrice groups on salivary pH
after an acidic surge (p=1.00)
Summary
Summary
50
SUMMARY
Currently though various professionally available methods are there to
prevent white spot lesions, the home care interventional methods are proven to
be the best preventive strategy to combat the initiation of the demineralization
that is dependent on the biofilm which in turn depends on pH changes in
saliva.
Tooth brushing and use of dentifrices are the universally available and
practiced home care interventional methods but their efficacy on maintaining
the neutral salivary pH is still unexplored to the core. Hence this study was
done to correlate the efficacy of water rinsing, tooth brushing with water, tooth
brushing with fluoridated and non-fluoridated dentifrice on the salivary pH
after sugar exposure.
Forty three children of age group 4-5 years with no caries or minimal
caries without any gender variation and any systemic diseases were selected
for this study. The experiment was conducted on four consecutive days. The
unstimulated saliva was collected using Dawe’s method in sterile containers
and pH was measured using color coded pH strips.
On each day of experiment, the baseline salivary pH was obtained
followed by which the children were asked to consume apple juice (as a sugar
exposure) and the fall in pH was again recorded; the children were then asked
to follow the interventional methods (day 1- water rinsing, day 2-brushing
Summary
51
with water, day 3 –brushing with non-fluoridated dentifrice, day 4- brushing
with fluoridated dentifrice) after which the salivary pH was again recorded.
The mean value was calculated, tabulated and statistically analyzed
using analysis of variance (ANOVA) and paired t-test.
The study results showed that though water could possibly increase the
salivary pH after a sugar attack, it failed to bring back the pH to the baseline
(p<0.001), but brushing with water proved to be potent than water rinsing in
bringing the pH near the neutral value (p=0.002).
Brushing with dentifrice proved to be the best method by bringing the
salivary pH to a more alkaline pH. However there was not much difference
between the brushing with non-fluoridated or fluoridated dentifrice group
(p=1.00).
The present study concluded that water can be used as an intermediate
intervention to revert the salivary pH until a definitive intervention like
toothbrush and dentifrice is available. Tooth brushing with dentifrice is the
better home care interventional method to succumb the salivary fall.
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Annexures
Annexure I: Screening Form
Name: Number:
Age:
Gender:
Date:
Chief complaint:
History:
Brushing technique:
Tooth Paste:
Adjuvant aids:
Diagnosis:
Treatment plan:
Annexures
ANNEXURE-II
Name Age Dft Plaque
score
Brushing
technique
Freq
uenc
y
Tooth paste
Day
1.p
h1
Day
1.p
h2
Day1.
water
Day2
.ph1
Day2
.ph2
Day
2.to
oth
bru
sh
Day
3.p
h1
Day
3.p
h2
Day3
.non-
fluor
idate
d
Day
4.p
h1
Day4
.ph2
Day4.f
luorid
ated
Jeevajothi 5 0 0.8 horizontal 2 pepsodent 7 5 6.5 8 4 7.5 8 4 9 8 4 8.5
Dinesh 5 0 1.0625 horizontal 2 colgate 7.5 5 6 8 5 7.5 7.5 5 8.5 7.5 5 8
Sridhar 5 0 0.875 horizontal 1 colgate 8 5 6.5 7.5 5 7 7.5 4 8 7.5 5 8.5
Janani 5 0 0.8875 1 colgate 7.5 5 6.5 7 4 7 7.5 4 8 7.5 4 8.5
Yaswanthkumar 5 0 1.062 horizontal 1 colgate 7 5 6 7.5 4 6.5 7.5 4 8.5 7.5 4 8
Siva 5 0 0.925 horizontal 2 colgate 7.5 5 6 7.5 4 7 7 4 8 7.5 4 8.5
Mhd.
Wasimakram 5 0 0.9125
horizontal &
vertical 2 close-up 8 5 6.5 7.5 4 7 7.5 4 8 7.5 4 8.5
R.k. Hariharan 5 0 0.1025 horizontal 1 colgate 8 6 6.5 8 5 7.5 7.5 6 8 8 6 9
Aashikabanu 5 0 0.8875 horizontal 2 pepsodent 6.5 4 5 7.5 4 7 7 5 8 7 5 8
Seethadevi 5 0 0.625 horizontal 1 colgate 7 5 6 7.5 4 6.5 7 4 8 7.5 4 8.5
Vinodha 4 0 0.65 vertical 1 colgate 7.5 5 6.5 7 4 6.5 7 4 8 7.5 4 8.5
Ajay 5 0 0.7125 horizontal 1 colgate 7.5 5 6.5 7.5 4 7 7 4 8.5 7.5 4 8.5
Anusree 5 0 0.4625 horizontal 2 colgate 8 6 6.5 7.5 5 6 8 5 9 8 5 8.5
Someswar 5 0 0.5375 horizontal 1 colgate 7.5 4 6 8 6 7.5 7.5 4 8 7.5 4 8.5
Sanoli 5 0 0.475 horizontal 2 colgate 7.5 6 6.5 7 6 7 7 6 7.5 7.5 6 8.5
Sanjay 5 0 0.475 horizontal 1 colgate 7 5 6 7.5 6 7 7.5 5 8 7.5 4 8.5
Barkithnisha 5 0 0.8 vertical 2 colgate 8 5 7 8 5 6.5 7.5 4 7 8 4 8.5
Kaviya 5 0 0.925 horizontal 1 dabur 7.5 4 6.5 7 5 6 7 4 8.5 7 4 8
Roshanprasanna 5 0 0.609 horizontal 1 pepsodent 7 5 6 7.5 4 6.5 7 5 8.5 7.5 5 9
Manikandan 5 0 0.775 horizontal 1 colgate 7.5 5 6.5 7 4 6.5 7.5 4 8 7 4 8
Yuvanesh 5 0 0.725 horizontal 1 colgate 8 6 5 7.5 5 6.5 7 5 8 7.5 5 8.5
Hemnath 5 0 0.8 horizontal 1 colgate 7 5 6.5 7.5 4 7 7 4 8 7.5 4 8.5
Annexures
Yashini 6 0 0.8875 horizontal 1 colgate 8 5 6.5 8 4 6 8 4 9 8 4 8.5
Mohamadtahir 5 0 0.7 horizontal 1 colgate 6.5 4 5 7.5 5 6.5 7 4 7.5 7.5 4 8
Priyan 5 0 0.6375 horizontal 1 colgate 7 4 6 8 5 7 7 4 8.5 7.5 4 8.5
Kathirvel 5 0 0.7625 horizontal 2 colgate 7.5 5 7 8 5 6.5 7.5 4 8.5 7.5 4 8
Bhavadharini 5 0 0.8 horizontal 1 colgate 6.5 5 6 6.5 4 6 6 4 8 6.5 4 8.5
Thendralmathi 4 1 0.775
horizontal
and vertical 1 colgate 7 5 6 7.5 6 6.5 7 5 8 7 5 8.5
Shaikawood 4 1 0.8875 horizontal 1 colgate 6.5 4 5 7 4 6 7 4 8 7 4 8.5
Akash 5 1 0.775 horizontal 1 colgate 7.5 4 6 7 5 6.5 7 4 9 7 4 8.5
Saranya 5 1 0.9125 horizontal 1 colgate 7.5 4 6 7 5 6 7.5 4 8.5 7.5 4 8
Sreebarath 4 2 0.6625 horizontal 1 colgate 7.5 6 6.5 7.5 5 6.5 8 5 9.5 8 5 8.5
Varshini 5 2 0.8875 horizontal 2 colgate 8 5 6 7.5 4 6.5 7.5 4 8 7.5 4 8.5
Thiyanesh raja 6 2 0.8875 horizontal 2 colgate 7.5 4 6 7 5 6.5 7 4 8.5 7 4 8
Lakshmi priya 5 2 0.725 horizontal 1 colgate 7.5 5 6.5 7 6.5 7.5 7.5 5 8.5 7.5 5 8
Nigitha 5 2 0.975
horizontal
and vertical 1 colgate 7 4 5 7.5 5 6.5 7 4 8 7.5 4 8
Sahana 5 2 1.0375 horizontal 1 dabur 7.5 4 7.5 7.5 5 7 7.5 4 8.5 7.5 4 9
Sandhiya 5 2 0.9375 horizontal 2 pepsodent 7 5 7.5 7 6 7.5 7 4 8.5 7.5 5 8.5
Sridharshanaagait
ian 5 3 0.9125 vertical 1 himalaya 7 6 7.5 7 4 6.5 7.5 4 8.5 7 4 8.5
Harini 5 3 0.7625 horizontal 1 colgate 8 4 7 7.5 5 7 7.5 5 9 7.5 4 8.5
Yagov 5 3 1 horizontal 2 colgate 8 6.5 7.5 7.5 6 7 8 5 9 8 6 9
Lavanya 5 3 0.8125 horizontal 2 colgate 7.5 6 7.5 7.5 5 7 7 5 8.5 7.5 5 8
Akash.d 5 3 0.6625 horizontal 1 colgate 7 4 7.5 7.5 5 6.5 7.5 4 8 7.5 4 8.5
Annexures
ANNEXURE- III
CONSENT FORM
I___________________________, the parent/guardian
of__________________________, herby give consent for the participation of my
son/daughter in the study titled “Comparative Evaluation of Efficacy of 4 Different
Interventional Methods on Salivary pH after an Acidic Surge” being conducted by Dr.K.
Lakshmikumari Alias Sudharashini, a postgraduate student of Ragas dental college and
hospital, Chennai. Under the guidance of Dr.M.Jayanthi, Prof and Head, department of
pedodontics and preventive dentistry. I have been clearly informed about the
procedure/techniques of the study and I voluntarily, unconditionally, freely give my
consent for the active participation of my child without any form of pressure and in a
mentally and conscious state.
Signature of the investigating doctor
Signature of the Patient’s parent/ Guardian.
Annexures
ANNEXURE-IV
சிகிசசஒுதபிவ
____________________________ஆகியநா _____________________ எகிற
எுழசதயிவா/பபுதிசயஆராுபாகஒுதஅளிகிறற.றேு
, இதஆராயிசைறேககாவதிைாவிசளயூியநசேகசளு,
அதைாவிசளயூியஅகசளகியகசளுஅறியகபறபி,
நாஎவிதஅசுேிறிதைிசசயாகு,
ுுேைுடஎுசடயசேததிசைஅளிகிறற.
சககயாப:
றததி, இட:
சாசிக;
(கபறறாிகபய) (ுழசதயிகபய, வயு)
Annexures
ANNEXURE-V