RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE, KARNATAKA

ANNEXURE -II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF THE CANDIDATE AND ADDRESS ( in block letters ) Dr. ENA SHARMA THE OXFORD DENTAL COLLEGE , HOSPITAL AND RESEARCH CENTREHOSUR ROAD,BOMMANAHALLI, BANGALORE 560068

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NAME OF THE INSTITUTIONTHE OXFORD DENTAL COLLEGE, HOSPITAL AND RESEARCH CENTRE

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COURSE OF THE STUDY AND SUBJECT MASTER OF DENTAL SURGERY PERIODONTICS

4DATE OF ADMISSION TO COURSE MAY 5, 2010

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TITLE OF THE TOPIC

A RANDOMISED STUDY TO COMPARE SALIVARY pH, CALCIUM, PHOSPHATE AND CALCULUS FORMATION AFTER USING ANTICAVITY DENTIFRICES CONTAINING RECALDENT (CCP-ACP) AND FUNCTIONALIZED TRI-CALCIUM PHOSPHATE (fTCP)

6BRIEF RESUME OF INTENTED WORK

6.1 NEED FOR THE STUDY

In the last decade there has been a veritable explosion of interests in technologies which have shown to have value for remineralization of enamel and dentine and to arrest the demineralization of teeth.

Dentifrices with active ingredients of Recaldent (GC Tooth Mousse PlusTM) and fTCP (3M ESPE ClinProTM Tooth Creme) have taken a surge in this regard. These dentifrices work by providing calcium, fluoride and phosphate ions and optimizing the pH of oral environment.1 Salivary components play a critical role in controlling the equilibrium between demineralization and remineralization.

Recaldent is casein phosphopeptide amorphous calcium phosphate (CCP-ACP) with 900ppm of fluoride from 0.2% sodium fluoride, acts by adhering to soft tissue, plaque, pellicle, and hydroxyapatite delivering amorphous calcium, phosphate and fluoride to prevent demineralization and improve remineralization.2 A second action of this dentifrice is that it also increases the pH of saliva thereby enhancing the anticaries activity.3

Functionalised Tricalcium Phosphate (fTCP) is an innovative calcium based additive which increases the bioavailability of calcium and fluoride to facilitate remineralization.1

According to mineral precipitation theory for calculus formation, calcification of plaque will occur in particular locus when pH, calcium, and phosphorous concentration are high enough to allow for precipitation of a calcium phosphate salt.4 As per mechanism of action of the above mentioned dentifrices, its usage may lead to an undesirable effect of calculus formation.1,5,6,7 This calculus brings bacterial overlay closer to gingiva, makes plaque removal more difficult for the patient and has the potential to cause gingivitis.8

Hence a study is designed in human subjects to evaluate the pH of saliva, concentration of calcium, inorganic phosphate in saliva before and after usage of dentifrices containing Recaldent (GC Tooth Mousse PlusTM) and fTCP (3M ESPE ClinProTM Tooth Crme) along with clinical evaluation of calculus formation.

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6.2 REVIEW OF LITERATURE

Laurence j Walsh reviewed various anticavity tooth pastes. He stated that Recaldent (CCP-ACP) and Functionalised tri-calcium phosphate (fTCP) containing dentifrices improved remineralization and prevent further demineralization by providing calcium, phosphate, fluoride and optimizing pH of oral cavity. He also stated that using fTCP can enhance the levels of calcium, phosphate in plaque fluid and saliva. fTCP operates as a remineralizing agents at a neutral or alkaline pH.1

Llena C et al reviewed the role of different casein phosphopeptide amorphous calcium Phosphate based (CCP-ACP)compounds in controlling demineralization/remineralization. They reported that CCP has shown to stabilize calcium and phosphate preserving them in an amorphous or soluble form known as amorphous calcium phosphate (ACP). Calcium and phosphate are essential components of enamel and dentine and form highly insoluble complexes, but in presence of CCP they remain soluble and biologically available.2

In a study conducted by Marchisio O et al Twenty-Five patients with fixed orthodontic appliances were given CCP-ACP dentifrices for 3 weeks and this was suspended for next 3weeks. They concluded that there was an increase in the salivary pH(76% of the patients) but only a marginal increase in the plaque pH ( 48% of the patient).3

According to mineral precipitation theory of calculus formation by Buchard it was reported that increase liberation of carbon dioxide from saliva cause an alkalization of saliva with a resultant precipitation of calcium salts to form calculus.4

Ye Jin and Hak-Kong Yip reviewed that super saturation of saliva and plaque fluid with respect to calcium phosphates is the driving force for plaque remineralization. Both salivary flow rate and plaque pH appear to influence the saturation degree of calcium phosphates.5 They also stated that fluoride has the potential to increase the plaque pH to promote remineralization. Fluoride present in saliva from the diet , toothpaste, mouthrinse can promotes calculus formation, which is an undesirable effect of fluoride.5

Rohiotis C et al conducted a study on the characterization of oral biofilms formed on germanium crystals mounted in the custom made retainers of removable orthodontic appliance in situ in presence or absence of CCP-ACP agents. They stated that presence of CCP-ACP agents delays in biofilm formation, increase in Ca/O, Ca/P and decrease in K/CL ratio and favored the nucleation and crystallization of calcium phosphates, possibly in apatitic form, in matured biofilms.6

A study undertaken by Sudhir S to evaluate the relationship of salivary calcium, phosphorous, protein and pH with regard to periodontal disease. A positive correlation between the levels of calcium and severity of disease was observed. In this study it was also suggested, that monitoring for change in salivary composition might be useful tool to establish periodontal health status. Suggestion is to carry out more study closer to the seat of periodontal disease such as within plaque, or on the calcification of plaque.7 Komkham P and Juan M has included 439 Thai children of age 11-13 years in this study to examine the relationship of calculus to caries ,gingivitis, and salivary conditions which may contribute on calculus accumulation. Study demonstrated the high association between gingivitis and plaque status with calculus formation.8

6.3 Objectives of the Study

1. To estimate pH of saliva, concentration of calcium and inorganic phosphate in saliva before and after usage of Recaldent (GC Tooth Mousse PlusTM) , fTCP (3M ESPE ClinProTM Tooth Crme) and Placebo dentifrice.

2. To evaluate the effect of Recaldent (GC Tooth Mousse PlusTM), fTCP (3M ESPE ClinProTM Tooth Crme) and Placebo dentifrice on dental calculus formation.

3. To determine the effect of calculus formation on Gingiva.

7MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

Patients visiting the Department of Periodontics at the Oxford Dental College Hospital and Research Centre, Bommanahalli, Bangalore.

7.2 METHOD OF COLLECTION OF DATA:

45 Patients satisfying below mention inclusion and exclusion criteria will be recruited. Patients will be randomized in to three groups of 15 each. Informed consent will be obtained from all the patients who will be participating in this study.

INCLUSION CRITERIA

1. Age group between 18-50yrs.2. Systemically healthy subjects.3. Patient with at least 28 teeth.4. Patients with clinically healthy gingiva and mild gingivitis.

EXCLUSION CRITERIA

1. Smokers and chronic alcoholics.2. Medically compromised patients.3. Subjects who are on long term use of drug such as NSAIDS, corticosteroids and hormone replacement therapy.4. Pregnant and lactating women.5. No history of scaling and root planning in past 6 months.6. Patients with unrestored /symptomatic teeth with caries, erosion and abrasion.7. Patients on calcium and vitamin D supplements.

STUDY DESIGN

For all recruited patients scaling and root planning will be carried and oral hygiene instructions will be given, all clinical parameters and indices will be brought to zero. All the patients will be instructed to use placebo tooth paste and to follow oral hygiene instructions for next 21 days. After 21 days the patients will be randomly categorized in to 3 Groups, Group A, Group B and Group C of 15 subjects each and baseline parameters will be recorded. Group A patients will be instructed to use Placebo Tooth paste for next 21 days.Group B patients will be instructed to use Recaldent (GC Tooth Mousse Plus TM) for next 21 days.Group C patients will be instructed to use fTCP (3M ESPE ClinProTM Tooth Crme) for next 21 days.At the end of study period all the clinical parameter will be recorded again.

The following clinical parameters and investigations will be recorded for all the patients.

1. Plaque index (Sillness and Loe) 8.2. Calculus index (NIDR).8 3. Gingival index (Loe and Sillness).8 Above clinical parameters will be taken on three occasions.a. During patients first visit.b. At baseline on 21st day.c. At the end of study 42nd day.4. Concentration of Calcium, inorganic phosphate will be measured in Saliva by standard colorimetric method .9

5. pH of saliva will also be measured by using digital pH meter.8

Above two investigations will be carried out at the end of 21st day and 42nd day.

METHOD OF COLLECTION OF SALIVA SAMPLE

Saliva samples will be collected at baseline and at the end of study. Before collecting the saliva samples patients will be instructed to refrained from consuming food and beverages for one hour prior to collection.10 Saliva samples will be collected by Navazesh swab method between noon and 2pm.10,11

Salivary samples will be centrifuged to remove particulate matter and bacteria which is clear supernatant.11 2ml of clear supernatant saliva clarified human whole saliva (CHWS) will be pipette out in to polypropylene tubes and saliva will stored in sealed test tube at-200c.All 90 samples will be analyzed for the levels of calcium, inorganic phosphate by standard colorimetric method and pH of saliva by the digital pH meter.8,9

The results will be statistically analyzed by ANOVA test.

Total duration of the study will be one year.

7.3 Does this require any investigation or intervention to be conducted on patients or others or animals?

Yes, saliva samples will be collected, and oral hygiene procedure will be render to all the recruited patients.

7.4 Has ethical clearance been obtained from your institution?

Yes ,a certificate is attached

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LIST OF REFERENCES:

1. Walsh LJ: Contemporary technologies for remineralization therapies: A Review. International Dentistry SA ;11(6):6-15

2. Llena C, Forner L, Baca P: Anticariogenicity of casein phosphopeptide amorphous calcium phosphate: A review of the literature. J Contenp Dent Pract 2009; 10(3):1-9.

3. Marchisio O, Esposito MR, Genovesi A: Salivary pH level and bacterial plaque evaluation in orthodontic patients treated with Recaldent products. Int J Dent Hyg 2010; 3:232-236.

4. Hazen SP: Supragingival Dental Calculus. Perio 2000 1995; 8:125-136.

5. Ye jin, Hak-Kong Yip: Supragingival Calculus: Formation and Control. Crit Rev Oral bio med 2002; 13 (5):426-441.

6. Rohiotis C, Vougiouklakis G, Eliades G: Characterization of oral films formed in the presence of a CCP-ACP agent: an in situ study. J Dent.2008; 36(4):272-280.

7. Shetty S: Quantitative evaluation of salivary calcium, phosphorus, protein and pH in health and disease periodontium. Annals and Essentials 2010; 2(4):21-24.

8. Pattanaporn K, Navia JM: The relationship of dental calculus to caries, gingivitis and selected salivary factor in 11-13 Year old children in ching Mai, Thailand. J periodontol 1998; 9:955-961.

9. Larsen MJ, Jensen AF, Madsen DM et al: Individual variations of pH, buffer capacity and concentration of calcium and Phosphate in un-stimulated whole saliva. Arch Oral Bio1999; 44:111-117.

10. Navazesh M: Methods of collection of saliva: Annals of New York Academy Sciences1993; 694:72-77.

11. Navazesh M, Christensen CM: A comparison of whole mouth resting and Stimulated Salivary measurement procedure. J Dent Res 1982; 61(10):1158-1168.

9 Signature of the Candidate

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Remarks of The Guide

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11.1 Name and Designation of The Guide

11.2 Signature

11.3 Head Of Department

11.4 Signature Dr A V RAMESHPROFESSOR, VICE PRINCIPALDEPARTMENT OF PERIODONTICS

Dr C. D. DWARKANATHPROFESSOR AND HEAD,DEPARTMENT OF PERIODONTICS

1212.1 Remarks of the Chairman and Principal

12.2 Signature