JIndianSocPedodPrevDent302146-1554461_041904

146 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |

Original article

Effect of casein phosphopeptide - amorphous calcium phosphate containing chewing gum on salivary concentration of calcium and phosphorus: An in-vivo study

Santhosh BP, Jethmalani P1, Shashibhushan KK2, Subba Reddy VV2

Department of Pediatric Dentistry, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh, 1Department of Pediatric Dentistry, Eluru, Duggiralu,W.G district, Andhra Pradesh, 2Department of Pediatric Dentistry, College of Dental Sciences, Davangere, Karnataka,India.

Correspondence: Dr. Santhosh B.P, Department of Pediatric Dentistry, Chhattisgarh Dental College and Research Institute, Rajnandgaon-491441 Chhattisgarh,India. E-mail: [email protected].

Abstract

Aim: Caries clinical trials of sugar-free chewing gum have shown that the gum is noncariogenic and in fact has anticariogenic effect through the stimulation of saliva. Sugar-free gums, therefore, may be an excellent delivery vehicle for safe and effective additive, capable of promoting enamel remineralization. Casein phosphopeptide – amorphous calcium phosphate (CPP-ACP) nanocomplexes incorporated into sugar-free chewing gum have shown to remineralize enamel subsurface lesions in situ. So this study was conducted to evaluate the effect of CPP–ACP containing sugar-free chewing gum on salivary concentration of calcium and phosphorous. Materials and Methods: Unstimulated saliva from each 24 selected subjects was collected. Then each subject was given two pellets of chewing gum containing CPP-ACP and asked to chew for a period of 20 min, after which saliva samples were collected from each individual. Once all the samples were collected they were assessed for calcium and phosphorous concentration using affiliated reagent kits and photometer. Statistical Analysis Used: Data obtained were analyzed using student’s paired t test. Results: Significant difference was found in the calcium and phosphorus concentration of saliva before and after chewing CPP-ACP containing chewing gum. Conclusions: Chewing of CPP–ACP containing chewing gum showed a significant increase in the salivary concentration of calcium for a prolonged period of time hence it may help in the remineralization of tooth surfaces.

Key words

Calcium concentration, casein phosphopeptide – amorphous calcium phosphate , phosphorus concentration, photometer, saliva

IntroductionChewing gums have the potential of being an effective vehicle for delivering therapeutic agents because they permit protracted contact of the agent with the teeth with minimal efforts on the part of the patient.[1]

Casein phosphopeptide – amorphous calcium phosphate (CPP–ACP) nanocomplexes have been demonstrated to have anticariogenic activity in laboratory, animal, and human in situ experiments. CPP–ACP nanocomplexes have been proven to have reduced caries activity. CPP–

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Santhosh, et al.: CPP-ACP chewing gum and salivary calcium and phosphorus concentration

147JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |

ACP promotes remineralization and reduces mineral loss caused by exposure to acidic environment.[2]

The anticariogenic potential of CPP–ACP has been attributed to the ability of the CPP to localize amorphous calcium phosphate at the tooth surface, thereby, helping to maintain a state of super saturation with respect to tooth mineral.[3]

Calcium phosphate concentrations in saliva and in plaque can also increase tooth mineral saturation and an increased cariostatic effect might be anticipated with gum fortified with these agents. Furthermore, gums have advantages as calcium phosphate delivery vehicles.(1) They can be made to contain a large amount of

mineral ions, with a single stick of gum potentially holding nearly as much calcium as a liter of a typical remineralizing solution or saliva.

(2) They can be chewed over a relatively extended period, while the practical application time for a remineralizing rinse is about 1 min.[4]

Hence, chewing gums can be excellent vehicles to provide therapeutic agents to the dentition without much effort by the patient. Recently CPP–ACP incorporated sugar-free chewing gums are commercially available. Hence, the purpose of this study is to evaluate and estimate the salivary concentration of calcium and phosphorus before and after chewing commercially available sugar-free chewing gums containing CPP–ACP namely TRIDENTTM.

Materials and Methods

The sample population consisted of 24 children aged between 8–14 years (average age 10.33 years), with good oral hygiene and no active carious lesions.

[Figure 1] Collection of sample was in the morning hours and in children who had breakfast two hours before and had not taken food or drink in between this period.

As the procedure required patient intervention, ethical clearance was obtained from the institution and written consent was taken from the parents of the children.

Equipment used in the studyBiosystems Semi-auto analyzer BTS-310 (Photometer) ( Dr. Reddy’s Laboratories limited) [Figure 2].

Materials used in the study1. CPP-ACP containing chewing gums (TRIDENTTM

Cadburry Adams USA) servings – 2 pellets – 3 g.2. Serum calcium and serum phosphorus reagent kits

(ACCUCARETM Lab-care Diagnostics Pvt India).[Figure 3].

Methods

First the child was comfortably seated on the dental chair and was asked to rinse the mouth with water. Two minutes later the subject was asked to spit saliva into saliva collecting glass beaker till 1.5 mL of saliva was collected.[Figure 4] Then the sample was labeled BEFORE SAMPLE – 1 and stored.

Then the subject was given two pellets of CPP-ACP containing chewing gum. [Figure 5] and was asked to chew the gum for 20 min. After this subject was asked to spit the chewing gum and immediately asked to spit saliva in the glass beaker, till 1.5 mL of saliva was collected. [Figure 6] Then the sample was labeled AFTER SAMPLE – 1 and stored.

Following the same procedure, all the samples were collected and labeled (24 saliva samples collected before

Figure 2: BTS 310 semi-auto analyzer - photometerFigure 1: No active caries in subjects





chewing ACP–CPP containing chewing gum and 24 saliva samples collected after chewing two pellets of ACP–CPP containing chewing gum for 20 min), and then these samples were taken immediately to the laboratory and assessed for their calcium and phosphorus concentration using serum calcium and serum phosphorus reagent kits and photometer. [Figure 7]

Once the values of all the 96 samples were obtained,

they were analyzed statistically by student’s paired t-test. P-value of 0.05 or less was set for statistical significance.

Results

The results showed that the mean and standard deviation of calcium concentration of saliva samples before chewing CPP-ACP chewing gum was 7.075 mg/ dL and 3.964 mg/dL, respectively, and the mean and standard deviation of calcium concentration of saliva samples after chewing CPP-ACP containing chewing gum for 20 min was 12.075 mg/dL and 4.477 mg/dL [Table 1]. Hence, these results showed that there was a mean 70.6% increase in the calcium concentration of saliva after chewing CPP-ACP containing chewing gum for 20 minutes & the paired t-test value was 7.5 [Table 2] that was highly significant.

Figure 4: Collection of saliva before chewing CPP-ACP containing chewing gum

Figure 5: Pellets of chewing gum given to the subjectFigure 6: Collection of saliva after chewing CPP-ACP containing chewing gum for 20 minutes

Figure 7: Reagent kits added with salivary samples in laboratory

Figure 3: Materials used for the study




149JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2012 | Issue 2 | Vol 30 |

Results also showed that the mean and standard deviation of phosphorus concentration of saliva samples before chewing CPP–ACP chewing gum was 17.475 mg/dL and 3.549 mg/dL respectively and the mean and standard deviation of phosphorus concentration of saliva samples after chewing CPP–ACP containing chewing gum for 20 min was 12.525 mg/dL and 3.040 mg/dL [Table 1]. Hence, these results showed that there was also a mean 28.3% decrease in phosphorus concentration of saliva and the paired t- test value was 9.8 that was highly significant [Table 2].

Discussion

Dental caries is a multifactorial local disease[5] and it is the most common disease in childhood.[6] There is no doubt that saliva significantly influences the caries process and in some way necessary to maintain the integrity of the teeth.[5]

The balance between demineralization and reminer-alization of teeth depends on the salivary calcium and phosphorus concentration but conflicting results have been reported by investigators of calcium and

phosphorous contents of saliva and their relationship to dental caries.[7] Karshan[7] observed that salivary calcium concentration decreased with the increasing carious activity.

Casein phosphopetides (CCP) containing the cluster sequence Ser(p)-Ser(p)-Ser(p)-Glu-Glu- have a remarkable ability to stabilize amorphous calcium phosphate (ACP) in the metastable solution. Through the multiple phosphoseryl residues, the CPP binds to form nanoclusters of ACP, preventing their growth to the critical size required for nucleation and phase transformation.[2] CPP can stabilize over 100 times more calcium phosphate than is normally possible in an aqueous solution.[8]

The use of sugar-free chewing gum has been increasingly accepted as one adjunct to oral hygiene procedures. It has become part of caries prevention program. Chewing gum not only acts as a salivary stimulant but may also be useful vehicles for delivering agents such as fluoride, chlorhexidine, calcium and phosphorus on to the tooth surfaces.[9]

In this study, Trident white sugar-free chewing gum containing Recaldent a milk derived protein, which contains CPP–ACP was used. The results showed the mean value of calcium and phosphorus concentration of saliva before chewing CPP–ACP containing gum was 7.074 and 17.478 mg/dL respectively which is comparable to normal calcium and phosphorus values of saliva. The results of this study showed a significant change in calcium and phosphorus concentration of saliva before and after chewing CPP–ACP containing chewing gum for 20 min.

There was a mean 70.6% increase in calcium concentration of saliva after chewing the CPP–ACP containing gum for 20 min; whereas there was a mean 28.3% decrease in phosphorous concentration of saliva.

Studies have shown that significant decrease in the phosphorus concentration of stimulated saliva when compared with that of unstimulated saliva. [1] As the

Table 1: Range and SD of calcium and phosphorous concentration of saliva before and after chewing CPP–ACP containing chewing gumTime of assessment Range mg/dL Mean mg/dL SD mg/dLCalcium concentration of saliva before chewing CPP-ACP containing gum

0.6-16.8 7.075 3.964

Calcium concentration of saliva after chewing CPP-ACP containing gum for 20 min

4.8-22.8 12.075 4.477

Phosphorous concentration of saliva before chewing CPP-ACP containing gum

12-24 17.475 3.549

Phosphorous concentration of saliva after chewing CPP-ACP containing gum for 20 min

6.6-18.6 12.525 3.040

Table 2: Mean difference of salivary concentration of calcium and phosphorus before and after chewing CPP-ACP containing chewing gumParameters Mean ± SD Mean Difference

(after- before)% difference from mean

t* value SignificantBefore chewing gum CPP-ACP

containing gum

After chewing gum CPP-ACP

containing gum for 20 min

Calcium (mg/dL) 7.075 ± 3.964 12.075 ± 4.477 5 70.6 7.5 P < 0.001 HSPhosphorus (mg/dL) 17.475 ± 3.549 12.525 ± 3.040 -4.95 28.3 9.8 P < 0.001 HS*Paired t test HS = highly significant





flow rate increases, the concentration of phosphorus falls. The average percentage difference of phosphorus between the unstimulated and stimulated saliva is 29%. But unstimulated saliva is well saturated with phosphorus.[10]

Hence, the decrease in the salivary concentration of phosphorus after chewing CPP–ACP containing chewing gum can be attributed to these physiological reasons and also may be due to relatively late collection of salivary samples in the current study (20 min after chewing started) and so it can be noted here that after analysis of the results, there was no significant change in the phosphorus concentration of saliva after chewing CPP–ACP containing chewing gum for 20 min.

However, important point to be noted here is that there was a highly significant increase in calcium concentration of saliva after chewing CPP–ACP containing chewing gum, which was 70.6%. Hence, saliva was super saturated with calcium even after chewing CPP–ACP containing chewing gum for 20 min.

With this discussion and results of this study it can be concluded that CPP–ACP containing chewing gum would increase the level of calcium concentration of saliva, thereby supplying calcium to the whole dentition for a prolonged period and the phosphorus concentration of saliva remains unaffected after chewing the gum for 20 min. Hence, this supply of relative higher concentration of calcium and phosphorus (which is normally present in high concentration in saliva), to the tooth surface may aid in remineralization of tooth surfaces in addition to the mechanical cleansing while chewing.

However, it also remains to be evaluated the changes in salivary concentration of calcium and phosphorus at different time intervals after chewing CPP–ACP containing sugar-free chewing gum is started so that optimum amount of time for chewing these gums can be recommended.

Finally, this study results indicate a positive remineralization potential of CPP–ACP containing sugar-free chewing

gum as it has shown to significantly elevate the calcium concentration of saliva for a prolonged period of time and also contribute to oral hygiene by mechanical cleansing the teeth with an added advantage of enjoying the pleasure of chewing the gum both by children and adults.

References

1. Chow LC, Takasi S, Shern RJ, Chow TH, Takagi KK, Sieck BA. Effects on whole saliva of chewing gums containing calcium phosphates. J Dent Res 1994;73:26-32.

2. Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. J Dent Rest 2001;80:2066-70.

3. Mazzaoui SA, Burrow MF, Tyas MJ, Doshper SG, Eakins D, Reynolds EC. Incorporation of casein phosphopeptide, amorphous calcium phosphate into a glassionomer cement. J Dent Res 2003;82:914-8.

4. Vogel GL, Zhang Z, Carey CM, Ly A, Chow LC, Proskin HM. Composition of plaque and saliva following sucrose challenge and use of an a-tricalcium phosphate containing chewing gum. J Dent Res 1998;77:518-24.

5. Hegde AM, Neekhra V, Shetty S. Evaluation of levels of nitric oxide in saliva of children with rampant caries and early childhood caries: A comparative study. J Clin Pediatric Dent 2008;32: 283-6.

6. Shahrabi M, Nikfarjam J, Alikhani A, Akhoundi N, Ashtiani M, Seraj B. A comparison of salivary calcium, phosphate, and alkaline phosphatase in children with severe, moderate caries, and caries free in Tehran’s kindergartens. J Indian Soc Pedod Prev Dent 2008;26:74-7.

7. Karshan M. Factors in saliva correlated with dental caries. J Dent Res 1939;18:395-407.

8. Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: A review. Spec Care Dentist 1998;18:8-16.

9. Itthagarun A, Wei SH. Chewing gum and saliva in oral health. J Clin Dent 1997;8:159-62.

10. Edgar WM. Saliva: Its secretion, composition and functions. Br Dent J 1992;172:305-12.

How to cite this article: Santhosh BP, Jethmalani P, Shashibhushan KK, Subba Reddy VV. Effect of casein phosphopeptide - amorphous calcium phosphate containing chewing gum on salivary concentration of calcium and phosphorus: An in-vivo study. J Indian Soc Pedod Prev Dent 2012;30:146-50.

Source of Support: Nil, Conflict of Interest: None declared.



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JIndianSocPedodPrevDent302146-1554461_041904