Original Research Article

Comparative Evaluation of Newer Journal of Indian Orthodontic Society

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Remineralizing Agents on Surface © 2020 The Author(s)

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Characteristics of Tooth Surface After DOI: 10.1177/0301574220965701
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Slenderization: An In Vitro Study

Renu Nanwal1, Seema Gupta1, Eenal Bhambri1, Sachin Ahuja1, and Ridhi Kothari1

Abstract
Aim: The aim of the present study was to compare the effects of remineralizing agents (nano-hydroxyapatite [n-HAP],
NovaMin, calcium sucrose phosphate [CaSP], and Pro-Argin) on surface characteristics of slenderized enamel using Vickers
microhardness and scanning electron microscope–energy dispersive X-ray (SEM-EDX) analysis.
Materials and Method: Sixty extracted premolar teeth were divided into 6 groups: group 1—natural teeth; group 2—
slenderization and polishing; group 3—n-HAP; group 4—NovaMin; group 5—CaSP; and group 6—Pro-Argin. Remineralizing
agents were applied for 21 days. Specimens were evaluated using Vickers microhardness and SEM-EDX analysis.A 1-way analysis
of variance (ANOVA) and post-hoc Tukey honestly significant difference (HSD) test were used for intragroup comparisons.
Results: Among all remineralizing agents, CaSP showed significantly maximum surface microhardness, followed by NovaMin,
n-HAP, and Pro-Argin. SEM also showed increased surface roughness for all remineralizing agents. EDX showed maximum
increase in mineral content obtained with CaSP.
Conclusion: All remineralizing agents significantly remineralized the stripped enamel surface. CaSP demonstrated promising
results by effectively and significantly remineralizing the enamel lesions as compared to other test agents.

Keywords
Calcium sucrose phosphate, NovaMin, scanning electron microscopy, dental enamel, artificial saliva

Introduction Some studies have shown significant changes on the

enamel surface after applying remineralizing agents. In a
Dental crowding is the most common problem in orthodontic study conducted by Wang et al,5 the authors concluded that
patients. There are different methods to relieve dental bioactive-glass-containing toothpaste occludes dentinal
crowding: arch expansion, anterior teeth proclination, tubules and resists acid challenge, and it may be useful
distalization of the teeth, extraction, or slenderization.1 for the treatment of dentine hypersensitivity and dentine
Slenderization is defined as clinically removing a part of the remineralization. Another study conducted by Swarup
enamel from an interproximal area by grinding. Abrasive strips, and Rao6 concluded that nano-hydroxyapatite (n-HAP)
discs, or burs can be used to perform slenderization. Several particles have more potential to remineralize initial caries
studies have investigated the detrimental effects of enamel than 2% sodium fluoride. George et al7 also evaluated the
slenderization.2 Studies have shown that air-rotor stripping microhardness of enamel after the application of Toothmin
leaves deep grooves/furrows on the enamel surface, which
creates plaque-retentive areas, whichever polishing method is 1
Department of Orthodontics & Dentofacial Orthopaedics, Surendera

used.3 This roughness of enamel surfaces plays a major role Dental College & Research Institute, Sri Ganganagar, Rajasthan, India
in initial adhesion and the retention of oral microorganisms.
Corresponding author:
Therefore, these abraded enamel surfaces have been reported
Renu Nanwal, Post graduate student, Department of Orthodontics &
as having more risk for demineralization than intact surfaces Dentofacial Orthopaedics, Surendera Dental College & Research Institute,
under in vitro conditions. This has been attributed to the Sri Ganganagar, Rajasthan 335001, India.
removal of less-soluble-fluorapatite‑rich enamel layer.4 E-mail: dr.renu07@gmail.com

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2 Journal of Indian Orthodontic Society

(calcium sucrose phosphate [CaSP]) on bleached enamel, After 21 days, on completing the remineralizing
and they found that Toothmin significantly improved the procedures, the root portion of the crown was removed. Each
microhardness. crown was sectioned with a low-speed diamond disc under
Therefore, this study was planned to investigate the water lubrication, along the long axis of the tooth, separating
remineralization effect of n-HAP particles, NovaMin, the mesial and distal surfaces for the study.8 Thus, 108
Pro-Argin (all of which are also used as desensitizing agents), enamel slices were obtained. Then, samples were used for
and CaSP (known as a remineralizing agent) on a stripped microhardness, surface roughness, and elemental analysis.
tooth surface by measuring its surface microhardness and To carry out the microhardness test, the teeth were
surface characteristics and by performing surface elemental embedded in self-curing acrylic resin, leaving the proximal
analysis. enamel surfaces uncovered. Microhardness was assessed
with Vickers hardness test for all the samples (Mitutoyo
MVK H1, Japan). An indenter of microhardness tester
Materials and Method
with a square-based pyramidal diamond was applied on the
The present in vitro study was conducted on a sample of 60 stripped surfaces under a load of 200 g for 10 seconds. For
extracted human premolar teeth. The sample size required each sample, 3 indentations were made, and then the mean
for the study was 16 proximal surfaces per group (with α = value was taken to represent the Vickers hardness value of
0.05, β = 0.2, power = 90%, coefficient of variation = 10). that sample.
Therefore, the sample size of 18 proximal surfaces per group After the microhardness test, all the samples were
was decided for the study. removed from the acrylic block and dried for scanning
Inclusion criteria for teeth selection were teeth free electron microscope–energy dispersive X-ray (SEM-EDX)
from caries, cracks, abrasions, stains, restoration, and analysis (JEOL JSM6510LV, Japan). The samples were then
demineralization. The selected teeth were stored in distilled dehydrated in ascending degrees of alcohol in the following
water until needed, after rinsing with water to remove any manner:
blood/tissue remnants.7 The samples were divided into 6 •• 40% ethanol for 5 minutes;
groups. Each tooth was mounted in plaster in an arch form •• 70% ethanol for 5 minutes;
in a group with roots embedded up to the cervical line in •• 90% ethanol for 5 minutes; and
the plaster to enhance the control and manipulation of the •• Absolute ethanol for 15 minutes.
samples.
After the dehydration with ethanol, samples were completely
Group 1: No slenderization was done. dried with CPD (critical point drying; Leica EM CPD300,
Group 2: Slenderization was done, followed by polishing. Vienna, Austria). Then, samples were placed in an incubator
Group 3: n-HAP (Aclaim; Group Pharmaceuticals, India) at 37°C for 3 days. Following this, dried samples were
was applied after slenderization and polishing. mounted on aluminum stubs, sputter coated with gold for 2
Group 4: NovaMin (Vantej Toothpaste; Dr. Reddy’s minutes, and SEM was done at the center of each test surface
Laboratories, Hyderabad, India) was applied after at standardized magnification (2500×) for comparative
slenderization and polishing. evaluation of surface characteristics. The quantitative
Group 5: CaSP (Toothmin; Biodental Remin, Australia) assessment of the changes in the mineral profile (calcium and
was applied after slenderization and polishing. phosphorus content) was done through an SEM-fitted EDX
Group 6: Pro-Argin (Colgate Sensitive Plus; Colgate- analysis.
Palmolive, India) was applied after slenderization and
polishing.
In all groups except group 1, slenderization was done with
Baseline Examination
a diamond disc (8934A 900 220, Komet Dental Gebr.
Samples obtained from group 1 as positive control and
Brasseler, Lemgo, Germany), followed by polishing with a
samples obtained from group 2 as negative control were
Sof-Lex disc (3M dental products) under water spray with
subjected to microhardness analysis, SEM evaluation, and
10 and 20 strokes, respectively.8 The amount of enamel
EDX elemental analysis over the tooth surface.
reduction was standardized to 0.5 mm per proximal surface,2
which was measured using an incremental thickness gauge.
After the stripping procedures, each tooth was removed from Statistical Analysis
the plaster. Artificial saliva was used to store the samples
at 37°C (pH 7.4) for 21 days during the procedure, which The statistical analysis was done using the SPSS software
was replaced every 24 hours.5 In groups 3 to 6, a toothbrush (SPSS for Windows, release 7.5.1, Chicago, IL, version 23),
having extra-soft bristles, with a remineralizing agent, was and it included mean, standard deviations, and graphical
applied to the occlusal surface at an inclination of about 90° representations using graphs and tables. A 1-way analysis of
for 150 strokes/min for 2 minutes.5 variance (ANOVA) was performed to examine the effect of
Nanwal et al. 3

remineralizing agent application on the slenderized surfaces. On comparing SEM images (Figure 1), the smoothest
Intergroup comparisons were made for the evaluation of enamel surface was seen in the negative control, while the
efficiency of the remineralizing agents. The post-hoc Tukey roughest enamel surface was seen in the positive control.
HSD test was used for intergroup comparisons. The results Among all remineralizing agent application groups, the
were evaluated with a 95% confidence interval, and the CaSP group showed the roughest enamel surface, which was
significance level was set at P < .05. comparable to the natural tooth.
On comparing all EDX values for calcium (Figures 2 and 3),
the results showed that there was a significant increase in
Results calcium content in all remineralizing agent application groups
from the negative control, while intergroup comparison
The results of the Vickers microhardness test are shown in among these groups showed nonsignificant differences. On
Table 1. The hardest enamel surface was obtained for the comparing all EDX values for phosphorus (Figures 4 and 5),
positive control group (412.12 ± 5.43 VHN). Minimum the results showed that there was a significant increase in
microhardness was obtained in the negative control group phosphorus content in all remineralizing agent application
(306.07 ± 2.85 VHN). Among all remineralizing agent groups from the negative control, while intergroup comparison
application groups, maximum surface microhardness was among these groups showed a significantly higher phosphorus
obtained in the CaSP group (394.34 ± 3.19 VHN). content in the CaSP and NovaMin groups.

Table 1. Vickers Microhardness Analysis

Groups Sample No. Max. Min. Mean SD Std. Error P-Value

Positive control 18 418.3 402 412.12 5.43 1.280
Negative control 18 311 301 306.07 2.85 0.671
n-HAP 18 363.7 358 361.43 1.37 0.323
<.0001*
NovaMin 18 373 364.7 369.07 2.99 0.704
CaSP 18 398 387.7 394.34 3.19 0.751
Pro-Argin 18 340.3 333 334.81 1.70 0.401
Source: Vicker’s microhardness test was performed in Spectro Analytical Lab, Delhi.
Note: *p < 0.01 highly significant.

A B

C D

E F

Figure 1. SEM Photomicrographs (2500× Magnification) of Enamel Surfaces: A—group 1; B—group 2; C—group 3; D—group 4; E—group
5; and F—group 6
Source: SEM- EDX was performed in Sai Lab, Patiyala.
4 Journal of Indian Orthodontic Society

Discussion
Calcium Weight
40.00 35.90
31.78
34.13 35.22
31.98
Interproximal enamel stripping is a common orthodontic
35.00
30.00
29.28
procedure to correct tooth crowding and tooth-size
25.00
20.00
discrepancies and to eliminate black triangles between
15.00
10.00 4.57
adjacent teeth caused by gingival recession.8 Some studies
2.91
5.00
0.00
1.54 1.90 2.24 1.63
have shown that stripping can increase the susceptibility of
Posive Negave
control control
n-HAP Novamin CaSP Proargin proximal enamel surfaces to demineralization, risk of caries,
hypersensitivity, risk of periodontal diseases, etc.9,10 Therefore,
Figure 2. Comparison of Mean and SD of Calcium in Weight remineralization through the application of a remineralizing
Percentage for All Groups agent is advocated. Remineralization is the process whereby
Source: Vicker’s microhardness test was performed in Spectro Analytical calcium and phosphate ions are supplied from a source
Lab, Delhi and SEM- EDX was performed in Sai Lab, Patiyala. external to the tooth to promote ion deposition into crystal
voids in demineralized enamel to produce a net mineral gain.
There are various fluoridated and non-fluoridated
Calcium Atomic remineralizing agents that are available. Fluoride has certain
20.00 18.04
16.76 17.32 17.63
16.74
limitations, due to which non-fluoridated remineralizing
18.00
16.00
15.56
agents are recommended.
14.00
12.00
10.00
8.00
6.00 Reasons to Search for Alternatives to Fluorides11
4.00
0.90 0.62 0.92 1.01 1.31 0.65
2.00
0.00
Positive Negative n-HAP Novamin CaSP Proargin
1. Fluoride is highly effective on smooth-surface caries.
control control
Its effect seems to be more limited on pit and fissure
Figure 3. Comparison of Mean and SD of Calcium in Atomic caries.
Percentage for All Groups 2. A high-fluoride strategy cannot be followed, as it has
Source: Vicker’s microhardness test was performed in Spectro Analytical potential for adverse effects (eg, fluorosis) due to
Lab, Delhi and SEM- EDX was performed in Sai Lab, Patiyala. overexposure to fluoride.
Non-fluoridated remineralizing agents act through different
Phosphorus Weight mechanisms. Some agents interact with tooth enamel, some
Phosphorus Weight neutralize the bacterial acid, while others act as anti-plaque
25.00
agents.12 Several similar studies have also been done to evaluate
20.00
25.00
20.05
17.03
18.69 19.61
17.15 the desensitizing and/or remineralizing efficiency of different
20.05 15.22
15.00
20.00
15.22
17.03
18.69 19.61
17.15 agents like casein phosphopeptide-amorphous calcium
10.00
15.00 phosphate (CPP-ACP), n-HAP, NovaMin, CaSP, Pro-Argin,
3.56
5.00
10.00 2.20
1.07 1.35 1.77 1.11 etc.8,13-15 However, no study has been done till date performing
3.56
0.00
5.00 2.20 1.77
1.35 Novamin
1.07 n-HAP
Positive Negative 1.11
CaSP Proargin both quantitative and qualitative analysis. Therefore, this
control control
0.00
Positive Negative n-HAP Novamin CaSP Proargin study was done to compare n-HAP, NovaMin, CaSP, and
control control
Figure 4. Comparison of Mean and SD of Phosphorus in Weight Pro-Argin using two quantitative (Vickers microhardness and
Percentage for All Groups EDX) analyses and one qualitative analysis (SEM) for better
Source: Vicker’s microhardness test was performed in Spectro Analytical authentication of the results.
Lab, Delhi and SEM- EDX was performed in Sai Lab, Patiyala. Group 1 showed maximum surface microhardness and
elements like calcium and phosphorus, which is in accordance
Phosphorus Atomic
with various studies.4,8,16,17,20 Bayram et al8 also found
13.03 Phosphorus12.27
Atomic
14.00
12.00 10.46
11.62
12.69
11.61 maximum surface microhardness and roughness in natural
14.00
10.00
13.03
11.62
12.27 12.69
11.61 teeth. Arman et al16 found maximum surface microhardness
12.00 10.46
8.00
10.00
in permanent teeth without any stripping procedure. Swarup
6.00
8.00
4.00 and Rao6 also found maximum calcium/phosphorus ratio
1.56
6.00
2.00
4.00
1.02 0.60 0.87 1.09 0.59 before demineralization. Jeong et al17 found maximum surface
0.00
2.00 1.02 Negative
Positive 0.60 n-HAP 1.09
0.87 Novamin
1.56
CaSP Proargin
0.59 microhardness before demineralization. Along with all these
control control
0.00
Positive Negative n-HAP Novamin CaSP Proargin
results, SEM also presented a higher surface roughness for
control control
the intact surface with enamel prism cores and interspersed
Figure 5. Comparison of Mean and SD of Phosphorus in Atomic smooth areas, which is in accordance with Bayram et al,8 while
Percentage for All Groups contradictory results were seen where interproximal stripping
Source: Vicker’s microhardness test was performed in Spectro Analytical was done with bur, either with or without polishing, which is
Lab, Delhi and SEM- EDX was performed in Sai Lab, Patiyala. in accordance with Meredith et al18 and Bhambri et al.4
Nanwal et al. 5

Group 2 showed minimum surface microhardness and it first releases sodium ions, which elevates the pH to the range
elements like calcium and phosphorus. This is in accordance essential for HAP formation (7.5–8.5). Then, calcium and
with all the studies that evaluated the demineralization and phosphate are released to supplement the normal levels found
remineralization efficiency of a remineralizing agent, such in saliva. This increase in ionic concentration, combined
as Soares et al,14 Raghu and Ananthakrishna,19 Gangrade with an increase in pH, causes the ions to precipitate onto the
et al,20 Swarup and Rao,6 etc. Some studies have also tooth surface, which form calcium hydroxycarbonate apatite
shown decreased surface microhardness after interproximal (HCA). HCA has a similar chemical structure to the enamel
stripping, like Bayram et al.8 The results of these showed that crystals, thereby almost reproducing the layer of enamel that
a stripped enamel surface has a higher caries risk. Twesme was lost. Bioactive-glass formulation, which has been used
et al21 found more lesion depth in a stripped enamel surface extensively in research studies, is commonly known as 45S5.
than in an intact surface. Zachrisson et al22 and Lapenaite et It contains 45 wt% SiO2, 24.5 wt% Na2O, Ca, O, and 6 wt%
al9 also found a higher caries risk in stripped enamel surfaces. P2O5. These particles have been shown to release ions like Na,
In the current study, the negative control showed a smoother Ca, P, etc, and transform into HCA for up to 2 weeks. Finally,
surface, which is in accordance with Bayram et al,8 Bhambri these particles completely transform into HCA.20
et al,4 and Meredith et al18 who showed smoother surfaces n-HAP also showed significantly increased surface
when interproximal stripping was done with a disc followed microhardness and increased surface roughness in the
by polishing with a disc. SEM images than the negative control, which is in
The CaSP group showed remineralization efficiency, accordance with the EDX results also. This confirms the
which is in accordance with Gangrade et al,20 Menon et al,23 remineralizing efficiency of n-HAP. This is in accordance
Raghu et al,19 and George et al.7 In the present study, the EDX with Carvalho et al,27 Soares et al,14 and Haghgoo et
analysis showing increased calcium and phosphorus ions al.28 HAP is the main constituent of the dental tissues
in specimens treated with CaSP, supporting the increased presenting in enamel and dentine, with 95 wt% and 75
surface microhardness and surface roughness as seen in the wt%, respectively. HAP, as in bone, is responsible for the
SEM images, which confirmed the remineralizing efficiency mechanical behavior of the dental tissues. Poorly crystalline
of CaSP. As surface microhardness depends mainly on hydroxyapatite (HA) nanocrystals, in addition to the
mineral content, especially the inorganic content of enamel, excellent biological properties of HA, such as nontoxicity
the reason for the above findings was CaSP’s higher water and lack of inflammatory and immunizer responses, have
solubility, which provides for higher concentrations of free bioresorption properties under physiological conditions.
calcium and phosphorus ions.24 Toothmin contains CaSP This property can be modulated by modifying its degree
and inorganic calcium phosphate, in which 10% to 12% of crystallinity, which is achieved by the implementation
calcium and 8% to 10% phosphorus by weight are found. of innovative synthesis with a nanosize crystals control.20
As it is completely soluble in water at all pH values, it is The nanocrystals of phosphate are smaller than 100 nm,
able to provide high concentrations of calcium and phosphate improving the bioactivity of the agent due to the increase in
ions in the oral cavity without precipitation. It has been the superficial area and wettability of HAP nanoparticles.
suggested that a 1% Toothmin solution contains about 30 The calcium phosphate nanocrystals penetrate deeper into
× 10−3 M calcium and 10 × 10−4 M sucrose phosphate ions, the demineralized subsurface, forming a “reservoir-like”
while saliva contains only about 1.4 × 10−3 M calcium and 4 deposit of calcium and phosphate ions.26
× 10−3 M phosphate ions. Therefore, the high concentrations The Pro-Argin group also showed significantly more
of calcium and phosphate ions in Toothmin facilitates rapid surface microhardness and surface roughness in the SEM
remineralization of enamel.7,20 images than the negative control, which was supported by
NovaMin also showed remineralizing efficiency in the EDX results, with increased calcium and phosphorus
the present study, which is in accordance with Wang et at the same time. These results confirm its remineralizing
al,5 Narayana et al,25 Sreekumar et al,26 and Aggarwal et efficiency. Similar findings were seen in previous studies,
al.15 In accordance with the results obtained using Vickers such as Kulal et al,29 Poggio et al,30 and Yesilyurt et al.13
microhardness test and the increased surface roughness in Pro-Argin contains arginine, an amino acid naturally found
the SEM images, in NovaMin-treated specimens, the EDX in saliva, and a compound of insoluble calcium in the form
analysis showed large amounts of calcium and phosphorus, of calcium carbonate. Arginine and calcium carbonate bind
confirming the remineralizing properties of NovaMin. to the dentin–enamel negatively charged surface, creating
NovaMin (calcium sodium phosphosilicate) is an inorganic a protective layer, resistant to acid stimuli, that covers the
compound that reacts in aqueous environments to release surface defects and occludes the exposed dentinal tubules
calcium, sodium, and phosphate ions over time. Originally, with a consequently reduced sensitivity.30
NovaMin was developed as a bone regenerative material, but Comparing all results, in the present study, among all
it has been shown to be effective also at physically occluding remineralizing agents, CaSP showed the maximum increase
dentinal tubules through the development of a HAP-like in surface microhardness, calcium and phosphorus content,
mineral layer.15 When it comes in contact with saliva or water, and surface roughness, comparable to the natural tooth.
6 Journal of Indian Orthodontic Society

Limitations of the Study Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to
The present study has some limitations. As remineralization the research, authorship, and/or publication of this article.
of an enamel surface in the oral cavity is a complex procedure,
the limitations of this in vitro study include difficulty in Funding
precisely simulating the biological aspects of caries and the
The authors received no financial support for the research, author-
multitude of intraoral conditions, like the role of enzymes that
ship, and/or publication of this article.
contribute to dental caries. Since solutions are composed of
inorganic ions only, the effects of salivary proteins, pellicle,
References
and plaque on mineralization inhibition have not been taken
into consideration. Other confounding factors involve the 1. Choudhary A, Gautam AK, Chouksey A, Bhusan M, Nigam
possibility of experimental errors and dissimilarities in the M, Tiwari M. Interproximal enamel reduction in orthodontic
microstructure of the enamel between specimens. Further treatment: a review. J App Dent Med Sci. 2015;1(3):123-127.
clinical trials are required to authenticate the results for future 2. Giulio AB, Matteo Z, Serena IP, Silvia M, Luigi C. In vitro
clinical applications. evaluation of casein phosphopeptide-amorphous calcium
phosphate (CPP-ACP) effect on stripped enamel surfaces. A
Conclusion SEM investigation. J Dent. 2009;37:228-232.
3. Paganelli C, Zanarini M, Pazzi E, Marchionni S, Visconti L.
On the basis of the observations and results of the present Alessandri BG. Interproximal enamel reduction: an in vivo
study with its limitations, the following conclusions can be study. Scanning. 2015;37:73-81.
drawn: 4. Bhambri E, Kalra JP, Ahuja S, Bhambri G. Evaluation of enamel
•• Interproximal stripping decreased the surface surfaces following interproximal reduction and polishing with
microhardness, surface roughness, and mineral
different methods: a scanning electron microscope study.
content. The remineralizing agents improved the
Indian J Dent Sci. 2017;9:153-159.
surface characteristics of slenderized enamel.
•• In terms of surface microhardness, all remineralizing 5. Wang Z, Jiang T, Sauro S, et al. The dentine remineralization
agents significantly increased the surface activity of a desensitizing bioactive glass-containing toothpaste:
microhardness of slenderized enamel. There were an in vitro study. Aust Dent J. 2011;56:372-381.
significant differences among all the remineralizing 6. Swarup JS, Rao A. Enamel surface remineralization:
agents used. Among them, the maximum surface using synthetic nanohydroxyapatite. Contemp Clin Dent.
microhardness was achieved by CaSP, followed by 2012;3(4):433-443.
NovaMin, n-HAP, and Pro-Argin. 7. George L, Baby A, Dhanapal TP, Charlie KM, Joseph A,
•• According to SEM evaluation, interproximal Varghese AA. Evaluation and comparison of the microhardness
stripping with a disc, followed by polishing, of enamel after bleaching with fluoride free and fluoride
decreased the surface roughness and created a containing carbamide peroxide bleaching agents and post
smoother surface, as an aprismatic layer was lost in
bleaching anticay application: an in vitro study. Contemp Clin
the procedure. All remineralizing agents increased
Dent. 2015;6:S163-S166.
the surface roughness through new apatite layer
formation. 8. Bayram M, Kusgoz A, Yesilyurt C, Nur M. Effect of casein
•• EDX elemental analysis was found to be an phosphopeptide amorphous calcium phosphate application
efficient method to quantify the changes in mineral after interproximal stripping on enamel surface: an in vivo
content. It provided validation of the effectiveness study. Am J Orthod Dentofacial Orthop. 2017;151:167-173.
of remineralizing agents. According to the EDX 9. Lapenaite E, Lopatiene K. Interproximal enamel reduction as a
results, all remineralizing agents were capable of part of orthodontic treatment. Stomatolog Balt Dent Maxillofac
increasing the mineral content that had been lost J. 2014;16:19-24.
during interproximal stripping. Among all the 10. Rossouw PE, Tortorella A. Enamel reduction procedures in
remineralizing agents, maximum increase in mineral orthodontic treatment. J Can Dent Assoc. 2003;69:378-383.
content was seen with CaSP, followed by NovaMin,
Pro-Argin, and n-HAP, although the differences were 11. Goswami M, Saha S, Chaitra TR. Latest developments in
nonsignificant. non-fluoridated remineralizing technologies. J Ind Soc Pedod
•• Overall, CaSP can be considered as the best Prev Dent. 2012;30:2-6.
remineralizing agent to prevent the detrimental 12. Kalra DD, Kalra RD, Kini PV, Allama PCR. Non fluoride
effects of interproximal stripping, followed by remineralization: an evidence-based review of contemporary
NovaMin, n-HAP, and Pro-Argin. technologies. J Dent Allied Sci. 2014;3:24-33.
Nanwal et al. 7

13. Yesilyurt C, Sezer U, Ayar MK, Alp CK, Tasdemir T. The effect risk in posterior teeth. Am J Orthod Dentofacial Orthop.
of a new calcium-based agent, Pro-Argin, on the microhardness 2011;139:90-98.
of bleached enamel surface. Aus Dent J. 2013;58:207-212. 23. Menon LU, Varma RB, Kumaran P, Xavier AM, Govinda BS,
14. Soares R, Ataide IDND, Fernandes M, Lambor R. Assessment Kumar JS. Efficacy of a calcium sucrose phosphate based
of enamel remineralisation after treatment with four different toothpaste in elevating the level of calcium, phosphate ions in
remineralising agents: a scanning electron microscopy (SEM) saliva and reducing plaque: a clinical trial. Contemp Clin Dent.
study. J Clin Diag Res. 2017;11(4):ZC136-ZC141. 2018;9:151-157.
15. Aggarwal A, Gupta SK, Singh K, Bindra SPS. Comparative 24. Kaur G, Sanap AU, Aggarwal SD, Kumar T. Comparison
evaluation of protective potential of Toothmin and of two different remineralizing agents on microhardness of
NovaMin containing toothpastes on enamel surface under bleached enamel: results of an in vitro study. Indian J Dent
confocal microscope: an in vitro study. Dent J Adv Stud. Res. 2015;26:176-179.
2016;4(II):113-116. 25. Narayana SS, Deepa VK, Ahamed S, Sathish ES, Meyappan
16. Arman A, Cehreli SB, Ozel E, et al. Qualitative and quantitative R, Kumar S. Remineralization efficiency of bioactive glass on
evaluation of enamel after various stripping methods. Am J artificially induced carious lesion an in-vitro study. J Ind Soc
Orthod Dentofac Orthop. 2006;130:131.e7-131.e14. Pedod Prev Dent. 2014;32:19-25.
17. Jeong SH, Jang SO, Kim KN, Kwon HK, Park YD, Kim BI. 26. Sreekumar P, Kumaran P, Xavier AM, Varma BR, Kumar SJ.
Remineralization potential of new toothpaste containing nano- Qualitative and quantiative comparison of the remineralization
hydroxyapatite. Key Eng Mat. 2006;309-311:537-540. potential of three suitable material—an in vitro SMH and SEM
18. Meredith L, Farella M, Lowrey S, Cannon RD, Mei L. Atomic study. J Clin Diagn Res. 2019;13(1):ZC01-ZC04.
force microscopy analysis of enamel nanotopography after 27. de Carvalho FG, Vieira BR, dos Santos RL, Carlo HL, Lopes
interproximal reduction. Am J Orthod Dentofac Orthop. PQ, De Lima BASG. In vitro effects of nano-hydroxyapatite
2017;151:750-757. paste on initial enamel carious lesions. Pediatr Dent.
19. Raghu TN, Ananthakrishna S. Remineralization potential of 2014;36:E85-E89.
calcium sucrose phosphate on deminearalized enamel: results 28. Haghgoo R, Ahmadvand M, Moshaverinia S. Remineralizing
of an in vitro study. J Int Oral Health. 2016;8(6):704-708. effect of topical novamin and nano-hydroxyapatite on
20. Gangrade A, Gade V, Patil S, Gade J, Chandhok D, Thakur caries-like lesions in primary teeth. J Contemp Dent Pract.
D. In vitro evaluation of remineralization efficacy of 2016;17(8):645-649.
different calcium and fluoride-based delivery systems on 29. Kulal R, Jayanti I, Sambashivaiah S, Bilchodmath SP. An
artificially demineralized enamel surface. J Conserv Dent. in vitro comparison of nano hydroxyapatite, novamin and
2016;19:328-331. proargin desensitizing toothpastes—a SEM study. J Clin Diag
21. Twesme DA, Firestone AR, Heaven TJ, Feagin FF, Jacobson A. Res. 2016;10(10):ZC51-ZC54.
Air-rotor stripping and enamel demineralization. Am J Orthod 30. Poggio C, Ceci M, Beltrami R, Lombardini M, Colombo M.
Dentofac Orthop. 1994;105:142-152. Atomic force microscopy study of enamel remineralization.
22. Zachrisson BU, Minster L, Ogaard B, Birkhed D. Dental Annali di Stomatologia. 2014;98(3):98-102.
health assessed after interproximal enamel reduction: caries