Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2016; 61: 196–202

doi: 10.1111/adj.12367

Effect of flavonoids on remineralization of artificial root

caries
DJ Epasinghe,* CKY Yiu,† MF Burrow‡
*Oral Biosciences, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
†Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China.
‡Biomaterials, Melbourne Dental School, The University of Melbourne, Victoria, Australia.

ABSTRACT
Background: This study compared the effects of three flavonoids, including proanthocyanidin, naringin and quercetin on
remineralization of artificial root caries.
Methods: Demineralized root fragments (n = 75) were randomly divided into five groups for treatment with the reminer-
alizing agents for 10 minutes: (1) 6.5% proanthocyanidin; (2) 6.5% naringin; (3) 6.5% quercetin; (4) 1000 ppm
fluoride; and (5) deionized water (control). The demineralized samples were pH-cycled through treatment solutions,
acidic buffer and neutral buffer for eight days at six cycles per day. The remineralization effects were evaluated using
Knoop microhardness, transverse microradiography (lesion depth and mineral loss) and confocal laser scanning micro-
scopy. Microhardness at different lesion depths was analysed with two-way ANOVA and Tukey’s test, while lesion
depths and mineral loss were analysed with one-way ANOVA and Tukey’s test.
Results: Artificial caries lesions treated with fluoride and flavonoids showed significantly greater hardness than the
control group (p < 0.05). Both lesion depths and mineral loss of the flavonoid treated groups were significantly lower
than the control group (p < 0.05), but significantly higher than the fluoride treated group. No significant difference in
lesion depth and mineral loss was found among the three flavonoids (p > 0.05).
Conclusions: All three flavonoids showed positive effects on artificial root caries remineralization, which are significantly
lower than that of 1000 ppm fluoride.
Keywords: Naringin, proanthocyanidin, quercetin, remineralization, root caries.
Abbreviations and acronyms: CLSM = confocal laser scanning microscopy; NR = naringin; PA = proanthocyanidin; QC = quercetin.
(Accepted for publication 14 August 2015.)

a preventive regime to address the problem using

INTRODUCTION
minimal intervention treatment tailored to the patient’s
With the improvement in oral health care, the rate of needs.5 The modern concepts of minimum interven-
edentulism has reduced significantly over the years in tion dentistry place strong emphasis on arresting and
Australia.1 However, with the increased number of nat- reversing incipient lesions, using appropriate topical
ural teeth present and in the elderly population, the risk remineralizing agents.6 Although fluoride is a remark-
and prevalence of caries have increased.2 There is also a able remineralizing agent of enamel, it is less effective
concomittent increase in the prevalence of periodonton- on dentine.7 This could be attributed to the presence
tal disease with the decreasing rate of edentulism in the of a highly organized collagen matrix with less
elderly. Gingival recession resulting from the periodon- mineral content in dentine, making it more susceptible
tal diseases leave the root surfaces exposed to the devel- to degradation by free- and collagen-bound proteases.8,9
opment of root caries, which has important Thus, there is a need for development of novel strate-
implications for preventive and restorative treatments.3 gies to preserve the organic dentine matrix and
In contrast to young people, early intervention and promote remineralization, which is required to reduce
conservative treatment to arrest dental disease are root caries progression.10
preferred in the elderly as complex restorative treat- Flavonoids are a group of bioactive molecules that
ments may be difficult for them to maintain with are capable of performing various biological processes
advancing age.4 As root caries is very common among that have antioxidant, antibacterial and anti-inflam-
the elderly, oral health care providers should establish matory properties.11 They are consumed in high
196 © 2016 Australian Dental Association
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Remineralization of artificial root caries by flavonoids

amounts in fruits and vegetables. Apart from having three different types of flavonoids on remineralization
varying degrees of antioxidant, anti-inflammatory and of artificial root caries lesions by evaluating micro-
anti-tumour effects, flavonoids can interact with hardness, lesion depth and mineral loss following
proteins, such as collagen and receptor molecules or treatment of the three flavonoids. The microhardness
anions, like calcium and iron.12–15 data is related to microhardness testing, while lesion
Recently, the application of flavonoids in dentistry depth and mineral loss to transverse microradiogra-
has become popular. Several flavonoids, such as hes- phy, as an indirect measure of remineralization. The
peridin, green tea extract, genipin and proanthocyani- null hypothesis tested was that the tested flavonoids
din have been proven beneficial in promoting oral had no effect on remineralization of artificial root
health.12,16,17 Hesperidin preserves dentine collagen caries.
and stimulates mineral deposition on root surface
caries.16 Green tea extract has been shown to reduce
MATERIALS AND METHODS
erosion and abrasion, and to facilitate preservation of
the dentine matrix, in vitro and in situ.18–20
Materials
Cranberry extract inhibits the formation of dental
biofilm and reduces plaque formation.21 QC and NR were obtained from Sigma-Aldrich with
Proanthocyanidin (PA), a plant flavonoid belonging a purity of 95% and 93%, respectively. PA was
to the flavanol group, has been reported to have a obtained from International Laboratory of USA, with
remineralization effect on artificial root caries.12,17 PA a purity of >95% oligomeric proanthocyanidin. A
is prevalent in pine bark, elm trees and grape seed.18 6.5% (w/v) solution of each flavonoid in phosphate
PA is also commonly available in vegetables and buffer (0.025 M KH2PO4, 0.025M K2HPO4, pH 7.4)
fruits, but in lower concentrations. Quercetin (QC) was used in this study. The chemical structures of the
belongs to the flavonol group and is found in citrus three tested flavonoids are shown in Fig. 1. Sodium
fruit. It has a collagen cross-linking effect and stimu- fluoride solution (1000 ppm F, Fisher Chemical, USA)
lates growth of bone mass.19,20 Naringin (NR) is a fla- was used as a positive control, while deionized water
vonone glycoside, mainly present in apples and was used as a negative control.
onions. It exhibits a strong affinity towards collagen
and improves the quality of bone.13,21 These three
Preparation of dentine specimens
types of flavonoids share a common basic structural
feature, mainly a benzopyrine ring, but differ accord- Forty extracted sound human third molars that had
ing to the number and types of groups attached to the been stored in a 0.5% chloramine T solution at 4 °C
benzene ring.22 The attachment of different functional were used within one month after extraction. The
groups in different positions can alter the biological teeth were collected after the patients’ informed
effects of the flavonoids.22 consent had been obtained under a protocol reviewed
Being an oligomeric molecule, PA presents with a and approved by the Institutional Review Board, The
larger molecular size, which may limit its penetration University of Hong Kong (UW 11-242). The teeth
into demineralized dentine and therefore its remineral- were thoroughly cleaned. Seventy-five root fragments
ization potential. Furthermore, staining of dentine by (5 mm x 5 mm x 5 mm) were obtained from the
PA also presents a clinical problem. Conversely, QC cervical root portions of the teeth. A window of
and NR are both flavonoids, belonging to flavonol 3 mm x 4 mm was created on the surface by applying
and flavonone glycoside groups. They have similar acid resistant nail varnish (Revlon Corp., NY, USA)
molecular structure to PA, but of smaller molecular to the root surface.
sizes, which may facilitate their penetration into dem-
ineralized dentine and enhance the remineralization
Lesion formation
effect.
In our previous study, PA, QC and NR have been Lesion formation and pH-cycling were performed
examined for their effects on the mechanical proper- following the protocol used by Xie et al.12 The root
ties of dentine. Although not as effective as PA, with fragments were placed in a demineralizing solution
prolonged treatment (30 minutes to 1 hour), both QC (2.2 mM CaCl2.2H2O, 2.2 mM KH2PO2, 50 mM
and NR enhanced the ultimate tensile strengths and acetate, pH 4.6) for 96 hours at 37 °C to create lesions
modulus of elasticity of demineralized dentine.23 It 70–100 lm deep according to the previous study.12 In
has also been shown that PA acted simultaneously order to maintain the baseline lesion, the fragments
with CPP-ACP and CPP-ACFP to promote remineral- were rinsed thoroughly with deionized water. One half
ization of artificial root caries.24 However, no studies of the window of each specimen was covered with the
have compared the remineralization effect of PA, QC acid resistant nail polish (Revlon Corp., NY, USA) to
and NR. Hence, this study compared the effect of maintain a reference baseline lesion.
© 2016 Australian Dental Association 197
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DJ Epasinghe et al.

Fig. 1 Chemical structures of the tested flavonoids.

Remineralization regimen transverse microradiography and confocal laser scan-

ning microscopy (CLSM) analysis.
The demineralized root fragments were randomly
For the microhardness test, polishing of the embed-
divided into five groups (n = 15 per group) based on
ded samples was performed on a water-cooled polish-
treatments: (1) 6.5% PA; (2) 6.5% NR; (3) 6.5%
ing unit (EcoMet 3000, Buehler, Lake Bluff, IL, USA)
QC; (4) 1000 ppm fluoride solution as NaF; and (5)
with abrasive papers (400-, 600- and 1200-grit)
control (deionized water). All specimens were pH-
followed by polishing with 0.9, 0.6, 0.3 and 0.1 lm
cycled through the treatment solutions (10 minutes),
diamond suspensions (Metaldi Supreme, Buehler,
acidic buffer (50 mM acetate; 2.25 mM CaCl2.2H2O;
Lake Bluff, IL, USA). The residue was removed by
1.35 mM KH2PO4; 130 mM KCl; pH 5.0; 30 min-
ultrasonically cleaning the samples for 2 minutes.
utes) and neutral buffer (20 mM HEPES; 2.25 mM
Cross-sectional microhardness measurements perpen-
CaCl2.2H2O; 1.35 mM KH2PO4; 130 mM KCl, pH
dicular to the demineralized surface (Leica, Tukon
7.0; 10 minutes). Six demineralization–remineraliza-
200, Germany) were performed at 20, 50, 80, 110
tion cycles were performed each day and continued
and 140 lm from the surface using Knoop hardness
for eight days. A 250 mL polystyrene jar was used for
indentation at a 25 g load for 15 seconds in an ambi-
the in vitro pH-cycling experiments. All solutions
ent environment. Measurements were performed for all
were freshly prepared just before use. The specimens
the samples at three different locations at each depth.
were stored in a neutral buffer overnight at 37 °C.

Transverse microradiography
Microhardness test
The remaining halves of the specimens (n = 5 per
After eight days of pH cycling, five specimens from
group) were dehydrated using a series of ethanol
each treatment group were rinsed in deionized water
solutions from 20% to 100%, followed by a transitional
for 2 minutes and sectioned into two halves. One half
medium containing propylene oxide. The specimens
of the specimens was embedded perpendicular to the
were then embedded in epoxy resin and sectioned longi-
demineralized surface in epoxy resin for microhard-
tudinally through the lesion centre into 200  20 lm
ness measurement. The other half was used for
198 © 2016 Australian Dental Association
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Remineralization of artificial root caries by flavonoids

thick sections (Isomet, Buhler Ltd, Lake Bluff Ltd, IL, the normality (checked by Kolmogorov–Smirnov test)
USA). The 200  20 lm thick sections were X-rayed and the equal variance assumptions (checked by modi-
together with an aluminium step wedge at 12 kV and fied Levene test) of the data were valid, two-way
4 mA for 45 seconds. The reading of the step wedge ANOVA (remineralization treatments vs lesion
was transformed into a mineral content number and depths) and post hoc Tukey multiple comparison test
used for calculating lesion depth and mineral loss. were used to examine the effect of various remineral-
Microradiographic plates were processed (Eastman ization treatments on microhardness, while one-way
Kodak Co., Rochester, NY, USA) and the radiographic ANOVA and post hoc Tukey multiple comparison
images were exported to the computer via a CCD cam- test were used to examine the effect of various
era from the microscope. Lesion depth was defined as remineralization treatments on lesion depth and
the distance from the lesion surface to the site where mineral loss. A level of significance of a = 0.05 was
the mineral content was more than 95% for the sound set in all statistical tests.
dentine. Mineral loss was evaluated by computing the
area obtained by plotting the vol% mineral profile
RESULTS
towards lesion depth in each dentine section, with
the sound dentine set as 48 vol% mineral contents.25 Table 1 presents the cross-sectional microhardness
measurements of the artificial caries lesion from the
different treatment groups at different lesion depths
Confocal laser scanning microscopy
from the surface. Results of two-way ANOVA indi-
The remaining specimens (n = 10 per group) were cated that the factors ‘remineralization treatments’
embedded in epoxy resin at the wet stage, sectioned (p < 0.001) and ‘lesion depth’ (p < 0.001) had signifi-
into 200  20 lm thick sections using a diamond cant effects on microhardness. The interaction
wafering blade immediately after setting of the resin between the two factors was also significant
under water cooling (Isomet, Buhler Ltd, Lake Bluff, (p < 0.001). Except the NR treated group at 110 lm,
IL, USA) for CLSM evaluation. Prepared dentine artificial caries lesions treated with fluoride and
sections were stained with a freshly prepared 0.1% flavonoids showed significantly greater microhard-
Rhodamine B solution (Sigma-Aldrich Chemical ness values than the control group at all lesion
Corp., Milwaukee, WI, USA) for 1 hour, and rinsed depths (p < 0.05). No significant differences in
three times with deionized water. Samples were microhardness values were observed among the fluo-
analysed with a CLSM (Zeiss LSM 510, Carl Zeiss ride and flavonoid treated groups up to 80 lm deep
Inc., Germany), using an argon laser with a 529 nm (p > 0.05), but the fluoride group showed signifi-
excitation wavelength. Areas were scanned between cantly higher hardness values at 110 lm and
10 lm and 50 lm below the cut surface to reduce the 170 lm (p < 0.05).
influence of the smear layer created during the cutting Table 2 summarizes the lesion depth and mineral
and polishing procedures. loss obtained from transverse microradiography. The
one-way ANOVA indicated the factor ‘remineraliza-
tion treatments’ had a significant effect on lesion
Statistical analysis
depth (p < 0.001) and mineral loss (p < 0.001). The
The microhardness data, lesion depth and mineral loss fluoride group showed the lowest lesion depth and
data were analysed using a statistical package mineral loss, when compared to all the other groups
(SigmaStat Version 16, SPSS, Chicago, IL, USA). As (p < 0.001). No significant differences in lesion depth

Table 1. Cross-sectional microhardness of the artificial caries lesions of different treatment groups
Depth from surface (lm) Knoop hardness numbers

Control Fluoride Proanthocyanidin Naringin Quercetin

30 3.2  0.55A,a
8.66  1.83A,b
8.99  2.27A,b
8.85  3.53A,b
8.98  4.2A,b
50 7.42  1.5B,a 11.50  4.75A,b 11.98  2.85A,b 11.03  3.40A,b 10.43  2.54A,b
80 14.52  3.69B,a 26.95  2.61B,b 25.72  6.26B,b 23.28  7.39B,b 25.15  9.37B,b
110 26.02  4.33D,a 49.97  14.06C,c 38.92  6.72C,b 35.76  16.61C,a,b 37.81  14.81C,b
140 36.58  2.81E,a 57.97  19.10C,b 49.53  11.43D,b 47.86  17.53D,b 48.09  14.76D,b
170 44.85  7.38F,a 73.62  12.02D,d 66.29  16.24E,b,c 62.29  19.94E,b 69.14  8.44E,b,c

Values are means and standard deviations.

Upper case indicates statistically significant differences between depths (p < 0.05) and lower case indicates statistically significant differences
between treatments (p < 0.05).

© 2016 Australian Dental Association 199

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DJ Epasinghe et al.

Table 2. Effect of remineralization treatments on (a)

mineral loss and lesion depth of the artificial root caries
lesions evaluated using transverse microradiography
Remineralization Mineral loss (DZ, vol%) Lesion depth (lm)
treatments

Control 4214.07  707.42a 164.36  40.63a

Fluoride 1206.66  396.53b 62.53  15.84b
(b)
Proanthocyanidin 2132.84  755.53c 101.52  16.58c
Naringin 1825.61  797.20c 90.95  27.09c
Quercetin 1793.38  606.02c 93.73  23.09c

Values are means and standard deviations.

Groups identified by different superscripts are significantly different
(p < 0.05).

(c)
and mineral loss were observed among the three
tested flavonoids (p > 0.05).
Figure 2 shows representative transverse microra-
diographic images of artificial root caries lesions from
different treatment groups. The control group showed
the deepest and least mineralized lesion (Fig. 2a). Both
fluoride (Fig. 2b) and flavonoid treatments (Fig. 2c–e) (d)
reduced lesion depths. However, the fluoride treated
dentine showed a thicker, well-defined surface miner-
alized layer (Fig. 2b), when compared to the flavo-
noid-treated dentine groups (Fig. 2c, 2d and 2e).
Some mineral deposition was observed throughout the
body of lesions in the flavonoid-treated dentine groups
(Fig. 2c–e). (e)
Figure 3 shows representative CLSM images of
artificial caries lesions from the different treatment
groups. The red fluorescent band representing the
caries lesion was reduced in both fluoride and flavo-
noid treated groups, when compared to the control
group, indicating that both fluoride and flavonoids Fig. 2 Transverse microradiographic images of artificial root caries
enhanced remineralization of artificial root lesions. lesions of different treatment groups: (a) control; (b) 1000 ppm fluoride;
However, in the flavonoid treated groups, the red (c) 6.5% proanthocyanidin; (d) 6.5% naringin; (e) 6.5% quercetin (P:
precipitation band; L: lesion; D: sound dentine). The white arrowhead
fluorescent band was less well-defined than the fluo- that lies within the radiolucent area represents the lesion and the radiopa-
ride treated group. A thick dense band was observed que area above the lesion represents mineral deposition during the rem-
on the surface of fluoride treated lesions. ineralization process. The radiopaque area below the lesion is sound
dentine.

DISCUSSION
loss measurements from the transverse microradio-
Our study compared the effects of three flavonoids, graphs, all three tested flavonoids inhibited demineral-
PA, QC and NR, belonging to three different classes ization and promoted remineralization of artificial
of flavonoids, flavanol, flavonol and flavonone root caries lesions. The microhardness of the artificial
glycoside, on remineralization of artificial root caries. caries lesion of the flavonoid treated groups was
The allocation of root fragments within groups was significantly higher compared to the control. Hence,
done randomly and there is a possibility that the root the null hypothesis that the tested flavonoids had no
fragments from one tooth might have been included effect on remineralization of artificial root caries was
in the same group. However, as only two root frag- rejected. However, the remineralization effect of the
ments were obtained from a single tooth for each flavonoids was less than fluoride.
group, the effect of data clustering is minimal. Enamel caries is caused by acid dissolution of min-
Knoop hardness number values were used in the erals by bacteria. Remineralization of enamel mainly
current study together with transverse microradiogra- occurs in an inorganic environment with homogenous
phy and CLSM as indirect measurements of reminer- hydroxyapatite crystal seeds. In contrast, dentine car-
alization. According to the lesion depth and mineral ies involves both demineralization and breakdown of
200 © 2016 Australian Dental Association
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Remineralization of artificial root caries by flavonoids

(a) The organic phase of dentine consists of 90% type I

collagen and 10% non-collagenous proteins. The
remineralizaton process in dentine is controlled
through the interactions of mineral crystallites with
the collagen matrix; therefore, the organic matrix of
dentine plays a major role in demineralization and
remineralization.12 Preservation of the demineralized
dentine matrix, which acts as a template for mineral
(b) deposition, is essential for remineralization of dentine
to occur. Inhibition of mineral loss in the flavonoid
treated groups could be attributed to stabilization of
the collagen matrix. PA is a well-known collagen
cross-linker; the phenolic hydroxyl groups of PA can
form hydrogen bonds with the amide carbonyl or
hydroxyl groups of the collagen, enhancing the mechan-
ical properties of collagen fibrils.26 It also inhibits both
soluble and matrix-bound matrix metalloproteinases
(c)
and cysteine cathepsins in dentine, increasing the resis-
tance of collagen fibrils to degradation by enzymatic
digestion.27 Furthermore, the stabilized collagen matrix
acts as a mechanical barrier, which prevents ingress of
acid and further loss of calcium and phosphate ions
from the carious lesions.
It is likely that PA, QC and NR may all form com-
plexes with calcium ions as they all contain hydroxyl
(d) groups in their molecular structure. Minerals are
deposited on both the surface and subsurface layers of
demineralized dentine. The mineral deposition in the
subsurface layer may form nucleation sites for
hydroxyapatite crystals. Furthermore, the negatively
charged non-collageneous proteins in the organic
matrix contain highly charged phosphorylated serine
and threonine residues. These residues may also
(e) attract and trap calcium ions leading to nucleation
and growth of hydroxyapatite. The hydroxyapatite
residues in demineralized dentine could act as sites for
apatite nucleation and growth of hydroxyapatite in
the presence of calcium and phosphate, enabling
remineralization and partial recovery of the mechanical
properties of the demineralized dentine.28
Dentine consists mainly of an organic matrix with a
Fig. 3 Representative confocal laser scanning microscopy images of
artificial caries lesions of different treatment groups stained with Rhodamine higher percentage of collagen and non-collagenous
B: (a) control; (b) 1000 ppm fluoride; (c) 6.5% proanthocyanidin; (d) proteins.29 The mineral phase is distributed in the
6.5% naringin; (e) 6.5% quercetin (P: precipitation band; L: lesion; D: extrafibrillar and intrafibrillar compartments of colla-
sound dentine). The red fluorescence area where the black arrowhead is
represents the lesion. The dark area above the lesion is mineral deposi- gen. While extrafibrillar mineral is deposited in inter-
tion though the remineralization process. The dark area below the stitial spaces between collagen fibrils, intrafibrillar
lesion is sound dentine. minerals are deposited within gap zones and microfib-
rillar spaces. Recent advancements in remineralization
of dentine have shown the importance of a hierarchi-
the collagen matrix. Remineralization of dentine cal assembly of minerals in collagen fibrils to enhance
occurs in an organic environment within a demineral- the mechanical properties of dentine.9,30
ized collagen matrix. According to Paven et al.,17 the Although all the tested flavonoids inhibited
formation of a hypermineralized surface layer by fluo- demineralization and enhanced remineralization of
ride prevents remineralization in deeper parts of the dentine in the present study, there is no evidence of
lesions. Hence, it is necessary to find alternative intrafibrillar mineral deposition. Intrafibrillar mineral-
methods for dentine remineralization. ization is necessary to recover the mechanical properties
© 2016 Australian Dental Association 201
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DJ Epasinghe et al.

to remineralize dentine functionally.30 Recently, the 17. Pavan S, Xie Q, Hara AT, et al. Biomimetic approach for root
caries prevention using a proanthocyanidin-rich agent. Caries
introduction of polyvinyl phosphonic acid to the Res 2011;45:443–447.
collagen matrix has been shown to stimulate intrafibril-
18. Fine AM. Oligomeric proanthocyanidin complexes: history,
lar mineralization.31 Further studies will be conducted structure, and phytopharmaceutical applications. Altern Med
to stimulate intrafibrillar mineralization of flavonoid Rev 2000;5:144–151.
treated collagen fibril matrix with conjugation of 19. Zhai W, Lu X, Chang J, et al. Quercetin-crosslinked porcine
various non-collagenous molecules and acidic groups. heart valve matrix: mechanical properties, stability, anticalci-
fication and cytocompatibility. Acta Biomater 2010;6:389–
395.
CONCLUSIONS 20. Trivedi R, Kumar A, Gupta V, et al. Effects of Egb 761 on
bone mineral density, bone microstructure, and osteoblast
Within the limits of this study, it may be concluded that function: possible roles of quercetin and kaempferol. Mol Cell
Endocrinol 2009;302:86–91.
all three flavonoids, proanthocyanidin, naringin and
21. Habauzit V, Sacco SM, Gil-Izquierdo A, et al. Differential
quecertin are equally effective in inhibiting demineral- effects of two citrus flavanones on bone quality in senescent
ization and enhancing remineralization of artificial root male rats in relation to their bioavailability and metabolism.
caries lesions. It was also found that the remineralizing Bone 2011;49:1108–1116.
potential of the flavonoids was lower than fluoride. 22. Heim KE, Tagliaferro AR, Bobilya DJ. Flavonoid antioxidants:
chemistry, metabolism and structure-activity relationships. J
Nutr Biochem 2002;13:572–584.
REFERENCES 23. Epasinghe DJ, Yiu CK, Burrow MF, et al. Effect of flavonoids
on the mechanical properties of demineralised dentine. J Dent
1. Hopcraft MS. Dental demographics and metrics of oral diseases 2014;42:1178–1184.
in the ageing Australian population. Aust Dent J 2015;60(Suppl
1):2–13. 24. Epasinghe DJ, Yiu CK, Burrow MF. Synergistic effect of proan-
thocyanidin and CPP-ACFP on remineralization of artificial
2. Griffin SO, Griffin PM, Swann JL, et al. Estimating rates of root caries. Aust Dent J 2015;60:463–470.
new root caries in older adults. J Dent Res 2004;83:634–638.
25. van der Veen MH, ten Bosch JJ. An in vitro evaluation of fluo-
3. Matthews DC, Clovis JB, Brillant MG, et al. Oral health status rescein penetration into natural root surface carious lesions.
of long-term care residents–a vulnerable population. J Can Dent Caries Res 1993;27:258–261.
Assoc 2012;78:c3.
26. Bedran-Russo AK, Castellan CS, Shinohara MS, et al. Charac-
4. Murray CG. Advanced restorative dentistry – a problem for the terization of biomodified dentin matrices for potential preven-
elderly? An ethical dilemma. Aust Dent J 2015;60(Suppl tive and reparative therapies. Acta Biomater 2011;7:1735–
1):106–113. 1741.
5. Lewis A, Wallace J, Deutsch A, King P. Improving the oral 27. Epasinghe DJ, Yiu CK, Burrow MF, et al. The inhibitory effect
health of frail and functionally dependent elderly. Aust Dent J of proanthocyanidin on soluble and collagen-bound proteases. J
2015;60(Suppl 1):95–105. Dent 2013;41:832–839.
6. Walsh LJ, Brostek AM. Minimum intervention dentistry princi- 28. Srot V, Bussmann B, Salzberger U, et al. Linking microstructure
ples and objectives. Aust Dent J 2013;58(Suppl 1):3–16. and nanochemistry in human dental tissues. Microsc Microanal
7. ten Cate JM. Remineralization of deep enamel dentine caries 2012:1–15.
lesions. Aust Dent J 2008;53:281–285. 29. Landis WJ, Hodgens KJ, Arena J, et al. Structural relations
8. Deyhle H, Bunk O, Muller B. Nanostructure of healthy and between collagen and mineral in bone as determined by high
caries-affected human teeth. Nanomedicine 2011;7:694–701. voltage electron microscopic tomography. Microsc Res Tech
1996;33:192–202.
9. Dai L, Liu Y, Salameh Z, et al. Can caries-affected dentin be
completely remineralized by guided tissue temineralization? 30. Kinney JH, Habelitz S, Marshall SJ, et al. The importance of
Dent Hypotheses 2011;2:74–82. intrafibrillar mineralization of collagen on the mechanical prop-
erties of dentin. J Dent Res 2003;82:957–961.
10. Preston AJ. Dental management of the elderly patient. Dent
Update 2012;39:141–143. 31. Gu LS, Kim YK, Liu Y, et al. Immobilization of a phospho-
nated analog of matrix phosphoproteins within cross-linked
11. Visioli F, De La Lastra CA, Andres-Lacueva C, et al. Polyphe- collagen as a templating mechanism for biomimetic
nols and human health: a prospectus. Crit Rev Food Sci Nutr mineralization. Acta Biomater 2011;7:268–277.
2011;51:524–546.
12. Xie Q, Bedran-Russo AK, Wu CD. In vitro remineralization
effects of grape seed extract on artificial root caries. J Dent Address for correspondence:
2008;36:900–906. Professor Cynthia Yiu
13. Wong RW, Rabie AB. Effect of naringin collagen graft on bone Paediatric Dentistry and Orthodontics
formation. Biomaterials 2006;27:1824–1831. Faculty of Dentistry
14. Robak J, Gryglewski RJ. Bioactivity of flavonoids. Pol J Phar- The University of Hong Kong
macol 1996;48:555–564.
Prince Philip Dental Hospital
15. Kostyuk V, Potapovich A, De Luca C. The promise of plant
polyphenols as the golden standard skin anti-inflammatory
34 Hospital Road
agents. Curr Drug Metab 2010;11:414–424. Hong Kong SAR
16. Hiraishi N, Sono R, Islam MS, et al. Effect of hesperidin China
in vitro on root dentine collagen and demineralization. J Dent Email: [email protected]
2011;39:391–396.

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