الفهرس 
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Abstract
The emergence of the minimal invasive dentistry philosophy has clearly emphasized on the need for clinically effective materials and measures capable of remineralizing early enamel caries lesions.
Although fluoride has been the gold standard of remineralization of white spot lesions (WSL), some studies have claimed that it is capable of remineralizing outer 30ųm of enamel surface only, while other studies stated that its ability to reduce caries prevalence in some populations is reaching a plateau. Therefore, alternative remineralizing materials have been recently developed claiming that these have advantages over the remineralization using fluoride. These include their ability to promote deeper remineralization, reduce potential risks associated with the use of highly fluoridated products, and to control dental caries over a lifetime.
That’s why studies have been lately focusing on the development of new remineralizing materials that are capable of remineralizing subsurface carious lesions. Among these materials, the biomimetic remineralization concept has emerged. This concept states that specific materials are capable of mimicking the natural mineralization process of the enamel structure, namely the biomineralization process and therefore was named ‘biomimetic remineralization’.
Self-assembling peptide P11-4 (SAP P11-4) and nanohydroxyapatite (nHa) are examples of commercially available biomimetic remineralizing materials. Other non-commercially available materials include dentin phosphoprotein 8DSS peptide, electrically accelerated and enhanced remineralization (EAER), leucine rich amelogenin peptide, and poly amido-amine dendrimers (PAMAM).
Other non-fluoride remineralizing technologies include calcium phosphate systems, polyphosphate systems, and natural remineralizing agents.
The study comprised an in-vitro and an in-vivo experiments.
The aim of the in-vitro experiments was to compare the caries prevention and inhibition of lesion progression using SAP P11-4 against those of other established measures in-vitro including fluoride varnish (FV), fluoride mouthwash (FMW), casein phosphopeptide amorphous calcium phosphate with and without fluoride (CPP-ACP and CPP-ACPF), nHA, and resin infiltration, hypothesizing SAP P11-4 to have no superior caries-preventive and arresting properties compared to the other materials under investigation.
The in-vitro experiment comprised two sub-experiments, where the caries preventive as well as caries arrest capability were measured by analyzing the difference in mineral loss and lesion depth at baseline and after pH cycling using transverse microradiography (TMR) on extracted sound primary anterior teeth.
In Experiment no.1 (Prevention Study) when comparing the caries preventive effect among six groups, where a total of 120 teeth were used (n=20/group), there was a statistically significant difference found in the difference in mineral loss and lesion depths of the FV groups followed by FMW compared to the other groups.
In Experiment no.2 (Arrest Study), there was no statistically significant difference in the difference of mineral loss and lesion depth among all four groups.
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In the in-vitro study (Experiment no.1 Prevention Study) established means like FV and FMW were found to reduce mineral loss, having the least mineral loss difference, while novel strategies like SAPP, CPP-ACP, CPP-ACPF and nHA did not have any significant preventive effect in vitro. Lesion depth findings were similar to those of mineral loss, where FV and FMW had the least lesion depth difference compared to SAPP, CPP-ACP, CPP-ACPF and nHA.
Furthermore, in the in-vitro study (Experiment no.2 Arrest Study) four agents were tested for their remineralizing effect, namely self-assembling peptide P11-4 for repair (SAPR), fluoride varnish (FV), casein-phosphopeptide amorphous calcium phosphate fluoride (CPP-ACPF) and resin infiltration (RI). Self-assembling peptide (SAPR) was the main material under investigation, that is claimed to provide subsurface remineralization compared with FV, the gold standard remineralizing agent. We also compared against CPP-ACPF and RI.
There was no statistically significant difference regarding the four groups in their ability to inhibit lesion progression. Nevertheless, when comparing the four groups, RI was found to inhibit the lesions most effectively from progressing, followed by FV, while again novel strategies like CPP-ACPF and SAPR did not have any significant inhibition of lesion progression effect in vitro. We accepted our null hypotheses.
The in-vivo study was done to compare the biomimetic remineralization of early carious lesions using self-assembling Peptide P11-4 versus FV on the enamel of primary anterior teeth hypothesizing that SAP P11-4 to have no superior remineralizing effect over FV and to assess patient satisfaction/ dissatisfaction regarding each intervention.
A total of 10 patients with 40 primary anterior teeth affected with white spot lesions of ICDAS II scores 1 and/or 2 were included in this study. Patients’ teeth received randomly the assigned interventions at baseline and were followed up at 3 months, 6months, and 12 months.
At baseline, 3month, 6months, and 12 months patients’ teeth were scored using ICDAS II scoring system and light-induced fluorescence represented by the SOPROLIFE system.
In addition, Patient satisfaction/ dissatisfaction was investigated using a five-point pictorial Likert scale after finishing each intervention by letting the patients choose a smiley face that represented how they felt about the conducted treatment. There was a statistically significant difference showing more satisfaction for SAPR versus FV intervention.
In the in-vivo study, there was a statistically significant difference in the self-assembling peptide for repair (SAPR) group compared to fluoride varnish (FV) regarding its ability to remineralize white spot lesions in primary anterior teeth between baseline-6 months as well as baseline-12 months, while there was no statistically significant change in the WSL in the FV group along the treatment intervals.
This was measured using light induced fluorescence, the SOPROLIFE system, ICDAS II scoring system, and transformed quantitatively using computer software the Autodisk Autocad system.
In SAPR group the ICDAS II scores 2 were significantly decreased between baseline (B)-3months (3M), baseline (B)-6months (6M), and baseline-12 months (12M), while for FV group ICDAS II scores 2 were significantly decreased between baseline- 6months and baseline-12months. When comparing the ICDAS II scores between SAPR and FV groups, there was a statistically significant decrease in ICDAS II scores for SAPR group at 3M (p value=0.001), 6M (p value=0.013), and at 12M (p value=0.016).
Since SAPR was able to decrease the white spot lesions among recruited primary anterior teeth significantly more than FV, we hence rejected our null hypothesis.
Based on the findings of both studies, we recommend that further studies investigate the combination between SAP P11-4 and FV in anterior as well as posterior primary teeth smooth surface lesions.
In addition, investigations should try to find different image standardization methodologies when using light induced fluorescence like SOPROLIFE system.
Future studies should try to manufacture self-assembling peptides in laboratories and compare them to the commercially available products to find economic alternatives.
In vitro studies done on de-and remineralization should try to preserve the aprismatic enamel layer even when using ground specimens. This can be done by the use of artificial saliva with ground sections and the evaluating the formation of the aprismatic enamel layer under scanning electron microscopy before the application of interventions.