ORIGINALTuna ARTICLE et al

Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) May Be an Alternative Preventive Therapy in Children with Cerebral Palsy Didem Öner Özdasa/Elif Bahar Tunab/Esra Yamac Yilmazc/Zeynep Ayteped Purpose: To evaluate the effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on the buffering capacity of saliva and plaque pH in individuals with cerebral palsy (CP). Materials and Methods: A total of 15 3- to 8-year-old subjects with CP living in a governmental institution were included in this study. Dental plaque pH and the buffering capacity of saliva were measured at the first visit (baseline) and accepted as control values. CPP-ACP complex (GC Tooth Mousse) was applied to the children twice a day. Measurements were repeated after the 1st, 2nd, 3rd, 4th, 6th and 8th weeks. Results: Plaque indicator data show decreased acidogenicity in the 8-week period. Although there were no significant differences between the baseline and the 1st, 2nd and 3rd weeks’ pH scores, a statistically significant difference was observed between the initial and 4th, 6th and 8th weeks’ plaque pH scores. Saliva buffer scores were found to statistically significant increase between baseline and the 3rd, 4th, 6th and 8th weeks. Conclusion: Daily application of 10% w/v CPP-ACP paste is effectively changes saliva buffering capacity and plaque pH, thus promoting caries prevention in the primary and mixed dentition of CP children. Key words: buffering capacity, cerebral palsy, CPP-ACP, plaque pH, saliva Oral Health Prev Dent 2015;13:441-448 doi: 10.3290/j.ohpd.a33090

T

he term cerebral palsy (CP) refers to a collection of syndromes characterised by motor impairment as a result of injury or damage to the young developing brain with visual and/or hearing distura

Assistant Professor, Department of Paediatric Dentistry, Faculty of Dentistry, Istanbul Aydin University, Istanbul, Turkey. Performed experiments and analyzed data, wrote and proofread the manuscript, discussed results and commented on manuscript at all stages.

b

Associate Professor, Department of Paediatric Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey. Performed experiments and analyzed data, wrote and proofread the manuscript, discussed results and commented on manuscript at all stages.

c

Paediatric Dentist, Department of Paediatric Dentistry, Okmeydani Dental Hospital, Istanbul, Turkey. Performed experiments and analyzed data, discussed results and commented on manuscript at all stages.

d

Professor, Department of Paediatric Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey. Supervised project, discussed results, commented on manuscript at all stages.

Correspondence: Associate Professor E. Bahar Tuna, Istanbul University Faculty of Dentistry, Department of Pedodontics, 34093, Capa, Istanbul, Turkey. Tel: +90-212-414-2020/20283, Fax: +90212-531-0515. Email: [email protected]

Vol 13, No 5, 2015

Submitted for publication: 16.07.13; accepted for publication: 30.09.13

bances, altered sensory perceptions, seizures, cognitive impairments and, most frequently, alteration of motor coordination. It can occur prenatally (about 75%), during childbirth (about 5%) or after birth (about 15%) up to about age three.4 This condition is the most common cause of severe physical disability in childhood,19 with an estimated prevalence of 2.4 per 1000 children with variations among developed and developing countries.15,35 The prevelance of CP in Turkey was determined as 5–8 cases per 1000 live births in Turkey in a crosssectional study.35 CP patients are known to have a high incidence of feeding difficulties with food loss due to excessive drooling, coughing, choking and poor motor control. They experience dysphagia (difficulty swallowing), vomiting and recurrent chest infections. CP is also associated with abnormal muscle tone, which often leads to difficulties with sucking, spoon-feeding, chewing and self-feeding.11,36 CP itself does not cause any unique oral abnormalities. However, several conditions in children with

441

Tuna et al

CP are more common or more severe than in the general population.23 Children with CP have a higher incidence of gastroesophageal reflux, as well as episodes of vomiting. Both of these problems may contribute to dental erosion and loss of tooth structure. The prevention of dental erosion is also an important consideration in the dental care for individuals with handicaps.13 Several studies showed that caries is prevalent among people with CP, primarily because of inadequate oral hygiene.7,8,12 The more common oral conditions in individuals with CP include higher mean decayed, missing and filled surfaces index (DMFT/dmft), higher plaque index, tendency for delayed eruption of permanent molars, malocclusion7 and high rates of bruxism.24 Bruxism, abnormal attrition and spontaneous dislocation or subluxation of the TMJ are also common.24 Malocclusion in people with CP usually involves misaligned teeth with musculoskeletal problems. An open bite with protruding anterior teeth is common and is typically associated with tongue thrusting. Excessive drooling can be seen due to the inability to close the lips and open bite. Malocclusion can cause an abnormal facial appearance, misalignment of teeth, breathing through the mouth, drooling and difficulties in biting and chewing. Dysphagia is another problem in people with CP, meaning that food may stay in the mouth longer than usual, increasing the risk for caries.23 Traditionally, caries prevention has consisted of individual dietary analysis, advice and counseling, the use of systemic or topical fluorides and fissure sealants. Home care aids such as electric toothbrushes may be helpful in maintaining good oral hygiene in these children.4,13 Preventive measures include enhancement of the acid resistance of dental tissues and remineralisation, which requires calcium, phosphate and fluoride, all of which are components of saliva.17 The food group most recognised as exhibiting anticaries activity is dairy products (milk, milk concentrates and powders, cheese). The bovine milk phosphoprotein, casein, which is known to interact with calcium and phosphate and is a natural food component, is an obvious candidate for an anticariogenic food and toothpaste additive. However, this is precluded by organoleptic properties and the very high levels required for activity.14,27,28,30 Recently, results from several in vitro studies showed that CPP-ACP derived from cow’s milk reduces the demineralisation of dental tissues and enhances the remineralisation process.16,33,34 This effect occurs because casein, an amino acid, can

442

adjust to acid-base environments.31 At acidic pH, ACP separates from CPP, thereby increasing salivary calcium and phosphate levels. Moreover, CPP has a remarkable ability to stabilise the level of calcium phosphate in the saliva by preventing precipitation of calcium and phosphate.3,22,26 Currently, the most commonly used mode of CPP-ACP application in the human oral environment is via sugar-free sorbitol or xylitol-based chewing gum, milk, mouthrinses, sugar-free lozenges and topical dental cream.25,41 However, there have been only a studies which have focused on preventive oral health applications for children with CP. Therefore, the aim of this study was to evaluate the effect of the CPP-ACP molecule in Tooth Mousse (GC; Tokyo, Japan) on the buffering capacity of saliva and plaque pH in children with CP.

MATERIALS AND METHODS Group selection The study included a total of 15 subjects (9 boys, 6 girls) ages 3–8 years (mean: 5.6 ± 2 years) with a medical diagnosis of a severe form of CP living in a large government institution in Istanbul, Turkey. These patients have had life-long personal care and day-to-day supervision. Patients were included if they had: (i) no previous surgical procedures for saliva control and/or blockage treatment with botulinum toxins, (ii) no use of drugs that would interfere with the saliva secretion (anticholinergic and neuroleptic drugs, benzodiazepines) for at least 72 h and (iii) no history of trauma or tumours in the oral cavity. The study met the ethical standards of the current revision of the Helsinki declaration of 1975. The patients’ parents/caregivers were informed of the objectives of the study and informed consent was obtained from the parents or caregivers. The government institution and the Ministry of Family and Social Policies Council also approved the study protocol for all patients.

Study design At the first visit, a face-to-face interview was performed with the caregivers and a dietary habits questionnaire was answered. The questionnaire detailed the consumption and frequency of acid

Oral Health & Preventive Dentistry

Tuna et al

Table 1 Plaque acidogenicity at baseline and each follow-up within the 8-week observation period Plaque indicator

n

pH>7

n

pH>6.5

n

pH>6

n

pH 0.05), statistically significant differences were observed between baseline and the 4th, 6th and 8th weeks’ scores (p = 0.039, p = 0.042, p = 0.018, respectively). A significant

443

Tuna et al

Table 2 Statistical significance of changes in plaque acidogenicity related to time elapsed McNemar’s test

Plaque indicator

Dunn’s Multiple Comparison Test

Initial/ 1st week

0.725

Initial/ 1st week

0.15

Initial/ 2nd week

0.289

Initial/ 2nd week

0.06

Initial/ 3rd week

0.227

Initial/ 3rd week

0.004*

Initial/ 4th week

0.039*

Initial/ 4th week

0.001*

Initial/ 6th week

0.042*

Initial/ 6th week

0.001*

Initial/ 8th week

0.018*

Initial/ 8th week

0.001*

1st week / 2nd week

0.289

1st week / 2nd week

0.831

1st week / 3rd week

0.07

1st week / 3rd week

0.113

1st week / 4th week

0.02*

1st week / 4th week

0.111

1st week / 6th week

0.002*

1st week / 6th week

0.003*

1st week / 8th week

0.0001*

1st week / 8th week

0.001*

2nd week / 3rd week

0.453

2nd week / 3rd week

0.217

2nd week / 4th week

0.021*

2nd week / 4th week

0.217

2nd week / 6th week

0.039*

2nd week / 6th week

0.02*

2nd week / 8th week

0.008*

2nd week / 8th week

0.001*

3rd week / 4th week

0.031*

3rd week / 4th week

0.605

3rd week / 6th week

0.016*

3rd week / 6th week

0.054

3rd week / 8th week

0.01*

3rd week / 8th week

0.347

4th week / 6th week

0.658

4th week / 6th week

0.438

4th week / 8th week

0.453

4th week / 8th week

0.401

6th week / 8th week

0.687

6th week / 8th week

0.185

*Significant at p < 0.05, McNemar’s Test.

Saliva buffering capacity

*Significant at p < 0.05, Dunn’s Multiple Comparison Test.

Table 3 Buffering capacity of saliva at baseline and follow-up intervals

444

Table 4 Intergroup comparison of saliva buffering capacity relative to time intervals

Saliva buffer

Mean ± SD

Baseline

6.87 ± 1.69

1st week

7.93 ± 1.98

2nd week

8.00 ± 1.41

3rd week

9.20 ± 1.37

4th week

9.47 ± 1.64

6th week

10.40 ± 1.68

8th week

10.87 ± 1.25

Kruskal-Wallis

43.69

p

0.0001

increase in plaque pH level was observed between the 1st (p = 0.02; p = 0.002; p = 0.0001), 2nd (p = 0.021; p = 0.039; p = 0.008) and 3rd week (p = 0.031; p = 0.016; p = 0.01) compared with the 4th, 6th and 8th weeks, respectively. No significant differences were found between the 4th-, 6th- and 8th-week scores (p > 0.05). Plaque indicator data show decreased acidogenicity over time (Fig 1). In terms of the buffering capacity of saliva, significant differences were observed between baseline and the weekly interval scores (p = 0.0001) (Table 3). Saliva buffering scores showed a statistically significant increase in salivary pH between baseline and the 3rd, 4th, 6th and 8th weeks (p = 0.004; p = 0.001). Significantly lower buffer scores were determined in 1st (p = 0.003,

Oral Health & Preventive Dentistry

very low

low

Salvia buffering capacity

normalhigh

Tuna et al

12 11 10 9 8 7 6 5 4 3 2 1 0 Initial

1st week

2nd week

3rd week

4th week

6th week

8th week

Fig 1  Plaque indicator data shows decreasing acidogenicity over the 8-week observation period.

pH>7

pH>6.5

pH>6

pH>5.5

70 60

dmft average

50 40 30 20 10 0 Initial

1st week

2nd week

3nd week

4th week

6th week

8th week

Fig 2  Saliva buffering capacity increased over the 8-week observation period.

p = 0.001) and 2nd (p = 0.02, p = 0.001) week compared with 6th- and 8th-week samples. No significant differences were found for the other time intervals (p > 0.05) (Table 4). Saliva buffering scores showed an increased buffering capacity during the 8-week observation period (Fig 2).

DISCUSSION Due to physical disabilities, spasticity and other associated problems, children with CP are partially or totally dependent on their parents or another person for effective toothbrushing, because brushing requires coordinated muscular movements and motor strength of the upper extremities.36 Many of these children may be anxious be-

Vol 13, No 5, 2015

cause of poor understanding or difficulty in communicating. Differences in concentration of the saliva contents between the CP population and the healthy population have been observed and found to be flow-rate dependent in some studies.6,13 It is important to note that with a reduced flow rate, the pH, buffering capacity and the absolute quantities of antibacterial constituents of the saliva are reduced in this patient group.6 CPP has been improved by combination with ACP. CPP-ACP paste has been demonstrated to have anticariogenic activity and a remineralisation effect on enamel subsurface lesions in the laboratory, animal and human in situ experiments, as well as randomised, controlled caries clinical trials.16,29,33,34 The CPP composition stabilises high

445

Tuna et al

concentrations of calcium and phosphate ions together with fluoride ions at the tooth surface by binding to the pellicle and plaque. Although the calcium, phosphate and fluoride ions are stabilised by the CPP, the ions are freely bioavailable to diffuse down concentration gradients into enamel subsurface lesions, thereby effectively promoting remineralisation in vivo.22,29 The material appears to be very safe for human use in oral care products, dental professional products and foods.40 In animal and in vitro studies, CPP-ACP and fluoride have been shown to have an additive effect in reducing caries experience and remineralising enamel subsurface lesions.5 It was shown that children in residential care experience lower caries prevalence than children living with their families in Turkey.1 For this study, due to standardised health care, diet and feeding habits, a governmental institution was chosen, at which CPP-ACP paste was applied in the children by the same caretaker at the same times during the day over the observation period. Saliva buffer scores significantly increased in the 3rd, 4th, 6th and 8th weeks (not during the first 2 weeks). Based on our results, it may be concluded that CPP-ACP application helps to increase the stimulation of saliva. Several conditions are more common or more severe in people with CP than in the general population. Dos Santos et al7 showed that children of both sexes with CP and permanent dentition had higher plaque indices than children without CP. Residual food and mouth breathing have been frequently found in CP children,32 both of which favour caries development. In CP patients with a seizure disorder, the anti-seizure medications, especially phenytoin sodium (Dilantin), are strongly associated with gingival overgrowth. In turn, the gingival overgrowth complicates oral hygiene procedures, making control of dental plaque more difficult and potentially leading to tooth decay. Additionally, the semi-solid foods caregivers may prepare for people with this problem tend to adhere to the teeth.23 Developmentally retarded children are usually bottle-fed and weaned at an older age, thus increasing the risk of early childhood caries. In the prevention of caries, one of the most important functions of saliva is to neutralise organic acids and provide buffering. In the mouth, fermentable carbohydrates are transformed into acids by microorganisms, reducing the pH of bacterial plaque. When CPP-ACP is applied to the tooth surface, it binds to the biofilms, plaque, bacteria, hydroxyapatite and sur-

446

rounding soft tissues, localising bio-available calcium and phosphate.27 CPP-ACP solutions are efficient remineralising solutions; they consume the acid causing enamel lesions and can help in remineralisation by generating more CaHPO4, thus maintaining its concentration gradient in the lesion.30 The increase in plaque calcium and phosphate ions and ion pairs would offset any drop in pH, thereby preventing enamel demineralisation and restoring the pH equilibrium of the mouth. Saliva also enhances the effectiveness of CPP-ACP and the flavour of Tooth Mousse helps to stimulate saliva flow.37 The test used in this study assessed total acid production and assesses how readily the plaque can produce acids when exposed to sucrose. Plaque pH increased to > 6.5 in 7 children and > 7 in 8 children after 8 weeks of CPP-ACPcontaining Tooth Mousse application. In this group of children, another problem is the risk of swallowing toothpaste. Recently, different ingredients in toothpastes such as aloe vera and CPP have appeard on the market and may be an alternative to regular toothpastes. Martens et al21 showed that the application of chlorhexidine on regular basis is very useful in the oral care of this group of children. CPP-ACP has a clear advantage over fluoride-based materials because it can be swallowed. CPP also resists degradation by intestinal bacteria and is excreted in the feces.18 In this group of CP patients, it was almost impossible to rinse the mouth or avoid swallowing excess toothpaste after brushing the teeth. Under such conditions, using a toothpaste containing CPP is highly advantageous. Some in situ clinical studies found CPP-ACP to be superior in remineralisation of subsurface enamel lesions to other forms of calcium phosphate.10,20,29,39 In a further in situ clinical study, enamel remineralised with CPP-ACP was shown to be more acid resistant than normal tooth enamel, which is a calcium-deficient carbonated apatite.2 These results suggest that CPP-ACP remineralised enamel should be more resistant to caries than normal tooth enamel.5 Moreover, the combination of CPP-ACP nanocomplexes and fluoride in toothpaste provide a greater concentration of fluoride ions in the dental biofilm and a greater increase in remineralization.9 In general, bioactive peptides with anticariogenic activity have multiple properties that help prevent caries, including bacterial inhibition, competitive exclusion to enamel binding sites, improved buffering capacity in the pellicle surrounding the teeth, reduced demineralisation and en-

Oral Health & Preventive Dentistry

Tuna et al

hanced remineralisation of enamel.28,31 As a general rule, the longer CPP-ACP is maintained in the mouth, the more effective the end result will be.37 In the present study, although statistically significant differences were observed in saliva buffering capacity after the 1st week, statistically significant differences in plaque pH scores were observed only after the 4th week. In this study, CPP-ACP application twice a day showed significantly increased saliva buffering capacity scores during the 8-week period. It was thought that long-term regular application of the paste caused these results. The usual diet of patients with CP may be rich in pasty or semi-solid food and carbohydrates, and their impaired motor skills make it difficult to cleanse the mouth and maintain an adequate level of oral hygiene.32 Hence, parental counseling about diet, oral hygiene procedures and the use of fluorides should be started early. Manual dexterity is usually poor, but favourable results are often possible with an electric toothbrush or a modified handle to the normal brush. The caregiver responsible for supervising daily oral hygiene should be particularly careful to limit the amount of fluoridated toothpastes used by these children, as they are likely to swallow it. Caregivers should also schedule regular check-ups for professional toothcleaning, fluoride treatments and sealants.

CONCLUSIONS The results of this study suggests that CPP-ACP complex can promote saliva buffering capacity and increase plaque pH. Therefore, it may be a good alternative strategy in CP individuals who suffer from dental erosion and caries and are generally in need of more intensive oral hygiene attention. Dentistry has become an important part of the multidisciplinary approach to providing health care for patients with cerebral palsy and the severe handicapping conditions that frequently accompany this neuromuscular disorder. There is a certain need for better organisation of the preventive paediatric and dental care in order to increase the level of dental health in this challenged population. The early diagnosis of oral manifestations and early access to dental treatment based on an integrated approach can improve the quality of life of these patients by minimising complications and promoting caries prevention. It is also important to educate caregivers about the oral and dental health of these patients, such as inspecting the mouth, re-

Vol 13, No 5, 2015

moving any residual food or medicine from the mouth after eating and emergency procedures for accidents involving oral trauma.

REFERENCES 1. Aytepe Z, Tuna EB, Ilhan B, Öner-Özdas D, Yamac E. An investigation of the caries experience of children with an intellectual disability living in a residential centre or at home. JODH 2009;10:87–90. 2. Cai F, Manton DJ, Shen P, Walker GD, Cross KJ, Yuan Y, Reynolds C, Reynolds EC. Effect of addition of citric acid and casein phosphopeptide-amorphous calcium phosphate to a sugar-free chewing gum on enamel remineralization in situ. Caries Res 2007;41:377–383. 3. Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds EC. Enamel subsurface lesion remineralisation with casein phosphopeptide stabilised solutions of calcium, phosphate and fluoride. Caries Res 2008;42:88–97. 4. Costa MMT, Afonso MT, Ruviere DB, Aguiar SMH. Prevalence of dental trauma in patients with cerebral palsy. Spec Care Dentist 2008;28:61–64. 5. Cross KJ, Huq L, Palamara JE, Perich JW, Reynolds EC. Physicochemical characterization of casein phosphopeptide-amorphous calcium phosphate nanocomplexes. J Biol Chemistry 2005;280:15362–15369. 6. Davis MJ. Parotid salivary secretion and composition in cerebral palsy. J Dent Res 1979;58:1808. 7. dos Santos MT, Masiero D, Simionato MRL. Risk factors for dental caries in children with cerebral palsy. Spec Care Dentist 2002; 22:103–107. 8. dos Santos MT, Nogueira ML. Infantile reflexes and their effects on dental caries and oral hygiene in cerebral palsy individuals. J Oral Rehabil 2005;32:880–885. 9. El-Sayed I, Amal S, Badr Y. Combining casein phosphopeptide-amorphous calcium phosphate with fluoride: synergistic remineralization potential of artifically demineralized enamel or not? J Biomed Opt 2009;14:044039. 10. Ferrazzano GF, Amato I, Cantile T, Sangianantoni G, Ingenito A. In vivo remineralising effect of GC tooth mousse on early dental enamel lesions: SEM analysis. Int Dent J 2011;61:210–216. 11. Goncalves GKM, Carmagnani FG, Correa MSNP, Duarte DA, Santos MTB. Dental erosion in cerebral palsy patients. J Dent Child 2008;75:117–120. 12. Guaré RO, Ciamponi AL. Dental caries prevalence in the primary dentition of cerebral palsied children. J Clin Pediatr Dent 2003;27:287–292. 13. Guaré RO, Ferreira MC, Leite MF, Rodrigues JA, Lussi A, Santos MT. Dental erosion and salivary flow rate in cerebral palsy individuals with gastroesophageal reflux. J Oral Pathol Med 2012;41:367–371. 14. Gurunathan D, Somasundaram S, Kumar S. Casein phosphopeptide-amorphous calcium phosphate: a remineralizing agent of enamel. Aust Dent J 2012;57:404–408. 15. Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R. How common are the “common” neurologic disorders? Neurology 2007;68:326–337. 16. Iijima Y, Cai F, Shen P et al. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phoshate. Caries Res 2004;38:551–556.

447

Tuna et al 17. Imfeld T. Prevention of progression of dental erosion by Professional and individual prophylactic measures. Eur J Oral Sci 1996;104:2:215–220. 18. Kasai T. CPP, Casein phosphopeptides. Foods & Food Ingred J Jpn 2003;208:167–173. 19. Kuban KC, Leviton A. Cerebral palsy. N Engl J Med 1994;330:188–195. 20. Manton DJ, Walker GD, Cai F, Cochrane NJ, Shen P, Reynolds EC. Remineralization of enamel subsurface lesions in situ by the use of three commercially available sugar-free gums. Int J Paediatr Dent 2008;18:284–290. 21. Martens L, Marks L, Kint J. The use of chlorhexidine as a preventive and theraupetic means of plaque control in the handicapped. Review of the literature and definitive advise for application. Rev Belge Med Dent 1997;52:27–37. 22. Moezizadeh M, Moayedi S. Anticariogenic effect of amorphous calcium phosphate stabilized by casein phosphopeptide: a review article. Res J Biol Sci 2009;4:132–136. 23. National Institute of Dental and Craniofacial Research. Practical oral care for people with cerebral palsy. Available at http://www.nidcr.nih.gov/oralhealth/topics/ developmental disabilities/practicaloralcarepeoplecerebralpalsy. html, Accessed May 19 2013. 24. Oliveira CA, de Paula VA, Portela MB, Primo LS, Castro GF. Bruxism control in a child with cerebral palsy. ISRN Dent 2011:146915. 25. Panich M, Poolthong S. The effect of casein phosphopeptide-amorphous calcium phosphate and a cola soft drink on in vitro enamel hardness. JADA 2009;140:455–460. 26. Reynolds EC, Cai F, Shen P, Walker GD. Retention in plaque and remineralization of enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82:206–211. 27. Reynolds EC, Cain CJ, Webber FL et al. Anticariogenicity of calcium phosphate complexes of tryptic casein phosphopeptides in the rat. J Dent Res 1995;74:1272–1279. 28. Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. Spec Care Dentist 1998;8:8–16. 29. Reynolds EC. Calcium phosphate- based remineralization systems: scientific evidence? Aust Dent J 2008;53:268– 273.

448

30. Reynolds EC. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997;76:1587–1595. 31. Reynolds EC. The prevention of sub-surface demineralization of bovine enamel and change in plaque composition by casein in an intraoral model. J Dent Res 1987;66:1120– 1127. 32. Rodrigues dos Santos MT, Masiero D, Novo NF, Simionato MR. Oral conditions in children with cerebral palsy. J Dent Child (Chic) 2003;70:40–46. 33. Rose RK. Binding characteristics of Streptococcus mutans for calcium and casein phosphopeptide. Caries Res 2000;34:427–431. 34. Rose RK. Effects of an anticariogenic casein phosphopeptide on calcium diffusion in streptococcal model dental plaques. Arch Oral Biol 2000;45:569–575. 35. Serdaroglu A, Cansu A, Ozkan S, Tezcan S. Prevalence of cerebral palsy in Turkish children between the ages of 2 and 16 years. Dev Med Child Neurol 2006;48:413-416. 36. Subasi F, Mumcu G, Koksal L, Cimilli H, Bitlis D. Factors affecting oral habits among children with cerebral palsy: pilot study. Pediatr Int 2007;49:853–857. 37. Tung MS, Eichmiller FC. Amorphous calcium phosphates for tooth mineralization. Compend Cont Educ Dent 2004;25:9–13. 38. World Health Organization. Oral health surveys: basic methods, ed 4. Geneva: World Health Organization, 1997:65. 39. Vashisht R, Kumar A, Indira R, Srinivasan MR, Ramachandran S. Remineralization of early enamel lesions using casein phosphopeptide amorphous calcium phosphate: an ex vivo study. Contemp Clin Dent 2010;1:210–213. 40. Yengopal V, Mickenautsch S. Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. Acta Odontol Scand 2009;67:321–332. 41. Xiaojun D, Jing L, Xuehua G, Hong R, Youcheng Y, Zhangyu G, Sun J. Effects of CPP-ACP paste on the shear bond strength of orthodontic brackets. Angle Orthod 2009;79:945–950.

Oral Health & Preventive Dentistry

Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) May Be an Alternative Preventive Therapy in Children with Cerebral Palsy.

To evaluate the effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on the buffering capacity of saliva and plaque pH in individuals...
137KB Sizes 0 Downloads 6 Views