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Dental care for M&Mers – Part III

CPP-ACP: your special partner against decay and erosion.

As you might have noticed, problem 1: (caries/tooth decay) and problem 2: (Erosion) both cause the problem of demineralization.

Reduction of demineralization and an increase in remineralization can occur when saliva and the tooth surface has a high level of tooth-required minerals within it.

In earlier years, it was noticed that dairy products exhibited anticariogenic activity.
Using in vitro, animal and in situ caries models, the components largely responsible for this anticariogenic activity have been identified as casein, calcium and phosphate (3,4,5). Nowadays it is known that a significant anticariogenic effect can be attributed to multiphosphoseryl containing sequences of casein and their ability to stabilise calcium phosphate. These sequences can be released enzymically as casein phosphopeptides (CPP), which stabilize amorphous calcium phosphate (ACP) in solution, by the formation of CPP-ACP nanocomplexes (6).

Factor 1: CPP-ACP has direct influences upon the bacteria associated with caries formation and progression.

CPP has been shown to inhibit adherence of oral bacteria to saliva-coated hydroxyapatite beads.7 By selectively inhibiting streptococcal adhesion to teeth, CPP could modulate the microbial composition of dental plaque and favour establishment of less cariogenic species (and hence less cariogenic plaque) (7,8,9). This would lead to the control of acid formation in dental plaque, in turn reducing hydroxyapatite dissolution from tooth enamel (10).

Factor 2: Caries is influenced by saliva constituents

Certain constituents in saliva and plaque can modify the demineralization and remineralization process. The major constituents of hydroxyapatite are calcium and phosphorus, which are lost from tooth structure in the demineralization process. It is thought that higher plaque levels of calcium and phosphorus result in a higher degree of saturation in respect to enamel mineral in plaque fluid, leading to the reduction of demineralization and the increase of remineralization (11). Several authors have also observed a relationship between higher plaque calcium and phosphorus levels and lower caries experience (15,16 ).

A major anticariogenic mechanism of CPP-ACP is the incorporation of CPP-ACP nanocomplexes into plaque and onto tooth surfaces. Localized CPP-ACP nanocomplexes purportedly act to buffer the free calcium and phosphate ion activities, maintaining a state of supersaturation in tooth enamel, thus preventing enamel demineralization and enhancing remineralization (17). CPP modulates the precipitation of calcium phosphate by forming amorphous dicalcium phosphate nanoclusters, which regulates mineral flow in tissues and biological fluids (18).

The CPP can stabilize over 100 times more calcium phosphate than is normally possible in aqueous solution at neutral or alkaline pH before spontaneous precipitation (19). It is this ability to prevent precipitation that enables CPP-ACP complexes to maintain a state of supersaturation in tooth enamel, which acts as a reservoir preventing enamel demineralization and enhancing remineralization (13, 5). CPP-ACP also works by increasing the number of potential calcium-binding sites, thereby decreasing the calcium diffusion constant. This large effect decreases the rate of calcium loss from plaque during a cariogenic attack and provides a potential source of calcium for subsequent remineralization (17).

The maintenance of high extracellular concentrations of calcium have been suggested to be bactericidal or bacteriostatic to species of streptococcus by way of various speculated mechanisms. High concentrations have been suggested to induce streptococcal membrane permeability and partial lysis (9). This is another way whereby CPP-ACP has caries preventive potential.

Factor 3: CPP-ACP buffers pH changes

When acid is generated by dental plaque bacteria, the CPP-bound ACP would buffer plaque pH and in so doing would dissociate to calcium phosphate ions. The increase in plaque calcium and phosphate ions and ion pairs would offset any fall in pH, thereby preventing enamel demineralization (8).

Chewing gums and mints

All sugar-free gums and mints inherently stimulate the flow of saliva, which leads to an increase in the buffering effect, as well as the enhancement of remineralization and increased clearance of sugars from the mouth. CPP-ACP has been incorporated into sugar-free chewing gums and mints to increase the caries-preventive potential of these products. While chewing gums and eating mints may not ever replace brushing and flossing, these products can provide caries preventive benefits in a more convenient form. These sugarfree gums and mints come under the brand name of Recaldent.

Limitations to application: people with allergies to casein

Individuals with allergies or severe sensitivity to milk or milk-based products are at risk of a serious or life-threatening allergic reaction when they use products containing CPP-ACP. Packaging currently alerts consumers to the contents of casein within CPP-ACP products.

Branded products:

In the U.S., PROSPEC™ MI Paste made by GCAmerica.

In Europe, Asia and Australia GC calls it Tooth Mousse.

Chewing gum and lozenges come in the brand name Recaldent.

Usage:

I would recommend usage as soon as you wake and before you brush your teeth at night. Also at times where you have eaten a heavy sugary/acidic meal it would be wise to use it after that.

You’ll find it will help you with tooth sensitivity issues, or areas you think are softening/becoming decayed.

I recommend placing little dabs of the paste/mousse on your finger and rub over areas of your teeth. It’s non toxic and some flavour are quite nice. You just leave it on your teeth and don’t eat or drink for a period of time. There is no need to spit it out.

Other useful products:

  • Chlorhexidine: This is a chemical agent that can be used for plaque control. The use of it is advocated at times when you find it difficult to brush, such as when you have had surgery, when you injure your brushing hand, or when you are of high risk of caries, such as chronically low levels of saliva. It should never be regarded as a long term substitute for brushing. There are side effects which relate to its use, and thus it is recommended to only use when in times of real need, and for short periods of time. The side effects are staining of the teeth, dulling of taste buds, possible saliva gland swelling, and painful sensitizing the oral soft tissues by removal of the surface layers of cells (18).

 

  • Xylitol: This is a sweet tasting sugar alcohol that is placed in some chewing gums. You can buy the chewing gum or buy xylitol free form, and use it as a sweetener. It cannot be utilized by oral microorganisms, so as a sweetener it wont promote caries, and regular use actually reduces the levels of negative microorganisms within the mouth (18).

Summary of what you can do

As stated before, reduce the amount and frequency of sugars/carbohydrates and acids. Be careful of when you time intake of sugars/carbohydrates and acids, including supplements.

Now you know about caries, erosion and CPP-ACP I can advise when to brush and floss.

Brush at least 2 times a day:

  • In the morning, preferably at least 10 minutes after you have placed your CPP-ACP paste.
  • In the evening, the last thing you do at night. Brush preferably at least 10 minutes after you have placed your CPP-ACP paste. Don’t eat or drink after brushing. Drinking water is fine.
  • Brushing gently after every meal or snack would give you better protection. But there are issues to consider here as well, especially after high acid meals. I advise you not to brush your teeth after eating a highly acidic meal. Possibly, after eating the highly acidic meal/supplements, use the CPP-ACP paste and brush 10 minutes after that.

Rinse your mouth with water after sugary/acidic meals/drinks.

Keep hydrated. But be careful not to be constant sipper of water. The more you sip as opposed to drink a large glass in one go, the more your beneficial saliva will be diluted and less able to reduce demineralization, and less able to increase remineralization.

Chew gum, stimulate saliva after a meal to buffer acids, and clear sugars.

References

1 UCLA School of Dentistry. Dental Caries. 2004
2 Bodart F, Deconnick G, Martin MT. Large scale study of tooth enamel. IEEE Trans Nucl Sci 1981; NS-28:1401-1403

3 Harper DS, Osborn JC Clayton R, Hefferren JJ. Cariostatic evaluation of cheeses withdiverse physical and compositional characteristics. Caries Res 20:123-30, 1986. Cited by Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilised by casein phosphopeptides: a review. Spec Care Dentist 1998 Jan-Feb;18(1):8-16.

4 Krobicka A, Bowen WH, Pearson S, Yang DA. The effects of cheese snacks on caries in desalivated rats. J Dent Res 66:1116-9, 1987. Cited by Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilised by casein phosphopeptides: a review. Spec Care Dentist 1998 Jan-Feb;18(1):8-16.

5 Reynolds EC, del Rio A. Effect of casein and whey protein solutions on caries experienceof the rat. Arch Oral Biol 29:927-33, 1984. Cited by Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilised by casein phosphopeptides: a review. Spec Care Dentist 1998 Jan-Feb;18(1):8-16.

6 Reynolds EC. Dairy components in oral health [abstract]. Aust. J. Dairy Technol. 2003;58, 79-81
7 Neeser JR, Golliard M, Woltz A, Rouvet M, Dillmann ML, Guggenheim B. In vitro modulation of oral bacterial adhesion to saliva-coated hydroxyapatite beads by milk casein derivatives. Oral Microbiol Immunol. 1994 Aug;9(4):193-201 Cited by Aimutis WR. Bioactive properties of milk proteins with particular focus on anticariogenesis. J Nutr. 2004 Apr;134(4):989S-95S.

8 Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilised by casein phosphopeptides: a review. Spec Care Dentist 1998 Jan-Feb;18(1):8-16.

9 Rose RK. Binding characteristics of streptococcus mutans for calcium and casein phosphopeptide. Caries Res 2000;34:427-431.

10 Reynolds EC, Riley PF, Storey E. Phosphoprotein inhibition of hydroxyapatite dissolution. Calcif Tissue Int. 1982;34 Suppl 2:S52-6. Cited by Aimutis WR. Bioactive properties of milk proteins with particular focus on anticariogenesis. J Nutr. 2004 Apr;134(4):989S-95S.

11 Moreno EC, Margolis HC. Composition of human plaque fluid. J Dent Res.1988 Sep;67(9):1181-9. Cited by Reynolds EC, Cai F, Shen P, Walker, GD. Retention in Plaque and Remineralisation of Enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82(3):206-211.

12 Ashley FP. Calcium and phosphorous concentrations of dental plaque related to dental caries in 11 to 14 year – old male subjects. Caries Res 1975a 9:351-362 Cited by Reynolds EC, Cai F, Shen P, Walker, GD. Retention in Plaque and Remineralisation of Enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82(3):206-211.

13 Shaw L, Murray JJ, Burchell CK, Best JS. Calcium and phosphorous content of plaque and saliva in relation to dental caries. Caries Res 198317:543-548 Cited by Reynolds EC, Cai F, Shen P, Walker, GD. Retention in Plaque and Remineralisation of Enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82(3):206-211.

14 Reynolds EC, Cai F, Shen P, Walker, GD. Retention in Plaque and Remineralisation of Enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res 2003;82(3):206-211.

15 C. Holt, N. M. Wahlgren and T. Drakenberg. Ability of a b-casein phosphopeptide to modulate the precipitation ofcalcium phosphate by forming amorphous dicalcium phosphate nanoclusters. Biochem. J. 1996 314, 1035-1039

16 Holt C, van Kemenade MJJM. The interaction of phosphoproteins with calcium
phosphate. In: Calcified Tissue. Hukins DWL., editor. Boca Raton, FL: CRC Press,1989. Cited by Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilised by casein phosphopeptides: a review. Spec Care Dentist 1998 Jan-Feb;18(1):8-16.

17 Rose RK. Effects of an anticariogenic casein phosphopeptide on calcium diffusion in streptococcal model dental plaques. Arch Oral Biol. 2000 Jul;45(7):569-75.

18 Kidd EAM. Essentials of dental caries. 3rd ed. Oxford: Oxford University Press; 2005. p.83-85, 103

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