ON SALIVARY pH AFTER AN ACIDIC SURGE
Dissertation Submitted to
THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY
In Partial Fulfillment for the Degree of MASTER OF DENTAL SURGERY
BRANCH VIII
PAEDODONTICS AND PREVENTIVE DENTISTRY
APRIL 2016
guide and mentor, Prof and H.O.D.,Dr.M.JAYANTHI, MDS.,whose guidance filled me with wisdom and passion over dentistry, her down to earth personality and simplicity is a very rare holding. Her brassbound as well as liberal poise towards training us has changed us in many ways; has made us to check the depth of our inventiveness and originality and she has always been an immense support for our fascination over clinical, theoretical and research oriented progress. My education would not be comprehensively intact without her invaluable erudition and sound judgment. My deepest and sincere thanks will not be adequately sufficient for all the righteousness and virtue she has instilled in me.
I also profoundly express my sincere thanks to Dr.NILAYA REDDY,MDS., DNB., an eminent, enlightened Professor, for her extraordinary support and consistent encouragement throughout the course of study and mainly for acquiring self-confidence and excellency in clinical work, during my post-graduation. Her ultra-practicable mode of tutelage has helped me greatly in thinking out of the box.
Special thanks to Dr.S.RAMACHANDRAN,MDS., Principal and DR.AZHAGARASEN, MDS., Vice principal, for providing me with an opportunity to utilize the facilities in their reputed and esteemed institution.
Elangovan MDS, senior lecturer for their steadfast encouragement/guidance during my post-graduation and teaching me the importance of patience and love and care towards patients.
I am also thankful to former faculty memberDr. Girija, MDS.,for her help and support during the first half of my post-graduation program.
I am thankful for my co-P.G. Dr.R.P.Ramadevi, who was such a large part of my P.G. life. Her support and friendship was constant during these last years, and I deeply appreciate it.
I would like to express my sincere thanks to my fellow postgraduate colleagues, Dr.Porselvi, Dr.Madhan, Dr.Deebiga, Dr.Keerthi, Dr.Devi Chandrikafortheir encouragement throughout my studies and postgraduate course. Special thanks to Dr.Bhuvanesswari, for being a friend more than a colleague and helping me out whenever I was down and confused.
My Dad MR.KARTHIGEYAN, MomMRS.GEETHALAKSHMI and my family members have stood unwaveringly behind me at all times. I wouldn’t be here if they were not supportive in part and parcel of my post
graduation. There were times when I needed them most and they were there as stanchions helping me with the herculean job. I take this opportunity to acknowledge them for their unconditional love and support. Words really do
helped me on clinical side to provide good treatment for patients. My post graduation wouldn’t be complete if I don’t thank my patients who helped me gain knowledge and showed me the newer perspectives of my life.
Above all, my greatest thanks belong to God, for sheltering and standing by me despite everything and making my life joyful and complete. I owe everything to the Almighty.
“CARPE DIEM”
S.NO. TITLE PAGE NO.
1. INTRODUCTION 1
2. AIMS AND OBJECTIVES 5
3. REVIEW OF LITERATURE 6
4. MATERIALS AND METHODS 35
5. RESULTS 40
6. DISCUSSION 43
7. CONCLUSION 49
8. SUMMARY 51
9. BIBLIOGRAPHY 53
10. ANNEXURES
NO.
TITLE PAGE NO.
1.
MEAN VALUES OF THE pH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER VARIOUS INTERVENTIONAL METHODS
2.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER WATER RINSING AND BRUSHING WITH WATER
3.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE WITH BRUSHING WITH WATER AND BRUSHING WITH NON-FLUORIDATED DENTIFRICE
4.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE WITH WATER RINSING BRUSHING WITH FLUORIDATED DENTIFRICE AND BRUSHING WITH NON-FLUORIDATED DENTIFRICE
5.
MEAN VALUES COMPARING THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND BRUSHING WITH NON- FLUORIDATED AND BRUSHING WITH FLUORIDATED DENTIFRICE
GRAPH
NO. TITLE PAGE NO.
1.
GRAPH DEPICTING MEAN VALUES OF THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER VARIOUS INTERVENTIONAL METHODS2.
GRAPH DEPICTING MEAN VALUES OF THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER WATER RINSING3.
GRAPH DEPICTING MEAN VALUES OF THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER BRUSHING WITH WATER4.
GRAPH DEPICTING MEAN VALUES OF THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER BRUSHING WITH NON-FLUORIDATED DENTIFRICE5.
GRAPH DEPICTING MEAN VALUES OF THE PH CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND AFTER BRUSHING WITH FLUORIDATED DENTIFRICEFIGURE NO.
TITLE PAGE NO.
1.
ARMAMENTARIUM (FOR SCREENING)
2.
ARMAMENTARIUM (FOR EXPERIMENTAL PART)
3.
SCREENING PATIENTS BASED ON INLCUSION CRITERIA
4.
CHILDREN GIVEN APPLE JUICE TO RECORD FALL IN THE SALIVARY pH
5.
CHILDREN ASKED TO FOLLOW INTERVENTIONAL METHOD
6.
COLLECTION OF SALIVA AFTER INTERVENTIONAL METHOD
7.
MEASURING PH USING COLOUR CODED PH STRIPS
S.NO. TITLE
I SCREENING FORM
II MASTER SHEET
III CONSENT FORM- ENGLISH
IV CONSENT FORM – TAMIL
V INSTITUTIONAL REVIEW BOARD APPROVAL CERTIFICATE
Introduction
1
INTRODUCTION
Dental caries is a significant public dental health problem affecting 60- 90% of school children in developed countries1 (WHO, 2003). The changing dietary habits with modernization haveleadto an increase in consumption of sugared items in diet which is directly responsible for the increased prevalence of dental caries.
The extensive study material available on dental caries has made clear that it is a multifactorial disease and the interface between the saliva and oral tissues is the site of many dynamic reactions which affects both the soft tissues and hard tissues of the mouth. Saliva provides this physiologic environment where the complex interactions between the agents, host and the environment occurs. The salivary parameters which affect the enamel stability in the oral environment are pH of saliva, salivary flow rate, oral clearance, concentrations of calcium, phosphate & fluoride and salivary levels of microorganisms.The research work by Stephan in 1940’s showed that the pH decrease was
inversely and clearly related to dental caries activity. The more basic the pH of the saliva more is the reminerlization of tooth surface by precipitation of bicarbonate ions. The pH at which the saliva ceases to be saturated is referred to as “critical pH” (5.0 to 5.5) and below this value, the inorganic components
of the teeth may dissolve in it. As the demineralization progresses so will the carious lesion leading to the loss of tooth structure2. The study by Anderson et al proved that the decreased concentration of calcium and phosphate ions in
2 primary teeth enamel predisposes them for faster demineralization and also at a higher salivary pH.3
The continuous failure of attempts to quit dietary sugar intake in children had lead to the reconsideration of the key role of the buffering action of salivary pH against the caries and the changing paradigms of caries intervention. Some of the interventional methods act locally whereas others act systemically. The salivary pH being an important biomarker for dental caries, the ideal intervention should be targeted towards the maintenance of salivarypH. Preventive strategies are considered as top priority in dental health program for the high-risk individuals. Some of the most commonly practiced preventive strategies are water rinsing, brushing, tooth powder, fluoridated and non-fluoridated tooth pastes, mouth washes,sugar free chewing gums, systemic water fluoridation, pit and fissure sealants and professionally applied topical fluoride formulations. Among all the methods, the most childfriendly and daily applicable method is brushing with a dentifrice.
Water rinsing after meals has been advised universally as it has property of reducing salivary pH after a pH challenge4(Elen De Souza Tolentino) but on the contrary study by Mirjalili has proved that it is no superior to brushing and chewing sugar free gums5.
Tooth brushing alone without dentifrice was found to be beneficial to the teeth by increasing both salivary ph and salivary flow rate6 (A J M Ligtenberg). On the contrary a study conducted by Mirjalili et al concluded
3 that brushing without dentifrice was not so effective in bringing about the desired positive change in pH following a sugar exposure5. Studies have shown that maintenance of oral hygiene with brushing is influenced by multiple variables, as shown in different studies: no. of bristles, thickness of bristles, brushing technique, etc.
On the other hand use of dentifrices along with brushing was seen to be beneficial in increasing the salivary pH7 (Chand et al), and in decreasing the microbiological load in plaque8,9,10,11,12
(JOkpalugo, Surdacka, Sudhapatil, Rahul Deshpande, Wafa K.M. Talha). But in areview by Burt, it was noted that the suggested upper limit of fluoride intake is being reached in many children by ingestion of fluoride from dentifrices13. The alkaline pH of toothpastes helps neutralize the salivary acids which cause tooth decay;
whereas very little documentary evidence supporting this fact is available.
School environment mandates short break times and quick meals and since children spend most of the time at schools, the possibility of brushing after every meal or snack may not be practically feasible. Since water rinsing can wash large food particles and dilute oral contents, it appears to be a logical emergency substitute for brushing teeth. Although not based on any reliable data, most clinicians encourage patients to swish and swift with water whenever tooth brushing is not possible. Hence the present study was undertaken to compare the efficacy of water rinsing, brushing without
4 dentifrice, brushing with non-fluoridated dentifrice and brushing with fluoridated dentifrice in maintaining the salivary pH following an acidic surge.
Aims and objectives
5
AIMS AND OBJECTIVES
1. To evaluate the efficacy of water rinsing as an interventional method on the salivary pH after an acidic surge
2. To evaluate the efficacy of brushing with water as an interventional method on the salivary pH after an acidic surge
3. To evaluate the efficacy of brushing with non-fluoridated dentifrice as an interventional method on the salivary pH after an acidic surge 4. To evaluate the efficacy of brushing with fluoridated dentifrice as an
interventional method on the salivary pH after an acidic surge
5. To evaluate and compare the efficacy of four interventional methods (water rinsing, brushing with water, brushing with non-fluoridated dentifrice and brushing with fluoridated dentifrice) on the salivary pH after an acidic surge.
Review of Literature
6
REVIEW OF LITERATURE
Zimmer S, Didner B, Roulet J.F conducted a study to evaluate the
efficacy of triple headed tooth brush on plaque removal. Thirty healthy volunteers, aged 6–60 years, participated in this single blind cross-over study.
They were randomly assigned to 3 groups (A, B, C) with 12 participants each.
To obtain a plaque-free condition at the baseline, professional tooth cleaning was performed in each participant. After instructions on how to use the toothbrushes, each group started the experiment with a different type of toothbrush. After 1 week of application, the Quigley-Hein plaque index (QHI) and the proximal plaque index (API) were used to assess the oral hygiene status of each participant. This was followed by 1 week of recess before each group switched to the next type of toothbrush. The duration of the study was 5 weeks. All examinations were performed by a single examiner. Compared to the 2 other brushes, the Superbrush was more effective in removing plaque (medians of QHI: 0.84 versus 1.56 (Elmex) and 1.56 (Braun); p<0.001;
medians of API: 0.69 versus 0.94 (Elmex) and 0.87 (Braun); p<0.001). The study indicated that the triple headed design of toothbrush may be an effective alternative to commonly used toothbrushes.14
Davies, Worthington et al (2002) conducted a study to check the efficiency of fluoride dentifrice on reducing dental caries in 5-6 yr old children. 7,422 children were randomly assigned to one of the 2 groups:
group1 (dentifrice containing 440ppm of fluoride; Colgate gel 0-6 years)
7 group2 (dentifrice containing 1450ppm fluoride, Colgate regular). Free toothpastes were given to children of age 12 months based on the group and were reviewed at three monthly intervals and were asked to use the dentifrice up to the age of 5-6years. At the end of the study 3731 children remained as the study population and the efficacy was measured based on the dmft index.
Thus there was 16% reduction of caries experience in high fluoride group (1450ppm fluoride) (p<0.05). The study concluded that the use of high fluoride dentifrice reduces caries in kids residing in fluoride deprived areas.15
McCracken GI, Janssen J, Swan M, Steen N, de Jager M, Heasman PA. et al (2003) conducted a randomised, single-blind, 16-cell, cross-over trial to compare the efficacy of plaque removal capacity of a powered toothbrush (PTB) used with four brushing forces (75, 150, 225 and 300 g) and over four brushing times (30, 60,120 and 180 s). Twelve volunteers (18–30 years) were recruited and trained to use the powered tooth brush. Each subject was asked to abstain from all oral hygiene procedures for 24 hrs prior to each brushing event, to allow plaque accumulation. Plaque was recorded using a modified Quigley & Hein index (PI) at six points per tooth before and after each episode of brushing, and the differences in the means (pre- to post- brushing) were compared. Three-way ANOVA was undertaken to compare differences between plaque-removing efficacy for the 16 combinations of force and time. All 12 subjects participating completed the 16 combinations of force and time over which plaque removal was assessed. Subjects, brushing
8 time and brushing force were used as fixed effects within the analysis. The study results showed statistically significant differences in PI reductions were found between different brushing times and forces over all tooth surfaces (p<0.001). The interaction of varying brushing force and brushing time was significant for full mouth (FM) and interproximal (IP) sites (p=0.03). No statistical significance was demonstrated for smooth surface (SS) sites, nor was it detected for the interaction of subjects with brushing force or subjects with brushing time (p=0.05). The study concluded that brushing time and brushing force have significant effects upon the level of plaque removal by a PTB, and at 120 s brushing time the improvement in plaque removal with forces in excess of 150 g was negligible.16
Sirosiri Taweboon, Boonyarit Thaweboon et al (2004) conducted a study to determine the levels of secretory IgA (sIgA), salivary pH, salivary flow and mutans streptococci and candida levels in saliva of children with rampant caries compared to those who were caries free. Thirty children, aged 62 to 123 months were selected for this study and were classified under 2 groups caries free and rampant caries group (children with >5 cavities (or) >10 surfaces involved). Children with cooperative ability, normal growth and development absence of congenital or systemic diseases, absence of any dental abscesses, absence of any medication therapy, no infection 3 months prior to experiment were included in this study. Each child was instructed not to eat or drink anything for 2 hours before appointment. Whole saliva was stimulated and collected for 5 minutes. Salivary pH was determined using microelectrode
9 pH meter. The results of the study concluded that there was increased sIgA concentration in rampant caries group when compared to non- carious group.
Children with rampant caries had salivary pH of 6.59±0.32 whereas children without caries had a mean value of 7.08±0.13. Salivary flow rates were similar in both the groups. There was significant increase in the MS levels in rampant caries group when compared to that of non carious group (p<0.05). The study concluded that rampant caries was attributed to the increased MS count and candida counts and also because of increased salivary pH whereas salivary flow rate did not have any influence on the presence of caries.17
Stookey, Man et al (2004) conducted a study to compare and evaluate the anticaries effectiveness of three fluoride containing dentifrices. The three different toothpastes used for this study were low-dose fluoride (500ppm F, low NaF group), high dose (2800 ppm F, high NaF group) and an experimental 0.454% stabilized stannous fluoride (1100 ppm F) with sodium hexametaphosphate (SnF2 – HMP group) and each was compared to relatively normal sodium fluoride dentifrice (positive control). 955 individuals of mean age 10.6 years (9-12 years) were randomly assigned to one of the four groups.
Two calibrated examiners were asked to check for the baseline status by visual and tactile observation of caries as DMFS which was also supplemented by radiographs at the baseline, 12 months and 24 months for each subject. At the end of the two year period, considering that all individuals at least attended 60% of supervised brushing sessions, the study results showed that
10 significantly less caries was observed in high- NaF group compared to that of control group. The study concluded that there was no increase in caries in all these groups but the caries experience significantly decreased in SnF2-HMP than the control group.18
Surdacka A, Stopa J (2005) conducted a study to evaluate the effect of xylitol on oral cavity environment. The tests were carried out on 34 students who were divided into 2 groups: A and B with 17 students in each group. The initial clinical examination was carried out after 2 and 4 months of brushing teeth with fluoride toothpaste with xylitol (group A) and fluoride toothpaste without xylitol (group B). Clinical examination related to the evaluation of the hygienic condition of the mouth, plaque index (PLI) and hygiene index (HI), gingival index (GI), and gingival bleeding index (GBI) and Decayed Missing Filled Teeth (DMF-t) and Decayed Missing Filled Surfaces (DMF-s) was performed. 10 people from each group underwent a test on saliva secretion focusing on the number of S.mutans (SM) and L.acidophilus (LB). The parameters that were checked were salivary pH, as well as the amount of saliva and the level of fluoride in saliva. No significant differences in the tested parameters were observed between the two groups. The results of the tests after 2 and 4 months of using both toothpastes pointed out the improvement of the hygienic condition of the mouth and gums. The study concluded that tooth paste with xylitol had influence on the decrease of the number of S.mutans in saliva, the amount of secreted saliva and the increase
11 of pH value. The use of toothpaste with xylitol as well as without xylitol caused the increase of mean values of fluoride in saliva. Xylitol added to the toothpastes has a positive influence on the quality of the oral environment.9
Arnold W, Andreas Dorow et al (2006) conducted a study to check the efficacy of four fluoride tooth pastes on enamel demineralization. Ninety human premolars were demineralized in a pH of 4.8 (3x3mm window was created). The teeth were divided into 6 groups and the lower half of the window was covered with varnish serving as control. The teeth were immersed in a tooth paste slurry containing the tooth paste based on the group;
Group 1 (placebo tooth paste), Group 2 (Remineralisation solution), Group 3 (Elemen Anti caries tooth paste), Group 4 (Elemen sensitive), Group 5 (Blend – a med complete), Group 6 (colgate GRF). Ten teeth of each group were used
for the determination of F content in the superficial enamel layer and acid solubility. Six teeth of each group were evaluated under polarised light microscopy. The results of the study showed remineralisation of enamel. The superficial fluoride levels were increased significantly in Elemen groups and Blend –a – med group (p<0.001).The study concluded that, tooth pastes with amine also caused remineralistion followed by sodium fluoride and sodium monoflurophosphate formulations.19
AJM Ligtenberg, HS Brand (2006) conducted a study to evaluate the change in salivary pH before and after brushing with and without toothpaste.
12 Eighty healthy volunteers participated in this study; subjects were randomly distributed with regard to age, history of smoking, and the use of oral contraceptives and other medication. All subjects were instructed to refrain from smoking, eating, drinking caffeine-containing beverages and tooth brushing at least 1 hour prior to the experiment, which took place between 13.00 and 15.00 hours. Unstimulated whole saliva was collected in pre- weighed tubes for 2 min. Next, the volunteers brushed their teeth according to the Bass method for 2 min, using a new Lactona IQ soft tip with either water (22 persons), Elmex mentholfree toothpaste (29 persons), Elmex, anti-caries toothpaste (13 persons) or Parodontax (16 persons). Immediately after tooth brushing, toothpaste with residual saliva was expectorated. Thereafter, collection of saliva was started. Saliva was collected without stimulation for 2 min at 0, 10, 30 and 60 min after tooth brushing. The secretion rates were determined gravimetrically (1 g ¼ 1 ml) and expressed as mg ml). Salivary pH was measured with pH indicator strips (4.0–7.0 and 6.5–10.0, Merck, Darmstadt, Germany). Subsequently, equal volumes of 5 mL HCl and saliva were mixed and the final pH of this solution was used as an indication of the buffer capacity (titrated pH). For statistical analysis, repeated measures multi- analysis of variance was used followed by paired t-tests or independent samples t-tests where appropriate (SPSS version 10.0: SPSS Inc, Chicago, IL, USA). Tooth brushing induced transient changes in the salivary flow rate, pH and buffering capacity. After brushing with water, the salivary secretion rate increased significantly for 60 min suggesting tooth brushing mechanically
13 stimulates saliva secretion. When compared with brushing with water, the secretion rates enhanced significantly after brushing with toothpaste. The study concluded that one of the beneficial side effects of tooth brushing is an enhancement of the salivary flow rate what may result in increased oral clearance. This effect is independent of the gustatory stimulus of the toothpaste, as tooth brushing with water already results in a significant increase.6
Hiroshi Sano, Syozinakashima et al 2007 conducted an in vitro experiment study to evaluate the remineralization effect of a xylitol and fluoride containing tooth paste on human enamel using four kinds of the toothpastes formulations were used 1) without sodium fluoride and xylitol 2)with 500ppm of sodium fluoride 3) with 500ppm of sodium fluoride with xylitol 4) a silica based tooth paste with 500 ppm of sodium .Where artificial subsurface lesion by deminerlization. The sectioned teeth were randomly divided into one of 4 groups. The remineralization was done by applying 1.5 ml of tooth paste slurry for 3 min twice a day at 25 degree celcius for 4 hours daily. The enamel were assessed for degree of remineralization using QLF acquisition. The results showed no significant difference among the four treatment groups with respect to their baseline values. The study concluded that tooth paste containing 500ppm of sodium fluoride and 5 % xylitol enhances the reminerlization of early caries lesion for 14 days treatment
14 period compared to tooth paste containing only 500ppm of sodium fluoride and the other 2 groups.20
Ravi V Shirahatti, Anil V Ankola, L Nagesh (2007) conducted a study to know the effect of chewing fennel seeds on plaque pH and salivary pH. Twenty subjects were recruited based on eligibility criteria and were informed not to use any oral hygiene measures 24 hours prior to appointment.
The resting plaque and salivary pH was measured to record the baseline data.
For measurement of salivary pH 2 ml. of stimulated saliva was taken. The measurement of the plaque pH was done as follows. The plaque was collected from buccal surfaces of the designated posterior teeth and pH measured by pooling the plaque. The collected pooled plaque was thoroughly mixed with 10 milliliters of distilled water and pH determined using a previously calibrated glass combination electrode. After the subjects chewed seeds for five minutes resultant plaque and salivary pH were measured again. A third saliva sample was taken and pH measured five minutes later. The Results showed a very transient drop in salivary pH on chewing the seeds was observed (0.56 + 0.46). However plaque pH did not show any significant change. The study concluded that the drop in pH is not sustained and is returning to normal limits within five minutes after chewing the seeds suggesting that the seeds have very little Cariogenic potential.21
15 Sudha Patil, Karthik Venkataraghavan (2007) conducted a study to assess the anti-microbial effect of two commercially available toothpastes and to compare and evaluate the effect of the two toothpastes on Streptococcus mutans count level. One hundred student participants in the age group of 4-6 years with dmf = 0 were selected. A Baseline saliva sample was taken and cultured for mutans streptococci, the colonies counted and noted. The 100 participants were randomly divided into two groups with 50 participants in each group. Group I was provided with Himalaya Herbals Dental cream containing Neem, Group II was provided with 458 ppm containing fluoride toothpaste Cheerio gel. The toothpastes and toothbrush were provided over a period of 5 months for home care use. Instructions were given to the parents on brushing technique, amount of paste to be used and twice daily brushing with the pastes, with specific instructions that the child should not use other toothpastes during these 5 months. The saliva sample was then collected and streptococcus mutans estimated in 4 phases, 1) 15 days 2) 30 days 3) 90 days 4) 150 days. The results showed that there was a steady decrease in the bacterial count over a period of 5 months; the overall percentage decrease in Group I being 90.69% and Group II being 89.69%. However, between the toothpastes there was no statistically significant difference in the bacterial count and both the toothpastes were efficacious in reducing the bacterial count. Hence it was concluded that both Herbal toothpaste containing Neem and Fluoridated toothpastes are efficacious in combating caries and both can be used as a regular home care preventive measure in combating caries in
16 children. The study concluded that both the toothpastes have a good antimicrobial effect on caries producing salivary streptococcus mutans bacteria. Toothpastes containing Neem as well as fluoridated toothpaste are equally efficacious against caries producing bacteria.10
Wafa K. M. Talha , Manal E said in (2008) conducted a study to compare the effect of Meswak and fluoride and fluoride tooth pastes on the S.
mutans and Lactobacilli count in dental plaque and to compare the effect of both types of tooth pastes on plaque and salivary pH. Forty children of both sexes ranging in age 7-9 years with completely erupted first permanent molars and permanent upper incisors, apparently healthy with no history of systemic diseases, none of them were under anti microbial agents who had DMF ranging from 4-8 were included in the study. All patients were instructed to brush twice daily, refrain from any other oral hygiene procedures and continue their dietary routine throughout the study. Pooled plaque samples were collected from buccal surface of incisors and the salivary collection was done by asking the patient to expectorate unstimulated (resting) saliva over 10 minutes. A portable pH meter was used to analyze the salivary pH. There was significant pH change in the Meswak group whereas the fluoride group did not show any change (significant) (p=0.033) (0.063). There was no difference in salivary pH in both Meswak and fluoride group (p-0.688 and p-0.834). There was significant decrease in S.mutans CFU in fluoridated group (p-0.026). The study concluded that both tooth pastes have good antimicrobial effect but
17 fluoridated group had a higher decrease in CFU. Whereas Meswak toothpaste raised plaque pH suggesting a positive role in the reduction and prevention of dental caries.12
M.T. Kato, M.Lancia et al (2009) conducted an in-vitro study to evaluate the preventive effect of commercial desensitising tooth paste on Bovine enamel against erosions. One hundred Bovine teeth were prepared as blocks which were randomly allocated into 5 groups (20 in each group).
Group 1; Sensodyne pro enamel (1,425 ppm fluoride and 5% KNO3), Group 2; Sensodyne original (no fluoride 10% Srcl2), colgate sensitive (1,450 ppm sodium monofluoride phosphate, 5%KNO3) crest (fluoride only tooth paste (1,100 ppm of NaF) and water (Negative control). All the experimental teeth blocks were exposed to four cycles of alternating demineralisation (cola, 10 min) and mineralisation (artificial saliva 1 hr). Before and between the cycles of demineralisation and remineralisation the teeth were treated with tooth paste slurries or negative control (water) for 1 min duration. The erosive tissue loss was analyzed by profilometry. The results showed that the mean erosive depth was significantly less for colgate sensitive (0.04+-0.00) followed by sensodyne original (0.06+_0.01) and crest (0.07+_0.01) than that of sensodyne proenamel (2.36+_0.25) or water (2.92+_0.24). The study concluded that the tooth pastes that contained both fluoride and desensitising agents reduced enamel erosion but they did not have an additive effect. In addition the study concluded that, combination of KNO3 and F did not reduce the erosion.22
18 J.Okpalugo, k Ibrahim et al (2009) conducted a study to evaluate the effectiveness of seven branded tooth paste formulations in reducing oral flora.
seven brands of tooth pastes were selected for the study .two contained triclosan too4 and too6, four contained fluoride, too1, too2, too5 and too7 and one tooth paste and herbal too3, all the tooth paste brands were assessed for their microbial load after which each individual used the tooth paste 12 hourly on three consecutive occasion as the only oral hygiene measure . After the procedure the saliva was collected and were cultured on agar plate using pour technique analysis of microbial load showed that tooth paste containing two antibacterials (sodium fluoride+ triclosan) had more reduction in antibacterial load than non – triclosan containing tooth paste (P=0.009).8
Preethi BP, Maitreyee D.S, Dodawood R (2010) conducted a study to estimate the endogenous pH and titrable acidity of fruit juices and assessed their effect on the pH of the plaque in carious and non-carious groups. Twenty four volunteers aged 20-30 years were divided into carious groups (DMFT<3) NM carious group(DMFT=0) and were randomly allocated in one of the four fruit juices group (freshly prepared apple juice, freshly prepared sweet lime juice, ready to drink frooti, ready to drink pulpy orange group). Plaque pH was collected at baseline and at 1, 5, 10, 15, 30 mm after consumption of fruit juices and was assessed using PH meter. The results of the study showed that the PH of frooti, apple, pulpy orange and sweet lime was found to be 3.43, 4.52, 2.31 and 3.76 respectively. The study concluded that ready to drink fruit
19 juices have more acidic nature when compared to that of freshly prepared fruit juices which has more cariogenic potential especially for the caries active group.23
M. Ribelles Llop, F. Guinot Jimeno (2010) conducted a study to compare variations in salivary flow rate, pH, buffering capacity and levels of Streptococcus mutans in baseline conditions and after chewing paraffin pellets or xylitol chewing gum in children between the ages of 6 and 12 years who eat lunch in a school canteen. The study sample consisted of 90 children divided into 2 study groups, and a control group. The baseline data was recorded in the first phase soon after the lunch and were compared with the data recorded in the second phase, after 15 minutes of chewing xylitol-sweetened chewing gums or paraffin pellets, depending on the study group. Salivary flow rate was measured by collecting the stimulated saliva in a graduated beaker. Levels of pH were measured using a Cyberscan pH 110 pH meter (Eutech Instruments®). Buffer strips and the CRT bacteria test (Ivoclar-Vivadent) was used to measure buffering capacity and levels of S. mutans, respectively. The data obtained after sample collection were compared by means of a 1-way analysis of variance using the StatGraphics Plus statistical software package, version 5.0. Statistically significant differences were found (p <.05) when pH, buffering capacity and levels of S. mutans were compared between the 3 groups. Comparison of salivary flow rates revealed no statistically significant differences (p >.05), though salivary flow rates were higher in the groups
20 where gum was chewed. The study concluded that the effect of chewing is essential to the stimulation of salivary flow and the resulting recovery of pH levels and reduction of levels of S.mutans in saliva.24
Updesh Masih, Manisha Prabhakar, et al (2010) conducted a study to compare the human plaque pH changes after consumption of milk and infant milk formulae. Thirty school going children of age group 8 – 12 years with dmft/DMFT<3 who were free of any dental or systemic problems. All the children were given oral prophylaxis followed by which they were abstained from oral hygiene measures for to ensure uniform plaque accumulation.
Baseline plaque samples were collected followed by which they were told to swish for 40 sec and either spit or swallow the milk formulae based on their convenience. Plaque samples were taken from teeth no 46, 44/84, 36, 34/74 at 5, 10, 20 and 30 min interval respectively. The children were again asked to report after 5 days and the entire experiment was repeated except for the milk formulae that were changed. The study confirmed that all milk formulae can be recommended for diet counseling but lactodex 2 gave better result pH - 6.487 ±0.142 than lactogen – 6.323±0.131 and amul spray pH – 6.o24
±0.3130.25
Apiwan Smutkeeree, Norawan Rojlakkanawong & Veeritta Yimcharoen (2011) conducted a study to compare the efficacy between the horizontal scrub and modified Bass methods in visually impaired students.
21 Sixty visually impaired students, aged 10–12 years, were recruited to a randomized controlled clinical trial. At baseline, plaque index (PI) and gingival index (GI) were assessed, and then subjects were randomly divided into the horizontal Scrub and modified Bass groups. Subjects received verbal and tactile tooth brushing instruction and used their assigned methods twice daily. They were recalled at 1 and 6 months for clinical measurement and reinforce of instruction. Significance of plaque index and gingival index over time was compared using the paired t-test and between brushing group at each time point using the t-test. The study results showed that over the 6-month period, there were significant reductions from baseline for the mean PI and GI in both groups (P < 0.001). There were no significant differences between two methods at each time point (P > 0.05).the study concluded that both the horizontal Scrub and modified Bass methods can be effectively reduced plaque index and gingival index in visually impaired students. The efficacy of both methods was not different.26
Elen de Souza Tolentino, Luiz Eduardo Montenegro Chinellato (2011) conducted a study to evaluate saliva and tongue coating pH before and after use of different oral mouthrinses. Fifty patients aged 18 years of both sexes allocated in 5 groups whose Saliva and tongue coating pH of measured respectively by a digital pH meter and color pH indicators, Each patient underwent three collections of saliva samples: at the beginning of the consultation,30 min after rising (phases before, after, and 30 min, respectively.
22 The volunteers were randomly divided into 5 different mouthrinses (10 persons in each group): cetilpiridine chloride associated with sodium chloride, triclosan, enzymatic solution, essential oil and distilled water. Only triclosan and essential oil increased salivary pH immediately after rising. The difference in the salivary pH between the groups before and 30 min phases was significant (p>0.05). The enzymatic solution decreased salivary and tongue coating pH immediately after rinsing. According to the methodology applied in this study, it may be concluded that: In a situation of physiological halitosis, salivary pH tended to be acidic while tongue coating pH tended to be alkaline, even after the use of mouthrinses; Only triclosan and essential oil mouthrinses increased salivary pH immediately after rising; The enzymatic solution was able to decrease saliva and tongue coating pH immediately after rising.4
Sabyachi Saha, Gerdamariahelly Venkatarayappa (2011) checked the effect of commonly consumed fresh fruit juices and commercially available fruit juice on pH of saliva at various time intervals. The double – blinded study was done in 40 volunteers of age group 18 – 20 years , 17 males – 23 females with DMFT<3. Baseline salivary pH was estimated using digital
pH meter. Volunteers were asked to drink the juices and the salivary pH was estimated at 1min., 5 min, and 15 min, 30 min after drinking juice. The result of this study concluded that all the juice causes a fall in salivary pH. Drop in pH was significant in commercially available juice than freshly prepared juice p=0.001 after 1 min and p = 0.005 after 5 minutes.27
23 Kristina Peros et al (2012) conducted a study to evaluate the antimicrobial effect of different frequencies of brushing with fluoride dentifrice on the streptococcus mutans and lactobacilli in children undergoing orthodontic treatment. Twenty two patients scheduled for fixed orthodontic treatment were divided into two groups with different hygiene regimes.
Group1 (brushed four times daily) and Group2 (brushed twice daily).
Unstipulated saliva was obtained at before placement of appliance and 6, 12 and 18 weeks after placement (i.e during therapy). The results showed that the salivary streptococcus mutans were significantly reduced throughout the experimental period in the group that brushed four times a day (p<0.05).
However they had little effect on lactobacillus population. The study concluded that brushing with 0.32% NaF decreased the salivary mutans streptococci significantly.28
Malgorzata Klukowska, Juliem Grender, Hans Timm (2012) conducted a study to determine the effectiveness of a new multi-directional power toothbrush in reducing plaque when compared to a standard manual toothbrush control in a single brushing design. The study was a randomized, replicate use, single-brushing, two-treatment, four-period, examiner-blinded crossover clinical trial at a single center. Qualified subjects entered an acclimation phase, after which they were randomly assigned to one of four treatment sequences specifying the order of use of the two test toothbrushes: a
24 novel multi-directional power toothbrush with a 2-D drive and an American Dental Association (ADA) reference soft manual brush. Subjects used each brush twice over the course of the trial. At each of the four period visits, after abstaining from oral hygiene for 24 hours, participants received a baseline (pre-brushing) Turesky Modification of the Quigley-Hein Plaque Index (TMQHPI) examination. They then brushed under supervision with the brush assigned for that period for 2 minutes (multi-directional power brush) or as customary (manual brush control). Subjects were then re-examined for TMQHPI post-brushing to determine the plaque removal efficacy of the respective brushes. A washout phase of 2-5 days separated treatment periods.
TMQHPI scores were averaged on a per-subject basis, and analyzed using a mixed model analysis of covariance for a crossover design. The study results showed that both the multi-directional power and manual control brushes produced statistically significant mean whole mouth TMQHPI plaque reductions compared to baseline (P< 0.001). Comparing the brushes, the power brush provided a 7.9% significantly superior mean whole mouth plaque reduction relative to the manual brush control (P= 0.003). The study concluded that both the brushes performed well in plaque removal capacity but the powered brush was superior when compared to that of manual brush.29
Chand S, Gulati P, Dhingra S conducted a study to estimate the pH of commercially available dentifrices and evaluating its effect on salivary pH after brushing. 60 study subjects were selected and were divided into 12
25 groups (each group comprises of 5 subjects). The salivary pH was directly estimated using the digital pH meter calibrated using buffers of pH 4, 7 and 9.
Paired t test was used to compare the changes in the mean salivary pH after brushing in each group. One way ANOVA and Tukey’s test was used to
compare the changes in mean salivary pH after brushing between different groups. The results showed that the pH of different types of commercially available dentifrices which were used in the study was found to be 8.4, 7.9, 7.9, 6.7, 7.2, 8.3, 8.4, 7.1, 6.5, 5.6, 8.2 and 6.5 respectively. Difference in mean salivary pH after brushing was found to be statistically significant for Colgate, Neem active group, Vicco, Triguard, Colgate active salt, Dabur, Meswak, Dabur Babool, Close-up active gel, RA Thermoseal, Daburlal Dantmanjan, Colgate powder groups. Mean salivary pH (before and after brushing) between study groups showed a statistically significant difference.
The study found a statistically significant affect of pH of these dentifrices on the salivary pH as it was found that there was significant increase in mean salivary pH of study subjects after brushing with various dentifrices (P<0.05) except for MDH Dantmanjan dentifrice(P>0.05). The study concluded that the pH of saliva increases after brushing in each commercially available dentifrice group.7
Isha Goel, S. Nawit et al (2013) conducted a study to assess the effect of carbonated drink and fruit juice on salivary pH in children. Thirty nine children of age group 8-12 years were included in this study who were free of
26 any systemic diseases and whose dmft/ DMFT index was <2. The base line salivary pH was determined from unstimulated saliva, followed by which the children were asked to take carbonated soft drink (Mirinda) on the first day and fruit juice (Tropicana) on day 2. The base line saliva was taken followed by salivary samples collected at 5, 10 15 and 30 min. The salivary pH was determined using a digital pH meter. There was significant fall in pH after intake of carbonated drink when compared to fruit juice group (0.579+0.136 mean difference; p<0.001). The study concluded that the regular use of such drinks should be discouraged as it may cause dental erosions and also caries in children.30
P. Moeiny, N. Shafizadeh, SH. Biabani, F. Raofie, MJ. Kharazifard conducted a study to evaluate the efficacy of three fruit juices on plaque pH.
In this randomized clinical trial, 10 healthy dental students were selected based on the inclusion criteria namely the amount of streptococcus mutans and lactobacillus in the saliva, salivary secretion rate, buffering capacity of saliva, absence of active dental caries, absence of systemic disease and etc. Dental plaque pH in certain areas of the 4 mouth quadrants was measured by 5 MetroHM microelectrode and digital pH meter before and 2 to 60 minutes after the consumption of Children orange juice, orange nectar with pulp, pineapple nectar and 10% sucrose solution. The pH curve at different time points was then drawn for each product. Data were analyzed statistically by repeated measures ANOVA (P<0.05).The maximum drop in plaque pH
27 occurred 2 minutes after consumption. The time spent below the critical pH was the longest for orange nectar with pulp (10.75 ±2.24) and shortest for pineapple nectar (3.46 ± 1.14) .At sixty minutes of study, plaque pH returned to its baseline value after consumption of all fruit juices except for orange nectar with pulp).The study concluded that after consumption of orange nectar with pulp, the mean plaque pH was significantly lower in comparison to other juices and the time spent under the critical plaque pH was the longest and the orange nectar had an increase risk of causing enamel demineralization.31
Priya Subramaniam, Krishna kumar et al (2013) conducted a study to evaluate the change in salivary pH following use of commonly prescribed homeopathic medicines in children. Forty five normal and healthy children were divided into 3 Groups of 15 children each. Group 1 was given a placebo, Group 2 was given chamomilla and Group 3 was given arsenicum. Each child was given 2 pellets to be placed under their tongue and allowed to dissolve completely. Unstimulated salivary samples were collected baseline and following 5, 15, 30 and 60 minutes of administration. There was significant reduction in salivary pH at 5, 15 and 30 minutes in chamomilla and arsenicum Group. (pH- 5.40, 5.16 respectively) (p-0.000). In all groups, salivary pH did not return to baseline values even after I hr of administration of the homeopathic pellets. The study concludes that when homeopathic medicines are given on long duration, they might act as carious acting agents.32
28 Rokaya D, Manipal S, Bajracharya M (2013) conducted a study to see the effect of two chewing gums on pH of saliva. Four hundred and forty five school children of both sexes in Kathmandu were divided into two groups; sugar-free group (n=222) and sugar-based group (n=223). The pH was measured with Universal pH indicator at different time intervals; 5 minutes before meal & 10 minutes after meal. Then 15 minutes after meal each group were given two different types of chewing gums; sugar-free and sugar-based.
Then the students were allowed to chew for 5 minutes and the pH was measured, i.e. 20 minutes after meal. In sugar-based group, the mean pH 5 minutes before meal was 6.9484 and the mean pH 10 minutes after meal was 4.8161. In sugar-free group, the mean pH 5 minutes before meal was 6.927 and the mean pH 10 minutes after meal was 4.7927. The mean pH after 20 minutes after meal in sugar-based chewing gum was 8.977 whereas in sugar free, pH was 9.240. The differences between sugar-free gum and sugar-based gum groups were analyzed by Student’s T-test at the 5% level of significance.
It shows that, though after using chewing-gums, the pH of saliva raised but statistically, there was no significant difference between sugar-free and sugar- based chewing gum groups. The study concluded that the chewing gum stimulates the pH of saliva which demonstrates the beneficial effects on the oral health. In this study, there is no significant difference between sugar-free and sugar-free chewing gum.33
29 Shikhar Kumar, Suma Sogi H. P., Indushekar K. R. (2013) conducted a study to evaluate the salivary and dental plaque pH changes after consumption of sugared and sugar-free (xylitol) chewing gums in children. A total of thirty school children were selected for this study and were divided into two equal groups and given both chewing gums for the experiment.
Group A children were subjected to sugared chewing gum (Happydent White Chewing Gum) and Group B children were subjected to sugar-free chewing gum (Happydent White Xylit Chewing Gum). The plaque samples were collected from buccal and palatal surfaces of the maxillary teeth; and buccal and lingual surfaces of the mandibular teeth with the help of a sterile spoon excavator. These plaque samples were then dispersed in a test tube containing double de-ionized distilled water. The dental plaque samples that were obtained were then subjected to pH measurements. The values displayed digitally were taken as control values. Then the children were given 1 pellet of sugared chewing gum to chew for 10 min. After 10 min the chewing gum was discarded. The saliva and the dental plaque samples were then collected immediately by the same procedure as mentioned earlier and up to 1 h at a time interval of 15, 30 and 60 min. Following this, the collected saliva and the dental plaque samples were subjected to pH measurements. The values displayed digitally were taken as experimental values. After this, a thorough oral prophylaxis was done for all the children of Group A. The children were then given proper oral hygiene instructions and oral hygiene measures were reinforced in them. Similarly, the above mentioned entire procedure was
30 carried out in all the selected 15 children of Group B (all the children were given 1 pellet of sugar-free chewing gum instead of sugared chewing gum).
The pH values were assessed with the help of a pH meter. The results showed that children consuming the sugar-free (xylitol) chewing gum showed a marked increase in the pH of saliva and plaque when compared to their counterpart. All these values had a significant difference of P ≤ 0.0001. The
study concluded that xylitol is a safe all natural sweetener which helps to reduce tooth decay. It plays a unique role in preventive strategies for better health.34
Ali Nozari, Faezel Ghaderi, Saced Madadelhi (2014), Conducted a study to assess the ph change in plaque saliva solutions with four customary used infants with formulas. Plaque saliva samples were collected from twenty five children. Infant milk formulas including bebalac 1, nan 1, nan 2, and aptamil 1 were prepared and added to 4 respective tubes of saliva – plaque solution , the pH samples were measured at 10 min interval (10 -60 min) at 37 ˚c . All the infant milk formulas caused significant pH drop in all the
samples. The study concluded that Nan 1 and Nan 2 caused decreased fall in pH when compared to Bebelac and Aptamil as all the other ingredients were same in all 4 milk formulae.35
Narges Mirgalili, Mohammad Harsan, JafarFarahman (2014) conducted a study to investigate the effect of tap water rinsing compared to
31 tooth brushing and chewing gums on salivary pH after consumption of sugar solution. Salivary samples were collected from 60 participants of age group 20-25 years of age including both sexes who were of any dental (or) periondontal diseases with normal oral pH of 6.2-7.4. In the first attempt unstimulated salivary pH was obtained followed by which all participants were asked to swish with 50% sugar solution for one minute. A minute later, salivary pH was obtained. The final sample was taken 1minute after they were asked to rinse their mouth with water. On the second day similar procedure was done except that the water was replaced with brushing without dentrifice and on the third day the intervention was changed to xylitol containing chewing gum xylitol. The data was analyzed using ANOVA and paired T- Test. This study concludes that, sugar free gum is a beneficial inter rim oral hygiene whereas water on the contrary is neither beneficial as inter rim oral hygiene measure nor as an anti-caries adjunct to tooth brushing.5
Paola A. Belardinelli, Rosana A. Morelatto, Tomás E. Benavidez, Ana M. Baruzzi, Silvia A. López de Blanc (2014) conducted a study to evaluate the effect of two commercially available mouthwashes on salivary pH and correlate it with age, buffer capacity and saliva flow rate in healthy volunteers. A crossover phase IV clinical study involving three age-based groups was designed. Two commercial mouthwashes (MW), Cool Mint Listerine® (MWa) and Periobacter® (MWb) were used. The unstimulated saliva of each individual was first characterized by measuring flow rate, pH,
32 and buffer capacity. Salivary pH was evaluated before rinsing with a given MW, immediately after rinsing, 5 minutes later, and then every 10 min (at 15, 25, 35 min) until the baseline pH was recovered. Paired t-test, ANOVA with a randomized block design, and Pearson correlation tests were used. Averages were 0.63 mL/min, 7.06, and 0.87 for flow rate, pH, and buffer capacity, respectively. An immediate significant increase in salivary pH was observed after rinsing, reaching average values of 7.24 (MWb) and 7.30 (MWa), which declined to an almost stable value 15 minutes. It was evident that pH of the external agent alone is not a good indicator for its erosive potential because biological systems tend to neutralize it. The study concluded that that the pH of the external agent alone is not a good indicator for its erosive potential because biological systems tend to neutralize sudden changes in pH generated by these agents.36
Rahul R. Deshpande, Priyankakachare, et al (2014) conducted a study to compare the antimicrobial efficacy of two commercially used tooth pastes. Patients of age group 6-12 years in mixed dentition period with high caries experience were included this study. The subjects were told to rinse with water and salivary samples were collected from the floor of their mouth.
The toothpastes were diluted at 25%, 50% and 100% concentrations. The salivary samples were cultivated in nutrient agar plates in which dentrifice concentrations were introduced in each well. The antimicrobial activity was evaluated by measuring the diameter of zones of inhibition. The fluoridated
33 tooth paste showed increased antimicrobial efficacy on all concentrations compared to that of herbal tooth paste (p<0.05).This study has proved that fluoridated tooth paste remains as a gold standard as far as antimicrobial efficacy is concerned.11
Sanjyot Mulay, Hansa Jain (2014) conducted a study to evaluate &
compare change in salivary flow rate & pH after chewing xylitol & sorbitol containing chewing gums. It was a randomized controlled study was conducted on 60 healthy males between the age group of 20-40 years, who were non-smoker, non tobacco chewer, having OHI index <3 and carious lesions between 2-5. The selected patients were equally segregated into two groups, Group X - Xylitol & Group S - Sorbitol [n=30]. Patients were first asked to chew paraffin wax [control] for five minutes. After a rest time of 5 minutes the medicated gum was chewed for the same time period. They were asked to spit the hoarded saliva in a calibrated saliva collection cup. The collected saliva was measured and the pH was noted using pH strips. The study results showed that both the chewing gums caused increase in salivation but xylitol comprising chewing gum showed marked increase in comparison to sorbitol gum, although the result was not statistically significant. Though clinically rise in pH was just 1.33 and 1.10, but statistically it was found significant, i.e. the ‘p’ value 0.002. It was concluded in the study that chewing gums containing xylitol are more effective in increasing the salivary flow rate,
34 this can be used in patients suffering from severe caries and disease leading to hypoptyalism and xerostomia.37
Srinivasan, Schimmel et al (2014) conducted a study to evaluate the effectiveness of the application of a high fluoride tooth paste on root caries. A total of 130 participants with diagnosed root caries were taken up for this study and were divided into two groups: Group 1 (Test group with intervention of 5000 ppm F containing high fluoride dentrifice) and Group 2 (control Group- intervention with regular fluoride containing tooth paste with 1350 ppm of fluoride). Clinical examinations and surface hardness scoring of the carious lesions were performed for each subject at specified time intervals (To- at base line, T1 at 3 months, T3 at 6 months after intervention). Two way ANOVA was done. The results revealed that the hardness was significantly higher in high fluoride group compared to the control (p<0.0001). The study concluded that use of high fluoride tooth pastes significantly improves the surface hardness of untreated root caries compared to that of normal tooth pastes.38
Materials and Methods
35
MATERIALS AND METHODS
Forty three school going children aged 4-6 years of both the sexes who were willing to participate with informed written consent signed by their parent/guardian/teacher participated in the present study to test the efficacy of four different interventional methods i.e. water rinsing, brushing without dentifrice, brushing with non-fluoridated dentifrice and brushing with fluoridated dentifrice on salivary pH during the experimental period.
Armamentarium:
Mouth mirror
Explorer
Cotton
Tweezers
Sterile container
pH strips
De-Ionized(distilled) water
Kids toothbrush
Fluoridated dentifrice
Non-fluoridated dentifrice
Stop watch
Freshly prepared apple juice
36 Criteria for inclusion:
1. Children with overall good general/oral health ( with no systemic illness or oral disorders)
2. Children with minimal or no caries ( dmft = 0-3) 3. No antibiotic coverage for past one month
4. With no acute intra-oral or extra-oral lesions (soft tissue swelling, pus discharge, sinus or fistula opening)
5. Child with co-operative ability.
Criteria for exclusion:
1. Children with active dental or periodontal diseases 2. Children with debilitating systemic diseases 3. Children with extensive caries (dmft>3)
4. Children who wore orthodontic appliances and crowns.
5. Children whose parents were not acceptable for the study 6. Children lacking co-operative ability.
Clinical and sampling procedure:
Forty three school going children of both sexes aged 4-6 years were selected from a residential school for the present study following the inclusion criteria and an informed written consent was obtained from the parents of the children. The children and parents were explained about the study. The study
37 was carried out between 9 a.m to 12 p.m. There were no restrictions placed on the diet and usual oral hygiene measures of the participants.
The experimental trial was divided to four consecutive days of intervention.
Day 1: rinsing with water
Day 2: brushing without dentifrice
Day 3: brushing with non-fluoridated dentifrice
Day4: brushing with fluoridated dentifrice
Saliva collection:
For the collection of unstimulated saliva, the children were asked to sit comfortably; the baseline saliva collection was done within a period of 30-60 seconds by Dawe’smethod.39The children were asked to pool unstimulated
saliva in the floor of the mouth followed by which they were asked to expectorate inside the sterile container.
Total sample (n=53)
Day 1 (Water rinsing)
Day 2 (Brushing)
Day 3 (Brushing with non-fluoridated
dentifrice)
Day 4 (brushing with
fluoridated dentifrice)
38 Preparation of apple juice:
Freshly prepared apple juice was used for this study. An average sized apple was blended along with two tablespoons of sugar. The blended mixture was then filtered and used for the study.
Experimental methodology:
On the first day, after taking unstimulated baseline saliva samples, then the subjects were asked to drink 50 ml of freshly prepared apple juice in one minute and to swish and drink carefully in order to maintain a uniform method in drinking. A minute later, a saliva sample was obtained from each participant. Immediately, they rinsed their mouth with tap water for 1 min. A third saliva sample was taken after another 1 min. On the second day, the subjects repeated the first two steps (i.e. saliva collection before and after juice consumption). Then they were asked to brush their teeth instead of rinsing their mouth with tap water. The third sample was collected 1 min after brushing. On the third day of experiment the children were asked to follow the same steps except for the intervention method which was brushing with non- fluoridated toothpaste. On the final day of experiment, the participants brushed with fluoridated toothpaste as the intervention method after the initial steps of saliva collection before and after fruit juice consumption.
39 Measurement of pH:
The collected salivary samples were pooled with 10 ml of distilled water and the acidities were checked using pH strips twice. The pH test strip was dipped in the salivary sample for 30 seconds to record optimal color change; after which it was removed and the change of color was compared with the color coded chart that was given along with the pH strip pack. Based on the calorimetric change of the strip; the pH of the saliva was recorded.
Statistical analysis:
The changes in the pH measurements were tabulated and analyzed with SPSS software (version 17.0 for Windows) by analysis of variance (ANOVA) and Paired T-test.
Figures
FIGURE 2: ARMAMENTARIUM (FOR EXPERIMENTAL PART)
FIGURE 3: SCREENING PATIENTS
FIGURE 4: CHILDREN GIVEN APPLE JUICE TO RECORD FALL IN THE SALIVARY pH
FIGURE 5: CHILDREN ASKED TO FOLLOW INTERVENTIONAL METHOD
METHOD
FIGURE 7: MEASURING pH USING COLOUR CODED pH STRIPS
