COMPARATIVE EVALUATION OF EFFICACY OF FOUR DIFFERENT ...

COMPARATIVE EVALUATION OF EFFICACY OF

FOUR DIFFERENT INTERVENTIONAL METHODS

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

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ACKNOWLEDGMENT

The very first person, I would like to thank is my dedicated, eminent,

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.

I would also like to express my heartfelt gratitude to Dr.Vijayaprabha,

MDS.,Dr. Sakthivel, MDS.,Dr. Poornima, MDS.,, Readers, Dr. Arun

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

not express gratitude. I would like to dedicate my work to my family who never

gave a second thought in allowing me pursue my dreams.

I would like to mention a special thanks to the non-teaching staffs, who

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”

CONTENTS

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

LIST OF TABLES

TABLE

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.


AFTER SUGAR EXPOSURE WITH BRUSHING WITH WATER

AND BRUSHING WITH NON-FLUORIDATED DENTIFRICE

4.


AFTER SUGAR EXPOSURE WITH WATER RINSING

BRUSHING WITH FLUORIDATED DENTIFRICE AND

BRUSHING WITH NON-FLUORIDATED DENTIFRICE

5.


AFTER SUGAR EXPOSURE AND BRUSHING WITH NON-

FLUORIDATED AND BRUSHING WITH FLUORIDATED

DENTIFRICE

LIST OF GRAPHS

GRAPH

NO. TITLE PAGE NO.

1. GRAPH DEPICTING MEAN VALUES OF THE PH

CHANGES IN SALIVA AFTER SUGAR EXPOSURE AND

AFTER VARIOUS INTERVENTIONAL METHODS



AFTER WATER RINSING



AFTER BRUSHING WITH WATER



AFTER BRUSHING WITH NON-FLUORIDATED

DENTIFRICE



AFTER BRUSHING WITH FLUORIDATED DENTIFRICE

LIST OF FIGURES

FIGURE

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

LIST OF ANNEXURES

S.NO. TITLE

I SCREENING FORM

II MASTER SHEET

III CONSENT FORM- ENGLISH

IV CONSENT FORM – TAMIL

V INSTITUTIONAL REVIEW BOARD APPROVAL CERTIFICATE

Introduction

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

Introduction

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

Introduction

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

Introduction

4

dentifrice, brushing with non-fluoridated dentifrice and brushing with

fluoridated dentifrice in maintaining the salivary pH following an acidic surge.

Aims and objectives

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.39

The 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

Figures

FIGURE 1: ARMAMENTARIUM (FOR SCREENING)

FIGURE 2: ARMAMENTARIUM (FOR EXPERIMENTAL PART)

Figures

FIGURE 3: SCREENING PATIENTS

FIGURE 4: CHILDREN GIVEN APPLE JUICE TO RECORD FALL IN

THE SALIVARY pH

Figures

FIGURE 5: CHILDREN ASKED TO FOLLOW INTERVENTIONAL

METHOD

FIGURE 5: CHILDREN ASKED TO FOLLOW INTERVENTIONAL

METHOD

Figures

FIGURE 6: COLLECTION OF SALIVA AFTER INTERVENTIONAL

METHOD

FIGURE 7: MEASURING pH USING COLOUR CODED pH STRIPS

Results

Results

RESULTS

Salivary sample of forty three children were analyzed for pH changes

on four consecutive days of experiment to assess the effect of various

interventional measures after sugar exposure. The results were analyzed using

the one way ANOVA (SPSS software version 17.0)

The mean pH on day 1 at baseline was 7.384±0.37 and after sugar

exposure it fell significantly to 4.895±0.72. The salivary pH increased

significantly to 6.337±0.69 after water rinsing (p=0.00). The fall in the

salivary pH increased significantly after rinsing with water but did not reach

the baseline salivary pH.(Table 1 and Graph 2)

The mean pH on day 2 was 7.430±0.39 at baseline and after sugar

exposure decreased significantly to 4.779±0.74. After brushing without

dentifrice the salivary pH increased to 6.733±0.45 (p=0.00).The fall in the

salivary pH increased significantly after brushing but failed to reach the

baseline salivary pH.(Table 1 and Graph 3)

The mean pH on day 3 was 7.302±0.60 at baseline and decreased

significantly to 4.372±0.57 after the sugar challenge. After brushing with non-

fluoridated tooth paste there was significant increase in salivary pH to

8.291±0.47.(p=0.00)(Table 1 and Graph 4)

The mean pH on day 4 at baseline was 7.465±0.33 and decreased to

4.395±0.62 after the sugar intake. After brushing with fluoridated tooth paste

Results

the salivary pH increased to 8.407±0.29 and the increase was highly

significant with p=0.00.(Table 1 and Graph 1)

On comparing between various groups, there is no significant

difference in the salivary pH of baseline (p=0.251) as well as after sugar

challenge (p=0.368).(Table 1 and Graph 1)

But a significant increase was seen in the salivary pH, when brushing

was performed using fluoridated and non-fluoridated tooth paste (p=0.00)

(Table 1 and Graph 1) compared to that of brushing without dentifrice and

water rinsing groups. When water rinsing and brushing without dentifrice was

compared, brushing without dentifrice was proved to be superior when

compared to water rinsing (p=0.002) (Table 1 and Graph 1)

There was no significant difference among brushing with fluoridated

and non-fluoridated toothpaste groups in increasing the salivary pH after sugar

exposure(p=1.00) (Table 1 and Graph 5).

Tables and Graphs

Tables and Graphs

Table 1: Mean values of the pH changes in saliva after sugar exposure and after various interventional methods

Day of

experiment

Salivary pH at

Baseline ±

std.deviation

Baseline

salivary pH

Std.error

Salivary pH

after sugar

exposure±

std.deviation

Salivary

pH after

sugar

exposure

Std.error

Salivary pH

after

intervention±

Std.deviation

After

intervention

Std.error

P value

Day 1 7.384±0.37 .0703 4.895±0.72 .1098 6.337±0.69 .1062 0.000

Day 2 7.430±0.39 .0566 4.779±0.74 .1132 6.733±0.45 .0693 0.000

Day 3 7.302±0.60 .0603 4.372±0.57 .0882 8.291±0.47 .0730 0.000

Day 4 7.465±0.33 .0510 4.395±0.62 .0949 8.407±0.29 .0448 0.000

P value 0.251 0.368 0.000

pvalue : p values at 95% confidence level

Inter group comparison:

Baseline salivary pH: 0.251 N.S; Salivary pH after sugar exposure: 0.368 N.S;

Salivary pH after intervention: 0.000 *

Salivary pH after intervention – water rinsing Vs brushing without dentifrice: 0.002*

Salivary pH after intervention –brushing without dentifrice Vs brushing with fluoridated or non-fluoridated

dentifrice:: 0.000*

Salivary pH after intervention –brushing with fluoridated dentifrice Vs non-fluoridated dentifrice: 1.000 N.S

*- significant N.S- non-significant

Tables and Graphs

Graph 1: Mean values of the pH changes in saliva after sugar

exposure and after various interventional methods

0

1

2

3

4

5

6

7

8

9

Day 1 Day 2 Day 3 Day 4

Baseline

After sugar

exposure

After

intervention

X- axis: Days of Experiment

Y- axis: Salivary pH

Tables and Graphs


exposure and after water rinsing

7,384

4,895

6,337

0

1

2

3

4

5

6

7

8

Baseline After sugar

exposure

After water

rinsing

X- axis: Salivary Samples


Tables and Graphs


exposure and after brushing with water

7,43

4,779

6,733

0

1

2

3

4

5

6

7

8


exposure

After brushing with

water



Tables and Graphs


exposure and after brushing with non-fluoridated dentifrice

7,302

4,372

8,291

0

1

2

3

4

5

6

7

8

9


exposure

After brushing

with non-

fluoridated

dentifrice



Tables and Graphs


exposure and after brushing with Fluoridated dentifrice

7,465

4,395

8,407

0

1

2

3

4

5

6

7

8

9

Baseline After sugar exposure After brushing with

fluoridated dentifrice



Discussion

Discussion

43

DISCUSSION

Research on caries shows its rise in children especially the very young

and poor is related to the consumption of increasingly available inexpensive

foods containing excess sugars and ubiquitous habit of snacking and drinking

sweetened drinks. However not all children are equally affected due to the

variation in the factors that are responsible for caries.

The initiation of demineralization and reminerlization takes place at

the saliva-tooth interface with biofilm formation, which is a natural process

and the dynamic reactions taking place in the biofilm affects the hard tissues

leading to formation of caries. These dynamic changes are pH dependent. The

critical pH is one at which the solution (saliva) is saturated with a particular

mineral such as enamel (calcium, phosphate, hydroxyl ions). At the critical pH

the rate of forward reaction (mineral dissolution) is equal to that of backward

reaction (mineral precipitation). When there is imbalance between the

solubility product and ionic product, reminerlization or demineralization takes

place. The enamel solubility is influenced by impurities present in

hydroxyappatite (fluoride and carbonate) which differs from person to person.

If there is lesser concentration of calcium and phosphate ions in the saliva then

the critical pH will be high and vice versa. The calcium and the phosphate ions

in the saliva act as a driving force for the hydroxyappatite crystals to

precipitate. When normal oral pH is achieved after an acidic challenge

reminerlization is favored by positive thermodynamic condition3, 40, 41, 42,

Discussion

44

43(Anderson, Bradshaw and Lynch, 2013; Davies and Blinkhorn, 2013;

Elkassas and Arafa, 2014; Shetty et al., 2014).

The salivary pH is lower and is more acidic in the rampant caries

group when compared to that of caries resistant group23, 44, 45

(B.P.Preethi et al

and Kuriakose et al, Sissons et al, Ahmadi-Motamayel et al). The end result of

all these contributing factors is demineralization of teeth.

According to Cawfield the main dietary changes takes place in the

kindergarten age group after the eruption of all the primary molars46

. In

children, lower salivary calcium ions concentration means a higher critical pH

and a lower driving force for reminerlization compared to adults (Anderson)3.

So it is important to implement the preventive strategies targeting the salivary

ph and biofilm formation to control caries. Dentifrices and tooth brushes are

not readily available in the school environment for fighting against the acid

surge which usually follows any snacking. Whereas availability of water is

profound and is easy for children to swish and swirl which might have a

positive effect in the salivary pH. Hence this study was done in children of 4-5

years without gender variation who are more susceptible to caries when

compared to that of adults with an aim to detect the efficacy of water rinsing,

tooth brushing without dentifrice and brushing with fluoridated and non-

fluoridated toothpastes in reducing the salivary pH following an acid attack.

“Home-care” means the sum effect of motivation, knowledge, oral

hygiene aids and motor skill. The use of fluoride has been cornerstone of

Discussion

45

caries prevention programmes and the use of fluoridated toothpaste is by far

the most common form of caries control in use today. The caries preventive

effect of low fluoride dentifrices for kids may be less than that of adult

dentifrices but considering the fact that most of the children swallow

toothpaste while brushing which may result in an unfavorable effect causing

enamel hypo mineralization by fluorosis, so the use of non-fluoridated

toothpaste under 6 yrs of age seems warranted. While many non-fluoridated

dentifrices claim to have antimicrobial properties and have caries preventive

action, very little research has been conducted to validate the immediate action

of fluoride on salivary pH.

In our study whole saliva was collected using Dawe’s method39; whole

saliva was collected for a 5 min time span. The subject was seated at a low

table and asked to swallow residual saliva present in the mouth before the

beginning of collection and then, with the head down and mouth slightly open,

saliva was allowed to drip from the lower lip into a small sterile container.

pH strips were used in determining the salivary pH in this study as it

was available chair side, user friendly, gave immediate results and it could

also be used for patient education.

In the present study results, water was found to cause a significant rise

in pH although it did not reach the baseline value. Water has a positive effect

in dislodging the loosely stuck food debris from the teeth, also the pH of water

being neutral will help in increasing the pH of saliva and plaque, thereby

Discussion

46

increasing the calcium and phosphate ions in them47

(Tenuta et al). However it

was found to have the least effect in altering the salivary pH when compared

with other groups (p<0.001) after a sugar exposure owing to the fact that it

dilutes the oral fluids and has almost no documented cleansing effect on dental

plaque and water attenuates the original buffering capacity of the saliva by

diluting it which seems to explain why tap water did not enhance oral pH

when compared to that of other groups in this trial; which was similar to the

studies conducted by Mirjalili et al5 and Tolentino et al

4.

Brushing is potent in removing the plaque and debris because of its

mechanical action stimulating the salivary flow rate; even though brushing

with dentifrice is considered as a gold standard. There was a significant

difference in the salivary pH between the brushing without dentifrice group

and brushing with dentifrice groups (p=0.000), which is contradictory to a

study conducted by Ligtenberg6 in which brushing without dentifrice did not

make much of a difference in increasing the salivary pH compared to that of

brushing with dentifrice, which was attributed to the fact that even though

brushing had a mechanical effect increasing the salivary pH, the gustatory

stimulus provided by the dentifrices had an increased effect along with

brushing in increasing the salivary pH.

There was significant increase in the salivary pH after brushing with

fluoridated tooth paste. The fact that salivary pH increased significantly after

brushing with dentifrice was because of the combination of mechanical and

Discussion

47

chemical stimulations on the saliva. Fluoride dentifrices provide a substantial

protective effect against lesion formation and lesion progression. Twice a day

application of fluoridated dentifrice substantially reduced the dissolution of

sound enamel, as well as enamel with lesions produced by subsequent acid

challenge21

(Ravi Shiratti). However in the present study not much difference

was present between the fluoridated and non-fluoridated groups in increasing

the salivary pH (p=1.00); which was because the efficacy of fluoridated and

non-fluoridated toothpastes differ mainly by their ant-microbial efficacy on

prolonged use and as intermediate cleansing agents, both did not make much

of difference.

The study concluded that tooth brushing with dentifrice regardless of

its fluoride content is the best method of intervention to retaliate an acidic

surge whereas water and brushing without dentifrice can be used as an

intermediate intervention to partially attenuate the fall in the salivary pH

following an acid attack.

This study was done in caries free and minimal caries group, the fall in

pH takes more time to reach to the baseline level in the high caries children48

(Widowati); so further studies should be performed on high carious children to

know the outcome in high carious group. The interventional methods used in

this study are use of water rinsing, brushing without dentifrice, brushing with

non-fluoridated and fluoridated tooth pastes further studies should be done to

evaluate the efficacy of other interventional methods like use of mouthwashes,

Discussion

48

chewing gums and flossing. The effect of the interventional methods on

salivary pH was the preliminary concern of this experimental study future

research of efficacy of the interventional methods on the plaque biofilm will

give a detail of the supremacy of the interventional methods against the

demineralization process.

Conclusion

Conclusion

48

CONCLUSION

1. There was no significant difference in the baseline salivary pH on all

four experimental days (p=0.251)

2. No significant difference was present in the fall in salivary pH after

sugar exposure during the four days of experiment (p=0.368)

3. Water rinsing caused the salivary pH to rise after sugar exposure

(p<0.01) but less than that of the baseline.

4. Tooth brushing with water also caused a rise in salivary pH after sugar

exposure slightly below the level of the baseline pH (p<0.01).

5. Tooth brushing with non-fluoridated dentifrice was potent in

increasing the salivary pH above the baseline value after sugar

exposure (p<0.01).

6. Tooth brushing with fluoridated tooth paste caused an increase in the

salivary pH beyond the baseline salivary pH after an acidic surge

(p<0.01).

7. Water rinsing was the least effective when compared to brushing

without dentifrice (p=0.002), brushing with fluoridated dentifrice

(p<0.001) and non-fluoridated dentifrice (p<0.001).

8. Tooth brushing with water was better than water rinsing in increasing

the salivary pH after the sugar exposure (p=0.02) but less effective

when compared to brushing with non-fluoridated dentifrice (p<0.01)

and fluoridated dentifrice (p<0.001).

Conclusion

49

9. Among all the interventional methods, tooth brushing with fluoridated

and non-fluoridated dentifrice was better in increasing the salivary ph

to an alkaline limit (p<0.01).

10. No significant difference was seen between the efficacy of brushing

with non-fluoridated and fluoridated dentifrice groups on salivary pH

after an acidic surge (p=1.00)

Summary

Summary

50

SUMMARY

Currently though various professionally available methods are there to

prevent white spot lesions, the home care interventional methods are proven to

be the best preventive strategy to combat the initiation of the demineralization

that is dependent on the biofilm which in turn depends on pH changes in

saliva.

Tooth brushing and use of dentifrices are the universally available and

practiced home care interventional methods but their efficacy on maintaining

the neutral salivary pH is still unexplored to the core. Hence this study was

done to correlate the efficacy of water rinsing, tooth brushing with water, tooth

brushing with fluoridated and non-fluoridated dentifrice on the salivary pH

after sugar exposure.

Forty three children of age group 4-5 years with no caries or minimal

caries without any gender variation and any systemic diseases were selected

for this study. The experiment was conducted on four consecutive days. The

unstimulated saliva was collected using Dawe’s method in sterile containers

and pH was measured using color coded pH strips.

On each day of experiment, the baseline salivary pH was obtained

followed by which the children were asked to consume apple juice (as a sugar

exposure) and the fall in pH was again recorded; the children were then asked

to follow the interventional methods (day 1- water rinsing, day 2-brushing

Summary

51

with water, day 3 –brushing with non-fluoridated dentifrice, day 4- brushing

with fluoridated dentifrice) after which the salivary pH was again recorded.

The mean value was calculated, tabulated and statistically analyzed

using analysis of variance (ANOVA) and paired t-test.

The study results showed that though water could possibly increase the

salivary pH after a sugar attack, it failed to bring back the pH to the baseline

(p<0.001), but brushing with water proved to be potent than water rinsing in

bringing the pH near the neutral value (p=0.002).

Brushing with dentifrice proved to be the best method by bringing the

salivary pH to a more alkaline pH. However there was not much difference

between the brushing with non-fluoridated or fluoridated dentifrice group

(p=1.00).

The present study concluded that water can be used as an intermediate

intervention to revert the salivary pH until a definitive intervention like

toothbrush and dentifrice is available. Tooth brushing with dentifrice is the

better home care interventional method to succumb the salivary fall.

Bibliography

Bibliography

Bibliography

BIBLIOGRAPHY

1. WHO, The world oral health report 2003.

Http://www.who.int/oral_health/media/en/orh/report03/en.pdf, 2003.

2. Stephan R.M. Changes in hydrogen-ion concentration on tooth

surfaces and in carious lesions. J Am Dent Assoc 1940;27:718–23.

3. Andersen P, Hector M.P, Rampersad M.A. Critical pH in resting

and stimulated whole saliva in groups of children and adults. Int J Paed

Dent 2001;11:266-73.

4. Tolentino E De S, Chinellato Lem, Tarzia O. Saliva and tongue

coating pH before and after use of mouthwashes and relationship with

parameters of halitosis. Journal of applied oral science. 2011; 19(2):

90-4.

5. Narges Mirjalili, Mohammad-Hassan Akhavan Karbassi and

Jaffar Farahman. Comparing tap water mouth rinse with tooth

brushing and sugar-free chewing gum: Investigating the validity of a

popular belief. J Dent Oral Hyg. 2014; 6(2):22-5

6. Ligtenberg AJ, Brand HS, Bots CP, Nieuw Amerongen AV. The

effect of toothbrushing on secretion rate, pH and buffering capacity of

saliva. Int J Dent Hyg 2006;4(2):104-5.

7. Chand S, Gulati P, Dhingra S, Swatika. Estimating the pH of

commercially available dentifrices and evaluating its effect on salivary

pH after brushing. J Oral Health Comm Dent 2013;7(1):12-6

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ligtenberg%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=16637913

http://www.ncbi.nlm.nih.gov/pubmed/?term=Brand%20HS%5BAuthor%5D&cauthor=true&cauthor_uid=16637913

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bots%20CP%5BAuthor%5D&cauthor=true&cauthor_uid=16637913

http://www.ncbi.nlm.nih.gov/pubmed/?term=Nieuw%20Amerongen%20AV%5BAuthor%5D&cauthor=true&cauthor_uid=16637913

http://www.ncbi.nlm.nih.gov/pubmed/16637913

Bibliography

8. Okpalugo J, Ibrahim K, Inyang US. Toothpaste formulation efficacy

in reducing oral flora. Trop J Pharm Res. Feb 2009; 8 (1): 71-7

9. Surdacka A, Stopa J. The effect of xylitol toothpaste on the oral

cavity environment. The journal of preventive medicine 2005;13(1-

2):98-107.

10. Patil S, Venkataraghavan K, Anantharaj A, Patil S. Comparison of

two commercially available toothpastes on the salivary streptococcus

mutans count in urban preschool children-an in vivo study. Group.

International dentistry SA, 2010;1(50):53720.

11. Deshpande R et al. comparative evaluation of antimicrobial efficacy

of 2 commercially available dentifrices against salivary microflora. Int

J Pharm Pharmsci. 2014; 6(6): 72-4

12. Wafa K M, Manal El Said, Omar M, Eissa A. The effect of meswak

and fluoride toothpastes on dental plaque, a comparative clinical and

microbiological study, J Nature and Sci. 2013; 11 (9)

13. Burt B A. The changing patterns of systemic fluoride intake. J dent res

1992; 71: 1228–37.

14. Zimmer S, Didner B, Roulet J. F. Clinical study on the

plaque‐removing ability of a new triple‐headed toothbrush. J Clin

Perio, 1999; 26(5): 281-5.

15. Davies G. M, Worthington H. V, Ellwood R. P, Bentley E. M,

Blinkhorn A. S, Taylor G. O, & Davies R. M. A randomised

controlled trial of the effectiveness of providing free fluoride

Bibliography

toothpaste from the age of 12 months on reducing caries in 5-6-year-

old children. Community dental health. 2002; 19(3):131-6.

16. Mccracken G. I, Janssen J, Swan M, Steen N, De Jager M, &

Heasman P. A. Effect of brushing force and time on plaque removal

using a powered toothbrush. Journal of clinical periodontology.

2003; 30(5): 409-13.

17. Thaweboon S, Thaweboon B, Soo-Ampon S. The effect of xylitol

chewing gum on mutans streptococci in saliva and dental plaque.

Southeast Asian J Trop Med Public Health. 2004 Dec; 35(4):1024-7.

18. Stookey G. K, Mau M. S, Isaacs R. L, Gonzalez-Gierbolini C,

Bartizek R. D, Biesbrock A. R. The relative anticaries effectiveness

of three fluoride-containing dentifrices in Puerto Rico. Caries

research. 2004; 38(6): 542-50.

19. Arnold W. H, Dorow A, Langenhorst S, Gintner Z, Bánóczy J,

Gaengler P. Effect of fluoride toothpastes on enamel demineralization.

BMC Oral Health. 2006; 6(1): 8.

20. Sano H, Nakashima S, Songpaisan Y, & Phantumvanit P. Effect of

a xylitol and fluoride containing toothpaste on the remineralization of

human enamel in vitro. Journal of oral science. 2007; 49(1):67-73.

21. Shirahatti R, Ankola V, Nagesh L, Seema Hallikerimath; The

effects of three different pastes on enamel caries formation and lesion

depth progression- an in vitro study. J Oral Health Comm Dent

2007;1(1):1-6

Bibliography

22. Kato M. T, Lancia M, Sales-Peres S. H. C, & Buzalaf M. A. R.

Preventive effect of commercial desensitizing toothpastes on bovine

enamel erosion in vitro. Caries research. 2010; 44(2): 85-9.

23. Preethi B P, Maitreyee D S, Dodawood R. effect of four fruit juices

on pH of dental plaque, a four period cross over study. J Clin Diag

Res, 2010;(4):2587-93.

24. Ribelles L. M, Guinot J. F, Mayné A. R, & Bellet D. L. Effects of

xylitol chewing gum on salivary flow rate, pH, buffering capacity and

presence of Streptococcus mutans in saliva. European journal of

paediatric dentistry: Official Journal of European Academy of

Paediatric Dentistry. 2010; 11(1): 9-14.

25. Masih U, Mahay P, Prabhakar M, & Joshi J. A comparative study

of acidogenic potential of milk and commonly used milk formulae. Int

J of Dent Clin, 2010; 2(4).

26. Smutkeeree A, Rojlakkanawong N, & Yimcharoen V. A 6‐month

comparison of tooth brushing efficacy between the horizontal Scrub

and modified Bass methods in visually impaired students. Int J Paed

Dent, 2011; 21(4):278-83.

27. Saha S, Jagannath G. V, Jagannath V, Shivkumar S, & Pal S. K.

(2011). Effect of commonly consumed fresh fruit juices and

commercially available fruit juices on pH of saliva at various time

intervals. Journal Of International Dental And Medical Research, 4(1),

7-11

Bibliography

28. Peros K, Mestrovic S, Anic-Milosevic S, Rosin-Grget K, Slaj M.

Antimicrobial effect of different brushing frequencies with fluoride

toothpaste on Streptococcus mutans and Lactobacillus species in

children with fixed orthodontic appliances. The Korean Journal of

Orthodontics.2012; 42(5): 263-9.

29. Klukowska M, Grender J. M, & Timm H. A single-brushing study

to compare plaque removal efficacy of a new power brush to an ADA

reference manual toothbrush Age (SD). 2012; 45(8.63): 25-60.

30. Goel I, Navit S, Mayall S. S, Rallan M, Navit P, & Chandra S.

Effects of Carbonated Drink & Fruit Juice on Salivary pH of Children:

An in Vivo Study. International Journal of Scientific Study. Oct 2013;

1(3):60-9.

31. Moeiny P, Shafizadeh N, Biabani S. H, Raofie F & Kharazifard M.

J. (2013). Evaluation of the Effect of Three Different Iranian Industrial

Fruit Juices on Plaque pH. Journal of Islamic Dental Association of

IRAN (JIDAI); 25(2): 2.

32. Subramaniam P, & Nandan N. (2012). Cariogenic potential of

pediatric liquid medicaments-An in vitro study. J Clin Paed

Dent, 36(4): 357-62.

33. Humagain M, Rokaya D, Manipal S. S, Bajracharya M,

Tamrakar M, & Upadhyaya S. Relationship between the age and

salivary pH following sugar based and non-sugar based chewing gum

Bibliography

usage among Nepalese school children. International Journal of Dental

Clinics. 2013. Sep 30; 5(3).

34. Kumar S, Sogi, S. H, & Indushekar K. R. Comparative evaluation of

the effects of xylitol and sugar-free chewing gums on salivary and

dental plaque pH in children. Journal of Indian Society of Pedodontics

and Preventive Dentistry. 2013; 31(4): 240.

35. Nozari A, Ghaderi F, Madadelahi S. pH-value decrement of saliva-

plaque solution after mixing with four customary used infant

milkformulas: An in vitro study. J Pediatr Dent 2014;2:92-5

36. Belardinelli P.A, Morelatto R. A, Benavidez T. E, Baruzzi A. M,

López de Blanc S.A. Effect of two mouthwashes on salivary pH. Acta

Odontológica Latinoamericana. 2014; 27(2):66-71.

37. Mulay S, & Jain H. Change in Salivary Parameters: Flow and pH

after chewing Xylitol and Sorbitol Chewing Gums. Archives of Oral

Sciences & Research 2014;4(1):38-49.

38. Srinivasan M, Schimmel M, Riesen M, Ilgner A, Wicht M. J,

Warncke M, & Noack M. J. High‐fluoride toothpaste: a multicenter

randomized controlled trial in adults. Community dentistry and oral

epidemiology. 2014; 42(4): 333-40.

39. Dawes C. Considerations in the development of diagnostic tests on

saliva. Annals of the New York Academy of Sciences. 1993 Sep

1;694(1):265-9.

Bibliography

40. Bradshaw DJ, Lynch RJ. Diet and the microbial aetiology of dental

caries: new paradigms. International dental journal. 2013 Dec

1;63(s2):64-72.

41. Davies RM, Blinkhorn AS. Preventing Dental Caries: Part 1 the

scientific rationale for preventive advice. Dent. Update, 2013;

40(9):719-20, 722, 724-6.

42. Elkassas D, Arafa A. Remineralizing efficacy of different calcium-

phosphate and fluoride based delivery vehicles on artificial caries like

enamel lesions. J. Dent. 2014; 42(4):466-74.

43. Shetty S, Hegde MN, Bopanna TP. Enamel remineralization

assessment after treatment with three different remineralizing agents

using surface microhardness: An in vitro study. Journal of conservative

dentistry: JCD. 2014 Jan;17(1):49-52.

44. Sissons CH, Wong L, Shu M. Factors affecting the resting pH of in

vitro human microcosm dental plaque and Streptococcus mutans

biofilms. Archives of oral biology. 1998 Apr 6;43(2):93-102.

45. Ahmadi-Motamayel F, Goodarzi MT, Hendi SS, Abdolsamadi H,

Rafieian N. Evaluation of salivary flow rate, pH, buffering capacity,

calcium and total protein levels in caries free and caries active

adolescence. Journal of Dentistry. 2013 Apr 30;5(4):35-9.

46. Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of

mutans streptococci by infants: evidence for a discrete window of

infectivity. Journal of Dental Research. 1993 Jan 1;72(1):37-45.

Bibliography

47. Tenuta LM, Zamataro CB, Del Bel Cury AA, Tabchoury CP,

Cury JA. Mechanism of fluoride dentifrice effect on enamel

demineralization. Caries research. 2009;43(4):278-85.

48. Witjaksono W. Saliva pH Changes in Patients with High and Low

Caries Risk after Consuming Organic (Sucrose) and Non-Organic

(Maltitol) Sugar. The International Medical Journal of Malaysia.

2013;12(2).

Annexures

Annexure I: Screening Form

Name: Number:

Age:

Gender:

Date:

Chief complaint:

History:

Brushing technique:

Tooth Paste:

Adjuvant aids:

Diagnosis:

Treatment plan:

Annexures

ANNEXURE-II

Name Age Dft Plaque

score

Brushing

technique

Freq

uenc

y

Tooth paste

Day

1.p

h1

Day

1.p

h2

Day1.

water

Day2

.ph1

Day2

.ph2

Day

2.to

oth

bru

sh

Day

3.p

h1

Day

3.p

h2

Day3

.non-

fluor

idate

d

Day

4.p

h1

Day4

.ph2

Day4.f

luorid

ated

Jeevajothi 5 0 0.8 horizontal 2 pepsodent 7 5 6.5 8 4 7.5 8 4 9 8 4 8.5

Dinesh 5 0 1.0625 horizontal 2 colgate 7.5 5 6 8 5 7.5 7.5 5 8.5 7.5 5 8

Sridhar 5 0 0.875 horizontal 1 colgate 8 5 6.5 7.5 5 7 7.5 4 8 7.5 5 8.5

Janani 5 0 0.8875 1 colgate 7.5 5 6.5 7 4 7 7.5 4 8 7.5 4 8.5

Yaswanthkumar 5 0 1.062 horizontal 1 colgate 7 5 6 7.5 4 6.5 7.5 4 8.5 7.5 4 8

Siva 5 0 0.925 horizontal 2 colgate 7.5 5 6 7.5 4 7 7 4 8 7.5 4 8.5

Mhd.

Wasimakram 5 0 0.9125

horizontal &

vertical 2 close-up 8 5 6.5 7.5 4 7 7.5 4 8 7.5 4 8.5

R.k. Hariharan 5 0 0.1025 horizontal 1 colgate 8 6 6.5 8 5 7.5 7.5 6 8 8 6 9

Aashikabanu 5 0 0.8875 horizontal 2 pepsodent 6.5 4 5 7.5 4 7 7 5 8 7 5 8

Seethadevi 5 0 0.625 horizontal 1 colgate 7 5 6 7.5 4 6.5 7 4 8 7.5 4 8.5

Vinodha 4 0 0.65 vertical 1 colgate 7.5 5 6.5 7 4 6.5 7 4 8 7.5 4 8.5

Ajay 5 0 0.7125 horizontal 1 colgate 7.5 5 6.5 7.5 4 7 7 4 8.5 7.5 4 8.5

Anusree 5 0 0.4625 horizontal 2 colgate 8 6 6.5 7.5 5 6 8 5 9 8 5 8.5

Someswar 5 0 0.5375 horizontal 1 colgate 7.5 4 6 8 6 7.5 7.5 4 8 7.5 4 8.5

Sanoli 5 0 0.475 horizontal 2 colgate 7.5 6 6.5 7 6 7 7 6 7.5 7.5 6 8.5

Sanjay 5 0 0.475 horizontal 1 colgate 7 5 6 7.5 6 7 7.5 5 8 7.5 4 8.5

Barkithnisha 5 0 0.8 vertical 2 colgate 8 5 7 8 5 6.5 7.5 4 7 8 4 8.5

Kaviya 5 0 0.925 horizontal 1 dabur 7.5 4 6.5 7 5 6 7 4 8.5 7 4 8

Roshanprasanna 5 0 0.609 horizontal 1 pepsodent 7 5 6 7.5 4 6.5 7 5 8.5 7.5 5 9

Manikandan 5 0 0.775 horizontal 1 colgate 7.5 5 6.5 7 4 6.5 7.5 4 8 7 4 8

Yuvanesh 5 0 0.725 horizontal 1 colgate 8 6 5 7.5 5 6.5 7 5 8 7.5 5 8.5

Hemnath 5 0 0.8 horizontal 1 colgate 7 5 6.5 7.5 4 7 7 4 8 7.5 4 8.5

Annexures

Yashini 6 0 0.8875 horizontal 1 colgate 8 5 6.5 8 4 6 8 4 9 8 4 8.5

Mohamadtahir 5 0 0.7 horizontal 1 colgate 6.5 4 5 7.5 5 6.5 7 4 7.5 7.5 4 8

Priyan 5 0 0.6375 horizontal 1 colgate 7 4 6 8 5 7 7 4 8.5 7.5 4 8.5

Kathirvel 5 0 0.7625 horizontal 2 colgate 7.5 5 7 8 5 6.5 7.5 4 8.5 7.5 4 8

Bhavadharini 5 0 0.8 horizontal 1 colgate 6.5 5 6 6.5 4 6 6 4 8 6.5 4 8.5

Thendralmathi 4 1 0.775

horizontal

and vertical 1 colgate 7 5 6 7.5 6 6.5 7 5 8 7 5 8.5

Shaikawood 4 1 0.8875 horizontal 1 colgate 6.5 4 5 7 4 6 7 4 8 7 4 8.5

Akash 5 1 0.775 horizontal 1 colgate 7.5 4 6 7 5 6.5 7 4 9 7 4 8.5

Saranya 5 1 0.9125 horizontal 1 colgate 7.5 4 6 7 5 6 7.5 4 8.5 7.5 4 8

Sreebarath 4 2 0.6625 horizontal 1 colgate 7.5 6 6.5 7.5 5 6.5 8 5 9.5 8 5 8.5

Varshini 5 2 0.8875 horizontal 2 colgate 8 5 6 7.5 4 6.5 7.5 4 8 7.5 4 8.5

Thiyanesh raja 6 2 0.8875 horizontal 2 colgate 7.5 4 6 7 5 6.5 7 4 8.5 7 4 8

Lakshmi priya 5 2 0.725 horizontal 1 colgate 7.5 5 6.5 7 6.5 7.5 7.5 5 8.5 7.5 5 8

Nigitha 5 2 0.975

horizontal

and vertical 1 colgate 7 4 5 7.5 5 6.5 7 4 8 7.5 4 8

Sahana 5 2 1.0375 horizontal 1 dabur 7.5 4 7.5 7.5 5 7 7.5 4 8.5 7.5 4 9

Sandhiya 5 2 0.9375 horizontal 2 pepsodent 7 5 7.5 7 6 7.5 7 4 8.5 7.5 5 8.5

Sridharshanaagait

ian 5 3 0.9125 vertical 1 himalaya 7 6 7.5 7 4 6.5 7.5 4 8.5 7 4 8.5

Harini 5 3 0.7625 horizontal 1 colgate 8 4 7 7.5 5 7 7.5 5 9 7.5 4 8.5

Yagov 5 3 1 horizontal 2 colgate 8 6.5 7.5 7.5 6 7 8 5 9 8 6 9

Lavanya 5 3 0.8125 horizontal 2 colgate 7.5 6 7.5 7.5 5 7 7 5 8.5 7.5 5 8

Akash.d 5 3 0.6625 horizontal 1 colgate 7 4 7.5 7.5 5 6.5 7.5 4 8 7.5 4 8.5

Annexures

ANNEXURE- III

CONSENT FORM

I___________________________, the parent/guardian

of__________________________, herby give consent for the participation of my

son/daughter in the study titled “Comparative Evaluation of Efficacy of 4 Different

Interventional Methods on Salivary pH after an Acidic Surge” being conducted by Dr.K.

Lakshmikumari Alias Sudharashini, a postgraduate student of Ragas dental college and

hospital, Chennai. Under the guidance of Dr.M.Jayanthi, Prof and Head, department of

pedodontics and preventive dentistry. I have been clearly informed about the

procedure/techniques of the study and I voluntarily, unconditionally, freely give my

consent for the active participation of my child without any form of pressure and in a

mentally and conscious state.

Signature of the investigating doctor

Signature of the Patient’s parent/ Guardian.

Annexures

ANNEXURE-IV

சிகிசசஒுதபிவ

____________________________ஆகியநா _____________________ எகிற

எுழசதயிவா/பபுதிசயஆராுபாகஒுதஅளிகிறற.றேு

, இதஆராயிசைறேககாவதிைாவிசளயூியநசேகசளு,

அதைாவிசளயூியஅகசளகியகசளுஅறியகபறபி,

நாஎவிதஅசுேிறிதைிசசயாகு,

ுுேைுடஎுசடயசேததிசைஅளிகிறற.

சககயாப:

றததி, இட:

சாசிக;

(கபறறாிகபய) (ுழசதயிகபய, வயு)

Annexures

ANNEXURE-V

COMPARATIVE EVALUATION OF EFFICACY OF FOUR DIFFERENT ...

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