MICA (P) No.

116/05/2009

I KDN: PPS 1681/03/2009 (020069) I JUL/AUG 2009 Vol 2, No. 6

The current status of

tooth crmes for enamel
remineralization

n recent years it has become easy for the dental

practitioner to become confused regarding
the bona des of the many agents which have
been promoted as agents for remineralizing enamel.
This article looks at the process of remineralization,
and from that examines some current products and
therapies, to try to make sense of the fruit salad of
apples, oranges and pears. The characteristics of
an ideal remineralizing agent are summarized in
Table 1 [1], and this gives a useful measure of how the
available materials and technologies perform.

DENTAL INC. July/August 2009

Enamel minerals: back to nature

38

The mineral in human enamel is not pure

hydroxyapatite, but rather a mixture of compounds
including a number of carbonated apatites, which
together occupy up to 98 weight per cent and up
to 96 volume per cent, when constitutional water
is included. Of these various apatites, uorapatite
is less acid soluble than hydroxyapatite, which in
turn is less soluble than carbonated apatite. While
it is somewhat simplistic, looking at the major
apatites makes it clear that the ratio of components
required for remineralization is 10 calcium ions to 6
phosphate ions to either 2 uoride or 1 hydroxyl ions
or 1carbonate ion, a ratio of 5:3:1. It is also clear that
calcium availability remains the singular limiting

factor in enamel remineralization, and herein lies the

problem, since the majority of calcium compounds
are very insoluble. If we want remineralization then
we will need calcium and phosphate ions (ideally
assisted by uoride) to rebuild a new surface on
existing crystal remnants and this must occur in
subsurface lesions, and not simply precipitate onto
the surface.

Making it real
If one is going to assess potential remineralization
agents, this must be done in realistic conditions, such
as by using in situ models where enamel slabs are
carried in patients mouth and removed in order to
measure mineral changes. This aproach is necessary
to take into account the effects of saliva, particularly
its glycoproteins (which adsorb onto tooth structure
to form pellicle) and its phosphoproteins (which
regulate calcium saturation). The early pellicle
glycoproteins, acidic proline-rich proteins and
statherin, promote remineralization of the enamel
by attracting and binding calcium ions, attaching
strongly to hydroxyapatite, and inhibiting crystal
growth and precipitation of calcium phosphate salts.
[2]
In situ studies which examine enamel slabs that have
been in the mouth of patients allow full expression of
the impacts of saliva. In contrast, some laboratory

in a patients mouth, (2) there has been a direct

comparison of ClinPro and Tooth Mousse Plus in a
controlled clinical trial and there was a statistically
signicant benet of the former over the latter;
and (3) there is evidence that the formula of ClinPro
prevents dental caries (reduces caries increment) in
controlled clinical trials, at least to the same level
seen with conventional toothpastes, if not better.
Regrettably, at the time of writing, none of these
three statements are correct.
The dry physical chemistry approach
which was used to evaluate ClinPro measures
uoride release from a toothpaste (a standard test
conguration used for toothpaste registration
by the US FDA), but is a not a measure of, nor a
surrogate for actual remineralization of enamel
under real-life clinical conditions. Laboratory in
vitro testing protocols using ionic solutions are
known to have signicant limitations, and cannot
simulate the complex biological processes involved.
[4,5]
Remineralization, after all, is not just a chemical
reaction; it is a natural biological process.

CLINICAL

bench models exclude the involvement of saliva,

and this can lead to nonsensical interpretations
from the standpoint of clinical practice. [3] This is a
problem which has plagued both the historical and
the more recent literature on remineralization. A
particular problem occurs when investigators take
a dry physical chemistry approach rather than a
wet natural biological approach to planning and
executing their experiments.
A current (July 2009) example of this dilemma
is the somewhat simplistic advertising statement
which compares a recently developed toothpaste
(3M Espe ClinPro Tooth Crme) with an established
topical remineralizing agent (GC Tooth Mousse Plus
), with the words (quoted from the 3M website)
Introducing Clinpro Tooth Crme, the winning
formula that helps prevent cavities. Strengthens
teeth and reverses white spot lesions better than
GC Tooth Mousse Plus. This statement as worded
would naturally lead the reader to believe that
(1)
there is published evidence that ClinPro can
cause visible reversal of a natural white spot lesion

Table 1. Requirements of an ideal remineralization material

fTCP Technology, as used in
ClinPro Tooth Creme

CPP-ACP Technology, as used in GC

Tooth Mousse and Tooth Mousse Plus

Diffuses into the

subsurface, or delivers
calcium and phosphate
into the subsurface

Subsurface effects up to
15 microns (microhardness
testing).

Subsurface effects up to 150 microns

(microhardness testing and mineral
analysis of forming apatites)

No clinical studies available

at the time of writing.

Visual and radiographic reversal of

white spot lesions in patients in trials

Does not deliver an

excess of calcium

NA

Yes

Does not favour calculus

formation

NA

Yes

Works at an acidic pH

NO

Yes (down to pH 5.3)

Boosts the remineralizing

properties of saliva

NA

Yes

For novel materials, shows

a benet over uoride

Lab data Yes

Animal models - NA
Clinical - NA

Lab data Yes

Animal models - Yes
Clinical - Yes

Parameters of an ideal material are based on Zero, 2006 [Ref. 1]. NA = data not available.

DENTAL INC. July/August 2009

Parameter

39

USERREPORT
CLINICAL
TECHNOLOGY
DENTAL INC. July/August 2009

40

The argument could also be made that a

comparison of the two is an apples versus organs
situation, since ClinPro is a uoride toothpaste
and therefore should release some uoride; whilst
Tooth Mousse Plus is a pH-response long acting
remineralizing crme which should not release
much of its bound uoride or calcium or phosphate
until triggered by acidic pH conditions to do so.
Details of product composition and other points of
information regarding these products are presented
in Table 2.
With ClinPro, it is unclear how much of the calcium
contained in the product is bio-available, and how
much would be expectorated along with toothpaste
at the completion of toothbrushing. Assuming a
best case scenario where similar amounts of each
product are used, ClinPro could only deliver a small
amount of unbound, non-stabilized calcium in the 2
minutes of brushing before being expectorated from
the mouth, whilst Tooth Mousse Plus delivers large
amounts of stabilized calcium over an extended time
period. One would expect therefore rather different
clinical effects because of the different levels of
calcium release and from the stability or otherwise
of this released calcium, but not from the uoride
levels which would likely be similar.
So, is there any clinical evidence of visible
reversal of a natural white spot lesion in a patients
mouth? There is published work showing this with
GC Tooth Mousse, with the rst of these perhaps
being an early clinical case of a patient treated by
this author in 2004 over a period of 12 weeks [6]. Of
much greater importance than this anecdote is the
recent controlled clinical trial which documented
visible reversal of white spot lesions in orthodontic
patients over 12 weeks. Tooth Mousse was shown to
be achieve this, and to be superior to a conventional
1000 ppm uoride toothpaste. [7,8] Tooth Mousse and
Tooth Mousse Plus differ in that the latter has 900
ppm uoride within its composition (gained from
the addition of 0.2% sodium uoride). At the present
time there has been limited research on the TCP
technology used in ClinPro [9-10] and thus it would
be premature to make assertions of superiority,
one way or the other, until proper clinical trials are
conducted.

Nature thought of it rst

The problem of stabilizing calcium ions so that bioavailable calcium can be delivered when needed is
a major biological challenge which impacts on all
dental and other hard tissues in the body. Within
milk, the casein phosphopeptides (CPP) stabilize
calcium and phosphate ions through the formation
of complexes. The calcium phosphate in these
complexes is biologically available for intestinal
absorption, and the same concept has now been
applied to create materials with bio-available
calcium and phosphate in the appropriate form and
molecular ratio for remineralization of subsurface
lesions in enamel. Clusters of phosphorylated seryl
residues are responsible for the interaction which
occurs in bovine milk between the caseins and
calcium phosphate. [12]
Understanding this natural process of calcium
stabilization, transport, and delivery and applying
it to dentistry resulted in the development of CPPACP technology by Professor Eric Reynolds and
co-workers at the University of Melbourne, and its
inclusion into chewing gums (such as Recaldent
gum and Trident White) as well as into the
Tooth Mousse crmes.
There is extensive clinical as well as
laboratory evidence for the effects of CPP-ACP
as a remineralizing agent, as well as a truly anticariogenic agent, with the latter being demonstrated
in both animal and in situ human caries models [2,3,6-8,
12-22]
. The material is pH responsive, with increasing
pH increasing the level of bound ACP and stabilizing
free calcium and phosphate, so that spontaneous
precipitation of calcium phosphate does not occur.
This is also inherently an anti-calculus action, as
well as evidence that CPP-ACP may inuence the
properties and behaviour of dental plaque through (1)
binding to adhesin molecules on mutans streptococci
and thus impairing their incorporation into dental
plaque, (2) elevating plaque calcium ion levels
to inhibit plaque fermentation; and (3) providing
protein and phosphate buffering of plaque uid pH,
to suppresses overgrowth of aciduric species under
conditions where fermentable carbohydrate is in
excess.

Table 2. A stepwise comparison of two products

TCP (USA).

CPP-ACP (Australia)

3 laboratory studies of
physical aspects. No clinical
trials, or systematic reviews.

Large literature (> 45 published

papers) including randomized
controlled clinical trials and
systematic reviews

Production

Chemical synthesis of TCP,

followed by ball milling to
create particles with surface
coating of SLS

Puried natural peptides isolated

from bovine milk casein proteins
and then complexed with
forming nanoparticles of ACP

Fluoride level (label)

950 ppm from 0.21% NaF

900 ppm from 0.2% NaF

Calcium-based ingredient

0.5 % TCP (500 ppm)

Ca3P2O8

10% CPP-ACP (10,000 ppm)

Ionic concentrations

48 mM Calcium
32 mM Phosphate
50 mM Fluoride

325 mM Calcium
187 mM Phosphate
48 mM Fluoride

(assuming maximal release

occurs; however no data on
bioavailability exists)

(measured bioavailability, with

90% ion release in 30 minutes)

Ratio of ionic species Calcium :

Phosphate : Fluoride

1 Ca: 0.6 P: 1 F

6.8 Ca : 4 P : 1 F

Calcium ion release

Not yet documented for this

product

Complete release of calcium ions

over 30 minutes following acid
challenge

Application

Toothpaste, Expectorated
after use.

Crme, applied topically and left

in place

Exposure time

2 minutes (duration of
toothbrushing)

2-3 hours (protein binding and

then slow proteolysis)

Interaction with saliva

Saliva dissolves SLS

(detergent) coating on
particles.

CPP-ACP phosphoprotein works

in partnership with salivary
phosphoproteins to deliver and
stabilize calcium

Enhancement of calcium levels

in saliva and dental plaque

No data available

Yes a property of the

phosphoproteins

Stabilization of calcium ions

in saliva and plaque uid to
prevent precipitation

No

Yes a property of the

phosphoproteins

Binding to pellicle or soft tissues

No

Yes - a property of the

phosphoproteins

Technology foundation

DENTAL INC. July/August 2009

GC Tooth Mousse Plus

CLINICAL

ClinPro Tooth Creme

41

USERREPORT
CLINICAL
TECHNOLOGY

Conclusions: apples and oranges

Looking at the evidence base available at the
present time, it is important to clearly distinguish
between these two products. In fact, one could
argue that they share only two features their
nominal fluoride concentrations are similar, and
both use vanilla as a flavour. In fact, human in situ
and clinical trial data is needed to support the use

of ClinPro over other common 1000 ppm fluoride

toothpastes, to validate the inclusion of TCP into
a toothpaste formulation. Dental professionals
should remember that it takes significant time
(and expense) to establish the bona fides of a
new technology, and that a watching brief
is important in working through the various
products and their therapeutic claims.

REFERENCES
1 Zero DT. Dentifrices, mouthwashes, and remineralization/
2

3
4
5
6
7

8
9
10

11

DENTAL INC. July/August 2009

12

42

caries arrestment strategies. BMC Oral Health. 2006;6

(Suppl 1):S9-S22.
Huq L, Cross KJ, Ung M, Reynolds EC. A review of protein
structure and gene organization for proteins associated
with mineralised tissue and calcium phosphate
stabilization encoded on human chromosome 4. Arch
Oral Biol. 2005; 50:599-609.
Reynolds EC. Calcium phosphate-based
remineralization systems: scientic evidence? Aust Dent
J. 2008;53(3):268-73.
White DJ. The application of in vitro models to research
on demineralization and remineralization of the teeth.
Adv Dent Res. 1995;9(3):175-93.
Roberts AJ. Role of models in assessing new agents
for caries prevention - non-uoride. Adv Dent Res.
1995;9(3):304-11.
Walsh LJ. GC Tooth Mousse Portfolio, 4th edn. 2006.
Singapore, GC Asia Dental Pte Ltd. pp. 14-15.
Morgan MV, Bailey DL, Adams GG, Tsao C, Hyslop
A, Escobar K, Manton D, Reynolds EC. A clinical trial
measuring white spot lesion progression and regression.
J Dent Res (Sp. Iss). IADR 2008 Toronta, Abstract 0112.
Clinical trial of Tooth Mousse on white spot lesions. J Dent
Res 2009 (In press).
Karlinsey RL, Mackey AC. Solid-state preparation and
dental application of an organically modied calcium
phosphate. J Mater 2009 (In press).
Karlinsey RL, Mackey AC, Stookey GK. In vitro
remineralisation efcacy of NaF systems containing
unique forms of calcium: a pilot study. Am J Dent (In
press). 2009.
Karlinsey RL, Mackey AC, Stookey GK, Pfarrer A. In vitro
assessments of experimental NaF dentifrices containing
a prospective calcium phosphate technology. Am J
Dent (In press). 2009.
Cross KJ, Huq NL, Palamara JE, Perich JW, Reynolds
EC. Physicochemical characterization of casein
phosphopeptide-amorphous calcium phosphate
nanocomplexes. J Biol Chem. 2005;280(15):15362-9.

13 Walsh LJ. Tooth Mouse: anthology of applications. 2007,

Singapore: GC Asia Pte Ltd.

14 Cross KJ, Huq NL, Reynolds EC. Casein phosphopeptides

15

16
17

18

19

20

21

22

in oral health - chemistry and clinical applications. Curr

Pharm Des. 2007;13(8):793-800.
Reynolds EC. Anticariogenic complexes of
amorphous calcium phosphate stabilized by casein
phosphopeptides: a review. Spec Care Dentist.
1998;18(1):8-16.
Reynolds EC. Remineralization of enamel subsurface
lesions by casein phosphopeptide-stabilized calcium
phosphate solutions. J Dent Res. 1997;76(9):1587-95.
Manton DJ, Walker GD, Cai F, Cochrane NJ, Shen P,
Reynolds EC. Remineralization of enamel subsurface
lesions in situ by the use of three commercially available
sugar-free gums. Int J Paediatr Dent. 2008;18(4):284-90.
Walker G, Cai F, Shen P, Reynolds C, Ward B, Fone C,
Honda S, Koganei M, Oda M, Reynolds E. Increased
remineralization of tooth enamel by milk containing
added casein phosphopeptide-amorphous calcium
phosphate. J Dairy Res. 2006;73(1):74-8.
Morgan MV, Adams GG, Bailey DL, Tsao CE, Fischman SL,
Reynolds EC. The anticariogenic effect of sugar-free gum
containing CPP-ACP nanocomplexes on approximal
caries determined using digital bitewing radiography.
Caries Res. 2008;42(3):171-84.
Reynolds EC, Cai F, Cochrane NJ, Shen P, Walker
GD, Morgan MV, Reynolds C. Fluoride and casein
phosphopeptide-amorphous calcium phosphate. J Dent
Res. 2008 ;87(4):344-8.
Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds
EC. Enamel subsurface lesion remineralisation with
casein phosphopeptide stabilised solutions of calcium,
phosphate and uoride. Caries Res. 2008;42(2):88-97.
Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds
EC. Acid resistance of enamel subsurface lesions
remineralized by a sugar-free chewing gum containing
casein phosphopeptide-amorphous calcium phosphate.
Caries Res. 2004;38(6):551-6.

ABOUT THE EXPERT

Laurence J. Walsh is Professor of Dental Science at The University of Queensland in Brisbane, Australia,
and has been the Head of the School of Dentistry for the past 6 years. He is a clinical specialist in special
needs dentistry, and has been researching preventive agents for the past 25 years. He developed the
clinical protocols which are currently used with the Tooth Mousse series of products in his clinical practice.
He has served for many years as an advisor to a range of dental companies involved in preventive
dentistry. He has no nancial interests in either the Tooth Mousse or ClinPro products discussed in this article.

PROVEN FACTS
ACTION

Inhibition of caries in an animal model

OTHER
CALCIUM
PHOSPHATE
SYSTEMS

RECALDENTTM
CPP-ACP
EVIDENCE

Reynolds et al., 1995

(J Dent Res, 74, 1272-1279)

Yamaguchi et al., 2007

Inhibition of dentine demineralisation

in vitro

Promotion of dentine remineralisation

in vitro

Rahiotis & Vougiouklakis, 2007

Inhibition of plaque formation in situ

Rahiotis et al., 2008

Inhibition of enamel demineralisation in situ

(Caries Res, 41, 204-207)

Rahiotis & Vougiouklakis, 2007

(J Dent, 35, 695-698)

(J Dent, 35, 695-698)

(J Dent, 36, 272-280)

Reynolds, 1987

(J Dent Res, 66, 1120-1127)

Reynolds, 1998

(Spec Care Dentist, 18, 8-16)

11 publications including

Promotion of enamel subsurface lesion

remineralisation in situ

Shen et al., 2001

(J Dent Res, 80:2066-2070)

Iijima et al., 2004

(Caries Res, 38, 551-556)

Manton et al., 2008

(Int J Paediatr Dent, 18, 284-290)

Inhibition of caries progression and

promotion of regression of caries in
a randomised controlled clinical trial

Morgan et al., 2008

Promotion of enamel subsurface lesion

remineralisation in a randomised
controlled clinical trial

Bailey et al., 2009

(Caries Res, 42,171-184)

(J Dent Res, Submitted)

GC Asia Dental Pte Ltd

19 Loyang Way #06-27

Singapore 508724
T +65 6546 7588 F +65 6546 7577
E gcasia@singnet.com.sg
www.gcasia.info

GC Tooth Mousse contains

RECALDENTTM (CPP-ACP), an unique ingredient
developed at The School of Dental Science,
The University of Melbourne, Victoria, Australia.
RECALDENT and RECALDENT Device
are trade marks used under licence.

DENTAL INC. July/August 2009

No other system
comes close to
matching what
nature has developed