RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE – II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

(IN BLOCK LETTERS)

Dr. AMRITA CHAKRABORTYPOST GRADUATE STUDENT,DEPARTMENT OF PEDODONTICS ANDPREVENTIVE DENTISTRY,BAPUJI DENTAL COLLEGE ANDHOSPITAL,DAVANGERE-577004.KARNATAKA

2. NAME OF THE INSTITUTION BAPUJI DENTAL COLLEGE AND

HOSPITAL, DAVANGERE– 577 004.

KARNATAKA.

3. COURSE OF STUDY AND

SUBJECT

MASTER OF DENTAL SURGERY (M.D.S) IN

PEDODONTICS & PREVENTIVE

DENTISTRY.

4. DATE OF ADMISSION TO

COURSE 03-09-2012

5. TITLE OF THE TOPIC IMPACT OF A MODIFIED CARBONATED

BEVERAGE ON THE EROSION OF

TOOTH ENAMEL OF PRIMARY AND

PERMANENT TEETH: AN IN VITRO

STUDY

6. BRIEF RESUME OF THE INTENDED WORK:

6.1: Need for the study:

Consumption of soft drinks has increased dramatically since 1950.

There is a growing body of evidence to suggest that acidic foods and soft drinks may be

important in the development of erosion.

These acidic drinks have low concentration of calcium and phosphate. When enamel

dissolves in vivo, the dissolution can lead to either a carious lesion or erosion.

The amount of minerals lost in erosion depends on the pH, the buffering capacity and

the period of exposure to the acidic liquid.

It is well known that primary and permanent enamel surfaces are morphologically

different from one another and that the former is more porous, less mineralized, has

more carbon dioxide and carbonates and less phosphorous and calcium phosphate in its

composition

Since it is extremely difficult to make children and teenagers stop drinking soft drinks

due to the effective marketing strategies and peer pressure in place, thus has arisen the

necessity of this study to determine if there is an alternate method whereby, the

carbonated beverages could be made less harmful or rather less erosive in the oral

environment.

6.2: Review of Literature :

Lifestyle changes and a rise in the consumption of acidic foods and beverages have

led to an increase in the prevalence of dental erosion around the world in recent

years. [5]

High prevalence numbers for consumption of acidic beverages ranging from 30% to

68%, especially among children and adolescents. [10]

The erosive effect of fruit juices and similar citrate products have been recognized

since a long time with references dating back to Darby (1892) and Miller (1907).[3]

Dental erosion has been defined as a loss of tooth surface caused by intrinsic and

extrinsic factors.[8]

Enamel erosion involves the disintegration of calcium phosphate into calcium and

phosphate ions.[4]

Deciduous enamel wears at a faster rate than permanent when exposed to a fruit

drink of low pH.[6]

The softening of primary enamel surface due to erosion by presenting a decrease in

the Knoop hardness, possibly due to mineral loss caused by acidic beverage intake

has been demonstrated.[11]

The reduction of acidic potential of carbonated beverages by calcium phosphate and

sodium fluoride has been demonstrated.[1]

Fluoride catalyzes the diffusion of calcium and phosphate into the tooth surface,

which in turn remineralises the crystalline structures in the dental cavities.[5]

HYPOTHESIS:

Research hypothesis:

1) There will be a change in extent of tooth erosion when the carbonated beverage is modified with sodium fluoride.

2) There will be a change in extent of tooth erosion when the carbonated beverage is modified with calcium phosphate.

3) There will be a difference in the erosive effect caused by carbonated beverages on primary teeth versus that of permanent teeth.

Null hypothesis:

4) There will be no change in extent of tooth erosion when the carbonated beverage is modified with sodium fluoride.

5) There will be no change in extent of tooth erosion when the carbonated beverage is modified with calcium phosphate.

6) There will be no difference in the erosive effect caused by carbonated beverages on primary teeth versus that of permanent teeth.

6.3 Objectives of the study:

7) To determine the erosive effect of carbonated beverage when

modified with sodium fluoride on primary and permanent teeth.

8) To determine the erosive effect of carbonated beverage when

modified with calcium phosphate on primary and permanent

teeth.

9) To compare the erosive effect of the beverages on primary and

permanent teeth.

MATERIALS AND METHODS :

SAMPLE SIZE DETERMINATION :

Based on the information available on enamel erosion with different media, using the

following formula the minimum sample size required has been calculated.

n=2 t 2 s 2 d2

where, t = theoretical value of t distribution with 95% confidence = 2.13

s = amount of variation expected in enamel erosion = 1.0µm

d = minimum expected difference in enamel erosion = 1.22µm

level of significance = 5%

power of study = 80%

hence, n = 2x(2.13) 2 x(1) 2 = 6.1 (1.22)2

Due to unknown observer/instrumentation error, the sample size is increased to 8 in

each group.

7.1 Source of data:

1. Human permanent third molars which have been extracted and have

intact crowns are collected. [5]

2. Human primary molars, which have reached their natural stage of

exfoliation with intact crowns are collected. [5]

3. The extracted teeth should be sound with relatively planar buccal and

lingual surfaces, free from cracks or other artifacts

4. The carbonated beverage used is SPRITE (COCA-COLA CO.) which

is available in the market.

5. The sodium fluoride, calcium phosphate and ingredients for TISAB II

solution are obtained from pharmacology dept.

Materials required:

a. Extracted human permanent third molar and primary molars

b. Carbonated beverage, SPRITE (Coca-Cola Co.)

c. Sodium fluoride

d. Calcium phosphate

e. Distilled deionized water

f. TISAB II solution

g. Dental floss

h. Microtome

i. Polarized light microscope

j. Atomic absorption spectrophotometer

k. Colour spectroscope

l. Orion microprocessor

m. Vicker’s indenter

7.2 Method of Collection of Data:

Study design: Experimental, in-vitro and between group study.

TEST DRINK:SPRITE (Coca-Cola Co.), a carbonated beverage, at room temperature will be used for the study.

The composition of sprite according to the manufacturers is:1. water2. sugar3. carbonic acid4. citric acid5. sodium citrate

BASELINE TITERS:

• DETERMINATION OF pH OF SPRITE: Digital pH meter• ESTIMATION OF CALCIUM AND PHOSPHATE IN UNMODIFIED

SPRITE The calcium content will be measured using atomic absorption Spectrophotometer [9]

The phosphorous content will be measured by Color Spectroscopy [9]

ESTIMATION OF FLUORIDE IN UNMODIFIED SPRITE [3]

The fluoride will be measured by adding 10ml of sprite to 2ml of TISAB (TOTAL IONIC STRENGTH ACID BUFFER) II solution.

The orion microprocessor is used for the analysis.

USE OF TISAB II SOLUTION:1. To provide a constant background ion strength

2. Decomplex fluoride from aluminium, iron etc3. To adjust the pH between 5 – 5.5 to render the solution fit for

estimation and free from interference

SL NO TEST DRINK NATURE OF DRINK1. GROUP A UNMODIFIED SPRITETM

2. GROUP B SPRITETM WITH SODIUM FLUORIDE250mg OF NaF + 300ml OF SPRITETM [1]

3. GROUP C SPRITETM WITH CALCIUM PHOSPHATE40mmol/L Ca+28mmol/L PO4+300ml

OF SPRITETM [1]

4. GROUP D DISTILLED DEIONISED WATER

PREPARATION OF TOOTH SAMPLE:• The tooth surface is painted with nail varnish prior to

experimentation and a window measuring 4mm x 4mm is left for exposure

• A small hole is drilled into the tooth root and laced with dental floss for suspension

• Each tooth is immersed in 300 ml of each solution for duration of 5 mins under agitation by a stirrer 3 times a day with 4-h intervals between the immersion cycles, during a 60 days experimental period.[11]

• The teeth are then removed from the beverage, rinsed with water and dried.

• After rinsing with water, the teeth are stored in 15 ml of artificial saliva at 37oC until the next immersion cycle.[11]

• The window area on the enamel is examined macroscopically for any change in the appearance of the surface enamel prior to

preparation of each section

MOUNTING AND SECTIONING: [8]

• Each tooth is mounted in self-curing acrylic resin

• The teeth are then sectioned through the windows using a

microtome

• Two 100 – 150 micrometer sections are removed of each tooth

sample and stored under water.

MEASURING THE DEPTH OF EROSION [9]

A polarized light microscope with x4 magnification is used to identify the changes in the exposed tooth surface. Image analysis software is then used to measure the depth of the lesion.The lesion depth is defined as, the mean distance (in micrometers) between a straight line representing the regular tooth structure and a line drawn at the base of Remineralisation.The depth of erosion is measured for each test group and the values noted.

MEASURING THE AMOUNT OF EROSION [9]

The calcium and phosphate concentration of the drink in each group is measured before and after the tooth specimen is immersed into each drink.The values obtained are compared with the amount of calcium and phosphate present in the drink before modification and after modification and also after the tooth has been immersed into the drink for the specified period of time.This will give an estimate of the amount of calcium and phosphate

that has leached out from the tooth during the period it was immersed in the drink.Calcium content is measured by atomic absorption spectrophotometry.Phosphate is measured by color spectroscopy.

MEASURING SURFACE MICRO HARDNESS [8]

For measuring the surface micro hardness a VICKER’S INDENTER is used. Two vicker’s micro hardness indentations are performed along the horizontal line of the cut section. 50g load is applied for 10s. The micro hardness test is performed first at the exposed surface and then the non-exposed surface to obtain a comparative value.

STATISTICAL ANALYSIS:

One way ANOVA will be used for multiple comparisons followed by

Post-hoc tukey’s for group size determination

7.3: Does the study require any investigation or interventions to be conducted on

patients or other humans or animals? If so, please describe briefly:

Yes, this study requires the collection of teeth extracted for therapeutic reasons.

7.4 : Has ethical clearance been obtained from your institution in case of 7.3

Yes, recommendations of ethical committee are enclosed.

8. LIST OF REFERENCES:

1. Sardana V, Balappanavar AY, Patil GB, Kulkarni N, Sagari SG et al. Impact of a modified carbonated beverage on human dental plaque andsalivary pH. J Indian Soc Pedod Prev Dent 2012;1(30):7-12.

2. DJ Manton, F Cai, Y Yuan, GD Walker, NJ Cochrane, C Reynolds et al.Effect of CCP-ACP added to acidic beverages on enamel erosion in vitro.Australian Dental Journal 2010;55:275-279.

3. Nirmala SVSG, Subha Reddy VVA comparative study of pH modulation and trace elements of various fruitjuices on enamel erosion: An invitro study. J Indian Soc Pedod Prev Dent 2011;29(3):205-215.

4. San Ling Zhou, Jun Zhou, Shigeru Watanabe, Koji Watanabe, Ling Ying Wen et al. Invitro study of the effects of fluoride – releasing dental materials on

remineralisation in an enamel erosion model. Journal of dentistry 2012;40:255-263.

5. Christiana Murakami, Marcelo Bonecker, M Correa, Fausto Mendes,C Rodrigues. Effect of fluoride varnish and gel on dental erosion in primary andpermanent teeth. Archives of oral biology 2009;57:997-1001.

6. ML Hunter, NX West, JA Hughes, RG Newcombe, M Addy. Erosion of deciduous and permanent dental hard tissue in the oral environment. Journal of dentistry 2000;28:257-263.

7. Paula Waterhouse, Sheyla Auad, June H Nunn, Ian N Steen, Paula Moynihan. Diet and dental erosion in young people in South East brazil.International Journal of Paediatric Dentistry 2008;18:353-360.

8. Stephanie Wagoner, Teresa Marshall, Fang Qian, James Wefel. Invitro enamel erosion associated with commercially available original flavour and sour versions of candies. JADA 2009;140(7):906-913.

9. MJ Larsen, B Nyvad. Enamel Erosion by some soft drinks and fruit juices relative to their pH, buffering effect and contents of calcium phosphate. Caries Res 1999;33:81-87.

10. Van Rijkom H, Truin G, Frencken J, Konig K, van’t Hof M, Bronkhorst E et al. Prevalence, distribution and background variables of smooth-bordered tooth wear in teenagers in the Hague, the Netherlands. Caries Res 2002;36:147–54.

11. C Torres, M Chinelatti, J Gomes-Silva, F Rizoli, M Oliveria et al. Surface and subsurface erosion of primary enamel by acid beverages over time. Braz Dent J 2010;21(4):337-345