Cariology

ON THE SALIVARY MICROSCRYSTALLIZATION INDEX VARIATION IN

PATIENTS WITH DENTAL EROSION LESIONS

Galina PANCU¹, Simona STOLERIU², Gianina IOVAN³, Angela GHEORGHE², Irina

NICA¹, Nicoleta TOFAN4, Sorin ANDRIAN5

¹ Univ. Assistant, Dept. Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, ”Gr.T.Popa” UMPh of Iaşi,
Romania
² Lecturer, Dept. Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, ”Gr.T.Popa” UMPh of Iaşi, Romania
³ Associate Professor, Dept. Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, ”Gr.T.Popa” UMPh of Iaşi,
Romania
4
PhD Student, Dept. Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, ”Gr.T.Popa” UMPh of Iaşi,
Romania
5
Professor, Dept. Odontology-Periodontology, Fixed Restorations, Faculty of Dental Medicine, ”Gr.T.Popa” UMPh of Iaşi, Romania
Corresponding author: pancu.galina@yahoo.com

Abstract the action of various - behavioural, biological,

The aim of this study was to evaluate the variation of
salivary micro-crystallization saliva index (IMK) in patients
with gastroesophageal reflux desease, after utilisation of a
remineralization product.
Materials and method. Twelve patients suffering from
gastroesophageal reflux were included in the study.
Unstimulated saliva was collected in the same day and at
the same hour for each patient. A total amount of 0.5 ml of
unstimulated saliva was placed on a glass plate, dried for
30 min in a thermostate at +37oC, then analyzed on a Nikon
Eclipse E 600 device. The images were saved and stored in
a computer. The IMK index was determined using formula:
IMK= none of the eye network points projected on crystals/
none of the eye network points projected on the entire
saliva drop. All patients were subjected to dental hard
tissues remineralization using Recaldent MI Paste (GC
Corporation) for 3 weeks, after which the IMK index was
determined for each patient. Results. The appearance of
crystals formed by saliva precipitation on the plates
corresponds to one of these aspects: dendrite-shaped
crystals, camomile flower, multiple points, micronetwork,
cube or egg-shaped forms. The mean values of the IMK
index varied from 0.4 before treatment to 0.9 after
remineralization with Recaldent MI Paste.
Conclusions. Recaldent MI Paste increased the
remineralization capacity of saliva when applied to
patients with gastroesophageal reflux disease.
Keywords: saliva, salivary micro-crystallization index,
Recaldent MI Paste, remineralization
1. INTRODUCTION
Dental erosion (DE) is a noncarious dental
lesion (NCDL) causing loss of the hard dental
tissues (enamel, dentine and cement) following
chemical, mechanical - factors, acting
simultaneously, without interference of any
bacterial factor. The major pathogenic mechanism
implied in the initiation and development of DE
is represented by dissolution of hydroxiapatite
and tissues demineralization, produced by a
prolonged exposure to various extrinsic and
intrinsic acids [1]. The most frequently implied
extrinsic factors refer to: a high consumption of
acid foods and beverages or citric juices,
medication with acid pH, or professional
exposure in acid environments [2-7]. Enamel
dissolution starts when pH decreases under 5.5,
whereas dentine dissolution starts when pH
decreases under 6.0 [8-11].
The development, evolution and prognostic
of DE depend on both frequency and time of acid
exposure, and prevention strategies applied. The
biological protective factors that can counteract
the erosive ones are saliva and the acquired
pellicle [12,13]. An efficient salivary support can
stop demineralization. Many researches [14,15]
recommend the use of remineralisation agents
with calcium and fluoride ions. The synergistic
action of these three elements appears as the
most efficient [16,17]. The actual preventive
strategies in DE management include: removal
of causal factors, diet advices, oral health
education and optimization of salivary
parameters.

International Journal of Medical Dentistry 189

Galina PANCU, Simona STOLERIU, Gianina IOVAN, Angela GHEORGHE, Irina NICA, Nicoleta TOFAN, Sorin ANDRIAN
The mineral content and salivary mucins
sustain the remineralisation ability of saliva.
Mucins are salivary proteins with role in trans-
epithelial migration of Na+, K+, Cl- ions, as
well as in the bio-crystallization ability of
saliva. The organic matrix of salivary mucins
represents a support for the development of
crystals growth. They influence the dimension,
form of anorganic deposits and structure of
crystals resulted after dehydration of the
salivary drop [18,19].
The optical properties of these structures
can suffer changes under the action of the
external factors intervening in the crystallization
process, or as a response to the internal changes
in the organism. These saliva features proved
to be especially useful in both diagnostic and
research [20,21]. The morphological changes of
saliva and its micro-crystallization properties
can be used to detect the qualitative and
quantitative deficiencies of salivary mucin
composition, associated to various systemic
diseases or intoxications.
Gastroesophageal reflux, (GERD), associated
with gastric acid regurgitation and/or chronic
vomiting, represents one of the intrinsic factors
implied in the debut and development of
dental erosions [22-25]. The remineralisation
agents can influence the remineralisation
potential of saliva and thus counteract the
erosive effect specific to GERD patients. Recent
studies have proved the anti-erosive effect of
a paste with casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP) [26-29].
The aim of this study is to assess the variations
of saliva remineralising potential using the IMK
micro-crystallization index after the
remineralisation therapy applied to GERD
patients.
2. MATERIALS AND METHOD
The study group included 12 patients,
recently diagnosed with GERD, without
treatment, and dental erosions under treatment
in the Dental Clinic of the ”M.Kogalniceanu”
UMPh of Iasi. The micro-crystallization saliva
190
index (IMK) was assessed at baseline and after
3 weeks of local applications (2 times daily)
with MI Paste Plus (GC Corporate), by using the
RECALDENT™* technogy, that contains CPP-
ACPF (Casein Phospho Peptide-Amorphous
Calcium Phosphate-Fluor). The fluoride content
is 0.2% w/w (900 ppm).
The protocol for IMK assessment involves
the following steps: unstimulated saliva was
collected in a test glass at 12 a.m., after which
0.5 ml of saliva were applied on a microscope
slide dried for 30 min (+37oC). The slides were
assessed microscopically (with a Nikon Eclipse
E 600 device). The digital images were archived
with a specific software. The samples were
collected at baseline and after 3 weeks of
Recaldent MI Paste topical applications. After
IMK calculation using a standardised formula,
the results were classified into three categories:
high, mean, low.
The basic criteria characterising the ability of
the oral fluid to mineralise the dental tissues and
to form crystals is the dimension of crystal
structure, measured by IMK (micro-crystallization
saliva index).
number of points of numbering grill ,
projected on crystals
IMK =
number of points of the numbering grill,
projected on saliva drop
IMK = 0.6÷1 (high level of micro-crystallization);
IMK = 0.4÷0.6 (mean level of micro-crystallization);
IMK = 0÷0.4 (low level of micro-crystallization).
3. RESULTS
The categories of micro-crystallization are
classified as: tree-fern, flake or camomile flower,
multiple points, micronetwork, lenticular or
cubic structures, banded structures, or
combinations (fig.1a, b).
The mean IMK values varied between 0.4 at
baseline and 0.9, respectively, after three weeks
of treatment with MI Paste Plus (tab.1, fig. 2).
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 ON THE SALIVARY MICROSCRYSTALLIZATION INDEX VARIATION IN PATIENTS WITH DENTAL EROSION LESIONS

Table 1. IMK values before and after of hard dental tissues. Demineralization is
treatment with MI Paste Plus associated with the loss of calcium and phosphate
ions from the hard dental tissues. The
IMK Index remineralisation mechanisms are stimulated by
before after the presence of high levels of calcium and
No.
treatment treatment phosphate ions in saliva [31]. Leus P.A. proved
the existence of a correlation between the
1. 0.5 0.8
remineralisation abilities of saliva and the type
2. 0.4 1.0
of structure resulting after the crystallization of
3. 0.3 0.9
saliva drop on a microscope slide [32-34].
4. 0.2 0.7
For patients with high saliva remineralisation
5. 0.6 1.0
ability, in 93.5% of cases the micro-crystalization
6. 0.7 0.9
had a ”tree-fern” aspect with the tendency of
7. 0.3 0.8
distribution from the center towards the external
8. 0.5 1.0
areas of the saliva drop. For patients with low
9. 0.2 1.0
saliva remineralisation ability, in 87% of cases
10. 0.3 1.0
the crystal structure was absent or diffuse, and
11. 0.3 0.9
the saliva contained a few crystals in the visual
12. 0.4 0.8
field, or aciform crystals distributed in the visual
Mean 0.4 0.9
field or grouped in the peripheric areas of the
saliva drop.
Understanding of these processes requests the
analysis of enamel, which is a compact, dense,
homogenuous structure built-up by prisms
containing 97% calcium and phosphate ions.
Each prism contains hundreds of crystals
distributed in a specific network and representing
different forms of apatite. These crystals have
different solubility degrees, the less soluble one
being hydroxyapatite. Saliva is a reservoir of
calcium and phosphate ions when pH is
a) b) maintained around 7.0. The remineralisation
Fig. 1. Saliva micro-crystallization aspects process decreases when pH decreases under 7.0,
a) at baseline, b) after treatment and is almost absent when pH = 5.5 (for enamel)
and pH = 6.8 (for dentine). The demineralization
processes damage and destroy the enamel
prisms. The surface layer of enamel becomes
more porous, and conditions are created to
initiate incipient carious lesions or dental erosion
[35,36]. The solution for these pathological
changes calls for a regenerative approach,
assuming the realization and use of materials
Fig. 2. IMK values at baseline and
containing phosphate calcium and fluoride,
3 weeks after treatment with MI Paste
characterised by the ability to penetrate deeply
into the dental tissues and to restore the affected
4. DISCUSSION structure.
In agreement with the results of other
researches [14-17], the present study confirms
Continuous demineralisation and the relation between a constant and efficient
remineralisation processes occur on the surfaces supply of minerals (calcium phosphate and

International Journal of Medical Dentistry 191

Galina PANCU, Simona STOLERIU, Gianina IOVAN, Angela GHEORGHE, Irina NICA, Nicoleta TOFAN, Sorin ANDRIAN
fluoride) in saliva and bacterial plaque, and the
increase of saliva remineralisation potential
associated with arresting of the acid erosive
effect. Tricalcium phosphate, amorphous calcium
phosphate and casein phosphopeptide-
amorphous calcium phosphate (CPP-ACP) can
successfully carry out this role.
5. CONCLUSIONS
The remineralisation agent MI Paste Plus
increases the remineralisation potential of saliva
and may be recommended for preventing and
counteracting the erosive effect of an acid
environment in patients with dental erosions
and RGE. The possibility to test the
remineralisation ability of saliva, using IMK,
represents an important tool for assessing the
evolution and success of the treatment. The IMK
index, a parameter expressing the remineralisation
ability of saliva, can be assessed using a simple,
accessible and inexpensive technology.
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