Remineralization with CPP-ACP: - GC Europe

mid 

Remineralization with CPP-ACP: 

minimum intervention, maximum return 

the evidence 

Hands on, 

drills off 

Remineralisation with CPP-ACP’ to MIH: 

the treatment protocol 

Remineralisation 

with CPP-ACP 

MID 

resources 

Issue 3

Prevention starts with 

risks identification 

and personal motivation 

Plaque Indicator Kit from GC. 

Identify plaque cariogenicity and age within 5 minutes 

GC EUROPE N.V. 

Head Office 

Tel. +32.16.74.10.00 

info@gceurope.com 

www.gceurope.com 

GC UNITED KINGDOM Ltd. 

Tel. +44.1908.218.999 

info@uk.gceurope.com 

www.uk.gceurope.com 

Plaque formation is a 

normal occurrence for 

most of the population. 

To determine the potential 

damage plaque can cause 

and discover exactly which 

plaque sites are more 

problematic than others can 

be difficult to identify. 

Plaque Indicator Kit is a simple and 

inexpensive test that quickly identifies 

and visually communicates the problem 

to motivate and educate patients. 

Minimum 

Intervention


What’s inside 

MID 3 video 

4. MID Worldwide 

mid 

Issue 3 

Thanks to the cooperation of academia, the profession and industry leadership 

by GC, Minimum Intervention Dentistry principles are adopted and promoted 

around the world, to the ultimate bene t of the patient community. 

6. Q&A 

Dr Graham Mount answers a question about what he has found to be the most 

e ective way to apply CPP-ACP 

7. Resources 

Networks, websites, books, events and journal articles relating 

to advances in MID 

8. Practice perspectives 

• Hands on, drills off 

10. Clinical corner 

• MIH: the evidence and treatment protocol 

• White spot reversal protocol 

• Topical CPP-ACP crème (Tooth Mousse): more evidence 

that demands a verdict 

26. Evidence 

• A closer look at remineralisation and CPP-ACP 

30. MI toolkit 

• Tooth Mousse: All you need to know 

mi.gceurope.com

worldwide 

MID Worldwide 

Thanks to the cooperation of academia, the profession and industry leadership 

by GC, Minimum Intervention Dentistry principles are adopted and promoted 

around the world, to the ultimate bene t of the patient community. 

Dr Matteo Basso 

As a student, I did my internship in 

the Department of Periodontology 

at the University of Milan, directed by 

Professor Roberto Weinstein. In that 

department, the concepts of minimally 

invasive dentistry had been rmly 

ingrained for many years and advanced periodontal 

procedures were envied and admired nationally and 

internationally. Here I learnt the importance of the 

preservation of healthy tissue as a fundamental condition 

for the success of treatment, both functionally and 

aesthetically. After graduation and obtaining a PhD, I 

became the head of restorative dentistry at the university 

dental clinic, IRCCS Galeazzi Orthopaedic Institute 

in Milan (Italy). There, I realized it was a good approach 

to change concepts of minimally invasive therapy, 

Italy MID 

possible only when a disease is already established, 

towards the concept of ‘minimum intervention’, in other 

words to intervene when the disease has not yet had an 

irreversible e ect on the teeth and gums. 

The literature helped us to comprehend what ‘minimum 

intervention’ actually is. And so, the traditional 

department of restorative dentistry quickly evolved 

into a new department, built on these ideas, called the 

Center of Aesthetic and Mininvasive Oral Rehabilitation 

(CROME). The goal of this centre is to intervene early in 

carious disease, seeking not only to treat cavities, however 

necessary, but also to understand why the carious 

lesions manifested themselves in the rst place. One of 

our challenges is to see if you can change the susceptibility 

of patients in order to protect their teeth and masticatory 

ability. It was not so easy to explain to patients 

all the reasons and the importance of this approach, 

4 mid worldwide 

mi.gceurope.com

China 

but after several years, we can say that the programme 

is a big success in tooth preservation. To create a form of 

restorative dentistry that can prevent the intervention of 

the periodontist, the prosthodontist or implantologist for 

as long as possible is the main goal for me and my sta . 

The adoption of the MID, once understood, is very 

simple. However, we cannot hide that the rst and biggest 

challenge is the identi cation of clear guidelines for the 

correct application of MID into the clinical reality of each 

dentist. Still too many dentists observe the magni cent 

results of some colleagues who publish books and 

magazines on MID, but still wonder how they can integrate 

it into their own situations. Some are even afraid to make 

the patients pay for preventive diagnostic procedures, and 

therefore they prefer not to perform diagnosis and tests, 

intervening when there is already an established disease 

or, even worse, when the disease can be only treated 

Dr Zhouqun Yan, GC China 

There is an increasing awareness of MI among the Chinese 

dental profession. This is due to information in international 

journals and returning overseas dentists who have studied 

abroad for postgraduate degrees or special research projects. 

However, due to the requirement of an import license for any 

item regarded as a dental device, most ‘state of the art’ items 

including MI products are not available for Chinese dentists at the same time as 

other countries. Some successful items take years to satisfy the strict governmental 

requirements. To emphasise this, Tooth Mousse was only launched in China at 

the end of 2009. At present, most of the products available in China t into the 

repair category of the MI concept and products like GC Fuji IX GP are popular in 

government dental clinics. It is di cult to embrace the complete MI concept in 

the majority of government clinics at this stage but private dentists have already 

realized the MI concept of diagnosis, prevention and repair is the future. 

In the large cities like Beijing and Shanghai, it is possible to run a successful 

dental practice based on MI principles. However, more information and education 

about MI is the key to boost the concept in these cities. 

GC Fuji IX GP is the bestselling MI product in China and complies with the 

‘easier, faster and better’ concept of Dr Gordon Christensen and other leading 

clinicians around the world. Economic reasons dictate that only the hand-mix 

version of Fuji IX GP is popular here. This special high strength glass ionomer 

has changed the way dentists work throughout China. It is also important to 

understand that China is a developing country and the ART technique is very 

important in remote areas. GC is working together with local KOLs and government 

departments to boost the availability of ART there. Fuji IX GP is the key to 

the success in these areas and overall sales have doubled over the past 2 years. 

MI dentistry is the future. It is not only a GC story but the future for the 

dental profession everywhere in the world. It is not something that costs extra 

money but can help dentists earn more. MI will eventually reduce costs for 

patients if they are also educated in proper oral care and embrace the principles 

as there will be less invasive treatment necessary. One of the exciting long 

term projects will be to work with policymakers to train dental professionals to 

identify and heal early lesions rather than watch and wait for them to progress 

to cavitation. MI will mean that dentists and nurses will be busier than ever but 

with many new and di erent roles in the practice. 

conservatively with the ‘drill, ll and bill’ option. 

Sometimes dentists are not helped by di erent 

situations in European countries: for example, in some 

countries there is no profession of the dental hygienist, 

a role in other countries which is championing the MID 

drive. The MID principles are certainly not so easy to 

introduce immediately into clinical daily practice, because 

it requires dentists to evaluate their own resources 

(sta , hygienist, number of dental chairs, availability of 

patients) and sometimes to signi cantly change their 

habits of diagnosis and treatments. 

Minimum intervention dentistry is a eld that is in 

continuous expansion. Its potential results, in terms of 

successful treatment with aesthetic success and conservation 

of the masticatory function, are huge compared 

to its di usion, which is unfortunately still small within 

the national territory. 

mid worldwide 

5

Q&A 

The question below was sent to 

Dr Graham Mount in response 

to his article in MID 2 

Name: Jack Stellpflug 

Country: USA 

Question: Can Dr Mount comment on the most effective way he has found to apply CCP-ACP? 

Answer – Dr Graham Mount 

Dear Jack Stellpflug, 

The material CCP-ACP, developed in Melbourne, came from a desire to be able to 

remineralise a demineralised enamel or dentine lesion in depth. As you are aware the 

application of fluoride in one form or another will tend to remineralise the surface 

first and will tend to prevent the further penetration of ions in to the depths of the 

lesion. This may well minimize the further demineralisation of the area but it will not 

overcome the level of porosity of the tooth structure in depth. In other words a ‘white 

spot lesion’ may well remain visible to the naked eye even though the lesion is sealed 

from further loss of ions in the short term. 

On the other hand the CPP-ACP will penetrate to the full depth of the 

demineralisation and will successfully deposit both calcium and phosphate ions to 

the full depth of the lesion thus overcoming the ‘white spot’ entirely. Add the fluoride 

ion to it and the resistance to further demineralisation will be further enhanced – that 

is, use Tooth Mousse Plus. 

This means that the preferred timing and method of application will be to apply 

when the disease is first diagnosed and before any other fluoride therapy has 

been introduced. The most effective way is to make a personal plastic ‘pull-down’ 

specifically for the patient. Apply daily, carry out normal hygiene then apply pulldown 

loaded with CPP-ACP paste and leave in place for say 15 minutes on each 

occasion. Treatment may need to last for 2 weeks or thereabouts, longer if desired. 

As part of an overall anti-caries discipline for the high risk patient or one with cervical 

sensitivity it can also be applied with the finger after cleaning any time and leave it 

on the teeth for as long as you like. It will wash away quite quickly of course but in 

the meantime will have transferred a reasonable dose of ions to the dentine beneath 

assisting in closing over the tubules. 

Yours sincerely, 

Graham Mount 

Melbourne, Australia 

6 q&a 

mi.gceurope.com

MID resources 

This is a collection of online resources on MID for dental professionals and patients 

Online 

Dental Village 

Dentalvillage is an online resource developed my two dental hygienists, 

Dave Bridges and Tim Ives who are passionate about raising the profi le 

of MID among the public and healthcare professions. The site has up 

to date information on this fresh approach to preventing dental decay 

and periodontal (gum) diseases. 

Excerpt: The focus is on maximum conservation of demineralised, noncavitated 

enamel and dentine. Once control of the infection is achieved, 

the patient’s caries risk status and evidence of lesion demineralisation 

can be monitored over extended periods. These principles can also 

be applied to the treatment and management of periodontal disease. 

Minimally Invasive Periodontal Management relies heavily on patient 

involvement, ownership and management of their own disease. The 

patient reduces their own infl ammation under guidance of the clinician 

and operative treatment is kept as minimal as possible. 

Click here: dentalvillage.co.uk 

Dental Caries Classi cation Grid 

An online resource run by Graham Mount, Wyatt Rory Hume and 

Brian Monteith has an interactive dental caries classifi cation grid 

based on MID principles that introduces an alternative to the GV Black 

classifi cation system. 

Excerpt: A revised understanding of the caries lesion 

In recent times the term “Minimal Intervention Dentistry” has been 

coined to describe a new approach to the treatment of early carious 

lesions. It is now clearly acknowledged that caries is a bacterial disease 

and treatment should therefore revolve primarily around overcoming 

the infection. 

Click here: http://www.midentistry.org/grid.html 

California Dental Association Journal Back Issues 

The California Dental Association has made the back issues of its journal 

available for download online through its website. 

Excerpt: The Journal of the California Dental Association is an awardwinning 

monthly peer-reviewed scientifi c publication keeps dentists 

up-to-date about scientifi c advances, business management strategies 

and new products. It also features thought-provoking editorials, 

comprehensive statewide continuing education listings, California 

practices for sale, and dentistry’s favourite humour columnist - Dr Bob, 

Robert E. Horseman, DDS. 

Click here: http://www.cda.org/publications/journal_of_the_ 

california_dental_association 

MID patient factsheet 

Academy of General Dentistry has compiled a useful document that 

explains the principles of MID to patients 

Click here: http://www.midentistry.com/AGD-MI.pdf 

Professor Brian Nový articles 

Professor Nový is featured in the USA 

version of the MID ezine, compiled by GC 

America – click here to read the issue 

He is a renowned MID advocate and 

here is a list of some of his most recent 

publications: 

The Material Science of Minimally 

Invasive Restorations. Compendium of 

Continuing Education in Dentistry, July 

2008. 

Salivary Diagnostics: Practical 

Applications. AGD Impact. September 2009. 

Glass ionomers: Invaluable materials in 

today’s dental operatory. National Network 

for Oral Health Access Quarterly Newsletter. 

Winter 2009: 2(1). 

Profi le in Oral Health: Treating the Caries 

Disease, an interview with Dr. Brian B. Nový. 

Dental Town Magazine. April 2009 10(4): 

90-94. 

Dental Caries: A pH mediated disease. 

Journal of the California Dental Hygienist’s 

Association, Winter 2010: 25(1). 

Social media 

Here is an overview of MID related resources 

that you can follow through social media 

Facebook 

MI Paste (Tooth Mousse) fanpage 

Click here: http://www.facebook.com/#!/ 

mi.paste?ref=ts 

Twitter 

MI Paste (Tooth Mousse) 

Click here: http://twitter.com/mipaste 

Carifree 

Click here: http://twitter.com/CariFree 

resources 

7

Hands on, drills off 

Dr Kirk Young is the practice principal and owner of Young’s Dental Practice, which was 

awarded the 2009 Preventive Practice of the Year award. MID recently spoke to him about his 

practice and what motivates him to pursue MID. 

“I always 

preferred 

doing 

prevention 

rather than 

extractions 

anyway” 

MID: What goes into achieving the title of 

Preventive Practice of the Year? 

Dr Kirk Young: According to the judges 

of this award, our dedication to improving 

patient care, passion and enthusiasm for MID 

in our practice is evident. In our practice we 

also have a physiotherapy and sports injury 

clinic and this all contributes to us being an 

overall preventive practice. An essential part 

of our success is excellent teamwork: from the 

reception staff, the nurses to the hygienists 

and dentists. 

The MI systems, materials and techniques 

that we have put in place at the practice 

have taken us many years to implement fully 

and we have spent a great deal of time and 

consideration on each. It certainly didn’t 

happen overnight! 

Years ago I was looking for a mentor in 

dentistry to inspire me. I met Hien Ngo at 

a conference and heard him speak quite 

a few times and his ideas influenced me 

tremendously. I always preferred doing 

prevention rather than extractions anyway. 

Another move in the right direction came 

when we stopped being an NHS practice 

four years ago. When the new NHS contract 

was announced I realised that the prevention 

component was not included. I felt we couldn’t 

give patients adequate care in prevention on 

the NHS so we became a private practice. 

We told the patients what was happening 

and why we were changing and they 

had already become used to our way of 

performing preventive dentistry. We always 

try to keep the patients involved – our 

website has many resources on MID and 

prevention for them. 

Winning the award has been a great 

recognition for the whole team and confirmed 

to us that what we are doing with MID and 

prevention is the way forward. 

MID: What techniques and strategies have 

you found to work best for doing preventive 

dentistry? 

Dr Kirk Young: Keeping patients informed 

is crucial. We have to show them what we 

have to offer and we do this through our 

newsletter, which every patient receives at a 

recall appointment. In it we publish content 

about the benefits of MID and prevention, 

and we highlight the equipment that helps 

us to practice preventively, such as Cariescan, 

The Wand, Healozone and Velopex. 

Using an intraoral camera is another 

excellent way get the patient involved in the 

problem. You don’t just tell them they have a 

disease, but you also show them where it is, 

how it looks and what it is doing. One of the 

cornerstones of MID is that it’s not a one way 

partnership between the patient and dentist. 

You need increased patient involvement to 

make this work. 

Education the team is another important 

facet and we have spent a great deal of time 

training together with the whole team. When 

the team members fully understand the 

8 practice perspectives 

mi.gceurope.com

enefits of MID they can explain it better to 

the patients and communicate the benefits 

more effectively to them. 

We also make use of questionnaires and 

work through these with the patients, in order 

to assess their caries risk. Our staff members 

are fully trained to undertake this because we 

find that sometimes the patients feel more 

comfortable to share this kind of information 

with the staff members. Everyone is focused on 

the practice having healthy and happy patients. 

MID: To what extent do you conduct practice 

based research in MID topics? 

Dr Kirk Young: Everything is recorded 

in our practice. Every patient fills out a 

comprehensive MID questionnaire, which 

is evaluated at every recall to see what 

treatment has worked or to monitor the 

progress. Our practice management software 

allows us to record all this data so we can 

chart the patient’s progress at each recall. At 

every appointment we measure the caries 

risk using the ‘traffic light system’ which is 

determined by using the intra-oral camera 

and questionnaires. All the oral hygiene and 

dietary advice given to each patient is also 

recorded to we can track their behaviour. 

Last year my practice data was used by Dr 

Avijit Banerjee at a conference presentation. 

I think it’s important to not only practice MID 

but to record and capture how we are treating 

patients so we can build the evidence base. 

MID: What advice would you give dentists 

who are considering moving over to an MIDcentered 

practice model? 

Dr Kirk Young: 

• Invest in team building and training. 

• Teach patients to self-prevent tooth decay 

proactively, rather than treating it reactively 

• Build your practice systems up gradually 

• Go to talks, attend courses with your team, 

join study groups; try to get as much 

information about MID as you can. 

• Invest in dental caries detection systems 

such as Diagnodent, Cariescan, SapproLife 

and use them every day 

• Make use of remineralisation products – they 

have a huge body of evidence behind them 

that support their efficacy 

• Keep on top of new developments: Air 

abrasion is another emerging aspect to MID 

- new research shows that bioactiveglass 

material can cut through enamel very 

quickly and can kickstart the reminerlisation 

process in the teeth 

I am still surprised to see how few dentists 

have intraoral cameras in their practices. In 

some countries this is second nature. I hope 

to see this change in the UK. MID is the 

buzzword in dentistry at the moment, it is no 

longer a marginal activity, everyone is talking 

about it. It is the way forward for dentistry 

For more information about the practice visit 

www.youngsdentalpractice.co.uk 

A day in the life at Young’s Dental Practice 

Sally Wright, practice manager 

I enjoy most being part of a team who are all working towards the same goal - for all clients to be 

dentally fit etc. I also enjoy organising Kirk’s lectures and taking part in them and co-ordinating 

with the dental companies supporting MID. I probably gain most enjoyment from patient 

interaction especially when involving them in their care which includes oral health, diet and 

grinding advice. 

My specific roles include educating patients by oral hygiene instruction and diet advice, 

grinding appliance demonstration and advice. I also give patients information on the techniques 

and equipment we use such as air abrasion for MID. I am responsible for doing MID marketing by creating leaflets, 

website updates and brochures. I help with MID lectures and discussions with GDPs / VDPs and I advise patients on 

different most up to date products to assist them at home in prevention. 

I think we have been so successful as a team because we are all big believers in MID. We also spend a large 

amount of time with our patients implementing MID and great part of it is education. We also use intra-oral cameras 

routinely for examinations and patients are offered separate time with a DCP for any advice. 

practice perspectives 

9

MIH: the evidence and treatment protocols 

By Dr Felicity Crombie and Dr David Manton 

While developmental defects have long been 

identified in human enamel, recently a new condition 

has been described: molar incisor hypomineralisation 

(MIH). First suggested as a distinct diagnosis by 

Weerheijm et al in 2001 it is defined as demarcated, 

qualitative defects of enamel (hypomineralisation) of 

systemic origin of one to four permanent first molars, 

frequently associated with affected incisors 1. Given 

the propensity of affected molars to break down 

rapidly and/or develop caries there is some debate 

as to whether this condition constitutes a new entity 

or has simply become more apparent as caries rates 

decrease and accurate diagnosis improves, both in 

regards to differentiating between true hypoplasia 

and post-eruptive breakdown (PEB) and recognition 

of abnormal caries patterns/presentation. The 

distribution of the condition is often asymmetric, 

with marked variation in severity common within an 

individual. The likelihood that incisors are affected 

has been reported to increase as the number and 

severity of molar lesions increases 2 . 

Affected teeth present patients and clinicians 

alike with many challenges with aesthetic issues, 

hypersensitivity, difficulty achieving adequate local 

analgesia and difficulty providing adequate and 

enduring restorations all reported in association with 

MIH1,3. Children with teeth affected by MIH undergo 

up to ten times the treatment of unaffected children 

by the age of 8 years and have significantly higher 

levels of dental anxiety 

and phobia 4,5. These 

factors combined 

with the 

fact that extraction is often the most appropriate 

definitive treatment option means general 

anaesthetic management, with its attendant increase 

in risk and cost, is often required 6-8. 

Prevalence 

Prevalence studies are increasingly investigating MIH 

specifically and using newly developed indices tailored 

for this purpose 9,10 ; however the majority of published 

studies have used either non-standard indices or 

the Developmental Defects of Enamel (DDE) Index. 

Caution must therefore be applied when interpreting 

prevalence data as the DDE Index has the potential to 

both over- and under- estimate the true prevalence 

of MIH since: MIH is not the only cause of demarcated 

enamel defects; caries, PEB, restoration and extraction 

are not accounted for by the DDE Index and PEB may 

be classified incorrectly as hypoplasia. 

A recent review of MIH prevalence data found that 

the prevalence varied widely with values from 2.4% 

to 40.2% reported11. The majority of studies were 

performed using European populations and ranged 

from 2.4% in Germany and Bulgaria to 37.5% in 

Denmark. Worldwide a low prevalence has been 

reported in Hong Kong (2.8%) and Libya (2.9%) 

increasing to 13.7% in Kenya, 22% in Australia 

and up to 40.2% in Brazil. The lack of standardized 

examination protocols as well as the aforementioned 

index limitations must be considered when 

comparing these results. Although difficult to 

establish given the lack of reliable, comparable 

prevalence data worryingly many clinicians feel the 

prevalence of MIH is increasing3, 12. 

Aetiological factors 

The limitations of experimental design and study 

comparability identified for prevalence data also 

apply to a review of MIH aetiology. Bearing this in 

mind a critical literature review found: very little 

evidence to support a relationship between 

breast-feeding or fluoride exposure and 

demarcated enamel defects; moderate 

evidence that exposure to PCB/dioxins may 

be associated with an increased prevalence 

of these lesions; maternal factors, birth 

complications, nutritional status, childhood 

illness and medical conditions appear to 

exert some influence on the prevalence 

of enamel defects generally, but the type of 

defect and the specific aetiological factors 

are not yet clear 13 . It is also likely that, in 

addition to the environmental exposures 

so far identified, genetic susceptibility may 

10 clinical corner 

mi.gceurope.com

the disease itself, the associated fever, the treatment 

administered or a combination which is responsible 14. 

Tooth properties 

As with the clinical presentation of MIH, lesions 

studied in vitro are often highly variable, however 

some significant findings for enamel affected by MIH 

include: increased porosity; decreased hardness; 

decreased mineral content; increased carbonate 

content; increased protein content and abnormal 

ultrastructure, etching patterns and bonding 

properties. Discrete areas of >25% porosity have 

been observed, though the bulk of lesions are less 

than 10%. Both microhardness and nanohardness 

is significantly reduced (up to a 70% reduction) as 

is mineral content (> 45% decrease) compared to 

normal enamel 15-17 . For both hardness and mineral 

content the gradient is abnormal with harder and 

more mineralised enamel found toward the dentinoenamel 

junction 16,17. For each of these properties the 

most severe areas are almost always in the outer half 

of enamel and a surface layer of reduced porosity and 

increased hardness and mineral content is observed, 

even in areas with PEB, while cervical regions appear 

unaffected. Higher carbon levels have been reported 

using secondary ion mass spectrometry which can 

reflect either a higher proportion of carbonated 

apatite or increased organic component 18 : in fact 

it appears to be a combination, with MIH lesions 

containing 3-15 times the protein (primarily 

exogenous) and 1.6 times the carbonate content of 

normal enamel 14,19. 

The ultrastructure of the enamel, observed under 

scanning electron microscopy (SEM) is also affected 

with increased disorganisation, abnormal prism 

core and inter-prismatic appearance and abnormal 

etching patterns reported 20,21 . The enamel-adhesive 

interface is markedly different and associated with 

reduced bond strengths to resin composite, however 

in the majority of cases failure was cohesive within 

the enamel 22 . Bacterial invasion of dentine tubules, 

and associated inflammatory change (secondary 

“Children with teeth affected by 

MIH undergo up to ten times the 

treatment of unaffected children 

by the age of 8 years and have 

significantly higher levels of dental 

anxiety and phobia” 

dentine formation), under apparently intact 

hypomineralised enamel has also been demonstrated 

using SEM techniques 23. Other investigations of 

the pulp status of MIH affected teeth have reported 

increased expression of an inflammatory mediator 

implicated in pain development, an increase in 

immune cells and increased innervation and 

vascularisation, providing a reason for the increased 

sensitivity and refractory nature with anaesthesia of 

these teeth 24,25. 

Management 

Unfortunately it is, as yet, impossible to use evidence 

based dentistry in the treatment of MIH as, while 

recommendations are supported theoretically by 

research evidence, only very limited clinical data 

is available. Generally it is advised clinicians utilize 

the apparently sound cervical enamel for bonding 

of ‘permanent’ restorations as marginal breakdown 

is otherwise commonly observed, however this 

strategy does involve the sacrifice of a great amount 

of enamel 26-28. Glass ionomer cements are often 

recommended, especially for early protection of 

the enamel, but currently there is no evidence 

beyond anecdotal for using this material either in 

vitro or in vivo 26, 27 . Despite this a recent European 

Academy of Paediatric Dentistry policy document 

for MIH management included GIC restorations in its 

recommendations 29 . 

Also suggested was the use of preformed crowns 

which have been found to perform well and do not 

1: Hypomineralised tooth demonstrating both severe (post-eruptive breakdown on distal cusps) and mild (white 

demarcated opacity on mesio-buccal cusp tip) lesions. 2: Polished hypomineralised lesion demonstrating demarcated 

defect edge. 3: Polarised light image (water imbibition) demonstrating surface layer of improved physical properties in 

area of post-eruptive breakdown (blue layer). 4: Clinical images of hypomineralised teeth demonstrating demarcated 

opacities, post-eruptive breakdown and cavitation even before complete eruption. 

treatment plan 

11

vitro or in vivo 26, 27. Despite this a recent European 

Academy of Paediatric Dentistry policy document 

for MIH management included GIC restorations in its 

recommendations 29 . 

Also suggested was the use of preformed crowns 

which have been found to perform well and do not 

need extensive tooth preparation thus conserving 

maximum tooth structure, and therefore options, for 

future treatments as these restorations cannot really 

be considered a permanent solution 29,30. Given the 

eventual outcome the restoration cycle, the rapidity 

with which MIH teeth can pass through this cycle 

and the costs associated with treatment (potentially 

endodontic treatment, fixed prosthodontics and 

eventual replacement with an implant at a relatively 

young age as other options are exhausted) it 

is recommended that extraction, ideally with 

consultation and co-ordination with orthodontic 

advice, be considered for severely affected teeth. 

Acceptable outcomes, even without (but preferably 

with) orthodontic intervention, can be achieved 

and cases should be assessed as to whether this 

option is more appropriate if extensive treatment 

seems otherwise inevitable 6,7,29 . It is commonly 

requested that extractions be delayed until the most 

orthodontically favourable time in which case interim 

restorations or preventive strategies may be needed 

in the interim. Preventive advice is based on the early 

caries/remineralisation model utilizing CPP-ACP, 

fluoride products and fissure sealants, however again 

the efficacy of such treatments is anecdotal only 29. 

References 

1. Weerheijm, K.L., B. Jalevik, and S. Alaluusua, Molar-incisor 

hypomineralisation. Caries Research, 2001. 35(5): p. 390-1. 

2. Weerheijm, K.L., et al., Prevalence of cheese molars in 

eleven-year-old Dutch children. Journal of Dentistry for 

Children, 2001. 68(4): p. 259-62. 

3. Crombie, F.A., et al., Molar incisor hypomineralization: a survey 

of members of the Australian and New Zealand Society 

of Paediatric Dentistry. Aust Dent J, 2008. 53(2): p. 160-6. 

4. Leppaniemi, A., P.L. Lukinmaa, and S. Alaluusua, Nonfluoride 

hypomineralizations in the permanent first molars 

and their impact on the treatment need. Caries Research, 

2001. 35(1): p. 36-40. 

5. Jalevik, B. and G.A. Klingberg, Dental treatment, dental fear 

and behaviour management problems in children with 

severe enamel hypomineralization of their permanent first 

molars. International Journal of Paediatric Dentistry, 2002. 

12(1): p. 24-32. 

6. Williams, J.K. and A.J. Gowans, Hypomineralised first 

permanent molars and the orthodontist. European Journal 

of Paediatric Dentistry, 2003. 4(3): p. 129-32. 

7. Mejare, I., E. Bergman, and M. Grindefjord, Hypomineralized 

molars and incisors of unknown origin: treatment outcome 

at age 18 years. International Journal of Paediatric 

Dentistry, 2005. 15(1): p. 20-8. 

8. Crabb, J.J. and W.P. Rock, Treatment planning in relation 

to the first permanent molar. British Dental Journal, 1971. 

131(9): p. 396-401. 

9. Jalevik, B., et al., The prevalence of demarcated opacities 

in permanent first molars in a group of Swedish children. 

Acta Odontologica Scandinavica, 2001. 59(5): p. 255-60. 

10. Jasulaityte, L., J.S. Veerkamp, and K.L. Weerheijm, Molar 

incisor hypomineralization: review and prevalence data 

from the study of primary school children in Kaunas/Lithuania. 

European Archives of Paediatric Dentistry: Official 

Journal of the European Academy of Paediatric Dentistry, 

2007. 8(2): p. 87-94. 

11. Jalevik, B., Prevalence and Diagnosis of Molar-Incisor- 

Hypomineralisation (MIH): A systematic review. Eur Arch 

Paediatr Dent. 11(2): p. 59-64. 

12. Weerheijm, K.L. and I. Mejare, Molar incisor hypomineralization: 

a questionnaire inventory of its occurrence in 

member countries of the European Academy of Paediatric 

Dentistry (EAPD). International Journal of Paediatric Dentistry, 

2003. 13(6): p. 411-6. 

13. Crombie, F., D. Manton, and N. Kilpatrick, Aetiology of 

molar-incisor hypomineralization: a critical review. Int J 

Paediatr Dent, 2009. 19(2): p. 73-83. 

14. 57th Annual ORCA Congress July 7-10, 2010, Montpellier, 

France Abstracts. Caries Research. 44(3): p. 172-244. 

15. Mahoney, E., et al., Mechanical properties across hypomineralized/hypoplastic 

enamel of first permanent molar teeth. 

European Journal of Oral Sciences, 2004. 112(6): p. 497-502. 

16. Fearne, J., P. Anderson, and G.R. Davis, 3D X-ray microscopic 

study of the extent of variations in enamel density in first 

permanent molars with idiopathic enamel hypomineralisation. 

British Dental Journal, 2004. 196(10): p. 634-8; 

discussion 625. 

17. Anonymous, 56th Congress of the European-Organisation-for-Caries-Research 

(ORCA), Budapest, HUNGARY, July 

01 -04, 2009. Caries Research, 2009. 43(3): p. 179-241. 

18. Jalevik, B., et al., Secondary ion mass spectrometry and 

X-ray microanalysis of hypomineralized enamel in human 

permanent first molars. Archives of Oral Biology, 2001. 

46(3): p. 239-47. 

19. Mangum, J.E., et al., Surface integrity governs the 

proteome of hypomineralised enamel. Journal of Dental 

Research, Accepted for publication, April 2010. 

20. Mahoney, E.K., et al., Mechanical properties and microstructure 

of hypomineralised enamel of permanent teeth. 

Biomaterials, 2004. 25(20): p. 5091-100. 

21. Jalevik, B., W. Dietz, and J.G. Noren, Scanning electron 

micrograph analysis of hypomineralized enamel in 

Affected anterior teeth tend to present aesthetic 

problems only, rather than the breakdown, sensitivity 

and increased caries risk found when molars are 

involved. Management is therefore usually more 

straightforward and options include: microabrasion, 

bleaching and sealant and direct or eventually 

indirect restorations to improve the appearance 29. 

In conclusion, the apparent increasing prevalence 

of MIH creates the need for greater practitioner 

knowledge regarding the diagnosis of the condition 

and also the treatment options possible. 

About the authors 

Dr Felicity Crombie completed 

her BDSc with Honours at the 

University of Melbourne and works 

in private practice as well as teaching 

undergraduates. In 2007 Dr Crombie 

started her PhD studies investigating 

the properties of molars affected 

by enamel hypomineralisation and 

subsequently has published and presented on the 

topic of molar hypomineralisation 

locally and internationally. 

David John Manton [BDSc MDSc 

PhD FRACDS FICD] is the convener 

of Paediatric Dentistry at the 

Cooperative Centre for Oral Health 

Science, Melbourne Dental School, 

University of Melbourne. 

permanent first molars. International Journal of Paediatric 

Dentistry, 2005. 15(4): p. 233-240. 

22. William, V., et al., Microshear bond strength of resin 

composite to teeth affected by molar hypomineralization 

using 2 adhesive systems. Pediatric Dentistry, 2006. 28(3): 

p. 233-41. 

23. Fagrell, T.G., et al., Bacterial invasion of dentinal tubules 

beneath apparently intact but hypomineralized enamel 

in molar teeth with molar incisor hypomineralization. 

International Journal of Paediatric Dentistry, 2008. 18(5): p. 

333-340. 

24. Rodd, H.D., et al., Pulpal status of hypomineralized permanent 

molars. Pediatric Dentistry, 2007. 29(6): p. 514-20. 

25. Rodd, H.D., et al., Pulpal expression of TRPV1 in molar incisor 

hypomineralisation. European Archives of Paediatric 

Dentistry: Official Journal of the European Academy of 

Paediatric Dentistry, 2007. 8(4): p. 184-8. 

26. William, V., L.B. Messer, and M.F. Burrow, Molar incisor hypomineralization: 

review and recommendations for clinical 

management. Pediatric Dentistry, 2006. 28(3): p. 224-32. 

27. Mathu-Muju, K. and J.T. Wright, Diagnosis and treatment 

of molar incisor hypomineralization. Compendium of 

Continuing Education in Dentistry, 2006. 27(11): p. 604-10; 

quiz 611. 

28. Lygidakis, N.A., A. Chaliasou, and G. Siounas, Evaluation 

of composite restorations in hypomineralised permanent 

molars: a four year clinical study. European Journal of 

Paediatric Dentistry, 2003. 4(3): p. 143-8. 

29. Lygidakis, N.A., et al., Best Clinical Practice Guidance for 

clinicians dealing with children presenting with Molar- 

Incisor-Hypomineralisation (MIH) An EAPD Policy Document. 

Eur Arch Paediatr Dent, 2010. 11(2): p. 75-82. 

30. Zagdwon, A.M., S.A. Fayle, and M.A. Pollard, A prospective 

clinical trial comparing preformed metal crowns and cast 

restorations for defective first permanent molars. European 

Journal of Paediatric Dentistry, 2003. 4(3): p. 138-42. 

12 clinical corner 

mi.gceurope.com

White spot reversal protocol 

The following protocols were developed by clinicians in their own 

dental practices in the USA, and published by GC America. 

Steps to white spot reversal 

• Take photos of the white spot lesion prior to the 

start. 

• It is important during microabrasion for the 

clinician not to over abrade the tooth surface, 

careful attention needs to be paid to the etching 

materials, their concentrations and application 

time. 

• Apply 37% phosphoric acid gel to white spot 

lesions, (10/15 sec. To 2 min. – suggested to be 

conservative), Rinse. 

• Gently pumice for 10 - 20 sec., (with non 

fluoridated, non glycerine pumice - suggest flour of 

pumice), Rinse. 

• Review the effect sometimes may have to etch a 

second time. 

• Some dentists prefer to pumice first, then etch. 

• Apply thick layer of MI Paste to the etched teeth for 

5 minutes. 

• Instruct patient to use MI Paste 2X daily for 5 

minutes. 

• Custom tray is optional. 

• Have patient return for evaluation in 7 -10 days. 

• Repeat procedure if necessary. 

Successful cases 

Clinician: Dr Scott Munro - Racine, WI, USA 

Before 

After 

Treatment protocol followed: 

09/18/07 3 Minute Etch, 5 Minute MI Paste Treatment 




- Bleach 15% Opalescence 

10/18/07 3 Minute Etch, 5 Minute MI Paste Treatment- 

Bleach 15% Opalescence 



Notes 

• No restorative work was done on patient 

• MI Paste was used and some light microabrasion 

was done on cusp tips. #9 wasn’t bleached 

internally, but was whitened with ZOOM in office. 

Patient wore trays for 5 minutes, twice daily. 

clinical corner 

13

Clinician: Dr Stephanie Benton - Grand Rapids, MI, USA 

Before 


• Teeth were etched twice, for 20 second intervals. 

• No pumice was used. 

• MI Paste was placed immediately on teeth following etching and wore trays at night time only. 

• Immediate results were seen over the first weekend. 

• Patient continued to wear the trays for 2-3 weeks at night time. 

Clinician: Dr Brett Kessler - Denver, CO, USA 

Before 

Before close-up 


• Etched # 8 & 9 for 3 minutes 

• Gave MI Paste with trays to 15 minutes before bed, 

after 3 days 

• Patient used MI Paste for the spots were gone. 

14 


After 

After 

After close-up 

• The after photos are 2 weeks after the one time 

etching and daily use. 

• The patient used approximately 1/2 of the tube of 

MI Paste to achieve these results. 

mi.gceurope.com

Clinician: Dr Ivan A. Serdar - San Francisco, CA, USA 

Before 

After 


12/02/08 - Pumice, rinse, 1 minute etch with 37% 

Phosphoric acid, rinse, blot, 5 minutes MI Paste. 



01/26/09 - Pumice, rinse, minute etch with 

Phosphoric acid, rinse, blot, minutes Paste. 







Notes 

Patient used trays at home for the duration of this 

treatment and placed MI Paste in her trays for 5 

minutes, twice a day. Patient also used regular 

strength Whitestrips at home for three weeks. 

Clinician: Dr Rubin and Dr Pong - Cincinnati, OH, USA 

Before 

After 


• 2 Minute etch with 37% phosphoric acid (blue gel) 

• Heavy pumice 

• Dispense tube of MI Paste or MI Paste Plus. Patient 

apply/rub 

• MI Paste with finger to affected areas for 10 

seconds, daily at bedtime. Re-evaluate in 2 weeks 

• Repeat sequence as needed for desired result. 

• Treatment was over the course of 1 month 

9/3/2008-9/29/2008. 


15

Topical CPP-ACP crème (Tooth Mousse): 

more evidence that demands a verdict 

By Laurence J Walsh 

Casein Phosphopeptide-Amorphous Calcium 

Phosphate (CPP-ACP) is a unique naturally derived 

protein-based remineralizing technology which is now 

used globally in chewing gums and topical crèmes. 

The unique phosphopeptides are derived from milk 

caseins, and are complexed with amorphous calcium 

phosphate, to form stable complexes which are 

nanoparticles of some 2 nm in diameter with a large 

surface area for mineral exchange Cross et al. 2006). 

The configuration of the ACP in the CPP-ACP complex 

differs completely from that found in macromolecular 

aggregates of ACP, as has been included in some 

current prophylaxis pastes and bleaching gels. 

CPP-ACP nanocomplexes act as biological 

calcium phosphate delivery vehicles, and are 

able to boost levels of bio-available calcium and 

phosphate in saliva and plaque fluid without causing 

indiscriminate precipitation of calcium salts. This 

makes this material particularly effective in the 

remineralization of early enamel lesions, and in the 

treatment of other types of enamel opacities. The 

efficacy of these nanocomplexes as anti-cariogenic 

agents has been demonstrated in numerous animal 

and in situ human caries studies (Reynolds 1997, 

1998, 2008, 2009; Cross et al. 2007), as well as in 

clinical trials. Over the past decade, the use of 

products containing CPP-ACP nanocomplexes has 

become a well established part of clinical practice 

across the globe. The clinical use of this technology 

is supported by a large body of refereed papers and 

conference presentations as well as by systematic 

reviews, the highest form of evidence in the 

pyramid of evidence-base practice. For example, a 

2006 systematic review focused on chewing gums 

and lozenges enriched with CPP-ACP (Yengopal & 

Mickenautsch, 2006 & 2009), identified over 120 

journal articles on CPP-ACP technology, which 

included laboratory trials and animal studies as well 

as clinical trials and numerous in situ clinical studies. 

In Australia and in many other parts of the world, 

the most commonly used CPP-ACP product is the 

topical crème which contains 10% CPP-ACP. This 

product, which is known alternatively as Tooth 

Mousse or MI Paste, is intended for both in-office 

and at-home use. The purpose of this article is 

to summarize the global research effort which 

underpins the current clinical applications of Tooth 

Mousse (TM) and its related fluoride-containing 

counterpart, Tooth Mousse Plus (TMP). The article 

draws on the refereed literature, including both 

journal papers and presentations at international and 

regional meetings of the International Association for 

Dental Research (IADR), the peak international body 

for dental research, over the period from January 

2002 to August 2010. 

Bio-availability of calcium and phosphate ions 

In most preventive protocols, TM is applied daily in a 

pea-size amount using a finger to the labial surfaces 

of the teeth immediately before bed. By dissolving 

slowly, the material contributes bio-available calcium 

and phosphates to the saliva, and is able to promote 

remineralization at a time when salivary defenses are 

at their lowest point. TM can be used in patients of all 

ages as the material is classified as safe to ingest. 

The release of ions from TM has been examined in 

considerable detail. The release of ions at neutral pH 

was reported by Paterson et al. (2008) who dissolved 

TM directly into deionized water and then used a 

calcium ion-selective electrode to measure calcium 

ion release. The free calcium ion concentration in 

the solution increased with time in a saturating 

exponential manner, with approximately 95 % release 

after only 15 minutes. This rapid release means that 

when the crème is applied to tooth surfaces there 

will be a rapid increase in calcium ion concentration 

in the plaque fluid and saliva. Their supersaturation 

for calcium with respect to tooth enamel drives 

remineralization and prevents mineral loss. 

Comparative studies with a broad range 

of toothpastes, gels, liquids claimed to have 

remineralizing or desensitizing actions (including 

NovaMin ®, ClinPro ® Tooth Creme, Clin Pro 5000, 

and ReminPro ®) reveal that calcium contained in 

these products has low water solubility and poor 

bio-availability, unlike the situation for TM and TMP. 

The level of water soluble calcium per gram of crème 

in TM or TMP (321.8 ± 2.6 µmol/g) is some 14 times 

or greater than any of these other products (Cai et 

al. 2009; Yasuda et al. 2010). Tooth Mousse Plus also 

has been shown to contain the highest amount of 

water soluble phosphate (245.7 ± 2.7 µmol/g) of any 

currently available products. The rapid release of 

calcium ions (within 1 hour) has been confirmed in 

other studies of TM, including those conducted by 

commercial competitors (Burwell et al. 2009). 

The high water solubility and bioavailability of the 

calcium, phosphate and fluoride in TM and TMP is 

due to this being a protein technology (containing 

casein phosphopeptides), whereas all other marketed 

16 Clinical corner 

www.gceurope.com

Table 1. Prevention and treatment of enamel caries using Tooth Mousse in laboratory models 

Author Year Location Design Outcomes 

products are inorganic in nature and lack the ability 

to stabilize the calcium and phosphate ions. 

Prevention of mineral loss in caries models 

Topical application of TM immediately before a 

cariogenic challenge has been shown to prevent 

Enamel caries 

Sato 2003 Tokyo Enamel slabs with demin gel TM buffered acids produced 

(microhardness) by S. mutans 

TM reduced enamel demin from 

acidic gel and S. mutans fermentation. 

Takamizawa 2005 Tokyo Enamel slabs with demin gel TM preserved the inorganic component 

(ultrasound) of enamel by preventing demin. 

Sakaguchi 2005 Tokyo Enamel slabs with demin gel TM preserved the inorganic component 

(QLF) of enamel by preventing demin. 

Sudjalimi 2006 Melbourne Extracted teeth in demin gel TM reduced mineral loss around 

(QLF) orthodontic brackets. 

Manton 2007 Melbourne Enamel slabs with white TM caused more remin of white spot 

spot lesions lesions than human saliva. 

Lovel 2007 Liverpool Enamel slabs with white TM was more effective than 1000 ppm 

spot lesions (QLF) F toothpaste in promoting remin of WSL 

Kim 2007 South Korea Enamel slabs with WSL TM was more effective than 3000 ppm 

(microhardness) F solution in preventing demin. 

Kumar 2008 Hong Kong Enamel slabs with WSL TM remineralized WSL and showed a 

higher remineralizing potential when 

applied after the use of a fluoride 

toothpaste. 

Adebayo 2008 Melbourne Enamel slabs TM treatment of intact enamel 

improves resistance to phosphoric 

acid etching 

Kao 2008 West Virginia Enamel slabs TM treatment increases acid resistance 

of enamel when exposed to a demin gel. 

Setien 2008 Dallas Enamel slabs with WSL TM treatment increased the 

(microhardness) microhardness of demineralized enamel. 

Theerapiboon 2008 Bangkok Enamel slabs with WSL (PLM) TM treatment reduced lesion volume 

and caused remin in WSL in both 

permanent and deciduous enamel. 

Huang 2008 Minneapolis Enamel slabs eroded TM treatment improved enamel 

with Coke® hardness more than artificial saliva. 

Kallayahi 2008 Bangkok Enamel slabs TM treatment protected enamel from 

(microhardness) softening from cola drink exposure. 

Behnan 2009 Ann Arbor Enamel slabs TM prevented enamel demineralization 

(QLF) around orthodontic brackets during 

an in-vitro acid challenge. 

Elsayad 2009 Cairo Molar teeth with demin TM caused remin, which was enhanced 

when F was added simultaneously. 

Chapman 2010 Bristol Enamel slabs (profilometry) TMP and TMP reduced enamel surface 

loss from citric acid challenge. 

F = fluoride, QLF = Quantitative light fluorescence; PLM = polarizing light microscopy, WSL = white spot lesions. 

demineralization of enamel during subsequent 

challenge, and also to reduce the pH reduction 

caused by S. mutans fermentation (Sato et al. 2003). 

This capacity to buffer acids produced by cariogenic 

bacteria adds to other ecological effects of TM on 

dental plaque. TM has benefits in preventing root 


17

surface caries as well as enamel caries (Tables 1-3). 

Numerous laboratory studies have documented that 

TM is more effective than saliva for remineralization 

after caries- and erosion-like assaults to the enamel 

(Table 1). This holds true regardless of the methods 

which are used to assess the integrity of the 

enamel. Preventive benefits of TM and TMP are now 

recognized to extend to root surfaces as well as 

enamel (Table 2), and evidence of arrest and reversal 

of root surface caries has also been presented (Vlacic 

et al. 2007). 

As well as effects mediated through promoting 

remineralization and inhibiting demineralization, it is 

now recognized that TM can exert ecological effects 

on the dental plaque biofilm. A recent large scale 

clinical trial reported that daily use of TM in infants 

from the time of first tooth eruption had similar 

effects on plaque acid production as daily use of 

0.12% chlorhexidine gel (Plonka et al. 2010). 

Visible reversal of white spot carious lesions 

Early case reports of visible reversal of enamel white 

spot lesions (WSL) in young adult patients in Australia 

Table 2. Other Laboratory Studies of Tooth Mousse 

(Walsh 2004; Walsh 2007) and later in Japan (from 2002) 

(Reynolds & Walsh, 2005), Europe (Ardu et al. 2007) and 

North America (Milnar, 2007) have been followed by in 

situ studies of laboratory-created WSL (Manton et al. 

2007) and full scale randomized controlled clinical trials 

in patients with naturally occurring WSL (Andersson 

et al. 2006; Kitasako et al. 2009; Bailey et al. 2009; Zhou 

et al. 2009; Yazicioglu et al. 2010). Cases of reversal of 

moderate fluorosis have also been presented (Walsh 

2003; Walsh 2004; Reynolds & Walsh 2005; Walsh 2007; 

Ng & Manton 2007). 

Recent reviews have concluded that predictable 

remineralization of enamel white spot lesions 

(WSL) can be achieved clinically by using frequent 

applications of TM as a self-administered topical 

therapy (Ilena et al. 2009; Reynolds 2009). This 

significant body of work (summarized in Table 3) 

demonstrates that dramatic cosmetic changes occur 

in enamel as WSL undergo reversal during treatment 

with TM on a daily basis. A particular risk group where 

TM is useful for gaining regression of white spot 

lesions is patients who are undergoing orthodontic 

treatment (Table 4). 


Root caries 

Hicks 2005 Houston Root segments with demin gel TM enhanced the resistance of root 

(PLM) surfaces to artificial caries formation, 

when compared with fluoride rinse 

(0.05% NaF). 

Rahiotis 2007 Athens Dentine slabs with demin gel TM treatment reduced demin and 

enhanced remin of dentine. 

Xie 2007 Chicago Root segments with demin gel TM treatment increased the hardness 

(microhardness) of dentine. 

Trajtenberg 2007 Houston Root segments with demin gel TM treatment improved caries 

(PLM) resistance of root surfaces. 

Garcia-Godoyi 2009 Fort Lauderdale Root segments with demin gel TM and TMP protected root surfaces 

(PLM) from an artificial caries challenge. 

Other applications 

Wong 2010 Melbourne Teeth undergoing bleaching A 2 week application of TM prior to 

the use of an in-office bleaching gel did 

not adversely affect the bleaching 

effectiveness, but reduced the levels of 

hydrogen peroxide entering the pulp 

chamber. 

Augustson 2010 Minneapolis Enamel eroded with HCl After HCL erosion, 60 minutes exposure 

(microhardness) to TMP or TM (but not 3000 ppm F rinse) 

increased the enamel hardness. Greater 

recovery seen with TMP than with TM. 

Gomes 2010 San Paulo De-proteinated enamel TM applied after in-office bleaching 

helped to restore the glossy nature of 

the enamel surface. 


www.gceurope.com

Table 3. Selected clinical studies of CPP-ACP products 


While it is now well established that TM can cause 

reversal of WSL, it is remarkable that there are as 

yet no clinical trials or case reports in the literature 

showing visual reversal of enamel WSL for other 

agents such as NovaMin or ClinPro Tooth Crème 

which claim to have remineralizing actions. 

TMP is a potent agent for promoting regression and 

reversal of WSL. Mixtures of CPP-ACP with fluoride 

(TMP) and CPP-ACFP solutions have been shown 

to remineralize enamel subsurface lesions in vitro 

by depositing fluorapatite. This remineralization is 

accompanied by improved translucency and reduced 

opacity of the white spot lesions, as reversal occurs 

and mineral content increases (Cochrane et al. 2006). 

Chewing Gums 

Cai 2003 Melbourne RCT, in situ model, N=10, Incorporation of CPP-ACP into a lozenge 

over 14 days increased enamel subsurface lesion 

remineralization relative to a control 

sugar-free lozenge. 

Manton 2005 Melbourne RCT, in situ model, N=10, CPP-ACP gum produced 75-107% more 

over 14 days remineralization than sugar-free gums. 

Cai 2006 Melbourne RCT, in situ model, N=10, CPP-ACP gum produced more 

over 14 days remineralization than chewing with 

placebo gum. Extended acid challenge 

of the remineralized lesions showed that 

the mineral formed was more acid 

resistant. 

Iijima 2006 Nagasaki RCT, in situ model, N=20, CPP-ACP gum produced remin of 

over 14 days subsurface enamel with mineral of 

higher crystallinity and greater acid 

resistance than when remin occurs with 

saliva. 

Morgan 2008B Melbourne RCT, N=2720 children, CPP-ACP sugar-free gum slowed 

over 2 years progression and enhanced regression of 

approximal caries relative to a control 

sugar-free gum. 

Toothpaste 

Reynolds 2006 Melbourne RCT, in situ model, N=10, Toothpaste with 2% CPP-ACP produced 

over 14 days remin similar to 2800 ppm F toothpaste. 

Rao 2009 Manipal RCT, N=150 children, Toothpaste with 2% CPP caused a 

over 2 years significant reduction in caries increment 

versus placebo, and was equally as 

effective as a toothpaste containing 

1190 ppm F. 

Mouthrinse 

Shen 2006 Melbourne RCT, in situ model, N=10, Mouthrinse containing 0.5% CPP-ACP 

over 10 days at pH 5.5 produced greater remin of 

enamel subsurface lesions than the 

same rinse at pH of 7.0. 

RCT = randomized controlled clinical trial. 

Treatment of cervical dentinal hypersensitivity (CDH) 

There is a significant literature regarding the strong 

interactions which occur between TM and dentine 

(Adebayo et al. 2008 A&B, 2009, 2010). One of the first 

clinical trials using TM to treat CDH was undertaken 

in Belgium in 2004. The study involved 11 private 

practitioners, whose patients with CDH were instructed 

to apply TM for 21 days, immediately after the evening 

brushing, leaving the material for 3 minutes, and 

spreading it across the mouth, and then leaving it 

in place during sleep. The patient cohort reported a 

reduction in sensitivity, particularly to stimulation with 

air as opposed to tactile stimuli. Daily diaries which 

recorded symptoms of CDH showed a progressive 


19

eduction from the first day of treatment over the 

following 3 weeks. Half of the treated patients reported 

that the general reduction in CDH symptoms was 

sufficiently great that they wished to repeat the 

treatment if symptoms of sensitivity recurred (Poitevin 

et al. 2004). A later series of randomized controlled 

clinical trials conducted in Brisbane showed that TM 

reduced sensitivity to air, osmotic, thermal and tactile 

stimuli, with equal effectiveness to potassium nitrate 

toothpaste (Walsh et al. 2006; Vlacic 2007, Walsh 2010). 

This finding has been confirmed by more recent studies 

(Duan et al. 2009). This aligns with studies which show 

that a single application of TM can coat and partially 

occlude dentine tubules, and resist thermocycling 

(Hiller et al. 2008), but is insufficient to give permanent 

resolution of sensitivity symptoms (Table 5). 

Tooth Mousse Plus 

CPP is able to stabilize amorphous calcium fluoride 

phosphate (CPP-ACFP), which allows additive effects 

on remineralization compared with the fluoride or 

Table 4. Clinical trials showing reversal of WSL by Tooth Mousse 

CPP-ACP alone (Cochrane et al. 2006; Sakaguchi 

et al. 2006). Moreover, CPP-ACP promotes the 

incorporation of fluoride into plaque and sub-surface 

enamel, producing effects superior to those which 

can be achieved using fluoride alone (Reynolds 

et al. 2006) (Table 5). Early studies showed that 

addition of 900 ppm fluoride to TM increased the 

acid resistance of the product formed when enamel 

lesions were remineralized, compared with using 

TM alone (Kariya et al. 2004). This level of fluoride 

was designed to provide the correct ionic ratio of 

components for remineralization. The inclusion of 

fluoride in TM to create TMP has been shown to 

enhance the resistance of enamel surfaces to in vitro 

caries formation, compared with TM or fluoride alone 

(Hicks 2006). A range of studies support the greater 

potential of TMP as a treatment agent over and above 

TM (Table 6). 

Direct comparisons of TMP with TM show the 

superior remineralizing capabilities of Tooth Mousse 

Plus, however, because of its fluoride content (900 


Reversal of white spot lesions 

Manton 2006 Melbourne RCT, in situ model, N=6, TM produced 551% more remin of 

over 10 days enamel WSL than the placebo crème. 

Sakaguchi 2006 Tokyo In situ study, N=5 subjects, TM gave greater remin than 950 ppm 

7 days fluoride toothpaste, and even greater 

remin occurred with TMP, indicating 

synergy of fluoride with CPP-ACP. 

Vlacic 2007 Brisbane RCT, N=16, over 12 months TM in patients with salivary dysfunction 

arrested cervical lesions, and improved 

the stimulated salivary flow rate and pH 

over time. 

Andresson 2007 Halmstad Cohort study, N=26, TM caused a reduction in post- 

over 12 months orthodontic WSL over time, and was 

better than F mouthwash combined 

with F toothpaste. 

Morgan 2008A Melbourne RCT, N=45 subjects, 12 weeks TM produced more regression of WSL 

remaining after orthodontics than the 

placebo control at 12 weeks. 

Kitasako 2009 Tokyo Cohort study, N=7 subjects, TM produced remineralization of WSL 

6 months over 6 months, and increased the surface 

pH of the lesions (using a micro sensor). 

Zhou 2009 Changchun Cohort study, N=10 subjects, TMP reduced visible enamel 

2 months demineralization and improved the 

appearance of long-standing post- 

orthodontic WSL. 

Reynolds 2010 Melbourne RCT, in situ model, N=6, TM and TMP (but not ClinPro) increased 

over 10 days salivary calcium and phosphate levels, 

and caused remin of enamel WSL. 

Yazicioglu 2010 Istanbul Cohort study, N=26, TMP caused remineralization of WSL on 

over 28 days both smooth and occlusal surfaces. 


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ppm), TMP is not suitable for use in children aged 

less than 7 years, because of concerns regarding 

ingestion of fluoride. 

CPP-ACP inclusion in chewing gums 

The inclusion of CPP-ACP in chewing gums (such as 

Recaldent ) is a well established caries preventive 

measure (Table 3). Early studies of this approach used 

in situ studies (Cai et al. 2003) and then progressed 

to randomized, double blind cross-over designs to 

compare CPP-ACP containing gums with several 

commercial sugar-free gums. Subjects in these 

studies chewed the various gums for a 20 minute 

period 4 times per day for 14 days. By using paired 

Table 5. Selected clinical studies of Tooth Mousse 

enamel half slabs, precise determinations of mineral 

levels could be made. These studies showed that CPP- 

ACP gum produced 75-107% more remineralization 

than sugar-free gums (Manton 2005). It is well known 

that xylitol-based gums reduces the caries increment, 

but have little or no effect on approximal caries 

(Antonio et al. 2009). In contrast, gums containing 

CPP-ACP are highly effective at remineralizing 

WSL, and have been shown to arrest and reverse 

approximal lesions in a large scale clinical trial 

(Morgan et al. 2008 A & B). 

Recaldent gum is ideally suited to both child and 

adult patients where a lifestyle activity is linked to 

sub-clinical dehydration, and the patient suffers the 


Cervical dentinal hypersenitivity 

Poitevin 2004 Leuvin Cohort study, N=61 subjects, TM reduced sensitivity air and tactile 

over 21 days stimuli. 

Kowalczyk 2006 Poland Cohort study, N=13 subjects, A single application of TM gave 

over 4 weeks immediate benefit on response to air 

stimulation. There was no further 

treatment so relapse occurred. 

Walsh 2006 Brisbane RCT, N=36 subjects, TM reduced sensitivity to air, osmotic, 

over 56 days, versus thermal and tactile stimuli, with equal 

potassium nitrate toothpaste effectiveness to potassium nitrate 

toothpaste. 

Vlacic 2007 Brisbane RCT, N=12, over 12 months TM caused a progressive reduction in 

sensitivity to air stimulation, and also 

improved stimulated salivary flow and pH. 

Duan 2009 Wuhan RCT, N=30 subjects, 14 days TM reduced sensitivity with equal 

effectiveness to potassium nitrate gel. 

Other applications 

Aytepe 2008 Istanbul Cohort study, N=15 children, TM elevated saliva buffering capacity 

56 days and plaque pH over 8 weeks in children 

with cerebral palsy. 

Caruana 2009 London RCT, N=15 subjects TM applied immediately before a sucrose 

challenge reduced plaque acid 

production. 

Rahiotis 2009 Athens Cohort study, N=6 subjects, A single application of TM forms a 

8 hours. surface coating which attaches to metal 

surfaces, making these smoother. These 

surface films retain calcium phosphates. 

Amornpipithkul 2009 Bangkok Cohort study, N=21 children, Daily application of TM increased plaque 

14 days calcium and inorganic phosphate levels 

in a time-dependent manner. 

Baroni 2010 Bologna Cohort study, n=30 children, TM improved the morphology and 

3 years microstructure of the enamel in teeth 

affected by molar incisor hypoplasia. 

Plonka 2010 Brisbane RCT, N=345 infants, 2 years TM suppressed the emergence of S. 

mutans in the oral microflora, and 

lowered dental plaque acid production. 


21

problems from depressed salivary pH and flow under 

resting conditions. Because gum can be incorporated 

into a range of outdoor and exerting activities, the 

introduction of Recaldent gum should be considered 

for patients who undertake strenuous activity, for 

example, through outdoor exercise, outdoor work, or 

Table 6. Studies of CPP-ACP with fluoride (Tooth Mousse Plus) 

gym training sessions. The timing is important since 

the stimulation of salivary flow achieved by the gum 

will occur at a time when otherwise resting flow and 

pH would be depressed. Recaldent gum provides an 

excellent preventive effect, and is easily incorporated 

into a busy modern lifestyle. 


Kariya 2004 Tokyo In vitro, enamel slabs with TMP reduced enamel mineral loss 

demin gel compared with TM. Acid resistance of 

remineralized lesions was greater for 

TMP compared with TM. 

Hicks 2006 Houston In vitro, enamel slabs with TMP enhanced the resistance of enamel 

demin gel surfaces to in vitro caries formation 

compared with TM or fluoride alone. 

Itthagarun 2006 Gold Coast In vitro, enamel slabs with TM remineralized initial enamel lesions, 

demin gel and gave more remineralization when 

applied as a topical coating after the use 

of fluoride toothpaste. 

Sudjalimi 2006 Melbourne In vitro, extracted teeth in TMP was better at reduced mineral loss 

demin gel (QLF) around orthodontic brackets than TM 

or fluoride alone. 

Reynolds 2006 Melbourne RCT, in situ model, N=10, Toothpaste containing 2% CPP-ACP 

over 14 days plus 1100 ppm F was superior to paste 

with CPP-ACP alone and to 2800 ppm F 

toothpaste. Remineralized lesions were 

relatively acid resistant. 

Reynolds 2006 Melbourne RCT, N=10, over 14 days Mouthrinses containing 2% CPP-ACP 

plus 450 ppm F increased the 

incorporation of fluoride ions into plaque 

to achieve over double that obtained 

with 450 ppm F rinse alone. 

Sakaguchi 2006 Tokyo In situ study, N=5 subjects, TMP gave greater remin than either TM 

7 days or 950 ppm fluoride toothpaste. 

Kim 2007 Sth Korea In vitro, enamel slabs with TMP was more effective than TM alone 

WSL (microhardness) or 3000 ppm F solution in preventing 

demin. 

Turssi 2008 San Paulo In vitro, enamel slabs with Treatment of eroded enamel with TMP 

erosion lesions (microhardness) reduced progression of erosion 

compared with the untreated control. 

Cochrane 2008 Melbourne In vitro, enamel slabs with WSL CPP-ACP and CPP-ACFP solutions 

promoted high levels of remineralization 

throughout the body of enamel WSL. 

Hamba 2010 Tokyo In vitro, enamel slabs with TMP prevented demineralization more 

demin gel (micro CT) effectively than TM without F, and F alone. 

Hicks 2010 Houston In vitro, enamel slabs with TMP reduced lesion depths as effectively 

demin gel (PLM) as a 5000 ppm F toothpaste despite 

having a fluoride content of only 900 

ppm F. 

Cochrane 2010 Melbourne In vitro, enamel slabs with TMP produced high percentages of 

WSL and orthodontic brackets remineralization of WSL, which reduced 

the extent of enamel damage caused by 

bracket removal subsequently. 

RCT = randomized controlled clinical trial. 


www.gceurope.com

Extending the range of clinical applications 

The addition of CPP-ACP to existing foods has 

been shown to enhance their dental health 

benefits. Addition of CPP-ACP to cheese and milk 

at concentrations from 0.2-0.5% has been shown 

in laboratory studies to reduce mineral loss in 

enamel cased by acid exposure, and to enhance 

remineralization (Minami et al. 2004; Walker et al. 

2009). 

Likewise, TM has been shown to increase the 

hardness of enamel which has been eroded by 

repeated contact with acidic drinks such as colas, 

improving mineral uptake beyond that possible 

with saliva alone (Sukasaem et al. 2006; Huang & 

Tantbironj 2008). Topical application of TM reduces 

the extent of softening and mineral loss caused by 

subsequent exposure to erosive beverages (Kallayathi 

et al. 2008). 

CPP-ACP has potential as an additive to acidic 

drinks to prevent dental erosion. A key factor in such 

an approach is to estimate the lowest concentration 

of CPP-ACP which can be added to erosive drinks to 

eliminate the risk of erosion to enamel. Past research 

work on this topic has explored this issue using 

Powerade, to which was added varying amounts 

of CPP-ACP from 0.063% up to 0.25%. Analysis of 

the surface characteristics of enamel slabs in the 

laboratory setting using stereomicroscopy, scanning 

electron microscopy and surface profilometry 

demonstrated that adding CPP-ACP at 0.25% raised 

the pH from 2.70 to 3.90, and lowered the titratable 

acidity from 1.83 to 1.36). Enamel loss from etching 

reduced from 3.87µm to 0.19µm, which was identical 

to enamel samples kept in distilled water (0.25µm). 

A reduction in the erosive step defect occurred at 

concentrations down to 0.09%. Overall, the erosive 

potential of Powerade was attenuated or eliminated 

completely by the addition of low concentrations of 

CPP-ACP (Ramalingham et al. 2002 & 2005). 

There is also interest in including CPP-ACP in dental 

materials, such as glass ionomer cements (Mazzaoui 

et al. 2003) and zinc oxide non-eugenol temporary 

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About the author: 

Professor LAURENCE WALSH BDSc 

PhD DDSc GCEd FFOP(RCPA) FICD 

FPFA Laurence Walsh is Professor 

of Dental Science and Head of 

the School of Dentistry at the 

University of Queensland. He is a 

dental specialist in special needs 

dentistry and maintains a part time clinical practice 

in that field. Laurence is actively involved in the 

dental profession at a range of levels both nationally 

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H. SUKASAEM, M. PANICH, and S. 

POOLTHONG. Effect of CPP-ACP on Hardness 

of Enamel Eroded by Cola-drink. J Dent Res 

85(Spec Iss B):1673, 2006. 

T. TAKAMIZAWA, K. YAMAGUCHI, M. 

MIYAZAKI, K. HINOURA, and B.K. MOORE. 

Effect of CPP-ACP Paste on Demineralization of 

Bovine Tooth. J Dent Res 84(Spec Iss A): 1916, 

2005. 

U. THEERAPIBOON, R. PUANAIYAKA, and C. 

MANEENUT. Remineralization of Artificial Caries 

by CPP-ACP Paste. J Dent Res 87(Spec Iss 

B):3274, 2008. 

C.P. TRAJTENBERG, C. FLAITZ, and J. HICKS. 

CPP-ACP Paste with Fluoride: In Vitro Root 

Surface Caries Formation. J Dent Res 86(Spec 

Iss A):0500, 2007. 

C.P. TURSSI, F.A. MAEDA, D.C.F. MESSIAS, 

F.C. REHDER NETO, D. GALAFASSI, and M.C. 

SERRA. 2499 Progression of erosion following 

use of calcium and phosphorus compounds. J 


J. VLACIC. In vivo and in vitro investigations 

of laser and non-laser therapies in treatment 

of root surface erosion and root surface caries. 

PhD thesis, University of Queensland, Brisbane, 

2007. 

J. VLACIC, I.A. MEYERS and L.J.WALSH. 

Combined CPP-ACP and photoactivated 

disinfection (PAD) therapy in arresting root 

surface caries: a case report. Brit Dent J 

203(8):457-459, 2007. 

G.D. WALKER, F. CAI, P. SHEN, D.L. BAILEY, 

Y, YUAN, N.J. COCHRANE, C. REYNOLDS 

and E.C. REYNOLDS. Consumption of milk 

with added casein phosphopeptide-amorphous 

calcium phosphate remineralizes enamel 

subsurface lesions in situ. Aust Dent J 54(3):245- 

249, 2009. 

L.J. WALSH. Tooth Mousse Portfolio. GC Asia 

Dental Pte Ltd, Singapore, 2003. 

L.J. WALSH. Tooth Mousse Portfolio 2. GC Asia 

Dental Pte Ltd, Singapore, 2004. 

L.J. WALSH. Tooth Mousse: Anthology of 

Applications, GC Asia Dental Pte Ltd, Singapore, 

2007. 

L.J. WALSH. The effects of GC Tooth Mousse on 

cervical dentinal sensitivity: a controlled clinical 

trial. Internat Dent (Australas Edn) 5(1):16-23, 

2010. 

L.J. WALSH, W.S. WANG, A. CAKAR, C. 

DEVANI, K.K. TRAN, and A. HALL. Effect of 

CPP-ACP versus Potassium Nitrate on Cervical 

Dentinal Hypersensitivity. J Dent Res 85(Spec 

Iss B):0947, 2006. 

R. WONG, J. PALAMARA, and P.R. WILSON. 

Incorporation of Casein Phosphopeptide- 

Amorphous Calcium Phosphate into a Temporary 

Cement. J Dent Res 85(Spec Iss B):0653, 2006. 

R.H. WONG, A.W. WONG, D. SIVAPALAN, 

M.H. NGUYEN, A.M. HO, A.S. WANG, and S.E. 

LAU. Penetration of Bleaching Agents in Tooth 

MousseTM Treated Bovine Incisors. J Dent Res 

89(Spec Iss B):4019, 2010. 

K. YAMAGUCHI, M. MIYAZAKI, T. 

TAKAMIZAWA, H INAGE and B.K. MOORE. 

Effect of CPP-ACP paste on mechanical 

properties of bovine enamel as determined by an 

ultrasonic device. J Dent 34(3):230-236, 2006. 

E. YASUDA, T. SATO, S. KATO, L. CHEN, and 

E. YOSHII. Comparative Study on CPP-ACP and 

TCP Based Products. J Dent Res 89(Spec Iss 

A):317, 2010. 

O. YAZICIOGLU, B. YAMAN, A. GULER, R. 

ASIYEV, and F. KORAY. Quantitative Evaluation 

of the Effect CPP-ACP on Enamel Caries. J Dent 

Res 89(Spec Iss B):3232, 2010. 

V. YENGOPAL and S. MICKENAUTSCH. 


Phosphate (CPP-ACP) – a Systematic Review. J 

Dent Res 85(Spec Iss C): 010, 2006. 

V. YENGOPAL and S. MICKENAUTSCH. Caries 

preventive effect of casein phosphopeptideamorphous 

calcium phosphate (CPP-ACP): a 

meta-analysis. Acta Odontol Scand 21:1-12, 

2009. 

Q. XIE, C.D. WU, and A.K.B. BEDRAN-RUSSO. 

Remineralization Effects of CPP-ACP and 

Proanthocyanidin on Artificial Root Caries. J 

Dent Res 86(Spec Iss A):0512, 2007. 

C.H. ZHOU, X.H. SUN, X.C. ZHU. 

Quantification of remineralized effect of casein 

phosphopeptiode-amorphous calcium phosphate 

on post-orthodontic white spot lesion. Shanghai 

Kou Qiang Yi Xue 18(5): 449-454, 2009. 


25

A closer look at remineralisation and CPP-ACP 

As a publication, MID believes in the importance of informing dentists about the 

evidence available on MI topics so they can make scientifically sound choices in the 

treatment of their patients. In the research-clinical application jigsaw puzzle, it is 

essential to make all the pieces fit in order to see the whole picture. 

This process is outlined in the flow diagram below 

Systematic review -> academic explanation -> clinical application 

Systematic Review 

Title: Caries preventive effect of casein phosphopeptideamorphous 

calcium phosphate (CPP-ACP): a meta-analysis 

Objective. This systematic review with meta-analyses 

sought to answer the following question: ‘‘Does CPP-ACP 

[casein phosphopeptide-amorphous calcium phosphate], 

when introduced into the oral environment, provide any 

caries-preventive benefit superior to that of any other 

intervention or placebo?’’ 

Material and methods. Seven electronic databases were 

searched for trials relevant to the review question. Twelve 

articles were accepted after application of inclusion and 

exclusion criteria. 

Results. Of the accepted articles, five in situ 

randomized control trials (RCT) could be pooled for metaanalyses. 

During the short-term (7_21 days) in situ trials, 

participants wore appliances containing enamel slabs that 

were analyzed in the laboratory after exposure to CPP- 

ACP. The pooled in situ results showed a weighted mean 

difference (WMD) of the percentage remineralization 

scores in favor of chewing gum with 18.8 mg CPP-ACP as 

compared to chewing gum without CPP-ACP (WMD _8.01; 

95% CI: _10.54 to _5.48; p_0.00001), as well as compared 

to no intervention (WMD_13.56; 95% CI: _16.49 to _10.62; 

p_0.00001). A significant higher remineralization effect 

was also observed after exposure to 10.0 mg CPP-ACP 

(_7.75; 95% CI: _9.84 to _5.66; p_0.00001). One long-term 

in vivo RCT (24 months) with a large sample size (n_2720) 

found that the odds of a tooth surface’s progressing to 

caries was 18% less in subjects who chewed sugar-free 

gum containing 54 mg CPP-ACP than in control subjects 

who chewed gum without CPP-ACP (p_ 0.03). 

Conclusion. Within the limitations of this systematic 

review with meta-analysis, the results of the clinical in 

situ trials indicate a short-term remineralization effect of 

CPP-ACP. Additionally, the promising in vivo RCT results 

suggest a caries preventing effect for long-term clinical 

CPP-ACP use. Further randomized control trials are 

needed in order to confirm these initial results in vivo. 

Article details : 

Yengopal V, Mickenautsch S. Caries preventive effect of 

casein phosphopeptide-amorphous calcium phosphate 

(CPP-ACP): a meta-analysis. Acta Odontol Scand 2009; 67: 

321-32. 

The academic explanation 

Dr Steffen Mickenautsch, 

academic researcher in 

Johannesburg, South Africa 

MID: Of all the studies available 

on this subject, why were you 

only able to use 5 for your meta 

analysis? 

Steffen Mickenautsch: Firstly, we 

had to exclude other studies because they were either: 

conducted in the laboratory and not in the clinic; done on 

animal and not on human tissue or did not compare CPP- 

ACP against anything else. 

The problem with studies from the laboratory is that 

one really cannot be sure that the results would be the 

same in the ‘real’ world. The same is valid when studying 

the effect of treatments on animal tissue. The results of 

either are important to justify whether studies should be 

conducted on patients or not, because it is not ethical 

to study new treatments on humans if laboratory and/ 

or animal studies show that these are not successful. 

Therefore, laboratory and/or animal studies are important 

first steps for testing new drugs or treatments before they 

can be allowed to be tested on humans. However, in our 

systematic review we wanted to know whether CPP- 

ACP is beneficial for clinical use on patients and neither, 

laboratory nor animal studies, can answer this question. 

That is why we had to exclude them. 

Clinical studies that fail to compare a new type of 

treatment against another, (preferably the type of standard 

treatment commonly used to date) are unable to answer 

the question whether the new treatment is better, the same 

or worse. But this was exactly what we were trying to find 

out, thus we could not include these types of studies either. 

After all these considerations we had 11 studies 

available to work with. From these, 5 were similar enough 

to be combined in a meta-analysis. A meta-analysis is a 

statistical method by which the separate results of several 

studies are combined to one average result. However, in 

order to be able to do this the studies need to be similar, 

e.g. in their methods and outcomes, before they can be 

combined. Otherwise the meta-analysis would produce 

meaningless results. 

26 evidence 

mi.gceurope.com

We reviewed the other 6 studies separately in our 

systematic review without including them in the metaanalysis. 

MID: What criteria did the 5 that you selected meet and 

why is this important? 

Steffen Mickenautsch: These 5 studies compared CPP- 

ACP against other types of treatments. They provided 

information on how well each, the CPP-ACP and the other 

treatment worked on patients and then compared both 

results to find out which one was better. This was exactly 

what we needed to know. In addition, they all fulfilled the 

requirements for meta-analysis; they all used CPP-ACP in 

dental chewing gum; they included the same CPP-ACP 

concentration; study length and used the same type of 

other treatment for comparison. 

MID: Please explain your introduction: “The advantages 

of meta-analysis over qualitative synthesis is that it 

provides the opportunity to identify a treatment effect as 

statistically significant (p

MID: In your conclusion it states that this meta 

analysis shows that CPP-ACP does have a short term 

remineralising effect – what should a practising dentist 

who reads this understand about this statement? 

Steffen Mickenautsch: If a patient is identified to have a 

high caries activity or a high risk to develop cavities in the 

near future, the established short-term effect promises 

that CPP-ACP is able to stop the further progression of 

(non-cavitated) carious lesions and is able to prevent the 

development of such. Therefore, CPP-ACP may be used 

as one immediate intervention in the treatment of such 

patients. 

MID: You also looked at one study that examined the 

long-term effect of CPP-ACP – what were the important 

elements of this particular study? 

Steffen Mickenautsch: In that study, patients were given 

CPP-ACP containing chewing gum over the period of 2 

years and were compared to similar patients that chewed 

sugar-free chewing gum without CPP-ACP. The result 

showed that patients using the CPP-ACP containing gum 

had 18% lesser likelihood of caries progression. This result 

was statistically significant, thus very unlikely to be a 

coincident. All patients had active caries and the CPP-ACP 

gum showed to be more effective to stop further progress 

of the existing carious lesions. In that regard one has to 

remember that sugar-free chewing gum is considered 

to be effective against caries too. That means, that the 

group of patients without the CPP-ACP would have also 

experienced an anticaries effect. Only, this effect was 

observed to be larger in the CPP-ACP group. 

MID: Is this systematic review conclusive or is more 

research needed? 

Steffen Mickenautsch: From an academic point of view, 

the current knowledge about CPP-ACP allows us to be 

optimistic about the claim that CPP-ACP is effective 

against caries. The currently available studies provide 

evidence that this claim is not only plausible but also 

tends to prove it to be correct rather than disproving it. To 

have more high quality research will be of advantage to 

validate and strengthen this claim even further. 

“In my practice the compliance rate and repurchase 

of the Tooth Mousse / Mi paste has 

been very high, and this indicates to me that 

the patients are happy with the results, and 

find value in the products.” 

Andrew Brostek 

The clinical application 

Dr Andrew Brostek, private 

dentist in Perth, Australia 

MID: For how many years have you 

been using Tooth Mousse/MI Paste 

in your practice? 

Andrew Brostek: I began soon 

after it was first made available in 

Australia, but have used it more 

intensively in the last three years. 

MID: What factors made you decide to start using it in 

your practice and recommend it to your patients in the 

first place? 

Andrew Brostek: After being exposed to the information 

about CPP-ACP presented at several Continuing Education 

courses, and then reading some of the early studies 

published by Professor Eric Reynolds and his University 

of Melbourne research group, I realised that using 

the products containing CPP-ACP (GC Tooth Mousse 

/ Mi Paste, Tooth Mousse Plus (CPP-ACFP) and the GC 

Recaldent chewing gum) had great potential to benefit 

my patients. 

MID: After reading the abstract of the meta-analysis 

on the remineralising effect of CPP-ACP, how will this 

affect the way in which you use and prescribe Tooth 

Mousse/MI Paste in your practice, if at all? 

Andrew Brostek: The publication of this meta-analysis 

review reinforces my own belief in the effectiveness of 

CPP-ACP, based on my own clinical experiences with 

compliant patients. Evidence based dentistry is essential 

to guide clinicians in improving treatment protocols, and 

I await further data from in vivo trials to confirm these 

results. In terms of prescribing, I use the fluoride versions 

CPP-ACFP i.e. Tooth Mousse Plus/ Mi Paste Plus for high 

risk patients over the age of 7 years, as study results show 

an increased lesion preventive effect with the fluoride 

combination. I usually prescribe nightly application of a 

pea-sized amount of the Tooth Mousse Plus / Mi paste 

Plus (immediately before bed), but in very high caries 

rate patients, I prescribe both a morning and nightly 

application, with concomitant use of Recaldent gum 

at least twice per day (10 minutes per application). As 

evidenced by studies, chewing the CPP-ACP gum, three 

times per day was very effective in caries-rate reduction. 

MID: Do you find this meta-analysis easy to interpret, 

in terms of applying this to your daily practice? 

Andrew Brostek: My understanding of the value of metaanalysis 

is to provide a more objective assessment of the 

available statistically significant literature. So yes, it does 

have value to me in suggesting improved protocols. Again 

28 evidence 

mi.gceurope.com

Patient with extensive white spot lesions After two months, showing partial remineralisation after 

twice daily application of CPP-ACP 

speaking as a full-time clinician, I am very interested in any 

improvement in caries-preventive benefit and particularly 

in achieving enamel remineralisation. 

My daily practice protocols vary depending on the 

patient lesion presentation. For poor compliance patients 

with rampant caries, I mainly rely on prescribing twicedaily 

brushing with a high-dose fluoride (5000 ppm) 

toothpaste, and clinician-applied fluoride varnish at recall. 

The prevention of demineralisation by the use of high 

concentrations of fluoride is of critical importance in our 

anti-caries chemical armentarium. 

But for compliant high-risk patients with multiple early 

lesions (white-spot lesions) I use a slightly different protocol 

emphasising the use of CPP-ACP. To achieve increased 

remineralisation of these white spot lesions, especially 

in younger people with unaesthetic anterior lesions, I 

prescribe daily CPP-ACP (or CPP-ACFP) Tooth Mousse / Mi 

Paste application, in combination with twice-daily tooth 

brushing with a lower fluoride concentration (1000 ppm) 

toothpaste. This allows greater sub-surface remineralisation 

of non-cavitated lesions, evidenced over time by the 

reversal of the white-spot appearance. Unfortunately 

utilising a higher 5000 ppm fluoride toothpaste will seal 

off the unaesthetic surface scar rapidly, not allowing the 

deeper subsurface remineralisation to occur. Of course, 

regular effective plaque removal, diet and lifestyle 

modification, normal saliva quality and quantity, are all 

important factors in modifying the disease risk and aiding 

in tooth remineralisation. 

MID: As a busy clinician, how do you keep yourself 

updated on developments in clinical evidence in 

dentistry, particularly in MID? 

Andrew Brostek: That’s a tough question, as most 

of us are fairly busy in our own dental practices. The 

role of Continuing Education courses is important and 

attendance is compulsory in Australia. Belonging to 

various professional dental bodies helps, as it entitles you 

to some dental journal subscriptions, and staying current 

is important. I think that allows most of us to entertain our 

own specific dental interests. 

MID: Some dental academics say that clinicians and the 

practice-based evidence they record is very important 

in filling the gaps left by academic research studies. 

Have you captured and recorded any interesting data 

on remineralisation with Tooth Mousse/MI Paste since 

you’ve started using it? If so, what are some of the 

most interesting trends that you’ve noticed? 

Andrew Brostek: I find recording practice-based 

evidence hard to do in a typical busy day. Many of you 

may identify with my daily problems, where some patients 

come late to appointments, or extra ‘pain’ patients are 

over-booked into an already busy schedule. My main 

contribution is to have my dental camera handy to 

document any interesting dental issues quickly. 

My belief in CPP-ACP has been reinforced by observing 

non-cavitated white-spot lesions becoming remineralised 

over periods of between six weeks and 3 months with 

regular daily use of the Tooth Mousse / Mi paste by 

the patient. Progress is easy to observe, as the lesions 

change from the surface white scar to a relatively normal 

tooth appearance. The clinical protocol I use to achieve 

this is quite simple: The enamel lesion is etched with 

phosphoric acid for 10 seconds and then Tooth Mousse / 

Mi Paste is immediately applied. The patient then applies 

the Tooth Mousse nightly until lesion reversal occurs. In 

difficult cases, I might re-etch at one-month recall, or 

even additionally at the two-month recall, to aid CPP-ACP 

penetration by removing surface protein from the enamel. 

In my practice the compliance rate and re-purchase 

of the Tooth Mousse / Mi paste has been very high, and 

this indicates to me that the patients are happy with 

the results, and find value in the products. Many of the 

mothers are also using the CPP-ACP products on their 

younger children’s teeth for caries prevention. 

In conjunction with our individual patient caries risk 

assessment protocols (diet /lifestyle analyses, and the use 

of saliva and plaque testing on select patients) and then 

specific treatment targeting (such as the use of CPP-ACP), 

my dental hygienists and I believe we are benefitting our 

patients, and practising modern 21st century dentistry. 

evidence 

29

MI toolkit 

1 

30 mi toolkit 

mi.gceurope.com 

2 

4

What’s inside the tube? 

Tooth Mousse, also known as MI Paste in 

some regions of the world, is considered the 

number one remineralizing paste that is 

backed by sound scientific evidence. 

For low to medium risk patients, MI Paste 

or Tooth Mousse is recommended. However, 

for patients with high risk, MI Paste 

Plus/Tooth Mousse Plus contains 

additional 900ppm Flouride and 

is therefore better suited to 

their oral health requirements. 

3 

Studies that prove the clinical superiority of GC Tooth 

Mousse/MI Paste are: 

z The only remineralizing cream with proven a scientific 

record with more then 200 scientific references 

and having sold material for more than 160 million 

applications worldwide since the original Australasian 

introduction in 2002 

Abstract 3645 - IADR 2010, Barcelona, Spain. Comparison of Tooth 

Mousse (MI Paste) with Clinpro in situ. E Reynolds, F Cai, P. Shen, G 

Walker, Y Yuan, N Cochrane, D Manton, C Reynolds. Oral Health CRC, 

Melbourne Dental School, University of Melbourne, Australia 

z Searching from 7 databases and about 3500 articles, it 

has been concluded that Tooth Mousse/MI Paste Plus 

does Remineralization and has Caries protection effect. 

V. YENGOPAL & S. MICKENAUTSCH. University of the Witwatersrand, 

South Africa. Acta Odontologica Scandinavica 2009 

Click on the numbers to learn more 

1. GC Tooth Mousse offers Three-in-One solution 

5 

2. Uses for Tooth Mousse/MI Paste 

mi toolkit 

3. Contraindications 

4. Application methods 

5. Packaging 

6. Additional instructions 

6 

31

The Science behind Remin 

The only Reminaralizing cream with proven a Scientific record with more then 200 

scientific references and having sold material for more than 160 million applications 

worldwide since the original Australasian introduction in 2002* 

Articles identified through 

keyword search in 

databases (n=3459) 

Articles included for more 

detailed review (n=35) 

Articles accepted (n=12) 

Randomized control trials 

(n=11) 


included in meta-analysis 

(n=5) 

Articles without relevance 

to review questions 

excluded (n=3424) 

Articles excluded due 

to non-compliance with 

exclusion criteria (n=3424) 

Systematic review (n=1) 


not included in metaanalysis 

(n=6) 

Searching from 7 databases and about 3500 articles, it has been concluded that Tooth Mousse/MI 

Paste Plus does Remineralization and has Caries protection effect.* 

*V. YENGOPAL & S. MICKENAUTSCH. University of the Witwatersrand, South Africa. Acta Odontologica Scandinavica 2009 

32 mi toolkit 

mi.gceurope.com

PLACEBO 

RECALDENT HIGH FLOURIDE PRODUCTS 

PLACEBO PASTE 

1000PPM F PASTE 

CLINPRO 

5000PPM F PASTE 

TOOTH MOUSSE 

MI PASTE PLUS 

Notice no change in the demineralised White 

Spot Lesion after the use of a Placebo Paste 

Notice the hard hypermineralised layer 

formed due to the very high fluoride ppm, 

this acts like a hard shell preventing the 

Remineralization of the underlying White 

Spot Lesion lesion. 

Concluding that Ca and PO4 are the most 

crucial elements for Remineralization and 

Fluoride only acts as a catalyst. 

Notice no Hard impervious layer as compared 

to High Fluoride containing products. 

Tooth Mousse and MI Paste Plus show a 

uniform Remineralization of the Enamel and 

Dentine structures. However, MI Paste Plus 

shows higher Remineralization due to the fact 

that Fluoride acts as a catalyst to encourage 

Calcium and Phosphate to enter inside the 

Tooth structure 

*Abstract 3645 - IADR 2010, Barcelona, Spain. Comparison of Tooth Mousse (MI Paste) with Clinpro in situ. E Reynolds, F Cai, P. Shen, G Walker, 

Y Yuan, N Cochrane, D Manton, C Reynolds. Oral Health CRC, Melbourne Dental School, University of Melbourne, Australia 

mi toolkit 

33


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Issue 3

Remineralization with CPP-ACP: - GC Europe

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