Two-Year Caries Clinical Study of the Efficacy of Novel Dentifrices Containing 1.5% Arginine, an Insoluble Calcium Compound and 1,450 ppm Fluoride

Abstract

A 2-year double-blind randomized three-treatment controlled parallel-group clinical study compared the anti-caries efficacy of two dentifrices containing 1.5% arginine, an insoluble calcium compound (di-calcium phosphate or calcium carbonate) and 1,450 ppm fluoride (F), as sodium monofluorophosphate, to a control dentifrice containing 1,450 ppm F, as sodium fluoride, in a silica base. The 6,000 participants were from Bangkok, Thailand and aged 6-12 years initially. They were instructed to brush twice daily, in the morning and evening, with their randomly assigned dentifrice. Three trained and calibrated dentists examined the children at baseline and after 1 and 2 years using the National Institute of Dental Research Diagnostic Procedures and Criteria. The number of decayed, missing and filled teeth (DMFT) and surfaces (DMFS) for the three study groups were very similar at baseline, with no statistically significant differences among groups. After 1 year, there were no statistically significant differences in caries increments among the three groups. After 2 years, the two groups using the dentifrices containing 1.5% arginine, an insoluble calcium compound and 1,450 ppm F had statistically significantly (p < 0.02) lower DMFT increments (21.0 and 17.7% reductions, respectively) and DMFS increments (16.5 and 16.5%) compared to the control dentifrice. The differences between the two groups using the new dentifrices were not statistically significant. The results of this pivotal clinical study support the conclusion that dentifrices containing 1.5% arginine, an insoluble calcium compound and 1,450 ppm F provide significantly greater protection against caries lesion cavitation, in a low to moderate caries risk population, than dentifrices containing 1,450 ppm F alone.

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Original Paper
Caries Res 2013;47:582–590
DOI: 10.1159/000353183
Two-Year Caries Clinical Study of the Efficacy of
Novel Dentifrices Containing 1.5% Arginine,
anInsoluble Calcium Compound and 1,450 ppm
Fluoride
P.Kraivaphan  a C.Amornchat  a T.Triratana  a L.R.Mateo  b R.Ellwood  c
D.Cummins  c W.DeVizio  c Y.-P.Zhang  c
a  Faculty of Dentistry, Mahidol University, Bangkok , Thailand;
b  LRM Statistical Consulting, Hoboken, N.J. , and
c  Colgate-Palmolive Technology Center, Piscataway, N.J. , USA
and 1,450 ppm F had statistically significantly (p < 0.02) low-
er DMFT increments (21.0 and 17.7% reductions, respective-
ly) and DMFS increments (16.5 and 16.5%) compared to the
control dentifrice. The differences between the two groups
using the new dentifrices were not statistically significant.
The results of this pivotal clinical study support the conclu-
sion that dentifrices containing 1.5% arginine, an insoluble
calcium compound and 1,450 ppm F provide significantly
greater protection against caries lesion cavitation, in a low to
moderate caries risk population, than dentifrices containing
1,450 ppm F alone. Copyright © 2013 S. Karger AG, Basel
The introduction of fluoride (F) as a caries-preventive
agent is one of the great public health success stories. Flu-
oride toothpastes, in particular, are believed by experts to
have contributed significantly to the dramatic decline in
dental caries observed around the world [Bratthall et al.,
1996]. However, a recent survey conducted in the United
States has confirmed a previous finding that dental caries
is still the most common chronic disease in children
Key Words
Arginine · Caries · Fluoride · Prevention · Treatment
Abstract
A 2-year double-blind randomized three-treatment con-
trolled parallel-group clinical study compared the anti-caries
efficacy of two dentifrices containing 1.5% arginine, an in-
soluble calcium compound (di-calcium phosphate or calci-
um carbonate) and 1,450 ppm fluoride (F), as sodium mono-
fluorophosphate, to a control dentifrice containing 1,450
ppm F, as sodium fluoride, in a silica base. The 6,000 partici-
pants were from Bangkok, Thailand and aged 6–12 years ini-
tially. They were instructed to brush twice daily, in the morn-
ing and evening, with their randomly assigned dentifrice.
Three trained and calibrated dentists examined the children
at baseline and after 1 and 2 years using the National Insti-
tute of Dental Research Diagnostic Procedures and Criteria.
The number of decayed, missing and filled teeth (DMFT) and
surfaces (DMFS) for the three study groups were very similar
at baseline, with no statistically significant differences
among groups. After 1 year, there were no statistically sig-
nificant differences in caries increments among the three
groups. After 2 years, the two groups using the dentifrices
containing 1.5% arginine, an insoluble calcium compound
Received: March 8, 2013
Accepted after revision: May 22, 2013
Published online: August 28, 2013
Yun-Po Zhang
Colgate-Palmolive Technology Center
909 River Road
Piscataway, NJ 08855-1343 (USA)
E-Mail yun_po_zhang  @  colpal.com
© 2013 S. Karger AG, Basel
0008–6568/13/0476–0582$38.00/0
www.karger.com/cre
Clinical trial registration No. TCTR20130801001.
 is is an Open Access article licensed under the terms of the
Creative Commons Attribution-NonCommercial 3.0 Un-
ported license (CC BY-NC) (www.karger.com/OA-license),
applicable to the online version of the article only. Distribu-
tion permitted for non-commercial purposes only.

Two-Year Caries Clinical Study Caries Res 2013;47:582–590
DOI: 10.1159/000353183
583
[United States Department of Health and Human Ser-
vices, 2000, 2010], and several epidemiological studies
conducted over the past decade indicate that dental caries
remains a significant challenge. Bagramian et al. [2009]
found increases in caries for children and adults, quoting
numerous studies to support this view. The data point to
gross disparities in prevalence and treatment of dental
caries globally. A recent review [Cummins, 2013] identi-
fied diverse and changing global patterns of caries devel-
opment, driven by the opposing forces of increased sugar
consumption and effective oral hygiene and the use of
fluoride, as well as divergent trends in caries experience,
driven by deeper-rooted social and environmental fac-
tors. This increase in dental caries has signaled concerns
of a pending public health crisis and the need to invigo-
rate previously successful public health programs [Ba-
gramian et al., 2009]. Whilst such measures can undoubt-
edly be successful again, new strategies are needed to sup-
plement existing measures to reduce caries risk and
improve dental health globally [National Institute of
Health Consensus Development Panel, 2001; Pitts and
Stamm, 2004]. More effective oral hygiene products, es-
pecially dentifrices that deliver superior caries preven-
tion, have an important role to play in continued progress
with the caries problem [Whelton, 2004].
Fluoride targets the tooth surface to arrest and reverse
the caries process. However, fluoride has limitations un-
der pathogenic conditions, because it does not target den-
tal plaque as its primary mode of action. New strategies
to deliver superior caries prevention would ideally com-
plement the effects of fluoride while targeting plaque
pathogenicity. Despite sustained research in this area, few
conceptual approaches to reduce plaque pathogenicity
have progressed to clinically validated cost-effective
products [Cummins, 2013]. Recently, however, a new
dentifrice technology based upon 1.5% arginine and an
insoluble calcium compound to reduce plaque pathoge-
nicity and enhance re-mineralization, in combination
with fluoride, has been developed and clinically validated.
This clinical validation comprises a series of five studies
of 6 months duration which assessed the efficacy in ar-
resting and reversing (re-mineralizing) early, reversible
enamel lesions and root caries lesions. The studies dem-
onstrated that innovative dentifrices containing 1.5% ar-
ginine, an insoluble calcium compound and fluoride
[Cummins, 2013] provide superior caries benefits in chil-
dren and adults to dentifrices containing fluoride alone
[Hu et al., 2013; Souza et al., 2013; Srisilapanan et al.,
2013; Yin et al., 2013a, b]. Further, it includes in situ clin-
ical studies which showed that these dentifrices inhibit
de-mineralization and enhance re-mineralization more
effectively than dentifrices with fluoride alone [Cantore
et al., 2013]. In these clinical efficacy studies, two sources
of insoluble calcium compound, di-calcium phosphate
and calcium carbonate, were evaluated and shown to be
interchangeable without impact on efficacy.
The aim of this pivotal 2-year double-blind random-
ized three-treatment controlled parallel-group clinical
study was to investigate the efficacy of two dentifrices
containing 1.5% arginine, an insoluble calcium com-
pound and 1,450 ppm F in preventing caries lesion cav-
itation compared to a dentifrice with 1,450 ppm F alone.
The two sources of insoluble calcium compound, di-cal-
cium phosphate and calcium carbonate, which were
previously evaluated, were directly compared in this
study.
Subjects and Methods
This double-blind randomized three-treatment controlled par-
allel-group clinical study was conducted in Bangkok, Thailand,
where the fluoride level in tap water is <0.3 ppm [Metropolitan
Waterworks Authority, 2007]. Prior to initiation of the study, the
protocol and pertinent documents were reviewed and approved
bythe Mahidol University Institutional Review Board.
Schools were selected to take part in the study based on the
known caries risk of their students, levels of cooperation of the
staff, students and parents/guardians, and low population mobil-
ity determined during previous studies in the area and pilot inves-
tigations. Study participants volunteering to take part were school-
children aged 6–12 years, with recruitment focused on classes with
8- and 9-year-old children predominantly. Written informed con-
sent to take part was obtained from a parent or legal guardian. The
children were selected based on the following inclusion and exclu-
sion criteria.
Inclusion Criteria
(1) Children in elementary or middle school who had at least
four permanent molars fully erupted and at least one permanent
central and/or lateral incisor erupted. (2) Informed consent form
signed by parent or legal guardian to permit participation of their
child in the study.
Exclusion Criteria
(1) Presence of orthodontic appliances. (2) Any condition
which, in the opinion of the investigator, would hinder participa-
tion by the potential subject. The reason for any such exclusion was
to be carefully documented by the investigator. (3) Participation in
any other clinical study during the 3 months preceding the clinical
study. (4) History of allergies or other adverse reactions to argi-
nine, oral care products or their ingredients.
Qualified subjects were randomly assigned to one of the three
study treatments using a randomization table generated central-
ly by the study statistician. Two groups received one of the two
dentifrices each containing 1.5% arginine, an insoluble calcium

Kraivaphan/Amornchat/Triratana/Mateo/
Ellwood/Cummins/DeVizio/Zhang
Caries Res 2013;47:582–590
DOI: 10.1159/000353183
584
compound – either di-calcium phosphate (test dentifrice 1; Col-
gate-Palmolive, New York, N.Y., USA) or calcium carbonate
(test dentifrice 2; Colgate-Palmolive) – and 1,450 ppm F as so-
dium monofluorophosphate. The third group received a silica-
based dentifrice containing 1,450 ppm F as sodium fluoride (flu-
oride control dentifrice; Procter & Gamble, Cincinnati, Ohio,
USA).
Each subject was provided with three 150-ml tubes of their as-
signed dentifrice and a manual toothbrush (Colgate soft-bristled
adolescent-size toothbrush) every 2 months for their exclusive use
at home. The tubes of dentifrice were completely wrapped in white
tape so that neither the examiners nor the subjects were aware of
the identity of the product they were using. Participants were in-
structed to brush their teeth twice daily, in the morning and eve-
ning, at home. No instructions on rinsing behavior were provid-
ed and subjects brushed as per their established daily routine.
School nurses monitored the tooth brushing of subjects by inter-
view, collection of used toothpaste tubes and assessment of oral
hygiene. Classroom teachers also reinforced the importance of at
home brushing to the participants and parents/guardians to en-
sure that, within the constraints of a home use unsupervised set-
ting, subjects brushed their teeth twice daily. When the subjects
received new supplies of dentifrice and toothbrushes, the clinical
team checked and reviewed returned/used dentifrices to help en-
sure compliance.
The sample size per group was estimated, based on pilot data
and previous investigations conducted in the population, using
the following assumptions: (1) a 2-year study period, (2) three
treatment groups, (3) coefficient of variation = 1.1, (4) power =
0.8, (5) α = 0.05, two sided t test, (6) a 10% difference between
products, (7) 10% annual attrition of subjects. With these assump-
tions, the required minimum sample size to satisfy the American
Dental Association Council on Dental Therapeutics criterion for
superior efficacy (10% difference between test and control prod-
ucts) at the end of the 2-year period of product use was approxi-
mately 1,920 subjects per group.
Clinical examinations were performed in school classrooms,
using portable dental surgery equipment, at baseline and after 1
and 2 years of product use using the criteria and methods de-
scribed by the National Institute of Dental Research [1991].
Clinical Examination and Scoring Procedure for Coronal
Caries
Caries examinations were conducted by three trained and cal-
ibrated examiners in accordance with the established criteria
[United States Department of Health, Education and Welfare,
1978; National Institute of Dental Research, 1991] after cleaning
and drying the teeth. Each of the three examiners performed clin-
ical examinations for the same subjects (approximately 2,000) at
baseline and after 1 and 2 years of product use. The examinations
were conducted using a halogen light source with an attached den-
tal mouth mirror (Miltex Inc., York, Pa., USA) and a #23 single-
end dental explorer (Miltex Inc.). A visual-tactile assessment of
dental caries status was made using the explorer to confirm con-
tinuity of the enamel surface. The status of all tooth surfaces for
each permanent tooth was assessed, with the exception of third
molars. Subsequently decayed, missing and filled teeth (DMFT)
and surfaces (DMFS) scores were calculated for each participant
and then the mean DMFT and DMFS scores were calculated for
each dentifrice group.
Examiner Calibration
Training and calibration of the three caries examiners was con-
ducted by an experienced clinician (Dr. Augusto Elias Boneta,
University of Puerto Rico, Puerto Rico). The first part of the train-
ing and calibration was a discussion of diagnostic criteria, exami-
nation methods and procedures. In the second part, the examiners
were calibrated for inter- and intra-examiner reliability using a
representative sample of subjects. The inter- and intra-examiner
reliability was quantified using an unweighted kappa statistic. A
threshold of ≥ 0.75 was used to qualify the examiners.
Oral Soft and Hard Tissue Assessment
The three dental examiners visually examined the oral cavity
and peri-oral area of the subjects, whom they had evaluated for
caries, using the same dental light and dental mirror used for the
caries assessments. This examination included an evaluation of the
soft and hard palate, gingival mucosa, buccal mucosa, mucogingi-
val fold areas, tongue, sublingual and submandibular areas, sali-
vary glands, tonsillar and pharyngeal areas. In the event that the
clinical examiner identified oral conditions that required further
investigation or treatment, children were referred to their family
dentist or community dental service.
Adverse Events
Adverse events were obtained from interviews with each sub-
ject and from a dental examination by each examiner at each ap-
pointment.
Statistical Analysis
Statistical analyses were performed for both the DMFT and
DMFS scores for all subjects completing the study. Comparisons
of the treatment groups with respect to baseline scores were per-
formed using conventional analysis of variance (ANOVA). The
results were later confirmed using non-parametric tests (Kruskal-
Wallis). Comparisons between the treatment groups with respect
to gender were performed using χ
2 tests and for age using ANOVA.
Comparisons among treatment groups with respect to baseline-
adjusted incremental DMFT and incremental DMFS scores at the
1- and 2-year examinations were performed using analysis of co-
variance (ANCOVA). Post-ANCOVA pairwise comparisons of
the study treatments were performed using the Tukey test for mul-
tiple comparisons. Non-parametric tests were also run to confirm
the pairwise comparisons with probability corrections for multiple
comparisons [Gibbons, 1997]. All statistical tests of hypotheses
were two-sided and employed a level of significance of α = 0.05.
R e s u l t s
Nine elementary schools in Bangkok, Thailand with a
total of 9,082 subjects were first approached to take part;
8,989 consented and 6,090 met the inclusion criteria. Of
these, 6,000 were assigned to one of the three study
groups, whereas 90 who were unavailable for examina-
tion were excluded from the study ( fig.1 ).
Inter- and intra-examiner calibration was performed
for each of the three examination periods. The kappa sta-

Two-Year Caries Clinical Study Caries Res 2013;47:582–590
DOI: 10.1159/000353183
585
tistics for inter- and intra-examiner reproducibility of
DMFT and DMFS were all >0.83, indicating a high level
of agreement within and between the three examiners.
Throughout the study, no adverse effects on the oral
hard or soft tissues were observed or reported.
B a s e l i n e D a t a
The gender and age of the study subjects who complet-
ed the study are presented in figure 1 for the three study
groups. The three groups did not differ significantly with
respect to these characteristics. The percentages of chil-
dren aged 6, 7, 8, 9, 10, 11 and 12 years at baseline were 0.59,
10.01, 32.94, 38.60, 16.87, 0.89 and 0.10%, respectively.
Summaries of the baseline data for the DMFT and
DMFS scores are presented in table1 . The mean baseline
DMFT scores for test dentifrice 1, test dentifrice 2 and the
fluoride control dentifrice were 0.51 ± 0.97, 0.49 ± 0.94
and 0.49 ± 0.97, respectively. The mean baseline DMFS
scores were 0.73 ± 1.62 for test dentifrice 1, 0.67 ± 1.56 for
test dentifrice 2 and 0.71 ± 1.63 for the fluoride control
dentifrice. No statistically significant differences in either
DMFT or DMFS were indicated among the three groups
( table2 ).
One-Year Data Incremental DMFT and DMFS Scores
The mean incremental DMFT scores measured after
1year of product use are shown in table1 and were 0.25±
0.72, 0.26 ± 0.69 and 0.24 ± 0.63 for test dentifrice 1, test
dentifrice 2 and the fluoride control dentifrice, respec-
tively. After only 1 year of product use, no statistically
Baseline
12 months
2,000 (F: 991, M: 1,009)
Mean age: 8.6±0.93
1,855 (145 lost to follow-up)
2,000 (F: 995, M: 1,005)
Mean age: 8.6±0.93
1,861 (139 lost to follow-up)
2,000 (F: 1,006, M: 994)
Mean age: 8.6±0.94
1,837 (163 lost to follow-up)
Left school
Not available for exam
Participated in other study
24 months
115
21
9
1,679 (176 lost to follow-up)
113
15
11
1,693 (168 lost to follow-up)
123
27
13
1,684 (153 lost to follow-up)
Left school
Not available for exam
Participated in other study
Orthodontic appliances
132
20
19
5
130
17
16
5
123
16
9
5
Consent acquired from 8,989
6,000 subjects had baseline examinations and
were randomly assigned to products
1.5% arginine, 1,450 ppm F,
di-calcium phosphate
(test dentifrice 1)
1.5% arginine, 1,450 ppm F,
calcium carbonate
(test dentifrice 2)
1,450 ppm F,
silica
(fluoride control dentifrice)
Consent requested for 9,082 eligible subjects aged
6–12 years from 9 schools
93 did not consent
90 subjects unavailable at time of exam
2,899 subjects did not meet inclusion criteria
58 had orthodontic appliances
2,378 did not have four permanent molars erupted
463 did not have permanent incisor erupted
Fig. 1. Disposition of subjects in the 2-year clinical study.

Kraivaphan/Amornchat/Triratana/Mateo/
Ellwood/Cummins/DeVizio/Zhang
Caries Res 2013;47:582–590
DOI: 10.1159/000353183
586
significant differences were indicated among the three
dentifrice groups with respect to reduction in incremen-
tal DMFT scores.
The mean incremental DMFS scores measured after
1year of product use are shown in table1 and were 0.38±
1.13, 0.38 ± 1.09 and 0.37 ± 0.98 for test dentifrice 1, test
dentifrice 2 and the fluoride control dentifrice, respec-
tively. Likewise, no statistically significant differences
were indicated among the three dentifrice groups with
respect to reduction in incremental DMFS scores after
1year of product use ( table2 ).
Two-Year Data Incremental DMFT and DMFS Scores
The mean incremental DMFT scores measured after
2years of product use are presented in table1 . They were
0.49 ± 1.00, 0.51 ± 1.01 and 0.62 ± 1.03 for test dentifrice
1, test dentifrice 2 and the fluoride control dentifrice, re-
spectively. Relative to the fluoride control dentifrice, both
test dentifrice 1 and test dentifrice 2 exhibited statistical-
ly significant reductions ( table2 ) in incremental DMFT
scores (21.0 and 17.7%, respectively). However, no statis-
tically significant difference was observed between the
two test dentifrices in incremental DMFT scores after
2years of product use ( table2 ). The statistical significance
of differences was subsequently confirmed using non-
parametric methods [Gibbons, 1997] with comparisons
between both test dentifrices and the fluoride control
dentifrice of p < 0.001. No significant difference between
the two test dentifrices (p > 0.05) was observed.
The mean incremental DMFS scores measured after
2years of product use are also shown in table1 . They were
0.76 ± 1.68, 0.76 ± 1.59 and 0.91 ± 1.67 for test dentifrice
1, test dentifrice 2 and the fluoride control dentifrice, re-
spectively. Relative to the fluoride control dentifrice, both
test dentifrice 1 and test dentifrice 2 exhibited statistically
significant reductions ( table 2 ) in incremental DMFS
scores after 2 years of product use (16.5 and 16.5%, respec-
tively). The incremental DMFS scores for the two test den-
tifrices after 2 years of product use, however, were not sta-
tistically significantly different ( table2 ). The statistical sig-
nificance of differences was again subsequently confirmed
using non-parametric methods [Gibbons, 1997] with
comparisons between both test dentifrices and the fluoride
control dentifrice of p < 0.001. No significant difference
between the two test dentifrices (p > 0.05) was observed.
D i s c u s s i o n
Fluoride has long been recognized for its anti-caries
benefits and the efficacy of fluoride dentifrices in prevent-
ing caries has been well documented [Marinho et al.,
Table 1. Summary of the baseline DMFT and DMFS scores and 1- and 2-year caries increments for subjects who completed the 2-year
clinical study
Treatment n DMFT (mean ± SD) DMFS (mean ± SD)
baseline 1 year 2 years ba seline 1 year 2 years
Test dentifrice 1 1,679 0.51±0.97 0.25±0.72 0.49±1.00 0.73±1.62 0.38±1.13 0.76±1.68
Test dentifrice 2 1,693 0.49±0.94 0.26±0.69 0.51±1.01 0.67±1.56 0.38±1.09 0.76±1.59
Control dentifrice 1,684 0.49±0.97 0.24±0.63 0.62±1.03 0.71±1.63 0.37±0.98 0.91±1.67
Table 2. Summary of the statistical significances of differences between subjects in the three groups for those who completed the 2-year
clinical study
Comparison between dentifrices Statistical significance of the pairwise comparisons
DM FT increment DMFS increment
1 year 2 years 1 year 2 years
Test dentifrice 1 × test dentifrice 2 0.99 0.82 0.94 0.96
Test dentifrice 1 × control dentifrice 0.91 0.001 0.99 0.009
Test dentifrice 2 × control dentifrice 0.85 0.007 0.886 0.02

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2009; Walsh et al., 2010]. However, despite active re-
search on new ingredients and innovative formulations,
significant enhancements to the clinical efficacy of denti-
frices formulated with 1,450 ppm F, the maximum per-
mitted level of fluoride in mass-marketed dentifrices,
have not, until now, been forthcoming. A new technolo-
gybased upon 1.5% arginine and an insoluble calcium
compound in combination with 1,450 ppm F has demon-
strated great promise in clinical studies of 6 months dura-
tion, providing statistically significant and clinically
meaningful anti-caries efficacy compared to dentifrices
with 1,450 ppm F alone [Cummins, 2013].
The results of this pivotal 2-year clinical study dem-
onstrate (1) that the two dentifrices containing 1.5% ar-
ginine, an insoluble calcium compound and 1,450 ppmF
provide statistically significant (p < 0.05) reductions in
incremental DMFT and DMFS scores compared to the
control dentifrice containing 1,450 ppm F alone and (2)
that the two arginine-containing dentifrices with either
di-calcium phosphate or calcium carbonate provided
similar levels of efficacy in preventing the formation of
new cavitated caries lesions. It was important to evaluate
efficacy for both sources of insoluble calcium com-
pound, di-calcium phosphate and calcium carbonate, in
this pivotal study as both abrasive systems will be avail-
able to consumers. Importantly, the percent reductions
in mean caries increment for the two dentifrices relative
to the fluoride-only control, over the relatively short
time period for cavitated caries lesion formation of
2years, exceed the accepted criterion for superior anti-
caries efficacy of 10% [American Dental Association
Council on Dental Therapeutics, 1988; Proskin et al.,
1995], highlighting the clinical relevance of the results.
The results are also highly significant relative to the ef-
fects of 1,450 ppm F toothpaste which provides statisti-
cally significant reductions of approximately 25% rela-
tive to fluoride-free toothpaste [Marinho et al., 2009],
typically over time periods longer than 2 years, an effect
recognized by caries experts to be the primary factor in
reducing caries on a population basis [Bratthall et al.,
1996].
Although there is strong scientific evidence that the
anti-caries efficacy of marketed toothpastes with sodium
fluoride, typically with a silica base, is comparable to the
anti-caries efficacy of marketed toothpastes with sodium
monofluorophosphate, typically with a calcium base
[Saporito et al., 2000; Marinho et al., 2009], there are
some authors who have suggested the superiority of these
sodium fluoride formulations [Stookey et al., 1993]. For
this reason, a silica-based sodium fluoride dentifrice was
used as the control formulation in this study. Amongst
the five clinical studies of 6 months duration and the in
situ clinical studies which demonstrated the great prom-
ise of this technology, several have used calcium-based
sodium monofluorophosphate toothpastes as matched
controls and have also demonstrated superior anti-caries
efficacy for the toothpaste containing 1.5% arginine
[Cantore et al., 2013; Souza et al., 2013; Srisilapanan et al.,
2013].
The results of this pivotal 2-year caries clinical study
which assessed the development of cavitated caries le-
sions are highly consistent with the outcomes of the
shorter-term clinical studies that focused on the re- and
de-mineralization of early, reversible enamel and dentin
lesions. Importantly, this is the first time that a new caries
prevention dentifrice containing 1,450 ppm F has been
shown to provide superior efficacy at multiple stages
within the caries continuum versus a dentifrice with
1,450 ppm F alone. Specifically, this clinical study has
shown superior efficacy of dentifrices containing 1.5% ar-
ginine, an insoluble calcium compound and 1,450 ppm F
compared to 1,450 ppm F alone, over the 2-year time
frame appropriate to the irreversible stage of cavitation,
and has also demonstrated both qualitatively and quanti-
tatively comparable results to the five clinical studies over
the 6-month time frame appropriate to the arrest and re-
versal of the early stages of the caries process.
Three studies, using quantitative light-induced fluo-
rescence, have each shown that the new dentifrice con-
taining 1.5% arginine, an insoluble calcium compound
and 1,450 ppm F is significantly more effective in arrest-
ing and reversing coronal caries lesions in children than
a dentifrice containing 1,450 ppm F alone [Srisilapanan
et al., 2013; Yin et al., 2013a, b]. In one study, after
6months of product use, improvements from baseline in
ΔQ (lesion volume) were 50.7, 32.3 and 11.4% for the
new arginine-containing dentifrice, a matched positive
control dentifrice and a matched negative control denti-
frice, respectively. The differences between the new den-
tifrice and the positive control were statistically signifi-
cant (p = 0.003) [Yin et al., 2013a]. In a second study,
after 6 months of product use, improvements from base-
line in ΔQ (lesion volume) were 50.6, 34.0 and 13.1% for
the new arginine-containing dentifrice, a silica/sodium
fluoride positive control dentifrice and a matched nega-
tive control dentifrice, respectively. The differences be-
tween the new dentifrice and the positive control were
statistically significant (p = 0.008) [Yin et al., 2013b]. In
a third study, after 6 months of product use, improve-
ments from baseline in ΔQ (lesion volume) were 44.6 and

Kraivaphan/Amornchat/Triratana/Mateo/
Ellwood/Cummins/DeVizio/Zhang
Caries Res 2013;47:582–590
DOI: 10.1159/000353183
588
28.9% for the new arginine-containing dentifrice and a
matched positive control dentifrice, respectively. The dif-
ference between the new dentifrice and the positive con-
trol was statistically significant (p < 0.001) [Srisilapanan
et al., 2013].
Two root caries studies in adults have each shown
that the new dentifrice containing 1.5% arginine and
1,450 ppm F in a calcium base is significantly more effec-
tive in arresting and reversing root caries lesions than a
dentifrice containing 1,450 ppm F alone [Hu et al., 2013;
Souza et al., 2013]. In one study, after 6 months of product
use, clinical hardness measures showed that only one le-
sion (0.7%) was worse in the new dentifrice group com-
pared to 9.0 and 18.2% in a silica/sodium fluoride positive
and a matched negative control group, respectively. In
addition, 61.7, 56.0 and 27.0% of lesions showed im-
provement for the new arginine-containing dentifrice,
the positive control dentifrice and the negative control
dentifrice, respectively. The differences in the distribu-
tion of lesion change scores between the new dentifrice
and the positive control were statistically significant (p =
0.006) [Hu et al., 2013]. In the second study, after 6months
of product use, 70.5% of root caries lesions improved for
subjects using the new dentifrice compared to 58.1% for
subjects in a matched positive control group. The differ-
ence in the number of root caries lesions being hardened
in the new dentifrice and positive control groups was sta-
tistically significant (p < 0.05) [Souza et al., 2013].
The fact that the three enamel caries studies and the
two root caries studies described above demonstrated sta-
tistically significant differences between the arginine-
containing dentifrices and positive control dentifrices in
only 6 months is consistent with the time scale of forma-
tion and reversal of early non-cavitated caries lesions. It
was not expected that, in the present study, differences
between products in respect to cavitation would be seen
until the 2-year time point. This is consistent with other
conventional caries clinical trials [Marinho et al., 2009]
and reflects the time required for cavitated lesions to de-
velop to clinically detectable thresholds using conven-
tional visual-tactile methods. The 6-month enamel and
root caries clinical trial methods that assess re- and de-
mineralization of early, reversible caries lesions show
great potential to significantly reduce development cycles
and provide a greater understanding of modes of action
of anti-caries products [Ellwood et al., 2012].
In this 2-year clinical study, the DMFT increments of
between 0.49 and 0.62 are relatively small. This likely re-
flects that the population participating in this study com-
prised subjects with low to moderate caries risk, rather
than with high risk seen in some populations around the
world. Interestingly, the caries scores in this study popu-
lation are representative of Thailand as a whole, as a re-
cent survey [Bureau of Dental Health, Ministry of Public
Health, 2012] showed that 12-year-olds have mean DMFT
scores of 1.3 and 1.4 in Thailand and in Bangkok, respec-
tively.
In fact, it is unusual to be able to demonstrate superior
efficacy of anti-caries products relative to controls in such
a low to moderate caries risk population, and most stud-
ies are conducted in high caries risk groups [Marinho et
al., 2009] to increase discrimination between products
[Ellwood et al., 2012]. The ability of this study to demon-
strate superior efficacy for the arginine-containing denti-
frice relative to the fluoride only control could, thus, be
viewed as a strength of the study. Notwithstanding this,
as described previously, the efficacy of the arginine-con-
taining dentifrice was demonstrated in three quantitative
light-induced fluorescence studies in populations with
higher caries risk and also in two populations with root
caries. The consistent findings of clinical studies in such
diverse populations suggest that the findings of these
studies would be applicable to a wide range of popula-
tions and age groups.
The results of this pivotal 2-year clinical study, as well
as the results of the five 6-month clinical studies, are also
consistent with the results of in situ clinical studies which
demonstrated that these arginine-containing dentifrices
inhibit de-mineralization and enhance re-mineralization
more effectively than dentifrices with fluoride alone
[Cantore et al., 2013]. The superior caries protection ben-
efits of these dentifrices are delivered through a combina-
tion of the well-known effects of fluoride and a unique
mechanism of action of the arginine and insoluble calci-
um compound [Cummins, 2013].
Independent clinical studies provide further insights
into this unique mechanism of action. Firstly, in situ am-
monia production from salivary arginine via the arginine
deiminase system in dental plaque is positively associated
with reduced caries experience [Nascimento et al., 2009;
Gordan et al., 2010], indicating the importance of ammo-
nia production in caries prevention. Further, it has been
shown that fluoride-free toothpaste containing 1.5% ar-
ginine significantly increased arginine deiminase system
activity in caries-active individuals, indicating that exog-
enous arginine can reduce caries risk by increasing argi-
nine deiminase system activity [Nascimento et al., 2009].
Additionally, a 2-year clinical study has demonstrated
that this fluoride-free toothpaste containing 1.5% argi-
nine provides equivalent anti-caries efficacy to a silica-

Two-Year Caries Clinical Study Caries Res 2013;47:582–590
DOI: 10.1159/000353183
589
based toothpaste containing 1,100 ppm [Acevedo et al.,
2005], indicating that exogenous arginine may provide
clinically meaningful caries prevention.
C o n c l u s i o n
The results of this pivotal 2-year caries clinical study
support the conclusion that dentifrices containing 1.5%
arginine, an insoluble calcium compound and 1,450ppmF
as sodium monofluorophosphate provide significantly
greater protection against caries lesion cavitation, in a low
to moderate caries risk population than dentifrices con-
taining 1,450 ppm F alone.
Acknowledgement
The authors would like to thank both the nine schools in-
volved in this study and the clinical trial team of Mahidol Univer-
sity for their support and enthusiasm in conducting this study.
They also would like to thank Dr. Augusto Elias Boneta for his
dedication and expertise in training and calibrating the clinical
examiners.
Author Contributions
Dr. Petcharat Kraivaphan: leading examiner; Dr. Choltivha
Amornchat: examiner and logistics; Dr. Terdphong Triratana: prin-
cipal investigator and examiner; Mr. Luis R. Mateo: statistics; Dr.
Roger Ellwood: manuscript, discussion, data interpretation and sta-
tistics; Dr. Diane Cummins: manuscript, discussion, data interpre-
tation and statistics; Dr. William DeVizio: sponsor and discussion
in study design; Dr. Yun-Po Zhang: study design, monitoring, man-
uscript, discussion, data interpretation and corresponding author.
Disclosure Statement
This research was funded by Colgate-Palmolive. Drs. Kraivaphan,
Amornchat, Triratana and Boneta and Mr. Mateo were funded by
Colgate-Palmolive to conduct this study. Drs. Ellwood, Cummins,
DeVizio and Zhang are employees of Colgate-Palmolive.
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