Fluorides for the prevention of white spots on teeth during fixed brace treatment

Effect of Biomin F toothpaste and Diode laser on remineralization of white spot lesions (in vitro study)

BACKGROUND

White-spot lesions are considered an initial carious stage characterized by an outer enamel layer with significantly reduced mineralization. This study was conducted to assess the combined effect of Biomin F toothpaste and Diode laser on remineralization of white spot lesions.

MATERIALS AND METHODS

An invitro study conducted on a total of 30 premolars divided into three groups; Group A (Biomin F Tooth paste), Group B (Biomin F with laser application for 30 sec), Group C (Negative control). The three groups were submitted to three stages; stage 1:Baseline,stage 2:After demineralization ,and stage 3:After remineralization. In each stage, elemental analysis(calcium, phosphorus, and fluoride)was measured quantitatively using Energy Dispersive X-ray (EDX) analysis and qualitatively by micrographs using scanning electron microscope. The data were tested to find significant difference between mineral changes during stages by using (ANOVA) test and Bonferroni test.

RESULTS

Calcium, phosphorus and fluoride ions decreased in all groups after demineralization. In stage 3, after application of remineralizing agents, Calcium ions increased significantly in groups A and B where p<.05. As regards to the phosphorus ions, a significant increase was observed in all groups with group A showed the highest gain as phosphorus level percentage change (%mass) was 56.52±18.02 . Fluoride ions increased significantly in groups A and B (p<0.05) but decreased significantly in group C. There was no statistical significant difference between group A and B (p ≥.05) in calcium, phosphorus, and fluoride level after remineralization.

CONCLUSION

Within the limitation of the present study, we concluded that Biomin F toothpaste is promising in the repairing of white spot lesions on the surface of the demineralized enamel. Diode laser did not affect the remineralizing ability of Biomin F toothpaste.

Prevention of demineralization during multi-bracketed fixed orthodontic treatment: An overview of systematic reviews

BACKGROUND

Demineralization during multi-bracketed fixed orthodontic treatment is a well-known problem.

AIM

To systematically evaluate the evidence for the prevention of enamel demineralization during multi-bracketed fixed orthodontic treatment.

DESIGN

Systematic reviews (with or without meta-analysis) that have appraised the primary studies on the prevention of demineralization during multi-bracketed fixed orthodontic treatment were searched systematically and included as per pre-defined eligibility criteria. The risk of bias of the included reviews was assessed by two authors using the ROBIS tool and AMSTAR-2 tool.

RESULTS

Twenty-nine reviews conducted on 128 exclusive primary studies were included for the present overview; 23 of these reviews were assessed to be of a high risk of overall bias, 5 were of low risk, and 1 review was of unclear risk of bias.

CONCLUSIONS

Predominantly, the published reviews have focused on fluorides, whereas some reviews have also studied the role of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), reminder therapy, lasers, and sealants. Professional fluorides, sealants, reminder therapy, and lasers might be valuable interventions to prevent demineralization during orthodontic treatment based on the conclusions of reviews with high quality; however, further studies are required to elucidate the role of CPP-ACP, chlorhexidine varnish, and powered toothbrushes.

Antimicrobial Effect of Orthodontic Materials on Cariogenic Bacteria Streptococcus mutans and Lactobacillus acidophilus

BACKGROUND White spot lesions (WSLs) are a common complication after orthodontic treatment. The aim of this study was to characterize and compare the antimicrobial properties of selenium-containing vs. fluoride-containing orthodontic materials. MATERIAL AND METHODS Antibacterial efficacy of orthodontic materials (SeLECT Defense bonding agent, Adhesive agent, Band Cement, Transbond Plus SEP bonding agent, Transbond Plus Adhesive agent, Fuji I Band cement, Fuji Ortho LC Adhesive agent, Ortho Solo Bonding agent, Transbond XT bonding agent, and Transbond XT primer) was tested with the inhibition of 2 bacterial strains: S. mutans (ATCC 10449) and L. acidophilus (ATCC 4356). The antimicrobial efficacy of the materials was measured by agar diffusion test. The diameters of inhibition zones around each disk were measured in millimeters (mm). RESULTS Materials containing selenium and fluoride showed significant differences from the negative control (both p<0.001). Orthodontic materials containing fluoride as a potential antimicrobial agent showed larger zones of inhibition in total (9.1±2.6 mm), the selenium group was the second-most effective (4.7±4.9 mm), and the group without any potential antimicrobial agent showed the least antimicrobial effect (0.9±1.0 mm). Materials from the group with no antibacterial agent were not significantly different from the negative control group (p>0.05). CONCLUSIONS Materials containing selenium carried the most significance when comparing microorganisms with the agent, since they were the only ones showing difference between the 2 microorganisms. They showed statistically significant difference in efficacy against S. mutans, and poor antimicrobial effect against L. acidophilus. These data suggest that orthodontic materials containing selenium might have the potential to prevent WSLs due to their antimicrobial properties.

Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment

BACKGROUND

Early dental decay or demineralised lesions (DLs, also known as white spot lesions) can appear on teeth during fixed orthodontic (brace) treatment. Fluoride reduces decay in susceptible individuals, including orthodontic patients. This review compared various forms of topical fluoride to prevent the development of DLs during orthodontic treatment. This is the second update of the Cochrane Review first published in 2004 and previously updated in 2013.

OBJECTIVES

The primary objective was to evaluate whether topical fluoride reduces the proportion of orthodontic patients with new DLs after fixed appliances. The secondary objectives were to examine the effectiveness of different modes of topical fluoride delivery in reducing the proportions of orthodontic patients with new DLs, as well as the severity of lesions, in terms of number, size and colour. Participant-assessed outcomes, such as perception of DLs, and oral health-related quality of life data were to be included, as would reports of adverse effects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 1 February 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 1 February 2019), MEDLINE Ovid (1946 to 1 February 2019), and Embase Ovid (1980 to 1 February 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Parallel-group, randomised controlled trials comparing the use of a fluoride-containing product versus a placebo, no treatment or a different type of fluoride treatment, in which the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment.

DATA COLLECTION AND ANALYSIS

At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. Cochrane's statistical guidelines were followed.

MAIN RESULTS

This update includes 10 studies and contains data from nine studies, comparing eight interventions, involving 1798 randomised participants (1580 analysed). One report contained insufficient information and the authors have been contacted. We assessed two studies as at low risk of bias, six at unclear risk of bias, and two at high risk of bias. Two placebo (non-fluoride) controlled studies, at low risk of bias, investigated the professional application of varnish (7700 or 10,000 parts per million (ppm) fluoride (F)), every six weeks and found insufficient evidence of a difference regarding its effectiveness in preventing new DLs (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.14 to 1.93; 405 participants; low-certainty evidence). One placebo (non-fluoride) controlled study, at unclear risk of bias, provides a low level of certainty that fluoride foam (12,300 ppm F), professionally applied every two months, may reduce the incidence of new DLs (12% versus 49%) after fixed orthodontic treatment (RR 0.26, 95% CI 0.11 to 0.57; 95 participants). One study, at unclear risk of bias, also provides a low level of certainty that use of a high-concentration fluoride toothpaste (5000 ppm F) by patients may reduce the incidence of new DLs (18% versus 27%) compared with a conventional fluoride toothpaste (1450 ppm F) (RR 0.68, 95% CI 0.46 to 1.00; 380 participants). There was no evidence for a difference in the proportions of orthodontic patients with new DLs on the teeth after treatment with fixed orthodontic appliances for the following comparisons: - an amine fluoride and stannous fluoride toothpaste/mouthrinse combination versus a sodium fluoride toothpaste/mouthrinse, - an amine fluoride gel versus a non-fluoride placebo applied by participants at home once a week and by professional application every three months, - resin-modified glass ionomer cement versus light-cured composite resin for bonding orthodontic brackets, - a 250 ppm F mouthrinse versus 0 ppm F placebo mouthrinse, - the use of an intraoral fluoride-releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The last two comparisons involved studies that were assessed at high risk of bias, because a substantial number of participants were lost to follow-up. Unfortunately, although the internal validity and hence the quality of the studies has improved since the first version of the review, they have compared different interventions; therefore, the findings are only considered to provide low level of certainty, because none has been replicated by follow-up studies, in different settings, to confirm external validity. A patient-reported outcome, such as concern about the aesthetics of any DLs, was still not included as an outcome in any study. Reports of adverse effects from topical fluoride applications were rare and unlikely to be significant. One study involving fluoride-containing glass beads reported numerous breakages.

AUTHORS' CONCLUSIONS

This review found a low level of certainty that 12,300 ppm F foam applied by a professional every 6 to 8 weeks throughout fixed orthodontic treatment, might be effective in reducing the proportion of orthodontic patients with new DLs. In addition, there is a low level of certainty that the patient use of a high fluoride toothpaste (5000 ppm F) throughout orthodontic treatment, might be more effective than a conventional fluoride toothpaste. These two comparisons were based on single studies. There was insufficient evidence of a difference regarding the professional application of fluoride varnish (7700 or 10,000 ppm F). Further adequately powered, randomised controlled trials are required to increase the certainty of these findings and to determine the best means of preventing DLs in patients undergoing fixed orthodontic treatment. The most accurate means of assessing adherence with the use of fluoride products by patients and any possible adverse effects also need to be considered. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DLs on patient satisfaction with treatment.

Effects of fluoride versus amorphous calcium phosphate solutions on enamel microhardness of white spot lesions: An in-vitro study

Background

Development of white spot lesions around orthodontic fixed orthodontic appliances is a common finding, especially in patients with poor oral hygiene. One of the conservative interventions for regression of these lesions is using chemical solutions. The current study aimed to compare the effectiveness of fluoride and amorphous calcium phosphate (ACP) on microhardness improvement of affected enamel.

Material and Methods

Forty-five intact human incisor teeth were selected and randomly divided into 3 groups of 15. Fluoride group, ACP group and artificial saliva group (control group). Inducing of white spot lesion was done by PH-cycling model. Samples of the first and second group were submerged into 0.05% fluoride and 0.05% ACP solutions respectively for one minute a day. The rest of the time, all specimens were put in artificial saliva, which was incubated in 37 °c temperature. Microhardness of specimens was assessed by Vickers microhardness test in three stages: 1: Baseline microhardness assessment that was done before induction of white spot lesion, 2: Secondary microhardness assessment that was done after induction, 3: Final microhardness assessment that was done after chemical treatment. The SPSS 11.5 software was used for statistical analysis and p< 0.05 was considered as significant.

Results

Microhardness of specimens in the fluoride and ACP groups had significantly improved after the treatment (between secondary assessment and final assessment). In the control group, no significant improvements were observed. In final assessment, there were significant differences between the ACP and control groups, but no significant differences were found neither between the fluoride and ACP, nor the Fluoride and control groups.

Conclusions

According to the current study, both 0.05% ACP and 0.05% fluoride solutions enhanced enamel micro-hardness in treatment of white spot lesion.

Key words:Microhardness, amorphous calcium phosphate, fluoride, white spot lesion.

Colorimetric evaluation of white spot lesions following external bleaching with fluoridation: An in-vitro study

Objective

This study was performed to investigate the effects of external tooth bleaching with flouridation on the appearance of white spot lesions (WSLs) in vitro.

Methods

In total, 125 bracket-bonded bovine incisor enamel blocks with artificial WSLs were randomly divided into a control group and four treatment groups (home bleaching, home bleaching + fluoridation, in-office bleaching, and in-office bleaching + fluoridation). A spectroradiometer (SR) and digital images (DIs) were used to evaluate colorimetric parameters (Commission Internationale l'Eclairage L^*a^*b^*) for all specimens. Color measurements were obtained before WSL formation (T1), after WSL formation (T2), and after completion of the external tooth bleaching treatment (T3).

Results

The SR-based color change after bleaching was significantly greater in the treatment groups than in the control group (p < 0.05). SR-based lightness (L^*) and red-green (a^*) values were significantly higher at T2 than at T1 (p < 0.001), with no significant changes in yellow-blue (b^*) values. At T3, SR-based L^* values had increased while a^* and b^* values had decreased in the treatment groups (p < 0.001). The DI-based color difference between the sound enamel and WSL areas (ΔE^*DI) increased significantly from T1 to T2 in all groups (p < 0.001) and significantly decreased from T2 to T3 in the treatment groups (p < 0.001). No significant differences in ΔE^*DI at T3 were shown between the four treatment groups (p > 0.05).

Conclusions

The findings of this study suggested that external tooth bleaching with fluoridation can alleviate the conspicuity of WSLs.

Integrity testing of a smooth surface resin sealant around orthodontic brackets using a new Fluorescence-aided Identification Technique (FIT)

OBJECTIVE:

To investigate the integrity of a fluorescing resin-based sealant placed around orthodontic brackets using the Fluorescence-aided Identification Technique (FIT).

MATERIALS AND METHODS:

Standard brackets were bonded to the buccal surfaces of 17 extracted sound permanent premolar crowns sealed with ProSeal^®. Specimens were thermocycled (20,000 cycles, 5-55°C), and toothbrushing was simulated using an electric toothbrush and artificial aqueous toothpaste slurry. Changes in the sealed area were measured after one, two, three, and four alternating thermocycling-brushing cycles simulating 2 years of wear. Digital images were captured applying FIT (405 nm) using a digital camera-equipped stereomicroscope. ImageJ was used to measure sealant integrity and loss.

RESULTS:

There was a time-dependent decrease in sealed areas by between 21% and 100% (mean 54%). The sealant lost its integrity immediately after the first cycle, and unfilled areas were observed in all samples.

CONCLUSIONS:

The analyzed sealant lost its integrity over time. Using the proposed FIT, sealed surfaces were easily verified and quantified.

An In Vitro Study on the Effect of Amorphous Calcium Phosphate and Fluoride Solutions on Color Improvement of White Spot Lesions

The ability of remineralizing agents to improve the color of white spot lesions (WSL) is an important aspect that should be investigated. The aim of this study was to evaluate the effects of 0.05% amorphous calcium phosphate (ACP), 0.5% ACP, and 0.05% fluoride solutions, as well as artificial saliva on the color improvement of white spot lesions (WSLs). In this in vitro study, 50 human premolar teeth were randomly classified into five groups. At baseline, all the samples were assessed by using a colorimeter (E0). Then, white spot lesions were induced on the surface of the teeth by means of a pH-cycling model, and the colorimeter was used again (E1). Afterwards, samples of the 1st and 2nd groups were kept in 0.05% ACP and 0.5% ACP solutions for 1 min/day, respectively. The 3rd group specimens were placed in 0.05% fluoride solution for 1 min/day. The other two groups were kept in artificial saliva and distilled in water separately. All the samples were assessed by the colorimeter for a third time (E2). We found no significant difference between the groups in ∆E1. There was also no significant difference among 0.05% ACP solution, 0.5% ACP solution, 0.05% fluoride solution, and artificial saliva considering ∆E2. However, a significant difference was noted between the above-mentioned solutions and distilled water in ∆E2. With respect to ∆E3, there were considerable differences between ACP solution and artificial saliva. The same results were obtained for the difference between fluoride solution and artificial saliva. However, no significant difference was found among 0.05% ACP, 0.5% ACP, and 0.05% fluoride solutions in terms of ∆E3. In Conclusion, ACP is as effective as fluoride in the color improvement of WSLs and the recommended treatment for this purpose is daily use of 0.05% ACP, 0.5% ACP or 0.05% fluoride solutions.

Assessment of Iranian orthodontists' practice with regard to the prevention and treatment of white spot lesions

INTRODUCTION

White spot lesions (WSLs) are common adverse effect of orthodontic treatment, which can be prevented and treated by orthodontists. This study was conducted to assess Iranian orthodontists' practice regarding the prevention and treatment of WSLs in their patients.

METHODS

In this cross-sectional study, 109 Iranian orthodontists were selected from the Iranian Association of Orthodontists' directory by cluster sampling. For data collection, a questionnaire was designed and its validity and reliability was confirmed (Cronbach's α =0.85). The questionnaire included eight general questions and eight questions about practice with regard to the prevention and treatment of WSL. Data were analyzed by descriptive tests, ANOVA test, and t-test in SPSS 20 software. P < 0.05 was considered statistically significant.

RESULTS

The mean score of orthodontists' practice was 7.62 (range: 0-8), and 94.4% of the participants were rated as good, while 3.7% and 1.9% were rated as moderate and weak, respectively. Women's score was significantly higher than that of men (P = 0.001). With increasing participants' age, their practice has been improved (P = 0.001), but there was no significant relation between years of experience and their practice (P = 0.230). Nearly 94.4% of the orthodontists prescribed fluoride products. Toothpastes and fluoride mouth rinses were the most common prescribed products (34%).

CONCLUSIONS

With regard to Iranian orthodontists' practice, it was fortunate to note that majority of the respondents were taking care of their patients with regarding to the prevention and treatment of WSLs. For enhancing their competencies, it is recommended to plan educational courses which are useful for promoting their knowledge and practice about new products and procedures used for the prevention and treatment of WSLs.

Prevention and Treatment of White Spot Lesions in Orthodontic Patients

Decalcification of enamel, appearing as white spot lesions (WSLs), around fixed orthodontic appliances is a major challenge during and after fixed orthodontic treatment by considering the fact that the goal of orthodontic treatment is to enhance facial and dental esthetic appearance. Banded or bonded teeth exhibit a significantly higher rate of WSLs compared to the controls with no braces as fixed appliances and the bonding materials promote retention of biofilms. These lesions are managed in the first step by establishing good oral hygiene habits and prophylaxis with topical fluorides, including high-fluoride toothpastes, fluoride mouthwashes, gels, varnishes, fluoride-containing bonding materials, and elastic ligatures. Recently, other materials and methods have been recommended, including the application of casein phosphopeptides-amorphous calcium phosphate, antiseptics, probiotics, polyols, sealants, laser, tooth bleaching agents, resin infiltration, and microabrasion. This article reviews the currently used methods to manage enamel demineralization during and after orthodontic treatment and the risk factors and preventive measures based on the latest evidence.

Prevention and Treatment of White Spot Lesions During and After Treatment with Fixed Orthodontic Appliances: a Systematic Literature Review

Objectives

The aim of the systematic literature review is to update the evidence for the prevention of white spot lesions, using materials containing fluoride and/or casein phosphopeptide-amorphous calcium phosphate during and after treatment with fixed orthodontic appliances.

Material and Methods

Information search for controlled studies on humans published between January 2008 and February 2016 was performed in PubMed, ScienceDirect, Embase, The Cochrane Library. Inclusion criteria were: the English language, study on humans, patients undergoing orthodontic treatment with fixed appliances, randomized or quasi-randomized controlled clinical studies fluoride-containing product or casein derivates used throughout the appliance therapy or straightaway after debonding.

Results

326 articles were reviewed (Embase 141, PubMed 129, ScienceDirect 41, Cochrane 15). Twelve clinical studies fulfilled all inclusion criteria. Use of fluoridated toothpaste had a remineralizing effect on white spot lesions (WSLs) (P < 0.05); fluoride varnish and casein supplements were effective in prevention and early treatment of WSLs (P < 0.05).

Conclusions

Early detection of white spot lesions during orthodontic treatment would allow implementing preventive measures to control the demineralization process before lesions progress. The systemic review has showed that the usage of fluoride and casein supplements in ameliorating white spot lesions during and after fixed orthodontic treatment is significantly effective. However the use of casein phosphopeptide-amorphous calcium phosphate can be more beneficial than fluoride rinse in the reduction of demineralization spots.

Assessment of White Spot Lesions and In-Vivo Evaluation of the Effect of CPP-ACP on White Spot Lesions in Permanent Molars of Children

INTRODUCTION

As hindrance of remineralisation process occurs during orthodontic therapy resulting in decalcification of enamel because number of plaque retention sites increases due to banding and bonding of appliances to teeth.

AIM

The present analytic study was undertaken to assess the occurrence of white spot lesions in permanent molars of children with and without orthodontic therapy and to evaluate the effect of Casein PhosphoPeptide-Amorphous Calcium Phosphate (CPP-ACP) on white spot lesions in post-orthodontic patients in a given period of time.

MATERIALS AND METHODS

The study comprised of examination of 679 first permanent molars which were examined to assess the occurrence of smooth surface white spot lesions in children of 8 to 16 years age group. Group I comprised subjects without any orthodontic treatment and Group II comprised of subjects who had undergone orthodontic therapy. The sample size was calculated using the epi-info6 computer package. Treatment group included 20 post-orthodontic patients examined with at least one white spot lesion within the enamel who received remineralizing cream (GC Tooth Mousse, Recaldent, GC Corporation.) i.e., CPP-ACP cream two times a day for 12 consecutive weeks. Computerized image analysis method was taken to evaluate white spot lesions. These frequency and percentages were compared with chi-square test. For comparison of numeric data, paired t-test was used.

RESULTS

Of the total 278 (49.6%) first permanent molars showed occurrence of smooth surface white spot lesions out of 560 in Group I and 107 (89.9%) first permanent molars showed presence of white spot lesions out of 119 debanded first permanent molars of children examined in Group II. CPP-ACP therapy group showed reduction in severity of codes which was found to be highly significant after 12 weeks and eight weeks on gingival-third, p-value (<0.001) and significant after eight weeks and four weeks on middle-third according to ICDAS II criteria and computerized image analysis.

CONCLUSION

CPP-ACP therapy minimum for 12 weeks is highly recommended as post-orthodontic treatment need in management of smooth surface white spot lesions on teeth undergoing fixed orthodontic therapy according to the present study.

[Increased susceptibility for white spot lesions by surplus orthodontic etching exceeding bracket base area]

INTRODUCTION

There is a paucity of information with regard to the susceptibility of iatrogenic white spot lesion formation after inattentive, surplus orthodontic etching with 30% phosphoric acid and the subsequent provision or absence of adequate oral hygiene.

METHODS

Ninety sound enamel specimens were randomly allocated to 6 trial groups (N = 15 each) for etching with 30% phosphoric acid for either 15 seconds and standardized daily enamel brushing or no brushing, etching for 30 seconds with daily brushing or no brushing, or nonetched controls with brushing or no brushing. Nutritive acidic assaults were simulated by demineralization cycles 3 times per day for 1 hour with interim storage in artificial saliva. Lesion depths in terms of percentage of fluorescence loss (delta F, delta Q) and lesion extension compared with the baseline were assessed by using quantitative light-induced fluorescence after 2, 7, 14, 21, and 42 days. Etching duration, trial time elapse, and oral hygiene, as well as the significance of factor interactions, were analyzed with 3-way analysis of variance (α=5%).

RESULTS

The impact of the factors of enamel brushing, trial time elapse, and etching each had a comparably significant effect on lesion progression. The effect of surplus etching on white spot lesion formation was significantly enhanced by the simultaneous absence of enamel brushing and also the progression of trial time. The combination of 30 seconds of surplus etching with inadequate oral hygiene was especially detrimental.

CONCLUSIONS

Excessive surplus orthodontic etching of the complete labial enamel surface, instead of the bracket bases only, must be avoided to prevent iatrogenic white spot lesions. Etching times not exceeding 15 seconds are favorable.

Xylitol-containing products for preventing dental caries in children and adults

BACKGROUND

Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety.

OBJECTIVES

To assess the effects of different xylitol-containing products for the prevention of dental caries in children and adults.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta-analysis, we used a fixed-effect model. We planned to use a random-effects model in the event that there were four or more studies in a meta-analysis.

MAIN RESULTS

We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias.The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride-only toothpaste (PF -0.13, 95% CI -0.18 to -0.08, 4216 children analysed, low-quality evidence).The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low-dose xylitol syrup (2.67 g per day) consumed for 1 year.The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence).There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol.Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea.

AUTHORS' CONCLUSIONS

We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride-only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse-effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol-containing products can prevent caries in infants, older children, or adults.

[White spot lesions and orthodontic treatment. Prevention and treatment]

Decalcification of the enamel surface adjacent to fixed orthodontic appliances, in the form of white spot lesions, is a common and frequent well-known side-effect of orthodontic treatment. Fixed appliances and the bonding materials increase the retention of biofilm and encourage the formation of white spot lesions. Management of these lesions begins with a good oral hygiene regime and needs to be associated with use of fluoride agents (fluoridated toothpaste, fluoride containing mouth rinse, gel, varnish, bonding materials, elastic ligature), CPP-ACP, antiseptics, LASER, tooth whitening, resin infiltration, micro-abrasion. The purpose of this review is to access the direct evidence regarding the prevention and management of white spot lesions during and after orthodontic treatment.

Influence of sport mouthguards on the ecological factors of the children oral cavity

BACKGROUND

The use of fixed and/or removable dental devices is an attributable factor that may affect the oral cavity homeostasis. The aim of this study was to monitor the oral environmental changes caused by dental devices, as sports mouthguards with the aid of a chair-side test.

METHODS

Sixty children with sports-mouthguards were analyzed at baseline (T0), after 6 months of dental devices use (T1), after a year (T2) and after almost 6 months without using it (T3). At T0, a clinical monitoring was performed and the DMFT index was recorded. At each time of observation, the following parameters were recorded: FMPS, FMBS, unstimulated-flow rate, saliva consistency, resting pH, stimulated saliva, buffer capacity, the CFU/ml of Streptococcus mutans.

RESULTS

In 60 subjects, mean age 9.9 ± 1.2, mean value of DMFT 1.55 ± 1.29,dmf-t 3.43 ± 1.21, FMPS and FMBS values increased significantly at T2. The values of unstimulated flow rate vary significantly within the observation times. The pH value and the buffering capacity reduced significantly at T2. The tests for the detection of S. mutans were negative in all the subjects in several observation times. All patients regularly used fluoridated toothpaste and comply with normal standards of oral hygiene; but over time the patients lost their initial motivation.

CONCLUSIONS

Sport treatment with dental devices dues to changes in oral ecological factors: increases FMPS, FMBS and reduces the buffering capacity and the salivary pH. The use of removable devices increases the retentive plaque surfaces and inhibits the protective effect of saliva.The so-called "chair-side" tests were able to easily monitor patients and to determine the risk of oral disease during sport treatment.

The effects of three different mouth rinses in a 4-day supragingival plaque regrowth study

OBJECTIVE

This study compares the effects of three different mouth rinses with respect to reducing Streptococcus mutans (S. mutans) colony counts on the teeth and tongue surfaces.

MATERIALS AND METHODS

In this study, comparison tests using the alcohol-free 0.1% chlorhexidine mouth rinse, alcohol-containing essential oil mouth rinse, and alcohol-free essential oil-containing mouth rinse were conducted. Patients were instructed to avoid mechanical cleaning with either a toothbrush or toothpick for 4 days. The first samples were collected from teeth surfaces and the dorsum of the tongue after a professional cleaning, and the second samples were collected after a 4-day plaque re-growth period. The supragingival plaque from the buccal surfaces of teeth #11, 14, 31, 34 as well as samples from the dorsum of the tongue, were assessed using the Dentocult(®) strips.

RESULTS

The Listerine(®) and Ondrohexidine(®) groups did not show any statistically significant differences between the values of the two samples (P = 0.734, P = 0.307). The MC(®) group and the control group showed significantly higher results than the first sample values. The effectiveness of the mouth rinses on S. mutans colony counts from the teeth surfaces were higher in the Listerine(®), Ondrohexidine(®), and Mouthwash Concentrate(®) groups. The difference between the first and second samples of the S. mutans colony counts from the tongue surface was found to be statistically significant, and S. mutans colony counts were higher than the first sample (P = 0.015).

CONCLUSION

Alcohol and essential oil-containing Listerine(®) mouth rinse, alcohol-free Ondrohexidine(®), alcohol-free essential oil-containing MC(®) mouth rinse had the same effect on S. mutans counts, higher than the 1% alcohol solution on teeth surface. They had the ability to maintain the S. mutans counts at the same level for 4 days in patients who did not perform any mechanical oral hygiene regimen.

Methodological quality and implications for practice of systematic Cochrane reviews in pediatric oral health: a critical assessment

BACKGROUND

To ensure evidence-based decision-making in pediatric oral health, Cochrane systematic reviews that address topics pertinent to this field are necessary. We aimed to identify all systematic reviews of paediatric dentistry and oral health by the Cochrane Oral Health Group (COHG), summarize their characteristics and assess their methodological quality. Our second objective was to assess implications for practice in the review conclusions and provide an overview of clinical implications about the usefulness of paediatric oral health interventions in practice.

METHODS

We conducted a methodological survey including all paediatric dentistry reviews from the COHG. We extracted data on characteristics of included reviews, then assessed the methodological quality using a validated 11-item quality assessment tool (AMSTAR). Finally, we coded each review to indicate whether its authors concluded that an intervention should be implemented in practice, was not supported or was refuted by the evidence, or should be used only in research (inconclusive evidence).

RESULTS

We selected 37 reviews; most concerned the prevention of caries. The methodological quality was high, except for the assessment of reporting bias. In 7 reviews (19%), the research showed that benefits outweighed harms; in 1, the experimental intervention was found ineffective; and in 29 (78%), evidence was insufficient to assess benefits and harms. In the 7 reviews, topical fluoride treatments (with toothpaste, gel or varnish) were found effective for permanent and deciduous teeth in children and adolescents, and sealants for occlusal tooth surfaces of permanent molars.

CONCLUSIONS

Cochrane reviews of paediatric dentistry were of high quality. They provided strong evidence that topical fluoride treatments and sealants are effective for children and adolescents and thus should be implemented in practice. However, a substantial number of reviews yielded inconclusive evidence.

Minimal intervention dentistry II: part 2. Management of caries and periodontal risks in general dental practice

The long-term clinical management of caries and periodontal diseases requires a double approach, one that is concerned with both treatment and prevention. Dentists should recognise the risk factors and their likely triggers to be able to implement the right strategy as early as the diagnostic phase. This comprehensive assessment can easily be done in general practice. All it takes is to combine the patient's general information with the systemic and behavioural factors, and the clinical observations with the local factors. The resulting patient profile can thus effectively support treatment by providing the necessary explanations, advice or prescriptions in relation with the clinical procedures. The modifiable risk factors need to be monitored and the behaviours changed to stabilise or limit disease progression. The practitioner's active approach is meant to meet the patient's demand for preventive counselling.

Are self-ligating brackets related to less formation of Streptococcus mutans colonies? A systematic review

OBJECTIVE

To verify, by means of a systematic review, whether the design of brackets (conventional or self-ligating) influences adhesion and formation of Streptococcus mutans colonies.

METHODS

SEARCH STRATEGY

four databases (Cochrane Central Register of Controlled Trials, Ovid ALL EMB Reviews, PubMed and BIREME) were selected to search for relevant articles covering the period from January 1965 to December 2012.

SELECTION CRITERIA

in first consensus by reading the title and abstract. The full text was obtained from publications that met the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data using the following keywords: conventional, self-ligating, biofilm, Streptococcus mutans, and systematic review; and independently evaluated the quality of the studies. In case of divergence, the technique of consensus was adopted.

RESULTS

The search strategy resulted in 1,401 articles. The classification of scientific relevance revealed the high quality of the 6 eligible articles of which outcomes were not unanimous in reporting not only the influence of the design of the brackets (conventional or self-ligating) over adhesion and formation of colonies of Streptococcus mutans, but also that other factors such as the quality of the bracket type, the level of individual oral hygiene, bonding and age may have greater influence. Statistical analysis was not feasible because of the heterogeneous methodological design.

CONCLUSIONS

Within the limitations of this study, it was concluded that there is no evidence for a possible influence of the design of the brackets (conventional or self-ligating) over colony formation and adhesion of Streptococcus mutans.

Fluorides for the prevention of early tooth decay (demineralised white lesions) during fixed brace treatment

BACKGROUND

Demineralised white lesions (DWLs) can appear on teeth during fixed brace treatment because of early decay around the brackets that attach the braces to the teeth. Fluoride is effective in reducing decay in susceptible individuals in the general population. Individuals receiving orthodontic treatment may be prescribed various forms of fluoride treatment. This review compares the effects of various forms of fluoride used during orthodontic treatment on the development of DWLs. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

The primary objective of this review was to evaluate the effects of fluoride in reducing the incidence of DWLs on the teeth during orthodontic treatment.The secondary objectives were to examine the effectiveness of different modes of fluoride delivery in reducing the incidence of DWLs, as well as the size of lesions. Participant-assessed outcomes, such as perception of DWLs, and oral health-related quality of life data were to be included, as would reports of adverse effects.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 31 January 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12); MEDLINE via OVID (1946 to 31 January 2013); and EMBASE via OVID (1980 to 31 January 2013).

SELECTION CRITERIA

We included trials if they met the following criteria: (1) parallel-group randomised clinical trials comparing the use of a fluoride-containing product versus placebo, no treatment or a different type of fluoride treatment, in which (2) the outcome of enamel demineralisation was assessed at the start and at the end of orthodontic treatment.

DATA COLLECTION AND ANALYSIS

At least two review authors independently, in duplicate, conducted risk of bias assessments and extracted data. Authors of trials were contacted to obtain missing data or to ask for clarification of aspects of trial methodology. The Cochrane Collaboration's statistical guidelines were followed.

MAIN RESULTS

For the 2013 update of this review, three changes were made to the protocol regarding inclusion criteria. Fourteen studies included in the previous version of the review were excluded from this update for the following reasons: five previously included studies were quasi-randomised, a further five were split-mouth studies, three measured outcomes on extracted teeth only and in one, the same fluoride intervention was used in each intervention group of the study.Three studies and 458 participants were included in this updated review. One study was assessed at low risk of bias for all domains, in one study the risk of bias was unclear and in the remaining study, the risk of bias was high.One placebo-controlled study of fluoride varnish applied every six weeks (253 participants, low risk of bias), provided moderate-quality evidence of an almost 70% reduction in DWLs (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.21 to 0.44, P value < 0.001). This finding is considered to provide moderate-quality evidence for this intervention because it has not yet been replicated by further studies in orthodontic participants.One study compared two different formulations of fluoride toothpaste and mouthrinse prescribed for participants undergoing orthodontic treatment (97 participants, unclear risk of bias) and found no difference between an amine fluoride and stannous fluoride toothpaste/mouthrinse combination and a sodium fluoride toothpaste/mouthrinse combination for the outcomes of white spot index, visible plaque index and gingival bleeding index.One small study (37 participants) compared the use of an intraoral fluoride-releasing glass bead device attached to the brace versus a daily fluoride mouthrinse. The study was assessed at high risk of bias because a substantial number of participants were lost to follow-up, and compliance with use of the mouthrinse was not measured.Neither secondary outcomes of this review nor adverse effects of interventions were reported in any of the included studies.

AUTHORS' CONCLUSIONS

This review found some moderate evidence that fluoride varnish applied every six weeks at the time of orthodontic review during treatment is effective, but this finding is based on a single study. Further adequately powered, double-blind, randomised controlled trials are required to determine the best means of preventing DWLs in patients undergoing orthodontic treatment and the most accurate means of assessing compliance with treatment and possible adverse effects. Future studies should follow up participants beyond the end of orthodontic treatment to determine the effect of DWLs on participant satisfaction with treatment.

Fluoride releasing and enamel demineralization around orthodontic brackets by fluoride-releasing composite containing nanoparticles

INTRODUCTION

Fluoride-containing materials have been suggested to control enamel demineralization around orthodontic brackets during the treatment with fixed appliances. The improvement of their properties has been made through innovations, such as the application of nanotechnology by incorporation of nanofillers.

OBJECTIVE

This in vitro study evaluated the capacity of fluoride releasing and enamel demineralization inhibition of fluoride-releasing nanofilled cement around orthodontic brackets using an artificial caries biofilm model.

MATERIALS AND METHODS

Forty bovine enamel discs were selected by evaluating surface microhardness and randomized into four groups (n = 10): non-fluoride-releasing microfilled composite, fluoride-releasing microfilled composite, resin-modified glass ionomer cement (RMGI), and fluoride-releasing nanofilled composite (FN). After brackets bonding in each disc, the specimens were subjected to a cariogenic challenge through a Streptococcus mutans biofilm model. After the experimental period, the biofilm formed around the brackets was collected for fluoride analysis and the mineral loss around the brackets was determined by integrated demineralization via cross-sectional microhardness measurement at 20 and 70 μm from the bracket margin. Additionally, samples of each group were subjected to energy-dispersive X-ray spectroscopy (EDX) analysis examined under a scanning electron microscopy (SEM). ANOVA followed by Tukey test were applied for fluoride concentration and mineral loss data, respectively.

RESULTS

At both distances, only RMGI statistically differed from the other groups presenting the lowest demineralization, although there was a trend to a lower demineralization of enamel around brackets in FN group. Similar condition was found to fluoride concentration and EDX/SEM analysis.

CONCLUSIONS

Under the cariogenic exposure condition of this study, the fluoride-releasing nanofilled material had similar performance to fluoride-releasing microfilled materials.

CLINICAL RELEVANCE

The presence of nanofillers in the fluoride-releasing materials studied did not promote further benefits against caries lesion development around brackets and presented inferior demineralization inhibition than the resin-modified glass ionomer material.

A contemporary review of white spot lesions in orthodontics

White spot lesions (WSL) associated with fixed orthodontic appliances are a common adverse effect of orthodontic treatment and represent a significant challenge to achieving esthetic excellence. The purpose of this article is to review the current evidence regarding diagnosis, risk assessment, prevention, intratreatment management, and postorthodontic treatment of WSL, and to provide clinical recommendations useful for both the orthodontist and the general dentist. Caries risk assessment should be incorporated into initial evaluations of orthodontic patients, and risk-specific prevention and management protocols can help to eliminate or minimize this clinical problem. There are multiple options for treatment of WSL, ranging from conservative to invasive techniques; the severity of lesions is a determinant of which option is most appropriate.

CLINICAL SIGNIFICANCE

White spot lesions associated with orthodontic treatment are a common problem that can be minimized with appropriate prevention, management, and treatment approaches.

Efficacy of different strategies in protecting enamel against demineralization during fixed orthodontic treatment

BACKGROUND AND OBJECTIVE

Sealant application is a common strategy for preventing enamel demineralization during multibracket treatment. The aim of this study was to assess the efficacy in enamel demineralization prevention of two fluoride-containing enamel varnishes compared to a non-fluoride varnish, weekly fluoride gel application, and a non-treated control group.

MATERIALS AND METHODS

Enamel specimens obtained from 75 human upper permanent incisors were randomly allocated to five trial groups (each n = 15): A), ProSeal (Reliance), B), Maximum Cure® (Reliance), C), CervitecPlus (Ivoclar Vivadent, Schaan, Liechtenstein), D) elmex® gelée (GABA, Lörrach, Germany), and E), a non-treated control group. Groups A-C received a baseline varnish application, whereas group D specimens received a once weekly gel application for 2 min. Six demineralization cycles per day were carried out for 5 min each using 0.05 M citric acid, with the specimens stored in remineralization solution between cycles. Lesion depth expressed in percentage fluorescence loss (Δ-F in %) compared to baseline (T0) was assessed quantitatively with light-induced fluorescence (QLF) after 3 (T1), 7 (T2), 14 (T3), and 30 (T4) days globally and for each time point, and analyzed for compounds using the Kruskal-Wallis test (α = 5%), and additional one-sample Wilcoxon tests for each time/compound combination (Bonferroni-corrected α-levels α* = 0.05/4 = 0.0125).

RESULTS

Significant fluorescence loss revealing greater lesion depth was detected in the untreated controls (E) at T3, and in groups A (ProSeal) and C (CervitecPlus) at T4. No significant Δ-F changes were seen in the specimens from groups B (Maximum Cure®) and D (elmex® gelée).

CONCLUSION

Maximum Cure® sealant seems to offer efficient protection against demineralization during fixed orthodontic treatment, as does weekly application of elmex® fluoride gel.

A review on prevention and treatment of post-orthodontic white spot lesions - evidence-based methods and emerging technologies

Objective:

The aim of this paper was to update the evidence for primary and secondary prevention (treatment) of white spot lesions (WSL) adjacent to fixed orthodontic appliances.

Material and methods:

A search for relevant human clinical trials published in English between 2004 and March 2011 retrieved 25 publications that fulfilled the inclusion criteria. The papers were assessed for prevented fraction and/or absolute risk reduction when possible.

Results and conclusions:

The findings consolidated the use of topical fluorides in addition to fluoride toothpaste as the best evidence-based way to avoid WSL. The mean prevented fraction based on 6 trials was 42.5% with a range from -4% to 73%. The recent papers provided the strongest support for regular professional applications of fluoride varnish around the bracket base during the course of orthodontic treatment. For the treatment of post-orthodontic WSL, home-care applications of a remineralizing cream, based on casein phosphopeptide-stabilized amorphous calcium phosphate, as adjunct to fluoride toothpaste could be beneficial but the findings were equivocal. For emerging technologies such as sugar alcohols and probiotics, still only studies with surrogate endpoints are available. Thus, further well-designed studies with standardized regimes and endpoints are needed before guidelines on the non-fluoride technologies can be recommended.

White-spot lesions during multibracket appliance treatment: A challenge for clinical excellence

INTRODUCTION

White-spot lesions (WSL) are one of the most undesired side effects of multibracket appliance treatment (MB). The aim of this study was to investigate the incidence and further course of WSL during and after MB.

METHODS

Four hundred patients (168 boys, 232 girls) meeting the inclusion criteria--all maxillary front teeth fully erupted and visible before treatment, no fillings or structural abnormalities, MB duration of at least 1 year, and retention period of at least 1 year--were selected. The patients' average age was 13.7 years (SD, 3.5), and the average MB time was 1.9 years (SD, 3.6). All patients received standardized general prophylactic instructions. A modification of the WSL index was used to evaluate the 4 maxillary front teeth on introral photos before and after treatment, and after retention.

RESULTS

Before treatment, 32.3% of the patients had WSL. After MB, 73.5% of the patients presented WSL. The incidence of WSL during MB was 60.9% of the patients. After treatment, most patients (63.3%) had mild lesions, but the remaining were affected severely with (26.9%) and without (9.9%) cavitations. Only 26% of the patients were free of WSL all the time. After the retention phase, most (57.1%) of the WSL patients after treatment showed improvement, 26% remained unchanged, and 16.7% deteriorated. Male WSL patients tended to show more severe WSL than did the girls. There was a tendency for increased WSL development during the adolescent years compared with the preadolescent and postadolescent age groups.

CONCLUSIONS

With only standardized general prophylactic measures, new WSL developing on the maxillary front teeth during MB remain a frequent undesired side effect, affecting 60.9% of patients and counteracting our efforts for clinical excellence.

Cochrane systematic reviews in orthodontics

INTRODUCTION

The Cochrane Collaboration is an international scientific not-for-profit organization the purpose of which is to produce and distribute systematic reviews of randomized clinical trials. The aim of this paper is to list the different existing Cochrane systematic reviews in the field of dentofacial orthopedics (DFO) and to analyse their main features.

MATERIAL AND METHODS

The choice of Cochrane systematic reviews based on dentofacial orthopedics was made from the exhaustive list published by the Cochrane Oral Health Group.

RESULTS

A total of 12 systematic Cochrane reviews related to dentofacial orthopedics were listed. All concluded on the need to conduct randomized clinical trials using more appropriate methodologies and comprising larger samples. None of these systematic reviews offered clear proof supporting any one form of treatment or treatment modality.

DISCUSSION

Despite the lack of relevant conclusions in the still meagre number of Cochrane systematic reviews related to DFO, it is essential for orthodontists to regularly consult the reviews in the framework of their daily evidence-based orthodontic practice. This is true too for orthodontic researchers as clinical DFO research needs to be extended with the setting up of methodologically unquestionable randomized clinical trials. However, there exist alternatives to randomized clinical trials offering a lower level of proof but which are better suited to the field of dentofacial orthopedics.

Treatment of post-orthodontic white spot lesions with casein phosphopeptide-stabilised amorphous calcium phosphate

This study aims to investigate the effect of topical applications of 10% casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSL) detected after treatment with fixed orthodontic appliances. Sixty healthy adolescents with ≥1 clinically visible WSL at debonding were recruited and randomly allocated to a randomised controlled trial with two parallel groups. The intervention group was instructed to topically apply a CPP-ACP -containing agent (Tooth Mousse, GC Europe) once daily and the subjects of the control group brushed their teeth with standard fluoride toothpaste. The intervention period was 4 weeks and the endpoints were quantitative light-induced fluorescence (QLF) on buccal surfaces of the upper incisors, cuspids and first premolars and visual scoring from digital photos. The attrition rate was 15%, mostly due to technical errors, and 327 lesions were included in the final evaluation. A statistically significant (p < 0.05) regression of the WSL was disclosed in both study groups compared to baseline, but there was no difference between the groups. The mean area of the lesions decreased by 58% in the CPP-ACP group and 26% in the fluoride group (p = 0.06). The QLF findings were largely reflected by the clinical scores. No side effects were reported. Topical treatment of white spot lesions after debonding of orthodontic appliances with a casein phosphopeptide-stabilised amorphous calcium phosphate agent resulted in significantly reduced fluorescence and a reduced area of the lesions after 4 weeks as assessed by QLF. The improvement was however not superior to the "natural" regression following daily use of fluoride toothpaste.

Cochrane reviews of randomized trials of fluoride therapies for preventing dental caries

AIM

To present the evidence summarized in the Cochrane fluoride reviews.

STUDY DESIGN

An overview of the results of selected systematic reviews.

METHODS

Relevant systematic reviews published in the Cochrane Database of Systematic Reviews (CDSR) were identified by searching 'The Cochrane Library issue 4, 2008', using the terms 'Fluoride' and 'Caries'. Complete Cochrane reviews assessing the effectiveness of any fluoride-based intervention for preventing caries were selected, and their main features and findings were reviewed.

RESULTS

14 papers were identified of which 11 were relevant full-text reviews. The results were assessed of 7 reviews published from 2002 to 2004 concerning the relative effectiveness of 4 topical fluoride treatments (toothpastes, gels, varnishes and mouthrinses) in preventing caries in children and adolescents. Comparisons in these reviews were made against non-fluoride controls, against each other, and against different combinations. Findings from 4 reviews published between 2004 and 2006, assessing other fluoride modalities (slow release devices, milk), specific comparison/site (fluoride varnishes versus sealants in occlusal surfaces), and particular population and caries outcome (fluorides for white spot lesions in orthodontic patients) were also assessed. The 7 reviews confirm a clear and similar effectiveness of topical fluoride toothpastes, mouthrinses, gels and varnishes for preventing caries, and show that additional caries reduction can be expected when another topical fluoride is combined with fluoride toothpaste. Evidence is insufficient to confirm the effectiveness of slow release fluoride devices and fluoridated milk. The comparative effectiveness of other modes of delivering fluoride, such as to orthodontic patients is also as yet unclear. Fissure sealants appear more effective than fluoride varnish for preventing occlusal caries but the size of the difference is unclear.

CONCLUSIONS

The benefits of topical fluorides are firmly established based on a sizeable body of evidence from randomized controlled trials. The size of the reductions in caries increment in both the permanent and the primary dentitions emphasizes the importance of including topical fluoride delivered through toothpastes, rinses, gels or varnishes in any caries preventive program. However, trials to discern potential adverse effects are required, and data on acceptability. Better quality research is needed to reach clearer conclusions on the effects of slow release fluoride devices, milk fluoridation, sealants in comparison with fluoride varnishes, and of different modes of delivering fluoride to orthodontic patients.

Preventive effect of fluoridated orthodontic resins subjected to high cariogenic challenges

The aim of the present study was to evaluate the in vitro caries preventive effect of fluoridated orthodontic resins under pH cycling with two types of acid demineralizing saliva. Brackets were bonded to 60 bovine incisors, using either Transbond Plus Color Change (n=30) or Orthodontic Fill Magic (n=30) orthodontic resins. Each group of resin was divided into 3 subgroups (n=10): immersion in remineralizing artificial saliva for 14 days, pH cycling with high cariogenic challenge in acid saliva with pH 5.5, and acid saliva with pH 4.5. After 14 days of pH cycling, the caries preventive effect on the development of white spot lesion was evaluated considering the presence of inhibition zones to white spot lesions using two scores: 0= absence and 1= presence. Kruskal Wallis and Mann-Whitney tests (a=0.05) were used. Formation of white spot lesions was observed only under pH cycling using acid saliva with pH 4.5; with Transbond Plus Color Change being significantly more effective (p<0.05) in preventing the appearance of white spot lesions effect than Orthodontic Fill Magic. The acidity of the demineralizing solution influenced the formation of white spot lesions around orthodontic brackets under highly cariogenic conditions. Transbond Plus Color Change resin presented higher caries preventive effect than Orthodontic Fill Magic.

Fluoride release and cariostatic potential of orthodontic adhesives with and without daily fluoride rinsing

INTRODUCTION

In this study, we aimed to evaluate the fluoride-release profiles and caries lesion development in an enamel model with brackets cemented with 4 orthodontic adhesives with and without daily fluoride exposure.

METHODS

Four orthodontic adhesives (Ketac Cem mu, 3M ESPE, Seefeld, Germany; Fuji Ortho LC, GC Corporation, Tokyo, Japan; Light-Bond, Reliance Orthodontic Products, Itasca, Ill; and Transbond XT, 3M Unitek, Monrovia, Calif) were used. Brackets were bonded on bovine enamel with each adhesive (n = 10) and subjected to alternate cycles of demineralizing (pH 4.55) and remineralizing (pH 6.8) solutions. Unbracketed enamel samples served as a reference. Five samples from each group were immersed in a fluoride mouth rinse (250 ppm fluoride) for 1 minute each day (test groups). Fluoride release was measured at regular intervals over 28 days. The mineral distribution of peribracket enamel after 28 days was quantified by transversal microradiographs.

RESULTS

Fluoride-release profiles of Ketac Cem mu, Fuji Ortho LC, and Light-Bond were high for the first 24 hours and reached a constant level after 2 weeks. Fuji Ortho LC released significantly more fluoride than did the other adhesives in both the control and test groups (P <0.01, repeated measures ANOVA and Bonferroni test). Enamel bonded with Fuji Ortho LC had significantly shallower lesions and less mineral loss (P <0.01, 2-way ANOVA, and Tukey HSD).

CONCLUSIONS

Bonding of orthodontic brackets with Fuji Ortho LC resulted in less peribracket enamel demineralization with and without daily fluoride rinsing, mainly due to its better fluoride-release profile. In contrast, Transbond XT and Light-Bond offered few cariostatic effects to the enamel.

Evidence-based caries, risk assessment, and treatment

Dental caries is a dietary and host-modified biofilm disease process, transmissible early in life that, if left untreated, will cause destruction of dental hard tissues. If allowed to progress, the disease will result in the development of caries lesions on tooth surfaces, which initially are noncavitated (eg, white spots), and eventually can progress to cavitation. The "medical model," where the etiologic disease-driving agents are balanced against protective factors, in combination with risk assessment, offers the possibility of patient-centered disease prevention and management before there is irreversible damage done to the teeth. This article discusses how to use evidence supporting risk assessment and management strategies for the caries process.

Effect of different bonding agents on prevention of enamel demineralization around orthodontic brackets

INTRODUCTION

Demineralization around the bracket is an undesired side effect of orthodontic treatment. The aim of this in-vitro study was to evaluate the efficacy of 5 bonding agents to prevent enamel demineralization. Two quantification methods were used.

METHODS

Eighty-five extracted teeth were randomly allocated to 5 groups: (1) Transbond Plus SEP and Transbond XT (both, 3M Unitek, Seefeld, Germany), (2) 37% phosphoric acid, Pro Seal (Reliance Orthodontic Products, Itasca, Ill) and Transbond XT, (3) Clearfil Protect Bond (Kuraray Medical, Okayama, Japan) and Transbond XT, (4) 37% phosphoric acid and Light Bond (Reliance Orthodontic Products), and (5) Ortho Conditioner and Fuji Ortho LC (both, GC, Tokyo, Japan). In-vitro caries was created by pH cycling for 30 days. After demineralization, the teeth were scanned with a commercial cone-beam microtomographic system. Then the teeth were examined by polarized light microscopy.

RESULTS

The 2 methods of examination showed significant differences among the 5 groups according to lesion depth and mineral loss (P < 0.01). The resin-modified glass ionomer cement (group 5) had the lowest values for lesion depth and mineral loss.

CONCLUSIONS

Fuji Ortho LC showed a significantly smaller lesion depth and less mineral loss compared with the other materials. The cone-beam microtomographic system is suitable for evaluation of subsurface lesions and has considerable advantages.

Fluoride varnish reduces white spot lesions during orthodontic treatment

DESIGN

This was a randomised controlled trial (RCT) set in a community dental practice.

INTERVENTION

The test varnish was a commercially available product, Fluor Protector (Ivoclar Vivadent, Schaan, Liechtenstein), containing 0.1% fluoride as difluorosilane in a polyurethane varnish base. The placebo varnish applied had an identical composition but without fluoride.

OUTCOME MEASURE

The incidence and prevalence of white spot lesions (WSL) on the upper incisors, cuspids and premolars were recorded, as scored from digital photographs by two independent examiners. In the case of disagreement, cases were re-examined until a consensus was achieved.

RESULTS

The incidence of WSL during the treatment period was 7.4% in the fluoride varnish group compared with 25.3% placebo group (P <0.001). The mean progression score was significantly lower in the fluoride varnish group than in the placebo group, (0.8 +/- 2.0 vs 2.6 +/- 2.8; P <0.001). The absolute risk reduction was 18% and the number-needed-to-treat was calculated to be 5.5 (95% confidence interval, 3.7-10.9).

CONCLUSIONS

The results strongly suggest that regular topical fluoride varnish applications may reduce the development of WSL adjacent to the bracket base during treatment with fixed appliances.

Caries preventive measures used in orthodontic practices: an evidence-based decision?

INTRODUCTION

Although it is well known that treatment with fixed appliances increases the risk of enamel demineralization, little information is available about preventive measures that orthodontists actually use. This study was executed to survey measures used in orthodontic practices to prevent decalcifications during fixed appliance treatment, and to compare these measures with the available evidence-based information.

METHODS

A questionnaire was sent to all privately practicing orthodontists in the Netherlands who were affiliated with the Dutch Dental Association.

RESULTS

Of 229 orthodontists, 178 (78%) returned the questionnaires. Most of the orthodontists had a basic practice protocol for preventing demineralizations at the start of treatment. This protocol nearly always included oral hygiene instructions. If demineralizations occurred, 99% of the orthodontists took extra measures. Comparing the measures applied in the orthodontic practices with the evidence from a systematic review, a number of differences became apparent. The additional use of chlorhexidine or toothpaste with a high fluoride concentration (which has been demonstrated to have an inhibitive effect) is rarely prescribed. Fluoride rinse is prescribed most often, although there is not any high-quality, long-term study that demonstrates a caries preventive effect in orthodontic patients. Sixty-eight percent of the orthodontists considered it necessary to develop a practice guideline for preventing demineralizations.

CONCLUSIONS

Orthodontists do not implement the available evidence in order to prevent enamel demineralizations during fixed-appliance treatment. A practice guideline incorporating this information should be developed.