Effectiveness of remineralizing agents in the prevention and reversal of orthodontically induced white spot lesions: a systematic review and network meta-analysis

White spot lesion-related perception of aesthetics and treatment satisfaction among orthodontic patients, orthodontists and other dental specialists

OBJECTIVE

To investigate the impact of various degrees of white spot lesions (WSLs) of maxillary anterior teeth on the aesthetic perception and treatment satisfaction among orthodontic patients, orthodontists and other dental specialists and to evaluate the differences among the three groups.

METHODS

A total of 45 orthodontic patients (OP), 45 orthodontists (OR) and 45 other dental specialists (OS) were recruited. Subjective evaluations of perceived aesthetics and treatment satisfaction were performed towards eight digitally generated photographs of maxillary anterior teeth with incremental degrees of WSLs using a numerical visual analogue scale (VAS) from 0 to 100. Data were collected and analysed with descriptive statistics, repeated one-way analysis of variance and multivariable generalized estimating equations.

RESULTS

A total of 135 valid questionnaires were collected. Regarding aesthetic scores for WSLs, OP gave more positive scores than OR and OS (p < .05) towards excessive white spot formation without colouration and were more tolerant than OR (p < .05) towards excessive white spot formation with slight colouration. The level of treatment satisfaction for slight to severe WSLs without cavitation was higher in OP than OR. Patients with higher education levels had more negative scores for aesthetic perception and treatment satisfaction (p < .05). Patients who brushed teeth more frequently scored lower in treatment satisfaction (p < .05).

CONCLUSIONS

Orthodontists were the most critical when evaluating aesthetics and treatment satisfaction for slight to severe WSLs without cavitation. For orthodontic patients, better oral hygiene habits and higher education levels were associated with more critical attitudes towards WSLs.

Evaluation of the remineralization potential of self-assembling peptide P11-4 with fluoride compared to fluoride varnish in the management of incipient carious lesions: a randomized controlled clinical trial

OBJECTIVES

The present trial's aim was to compare the remineralization potential of self-assembling peptide P11-4 combined with fluoride to that of fluoride varnish.

MATERIALS AND METHODS

Twenty-eight participants with 58 incipient carious lesions were enrolled in the present trial. Participants were randomly divided into two groups with 14 participants and 29 incipient lesions in each group. Patients were assigned either to self-assembling peptide combined with fluoride (Curodont Repair Fluoride Plus™) or sodium fluoride varnish (NaF, Bifluorid 10) groups. Both agents were applied according to the manufacturer's instructions on non-cavitated incipient carious lesions. Lesions were assessed by two calibrated and blinded assessors at baseline, and after one-, three- and six-months using a laser fluorescence device (DIAGNOdent).

RESULTS

Although laser fluorescence scores significantly improved in both groups over time (p < 0.05), no notable differences were evident between both groups at one-month (p > 0.05). Yet, at three- and six-months statistically lower laser fluorescence readings were evident in the self-assembling peptide combined with fluoride group in comparison to the fluoride alone group (p < 0.05). There was 60% less risk for caries progression for Curodont Repair Fluoride Plus™ when compared to NaF varnish after six months. Self-assembling peptide combined with fluoride was able to change 65.5% of non-cavitated carious lesions from DIAGNOdent score 3 (11-20) to score 1 (0-4). Fluoride varnish was able to change 13.8% of the lesions from score 3 to score 1 after six months.

CONCLUSIONS

The self-assembling peptide combined with fluoride varnish showed higher remineralization potential than fluoride varnish alone for incipient carious lesions over a six-months follow up.

CLINICAL RELEVANCE

The combination of self-assembling peptide P11-4 and fluoride could offer a new tool in managing incipient carious lesions.

Development of Tooth Brushing Recommendations Through Professional Consensus

INTRODUCTION

Despite being a largely preventable disease, untreated caries of permanent teeth is estimated to affect almost 2 billion people worldwide, which is followed by severe periodontal disease. The aim of this work was to provide a professional consensus on tooth brushing methods and associated oral hygiene behaviours and develop evidence-informed recommendations.

METHODS

An initial scoping search was undertaken to identify systematic reviews of relevance and key questions. This was followed by comprehensive evidence mapping of the literature focussing on systematic reviews and clinical guidelines. Electronic searches of several databases including MEDLINE (via Ovid), Embase (via Ovid), Epistemonikos, and The Cochrane Library were undertaken from 2000 to May 2022, alongside a guideline repository search. Considered Judgement Forms were developed detailing the underpinning evidence, balance between benefits and harms, potential impact on the population, and feasibility of implementation. An online survey comprising 22 draft recommendations was distributed to international members of all FDI committees, including the FDI Council. Participants were asked to indicate to what level they agreed or disagreed with for each recommendation and to provide feedback. The Considered Judgement Forms were provided for reference.

RESULTS

Three hundred ten records were identified and mapped to different aspects of tooth brushing methods and associated behaviours. Research literature informed 7 Considered Judgement Forms comprising 12 questions with draft recommendations. Twenty-five participants from Asia, Europe, North and South America, Africa, and Australia provided feedback on the recommendations. More than 70% of respondents showed agreement with 21 of the 22 draft recommendations. Final recommendations were drafted with associated strength of recommendation.

CONCLUSION

Using a robust methodology and an international professional consensus, a set of evidence-informed recommendations was developed. These recommendations provide clinicians with practical guidance to facilitate communications with patients that may help to reinforce individual-level preventive strategies.

Remineralizing effect of the association of nano-hydroxyapatite and fluoride in the treatment of initial lesions of the enamel: A systematic review

OBJECTIVE

Assessed the effect of dental products containing nano-hydroxyapatite (nano-HA) + fluoride on the remineralization of white spot lesions (WSL) in vivo or in situ.

METHODS

Seven databases were explored using a two-pronged approach (intervention/treatment). After screening, full-text assessment, and further exclusion, the qualitative synthesis of five studies (four clinical and one in situ) was performed. Based on the Cochrane collaboration guidelines relevant data of the studies were collected and summarized. The Cochrane risk of bias tool for randomized trials (RoB 2.0) was used to appraise the studies' methodological quality and the GRADE guidelines to assess their level of evidence. The RoB 2.0 domains were rated on their risk of bias (RoB) as low, high, or with some concerns, and an adaptation of the tool was used to the in situ study.

RESULTS

The included studies assessed 151 WSL in anterior permanent teeth, on patients with varying ages. The protocol application, treatment length (7d-12 w), and control groups varied greatly between the studies making the performance of a quantitative analysis unfeasible. The general RoB of the clinical studies was classified as being of low risk (n = 2) or some concerns (n = 2). The in situ study was considered as being of low risk. The level of the evidence was moderate. Most of the studies found moderate evidence regarding the superiority of this association in clinical settings.

CONCLUSION

Even with the nano-HA + fluoride promising results for the remineralization treatment of WSL, due to the restricted number of studies and types of products, its extended use cannot be recommended based on the current systematic review, especially when considering the moderate level of the evidence found.

CLINICAL SIGNIFICANCE

Due to the biocompatibility and higher surface coverage of nano-HA and the remineralization capacity of fluoride formulations, the association of these elements to remineralize WSL has been positively reported. After the collection and qualitative appraise of the data, the clinical evidence of the use of these dental products is promising but limited.

Effect of Dentifrice Ingredients on Volume and Vitality of a Simulated Periodontal Multispecies Biofilm

The aim of this in vitro study was to investigate the effect of different toothpaste ingredients on biofilm volume and vitality in an established non-contact biofilm removal model. A multi-species biofilm comprising Porphyromonas gingivalis, Streptococcus sanguinis, and Fusobacterium nucleatum was grown on protein-coated titanium disks. Six disks per group were exposed to 4 seconds non-contact brushing using a sonic toothbrush. Four groups assessed slurries containing different ingredients, i.e., dexpanthenol (DP), peppermint oil (PO), cocamidopropyl betaine (CB), and sodium hydroxide (NaOH), one positive control group with the slurry of a toothpaste (POS), and a negative control group with physiological saline (NEG). Biofilm volume and vitality were measured using live-dead staining and confocal laser scanning microscopy. Statistical analysis comprised descriptive statistics and inter-group differences. In the test groups, lowest vitality and volume were found for CB (50.2 ± 11.9%) and PO (3.6 × 105 ± 1.8 × 105 µm3), respectively. Significant differences regarding biofilm vitality were found comparing CB and PO (p = 0.033), CB and NEG (p = 0.014), NaOH and NEG (p = 0.033), and POS and NEG (p = 0.037). However, no significant inter-group differences for biofilm volume were observed. These findings suggest that CB as a toothpaste ingredient had a considerable impact on biofilm vitality even in a non-contact brushing setting, while no considerable impact on biofilm volume was found.

White spot lesions in fixed orthodontic treatment: Etiology, pathophysiology, diagnosis, treatment, and future research perspectives

White spot lesions (WSLs) refer to localized areas of hypo-mineralization limited to the enamel of the teeth surface, which is noticeable clinically to the naked eye on drying of the teeth. During fixed orthodontic treatment, it is very hard for the patient to maintain excellent oral hygiene as the brackets, bands, wires, elastics, and other appliances and attachments worn intra-orally provide a platform for food retention, plaque formation, and then colonization by acidogenic bacteria like Streptococcus mutans and Lactobacillus. This review aims to elaborate and focus on etiology, pathophysiology, diagnosis, treatment aspect, and future scope for research about the WSLs occurring due to fixed orthodontic treatment.

Effect of patients' attitude and perception of oral hygiene on white spot lesion development and plaque accumulation during orthodontic treatment : A survey of patients with fixed appliances

PURPOSE

To explore the impact of oral hygiene practices, as well as beliefs and attitudes toward orthodontic treatment on white spot lesion (WSL) development and plaque accumulation in orthodontic patients.

MATERIALS AND METHODS

A total of 106 individuals (61 female, 45 male) patients aged 10-49 years who were treated with fixed appliances treatment completed a 14-question survey regarding aspects of their oral hygiene (OH) and orthodontic visits. The number of teeth with WSL and the plaque indexes were recorded for each patient. Poisson regression and linear regression models were used to analyze the association of survey responses with the observed WSLs and plaque accumulation, respectively.

RESULTS

Participants of both sexes reported similar beliefs about OH (66% agreed to the importance of OH statements), practiced proper OH (69% good practices), and reported a similar perception regarding the quality of their OH routine and of their orthodontic treatment. However, in total, none of the findings was significantly related to the development of WSLs or plaque accumulation. Significantly fewer WSLs were observed in male patients who perceived themselves as having good control over OH. Female participants reported significantly higher expectations regarding posttreatment smile improvement compared to males. Overall, responses by male participants were deemed to be more accurate than those by female participants when related to WSL development and plaque accumulation.

CONCLUSION

Our survey hints at a possible relationship between WSL formation and patients' sense of control over OH routine in males. Future studies should further explore the effect of sex on the attitude toward and perception of OH in orthodontic patients. This survey highlights the multifactorial nature of WSL development in orthodontic patients and the complexity of predicting patient compliance.

In-vitro effect of a single application of CPP-ACP pastes and different fluoridated solutions on the prevention of dental caries around orthodontic brackets

OBJECTIVE

To assess the in-vitro effect of single applications of CPP-ACP pastes and different fluoridated solutions on the prevention of dental caries around orthodontic brackets.

MATERIAL AND METHODS

Tooth/bracket sets (n=65) were immersed in artificial saliva (1h at 37ºC) and randomly subjected to single applications (100µL; 1min) of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP emulsion), CPP-ACP with fluoride (CPP-ACPF emulsion), solutions of titanium tetrafluoride (TiF4) or sodium fluoride (NaF), or no treatment (CG). Multispecies biofilm (5 x 105 CFU/mL) was formed in the presence of 2% sucrose. After 24 h, the pH and the concentration of total soluble fluoride (TSF) were analyzed by culture medium. The presence of active white spot lesions (WSL) evaluated by macroscopic examination and the percent surface mineral loss (%SML) were analyzed. Also, the topography of enamel was detected by analysis of scanning electron microscopy (SEM). The data was assessed by chi-square, Kruskal-Wallis, and Mann-Whitney tests (p < 0.05).

RESULTS

Fluoride-containing compounds led to a smaller pH reduction than did CPP-ACP and CG (p<0.05). There was difference in TSF between the groups (p<0.05), denoted as TiF4> NaF > CPP-ACPF > CPP-ACP > CG. Regarding the presence of WSL and %SML, the NaF group obtained lower values (p<0.05), while TiF4 and CPP-ACPF were similar (p>0.05). SEM demonstrated that fluoride-free groups had a larger surface dissolution.

CONCLUSION

Fluoridated groups including solutions and CPP-ACPF were more effective than CPP-ACP in reducing enamel demineralization around orthodontic brackets after a single application.

Effect of re-mineralizing surface treatment on the shear bond strength of orthodontic bracket: A systematic review and meta-analysis of in-vitro studies

INTRODUCTION

Re-mineralizing surface pretreatment is essential for both controlling and preventing white spot lesion (WSL) throughout the time of fixed orthodontic treatment. It is also important that the re-mineralizing have no negative impact on the bonding between the bracket, adhesive, and enamel. Therefore, this review is aimed to investigate the orthodontic brackets' shear bond strength after re-mineralizing surface treatment of enamel.

MATERIAL AND METHODOLOGY

The review was conducted following the PRISMA 2020 guidelines. In-vitro experimental studies measuring shear bond strength (SBS) of orthodontic brackets on both demineralized and intact enamel following re-mineralizing surface treatment were included. Database search was done in PubMed, Scopus, and Science Direct during July 2023. Methodological quality of the studies was assessed according to the guidelines for the reporting of pre-clinical in-vitro studies. Both qualitative and quantitative analyses of the included studies were done.

RESULTS

Matching the inclusion criteria, 46 and 37 studies were selected for qualitative and quantitative analysis respectively. On intact enamel re-mineralizing agents had no negative impact on the brackets' SBS. On the contrary, they seemed to enhance the bond strength remarkably on the demineralized enamel.

DISCUSSION

Re-mineralizing surface pretreatment is crucial prior to fixed orthodontic treatment as it did not reduce the bond strength. Although, it cannot be judged depending solely on the in-vitro results with high heterogeneity. Clinical evidence is required to support the statement.

Comparative evaluation of four treatments for postorthodontic white spot lesions: a randomized controlled trial

OBJECTIVES

To evaluate the treatment efficacy of fluoride toothpaste alone and those of adjunctive use of resin infiltration, sodium fluoride varnish, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs).

MATERIALS AND METHODS

Seventy-nine patients (356 teeth) with WSLs after orthodontic treatment were randomly allocated into four groups. The WSLs of the participants received resin infiltration only at baseline, and the other groups received fluoride varnish, CPP-ACP mousse, and placebo treatment every 6 months, respectively. A toothpaste containing 1400 ppm fluoride and toothbrushes were distributed to all participants, and oral hygiene instructions were provided. Photos of the teeth with WSL were taken to compare the change between groups which was measured by ImageJ software.

RESULTS

Twelve months later, different degrees of reduction in the area of WSLs were observed in all groups. The percentage of lesion area reduction in WSLs in the resin infiltration group was 46.6%, which was significantly higher than that in fluoride varnish group (26.6%), CPP-ACP group (28.6%), and control group (29.8%), and the differences were statistically significant (p < 0.001).

CONCLUSIONS

This study shows that after 1-year follow-up, the use of fluoride toothpaste, with or without the use of fluoride varnish or CPP-ACP, can reduce the area of WSLs. While resin infiltration can immediately improve dental aesthetics and continuously improved in 12 months, resin infiltration group showed much better results than other groups.

TRIAL REGISTRATION

Clinical Trials Registration Number: ChiCTR2000032516.

CLINICAL SIGNIFICANCE

The use of fluoride toothpaste, with or without adjunctive use of fluoride varnish and CPP-ACP, can reduce the area of WSLs, while resin infiltration treatment has additional effect and can immediately improve dental aesthetics.

Methodological quality of network meta-analysis in dentistry: a meta-research

This meta-research aimed to provide an overview of the methodological quality and risk of bias of network meta-analyses (NMA) in dentistry. Searches for NMA of randomized clinical trials with clinical outcomes in dentistry were performed in databases up to January 2022. Two reviewers independently screened titles/abstracts, selected full texts, and extracted the data. The adherence to PRISMA-NMA reporting guideline, the AMSTAR-2 methodological quality tool, and the ROBIS risk of bias tool were assessed in the studies. Correlation between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results was also investigated. Sixty-two NMA studies were included and presented varied methodological quality. According to AMSTAR-2, half of the NMA presented moderate quality (n = 32; 51.6%). The adherence to PRISMA-NMA also varied. Only 36 studies (58.1%) prospectively registered the protocol. Other issues lacking of reporting were data related were data related to the NMA geometry and the assessment of results consistency, and the evaluation of risk of bias across the studies. ROBIS assessment showed a high risk of bias mainly for domains 1 (study eligibility criteria) and 2 (identification and selection of studies). Correlation coefficients between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results showed moderate correlation (rho < 0.6). Overall, NMA studies in dentistry were of moderate quality and at high risk of bias in several domains, especially study selection. Future reviews should be better planned and conducted and have higher compliance with reporting and quality assessment tools.

Antibacterial and fluorescent clear aligner attachment resin modified with chlorhexidine loaded mesoporous silica nanoparticles and zinc oxide quantum dots

OBJECTIVES

To develop an antibacterial and fluorescent clear aligner attachment resin via the incorporation of chlorhexidine loaded pore-expanded mesoporous silica nanoparticles (CHX@pMSN) and amino-silane functionalized zinc oxide quantum dots (aZnO_QDs), and to evaluate its antibacterial activity, fluorescence capability, esthetic properties, mechanical performance and biocompatibility.

METHODS

CHX@pMSN and aZnO_QDs were incorporated into the commercial resin composites (Filtek Z350 XT, 3M) at different mass fractions, control group: Filtek; fluorescent attachment resin (FAR): Filtek + 3 wt% aZnO_QDs; antibacterial and fluorescent attachment resin (AFAR)-1: Filtek + 3 wt% aZnO_QDs + 1 wt% CHX@pMSN; AFAR-2: Filtek + 3 wt% aZnO_QDs + 3 wt% CHX@pMSN; AFAR-3: Filtek + 3 wt% aZnO_QDs + 5 wt% CHX@pMSN. CHX release, antibacterial activity, fluorescence capability, color change, stain resistance, degree of conversion, depth of cure, polymerization shrinkage, water sorption and solubility, softening in solvent, flexural strength, flexural modulus, shear bond strength, and cytotoxicity were evaluated comprehensively.

RESULTS

CHX could be continuously released from the AFAR groups for up to 30 days. CFU, MTT, lactic acid production, SEM and CLSM evaluation showed AFAR-2 and AFAR-3 could effectively inhibit S. mutans biofilms even after 1-month aging. Only AFAR-3 showed clinically perceptible color change and all the experimental groups were not more susceptible to staining. AFAR-1 and AFAR-2 could suppress polymerization shrinkage and enhance the resistance to degradation without compromising other properties, including degree of conversion, water sorption and solubility, flexural strength, flexural modulus, and shear bond strength. Depth of cure of all the four experimental groups was significantly decreased (p < 0.05) but still within the ISO standard. CCK-8 assay and live/dead cell staining denied the cytotoxicity of experimental resins. Fluorescence intensity tests showed that FAR and AFAR-2 could emit strong yellowish fluorescence under the excitation of ultraviolet for up to six months.

CONCLUSIONS

AFRA-2 possessed long-term antibiofilm activity, strong fluorescence capability and satisfying biocompatibility without compromising esthetic and mechanical properties. This study proposed a new strategy for reducing bacteria accumulation around the attachment, which is also promising in helping orthodontists to remove the attachment thoroughly and precisely.

Recent advances in antibacterial coatings for orthodontic appliances

In the process of orthodontic treatment, the presence of orthodontic appliances makes it difficult to clean tooth surfaces. This can lead to an increased level of bacterial colonization, resulting in enamel demineralization and periodontal diseases. Considering the large surface area that orthodontic appliances usually have and that they can be in direct contact with bacteria throughout the treatment, modifications in the form of coatings on the surface of orthodontic appliances can be an effective and practical approach to reducing bacterial proliferation and preventing relevant adverse effects. In this mini-review, we discuss various antibacterial coatings which have been applied onto orthodontic appliances in recent 5 years, as well as their antibacterial mechanisms and methods for the preparation of these coatings. From this mini-review, both orthodontists and researchers can get the latest findings in the field of antibacterial coatings onto orthodontic appliances, which is helpful for the decision-making in clinical practice and research activities.

Synergistic remineralization of enamel white spot lesions using mesoporous bioactive glasses loaded with amorphous calcium phosphate

Objectives: The purpose of this study was to create a new delivery system that can synergistically remineralize enamel white spot lesions (WSLs). Materials and methods: The delivery system (PAA-ACP@aMBG) was prepared by using aminated mesoporous bioactive glasses (aMBG) as the carrier loaded with polyacrylic-stabilized amorphous calcium phosphate (PAA-ACP). The materials were characterized by transmission electron microscopy (TEM), X-ray powder diffraction (XRD), inductively coupled plasma-optical emission spectrometry (ICP-OES), and so on. Forty-eight artificial WSLs enamel samples were randomized to four groups: artificial saliva (negative control, NC), casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), PAA-ACP@aMBG, and MBG. The effects of demineralization and remineralization of the enamel surface were compared by means of surface microhardness (SMH) measurements, surface color change measurements, fluorescence microscopy (FM), X-ray diffraction (XRD) analysis and scanning electron microscopy (SEM). Results: There was no significant difference in the surface microhardness recovery rate (SMHRR) or color recovery rate (CRR) among the CPP-ACP group, PAA-ACP@aMBG group and MBG group (P>0.05), but these values were significantly higher than those in the NC group (p < 0.01). FM demonstrated that the remineralization depth in the PAA-ACP@aMBG group was significantly greater than that of the remaining three groups (p < 0.01). SEM analysis indicated that the enamel demineralization marks in the PAA-ACP@aMBG group, CPP-ACP group, and MBG group were obscured by mineral deposition. Conclusions: PAA-ACP@aMBG showed good mineralization properties, implying its great potential for clinical application.

A novel amelogenesis-inspired hydrogel composite for the remineralization of enamel non-cavitated lesions

Enamel non-cavitated lesions (NCLs) are subsurface enamel porosity from carious demineralization. The developed enamel cannot repair itself once NCLs occurs. The regeneration of mineral crystals in a biomimetic environment is an effective way to repair enamel subsurface defects. Previously, an amelogenin-derived peptide named QP5 was proven to repair demineralized enamel. In this work, inspired by amelogenesis, a novel biomimetic hydrogel composite containing the QP5 peptide and bioactive glass (BG) was designed, in which QP5 could promote enamel remineralization by guiding the calcium and phosphorus ions provided by BG. Also, BG could adjust the mineralization micro-environment to alkalinity, simulating the pH regulation of ameloblasts during enamel maturity. The BQ hydrogel composite showed biosafety and possessed capacity for enamel binding, ion release and pH buffering. Enamel NCLs treated with the BQ hydrogel composite showed a higher reduction in lesion depth and mineral loss both in vitro and in vivo. Moreover, compared to the hydrogels containing only BG or QP5, groups treated with the BQ hydrogel composite attained more surface microhardness recovery and color recovery, exhibiting resistance to erosion and abrasion of the remineralization layer. We envision that the BQ hydrogel composite can provide a biomimetic micro-environment to favor enamel remineralization, thus reducing the lesion depth and increasing the mineral content as a promising biomimetic material for enamel NCLs.

Resin Infiltration of Non-Cavitated Enamel Lesions in Paediatric Dentistry: A Narrative Review

The resin infiltration (RI) technique was introduced as one of the minimal intervention dentistry strategies in addressing dental caries among the paediatric population. This technique used the low-viscosity resin monomer to infiltrate the non-cavitated carious lesion and other developmental enamel porosities, thus allowing the conservation of the tooth structure. This narrative review aims to explore the value of RI in Paediatric Dentistry. Through our search of the literature, the development of the material, their clinical applications and shortcomings, as well as the innovation that has been carried out to improve the current RI, were discussed. There are number of high-level evidence supporting the use of RI in arresting non-cavitated proximal caries lesions in primary and permanent teeth, but its efficacy in managing anterior white spot lesions is still unclear. Limited penetration depth, not radiopaque and questionable long-term colour and material stability were among the limitation of the material. Various laboratory-based studies have been conducted to improve the current properties of RI. Nevertheless, RI has emerged as one of the important micro-invasive techniques in addressing non-cavitated and anterior white-spot enamel lesions in children and adolescents with great success.

Correlation of quantitative light-induced fluorescence and qualitative visual rating in infiltrated post-orthodontic white spot lesions

OBJECTIVES

The aim of this prospective, clinical single-centre study was to evaluate the masking efficacy of post-orthodontic resin infiltration after 12-month follow-up and correlate quantitative and qualitative outcome measures.

METHODS

Patients with completed fixed orthodontic treatment and the presence of one or more vestibular active non-cavitated white spot lesion/s (WSL) [ICDAS 1 or 2 (International Caries Detection and Assessment System)] were provided with resin infiltration 3-12 months after bracket removal. All patients (n = 31) participating before (t0) intervention were invited again and examined after 12 months (t2). Enamel demineralization was scored using quantitative light-induced fluorescence [QLF (DeltaF[flourescence], DeltaQ[lesion volume], White Spot Area)] and qualitative visual rating [11-point Likert-scale from 0 (no lesions visible on any tooth) to 10 (all teeth affected on the entire vestibular surface)].

RESULTS

In 17 patients (7 female and 10 male) 112 WSL (ICDAS 1: n = 1; ICDAS 2: n = 111) in 112 teeth were (re)examined. Before treatment (t0) a significant, weak (DeltaF), and moderate (DeltaQ, White Spot Area) correlation was observed between the quantitative and the qualitative rating (P < 0.002) [median DeltaF: -7.31 (-10.4/-6.58)%; DeltaQ:-2.25 (-10.8/-0.41)% mm2; White Spot Area: 0.34 (0.05/1.16) mm2; visual rating:3.7 ± 1.2]. Resin infiltration led to significantly increased fluorescence and decreased visual scores (P < 0.001) 7 days (t1) and 12 months (t2) after treatment. No significant changes based on DeltaF [-6.55 (-7.29/-6.08)%] and on visual ratings [1.0 ± 1.0] were observed between t1 and t2 (P = 1.000). After 7 days (t1) the correlation between the quantitative and the qualitative ratings remained significant, weak to moderate (P < 0.002). After 12 months (t2) the correlation was (non-)significant and weak for DeltaF, DeltaQ, and White Spot Area (P ≤ 0.097).

LIMITATIONS

Since the overall masking efficacy of resin infiltration has been shown previously, an untreated control group was omitted.

CONCLUSIONS

When assessing the masking efficacy of infiltrated post-orthodontic WSL only a weak to moderate correlation was found between QLF values and visual ratings. Furthermore, over time this correlation decreased. Thus, it remains unclear if QLF is a viable method to assess and quantify infiltrated post-orthodontic WSL over time.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID:DRKS00005067).

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2021 dental literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to coverage of this broad topical area. Specific subject areas addressed, in order of the appearance in this report, include COVID-19 and the dental profession (new); prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders; sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence daily dental treatment decisions with an emphasis on future trends in dentistry. With the tremendous volume of dentistry and related literature being published daily, this review cannot possibly be comprehensive. Rather, its purpose is to update interested readers and provide important resource material for those interested in pursuing greater details on their own. It remains our intent to assist colleagues in negotiating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the patients and dental problems they encounter.

Fluoride varnish, ozone and octenidine reduce the incidence of white spot lesions and caries during orthodontic treatment: randomized controlled trial

This randomized, parallel, controlled trial assessed the effect of fluoride varnish, ozone and octenidine on white spot lesions (WSLs) and caries during orthodontic treatment. Patients were enrolled between 1st September 2017 and 31st August 2020 at initiation of orthodontic treatment in Department of Interdisciplinary Dentistry Pomeranian Medical University in Szczecin, Poland. All participants were randomly assigned to four study and one control groups using number random generator. However, investigators were not blinded due to the nature of the study. Groups I, II, III, IV had professional cleaning and varnishing (5% NaF) every 4 weeks. Groups II and IV had in-office ozone therapy before varnishing, groups III and IV received domestic octenidine mouthrinse. Group K had no professional hygienic or prophylactic procedures. WSLs were assessed at T0 and then every 4 weeks (T1-T4) and caries-at T0 and T4. The specific objective was to assess the influence of fluoride varnish, ozone and octenidine on the incidence of white spot lesions and caries during orthodontic treatment. The primary outcome of this report was the highest number of WSLs in group K and the lowest percentage of patients with WSLs in group IV. Each group comprised 30 randomized participants; they were all analyzed. No WSLs were found at T0, but they were stated in all groups at T4. The numbers of patients with WSLs significantly increased between T0-T4 in groups I and K. Group IV had the lowest percentage of patients with WSLs in T1-T4. WSLs in group IV were found no earlier than at T2. Group K had the highest percentage of WSLs at T4: 26%. At T0 all the groups had DMFs above 0 with a significant increase at T4. No side effects of the introduced prophylaxis were observed in any group. Caries is an important problem of fixed orthodontic treatment. Even an extremely intensive prophylaxis could not completely prevent WSLs and caries. Simultaneous application of fluoride varnish, ozone gas exposure and octenidine appears to have a beneficial effect in limiting the development of WSLs.Trial registration: NCT04992481.

Management of white spot lesions induced during orthodontic treatment with multibracket appliance: a national-based survey

OBJECTIVES

The study aimed to survey current strategies against enamel demineralization during multibracket therapy (MBT) and guide a prevention concept based on existing scientific evidence.

MATERIALS AND METHODS

The survey comprised questions on the prevention and management of white spot lesions (WSL). The questionnaire was sent via email to orthodontists working in practices and universities throughout Germany. The analysis involved descriptive statistics using the chi-square test (p < 0.05).

RESULTS

A prevention protocol was used before MBT by 80.6% of the participants. Less than a quarter of the participants regularly applied topical fluoride (gel or varnish) during MBT. According to the respondents' assessment, the prevalence of WSL during MBT is 11.6%, mainly observed in 12- to 15-year-old male patients. Orthodontists graduating after 2000 tended to recommend and apply fluoride-containing materials more often than their senior colleagues (p = 0.039). Participants from private practices applied fluoride varnish or gel more frequently than those from university clinics (p = 0.013). Fluoridation was the most common (70.7%) treatment for WSL after MBT, followed by resin infiltration (21.2%). The majority (80.9%) of the participants favor a guideline for preventing WSL.

CONCLUSIONS

WSL prevention during MBT is challenging. Males in puberty are predominantly affected. Younger orthodontists are more concerned about the prevention of WSL during MBT.

CLINICAL RELEVANCE

The non-negligible prevalence of individuals with WSL emphasizes the need for dental education and health care reform. This would help to implement standardized procedures and establish innovative applications.

Efficacy of sealants and bonding materials during fixed orthodontic treatment to prevent enamel demineralization: a systematic review and meta-analysis

To analyse clinical studies investigating coating agents such as sealants and other bonding materials to prevent the initiation or inhibit the progress of white spot lesions (WSL) during orthodontic treatment with fixed appliances. Electronic databases (Pubmed, CENTRAL, EMBASE) were screened for studies. No language restrictions were applied. Study selection, data extraction and quality assessment were done in duplicate. Primary outcome included assessment of WSL with visual-tactile assessment and/or laser fluorescence measurements. Twenty-four studies with 1117 patients (age: 11–40 years) and 12,809 teeth were included. Overall, 34 different sealants or bonding materials were analysed. Fourteen studies analysed fluoride and 14 studies non-fluoride releasing materials. Meta-analysis for visual tactile assessment revealed that sealants significantly decreased the initiation of WSL compared to untreated control (RR [95%CI] = 0.70 [0.53; 0.93]; very low level of evidence). Materials releasing fluoride did not decrease initiation of WSL compared to those with no fluoride release (RR [95%CI] = 0.84 [0.70; 1.01]; very low level of evidence). For laser fluorescence measurements no meta-analysis could be performed. The use of sealants seems to be effective in preventing the initiation of post-orthodontic WSL. Furthermore, there is no evidence supporting that fluoride-releasing sealants or bonding materials are more effective than those without fluoride release. No gold standard prevention strategy to prevent WSL during treatment with fixed orthodontic appliances has been established yet. However, based on only a limited number of studies the use of sealants seems to be effective in preventing the initiation of post-orthodontic WSL.

Protocol for the development of a Core Outcome Set for trials on the prevention and treatment of Orthodontically induced enamel White Spot Lesions (COS-OWSL)

BACKGROUND

Enamel white spot lesions (WSLs), characterized by an opaque, matt, and chalky white appearance of enamel, are a sign of incipient caries. WSLs are common in orthodontic practice and can affect both the oral health and dental aesthetics of patients. Extensive studies have been conducted to evaluate the effectiveness of prevention or treatment for orthodontically induced enamel WSLs. However, substantial heterogeneity has been found in the outcomes used for the prevention and treatment of WSLs in literature, which prevents researchers from comparing and combining the results of different studies to draw more decisive conclusions. Therefore, we aim to develop a Core Outcome Set for trials on the prevention and treatment of Orthodontically induced enamel White Spot Lesions (COS-OWSL).

METHODS

The development of COS-OWSL comprises four phases: (1) a scoping review to identify and summarize all existing outcomes that have been used in trials on the prevention or treatment of orthodontically induced WSLs; (2) qualitative interviews with orthodontic patients without (for prevention) and with WSL-affected teeth (for treatment) and relevant dental professionals to identify additional outcomes relevant to them; (3) Delphi surveys to collect opinions from key stakeholders including patients, dental professionals, and researchers and to reach a preliminary consensus; and (4) a consensus meeting to develop the final COS-OWSL.

DISCUSSION

The COS-OWSL will be developed to facilitate the synthesis of evidence regarding the prevention and treatment of orthodontically induced WSLs and to promote the consistent use of relevant patient-important outcomes among future studies in this field.

TRIAL REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) initiative (the COS-WSL project) 1399.

Surface Characteristics, Fluoride Release and Bond Strength Evaluation of Four Orthodontic Adhesives

Orthodontic adhesives have similar properties in terms of fluoride release, roughness, shear bond strength or cement debris for specific clinical conditions. Three commercial consecrated orthodontic adhesives (Opal Seal^®, Blugloo^®, Light Bond^®) were compared with an experimental orthodontic material (C1). Brackets were bonded to enamel using a self-etch technique followed by adhesive application and then de-bonded 60 days later. Share bond strength evaluation, scanning electron microscopy, atomic force microscopy and fluoride release analysis were performed. The highest amount of daily and cumulative fluoride release was obtained for the experimental material, while the lowest value was observed for Opal Seal^®. The materials evaluated in the current study presented adequate shear bond strength, with the experimental material having a mean value higher than Opal Seal and Blugloo. The atomic force microscopy measurements indicated that the smoothest initial sample is Opal Seal^® followed by Light Bond^®. Scanning electron microscopy evaluation indicated different aspects of cement debris on the enamel and/or bracket surface, according to the type of adhesive. The experimental material C1 presented adequate properties in terms of shear bond strength, fluoride release, roughness and enamel characteristics after de-bonding, compared to the commercial materials. Under these circumstances, it can be considered for clinical testing.