Effectiveness of professional fluorides against enamel white spot lesions during fixed orthodontic treatment: A systematic review and meta-analysis

Graphene as a promising material in orthodontics: A review

Graphene is an extraordinary material with unique mechanical, chemical, and thermal properties. Additionally, it boasts high surface area and antimicrobial properties, making it an attractive option for researchers exploring innovative materials for biomedical applications. Although there have been various studies on graphene applications in different biomedical fields, limited reviews have been conducted on its use in dentistry, and no reviews have focused on its application in the orthodontic field. This review aims to present a comprehensive overview of graphene-based materials, with an emphasis on their antibacterial mechanisms and the factors that influence these properties. Additionally, the review summarizes the dental applications of graphene, spotlighting the studies of its orthodontic application as they can be used to enhance the antibacterial and mechanical properties of orthodontic materials such as adhesives, archwires, and splints. Also, they can be utilized to enhance bone remodeling during orthodontic tooth movement. An electronic search was carried out in Scopus, PubMed, Science Direct, and Wiley Online Library digital database platforms using graphene and orthodontics as keywords. The search was restricted to English language publications without a time limit. This review highlights the need for further laboratory and clinical research using graphene-based materials to improve the properties of orthodontic materials to make them available for clinical use.

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.

Enamel Matrix Derivative, 58S5 Bioactive Glass, and Fluoride Varnish for Enamel Remineralization: A Multi-analysis Approach

PURPOSE

This study aimed to evaluate the enamel remineralization efficacy of enamel matrix derivative (EMD), experimental bioactive glass (BAG), and fluoride varnish in vitro.

METHODS AND MATERIALS

Artificial initial caries lesions were developed on fifty human enamel specimens using demineralization solution (pH 4.5, 37°C, 96 hours). Specimens were randomly assigned to five groups (n=10): I-5% NaF varnish (Enamelast), II-experimental 58S5 BAG+37% phosphoric acid (PA), III-EMD (Emdogain) + Ethylenediaminetetraacetic Acid (EDTA), IV-EMD+37% PA, V-Control (untreated). All remineralization agents were applied with pH cycling for seven days. The specimens were scanned by spectral domain optical coherence tomography (SD-OCT) at baseline, at demineralization, and after pH cycling. Lesion depths were measured using image analysis software (ImageJ). Lesions were evaluated using surface microhardness (SMH) and two fluorescence methods (FluoreCam and DIAGNOdent Pen [DDPen]). The data were statistically analyzed by Kruskal Wallis, Friedman, and Wilcoxon tests (α=0.05).

RESULTS

According to SD-OCT results, fluoride varnish was found to be the most effective agent in reducing lesion depth (p=0.005). All agents increased the SMH values after pH cycling. No significant difference was found among fluoride varnish, BAG, and EMD+PA groups. These SMH values were significantly higher than EMD+EDTA and control groups (p<0.001). All groups showed lower DDPen scores compared with the control group (p<0.001), however, no significant difference was found among the remineralization agents. In FluoreCam assessment, size and intensity values of all treated groups showed improvement. However, there was no significant difference between the treatment groups in terms of FluoreCam size measurements (p=0.186).

CONCLUSION

58S5 BAG and EMD+PA have remineralization capacity as effective as fluoride varnish. EMD+PA showed better SMH and lesion intensity results than EMD+EDTA.

Long term remineralizing effect of casein phosphopeptide amorphous calcium phosphate in white spot lesions: A systematic review and meta-analysis

BACKGROUND

White spot lesions (WSLs) appear as white, opaque areas on the teeth and are caused by a demineralization of the enamel.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to determine whether casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has beneficial effects on WSLs and provides remineralizing benefits that are superior to those of placebo or no treatment.

METHODS

Following a thorough analysis of the literature across major online sources, 103 papers - 54 of which underwent in-depth evaluation - were found. We used inclusion and exclusion criteria to choose research articles that were appropriate for our review.

RESULTS

10 papers met this review's requirements and were subsequently included. As compared to the controls, CPP-ACP demonstrated increased efficacy in treatment of WSLs in terms of remineralisation and other parameters which included microhardness tests and enamel surface roughness. The forest plots present the results of meta-analyses comparing the effect of CPP-ACP versus control/other agents on white spot lesions (WSLs). In terms of odds ratios (OR), CPP-ACP showed a small increase in the odds of WSLs compared to control/other agents. In-vitro studies showed no significant difference in relative risk (RR) between CPP-ACP and control/other agents. Randomized control trials indicated a small increase in the risk of WSLs with CPP-ACP treatment, but the overall effect was not statistically significant.

CONCLUSION

There was evidence to support the use of CPP-ACP over other agents for WSL prevention or treatment, but further research is needed to confirm these findings.

Surface topography and spectrophotometric assessment of white spot lesions restored with nano-hydroxyapatite-containing universal adhesive resin: an in-vitro study

BACKGROUND

White spot lesion (WSL) is a main shortcoming accompanied by orthodontic treatment. It impairs the esthetic, surface hardness, and surface texture of enamel. So, this study was conducted to analyze the surface characteristics and color change of white spot lesions treated with nano-hydroxyapatite (nHA)-enriched universal adhesive resin.

MATERIALS AND METHODS

Eighty sound human permanent molars crowns were sectioned into two halves, producing 160 specimens. 16 specimens were left untreated, and 144 specimens were artificially-demineralized to generate WSLs. The specimens were classified according to the treatment approach applied as follows: I; Sound enamel, Group II; artificially-created WSLs, Group III; ICON resin-restored WSLs, Group IV; Universal adhesive resin-restored WSLs, Group V; 0.5 wt% nHA-containing universal adhesive resin-restored WSLs, Group VI; 1 wt% nHA-containing universal adhesive resin- restored WSLs, and Group VII; 3 wt% nHA-containing universal adhesive resin-restored WSLs, Group VIII; 5 wt% nHA-containing universal adhesive resin-restored WSLs, Group IX; 7 wt% nHA-containing universal adhesive resin-restored WSLs, and Group X; 10 wt% nHA-containing universal adhesive resin-restored WSLs. Some surface characteristics and color changes were assessed. Data was collected and analyzed statistically using ANOVA and the Tukey test at p < 0.05.

RESULTS

Surface microhardness of WSLs was significantly improved with all investigated ratios of nHA-containing universal adhesive (p < 0.0001), with the highest mean belonging to 10 wt% nHA-containing universal adhesive resin treated WSLs. All ratios of nHA-containing universal adhesive resin significantly reduced the surface roughness of WSLs (p < 0.0001). The investigated ratios of 1, 3, 5, 7, and 10 wt% nHA-containing universal adhesive resin treatment approach could mask the WSLs significantly (p < 0.0001).

CONCLUSIONS

Nano-hydroxyapatite-containing universal adhesive is a promising contemporary approach for the management of WSLs, coupled both the remineralizing concept and the minimally invasive resin infiltration.

White spot lesions in orthodontics: consensus statements for prevention and management

OBJECTIVE

To establish consensus recommendations for clinicians to manage white spot lesions (WSLs) during orthodontic treatment.

MATERIALS AND METHODS

Three task force members reviewed the literature to identify best practices for minimizing WSLs during orthodontic treatment. Each draft statement was read to the task force members by a facilitator, followed by voting, accepting, or editing if necessary. The statements were then sent electronically by an independent third party (Magellan Medical Technology Consultants Inc, Minneapolis, Minn) to a previously formed content validation panel consisting of 20 independent private practitioners and clinical academicians for validation.

RESULTS

Twenty-one statements were developed and sent for content validation. While 19 statements achieved a content validation index (CVI) of 0.78, two items did not. These items were edited by the task force members based on qualitative feedback from content validation participants. Each of these revised statements did achieve a CVI of 0.78 on second evaluation from the content validation panelists and therefore were included in this document.

CONCLUSION

To reduce the risk of WSLs, it is essential to implement individualized caries management measures based on a comprehensive assessment of the patient's oral and systemic health. Effective at-home and professional mechanical and chemical plaque control should be implemented for high-risk orthodontic patients. Fluoride to support prevention and materials such as orthodontic sealants should also be used to provide a physical barrier around the brackets in high-risk patients. By following these guidelines, orthodontic professionals can help promote oral health and minimize the need for restorative treatment.

Masking-efficacy and caries arrestment after resin infiltration or fluoridation of initial caries lesions in adolescents during orthodontic treatment-A randomised controlled trial

OBJECTIVES

The aim of this randomised, controlled, split-mouth trial was to assess the masking results in initial caries lesions (ICL) that were either resin infiltrated or fluoridated during treatment with fixed orthodontic appliances.

METHODS

Adolescent patients (age range:12-18years) with fixed orthodontic appliances who had developed ICL [ICDAS 1 or 2 (International Caries Detection and Assessment System)] during orthodontic treatment were consecutively recruited and randomly assigned to either resin infiltration with up to 3 etching procedures (Group:Inf) or to 3-monthly application of a fluoride varnish (Group:FV). Both interventions were performed according to the manufacturer's recommendations. Primary and secondary outcomes (ΔE, ICDAS, DIAGNOdent) included the evaluation of the appearance of the ICL before (T0), 1 week after (T1) treatment and at the last appointment before debonding (T2).

RESULTS

Fifteen patients (8females, 7males) with 57ICL were included. Mean (SD) observation time at the last appointment before debonding was 0.5 (0.3) years. At T0 FV and Inf did not differ significantly in ΔE (median ΔE0,FV(25th/75th percentiles):11.6 (8.7/20.3): ΔE0,Inf:15.1 (11.4/19.5); pT0 = 0.135), ICDAS (pT0 = 0.920) and DD (pT0 = 0.367). At T1 and T2 ΔE values (pT1<0.001, pT2<0.001), ICDAS scores (pT1<0.001, pT2<0.001) and DIAGNOdent values (pT1 = <0.001, pT2 = <0.001) for Inf were significantly reduced whereas ΔE values (pT1 = 0.382, pT2 = 0.072) and ICDAS scores (pT1 = 0.268, pT2<0.001) for FV remained unchanged.

CONCLUSIONS

Resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances both immediately after application and at the last appointment before debonding. Furthermore, the visual appearance of fluoridated lesions was not as satisfactory as that of the infiltrated ones at both T1 and T2.

CLINICAL SIGNIFICANCE

Resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances both immediately after application and at the last appointment before debonding. Furthermore, the visual appearance of fluoridated lesions was not as satisfactory as that of the infiltrated ones immediately after first application as well as half a year after application.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00011797).

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.

Evaluation of Nano TiO2 Modified Orthodontic Composite Effects on S. mutans Population and Enamel Demineralization in Fixed Orthodontic Patients; a Split Mouth Randomized Controlled Clinical Trial

The high incidence of demineralization around orthodontic brackets has led to the development of preventive measures. Incorporation of antibacterial or remineralizing agents into orthodontic adhesives is an attractive method. This single-center, split-mouth, randomized controlled clinical trial was conducted to assess the effect of a modified composite containing TiO2 nanoparticles on the Streptococcus mutans population and to prevent demineralization around orthodontic brackets. Each participant was assigned a random sequence (AB or BA). During the bonding session, the control lateral incisor was bonded with a conventional composite and the contralateral incisor was bonded with a composite containing nano TiO2 particles (1%weight). The eligibility criteria included the presence of S. mutans in the dental plaque and absence of active caries, fractures or cracks. The S. mutans count in the dental plaque immediately around the brackets was evaluated at baseline and 1, 3, and 6 months after bonding. The specificity of the colonies was determined by PCR. The DIAGNOdent score was assessed at baseline and re-assessed every month up to the sixth month. Salivary samples were collected at T0, T1, and T3 to assess the amount of Ti released from the composite. The cytotoxicity of the modified composites was evaluated using an MTT assay. Participants, examiners, and data analyzers were blinded to the test and intervention groups. Forty-two patients ranging from 12 to 25 years were enrolled in this study. The amount of Ti released into saliva was insignificant and far below the toxic level. There was no significant difference between the S. mutans counts of the studied tooth S. mutans counts at any time point evaluated. DIAGNOdent scores on both sides increased significantly after the first month. However, this increase was higher on the test side (p < 0.001), and a significant difference of 2.6 scores remained throughout the study period. No severe adverse events were observed. Orthodontic composites containing TiO2 nanoparticles may prevent demineralization induced around brackets during orthodontic treatment. However, the antibacterial effects were not statistically significant.Registration: The protocol was registered with the IRCT.ir (IRCT20140215016582N6).

Prevention of white spot lesions with fluoride varnish during orthodontic treatment with fixed appliances: a systematic review

BACKGROUND

Fluoride varnish (FV) is an established technology for primary and secondary caries prevention.

OBJECTIVE

The aim of this review was to evaluate the preventive effect of FV on development of white spot lesions (WSL) when regularly applied during orthodontic treatment with fixed appliances.

SEARCH METHODS

We searched PubMed, Scopus and Google Scholar up to October 2022 using predetermined keywords.

SELECTION CRITERIA

We included randomized controlled trials of a duration of minimum 12 months and at least quarterly FV applications.

DATA COLLECTION AND ANALYSIS

Based on abstracts, we retrieved full-text papers, extracted key outcome data, and assessed risk of bias. Primary outcome was prevalence of WSLs on subject level after debonding. We conducted a narrative synthesis and pooled comparable outcome data in a random effects model.

RESULTS

We included seven studies covering 666 patients and assessed four publications with low or moderate risk of bias and three with high. The prevalence of WSLs at debonding varied between 12 and 55%. All studies presented results in favour for the FV intervention, one reached statistical significance on subject level. Five studies provided data for a meta-analysis. The pooled risk ratio was 0.64 [95% CI: 0.42, 0.98], indicating a statistically significant preventive effect. Certainty of evidence was graded as very low after reducing for risk of bias, inconsistency and imprecision.

LIMITATIONS

We pooled data on subject level and did not consider lesion severity on tooth level.

CONCLUSIONS AND IMPLICATIONS

Even if the certainty of evidence was very low, it was shown that FV can prevent development of WSL when regularly applied during orthodontic treatment. Larger investigations reporting a core outcome set are required to increase the certainty of evidence.

REGISTRATION

PROSPERO database (CRD42022370062).

White Spots: Prevention in Orthodontics-Systematic Review of the Literature

Early-stage dental demineralization, called white spots (WS), get their name from the characteristic colour that enamel takes on due to the acid attack of salivary cariogenic bacteria. They are often associated with fixed orthodontic therapy (FOT) and, if left untreated, evolve into caries with repercussions on oral health and dental aesthetics. This review aims to identify the most effective prophylaxis strategies to prevent WS during FOT. The search for the reviewed studies was conducted on the Pubmed, Scopus, and Web of Science databases, selecting English-only articles published in the 5 years from January 2018 to January 2023. The keywords used were "WS" and "fixed orthodontic*", using "AND" as the Boolean operator. A total of 16 studies were included for qualitative analysis. Prevention begins with maintaining proper oral hygiene; fluoride in toothpaste, mouthwashes, gels, varnishes, and sealants can be added to prophylaxis and used regularly. Using a laser in combination with fluoride helps prevent the occurrence of WS and assists in the repair processes of initial lesions. Further studies are needed to establish international guidelines for preventing WS in orthodontically treated patients.

Caries-preventive effectiveness of two different fluoride varnishes: A randomised clinical trial in patients with multi-bracketed fixed orthodontic appliances

BACKGROUND

Patients with multi-bracketed fixed orthodontic appliances are at a higher risk of developing enamel demineralisation.

AIM

To compare the efficacy of the quarterly application of two varnishes in preventing white spot lesions (WSLs) during multi-bracketed fixed orthodontic treatment.

DESIGN

Ninety-nine patients were randomly allocated into three intervention groups: Group A-standard oral hygiene instructions (OHI); Group B-5% sodium fluoride (NaF) varnish with standard OHI; and Group C-NaF plus tricalcium phosphate varnish with standard OHI. The outcome was assessed at 6-monthly intervals using a quantitative laser fluorescence device, clinical evaluation and photographic evaluation on six maxillary anterior teeth. A logistic regression model using generalised estimating equations with the intervention group, time and their interaction was used to compare the occurrence of WSLs, whereas the independent-samples Kruskal-Wallis test was used to compare the means of fluorescent values among different groups at p = .05.

RESULTS

Generalised estimating equations (with intervention and time as predictors) showed that only the effect of time was found to be significant (p < .001), whereas there was no significant difference among the three intervention groups (p = .305) using clinical assessment or photographic assessment (p = .599). At the 18-month follow-up, sodium fluoride (NaF) varnish with standard OHI was shown to reduce the odds of WSLs by 55% (p = .200), and NaF plus tricalcium phosphate varnish with standard OHI by 42% (p = .327).

CONCLUSION

The study failed to demonstrate that the quarterly application of both the study varnishes with OHI provided additional benefits compared with standard OHI alone in preventing WSLs, taking the effect of time of follow-up into consideration. There were higher odds of developing WSLs with an increased duration of orthodontic treatment.

Novel dental resin infiltrant containing smart monomer dodecylmethylaminoethyl methacrylate

Objectives

White spot lesions (WSLs) are prevalent and often lead to aesthetic problems and progressive caries. The objectives of this study were to: (1) develop a novel resin infiltrant containing smart monomer dodecylmethylaminoethyl methacrylate (DMAEM) to inhibit WSLs, and (2) investigate the effects of DMAEM incorporation on cytotoxicity, mechanical properties, biofilm-inhibition and protection of enamel hardness for the first time.

Methods

DMAEM was synthesized using 1-bromododecane, 2-methylamino ethanol and methylmethacrylate. DMAEM with mass fractions of 0%, 1.25%, 2.5% and 5% were incorporated into a resin infiltant containing BisGMA and TEGDMA. Cytotoxicity, mechanical properties and antibacterial effects were tested. After resin infiltration, bovine enamel was demineralized with saliva biofilm acids, and enamel hardness was measured.

Result

DMAEM infiltration did not increase the cytotoxicity or compromise the physical properties when DMAEM mass fraction was below 5% (p > 0.05). Biofilm metabolic activity was reduced by 90%, and biofilm lactic acid production was reduced by 92%, via DMAEM (p < 0.05). Mutans streptococci biofilm CFU was reduced by 3 logs (p < 0.05). When demineralized in acid and then under biofilms, the infiltrant + 5% DMAEM group produced an enamel hardness (mean ± sd; n = 6) of 2.90 ± 0.06 GPa, much higher than 0.85 ± 0.12 GPa of the infiltrant + 0% DMAEM group (p < 0.05).

Significance

A novel resin infiltrant with excellent mechanical properties, biocompability, strong antibacterial activity and anti-demineralization effect was developed using DMAEM for the first time. The DMAEM resin infiltrant is promising for inhibiting WSLs, arresting early caries, and protecting enamel hardness.

Short-term efficacy of caries resin infiltration during treatment with orthodontic fixed appliances. A randomized controlled trial

OBJECTIVES

Objective of this trial was to assess the masking results in initial caries lesions (ICL) that were resin infiltrated during fixed orthodontic treatment in comparison to contralateral teeth that were fluoridated only.

TRIAL DESIGN

A randomized, controlled, split-mouth trial.

METHODS

Adolescent patients (age range: 12-18 years) with fixed orthodontic appliances who had developed ICL [ICDAS 1 or 2 (International Caries Detection and Assessment System)] during orthodontic treatment were consecutively recruited and randomly assigned to either resin infiltration (Icon) with up to 3 etching procedures (Inf) or to a fluoride varnish (Tiefenfluorid) (FV). Both interventions were performed according to the manufacturer's recommendations. Outcome assessors were blinded to the applied intervention. Primary and secondary outcomes included the evaluation of the appearance of the ICL before (T0) and 1 week after (T1) treatment by digital photographs (ΔE), laser fluorescence readings (DD), and ICDAS scores.

BLINDING

Due to the treatment nature neither the operators nor the patients could be blinded. However, outcome assessors and the statistician were blinded.

RESULTS

Fifteen patients (9 female) with 60 ICL were included (mean age: 14.6 years). At baseline FV and Inf did not differ significantly in ΔE (median ΔE0,T (25th/75th percentiles):10.7(9.1/20.9): ΔE0,I:13.4(10.3/18.5); P = 0.469), DD (P = 0.867) and ICDAS (P = 0.521). One-week after treatment (T1) ΔE values (P < 0.001), DD values (P < 0.001), and ICDAS scores (P = 0.014) for Inf were significantly reduced, whereas ΔE values (P = 0.125) and ICDAS scores (P = 0.073) for FV remained unchanged.

LIMITATION

Natural remineralizing in the standard interventional control group cannot be observed yet, since up to 6 months are needed to naturally remineralize ICL.

CONCLUSIONS

Based on our short-term data, resin infiltration effectively masked ICL during treatment with fixed orthodontic appliances. Fluoridation was not able to immediately improve the visual appearance of ICL. Further longer-term assessment should focus not only on the aesthetic outcome, but also on the caries inhibitory effect of resin infiltration during treatment with fixed orthodontic appliances.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00011797).

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.

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.

Application of antibacterial nanoparticles in orthodontic materials

During the orthodontic process, increased microbial colonization and dental plaque formation on the orthodontic appliances and auxiliaries are major complications, causing oral infectious diseases, such as dental caries and periodontal diseases. To reduce plaque accumulation, antimicrobial materials are increasingly being investigated and applied to orthodontic appliances and auxiliaries by various methods. Through the development of nanotechnology, nanoparticles (NPs) have been reported to exhibit excellent antibacterial properties and have been applied in orthodontic materials to decrease dental plaque accumulation. In this review, we present the current development, antibacterial mechanisms, biocompatibility, and application of antibacterial NPs in orthodontic materials.

Effect of a mouth rinse and a high-fluoride toothpaste on caries incidence in orthodontic patients: A randomized controlled trial

INTRODUCTION

The objective was to evaluate the effect of a fluoride mouth rinse and a high-fluoride toothpaste on caries incidence in patients undergoing orthodontic treatment with fixed appliances.

METHODS

In this 3-armed, parallel-group, randomized controlled trial, patients referred to the Specialist Clinic of Orthodontics, Mölndal, Sweden, were randomly allocated to 1 of the 3 groups. (1) Fluoride mouth rinse (FMR) group: 0.2 % sodium fluoride (NaF) mouth rinse plus 1450 ppm fluoride (F) toothpaste; (2) High-fluoride tootpaste (HFT) group: 5000 ppm F toothpaste; and (3) Control (CTR) group: 1450 ppm F toothpaste. The generation of a randomization sequence was performed in blocks of 30. Inclusion criteria included patients scheduled for treatment with fixed appliances in the maxillary and mandibular arch aged 12-20 years. The primary outcome variable was the change in Decayed Initial Filled Surfaces (ΔDiFS) based on radiographs taken before and after the treatment. For statistical comparisons between groups, the Kruskal-Wallis test were used for continuous variables, whereas the Mann-Whitney U-test was used for pairwise group comparisons. Furthermore, the risk ratio (RR) and 95% confidence interval (CI) based on clinically relevant cutoffs (DiFS ≥2) were calculated to compare the increase of caries during orthodontic treatment between 2 groups. The Cochran-Mantel-Haenszel method was used to adjust RR for baseline values. Blinding was employed during the caries registration and the data analysis.

RESULTS

In total, 270 participants were randomized, with 15 patients dropping out, such that 255 patients were included in the statistical analyses. Recruitment was from October 2010 to December 2012. An increase in DiFS (≥1 DiFS) during treatment was observed in 48.3% of the FMR group, 42.0% of the HFT group, and 35.6% of the CTR group. There was no significant difference between the groups regarding increased DiFS (P = 0.17). The risk of increase in DiFS ≥2 during orthodontic treatment was 31.0% in the FMR group, 25.9% in the HFT group, and 18.4% in the CTR group. The RR for an increase of ≥2 DiFS during orthodontic treatment was 1.38 (95% CI, 0.81-2.34; P = 0.23) for FMR vs CTR, 1.21 (95% CI, 0.70-2.10; P = 0.51) for HFT vs CTR, and 0.93 (95% CI, 0.57-1.49; P = 0.76) for HFT vs FMR.

CONCLUSIONS

In patients who demonstrate a low prevalence of caries and are undergoing orthodontic treatment, daily use of high-fluoride toothpaste or fluoride mouth rinse in combination with regular toothpaste does not appear to significantly alter the caries incidence compared with the use of regular toothpaste.

TRIAL REGISTRATION

The trial was registered in the FoU i Sverige research database (http://www.fou.nu/is/sverige), with registration no. 236251.

PROTOCOL

The protocol was not published before trial commencement.

FUNDING

Local Research and Development Board for Gothenburg and South Bohuslän (grant no. 768531); and The Swedish Patent Revenue Fund (grant number EKF-780/19).

Efficacy of nano-hydroxyapatite on caries prevention-a systematic review and meta-analysis

INTRODUCTION/OBJECTIVES

The review systematically explored in vivo or in situ studies investigating the efficacy of nano-hydroxyapatite (nHA) to reduce initiation of or to remineralize initial caries lesions.

DATA

Prospective controlled (non-)randomized clinical trials investigating the efficacy of a nHA compared to any other (placebo) treatment or untreated/standard control.

SOURCES

Three electronic databases (Central Cochrane, PubMed-MEDLINE, Ovid EMBASE) were screened. Outcomes were, e.g., ICDAS score, laser fluorescence, enamel remineralization rate, mineral loss, and lesion depth. No language or time restrictions were applied. Risk of bias and level of evidence were graded using the Risk of Bias 2.0 tool and GRADE profiler.

STUDY SELECTION/RESULTS

Five in vivo (and 5 in situ) studies with at least 633 teeth (1031 specimens) being assessed in more than 420 (95) patients were included. No meta-analysis could be performed for in vivo studies due to the high heterogeneity of the study designs and the variety of outcomes. In situ studies indicate that under demineralization conditions, NaF was able to hinder demineralization, whereas nHA did not; simultaneously, nHA did not differ from the fluoride-free control. In contrast, under remineralizing conditions, nHA and NaF show the same remineralizing potential. However, the level of evidence was very low. Furthermore, six studies showed a high risk of bias, and six studies were funded/published by the manufacturers of the tested products.

CONCLUSION

The low number of clinical studies, the relatively short follow-up periods, the high risks of bias, and the limiting grade of evidence do not allow for conclusive evidence on the efficacy of nHA.

CLINICAL RELEVANCE

No conclusive evidence on the efficacy of nHA could be obtained based on the low number of clinical studies, the relatively short follow-up periods, the high risks of bias, the limiting grade of evidence, and study conditions that do not reflect the everyday conditions.

Casein phosphopeptide amorphous calcium phosphate and universal adhesive resin as a complementary approach for management of white spot lesions: an in-vitro study

Background

White spot lesion (WSL) is the most common consequence during and after orthodontic treatment. This study was conducted to investigate the ability of casein phosphopeptide amorphous calcium phosphate (CPP-ACP) coupled with universal adhesive resin to treat white spot lesions.

Material and methods

Forty-five extracted premolars were sectioned to create 90 specimens. Seventy-five specimens were demineralized to generate artificially created WSLs. Different strategies have been applied for the management of the artificially created WSLs. Six experimental groups were employed: Group I: sound enamel (control), Group II: demineralized enamel (artificially-created WSLs), Group III: ICON resin-treated WSLs, Group IV: CPP-ACP-treated WSLs, Group V: universal adhesive resin-treated WSLs, and Group VI: CPP-ACP followed by universal adhesive resin-treated WSLs. Assessment of color stability using a spectrophotometer, surface microhardness using a Vickers tester, and surface roughness using a profilometer was done. The surface topography of representative specimens from each experimental group was inspected using a scanning electron microscope. Collected data were analyzed using one-way ANOVA followed by Tukey’s post hoc test at p ≤ 0.05.

Results

White spot lesions treated with CPP-ACP and subsequently coated with universal adhesive resin (Group VI) exhibited a significantly lower ΔE than both CPP-ACP (Group IV) and universal adhesive resin-treated (Group V) groups (p ≤ 0.05), but it was not significantly different from the ICON resin-treated group (Group III). For surface microhardness, WSLs treated with CPP-ACP and consequently coated with universal adhesive resin (Group VI) recorded the highest mean that was significantly different from both ICON resin (Group III) and universal adhesive resin-treated (Group V) groups (p ≤ 0.05). All the tested strategies (ICON resin, CPP-ACP, universal adhesive resin, and CPP-ACP followed by universal adhesive resin) significantly lowered the surface roughness of the WSLs (p ≤ 0.05), while no significant difference was detected among them.

Conclusions

Combining a considerable caries remineralizing program using CPP-ACP with subsequent universal adhesive resin infiltration could be a promising approach to manage WSLs efficiently through increasing surface microhardness and restoring esthetic while developing a smoother surface.

Prevention of Caries and Dental Erosion by Fluorides-A Critical Discussion Based on Physico-Chemical Data and Principles

Dental erosion is a common problem in dentistry. It is defined as the loss of tooth mineral by the attack of acids that do not result from caries. From a physico-chemical point of view, the nature of the corroding acids only plays a minor role. A protective effect of fluorides, to prevent caries and dental erosion, is frequently claimed in the literature. The proposed modes of action of fluorides include, for example, the formation of an acid-resistant fluoride-rich surface layer and a fluoride-induced surface hardening of the tooth surface. We performed a comprehensive literature study on the available data on the interaction between fluoride and tooth surfaces (e.g., by toothpastes or mouthwashes). These data are discussed in the light of general chemical considerations on fluoride incorporation and the acid solubility of teeth. The analytical techniques available to address this question are presented and discussed with respect to their capabilities. In summary, the amount of fluoride that is incorporated into teeth is very low (a few µg mm-2), and is unlikely to protect a tooth against an attack by acids, be it from acidic agents (erosion) or from acid-producing cariogenic bacteria.

A Hydroxypropyl Methylcellulose Film Loaded with AFCP Nanoparticles for Inhibiting Formation of Enamel White Spot Lesions

Objective

This study investigated the effects of mineralizing film consisting of hydroxypropyl methylcellulose (HPMC) and amorphous fluorinated calcium phosphate (AFCP) nanoparticles on enamel white spot lesions (WSLs).

Material and Methods

The AFCP nanoparticles and mineralizing film were prepared via nanoprecipitation and solvent evaporation, respectively. They were characterized with Fourier transform infrared spectroscopy (FTIR), X-ray powder diffraction (XRD), transmission electron microscopy (TEM), selected area electron diffraction (SAED), scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDX), inductively coupled plasma atomic emission spectrometry (ICP-AES), and fluoride ion selective electrode. Thirty-two human enamel slices (4 mm × 4 mm × 1.5 mm) were highly polished and randomly assigned to four groups: negative control (no treatment); pure HPMC film; mineralizing film; GC Tooth Mousse Plus^® (contains 10% CPP-ACP and 0.2% NaF). Subsequently, samples were challenged by a modified pH-cycling and characterized by color measurement, Micro-CT, SEM/EDX, and nanoindentation.

Results

The mineralizing film could sustain release of Ca, P and F ions over 24 h and maintain AFCP nanoparticles in metastable state over 8~12 h. During 4 weeks of pH cycling, the mineralizing film group exhibited least color change (∆E), mineral loss and lesion depth (120 ± 10 µm) among four groups (p < 0.05). SEM findings revealed that the porosities among enamel crystals increased in negative control and pure HPMC film groups after pH cycling, whereas in mineralizing film group, the original microstructure of enamel was well conserved and mineral deposits were detected between enamel prisms. Mineralizing film group demonstrated a least reduction of nanomechanical properties such as elastic modulus of 77.02 ± 6.84 GPa and hardness of 3.62 ± 0.57 GPa (p < 0.05).

Conclusion

The mineralizing film might be a promising strategy for prevention and management of WSLs via inhibiting enamel demineralization and promoting enamel remineralization.

Novel nanostructured resin infiltrant containing calcium phosphate nanoparticles to prevent enamel white spot lesions

OBJECTIVES

The objective of this study was to develop a novel nanostructured resin infiltrant containing nanoparticles of amorphous calcium phosphate (NACP) to treat enamel white spot lesions (WSLs). Physical properties and the therapeutic effect of the new resin infiltrant were investigated for the first time.

METHODS

NACP was incorporated into ICON (Icon caries infiltrant, DMG, Germany) with different mass fractions. Cytotoxicity, degree of conversion, surface hardness, calcium (Ca) and phosphorus (P) ions release concentrations were tested. After application to the demineralized enamel samples, the color changes were determined. Surface and cross-sectional hardness were measured, scanning electron microscopy (SEM) images were taken on the cross-section of samples to observe microstructure changes after 14-day pH cycling.

RESULTS

Incorporating 10%-30% of NACP did not compromise the biocompatibility and physical properties of the resin infiltrant. ICON + 30% NACP group had long-lasting and high level of Ca and P ion release. After 14-day pH cycling, enamel surface hardness of ICON + 30% NACP group was 1.83 ± 0.21 GPa, significantly higher than the control group (1.32 ± 0.18 GPa) (p < 0.05). ICON + 30NACP group had the highest cross-sectional enamel hardness among all groups (p < 0.05), especially at 50 μm and 100 μm depth. SEM images showed that apparent enamel prism and inter-prism gaps in negative control were masked by mineral deposition in ICON + 30% NACP group.

SIGNIFICANCE

The novel ICON+30% NACP infiltrant is promising to inhibit enamel WSLs, protect the enamel and increase its hardness.

Biocompatible orthodontic cement with antibacterial capability and protein repellency

BACKGROUND

White spot lesions (WSLs) often occur in orthodontic treatments. The objectives of this study were to develop a novel orthodontic cement using particles of nano silver (NAg), N-acetylcysteine (NAC) and 2-methacryloyloxyethyl phosphorylcholine (MPC), and to investigate the effects on bonding strength, biofilms and biocompatibility.

METHODS

A commercial resin-modified glass ionomer cement (RMGIC) was modified by adding NAg, NAC and MPC. The unmodified RMGIC served as the control. Enamel bond strength and cytotoxicity of the cements were investigated. The protein repellent behavior of cements was also evaluated. The metabolic assay, lactic acid production assay and colony-forming unit assay of biofilms were used to determine the antibacterial capability of cements.

RESULTS

The new bioactive cement with NAg, NAC and MPC had clinically acceptable bond strength and biocompatibility. Compared to commercial control, the new cement suppressed metabolic activity and lactic acid production of biofilms by 59.03% and 70.02% respectively (p < 0.05), reduced biofilm CFU by 2 logs (p < 0.05) and reduced protein adsorption by 76.87% (p < 0.05).

CONCLUSIONS

The new cement with NAg, NAC and MPC had strong antibacterial capability, protein-repellent ability and acceptable biocompatibility. The new cement is promising to protect enamel from demineralization during orthodontic treatments.

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.

Efficacy of resin infiltration to mask post-orthodontic or non-post-orthodontic white spot lesions or fluorosis - a systematic review and meta-analysis

OBJECTIVE

The present review systematically analyzed clinical studies investigating the efficacy of resin infiltration on post-orthodontic or non-post-orthodontic, white spot lesions (WSL), or fluorosis.

MATERIALS

Five electronic databases (Central, PubMed, Ovid MEDLINE, Ovid EMBASE, LILACS) were screened. Article selection and data abstraction were done in duplicate. No language or time restrictions were applied. Outcomes were visual-tactile or DIAGNOdent measurements.

RESULTS

Eleven studies with 1834 teeth being affected in 413 patients were included. Nine studies were randomized control trials, one a prospective cohort study, and one had an unclear study design. Meta-analysis could be performed for "resin infiltration vs. untreated control," "resin infiltration vs. fluoride varnish," and "resin infiltration without bleaching vs. resin infiltration with bleaching." WSL being treated with resin infiltration showed a significantly higher optical improvement than WSL without any treatment (standard mean difference (SMD) [95% CI] = 1.24 [0.59, 1.88], moderate level of evidence [visual-tactile assessment]) and with fluoride varnish application (mean difference (MD) [95% CI] = 4.76 [0.74, 8.78], moderate level of evidence [DIAGNOdent reading]). In patients with fluorosis, bleaching prior to resin infiltration showed no difference in the masking effect compared to infiltration alone (MD [95% CI] = - 0.30 [- 0.98, 0.39], moderate level of evidence).

CONCLUSION

Resin infiltration has a significantly higher masking effect than natural remineralization or regular application of fluoride varnishes. However, although the evidence was graded as moderate, this conclusion is based on only very few well-conducted RCTs.

CLINICAL RELEVANCE

Resin infiltration seems to be a viable option to esthetically mask enamel white spot lesions and fluorosis.

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.

Effect of Chlorhexidine Varnish and Fluoride Varnish on White Spot Lesions in Orthodontic Patients- a Systematic Review

Aim:

The aim of this study is to critically review the studies that studied the effect of Chlorhexidine varnish and fluoride varnish on White Spot Lesion (WSL) in patients undergoing orthodontic treatment.

Materials and Methods:

The electronic database PubMed, The Cochrane Library, Medline, Embase, Google Scholar, Web of Knowledge along with a complimentary manual search of all orthodontic journals till the first week of December 2019 was searched. English language study performed on humans, randomized or nonrandomized clinical trials, comparing the effect of fluoride and chlorhexidine varnish on WSL was included in the review. Quality assessment of included studies was performed.

Clinical Significance:

The need for an adjunct oral hygiene aid to reduce the incidence and prevalence of white spot lesions in orthodontic patients is necessary. The use of these varnishes will aid in the same and thus make the adverse effects of fixed orthodontic treatment negligible.

Review of Literature:

Enamel demineralization is a significant risk associated with orthodontic treatment when oral hygiene is poor. Prevention of demineralization during orthodontic treatment is one of the greatest challenges faced by clinicians despite modern advances in caries prevention. The development of White Spot Lesions (WSLs) is attributed to prolonged plaque accumulation around the brackets.

Results:

The search identified a total of 3 studies that were included in this review. One study had Low risk of bias and the remaining 2 studies had moderate overall risk. Results showed that there was a reduction in the incidence of white spot lesions in orthodontic patients after application of chlorhexidine and Fluoride varnish.

Conclusion:

Low level evidence is available to conclude that the use of chlorhexidine varnishes and fluoride varnishes reduces the prevalence of white spot lesions in patients undergoing fixed orthodontic treatment. Due to its limitations, the results of this systematic review should be handled with caution and further well-planned Randomized Clinical Trial (RCT) are needed to provide a discrete conclusion.

Efficacy of a self-assembling peptide to remineralize initial caries lesions - A systematic review and meta-analysis

INTRODUCTION/OBJECTIVES

The present review systematically analyzed clinical studies investigating the efficacy of self-assembling peptides (SAP) to reduce initiation of or to remineralize initial caries lesions.

DATA

Prospective controlled (non-)randomized clinical trials investigating the efficacy of a self-assembling peptide compared to any other (placebo) treatment or untreated/standard control. Outcomes were visual analog scale (VAS), laser fluorescence, ICDAS score or morphometric measurements.

SOURCES

Three electronic databases (Central, PubMed, Ovid EMBASE) were screened. No language or time restrictions were applied.. Risk of Bias and level of evidence was graded using Risk of Bias 2.0 tool and Grade Profiler 3.6.

STUDY SELECTION/RESULTS

Seven studies with 508 teeth being affected in 294 patients were included. All studies were randomized controlled trials (RCT), five with a split-mouth and two with a parallel-arm design. Meta-analysis could be performed for SAP (plus fluoride varnish (FV)) vs. no treatment (plus FV) (control treatment). Depending on the outcome after up to 12 months SAP showed a significantly higher optical improvement than the control treatment (laser fluorescence: Standardized Mean Difference (SMD)[95 %CI] = -0.87[-1.39,-0.34; VAS: Mean Difference (MD)[95 %CI] = -35.38[-43.13,-27.64]) or no significant difference could be observed (ICDAS/activity score; Relative Risk (RR)[95 %CI] = 0.6[0.21,1.74]; morphometric measurements: SMD[95 %CI] = -1.95[-4.54,0.65]). Level of evidence was very low for all 4 outcomes. Furthermore, six studies showed a high risk of bias and six studies were (partially) funded by the manufactures of the tested products.

CONCLUSION

Based on a low number of clinical trials with relatively short follow up-periods and high risks of bias, self-assembling peptides may be a viable option to remineralize enamel caries.

CLINICAL SIGNIFICANCE

Self-assembling peptides may be a viable option to remineralize enamel caries. However, results should be interpretated with caution due the low number of clinical trials, the short follow-up periods and the limiting grade of evidence.

The additional benefit of professional fluoride application for children as an adjunct to regular fluoride toothpaste: a systematic review and meta-analysis

OBJECTIVE

To assess whether professional fluoride application (PFA) used in addition to regular fluoride toothpaste (RFT, ≥ 1,000 ppm) is more effective than RFT alone in children.

MATERIALS AND METHODS

A systematic search was conducted using the PubMed, Embase, Google Scholar and CENTRAL databases. Randomized controlled trials (RCTs) comparing the effectiveness of RFT + PFA and RFT alone were included. Meta-analyses with random-effects models were performed. The certainty of evidence was assessed using the GRADE approach.

RESULTS

A total of 2,729 records were identified from electronic and manual searches, which were screened by two reviewers independently and in duplicate. Six RCTs (5,034 participants) were included, of which four had high risk of bias and two had unclear risk of bias. The PFA used in all these trials was fluoride varnish (FV). In meta-analyses, no significant difference was observed between participants receiving FV + RFT and RFT alone of d(m/e)fs increment (mean difference (MD) - 0.17, 95% confidence interval (CI) - 0.60 to 0.26, P = 0.43, I² = 38%; 6 trials, 5,034 participants, moderate certainty evidence), incidence of caries (risk ratio (RR) 0.91, 95% CI 0.80 to 1.05, P = 0.21, I² = 41%; 4 trials, 4,487 participants, moderate certainty evidence) or changes in prevalence of caries (RR 0.89, 95% CI 0.78 to 1.01, P = 0.07, I² = 0%, 4 trials, 4,189 participants, low certainty evidence).

CONCLUSIONS

Low to moderate certainty evidence suggests that FV does not have significant additional caries-preventive benefit for children (under 8 years old) when provided as an adjunct to daily tooth brushing with RFT (≥ 1,000 ppm). There is insufficient evidence regarding the additional benefit of other PFA interventions.

CLINICAL RELEVANCE

The decision to apply FV to children needs to be made in light of their actual usage of RFT.

TRIAL REGISTRATION

PROSPERO (CRD42020165270).

Use of optical fluorescence for the diagnosis of dental biofilm in young permanent molars - A case series

BACKGROUND

Fluorescence appears clearly in oral biofilm in red tones, showing the presence of microorganisms in regions where there is biofilm accumulation. This study aims to evaluate the applicability and effectiveness of the diagnosis of oral biofilm with the optical fluorescence technique using the EVINCE (Evidenciador Clínico - MMOptics, São Carlos, SP, Brazil) equipment. Furthermore, to compare the efficacy of the optical fluorescence diagnostic method with the traditional method of clinical disclosure of Fuchsin-based dye biofilm and to observe their combined use.

METHODS

Sixteen children, aged between 7 and 12, were included in this case series, following the Oral Hygiene Index - Simplificated (OHI-S) evaluation. They were evaluated by 3 different professionals. The 1 st evaluator checked the OHI-S observing only with EVINCE. In the second stage, a 2nd evaluator performed the traditional disclosure technique with Fucsina, and finally a 3rd evaluator who observed with EVINCE the teeth previously stained in stage 2, combining the two methods. Descriptive analysis of the variables was performed and comparative tests of repeated measures to evaluate differences between the results of the three evaluation methodologies.

RESULTS

There is no significant difference between the observation made only with EVINCE and with the traditional methodology of plaque disclosure. However, there is a difference when the two techniques are used in the third evaluation moment, showing that the combination could provide better results.

CONCLUSIONS

The association of both the conventional method and the use of EVINCE showed a very satisfactory result for the diagnosis of the presence of biofilm.

The long observation in vitro of prevention effect of novel self-etching orthodontic adhesive modified with 2-methacryloxyethyl phosphorylcholine in enamel demineralization

The enamel demineralization is common in fixed orthodontics. Plaque accumulation around the bracket plays a critical role and could cause various degrees of white spot lesions (WSLs) on the surface of teeth. The 2-methacryloyloxyethyl phosphorylcholine (MPC) polymer is a biological polymer with protein repellent and an anti-bacterial adhesion effects. In this study, the enamel shear bond strength (SBS) and protein repellent property in vitro of self-etching orthodontic adhesive with MPC were evaluated. It was found that the self-etching adhesive with 0-7.5%MPC met the orthodontic clinical requirement on the SBS values at three different points of time. The incorporation of 7.5%MPC significantly reduced the bacterial adhesion and total microorganism of the yield biofilm. Moreover, the MTT assay showed that the amount of plaque metabolism in 7.5%MPC was the lowest among the groups. To conclude, the novel protein repellent self-etching adhesive was able to inhibit biofilm formation efficiently and minimize enamel demineralization.

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

OBJECTIVES

To compare the effectiveness of remineralizing agents in the prevention and reversal of white spot lesions (WSLs), which occur during fixed orthodontic treatment, through a systematic review and network meta-analysis.

MATERIALS AND METHODS

We reviewed controlled randomized clinical trial (RCT) data querying nine databases combined with a manual search (last search date: March 10, 2020). Of 2273 identified studies, 36 RCTs were finally included. After study selection and data extraction, pair-wise and network meta-analyses were performed to analyze the effectiveness of remineralizing agents in the prevention and reversal of WSLs in the short term (≤ 3 months) and long term (> 3 months). The risk of bias was assessed based on the Cochrane guidelines. Statistical heterogeneity, inconsistencies, and cumulative ranking were also evaluated.

RESULTS

In terms of WSL prevention, sodium fluoride (NaF) varnish had the highest cumulative ranking for the short-term decalcification index (99.3%); acidulated phosphate fluoride (APF) foam ranked first for long-term incidence (96.9%), followed by difluorosilane (Dfs) varnish and high-concentration fluoride toothpaste (HFT) (79.4% and 77.4%, respectively). In the reversal of WSLs, no significant difference was found among different agents or their combinations for the two available outcomes (short-term integrated fluorescence loss and short-term percentage of fluorescence loss).

CONCLUSIONS

In the prevention of WSLs, APF foam showed the best remineralizing effectiveness in the long term (after debonding), followed by Dfs varnish and HFT. It is unclear whether remineralizing agents can effectively reverse WSLs based on the existing evidence.

CLINICAL RELEVANCE

APF foam may be recommended as a remineralizing agent for preventing orthodontically induced WSLs.

PROSPERO REGISTRATION NUMBER

CRD42019116852.

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

This comprehensive review of the 2019 restorative dental literature is offered to inform busy dentists regarding remarkable publications and noteworthy progress made in the profession. Developed by the Scientific Investigation Committee of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to 1 of 8 sections of the report: (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information likely to influence day-to-day dental treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source material when greater detail is desired. As the profession moves toward evidence-based clinical decision-making, an incredible volume of potentially valuable dental literature continues to increase. It is the intention of this review and its authors to provide assistance in negotiating the extensive dental literature published in 2019. It is our hope that readers find this work useful in the clinical management of dental patients.

In vivo assessment of the corrosion of nickel-titanium orthodontic archwires by using scanning electron microscopy and atomic force microscopy

This study was undertaken to assess in vivo the corrosion in two commercial nickel-titanium (NiTi) orthodontic archwires removed from the oral cavity of patients using fluoride mouthwashes. Five volunteers took part in this study on the corrosion behavior of two brands of NiTi archwires (3M and AO (brand of archwire)) during use of two mouthwashes with neutral sodium fluoride 1.1%, one with acidulated fluoride 1.1%, and one with placebo and a control group. Each patient used one mouthwash in three different periods of time for 1 min a day for 30 days. The archwires were assessed with scanning electron microscopy and atomic force microscopy for qualitative and quantitative analysis. The values obtained with atomic force microscopy (AFM) were submitted to normality test, two-way analysis of variance, and Tukey's test at a significance level of 5%. The AFM images showed a gradual qualitative increase in the roughness of both types of wire between the treatments: control < placebo < neutral fluoride < acidulated fluoride. The arithmetic average of the roughness and root mean square of the roughness were similar. As for 3M archwires, only the acidulated fluoride group differed statistically from the others. As for AO archwires, the control and placebo groups did not differ from each other, but differed from the other fluoride treatments. The group using neutral fluoride also differed significantly from the acidulated fluoride group. 3M archwires were not affected by daily oral challenges. AO archwires were not affected by daily oral challenges either; their association with fluoride, either neutral or acidulated, increased their roughness.

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.

Evaluation of the value of re-wetting prior to resin infiltration of post-orthodontic caries lesions

OBJECTIVES

Assessment of the influence of colour changes during the re-wetting process as a possible predictor for the final result after resin infiltration to mask post-orthodontic white spot lesions.

MATERIALS AND METHODS

Resin infiltration (ICON; DMG, Hamburg, Germany) was performed according to the manufacturer's recommendation with the exception of repeated, at maximum three etching procedures based on the subjective decision of the dentist during a so called re-wetting process using ethanol. The masking effect by ethanol as well as after resin infiltration was evaluated by digital images taken before, for nine seconds during re-wetting and one week after treatment using CIE L*a*b* colour space.

RESULTS

Twenty-nine patients (16 female) with a total of 221 lesions (ICDAS 2) were included (mean age 16 years). Mean time after debonding the orthodontic appliances was ten weeks. Colour changes during re-wetting, evaluated in the first ten patients (71 lesions) showed a significant correlation between the minimum ΔE observed during re-wetting and the final ΔE after resin infiltration (r = 0.65, p < 0.001; Spearman correlation). The main drop in ΔE becomes visible after three seconds when performing the re-wetting process. Regarding the 221 lesions, resin infiltration significantly reduced the colour difference between sound and lesion areas from a baseline ΔE (25^th/75^th percentiles) of 10.9 (8.2/13.2) to a ΔE of 4 (2.1/5.8) after one week (p < 0.001). The number of etching procedures correlated significantly with baseline ΔE (p < 0.05).

CONCLUSIONS

The minimum ΔE observed during the re-wetting process seems to be a useful predictor for the final result of resin infiltration of post-orthodontic caries lesions. More prominent lesions with higher ΔE at baseline seem to require more erosion of the surface layer. In general, a significant and considerable clinical reduction of ΔE could be observed.

CLINICAL SIGNIFICANCE

We corroborate that resin infiltration technique is a very useful method to mask caries lesions having developed during treatment with fixed orthodontic appliances. Colour changes while re-wetting the lesions with ethanol seem to be a valuable indicator for the number of required etching procedures.

Fluoride varnish for the prevention of white spot lesions during orthodontic treatment with fixed appliances: a randomized controlled trial

Background

Self-applied and professional fluorides are key elements to limit caries-related side-effects during orthodontic treatment with fixed appliances.

Objective

To evaluate the effectiveness of a new fluoride varnish formula containing 1.5% ammonium fluoride in preventing white spot lesions (WSLs) in adolescents undergoing multi-bracket orthodontic treatment.

Subjects and methods

The study employed a randomized controlled triple-blinded design with two parallel arms. One hundred eighty-two healthy adolescents (12–18 years) referred to three orthodontic specialist clinics were eligible and consecutively enrolled. Informed consent was obtained from 166 patients and they were randomly allocated to a test or a placebo group (with aid of a computer program, generating sequence numbers in blocks of 15). In the test group, fluoride varnish was applied in a thin layer around the bracket base every sixth week during the orthodontic treatment, while patients in the placebo group received a varnish without fluoride. The intervention started at onset of the fixed appliances and continued until debonding. The endpoint was prevalence and severity of WSLs on the labial surfaces of the maxillary incisors, canines, and premolars as scored from high-resolution pre- and post-treatment digital photos with aid of a four-level score.

Results

One hundred forty-eight patients completed the trial, 75 in the test group and 73 in the placebo group (dropout rate 10.8%). The total prevalence of WSL’s on subject level after debonding was 41.8% in the test group and 43.8% in the placebo group. The number of patients exhibiting more severe lesions (score 3 + 4) was higher in the placebo group (P &lt; 0.05); the absolute risk reduction was 14% and the number needed to treat was 7.1.

Limitations

The multicentre design with somewhat diverging routines at the different clinics may have increased risk for performance bias. No health-economic evaluation was carried out.

Conclusions

Regular applications of an ammonium fluoride varnish reduced the prevalence of advanced WSL during treatment with fixed orthodontic appliances.

Clinical trial registration

ClinicalTrials.gov (NCT03725020).

Protocol

The protocol was not published before trial commencement.