Fluoride-Releasing Materials to Prevent White Spot Lesions around Orthodontic Brackets: A Systematic Review

The oral microbiota and periodontal health in orthodontic patients

The oral microbiota develops within the first 2 years of childhood and becomes distinct from the parents by 4 years-of-age. The oral microbiota plays an important role in the overall health/symbiosis of the individual. Deviations from the state of symbiosis leads to dysbiosis and an increased risk of pathogenicity. Deviations can occur not only from daily life activities but also from orthodontic interventions. Orthodontic appliances are formed from a variety of biomaterials. Once inserted, they serve as a breeding ground for microbial attachment, not only from new surface areas and crevices but also from material physicochemical interactions different than in the symbiotic state. Individuals undergoing orthodontic treatment show, compared with untreated people, qualitative and quantitative differences in activity within the oral microbiota, induced by increased retention of supra- and subgingival microbial plaque throughout the treatment period. These changes are at the root of the main undesirable effects, such as gingivitis, white spot lesions (WSL), and more severe caries lesions. Notably, the oral microbiota profile in the first weeks of orthodontic intervention might be a valuable indicator to predict and identify higher-risk individuals with respect to periodontal health and caries risk within an otherwise healthy population. Antimicrobial coatings have been used to dissuade microbes from adhering to the biomaterial; however, they disrupt the host microbiota, and several bacterial strains have become resistant. Smart biomaterials that can reduce the antimicrobial load preventing microbial adhesion to orthodontic appliances have shown promising results, but their complexity has kept many solutions from reaching the clinic. 3D printing technology provides opportunities for complex chemical syntheses to be performed uniformly, reducing the cost of producing smart biomaterials giving hope that they may reach the clinic in the near future. The purpose of this review is to emphasize the importance of the oral microbiota during orthodontic therapy and to use innovative technologies to better maintain its healthy balance during surgical procedures.

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.

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.

The Safety of Fluoride Compounds and Their Effect on the Human Body-A Narrative Review

Fluoride is one of the elements commonly present in the human environment. Due to its characteristics, it is very widely used in medicine, dentistry, industry or agriculture. On the other hand, its universality possesses a real threat to the human body in the form of acute and chronic poisoning. The aim of this paper is to characterize the properties of fluoride and its effects on the human body, as well as the sources of its occurrence. Particular emphasis is placed on the safety of its use and optimal dosage intake, which prevents accumulation and reduces its potential side effects. The positive effect of proper fluoride supply is widely described. In order to avoid overdose, it is best to consult a specialist to properly select the dosage.

Morphological Characteristics and Prevention of Tooth Enamel Demineralization during Orthodontic Treatment with Non-Removable Appliances

Despite the large number of studies on the effect of braces on teeth, there is no information on the dynamics of the state of the ultrastructure of the hard tissues of teeth during orthodontic treatment. The purpose of this study is to examine the state of the hard tissues of the teeth and carry out preventive measures to reduce the risk of complications in the process of orthodontic treatment using a non-removable device. Methods: For the in vitro study, 68 teeth were randomly divided into group A-no prophylactic treatment, and group B-treated with the fluorine varnish Tiefenfluorid. After 35 days, all the teeth were prepared for microscopic examination. The clinical study included 59 patients aged 12-17 years with orthodontic brackets. The split-mouth technique was used. The areas around the bracket of one-half of the oral cavity were treated with Tiefenfluorid every 6 months during the entire treatment period. The teeth of the second half of the oral cavity served as the control group. The data were processed in the SPSS19 package. Results: In vitro and clinical study results showed a statistically significant difference between the prophylactic and control groups of teeth in favor of the prophylactic group, where the statistical significance was p ≤ 0.01.

Evaluating changes in the color and luminosity of dental enamel after orthodontic treatment: A clinical study

The aims of this clinical study were to evaluate the Color change - ΔE (based on spectrophotometry and visual analysis) and luminosity - L* (based on spectrophotometry) of dental enamel surface (after orthodontic treatment) around the area where orthodontic brackets were fixed, based on different cementing materials such as a resin (R group) and resin-modified glass ionomer cement (RMGIC group). The split-mouth study initially comprised 14 patients. Orthodontic brackets were fixed to the upper central incisors with resin or RMGIC. The color of the buccal surface of each tooth was measured through spectrophotometry and visual examination before the bracket-fixation process. Four individuals were excluded during the follow-up; thus 10 patients were evaluated (n=10). Brackets were removed after 12 months of orthodontic treatment, tooth color measurement and visual examination were performed again, and Adhesive Remaining Index (ARI) was also measured. ΔE and L* results were subjected to Student's t-test and by repeated-measures analysis of variance, respectively (α=0.05). ARI data were analyzed in percentages. There was statistically significant difference in ΔE between groups; the R group showed statistically higher values of L* after orthodontic treatment. ARI of 2 and 3 prevailed in the RMGIC group, whereas the R group presented 0 and 1. After orthodontic treatment, the RMGIC group presented smaller changes in ΔE, and the increase in the white scale was observed on the enamel surface around the area where brackets were fixed in the R group. The visual analysis did not show color change on the evaluated teeth.

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.

Recent Advances in Direct Adhesive Restoration Resin-Based Dental Materials With Remineralizing Agents

Resin-based dental materials are popular restorative materials especially in direct adhesive restoration because of the excellent mechanical and esthetic properties. Toward the realization of minimally invasive dental procedures, direct composite resin adhesive restoration has become the main treatment for dental defects. In addition, for caries-affected dentin close to the pulp, conservation remineralization has been advocated to save the living pulp. However, the resin–dentin interface can be destabilized by various factors, especially the enzymatic degradation of collagen fibrils within the hybrid layer and polymer hydrolysis. Furthermore, for resin-based restorative materials, the marginal gap remains a major problem that can lead to the occurrence of secondary caries. To address these issues, research efforts have focused on the remineralization of mineral-depleted dental hard tissues using remineralizing bioactive substances. In this review, we first described various bioactive agents with remineralizing properties. Furthermore, we discussed recent advances in resin-based dental materials for enamel or dentin remineralization. Finally, we examined the current challenges and prospects of these emerging materials. This work aims to provide a theoretical foundation for the future development of resin-based dental materials in direct adhesive restoration with remineralizing agents.

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.

White Spots Prevalence and Tooth Brush Habits during Orthodontic Treatment

White spots (WS) are one of the most undesirable side effects in patients undergoing orthodontic therapy and are usually located around bracket bases and even detected under the molar bands. The aim of the present cross-sectional study was to evaluate the WS lesion during orthodontic therapy and the correlation between WS and oral hygiene habits. Patients requiring orthodontic treatment with a fixed appliance were screened for the inclusion/exclusion criteria, and 74 subjects were finally enrolled. Each patient received three examinations: at T0, the day of the application of the fixed appliance; at T1, three months later; and at T2, six months after treatment start. After calculating descriptive statistics, differences between groups were evaluated with an independent sample t-test. The first type error was set as p ≤ 0.01. The observed prevalence of WS lesions was 59.5% on T1 and 60.8% on T2. The most affected teeth result to be upper molars, lower left first molar, upper right central incisor and upper left lateral incisor, upper right canine, upper left first premolar, and lower right first molar. A higher frequency of daily tooth brushing was accompanied by a lower prevalence of WS. No significant effect of sex was observed.

Evaluation of enamel roughness after the removal of brackets bonded with different materials: In vivo study

The aims of this in vivo study were to evaluate the effect of bonding with resin-modified glass ionomer cement (RMGIC) and to assess enamel surface roughness before and after the removal of brackets bonded with composite or RMGIC from the maxillary central incisors. Fifteen orthodontic patients were selected for the study. For each patient, the teeth were rinsed and dried, and brackets were bonded with composite (Transbond XT) and RMGIC (Vitremer Core Buildup/Restorative). At the conclusion of orthodontic treatment, their brackets were removed. Dental replicas were made of epoxy resin in initial conditions (before bonded) and after polishing with an aluminum oxide disc system. Adhesive remnant index (ARI) and surface roughness was measured on the dental replicas and data were evaluated statistically by Mann-Whitney and paired t-test, respectively. No bracket debonding occurred during patients' treatment periods. It was verified that the ARI values of the two maxillary central incisors were similar (p = 0.665). For both bonding materials, the ARI value of 3 was predominant. After polishing, surface roughness was similar in the composite and RMGIC groups (0.245 μm and 0.248 μm, respectively; p = 0.07). In both groups, enamel surface roughness values were significantly lower after polishing compared with the initial condition (p < 0.001). RMGIC promoted efficiency in cementing brackets without fail during treatment; the choice of composite or RMGIC materials was not a factor that influenced the roughness of the enamel surface, however, polishing led to smoother surfaces than those found at the beginning of the treatment.

In vitro effect of experimental nanocomposites solutions on the prevention of dental caries around orthodontic brackets

This study aimed to evaluate the in vitro effect of a single application of experimental nanocomposite solutions on the prevention of dental caries around orthodontic brackets. The specimens were exposed to mesoporous silica (MS) nanocomposites containing fluoride by association with titanium tetrafluoride (TiF4) or sodium fluoride (NaF). Nanocomposites also could contain calcium and groups were described as MSCaTiF4, MSTiF4, MSCaNaF, MSNaF, and controls (TiF4, and NaF). Specimens were subjected to the formation of a multispecies biofilm to generate a cariogenic challenge. After 24h, both pH and total soluble fluoride concentration of the culture medium were assessed. Mineral loss was evaluated by percentage of surface mineral loss (%SML), mineral volume variation (ΔZ) of inner enamel and polarized light microscopy (PL). Linear (Ra) and volumetric (Sa) surface roughness and scanning electronic microscopy (SEM) were used to assess enamel topography. Statistical analyses were conducted considering p<0.05. MSNaF had the highest value of culture medium pH after cariogenic challenge, similarly to MSTiF4. All nanocomposite solutions released less fluoride than their controls NaF and TiF4 (p<0.05). All nanocomposite solutions presented lower %SML compared to their respective control groups (p<0.05). Lower Ra, Sa and ΔZ were observed for experimental groups compared to TiF4 (p<0.05). The results were confirmed by PL and SEM analysis. The experimental nanocomposite solutions contributed for lower enamel demineralization around orthodontic brackets.

A comparison of resin infiltration and microabrasion for postorthodontic white spot lesion

INTRODUCTION

The objective of this research was to evaluate and compare the effectiveness of microabrasion and resin infiltration for white spot lesions (WSLs).

METHODS

Patients with postorthodontic WSLs were enrolled and randomly assigned to the control, microabrasion, and resin-infiltration groups. Intraoral photographs were taken before and after (6 months later) treatment. WSL sizes were determined through ImageJ (Wayne Rasband, Kensington, Md). Integrated optical density (IOD) was determined for a WSL and its surrounding normal enamel through Image-Pro Plus (version 6.0; Media Cybernetics, Rockville, Md), and their differences of IOD were considered as the IOD surrogate for that WSL. The color change of WSL were measured through ΔE.

RESULTS

A total of 27 eligible patients were enrolled; 9 subjects were assigned to each group, resulting in 56 teeth in the control group, 72 in the microabrasion group, and 58 in the resin-infiltration group. The ratios of WSL size (after/before) were similar between the microabrasion and resin-infiltration group (43.94 ± 0.03% vs 45.02 ± 0.03%; P = 0.96 > 0.05), but those of the 2 groups were significantly lower than those of the control group (92.15 ± 0.02%) (P <0.001). Moreover, the ratios of IOD (after/before) were significantly lower in the resin-infiltration group (22.94 ± 0.02%) than in the microabrasion (78.11 ± 0.03%) and control (83.79 ± 0.02%) (P <0.001) groups. The highest ΔE improvement was obtained by infiltration, but there was no significant difference between microabrasion and control group.

CONCLUSIONS

Resin infiltration and microabrasion are comparably effective in reducing the sizes of WSL, but resin infiltration enjoys an esthetic advantage over microabrasion.

Effect of high-fluoride dentifrice and bracket bonding composite material on enamel demineralization adjacent to orthodontic brackets in vitro

Background

There is a lack of information about the association of high-fluoride dentrifrice and fluoride-containing bonding material to prevent enamel white spot lesions development adjacent to brackets. The aim of this in vitro study was to evaluate the effect of high-fluoride dentifrice and fluoride-containing bonding material on enamel demineralization adjacent to orthodontic brackets.

Material and Methods

Forty-eight enamel specimens with 7x7x2 mm were obtained from bovine incisors. Orthodontic brackets were bonded with fluoride-containing resin composite (OrthoCem®) or fluoride-free low viscosity resin. The specimens were submitted to an 8-day pH cycling that consisted in the daily immersion of specimens in the demineralizing solution for 4 h and in artificial saliva for 20 h in an incubator at 37° C. The treatments consisted in 5 min-immersion between the cycles of fluoride (F) suspensions containing 275 µg F/mL, 1,250 µg F/mL or distilled water (negative control). The 275 and 1,250 µg F/mL concentrations were used to simulate salivary dilution of 1,100 and 5,000 µg F/g dentifrices during toothbrushing. After the experiment, cross-sectional hardness was performed to analyze the lesion area of the specimens. Tukey post hoc test after two-way ANOVA with p at 5% was used as statistical analysis.

Results

The specimens treated with high-fluoride dentifrice showed significantly less demineralization in comparison with the other treatments (p>0.05). There was a significant difference in the cross-sectional hardness values for the specimens bonded with OrthoCem when compared to the low viscosity resin (p>0,05).

Conclusions

The use of high-fluoride dentifrice associated with fluoride-containing bonding material promoted a greater reduction of enamel demineralization adjacent to orthodontic brackets.

Key words:Demineralization, dentifrice, fluoride, bonding materials, orthodontic brackets.

Fluoride Ion Release Characteristics of Fluoride-Containing Varnishes—An In Vitro Study

Despite the latest advances in orthodontic treatment, white spot lesions remain a common side effect of fixed appliance therapy. An effective treatment for the prevention of white spot lesions is the use of fluoride-containing products. The aim of the present in vitro study was to check the durability of the tested products for their fluoride release into the surrounding solution. Three varnishes (Protecto CaF2 Nano one-step seal, Bifluorid 12 single dose, and Fluor Protector S) were applied to hydroxyapatite discs and kept in diluted Total Ionic Strength Adjustment Buffer III (TISAB III) solution for fluoride ion release measurement. A group of clear hydroxyapatite discs served as the control group. The carrier discs (N = 40) underwent three thermal cycling runs for 20 days. Before the first run and after each run, the fluoride ion concentration in the solution was measured at appointed times (T) T0, T1, T2, and T3. Fluoride ion release was highest at T1 for all products (median values for Protecto CaF2 Nano one-step seal: 0.09 ppm, Bifluorid 12 single dose: 37.67 ppm, and Fluor Protector S: 3.36 ppm) except for the control group, showing its peak at T0 (0.04 ppm). There was a significant difference between the tested fluoride varnishes at all measurement times. Bifluorid 12 achieved significantly higher fluoride release values than the other products (p < 0.05 at all measurement times). A solitary product application of only once or twice per year, as stated by the manufacturers, cannot be supported.

Powered toothbrushes for plaque control in fixed orthodontic patients: a network meta-analysis

BACKGROUND

Orthodontic patients are at greater risk due to the inability to clean around the components directly bonded to teeth. Hence, the aim of the present network meta-analysis is to compare the utility of powered toothbrushes in plaque control in patients with orthodontic brackets compared with manual tooth brushing.

METHODOLOGY

Necessary data were extracted and analysed for Risk of Bias. Heterogeneity was assessed using Chi-square and I² tests. Random effects model was used for both direct and mixed treatment comparisons. Standardized mean difference with 95% confidence interval was the effect estimate for plaque and bleeding scores and mean difference for pocket depth. Inconsistencies between the direct and indirect estimates were evaluated by H-statistics. GRADE approach was used to assess the quality of evidence.

RESULTS

Pooled results from 14 studies showed significantly higher plaque scores in patients using manual toothbrushes. Pooled results from 13 studies showed significant higher bleeding scores as well with manual brushes. There was a significant reduction in pocket depth with electric toothbrushes.

CONCLUSION

Powered toothbrushes are a promising alternative for plaque control in patients with fixed orthodontic brackets. Stronger evidence can be established with addition of long-term clinical trials based on the recommendations.

Fluoride varnish for white spot lesion prevention during orthodontic treatment: results of a randomized controlled trial 1 year after debonding

BACKGROUND

Topical fluorides are commonly recommended to prevent the development of white spot lesion (WSL) during treatment with fixed orthodontic appliances (FOAs), but the certainty of evidence is low, and long-term effects of fluoride preventive methods to reduce lesions seem to be rare.

OBJECTIVE

To evaluate the long-term effectiveness of professional applications of a fluoride varnish containing 1.5% ammonium fluoride in preventing WSL development in adolescents undergoing multi-bracket orthodontic treatment.

SUBJECTS AND METHODS

We performed a randomized controlled trial in which 166 healthy adolescents (12-18 years) from three different clinics were enrolled and randomly allocated to a test or a placebo group. The randomization was performed by a computer program, generating sequence numbers in blocks of 15. The fluoride varnish or the non-fluoride placebo varnish was applied in a thin layer around the bracket base every sixth week during the course of the orthodontic treatment (mean duration 1.7 years). We scored the prevalence of WSL on the labial surfaces of the maxillary incisors, canines and premolars immediately after debonding (baseline) and approximately 1 year after debonding, from digital photos with aid of a four-step score. The examiners were not involved in the treatment of the patients and blinded for the group assignment.

RESULTS

One hundred and forty-eight patients were available at debonding and 142 of them could be re-examined after 1 year (71 in the test and 71 in the placebo group). The 1-year attrition rate was 4.0%. On patient level, the prevalence of post-orthodontic WSLs (score ≥ 2) dropped by over 50% during the follow-up with no significant difference between the groups. On surface level, there were significantly fewer remaining WSLs in the test group compared with the placebo group (4.5% versus 10.4%; relative risk 0.44, 95% confidence interval 0.28-0.68).

LIMITATIONS

The compliance with fluoride toothpaste was not checked, and the patients' general dentists may have instigated additional risk-based preventive measures. No cost-benefit analysis was carried out.

CONCLUSIONS

This follow-up study displayed a small beneficial long-term effect of fluoride varnish in reducing WSL development during treatment with FOA.

REGISTRATION

NCT03725020.

PROTOCOL

The protocol was not published before trial commencement.

Possible association of periodontal disease with oral cancer and oral potentially malignant disorders: a systematic review

Background: Periodontitis has been associated with several systemic diseases and medical conditions, including oral cancer (OC). However, most studies reporting an association between OC and periodontal disease have used different clinical and radiographic criteria to define periodontal disease. This review aimed to evaluate the currently available evidence to determine an association between periodontal disease (extension and severity), OC, and oral potentially malignant disorders (OPMDs).Material and methods: A systematic search of studies published up to August 2018 was performed following the PRISMA guidelines in the electronic databases MEDLINE (PubMed) and COCHRANE (OVID). A methodological evaluation was made using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist.Results: Eight studies (case-control, cross-sectional and cohort) were included. An increased clinical attachment loss, plaque index, bleeding on probing, and radiographic bone loss was found in patients with OC and OPMDs. Differences in the methodological characteristics, case definition used for periodontal diseases, and OC location did not allow estimating the odds ratio required to conduct a meta-analysis.Conclusion: Some studies suggest a positive relationship between periodontal disease, OC, and OPMDs; however, the currently available evidence is insufficient to draw solid conclusions.

The lingual enamel morphology and bracket shear bond strength influenced by Nd:YAG laser and aluminum oxide sandblasting preconditioning

OBJECTIVES

This study aimed to investigate the influence of Nd:YAG laser and aluminum oxide sandblasting on the shear bond strength (SBS) of lingual brackets and to optically analyze the behavior of the enamel morphology.

MATERIALS AND METHODS

Thirty-five bovines' incisors teeth were divided into 5 groups (n = 7), according to the surface preconditioning: G1, control group; G2, Nd:YAG laser; G3, laser + aluminum oxide sandblasting (Al₂O₃); G4, Al₂O₃; and G5, Al₂O₃ + laser. All groups had lingual brackets bonded and shear debonded after 72 h. SBS values were analyzed, and the enamel morphology was evaluated by optical coherence tomography (OCT) and scanning electron microscope (SEM), before and after preconditioning surface. The optical attenuation coefficient (α) analysis was obtained from OCT images. Data analysis used the ANOVA test, followed by post hoc Tukey, Kruskal Wallis, and post hoc Dunn tests (significance of 5%).

RESULTS

The SBS values presented similarly among groups, but the value of α showed statistical difference (p-value = 0.0124) between G3 and G5 with the others. Optical analyses indicated a melting on the enamel that suffered laser irradiation for G2 and G5 and crystal surface disorganization for G4. Sandblasting partially removes the melting of the laser effect (G3).

CONCLUSION

The sandblasting is a dispensable step for bonding lingual brackets, and the melting of the enamel after laser irradiation does not compromise the bracket adhesive resistance.

CLINICAL RELEVANCE

The Nd:YAG laser became an interesting tool to prevent caries and decrease prevalence of white spot lesions in orthodontic treatments, without systemic effects in patients with genetic high risks of caries.

Effect of high-fluoride dentifrice and bracket bonding composite material on enamel demineralization in situ

OBJECTIVE

This in situ study evaluated the effect of high-fluoride dentifrice (5000 μg F^-/g) and fluoride-containing bonding composite resin on enamel demineralization adjacent to orthodontic brackets.

METHODS

Ten volunteers wore palatal appliances containing bovine enamel blocks with metallic brackets bonded with fluoride-free or fluoride-containing composite resin. During three phases of 14 days each, three dentifrices with different fluoride concentrations (0, 1100, and 5000 μg F^-/g) were tested. The cariogenic challenge consisted of 20% sucrose solution dripped 8x/day onto the dental blocks. At the end of each phase, biofilm formed was collected for fluoride analysis. Cross section hardness was performed in enamel blocks, and the lesion area was calculated. Data were analyzed by two-way ANOVA followed by Tukey post hoc test (α = 5%).

RESULTS

The only signicant factor for all the variables under study was the dentifrice. Smaller lesion area and higher fluoride concentration on biofilm were found in 5000 μg F^-/g group, irrespective of bonding composite resin (p < 0.001). Neither bracket-bonding composite resin nor the interaction between the factors was statistically significant (p > 0.05) for all the variables.

CONCLUSION

High-fluoride dentifrice is effective in reducing demineralization on enamel adjacent to orthodontic brackets, while the fluoride-containing bonding composite resin does not influence it.

CLINICAL SIGNIFICANCE

Since high-fluoride dentifrice was able to reduce demineralization adjacent to brackets, it can be an option to caries management in orthodontics patients.

Polymeric and inorganic nanoscopical antimicrobial fillers in dentistry

Failure of dental treatments is mainly due to the biofilm accumulated on the dental materials. Many investigations have been conducted on the advancements of antimicrobial dental materials. Polymeric and inorganic nanoscopical agents are capable of inhibiting microorganism proliferation. Applying them as fillers in dental materials can achieve enhanced microbicidal ability. The present review provides a broad overview on the state-of-the-art research in the field of antimicrobial fillers which have been adopted for incorporation into dental materials over the last 5 years. The antibacterial agents and applications are described, with the aim of providing information for future investigations. STATEMENT OF SIGNIFICANCE: Microbial infection is the primary cause of dental treatment failure. The present review provides an overview on the state-of-art in the field of antimicrobial nanoscopical or polymeric fillers that have been applied in dental materials. Trends in the biotechnological development of these antimicrobial fillers over the last 5 years are reviewed to provide a backdrop for further advancement in this field of research.

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.

Systematic reviews in orthodontics: Impact of the PRISMA for Abstracts checklist on completeness of reporting

INTRODUCTION

This study evaluated and compared the completeness of reporting of abstracts of orthodontics systematic reviews before and after the publication of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Abstracts Checklist (PRISMA-A).

METHODS

Abstracts of systematic reviews and meta-analyses in orthodontics published in PubMed, Latin American and Caribbean Health Sciences Literature, and the Cochrane Database of Systematic Reviews databases before March 23, 2018, that met the predefined inclusion and exclusion criteria, were evaluated using the 12 items of PRISMA-A, scoring each item from 0 to 2. Abstracts were classified into 2 groups: before and after publication of the PRISMA-A checklist. Three calibrated evaluators (intraclass correlation coefficient and kappa > 0.8) assessed the scores for compliance with the checklist. The number of authors, country of affiliation of the first author, performance of meta-analysis, and topic of the article were recorded. A regression analysis was performed to assess the associations between abstract characteristics and the PRISMA-A scores.

RESULTS

Of 1034 abstracts evaluated, 389 were included in the analysis. The mean PRISMA-A score was 53.39 (95% CI, 51.83-54.96). The overall score for studies published after the publication of the checklist was significantly higher than for studies published before (P ≤ 0.0001). The components returning significantly higher scores after publication of PRISMA-A were title (P = 0.024), information from databases (P = 0.026), risk of bias (P ≤ 0.0001), included studies (P ≤ 0.0001), synthesis of results (P ≤ 0.0001), interpretation of results (P = 0.035), financing and conflict of interest (P ≤ 0.0001), and registration (P ≤ 0.0001). These results showed the positive effect of PRISMA-A had on the quality of reporting of orthodontics systematic reviews. Nevertheless, the poor adherence revealed that there is still need for improvement in the quality of abstract reporting.

CONCLUSIONS

The quality of reporting of abstracts of orthodontic systematic reviews and meta-analyses increased after the introduction of PRISMA-A.

Comparative evaluation of Icon® resin infiltration and Clinpro™ XT varnish on colour and fluorescence changes of white spot lesions: a randomized controlled trial

Background

The aim of this trial was to comparatively evaluate Icon® resin infiltration and Clinpro™ XT varnish in restoring aesthetics of white spot lesions (WSLs) present post-orthodontic treatment.

Materials and methods

Two hundred forty WSLs were detected in 193 teeth of 12 patients. The participants were analysed—before intervention (T₀), immediately after intervention (T₁), 3 months later (T₂) and 6 months later (T₃), with a 1:1 allocation ratio for the application of Icon® resin infiltration and Clinpro™ XT varnish. Using a computer-generated allocation sequence, block randomization was done. A spectrophotometer was used to assess the colour of WSLs and the adjacent enamel, while a DIAGNOdent® was used to assess the fluorescence loss.

Results

Immediately after the intervention, Icon® resin infiltration showed statistically significant better improvement than Clinpro™ XT varnish in restoring the colour (p = 0.000); however, at 3 (p = 0.001) and 6 months (p = 0.000), this was reversed. Except at 3 months, the fluorescence loss sequentially reduced more for Icon® resin infiltration (4.48 ± 1.42 at T₀ to 1.48 ± 0.81 at T₃) and was not statistically significant.

Conclusions

Clinpro™ XT varnish showed significantly better improvement than Icon® resin infiltration in restoring the colour and lightness of the WSLs at 3 and 6 months. The fluorescence loss significantly recovered with both intervention methods between immediate application and at 6 months. However, Clinpro™ XT varnish-treated WSLs showed a statistically significant difference compared to the adjacent sound enamel at 6 months.

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.

Enamel demineralization around two different orthodontic bracket adhesive systems: An in vivo study

Objective

To compare the enamel demineralization around the two precoated adhesive bracket systems, APC Flash-Free and APC PLUS (3M Unitek, Monrovia, CA, USA), in clinical settings.

Material and method

This prospective experimental in-vivo study included 40 premolar teeth, which were planned for extraction due to orthodontic purposes. They were divided into two groups (Group A; n = 20 teeth were bonded with APC Flash Free ceramic brackets and group B; n = 20 teeth were bonded with APC Plus ceramic bracket). After four weeks, the teeth were extracted, sectioned, and examined under the Scanning Electron Microscope (SEM) to evaluate the amount of demineralization from the enamel surface to the deepest point.

Results

Findings revealed that the mean values of demineralization under SEM were significantly higher in APC Plus compared to APC Flash Free (149.95 µm vs. 112.96 µm, respectively) (P < 0.05). The difference between the two systems was mainly found in the middle part of the facial surfaces, while there were no differences between the two systems in the proximal parts.

Conclusion

The enamel demineralization around APC Flash-Free adhesive bracket system was significantly less than that of APC plus Adhesive bracket system, which can be due to the absence of the caries promoting adhesive flash during tooth bonding using the flash free system.

Current Enamel Remineralization Therapies Have Limited Effects on Postorthodontic White Spot Lesions

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Enamel remineralization therapies for treating postorthodontic white spot lesions: a systematic review. Fernández-Ferrer L, Vicente-Ruíz M, García-Sanz V, Montiel-Company JM, Paredes-Gallardo V, Almerich-Silla JM, Bellot-Arcís C. J Am Dent Assoc 2018; 149(9):778-86.e2.

SOURCE OF FUNDING

No financial support was reported.

TYPE OF STUDY/DESIGN

Systematic review.

Tooth demineralization and associated factors in patients on fixed orthodontic treatment

Dental demineralization was determined in patients at three time points during fixed orthodontic treatment. A multiple cross-sectional study included 108 patients divided into three different groups: (1) beginning of orthodontic treatment; (2) one year into treatment; and (3) two years into treatment. Demineralization was estimated using a DIAGNOdent pen. We obtained data from multiple tooth-by-tooth demineralization readings combined with salivary pH and patients' oral hygienic and dietary behaviors. A t-test for independent samples and Spearman´s correlation were performed. No demineralizations differences were found between the initial stage and one year into treatment. Between one and two years small differences were observed, but demineralization increased between the initial stage and second treatment year, predominating in upper right central incisors (p = 0.056), upper left lateral incisors (p = 0.040), both upper canines (p = 0.055 and p = 0.040, respectively) and first left premolars (p = 0.034 and p = 0.053, respectively). We did not find associations between oral hygiene and dietary behaviours or salivary pH. In conclusion, demineralization occurred in first year of treatment and increased during second year, predominating in the upper arch and the left side mainly in upper right central incisors, upper left lateral incisors, both upper canines, and first left premolars.