Caries-Preventive Effectiveness of a Fluoride Varnish: A Randomized Controlled Trial in Adolescents with Fixed Orthodontic Appliances

Probiotics for maintaining oral health during fixed orthodontic treatment: A systematic review and meta-analysis

INTRODUCTION

To systematically review the effect of probiotics on oral health during treatment with fixed orthodontic appliances.

METHODS

PubMed, Embase and the Cochrane Library were searched up to August 2022 using broad MeSH terms and keywords. Randomized clinical trials comparing a probiotic with a control/no treatment; at least 10 patients/group undergoing fixed orthodontic therapy; and reporting at least one oral health-related parameter were included.

RESULTS

The most reported parameters in the 14 included studies were the microbiological counts of mutans streptococci and lactobacilli, microorganisms associated with white spot lesions (WSL). A meta-analysis of these showed a positive effect of probiotics on mutans streptococci. Probiotic treatment led to significantly less patients with high counts and significantly more with low counts of these bacteria. An effect on the lactobacilli counts was not seen. However, the sole clinical study investigating WSL could not demonstrate a clinical effect of probiotics on these lesions. Additionally, one study reported encouraging results of probiotics on bad breath and one on the occurrence of traumatic oral lesions. One study found reduced counts of Porphyromonas gingivalis in the probiotic group. The clinical results of probiotics on plaque index were ambiguous: one study reported that probiotics reduce the plaque and gingival index, and two that probiotics had no significant influence on plaque index.

CONCLUSION

Probiotics are a promising option to lower mutans streptococci counts in patients undergoing fixed orthodontic therapy. However, due to the heterogeneity of the studies, it is not possible to draw conclusions about one specific probiotic.

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).

Effectiveness of amine fluoride mouthwash in preventing white spot lesions during fixed orthodontic therapy - A randomized control trial

Background and Aim

One of the main reasons that patients seek orthodontic treatment is aesthetics. Unfortunately, treatment with fixed orthodontic appliances can at times increase the chances of developing white spot lesions on the surfaces of teeth, thus creating a new aesthetic issue for the patient. The prevalence of white spot lesions (WSL) reported after treatment varies from 2% to 97%, and these lesions can occur despite increased attention to hygiene. Hence the aim of this study was to assess the effect of Amine fluoride mouthwash in preventing white spot lesions during fixed orthodontic therapy.

Materials and Methods

Study participants were randomly divided into two groups (Group A - experimental 25 patients and Group B - control 25 patients). The pre-intervention and post-intervention intra-oral digital photographs were analysed by using ImageJ software to assess the percentage of the facial surface affected on the teeth (10 maxillary teeth), which had white spot lesions.

Results

The mean value of WSLs showed significant difference between the experimental and control groups. Mean values of WSL in the experimental group decreased from 2 to 1.54 with a mean difference of 0.46 after 6 months of follow-up which indicated that amine fluoride mouthwash was effective in preventing WSLs during fixed orthodontic treatment.

Conclusion

WSLs scores were significantly reduced in patients who received the mouthwash when compared to patients who followed standard oral hygiene regimen with fluoridated toothpaste only. In clinical practice, amine fluoride mouthwash is an effective method for the prevention of WSLs during fixed orthodontic treatment.

Scanning electron microscopy evaluation of enamel surfaces using different air-polishing powders in the orthodontic setting: an in vitro study

PURPOSE

The aim of this in vitro study was to quantify and compare changes of the enamel surface caused by periodical use of different air-polishing powders during multibracket therapy.

METHODS

Bovine high-gloss polished enamel specimens were air-polished using an AIR-FLOW® Master Piezon with maximum powder and water settings. Each specimen was blasted with sodium bicarbonate (AIR-FLOW® Powder Classic, Electro Medical Systems, Munich, Germany) and erythritol (AIR-FLOW® Powder Plus, Electro Medical Systems). Blasting duration was adapted to the powders' cleaning efficacy and corresponded to 25 air-polishing treatments in a patient with braces. A spindle apparatus ensured uniform guidance at a distance of 4 mm and a 90° angle. Qualitative and quantitative assessments were performed with the use of low vacuum scanning electron microscopy. Following external filtering and image processing, arithmetical square height (S_a) and root mean square height (S_q) were determined.

RESULTS

Both prophy powders caused a significant increase in enamel roughness. Surfaces blasted with sodium bicarbonate (S_a = 64.35 ± 36.65 nm; S_q = 80.14 ± 44.80 nm) showed significantly (p < 0.001) higher roughness than samples treated with erythritol (S_a = 24.40 ± 7.42 nm; S_q = 30.86 ± 9.30 nm). The observed defects in enamel structure caused by sodium bicarbonate extended across prism boundaries. Prism structure remained intact after air-polishing with erythritol.

CONCLUSION

Both applied air-polishing powders led to surface alterations. Despite shorter treatment times, sodium bicarbonate was significantly more abrasive than erythritol. Clinicians must compromise between saving time and abrasively removing healthy enamel.

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.

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

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

Anti-Adherence and Antimicrobial Activities of Silver Nanoparticles against Serotypes C and K of Streptococcus mutans on Orthodontic Appliances

Background and Objectives: Streptococcus mutans (S. mutans) is the main microorganism associated with the presence of dental caries and specific serotypes of this bacteria have been related to several systemic diseases limiting general health. In orthodontics, white spot lesions (WSL), represent a great challenge for clinicians due to the great fluctuation of their prevalence and incidence during conventional orthodontic treatments. Although silver nanoparticles (AgNP) have been demonstrated to have great antimicrobial properties in several microorganisms, including S. mutans bacteria, there is no available information about anti adherence and antimicrobial properties of AgNP exposed to two of the most relevant serotypes of S. mutans adhered on orthodontic materials used for conventional therapeutics. The objective of this study was to determine anti-adherence and antimicrobial levels of AgNP against serotypes c and k of S. mutans on conventional orthodontic appliances. Materials and Methods: An AgNP solution was prepared and characterized using dispersion light scattering (DLS) and transmission electron microscopy (TEM). Antimicrobial and anti-adherence activities of AgNP were determined using minimal inhibitory concentrations (MIC) and bacterial adherence testing against serotypes c and k of S. mutans clinically isolated and confirmed by PCR assay. Results: The prepared AgNP had spherical shapes with a good size distribution (29.3 ± 0.7 nm) with negative and well-defined electrical charges (−36.5 ± 5.7 mV). AgNP had good bacterial growth (55.7 ± 19.3 µg/mL for serotype c, and 111.4 ± 38.6 µg/mL for serotype k) and adherence inhibitions for all bacterial strains and orthodontic wires (p < 0.05). The serotype k showed statistically the highest microbial adherence (p < 0.05). The SS wires promoted more bacterial adhesion (149.0 ± 253.6 UFC/mL × 104) than CuNiTi (3.3 ± 6.0 UFC/mL × 104) and NiTi (101.1 ± 108.5 UFC/mL × 104) arches. SEM analysis suggests CuNiTi wires demonstrated better topographical conditions for bacterial adherence while AFM evaluation determined cell wall irregularities in bacterial cells exposed to AgNP. Conclusions: This study suggests the widespread use of AgNP as a potential anti-adherent and antimicrobial agent for the prevention of WSL during conventional orthodontic therapies and, collaterally, other systemic diseases.

Awad I, K. Khalaf M, L. Alshami M. In vitro study of the antibacterial effect of plasma surface treatment using Argon gas on orthodontic stainless steel brackets against Streptococcus mutans and Lactobacillus acidophilus

Orthodontic treatment improves dental aesthetics. However, the prolonged duration of treatment and patient's oral hygiene results in more significant biofilm buildup and boosting concentrations of acidogenic bacteria, resulting in enamel demineralization. Plasma treatment technology has developed an interest in enhancing appliances' surface properties. The present study aimed to investigate cytotoxicity and antibacterial activity represented by anti-adhesion and anti-biofilm formation of Argon plasma treatment on orthodontic brackets against Streptococcus mutans and Lactobacillus acidophilus and evaluation the effect of change in plasma exposure duration on these properties in vitro. The study included three groups, group 1: untreated stainless steel brackets, group 2: brackets treated for 15 min, and group 3: brackets treated for 30 min. S.mutans and L.acidophilus were isolated from patients undergoing fixed orthodontic treatment. Microbiological tests included adhesion assay using plate counting method and biofilm formation assay using ELISA plate reader. S. mutans& L. acidophilus were cultivated in three groups, and their adherence and biofilm formation were measured and compared. The biocompatibility of treated stainless steel brackets was evaluated by MTT assay. Results showed that groups 2 & 3 had better anti-adhesion and anti-biofilm activity when compared with group 1, with a significant difference between group 1 &group 3, in which group 3 recorded the lowest biofilm formation and the highest anti- anti-A adhesion activity. MTT showed that groups 2 and 3 exhibited more than 80% cell viability after 24, 48, and 72 hours. Plasma surface treatment of metal brackets possesses antibacterial activity against S.mutans and L.acidophilus; alteration exposure time impacts the development of these properties. Keywords. Plasma treatment, Argon gas, orthodontic brackets, biofilm, antimicrobial.

Effectiveness of the Lorodent Probiotic Lozenge in Reducing Plaque and Streptococcus mutans Levels in Orthodontic Patients: A Double-Blind Randomized Control Trial

Orthodontic patients are at a significant risk for oral diseases due to increased plaque accumulation and oral bacterial dysbiosis. We aimed to determine the efficacy of the commercially available Lorodent Probiotic Complex at reducing plaque accumulation and Streptococcus mutans bacterial levels in adolescent orthodontic patients. Sixty adolescents undergoing fixed orthodontic treatment for a minimum of 6 months were recruited in a randomized, double-blind, parallel-group, placebo-controlled trial. They received either Lorodent probiotic lozenge (intervention, n = 30) or placebo lozenge (control, n = 30) orally every day for a 28-day administration period. Participants were assessed at four appointments (T1–T4) over a total of 56 days. Compliance and lozenge satisfaction were monitored. Saliva samples and supragingival plaques were collected for evaluation of S. mutans levels. Clinical assessment using a Plaque Index (PI) was used. Compliance with lozenge intake of all participants was over 90%. There was no significant change in the PI and composite PI scores in both placebo and probiotic groups at each time frame (all p &gt; 0.05) or the relative S. mutans DNA levels in the saliva and plaque between the probiotic and placebo groups. The findings of high compliance and satisfaction with the probiotic lozenges combined with the study's rigorous design offer a baseline for subsequent testing of further potential probiotics (of varying formulations, concentrations), especially in adolescents.

Long-term evaluation of orthodontic brackets shear bond strength with or without fluoride-releasing adhesive

BACKGROUND

The aim of this study was the evaluation of the long-term effect on shear bond strength (SBS) of orthodontic brackets treated with or without a fluoride-releasing system.

METHODS

A total of 80 bovine teeth were randomly divided into 2 groups (G1, G2): in G1 teeth were treated with a fluoride-releasing system (Fluor Protector, Ivoclar Vivadent, Schaan, Liechtenstein) and with spectrum (Micerium, Genoa, Italy); in G2 only spectrum was used. Shear bond strength (SBS) was measured in MPa 24 hours after bonding (T0) and after 30 (T1), 60 (T2), 90 (T3) and 180 days (T4).

RESULTS

A repeated measures ANOVA on rank-transformed data was used and differences in time between G1 and G2 were revealed (P<0.001). From 3 months mean measurement of G1 was higher than G2 (P=0.015). No difference was revealed between T3 and T4 in either group (P=0.48 for G1 and P=0.46 for G2).

CONCLUSIONS

After 3 months, G1 showed a significantly higher value than G2. Both groups did not show changes in shear bond strength between month 3 and month 6.

A novel method quantifying caries following orthodontic treatment

This retrospective pilot study used a newly developed evaluation tool to assess the prevalence and incidence of White Spot Lesions (WSL) before and after multibracket appliance (MB) therapy. Digital photographs of 121 adolescent patients (63 ♂, 58 ♀) with metal brackets were analyzed retrospectively before and after MB therapy. The labial surfaces of anterior teeth, canine teeth, and premolars in the upper (UJ) and lower jaws (LJ) were evaluated using the Enamel Decalcification Index (EDI) by Banks and Richmond (Eur J Orthod, 16(1):19-25, 1994, levels 0-3) and a specially developed digitally scaled graticule with concentric circles to quantify the extent of WSL (in %). The statistical data analysis was based on crosstabulations and logistic regression. Before MB, 69.4% of the patients presented at least one WSL and 97.5% after, an increase of 28.1%. Before MB, 18.4% of the tooth surfaces (TS) showed an EDI level of 1-3. After MB, 51.8% of the TS featured WSL. 18.2% of the TS showed a WSL to the extent of ≥ 20-100% before and 52.3% after MB. The incidence in the UJ (71-79%) as well as the LJ (64-76%) was highest for the first and second premolars and lowest for LJ incisors (22-35%). The probability for developing a new distal WSL is higher than developing gingival, mesial or occlusal WSL. Labial MB therapy drastically increases the risk of developing WSL. We verified a concise quantification of the extent of labial WSL with the evaluation index.

Efficacy of CPP-ACP fluoride varnish applied with and without acid etching in preventing enamel demineralization compared to light-curable fluoride varnish

Objectives

To compare efficacy of casein phosphopeptide (CPP)–amorphous calcium phosphate (ACP) fluoride varnish and light-curable resin modified glass ionomer fluoride varnish (FV) in preventing white spot lesions and evaluating acid etching prior to CPP-ACPFV application on its efficacy.

Materials and Methods

Molars and premolars were transected and halves divided into four groups (n = 18/group): (1) resin-modified glass ionomer FV: etched and Clinpro-XT varnish (3M ESPE, Pymble, New South Wales, Australia) application; (2) CPP-ACPFV: MI varnish (GC America, Alsip, IL) application; (3) Etch+CPP-ACPFV: etched and MI varnish application; (4) Control: etched and no surface treatment. To simulate 12 weeks in an intraoral environment, samples were subjected to thermocycling, brushing, and pH cycling. Enamel surface microhardness was evaluated at baseline and after the simulated 12 weeks. Representative samples were also assessed using scanning electron microscopy (SEM).

Results

At baseline there was no significant difference in microhardness among groups. After the simulated 12 weeks, all groups showed significant within-group differences (P &lt; .001). Control showed the highest percentage loss of surface microhardness (89%), followed by CPP-ACPFV (58%), RMGIFV (51%), and Etch+CPP-ACPFV (24%). The control group had a significant decrease in microhardness compared to all experimental groups (P &lt; .001). No difference was found between the RMGIFV and CPP-ACPFV varnish groups. The Etch+CPP-ACPFV group had significantly less decrease in microhardness compared to the RMGIFV (P &lt; .001) and CPP-ACPFV groups (P &lt; .001). With SEM, control samples showed signs of enamel surface damage, while experimental groups showed spherical particles on a relatively intact surface.

Conclusions

RMGIFV and CPP-ACPFV are effective in reducing enamel demineralization. Acid etching the enamel surface prior to CPP-ACPFV varnish application increased its efficacy.

Effect of nano-zinc oxide and nano-chitosan particles on the shear bond strength of dental composites used as orthodontic adhesive

BACKGROUND

This study aimed to evaluate the effect of the combination of zinc oxide nanoparticles (NPs) and chitosan NPs on the shear bond strength (SBS) of composites used for orthodontic bonding.

METHODS

Four groups of composites (n = 10), containing 0%, 1%, 5%, and 10% w/w NP fillers, respectively, were used to bond brackets to the surfaces of 40 intact bovine incisors. After 1000 rounds of thermal cycling at 5°C-55°C, all specimens were mounted in acrylic blocks. The SBS was tested using a universal testing machine, and the adhesive remnant index scores were registered using a stereomicroscope. Data were statistically analyzed using a 1-way ANOVA and the Kruskal-Wallis test.

RESULTS

The highest value of mean SBS was found in the control group, and the lowest value was found in the group with composite containing 10% NPs. The adhesive remnant index did not differ significantly among the groups (P = 0.823).

CONCLUSIONS

Incorporation of 1% and 5% zinc oxide and chitosan NPs had no effect on the SBS of composite, and the obtained SBS values were similar to that of the control group.

Evaluation of the preventive effect of two concentrations of xylitol varnish versus fluoride varnish on enamel demineralization around orthodontic brackets: a randomized controlled trial

BACKGROUND

The highly prevalent white spot lesions around orthodontic brackets necessitate introducing preventive materials without relying on patient compliance.

OBJECTIVE

To evaluate the antidemineralizing effect of two concentrations of xylitol varnish.

TRIAL DESIGN

Triple-blind, four-arm, parallel-group, single-center, randomized controlled clinical trial.

METHODS

A total of 120 orthodontic patients were randomly assigned to four groups (n = 30), using a computer-generated randomized block list. The treatment groups were: 10% xylitol, 20% xylitol, 5% fluoride, and placebo. Tooth demineralization was measured with DIAGNOdent at T1 (before treatment), followed by varnish application. At T2 (third month), the varnish was re-applied, and at the third (T2) and sixth (T3) months, and after treatment (T4), the demineralization was measured. The white spot lesion frequency was assessed visually after treatment. The participants, the clinician, and data assessors were all blinded to group assignments.

RESULTS

A total of 115 patients underwent per-protocol analyses. At T2, the mean DIAGNOdent numbers in the fluoride and 10% xylitol groups were significantly lower than the placebo group (P = 0.00), with a mean difference of 0.63 (95% CI, 0.15-1.10) and 0.5 (95% CI, 0.04-0.95), respectively. At T3, the fluoride and 10% xylitol groups had significantly lower mineral loss than the placebo group (P=0.046) with a mean difference of 0.52 (95% CI, 0.14-0.89) in the fluoride and 0.45 (95% CI, 0.03-0.86) in the 10% xylitol groups, respectively. However, at T4, only the mean for the 10% xylitol group was significantly different (P=0.049) from the placebo group, with a mean difference of 1.18 (95% CI, 0.42-1.93). Visual assessment showed that after treatment, the prevalence of white spot lesions in the fluoride (P=0.03) and 10% xylitol (P=0.00) groups was less than the placebo group with the odds ratio of 0.67 (95% CI, 0.46-0.96) and 0.43 (95% CI, 0.28-0.64), respectively.

CONCLUSION

The 10% xylitol varnish short-term effects on caries control were significantly greater than 20% xylitol varnish and placebo but similar to fluoride varnish. However, the 10% xylitol long-term effect was almost better than fluoride varnish.

TRIAL REGISTRATION

The protocol was registered at IRCT.ir under the code IRCT20180913041032N1.

How different time intervals between repeated applications of CPP-ACP fluoride varnish effect smooth surface enamel demineralization?

OBJECTIVES

To evaluate the preventive effects of different time intervals between repeated applications of the CPP-ACP fluoride varnish on enamel demineralization.

METHODS

Human teeth were sectioned and randomly allocated to three groups: 4-week, 6-week, and 12-week (N = 22/group). Baseline images of the enamel surfaces were obtained using the FluoreCam recording the area, intensity, and impact of baseline enamel demineralization. All groups received fluoride varnish applications at the beginning of the experiment. The varnish was reapplied every 4 or 6 weeks in the 4-week and 6-week groups, respectively. Following each application, the groups underwent thermo-cycling, tooth brushing and pH cycling to simulate the time effect. After 12 weeks, the enamel surfaces were reimaged using the FluoreCam. Within and between-group differences in the area, intensity and impact of demineralization were evaluated.

RESULTS

At baseline, there were no significant between-group differences for area, intensity, or impact. Statistically significant (p<0.001) enamel demineralization occurred over time within each group. There were significant between-group differences in the changes that occurred in area (P = 0.004), impact (P = 0.022), but not intensity. The 12-week had significantly larger areas of demineralization than the 6-week (P = 0.041) and 4-week (P = 0.001) groups. Changes in impact was significantly (P = 0.007) greater in the 12-week group than 4-week group, but not greater than the 6-week group. There were no statistically significant differences between 4- and 6-week groups in the changes of area, intensity, or impact.

CONCLUSION

Reapplication of the CPP-ACP fluoride varnish every 4-6 weeks, is more effective in reducing enamel demineralization compared to every 12 weeks.

Optical analysis of the behavior of sealants under mechanical, thermal and chemical stress

Regarding their resistance five sealants were tested in vitro after experiencing mechanical, thermal and chemical stress. Included for testing were two fluoride varnishes: Fluor Protector [FP] (Ivoclar Vivadent) and Protecto CaF2 Nano One-Step Seal [PN] (BonaDent) and three fluoride-composite filled sealants (with acid etch technique): Clinpro XT Varnish [CP] (3 M Espe), Pro Seal [PS] & Light Bond [LB] (Reliance Orthodontic Products) and a positive control group [CG] Tetric EvoFlow (Ivoclar Vivadent). The sealants were applied on 180 bovine teeth (n = 10/ sealer) in a standardized manner after bracket bonding. Mechanical pressure and its effect by simulating different time points and standardized electric cleaning protocol was tested first. Followed by thermal burden due to varying thermal stress and thirdly change in pH stress imitating chemical exposure were examined separately. A digital microscope and a grid incisal and apical to the brackets (n = 32 fields) was used to standardize the optical analysis. Material loss due to mechanical stress compared to CG (score 0.00) was CP (1.2%), FP (21.5%), LB (22.2%) and PN (81.1%). No significant difference to CG presented PS. Material loss due to thermal stress was CP (0.5%), PS (2%), FP (2.6%), LB (3.1%) and PN (39.9%). Material loss due to chemical stress was FP (1.8%), PS (2.1%), LB (5.5%) and PN (39.6%). No significant difference to CG presented CP. Only PS and CP had optically provable, good resiliance to mechanical, thermal and chemical stress. Significantly poorer outcomes in particular showed PN.

Shear bond strength of orthodontic brackets on intact and demineralized enamel after application of resin infiltrant, fluoride varnish and casein phosphopeptide-amorphous calcium phosphate remineralizing agents: in-vitro study

OBJECTIVE

To evaluate the effects of remineralizing agents on the shear bond strength (SBS) of orthodontic brackets bonded to intact and demineralized enamel.

MATERIAL AND METHODS

In this in-vitro study, 160 human premolars were divided into 8 groups, including group 1 with intact enamel as the positive control, group 2 with demineralized enamel as the negative control, groups 3-5 treated with fluoride varnish, Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) and resin infiltrant on intact enamel, and groups 6-8 treated with the same agents on demineralized enamel. Brackets were bonded using the conventional method, and the samples were thermocycled. SBS of the brackets was measured using a universal testing machine, and the adhesive remnant index (ARI) was assessed. Data were analysed with one-way ANOVA and post hoc statistical test at the significance level of 0.05.

RESULTS

SBS of the brackets in all groups with intact enamel was higher than that of their counterparts on demineralized enamel, which was only significantly different between groups 1 and 2 (P-value<0.001). SBS values of groups 7 and 8 were not significantly different from group 1 (P-value=1), yet the application of fluoride varnish on both intact (P-value=0.091) and demineralized enamel (P-value<0.001) created less SBS than in group 1.

CONCLUSIONS

All pre-treatment methods increased SBS of the brackets bonded to demineralized enamel, yet only the resin infiltrant and CPP-ACP produced SBS similar to that of intact enamel. Also, the use of fluoride varnish on intact enamel significantly reduced SBS.

Assessing the Effectiveness and Acceptability of a Personalized Mobile Phone App in Improving Adherence to Oral Hygiene Advice in Orthodontic Patients: Protocol for a Feasibility Study and a Randomized Controlled Trial

Background

Orthodontic treatment is a common health care intervention; treatment duration can be lengthy (2-3 years on average), and adherence to treatment advice is therefore essential for successful outcomes. It has been reported that up to 43% of patients fail to complete treatment, and there are currently no useful predictors of noncompletion. Given that the National Health Service England annual expenditure on primary-care orthodontic treatment is in excess of £200 million (US $267 million), noncompletion of treatment represents a significant inefficient use of public resources. Improving adherence to treatment is therefore essential. This necessitates behavior change, and interventions that improve adherence and are designed to elicit behavioral change must address an individual’s capability, opportunity, and motivation. Mobile phones are potentially an invaluable tool in this regard, as they are readily available and can be used in a number of ways to address an individual’s capability, opportunity, and motivation.

Objective

This study will assess the effectiveness and acceptability of a personalized mobile phone app in improving adherence to orthodontic treatment advice by way of a randomized controlled trial.

Methods

This study will be conducted in 2 phases at the Eastman Dental Hospital, University College London Hospitals Foundation Trust. Phase 1 is feasibility testing of the My Braces app. Participants will be asked to complete the user version of the Mobile Application Rating Scale. The app will be amended following analysis of the responses, if appropriate. Phase 2 is a randomized controlled trial to test the effectiveness and acceptability of the My Braces app.

Results

This study was approved by the London – Bloomsbury Research Ethics Committee on November 5, 2019 (reference 19/LO/1555). No patients have been recruited to date. The anticipated start date for recruitment to phase 1 is October 2020.

Conclusions

Given the availability, affordability, and versatility of mobile phones, it is proposed that they will aid in improving adherence to treatment advice and hence improve treatment completion rates. If effective, the applicability of this methodology to developing behavior change/modification interventions and improving adherence to treatment across health care provides an exciting opportunity.

Trial Registration

ClinicalTrials.gov NCT04184739; https://clinicaltrials.gov/ct2/show/NCT04184739

International Registered Report Identifier (IRRID)

PRR1-10.2196/18021

Anti-demineralization characteristics of surface pre-reacted glass-ionomer (S-PRG) filler-containing varnishes

This study investigated the anti-demineralization effects of surface pre-reacted glass-ionomer (S-PRG) filler-containing varnishes. Thirty-five bovine root specimens were divided into five treatment groups, with seven specimens each coated with 1) MI varnish (MIV), 2) F varnish (FV), 3) PRG varnish I (PV), 4) PRG varnish II (with sodium fluoride added, PVF), and 5) acid-resistant nail varnish (Control). A 3×1 mm area of the dentin surface adjacent to each varnish was demineralized for one week at 37°C. Integrated mineral loss (IML) of these lesions was determined by transverse microradiography, as was the amount of fluoride released by each material. IML was significantly lower in the PV and PVF groups than in the Control group, and was significantly lower in the PVF than in the MIV and FV groups. These findings indicated that S-PRG filler-containing varnishes, especially varnish containing sodium fluoride, had superior anti-demineralization effects on root dentin.

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.

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.

Time-dependent effects after enamel fluoride application on an acid etching system in orthodontic bracket bonding

OBJECTIVES

This study investigated the effectiveness of acid etching and bond strength in an orthodontic bonding system in accordance with various time periods after 1.23% acidulated phosphate fluoride (APF) gel applications.

MATERIALS AND METHODS

APF gel was applied on the enamel surface of bovine teeth, which were assigned to group F0. The tooth specimens were then immersed in distilled water for 1 (F1), 7 (F7), 14 (F14), 21 (F21) and 28 (F28) days. A group without fluoride pretreatment was a control group. All groups were etched with 35% phosphoric acid and evaluated using a surface hardness tester and scanning electron microscope (SEM). A shear bond strength (SBS) test was performed using a universal testing machine, and the bond failure modes were also examined.

RESULTS

After the 1.23% APF gel treatment, the hardness of the acid-etched enamel surface decreased as the immersion period increased. SEM images of the test groups showed etched patterns similar to control group as the immersion period increased. The SBS increased with increasing immersion period, whereas group F21 was not significantly different from the control group. Relatively high adhesive remnant index scores were identified as the ageing period increased.

CONCLUSIONS

The present study indicated that in order to obtain suitable bond strength, it is recommended to use an acid etching-based bonding system for the fixation of orthodontic appliances on the enamel surface 21 days after the use of APF gel.

CLINICAL RELEVANCE

Fluoride pre-treatment interferes with the acid etching effects on enamel, causing a reduction in the bond strength with orthodontic brackets.

In Vitro Comparison of Fluoride, Magnesium, and Calcium Phosphate Materials on Prevention of White Spot Lesions around Orthodontic Brackets

One common negative side effect of orthodontic treatment with fixed appliances is the development of white spot lesions (WSLs) around brackets. This study is aimed at comparing the efficacy of various oral hygiene practices in preventing enamel demineralization around orthodontic brackets under similar in vitro conditions. The study included 90 extracted bovine incisors, which were randomized into six groups: fluoride toothpaste (FT), nonfluoride toothpaste (NFT), fluoride varnish plus fluoride toothpaste (FV+FT), CPP-ACP varnish plus fluoride toothpaste (CPP-ACP+FT), medical minerals gel plus nonfluoride toothpaste (MMG+NFT), and no intervention (control). All groups were subjected to demineralization and remineralization cycles. Visual appraisals were used to evaluate the changes in the enamel surface appearance at the beginning and end of the experiment. The changes in the demineralization degree were evaluated by measuring the Ca⁺² concentration in the demineralization solution at different time points. The majority of teeth in the CPP-ACP+FT group exhibited no shift in appearance, whereas in the other groups, a slight change in enamel translucency was observed. At all the time points, the Ca⁺² concentration in the demineralization solution in the CPP-ACP+FT group was the least among all other groups. At day 5, MMG+NFT's preventive efficacy was significantly higher than FV+FT's, but at days 10, 15, and 19, their efficacy was similar. However, at all the time points, MMG+NFT's efficacy was significantly higher than that of control, whereas FV+FT's efficacy was decreased at days 10, 15, and 19 and was close to the efficacy of control. To fight WSLs, early diagnosis was of great importance and examination of the tooth surface after air-drying for 5 s was recommended.

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.

Demineralization detection in orthodontics using an ophthalmic optical coherence tomography device equipped with a multicolor fluorescence module

OBJECTIVES

Demineralizations such as white spot lesions are among the most prevalent side effects during orthodontic treatment. Fluorescence devices, including quantitative light-induced fluorescence (QLF), exploiting the intrinsic fluorescence of enamel and teeth and most recently optical coherence tomography (OCT) were introduced for early demineralization detection. In addition to near-infrared OCT scanning, multicolor modules allow for imaging with different laser wavelengths and the detection of reflective- and fluorescent light. The aim of this study was to evaluate a modified multicolor ophthalmic OCT device for the detection of early carious lesions in vitro and in vivo.

MATERIALS AND METHODS

Twenty-seven extracted lesion free human teeth were randomly assigned to three different demineralization protocols. Carious lesion detection was performed using macrophotography, OCT, and reflectance/fluorescence imaging using green laser and blue laser light. In addition, teeth of 5 orthodontic patients were OCT scanned, and fluorescence imaging using blue laser light was performed to assess demineralization after orthodontic therapy.

RESULTS

Both in vitro and in vivo, OCT allowed for precise determination of lesion depth and enamel loss. Fluorescence imaging using blue laser light was most sensitive for the detection of early demineralization in vitro and in vivo. However, established and severe demineralizations were also reliably detected by macrophotography in vitro and in vivo.

CONCLUSION

Demineralization can be detected with high sensitivity using blue fluorescence imaging with multicolor OCT devices.

CLINICAL RELEVANCE

In the future, OCT fluorescence imaging might be considered for longitudinal monitoring of dental hard tissue during orthodontic treatment in clinical trials.

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.

Comparison of the abrasive properties of two different systems for interproximal enamel reduction: oscillating versus manual strips

Background

The aim of the present investigation was to evaluate enamel reduction efficiency, abrasive property decay, and enamel effects between oscillating mechanical and manual systems for interproximal enamel reduction (IPR).

Methods

Three oscillating strips and three manual strips were tested on twelve freshly extracted premolars blocked in an acrylic cylinder pot by means of a material testing machine. Each strip underwent one test of 8 cycles (30 s each). Both abrasive tracks and teeth surfaces were qualitative evaluated before and after IPR by means of SEM analysis. Efficiency and abrasive property decay of both IPR systems were investigated by the amount of enamel reduction within the eight-cycle testing. Independent t-test was used to evaluate differences in variables between the two systems.

Results

Mechanical IPR system showed higher efficiency in terms of enamel reduction (p < 0.005) when compared with manual IPR system (0.16 mm and 0.09 mm, respectively). Quantity of removed enamel decreased throughout the 8 cycles for both systems. Less presence of enamel debris and detachment of abrasive grains were observed on mechanical strips rather than manual strips. SEM analysis revealed more regular surface of teeth undergone mechanical IPR procedures.

Conclusion

Oscillating diamond strips showed more controlled efficiency when compared with the manual IPR system leading to a more regular enamel surface.

Effects of Fluoride and Calcium Phosphate Materials on Remineralization of Mild and Severe White Spot Lesions

Fixed orthodontic treatments often lead to enamel demineralization and cause white spot lesions (WSLs). The aim of this study was to evaluate the mineralization degree of 2 types of WSLs based on ICDAS index and compare the remineralizing efficacy of 3 oral hygiene practices after 1 month and 3 months. 80 mild demineralized and 80 severe demineralized enamel specimens were randomized into three treatments: fluoride toothpaste (FT), fluoride varnish plus fluoride toothpaste (FV+FT), and CPP-ACP plus fluoride toothpaste (CPP-ACP+FT). Microhardness tester, DIAGNODent Pen 2190, and scanning electron microscope were used to evaluate the changes of mineralization degree. Both qualitative and quantitative indicators suggested that the mild and severe white spot lesions were different in the degree of mineralization. Severe WSLs demineralized much more seriously than mild lesions even after 3 months of treatment. Despite the variation in severity, both lesions had the same variation trend after each measure was applied: FT had weak therapeutic effect, FV + FT and CPP-ACP + FT were effective for remineralization. Their remineralizing efficacy was similar after 1 month, and combined use of CPP-ACP plus F toothpaste was more effective after 3 months. In order to fight WSLs, early diagnosis was of great importance, and examination of the tooth surface after air-dry for 5 seconds was recommended. Also, when WSLs were found, added remineralizing treatments were required.

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.

Glucosidase activity in dental biofilms in adolescent patients with fixed orthodontic appliances - a putative marker for white spot lesions - a clinical exploratory trial

OBJECTIVES

Approximately 25% of the adolescents in the Scandinavian population are treated with a fixed orthodontic appliance (FOA). Adverse effects such as enamel decalcification (white spot lesions - WSL), seem to affect over 30% of patients. WSL have only a limited ability to improve, thus seriously jeopardising the treatment outcome. The aim of present study was to explore the biofilm phenotype by investigating plaque collected: 1) adjacent to brackets, and 2) in gingival margin of maxillary incisors in adolescents with FOA. Incidence of WSL after treatment was also assessed.

DESIGN

In eight adolescent patients treated with FOA, supra-gingival plaque formed on: 1) brackets, and 2) along the gingival margin of the maxillary incisors, was collected after 6-8 months of treatment. The patients were documented before and after treatment by intraoral photos. Plaque samples were tested for glycosidase- (fluorogenic substrates) and protease (FITC-labelled casein substrate) activities. The plaque samples were visualised by Live/Dead BacLight stain, following which cells were investigated by confocal scanning laser microscopy.

RESULTS

In the collected plaque samples, all enzymes tested displayed small variations in activity between the individuals, except glucosidases, which varied significantly. Four patients developed WSL. The patients displayed higher glucosidase activity in plaque of brackets compared to patients without WSL. In seven patients, plaque at the gingival margin displayed higher protease activity than plaque of brackets.

CONCLUSIONS

The current study shows two distinct environmentally induced biofilm phenotypes: 1) brackets with higher glucosidase activity, and 2) gingival margin with higher protease activity. Glucosidase activity might thus be used as a putative biomarker for risk of WSL.

Influence of enamel sealing with a light-cured filled sealant before bracket bonding on the bond failure rate during fixed orthodontic therapy

PURPOSE

Fluoride-containing adhesives for enamel sealing are commonly used for the prevention of white spot lesions during fixed orthodontic treatment. Thus, we examined whether enamel sealing with L.E.D. ProSeal® (Reliance Orthodontic Products Inc., Itasca, IL, USA) before bracket bonding increases the rate of bond failure during orthodontic treatment.

METHODS

In 20 adolescents (11-16 years, 10 male/10 female) at the start of fixed therapy, self-ligating SmartClip™SL3 metal brackets (3M Unitek, Monovia, CA, USA) were bonded to cleaned and conditioned (40% H₃PO₄, 30 s) buccal enamel surfaces of all permanent teeth except molars using Transbond™ XT (3M Unitek). In a split-mouth design, either L.E.D. ProSeal® (1st/3rd quadrant) or Clinpro™ XT Varnish (2nd/4th quadrant; 3M Unitek) was applied to enamel surfaces before (ProSeal®) or after (Clinpro™ XT Varnish) bracket bonding (200 teeth each; light curing: 20 s, Ortholux™ Luminous, 3M Unitek). Cumulative bond failure as total number of teeth with bracket detachment since start of therapy was documented every 3 months for a total of 12 months.

RESULTS

Cumulative bond failure was higher for enamel sealing before bonding from 6 months onward reaching significance at 12 months (34/200) compared to sealing after bonding (24/200): p = 0.038; Cramér's V = 0.488; odds ratio (OR) = 1.5; relative risk (RR) = 1.4. The higher loss rate was limited to the lower arch, but evident within 3 months reaching significance at 9 and 12 months (p = 0.019/0.011, V = 0.636/0.630; OR = 1.7/1.75, RR = 1.5/1.6). In general, cumulative bond failure at 12 months was higher in the lower arch, but this was only significant for teeth sealed before bonding (p = 0.001, V = 0.303, OR = 3.4, RR = 2.8).

CONCLUSIONS

Enamel sealing with L.E.D. ProSeal® should be performed after bracket bonding to prevent increased bond failure and bracket loss in the lower dental arch.

Comparative assessment of conventional and light-curable fluoride varnish in the prevention of enamel demineralization during fixed appliance therapy: a split-mouth randomized controlled trial

Objective

To evaluate the effects of single application of a conventional versus light-curable fluoride varnish (LCFV) on prevention of enamel demineralization during fixed orthodontic treatment over a 4 month period.

Design

The research was designed as a split-mouth, randomized control trial (RCT).

Methods

Twenty-two patients requiring fixed orthodontic treatment with premolar extractions were included in the RCT. In each patient, two diagonal quadrants (i.e. upper right and lower left, or vice versa) were randomly assigned to receive conventional fluoride varnish or LCFV. After allocation of one intervention, the other diagonal quadrants received the second intervention. At specific time intervals, premolars were extracted and sectioned, and the demineralized lesion was assessed in each group.

Main outcome measures

The primary outcome was demineralized enamel lesion depth (DELD) at the end of 45, 90, and 120 days.

Randomization

A simple complete randomization list using random allocation rule (restricted randomization) was computer generated to ensure homogeneity of application of conventional or LCFV to each contralateral quadrant in a split-mouth design. Allocation concealment was not employed.

Blinding

Blinding was done only for outcome assessor because of clinical limitations.

Results

Twenty-two patients with 88 teeth were enrolled in the trial. After excluding the drop-outs, primary analysis was performed on 66 teeth distributed among two interventional groups. Mean difference between DELD among two groups was 36.6 µm [95 per cent confidence interval (CI) 34.61-38.55] and 58.5 µm [95 per cent confidence interval (CI) 55.65-61.43] at 90 and 120 days, respectively. Cluster level analysis performed by Paired t-test showed that DELD was significantly higher (P < 0.001) in the conventional fluoride varnish group at the end of 90 and 120 days as compared to LCFV group. No adverse effect was observed in any patient.

Limitations

Being a histologic study, the role of fluoride varnish could be assessed only for 4 months.

Conclusion

The result of this study indicate that single application of LCFV (Clinpro™ XT) can prevent enamel demineralization for longer duration (for up to 4 months) of time as compared to conventional fluoride varnish (Duraphat™, 45 days) during fixed appliance therapy.

Registration

The trial was registered retrospectively in the Clinical Trial Registry-India, number CTRI/2016/09/007232.

Resin-modified glass ionomer cement vs composite for orthodontic bonding: A multicenter, single-blind, randomized controlled trial

INTRODUCTION

In this study, we aimed to compare the incidence of new demineralized lesions and bond failures between 2 groups of participants wearing fixed orthodontic appliances bonded with either light-cured resin-modified glass ionomer cement or light-cured composite.

METHODS

This trial was a multicenter (6 centers: 2 teaching hospitals, 4 specialist orthodontic practices), single-blinded, randomized controlled trial with 2 parallel groups. Patients aged 11 years or older, in the permanent dentition, and about to start fixed orthodontic treatment in these 6 centers were randomly allocated to have either resin-modified glass ionomer cement or light-cured composite for bonding brackets, forward of the first molars. Pretreatment and day-of-debond digital photographic images were taken of the teeth and assessed by up to 5 clinical and 3 lay assessors for the presence or absence of new demineralized lesions and the esthetic impact. The assessors were masked as to group allocation.

RESULTS

We randomized 210 participants, and 197 completed the trial. There were 173 with complete before-and after-digital images of the teeth. The incidence of new demineralized lesions was 24%; but when the esthetic impact was taken into account, this was considerably lower (9%). There was no statistically significant difference between the bracket adhesives in the numbers with at least 1 new demineralized lesion (risk ratio,1.25; 95% confidence interval, 0.74-2.13; P = 0.403) or first-time bracket failure (risk ratio,0.88; 95% confidence interval, 0.67-1.16; P = 0.35). There were no adverse effects.

CONCLUSIONS

There is no evidence that the use of resin modified glass ionomer cement over light-cured composite for bonding brackets reduces the incidence of new demineralized lesions or bond failures. There might be other reasons for using resin modified glass ionomer cement.

REGISTRATION

This trial was registered at ClinicalTrials.govNCT01925924.

PROTOCOL

The protocol is available from the corresponding author on request.

The longevity of casein phosphopeptide-amorphous calcium phosphate fluoride varnish's preventative effects: Assessment of white spot lesion formation

OBJECTIVES

To test how long casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) fluoride varnish prevents enamel demineralization in vitro.

MATERIALS AND METHODS

Human molars and premolars were sectioned buccolingually and randomly assigned to two groups. Standardized pretreatment images of enamel surfaces were obtained using FluoreCam. The control group received no treatment, and the experimental group received an application of CPP-ACP fluoride varnish. Over simulated periods of 2, 4, 8, and 12 weeks, specimens were placed in a toothbrushing simulator, thermocycled, subjected to 9 days of pH cycling, and imaged with FluoreCam. Samples were sectioned and polished for polarized light microscope (PLM) evaluation.

RESULTS

There were statistically significant time ( P < .001) and varnish ( P < .001) effects on area, intensity, and impact of enamel demineralization. The control group showed significant and progressive demineralization over the 12 weeks ( P < .001). The experimental group revealed no significant demineralization during the first 4 weeks ( P > .05) and significant ( P < .001) increases thereafter. Experimental demineralization after 12 weeks was comparable to 2-week demineralization in the controls, with significant between-group differences ( P < .001) in enamel demineralization at all time points. PLM of the control and experimental groups revealed lesion depths of 90 ± 34 μm and 37 ± 9 μm, respectively.

CONCLUSIONS

Within the limitations of this in vitro study, CPP-ACP fluoride varnish prevents enamel demineralization for at least 4 weeks and limits demineralization up to 12 weeks.

[Oral and periodontal hygiene in orthodontic patients]

INTRODUCTION

Orthodontic appliances promote dental plaque retention and make tooth-brushing less easy. They result in both quantitative and qualitative changes in dental plaque, exposing orthodontic patients to dental caries and periodontal diseases.

MATERIALS AND METHODS

The authors explain the effects of orthodontic treatments on dental plaque and the occurrence of dental and periodontal problems; they emphasize the role of pathogenic bacteria and highlight the need for efficient (both individual and professional) control of dental plaque.

DISCUSSION

Therefore, orthodontists have to educate their patients on oral and periodontal hygiene in order to control this bacterial factor and to avoid the occurrence of dental and/or periodontal complications.

A comparison of different sealants preventing demineralization around brackets

AIM

Aim of the study was to compare how six different sealants resisted thermal, mechanical, and chemical loading in vitro.

MATERIALS AND METHODS

In all, 120 extracted human, nondecayed molars were divided into six groups (20 samples each) and embedded in resin blocks. The buccal surfaces of the tooth samples were polished and divided into three areas. Area A contained the product to be analyzed, area B was covered with colorless nail varnish (negative control), and area C remained untreated (positive control). The samples were stored in 0.1% thymol solution. To simulate a 3-month thermomechanical load, the samples were subjected to thermal cycling and a cleaning device. After 7 days incubation in a ten Cate demineralization solution (pH value: 4.6), the samples were dissected using a band saw and the lesion depths and demineralization areas were evaluated and compared microscopically.

RESULTS

The tooth surfaces treated with PRO SEAL® showed no demineralization. Mean lesion depths of 108.1, 119.9, 154.9, 149.2, and 184.5 μm were found with Alpha-Glaze®, Seal&Protect®, Tiefenfluorid®, Protecto®, and Fluor Protector, respectively. There was a significant difference between PRO SEAL® and the other products (p > 0.0001). There was no significant difference between the other products.

CONCLUSION

PRO SEAL® resisted thermal, mechanical, and chemical loading in vitro, providing protection against white spot lesions.

Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months-a randomized placebo-controlled clinical trial. Part I: photographic data evaluation

Background

White spot lesions (WSLs) are a frequent side-effect of multibracket appliance treatment. The effect of local fluoridation on post-orthodontic WSL is however inconclusive.

Objective

Assessment of WSL changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment.

Trial design

Randomized, single-centre, double-blind, parallel-group, placebo-controlled study.

Participants

Patients with not less than 1 WSL (modified score 1 or 2) on not less than 1 upper front teeth after debonding.

Interventions

Professional fluoride/placebo gel application during weeks 1-2; self-administered home application (weeks 3-24).

Outcomes

Photographic WSL assessment (dimension and luminance) of the upper front teeth (T0-T5).

Randomization

Random assignment to test (n = 23) or placebo group (n = 23) using a sequentially numbered list (random allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each).

Recruitment

The clinical study duration lasted from March 2011 to September 2013.

Blinding

Unblinding was performed after complete data evaluation.

Numbers analysed

Intent-to-treat analysis set comprising 39 participants (test: n = 21, placebo: n = 18).

Outcome

Dimensional WSL quantification showed limited reliability. Luminance improvement (%) of WSL, however, was seen after 6 months (test/placebo: tooth 12, 24.8/18.0; tooth 11, 38.4/35.4; tooth 21, 39.6/38.3; and tooth 22, 15.2/25.0). No statistically significant group difference existed. Data suggest that WSLs are difficult to measure with respect to reliability and repeatability and methods for monitoring WSLs in clinical trials require improvement/validation.

Harms

Similar adverse events occurred in both groups; none was classified as possibly related to the study product.

Limitations

The number of dropouts was higher than expected and the socio-economic status was not assessed. Furthermore, the unknown level of compliance during the home application phase must be considered as limitation.

Conclusion

Based on the results of this study, no difference could be detected with respect to the development of WSL under post-orthodontic high-dose fluoride treatment.

Registration

The study was registered with ClinicalTrials.gov (Identifier: NCT01329731).

Protocol

The protocol wasn't published before trial commencement.

Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months-a randomized placebo-controlled clinical trial. Part II: clinical data evaluation

Background

White spot lesions (WSL) frequently occur as side-effect of multibracket appliance treatment. The clinical effects of local fluoridation on post-orthodontic WSL and oral health development are however inconclusive.

Objective

In vivo monitoring of clinical WSL and oral health changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment.

Trial design

Randomized, single-centre, double-blind, parallel-group, placebo-controlled study.

Participants

Patients with not less than 1 WSL (modified score 1 or 2) on not less than 1 upper front teeth after debonding.

Interventions

Professional fluoride/placebo gel application during weeks 1-2; self-administered home application (weeks 3-24).

Outcomes

Clinical evaluation of WSL index, lesion activity, plaque index, gingival bleeding index, and decayed, missing, and filled teeth index as well as saliva buffer capacity and stimulated salivary flow rate (T0-T5).

Randomization

Random assignment to test (n = 23) or placebo group (n = 23) using a sequentially numbered list (random allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each).

Recruitment

The clinical study duration lasted from March 2011 to September 2013.

Blinding

Unblinding was performed after complete data evaluation.

Numbers analysed

Intention-to-treat analysis set comprised 39 participants (test: n = 21, placebo: n = 18).

Outcome

No clinical parameter except stimulated salivary flow rate (fluoride group: 1.1ml/min, placebo group: 0.74ml/min; P = 0.022) showed a statistically significant group difference after 24 weeks.

Harms

Several adverse events occurred similarly frequent in both groups; none was classified as possibly related to the study product.

Limitations

The number of dropouts was higher than expected and the socio-economic status was not assessed. Furthermore, the unknown level of compliance during the home application phase must be considered as limitation.

Conclusion

Based on the results of this study, no clinical effect of post-orthodontic high-dose fluoride treatment on WSL and oral health changes could be detected.

Registration

The study was registered with ClinicalTrials.gov (Identifier: NCT01329731).

Protocol

The protocol wasn't published before trial commencement.

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

The relation between orthodontic fixed appliances use and enamel demineralization is well established. Different preventive approaches have been suggested to this problem, but controversy remains about which is the best. The aim of this study was to perform a systematic review of clinical trials that investigated the effectiveness of materials containing fluorides to lute brackets or cover the bonding interface in order to inhibit the development and progression of white spot lesions. The null hypothesis was that fluoride materials do not affect the incidence of white spot lesions around brackets. A MEDLINE search was conducted for randomized clinical trials evaluating the development of white spot lesions in patients using fixed orthodontic appliances, followed by meta-analysis comparing the results for patients for whom dental materials containing fluorides were used (experimental group) to those for whom these materials were not used (control group). The pooled relative risk of developing white spot lesions for the experimental group was 0.42 (95% confidence interval: 0.25 to 0.72); hence, when fluoride-releasing materials are used, the patient has 58% less risk of white spot lesion development. Regarding white spot lesion extent, the pooled mean difference between the experimental and control groups was not statistically significant (-0.12; 95% confidence interval: -0.29 to 0.04). In conclusion, the results of the present systematic review suggest that fluoride-releasing materials can reduce the risk of white spot lesions around brackets. However, when white spot lesions had already occurred, there is no evidence that fluoride-releasing materials reduce the extent of these lesions.

Effect of Nd:YAG and CO2 Laser Irradiation on Prevention of Enamel Demineralization in Orthodontics: In Vitro Study

OBJECTIVE

The aim of this study was to investigate Nd:YAG and CO₂ laser effects in the prevention of demineralization in deeper layers of enamel via successive acid challenge cycles.

BACKGROUND DATA

Lasers are promising in the prevention of enamel demineralization around the orthodontic brackets; however, there are very few studies that evaluate if the effects of treatment could be extended after successive acid challenge cycles due to permanent enamel structural alterations.

MATERIALS AND METHODS

Human enamel samples were divided into five groups (n = 12): G1-application of 1.23% acidulated fluoride phosphate gel (AFP, control); G2-Nd:YAG laser irradiation (0.6 W, 84.9 J/cm², 10 Hz, 110 μs, contact mode); G3-Nd:YAG laser irradiation associated with AFP; G4-CO₂ laser irradiation (0.5 W, 28.6 J/cm², 50 Hz, 5 μs, and 10 mm focal distance); and G5-CO₂ laser irradiation associated with AFP. The samples were submitted to successive acid challenge cycles. Quantitative light-induced fluorescence and scanning electron microscopy were used to assess enamel demineralization. The data were statistically compared (α = 5%).

RESULTS

G1: 50.87 ± 4.57; G2: 47.72 ± 2.87; G3: 50.96 ± 4.01; G4: 28.21 ± 2.19; and G5: 30.13 ± 6.38. The CO₂ laser groups had significantly lower mineral losses than those observed in all other groups after successive acid challenge cycles.

CONCLUSIONS

Only the CO₂ laser (10.6 μm) irradiation prevents enamel demineralization around the orthodontic brackets even after exposure to successive acid challenges. The CO₂ laser at 10.6 μm showed a deeper effect in enamel regarding caries prevention.

Timing considerations on the shear bond strength of orthodontic brackets after topical fluoride varnish applications

Objectives:

To assess the best temporal association between the application of a fluoride varnish on enamel and bonding procedures.

Materials and Methods:

Eighty mandibular bovine incisors were used. Teeth were divided into 4 groups (20 per group); Groups 1–3 were treated with fluoride varnish (Fluor Protector, Ivoclar Vivadent, Schaan, Liechtenstein), and Group 4 served as control with no pretreatment. Tooth were stored in deionized water (37°C) and subjected to thermal cycling for 400 (Group 1), 800 (Group 2), and 2500 (Group 3) cycles corresponding, respectively, to 15, 30, and 90 days in order to simulate the three different timing of bracket bonding. Shear bond strength (SBS) was measured using an Instron Universal Testing machine. Tooth surfaces were examined under a stereomicroscope at 10× magnification to assess the amount of adhesive remnant index (ARI). One-way analysis of variance (ANOVA) and Tukey's honestly significant difference post-hoc test were used for the comparison of SBS values between groups (P < 0.05). The Chi-square test was used to examine differences among ARI scores. (P < 0.05).

Results:

One-way ANOVA and Tukey post-hoc test showed that the SBS of different groups were significantly different and was impacted by different timing of bonding (P < 0.05). The main differences were between the control group (17.02 ± 6.38 MPa) and Group 1 (6.93 ± 4.3 MPa). The ARI scores showed that there were no significant differences between the four tested groups.

Conclusions:

The SBS of the brackets bonded 15 days after the application of the fluoride was set back to an optimal value.

Control of White Spot Lesions with Use of Fluoride Varnish or Chlorhexidine Gel During Orthodontic Treatment A Randomized Clinical Trial

OBJECTIVE

To compare the effectiveness of fluoride varnish and 2% chlorhexidine gel for controlling active white spot lesions (WSLs) adjacent to orthodontic brackets.

STUDY DESIGN

Thirty-five orthodontic patients (17.2 ± 2.3 years old) presenting 60 WSLs adjacent to orthodontic brackets were enrolled in this randomized, blind, 3-armed and controlled clinical trial. The patients were randomly allocated to 1 of 3 arms: (1) two applications of 5% NaF varnish- F, with one-week interval, (2) two applications of 2% chlorhexidine gel-CHX, with one-week interval and (3) usual home care-control (CO). The WSLs were scored by using a DIAGNOdent pen. An independent examiner scored the surfaces using Nyvad criteria for caries assessment.

RESULTS

A total of thirty patients presenting 51 lesions completed the study. All treatments reduced the fluorescence values during the experimental period; however, F induced faster remineralization than CHX. After 3 months, 70.58 % were inactive considering all groups. DIAGNOdent pen and Nyvad presented a significant correlation.

CONCLUSION

After 3 months of treatment, F, CHX and CO were capable of controlling the WSLs adjacent to the orthodontic brackets. However, the treatment with F was capable of controlling the progression of the WSLs in a shorter period of time.

A 12-Week Assessment of the Treatment of White Spot Lesions with CPP-ACP Paste and/or Fluoride Varnish

This 12-week clinical study evaluated the impact of 10% CPP-ACP and 5% sodium fluoride varnish regimes on the regression of nonorthodontic white spot lesions (WSLs). The study included 21 children with 101 WSLs who were randomised into four treatment regimes: weekly clinical applications of fluoride varnish for the first month (FV); twice daily self-applications of CPP-ACP paste (CPP-ACP); weekly applications of fluoride varnish for the first month and twice daily self-applications of CPP-ACP paste (CPP-ACP-FV); and no intervention (control). All groups undertook a standard oral hygiene protocol and weekly consultation. Visual appraisals and laser fluorescence (LF) measurements were made in weeks one and twelve. The majority of WSLs in the control and FV groups exhibited no shift in appearance, whereas, in the CPP-ACP and CPP-ACP-FV groups, the lesions predominantly regressed. The visual and LF assessments indicated that the extent of remineralisation afforded by the treatments was of the following order: control ~ FV < CPP-ACP ~ CPP-ACP-FV. Self-applications of CPP-ACP paste as an adjunct to standard oral hygiene significantly improved the appearance and remineralisation of WSLs. No advantage was observed for the use of fluoride varnish as a supplement to either the standard or CPP-ACP-enhanced oral hygiene regimes.