Effectiveness of a Hydroxyapatite-Containing Toothpaste Versus Mouthwash in Preventing White-Spot Lesions During Fixed-Appliance Orthodontic Treatment: A Randomized Clinical Trial
Phase: NA
Conditions: Prevention of White Spot Lesions in Patients Undergoing Orthodontic Treatment
Sponsor: Heba Tahseen Almasri

        Republic of Iraq  
Ministry Higher Education 
      and scientific Research 
      University of Baghdad 
        College of Dentistry 
 
Effectiveness of a Hydroxyapatite-Containing Toothpaste 
Versus Mouthwash in Preventing White-Spot Lesions 
During Fixed-Appliance Orthodontic Treatment: A 
Randomized Clinical Trial 
 
A Protocol Submitted to 
the Council of the College of Dentistry, University of Baghdad in 
Partial Fulfillment of Requirements for the Degree of Master of 
Science in Orthodontics 
 
Heba Tahseen Almasri 
B.D.S. 
Supervised by: 
Asst. Prof. Dr. Noor Muhammed Hasan Garma 
BDS, MSc, PhD (Orthodontics) 
Baghdad-Iraq 
September, 2025 

Certification of the Supervisor 
 
This is to certify that the preparation and organization of this protocol entitled 
"Effectiveness of a Hydroxyapatite-Containing Toothpaste Versus Mouthwash 
in Preventing White-Spot Lesions During Fixed-Appliance Orthodontic 
Treatment : A   Randomized Clinical Trial " had been made by the master student 
Heba Tahseen Almasri under my supervision, at the Department of 
Orthodontics/College of Dentistry/University of Baghdad in partial fulfillment for 
the Degree of Master of Science in Orthodontics. 
 
 
 
Supervisor’s By 
 (Asst. Prof. Dr. Noor Muhammed Hasan Garma) 
 (BDS, MSc, PhD)  
Department of Orthodontics 
College of Dentistry/ 
University of Baghdad  
2025 
(The Supervisor) 

Study Protocol 
1 
 
 
Effectiveness of a Hydroxyapatite-Containing Toothpaste 
Versus Mouthwash in Preventing White-Spot Lesions During 
Fixed-Appliance Orthodontic Treatment: A Randomized 
Clinical Trial  
 
Introduction: 
 
Orthodontic treatment is widely recognized as an effective approach to improve 
dental and facial aesthetics, which play a crucial role in overall attractiveness and 
psychosocial well-being. A recent systematic review and meta-analysis confirmed 
that orthodontic therapy enhances facial attractiveness by approximately 9% 
compared with untreated individuals. However, despite these aesthetic benefits, fixed 
appliance therapy is associated with several side effects, most notably the 
development of white spot lesions (WSLs) (Kouskoura et al., 2022). 
The placement of fixed orthodontic appliances significantly increases dental biofilm 
accumulation around brackets and wires. Patients undergoing fixed-appliance 
orthodontic treatment show a higher concentration of plaque, particularly on the 
labial surfaces of anterior teeth, compared to pre-treatment levels. This accumulation 
is attributed to the brackets acting as retention sites, making oral hygiene 
maintenance more challenging and increasing the risk of enamel demineralization, 
gingival inflammation, and the WSLs (Kozak et al., 2021). 
WSLs represent the earliest stage of dental caries, characterized by subsurface 
demineralization of the enamel, which appears as opaque, non-cavitated white areas 

Study Protocol 
2 
 
 
on the tooth surface. These lesions indicate the onset of enamel decay and may 
progress to cavities if left untreated (Lopes et al., 2024). 
Fluoride has been widely used in toothpastes and mouthwashes for caries prevention; 
however, excessive or prolonged exposure has been associated with potential adverse 
effects. These include dental fluorosis, characterized by white or brown discoloration 
of teeth (Choi et al., 2012). 
Therefore, hydroxyapatite (HAP)-containing oral care products have emerged as a 
safe and effective alternative. Clinical evidence demonstrates that HAP can 
remineralize enamel, reduce the formation of WSLs, and provide preventive 
outcomes comparable to or better than fluoride, without the associated systemic or 
local side effects (Amaechi et al., 2019). Therefore, incorporating HAP-based 
toothpaste or mouthwash into daily oral hygiene routines during orthodontic 
treatment offers a biocompatible and reliable strategy to minimize enamel 
demineralization and improve clinical outcomes. 
Hydroxyapatite (HAP)-containing oral care products have been increasingly 
recognized for their ability to remineralize enamel and reduce the formation of 
WSLs. Clinical evidence confirms that HAP-containing toothpaste can re-mineralize 
enamel lesions effectively while enhancing tooth brightness without adverse effects 
(BMC Oral Health, 2022; Paszyńska et al., 2023). In addition, a mouthwash can 
significantly reduce interdental gingival bleeding, highlighting its role as an effective 
adjunct to mechanical oral hygiene (Saliasi et al., 2018).  Systematic reviews and 
meta-analyses have reported that mouth rinses can provide a benefit beyond 
mechanical oral hygiene alone in preventing plaque accumulation and gingivitis 
(Araujo et al., 2015). These findings underscore the relevance of incorporating both 
HAP-based oral care products and mouthwashes as preventive and supportive 
measures in modern dental care protocols. 

Study Protocol 
3 
 
 
Research Question: 
In patients undergoing fixed-appliance orthodontic treatment, which intervention 
hydroxyapatite-containing toothpaste, hydroxyapatite mouthwash, or conventional 
oral hygiene is most effective in preventing the development of white-spot lesions? 
 
Aim and Objectives: 
Aim: 
To evaluate and compare the effectiveness of a hydroxyapatite-containing 
toothpaste, a hydroxyapatite-containing mouthwash, and conventional oral hygiene 
products in preventing or reducing the incidence of white spot lesions (WSLs) during 
fixed-appliance orthodontic treatment. 
Primary Objectives: 
To evaluate the preventive effectiveness of two enamel remineralizing methods 
compared to the conventional method in reducing the risk of WSLs on the labial 
surfaces of upper and lower incisors, and canine teeth during six months of 
orthodontic treatment by monitoring:  
1. Severity of WSLs using the Gorelick index. 
2. Enamel integrity and early demineralization using Diagnodent Pen scores. 
3. Incidence of WSLs assessed using photographic documentation. 
 
Secondary Objectives: 
1. To assess oral health status using Gingival Bleeding Index (GBI), and Plaque 

Study Protocol 
4 
 
 
Index (PI). 
2. To measure salivary pH changes over the study period. 
Hypothesis: 
Null Hypothesis (H0): 
There is no significant difference in the incidence or severity of white-spot lesions 
among patients using hydroxyapatite toothpaste, hydroxyapatite mouthwash, or 
conventional oral hygiene during fixed-appliance orthodontic treatment. 
 
Alternative Null Hypothesis (H1): 
There is a significant difference in the incidence and severity of white-spot lesions 
among patients using hydroxyapatite toothpaste or hydroxyapatite mouthwash, with 
either intervention potentially showing superior preventive effectiveness. 
 
Methodology 
 
Study Design: 
This study is designed as a multicenter, parallel, randomized clinical trial. Each 
participant will be randomly assigned to one of the three groups: 
 • Group A: Participants will be instructed to brush their teeth three times daily with 
the hydroxyapatite-containing toothpaste and to rinse twice daily with a placebo 
mouthwash. 
 • Group B: Participants will be instructed to brush their teeth three times daily with 
a conventional fluoride toothpaste and to rinse twice daily with a hydroxyapatite-
containing mouthwash. 

Study Protocol 
5 
 
 
• Group C: Participants will be instructed to brush their teeth three times daily with 
a conventional fluoride toothpaste and to rinse twice daily with a placebo 
mouthwash. 
All interventions and assessments will be conducted throughout the study period. 
The same participant (orthodontic patient) will be evaluated at baseline (before 
bonding) and at 1, 3, and 6 months after the placement of orthodontic appliances. 
Participants will receive standardized oral hygiene instructions, and all assessments 
of white-spot lesions will be performed using Diagnodent Pen, Gorlick index (GI), 
digital photographs, Gingival Bleeding Index (GBI), Plaque Index (PI), and salivary 
pH measurements to minimize variability and ensure consistent data collection. 
Randomization and Allocation Concealment: 
Participants will be randomized into three parallel groups with an equal allocation 
ratio of 1:1:1 using a computer-generated randomization list created with GraphPad 
QuickCalcs. Allocation concealment will be achieved using sequentially numbered, 
opaque, sealed envelopes (SNOSE) prepared by an independent researcher not 
involved in recruitment. Each envelope will contain: 
 1. A group allocation card (A, B and C). 
 2. The assigned oral hygiene product in an opaque sealed bag. 
 3. Written instructions for product use. 
Envelopes will remain sealed until the day of bonding, at which point the clinician 
will open the envelope to reveal the participant’s group and provide the assigned 
intervention. The allocation list will be securely stored by the independent researcher 
and will not be accessible to the study team until after data collection and primary 

Study Protocol 
6 
 
 
statistical analysis are completed. 
Blinding: 
This study will be conducted under a double-blind design. Both the principal 
investigator and the participants will be blinded to group allocation. The toothpaste 
and mouthwash bottles will be coded and identical in appearance, color, and 
packaging, ensuring that neither the clinician nor the participant can identify which 
formulation (hydroxyapatite-containing or conventional) is being used. The code 
will be kept by an independent researcher who is not involved in the study procedures 
or data analysis and will only be revealed after the completion of data collection. 
All clinical assessments, including Gorelick Index (GI), Diagnodent Pen 
measurements , digital photography, Gingival Bleeding Index (GBI), Plaque Index 
(PI), and salivary pH, will be conducted without knowledge of participants’ assigned 
group. 
Settings: 
The study will be conducted at the Department of Orthodontics, University of 
Baghdad, as well as in selected private and public dental clinics that provide fixed-
appliance orthodontic treatment. All participants will be treated using conventional 
metal brackets to ensure standardization of the orthodontic appliance type. All 
procedures, including oral examinations and sample collections, will follow 
standardized protocols to ensure consistency and uniformity across all study sites. 
Subjects / Materials: 
Participant Recruitment: 
Participants will consist of patients requiring fixed-appliance orthodontic treatment 
due to malocclusion, crowding, or spacing issues. 

Study Protocol 
7 
 
 
Informed Consent: 
Written informed consent will be obtained from all participants prior to enrollment. 
Participants will receive a clear explanation of the study objectives, procedures, 
potential benefits, and possible risks. They will be informed that participation is 
voluntary and that they may withdraw at any time without affecting their ongoing 
treatment. Confidentiality of participant information will be maintained throughout 
the study and in all subsequent publications. 
 
Inclusion Criteria: 
All included participants will be drawn from those who will receive comprehensive 
orthodontic treatment and fulfill the following inclusion criteria:   
1. Complete permanent dentition up to the first premolar, with no intended 
extractions in orthodontic treatment plan. 
 2. Good overall health. 
 3. Good oral hygiene: full-mouth plaque score < 20%. 
 4. No bleeding upon probing after 30 seconds. 
 5. Discontinuous band of plaque at the gingival margin. 
 6. Normal stimulated salivary flow rate. 
 7. Normal buffer capacity (final pH between 6.0 and 7.0). 
 
Exclusion Criteria: 
1. History of previous orthodontic treatment. 

Study Protocol 
8 
 
 
2. Bleaching or topical fluoridation within the last six months. 
3. Severely rotated any of the study teeth (limiting the appearance of facial surfaces). 
4. Visible signs of caries, fluorosis, hypocalcification, or other developmental 
defects. 
5. Restoration on the labial surface of the study teeth. 
6. Systemic or endocrine conditions (e.g., cardiac pacemakers, diabetes mellitus). 
7. Craniofacial anomalies and clefts. 
Sample Size: 
The sample size for the present study was determined to provide 80% statistical 
power at a 5% significance level (α = 0.05) to detect a 1-unit difference in the 
decalcification index (Gorlick index) (Hoffman et al, 2014). Accordingly, the 
current study will include a total of 75 participants, equally distributed into three 
groups of 25 subjects each, to ensure adequate statistical power and to account for 
potential dropouts. 
Procedure / Intervention: 
• Group A: Participants will be instructed to brush their teeth three times daily with 
the hydroxyapatite-containing toothpaste and to rinse twice daily with a placebo 
mouthwash. 
 • Group B: Participants will be instructed to brush their teeth three times daily with 
a conventional fluoride toothpaste and to rinse twice daily with a hydroxyapatite-
containing mouthwash. 
• Group C: Participants will be instructed to brush their teeth three times daily with 
a conventional fluoride toothpaste and to rinse twice daily with a placebo 

Study Protocol 
9 
 
 
mouthwash. 
Toothbrushing Instructions: 
All participants will receive oral and written instructions, as well as a demonstration 
video, on proper toothbrushing technique using their assigned toothbrush. The 
technique applied will be the Modified Bass method, in which the toothbrush is 
positioned at the gum margin at a 45° angle, performing small vibratory movements 
while simultaneously moving along the dental arches to ensure that all accessible 
tooth surfaces are thoroughly cleaned (Farook, 2023). 
Each toothbrushing session will be performed for 2minutes, allocating 
approximately 30 seconds for each quadrant. Participants will be instructed to 
maintain this routine three times daily throughout the study period. 
Mouthwash Protocol: 
All participants will be instructed to use the mouthwash according to the following 
standardized protocol to ensure consistency across the study: 
 • Group A: Placebo mouthwash (purified water, flavoring agents). 
 • Group B: Hydroxyapatite-containing mouthwash. 
 • Group C (control group): Placebo mouthwash (purified water, flavoring agents). 
- Frequency of use: twice daily after brushing. 
-   Dosage: 15 ml of mouthwash per use. 
-  Rinsing duration: Participants will rinse the mouthwash for 30 seconds and 
then expectorate without swallowing. 
- rinsing instructions: Participants will be instructed not to eat, drink, or rinse 
with water for at least 30 minutes after using the mouthwash to maximize its 

Study Protocol 
10
 
 
effect. 
- Additional Instructions: Participants should shake the bottle well before each 
use. 
 
Patient Reminder System: 
To enhance adherence to the assigned oral hygiene regimen, all participants will be 
reminded weekly through one of the social media platforms. These messages will 
remind the participants in all groups to perform their assigned oral hygiene protocols. 
The messages will include brief instructions and practical tips for proper use the 
assigned toothpaste and mouthwash, and participants will be encouraged to confirm 
completion of their daily oral hygiene routine. This system is designed to improve 
compliance and ensure standardized adherence throughout the study period. 
 
 
 
 
 
 
 
 
 

Study Protocol 
11
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1: The intended CONSORT Flow Diagram of the Current Study. 
CONSORT = Consolidated Standards of Reporting Trials, PP = Per-Protocol Analysis (includes 
participants who fully adhered to the study protocol), ITT = Intention-to-Treat Analysis (includes all 
randomized participants, regardless of adherence), T4 = Time point4 (fourth follow-up visit). 
              Assessed for eligibility (n=x) 
Randomized (n=75) 
Group A 
(Toothpaste with 
HAP) 
GroupC (Control): 
conventional oral 
hygiene 
Lost to follow-up 
(n=x) 
Lost to follow-
up (n=x) 
Analyzed for PP 
 (n = X) 
 Analyzed for ITT at T4 
(n = X) 
Analyzed for PP 
(n = X) 
Analyzed for ITT atT4 
(n = X)  
Excluded (n=x) 
1.Not meeting 
inclusion criteria (n= 
x) 
 2.Declined to 
participate (n=x) 
3.Other reasons (n=x) 
Group B 
(mouthwash 
containing HAP) 
Lost to follow-up 
(n=x) 
Analyzed for PP 
 (n = X) 
 Analyzed for ITT at T4 
(n = X) 

Study Protocol 
12
 
 
Assessment of WSLs and Oral Health: 
White Spot Lesions (WSLs) and oral health parameters will be evaluated at baseline, 
1 month, 3 months, and 6 months using DIAGNOdent Pen readings, standardized 
digital photographs, Gorelick Index, Plaque Index (PI), and Gingival Bleeding Index 
(GBI). All assessments will follow standardized protocols to ensure consistency 
across participants. 
Photography and Gorelick Index Assessment 
All patients’ teeth were photographed using a digital camera. After drying with 
compressed air, three digital photographs (frontal, right, and left lateral) of each tooth 
were taken. A single investigator captured all images to ensure consistency in image 
quality. Photographs were taken at approximately 20° perpendicular to the buccal 
tooth surfaces (Papadimitriou et al., 2024). 
The photographs will be evaluated using the Gorelick Index (GI) as follows: 
(0) no white spot lesion present. 
 (1) visible white spots without surface interruption (mild decalcification). 
 (2) visible white spot lesion having a roughened surface but not requiring a 
restoration (moderate decalcification). 
 (3) visible white spot lesion with surface interruption (severe decalcification).  
(4) cavitation (Gorelick, Geiger & Gwinnett, 1982). 
 
Assessment of White Spot Lesions Using DIAGNOdent Pen: 
In this study, the cutoff values of the DIAGNOdent device will be adopted according 
to the manufacturer’s operating guide to standardize data collection in the clinical 

Study Protocol 
13
 
 
setting. Readings from 0–10 represent sound tooth structure, 11–20 indicate outer 
half enamel caries, 21–30 correspond to inner half enamel caries, and readings of 
≥30 are considered dentin caries (KaVo Dental, Biberach an der Riss, Germany). 
These values will serve as a reference for monitoring changes in white spot lesions 
during the study (Du et al., 2011; Gohar, Ibrahim and Safwat, 2023). 
Prior to each measurement, the device will be calibrated for every patient. Readings 
will be obtained from four locations on the labial/buccal surface of each tooth: 
gingival, occlusal, mesial, and distal, in accordance with the recommendation of 
(Banks & Richmond, 1994). After drying the tooth surface, the number 2 pen tip will 
be placed 1 mm from the bracket on the labial surface of the tooth being examined. 
The baseline measurement (T0) will be recorded in the patient’s dental chart. 
Subsequent assessments will be performed at 1, 3, and 6 months (T1, T3, and T6) 
after the placement of the orthodontic appliance. All measurements will be conducted 
by a single trained examiner to ensure consistency and reliability. 
 
 
Assessment of Plaque index: 
To determine the Plaque Index (PI) of the patients, the thickness of dental plaque 
was evaluated by probing the mesial, distal, buccal, and palatal surfaces of all teeth 
using a Williams periodontal probe. The plaque index for each individual was 
calculated by summing the scores obtained for each tooth and dividing by the number 
of teeth examined. The classification of the plaque index was based on Silness & 
Löe (1964): 
 • PI 0: No plaque in the area adjacent to the gingiva. 

Study Protocol 
14
 
 
 • PI 1: Thin film of plaque along the gingival margin, not visible to the naked eye. 
 • PI 2: Moderate accumulation of plaque visible on the gingival margin and in the 
gingival pocket. 
 • PI 3: Dense accumulation of plaque covering the gingival margin and filling the 
gingival pocket. 
 
Assessment of Gingival Bleeding Index (GBI): 
To evaluate the Gingival Bleeding Index (GBI), gingival bleeding was assessed on 
the mesial, distal, buccal, and palatal/lingual surfaces of all teeth using a Williams 
periodontal probe. The probe was gently inserted along the gingival margin and 
inside the gingival pocket, and bleeding was recorded approximately 30 seconds after 
probing. The index for each individual was obtained by summing the scores for all 
teeth and calculating the mean. 
The classification of the Gingival Bleeding Index was based on Löe & Silness 
(1963): 
 • GBI 0: Healthy gingiva with no bleeding. 
 • GBI 1: Slight bleeding on probing on one or more surfaces. 
 • GBI 2: Moderate bleeding observed on multiple surfaces. 
 • GBI 3: Profuse or spontaneous bleeding involving most or all surfaces. 
 
Saliva Collection and pH Measurement: 
Salivary samples will be collected from the participants. At the first stage, 

Study Protocol 
15
 
 
participants will be given a paraffin wax to chew, which stimulates saliva production, 
and they will be asked to swallow the pooled saliva. Then, they will be instructed to 
spit their saliva into a saliva-collecting tube for five minutes. At each designated time 
point, the pH of saliva will be measured using pH test strips. The strips will be soaked 
in the saliva for one minute, and the resulting color change, indicating pH values, 
will be recorded by comparing it with the accompanying reference chart (Alkarad, 
Alkhouli and Dashash, 2023; Campus et al., 2024). 
 • Patient compliance: monitored with a diary and product usage checks. 
Timetable: 
Phase 
Duration / Time Points 
Description 
Recruitment & 
Screening 
1 month 
Patient selection, 
informed consent, 
baseline assessment. 
Baseline Assessment 
Week 0 
Initial evaluation of 
WSLs using 
Diagnodent Pen, digital 
photos, Gorelick Index, 
GBI, PI, and salivary 
pH. 
Intervention & Follow-
up 
6 months 
Participants receive 
assigned oral care 
regimen (toothpaste 
and mouthwash). 
Measurements at 1 
month, 3 months, and 6 
months for WSLs and 
oral health parameters. 
Data Analysis 
1 month 
Statistical analysis of 
primary and secondary 
outcomes. 
 
Stopping Roles: 
• Any patient developing severe adverse reactions to the products. 

Study Protocol 
16
 
 
 • Patient withdrawal of consent.

Study Protocol 
17
 
 
Budget and Funding: 
The study is self-funded 
Ethical Approval: 
The protocol will be submitted to ethics committee 
 
 
Data Management and Analysis 
 
Further Considerations 
Pilot study: 
A pilot study will NOT be conducted 
 
Dissemination: 
Postgraduate Thesis  

Study Protocol 
18
 
 
References 
 
1. Kouskoura, T., Ochsner, T., Verna, C., Pandis, N. & Kanavakis, G., 2022. The 
effect of orthodontic treatment on facial attractiveness: a systematic review and meta-
analysis. European Journal of Orthodontics, 44(6), pp.636–649. 
doi:10.1093/ejo/cjat064. 
2. Kozak, U., Lasota, A. & Chałas, R., 2021. Changes in distribution of dental biofilm 
after insertion of fixed orthodontic appliances. Journal of Clinical Medicine, 10(23), 
p.5638. doi:10.3390/jcm10235638. 
3. Lopes, P.C. et al., 2024. White Spot Lesions: Diagnosis and Treatment – A Systematic 
Review. BMC Oral Health, 24(1), pp.1–10. doi:10.1186/s12903-023-03720-6. 
4. Choi, A.L., Sun, G., Zhang, Y. & Grandjean, P., 2012. Developmental fluoride 
neurotoxicity: a systematic review and meta-analysis. Environmental Health 
Perspectives, 120(10), pp.1362–1368. doi:10.1289/ehp.1104912. 
5.  Amaechi, B.T., AbdulAzees, P.A., Alshareif, D.O., Shehata, M.A., Lima, 
P.P.C.S., Abdollahi, A., Samadi Kalkhorani, P. & Evans, V., 2019. Comparative 
efficacy of a hydroxyapatite and a fluoride toothpaste for prevention and 
remineralization of dental caries in children. BDJ Open, 5:18. 
6. Paszyńska, E., Górska, R., Kaczmarek, U., et al., 2023. Caries-preventing effect of 
a hydroxyapatite-toothpaste in adults: A randomized, double-blind, clinical trial. 
Frontiers in Public Health, 11, p.1199728. https://doi.org/10.3389/fpubh.2023.1199728 
7. BMC Oral Health, 2022. Effects of hydroxyapatite toothpaste on tooth whitening and 
enamel remineralization: Clinical evaluation. BMC Oral Health, 22, p.345. 
https://doi.org/10.1186/s12903-022-02266-3 
8. Saliasi, I., Llodra, J.C., Bravo, M., Tramini, P., Dussart, C., Viennot, S. & 
Carrouel, F., 2018. Effect of a Toothpaste/Mouthwash Containing Carica papaya Leaf 

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Extract on Interdental Gingival Bleeding: A Randomized Controlled Trial. 
International Journal of Environmental Research and Public Health, 15(12), p.2660. 
Available at: https://doi.org/10.3390/ijerph15122660. 
9. Araujo, M.W.B., Charles, C.A., Weinstein, R.B., Parikh-Das, A.M., Zhang, J., & 
Gunsolley, J.C., 2015. Meta-analysis of the effect of an essential oil-containing 
mouthrinse on gingivitis and plaque. Journal of the American Dental Association, 
146(8), pp.610–622. Available at: https://doi.org/10.1016/j.adaj.2015.05.007. 
10. Hoffman, D.A., Clark, A.E., Rody Jr., W.J., McGorray, S.P. & Wheeler, T.T. 
(2015) ‘A prospective randomized clinical trial into the capacity of a toothpaste 
containing NovaMin to prevent white spot lesions and gingivitis during orthodontic 
treatment’, Progress in Orthodontics, 16: 25. 
11. Farook, F.F., 2023. The efficacy of manual toothbrushes in patients with fixed 
orthodontic appliances: a randomized clinical trial. BMC Oral Health, 23(1), p.35. 
12. Gorelick, L., Geiger, A.M. & Gwinnett, A.J., 1982. Incidence of white spot 
formation after bonding and banding. American Journal of Orthodontics, 81(2), 
pp.93–98. 
13. Banks, P. & Richmond, S., 1994. Enamel sealants: a clinical evaluation of their value 
during fixed appliance therapy. European Journal of Orthodontics, 16(1), pp.19–25. 
14. Silness, J. & Löe, H., 1964. Periodontal disease in pregnancy. II. Correlation between 
oral hygiene and periodontal condition. Acta Odontologica Scandinavica, 22(1), 
pp.121–135. 
15. Löe, H. & Silness, J., 1963. Periodontal disease in pregnancy. I. Prevalence and 
severity. Acta Odontologica Scandinavica, 21(6), pp.533–551. 
16. Du, M., Cheng, N., Tai, B., Jiang, H., Li, J. & Bian, Z., 2011. Randomized 
controlled trial on fluoride varnish application for treatment of white spot lesion after 
fixed orthodontic treatment. Clinical Oral Investigations, 16(2), pp.463–468. 
https://doi.org/10.1007/s00784-011-0520-4 

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17. Gohar, R. A. A. E. G., Ibrahim, S. H. & Safwat, O. M. (2023) ‘Evaluation of the 
remineralizing effect of biomimetic self-assembling peptides in post-orthodontic 
white spot lesions compared to fluoride-based delivery systems: randomized 
controlled 
trial’, 
Clinical 
Oral 
Investigations, 
27(2), 
pp. 
613-624. 
doi:10.1007/s00784-022-04757-7. 
18. Campus, G., Cocco, F., Wierichs, R.J., Wolf, T.G., Salerno, C., Arghittu, A., 
Dettori, M. & Cagetti, M.G., 2024. Effects of Hydroxyapatite-Containing 
Toothpastes on Some Caries-Related Variables: A Randomised Clinical Trial. 
International 
Dental 
Journal, 
74(6), 
pp.754–761. 
https://doi.org/10.1016/j.identj.2024.01.028. 
19. Alkarad, L., Alkhouli, M. & Dashash, M. (2023) ‘Remineralization of teeth with 
casein phosphopeptide-amorphous calcium phosphate: analysis of salivary pH and 
the rate of salivary flow’, BDJ Open, 9(1), p. 16. doi:10.1038/s41405-023-00141-z. 
 

 
 
 
University of Baghdad 
  College of Dentistry 
Research Ethics 
Committee 
                                                                                            Ref. number:1139 
 
                                                                                              Date: 1-12-2025 
Decision of the Research Ethics Committee 
 
To Heba Tahseen Almasri and Asst. Prof. Dr. Noor Muhammed Hasan 
Garma 
The Research Ethics Committee of the College of Dentistry, University of 
Baghdad has reviewed the submitted research project outlined below for 
ethical approval.  
Project No. 
1139425 
Project title 
Effectiveness of a Hydroxyapatite-Containing Toothpaste  
Versus Mouthwash in Preventing White-Spot Lesions  
During Fixed-Appliance Orthodontic Treatment:  
Randomized Clinical Trial 
Decision  
Approved   
 
This decision was made based on the following submitted items that 
have been received and reviewed by the committee: 
• Study protocol. 
• Application form and checklist for research that involves human 
subjects (if applicable). 
• Patient information sheet and consent form (if applicable). 
• Application form and checklist for research that involves animal 
experiments (if applicable). 
 
 
Prof. Dr. Salwan Y. Bede      BDS, FIBMS 
Chairman of the Research Ethics Committee 
Email: ethical.approval@codental.uobaghdad.edu.iq