The Effect of Different Remineralizing Agents on White Spot Lesions and Dental Plaque During Orthodontic Retention

Study Overview
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Brief Summary
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Dental caries is a decay process that breaks down the tooth. The earliest clinical signs of active dental caries is seen as 'white spot lesions' (WSLs). WSLs causes porosity below the tooth surface as a result of demineralization that gives the lesion a milky white appearance. Many WSLs persevere even a decade after orthodontic appliance removal and remain a cosmetic problem. After removal of fixed appliances, a considerable improvement of WSLs can be seen during the first 6-24 months, but the degree of improvement varies between individuals. Two common bacteria in dental plaque causes caries: Streptococcus mutans (SM) and Lactobacillus acidophilus (LA) in the plaque contributes to the initiation and progression of caries, respectively. A major strategy suggested to deal with existing WSL after debond is to facilitate remineralisation using remineralising agents that contain fluoride. This can be from daily use of fluoridated toothpastes or having additional dose of fluoride application. Certain agents also contain casein phosphopeptide-stabilize amorphous calcium phosphate (CPP-ACP) that is believed to have an antibacterial and buffering effect on plaque and interfere the growth and adherence of bacteria.

Detailed Description
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Rationale of the study : Currently there is insufficient evidence on the most effective regime of fluoride application to regress post orthodontic WSLs and how it affects the quality and quantity of oral microbial flora. The study aims to determine the effect of different remineralizing agents on white spot lesions and dental plaque of post-orthodontic treatment patients. The objectives are: To compare the tooth surface changes (based on ICDAS, optical changes and patient perception) of white spot lesion treated with different remineralizing agents during orthodontic retention To compare the bacterial count (including streptococcus and lactobacillus) in subjects with white spot lesions treated with different remineralizing agents during orthodontic retention To compare the salivary profile (flow rate, Ph, buffering capacity) in subjects with white spot lesion treated with different remineralizing agents during orthodontic retention Sample size calculation : Sample size was calculated using G-power. Given an effect size of 0.49 (Jung et al., 2014), 80% power of study, alpha of 5% and 7 measurements, the sample size required was 27. With a 10% dropout, the final sample size is 30. Methodology : A. Subjects screening and preparation Orthodontic patients treated with at least fixed appliances on the maxillary arch at the Faculty of Dentistry, University of Malaya whom are scheduled for debond, are invited to participate in this study. Participants will be screened for white spot lesions based on the inclusion and exclusion criteria. Participants will be randomly allocated to 3 groups that will receive remineralizing applications according to their allocated groups: Group 1 The participants in group 1 will act as control group as they will be advised in using fluoridated toothpaste to brush twice daily during the follow up periods. No other fluorides supplements will be allowed to use. Group 2 The participants in this group will received fluoride varnish (5% sodium fluoride) treatment. The labial surface of each tooth will be polished with non-fluoridated pumice powder and will be rinsed and dried thoroughly. Approximately 0.5-1.0ml fluoride varnish will be applied on the tooth surface (labially) with the paint-on method from canines to canines. After varnish application, patients will be advised not to drink for at least 30 minutes and not to brush teeth or eat food for the next 4 hours after application. Participants can brush teeth the night after application. The participants will be advised to brush their teeth daily with fluoridated toothpaste. Fluoride varnish application will be on 3 months intervals from first review visit (T1). No other fluorides supplements will be allowed to use. Group 3 The participants will be advised to use pea size CPP-ACP plus crème on the tooth surfaces using a clean fingers twice daily following brushing their teeth with fluoridated toothpaste. The participants will be taught to keep the CPP-ACP plus crème on the tooth surface for at least 3 minutes before rinsing the mouth. After application of CPP-ACP plus crème, participants will be advised not to drink or eat for at least 30 minutes. No other fluoride supplements will be allowed to use. During the first appointment (T0), Debond procedure will be done according to the standard protocol. Two sets of impression will be taken for the construction of study model, construction of the standard retainers and also for the research purpose. Participants will be screen for white spot lesion by using the Optical Coherence Tomography (Santec) . A jig will be constructed for reproducible positioning of the probe. Two maxillary teeth with the worst WSL will be selected for each patient to measure the lesion depth and integrated refractivity. The intraoral photos of the maxillary teeth will be taken. The salivary profile (flow rate, Ph, buffering capacity) will be measured using Saliva- Check BUFFER (GC America) according to the manufacturer's instruction. Plaque samples will be collected with sterile swabs from the enamel surface of each tooth with the identified WSL to measure the bacterial count. 1 day after T0, Participants will receive pressure formed or thermoplastic retainer in upper arch and instructed to wear their retainers all day (for at least 8 hours) and wear them after toothbrushing. ICDAS score and optical changes (lesion depth and integrated refractivity) of the white spot lesion will be measured. Participants will be given a set of questionnaires to assess the compliance to the remineralizing agent application and perception on the WSL. Treatment follow up The participants will be coordinated for follow up after 3 months (T1), 6 months (T2), 9 months (T3), 12 months (T4), and 18 months (T5) During the follow up visit , each participant will be subjected to the measurement of : tooth surface changes bacterial count salivary profile intraoral photos of maxillary teeth Participants will be given a set of questionnaires at every follow up visit to assess the compliance to the application of remineralizing agent and perception of the WSLs Statistical Analysis Data analysis will be done using the SPSS version 22. Descriptive date will be expressed as mean ± standard deviation (SD) unless otherwise stated. Repeated measurement ANOVA will be used for analysis of normally distributed variables. Kruskal-Wallis ANOVA will be used for non-normally distributed data. A value of P < 0.05 is considered statistically significant. The data collected will be analyzed using an intention-to-treat basis.

Official Title
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A Prospective, Open Label, Randomized Control Trial to Study the Effect of Different Remineralizing Agents on White Spot Lesions and Dental Plaque During Orthodontic Retention

Conditions
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Orthodontic Appliance Complication

Intervention / Treatment
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* Combination Product: Fluoridated toothpaste
* Combination Product: fluoride varnish (5% sodium fluoride)
* Combination Product: CPP-ACP plus crème group


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subjects on multibracket fixed appliance treatment Subjects with 2 or more bracketed surfaces with labial subsurface WSLs from upper right permanent canine (13) to upper left permanent canine (23) with an ICDAS II score of 1 and 2 will be selected. Indicated for thermoform or vacuum formed retainers on the upper arch. Exclusion Criteria: Systemic diseases or any physical anomalies. Subjects with intention to move out from Klang Valley area for the next 1.5 years. Periodontal diseases (pocket depth of more than 3mm). Smoker. Severe fluorosis or any enamel abnormalities. Antimicrobial agents or antibiotic therapy within the past 3 months. Orthognathic surgery cases, cleft lip and palate. Single arched lower fixed orthodontic treatment. Milk protein and benzoate preservatives (a common preservatives) allergies.

Ages Eligible for Study
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Minimum Age: 16 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Group 1 The participants in group one will act as control group as they will be advised in using fluoridated toothpaste to brush twice daily during the follow up periods Group 2 The participants in this group will received fluoride varnish (5% sodium fluoride) treatment Group 3 The participants will be advised to use pea size CPP-ACP plus crème (900ppm fluoride)
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Toothpaste group<br>Control group using fluoridated toothpaste | Combination Product: Fluoridated toothpaste<br>* Group 1 will act as control group. Participants will be advised to brush twice daily using fluoridated toothpaste during the follow up periods. No other fluorides supplements will be allowed to use.<br>* Other names: Colgate® Maximum cavity protection great regular flavour;|
| Experimental: Fluoride Varnish group<br>Fluoride varnish (5% sodium fluoride) application on 3 months interval | Combination Product: fluoride varnish (5% sodium fluoride)<br>* Approximately 0.5-1.0ml fluoride varnish will be applied on the tooth surface (labially) with the paint-on method fom canines to canines. No other fluorides supplements will be allowed to use.<br>* Other names: 22,600 ppm Sodium Fluoride varnish;|
| Experimental: CPP-ACP plus crème group<br>CPP-ACP plus crème application 2 times daily | Combination Product: CPP-ACP plus crème group<br>* Pea size CPP-ACP plus crème on the tooth surfaces using a clean fingers twice daily after brushing their teeth with fluoridated toothpaste. No other fluorides supplements will be allowed to use.<br>* Other names: GC Tooth Mousse Plus®;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| ICDAS score of the white spot lesion. | Changes in WSL measured based on ICDAS score : 0 No evidence of caries 1 Initial caries 2 Distinct visual change in enamel 3 Localised enamel breakdown due to caries with no visible dentine 4 Underlying dark shadow from dentine 5 Distinct cavity with visible dentine 6 Extensive distinct cavity with visible dentine | 18 months | 
| Optical changes (refractive index) of the white spot lesion. | Changes in WSL measured in lesion depths (LD in μm). | 18 months | 
| Patient perception of the WSL | Patient will be given a set of questionnaires at every follow up visit to assess the Compliance to the remineralizing agent application Perception on the WSL The perception will be based on the Likert scale | 18 months | 
| Dental plaque total bacterial count, Streptococcus count, Lactobacillus count. | Plaque samples will be collected with sterile swabs from the enamel surface of each tooth with the identified WSL to measure the bacterial count. The colony forming units of each plates is enumerated and the cfu/mL will be calculated | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Salivary profile (salivary flow rate) | The stimulated saliva will be collected by having the subject spit for 10 minutes into a sterile plastic graduated cup with 1-mL gradation marks Collected salivary volume was measured in millilitres, and salivary flow rate was calculated based on a collection time of 10 minutes (millilitres per minute). | 18 months | 
| Salivary profile (buffering capacity) | The saliva buffer capacity will be measured using strips (Saliva-Check BUFFER) and measured against standards assigned by the manufacturer Using a pipette, a saliva sample will be taken, and 1 drop will be placed on each of the 3 test pads. Test pads will change colour immediately, but the final colour will only detect after 2 minutes. Then the result will be calculated by adding the points according to the final colour of each pad. green - 4 points green/ blue - 3 points blue - 2 points red/blue - 1 point red - 0 points All points were counted, and result was determined: 0 - 5 points as very low buffering ability, 6 - 9 points as low, 10 - 12 points as normal/high. The buffering capacity is based on total points , 0-5 ( very low) , 6-9 (low), 10-12 (normal) | 18 months | 
| Salivary profile (pH) | The pH test strip will be placed inside the saliva collection cup for 10 seconds. The colour of the strip will be compared to the testing chart available in the kit . | 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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White Spot Lesion, Bacterial count( Streptococcus & Lactobacillus count), Salivary profile(salivary flow rate, buffering capacity, pH)