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

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

The Open Dentistry Journal 16 Apr 2021 SYSTEMATIC REVIEW DOI: 10.2174/1874210602115010151

Abstract

Aim:

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

Materials and Methods:

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

Clinical Significance:

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

Review of Literature:

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

Results:

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

Conclusion:

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

Keywords: Cervitec varnish, Fluoride varnish, White spot lesions, Orthodontic treatment, Chlorhexidine, Plaque.

1. INTRODUCTION

Enamel demineralisation adjacent to orthodontic brackets is one of the significant clinical problems associated with fixed orthodontic treatment. The number of patients who are willing to undergo orthodontic treatment has increased to a greater extent in recent years [1-5]. Fixed orthodontic treatment may take up to 1.5 to 2 years or more for its completion, depending on the type of malocclusion. Long term treatment will result in the formation of white spot lesions and in some cases, might affect the temporomandibular joint of the patient [6, 7]. An index has been developed for determining the need, complexity and severity of malocclusion for Indian population [8]. The difference in the ethnic variations and genetic predisposition of malocclusion showed the need for various analyses pertaining to the particular population [9]. White spot lesions develop as a result of prolonged plaque accumulation on the affected surface, commonly due to inadequate oral hygiene [9, 10]. The attitude towards oral hygiene varied between different patients [11]. The most frequent iatrogenic problem in orthodontics is white Spot Lesions (WSLs). Constant presence of fluoride ions in the vicinity of the enamel around the bracket bases helps protect against the development of WSLs [12]. Orthodontic brackets and auxiliaries used for fixed orthodontic treatment favour accumulation of dental biofilm, increasing the prevalence of periodontopathogenic and cariogenic bacteria and the risk for the development of white spot lesions and gingivitis [13-15]. A study on the contamination of toothbrushes showed that storage of toothbrush will affect the oral microbiological profile [16]. Clinically, the demineralization sites are detected as opaque and porous White Spots Lesions (WSLs) that may compromise the final result of the orthodontic treatment. The development of these lesions mainly occurs due to difficulties with oral hygiene. The incidence of WSLs during orthodontic treatment may vary between 15% and 85% [17].

After bracket placement, WSLs can be identified within 1 month, although it takes at least 6 months before caries become notable [18]. These lesions are predominantly in sites adjacent to brackets and are usually formed at the buccal surfaces, especially in the gingival region [19, 20]. Plaque also harbors the cariogenic bacteria, potentially capable of hard tissue damage, especially at the bracket margins [21]. Chemical and mechanical cleansing of the tooth surface with regular brushing and mouth rinses can help to reduce the formation of plaque and its accumulation. Therefore, it prevents dental and gingival diseases during orthodontic appliance therapy [22]. The efficacy of oral rinses in orthodontic patients has been studied earlier [23]. Patients with mouth breathing are more prone to the formation of white spot lesions around the bracket surfaces [24]. Good plaque control is very difficult in patients with fixed orthodontic appliances. To improve mechanical plaque removal, incorporation of a chemotherapeutic agent such as an antibacterial mouth rinse into the oral hygiene regimen can be helpful [25].

Several methods have been suggested to improve the cariostatic effect of fluoride at low pH. Acid-resistant coatings of calcium fluoride or titanium fluoride on the enamel surface and the use of fluoride in combination with antimicrobials have been suggested [26]. It is well known that chlorhexidine inhibits acid production in plaque and thus reduces the pH fall during sucrose challenges [27]. In an in situ study with specially banded premolars to be extracted, it was demonstrated that daily mouth rinsing with chlorhexidine and fluoride was more efficient in the reduction of mineral loss than was rinsing with fluoride alone [28].

However, chlorhexidine mouth rinses have several adverse effects, including a bitter taste and discoloration of the teeth and the tongue [29]. For such a rinse to be effective during orthodontic treatment, patients would have to rinse twice daily for 1 to 2 years. To overcome these limitations, the development of mouth rinses using natural materials such as watermelon has been studied earlier [30, 31]. In that respect, one study found that compliance with even the less objectionable fluoride mouth rinsing was less than 15% [32]. Therefore, there is a need for preventive programs for orthodontic patients that are less dependent on patient compliance. Several researchers have reported an antimicrobial effect in plaque when a varnish containing chlorhexidine and thymol (Cervitec, 1% chlorhexidine, 1% thymol; Vivadent, Schaan, Liechtenstein) is used [33-36]. The aim of this study is to review various studies that compare the effect of Chlorhexidine varnish with fluoride varnish on white spot lesions in patients undergoing orthodontic treatment.

2. STRUCTURED QUESTION

The question that needs to be addressed in this study is-

‘Does the use of chlorhexidine varnish prevent the incidence of white spot lesions as compared to the use of fluoride varnish in patients undergoing orthodontic treatment?’

3. MATERIALS AND METHODS

3.1. Registration and Protocol

This trial has been registered to PROSPERO (International prospective register of systematic reviews) and the registration number is CRD42019128488 in accordance with PRISMA checklist of systematic reviews and meta-analyses.

3.2. Source of Information and Selection of Studies

Two independent authors (A.G. and S.D.) screened the initial titles and abstracts to find all the eligible studies. The full texts were retrieved according to their inclusion and exclusion criteria. All differences of opinions were discussed and resolved.

3.3. Search Strategy

A systematic literature search was done to identify the articles that have described the effect of chlorhexidine and fluoride varnish on the incidence of white spot lesions in orthodontic patients. All the relevant articles were selected using PubMed, PubMed central and Cochrane database from April 1976 to the first week of December 2019. The search was performed using the keywords and terms mentioned in Fig. (1).

Fig. (1). Image showing the search methodology used in PUBMED database.

A complementary search was also done in other databases like the web of knowledge, google scholar, and a manual search was done in the following journals- World journal of orthodontics, American journal of orthodontics and Dentofacial orthopaedics, European journal of orthodontics, Journal of clinical orthodontics, Seminars in orthodontics and Angle orthodontics. Quality assessment of included studies was performed. The results were screened with title and abstract screening to select which studies will be included in this review. The references used in these studies were hand-searched to see if there were any clinical trials included. The date of the last search was done in December 2019.

3.4. Eligibility Criteria

The eligibility criteria were defined based on PICO research strategy for clinical practice based on scientific evidence.

3.5. Selection Criteria

The articles were screened based on title and abstract. Full text was then procured for the articles which fulfilled the inclusion criteria mentioned below. This review includes clinical trials and randomized control trials.

3.6. Selection fo Studies

3.6.1. Inclusion Criteria

  • (1)  Studies on patients undergoing fixed orthodontic treatment
  • (2)  Studies that used fluoride and chlorhexidine varnishes for the prevention and management of white spot lesions
  • (3)  Studies that used Pre-adjusted edgewise appliance (MBT system- conventional orthodontics)
  • (4)  Randomized control trials and clinical trials.

3.6.2. Exclusion Criteria

  • (1)  Studies on patients undergoing removable orthodontic treatment
  • (2)  Studies that used other modes of prevention and management of white spot lesions
  • (3)  Case reports, previous systematic reviews
  • (4)  Animal studies, Cross sectional studies, case series

3.7. Risk of Bias Assessment in Individual Studies

Two independent authors assessed the risk of bias for all the studies included. Another author was asked for advice and the final decision was made. Randomized trials were assessed using the Cochrane Risk of Bias (RoB 2.0) tool, Higgins JPT 2016 which involves judgement on seven headings as formulated by the Cochrane Group [37]. The risk of bias for each of the domains and overall risk of bias were made as per the recommendations of the RoB 2.0 tool.

Trials were classified overall as having a low risk of bias, some concerns of bias or a high risk of bias as described in the RoB 2.0 tool. Non-randomized trials were assessed NewCastle - Ottawa quality assessment scale [38]. The risk of bias for each of the headings and overall risk of bias was made as per the recommendations of the ROBINS-I tool [39]. Trials were classified overall as having no information, low risk, moderate risk, serious risk or critical risk of bias.

3.8. Evaluation of the Levels of Evidence

The possible influence of small study publication biases on review findings was considered and formed a part of the GRADE level of evidence (GRADEpro Guideline Development Tool, available online at gradepro.org) [40, 41]. The influence of small study biases was addressed by the risk of bias criterion ‘study size’. Assessment of the quality of evidence was based on Oxford's CEBM table [42].

4. RESULTS

Three articles were selected based on the inclusion criteria. The PRISMA flow chart is given in Fig. (2). Out of these studies, all three were randomized control trials.

4.1. Reporting and Interpretation of Results

This systematic review included mainly randomized clinical trials. These studies were of high and medium quality. The results which were achieved and interpreted from these articles suggested that use of chlorhexidine varnish separately or together with fluoride varnish reduces the prevalence of white spot lesions within the patients undergoing treatment. Shiva Alavi et al. [43] in their study, stated that a statistically significant decrease of WSLs was registered in the participants of chlorhexidine and fluoride groups throughout the three follow-ups but not within the control or the placebo groups. There have been no significant differences observed between the chlorhexidine and fluoride groups for demineralization. The clinical detection of WSLs has been dispensed primarily by means of visual inspection after air drying and tactile examination by probing. The introduction of several optical techniques during recent decades, including optical caries monitor, use of quantitative laser and light induced fluorescence, digital imaging with fiber-optic transillumination, laser fluorescence, and computer analysis of digital photographs, are suggested for WSL detection. Because of simple sampling, the unification of DMFS (Decay-missing-filling-surfaces) was difficult in every study. Restrepo et al.. [44], in their study, suggested that the association of fluoride and CHX failed to lead significant reduction within the development of WSLs on the buccal surface, as compared with fluoride only. The interpretation of the null findings should not consider unfavorable results, but it should note the relevance of the patients’ motivation to require care of their oral health. However, that style of approach was 100% acceptable, justifying that the relevance of the findings showing the F varnish was able to accelerate the regression of active WSLs, and it may be indicated for patients who were unmotivated or with difficulties in performing adequate oral hygiene practices. Although the above-mentioned study attained its objectives, some limitations were found. The sample size was very small; thus, studies with an increased sample size are necessary to verify the results. Furthermore, future studies with an extended follow-up time, like the inclusion of more clinically relevant outcomes, besides DDpen that presents some limitations, must be conducted to verify whether any significant difference is observed between the treatments. Bjørn Øgaard et al. [45] studied stepwise multivariate and correlation analyses to comprehend whether WSL development may be predicted earlier during the treatment with fixed appliances. Very low correlations and associations were found between WSLs at debonding and several other parameters registered during treatment. It may well be demonstrated that those patients who had MS in plaque and far visible plaque in the teeth 12 weeks after bonding and were non-compliant during the treatment had a significantly higher prevalence of white spots at debonding. The analysis also showed that 15% of the variation in WSL might be explained by the registered parameters. This was in step with findings that caries are difficult to predict, even in non-orthodontic patients. Generally, past caries experience is the best predictor of future caries increments in non-orthodontic patients. Few individuals have lesions on the labial surfaces before bonding of orthodontic appliances. Therefore, visible plaque round the appliance shortly after bonding may indicate a risk for WSL development during treatment. This declaration is supported by the observation that, when fluoride toothpaste is applied regularly, oral hygiene is the most vital thing explaining the variation in caries experience. In the above-mentioned study, the antimicrobial varnish and a placebo varnish were applied every week for 3 weeks before bonding. The results also showed that intensive application of the antimicrobial or the placebo varnish before bonding reduced the extent of MS in plaque significantly which both were equally effective. During this intensive 3-week period, the amount of plaque and gingival scores also decreased significantly in both groups.

4.2. Description of Studies

This systematic review included three articles, all three being randomized control trials which comprised an evaluation of the effect of chlorhexidine and fluoride varnish on incidence of white spot lesions in patients undergoing orthodontic treatment and are described in Table 1.

The summation table for each individual parameter is described in Table 2. The reduction shown in the prevalence of white spot lesions is described in Fig. (3).

Fig. (2). Image showing the PRISMA flow chart.
Table 1.
General information Of the selected articles in the systematic review.
Sno Author
Year of publication
Type of Study Study design Samples Age Groups Statistical Analysis Author conclusion
1 Shiva Alavi et al. 2018 In Vivo Randomized controlled Trial n=40 23 years
(18-34)
Group 1: Control
Group 2: Chlorhexidine varnish
Group 3: Fluoride varnish
Group 4: Placebo
Kruskal-wallis and Mann-Whitney tests Adding CHX gel and fluoride varnish to a patient's oral hygiene regimen can reduce the development of plaque and gingivitis and decrease WSLs in patients.
2 Restrepo M et al. 2016 In Vivo Randomized controlled Trial n=35 13-20 years Group 1: 5% Fluoride varnish
Group 2: 2%Chlorhexidine varnish
Group 3: Control
Repeated measures ANOVA and Tukey’s test The treatment with F varnish was capable of controlling the progression of WSLs in a shorter period of time.
3 Bjørn Øgaard et al. 2001 In Vivo Randomized controlled Trial n= 320 12-15 years Group 1: Both Chlorhexidiene and Fluoride varnish
Group 2: Fluoride varnish
Group 3: Control
Correlation analysis and Multiple regression analysis Cervitec significantly reduced the number of MS in plaque during the first 48 weeks of treatment . This didn’t significantly reduce the number of WSLs. The combination varnishes worked more efficiently.
Fig. (3). Graph showing the prevalence of white spot lesions.
Table 2.
Summation table for each individual parameter.
  S. No   Author and year of publication   Prevalence of white spot lesion in chlorhexidine group   prevalence of white spot lesion in fluoride group
  1.   Shiva Alavi et al. 2018   0.009 ± 0.01   0.215 ± 0.18
  2.   Restrepo M et al. 2016   17 lesions have reduced to 7 lesions
  (mean and SD not mentioned)
  15 lesions have reduced to 2 lesions (mean and SD not mentioned)
  3.   Bjørn Øgaard et al. 2001   1.07 ± 0.15   1.13 ± 0.28
Table 3.
Risk of bias assessment table for the studies included in the systematic review.
S. No.- Criteria Shiva Alavi et al. Restrepo M et al. Bjørn Øgaard et al.
I Study Design - - -
A Objective clearly formulated YES YES YES
B Sample size for each gender YES NO NO
C Sampling method clearly reported YES NO NO
D Inclusion criteria clearly reported NO YES NO
II Records taking process - - -
E Appropriate record materials stated YES YES YES
F Intervals at which records were taken were clearly mentioned YES YES YES
III Measurements - - -
G Measurement techniques clearly mentioned YES YES YES
H Definition of landmarks clearly defined YES YES YES
I Attempts to ensure quantity reliability YES YES YES
IV Statistical analysis - - -
J Statistical analysis appropriate for data YES YES YES
K Confidence intervals provided NO NO NO
- MODERATE LOW LOW

4.3. Risk of Bias in the Included Studies

The risk of bias assessment for the studies included in the systematic review was assessed using the Cochrane Risk of Bias (RoB 2.0) tool, Higgins JPT 2016 and is given in Table 3.

5. DISCUSSION

Varnish application was used as a method of prevention [46-54] and management [44, 55-59] of white spot lesions. Fluoride varnish was used for the prevention and management of white spot lesions [45, 53, 55, 60-63]. Application of ammonium fluoride around the bracket base every sixth week during orthodontic treatment with fixed appliances could prevent the development of advanced WSLs and this result reinforced the use of professional fluorides in orthodontic care [64]. Fluoride varnish containing CPP-ACP had good clinical success in reducing S. mutans count. Use of fluoride varnish containing CPP-ACP [65] and xylitol as a preventive intervention effectively prevents caries in children [66]. Professional topical fluoride application showed 25-30% reduction in the incidence of EWSLs after debonding, but the effect of professional fluoride application on complexity of EWSLs was unclear due to the concerns in interpreting DIAGOdent values to estimate EWSLs [67]

A varnish with 1% chlorhexidine and Thymol varnish (Cervitec plus) was used for the reduction in bacterial count [68-73] and for prevention and management [68, 74-79] of whitespot lesions. A study was conducted to compare the effect of single application and multiple application of varnish showed that multiple applications of Cervitec plus have an added benefit over the single application in the treatment of chronic periodontitis [80]. A study compared the effect of laser [81-84] and varnishes and stated that Er, Cr:YSGG laser can be recommended for cavity disinfection due to its superior antibacterial property [85]. A systematic review on Cervitec varnish had a weak level of evidence suggesting an effective antimicrobial property when Cervitec varnish is used against Streptococcus mutans [86]. Laser fluorescence using DIAGOdent [87-95] was used as a method for detection of white spot lesions and early caries on tooth surfaces [96-103].

The limitation of this systematic review is the use of a smaller number of randomized clinical trials which make the results obtained be a low-level evidence. The strength of this systematic review is that this is the only systematic review available on this topic studying the effect of chlorhexidine and fluoride varnish on the incidence of white spot lesions in orthodontic patients.

6. CLINICAL SIGNIFICANCE

The need for an adjunct oral hygiene aid to reduce the incidence and prevalence of white spot lesions in orthodontic patients is necessary. The use of these varnishes will reduce the incidence of white spot lesion formation and in their management in the orthodontic patients, thus making one of the adverse effects of fixed orthodontic treatment to be negligible.

CONCLUSION

Low-level evidence is available to come to a conclusion that the use of chlorhexidine varnishes and fluoride varnishes reduces the prevalence of white spot lesions in patients undergoing fixed orthodontic treatment. But the current systematic review must be interpreted with caution because of the small number of participants and their short observation period.

Thus, high-quality randomized controlled trials with higher sample size and longer duration studies to evaluate the potential of these varnishes on the incidence and prevalence of white spot lesions are needed to have a definite conclusion.

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declared no potential conflicts of interest with respect to the research, authorship, and. or publication of this article.

ACKNOWLEDGEMENTS

I would like to acknowledge my colleagues and my professors for guiding me through the process of this systematic review.

REFERENCE

1
Kamath MK, Arun AV. Perception of orthodontics. Int J Orofacial Res 2017; 2(1): 5.
2
Jayachandar D, Dinesh SPS. Factors affecting patient’s desire for seeking orthodontic treatment. Int J Ortho Rehab 2016; 7: 89.
3
Devishree RA, Felicita AS. A Survey on awareness of orthodontic treatment among male population reporting to dental clinic 2161024019 n.d.
4
Jebaraj S, Kumar N. Awareness of orthodontic treatment among law college students 2019; 12(3)
5
Jain RK, Dinesh S, Priya A, Kumar MP. Comparison of perception of smile by orthodontists and general dental practitioners-A questionnaire study 2019; 12(2)
6
Govindaraj A, Dinesh SP. Relationship between temporomandibular joint problem and malocclusion-An awareness survey among dental students and dentists 2019; 11(2)
7
Ezhil I, Arun AV, Kumar MP. Morphological changes of the mandibular condyle following orthodontic treatment 2018; 10
8
George AM, Vakil KK, Govindaraj A. Formulating a New Orthodontic Index: An Indian Board of Orthodontics Initiative. J Ind Orthodon Soc 2020; 54(4): 147-9.
9
Govindaraj A, Kumar SA. Reliability of Ashley Howe’s analysis in South Indian population 2019.
10
Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot lesions in orthodontic practice: a contemporary review. Aust Dent J 2006; 51(4): 284-9.
11
Ranjini P, Navaneethan R. Attitude of patients towards oral hygiene during orthodontic treatment. Int J Pharma Bio Sci 2016.
12
Justus R. Prevention of white spot lesions during orthodontic treatment. Clinical Dentistry Reviewed 2017; 2: 1.
13
Al Mulla AH, Kharsa SA, Kjellberg H, Birkhed D. Caries risk profiles in orthodontic patients at follow-up using Cariogram. Angle Orthod 2009; 79(2): 323-30.
14
Liu Y, Zhang Y, Wang L, Guo Y, Xiao S. Prevalence of Porphyromonas gingivalis four rag locus genotypes in patients of orthodontic gingivitis and periodontitis. PLoS One 2013; 8(4)e61028
15
Cerroni S, Pasquantonio G, Condò R, Cerroni L. Orthodontic fixed appliance and periodontal status: an updated systematic review. Open Dent J 2018; 12: 614-22.
16
Govindaraj A, Gurunathan D. Comparision of Contamination of Tooth Brush among Dental Students and Patients. Ind J Pub Health Res Develop 2019; 10(8)
17
Mitchell L. Decalcification during orthodontic treatment with fixed appliances—an overview. Br J Orthod 1992.
18
Øgaard B. White Spot Lesions During Orthodontic Treatment: Mechanisms and Fluoride Preventive Aspects. Semin Orthod 2008; 14: 183-93.
19
Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG. The effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod Dentofacial Orthop 1988; 93(1): 29-37.
20
Ahn SJ, Lim BS, Yang HC, Chang YI. Quantitative analysis of the adhesion of cariogenic streptococci to orthodontic metal brackets. Angle Orthod 2005; 75(4): 666-71.
21
Hickman J, Millett DT, Sander L, Brown E, Love J. Powered vs manual tooth brushing in fixed appliance patients: a short term randomized clinical trial. Angle Orthod 2002; 72(2): 135-40.
22
Vizitiu T, Ecaterina I. In vitro evaluation of effectiveness in reducing bacterial plaque of antimicrobial substances in patients treated with orthodontic appliances. Therap Pharm Clinic Toxicol 2011; 15(3)
23
Shahana RY, Muralidharan NP. Efficacy of mouth rinse in maintaining oral health of patients attending orthodontic clinics. J Pharm Res 2016.
24
Priyanka S, Felicita AS. PREVALENCE OF MOUTH BREATHING IN PATIENTS REPORTING FOR DENTAL TREATMENT. J Clin Dent 2015.
25
Tufekci E, Casagrande ZA, Lindauer SJ, Fowler CE, Williams KT. Effectiveness of an essential oil mouthrinse in improving oral health in orthodontic patients. Angle Orthod 2008; 78(2): 294-8.
26
Büyükyilmaz T, Øgaard B. Caries-Preventive Effects of Fluoride-Releasing Materials. Adv Dent Res 1995; 9: 377-83.
27
Rölla G, Melsen B. On the mechanism of the plaque inhibition by chlorhexidine. J Dent Res 1975; 54 Spec No B: B57-62.
28
Ullsfoss BN, Ogaard B, Arends J, Ruben J, Rölla G, Afseth J. Effect of a combined chlorhexidine and NaF mouthrinse: an in vivo human caries model study. Scand J Dent Res 1994; 102(2): 109-12.
29
Eriksen HM, Gjermo P. Incidence of stained tooth surfaces in students using chlorhexidine‐containing dentifrices. European Journal of Oral 1973.
30
Govindaraj A, Dinesh SP. Efficiency of watermelon extract against oral microflora particularly Lactobacillus-An in vitro study 2019.
31
Lakshmi T, Kumar A. Preliminary phytochemical analysis & invitro antibacterial activity of Acacia catechu willd Bark against Streptococcus mitis, Streptococcus sanguis & Lactobacillus…. Phytomedicine 2011.
32
Geiger AM, Gorelick L, Gwinnett AJ. Reducing white spot lesions in orthodontic populations with fluoride rinsing. American Journal of 1992.
33
Sandham HJ, Nadeau L, Phillips HI. The effect of chlorhexidine varnish treatment on salivary mutans streptococcal levels in child orthodontic patients. J Dent Res 1992; 71(1): 32-5.
34
Twetman S, Hallgren A, Petersson LG. Effect of an antibacterial varnish on mutans streptococci in plaque from enamel adjacent to orthodontic appliances. Caries Res 1995; 29(3): 188-91.
35
Twetman S, Petersson LG. Effect of different chlorhexidine varnish regimens on mutans streptococci levels in interdental plaque and saliva. Caries Res 1997; 31(3): 189-93.
36
Twetman S, Petersson LG. Efficacy of a chlorhexidine and a chlorhexidine-fluoride varnish mixture to decrease interdental levels of mutans streptococci. Caries Res 1997; 31(5): 361-5.
37
Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928.
38
Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25(9): 603-5.
39
Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919.
40
GRADEpro guideline development tool 2015. software
41
GRADEpro GDT. GRADEpro guideline development tool [software] McMaster University 2017.
42
Heneghan C. EBM resources on the new CEBM website. Evid Based Med 2009; 14(3): 67.
43
Alavi S, Yaraghi N. The effect of fluoride varnish and chlorhexidine gel on white spots and gingival and plaque indices in fixed orthodontic patients: A placebo-controlled study. Dent Res J (Isfahan) 2018; 15(4): 276-82.
44
Restrepo M, Bussaneli DG, Jeremias F, et al. Control of White Spot Lesions with Use of Fluoride Varnish or Chlorhexidine Gel During Orthodontic Treatment A Randomized Clinical Trial. J Clin Pediatr Dent 2016; 40(4): 274-80.
45
Øgaard B, Larsson E, Henriksson T, Birkhed D, Bishara SE. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod Dentofacial Orthop 2001; 120(1): 28-35.
46
Bishara SE, Ostby AW. White Spot Lesions: Formation, Prevention, and Treatment. Semin Orthod 2008; 14: 174-82.
47
Ferreira JMS, Aragão AKR, Rosa ADB, Sampaio FC, Menezes VA. Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial. Braz Oral Res 2009; 23(4): 446-51.
48
Demito CF, Rodrigues GV, Ramos AL, Bowman SJ. Efficacy of a fluoride varnish in preventing white-spot lesions as measured with laser fluorescence. J Clin Orthod 2011; 45(1): 25-9.
49
Perrini F, Lombardo L, Arreghini A, Medori S, Siciliani G. Caries prevention during orthodontic treatment: In-vivo assessment of high-fluoride varnish to prevent white spot lesions. Am J Orthod Dentofacial Orthop 2016; 149(2): 238-43.
50
Kronenberg O, Lussi A, Ruf S. Preventive effect of ozone on the development of white spot lesions during multibracket appliance therapy. Angle Orthod 2009; 79(1): 64-9.
51
Shafi I. Fluoride varnish reduces white spot lesions during orthodontic treatment. Evid Based Dent 2008; 9(3): 81.
52
Zabokova-Bilbilova E, Popovska L, Kapusevska B, Stefanovska E. White spot lesions: prevention and management during the orthodontic treatment. Prilozi (Makedon Akad Nauk Umet Odd Med Nauki) 2014; 35(2): 161-8. [Makedon Akad Nauk Umet Odd Med Nauki].
53
Kirschneck C, Christl J-J, Reicheneder C, Proff P. Efficacy of fluoride varnish for preventing white spot lesions and gingivitis during orthodontic treatment with fixed appliances-a prospective randomized controlled trial. Clin Oral Investig 2016; 20(9): 2371-8.
54
Lopatiene K, Borisovaite M, Lapenaite E. Prevention and Treatment of White Spot Lesions During and After Treatment with Fixed Orthodontic Appliances: a Systematic Literature Review. J Oral Maxillofac Res 2016; 7(2)e1
55
Du M, Cheng N, Tai B, Jiang H, Li J, Bian Z. Randomized controlled trial on fluoride varnish application for treatment of white spot lesion after fixed orthodontic treatment. Clin Oral Investig 2012; 16(2): 463-8.
56
Lapenaite E, Lopatiene K, Ragauskaite A. Prevention and treatment of white spot lesions during and after fixed orthodontic treatment: A systematic literature review. Stomatologija 2016; 18(1): 3-8.
57
He T, Li X, Dong Y, Zhang N, Zhong Y, Yin W. Comparative assessment of fluoride varnish and fluoride film for remineralization of postorthodontic white spot lesions in adolescents and adults over a 6-month American Journal of 2016.
58
Paula ABP, Fernandes AR, Coelho AS. Paula ABP, Fernandes AR, Coelho AS. Therapies for white spot lesions—a systematic review. Journal of Evidence 2017.
59
Restrepo M, Bussaneli DG, Jeremias F, et al. Control of white spot lesion adjacent to orthodontic bracket with use of fluoride varnish or chlorhexidine gel. ScientificWorldJournal 2015; 2015218452
60
Huang GJ, Roloff-Chiang B, Mills BE, et al. Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. Am J Orthod Dentofacial Orthop 2013; 143(1): 31-41.
61
Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The effectiveness of a fluoride varnish in preventing the development of white spot lesions. World J Orthod 2006; 7(2): 138-44.
62
Güçlü ZA, Alaçam A, Coleman NJA. A 12-Week Assessment of the Treatment of White Spot Lesions with CPP-ACP Paste and/or Fluoride Varnish. BioMed Res Int 2016; 20168357621
63
Singh S, Singh SP, Goyal A, Utreja AK, Jena AK. Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial. Prog Orthod 2016; 17(1): 25.
64
Sonesson M, Brechter A, Abdulraheem S, Lindman R, Twetman S. Fluoride varnish for the prevention of white spot lesions during orthodontic treatment with fixed appliances: A randomized controlled trial. Eur J Orthod 2019.
65
Gurunathan D, Somasundaram S. Casein phosphopeptide‐amorphous calcium phosphate: a remineralizing agent of enamel 2012.
66
Yadav S, Sachdev V, Malik M, Chopra R. Effect of three different compositions of topical fluoride varnishes with and without prior oral prophylaxis on Streptococcus mutans count in biofilm samples of children aged 2-8 years: A randomized controlled trial. J Indian Soc Pedod Prev Dent 2019; 37(3): 286-91.
67
Sardana D, Zhang J, Ekambaram M, Yang Y, McGrath CP, Yiu CKY. Effectiveness of professional fluorides against enamel white spot lesions during fixed orthodontic treatment: A systematic review and meta-analysis. J Dent 2019; 82: 1-10.
68
Baygin O, Tuzuner T, Ozel M-B, Bostanoglu O. Comparison of combined application treatment with one-visit varnish treatments in an orthodontic population. Med Oral Patol Oral Cir Bucal 2013; 18(2): e362-70.
69
Baygin O, Tuzuner T, Kusgoz A, Senel AC, Tanriver M, Arslan I. Antibacterial effects of fluoride varnish compared with chlorhexidine plus fluoride in disabled children. Oral Health Prev Dent 2014; 12(4): 373-82.
70
Sköld-Larsson K, Sollenius O, Petersson LG, Twetman S. Effect of topical applications of a novel chlorhexidine-thymol varnish formula on mutans streptococci and caries development in occlusal fissures of permanent molars. J Clin Dent 2009; 20(7): 223-6.
71
Ogaard B, Larsson E, Glans R, Henriksson T, Birkhed D. Antimicrobial effect of a chlorhexidine-thymol varnish (Cervitec) in orthodontic patients. A prospective, randomized clinical trial. J Orofac Orthop 1997; 58(4): 206-13.
72
Anand V, Govila V, Gulati M, Anand B, Jhingaran R, Rastogi P. Chlorhexidine-thymol varnish as an adjunct to scaling and root planing: A clinical observation. J Oral Biol Craniofac Res 2012; 2(2): 83-9.
73
Eronat C, Alpöz AR. Effect of Cervitec varnish on the salivary Streptococcus mutans levels in the patients with fixed orthodontic appliances. J Marmara Univ Dent Fac 1997; 2(4): 605-8.
74
Park K-J, Kroker T, Groß U, et al. Effectiveness of caries-preventing agents on initial carious lesions within the scope of orthodontic therapy. Korean J Orthod 2019; 49(4): 246-53.
75
Rai P, Pandey RK, Khanna R. Qualitative and Quantitative Effect of a Protective Chlorhexidine Varnish Layer Over Resin-infiltrated Proximal Carious Lesions in Primary Teeth. Pediatr Dent 2016; 38(4): 40-5.
76
da Silva ACB, da Silva DR, Maia AMA, de Oliveira PAP, Souza DCC, Sampaio FC. Prevention, Diagnosis and Treatment of Caries and Non-Carious Lesions in Orthodontic Patients 2015.
77
Karabekiroglu S, Erdur EA, Ileri Z. Effectiveness of Remineralization Treatments on Incipient Lesions: A Controlled Clinical Trial. Int J Oral Biol 2018.
78
Collaert B, Söderholm G, Bratthall G, De Bruyn H. Evaluation of a fluoride varnish for the treatment of dentine hypersensitivity. Dental Varnish Systems in Focus 2012; 20: 34.
79
Ancira-González L, Esparza-Villalpando V, Garrocho-Rangel A, Pozos-Guillén A. White spot lesion remineralisation agents in primary teeth: A systematic review. Oral Health Prev Dent 2018; 16(5): 391-400.
80
Sachdeva S, Grover V, Malhotra R, Kapoor A, Mohanty K. Comparison of clinical effectiveness of single and multiple applications of 1% chlorhexidine varnish (Cervitec Plus) along with scaling and root planing in patients with chronic periodontitis. J Indian Soc Periodontol 2018; 22(6): 523-8.
81
Poosti M, Ahrari F, Moosavi H, Najjaran H. The effect of fractional CO2 laser irradiation on remineralization of enamel white spot lesions. Lasers Med Sci 2014; 29(4): 1349-55.
82
Tufekci E, Dixon JS, Gunsolley JC, Lindauer SJ. Prevalence of white spot lesions during orthodontic treatment with fixed appliances. Angle Orthod 2011; 81(2): 206-10.
83
Harazaki M, Hayakawa K, Fukui T, Isshiki Y, Powell LG. The Nd-YAG laser is useful in prevention of dental caries during orthodontic treatment. Bull Tokyo Dent Coll 2001; 42(2): 79-86.
84
Haider SM, White GE, Rich A. Combined effects of argon laser irradiation and fluoride treatments in prevention of caries-like lesion formation in enamel: an in vitro study. J Clin Pediatr Dent 1999; 23(3): 247-57.
85
Arslan I, Baygin O, Bayram G, Akyol R, Tuzuner T. Effects of various agents and laser systems on antibacterial activity and microtensile bond strength when used for cavity disinfection. Journal of Dental Lasers 2019; 13: 12.
86
Tang X, Sensat ML, Stoltenberg JL. The antimicrobial effect of chlorhexidine varnish on mutans streptococci in patients with fixed orthodontic appliances: a systematic review of clinical efficacy. Int J Dent Hyg 2016; 14(1): 53-61.
87
Lussi A, Hibst R, Paulus R. DIAGNOdent: an optical method for caries detection. J Dent Res 2004; 83 Spec No C: C80-3.
88
Shi XQ, Welander U, Angmar-Månsson B. Occlusal caries detection with KaVo DIAGNOdent and radiography: an in vitro comparison. Caries Res 2000; 34(2): 151-8.
89
Shi XQ, Tranaeus S, Angmar-Månsson B. Validation of DIAGNOdent for quantification of smooth-surface caries: an in vitro study. Acta Odontol Scand 2001; 59(2): 74-8.
90
Aljehani A, Yang L, Shi X-Q. In vitro quantification of smooth surface caries with DIAGNOdent and the DIAGNOdent pen. Acta Odontol Scand 2007; 65(1): 60-3.
91
Shi XQ, Tranaeus S, Angmar-Månsson B. Comparison of QLF and DIAGNOdent for quantification of smooth surface caries. Caries Res 2001; 35(1): 21-6.
92
Attrill DC, Ashley PF. Occlusal caries detection in primary teeth: a comparison of DIAGNOdent with conventional methods. Br Dent J 2001; 190(8): 440-3.
93
Anttonen V, Seppä L, Hausen H. Clinical study of the use of the laser fluorescence device DIAGNOdent for detection of occlusal caries in children. Caries Res 2003; 37(1): 17-23.
94
Francescut P, Lussi A. Correlation between fissure discoloration, Diagnodent measurements, and caries depth: an in vitro study. Pediatr Dent 2003; 25(6): 559-64.
95
Shinaishin SF, Ghobashy SA, El-Bialy TH. Efficacy of light-activated sealant on enamel demineralization in orthodontic patients: an atomic force microscope evaluation. Open Dent J 2011; 5: 179-86.
96
Aljehani A, Tranaeus S, Forsberg CM, Angmar-Månsson B, Shi XQ. In vitro quantification of white spot enamel lesions adjacent to fixed orthodontic appliances using quantitative light-induced fluorescence and DIAGNOdent. Acta Odontol Scand 2004; 62(6): 313-8.
97
Krithikadatta J, Fredrick C, Abarajithan M, Kandaswamy D. Remineralisation of occlusal white spot lesion with a combination of 10% CPP-ACP and 0.2% sodium fluoride evaluated using Diagnodent: a pilot study. Oral Health Prev Dent 2013; 11(2): 191-6.
98
Mendes FM, Siqueira WL, Mazzitelli JF, Pinheiro SL, Bengtson AL. Performance of DIAGNOdent for detection and quantification of smooth-surface caries in primary teeth. J Dent 2005; 33(1): 79-84.
99
Jayarajan J, Janardhanam P, Jayakumar P. Efficacy of CPP-ACP and CPP-ACPF on enamel remineralization - an in vitro study using scanning electron microscope and DIAGNOdent. Indian J Dent Res 2011; 22(1): 77-82.
100
Krithikadatta J, Fredrick C, Abarajithan M, Kandaswamy D. Remineralisation of occlusal white spot lesion with a combination of 10% CPP-ACP and 0.2% sodium fluoride evaluated using Diagnodent: a pilot study. Oral Health Prev Dent 2013; 11(2): 191-6.
101
Tagtekin DA, Ozyoney G, Baseren M, et al. Caries detection with DIAGNOdent and ultrasound. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 106(5): 729-35.
102
Pinelli C, Campos Serra M, de Castro Monteiro Loffredo L. Validity and reproducibility of a laser fluorescence system for detecting the activity of white-spot lesions on free smooth surfaces in vivo. Caries Res 2002; 36(1): 19-24.
103
Benham AW, Campbell PM, Buschang PH. Effectiveness of pit and fissure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod 2009; 79(2): 338-45.