FEATURE This article has been peer reviewed.

Efficacious Materials in Minimizing White Spot Lesion in

Orthodontics: A Systematic Review

By Sadhana Swaraj, MDS; Ajit V Parihar, MDS; Kavin Prasanth, MDS; Shivam Verma,MDS; TP Chaturvedi MDS,
PhD

Abstract: Introduction: White spot lesions (WSLs) are unaesthetic but unavoidable common side effects of orthodontic treatment
with fixed appliances.1 The prevalence of WSLs based on post treatment evaluations only, ranges from 0% to 97%.6-8. Numerous studies
have reported that fluoride regimens have the ability to reduce caries during orthodontic treatment with fixed appliances.13 Various authors
have used fluoride in various forms to predict its efficacy in reducing WSLs. Recently, the use of bioactive glass show great promise as a novel
orthodontic bonding agent with adequate bond strength and ability for preventing white spot lesions. Materials and methods: In this
systematic review, we searched published materials related to white spot lesions and its prevention using general and specialist databases. Key
orthodontic journals were searched by hand, and 28 articles were extracted. Predefined inclusion criteria based on objective outcome measures
were applied to select the articles. Results: The articles were double extracted, and the qualitative analysis was done. The results were listed
in tables which included study design, examination methods, results, advantages and disadvantages. Conclusions: It may be concluded that
bioactive glass modified adhesives show great promise as a novel orthodontic bonding agent with adequate bond strength and potential for
preventing white spot lesions. Future in vivo studies would be needed to confirm the clinical efficacy of this material as an ideal orthodontic
adhesive.
Key Words: White spot lesions; orthodontic bonding; fluoride supplements; CPP ACP; GIC; Bioglass; demineralization around brackets

ntroduction main strategies include mechanical plaque control methods and

White spot lesions (WSLs) are a significant
problem in orthodontics. These are unaesthetic but
unavoidable common side effects of orthodontic
treatment with fixed appliances.1These are areas of decalcified
enamel clinically manifested as an opaque, white color lesion
representing the first stage of caries formation.2The clinical
manifestation is mainly due to the mineral loss in these lesions
which can be up to 50% leading to changes in hardness and
refractive index of the enamel resulting in scattering of light
giving the enamel a chalky, opaque appearance.3
The development of this clinical problem can be attributed
mainly to two factors: the first one being the difficulties in
performing oral hygiene procedures on bonded dental arches,
predisposing patients to an increase in plaque build- up on
tooth surfaces at the gingival margins adjacent to attachments,4
and the second one being the rapid increase in bacterial flora
predominantly Streptococcus mutans and Lactobacilli due to the
addition of orthodontic appliances in the mouth.5
The prevalence of WSLs based on post treatment
evaluations only, ranges from 0% to 97%.6-8 Despite many
attempt at comprehensive prophylaxis, the prevalence of
WSLs remains as high as 61% when debonding.9 Besides
compromising the aesthetics, presence of untreated WSLs
may lead to cavity formation, requiring further restorative
procedures. Therefore, both orthodontists and patients must
be conscious about preventing the development of WSLs. The
enhancement of enamel resistance using various approaches.
Patient education and the use of fluoride in the form of
paste, varnish, gel or solution is the first approach to be taken
to prevent demineralization. Fluoride acts by working as a
bactericidal agent at high concentrations, but its main action
is shifting solution equilibrium to favor the formation of
fluorohydroxyapatite.10-12
Numerous studies have reported that fluoride regimens
have the ability to reduce caries during orthodontic treatment
with fixed appliances.13 However, efficacy of administration of
fluoride as preventive measures by topical applications or home
rinse programs is limited due to unpredictable compliance of the
patient and the fact that it is not able to produce desired effect
in the localized area adjacent to brackets.
In order to eliminate the need for patient compliance which
is unpredictable and unreliable, various orthodontic bonding
agents with an ability to release ions such as fluoride, calcium,
and phosphate have been developed, but none have been able
to reduce the incidence of lesions around the brackets while
providing adequate mechanical and physical properties in order
to be accepted as an orthodontic bonding agent in daily practice
while potentially exhibiting an anticariogenic behavior.
However, if we look at the present scenario, a revolution
has taken place in the area of WSLs in the recent era of
orthodontic researches with the evolution of novel biomimetic
orthodontic adhesives prepared with the use of bioactive glass.

IJO  VOL. 29  NO. 4  WINTER 2018 49

50
Table 1
Study and Publication
13
Bjorn Ogaard et al
(AJODO 1988;4: 123-8)
Arnold M Geiger,
Leonard Crorelick et al15,
AJODO Jan 1988, 93(1)
Arnold M. Geiger 16
AJODO 1992;101: 403- 7
Bjorn Ogaard et al17
AJODO 1992;101:303-7 CT
L.Mitchell18
(British Journal of Orthodod,
1992,207-14
Kevin James Donly et al19
AJODO 1995;107:461-4
L.M. Trimpeneers et al20
AJODO 1996;110:218-22
PA . Banks et al21 ( 50 patients (366 experimental
European Journal of Orthod 19
(1997) 391-395
C.K.Chung et al22
Journal of dentistry 26(1998) 533-
538
A Bronwen Vorhies et al 23
AJODO 1998;114:668-74
Christopher J.Wenderoth24
AJODO 1999;116:629-34
P.A Banks et al25
EuropJourn 22(2000) 401-407
P.Shen et al26
J Dent Res 80(12); 2066-2070, 2001
Bjorn Ogaard et al9
AJODO 2001 120:28-35 CT
Jasmin Gorton et al27
AJODO (2003 123;10-4)
IJO  VOL. 29  NO. 4  WINTER 2018
Study design Experimental group Control group Examination methods
5 patients with 10 premolars (to be removed) given 0.2% NaF rinse, Topical application of No rinse used 1. Micro-radiography
fluoride rinse; 4 patients with 8 premolars (to be 0.6% F- at pH 1.9 2. Fluoride selective electrode
removed) no rinse given coupled to ionometer
101 patients with total 1567 teeth. 2 offices ACP gel for 3-5min followed by 0.05% No rinse used 1. Visual clinical examination
55 patients (LG) NaF spray or rinse in office. 0.05% NaF 2. Questionnaire for compliance
46 patients (AG) solution (home care)
206 patients; 89 males,117 females(87 from one Fluoride rinse(Neutral 0.05% sodium No rinse used 1. Visual clinical examination
office and 119 from the other) fluoride,10 ml) daily use before bed
time
6 patients with 10 pairs of premolars Orthodontic cement VP Heliosit orthodontic (F-) 1. Microradiography
862 (F-) 2. Fluoride release in water and saliva
by Orion ionometer.
24 patients with 18 females, 6 male No mix orthodontic composite Conventional no mix orthodontic 1 .Photographs
11 patients – test side (Direct) (f- releasing) composite (Right on) (no 2. Visual examination
13 patients - right side fluoride)
40 extracted permanent molars made with artificial GIC (Ketad Cem ESPE- Premier Zinc phosphate cement (Fleck’s 1. Polarized light microscopy
caries like lesions- half painted with acid protective Dental Products, Norristown , PA) Mizzy, Inc). 2. Photo micrographs
varnish and half acting as control
45 patients, 338 brackets bonded with the light Fluoride releasing visible light cured Conventional chemically cured 1. Intraoral photographs
cured material and 379 with the chemical cured material (orthonDental,Inc, Victoria, no-mix resin (Lee Insta-Bond, Lee
material, which result in clinical evaluation of 762 B.C, Canada). Pharmaceuticals, EI
bonded attachments. Monte, Calif)
Fluoride releasing rely –a-bond. Std rely-a-bond(Naf- adhesive) 1. Visual examination
371 control teeth) Composite (Reliance orthodontic
Random selection production) Inc. ,Itasca, IL) adhesive.
26 patients; 11 males, Compomer material (Dyractortho) Conventional resin adhesive 1. Saliva ,plaque, urine collection
15 females(Random selection) and resin modified GIC cement 2. Fluoride measurement.-orion
(vitremer) analyzer
72 extracted carious free human premolar divided 1.Advanced resinomer 1.XT composite resin 1. Photomicrographs projected with
into 3 groups(n=24) 2.FUJI Ortho LC hybrid GIC ×10 magnification
20 patients with a total of 225 metal brackets Dual-cured lightly filled BIS-GMA No sealant used 1. Photographs of all labial surfaces.
placed on anterior teeth 112 teeth-experimental; fluoride releasing sealant.
113 teeth- control.
94 patients (45 control and 49 experimental Fluoride releasing module and chain Standard elastomeric modules 1. Visual examination (Enamel
groups). Total no of control teeth 740. Total no of Fluoride I-ties Fluoride I-chain Arch and chain Decalcification Index)
experimental teeth 782. company Inc., USA
30 subjects taken who wore removable palatal CPP-ACP / sorbital based pellet Nil 1. Enamel sectioning and micro-
appliances with 6 human enamel half slabs gum CPP- ACP /sorbital based slab radiography
inset containing subsurface demineralization gum, CPP-ACP /xylitol based pellet
(Randomized cross-over double blind study) gum
110 patients divided into 2 groups 1.Cervitec,antimicrobial varnish Positive control -cervitec varnish 1. Visual examination
3 rd group(110 patients- control) 2.Fluorprotector ,fluoride varnish (without chlorhexidine thymol),
Control: no varnish
Double blind, randomized, controlled, clinical trial. F- release resin modified GIC Non fluoride release composite 1. Micro-hardness tester
80 participants 38% were male and 13(62%) were resin(trans bond ,3M) 2. Microscopic examination.
female
 Y.Iijima et al28
Caries Res 2004:
Marcoeli S de Maura et al29
AJODO 2006;103:357-63
S.Saranathan et al30
Caries Res 2008;42:88-97
Nasrin Farhadian31
AJODO2008:133:S95-8
DL Bailey et al32
J Dent Res 88(12); 1184-
IJO  VOL. 29  NO. 4  WINTER 2018
1153,2009
Dmitry Shungin et al34
AJODO 2010; 138:136. e1-
136.e8
Adam W. Benham et al33
Angle Orthodontist 2009; 79; 337-344
Roslyn J.Mayne3
AJODO 2011;139:e543-e551
Lauren Manfred et al35
AJODO 2013;83:97-103
Eser Tufekci et al36
AJODO 2014;146:207-214
Hussam Milly et al37
Dental Materials 42(2014)158-166
Hussam Milly et al38
Dental Materials 31(2015)522-533
Tao He et al39
AJODO 2016;149:810-9
51
Double blind randomized cross over design Sugar free chewing gum Sugar free chewing gum not 1. Sectioning and microradiography
with 10 adults subjects (5 males and 5 containing CPP-ACP containing CPP-ACP 2. Remineralisation data analyzing.
females) (RecaldentTM)
Aged 21 to 45 years
Split mouth design 14 patients Fluoridated antiplaque dentifrice. Non fluoridated dentifrice Cross sectional
RMGIC (FUJI Ortho LC),Concise Micro hardness analysis.
composite resin
Six different pH values (7.0,6.5,6.0,5.5,5.0 and 4.5) CPP—ACP AND CPP-ACFP NaF- solution 1.Spectrometry Sectioning
2.lapping and transverse micro
radiography Image analysis
3.EMPA(electron microprobe
analysis)
15 patients selected which undergo premolar Fluoride varnish (bifluoride 12, No varnish 1. Microphotographs
extraction 6% Calcium Fluoride, 6% Sodium
Split mouth design. Fluoride)
Forty five participants (aged 12-18 yrs) with 408 Remineralizing cream tooth mousse0 Placebo cream 1. Quantitative light induced
white spot lesions containing 10% w/v CPP-ACP (without CPP-ACP) fluorescence
23 participants-experimental 2. Analysis of digital photographs
22 participants- placebo 3. Visual inspection
30 participants; Four teeth –maxillary left and No mix acrylate or GIC Nil 1. Colour photographs
right central incisors, Mandibular right and left
canines in a split mouth design.
Split mouth design 30 males 30 females 60 Ultra seal XT plus clear sealant No sealant 1. Intraoral photographs
maxillary teeth, 358 mandibular teeth 2. Visual assessments
3. Diagnodent
75 third molars from community with fluoridated 1%(w/V)casein phosphopeptide Nil 1. Scanning electron microscope
water amorphous calcium fluoride
phosphate(CPP-ACFP)
50 extracted, non erupted, carious free teeth 4 BAG –bonds (62 Bag –Bond , 65BAG Transbond –XT (3 M Unitek, 1. Knoop hardness testing
collected & stored in chloramine T solution at –Bond , 81 BAG – Bond, and 85 BAG Monrovia, Calif) (Duramin-5, Struers)
40C, divided into 5 groups (n=10) – Bond)
14 patients - 72 teeth taken Fluoride releasing primer (opal seal ; Std. primer (transbond xi; 3M 1. Visual examination
Split mouth design ultra dent product South Jordan, Utah) Unitek) 2. Knoop hardness testing
32 human sample with artificial WSLs were BAG slurry Standardised remineralization 1. Knoop hardness
assigned to 4 experimental groups. PAA-BAG slurry solution (positive control) 2 . Microraman spectrometry in
Deionised water (negative streamline
control) 3. Non-contacts white light
profilometry
4. Scanning electron microscopy.
90 caries free human molars were divided into Air abrasion with BAG-polyacrylic acid Acid-etching using 37% 1. Non contact profilometry
9 groups(n=10) (PAA-BAG) powder phosphoric acid gel (positive 2. Optical coherence tomography
control) 3. Knoop micro-hardness.
Unconditioned (negative 4. Confocal laser scanning
control) microscopy
5. Scanning electron microscopy-
energy dispersive X-ray
spectrometry (SEM- EDAX)
240 patients with 597 teeth with WSL were Fluoride varnish or film treatment once Placebo treatment 1. Quantitative light –induced
randomized 1:1:1 to the varnish, film, and a month for 6 months. fluorescence parameters.
control groups. 72 patients in the control
groups , 69 patients in the varnish group,
70 patients in the film group.
52
Study
1. Bjorn Ogaard et al13
(AJODO 1988;4: 123-8)
2. Arnold M Geiger,
Leonard Crorelick et al15,
AJODO Jan 1988, 93(1)
3. Arnold M. Geiger 16
AJODO 1992;101: 403- 7
4. Bjorn Ogaard et al17
AJODO 1992;101:303-7 CT
5. L.Mitchell18
British Journal of Orthodod, 1992,
207-14
6. Kevin James Donly et al19
AJODO 1995;107:461-4
7. L.M. Trimpeneers et al20
AJODO 1996;110:218-22
8. PA . Banks et al21
(European Journal of Orthod 19
IJO  VOL. 29  NO. 4  WINTER 2018
Results
1. The lesion depth reduced by factor of 3 and
mineral loss reduced 60%
2. The outer surface of lesion contains more
mineral than body of lesion.
3. The lower the pH, fluoride solution increase the
fluoride uptake twice as much as neutral
fluoride solution
1. Maxillary lateral incisors and canines are most
affected and in mandible, first premolars are
most affected.
2. All moderate & severe white spot lesions (score
3&4) occur when brackets were bonded more
than 24 months, with the relationship being
statistically significant (r=0.8665).
3. Poor compliance was found in patients having
white spot in more than 20% of their banded
teeth.
1. The 33.5% exhibited one or more teeth with white
spot lesions.
2. Of the bonded teeth 11.9%showed white spot
lesions.
3. Greater number of white spots occurred in
patients treated more than 24 months.
1. Reduced lesion depth by 48%
2. Statically significant results of orthodontic
cement VP 862 by 5%
3. Fluoride release is significantly lesser in human
saliva at pH 7 than in water.
4. Fluoride release increases if salivary pH reduced
to 4
1. No significant difference found.
2. An overall similar reduction in size of areas of
decalcification. 3.For both test and control,
3. Failure rate of 6% for Direct and 15 % for right on,
but the difference was not significant.
4. The overall prevalence of decalcification was
18.5%and the average % of labial tooth surface
affected was 16.5%
1. Greater pore volume (demineralization) in
control lesion (p<0.001).
1. No significant difference between overall
decalcification rates for both adhesives.
2. .No significant difference between decalcifi-
cation rates of upper or lower teeth.
1. No significant difference in EDI scores between
experimental and control group (14.6%).
2. Bracket failure rates clinically statistically in both
Advantages
1. Significant reduction of lesion depth
2. Marked cariostatic effect
3. CaF deposit forms acid resistance
protection against cariogenic
challenges & also serve as significant
reservoir of fluoride release.
1. Significant reduction in decalcification on
labial surfaces of the teeth.
2. Reduced incidence and severity of white
spot lesions.
1. Statistically significant reduction of
enamel white spot lesions.
1. Long term mechanical properties
2. Significant caries protection instead of
patients cooperation
---
1. The GIC not only inhibits deminerali-
zation, but also demonstrate the ability
to remineralize enamel.
----
----
Disadvantages
1. The mechanism for caries protection behind
the bands is not completely known..
2. Fluoride increases the remineralization
speed, but complete in vivo repair is
inhibited by precipitation of fluoride in the
surface layer.
3. Daily fluoride rinsing may retard but not
completely inhibit lesion development
1. The one time topical application of APF gel
immediately after bonding appears to be of
little benefit in reducing the incidence of
white spot.
2. Fluoride rinse to be used continuously
throughout treatment.
3. Despite efforts to educate patients and
parents, more effective methods to change
behaviour patterns is needed to improve
patient compliance.
1. Despite educational efforts and supply of
rinse free of charge, only 13% of the patients
complied fully with its use, thus suggesting
further investigation into methods to improve
motivation and compliance.
1. pH dependent . More fluoride release at low
pH than neutral pH
1. No significant reduction in areas of
decalcification.
1. Bond failure may occur.
1. Bond strength of ORTHON is too weak for
routine bonding.
2. No significant difference between decalci-
fication and remineralisation rates.
1. The use of fluoride releasing resin does not
reduce enamel decalcification.
 (1997) 391-395
9. C.K.Chung et al22
Journal of dentistry 26(1998) 533-
538
10. A Bronwen Vorhies et al 23
AJODO 1998;114:668-74
IJO  VOL. 29  NO. 4  WINTER 2018
11. Christopher J.Wenderoth24
AJODO 1999;116:629-34
12. P.A Banks et al25
EuropJourn 22(2000) 401-407
13. P.Shen et al26
Dent Res 80(12); 2066-2070, 2001
14. Bjorn Ogaard et al9
AJODO 2001 120:28-35 CT
15. Jasmin Gorton et al27
AJODO (2003 123;10-4)
16. Y.Iijima et al28
Caries Res 2004:
53
groups.
1. No altered salivary or urinary fluoride
concentration 4 week post bonding but plaque
fluoride concentration increased significantly
around premolars bonded with vitremer .
2. No significant difference in cariostatic ability
detected between Dyract Ortho and Vitremer.
1. Enamel lesion depth and areas for composite
resins were significantly greater than
experimental group.
1. Experimental group decalcification rate 60%.
2. Control group-decalcification rate 62%.
3. No significant difference between experi-mental
and control group with respect to
decalcification, gingival irritation and plaque
accumulation.
1. No significant difference between the control
and experimental groups for mean age and
treatment time.
2. Post treatment enamel decalcification score per
tooth reduced by 49% (highly significant
P<0.001).
3. Enamel decalcification after treatment was
seen in 26% in experimental group & 73% in
control group (highly significant P<0.001).
J 1. The addition of CPP-ACP to either the sorbital or
xylitol based sugar free gum resulted in dose
related increase in enamel subsurface
remineralisation.
WSL, plaque accumulation ,and gingivitis were less
prevalent in the group received in organized
prophylaxis in the orthodontic clinics group (1 &
2) compared with the general dental clinic
(group3).
1. The micro hardness test showed significantly
more decalcification in the nonfluoride control
group (Highly significant).
2. No significant difference between the test and
control group for intraoral whole saliva fluoride
level (p=.06).
1. The 8 and 16 hour acid challenged of the lesions
remineralized with control gum resulted in 65.4
and 88 % and with CPP-ACP resulted in 35.5%
and 41.8 %.
1. CPP-ACP induced remineralized mineral was
1. The cariostatic ability of the fluoride 1. No convincing evidence of any systemic
releasing materials as combined group uptake of fluoride from vitremer or Dyract
was significantly better than that of the Ortho when the fluoride concentration in
control. saliva and urine were analyzed.
2. No significant difference in cariostatic ability
when each compared separately with the
control group.
1. Inhibition of enamel demineralization in
the hybrid GIC groups are related to the
release of fluoride from the cement itself
in both brushed and non-brushed
group.
2. All patients but particular patient’s with
poor plaque control could possibly
benefit from orthodontic appliances
bonded with hybrid GIC.
---- 1. Filled resin was quite viscous & difficult to
place with a brush in the limited spaces.
2. It was very difficult to determine the retention
rate of the sealant.
1. Clinically worthwhile reduction in ----
enamel decalcification during fixed
appliance therapy when they are
changed at each treatment visit.
1. Clinically enhanced remineralization ----
potential
1. The combination of antimicrobial and ----
fluoride varnishes more effectively
reduced the increment of new lesion of
maxillary incisors, that’s the area where
WSLs represent the largest esthetic
problem.
1. The use of GIC significantly reduced ----
enamel mineral loss and has local
effects also.
1. Superior remineralization of enamel ----
subsurface lesions in situ with mineral
that is more resistant to subsequent acid
challenge.
54
17. Marcoeli S de Maura et al29
AJODO 2006;103:357-63
18. S.Saranathan et al30
Caries Res 2008;42:88-97
19. Nasrin Farhadian31
AJODO2008:133:S95-8
20. DL Bailey et al32
J Dent Res 88(12); 1184-1153,2009
21. Dmitry Shungin et al34
AJODO 2010; 138:136.
136.e8
22. Adam W. Benham et al33
Angle Orthodontist 2009; 79; 337-
344
23. Roslyn J.Mayne3
AJODO 2011;139:e543-e551
24. Lauren Manfred et al35
IJO  VOL. 29  NO. 4  WINTER 2018
more resistant to subsequent acid challenge
1. Mineral loss in enamel surrounding bond with
RM-GIC was lower than that of composite bond
2. Enamel demineralisation was lower in subjects
who used experimental antiplaque fluoridated
formulation.
1. Theremineralization was pH dependent and both
CPP-ACP and CPP-ACFP solutions produced net
remineralization at all pH values.
2. CPP-ACP and CPP-ACFP treatments resulted in
mineral deposition throughout the entire lesion.
3. The calcium to phosphorus ratio of sound ,
remineralized and demineralized enamel were
all similar in the CPP-ACFP,CPP-ACP and fluoride
treated samples.
1. Mean depth of demineralization:
Experimental is-57.0±5.5µ
Control is-94.3±6.7 µ
2. Experimental lesion had approximately 90% less
demineralization than control teeth.
1. No statistically significant difference in total
product usage between the two treatment
groups.
2. The difference in transition score distribution
between the two treatment groups was not
statistically significant .
1. The teeth without sealants had 3.8 times the
number of WSL than were noted on the sealed
e1-
teeth.
2. These sealant shows no visible sign of
discoloration.
1. Significant differences in sum areas of WSL
between the first 4 examination in the 59
patients (P<0.001).
2. The lateral maxillary incisor & the mandibular
canines had been reported to the most
susceptible to WSL formation.
1. The treatment with 1% CPP-ACFP managed to
reduce areas of damage from an average of
60%to an average of 10%.
1. At 25 and 50µm deep at all distances from
bracket edge , all BAG-Bond Adhesives showed
1. Significant reduction of enamel 1. Special bands were required.
demineralization in both the occlusal 2. The study period was limited to a few weeks
and cervical regions of bracket base. as with other caries models.
1. Enhanced remineralisation of enamel ----
subsurface lesions.
1. One application eliminates time 1. Effective but are approved as a medical
consuming and costly repeated device not as routine caries-preventive
application during treatment. agent.
2. No repeated dose needed. 2. Bifluroide 12 has an acidic base, it might
3. Confounding factors are avoided. reduce the effect of fluoride itself.
---- 1. One or more non serious adverse events
(treatment– related or unrelated) were
recorded for 39 (86%) participants.
1. Significant reduction in enamel
demineralization during fixed
orthodontic treatment and should be
considered for use by clinicians to
minimize WSL
2. Effective sealing of the enamel surfaces
adjacent to orthodontic brackets,
resisted mechanical abrasion, and
remained well attached.
1. WSL areas were significantly reduced in
the short term and long term
perspectives with the use of fluoride
releasing GIC compared with an acrylic
bonding agent.
1. Reduction in the depth and area of
enamel damage.
2. The use of CPP-ACFP complexes might
return mineral to subsurface enamel in
WSLs , restore translucency similar to that
of sound enamel, and improve esthetics
in shallow lesions.
1. Best preventive effect against WSL
formation.
 AJODO 2013;83:97-103
25. Eser Tufekci et al36
AJODO 2014;146:207-214
significantly less reduction in hardness than
Transbond –XT(P<0.05)
2. At 100µm from bracket edge and depth at
25,50,75 µm , 81BAG-Bond had less reduction in
enamel microhardness than 62BAG-Bond and
65 BAG –Bond.
1. There were no statistically significant differences
in the number of WSL between two groups.
2. The primer retention was calculated 50%.
2. Combining an ideal bioactive glass into
resin adhesives helps to reduce
superficial enamel softening surrounding
orthodontic brackets compared to a
conventional resin adhesives.
1. No significant differences between the
efficacies of fluoride releasing primer and
control primer in reducing demineralization
over the duration of the study.

26. Hussam Milly et al37
Dental Materials 42(2014)158-166
1. BAG, PAA-BAG and the remineralization solution
exhibited statically significant higher surface
and cross section knoop hardness compared to
the negative control.
2. Micro Raman spectrometry detected significant
higher phosphate content with in treated
1. BAG and PAA-BAG enhance enamel WSL ----
remineralization, assessed by the
improved mechanical properties, higher
phosphate content and morphological
changes within the artificial lesions.

IJO  VOL. 29  NO. 4  WINTER 2018

groups compared to negative control groups.
3. Lesion depth was not significantly reduced.
27. Hussam Milly et al38 1. Reduced subsurface light scattering.
2. Increased Knoop micro hardness and mineral
Dental Materials 31(2015)522-533
content of the remineralized lesions (p<0.05).
3. SEM–EDX revealed mineral depositions covering
the lesion surface.
4. BAG slurry resulted in a superior remineralization
outcome, when compared to BAG paste
28. Tao He et al39 1. The products of fluorescence loss and lesion
area values were statistically associated with
AJODO 2016;149:810-9
time.
2. Comparison showed that the decrease in the 2
test groups were significantly greater than those
in the control groups.
3. Fluoride varnish may be more effective than
fluoride film.
1. Improved mechanical properties and ----
ultrastructural changes and enhanced
remineralization of WSL.
1. Treatment with fluoride varnish or fluoride ----
film induced greater remineralization of
white spot lesion.
2. Treatment with either fluoride varnish or
film can induced the greatest amount of
remineralization after orthodontics
therapy.
3. Fluoride varnish may be more effective
than fluoride film.

adhesives.14
articles included.
orthodontics practice.

Material and methods

researches in the area of interest.

was cross-disciplinary and included

studies were included;(2) Studies in

course of treatment; (3) Studies that

were the following: (1) Only human

incidence and severity of WSLs, and

Direct, and Web of Science. The full
Initial searches were made in the
articles, published bibliographies, and

lesions were checked, and the relevant

needed fixed orthodontic treatment at

least for one year and completed a full
of initial searches and also the strategy

or rematerializing agents to reduce the

novel orthodontic bonding agent with

of the trials in the process of exploring

adequate bond strength and ability for

following databases: Medline, Embase,

Our search strategy for this review

All the original research articles, review

in the desired area, the references of the

in which preventive measures were used

These materials show great promise as a

the Cochrane Library, PubMed, Science

preventing WSLs. Future in vivo studies

not subjected to precautionary measures

group were fully erupted and free of any

would be needed in this field to confirm

identify recent but uncited publications.

used by Cochrane review of orthodontic

After the electronic literature search

experimental group consisted of patients

awaited question of white spot lesions in

form of pit and fissure caries, cavitations,

which participants were the patients who
In order to have scope of more researches

or interventions; (4) Studies in which the

The inclusion criteria for our studies
selected articles and relevant reviews were

used included both controlled vocabulary

and full text terms as well. No limits were

included comparison groups in which the

also checked. The search strategy that was

teeth selected as experimental and control

in the form of comprehensive prophylaxis

visible defect on the buccal surfaces in the

internationally published research articles.

was over, a hand search was undertaken to

relevant citations in the field of white spot

set on year, publication status, or language

to determine its efficacy in solving the long

search was based on a preliminary platform

the clinical bond failure of this material and

control groups consisted of patients or teeth

55
or fluorosis; and, (5) Studies done on patients with overall good
oral health and good oral hygiene were selected.
The exclusion criteria were the following: (1) Studies on
bovine teeth were excluded; (2) Studies done on patients with
poor oral hygiene with high bleeding and plaque indices; (3)
Studies in which patients underwent remineralizing / non-
remineralizing therapy (e.g. bleaching, enamel micro abrasion,
or restoration) for WSLs after their orthodontic treatment.
From the titles and abstracts derived from the searches,
articles were excluded on the basis of inclusion and exclusion
criteria as discussed above in four stages. In Stage 1, non-relevant
citations were simply excluded. In Stage 2, all titles and abstracts
were reviewed by one reviewer to determine whether each article
met the predetermined inclusion and exclusion criteria. If the
reviewer was sure enough that with the information available,
the given article did not meet the inclusion criteria, it was
immediately excluded. In case of any doubt, the full article was
retrieved for thorough study, and the second opinion was taken
from another reviewer.
In Stage 3, all the articles selected in stage 1 were examined
by two independent reviewers to determine whether the
eligibility criteria were met. At this stage, care was taken to
exclude the articles with inappropriate study designs or no
outcome measures at both baseline as well as end point. The
articles not referenced correctly were also excluded.
In Stage 4, all included articles were thoroughly read and
relevant data were extracted from all of them. The clinical
methodologies of all the studies scrutinized finally were also
assessed by thoroughly examining the types of interventions and
Figure 1: Flowchart of included studies
56
outcomes in each one of them. The flow diagram of the search
strategy that we used in our review is depicted in Figure 1.
Results
The search results were categorized and arranged in order
from early to recent times. Out of many articles, the articles
which were related to our study were separated and fully verified.
There were 28 articles which provided information about the
occurrence of white spot lesions and its management during
orthodontic treatment. There were various materials used from
1988 to recent times to prevent these white spot lesions.
Fluoride plays an important role in prevention and
remineralization of white spot lesions. Various authors used
fluoride in various forms to check its efficacy in preventing white
spot lesions which were listed in Tables 1 and 2. In 1988, B.
Ogaard et al.13 used 0.2% NaF solution as a mouth rinse in his
study and found a significant reduction of lesion depth but not
completely inhibited lesion development.
Geiger15 in the same year also found a significant
reduction in decalcification of labial surfaces of the teeth and
the reduced incidence and severity of white spot lesions in his
study. In 1992, Geiger et al.16 again conducted a clinical study
to determine if rinsing frequency with a neutral 0.05% NaF
rinse influenced white spot lesion associated with orthodontic
brackets and found that the more closely patients complied with
the prescribed use, the more likely they could expect the decrease
in the occurrence of lesions. The fluoride release was found to be
pH-dependent and more rational in vivo than may be observed
in water.17
The use of fluoride releasing resin and its efficacy in
reducing white spot lesions was experimented by Trimpeneers
et al.18 in 1996 and P.A. Banks et al.19 in 1997. But there
was no significant difference in the decalcification rates and
remineralization rates because of these resins. Chung et al.20
conducted a study on the use of compomers and resin modified
GICs which reported only local effects and no systematic uptake
of fluorides and no significant difference in cariostatic ability
when each was compared separately with the control group.
The use of GICs was experimented by Donly et al.21
and the findings revealed that the GIC not only inhibits
demineralization but also demonstrate the ability to remineralize
enamel. The use of fluoride-releasing hybrid glass ionomer
bonding agents was advocated by Vorhies et al.22 in 1998.
Inhibition of enamel demineralization in the hybrid GIC
groups are related to the release of fluoride from the cement
itself in both brushed and non-brushed groups. All patients
but particularly those with poor plaque control could possibly
benefit from orthodontic appliances bonded with hybrid GIC.
The use of fluoride-releasing GICs were also evaluated by
Gorton et al.23 and significant reduction of enamel mineral loss
and local effects were noted.
The use of dual cured light filled BIS-GMA fluoride
releasing sealant was advocated by Wenderoth et al.24 in 1999.
There is no significant difference and filled resin was quite
viscous and difficult to place with a brush in the limited spaces.
The use of fluoride-releasing elastomeric modules and their
effects on white spot lesions was evaluated by Banks et al.25 in
2000, and he found clinically worthwhile reduction in enamel
IJO  VOL. 29  NO. 4  WINTER 2018
decalcification during fixed appliance therapy when they are
changed at each treatment visit.
The application of an antimicrobial varnish in combination
with a fluoride varnish was evaluated by Ogaard et al.9 and is
significantly more efficient in reducing white spot lesions on the
labial surfaces than application of the fluoride varnish alone.
The use of CPP-ACP-contained chewing gums for
reducing WSLs was clinically studied by Shen et al.26 in 2001
and Iijima et al.27 in 2004. It has superior remineralization
potential that is more resistant to acid challenge. The effect
of CPP-ACP and CPP-ACFP solutions on enamel subsurface
lesion remineralization in vitro were studied by Saranathan
et al.28 in 2008. The CPP-ACFP solutions produced greater
remineralization than the CPP-ACP solutions at pH 5.5
and below. The mineral formed in the subsurface lesions
was consistent with hydroxyapatite and fluorapatite for
remineralization with CPP-ACP and CPP-ACFP, respectively.
Remineralization of lesions with 1% CPP-ACFP before adhesive
removal significantly (p < 0.002) reduced the area and depth of
damage.
The use of fluoride varnish was studied by Farhadian et al.29
in 2008. Its advantage is that single application eliminates time
consuming and costly repeated application during treatment,
and confounding factors are avoided. It is very effective as a
medical device and not as a routine caries-preventive agent.
Recently, bio glass was used as effective measure to prevent
the occurrence of WSLs. It was described by Manfred et al.30
in 2013 and Milly et al31,32 in 2014 and 2015. Combining
an ideal bioactive glass into resin adhesives helps to reduce
superficial enamel softening surrounding orthodontic brackets
compared to a conventional resin adhesives.31 BAG and PAA-
BAG enhance enamel WSL remineralization, assessed by the
improved mechanical properties, higher phosphate content, and
morphological changes within the artificial lesions.31
Discussion
In 1988, Ogaard et al.13 conducted the study to investigate
the effect of fluoride on carious lesion development and on
lesions established during fixed orthodontic therapy. He
indicated that calcium fluoride formation may be a major aspect
of the mechanism of the cariostatic effect of topical fluoride.
Therefore, a fluoride solution with very low pH (1.9) that
induced large amounts of calcium fluoride was tested on lesion
development underneath orthodontic bands. Daily fluoride
mouth rinsing with a 0.2% solution of sodium fluoride (NaF)
retarded lesion development significantly, whereas the fluoride
solution with low pH inhibited lesion formation completely.
Fluoride applied as a mouth rinse to plaque-covered lesions
underneath orthodontic bands retarded lesion progression.
In 1988, Geiger et al.15 conducted the study in which an
experimental preventive fluoride program was routinely used in
the orthodontic offices of the authors. He included 101 patients
with a total of 1,567 teeth from two offices where he used ACP
gel for 3-5 min. followed by 0.05% NaF spray or rinse in office,
and advised 0.05% NaF solution as a home care procedure.
All moderate and severe white spot lesions (score 3 and 4)
occurred when brackets were bonded more than 24 months,
with the relationship being statistically significant(r=0.8665).
IJO  VOL. 29  NO. 4  WINTER 2018
He found that there was significant reduction in decalcification
of the labial surfaces of the teeth and the reduced incidence and
severity of white spot lesions.
In 1992, Mitchell et al.33 investigated the potential of a
fluoride-releasing bonding material for preventing decalcification
and to monitor its efficacy at retaining orthodontic brackets.
He compared the effectiveness of fluoride releasing no-mix
orthodontic composite (Direct) with conventional no-mix
composite (Right-On). He found an overall similar reduction
in the size of areas of decalcification in both test and control
groups, and no significant difference was found.
In 1992, Geiger et al.16 again conducted a clinical study
to determine if rinsing frequency with a neutral 0.05% NaF
rinse influenced white spot lesion associated with orthodontic
brackets. He found that only 13% of the 206 participants
fully complied with the rinse protocol, 42% of the subjects
used 10 ml approximately every other day, and 45% used rinse
less frequently. A significant dose-use response relationship
was noted in which dose rinsed at least once every other day
had fewer lesions (21%) than those who rinsed less frequently
(49%). It was concluded that a significant reduction in enamel
WSL can be achieved during orthodontic therapy through the
use of a 10 ml neutral NaF rinse. The more closely patients
complied with the prescribed use, the more likely they could
expect decrease in the occurrence of lesion.
In 1992, Ogaard et al.17 investigated the cariostatic potential
of a visible light-curing adhesive for the bonding of orthodontic
brackets. The fluoride adhesive reduced lesion depths by about
48% more than the non-fluoride adhesive (p< 0.05, t test). The
largest release of fluoride from the plates in water was observable
within the first week. However, a significant amount of fluoride
was still released after 6 months. He concluded that the regular
use of fluoride toothpastes is insufficient to inhibit lesion
development around orthodontic brackets. A fluoride-releasing
adhesive reduced lesion development significantly adjacent to
brackets compared with a non-fluoride adhesive. The fluoride
release was found to be pH-dependent and more rational in vivo
than may be observed in water.
In 1995, Donly et al.21 examined the remineralization
effect of GIC adjacent to orthodontic bands. With a sonic
digitizer, the area of the body of the lesion was measured in
each imbibition media, comparing the maintained varnished
out lesion to the lesion exposed to the cement; he demonstrated
a statistically significant reduction in the body of the lesions
(p<0.005) for those exposed to the GIC, and it had the ability to
remineralize the enamel also.
In 1996, Trimpeneers et al.18 conducted a clinical trial to
compare the effect of a visible light-cured fluoride-releasing
(F-releasing) material with a chemically-cured non-fluoride resin
on white spot formation during fixed orthodontic therapy. Fifty
patients entered the trial, and 762 brackets were bonded in a
crossover design. There was no significant difference between
the decalcification rates for both types of adhesives. When the
appearance of white spots was evaluated in an overall manner,
there was significantly more upper than lower decalcification.
In 1997,Banks et al.19 underwent a clinical trial to assess
the value of incorporating fluoride released from a commercially
available bonding adhesive (Rely-a-Bond) to determine the
57
extent of any protection provided against enamel decalcification.
Fifty patients undergoing fixed appliance therapy with a total
of 366 experimental and 371 control teeth were included in
the study. The results showed that 50% of patients and 13.5%
of teeth exhibited post-treatment decalcification. The addition
of fluoride to the adhesive did not significantly reduce the
incidence of enamel decalcification. Bond failure rates were
satisfactory for both experimental and control teeth.
In 1998, Chung et al.20 conducted a study to compare the
local and systemic uptake of fluoride released from a compomer
material (Dyract Ortho) a and resin modified GIC (Vitremer)
with that of conventional resin adhesive (Right On) and to
compared the cariostatic ability of each of the test materials with
that of resin control. He concluded that the fluoride released
from Dyract Ortho or Vitremer was likely to exert a local and
not a systemic effect. In a four week study, the cariostatic ability
of the fluoride-releasing cements, as a combined group, was
superior to that of the non–fluoride releasing control, but there
was no significant difference in cariostatic ability between the
two test material when each test was conducted separately with
the control..
In 1998,Vorhies et al.22 conducted a study to evaluate two
fluoride–releasing hybrid glass ionomer bonding agents for
inhibiting enamel demineralization surrounding orthodontic
brackets under two experimental conditions. His study indicated
significant difference in depth and area of demineralization
enamel such that lesion size was: TransbondTM XT no brush
>TransbondTM XT brush>Advance no brush=Advance
brush=Fuji Ortho LC no Brush=Fuji Ortho brush. The
promising results of this in vitro study warranted further clinical
investigation of hybrid glass ionomer adhesive as orthodontic
bonding agents to minimize enamel demineralization.
In 1999, Wenderoth et al.24 conducted study to see the
effects of a dual-cured lightly filled BIS-GMA fluoride releasing
sealant on white spot formation, gingival irritation, and plaque
accumulation during fixed orthodontic therapy. He found no
significant difference (p <.05) between the decalcification rates
of the treatment or control groups. Likewise, there was no
added benefit with respect to plaque accumulation or gingival
irritation.
In 2000, Banks et al.25 conducted prospective control
clinical trial to evaluate the effectiveness of stannous fluoride-
releasing elastomeric modules (Flour Ties) and chain (Flour I
Chain) in the prevention of enamel decalcification during fixed
appliance therapy. He found the overall reduction in enamel
decalcification of 49%, a highly significant difference (p<0.001).
A significant difference was seen in all but the occlusal enamel
zones. The majority (over 50%) of lesions occurred gingivally.
In 2001, Shen et al.26 conducted a study to determine the
ability of CPP-ACP in sugar-free chewing gum to remineralize
enamel subsurface lesions in a human in situ model. He
found that the addition of CPP-ACP to either sorbitol- or
xylitol-based gum resulted in a dose-related increase in enamel
remineralization, with 0.19, 10.0, 18.8, and 56.4 mg ofCPP-
ACP producing an increase in enamel remineralization of 9,
63, 102, and 152%, respectively, relative to the control gum,
independent of gum weight or type.
58
In 2001, Ogaard et al.9 conducted a randomized
prospective clinical study to test the hypothesis that application
of an antimicrobial varnish in combination with a fluoride
varnish is significantly more efficient in reducing white spot
lesions on the labial surfaces than application of the fluoride
varnish alone. A third aim was to investigate whether white
spot lesions development could be predicted early during
treatment. The antimicrobial varnish significantly reduced the
number of Streptococci mutans in plaque during the first 48
weeks of treatment. This effect did not result in significantly
less development of white spot lesions on the labial surfaces
compared with the group receiving only fluoride varnish
application. The best predictors for white spot lesions at
debonding were visible plaque and Streptococci mutans around
the appliance shortly after bonding.
In 2003, Gorton et al.23 conducted a study to test the
hypothesis that fluoride released by glass ionomer cement
inhibits the formation of carious lesions around orthodontic
brackets in-vivo. His results proved that using fluoride-releasing
glass ionomer cement for bonding orthodontic brackets
successfully inhibited caries in vivo. This cariostatic effect was
localized to the area around the brackets and was statistically
significant after four weeks.
In 2004, Iijima et al.27 conducted a clinical study to
investigate the acid resistance of enamel lesions remineralized
in situ by a sugar-free chewing gum containing casein
phosphopeptide-amorphous calcium phosphate nano-complexes
(CPP-ACP: Recaldent™). The gum containing CPP-ACP
produced approximately twice the level of remineralization as
the control sugar-free gum. The 8- and 16-hour acid challenge
of the lesions remineralized with the control gum resulted in
65.4 and 88.0% reductions, respectively, of deposited mineral,
while for CPP-ACP remineralised lesions, the corresponding
reductions are 30.5 and 41.8%.
In 2006, Maura et al.34 conducted a study to find the effects
of a fluoridated anti-plaque dentifrice on the development
of caries lesions adjacent to dental appliances bonded with
ionomeric material. The data results suggested that an anti-
plaque fluoridated dentifrice is superior to one that is only
fluoridated for reducing enamel demineralization adjacent to
dental material bonded with composite, but the effect seems
irrelevant when bonding is done with the ionomeric material.
In 2008, Saranathan et al.28 conducted a study to determine
the effect of ion composition of CPP-ACP and CPP-ACFP
solutions on enamel subsurface lesion remineralization in vitro.
CPP was found to stabilize high concentrations of calcium,
phosphate, and fluoride ions at all pH values (7.0–4.5).
Remineralization of the sub-surface lesions was observed at all
pH values tested with a maximum at pH 5.5. The CPP-ACFP
solutions produced greater remineralization than the CPP-
ACP solutions at pH 5.5 and below. The mineral formed in
the sub-surface lesions was consistent with hydroxyapatite and
fluorapatite for remineralization with CPP-ACP and CPP-ACFP,
respectively.
In 2008, Farhadian et al.28 conducted an in-vivo study
to evaluate the effects of a fluoride varnish on enamel
demineralization adjacent to bonded brackets. The mean
IJO  VOL. 29  NO. 4  WINTER 2018
lesion depths were 57.0 ± 5.5 µm in the test group and 94.3 ±
6.7 µm in the control group. There was significant reduction
(approximately 40%) in depth of demineralization in the
test group (p<.001). Fluoride varnish can be beneficial as a
preventive adjunct in reducing demineralization adjacent to
brackets.
In 2009, Bailey et al.35 conducted a clinical trial to test
whether, in a post-orthodontic population using fluoride
toothpastes and receiving supervised fluoride mouth rinses, more
lesions would regress than in participants using a remineralizing
cream containing casein phosphopeptide-amorphous calcium
phosphate compared with a placebo. Clinical assessments were
performed according to ICDAS II criteria. Ninety-two percent
of lesions were assessed as code 2 or 3. For these lesions, 31%
more had regressed with the remineralizing cream than with
the placebo (OR = 2.3, p = 0.04) at 12 weeks. Significantly
more post-orthodontic white spot lesions regressed with the
remineralizing cream compared with a placebo over 12 weeks.
In 2009, Benham et al.36 conducted a pilot investigation to
test the null hypothesis that highly filled (58%) resin sealants
do not prevent white spot lesions in patients undergoing active
orthodontic treatment. The hypothesis was rejected. Ultraseal
XT Plus clear sealant (Ultradent Products, South Jordon, Utah)
produced a significant reduction in enamel demineralization
during fixed orthodontic treatment and should be considered for
use by clinicians to minimize white spot lesions.
In 2010, Shungin et al.37 conducted a prospective study
to quantitatively analyze changes in white spots in general
and treatment-related WSLs during orthodontic treatment
and 12 year-follow up after treatment. He found that the
WSLs were significantly reduced during the 10 years follow up
and significantly lower with GIC than the acrylic material at
bonding. But, WSLs were not completely eliminated.
In 2011, Mayne et al.3 conducted an in-vitro study to
investigate enamel loss on bracket and adhesive removal when
the brackets were surrounded by WSL and to determine the
effect of remineralizing these lesions with a 1% (w/v) casein
phosphopeptide amorphous calcium fluoride phosphate (CPP-
ACFP) solution before bracket and adhesive removal. WSL
enamel around the bracket was more susceptible to iatrogenic
damage at adhesive removal compared with sound enamel.
Remineralization of lesions with 1% CPP-ACFP before adhesive
removal significantly (p<0.002) reduced the area and depth of
damage.
In 2013, Manfred et al.30 conducted a study to compare
changes in enamel micro-hardness adjacent to orthodontic
brackets after using bonding agents containing various
compositions of bioactive glass compared to a traditional resin
adhesive following a simulated caries challenge. The BAG-
Bonds tested in this study showed a reduction in the amount of
superficial enamel softening surrounding orthodontic brackets
compared to a traditional bonding agent. The results indicated
that clinically, BAG-Bonds may aid in maintaining enamel
surface hardness, therefore helping prevent white spot lesions
adjacent to orthodontic brackets.
In 2014, Tufekci et al.38 conducted an in-vivo study to
investigate the retention and the efficacy of primer (Opal
Seal; Ultra- dent Products, South Jordan, Utah) in reducing
IJO  VOL. 29  NO. 4  WINTER 2018
the formation of white spot lesions.The primer retention was
calculated as 50%. The results indicated no significant difference
between the efficacies of the fluoride-releasing primer and the
control primer in reducing demineralization over the duration of
the study.
In 2014, Milly et al.31 conducted a study to evaluate the
potential of bio-active glass (BAG) powder and BAG containing
polyacrylic acid (PAA-BAG) to remineralize enamel WSLs.
BAG, PAA-BAG, and the remineralization solution exhibited
statistically significantly higher surface and cross-section Knoop
micro-hardness compared to the negative control. Micro-Raman
spectroscopy detected significantly higher phosphate content
within the treated groups compared to the negative control
group. Lesion depth was not significantly reduced. SEM images
revealed mineral depositions with different sizes and shapes,
within BAG, PAA-BAG, and the positive control groups.
In 2015, Milly et al.32 conducted another study to evaluate
the effects of pre-conditioning enamel WSL surfaces using
bioactive glass (BAG) air-abrasion prior to remineralization
therapy. PAA-BAG air-abrasion removed 5.1± 0.6 m from
the lesion surface, increasing the WSL surface roughness. Pre-
conditioning WSL surfaces with PAA-BAG air-abrasion reduced
subsurface light scattering, increased the Knoop micro-hardness
and the mineral content
In 2016, He et al.39 conducted a 3-arm parallel randomized
trial to evaluate the effects of a fluoride varnish and a fluoride
film on the remineralization of WSLs around orthodontic
brackets after orthodontic treatment. After removal of the
orthodontic brackets, some natural remineralization of WSL
occurred, and daily use of fluoride toothpaste may be helpful
for this process. However, not all patients experienced this
remineralization, and treatment with fluoride varnish or fluoride
film induced greater remineralization of WSL. In addition, his
results suggested that fluoride varnish may be slightly more
effective than fluoride film.
Conclusion
Currently, there is no bonding agent in the market apart
from Bioactive glass modified adhesive which has the potential
to inhibit the formation of WSLs by releasing Ca2+ and PO43-
ions to prevent demineralization near the brackets while meeting
optimal bond strength requirements at the same time.
Many approaches have been used when we look back to
1988 until now, but none have been able to provide adequate
mechanical and physical properties in order to be accepted as
an orthodontic bonding agent while potentially exhibiting an
anticariogenic behavior.
The preventive approaches which had the ability to reduce
WSLs did not exhibit optimal bond strength to withstand the
forces of mastication and the stress exerted by the arch wires
while allowing for bracket debonding without causing damage
to the enamel surface. Therefore, it may be concluded that
bioactive glass modified adhesives show great promise as a novel
orthodontic bonding agent with adequate bond strength and
potential for preventing WSLs. Future in vivo studies would be
needed to confirm the clinical efficacy of this material as an ideal
orthodontic adhesive.
59
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28. Cochrane J, Saranathan S, Cai F, Cross KJ, Reynolds EC. Enamel
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357-63.
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IJO  VOL. 29  NO. 4  WINTER 2018
 Dr. Sadhana Swaraj is on the faculty of the
Department of Orthodontics, Faculty of Dental
Sciences, Institute of Medical Sciences, Banaras
Hindu University.
Dr. Shivam Verma is a Junior Resident II (MDS),
Department of Orthodontics, Faculty of Dental
Sciences, Institute of Medical Sciences, Banaras
Hindu University.

Dr. Ajit V Parihar is an Assistant Professor,

Department of Orthodontics, Faculty of Dental Dr. T.P. Chaturvedi is a Professor, Department of
Sciences, Institute of Medical Sciences, Banaras Orthodontics, Faculty of Dental Sciences, Institute
Hindu University. of Medical Sciences, Banaras Hindu University.

Dr. Kavin Prasanth is a Junior Resident III

(MDS), Department of Orthodontics, Faculty
of Dental Sciences, Institute of Medical Sciences,
Banaras Hindu University.

IJO  VOL. 29  NO. 4  WINTER 2018 61

 • Expand Your Practice
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in Dentistry
BROCK RONDEAU, Rondeau Seminars Limited
D.D.S., I.B.O., D.A.B.C.P., D-A.C.S.D.D., D.A.B.D.S.M., D.A.B.C.D.S.M.
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DIPLOMATE INTERNATIONAL BOARD OF ORTHODONTICS Provider for FAGD/MAGD credit.
DIPLOMATE AMERICAN BOARD OF CRANIOFACIAL PAIN Approval does not imply acceptance by any
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DIPLOMATE AMERICAN BOARD OF DENTAL SLEEP MEDICINE 3/1/2018 to 2/28/2021
DIPLOMATE AMERICAN BOARD OF CRANIOFACIAL DENTAL SLEEP MEDICINE Provider ID# 217653

Diagnosis & Treatment of TMD

2019 Course Date & Location
Toronto, ON.............................................March 1 & 2, 2019
Dates and hotels are subject to change
CE credits 12 hours lecture, 2 hours participation

Course Content
• Causes of TM Dysfunction • Five Stages of Derangement (disc displacement) • Anatomy of the TM Joint
• Clinical Examination · Clicking, slight pain • Muscles of Mastication
· Patient History · Range of Motion · More clicking, intermittent locking, moderate pain • How to File Insurance Claims for TM Dysfunction
· Muscle Palpation · Postural Assessment · Chronic closed lock, severe pain • Phase I: Splint Therapy (4 months)
• Joint Vibration Analysis (JVA) · Early degenerative joint disease, pain
• Phase II: Orthodontic Case Finishing (12-18 months)
• TMJ X-rays, Tomograms · Advanced degenerative joint disease (crepitus), pain
• Internal Marketing for TMJ Practice
• Differential Diagnosis • Types of Splints
· Aqualizer (temporary)
• External Marketing for TMJ Practice
· Intra-Capsular vs. Extra-Capsular • Bite Registration for Splint Therapy
· Flat Plane (acute injuries)
• Neurological tests to determine if the mandible is (phonetic bite) HANDS ON
in the correct position with the repositioning splint · Repositioning (anteriorly displaced discs)
· Anterior deprogrammer (clenching at night)
· Distraction Appliance (chronic closed lock)

Course Fee
Per Session Fee: $1,295 per session, per doctor
$495 per session, per staff member
(includes extensive course manuals for each session)
Participants must register 30 days prior to the course

Case Finishing & Mechanics *Also Available Online*

2019 Course Date & Location
Toronto, ON.............................................March 1 & 2, 2019
Dates and hotels are subject to change
CE credits 7 hours lecture, 7 hours participation
Course Fee Course limited to 15 people
Participants must register 30 days prior to the course
Per Session Fee: $1,295 per doctor or staff
(includes extensive course manual) Dr. Adrian Palencar, Diplomate IBO
Hands-On Wire Bending Course Objective
1st Order Wire Bends - Step-In and Step-Out 3. Mushroom “M” closing loop The purpose of this advanced course
2nd Order Wire Bends - Tip (Angulation) 4. Utility arches: is to help finish orthodontic cases
3rd Order Wire Bends - Torque (Inclination) • Neutral • Intrusive • Extrusive quickly and efficiently. This course
4th Order Wire Bends • Protrusive • Retrusive will increase your knowledge of wire
5. Overlay mechanics bending, which will enable you to
1. “V” bends 6. Tip back and tip forward torque and tip the crowns and roots
2. Step-up & step-down bend to assist with case finishing.

Rondeau
1-877-372-762529  NO. 4  WINTER 2018
62
Seminars r o n d e a u s e m iIJOn aVOL.
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