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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 51  |  Issue : 2  |  Page : 92-102

Evaluation of efficiency of two nanohydroxyapatite remineralizing agents with a hydroxyapatite and a conventional dentifrice: A comparative In vitro study


1 PG Student, Department of Orthodontics and Dentofacial Orthopedics, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
2 Reader, Department of Orthodontics and Dentofacial Orthopedics, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
3 Prof, Department of Orthodontics and Dentofacial Orthopedics, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
4 Prof. and HOD, Department of Orthodontics and Dentofacial Orthopedics, Krishnadevaraya College of Dental Sciences and Hospital, Bengaluru, Karnataka, India

Date of Submission16-Jan-2016
Date of Acceptance10-Mar-2017
Date of Web Publication17-Apr-2017

Correspondence Address:
Abhishek Singh
Department of Orthodontics and Dentofacial Orthopedics, Krishnadevaraya Dental College and Hospital, Hunasamaranahalli, Bengaluru - 562 157, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jios.jios_13_16

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  Abstract 


Aim: This study was designed to compare the relative efficiency of nanohydroxyapatite (n-Hap) Aclaim, n-HAp Apagard, Clinpro Tooth Crème and Colgate Total in remineralization. Settings and Design: One hundred and eight healthy maxillary first premolars devoid of decay, restoration, and attrition were used. Materials and Methods: Stainless steel premolar brackets were bonded on all the teeth. The teeth were randomly assigned into three groups and subgroups of 12 teeth each. The samples of each group were immersed separately in an artificial saliva solution for 23 h and acid solution for 1 h for 31 days, following by sectioning and observing under polarized light microscope. The depths of the demineralized enamel in each experimental and control section were measured at three sites of the gingival demineralized area. The first site D1, near the gingival margin, the second site D2 at middle third and the third site D3 near the occlusal margin of the gingival demineralized area. Statistical Analysis: One-way analysis of variance and Tukey test were used. Results: Aclaim and Apagard were most efficient in prevention of demineralization. Maximum depth of demineralization was observed at site D2. Conclusions: Aclaim and Apagard on daily application will provide maximum protection against enamel demineralization in orthodontic patients.

Keywords: Demineralization, dentifrice, nanohydroxyapatite


How to cite this article:
Singh A, Shetty B, Mahesh C M, Reddy VP, Chandrashekar B S, Mahendra S. Evaluation of efficiency of two nanohydroxyapatite remineralizing agents with a hydroxyapatite and a conventional dentifrice: A comparative In vitro study. J Indian Orthod Soc 2017;51:92-102

How to cite this URL:
Singh A, Shetty B, Mahesh C M, Reddy VP, Chandrashekar B S, Mahendra S. Evaluation of efficiency of two nanohydroxyapatite remineralizing agents with a hydroxyapatite and a conventional dentifrice: A comparative In vitro study. J Indian Orthod Soc [serial online] 2017 [cited 2017 Nov 21];51:92-102. Available from: http://www.jios.in/text.asp?2017/51/2/92/204602




  Introduction Top


One of the most difficult problems in the orthodontic treatment with fixed appliances is the control of enamel demineralization around the brackets.[1],[2] This leads to the formation of incipient caries which is commonly known as white spot lesion (WSL). This is a very unesthetic and a common side effect during orthodontic treatment. Demineralization is an early stage of dental caries that occurs when plaque is allowed to remain on the tooth surface for a critical length of time.[3],[4] Bands and brackets increase the retention of plaque and food on smooth tooth surfaces that would otherwise tend to have a low prevalence of caries.[4] These iatrogenic WSLs can lead to poor esthetics, and in severe cases, restorative treatment is needed.[1]

Enamel demineralization or caries development in the form of WSL on the labial surfaces is a serious side effect of treatment with fixed orthodontic appliances.[5] The WSL can be defined as “subsurface enamel porosity from carious demineralization.”[6]

WSLs are seen within 4 weeks in the absence of any fluoride supplementation after band/bracket placement.[7],[8] Enamel demineralization is an extremely rapid process which is due to the continuous cariogenic challenge in the plaque developed around brackets and loose fitting bands, and they constitute early forms of enamel caries that within certain limits have the potential for remineralization in the presence of fluoride.[9],[10] With the changes in technology which permit bonding than banding of teeth and the availability of preventive regimens such as fluoridated adhesives, varnishes, and mouth rinses or dentifrices, the frequency, prevention, and treatment of such iatrogenic damage have received renewed attention.[1]

A review of literature in 2005 showed great variations from 2% to 97% for the prevalence of WSL associated with orthodontic treatment.[11],[12] Such high caries prevalence is perhaps surprising even after more than 50 years of research on the use of fluoride in caries prevention. However, this high prevalence may be due to the high cariogenic challenge prevailing in the plaque around the orthodontic appliances. Proper oral hygiene is more difficult to maintain, and pH levels lower than 4.5 have been measured in the plaque around the brackets and the bands. At such low pH, the remaining phase is hampered, and more fluoride will not necessarily give better cariostatic effect.[8]

Clearly, the best approach during orthodontic treatment is to prevent lesions from occurring. However, once formed, many of these early lesions appear to be surface demineralization rather than a subsurface lesion with an intact surface zone.

Remineralization of these WSL is a natural phenomenon resulting in partial reversal of what is an early carious lesion.[13] This is one of the reasons many authors suggest repeated local application of fluoride during orthodontic treatment, along with thorough dental hygiene.[12],[14]

Remineralization is enhanced if appropriate conditions such as increase in calcium or fluoride concentrations in oral fluids are seen. Nano-hydroxyapatite (n-HAp) is one of the most biocompatible and bioactive materials with marked affinity to the enamel surface. These nano-sized particles are similar to the apatite crystals of tooth enamel in morphology and crystal structure.[15] n-HAp remineralizing agents have better affinity with hydroxyapatite crystals of enamel.

This study is designed to compare the relative efficiency of four dentifrices which are Aclaim (n-HAp), Apagard (n-HAp), Clinpro Tooth Crème (tricalcium phosphate and fluoride), and Colgate Total (fluoride) to inhibit demineralization adjacent to orthodontic brackets in vitro.


  Materials and Methods Top


A total of 108 noncarious maxillary first premolars with no visible enamel defects extracted for orthodontic purposes were used for this study. The premolars were extracted after obtaining the consent from the patients. Healthy teeth were used for the study which was devoid of decay, restoration, attrition, etc., For all hundred and eight samples, pre-adjusted edgewise stainless steel premolar brackets were bonded on the teeth with Transbond XT light cure composite resin (3M Unitek). Each bracket was cured with Bluedent LED smart light curing unit. Masking tape was used to cover the entire buccal surface area before bonding. A small window was left in the tape to accommodate a premolar bracket with 1 mm clearance on all sides of the base (4 mm × 1 mm). The enamel was conditioned with the etchant (3M ESPE, Bangalore, India) containing 37% phosphoric acid for 15 s. The teeth were then thoroughly washed and dried with moisture and oil free air spray for 15 s. A thin layer of Transbond XT light cure adhesive primer was painted over the etched enamel surface with a brush tip and was light cured for 5 s. Transbond XT adhesive paste (3M Unitek) was applied to the bracket base, and the brackets were positioned on the buccal surface at the height of contour mesiodistally, in the middle one-third oculus gingivally and parallel to the long axis of the tooth. The flash was removed with a scaler tip and the brackets were light cured for 20 s.

Masking tape was removed from the entire buccal surface area adjacent to brackets, and any residue of the tape was wiped away with ethanol and acid-resistant nail varnish was then painted on the rest of the tooth surfaces leaving the rectangular window (4 mm × 1 mm). The teeth were randomly assigned into three groups and subgroups of 12 teeth each. The sample size for Group I was 12 teeth. Each group and subgroup were coded with unique colored nail varnish [Figure 1] and the exposed window of enamel of each tooth was treated with application of respective materials [Figure 2].
Figure 1: Color coding in different groups

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Figure 2: Dentifrices used in the study

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  1. Group I - Control group did not receive any application [Figure 3]. It was not subdivided into groups
  2. Group II - Remineralizing paste was applied to the exposed enamel windows using finger and allowed to dry for 3 min. Following which, all the samples in the group were immersed in artificial saliva solution [Figure 4]
  3. Group III - Remineralizing paste was applied and brushed to the exposed enamel windows using toothbrush for 2 min and dried for 3 min. Following which, all the samples in the group were immersed in artificial saliva solution [Figure 5].
Figure 3: Group I

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Figure 4: Group II

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Figure 5: Group III

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The samples of each group were immersed separately in an artificial saliva solution for 23 h and acid solution for 1 h for 31 days.

After 31 days, the brackets were removed from all the teeth and then were mounted on acrylic cylindrical blocks. The samples of all the three groups were buccolingually sectioned through the center of bracket area with a hard tissue microtome [Figure 6].
Figure 6: A tooth section being cut in hard tissue microtome

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The sections were evaluated with polarized light microscopy (Olympus VX 52). Microphotographs of the gingival third of the buccal surface were taken with fixed ×4 magnification.

The depth of demineralization was measured using ProgRes ® Capture Pro 2.7.7 (JENOPTIK Optical Systems, Jena, Germany) image analysis software [Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16]. The depths of the demineralized enamel in each experimental section were measured at three sites of the gingival demineralized area. The first site D1 which was near the gingival margin of gingival demineralized area, the second site D2 at middle third of the gingival demineralized area, and the third site D3 near the occlusal margin of the gingival demineralized area. Similarly, the depths of the demineralized enamel in each control section were measured at three sites D1, D2, and D3. The means and standard deviations of the depths at the three sites were calculated. One-way analysis of variance (ANOVA) and Tukey test were used for statistical analysis.
Figure 7: PLM image Group I

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Figure 8: PLM image Group II Subgroup A1

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Figure 9: PLM image Group II Subgroup A2

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Figure 10: PLM image Group II Subgroup A3

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Figure 11: PLM image Group II Subgroup A4

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Figure 12: PLM image Group III Subgroup B1

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Figure 13: PLM image Group III Subgroup B2

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Figure 14: PLM image Group III Subgroup B3

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Figure 15: PLM image Group III Subgroup B4

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Figure 16: Measurement of depth of demineralization with image analysis software D1 = Depth of demineralizatioin in gingival third, D2 = Depth of demineralization in middle third, D3 = Depth of demineralizatioin in occlusal third. 1-Middle third area, 2-Occlusal third area, 3-Gingival third area

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The depth of demineralization was tabulated in the two experimental groups and the control group. Intergroup comparisons were made for evaluating the efficiency of mode of application of dentifrices. Intragroup comparisons were made for evaluating the relative efficiency of dentifrices.


  Results Top


One-way ANOVA and Tukey test were used for the study. One-way ANOVA has been used to test the difference between groups. ANOVA is a technique by which the total variation is split into two parts, one between groups and the other within the groups. If “F” value is significant, there is a significant difference between groups. To find out which mean between the two groups is significantly different post hoc analysis, Tukey test is performed. In case F value is not significant, it indicates that there is no significant difference between the groups and it stops the analysis at this stage and Tukey test is not used.

Data analysis was carried out using Statistical Package for Social Science (SPSS). SPSS 15.0 (IBM, India) has been used for analysis of the data, Microsoft Word and Excel have been used to generate graphs and tables. Graphical analysis was done between Group I, II, and III.

[Table 1] depicts a comparison of mean demineralization seen at gingival third area (D1), middle third area (D2), and occlusal third area (D3) of the gingival demineralized area in study groups using different dentifrices.
Table 1: Comparison of mean demineralization (in μ) seen at gingival third area (D1), middle third area (D2), and occlusal third area (D3) of the gingival demineralized area of teeth in study groups using different dentifrices

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[Table 2] depicts pairwise comparison between different dentifrices in different study groups at sites D1, D2, and D3 using Tukey test.
Table 2: Pair wise comparison between different dentifrices in different study groups at sites D1, D2, and D3 using Tukey test

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[Table 3] shows intergroup comparison of demineralization for different study groups on the basis of mode of application of dentifrices.
Table 3: Intergroup comparison of demineralization (in μ) for different study groups on the basis of mode of application of dentifrices

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[Table 4] depicts site-specific comparison of depth of demineralization in experimental groups.
Table 4: Site specific comparison of depth of demineralization (in μ) in experimental groups

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[Table 5] shows pairwise comparison between the sites D1, D2, and D3 using Tukey test.
Table 5: Pair wise comparison between the sites D1, D2, and D3 using Tukey test

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The graphs of the results obtained are shown from [Figure 17],[Figure 18],[Figure 19],[Figure 20],[Figure 21],[Figure 22],[Figure 23],[Figure 24].
Figure 17: Comparison of demineralization (in μ) between experimental groups and control group at site D1

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Figure 18: Comparison of demineralization (in μ) between experimental groups and control group at site D2

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Figure 19: Comparison of demineralization (in μ) between experimental groups and control group at site D3

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Figure 20: Intergroup comparison of demineralization (in μ) between different study groups on the basis of mode of application of dentifrices at gingival third area (D1)

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Figure 21: Intergroup comparison of demineralization (in μ) between different study groups on the basis of mode of application of dentifrices at middle the area (D2)

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Figure 22: Intergroup comparison of demineralization (in μ) between different study groups on the basis of mode of application of dentifrices at occlusal third area (D3)

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Figure 23: Site specific comparison of depth of demineralization (in μ) in Group II

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Figure 24: Site specific comparison of depth of demineralization in Group III

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  Discussion Top


The study was designed to simulate a commonly encountered situation in clinical orthodontics. Fixed appliances have already been placed, and at some point during treatment, it is determined that oral hygiene is poor and much time remains before completion of treatment.[16]

There is increased incidence of carious lesions on facial and lingual surfaces of both anterior and posterior teeth during treatment. Most common sites for plaque accumulation are around the cervical margins of the teeth and under the bands in areas where cementing medium has been washed out. A number of researchers have documented that increased caries activity was due to increased salivary concentration of lactobacilli, which they considered source of acid for enamel demineralization.[17]

A study done by Tschoppe et al. mainly showed that the different n-HAp toothpastes exert similar capacities to remineralize enamel and dentine subsurface lesions. Furthermore, the fluoride toothpaste displayed the lowest remineralizing effects on both hard tissues, along with an increase in lesion depths. n-HAp is considered one of the most biocompatible and bioactive materials and has gained wide acceptance in medicine and dentistry in recent years. Even though former attempts to use hydroxyapatites clinically did not succeed, synthesis of nano-scaled zinc carbonate n-HAp yielded a significant progress and showed considerable affinity to the enamel surface.[15]

The effectiveness of n-HAp containing toothpaste (Apagard) to physically occlude dentin tubules as a surrogate measure of its ability to clinically relieve dentin hypersensitivity was investigated by Amaechi et al. nano-particulate hydroxyapatite may act as a calcium and phosphate reservoir, helping to maintain a topical state of supersaturation of these ions with respect to tooth minerals. Use of a n-HAP-containing toothpaste has also been shown to elevate calcium concentrations in saliva. N-HAP in dentifrice is reported to function by directly filling up micropores on demineralized tooth surfaces, and when it penetrates the pores in tooth tissues, it acts as a template in the remineralization process by continuously attracting large amounts of calcium and phosphate ions from the remineralization solution to the tooth tissue, thus promoting crystal integrity and growth.[18]

In a study done by Shetty et al. it was mentioned that Aclaim calcium phosphate (nanoparticle hydroxyapatite) has received great attention because of its particle size that is <100 nm. These nanostructured materials can be kinetically protected on account of their sizes and can remain relatively stable under undersaturated condition; therefore, the prevention of enamel erosion is enhanced by the new nanolayer and is insensitive to dissolution, thus the enamel surface is protected under the acidic condition.[19]

In this present study, we compared the relative efficiency of:

  • n-HAp, Aclaim (Group Pharmaceuticals, India)
  • n-HAp, Apagard (Apadent, Sangi's Japan)
  • Clinpro Tooth Crème (3M ESPE) containing 0.21% NaF (950 ppm fluoride ion) and tricalcium phosphate and
  • Colgate Total (Colgate-Palmolive Company, India) to prevent enamel demineralization.


The demineralizing solution was made up of analytical grade chemicals. The demineralizing solution contained 2.2 mM CaCl2, 2.2 mM KH2 PO4, and 0.05M Acetic acid. Its pH was adjusted to 4.4 with 1 M KOH. The Artificial saliva solution contained 20 mmol/L KHCO3,3 mmol/L KHPO4, and1 mmol/L CaCl2 at a pH of 7.0. This solution approximates to the supersaturation of apatite minerals found in saliva. Similar solutions were used in the study done by Nasab et al.[20]

The samples were divided into three groups – Group I, II, and III. Each specimen of Group I, II, and III was studied for the extent of demineralization at three SITES-gingival third (D1), middle third (D2), and occlusal third (D3) of the gingival demineralized area. This particular site of demineralization was evaluated because the most common site for plaque accumulation is around the cervical margins of the teeth which is followed by demineralization.[17]

In both the experimental groups, the time of contact of the dentifrice to exposed enamel rods is kept 3 min which is hypothesized to simulate the routine application of dentifrices by the patients.

At site D1 on comparing Group II (finger application) with control group maximum demineralization was observed in control group followed by Clinpro Tooth Crème, Colgate Total, Apagard, and Aclaim whereas on comparing Group III (brush application) with control group maximum demineralization was seen in control group followed by Colgate Total, Clinpro Tooth Crème, Apagard, and Aclaim.

At site D2 on comparing Group II (finger application) with control group, maximum demineralization was observed in control group followed by Clinpro Tooth Crème, Colgate Total, Apagard, and Aclaim whereas on comparing Group III (brush application) with control group maximum demineralization was seen in control group followed by Colgate Total, Clinpro Tooth Crème, Apagard, and Aclaim.

At site D3 on comparing Group II (finger application) with control group, maximum demineralization was observed in control group followed by Colgate Total, Clinpro Tooth Crème, Apagard, and Aclaim whereas on comparing Group III (brush application) with control group maximum demineralization was seen in control group followed by Colgate Total, Clinpro Tooth Crème, Apagard, and Aclaim.

This study showed maximum mean demineralization at site D2 which may be due to crater shaped lesion formed gingival to the bracket area which is in accordance with the findings of Todd et al. In his study, he evaluated the ability of fluoride varnish, Duraflor to prevent demineralization of enamel surrounding brackets.[16]

When intergroup comparison of demineralization for different study groups were made on the basis of mode of application of dentifrices it was observed that more demineralization was seen in Group III (brush application) compared to Group II (finger application) with Clinpro Tooth Crème at D1 site, Colgate Total at D1, D2, and D3 site which is in accordance with Kumar et al.[21]

More demineralization was seen in Group II compared to Group III with Aclaim at site D1, D2, and D3, Apagard at site D1, D2, and D3, Clinpro Tooth Crème at site D2 and D3 which may be due to deeper penetration of dentifrice into the enamel rods when applied with toothbrush.

The study also revealed the most significant depth of demineralization at site D2 of Group III sub-group B4 (161.848 μ) when site-specific comparison of depth of demineralization in experimental groups was made.

In the present study, the efficiency of Aclaim and Apagard remineralizing pastes was found to be superior when compared to Clinpro Tooth Crème and Colgate Total.

In a study done by Amaechi et al., the effectiveness of n-HAP-containing toothpaste (Apagard) to physically occlude dentin tubules as a surrogate measure of its ability to clinically relieve dentin hypersensitivity was investigated. He also found that use of a n-HAP-containing toothpaste elevate calcium concentrations in saliva and caused the remineralization of early caries lesions.[18]

Results of our study have shown that Aclaim and Apagard on daily application will provide maximum protection against enamel demineralization in orthodontic patients, by the formation of new n-HAp layer which is insensitive to demineralization.

Prevention in demineralization was seen after application of all the four pastes namely Apagard, Aclaim, Clinpro Tooth crème and Colgate Total, but most significant being by Aclaim and Apagard.

Construction of simple and neat mechanics, which may reduce plaque accumulation and facilitate plaque removal, is, therefore, important for maintenance of a high standard of oral hygiene during orthodontic therapy.[17]

Limitations of the present study

The simulation of natural saliva for the study is not possible to its 100% accuracy levels. Hence, there may be a minimal difference in the values obtained as compared to the present study.

Scope for further study

There is further scope for other studies in terms of longer time intervals. Most studies conducted have been limited to a period of 30 days. Hence, studies to be conducted in future may be focused on longer time intervals of 3–6 months.





  1. Aclaim and Apagard were found to be most efficient in prevention of demineralization followed by Clinpro Tooth Crème and Colgate Total
  2. Maximum depth of demineralization was observed at site D2 (middle third) followed by D1 (gingival third), and least at D3 (occlusal third)
  3. There is no significant difference between brushing and topical application method.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod 1982;82:62-7.  Back to cited text no. 1
    
2.
Ogaard B, Rølla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization. Part 2. Prevention and treatment of lesions. Am J Orthod Dentofacial Orthop 1988;94:123-8.  Back to cited text no. 2
    
3.
Bishara SE, Ostby AW. White spot lesions: Formation, prevention and treatment. Semin Orthod 2008;14:174-82.  Back to cited text no. 3
    
4.
Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: Influencing factors. Caries Res 2005;39:41-7.  Back to cited text no. 4
    
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Ogaard B. Cariological aspect of treatment with fixed orthodontic appliances. Part I: Epidemological data. Kieferorthopaedia Messages 1992;5:13-8.  Back to cited text no. 5
    
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Zachrisson BU, Zachrisson S. Caries incidence and orthodontic treatment with fixed appliances. Scand J Dent Res 1971;79:183-92.  Back to cited text no. 6
    
7.
O'Reilly MM, Featherstone JD. Demineralization and remineralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofacial Orthop 1987;92:33-40.  Back to cited text no. 7
    
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Ogaard B, Rolla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization, part 1: Lesion development. Am J Orthod Dentofacial Orthop 1988;94:68-73.  Back to cited text no. 8
    
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Silverstone LM. Laboratory studies on the demineralization and remineralization of human enamel in relation to caries mechanisms. Aust Dent J 1980;25:163-8.  Back to cited text no. 9
    
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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;93:29-37.  Back to cited text no. 10
    
11.
Artun J, Brobakken BO. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod 1986;8:229-34.  Back to cited text no. 11
    
12.
Willmot D. White spot lesions during orthodontic treatment: Mechanisms and fluoride preventive aspects. Semin Orthod 2008;14:183-93.  Back to cited text no. 12
    
13.
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;120:28-35.  Back to cited text no. 13
    
14.
Basdra EK, Huber H, Komposch G. Fluoride released from orthodontic bonding agents alters the enamel surface and inhibits enamel demineralization in vitro. Am J Orthod Dentofacial Orthop 1996;109:466-72.  Back to cited text no. 14
    
15.
Tschoppe P, Zandim DL, Martus P, Kielbassa AM. Enamel and dentine remineralization by nano-hydroxyapatite toothpastes. J Dent 2011;39:430-7.  Back to cited text no. 15
    
16.
Todd MA, Staley RN, Kanellis MJ, Donly KJ, Wefel JS. Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod Dentofacial Orthop 1999;116:159-67.  Back to cited text no. 16
    
17.
Ogaard B. Prevalence of white spot lesions in 19-year-olds: A study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop 1989;96:423-7.  Back to cited text no. 17
    
18.
Amaechi BT, Mathews SM, Ramalingam K, Mensinkai PK. Evaluation of nanohydroxyapatite-containing toothpaste for occluding dentin tubules. Am J Dent 2015;28:33-9.  Back to cited text no. 18
    
19.
Shetty PA, Shetty D, Shetty S. A comparison of clinical efficacy of dentifrices containing calcium sodium phosphosilicate, nanoparticle hydroxyapatite and a dentifrice containing casein phosphopeptide amorphous calcium phosphate on dentinal hypersensitivity – A comparative triple blind randomized study. Adv Hum Biol 2014;4:57-64.  Back to cited text no. 19
  [Full text]  
20.
Nasab NK, Kajan ZD, Balalaie A. Effect of topacal C-5 on enamel adjacent to orthodontic brackets. An in vitro study. Aust Orthod J 2007;23:46-9.  Back to cited text no. 20
    
21.
Kumar VL, Itthagarun A, King NM. The effect of casein phosphopeptide-amorphous calcium phosphate on remineralization of artificial caries-like lesions: An in vitro study. Aust Dent J 2008;53:34-40.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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