• Users Online: 318
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2018  |  Volume : 52  |  Issue : 2  |  Page : 94-99

Comparison of various white spot lesion preventing medicaments: An In Vitro study

1 Prof. (Jr Grade), Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, KGMU, Lucknow, Uttar Pradesh, India
2 Prof., Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, KGMU, Lucknow, Uttar Pradesh, India
3 Professor and Head, Department of Orthodontics and Dentofacial Orthopaedics; Department of Oral Pathology and Microbiology, Faculty of Dental Sciences, KGMU, Lucknow, Uttar Pradesh, India

Date of Submission19-Aug-2017
Date of Acceptance24-Feb-2018
Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Saumya Kakkar
Room No. 202c, Buddha Hostel, KGMU, Lucknow, Uttar Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jios.jios_137_17

Rights and Permissions

Objective: The objective of the study is to evaluate and compare the effectiveness of various medicaments for inhibition of enamel demineralization. Materials and Methods: A total of 125 extracted premolars were equally divided into five groups. Group 1: Control, Group 2: Fluor-Protector, Group 3: TM Plus, Group 4: Enafix, and Group 5: Amflor. Apical third of the root of bracketed teeth was sectioned off to secure teeth to the inner surface of plastic lids of 20 ml specimen jars with adhesive wax with crown immersed in Ten Cates solution. Group 1 received no further treatment; Group 2 received a single application of Flour-Protector, and Group 3, Group 4, and Group 5 received 0.5 ml applications of TM Plus, Enafix, and Amflor, respectively. Specimens were then immersed in jars containing Ten Cates solution (pH 4.3). TM Plus, Enafix, and Amflor were reapplied over Group 3, Group 4, and Group 5, every 4 hours; Group 2 received a single application of Fluor-Protector during the period of 96 h. Longitudinal sections were done; linear demineralization depth was registered using a polarized light microscope. Results: Mean enamel demineralization of groups was measured in micrometers: Control was highest, i.e., 182.98 ± 7.10, followed by Enafix i.e., 167 ± 6.00; Amflor, i.e., 165 ± 4.94; Fluor-Protector, i.e., 159.72 ± 4.62; and TM Plus, i.e.,151 ± 6.21. On comparison of groups by analysis of variance, a P = 0.004 was found. On comparison by Tukey's test, P = 0.04 between Group 1 versus 2 and P = 0.002 between Group 1 versus 3 were found, and the rest was nonsignificant. Conclusion: TM Plus was found the best among different medicaments, followed by Fluor-Protector, Amflor, and finally Enafix.

Keywords: Enamel demineralization, medicaments, white spot lesion

How to cite this article:
Kakkar S, Singh G, Tandon P, Nagar A, Singh A, Chandra S. Comparison of various white spot lesion preventing medicaments: An In Vitro study. J Indian Orthod Soc 2018;52:94-9

How to cite this URL:
Kakkar S, Singh G, Tandon P, Nagar A, Singh A, Chandra S. Comparison of various white spot lesion preventing medicaments: An In Vitro study. J Indian Orthod Soc [serial online] 2018 [cited 2019 May 19];52:94-9. Available from: http://www.jios.in/text.asp?2018/52/2/94/230151

  Introduction Top

Everything in this world has some pros and cons so is with the orthodontic treatment. There is an improvement in patient's dental function, esthetics, and speech with orthodontic treatment, but the demerits of enamel demineralization adjacent to fixed orthodontic appliances cannot be ignored. White spot lesion observed during fixed appliance therapy mainly occurs due to the accumulation of cariogenic bacteria (Streptococcus mutans and Lactobacillus) around orthodontic brackets.[1],[2]

Previous studies have shown that the rate of decalcification in orthodontic patients was higher than those without orthodontic treatment [3],[4],[5] and teenagers were at higher risk of demineralization than adults. Various risk factors can contribute to the development of these incipient lesions. The production of microbial biofilm is promoted by carbohydrate-rich diet and poor oral hygiene. Hence, patients during orthodontic treatment are advised to maintain good oral hygiene, decrease sugary diet, and apply topical fluorides. Of the various forms of fluoride product (gels, varnishes, toothpaste, and mouth rinses), varnishes are easy to use and do not depend on patient cooperation. Fluoride varnish adheres to the tooth structure in a thin layer and releases fluoride for a long time. Apart from fluorides, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) has been also reported to possess topical anti-cariogenic effects due to its mechanism of formation of calcium and phosphate reservoir on the tooth surface.

More recently, products containing inorganic and other forms of fluoride also have come in the market. Very few studies are there to compare the various surface treatment medicaments. Hence, our aims and objectives are as follows:

  1. To evaluate and then compare the effectiveness of various commercially available surface treatment medicaments for the inhibition of enamel demineralization.

  Materials and Methods Top

The present study was conducted on 125 human extracted premolar teeth to determine the effectiveness of various surface treatment medicaments in preventing enamel demineralization. All teeth included in the present study were those that were extracted for orthodontic purposes. Ethical approval was obtained from King George’s Medical University Ref no.72nd ECM 11-B-Thesis/P34.

Inclusion criteria for tooth selection in the present study were followed according to Bishara et al.[6]

Inclusion criteria

  1. The tooth should be vital and fully erupted and at the time of extraction
  2. The tooth should be noncarious and devoid of any developmental defects.

The details of various surface treatment medicaments used in the study are presented in detail in [Table 1].
Table 1: Details of various surface treatment medicaments used in the study for prevention of white spot lesion

Click here to view

One hundred and twenty-five extracted premolars were equally divided into five groups of 25 teeth in each group.

  • Group 1: Control group
  • Group 2: Fluor-Protector group
  • Group 3: GC Tooth Mousse Plus group
  • Group 4: Enafix group
  • Group 5: Amflor group.

After proper cleaning of teeth, apical third of the root was sectioned off, and the teeth were secured to the inner surface of plastic lids of 20 ml specimen jars with adhesive wax upside down, and then crown were immersed in Ten Cates solution.[7] The specimens were then bracketed using light cure composite resin. Teeth in Group 1 received no further treatment and served as the Control; Group 2 received a single application of Flour-Protector varnish using applicator. Group 3, Group 4, and Group 5 received 0.5 ml applications of GC Tooth Mousse Plus, Enafix, and Amflor, respectively, using paintbrushes. All the specimens were then immersed in jars filled with 20 ml of constantly moving Ten Cates demineralizing solution at room temperature using a dental vibrator for intermittent periods. Ten Cates solution contains glacial acetic acid (50 mM/L) and CaHPO4 (2.2 mM/L) in deionized water with pH adjusted to 4.3. Every 4 h, teeth were removed from the solution, cleaned with deionized water, and given brushing strokes using a toothbrush to simulate normal tooth brushing. Then, after every 4 h, GC Tooth Mousse Plus, Enafix, and Amflor were reapplied over Group 3, Group 4 and Group 5; whereas the teeth in Group 2 received only a single application of Fluor-Protector during the total study period of 96 h. The immersion of specimens in the Ten Cates demineralizing solution for 96 h was expected to result in the creation of 100-μm deep enamel lesions and represents approximately 3 months of real time. The 4-hourly application of topical medicaments, therefore, corresponds to approximately 2 weekly applications. After 96 h, all the teeth were removed from the solution, thoroughly rinsed with distilled water. Sectioning was done with a diamond disc to obtain longitudinal sections of tooth surface near to brackets and then thinned to 150–200 μm thick using carborundum stone. Sections were examined using a polarized light microscope (Olympus, BX-51). Photomicrographs were then made under maximum illumination and 10x magnification using a photographic camera (Olympus E330). The digital photomicrographs were then analyzed with Image analyzer software (Image J 1.38 e, NIH, USA). The linear distance from the tooth surface (adjacent to brackets) to its greatest and least demineralization depth was registered.

Statistical analysis

Data were summarized as mean ± standard deviation (SD). The sample size was calculated using the following formula:

n = 2 × (Zα/2+Zβ) 2 SD2/d2

where n: Sample size per group

SD: Assumed SD

d: Difference in the means (effect size)

Zα/2: Significance level

Zβ: Power of the study.

Groups were compared by one-way analysis of variance (ANOVA), and the significance of the mean difference between the groups was done by Tukey's honestly significant difference post hoc test after ascertaining normality by Shapiro–Wilk's test and homogeneity of variance by Levene's test. A two-tailed (α = 2) P < 0.05 was considered statistically significant. Analyses were performed on ImageJ (Mac OS X, with built-in-editor and Java compiler, plus the BBEdit editor and the Ant build tool, the Research Services Branch, National Institute of Mental Health, Bethesda, Maryland, USA).

  Results Top

Intraoperator error

There was no significant difference in the values of depth of enamel demineralization when the readings were measured again after 20 days.

Results obtained are as summarized in [Table 2]. [Figure 1] shows the difference in the depth of Enamel Demineralization in GC Tooth Mousse Plus group and Control group.
Table 2: Enamel demineralization (μm) summary of five groups

Click here to view
Figure  1: Depth of enamel demineralization measured in the GC Tooth Mousse Plus group (a) and the Control group (b)

Click here to view

The mean enamel demineralization of Group 1, i.e., Control group, was the highest, i.e., 182.98 ± 7.10, followed by Group 4 (Enafix), i.e., 167 ± 6.00; Group 5 (Amflor), i.e., 165 ± 4.94; Group 2 (Fluor-Protector), i.e., 159.72 ± 4.62; and Group 3 (GC Tooth Mousse Plus), i.e., 151 ± 6.21, the least (Group 3< Group 2< Group 5< Group 4< Group 1).

On comparing the mean enamel demineralization of five groups, ANOVA showed significantly different enamel demineralization among the groups (P = 0.004) [Table 3].
Table 3: Comparison of mean enamel demineralization of five groups by analysis of variance

Click here to view

Furthermore, on comparing the mean difference in enamel demineralization between the groups, Tukey's test also showed a significant difference between Group 1 (Control) and Group 2 (Fluor-Protector) with a P = 0.044 and between Group 1 and Group 3 with a P = 0.002 and not significant among other groups (P > 0.05) [Table 4].
Table 4: Comparison of mean difference in enamel demineralization between the groups by Tukey's test

Click here to view

  Discussion Top

The most susceptible areas for enamel decalcification due to plaque accumulation around the bracket bases are in the middle and cervical thirds of the maxillary lateral incisors. These white spot lesions are one of the most serious complications of orthodontic therapy.[8],[9],[10],[11] White spot lesion occurs around 15%–91% as reported by Todd et al.[12] in patients after orthodontic treatment.

On visual examination by drying the tooth, they appear as an opaque whitish or grayish halo in between the cement and enamel and the periphery or margins surrounding the bracket. Ogaard et al.[13] reported that the duration between two sessions of orthodontic appointments is far more than the time required for these white spot lesion appearance. Although minerals present in the saliva play an active role in the recovery of the structural properties of the superficial lesions, deeper lesions are difficult to treat and recover.[14] Hence, it is advised to all the patients undergoing orthodontic treatment to apply various remineralizing agents during the entire treatment and even after the treatment if possible for better aesthetic results.

Although these topical fluorides used in various forms has been, to date, the most commonly used caries prevention protocol for the orthodontic patient. CPP-ACP and other forms of inorganic and organic fluoride have been introduced in recent years as supplements or substitutes for conventional fluoride-based systems. Therefore, this study was undertaken to evaluate and then compare the effectiveness of various surface treatment medicaments for the inhibition of enamel demineralization. The solution pH (4.3) and study period (96 h) were intentionally selected to limit the demineralization to white spot lesion for accurate measurement of the lesion depth.[9],[10]

In the present study, enamel demineralization scores of Group 3, i.e., GC Tooth Mousse Plus, was found to be around 151 μm which was least among all groups. These results showed that GC Tooth Mousse Plus is highly effective in reducing enamel demineralization among different medicaments available in the market. Furthermore, a statistically significant difference was found between Group1, i.e., Control, and Group 3, i.e., GC Tooth Mousse Plus, with a P = 0.002 [Table 4].

The effectiveness of GC Tooth Mousse Plus in enamel demineralization prevention is mainly due to its Recaldent (ACP-CCP) technology which stands for milk protein CPP-ACP which is also supported by Robertson et al.[15] (2011) and Joshi et al.[16] (2014). As the Tooth Mousse Plus contains bioavailable calcium ions, phosphate ions, and fluoride ions, its mechanism of remineralization is by increasing the intake of fluoride into the subsurface enamel along with a plaque to form fluorapatite. The mechanism of anti-cariogenicity for CPP-ACP Plus fluoride to enhance remineralization and reduce the extent of decalcification by increasing the levels of calcium, phosphate, and fluoride ions onto the surface of the tooth and within dental plaque was also observed by Joshi et al.[15]

Again, in the present study, a statistically significant difference was also found between Group 1 (Control) and Group 2 (Fluor-Protector) with a P = 0.044 [Table 4]. Mechanism of action of Fluor-Protector is that it has been found to remain in contact with enamel for several days due to their viscous nature and has been noted to create a durable physical barrier between the enamel and cariogenic solution. Being a silane lacquer, it has very low viscosity and a good wetting action, allowing it to penetrate into the enamel porosities and mimic the tagging effect of composite resins.[17] The ability of Fluor-Protector to significantly inhibit enamel demineralization has also been observed by Adriaens et al.,[11] Todd et al.,[12] and Vivaldi-Rodrigues et al.[18] An advantage of Fluor-Protector as reported by Farhadian et al.[19] is due to its slow release over time so that repeated doses are not needed.

There was no statistically significant difference found between Group 1 (Control) and Group 4 (Enafix) and between Group 1 and Group 5 (Amflor) with a P > 0.05 [Table 4]. However, Amflor has been found to be slightly better than Enafix in the present study.

Amflor toothpaste contains the active ingredient in the form of amine fluoride which is a new generation organic fluoride. Amflor toothpaste has been found to provide better results if it is compared to inorganic fluorides such as sodium fluoride. Amflor toothpaste provides long-term protection and has got superior anti-bacterial properties. It is basically an organic compound – noctadecyltrimethylen-diamine–N, N, N-tris [2-ethanol]-dihydrofluoride (C27H58N2O32HF) consisting of two functional groups, that is, one is a bound ionic fluoride group and the other one is a cationic amino group.[20] Galuscan et al.[21] and Shani et al.[22] have reported the beneficial effects of Amflor. They have reported the caries inhibitory properties of Amflor are due to its anti-glycolytic and surface active properties which involve accumulation of fluoride onto the surface of tooth by aligning the hydrophilic part toward the tooth surface while hydrophobhic part toward the oral cavity. Hence, the fluoride which gets accumulated onto the tooth surface readily forms calcium fluoride which acts as a labile fluoride reservoir.[21]

Finally, Enafix is a complex mixture of calcium sucrose phosphate with inorganic ACP. During brushing, calcium sucrose phosphate (anticay) in Enafix quickly breaks down and releases calcium, phosphate, and sucrose phosphate ions into the saliva. Calcium and phosphate ions rapidly adsorb onto the enamel, decrease the rate of enamel solubility under acidic conditions and at neutral pH, and increase the rate of remineralization. The added factor – sucrose phosphate anions – adsorbed onto the surface of tooth reduced the rate of acid dissolution. However, the shortcomings of this inorganic fluoride in comparison to organic fluoride present in Enafix are that it basically forms a thick layer of calcium fluoride by reaction with hydroxyapatite of enamel. Hellwig et al.[23] found that due to this thick layer of calcium fluoride formed, there is lower bioavailability of fluoride ions.

The most common drawback of these agents is that they are patient dependent. A potential drawback of this study is the inability to take into consideration the protective potential of the saliva. The salivary pellicle is thought to act as a diffusion barrier or permselective membrane on the enamel surface providing protective effects against remineralization from various acidic challenges in the oral cavity. The absence of the pellicle on the teeth, especially those in the control group, could possibly accentuate the advent and the extent of demineralization noted in the study. Still, none of the studies are done regarding the area etched during bonding as the amount of surface area etched during bonding also plays an important role in enamel demineralization. Therefore, still, more studies need to be done in this regard. Substantiation of the findings of this in vitro study is therefore necessary by undertaking clinical trials.

  Conclusion Top

The conclusions withdrawn from the present study are as follows:

  1. Demineralization was observed in all four groups treated with different medicaments although they were of variable degree
  2. Although Amflor and Enafix were not found statistically significant from Control, they also prevent the enamel demineralization and are also cost-effective.

Financial support and sponsorship

Intramural funding agency supported the study.

Conflicts of interest

There are no conflicts of interest.

  References Top

Sukontapatipark W, el-Agroudi MA, Selliseth NJ, Thunold K, Selvig KA. Bacterial colonization associated with fixed orthodontic appliances. A scanning electron microscopy study. Eur J Orthod 2001;23:475-84.  Back to cited text no. 1
Mattingly JA, Sauer GJ, Yancey JM, Arnold RR. Enhancement of Streptococcus mutans colonization by direct bonded orthodontic appliances. J Dent Res 1983;62:1209-11.  Back to cited text no. 2
Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod 1982;81:93-8.  Back to cited text no. 3
Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Orthod 1982;82:62-7.  Back to cited text no. 4
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. 5
Bishara SE, Soliman M, Laffoon J, Warren JJ. Effect of antimicrobial monomer-containing adhesive on shear bond strength of orthodontic brackets. Angle Orthod 2005;75:397-9.  Back to cited text no. 6
Ab-Ghani Z, Ngo H, McIntyre J. Effect of remineralization/demineralization cycles on mineral profiles of Fuji IX fast in vitro using electron probe microanalysis. Aust Dent J 2007;52:276-81.  Back to cited text no. 7
Chapman JA, Roberts WE, Eckert GJ, Kula KS, González-Cabezas C. Risk factors for incidence and severity of white spot lesions during treatment with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2010;138:188-94.  Back to cited text no. 8
Buren JL, Staley RN, Wefel J, Qian F. Inhibition of enamel demineralization by an enamel sealant, pro seal: An in-vitro study. Am J Orthod Dentofacial Orthop 2008;133:S88-94.  Back to cited text no. 9
Frazier MC, Southard TE, Doster PM. Prevention of enamel demineralization during orthodontic treatment: An in vitro study using pit and fissure sealants. Am J Orthod Dentofacial Orthop 1996;110:459-65.  Back to cited text no. 10
Adriaens ML, Dermaut LR, Verbeeck RM. The use of 'fluor protector', a fluoride varnish, as a caries prevention method under orthodontic molar bands. Eur J Orthod 1990;12:316-9.  Back to cited text no. 11
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. 12
Ogaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop 1988;94:68-73.  Back to cited text no. 13
Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent Res 2010;89:1187-97.  Back to cited text no. 14
Robertson MA, Kau CH, English JD, Lee RP, Powers J, Nguyen JT, et al. MI paste plus to prevent demineralization in orthodontic patients: A prospective randomized controlled trial. Am J Orthod Dentofacial Orthop 2011;140:660-8.  Back to cited text no. 15
Joshi YS, Nayak K, Kuttappa N, Menezes R, Marure P, Sawant S. Clinical evaluation of enamel demineralization during orthodontic treatment: An in vivo study using GC tooth mousse plus. J Indian Orthod Soc2014;48:233-8.  Back to cited text no. 16
  [Full text]  
Benson PE. Evaluation of white spot lesions on teeth with orthodontic brackets. Semin Orthod 2008;14:200-8.  Back to cited text no. 17
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;7:138-44.  Back to cited text no. 18
Farhadian N, Miresmaeili A, Eslami B, Mehrabi S. Effect of fluoride varnish on enamel demineralization around brackets: An in-vivo study. Am J Orthod Dentofacial Orthop 2008;133:S95-8.  Back to cited text no. 19
Madléna M, Nagy G, Gábris K, Márton S, Keszthelyi G, Bánóczy J, et al. Effect of amine fluoride toothpaste and gel in high risk groups of Hungarian adolescents: Results of a longitudinal study. Caries Res 2002;36:142-6.  Back to cited text no. 20
Galuscan A, Podariu AC, Jumanca D. The decreasing of the carious index by using toothpaste based on amine fluoride. Oral Health Dent Man Black Sea countries 2003;1:42-6.  Back to cited text no. 21
Shani S, Friedman M, Steinberg D. Relation between surface activity and antibacterial activity of amine-fluorides. Int J Pharm 1996;131:33-9.  Back to cited text no. 22
Hellwig E, Klimek J, Wagner H. The influence of plaque on reaction mechanism of MFP and naF in vivo. J Dent Res 1987;66:46-9.  Back to cited text no. 23


  [Figure 1]

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


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded293    
    Comments [Add]    

Recommend this journal