Control of White Spot Lesions with Use of Fluoride Varnish or Chlorhexidine Gel During Orthodontic Treatment A Randomized Clinical Trial

To compare the effectiveness of fluoride varnish and 2% chlorhexidine gel for controlling active white spot lesions (WSLs) adjacent to orthodontic brackets. Study design: Thirty-five orthodontic patients (17.2 ± 2.3 years old) presenting 60 WSLs adjacent to orthodontic brackets were enrolled in this randomized, blind, 3-armed and controlled clinical trial. The patients were randomly allocated to 1 of 3 arms: (1) two applications of 5% NaF varnish- F, with one-week interval, (2) two applications of 2% chlorhexidine gelCHX, with one-week interval and (3) usual home care-control (CO). The WSLs were scored by using a DIAGNOdent pen. An independent examiner scored the surfaces using Nyvad criteria for caries assessment. Results: A total of thirty patients presenting 51 lesions completed the study. All treatments reduced the fluorescence values during the experimental period; however, F induced faster remineralization than CHX. After 3 months, 70.58 % were inactive considering all groups. DIAGNOdent pen and Nyvad presented a significant correlation. Conclusion: After 3 months of treatment, F, CHX and CO were capable of controlling the WSLs adjacent to the orthodontic brackets. However, the treatment with F was capable of controlling the progression of the WSLs in a shorter period of time.

Chlorhexidine, Dental Caries, Fluorescence, Fluoride, Orthodontic Appliances, Tooth remineralization.

1. Al Mulla AH, Kharsa SA, Kjellberg H, et al. Caries risk profiles in orthodontic patients at follow-up using cariogram. Angle Orthod 79: 323-330, 2009.

2. Liu Y, Zhang Y, Wang L, et al. Prevalence of porphyromonas gingivalis four rag locus genotypes in patients of orthodontic gingivitis and periodontitis. PLoS One 8:e61028, 2013.

3. Mitchell L. Decalcification during orthodontic treatment with fixed appliances--an overview. Br J Orthod 19: 199-205, 1992.

4. Cury JA, Tenuta LM. Enamel remineralization: Controlling the caries disease or treating early caries lesions? Braz Oral Res 23: 23-30, 2009.

5. Stecksén-Blicks C, Renfors G, Oscarson ND, et al. Caries-preventive effectiveness of a fluoride varnish: a randomized controlled trial in adolescents with fixed orthodontic appliances. Caries Res 41: 455-459, 2007.

6. Petersson LG, Twetman S, Dahlgren H, et al. Professional fluoride varnish treatment for caries control: A systematic review of clinical trials. Acta Odontol Scand 62: 170-176, 2004.

7. Sari E, Birinci I. Microbiological evaluation of 0.2 % chlorhexidine gluconate mouth rinse in orthodontic patients. Angle Orthod 77: 881-84, 2007.

8. Yazıcıoğlu O, Ulukapı H. The investigation of non-invasive techniques for treating early approximal carious lesions: An in vivo study. Int Dent J 64: 1-11, 2014.

9. Zhang Q, van Palenstein Helderman WH, van’t Hof MA, et al. Chlorhexidine varnish for preventing dental caries in children, adolescents and young adults: A systematic review. Eur J Oral Sci 114: 449-455, 2006.

10. Autio-Gold J. The role of chlorhexidine in caries prevention. Oper Dent 33: 710-716, 2008.

11. Baeshen HA, Lingström P, Birkhed D. Effect of fluoridated chewing sticks (miswaks) on white spot lesions in postorthodontic patients. Am J Orthod Dentofacial Orthop 140: 291-297, 2011.

12. Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Res 33: 252-260, 1999.

13. Hadler-Olsen S, Sandvik K, El-Agroudi MA, et al. The incidence of caries and white spot lesions in orthodontically treated adolescents with a comprehensive caries prophylactic regimen--a prospective study. Eur J Orthod 34: 633-639, 2012.

14. Richter AE, Arruda AO, Peters MC, et al. Incidence of caries lesions among patients treated with comprehensive orthodontics. Am J Orthod Dentofacial Orthop 139: 657-664, 2011.

15. Boersma JG, van der Veen MH, Lagerweij MD, et al. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: Influencing factors. Caries Res 39: 41-47, 2005.

16. Tufekci E, Dixon JS, Gunsolley JC, et al. Prevalence of white spot lesions during orthodontic treatment with fixed appliances. Angle Orthod 81: 206-210, 2011.

17. Sonesson M, Twetman S, Bondemark L. Effectiveness of high-fluoride toothpaste on enamel demineralization during orthodontic treatment-a multicenter randomized controlled trial. Eur J Orthod 36: 678-682, 2014.

18. Shi XQ, Tranaeus S, Angmar-Månsson B. Comparison of QLF and diagnodent for quantification of smooth surface caries. Caries Res 35: 21-26, 2001.

19. Lussi A, Hack A, Hug I, et al. Detection of approximal caries with a new laser fluorescence device. Caries Res 40: 97-103, 2006.

20. Braga MM, de Benedetto MS, Imparato JC, et al. New methodology to assess activity status of occlusal caries in primary teeth using laser fluorescence device. J Biomed Opt 15: 047005, 2010.

21. Lussi A, Hibst R, Paulus R. Diagnodent: An optical method for caries detection. J Dent Res 83: 80-83, 2004.

22. Sköld-Larsson K, Fornell AC, Lussi A, et al. Effect of topical applications of a chlorhexidine/thymol-containing varnish on fissure caries assessed by laser fluorescence. Acta Odontol Scand 6: 339-342, 2004.

23. Du M, Cheng N, Tai B, et al. Randomized controlled trial on fluoride varnish application for treatment of white spot lesion after fixed orthodontic treatment. Clin Oral Investig 16: 463-468, 2012.

24. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device for detecting caries. J Am Dent Assoc 135: 1413- 1426, 2004.

25. Marinho VC, Worthington HV, Walsh T, et al. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 7: CD002279, 2013.

26. Moberg Sköld U, Petersson LG, Lith A, et al. Effect of school-based fluoride varnish programmes on approximal caries in adolescents from different caries risk areas. Caries Res 39: 273-279, 2005.

27. Symington JM, Perry P, Kumar A, et al. Efficacy of a 10% chlorhexidine coating to prevent caries in at-risk community-dwelling adults. Acta Odontol Scand 7: 497-501, 2014.

28. Restrepo M, Bussaneli DG, Jeremias F, et al. Control of white spot lesion adjacent to orthodontic bracket with use of fluoride varnish or chlorhexidine gel. ScientificWorldJournal 2015: 218452, 2015.

29. Lagerweij MD, ten Cate JM. Remineralisation of enamel lesions with daily applications of a high-concentration fluoride gel and a fluoridated toothpaste: An in situ study. Caries Res 36: 270-274, 2002.

30. Fernández CE, Tenuta LM, Zárate P, et al. Insoluble naf in duraphat® may prolong fluoride reactivity of varnish retained on dental surfaces. Braz Dent J 25: 160-164, 2014.

31. ten Cate JM, Buijs MJ, Miller CC, et al. Elevated fluoride products enhance remineralization of advanced enamel lesions. J Dent Res 87: 943-47, 2008.

32. Twetman S: Antimicrobials in future caries control? A review with special reference to chlorhexidine treatment. Caries Res. 38: 223-229, 2004.

33. Øgaard B, Larsson E, Henriksson T, et al. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod Dentofacial Orthop 120: 28-35, 2001.

34. Aykut-Yetkiner A, Kara N, Ates M, et al. Does casein phosphopeptid amorphous calcium phosphate provide remineralization on white spot lesions and inhibition of Streptococcus mutans? J Clin Pediatr Dent 38: 302-306, 2014.

35. Vyavhare S, Sharma DS, Kulkarni VK. Effect of three different pastes on remineralization of initial enamel lesion: an in vitro study. J Clin Pediatr Dent 39: 149-160, 2015.