Mohamed Said Ibrahim1*, HalaMunir2, Fady Hussein3 and Dalia El Boghdady3
1Master Degree, Orthodontic Department, Faculty of Dentistry, Cairo University, Giza, Egypt
2Professor of Orthodontics, Orthodontic Department, Faculty of Dentistry, Cairo University, Giza, Egypt
3Lecturer of Orthodontics, Orthodontic Department, Faculty of Dentistry, Cairo University, Giza, Egypt
*Corresponding Author: Mohamed Said Ibrahim, Master Degree, Orthodontic Department, Faculty of Dentistry, Cairo University, Giza, Egypt.
Received: March 01, 2021; Published: : March 29, 2021
Citation: Mohamed Said Ibrahim., et al. “Evaluation and Compare Effectiveness and Durability of ICON Resin Infiltration and Acidulated Phosphorus Fluoride in Treatment of Post-Orthodontic White Spot Lesions”. Acta Scientific Dental Sciences 5.4 (2021): 229-238.
Randomized clinical trial was conducted to evaluate of the effectiveness and durability of Icon resin infiltration compared to acidulated phosphorus fluoride in management of white spot lesions. Eighteen patients with an age range of 12 - 25 years which included both males and females were enrolled in this study. The scoring criteria according to the lightness scale were graded from 0 to 100. Patient satisfaction score was recorded using a visual analogue scale from 0 to 100 according to patient's own evaluation for each quadrant before, after intervention and after 3 months follow up. A significant improvement of WSL esthetics was found immediately after Icon resin application by 18.2% and 18.8% in both upper and lower arches respectively. However, after three months follow up it was significantly reduced to 15% in the upper and 17.2% in the lower arches. A slight improvement in esthetics of white spot lesions was found immediately after APF application by 7.2% in both upper and lower arches while, after three months follow up period it significantly improved from 7.2% to 10% Patient satisfaction scores revealed that before application, there was dissatisfaction among the patients of the perception of their teeth. However, greater satisfaction scores were found immediately after Icon resin and APF application and after 3 months follow up. This results suggest that Both Icon resin and acidulated phosphorus fluoride gel improved esthetics of white spot lesions.
Keywords: ICON Resin Infiltration; Acidulated Phosphorus Fluoride; White Spot Lesions
Recent years have witnessed an increased demand to seek orthodontic treatment. orthodontic presence of appliances and other devices such as wires, elastics and bands in oral cavity create a potential environment for plaque to accumulate around orthodontic brackets. plaque has accumulation around attachments and between them and gingival margin and on composite surfaces adjacent to adhesive retention elements. presence of orthodontic attachments makes teeth cleaning more difficult, this environment changes biological balance of mouth and increases patient’s risk of caries [1].
One of the most popular drawbacks of orthodontic treatment is the development of white spot lesions (WSLs) with a prevalence of 4.9% to 97% after treatment with an average of 72% due to either the acid etch used by the orthodontists or due to poor oral hygiene. Recent studies have shown that white spot.
Lesions could develop in a time so little as a few days to a few weeks of wearing the brackets [2].
White spot lesion is a demineralization of the enamel surface that appears due to imbalance between the normal remineralization by the saliva and bacterial acids that increase the demineralization of the enamel resulting in a subsurface hypomineralized enamel surface that cannot be reached by calcium ions from the saliva giving rise to chalky white spots of demineralized enamel surface which appears white because it scatters the light passing through it. Normally white spot lesions heal within the first three months, failure of doing so gives what is often called arrested white spot lesions and it is more likely to remain [3]. Earlier studies have shown that fluoride use casein phosphopeptide amorphous calcium phosphate or a combination of both gave very little or insignificant results to patient's esthetics improvement. Bleaching also did not improve esthetics of patients while, micro abrasion was a very aggressive way to deal with white spot lesions as it removes a large amount of the enamel surface of the patients [4].
Fluoride gels often referred to as acidulated phosphate fluoride or (“APF”) are used as both treatment and prevention of white spot lesions. It is claimed that because of its acidity large amount of fluoride is absorbed by the teeth during treatment giving not only marked esthetic improvement but also caries decreasing ability. Icon resin was introduced as a treatment alternative for incipient caries and smooth surface demineralization (WSLs) where it was marketed as a minimally invasive treatment for WSLs and it was claimed to infiltrate the lesions to its depth giving instant durable optimum esthetics.
Aim of this study was to evaluate and compare the effectiveness and durability of ICON resin infiltration and Acidulated Phosphorus Fluoride in treatment of post-orthodontic white spot lesions.
Randomized clinical trial (split mouth design) was performed in this study. Eighteen patients with an age range of 12 - 25 years which included both males and females (7 males - 11 females) were enrolled in this study having 216 white spot lesions (anterior only from canine to canine) in both upper and lower arches where the four quadrants were randomly divided into two groups:
Only patients with at least one tooth with white spot lesions in each quadrant and completed orthodontic treatment 90 days ago at least were considered eligible to participate in this trial after doing full periodontal therapy. Patients with enamel hypoplasia, dental fluorosis, tetracycline pigmentation. Periodontal pocketing of 3 mm or greater are considered not eligible for this study. Both treatments were randomly assigned either to the left or right quadrant. Because of the deferent material presentation and application methods only the patients were blinded in this study. No supplemental measure was taken to remove plaque from tooth surfaces, such as mouth rinse. Only standard tooth cleaning and oral hygiene instruction (tooth brushing and dental flossing) were provided in the visit of treatment. Excessive saliva in one or two quadrants of the mouth was removed by cotton rolls or by using an air syringe without excessive drying. The first reading was taken using VITA Easyshade® (Figure 1) before which complete dryness of the field was done. Calibration of the testing unit was done before the reading. The instrument was seated in the calibration block. It was insured that the hand piece was fully seated in the calibration holder. A short press over the reading button shortly afterwards the hand piece probe illuminated the calibration block. Initial calibration took a few seconds after the unit was switched on. Two short beeps indicated completion of calibration. The bleaching mode was selected to ensure a numerical value of the shade was obtained (Figure 2). ICON resin was applied according to the manufacturer instruction as follows (Figure 3). The enamel surface was etched by applying Icon-etch containing 15% hydrochloric acid gel for two minutes (Figure 4). Rinsed with water for 30 seconds then oil-free air was used to dry the etched enamel surface (Figure 5). Icon-dry was applied and was allowed to set for 30 seconds (Figure 6). The low viscosity infiltration resin was applied to the surface for three minutes with an applicator (Figure 7). Flossing was done to insure freeing of the contact area. Light cured for 40 seconds (Figure 8). On the other side Acidulated phosphorus fluoride (Figure 9) was applied according to the manufacturer instruction as following Fluoride gel was applied directly over the affected area using a small brush/swab to spread the gel over the labial surface of the teeth and to ensure complete coverage of the lesion then it was left in place for four minutes (Figure 10). Then rinsed with water for 30 seconds after which it was dried with oil-free air for another 30 seconds (Figure 11). Another assessment was taken and recorded (Figure 12). Each patient was handed visual analog scale scaled from 0 to 100 as 0 means not satisfied and 100 means the most satisfaction that could be obtained (Figure 13) the patient was instructed to look into a mirror and assess each quadrant alone. This procedure was made before, immediately after treatment and after 3 months. All patients were recalled after 3 months and another assessment was taken and recorded for durability assessment (Figure 14).
Figure 1-14
Statistical analysisStatistical analysis was performed using SPSS 20®1, Graph Pad Prism®2 and Microsoft Excel 20163. Data was represented as mean and standard deviation and P value was set at < 0.05. Comparison between the two groups at different follow up periods was performed by the Independent T-test. On the other hand, One Way ANOVA test was performed to compare between more than two groups followed by Tukey`s Post Hok test for multiple comparisons.
enamel mean lightness was (18.8 ± 2.6) for upper and (18.7 ± 1.6) in lower arches, while at white spot lesion enamel lightness was (24.6 ± 1.9) and (24.4 ± 4.3) for both upper and lower arches respectively. Mean lightness after immediate application of ICON resin was decreased to (20.1 ± 2.3) and (19.9 ± 1.7) for upper and lower arches respectively, after 3 months it increased to (20.9 ± 2.6) for upper and (20.2 ± 1.3) in the lower arches represented in table 1.
|
ICON |
Sound enamel |
WSL |
After immediate |
After 3 months |
P Value |
||||
|
M |
SD |
M |
SD |
M |
SD |
M |
SD |
||
|
Upper |
18.8a |
2.6 |
24.68b |
1.9 |
20.1c |
2.3 |
20.9c |
2.6 |
0.0001** |
|
Lower |
18.7a |
1.6 |
24.4b |
4.3 |
19.89c |
1.7 |
20.2c |
1.3 |
0.0001** |
Table 1 : Enamel lightness (L) after ICON resin application.
M: Mean, SD: Standard Deviation, P: Probability, ** P < 0.05.
Means with different letters are significant.
A significant difference in enamel lightness of white spot lesions was found in both arches (P < 0.05) immediately after ICON resin application, and after a result show a significant difference in enamel lightness of white spot lesions in both arches (P < 0.05) immediately after ICON resin application, and after a period of 3 months. However, insignificant difference was found in enamel lightness of white spot lesions between immediate resin application and after a period of 3 months. Enamel lightness of white spot lesions immediately after ICON resin application and after 3 months was significantly higher compared to sound enamel (18.8 ± 2.6) (Table 1).
Difference in enamel lightness (ΔL) for WSL before ICON resin application was (5.8 ± 2.6) for upper and (5.4 ± 2.9) and lower arches which decreased significantly after immediate resin application to (1.29 ± 0.2) and (1.2 ± 0.1) for both upper and lower arches respectively. After three months the change in lightness insignificantly increased compared to enamel lightness immediately after application onto (2.12 ± 0.4) and (2.1 ± 0.2) in both upper and lower arches respectively (Table 2).
|
ICON |
Δ L WSL Pre-application N (18) |
Δ L Immediate after N (18) |
Δ L After 3 months N (17) |
P value |
|||
|
M |
SD |
M |
SD |
M |
SD |
||
|
Upper |
5. 81a |
2.6 |
1.29b |
0.2 |
2.12c |
0.4 |
0.000** |
|
Lower |
5.4a |
2.9 |
1.20b |
0.1 |
2.1c |
0.2 |
0.000** |
Table 2: Change in Lightness (ΔL) in ICON resin group.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
Means with different letters are significantly different.
**: Significant difference.
The mean and standard deviation of sound enamel lightness before APF application was 18.6 ± 2.1) for upper and (18.4 ± 1.6) lower arches, while at the white spot lesion the enamel lightness was (23.5 ± 1.7) and (23.4 ± 3.8) for upper and lower arches respectively. The mean lightness after immediate application of APF gel was decreased to (21.8 ± 1.3) for upper and (21.7 ± 2.3) lower arches, after 3 months its significantly changed to (21.1 ± 2.1) and (20.8 ± 1.8) for both upper and lower arches respectively as represented in table 3.
|
APF |
Sound enamel N (18) |
WSL N (18) |
After immediate N (18) |
After 3 months N (17) |
P value |
||||
|
M |
SD |
M |
SD |
M |
SD |
M |
SD |
||
|
Upper |
18.6a |
2.1 |
23.5b |
1.7 |
21.8c |
1.3 |
21.1d |
2.1 |
0.0001** |
|
Lower |
18.4a |
1.6 |
23.4b |
3.8 |
21.7c |
2.3 |
20.8d |
1.8 |
0.0001** |
Table 3: Enamel lightness (L) after acidulated phosphorus fluoride application.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
Means with different letters are significantly different.
**: Significant difference.
A significant difference in enamel lightness of white spot lesions was found in both arches (P < 0.05) immediately after APF gel application, and after a period of 3 months. The enamel lightness was significantly decreased after 3 months compared to immediate application of APF gel. Enamel lightness of white spot lesions immediately after APF gel application and 3 months was significantly higher compared to sound enamel (18.8 ± 2.6) (Table 3).
Difference in enamel lightness (ΔL) for WSL before APF gel application was (5.25 ± 2.1) for upper and (4.7 ± 2.6) lower arches which decreased significantly after immediate APF application to (3.19 ± 0.5) and (3.12 ± 0.7) for both upper and lower arches respectively. After three months the change in lightness significantly decreased compared to enamel lightness immediately after application to (2.34 ± 0.7) and (2.42 ± 0.9) in both upper and lower arches respectively (Table 4).
|
APF |
Δ L WSL N (18) |
Δ L After immediate N (18) |
Δ L After 3 months N (17) |
P Value |
|||
|
M |
SD |
M |
SD |
M |
SD |
||
|
Upper |
5.25a |
2.1 |
3.19b |
0.5 |
2.34c |
0.7 |
0.000** |
|
Lower |
4.7a |
2.6 |
3.12b |
0.7 |
2.42c |
0.9 |
0.000** |
Table 4: Change of lightness (ΔL) in APF group.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
Means with different letters are significantly different.
**: Significant difference.
The enamel lightness was found to be significantly less after immediate ICON resin application (20.1 ± 2.3) and after 3 months (20.9 ± 2.6) compared to both immediate (22.8 ± 1.3) and after 3 months of APF application (21.8 ± 2.1) respectively (Table 5).
|
Upper |
Sound enamel N (18) |
WSL N (18) |
After immediate N (18) |
After 3 months N (17) |
||||
|
M |
SD |
M |
SD |
M |
SD |
M |
SD |
|
|
ICON |
18.8 |
2.6 |
24.6 |
1.9 |
20.1 |
2.3 |
20.9 |
2.6 |
|
APF |
18.6 |
2.1 |
24.3 |
1.7 |
22.8 |
1.3 |
21.8 |
2.1 |
|
P Value |
0.5 |
0.2 |
0.001** |
0.005** |
||||
Table 5: Comparison of Enamel lightness(L) between ICON and APF groups in the upper arch. N: Number M: Mean, SD: Standard Deviation, P: Probability level, **: Significant difference.
The enamel lightness was found to be significantly less after immediate ICON resin application (19.9 ± 1.7) and after 3 months (20.2 ± 1.3) compared to both immediate (21.7 ± 2.3) and after 3 months of APF application (20.8 ± 1.8) respectively (Table 6).
|
Lower |
Sound enamel N (18) |
WSL N (18) |
After immediate N (18) |
After 3 months N (17) |
||||
|
M |
SD |
M |
SD |
M |
SD |
M |
SD |
|
|
ICON |
18.8 |
1.6 |
24.5 |
4.3 |
19.9 |
1.7 |
20.2 |
1.3 |
|
APF |
18.4 |
1.6 |
23.4 |
3.8 |
21.7 |
2.3 |
20.8 |
1.8 |
|
P Value |
0.14 |
0.07 |
0.0001** |
0.007** |
||||
Table 6: Comparison of enamel lightness (L) between ICON and APF groups in the lower arch.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
**: Significant difference.
The enamel lightness difference was significantly less (1.29 ± 0.2) after immediate application of ICON resin compared to APF gel (3.19 ± 0.5). However, insignificant difference of enamel lightness difference was found after 3 months between both groups as represented in table 7.
|
Upper |
Δ L WSL N (18) |
Δ L After immediate N (18) |
Δ L After 3 months N (17) |
|||
|
M |
SD |
M |
SD |
M |
SD |
|
|
ICON |
5. 81 |
2.6 |
1.29 |
0.2 |
2.12 |
0.4 |
|
APF |
5.25 |
2.1 |
3.19 |
0.5 |
2.34 |
0.7 |
|
P Value |
0.06 |
0.0001** |
* |
|||
Table 7: Comparison of Enamel Lightness difference (ΔL) between ICON and APF groups in the upper arch.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
**: Significant difference.
The enamel lightness difference was significantly less (1.20 ± 0.1) after immediate application of ICON resin and 3 months after application (2.1 ± 0.2) compared to APF gel (3.12 ± 0.7) and (2.42 ± 0.9) respectively as represented in table 8.
|
Lower |
Δ L WSL N (18) |
Δ L After immediate N (18) |
Δ L After 3 months N (17) |
|||
|
M |
SD |
M |
SD |
M |
SD |
|
|
ICON |
5.4 |
2.9 |
1.20 |
0.1 |
2.1 |
0.2 |
|
APF |
4.7 |
2.6 |
3.12 |
0.7 |
2.42 |
0.9 |
|
P Value |
0.06* |
0.0001** |
0.0009** |
|||
Table 8: Comparison of Enamel Lightness difference (ΔL) between ICON and APF groups in the lower arches.
N: Number, M: Mean, SD: Standard Deviation, P: Probability Level.
**: Significant difference.
Percentage of change in lightness in the upper arch revealed that the percentage of change in ICON resin group was higher after immediate application (18.2%) than after 3 months (15%). On the other hand, the percentage of change in the APF group after immediate application of (7.2%) was lower than after 3 months (10%) as presented in table 9.
|
Upper |
Percentage of change after immediate |
Percentage of change after 3 months |
|
ICON |
18.2% |
15% |
|
APF |
7.2% |
10% |
Table 9: The percentage of change in lightness of both groups in upper arch.
Percentage of change in enamel lightness in the lower arch revealed that the percentage of change in ICON resin group was higher after immediate application (18.8%) than after 3 months (17.2%). On the other hand, the percentage of change in the APF group after immediate application was lower (7.2%) than after 3 months (11%) as compared to ICON resin group as presented in table 10.
|
Lower |
Percentage of change after immediate |
Percentage of change after 3 months |
|
ICON |
18.8% |
17.2% |
|
APF |
7.2% |
11% |
Table 10: The percentage of change in lightness of both groups in the lower arch.
Patient’s satisfaction was evaluated before treatment of white spot lesions, after treatment and three months follow up by using the visual analogue scale (VAS). In ICON resin group, the visual analogue scale was recorded before, immediately after treatment and after three months which was (12 ± 3.7), (82 ± 4.1) and (79 ± 4.7) as listed in table 11 and figure 11. In the APF group the visual analogue scale was recorded before, after treatment and after three months which was (13 ± 2.4), (65 ± 4.8) and (62 ± 4.2) as listed in table 11 and figure 11. One-way analysis of variance (ANOVA) test was performed to compare patient satisfaction between different follow up periods for both groups, which showed insignificant difference of patient satisfaction immediately after treatment with three months after treatment (Table 11).
|
|
Total No. of Cases |
Group I (Icon Resin Infiltration) |
Group II (Acidulated Phosphorus Fluoride) |
|
Before Treatment |
18 |
12 ± 3.7a |
13 ± 2.4a |
|
After Treatment |
18 |
82 ± 4.1b |
65 ± 4.8b |
|
After Three Months |
17 |
79 ± 4.7b |
62 ± 4.2b |
|
P-value |
|
0.00** |
0.00** |
Table 11: Evaluation of patient satisfaction (VAS) for both groups.
M: Mean, SD: Standard Deviation, P: Probability Level.
Values with same letter in the same column are insignificantly different.
Values with different letter in the same column are significantly different.
**: Significant difference.
White spot lesions development after orthodontic treatment is the most undesirable and common complication of orthodontic treatment that reduces the esthetic outcomes of orthodontic treatment with very high prevalence, which exaggerates on drying. One of the most accepted definitions by nearly 50% clinicians of white spot lesions is that an optical phenomenon due subsurface tissue loss.
Surface features of active initial carious lesions show widened inter-crystalline spaces and frequently minor fractures of the perikymata edges which act as diffusion pathways for acids and dissolved minerals [5].
It is well accepted that there are two trends for treating white spot lesions: arresting lesion progression, e.g. by remineralization and enhancing the esthetic appearance. Restoration of initial enamel lesions results in an unfavorable damage of the tooth structure. On the other hand, traditional treatment regimens for initial enamel caries lesions based on fluoride application might not be as efficient as expected in many cases. Therefore, instead of removing porous dental hard tissues at later stages of disease progression, filling micro-spaces and micro-porosities of the lesion at a much earlier stage of development has been considered. Thus, the sealing of initial enamel lesions by resins is considered a promising approach [6].
Study was aim to evaluate and compare the effectiveness and durability of ICON resin infiltration and Acidulated Phosphorus Fluoride in treatment of post-orthodontic white spot lesions.
Incidence of white spot lesions dramatically increases in pre-adolescents who receive orthodontic treatment. The incidence might be exaggerated in participants with poor oral hygiene or those whose oral hygiene decline during orthodontic treatments. The sample in this study included 18 patients having an age range of 12 - 25 years which included both males and females (7 males and 11 females). Both genders were included in our study as there was no clear evidence for sexual predilection to white spot lesions. In a study by Al Maaitah., et al. [7] it was proven that males and females were equally at risk.
Participants were selected in this study with no systemic diseases or following any medication that would reduce the salivary flow rate as it often shows a greater caries risk incidence than those of physiological reduced rates. Participants who had non-carious lesions (enamel hypoplasia, dental fluorosis, etc.) were excluded from the current study. These pathological conditions cause mutations in genes responsible for extracellular enamel matrix formation which indicates the use of a different treatment modality most probably restorative intervention [8].
A split mouth design was selected in this study to standardize the methodology and avoid bias which would reduce variables concerning difference in oral hygiene, habits and enamel quality between one person and another. This study design focused on the effect of the two interventions ICON resin and APF on white spot lesions immediately and after three months follow up period which resulted in matching or decreased variance between the quadrants, thereby reducing the required sample size.
Each participant randomly chose two slips of paper to assign either ICON or APF to the right or left side of the upper and lower arches. Both ICON resin and APF gel were then applied to the white spot lesions in both the upper and lower arches according to the manufacturer’s instructions. Vita Easyshade® compact was used in this study to measure the enamel lightness of sound enamel and WSL before ICON resin and APF gel application and the change in enamel lightness immediately and after 3 months follow-up. All patients were recalled after 3 months except one who was unable to return for assessment.
Active white spot lesions usually have a better prognosis to recover the enamel translucency than arrested white spot lesions because of their porosity and therefore easier penetration of calcium phosphate ions. Arrested lesions have a tendency to result in less favorable esthetic results because of the lack of enamel porosity and the formation of a remineralized layer in the outer part of the enamel [9].
Unfortunately, after orthodontic treatment, most white spot lesions have already been in a demineralization and remineralization cycle and are most likely arrested. Thus, the prognosis for optimal esthetic outcomes is more questionable. Nearly, half of white spot lesions might be arrested after debonding within not less than 90 days [10]. In the current study, treatment was commenced at least 3 months after orthodontic bracket removal to make sure that the esthetic improvement obtained during this study was due to actual treatment effect not due to the normal improvement occurring during the first three months.
White spot lesions can be either non-carious or carious. Carious white spot lesions appear rough, opaque, and porous, whereas non-carious lesions appear mostly smooth and shiny [2]. Enamel crystal dissolution begins with subsurface demineralization, creating pores between the enamel rods. The alteration of the enamel refractive index is a consequence of both surface roughness, loss of surface shine and alteration of the internal reflection, all resulting in visual enamel opacity, because porous enamel scatters more light than sound enamel [11].
As the white spot lesions show widening of the inter crystalline spaces due to subsurface tissue loss, the only change recorded in the enamel optical characters is its degree of saturation; which is scientifically termed the color value (L*). L* values do not change when the teeth are dry versus wet [12]. In this study all records were taken under dry conditions in order to obtain more uniform scores. Vita Easyshade® compact was used in this study as a mean of assessment after it was confirmed that it had the smallest mean deviation from the reference (spectrophotometer) when measuring the L* value [13].
Sound enamel has a refractive index (RI) of 1.62 while, the micro porosities of enamel caries lesions are filled with either a watery medium (RI 1.33) or air (RI 1.0). The difference in refractive indices between the enamel crystals and medium inside the porosities causes light scattering. Micro porosities of infiltrated lesions are filled with resin (RI 1.46) that, in contrast to the watery medium, cannot evaporate. Therefore, the difference in refractive indices between porosities and enamel is negligible and lesions appear similar to the surrounding sound enamel immediately. Aims of resin infiltration technique to create a diffusion barrier inside the lesion, by replacing lost minerals with resin, that is comprises of three consecutive steps: hydrochloric acid etching, ethanol drying and resin infiltration [14]. Difference in enamel lightness significantly improved from 5.8 to 1.29 for the upper arch and 5.4 to 1.2 in the lower arch immediately after Icon resin application with an improvement of WSL esthetics of 18.2% and 18.8% in upper and lower arches respectively. These results came in agreement with Knösel., et al. [15] who found significant increase in esthetic improvement which was shown immediately after resin application. However, after three months follow up the esthetics of WSL was significantly reduced to 15% in the upper and 17.2% in the lower arches where the difference in enamel lightness increased to 2.12 which was not in accordance with their findings, where esthetics was stable after three months with no statistically significant differences in the color of the infiltrated resin during the follow-up period.
Topical fluoride gels are thought to be the first step in WSL management. Based on the literature and compared with the evidence on preventing WSL during orthodontic treatment, there was a lack of reliable evidence to support the effectiveness of remineralizing agents for the treatment of post orthodontic white spot lesions. Nevertheless, for mild WSL, application of low concentrations of fluorides can be used in an attempt to arrest their progression with successful and more aesthetic treatment results [3].
A published systematic review fluoride has been considered as a gold standard in treatment of white spot lesions [16]. Another systematic review [17] reported that fluoride varnish could improve the remineralization of post orthodontic white spot lesions but its effect on dental esthetics was still unclear. Fluoride gels often referred to as acidulated phosphate fluoride or (“APF”) are used as both treatment and prevention of white spot lesions. It was claimed that because of its acidity large amount of fluoride was absorbed by the teeth during treatment giving not only marked esthetic improvement but also caries decreasing ability which is applied as a one-step application for 4 minutes [18].
Acidulated phosphorus fluoride depends on its acidic nature to penetrate white spot lesions and remineralizing it thus improving its esthetics. This study revealed a slight improvement in esthetics of white spot lesions by 7.2% immediately after APF application. Difference in enamel lightness significantly improved from 5.25 to 3.19 in the upper arch and 4.7 to 3.12 in the lower arch immediately after APF application. After three months follow up period of APF application the change in enamel lightness significantly decreased to 2.3 and 2.4 for upper and lower arches respectively where esthetics of WSL significantly improved from 7.2% to 10%which was in agreement with the results of Øgaard B [4] who concluded that when topical fluoride was applied, a calcium fluoride-like material (CaF2) builds up in plaque, on the tooth surface or in incipient lesions. The CaF2 acts as a reservoir of fluoride ions for release when pH was lowered during a carious attack. When associated with phosphate ions, CaF2 became more soluble and fluoride was released at a higher rate than the pure substance. According to Rita Sarmiento [19] fluoride reacts with the enamel forming calcium fluoride and fluorapatite which in turn acts as a slow-releasing agent enhancing the remineralization of the etched enamel and making it more resistant to acid dissolution.
Esthetics of white spot lesions significantly improved in both upper and lower arches after immediate application of Icon resin compared to APF gel. However, insignificant difference of WSL esthetics was found after 3 months follow up period between both groups. Despite the inherent subjectively in valuing outcome of white spot lesions treatment, most studies focused on physical properties and effectiveness of remineralization and ignored the perception of patients. The participant’s satisfaction was primarily assessed in this study because public perception is considered as the main factor that drives the demand for the esthetic dental treatment [20]. Patient’s perception of their teeth was determined before, immediately and 3 months after Icon and APF gel application using a VAS with a score from 1100.
In this study the VAS score for perception before treatment was 12 and 13 for Icon and APF respectively which revealed dissatisfaction among the patients in the perception of their teeth. This came in agreement with Huange., et al. [21] who found that white spot lesions were considered an esthetic discrepancy for all the patients after orthodontic treatment. The VAS score showed a significant increase from 12 to 82 after immediate application of Icon resin which was insignificantly changed after a 3 months follow up period. In the APF group the VAS score increased from 13 to 65 immediately after APF application which was almost unchanged to 62 these results conformed to the findings of Kim S., et al. 2011 [8].
In this study found that both Icon resin and acidulated phosphorus fluoride gel improved esthetics of white spot lesions, as well white spot lesions Esthetics was significantly higher after immediate application of Icon resin infiltration compared to acidulated phosphorus fluoride gel however, it was insignificantly different after 3 months follow up period. and Acidulated Phosphorus Fluoride showed esthetic improvement after three months follow up period.
Copyright: © 2021 Mohamed Said Ibrahim., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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