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PREVENTIVE DENTISTRY www.stomaeduj.com
ARREST OF EARLY CARIOUS LESIONS AFTER
Original Articles
PROFESSIONAL APPLICATION OF DIFFERENT FLUORIDE
AGENTS
Graciela Liliana Klemonskis1a , Celina Cornejo1b , Mariana Toral1c , Pablo Andrés Salgado1d , Aldo Fabián Squassi1e*
1
Chair of Department of Preventive and Community Dentistry, Faculty of Dentistry, University of Buenos Aires, Buenos Aires, Argentina
a
DDS, PhD, Associated Professor; e-mail: graciela.klemonskis@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0002-9644-7119
b
DDS; e-mail: celinacornejo@hotmail.com; ORCIDiD: https://orcid.org/0000-0002-7103-8271
c
DDS; e-mail: marianatoral@live.com.ar; ORCIDiD: https://orcid.org/0000-0002-9924-8027
d
Lic. Biol. Sc.; e-mail: pabloandsalgado@gmail.com; ORCIDiD: https://orcid.org/0000-0003-4232-7178
e
DDS, PhD, Chairman; e-mail: asquassi@gmail.com; ORCIDiD: https://orcid.org/0000-0001-7687-5805
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(1).art.2
Objective To compare the effectiveness of three professionally applied fluoride agents in arresting early
carious lesions in young permanent teeth.
Methods A quasi-experimental study was performed. Eligible population: School-children
aged 5-7 years presenting at least one permanent molar with early active carious lesion.
Sample: 107 dental surfaces with early occlusal carious lesions (lesion code=1-2; activity code=2 -ICDAS II
criteria-). Study design: (1) Baseline diagnosis, performed by 2 researchers (Kappa inter-observer: 0.8). (2)
Application of a protocol for cariogenic infection control. (3) Participant assignment to groups: matched
according to complexity of treatment needs at baseline: Group 1(G1) 5% NaF varnish Duraphat® (n=53);
Group 2 (G2) 5% NaF varnish containing β-TCP tricalcium phosphate (n=33) Clinpro White Varnish®; Group
3 (G3) resin-modified glass ionomer cement varnish Clinpro XT Varnish® (n=19). (4) Single professional
application of a fluoride agent. (5) Caries assessment 1 year post-treatment. Statistical analysis. The frequency
of (a) early caries lesion remineralization one year post-treatment and (b) carious lesions that remained active
but showed no progression 1 year post-treatment were calculated. Chi-Square and proportion comparison
tests for independent samples were used to evaluate differences among groups.
Results Proportion of arrested lesions 1-year post treatment: G1=54.5%, G2=43.4%, G3=47.4%. No statistical
difference was found among groups (p< 0.05). Proportion of lesions remaining active at 1 year showing no
caries progression: G1=69%, G2=80%, G3=100%. No statistical difference was found among groups (p< 0.05).
Conclusion The three professionally applied fluoride agents showed similar effectiveness in arresting early
carious lesions in young permanent teeth 1 year post-application.
KEYWORDS
Tooth Remineralization; Fluoride Varnishes; Caries Arrest; Preventive Dentistry; Topical Fluorides.
1. INTRODUCTION environment and the composition of the oral
microbiota. Imbalances in the resident microflora
The conventional treatment of caries lesions has have an impact on the environment, disrupting
historically focused on the mechanical treatment the demineralization/remineralization balance at
of the lesion. Such an approach [17] disregards the the biofilm-enamel interface. When this imbalance
ecological imbalances in the oral cavity, involves continues, the carious lesion becomes visible [7].
restorations that require replacement and which Fluoride plays a key role in the prevention and control
become larger with time, and can result in tooth loss. of dental caries. The cariostatic effect of fluoride can
Successive investigations have reported findings be attributed mainly to its ability to influence ion
that support a paradigm shift in the treatment exchange reactions at the plaque-enamel interface,
of caries. The “Ecological Plaque Hypothesis” [14- even at low concentrations (0.2-1ppm), facilitating
15] emphasizes the dynamic relation between the calcium and phosphate precipitation [6]. Because
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Klemonskis GL, Cornejo C, Toral M, Salgado PA, Squassi AF. Arrest of early carious lesions after professional
application of different fluoride agents. Stoma Edu J. 2020;7(1):15-19.
Received: October 25, 2019; Revised: November 27, 2019; Accepted: February 18, 2020; Published: February 19, 2020
*Corresponding author: Professor Aldo Squassi, Od, PhD, Chair of Preventive and Community Dentistry, Faculty of Dentistry, University of Buenos Aires,
Buenos Aires, Argentina. Marcelo T. de Alvear 2142, C1122AAH, Buenos Aires, Argentina
Tel/Fax: +54-11-5287-6254, e-mail: asquassi@gmail.com
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
Stoma Edu J. 2020;7(1): 15-19 pISSN 2360-2406; eISSN 2502-0285 15
Klemonskis G. L. et al.
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Original Articles
Figure 1. Sampling method.
of its inorganic composition, saliva contributes to Figure 2. Study design.
remineralization [10-12]. When fluoride is applied in
high concentrations (in vehicles such as varnishes ICDAS II criteria) [20].
and gels), a calcium fluoride precipitate is produced The study was conducted within the framework of a
on the surface of the enamel and in the plaque. dental care program for schoolchildren in suburban
This calcium fluoride acts as a temporary storage of neighborhoods, in school settings. Schoolchildren
fluoride, which is released when the pH drops [11]. complying with the eligibility criteria and whose
Hence, varnishes and gels deliver fluoride to the legal guardians signed the informed consent form
enamel surface and to the subsurface of carious were included in the study. Fifty-two subjects had at
lesions, where calcium fluoride deposits and acts least one early carious lesion in a permanent molar.
as a reservoir of fluoride ions [16]. The presence of The final study sample comprised 107 tooth surfaces
fluoride ions during the demineralization stage with early occlusal carious lesions.
guarantees the incorporation of fluoride into the
apatite crystals, forming crystalline structures that 2.1. Study design
are more resistant to acid challenge [21]. Fluorides The subjects were divided into three groups matched
can contribute both to decreasing lesion progression according to the caries treatment needs, which was
and to arresting or repairing lesions. determined according to the severity of the carious
These effects have been studied in vitro and in lesion (CTNI19 ≤ 6 – no caries lesion involving the
situ. A meta-analysis on four studies showed that pulp; does not require complex treatments / CTNI
5% sodium fluoride (NaF) varnish remineralized ≥ 7 – presence of caries lesion involving the pulp;
approximately two thirds of caries lesions in requires pulp therapy or surgery). The treatments
children [22]. Different compounds have been (professionally applied fluoride) were randomly
added to fluoride varnishes with the aim to achieve assigned to each group.
improved mineralizing effects. However, addition Group A: 5% Sodium Fluoride Varnish (Duraphat®)
of chlorhexidine or calcium fluoride has not shown Group B: Sodium Fluoride varnish containing β-TCP
significant clinical benefits [4-8-1]. tricalcium phosphate (Clinpro White Varnish®)
The addition of β tricalcium phosphate (βTCP) to Group C: Glass ionomer modified with fluoro-
fluoride varnish improved the protective ability of the aluminosilicate resin and calcium glycerophosphate
varnish on primary teeth, based on microhardness (Clinpro XT Varnish®). In compliance with the
readings[2]. protocol, all subjects received a preventive treat-
Objective: To compare the effectiveness of 3 ment protocol, which included measures to control
professionally applied fluorides in arresting incipient factors influencing the biofilm formation and
carious lesions in young permanent teeth. structure, such as biofilm retention sites and active
cavitated carious lesions: training and supervision
2. MATERIALS AND METHODS of oral tooth brushing, supragingival scaling in
cases presenting calculus, polishing of restorations,
A quasi-experimental study was conducted. Non- and restoration of cavitated carious lesions with no
probability consecutive sampling was used to pulpal involvement using an atraumatic restorative
select participants (Fig.1). A baseline diagnosis was technique(ART).
performed to identify eligible subjects. The eligible Primary and permanent teeth presenting
population comprised schoolchildren aged 5 to 7 caries lesions with pulpal involvement were
years, attending public schools in the city of Buenos endodontically treated or extracted according
Aires, presenting at least 1 permanent molar with to the type of pulpal involvement (PUFA
active incipient caries lesion (corresponding to lesion index) and size of the tooth remnant, thus
codes 1 and 2 and activity status 2 according to determining the subsequent restoration.The
16 Stoma Edu J. 2020;7(1):15-19 pISSN 2360-2406; eISSN 2502-0285
Arrest of early carious lesions
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Original Articles
Figure 3. Arrest of early carious lesion 1 year post-treatment. Figure 4. Early carious lesion progression 1 year post-treatment.
corresponding fluoride was applied on the lesions
once, following the manufacturers’ instruc-
tions. The lesions were assessed one year post-
fluoride application (simple blinding technique: the
examiner was blinded to the treatment allocation
of the subjects). The diagnosis and assessment of
the lesions were performed by two researchers who
were calibrated against a gold standard examiner
(Kappa interrater agreement value > 0.8).
The statistical analysis involved calculating the
frequency of (a) early carious lesion remineralization
one year post-treatment and of (b) carious lesions
that remained active but showed no progression
one year post-treatment. The groups were compared
using the Chi square test and the comparison of
proportions for independent samples. Due to the Figure 5. Early carious lesion progression among lesions remaining
sample size, a Bootstrap technique was apllied with active 1 year after treatment.
Montecarlo sampling methods (1000 samples -95%
CI level). A binomial exact test was used to compare
groups. progression, 91.4% of lesions in Group 1, 83.3% of
lesions in Group 2, and 100.0% of lesions in Group
2.2. Compliance with Ethical Requirements 3 showed no progression, with no significant
The caregivers/legal guardians of the schoolchildren differences among groups (Pearson Chi square test:
signed an informed consent form authorizing the df=2; p-value= 0,201) (Fig. 4).
child’s participation in the study. All the schoolchildren When considering the sub-set of lesions that
who participated in the study gave their assent remained active one year post-treatment, the
for the treatment. The present research work was percentage of lesions showing no caries progression
approved by the ethics committee of the University was 80.0% in Group 1, 69.0% in Group 2, and 100.0%
of Buenos Aires (UBACyT 20020120100324BA). in Group 3; no significant differences were observed
among groups (Fig.5).
3. RESULTS In all cases the tests were adjusted for all pairwise
comparisons within a row of each innermost
The percentage of early carious lesions that became subtable using the Bonferroni correction.
stabilized according to ICDAS II criteria one year In Group C, this category was not used in comparisons
post-treatment was 54.5% in Group 1 (Duraphat®), because its column proportion is equal to zero or
41.8% in Group 2 (Clinpro White varnish), and 47.4% one. After appliyng the Bootstrap technique, no
in Group 3 (Clinpro XT varnish). No statistically significant differences were found for caries arrest (p
significant differences were observed among groups value Exact Test= 0,577 (CI95%: 0,544-0,569)); caries
(Pearson Chi square test: df=2; p-value= 0,529). The progression (p value Exact Test= 0,225 (CI95%: 0,214-
tests were adjusted for all pairwise comparisons 0,236)); and early carious lesion progression among
within a row of each innermost subtable using the lesions remaining active (p value Exact Test= 0,274
Bonferroni correction (Fig. 3). As regards the caries (CI95%: 0,263-0,286).
Stoma Edu J. 2020;7(1): 15-19 pISSN 2360-2406; eISSN 2502-0285 17
Klemonskis G. L. et al.
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The results of the present study however, showed
Original Articles 54.4% caries arrest and 16.7% progression in the 5%
NaF treated group. The differences may be due to
the characteristics of the studied populations, the
setting where the studies were conducted, and the
diagnostic criteria applied in each study. The work
presented here is the first in vivo study on carious
* lesion arrest using a fluoride varnish containing
β-TCP tricalcium phosphate. Other studies evaluated
the effectiveness of professional application of fluo-
ride varnishes containing calcium fluoride (6%
Figure 6. Power analysis. Difluoride XII®) on remineralization of white spot
lesions in permanent anterior teeth, and found no
4. DISCUSSION differences compared to lesions treated with 5%
NaF varnish [8-1]. In the present work, goodness-
The professional application of fluoride varnishes of-fit was lower than 0.8. Further studies using a
to treat early enamel carious lesions is a non- larger sample size to decrease the probability of a
invasive, easy to use and low cost procedure com- beta error are necessary (Fig.6). As a strength of this
pared to conventional mechanical treatments. study, we consider that it contributes to the current
The effectiveness of fluoride varnishes in primary knowledge on the effectiveness of different fluoride
caries prevention has been widely investigated, and varnishes in arresting early occlusal carious lesions
recommendations for its use in primary and clinical in young permanent molars. The results presented
permanent dentitions are supported by conclusive here may prove relevant to decision making in the
scientific evidence [18-13]. Nevertheless, few studies private practice setting as well as in public health
have assessed the effect of fluoride on early carious care programs.
lesions, especially those located in the pit and fissure
system. According to a systematic review [22], six 5. CONCLUSION
clinical trials demonstrated the remineralizing effect
of 5% NaF varnish. The results of a meta analysis The three fluorides studied here showed similar
on four of the six clinical trials showed an overall effectiveness in arresting early carious lesions in
percentage of remineralised enamel caries of 63.6% young permanent teeth one year after application.
(CI 95%: 36.0% - 91.2%). A number of studies have
evaluated early carious lesion remineralization using CONFLICT OF INTEREST
5% NaF varnish, by measuring the reduction in white
spot lesion size 4-8, and determining the percentage The authors declare no conflict of interest.
of remineralized carious lesions, in a range between
81.2% and 71.4% [1-5-3]. The results of the works AUTHOR CONTRIBUTIONS
mentioned above are not comparable with the
results of the present study given the differences GLK: Data analysis, Manuscript drafting, CC and MT: Data
in the localization of the studied lesions, type of gathering, Data interpretation, PAS: Data interpretation, Data
dentition, frequency of application of the varnish, and analysis, AFS: Protocol design, Data interpretation, Manuscript
duration of the studies. The arrest and progression of revision.
active incipient occlusal caries in the first permanent
molars of six-year old children were analyzed [9]. The ACKNOWLEDGEMENTS
results after one year application of 5% NaF varnish
(Duraphat®) showed remineralization in 83.3% of The authors thank to Municipalidad de Tigre and Universidad de
lesions and caries progression in 5.5% of lesions. Buenos Aires (Grant UBACYT 20020120100324BA).
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Graciela Liliana KLEMONSKIS
DDS, PhD, Associated Professor
Chair of Preventive and Community Dentistry
Faculty of Dentistry
University of Buenos Aires
Buenos Aires, Argentina
CV
Graciela Liliana Klemonskis studied dental medicine at the Faculty of Dentistry, University of Buenos Aires, where she obtained
her DDS. After graduation, she pursued her professional training and attended a Master’s Program in Public Health (MSc) at
the same university. That program focused on Oral Health Systems and Services Management. She went on to get her PhD
in Dentistry, specializing in Epidemiology and Public Health. Dr Klemonskis is also a Researcher member at Institute of Public
Health Research, University of Buenos Aires.
Teaching areas: oral epidemiology; community dentistry; strategic planning; oral health systems and services.
Questions
Regarding this study…
1. … the final sample comprised:
qa. 107 tooth surfaces with early occlusal carious lesions;
qb. 52 tooth surfaces with early occlusal carious lesions;
qc. 94 tooth surfaces with early occlusal carious lesions;
qd. 45 tooth surfaces with early occlusal carious lesions.
2. … the proportion of arrested lesions 1-year post treatment was:
qa. less than 50% in the three groups with no statistical difference among groups;
qb. over 50% in the three groups with no statistical difference among groups;
qc. over 40% in the three groups with no statistical difference among groups;
qd. less than 40% in the three groups with no statistical difference among groups.
3. … the proportion of lesions showing progression 1-year post treatment was:
qa. less than 20% in the three groups with no statistical difference among groups;
qb. over 10% in the three groups with no statistical difference among groups;
qc. over 80% in the three groups with no statistical difference among groups;
qd. less than 10% in the three groups with no statistical difference among groups.
4. …subjects within experimental groups were matched according:
qa. caries experience;
qb. caries treatment needs;
qc. presence of restorations ;
qd. age.
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