/home/opencode/cpanel/stomaeduj_hacked/uploads/art-2-KLemonskis-1-2020.pdf 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. www.stomaeduj.com 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 www.stomaeduj.com 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. www.stomaeduj.com 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). REFERENCES 1. Almeida MQ, Costa OXI, Ferreira JMS, et al. 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[CrossRef ] [PubMed] Google Scholar 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. Stoma Edu J. 2020;7(1): 15-19 pISSN 2360-2406; eISSN 2502-0285 19