Impact of Two Remineralizing Agents on White Spot Lesions

Impact of Two Remineralizing Agents on White Spot Lesions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Impact of Two Remineralizing Agents on White Spot Lesions Ebaa Ibrahim Alagha This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-45862/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim of the study: This study evaluated the impact of two remineralizing agents containing casein phosphopeptide amorphous calcium phosphate (CPP ACP), and Tricalcium phosphate (TCP) on white spot lesions. Materials and Methods: A total of ninety freshly extracted upper premolars were divided in three equal groups (30 each). Group A: Control group. Group B: Varnish containing CPP–ACP. Group C: Varnish containing TCP. The teeth were subjected to Diagnodent test after inducing white spot lesions to assess any surface changes present on the teeth. The readings were repeated post demineralization and post-remineralization. Results : Statistically significant difference was present in the mean values between the tested groups. CPP-ACP group recorded higher mean value at demineralization when compared to TCP group. Statistically significant difference (p < 0.0001) was present between the baseline and the demineralization values. CPP-ACP group presented higher remineralization results when compared to TCP group. T-test proved a significant difference between the tested groups. Conclusion : CPP-ACP containing varnish had higher remineralizing effect when compared to TCP containing varnish. Clinical Significance: Recently, the focus of restorative dentistry has been directed toward a conservative approach. Prevention and non-restorative treatment of initial enamel caries is the main concern. Remineralization procedures are the most preferred way of regeneration of lost tooth structure. Dentistry Caries CPP–ACP varnish Diagnodent Remineralization TCP varnish Introduction Dental caries is one of the major dental challenging problems maybe more prominent than other infectious diseases such as hypertension and heart infections. (1) It is easily detectable and reversible at an early stage. Once the incipient lesion proceeds to cavitation, the condition becomes irreversible. That is why it is important to prevent the progression of caries at early stages, instead of developing treatment procedures to treat its advanced stages. (2) White spot lesions are the earliest macroscopic evidence of enamel caries. Early stages of tooth demineralization are reversed by saliva, which contains fluoride, calcium, and phosphate ions, buffering agents, and other substances. (3) After orthodontic treatment, studies proved that white spot lesions can develop within 1 month and it varies from 2%- 96% (4) and fluoride is the most commonly agent used to treat these white spot lesions such as topical fluorides (5) but the major inadequacy of the toothpastes, mouth rinses, and topical applications is their limited ability to remineralize enamel by the low concentration of calcium and phosphate ions available in saliva. (6) New remineralization materials have been launched out, among which the wellknown is the use of fluoride. (7) A few of them are bioactive glass, casein phosphopeptide–amorphous calcium phosphate (CPP–ACP), hydroxyapatite with fluoride. (8) Fluoride varnish is a standard remineralizing agent created to drag out the contact time between fluoride and the tooth surface acting as a moderate discharging store of fluoride. Including calcium phosphate salts, such as TCP to the varnish, may improve the mineralization of dentin. To upgrade the impact of the varnish, calcium and phosphate have been included. (9) Remineralization and anticariogenic mechanism of CPP–ACP includes the joining of nanocomplexes into dental plaque and onto the tooth surface, which in this manner acts as a calcium and phosphate reservoir.Several methods have been used to assess the degree of remineralization, including DIAGNOdent, quantitative light-induced fluorescence (QLF), scanning electron microscopy, polarized light microscope, x-ray spectrophotometer, standard photography, micro-computed tomography and transverse micro-radiography. (10) Diagnodent is a laser device measures fluorescence, early demineralization with good to excellent sensitivity and improves the demonstrative precision of location of non-cavitated carious lesions. (1) This study will use Diagnodent to evaluate the impact of two remineralizing agents containing casein phosphopeptide amorphous calcium phosphate (CPP ACP), and Tricalcium phosphate (TCP) on white spot lesions. Material and methods A total of ninety freshly extracted upper premolars were used in this study which were extracted for orthodontic purposesafter obtaining written informed consent from the patients. Ethics approval was obtained from the Research Ethical Committee, Al-Farabi Private Colleges in Jeddah-KSA (Approval No20-03/6). The sample size calculations were performed using G Power v3.1.3 software (University of Düsseldorf; Düsseldorf, Germany). A power analysis showed that a sample size of 30 specimens per group was found to meet the constraints of α = 0.05 and power = 0.90. Teeth were washed under water and scaled using a sharp hand scaler to remove any plaque, calculus, or soft tissue remnants then stored in normal saline at room temperature (approximate 25 o C) until used. Then, teeth sectioned vertically, mesiodistally into buccal and lingual haves by cutting machine (E96, USA) using a diamond disk (EDENTA Golden S.A.W, Swiss made). The buccal parts of the teeth were dried and painted with two layers of nail varnish uncovering a window of 2 × 2 mm on the center of the buccal surface of the teeth and left to dry. The teeth were divided into three groups according to the material used (30 each). Group A: Control group: Samples in artificial saliva. Group B: Varnish containing CPP–ACP (MI varnish GC, USA). Group B: Varnish containing TCP (3M, ESPE, M Vanish 5% Sodium Fluoride White Varnish with TCP, USA). Diagnodent (Kavo, Biberach, Germany) was used to examine if there are any surface changes on the labial window. Only samples with 3 and 7 values on the digital display were used in this study as Diagnodent score between 3 and 7 indicates normal enamel. (11) The baseline values of all groups were recorded. Samples were immersed in three glass containers with 12 ml of demineralizing solution according to each group for 9 days at room temperature (approximate 25°C) (12) to induce artificial caries like lesion. The demineralizing solution had the following composition: CaCl2 = 2.2 mM, NaH2PO4 = 2.2 mM, Lactic acid = 0.05 M, Fluoride = 0. 2pp, adjusted with 50% NaOH to a pH 4.5. (13) The pH of the demineralizing solution was checked during and after preparation of solution using digital pH meter. The solution was replaced every 3 days. (14) Then the samples washed with deionized water and dried with air syringe. Group (A): Control group teeth were placed in artificial saliva to prevent dehydration. (2) Group (B): Teeth were coated with varnish containing CPP-ACP using microbrush for 4 minutes every 24 hours and placed back in the artificial saliva solution without rinsing for 7 days. Group (C): Teeth were coated with varnish containing TCP in the same way as group (B). The composition of artificial saliva contains: (0.65 g/l potassium chloride, 0.058 g/l magnesium chloride, 0.165 g/l calcium chloride, 0.804 g/l dipotassium hydrogen phosphate, 0.365 g/l potassium dihydrogen phosphate, 2 g/l sodium carboxymethyl cellulose and distilled water) (15) Diagnodentwith probe tip B was used to measure the values. The device was calibrated against a porcelain standard before reading and after testing each 5 teeth. The probe tip B was kept perpendicular to the tooth surface. The values were recorded, tabulated, and statistically analyzed using one-way ANOVA and Tukey's multiple comparison tests. All data were analyzed by SPSS software (SPSS 16.0, Chicago, IL, USA) Results Statistically significant difference was present in the mean values between the tested groups. CPP-ACP group (14.73) recorded higher mean value at demineralization when compared to TCP group (13.87). Statistically significant difference (p < 0.0001) were present between the baseline and the demineralization values. CPP-ACP group (2.67) presented higher remineralization results when compared to TCP group (2.07). T-test proved a significant difference between the tested groups (p =0.019) (Table 1). Table (1): Comparison between Two Varnishes CPP-ACP TCP Total P Value Control (A) 3.60±0.507 3.40±0.737 3.50±0.630 0.394 After Demineralization (B) 14.73±0.884 13.87±0.516 14.30±0.837 0.003* After Remineralization (C) 2.67±0.817 2.07±0.458 2.37±0.718 0.019* p < 0.05—significant Discussion Diagnodent shows higher sensitivity and accuracy in enamel caries detection when compared with other conventional methods (visual and tactile examination and bitewing radiographs) (16) It was developed by Lussi in 2004, a value of 5–25 indicates early lesions, 26–35 indicates early dentin caries, and over 35 indicates deep dentin caries but it is most important disadvantage that it can give false positive results in the presence of plaque and calculus, or soft tissue remnants, therefore the teeth were cleaned properly in this study. (17) Two commercially available remineralizing agents were used: varnish containing CPP–ACP (MI varnish, GC, USA) and varnish containing TCP (3M, ESPE, M Varnish TM 5% Sodium Fluoride White Varnish with TCP, USA). CPP-ACP is a bioactive agent with a base of milk products able to bind calcium and phosphate ions to stabilize calcium phosphate in solution and to increase the level of calcium phosphate in dental plaque (18) It was used for the first time in 2009 to treat white spot lesions (19) and many studies proved it is positive effect in prevention of secondary caries. Karlinsey et al., (20) showed that adding calcium phosphate salts, such as tri-calcium phosphate (TCP), to the varnish may improve the mineralization of bovine dentin, but few studies have addressed the effect of tri-calcium phosphate on teeth. These two varnishes have different mechanism of action, but they both proved enhancement in the remineralization process. Remineralization is defined as the redeposition of lost minerals in enamel, and this term is used as a synonymous of repair or rehardening of enamel. (21) CCP-ACP is a source of the calcium and phosphate that inhibits demineralization and/or enhances remineralization. Prevention of demineralization is possible by the presence of casein which can buffer plaque acid either straightforwardly or through bacterial catabolism. It has the ability to discharge amino acids which accept protons and act as buffers. (8) Newly remineralization and anticariogenic mechanism of CPP–ACP includes the incorporation of nanocomplexes in the dental plaque and on the tooth surface and acts as a calcium and phosphate store, in addition to its high safety level. (22) The synergistic effect of CPP-ACP and fluoride in reducing the white spot lesions is related to the formation of CPP-stabilized amorphous calcium fluoride phosphate which increased the concentration of bioavailable calcium and phosphate particles. (23) Another studies proved that CPP reduce the adherence and functioning ofcariogenic streptococcus bacteria in the oral cavity. (24) In this study, statistically significant difference presented in the mean values between the tested groups. The mean value showed highdemineralization results for CPP-ACP group (14.73) when compared to TCP group (13.87). Statistically significant difference (p < 0.0001) was also presented between the tested groups at the baseline and the demineralization value. Best results in remineralization was observed in CPP-ACP group (2.67) when compared to TCP group (2.07). Significant difference was observed between the tested groups (p =0.019). Kamath et al., (25) in their study on the initial carious lesions evaluated the effect of different remineralizing materials includes tricalcium phosphate TCP, CPP-ACFP and nanohydroxyapatite and all these materials had a remineralization effect. TCP significant remineralizing effect is clarified by the high levels of calcium and phosphorus ions in addition to the presence of fluoride ions in the saliva which is considered as an appropriate remineralization solution which encourage the remineralization of the initial carious lesions. The results agreed with Bajaj et al., (26) who treated initial carious lesions with functional TCP milled with sodium lauryl sulfate. Enamel remineralization of different calcium–phosphate and fluoride delivery systems were assessed with Vyavhare et al., (27) who compared the remineralization potential of fluoride, nano-hydroxyapatite, and CPP-ACP and they stated that tested materials had high remineralization potential of fluoride. Also, Ebrahimi et al., (28) agreed with the results of multiple studies who proved significant reduction of white spot lesions after the use of products containing CPP-ACP or CPP-ACPF. The results of this study agreed with Damyanova et al., (29) who used Clinpro white varnish and TCP and stated that it is effective lessening demineralization within the subsurface layer and in improving the remineralization of surface and subsurface enamel layer. Majithia et al., (30) observed that varnish with CPP ACP with fluoride (MI Varnish) had better results in remineralization when compared to the other materials.Cochrane et al., (31) observed a fast discharge of calcium and inorganic phosphate particles under neutral condition which is reliable with the bioavailable nature of CPP ACP contained within the varnish and that was related to high water solubility of CPP-ACP. Savas et al., (32) recommended the use of CPP ACP containing fluoride varnish (MI Varnish) in the dental clinics as it improves the remineralization of incipient carious lesions after a single application. On the other hand, multiple remineralization researches done by Karabekiroglu et al., (33) and Robertson et al., (34) stated that the efficiency of casein phosphopeptide amorphus calcium phosphate is unreliable in reducing the white spot lesions. This was explained by El zankalouny et al., (15) who stated that the impact of CPP-ACP localizes the amorphous calcium phosphate by CPP onto the tooth surface, which makes a hypersaturation state regarding the tooth mineral. In another study, it was proved that CPP-ACP alone without the presence of fluoride could not prompt the formation of fluorapatite in the deep white spot lesions. (35) However, within the limitation of this study, as Diagnodent is not as precise as a scanning electron microscopy, further clinical trials are recommended to evaluate the effect of these agents and to speed up the repair process of the white spot lesions for better esthetic. Conclusion CPP-ACP containing varnish had higher remineralizing effect when compared to TCP containing varnish. Clinical Significance: Recently, the focus of restorative dentistry has been directed toward a conservative approach. Prevention and non-restorative treatment of initial enamel caries is the main concern. Remineralization procedures are the most preferred way of regeneration of lost tooth structure. Abbreviations TCP: Tricalcium phosphate CPP-ACP: Casein phosphopeptide-amorphous calcium phosphate °C: Degree Celsius or degree centigrade pH: Power of hydrogen SPSS: Statistical Package for the Social Sciences Declarations Ethics approval and consent to participate: Ethics approval was obtained from the Research Ethical Committee, Al-Farabi Private Colleges in Jeddah (Approval No20-03/6) and written informed consent was obtained from the donors. Consent to publish: Not applicable Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Self-funded. This research did not receive any financial support. Authors' contributions: EA designed the study and performed the experiments and collected the data and wrote and revise the manuscript. Acknowledgements: Not Applicable Corresponding Autor: Ebaa Ibrahim Alagha. Assistant Professor of Operative Dentistry, Restorative Department, Faculty of Dentistry, Al-Farabi Private Colleges, Jeddah, KSA. Authors' information: 1. Ebaa Ibrahim Alagha. Department of Restorative Dentistry, Al-Farabi Private Colleges, Faculty of Dentistry, Jeddah, Saudi Arabia. Address: 4438 Abdul Aziz Alqubaysi- Almarwa Jeddah, KSA Phone number: 00966542253510 E-mail address: [email protected] References 1. Yazicioğlu O, Yaman B, Güler A, Koray F. Quantitative Evaluation of the Enamel Caries Which Were Treated with Casein Phosphopeptideamorphous Calcium Fluoride Phosphate. Nig J of Clin Prac 2017;20(6): 686-92. 2. Ragendran R, Kunjusankaran R, Sandhya R, Anilkumar A, Santhosh R, Patil S. Comparative Evaluation of Remineralizing Potential of a Paste Containing Bioactive Glass and a Topical Cream Containing Casein Phosphopeptide-Amorphous Calcium Phosphate: An in Vitro Study. Pesq Bras Odonto e Clinic Int. 2019; 19. 3. Varma V, Hegde K, Bhat S, Sargod S, Rao H. Comparative Evaluation of Remineralization Potential of Two Varnishes Containing CPP–ACP and Tricalcium Phosphate: An In Vitro Study. Int j of clin ped dent. 2019;12(3), 233-6. 4. Dai Z, Liu M, Ma Y, Cao L, Xu H, Zhang K, Bai Y. Effects of Fluoride and Calcium Phosphate Materials on Remineralization of Mild and Severe White Spot Lesions. BioMed res int. 2019;16:1271523. 5. Singh S, Singh1 S, Goyal A, Utreja A, Jena A. Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial. Prog in ortho 2016;17(1):17-25. 6. Babu KG, Subramaniam P and Teleti S. Remineralization potential of varnish containing casein phosphopeptides-amorphous calcium phosphate with fluoride and varnish containing only fluoride: a comparative study. Sau J of Oral Sci. 2018;5(1): 35. 7. Jayarajan J, Janardhanam P, Jayakumar P; Deepika. Efficacy of CPPACP and CPPACPF on enamel remineralization – An in vitro study using scanning electron microscope and DIAGNOdent. Ind J Dent Res. 2011;22(1):7782. 8. Rajan R, Krishnan R, Bhaskaran B, Kumar S. A Polarized light microscopic study to comparatively evaluate four remineralizing agents on enamel viz CPP-ACPF, ReminPro, SHY-NM and colgate strong teeth. Int J of clinic ped dent. 2015;8(1):42-47. 9. Rirattanapong P, Vongsavan K, Saengsirinavin C, Pornmahala T. Effect of fluoride varnishes containing tri-calcium phosphate sources on remineralization of initial primary enamel lesions. Southeast Asi J of Trop Med and Pub Hea. 2014;45(2):499. 10. Tahmasbi S, Mousavi S, Behroozibakhsh M, Badiee M. Prevention of white spot lesions using three remineralizing agents: An in vitro comparative study. J Dent Res Dent Clin Dent Prospects. 2019;13(1):36–42. 11. Patil N, Choudhari S, Kulkarni S, Joshi S. Comparative evaluation of remineralizing potential of three agents on artificially demineralized human enamel: An in vitro study. J Conserv Dent. 2013;16(2):116–120. 12.Tahmasbi S, Adhami M, Valian A, Hamedi R. Effect of Three Different Remineralizing Agents on White Spot Lesions; AnIn Vitro Comparative Study. J Islam Dent Assoc Iran 2016; 28(3):98-103. 13. Yadav J, Desai H, Patel K, Patel N, Iyengar S. A comparative quantitative & qualitative assessment in orthodontic treatment of white spot lesion treated with 3 different commercially available materials-In vitro study. J Clin Exp Dent. 2019;11(9):e776-82. 14.Bahrololoomi Z, Musavi S, Kabudan M. In vitro evaluation of the efficacy of laser fluorescence (DIAGNOdent) to detect demineralization and remineralization of smooth enamel lesions. J Conserv Dent. 2013;16(4):362–366. 15. El-zankalouny S, Abd El Fattah W, El- Shabrawy S. Penetration depth and enamel microhardness of resin infiltrant and traditional techniques for treatment of artificaial enamel lesions. Alex Dent J. 2016; 41:20-5. 16. Goel A, Chawla HS, Gauba K, Goyal A. Comparison of validity of DIAGNOdent with conventional methods for detection of occlusal caries in primary molars using the histological gold standard: An in vivo study. J Indian Soc Pedod Prev Dent. 2009; 27(4):227-34. 17. Lussi A, Megert B, Longbottom C, Reich E, Francescut P. Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. European Journal of Oral Sciences. 2001;109(1):14-19. 18. Reema S, Lahiri P, Roy S. Review of casein phosphopeptides-amorphous calcium phosphate. The Chinese Journal of Dental Research. 2014;17(1):7-14. 19. Bailey D, Adams G, Tsao C, Hyslop A, Escobar K, Manton DJ, Reynolds E, Morgan M. Regression of post-orthodontic lesions by a remineralizing cream. Journal of Dental Research. 2009;88(12):1148-115. 20. Karlinsey R, Mackey A, Stookey G, Pfarrer A. In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent 2009;22(3):180-4. 21. Cury J, Tenuta L. Enamel remineralization: controlling the caries disease or treating early caries lesions? Braz Oral Res 2009;23(1):23-30. 22. Ma X, Lin X, Zhong T, Xie F. Evaluation of the efficacy of casein phosphopeptide-amorphous calcium phosphate on remineralization of white spot lesions in vitro and clinical research: a systematic review and meta-analysis. BMC Oral Health. 2019;30;19(1):295 23. Cross K, Huq N, Stanton D, Sum M, Reynolds E. NMR studies of a novel calcium, phosphate and fluoride delivery vehicle alphs (S1)-casein (59-79) by stabilized amorphous calcium fluoride phosphate nanocomplexes. Biomat. 2004;25(20):5061–9. 24. Temel S and Kaya B. Diagnosis, Prevention and Treatment of White Spot Lesions Related to Orthodontics.Int J Oral Dent Health 2019;5:(2):1-7. 25. Kamath P, Nayak R, Kamath S, Pai D. A comparative evaluation of the remineralization potential of three commercially available remineralizing agents on white spot lesions in primary teeth: An in vitro study. J of Ind Soc of Pedo and Prev Dent 2017;35(3):229-37. 26. Bajaj A, Poornima P, Praveen S, Nagaveni N, Roopa K, Neena I, Bharath K. Comparison of CPP-ACP, Tri-Calcium Phosphate and Hydroxyapatite on Remineralization of Artificial Caries Like Lesions on Primary Enamel -An in vitro Study. J of Clin Ped Dent; 2016;40(5):404-9. 27. Vyavhare S, Sharma D, Kulkarni V. Effect of three different pastes on remineralization of initial enamel lesion: an in vitro study. J Clin Ped Dent. 2015; 39(2):149-60. 28. Ebrahimi M, Mehrabkhani M, Ahrari F, Parisay I, Jahantigh M. The effects of three remineralizing agents on regression of white spot lesions in children: A two-week, single-blind, randomized clinical trial. J Clin Exp Dent. 2017;9(5):641-8. 29. Damyanova D. In Vitro Study of the Effects of Fluoride-Releasing Dental Materials on Re-Mineralization of Deciduous Teeth. IOSR J Dent Med Sci 2016;15(7):98–101. 30. Majithia U, Venkataraghavan K, Choudhary P, Trivedi K, Shah S, Virda M. Comparative evaluation of application of different fluoride varnishes on artificial early enamel lesion: An in vitro study. Indian J Dent Res 2016;27(5):521-7. 31. Cochrane N, Shen P, Yuan Y, Reynolds E. Ion release from calcium and fluoride containing dental varnishes. Aust Dent J 2014;59(1):100-5. 32. Savas S, Kavrìk F, Kucukyìlmaz E. Evaluation of the remineralization capacity of CPP ACP containing fluoride varnish by different quantitative methods. J Appl Oral Sci 2016; 24(3):198-203. 33. Karabekiroğlu S, Ünlü N, Küçükyilmaz E, Şener S, Botsali MS, Malkoç S. Treatment of post-orthodontic white spot lesions with CPP-ACP paste: A three year follow up study. Dent Mat J. 2017;36(6):791–7. 34. Robertson M, Kau C, English J, Lee R, Powers J, Nguyen J. MI Paste Plus to prevent demineralization in orthodontic patients: a prospective randomized controlled trial. Am J Orthop Dentofacial Orthop. 2011;140(5):660–8. 35. Reynolds E, Cai F, Cochrane N, Shen P, Walker G, Morgan M. Fluoride, and casein phosphopeptide- amorphous calcium phosphate. J Dent Res. 2008;87(4)344-8. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-45862","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":1141642,"identity":"d2e87bc0-0b37-43ee-b74c-054dd2dbe028","order_by":0,"name":"Ebaa Ibrahim Alagha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDCCAwxsQFKCgY8BxKgAspmZG4jTwgbWcgakhZEoLQwQLYxtICYBLXy3Dx978KPGQp6N/fi1Bz/n1UbztwO1/KjYhlOL5Lm0dMOeYxKGbTw55Ya9247nzjjM2MDYc+Y2Ti0GZ3jMJHjYJIBOykmT4N12LLcBqIWZsQ2fFv5vkn/+Sdi38b9Jk/w751jufMJaeNikedskEtsk0o9J8zbU5G4gpEXyDJu5sWyfRHKbxBs2aZljB3I3ArUcxOcXvjPMzx6++VZn28+f/kzyTU1d7rzzhw8++FGBWwsS4DEAEofBzAPEqAcC9gdAoo5IxaNgFIyCUTCSAAA1q1p08/aMLgAAAABJRU5ErkJggg==","orcid":"","institution":"Assistant Professor of Operative Dentistry,Department of Restorative Dentistry, Faculty of Dentistry, Al-Farabi Private College, Jeddah, KSA.","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ebaa","middleName":"Ibrahim","lastName":"Alagha","suffix":""}],"badges":[],"createdAt":"2020-07-20 10:14:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-45862/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-45862/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13568107,"identity":"c75fc080-e090-49cc-807a-d022077ed8dc","added_by":"auto","created_at":"2021-09-17 03:35:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":261227,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-45862/v1/7068fb7c-91b0-4821-9f94-91a129763b5a.pdf"}],"financialInterests":"","formattedTitle":"Impact of Two Remineralizing Agents on White Spot Lesions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDental caries is one of the major dental challenging problems maybe more prominent than other infectious diseases such as hypertension and heart infections. \u003csup\u003e(1)\u003c/sup\u003e It is easily detectable and reversible at an early stage. Once the incipient lesion proceeds to cavitation, the condition becomes irreversible. That is why it is important to prevent the progression of caries at early stages, instead of developing treatment procedures to treat its advanced stages.\u003csup\u003e (2)\u003c/sup\u003e White spot lesions are the earliest macroscopic evidence of enamel caries. Early stages of tooth demineralization are reversed by saliva, which contains fluoride, calcium, and phosphate ions, buffering agents, and other substances.\u003csup\u003e (3)\u003c/sup\u003e After orthodontic treatment, studies proved that white spot lesions can develop within 1 month and it varies from 2%- 96% \u003csup\u003e(4)\u003c/sup\u003e and fluoride is the most commonly agent used to treat these white spot lesions such as topical fluorides \u003csup\u003e(5)\u003c/sup\u003e but the major inadequacy of the toothpastes, mouth rinses, and topical applications is their limited ability to remineralize enamel by the low concentration of calcium and phosphate ions available in saliva.\u003csup\u003e (6) \u003c/sup\u003eNew remineralization materials have been launched out, among which the wellknown is the use of fluoride.\u003csup\u003e (7)\u003c/sup\u003e A few of them are bioactive glass, casein phosphopeptide\u0026ndash;amorphous calcium phosphate (CPP\u0026ndash;ACP), hydroxyapatite with fluoride. \u003csup\u003e(8) \u003c/sup\u003eFluoride varnish is a standard remineralizing agent created to drag out the contact time between fluoride and the tooth surface acting as a moderate discharging store of fluoride. Including calcium phosphate salts, such as TCP to the varnish, may improve the mineralization of dentin. To upgrade the impact of the varnish, calcium and phosphate have been included.\u003csup\u003e(9) \u003c/sup\u003eRemineralization and anticariogenic mechanism of CPP\u0026ndash;ACP includes the joining of nanocomplexes into dental plaque and onto the tooth surface, which in this manner acts as a calcium and phosphate reservoir.Several methods have been used to assess the degree of remineralization, including DIAGNOdent, quantitative light-induced fluorescence (QLF), scanning electron microscopy, polarized light microscope, x-ray spectrophotometer, standard photography, micro-computed tomography and transverse micro-radiography. \u003csup\u003e(10)\u003c/sup\u003eDiagnodent is a laser device measures fluorescence, early demineralization with good to excellent sensitivity and improves the demonstrative precision of location of non-cavitated carious lesions.\u003csup\u003e(1)\u003c/sup\u003e This study will use Diagnodent to evaluate the impact of two remineralizing agents containing casein phosphopeptide amorphous calcium phosphate (CPP ACP), and Tricalcium phosphate (TCP) on white spot lesions.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eA total of ninety freshly extracted upper premolars were used in this study which were extracted for orthodontic purposesafter obtaining written informed consent from the patients. Ethics approval was obtained from the Research Ethical Committee, Al-Farabi Private Colleges in Jeddah-KSA (Approval No20-03/6). The sample size calculations were performed using G Power v3.1.3 software (University of D\u0026uuml;sseldorf; D\u0026uuml;sseldorf, Germany). A power analysis showed that a sample size of 30 specimens per group was found to meet the constraints of \u0026alpha; = 0.05 and power = 0.90. Teeth were washed under water and scaled using a sharp hand scaler to remove any plaque, calculus, or soft tissue remnants then stored in normal saline at room temperature (approximate 25\u003csup\u003eo\u003c/sup\u003eC) until used. Then, teeth sectioned vertically, mesiodistally into buccal and lingual haves by cutting machine (E96, USA) using a diamond disk (EDENTA Golden S.A.W, Swiss made). The buccal parts of the teeth were dried and painted with two layers of nail varnish uncovering a window of 2 \u0026times; 2 mm on the center of the buccal surface of the teeth and left to dry. The teeth were divided into three groups according to the material used (30 each). Group A: Control group: Samples in artificial saliva. Group B: Varnish containing CPP\u0026ndash;ACP (MI varnish GC, USA). Group B: Varnish containing TCP (3M, ESPE, M Vanish 5% Sodium Fluoride White Varnish with TCP, USA). Diagnodent (Kavo, Biberach, Germany) was used to examine if there are any surface changes on the labial window. Only samples with 3 and 7 values on the digital display were used in this study as Diagnodent score between 3 and 7 indicates normal enamel. \u003csup\u003e(11) \u003c/sup\u003eThe baseline values of all groups were recorded. Samples were immersed in three glass containers with 12 ml of demineralizing solution according to each group for 9 days at room temperature (approximate 25\u0026deg;C) \u003csup\u003e(12)\u003c/sup\u003e to induce artificial caries like lesion. The demineralizing solution had the following composition: CaCl2 = 2.2 mM, NaH2PO4 = 2.2 mM, Lactic acid = 0.05 M, Fluoride = 0. 2pp, adjusted with 50% NaOH to a pH 4.5. \u003csup\u003e(13)\u003c/sup\u003e The pH of the demineralizing solution was checked during and after preparation of solution using digital pH meter. The solution was replaced every 3 days. \u003csup\u003e(14) \u003c/sup\u003eThen the samples washed with deionized water and dried with air syringe. Group (A): Control group teeth were placed in artificial saliva to prevent dehydration.\u003csup\u003e(2)\u003c/sup\u003e Group (B): Teeth were coated with varnish containing CPP-ACP using microbrush for 4 minutes every 24 hours and placed back in the artificial saliva solution without rinsing for 7 days. Group (C): Teeth were coated with varnish containing TCP in the same way as group (B). The composition of artificial saliva contains: (0.65 g/l potassium chloride, 0.058 g/l magnesium chloride, 0.165 g/l calcium chloride, 0.804 g/l dipotassium hydrogen phosphate, 0.365 g/l potassium dihydrogen phosphate, 2 g/l sodium carboxymethyl cellulose and distilled water) \u003csup\u003e(15)\u003c/sup\u003eDiagnodentwith probe tip B was used to measure the values. The device was calibrated against a porcelain standard before reading and after testing each 5 teeth. The probe tip B was kept perpendicular to the tooth surface. The values were recorded, tabulated, and statistically analyzed using one-way ANOVA and Tukey's multiple comparison tests. All data were analyzed by SPSS software (SPSS 16.0, Chicago, IL, USA)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStatistically significant difference was present in the mean values between the tested groups. CPP-ACP group (14.73) recorded higher mean value at demineralization when compared to TCP group (13.87). Statistically significant difference (p \u0026lt; 0.0001) were present between the baseline and the demineralization values. CPP-ACP group (2.67) presented higher remineralization results when compared to TCP group (2.07). T-test proved a significant difference between the tested groups (p =0.019) (Table 1).\u003c/p\u003e\n\n\n\u003cp\u003e\u003cstrong\u003eTable (1):\u003c/strong\u003e Comparison between Two Varnishes\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eCPP-ACP \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u003cstrong\u003eTCP \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eControl (A)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e3.60\u0026plusmn;0.507\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e3.40\u0026plusmn;0.737\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e3.50\u0026plusmn;0.630\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.394\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eAfter Demineralization (B)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e14.73\u0026plusmn;0.884\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e13.87\u0026plusmn;0.516\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e14.30\u0026plusmn;0.837\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.003*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eAfter Remineralization (C)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e2.67\u0026plusmn;0.817\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e2.07\u0026plusmn;0.458\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2.37\u0026plusmn;0.718\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.019*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep \u0026lt; 0.05\u0026mdash;significant\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDiagnodent shows higher sensitivity and accuracy in enamel caries detection when compared with other conventional methods (visual and tactile examination and bitewing radiographs)\u003csup\u003e(16)\u003c/sup\u003e It was developed by Lussi in 2004, a value of 5\u0026ndash;25 indicates early lesions, 26\u0026ndash;35 indicates early dentin caries, and over 35 indicates deep dentin caries but it is most important disadvantage that it can give false positive results in the presence of plaque and calculus, or soft tissue remnants, therefore the teeth were cleaned properly in this study. \u003csup\u003e(17)\u003c/sup\u003e Two commercially available remineralizing agents were used: varnish containing CPP\u0026ndash;ACP (MI varnish, GC, USA) and varnish containing TCP (3M, ESPE, M Varnish TM 5% Sodium Fluoride White Varnish with TCP, USA). CPP-ACP is a bioactive agent with a base of milk products able to bind calcium and phosphate ions to stabilize calcium phosphate in solution and to increase the level of calcium phosphate in dental plaque \u003csup\u003e(18)\u003c/sup\u003e It was used for the first time in 2009 to treat white spot lesions \u003csup\u003e(19)\u003c/sup\u003eand many studies proved it is positive effect in prevention of secondary caries. Karlinsey et al., \u003csup\u003e(20)\u003c/sup\u003e showed that adding calcium phosphate salts, such as tri-calcium phosphate (TCP), to the varnish may improve the mineralization of bovine dentin, but few studies have addressed the effect of tri-calcium phosphate on teeth. These two varnishes have different mechanism of action, but they both proved enhancement in the remineralization process. Remineralization is defined as the redeposition of lost minerals in enamel, and this term is used as a synonymous of repair or rehardening of enamel. \u003csup\u003e(21)\u003c/sup\u003e CCP-ACP is a source of the calcium and phosphate that inhibits demineralization and/or enhances remineralization. Prevention of demineralization is possible by the presence of casein which can buffer plaque acid either straightforwardly or through bacterial catabolism. It has the ability to discharge amino acids which accept protons and act as buffers.\u003csup\u003e(8)\u003c/sup\u003e Newly remineralization and anticariogenic mechanism of CPP\u0026ndash;ACP includes the incorporation of nanocomplexes in the dental plaque and on the tooth surface and acts as a calcium and phosphate store, in addition to its high safety level. \u003csup\u003e(22) \u003c/sup\u003eThe synergistic effect of CPP-ACP and fluoride in reducing the white spot lesions is related to the formation of CPP-stabilized amorphous calcium fluoride phosphate which increased the concentration of bioavailable calcium and phosphate particles.\u003csup\u003e(23) \u003c/sup\u003eAnother studies proved that CPP reduce the adherence and functioning ofcariogenic streptococcus bacteria in the oral cavity. \u003csup\u003e(24) \u003c/sup\u003eIn this study, statistically significant difference presented in the mean values between the tested groups. The mean value showed highdemineralization results for CPP-ACP group (14.73) when compared to TCP group (13.87). Statistically significant difference (p \u0026lt; 0.0001) was also presented between the tested groups at the baseline and the demineralization value. Best results in remineralization was observed in CPP-ACP group (2.67) when compared to TCP group (2.07). Significant difference was observed between the tested groups (p =0.019). Kamath et al.,\u003csup\u003e (25) \u003c/sup\u003ein their study on the initial carious lesions evaluated the effect of different remineralizing materials includes tricalcium phosphate TCP, CPP-ACFP and nanohydroxyapatite and all these materials had a remineralization effect. TCP significant remineralizing effect is clarified by the high levels of calcium and phosphorus ions in addition to the presence of fluoride ions in the saliva which is considered as an appropriate remineralization solution which encourage the remineralization of the initial carious lesions. The results agreed with Bajaj et al., \u003csup\u003e(26)\u003c/sup\u003e who treated initial carious lesions with functional TCP milled with sodium lauryl sulfate. Enamel remineralization of different calcium\u0026ndash;phosphate and fluoride delivery systems were assessed with Vyavhare et al.,\u003csup\u003e (27) \u003c/sup\u003ewho compared the remineralization potential of fluoride, nano-hydroxyapatite, and CPP-ACP and they stated that tested materials had high remineralization potential of fluoride. Also, Ebrahimi et al.,\u003csup\u003e (28) \u003c/sup\u003eagreed with the results of multiple studies who proved significant reduction of white spot lesions after the use of products containing CPP-ACP or CPP-ACPF. The results of this study agreed with Damyanova et al., \u003csup\u003e(29)\u003c/sup\u003e who used Clinpro white varnish and TCP and stated that it is effective lessening demineralization within the subsurface layer and in improving the remineralization of surface and subsurface enamel layer. Majithia et al., \u003csup\u003e(30)\u003c/sup\u003e observed that varnish with CPP\u001eACP with fluoride (MI Varnish) had better results in remineralization when compared to the other materials.Cochrane et al., \u003csup\u003e(31)\u003c/sup\u003e observed a fast discharge of calcium and inorganic phosphate particles under neutral condition which is reliable with the bioavailable nature of CPP\u001eACP contained within the varnish and that was related to high water solubility of CPP-ACP. Savas et al., \u003csup\u003e(32)\u003c/sup\u003e recommended the use of CPP ACP containing fluoride varnish (MI Varnish) in the dental clinics as it improves the remineralization of incipient carious lesions after a single application. On the other hand, multiple remineralization researches done by Karabekiroglu et al., \u003csup\u003e(33)\u003c/sup\u003e and Robertson et al., \u003csup\u003e(34)\u003c/sup\u003e stated that the efficiency of casein phosphopeptide amorphus calcium phosphate is unreliable in reducing the white spot lesions. This was explained by El zankalouny et al., \u003csup\u003e(15) \u003c/sup\u003ewho stated that the impact of CPP-ACP localizes the amorphous calcium phosphate by CPP onto the tooth surface, which makes a hypersaturation state regarding the tooth mineral. In another study, it was proved that CPP-ACP alone without the presence of fluoride could not prompt the formation of fluorapatite in the deep white spot lesions. \u003csup\u003e(35) \u003c/sup\u003eHowever, within the limitation of this study, as Diagnodent is not as precise as a scanning electron microscopy, further clinical trials are recommended to evaluate the effect of these agents and to speed up the repair process of the white spot lesions for better esthetic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCPP-ACP containing varnish had higher remineralizing effect when compared to TCP containing varnish.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eClinical Significance:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eRecently, the focus of restorative dentistry has been directed toward a conservative approach. Prevention and non-restorative treatment of initial enamel caries is the main concern. Remineralization procedures are the most preferred way of regeneration of lost tooth structure.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTCP: Tricalcium phosphate\u003c/p\u003e\n\u003cp\u003eCPP-ACP: Casein phosphopeptide-amorphous calcium phosphate\u003c/p\u003e\n\u003cp\u003e\u0026deg;C: Degree Celsius or degree centigrade\u003c/p\u003e\n\u003cp\u003epH: Power of hydrogen\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for the Social Sciences\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the Research Ethical Committee, Al-Farabi Private Colleges in Jeddah (Approval No20-03/6) and written informed consent was obtained from the donors.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSelf-funded. This research did not receive any financial support.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEA designed the study and performed the experiments and collected the data and wrote and revise the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eCorresponding Autor:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEbaa Ibrahim Alagha.\u003c/p\u003e\n\u003cp\u003eAssistant Professor of Operative Dentistry, Restorative Department, Faculty of Dentistry, Al-Farabi Private Colleges, Jeddah, KSA.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eAuthors' information:\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Ebaa Ibrahim Alagha. \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Restorative Dentistry, Al-Farabi Private Colleges, Faculty of Dentistry, Jeddah, Saudi Arabia.\u003c/p\u003e\n\u003cp\u003eAddress: 4438 Abdul Aziz Alqubaysi- Almarwa Jeddah, KSA\u003c/p\u003e\n\u003cp\u003ePhone number: 00966542253510\u003c/p\u003e\n\u003cp\u003eE-mail address: \u003ca href=\"mailto:[email protected]\"\u003e\u003cu\[email protected]\u003c/u\u003e\u003c/a\u003e\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1. Yazicioğlu O, Yaman B, G\u0026uuml;ler A, Koray F. Quantitative Evaluation of the Enamel Caries Which Were Treated with Casein Phosphopeptideamorphous Calcium Fluoride Phosphate. Nig J of Clin Prac 2017;20(6): 686-92.\u003c/p\u003e\n\u003cp\u003e2. Ragendran R, Kunjusankaran R, Sandhya R, Anilkumar A, Santhosh R, Patil S. Comparative Evaluation of Remineralizing Potential of a Paste Containing Bioactive Glass and a Topical Cream Containing Casein Phosphopeptide-Amorphous Calcium Phosphate: An in Vitro Study. Pesq Bras Odonto e Clinic Int. 2019; 19.\u003c/p\u003e\n\u003cp\u003e3. Varma V, Hegde K, Bhat S, Sargod S, Rao H. Comparative Evaluation of Remineralization Potential of Two Varnishes Containing CPP\u0026ndash;ACP and Tricalcium Phosphate: An In Vitro Study. Int j of clin ped dent. 2019;12(3), 233-6.\u003c/p\u003e\n\u003cp\u003e4. Dai Z, Liu M, Ma Y, Cao L, Xu H, Zhang K, Bai Y. Effects of Fluoride and Calcium Phosphate Materials on Remineralization of Mild and Severe White Spot Lesions. BioMed res int. 2019;16:1271523.\u003c/p\u003e\n\u003cp\u003e5. Singh S, Singh1 S, Goyal A, Utreja A, Jena A. Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial. Prog in ortho 2016;17(1):17-25.\u003c/p\u003e\n\u003cp\u003e6. Babu KG, Subramaniam P and Teleti S. Remineralization potential of varnish containing casein phosphopeptides-amorphous calcium phosphate with fluoride and varnish containing only fluoride: a comparative study. Sau J of Oral Sci. 2018;5(1): 35.\u003c/p\u003e\n\u003cp\u003e7. Jayarajan J, Janardhanam P, Jayakumar P; Deepika. Efficacy of CPPACP and CPPACPF on enamel remineralization \u0026ndash; An in vitro study using scanning electron microscope and DIAGNOdent. Ind J Dent Res. 2011;22(1):7782.\u003c/p\u003e\n\u003cp\u003e8. Rajan R, Krishnan R, Bhaskaran B, Kumar S. A Polarized light microscopic study to comparatively evaluate four remineralizing agents on enamel viz CPP-ACPF, ReminPro, SHY-NM and colgate strong teeth. Int J of clinic ped dent. 2015;8(1):42-47.\u003c/p\u003e\n\u003cp\u003e9. Rirattanapong P, Vongsavan K, Saengsirinavin C, Pornmahala T. Effect of fluoride varnishes containing tri-calcium phosphate sources on remineralization of initial primary enamel lesions. Southeast Asi J of Trop Med and Pub Hea. 2014;45(2):499.\u003c/p\u003e\n\u003cp\u003e10. Tahmasbi S, Mousavi S, Behroozibakhsh M, Badiee M. Prevention of white spot lesions using three remineralizing agents: An in vitro comparative study. J Dent Res Dent Clin Dent Prospects. 2019;13(1):36\u0026ndash;42.\u003c/p\u003e\n\u003cp\u003e11. Patil N, Choudhari S, Kulkarni S, Joshi S. Comparative evaluation of remineralizing potential of three agents on artificially demineralized human enamel: An in vitro study. J Conserv Dent. 2013;16(2):116\u0026ndash;120.\u003c/p\u003e\n\u003cp\u003e12.Tahmasbi S, Adhami M, Valian A, Hamedi R. Effect of Three Different Remineralizing Agents on White Spot Lesions; AnIn Vitro Comparative Study. J Islam Dent Assoc Iran 2016; 28(3):98-103.\u003c/p\u003e\n\u003cp\u003e13. Yadav J, Desai H, Patel K, Patel N, Iyengar S. A comparative quantitative \u0026amp; qualitative assessment in orthodontic treatment of white spot lesion treated with 3 different commercially available materials-In vitro study. J Clin Exp Dent. 2019;11(9):e776-82.\u003c/p\u003e\n\u003cp\u003e14.Bahrololoomi Z, Musavi S, Kabudan M. In vitro evaluation of the efficacy of laser fluorescence (DIAGNOdent) to detect demineralization and remineralization of smooth enamel lesions. J Conserv Dent. 2013;16(4):362\u0026ndash;366.\u003c/p\u003e\n\u003cp\u003e15. El-zankalouny S, Abd El Fattah W, El- Shabrawy S. Penetration depth and enamel microhardness of resin infiltrant and traditional techniques for treatment of artificaial enamel lesions. Alex Dent J. 2016; 41:20-5.\u003c/p\u003e\n\u003cp\u003e16. Goel A, Chawla HS, Gauba K, Goyal A. Comparison of validity of DIAGNOdent with conventional methods for detection of occlusal caries in primary molars using the histological gold standard: An in vivo study. J Indian Soc Pedod Prev Dent. 2009; 27(4):227-34.\u003c/p\u003e\n\u003cp\u003e17. Lussi A, Megert B, Longbottom C, Reich E, Francescut P. Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. European Journal of Oral Sciences. 2001;109(1):14-19.\u003c/p\u003e\n\u003cp\u003e18. Reema S, Lahiri P, Roy S. Review of casein phosphopeptides-amorphous calcium phosphate. The Chinese Journal of Dental Research. 2014;17(1):7-14.\u003c/p\u003e\n\u003cp\u003e19. Bailey D, Adams G, Tsao C, Hyslop A, Escobar K, Manton DJ, Reynolds E, Morgan M. Regression of post-orthodontic lesions by a remineralizing cream. Journal of Dental Research. 2009;88(12):1148-115.\u003c/p\u003e\n\u003cp\u003e20. Karlinsey R, Mackey A, Stookey G, Pfarrer A. In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent 2009;22(3):180-4.\u003c/p\u003e\n\u003cp\u003e21. Cury J, Tenuta L. 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Karabekiroğlu S, \u0026Uuml;nl\u0026uuml; N, K\u0026uuml;\u0026ccedil;\u0026uuml;kyilmaz E, Şener S, Botsali MS, Malko\u0026ccedil; S. Treatment of post-orthodontic white spot lesions with CPP-ACP paste: A three year follow up study. Dent Mat J. 2017;36(6):791\u0026ndash;7.\u003c/p\u003e\n\u003cp\u003e34. Robertson M, Kau C, English J, Lee R, Powers J, Nguyen J. MI Paste Plus to prevent demineralization in orthodontic patients: a prospective randomized controlled trial. Am J Orthop Dentofacial Orthop. 2011;140(5):660\u0026ndash;8.\u003c/p\u003e\n\u003cp\u003e35. Reynolds E, Cai F, Cochrane N, Shen P, Walker G, Morgan M. Fluoride, and casein phosphopeptide- amorphous calcium phosphate. J Dent Res. 2008;87(4)344-8.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Caries, CPP–ACP varnish, Diagnodent, Remineralization, TCP varnish","lastPublishedDoi":"10.21203/rs.3.rs-45862/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-45862/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAim of the study:\u003c/u\u003e\u003c/strong\u003e This study evaluated the impact of two remineralizing agents containing casein phosphopeptide\u001eamorphous calcium phosphate (CPP\u001eACP), and Tricalcium phosphate (TCP) on white spot lesions. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMaterials and Methods:\u003c/u\u003e\u003c/strong\u003e A total of ninety freshly extracted upper premolars were divided in three equal groups (30 each). Group A: Control group. Group B: Varnish containing CPP–ACP. Group C: Varnish containing TCP. The teeth were subjected to Diagnodent test after inducing white spot lesions to assess any surface changes present on the teeth. The readings were repeated post demineralization and post-remineralization. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eResults\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e Statistically significant difference was present in the mean values between the tested groups. CPP-ACP group recorded higher mean value at demineralization when compared to TCP group. Statistically significant difference (p \u0026lt; 0.0001) was present between the baseline and the demineralization values. CPP-ACP group presented higher remineralization results when compared to TCP group. T-test proved a significant difference between the tested groups. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConclusion\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e:\u003c/u\u003e CPP-ACP containing varnish had higher remineralizing effect when compared to TCP containing varnish. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cu\u003eClinical Significance: \u003c/u\u003e\u003c/strong\u003eRecently, the focus of restorative dentistry has been directed toward a conservative approach. Prevention and non-restorative treatment of initial enamel caries is the main concern. Remineralization procedures are the most preferred way of regeneration of lost tooth\u003cstrong\u003e\u003cu\u003e \u003c/u\u003e\u003c/strong\u003estructure.\u003c/p\u003e","manuscriptTitle":"Impact of Two Remineralizing Agents on White Spot Lesions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-08-04 16:16:26","doi":"10.21203/rs.3.rs-45862/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80910a6f-e2e8-40fb-92bf-0a349162ed34","owner":[],"postedDate":"August 4th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":240400,"name":"Dentistry"}],"tags":[],"updatedAt":"2020-08-14T18:04:19+00:00","versionOfRecord":[],"versionCreatedAt":"2020-08-04 16:16:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-45862","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-45862","identity":"rs-45862","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}