Remineralization Agents for the Treatment of White Spot Lesions

White Spot Lesion of Tooth Clinical Trial

Official title:

A Randomized Controlled Trial on the Remineralization Agents Used for the Treatment of White Spot Lesions

Clinical Trial Details — Status: Terminated

Administrative data

• NCT number: NCT04827966
• Other study ID #: MOHWS
• Status: Terminated
• Phase: N/A
• Start date: September 1, 2022
• Est. completion date: December 1, 2022

Study information

• Verified date: November 2023
• Source: Ministry of Health, Bahrain
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Clinically, formation of white spots can occur as early as 4 weeks into orthodontic treatment and very common in high caries risk individuals. When left untreated, the calcium loss continues, the enamel breaks down entirely, and a cavity appears. These can cause caries thereby leading to poor esthetics and patient dissatisfaction. The labio-gingival area of the lateral incisors is the most common site for WSL and the maxillary posterior segments are the least common site, with males affected more in comparison with females.Hence inducing remineralization of existing lesions is the key treatment to prevent cavitation.

Description:

White spot lesion (WSL) is the earliest sign of demineralization of the enamel and a common problem caused because of plaque accumulation and poor oral hygiene. These WSLs are of great concern in young patients, considering that esthetics is the prime reason for young patients to seek dental treatment. The appearance of these areas of demineralization should be prevented and appropriate strategies must be undertaken in remineralizing these lesions. A recent meta-analysis on the incidence and prevalence of these lesions in orthodontic patients included 14 studies indicated that the incidence of new carious lesions formed during orthodontic treatment in patients was 45.8% and the prevalence of lesions in patients undergoing orthodontic treatment was 68.4%. This is considerably high and needs urgent attention.

Enamel decalcification can occur as a result of orthodontic bracket or any other foreign body attached onto the tooth surface, and provoked by poor oral hygiene. It is an incipient caries in the subsurface beneath an intact enamel outer surface. It is characterized by chalky white appearance (WSLs) mostly around the brackets, and have different refractive index than intact enamel surface.If the WSL's are left untreated it can progress to break down the enamel surface and develop into advance stages of carious lesion that indicate esthetic restorations or in more advance cases a prosthodontic intervention.

Research has shown good evidence on non-invasive treatment of WSLs such as establishing good oral hygiene and the use of fluoride and non-fluoride remineralizing agents. Fluoride containing agents are available as high-fluoride toothpaste, fluoride mouthwash, gels and varnish. Recently, other non-fluoride materials and techniques such as casein phosphopeptide -amorphous calcium phosphate (CPP-ACP) has shown promising results.

Clinpro® is 5% sodium fluoride varnish and is indicated to be used for hypersensitive as well as for demineralized teeth. It flows smoothly on moist teeth and binds firmly to their surfaces. 1ml of Clinpro® contain 50 mg of sodium fluoride. Fluoride varnish placed around orthodontic brackets during treatment has been shown to reduce the incidence and prevalence of WSL. Tooth Mousse® contains Casein phosphopeptide-Amorphous calcium phosphate (CPP - ACP) is product from the milk casein. This delivers the necessary Calcium and Phosphate ions to the tooth, which will reduce the risk of caries and white spot by enhancing tooth remineralization. MI Paste® which is Casein phosphopeptide-Amorphous calcium phosphate fluoride (CPP-ACPF) additional contains fluoride in addition to CPP-ACP. The level of fluoride is 900ppm which approximates that in adult strength toothpastes. When CPP-ACPF is applied in the oral environment, it will bind to biofilms, plaque, bacteria, hydroxyapatite and soft tissue localizing bio-available calcium, phosphate and fluoride. Recent studies have investigated the remineralization potential of CPP-ACP combined with fluoride and have found a synergistic effect when these are administered together, which is the composition in MI paste. Patients who have previous history of milk protein allergy or lactose intolerance are not suitable to use MI paste or tooth mousse. This is based on the manufacturer's instructions. However, there is no published data on these allergic reactions to CPP-ACP products so far. 1.23% APF (Acidulated phosphate fluoride) gel is routinely used professional based fluoride for patients with high caries risk. Listerine® Sodium fluoride (0.2%) mouth rinses are effective in reducing caries and inhibit carbohydrate utilization of oral microorganisms by blocking enzymes involved in the bacterial glycolytic pathway studies have shown sodium fluoride mouth rinse to be effective in reducing S. mutans counts.

Considering the variety of agents that are available the aim of this clinical study is to compare Clinpro® 5% sodium fluoride plus tri calcium phosphate varnish, Tooth mousse® CPP-ACP without fluoride, MI Paste® CPP-ACP with fluoride and 0.2% sodium fluoride mouthwash in remineralization of white spot lesions.

Recruitment information / eligibility

• Status: Terminated
• Enrollment: 12
• Est. completion date: December 1, 2022
• Est. primary completion date: December 1, 2022
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Adult patients attending the dental clinic for treatment of white spot lesions on their teeth

• using fluoride toothpaste once or twice daily for brushing

• does not use any other form of fluoride

• history of recent fixed orthodontic treatment

• presenting with white spot lesions on minimum of three anterior or posterior teeth on the labial surfaces

• provide written informed consent

Exclusion Criteria:

• Patients who do not fit into the above mentioned inclusion criteria.

• Patients who are allergic to milk or any other milk products will be excluded from the study. Milk protein allergy and lactose intolerance tests will be performed on participants belonging to active comparators Tooth Mousse and MI paste which contain casein phosphoprotein before enrolling them in the trial.

• Patients who are vegan and do not use or consume any animal products

Related Conditions & MeSH terms

• White Spot Lesion of Tooth

Intervention

Other:
• Clinpro® 5% sodium fluoride plus tri calcium phosphate varnish
Clinpro® is 5% sodium fluoride varnish and is indicated to be used for hypersensitive as well as for demineralized teeth. It flows smoothly on moist teeth and binds firmly to their surfaces. 1ml of Clinpro® contain 50 mg of sodium fluoride
• Tooth Mousse® - Casein phosphopeptide-Amorphous calcium phosphate (CPP - ACP)s
Tooth Mousse® contains Casein phosphopeptide-Amorphous calcium phosphate (CPP - ACP) is product from the milk casein. This delivers the necessary Calcium and Phosphate ions to the tooth, which will reduce the risk of caries and white spot by enhancing tooth remineralization.
• MI Paste® -Casein phosphopeptide-Amorphous calcium phosphate fluoride (CPP-ACPF)
MI Paste® which is Casein phosphopeptide-Amorphous calcium phosphate fluoride (CPP-ACPF) additional contains fluoride in addition to CPP-ACP. The level of fluoride is 900ppm which approximates that in adult strength toothpastes.
• Zap® 1.23% APF gel - Acidulated phosphate fluoride
1.23% APF (Acidulated phosphate fluoride) gel is routinely used professional based fluoride for patients with high caries risk.
• Listerine fluoride mouthrinse
Listerine® Sodium fluoride (0.2%) mouth rinses are effective in reducing caries and inhibit carbohydrate utilization of oral microorganisms by blocking enzymes involved in the bacterial glycolytic pathway studies have shown sodium fluoride mouth rinse to be effective in reducing S. mutans counts

Locations

Country	Name	City	State
Bahrain	Halet bu maher health center	Muharraq

Sponsors (1)

Lead Sponsor	Collaborator
Ministry of Health, Bahrain

Country where clinical trial is conducted

Bahrain, 

References & Publications (8)

Cosma LL, Suhani RD, Mesaros A, Badea ME. Current treatment modalities of orthodontically induced white spot lesions and their outcome - a literature review. Med Pharm Rep. 2019 Jan;92(1):25-30. doi: 10.15386/cjmed-1090. Epub 2019 Jan 15. — View Citation

Fernandez-Ferrer L, Vicente-Ruiz M, Garcia-Sanz V, Montiel-Company JM, Paredes-Gallardo V, Almerich-Silla JM, Bellot-Arcis C. Enamel remineralization therapies for treating postorthodontic white-spot lesions: A systematic review. J Am Dent Assoc. 2018 Sep — View Citation

Goswami M, Saha S, Chaitra TR. Latest developments in non-fluoridated remineralizing technologies. J Indian Soc Pedod Prev Dent. 2012 Jan-Mar;30(1):2-6. doi: 10.4103/0970-4388.95561. — View Citation

Khoroushi M, Kachuie M. Prevention and Treatment of White Spot Lesions in Orthodontic Patients. Contemp Clin Dent. 2017 Jan-Mar;8(1):11-19. doi: 10.4103/ccd.ccd_216_17. — View Citation

Memarpour M, Shafiei F, Rafiee A, Soltani M, Dashti MH. Effect of hydroxyapatite nanoparticles on enamel remineralization and estimation of fissure sealant bond strength to remineralized tooth surfaces: an in vitro study. BMC Oral Health. 2019 May 28;19(1):92. doi: 10.1186/s12903-019-0785-6. — View Citation

Pradeep K, Kumar PR. Remineralizing agents in the non-invasive treatment of early carious lesions. Int J Dent Case Rep 2011; 1:73-84.

Sonesson M, Bergstrand F, Gizani S, Twetman S. Management of post-orthodontic white spot lesions: an updated systematic review. Eur J Orthod. 2017 Apr 1;39(2):116-121. doi: 10.1093/ejo/cjw023. — View Citation

Umeh OD, Utomi IL, Ndukwe AN, Izuka M. Demineralization preventive practices among Nigerian orthodontists-An evidence-based approach? Niger J Clin Pract. 2020 May;23(5):589-595. doi: 10.4103/njcp.njcp_315_19. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Enamel decalcification score recorded using Enamel decalcification index (EDI) by Banker and Richmond	The index is used to score the demineralisation of 4 tooth surfaces- mesial, distal, incisal and gingival.	Baseline (before treatment)
Primary	Enamel decalcification score recorded using Enamel decalcification index (EDI) by Banker and Richmond	The index is used to score the demineralisation of 4 tooth surfaces- mesial, distal, incisal and gingival.	3 weeks following treatment
Primary	Enamel decalcification score recorded using Enamel decalcification index (EDI) by Banker and Richmond	The index is used to score the demineralisation of 4 tooth surfaces- mesial, distal, incisal and gingival.	6 weeks following treatment
Primary	Enamel decalcification score recorded using Enamel decalcification index (EDI) by Banker and Richmond	The index is used to score the demineralisation of 4 tooth surfaces- mesial, distal, incisal and gingival.	9 weeks following treatment
Secondary	Number of patients with any adverse effects	Any adverse effects reported in the form of allergy , hypersensitivity, discoloration.	3 weeks
Secondary	Number of patients with any adverse effects	Any adverse effects reported in the form of allergy , hypersensitivity, discoloration.	6 weeks
Secondary	Number of patients with any adverse effects	Any adverse effects reported in the form of allergy , hypersensitivity, discoloration.	9 weeks