University of Iowa

Iowa Research Online

Theses and Dissertations

2010

The efficacy of ProSeal™, SeLECT Defense™,

OrthoCoat™, and Biscover LV™ resin sealants on
the prevention of enamel demineralization and
white spot lesion formation
Tanner Jay Clark
University of Iowa

Recommended Citation
Clark, Tanner Jay. "The efficacy of ProSeal™, SeLECT Defense™, OrthoCoat™, and Biscover LV™ resin sealants on the prevention of
enamel demineralization and white spot lesion formation." thesis, University of Iowa, 2010.
http://ir.uiowa.edu/etd/479.

This dissertation is available at Iowa Research Online: http://ir.uiowa.edu/etd/479

THE EFFICACY OF ProSeal™, SeLECT Defense™, OrthoCoat™, AND Biscover

LV™ RESIN SEALANTS ON THE PREVENTION OF ENAMEL

DEMINERALIZATION AND WHITE SPOT LESION FORMATION

by
Tanner Jay Clark

A thesis submitted in partial fulfillment

of the requirements for the Master of
Science degree in Orthodontics
in the Graduate College of
The University of Iowa

May 2010

Thesis Supervisor: Professor Robert. N. Staley

 Graduate College
The University of Iowa
Iowa City, Iowa

CERTIFICATE OF APPROVAL

_______________________

MASTER'S THESIS

_______________

This is to certify that the Master's thesis of

Tanner Jay Clark

has been approved by the Examining Committee

for the thesis requirement for the Master of Science
degree in Orthodontics at the May 2010 graduation.

Thesis Committee: __________________________________

Robert. N. Staley, Thesis Supervisor

___________________________________
James Wefel

___________________________________
Lina Moreno

___________________________________
Fang Qian
 To my wife, Sarah

To my family, Jeff, Barb, Frazier and MacKenzie

ii
 ACKNOWLEDGMENTS

I would like to thank Drs. Robert Staley, James Wefel, Lina Moreno and Fang

Qian for serving on my thesis committee and for all the help and support during this

project. I would also like to thank Maggie Hogan and Jeff Harless for their patience,

generous support, and insight in the laboratory procedures. I would also like to thank

Abbie Kershner and Andrea Schmidt for helping me prepare and section teeth during the

project.

I would also like to thank Dr. Tom Southard and the rest of faculty at the

University of Iowa Department of Orthodontics for giving me the opportunity to further

my education and pursue a career in orthodontics.

Lastly, I would like to thank my wife, Sarah, for being a great wife and friend –

you make me a better person.

iii
 TABLE OF CONTENTS

LIST OF TABLES...............................................................................................................v

LIST OF FIGURES ........................................................................................................... vi

LIST OF GRAPHS .......................................................................................................... .vii

INTRODUCTION ...............................................................................................................1
Purpose of this Study...............................................................................................4

LITERATURE REVIEW……………………………………………………………... .....6

Demineralization Process ........................................................................................6

Polarized Light Microscopy…………………...……………………………... ......7
Prevalence of Decalcification in Orthodontic Patients………………………......11
Decreasing Decalcification During Orthodontic Treatment…………………. ....12
The Mechanism of Action of Fluoride………………………………...... ............12
Fluoride Rinses……………………………………………………………… ......14
Fluoride Gel and Dentifrice…………………………………………………. ......14
Fluoride Varnishes…………………………………………………………... .....15
Fluoride-Releasing Elastomerics……………………………………………. ......16
Fluoride Containing Bonding Systems……………………………………..........17
Enamel Coatings and Sealants……………………………………………….......18
ProSeal™……………………………………………………………… ...............19
New Materials…………………………………………………. ..........................20

MATERIALS AND METHODS………………………………………………….… ......24

Tooth Preparation…………………………………………………………… ......24

Abrasion………………………………… .............................................................25
Demineralization…………………………………………………………….. .....25
Tooth Sectioning and Demineralization Evaluation………………………… .....25
Statistical Analysis…………………………………………………………... .....26

RESULTS…………………………………………………………………….……... ......36

DISCUSSION…………………………………………………………………….… .......43

Limitations of the Study ........................................................................................47

Future Directions…………………...……………………………... .....................49

SUMMARY AND CONCLUSIONS……………………………………………….. ......50

REFERENCES…………………………………………………………………….... ......51

iv
 LIST OF TABLES

Table

1. Descriptive statistics for mean lesion depth by treatment group ..............................40

2. Mean lesion depths by the type of sealant materials ................................................41

v
 LIST OF FIGURES

Figure

1. Clinical example of before (top) and after (bottom) treatment in a patient

exhibiting severe demineralization…………………………………………... ..........5

2. Diagram representing the processes of demineralization and

remineralization……………………………………………………………... .........22

3. Histologic zones of a carious lesion………………………………………… .........23

4. Tooth mounted in Exaflex® Putty………………………………………….. ..........27

5. Prototech Toothbrush Wear Simulator……………………………………... ..........28

6. Toothbrush centered over specimen……..…………………………...…….. ..........29

7. Force load application………………………………….…………………... ...........30

8. Slurry application………………....………………………………………... ...........31

9. Slurry recirculating apparatus…………………………...…………………. ...........32

10. Tooth prepared for acidic challenge……………………………………... ..............33

11. Cross-sectional view of demineralized enamel window………………........ ...........34

12. Measuring technique used by Image Pro Plus computer software (Media
Cybernetics, Silver Spring, Maryland) to record mean depth of the
lesion…………………………………………………. ............................................35

13. Composite of polarized light microscopy images of representative lesions

from all five treatment groups.…………………….……………… ........................41

vi
 LIST OF GRAPHS

Graph

1. Descriptive statistics for mean lesion depth by treatment group ..............................39

vii
 1

INTRODUCTION

Orthodontic patients often seek comprehensive orthodontic treatment for a variety

of reasons. The most common reasons for orthodontic therapy are to improve a patient’s

dental function and esthetics. Also, there are several psychological benefits derived from

orthodontic treatment. These include an improvement in a patient’s overall self-esteem

and attitude. Oftentimes, the orthodontic success of an ideal Angle Class I canine

occlusion is tarnished by the appearance of white spot lesions on the facial surface of

teeth after removing the fixed appliances. (Figure 1). Prevention of these white, opaque

areas throughout orthodontic treatment is essential to providing the patient with the most

esthetic outcome.
Demineralization is a complex process. It involves the loss of calcified tooth

structure resulting in an altered surface appearance, often white spot lesions. An opaque

white spot appears chalky, and if mineral loss continues, may result in frank cavitation of

the tooth surface (Mitchell et al., 1992). A dental restoration is needed if a lesion

progresses to cavitation. This is an undesirable outcome for either orthodontic or non-

orthodontic patients. However, patients undergoing orthodontic treatment with fixed

orthodontic appliances are often at a higher caries risk than normal because of the

increased difficulty in maintaining adequate oral hygiene. Oftentimes, the patient is

unable to remove all of the dental plaque and there is a continuous cariogenic challenge

adjacent to the orthodontic brackets, eventually leading to demineralization (Ogaard et

al., 1988).

A variety of preventive treatment products and regimens have been developed in

an attempt to limit the formation of these white spot lesions. Some of these methods

require the cooperation of the patient while others do not. Because of the higher caries

risk associated with patients undergoing orthodontic treatment, dentists and orthodontists

often use adjunctive fluoride therapy to help prevent demineralization. The most
 2

common method in orthodontics is with topical fluoride. Geiger et al. (1992) found a

dose response relationship between frequency of rinsing with 10ml of neutral 0.05%

sodium fluoride solution and degree of enamel protection. Those who rinsed at least

once every other day had 49% fewer lesions than those rinsing less frequently, where

21% exhibited white spot lesions. Alexander and Ripa (2000) reported even greater

results with regular use of a high potency sodium fluoride (1.1%) dentifrice or gel. Even

though these findings strongly support the use of fluoride in the orthodontic patient, each

requires appropriate patient compliance for effectiveness. Poor patient compliance has

always been one of the largest obstacles in orthodontic care. Geiger et al. (1988, 1992)

illustrated this problem in two separate studies where they found that only 12-13% of

patients reported excellent compliance with a home fluoride rinse program. This protocol

also included added reinforcement with oral hygiene instructions and education to

patients and parents throughout treatment.

Due to the large percentage of uncooperative patients, clinicians developed

alternative methods of decreasing demineralization that do not require patient

compliance. One approach that allows the orthodontist to control the frequency and

amount of product application are fluoride varnishes. Duraphat® (Colgate-Palmolive

Company, New York, New York), a viscous resinous lacquer consisting of 5% sodium

fluoride that hardens into a yellowish-brown coating, is one of the most frequently used

varnishes.

Although varnishes provide a significant benefit to high caries risk patients, one

drawback is that they often require multiple in-office applications. In an in vitro study,

Frazier (1993) found that a one-time application of an unfilled resin sealant (a

conventional pit and fissure sealant, Delton®, Dentsply) was 80 percent effective in

preventing demineralization. These results are promising, especially if the sealant could

be maintained throughout treatment without the need for reapplication. However, in this

study the mechanical wear of the sealant through toothbrushing was not addressed.
 3

Sealants, especially unfilled resins, are susceptible to wear and may develop cracks in the

surface or become entirely worn through (Gwinnett and Ceen, 1979).

In 2004, Reliance Orthodontic Products, Inc. (Itasca, Illinois) released an enamel

sealant specifically for orthodontic use. Pro Seal™, a light-cured fluoride sealant, is

highly filled and advertised as resisting toothbrush abrasion and normal wear for over

two years. Hu and Featherstone (2005) have shown a significant decrease in enamel

demineralization on teeth treated with Pro Seal™ and subjected to simulated mechanical

abrasion. This study used enamel microhardness profiles to evaluate product

performance, with teeth treated with Pro Seal™ demonstrating better profiles than those

treated with a fluoride varnish, etchant only, or an unfilled resin. Loucks et al. (2006)

found that Pro Seal™ provided a 92 % reduction in enamel demineralization and

withstood simulated toothbrush abrasion for 24 months. In addition, Pro Seal™ provided

significantly more protection than the unfilled sealant Delton® and the topical fluoride

varnish Fluor Protector™. Since the release and clinical success of Pro Seal™, other

dental manufacturers have formulated similar sealant materials that can provide the same

level of prevention against enamel demineralization. Many of these products have just

been released and have not been tested clinically.

Ortho-Coat™ is a similar product recently developed by Pulpdent® that is also a

light-cured fluoride releasing resin made specifically to place adjacent to and on

orthodontic brackets to decrease demineralization.

A new unfilled resin, called SeLECT™ Defense, has recently been developed by

ClassOne Orthodontics. It is also used for the prevention of whitespot formation during

orthodontic treatment. SeLECT™antimicrobial Technology has been incorporated into

brackets, archwires, molar bands, adhesive materials, and other devices, to prevent the

formation of plaque on or around the bracket area. SeLECT® Technology, by its

antimicrobial action, will inhibit the growth of bacterial plaque around orthodontic

brackets, thereby preventing demineralization (whitespot formation) around the brackets,

 4

and can withstand the abrasion from daily toothbrushing. Specifically, SeLECT®

Technology utilizes the properties of selenium for its antimicrobial effect. In small

doses, the selenium compound specifically kills the Streptococcus mutans and

Lactobacilli bacteria that come in contact with the treated surface.

The Biscover LV™ (BISCO, Inc.) is a low-viscosity, light-cured unfilled resin

formulation mainly used to polish and seal composite resin restorations and provisional

restorations. It can also be used to seal enamel prior to orthodontic bracket placement.

The resin cures without an oxygen-inhibited layer and is used also to prevent enamel

demineralization during orthodontic treatment.

These three resins show promise in their ability to prevent enamel

demineralization during orthodontic treatment. However, there long-term ability to

withstand toothbrush abrasion and intra-oral wear and demineralization has yet to be

studied.

Purpose of this Study

The purpose of this study is to compare, in vitro, the effectiveness of the resin

sealants ProSeal™, OrthoCoat™, SeLECT Defense™, and Biscover LV™ on the

inhibition of enamel demineralization after being subjected to extensive mechanical

toothbrush abrasion.
 5

Figure 1. Clinical example of before (top) and after (bottom) treatment in a

patient exhibiting severe enamel demineralization.
 6

LITERATURE REVIEW

Demineralization Process
Dental caries is a multifactorial disease. It involves the interaction of diet, dental

plaque containing bacteria, and host factors, such as tooth surface, saliva, and the

acquired pellicle (Zero, 1999). Dental caries is initiated via demineralization of tooth

mineral by organic acids. One model proposed by Harris and Garcia-Godoy (1999)

described a process in which plaque microorganisms on the tooth surface produce organic

acids in the presence of fermentable carbohydrates. As the plaque pH drops in response

to the production of these acids, a series of complex chemical and physical events are

initiated. At resting pH levels, plaque fluid is supersaturated with respect to calcium

phosphate. However, as the pH falls, this level of saturation is not maintainable. When

the critical pH (approximately 5.5) is reached, demineralization begins and the organic

acids are able to diffuse to the enamel surface through the acquired pellicle. After the

initial dissolution has occurred, less soluble solid phases of dicalcium phosphate

dihydrate and fluoridated hydroxyapatite precipitate out of the enamel. This sequence

occurs until an equilibrium is reached between the surrounding oral environment and the

enamel. Demineralization continues as the acid penetrates deeper through the enamel

rods until equilibrium is again reached.

The physical degradation observed on the enamel surface is a direct result of this

demineralization process. However, there is not a logical explanation why an intact

surface layer is often observed with the greater structural damage deeper into the enamel.

Featherstone and colleagues (2000) proposed that as the pH of the plaque falls, the

proportion of undissociated acids in the plaque fluid increases. These acids can diffuse

through the porous enamel matrix down a concentration gradient because they are

uncharged. The acids can dissociate once they penetrate to a certain depth where the pH

is higher. Here, the acids release protons, which attack the apatite lattice. The calcium
 7

and phosphate ions that are dissolved either diffuse outward into the plaque or

reprecipitate before escaping the enamel. This process maintains an intact surface zone.

After the pH has returned to normal levels, calcium, phosphate and fluoride reenter the

enamel and repair the damaged crystallites and begin the remineralization process (Figure

2).

The caries process is a dynamic cycle. There is a constant continuum between

periods of demineralization and remineralization. If the negative mineral balance

exceeds the rate of remineralization over an extended period of time, s carious lesion can

form. Carious lesions occur in several distinct stages. The earliest stage is the incipient

lesion and is characterized by both histologic, and eventually macroscopic, changes in

enamel. This state is also termed a sub-surface or white spot lesion. A white spot lesion is

the first clinical presentation of dental caries. The incipiency consists of an intact enamel

surface with loss of mineralization deeper within the enamel. Therefore, they often

present clinically with an opaque, white-chalky appearance that is due to the optical

properties of the demineralized enamel. Studies regarding lesion depth disagree on the

average depth of a white spot lesion. Ogaard et al. (1988) found average depth of a white

spot lesion under a band following four weeks of orthodontic treatment was 100 µm.

Glatz and Featherstone (1985) reported measurable demineralization, up to 75 µm deep

and with 25% mineral loss, in 4 weeks, especially gingival to the bands or brackets. Zero

(1999) noted that a white spot lesion must progress to a depth of 300 to 500 µm to be

clinically detectable.

If this process of demineralization continues, a white spot lesion will eventually

progress further into a surface cavitation. This is often termed an overt, or frank lesion.

Polarized Light Microscopy

Polarized light microscopy is often used to evaluate carious lesions because it

allows visualization of enamel demineralization and remineralization. There are several

 8

other methods of studying demineralization, including: light microscopy,

microradiography, surface hardness, electron microscopy, and confocal laser scanning

microscopy (Ogaard, 1996). The main advantage with polarized light microscopy is that

it permits both qualitative and quantitative evaluation due to its ease of visualization of

the color spectrum (Hicks, 1981).

A polarized light microscope includes a light microscope with the addition of a

polarizer and analyzer that are set perpendicular to one another. Both the polarizer and

the analyzer are made of prisms of calcite or a sheet of Polaroid, which only transmit

light oscillation in one plane (Weyrich, 1994). When a sample is placed between the

polarizer and the analyzer, the sample modifies the plane of light which produces a series

of interference colors.

When a crystal transmits light with equal velocity in all directions, the crystal is

called isotropic. The crystal is termed anisotropic when it transmits light at different

velocities and in different directions. Depending on the number of axes present,

anisotropic crystals are further divided into uniaxial and biaxial. Hydroxyapatite is a

uniaxial anisotropic crystal, because it has one optic axis that is coincident with its crystal

(“c”) axis. Hydroxyapatite is also birefringent, which involves splitting a light ray into

two components which travel at different velocities and are at right angles to one another.

This results in different color and light intensities being released (Weyrich, 1994). A

material that consists of non-cubic crystal is given a sign of birefringence determined by

the velocity of its resultant light rays. Slow rays are deemed positive (+) and fast rays are

deemed negative (-) (Theuns and Groenveld, 1977). The mineral, hydroxyapatite,

composes most of the enamel structure but there is also a small amount of organic

material (+) interspersed.

Birefringence can be indirectly measured through polarized light microscopy.

Enamel is a uniaxial birefringent object. Therefore, when enamel is oriented with its

optic axis parallel to the direction of plane polarized light propagation, it will behave as
 9

an isotropic crystal. If enamel is arranged with its optic axis in a plane perpendicular to

the direction of propagation, the light will split into two beams. These beams are referred

to as the extraordinary (ne) and ordinary (no) rays and they result in a series of

interference colors (Silverstone, 1967).

Birefringence is further subdivided into intrinsic birefringence and form

birefringence. Intrinsic birefringence refers to the difference between the refractive

indices of the extraordinary ray and the ordinary ray, or ne - no (Ogaard, 1996). There

are several factors which influence intrinsic birefringence, including: volume of

crystalline mineral, orientation of crystallites with respect to the light beam, and

birefringence of crystallites such that (ne – no)i = δ c(ne – no)HAP where (ne – no) i =

intrinsic birefringence, δ = pore volume occupied by crystallites, c = crystallite

orientation factor, and (ne – no) HAP = birefringence of crystallites (Theuns and

Groenveld, 1977).

Throughout the demineralization process, spaces between the enamel crystals

become larger. Form birefringence occurs when a medium that fills the voids in carious

enamel has a different refractive index. The amount of form birefringence produced is

determined by the size of the spaces and the refractive index of the medium. Form

birefringence will not be created if the medium has the same refractive index as enamel.

Therefore, different mediums are used when utilizing polarized light microscopy.

The total birefringence of enamel is the sum of 1) the negative intrinsic

birefringence of the inorganic material, 2) the positive intrinsic birefringence of the

organic material, 3) the positive form birefringence of the spaces in relation to the

mineral and possibly to the organic matter and 4) the positive form birefringence of the

organic material in relation to the mineral. The organic mineral content is very small so

it can be disregarded. Because there is a small amount of organic material in enamel, the

observed total birefringence is made up almost entirely of the intrinsic birefringence of

 10

the inorganic mineral and the form birefringence of the spaces in relation to the inorganic

mineral (Silverstone, 1967).

The enamel is divided into longitudinal sections so that the crystallites of apatite

are aligned along the length of the prism. When using polarized light microscopy, four

zones of a carious lesion are visible (Figure 3). These zones represent different amounts

of tissue loss, or open space, and are often compared by their percentage of pore volume.

The outermost layer of enamel, the surface zone, remains relatively intact (1-5% pore

volume) and is a zone of remineralization (Silverstone 1977; Gorelick and Geiger, 1982).

The second zone is called the body of the lesion and displays more tissue destruction than

any of the other zones. The pore volume in the body of the lesion is 5-25 percent. The

third zone is the dark zone, which is caused by dissolution of enamel cross striations.

This zone has a pore volume of 2-4 percent. Similar to the surface zone, remineralization

can occur in the dark zone. The fourth zone, which is the deepest of the four zones, is

termed the translucent zone and has a pore volume of 1 percent (Silverstone, 1967).

The superficial, dark, and translucent zones act as sieves that selectively exclude

imbibition media with molecular sizes greater than pore sizes present in these zones

(Hicks, 1981). Air, water, and potassium mercuric iodide dilutions (Thoulet’s solution)

are some of the mediums used in polarized light microscopy. Air (refractive index = 1.0)

corresponds with 1 percent pore volume, water (refractive index = 1.33) with 5 percent

pore volume, Thoulet’s 1.41 with 10 percent, and Thoulet’s 1.47 with 25 percent pore

volume.

A map can be made of the different zones by imbibing a longitudinally sectioned

lesion with different media,. These maps provide a qualitative assessment of internal

lesion pore volume. Also, quantitative information is easily obtained by measuring the

positively birefringent areas of the lesion in the various imbibition media. Image Pro

Plus software (Media Cybernetics, Silver Spring, Maryland) allows measurement of a

 11

polarized light photomicrograph for statistical analysis. This method does allow for

lesions to be quantified indirectly with a polarized light microscope (Hicks, 1981).

Prevalence of Decalcification in Orthodontic Patients

Decalcification presents both biological and esthetic concerns for orthodontists.

Fixed orthodontic appliances create significant plaque traps, leading to increased plaque

retention and subsequent white spot lesion formation. Accumulation of bacterial plaque

can also produce gingival inflammation and can contribute to degeneration of the

gingival attachment.

Ogaard et al., (1988) reported the presence of visible white spot lesions in

orthodontic patients within as little as four weeks without fluoride supplementation.

Zachrisson et al., (1971) demonstrated a linear, positive correlation between plaque

accumulation and carious lesion development in orthodontic patients.

In addition to presenting a significant threat to the patient’s oral health, often of

more concern to patients and parents is the negative impact that white spot lesions have

on facial esthetics. Decalcification of the facial surfaces of anterior teeth is very

common. When this occurs, the patient has a very unesthetic final result.

Many studies have investigated the prevalence of white spot lesions in

orthodontic patients and the findings are striking. Zachrisson and Zachrisson (1971)

reported in a longitudinal study that orthodontic treatment resulted in 89% of patients

developing white spot lesions. Boersma et al. (2005), observed that 97% of their subjects

displaying lesions after treatment. However, Ogaard (1989) found that only 4% of

orthodontically treated patients had no white spot lesions 5 years post treatment. Gorelick

et al. (1982) found non-developmental lesions in 50% of treated patients in contrast to

25% of non-treated controls. Similarly, other studies have shown an increase in white

spot lesions of 0-24% after treatment (Mizrahi, 1982; Stratemann, 1974). Although

varying amounts of decalcification have been presented in the literature, each study
 12

firmly agrees that decalcification poses a significant problem to orthodontists and the

patients they treat.

Alexander (2000), O’Reily (1987) and Geiger (1988) all found that white spot

lesions can appear in orthodontic patients as early as one month into treatment. Ogaard

(1989) and Gorelick et al. (1982) observed a high prevalence of white spot lesions on the

maxillary lateral incisors, mandibular first premolars, and mandibular canines. The

lowest incidence of white spots was in the maxillary posterior segment (Gorelick et al.

1982). Mizrahi (1982) found that most white spot lesions occur in the cervical and middle

thirds of the facial surface of teeth.

Decreasing Decalcification During Orthodontic Treatment

Immaculate oral hygiene is essential to protecting healthy enamel during orthodontic

treatment. Thorough oral hygiene instruction and diet counseling that emphasizes

reduced intake of fermentable carbohydrates are just a few methods to help prevent or

decrease demineralization in orthodontic patients. Besides its role in the prevention of

white spot lesions, proper nutrition is also essential for maintaining overall systemic

health during and after treatment.

The Mechanism of Action of Fluoride

Thorough tooth brushing, flossing, and routine prophylactic cleanings will minimize the

amount of dental plaque, thereby decreasing the probability of developing areas of

decalcification (Øgaard, 1989). But because a majority of patients often have inadequate

oral hygiene, orthodontists are forced to alternate approaches to help prevent

demineralization. The supplemental use of fluoride has long been utilized in the dental

field for caries prevention and also plays a critical role in orthodontics. The effectiveness

of fluoride in this preventive role is attributable to three principal mechanisms of action:

 13

1) inhibiting bacterial metabolism, 2) inhibiting demineralization, and 3) enhancing

remineralization.

To inhibit bacterial metabolism, fluoride inhibits the enzyme enolase, which is a

bacterial enzyme necessary for the breakdown of carbohydrates into pyruvic acid.

Without the activity of enolase, bacteria cannot utilize fermentable carbohydrates from

the diet in acid production. Bacteria have proteins with acidic side chains that form

bridges with calcium ions in the enamel. Fluoride competes with bacteria for these

binding sites and prevents adhesion because of its electronegative properties. (Levine,

1991).

Fluoride also has the ability to protect the enamel surface from demineralization

during an acid attack. Systemic fluoride is incorporated into the enamel by combining

with hydroxyapatite to form fluoroapatite. This allows the enamel to become less

soluble and more resistant to acidic challenge (Zipkin, 1970).

Although each of these mechanisms is beneficial, the primary method of action of

fluoride is remineralization. Following an acid attack and the pH rising above 5.5,

available calcium and phosphate are able to be integrated into the crystal structure to

rebuild the damaged areas. Fluoride enhances the process by strongly adsorbing to the

crystal surface, attracting calcium ions, which are then followed by phosphate ions.

These three ions are able to create a new crystalline structure between hydroxyapatite

(HAP) and fluorapatite (FAP), which is stronger and more acid-resistant than the

previous structure (Featherstone, 2000; Moreno et al., 1977; ten Cate et al., 1991).

Remineralization can occur in the presence of saliva alone. However, Arends and ten

Cate (1977) found a twofold increase in the rate of remineralization in the presence of

1ppm fluoride ion. Patients with a high-caries risk, such as those with orthodontic

appliances, would benefit from fluoride use because the presence of fluoride appears to

push the equilibrium in favor of remineralization. The orthodontist can utilize a variety
 14

of fluoride delivery systems during treatment. Fluoride can be introduced via dentifrice,

rinses, foams, gels, varnishes, bonding agents, cements, and even elastomers.

Fluoride Rinses
The advantage of adding fluoride to a patient’s oral hygiene protocol is well-

documented. Geiger et al. (1992) found a dose response relationship between frequency

of rinsing with 10ml of neutral 0.05% sodium fluoride solution and degree of enamel

protection. Those who rinsed at least once every other day had only a 21% occurrence of

white spot lesions, compared to 49% for the control group. Another in vivo study was

done by O’Reilly and Featherstone (1987). They found that patients whose used a

fluoride dentifrice and rinsed daily with a 0.05% sodium fluoride mouthrinse during the

first month of treatment had significantly higher enamel microhardness than those using

fluoride dentifrice alone. No visible demineralization was present at this time. However,

the authors concluded that the progression of any enamel surface softening could be

expected to result in observable white spots by the completion of treatment.

Fluoride Gel and Dentifrice

In addition to fluoride rinses, investigators have shown even superior protection

from high-potency fluoride dentifrice (Prevident® 5000 Plus) and gel (Prevident®

Neutral Sodium Fluoride Brush-On Gel), both containing 1.1% sodium fluoride. In 2000,

Alexander and Ripa, showed that subjects who used either the gel after brushing with

standard toothpaste (1000ppm) at bedtime, or the dentifrice only twice daily, showed

significantly fewer areas of demineralization than those adding a low-potency fluoride

rinse to standard brushing at bedtime (Phosflur®, 0.05%APF). The difference in

demineralization was clinically evident after one month of treatment and remained

statistically significant throughout the study (one month post-treatment). Baysan et al.

(2001) also compared the ability of two fluoridated dentifrices, one containing 5,000 ppm
 15

(PreviDent 5000 Plus®) and the other 1,100 ppm (Winterfresh Gel®), to reverse primary

root caries lesions. They concluded that the 5,000 ppm fluoride dentifrice was

significantly better at remineralizing the lesions than the 1,100 ppm fluoride dentifrice.

Eng (2009) found that a twice-daily treatment with either MI Paste™, MI Paste

Plus™, or PreviDent 5000 Plus™ showed statistically significant reduction in lesion

depth compared to controls. Recaldent™, is a complex of casein phosphopeptides and

amorphous calcium phosphate (CPP-ACP) and is the active ingredient in MI Paste™ and

MI Paste Plus™. He also found that CPP-ACP was effective in reducing lesion depth

while integrated within a paste. However, he noted that even though CPP-ACP showed a

statistically significant reduction in mean lesion depth, it remains uncertain whether this

equates to a clinical reduction of visible demineralization.

Fluoride Varnishes
The effectiveness of fluoride dentifrices, gels and rinses in decreasing enamel

demineralization is widely accepted. Acidulated fluoride gels and solutions have been

used since their inception in 1963. However, these methods require patient cooperation

to be effective. For example, Geiger et al. (1992) reported only 13% full compliance

among study patients with a fluoridated rinse protocol. This level of non-compliance

poses a problem for orthodontists. Many researchers have studied the effectiveness of

professionally applied varnishes to protect non-compliant patients from white spot

lesions. Two effective varnishes are Duraphat® and Duraflor®. They are both

composed of 5% sodium fluoride by weight and have a yellowish, sticky rosin base that

hardens when it comes into contact with saliva. This base serves as a protective coating

that allows the fluoride to persist on the enamel surface. Todd et al. (1999) reported a

50% decrease in lesion depth in extracted teeth treated with a single application of

varnish (Duraflor®) when compared to control teeth with no treatment. Wittenberger

(2003) also found decreased lesion depths (53%) with the use of Duraphat®.
 16

Juhlin (2004) found similar results for Duraphat®, with treated teeth showing a

decrease in lesion depth of 65%. In the same study, Juhlin also found an 86% reduction

in lesion depth obtained from the fluoride varnish Fluor Protector™, which was

significantly more effective than Duraphat®. Part of Fluor Protector’s™ efficacy may be

attributable to its behavior similar to that of a sealant in that it remains adhered to the

enamel surface for a period of time. In the study, complete removal of Duraphat® was

noted after approximately 9 days, while Fluor Protector™ was on the enamel surface

after the 27 day study. Loucks (2006) found that Fluor Protector™ resulted in a 47%

decrease in lesion depth when subjected to 24 months of simulated toothbrush abrasion

and a 96 hour acid challenge.

Vanish® (3M Omni, St. Paul, MN) is a fluoride varnish that has recently been

developed as an esthetic alternative to traditional fluoride varnish. Similar to Duraphat®,

Vanish® contains 5 percent sodium fluoride (22,600 ppm fluoride) but in a more esthetic,

clear or white color. Schemehorn et al. (2009) reported that Vanish® also has an increase

in fluoride-releasing efficiency over 24 hours compared with Duraphat® and Duraflor®.

Fluoride-Releasing Elastomerics
As an alternative to varnishes, clinicians have tried to use fluoride –releasing

elastomerics to reduce enamel demineralization. One study by Banks et al. (2000) found

a 10% decrease in the number of patients presenting with decalcification at the end of

treatment (as observed clinically) when utilizing fluoride releasing modules and chain

(Fluor-I-Ties, Fluor-I-Chain, Ortho Arch Company, Inc., Illinois, USA). However, these

modules do have several associated problems, including: have reduced elasticity,

significant staining, and lack of color availability. Although no chains showed clinical

failure in this study, Baty (1994) found that the Fluor-I-Chain retained only 14% of its

initial force after 1 week in distilled water, as compared to 38% in a conventional chain.
 17

Fluoride Containing Bonding Systems

Fluoride releasing cement systems, including composite resins, glass ionomer,

and resin-modified glass ionomers are also another method for non-compliant patients to

decrease demineralization.

One study by Ogaard et al. (1992) found a 48% reduction in lesion depths

adjacent to brackets bonded with a fluoride releasing composite (Orthodontic Cement VP

862), compared to those observed in teeth bonded with a non-fluoride adhesive. Glass

ionomer cements are another group of materials that decreases caries progression and

remineralizes enamel (Donly, 1995). A unique property of this material is that they can

absorb fluoride applied topically, and can therefore recharge and re-release the fluoride

over a longer period of time (Voss, 1993). Although these fluoride releasing composites

and glass ionomers are effective in inhibiting the caries process, there are drawbacks to

their use clinically. For example, studies by Fox (1990) and Voss (1993) show that the

bond strengths of these materials is lower than conventional composite resins and less

than ideal for clinical treatment.

The fluoride releasing properties of resin-modified glass ionomer cements is

similar to glass ionomer cements in their ability to uptake fluoride and re-release it over a

long period of time (Burgess and Chan, 1996). In 2002, Schmit et al. examined lesion

depths in teeth bonded with resin-modified glass ionomer cement (Fuji Ortho™ LC, GC)

and a non-fluoridated composite resin and found 50% smaller lesion depths in teeth

bonded with the RMGI. The authors also found shallower depth measurements near the

bracket. Pascotto et al. (2004), found the same RMGI material decreased enamel mineral

loss by 12% and had a positive effect on enamel microhardness.

Although the role of RMGI in preventing demineralization is clear, its use does

have some clinical drawbacks, in particular its ease of use by clinicians. Lippetz et al.

(1998) compared three different RMGIs (Advance™, Fuji Duet™, Fuji Ortho™ LC)

with a clinically proven composite resin (Concise™). They found no difference in bond
 18

strength of the materials 24 hours or 30 days following bonding. However, the clinical

handling properties have proven less than ideal, making many practitioners hesitant to

use it on their patients. Also, most RMGI are entirely or partially chemical cure. This

decreases efficiency because it makes for a longer working time and longer chair time for

the orthodontist.

Enamel Coatings and Sealants

Recently, enamel coatings and sealants have gained popularity for preventive

treatment. Fornell et al. (2002) found that a hydrophobic enamel-coating polymer had no

beneficial effects on gingival health, plaque and strep mutans levels, or enamel

demineralization when applied immediately after bonding and at 3 month intervals

throughout treatment. Enamel sealants have showed more promise in the prevention of

enamel demineralization. Frazier et al. (1996) found that 80% of teeth treated with a

light-cured unfilled resin (a conventional pit and fissure sealant, Delton®, Dentsply) just

after initial bond placement were completely protected from demineralization. The

remaining 20% of experimental teeth each had small, isolated areas that had “breaks” in

the sealant layer, leading to the associated demineralization. The author concluded that

surface contamination during etching or sealant placement and incomplete application of

etchant or sealant were the causes of these “breaks” in the sealant layer

Oxygen inhibition, a lack of complete surface layer polymerization, is another

cause for failure of enamel sealants. Composite resins undergo a reaction known as free-

radical polymerization. This reaction occurs in three stages: initiation, propagation, and

termination. During initiation, monomer particles are rapidly added to the free radical on

the polymer. This allows electrons to shift to the end of the growing chain, enables more

monomers to be incorporated into the polymer. This propagation continues until the free-

radical is terminated. Materials that will react with the free radical can inhibit this

reaction, thereby decreasing the rate of initiation/propagation and retarding the

 19

polymerization reaction. These materials can also expedite the rate of termination and

decreases the degree of polymerization or the molecular weight of the final polymer.

Materials such as hydroquinone, eugenol, or large amounts of oxygen will retard the

polymerization, causing an incomplete cure in the outer layer of composite resins. The

“degree of conversion” is one method to quantify a material’s polymerization and it

describes the percentage of bonds that are reacting. Craig (1997) found that photo-

initiated polymerization has a degree of conversion around 80%, whereas chemical cure

systems can have as low as 35% conversion in the air inhibited layer.

Joseph et al. (1992) found teeth with chemically activated resins showed almost

total absence of a cured sealant layer. However, light-polymerizing resins did show a

cured sealant layer. Although they can provide more enamel protection, they are still

susceptible to oxygen inhibition and incomplete surface polymerization.

Pro Seal™
A product receiving well-deserved attention for its ability to prevent

demineralization is Pro Seal™ (Reliance Orthodontics Products, Inc). It is now

considered the “gold standard” in orthodontics as a sealant material used to help prevent

enamel demineralization during orthodontic treatment. Loucks (2006) found that Pro

Seal™ provided a 92 % reduction in enamel demineralization and withstood simulated

toothbrush abrasion over a 24 month period. In addition, Pro Seal™ provided

significantly more protection than the unfilled sealant Delton® and the topical fluoride

varnish Fluor Protector™.

Pro Seal™ is a light-cured, fluoride containing sealant that is highly filled. It has

been shown to resist toothbrush abrasion and normal wear for over 24 months, which is

about the average time for comprehensive orthodontic treatment. It has a final sealant

polymerization of 100% without an oxygen inhibition layer, which creates a smooth,

even surface that helps prevent leakage, protects enamel and makes bonding paste
 20

cleanup easier. Pro Seal™ contains a fluorescing agent that is visible under UV light that

allows the orthodontist to monitor the coverage of the sealant at the time of placement

and early in treatment. The sealant’s added fluoride is in the form of a glass ionomer

powder similar to that used in many orthodontic bonding systems. Thus, the sealant

resembles a RMGI cement in that it can release fluoride to the enamel upon application.
The application of Pro Seal™ is very straightforward. The orthodontist first

begins with a prophylaxis and treatment of the enamel with conventional etchant or a self

etching primer. A thin layer of sealant is then applied and cured at close range with a

standard halogen bulb light or an LED light for 15 seconds per tooth. After curing, the

fixed appliances can then be placed directly on the treated enamel surface with any

chemical, light or dual cure paste with clinically acceptable bond strength anticipated.

Bishara et al. (2005) found the bond strength on teeth treated with Pro Seal™ to be

comparable to those bonded without the sealant. In addition, there was no significant

difference found between bonds receiving a separate curing for the sealant (10 sec) and

the cement (20 sec), as directed by the manufacturer, and those receiving a single curing

interval (20 sec) for the sealant and cement simultaneously.

New Sealant Materials

Since the release and clinical success Pro Seal™, other dental manufacturers have

formulated similar sealant materials that they claim can provide the same level of

prevention against enamel demineralization. Many of these products have just been

released and have not been tested clinically. One product, OrthoCoat™ (Pulpdent, Inc.)

is a similar product recently developed that, like ProSeal™, is a light-cured fluoride

releasing resin made specifically to place adjacent to orthodontic brackets to decrease

demineralization.

Another new resin, called SeLECT™ Defense, has recently been developed by

ClassOne Orthodontics. It is also used for the prevention of whitespot formation during
 21

orthodontic treatment. The product uses what the company calls SeLECT® Technology.

This mechanism, by its antimicrobial action, will inhibit the growth of bacterial plaque

around orthodontic brackets, thereby preventing demineralization around the brackets,

and can withstand the abrasion from daily toothbrushing. Specifically, SeLECT®

Technology utilizes the properties of selenium for its antimicrobial effect. In small

doses, the selenium compound is bactericidal to the Streptococcus mutans and

Lactobacilli bacteria that come in contact with the treated surface. The company has

taken this SeLECT™ antimicrobial Technology one step further and has incorporated it

into its brackets, archwires, molar bands, and adhesive material.

Biscover LV™ (BISCO, Inc.) is a low-viscosity, light-cured unfilled resin

formulation mainly used to polish and seal composite resin restorations and provisional

restorations. It can also be used to seal enamel prior to orthodontic bracket placement.

The resin cures without an oxygen-inhibited layer and is used also to prevent enamel

demineralization during orthodontic treatment.

 22

Figure 2. Diagram representing the processes of demineralization and

remineralization (Harris and Christen, 1995).
 23

Figure 3. Histologic zones of a carious lesion.

 24

MATERIALS AND METHODS

Tooth Preparation
Seventy-five non-carious extracted human molars were disinfected in Streck

Tissue Fixative (Streck Laboratories, La Vista, Nebraska) for one week. The remaining

soft tissue, calculus and bone were removed with a scaler and razor blade. Cusps were

then ground flat and the apices shortened to allow mounting in the tooth brush simulator.

A small hole was then drilled near the apex of each tooth so that dental floss could be fed

through to facilitate suspension of the teeth in solution.

The buccal surfaces were then polished with a prophylaxis cup for 3 seconds with

a mixture of non-fluoridated pumice and water and the teeth were randomly assigned to

one of 5 groups:

Group 1 (n=15) the control group, received no additional surface treatment

after pumicing.

Group 2 (n=15) was treated with 35% phosphoric acid and received a

single application of the unfilled resin sealant, Biscover LV™, per manufacturer’s

instructions.

Group 3 (n=15) was etched with 35% phosphoric acid and received a

single application of the filled resin sealant, ProSeal™, per manufacturer’s

instructions.

Group 4 (n=15) was etched with 35% phosphoric acid and received a

single application of the filled resin sealant, OrthoCoat™, per manufacturer’s

instructions.

Group 5 (n=15) was etched with 35% phosphoric acid and received a

single application of the unfilled resin sealant, SeLECT Defense™, per

manufacturer’s instructions.
 25

Teeth were then mounted in an acrylic ring and stabilized with a very high

viscosity vinyl polysiloxane impression material (Exaflex®Putty, GC America, Inc.) as

shown in Figure 4.

Abrasion
Mounted teeth were placed in the Prototech Toothbrush Wear Simulator (Proto-

tech, Portland, Oregon) and a soft bristled toothbrush (Oral-B Adult Soft 35, Oral-B

Laboratories, Iowa City, Iowa) was centered over the buccal surface. Each tooth was

subjected to 15,000 horizontal brush strokes at a rate of 120 strokes per minute. A

constant force of 280g was also applied to each brush to simulate normal manual

brushing force and a slurry of non-fluoridated toothpaste and water (1:3 ratio) was

constantly recirculated by the machine (van der Weijden et al., 1996). Slurry solution

and brush heads were changed between each treatment group. Figures 5-9 illustrate

various components of the machine and the abrasion protocol.

Demineralization
Teeth from all groups were painted with a thin layer of acid-resistant varnish (nail

polish), leaving an approximately 1mm window of exposed enamel on the buccal surface

(Figures 10 and 11). They were then placed in a constantly circulating, room-

temperature, standard tenCate Demineralizing Solution (pH = 4.4) consisting of: 2.20mM

Ca+2, 2.20mM PO43, 0.05M Acetic acid and 0.025ppm F- for 96 hours to generate

demineralized lesions (Frazier, 1996).

Tooth Sectioning and Demineralization Evaluation

Each tooth was visually examined for evidence of demineralization. Longitudinal

sections were then made buccolingually with a Series 1000 Deluxe hard tissue microtome

(Scientific Fabrication, Littleton, California) to yield sections that were 100 to 140 µm
 26

thick Before sectioning, digital photographs (Hitachi KP-D50 Digital Camera, Tokyo,

Japan) were made of one tooth from each group at 15x magnification (Nikon SMZ-10

Microscope, Tokyo, Japan) to grossly compare the exposed enamel window of each

treatment.

Sections were then soaked in deionized water and examined under polarized light

microscopy (Olympus BX50, Melville, New York). Three sections from each tooth were

photographed under maximum illumination and 4x magnification (SPOT, Diagnostic

Instruments, Inc., Sterling Heights, Michigan). On teeth that displayed demineralization,

Image Pro Plus 4.1 (Media Cybernetics, Silver Spring, Maryland) were utilized to obtain

an average lesion depth (µm) for each section. This program registered the largest and

smallest areas within the lesion and calculated an average depth for the section (Figure

13). The values for each of the three sections were then averaged to determine the lesion

depth reported for each tooth.

Statistical Analysis
Descriptive statistics were compiled from the results of the study. The one-way

analysis of variance (ANOVA) with post-hoc Ryan-Einot-Gabriel-Welsch multiple range

test was used to determine whether there was a significant difference in lesion depth

between sealant materials.

All tests employed a 0.05 level of statistical significance. SAS for Windows

(v9.1, SAS Institute Inc, Cary, NC, USA) was used for the data analysis.
 27

Figure 4. Tooth mounted in Exaflex® Putty.

 28

Figure 5. Prototech Toothbrush Wear Simulator.

 29

Figure 6. Toothbrush centered over specimen.

 30

Figure 7. Force load application.

 31

Figure 8. Slurry application.

 32

Figure 9. Slurry recirculating apparatus.

 33

Figure 10. Tooth prepared for acidic challenge.

 34

Figure 11. Cross-sectional view of demineralized enamel window.

 35

Figure 12. Measuring technique used by Image Pro Plus computer software (Media
Cybernetics, Silver Spring, Maryland) to record mean depth of the lesion.
 36

RESULTS

Seventy-five extracted non-carious third molars were randomly selected and

included in the study. They were divided into five experimental groups, comprising 15

teeth per group. Three sections were made from each tooth. During the sectioning

process, some enamel surfaces did not remain intact. Some of this can be attributed to

the sectioning process inadvertently removing the enamel surface. Graph 1 shows the

average lesion depths for each of the 15 teeth in each of the five groups.

The mean lesion depth (microns), standard deviation, and minimum and

maximum measurements for each group are reported in Table 1.

Descriptive statistics were conducted with the study data. The one-way ANOVA

with post-hoc Ryan-Einot-Gabriel-Welsch multiple range test was used to determine

whether there was a significant difference in lesion depth between sealant materials.

An underlying assumption in order to use the ANOVA is the normality of the

residuals. Normality of residuals was checked with a non-significant Shapiro-Wilk test

and normal probability plots. Since the assumption of normality was valid, the one-way

ANOVA was used to evaluate the performance of the sealant materials. All tests

employed a 0.05 level of statistical significance. Statistical analyses were carried out

with the statistical package SAS® System version 9.1(SAS Institute Inc, Cary, NC, USA).

Results of the one-way ANOVA revealed a significant effect for type of sealant

materials on the lesion depth (p<0.0001). The post-hoc Ryan-Einot-Gabriel-Welsch

multiple range test indicated that the mean lesion depth observed in ProSeal™ was

significantly lower than in the other four groups. Moreover, no significant difference was

found between SeLECT Defense™, OrthoCoat™, and Biscover LV™. Table 2 presents

the results of the post-hoc Ryan-Einot-Gabriel-Welsch multiple range test.

Results from this study indicated that ProSeal™ reduced enamel demineralization

by 82% when compared to controls. This was a significant reduction compared to the
 37

other three sealant materials and the control. Results also indicated that Biscover LV™,

OrthoCoat™, and SeLECT Defense™ all reduced enamel demineralization by 67%,

64%, and 64% compared to controls, respectively. However, there was no significant

difference between these three sealant materials.

Figure 13 are colored photomicrographs of representative samples from each of

the five groups. As seen in the illustrations, most of the teeth, with the exception of the

ProSeal™ group, had most of the sealant material worn away from the enamel surface.
 38

Graph 1. Mean lesion depths and standard deviation for each of the five treatment
groups.
 39

Mean Depth
Group Std Dev Min Max
N (µ
µm)

Control 107.28 14.61 73.70 130.46

15

SeLECT Defense™ 38.81 20.45 10.25 76.09

15

OrthoCoat™ 38.67 18.85 2.41 73.20

15

Biscover LV™ 35.28 13.29 13.03 58.32

15

ProSeal™ 19.55 14.22 0.00 60.43

15

Table 1. Descriptive statistics for mean lesion depth by treatment group.

 40

Sealant Materials Mean Lesion Depth Group

Comparisons***
(SD)
A
Control 107.28 (14.61)
B
SeLECT Defense™ 38.81 (20.45)
B
OrthoCoat™ 38.67 (18.85)
B
Biscover LV™ 35.28 (13.29)

ProSeal™ 19.55 (14.22) C

***means with the same letter are not significantly different using post-hoc
Ryan-Einot-Gabriel-Welsch multiple range test (P>.05).

Table 2. Mean lesion depths by the type of sealant materials.

 41

Control (n = 15) Biscover LV™ (n = 15)

Average Depth = 107.21µm Average Depth = 35.28µm
Std Dev = 14.61 Std Dev = 13.29

SeLECT Defense™ (n = 15)

Average Depth = 38.81µm
Std Dev = 20.45

Figure 13. Composite of polarized light microscopy images of representative lesions

from all five treatment groups.
 42

OrthoCoat™ (n = 15)
Average Depth = 38.67µm
Std Dev = 2.41

ProSeal™ (n =15)
Average Depth = 19.55µm
Std Dev = 14.22

Figure 13 - continued
 43

DISCUSSION

The purpose of this study was to compare, in vitro, the effectiveness of the resin

sealants ProSeal™, OrthoCoat™, SeLECT Defense™, and Biscover LV™ on the

inhibition of enamel demineralization after subjection to extensive mechanical toothbrush

abrasion. Seventy-five non-carious, non-restored extracted human molars were used in

the study. Fifteen teeth were used in each of the five groups.

This study gave results that were comparable with a similar study performed by

Loucks in 2006. In her study, Loucks compared the long-term resistance of wear and

demineralization of three materials - a filled and unfilled dental sealant and a fluoride

varnish. She had six conclusions from her study of Delton®, Fluor Protector™ and

ProSeal™:

1. All materials tested provided a significant reduction in enamel demineralization as

compared to untreated controls.

2. Fluor Protector™ resulted in a 47% decrease in lesion depth.

3. Delton® provided a significantly larger reduction in demineralization than Fluor

Protector™ (72%).

4. Pro Seal™ provided significantly more protection than Delton® (92% reduction).

5. Fluor Protector™, Delton®, and Pro Seal™ should all be considered effective

preventive treatments that do not require patient compliance for success.

6. Pending further clinical investigation, Pro Seal™ should be considered the “gold

standard” for preventing enamel demineralization in orthodontic patients.

With the exception of ProSeal™, the long-term resistance to wear and

demineralization is not documented for the other three materials tested in this study. It

would be beneficial to see how these other sealant materials compared to ProSeal™ in

their long-term resistance to toothbrush wear and in their ability to reduce

demineralization. Therefore, in order to simulate extensive toothbrush abrasion, each

 44

tooth was subjected to 15,000 strokes on the Prototech Toothbrush Wear Simulator.

Previous short term studies have subjected teeth to 10 brush strokes, twice per day, to

simulate normal hygiene (Juhlin, 2004; Wittenberger, 2003). Extending this brush

stroke protocol (20 strokes per day) out over a two year period resulted in a total brush

count of approximately 15,000. Similarly, Hu and Featherstone (2005) and Loucks

(2006) utilized this same brush count to approximate two years of toothbrush abrasion.

This study confirmed that Pro Seal™ can withstand long-term toothbrush

abrasion over a two-year simulated timeframe. This is supported by its 82% reduction in

enamel demineralization in comparison to controls. It should be noted that in addition to

having a small average lesion depth as a group, several of the teeth in the Pro Seal™

group had no detectable lesions at all. Also, many of the photomicrograph sections

showed a visible layer of ProSeal™ (Figure 13) remaining on the tooth after the

simulated wear and demineralization challenge. Being highly-filled resin, it is better able

to withstand long-term wear. In addition, Reliance, Inc. claims that the product has a

reported final sealant polymerization of 100% without an oxygen inhibition layer. This

ensures adequate thickness to resist abrasion and also creates a smooth, even resin

surface.

The results of these in vitro studies suggest that Pro Seal™ is an effective long-

term preventive sealant. However, future clinical studies are needed to determine if

ProSeal’s clinical performance is as successful as the results obtained here.

In this study, we were able to simulate the approximate amount of toothbrush

strokes that could be encountered over a typical orthodontic treatment timeframe.

However, because this was an in vitro study, factors such as mechanical and chemical

wear from food and drink and pH fluctuations could not be simulated in the research

design. Also, we did not take into account in the project varying pH levels and the

constant continuum between periods of demineralization and remineralization in the oral

cavity. Lastly, it is unknown how the small amount fluoride in Pro Seal™ may
 45

contribute to the remineralization of any exposed, demineralized enamel. Soliman et. al

(2006) measured the rate and amount of fluoride ions released over a 17 week period.

They found that ProSeal™ released fluoride ions into a solution with a high of 0.074 +/-

0.04 ppm/week/mm2 in the first week and to a low of 0.015 +/- 0.017 ppm/week/mm2 at

the end of the 17th week. They also determined that ProSeal™ had the ability to be

recharged with fluoride ions. More in vivo studies are needed to determine the clinical

significance of this “recharging” phenomenon.

Another aspect of ProSeal™ that was not addressed in the study was its long-term

esthetic appearance as a sealant around orthodontic brackets. Because it is a resin,

ProSeal™ may have a tendency to discolor, turn more yellow over time, and accumulate

more stain. This appearance may be even more noticeable in an orthodontic patient that

drinks coffee, tea, or dark liquids. If the sealant does remain in place throughout the

duration of treatment, factors such as food, drink and pH may affect its chemical

composition and appearance and create unsightly esthetics during treatment. At the end

of treatment, it is also very important to remove all of the remaining sealant material to

avoid long-term staining or discoloration of the sealant over time. This is best

accomplished with either a finishing bur or a polishing point to remove any residual

sealant after debonding.

SeLECT Defense™, OrthoCoat™, and Biscover LV™ also provided a significant

reduction in demineralization in comparison to controls. However, they did not have a

significant difference between them with respect to their ability to decrease

demineralization. Although these sealants were not as effective as ProSeal™ in their

reduction in demineralization, they do share the same limitations in this study as those

just mentioned above with ProSeal™.

The manufacturer of SeLECT Defense™ claims that the product utilizes the

properties of selenium to selectively kill Streptococcus mutans and Lactinobacillus

bacteria on the treated surface. This could theoretically reduce the caries process and
 46

reduce whitespot lesion formation. However, the antimicrobial action of this product was

not simulated or addressed in this study. Amaechi (2008) examined this product in an

artificial mouth study design, which is a continuous flow biofilm model, housed inside a

CO2 incubator maintained at a constant physiologic temperature of 37oF. In the 28 day

study, 90 teeth were assigned to six different groups. Amaechi found that SeLECT™

technology offered 100% prevention of the development of clinically visible whitespot

lesion around orthodontic brackets with an elastomeric ring. Second, microscopic

examination showed that SeLECT™ technology reduced enamel demineralization around

orthodontic brackets by 86% when the tooth was brushed twice daily and by 80% when

the tooth was not brushed. He also concluded that SeLECT™ technology was not

removed by toothbrushing within the 28 day study period (Amaechi, 2008).

In our study, SeLECT Defense™ did not withstand long-term wear, as evidence

by significant or complete abrasion of the unfilled sealant under microscopic examination

(Figure 13). The loss of the sealant protective layer led to lesion formation on the treated

teeth. To overcome this, perhaps the sealant needs to be reapplied at certain intervals to

maintain its protective layer throughout treatment. Also, in our study, we were not able

to address the antimicrobial action of SeLECT Defense™. If a clinical study or simulated

mouth environment with long-term wear for up to two years could be utilized as an

experimental design, perhaps a better conclusion could be drawn for the mechanical and

antimicrobial effectiveness of the sealant material. Future studies are needed to address

these issues.

Biscover LV™ is an unfilled resin mainly used as a polishing agent for dental

restorations. However, it can also be used as a sealant material around orthodontic

brackets. Similar to other unfilled resins, Biscover LV™, is more susceptible to long-

term wear. This was also evident in our study under microscopic examination. To

maintain a protective layer throughout complete orthodontic treatment, it appears that

Biscover LV™ needs to be reapplied again to maintain a protective layer to prevent

 47

demineralization. Additional studies are needed to determine the best intervals for

reapplication of Biscover LV™ during active treatment.

OrthoCoat™ is a filled resin specifically designed for placement around

orthodontic brackets. Because it is a filled resin, one would suspect that it would perform

just as well as ProSeal™ with respect to its ability to resist abrasion. However, this was

not found in this study. OrthoCoat™ performed similar to the unfilled resins, Biscover

LV™ and SeLECT Defense™. There is no explanation why this occurred, but perhaps a

different chemical composition of the product was the cause. Similar to ProSeal™,

OrthoCoat™ does release fluoride after it is applied to a tooth. The manufacturer of

OrthoCoat™ reports that the fluoride released from a 25 mm disk of the product ranges

from 5.80 ppm fluoride the first day to 18.15 ppm fluoride the ninth day. Future research
projects are needed to determine how the released fluoride affects the demineralization

process and also why, as a filled resin, it showed wear results similar to the other unfilled

resins.

Our study showed that OrthoCoat™, Biscover LV™ and SeLECT Defense™

did not resist long-term abrasion and demineralization as well as ProSeal™. However, if

these sealants were placed periodically throughout treatment at different intervals

throughout treatment, they may be better able to resist toothbrush abrasion and act as a

barrier to prevent demineralization. Future in vitro and in vivo research projects would

be needed on these products to determine their best intervals of placement during active

orthodontic treatment.

Limitations of the Study

The results reported in this study are based on an in vitro study that has several

inherent limitations. One limitation is that it is difficult to recreate the oral environment

outside of the mouth. Because this was strictly a demineralization study, remineralization

was not addressed in the study. In the oral cavity, teeth are constantly balancing between
 48

demineralization and remineralization. This is based on a variety of factors in the oral

environment, including diet, salivary pH, and oral hygiene to name a few. In addition,

saliva contains many other components such as proteins and bacteria that affect this

balance. Also, salivary flow cleanses the mouth throughout the day and replenishes ions

and minerals to the oral environment. These factors were not included in the study

design.

Another limitation of this study involves the use of the polarized light

microscope for analysis of the lesions. Although beneficial in being able to quantify

lesion depth for comparison to other treatment groups, the quantitative differences may

not correlate to the same degree as qualitative differences. In other words, a 40 µm

difference between groups may be statistically significant; however, a 40 µm difference

from a clinical, qualitative standpoint may not be distinguishable. Statistically significant

differences between ProSeal™ and the other three treatment groups were reported based

on mean lesion depth; however, whether or not these differences are clinically significant

remains undetermined. Other methods of analysis, such as quantitative light-induced

fluorescence, or even visual examination by an observer, may be beneficial in

determining clinically significant differences.

Finally, this study was limited by variability among teeth and within each tooth in

response to the acidic solution. As shown by the relatively high standard deviations of

lesion depth that was reported within treatment groups, there exists natural variability

among teeth in regards to enamel demineralization susceptibility. This variability was

illustrated in a study by Eberle et al. (2006) where only 130 teeth out of 200 showed

diffuse, white, opaque lesions after 90 hours of demineralization in an artificial caries

solution. In other words, 35% of the sample teeth were resistant to enamel

demineralization without any type of product treatment, which could potentially increase

the variability of demineralization studies.

 49

Future Directions
There are other possible areas of further research on ProSeal™, SeLECT

Defense™, OrthoCoat™, and Biscover LV™, such as: resistance to staining, possible

remineralization capabilities of the products, and how the materials hold up long-term in

vivo.
 50

SUMMARY AND CONCLUSIONS

The purpose of this study was to compare, in vitro, the effects of the unfilled resin

sealants, Biscover LV™ and SeLECT Defense™; and the filled resin sealants,

OrthoCoat™ and Pro Seal™, on the inhibition of enamel demineralization after

subjection to extensive mechanical toothbrush abrasion. After treatment with the

specified product, teeth received 15,000 brush strokes in order to simulate 2 years of

clinical toothbrush abrasion. Samples were then subjected to a single 96 hour course of

acidic challenge. The teeth were sectioned and the depth of enamel lesions was

determined using polarized light microscopy. Results showed that:

1. All materials tested provided a significant reduction in enamel demineralization as

compared to untreated controls.

2. SeLECT Defense™ and OrthoCoat™ both resulted in a 64% decrease in lesion

depth.

3. Biscover LV™ provided a 67% decrease in lesion depth

4. Pro Seal™ provided significantly more protection (82% reduction) than the other

three sealant materials: SeLECT Defense™, OrthoCoat™, and Biscover LV™.

5. Pro Seal™, SeLECT Defense™, OrthoCoat™, and Biscover LV™, should all be

considered effective preventive treatments that do not require patient compliance

for success.

6. Pending further clinical investigation, Pro Seal™ should still be considered the

“gold standard” for preventing enamel demineralization in orthodontic patients.

 51

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