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European Journal of Orthodontics, 2017, 634–640

Advance Access publication 2 March 2017

Randomized Controlled Trial

Effect of fluoride-releasing resin composite in

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white spot lesions prevention: a single-centre,
split-mouth, randomized controlled trial
Mohannad M. Alabdullah,1,* Alaa Nabawia,1,* Mowaffak A. Ajaj1 and
Humam Saltaji2
Department of Orthodontics, Faculty of Dentistry, University of Damascus, Damascus, Syria, 2Orthodontic Graduate

Program, School of Dentistry, University of Alberta, Edmonton, Alberta, Canada

*Contributed equally to this work.

Correspondence to: Humam Saltaji, Clinical Assistant Professor, Orthodontic Graduate Program, School of Dentist-
ry; 5–476, Edmonton Clinic Health Academy (ECHA); University of Alberta, 11405–87 Ave, Edmonton, Canada T6G 1C9;
E-mail: saltaji@ualberta.ca

Introduction:  The objective of this two-arm split-mouth randomized trial, was to evaluate the
ability of fluoride-releasing resin composite to prevent demineralization and white spot lesion
(WSL) formation, during orthodontic treatment with fixed appliances.
Methods:  Patients needing comprehensive orthodontic treatment were randomly allocated into
two groups, according to the half split-mouth technique. This trial examined a total of 300 teeth in
each group: the control group, in which brackets were fixed with a non–fluoride-containing adhesive
resin; and the intervention group, in which brackets were fixed with a fluoride-containing adhesive
resin. Eligibility criteria included Class I malocclusion in the permanent dentition, adequate oral
hygiene and no missing teeth, active caries, enamel demineralization, fluorosis staining, or heavy
restorations. The primary outcome was the formation of WSLs. Randomization was achieved using
a computer-generated random number table; blinding of the patients, assessor, orthodontist and
data analysist were achieved. The patients were followed for twelve months, during which time
their teeth were checked every three months. To investigate the differences in frequencies and
ranks of demineralization and WSL formation between the two groups, odds ratios were computed
using mixed modelling (to compensate for the clustered nature of the data) with intervention as a
fixed effect and patient as a random effect.
Results:  Thirty-four patients (ages, 13–25 years; mean age, 17.6) were randomized into a 1:1 ratio,
though four patients dropped out before the start of the treatment. The percentage of the teeth
showing the effects of demineralization and WSL formation, increased from 6.3% to 15% for the
control group after three and twelve months, respectively, and from 3% to 16.3% for the study
group, after three to twelve months, respectively. There were no significant differences between
the two groups and no interaction between time and treatment group in the visual inspections
(OR 0.79; 95% CI 0.52, 1.21), in DIAGNOdent examinations (OR 0.68; 95% CI 0.43, 1.06), or in
photographic images (OR 0.72; 95% CI 0.46, 1.11). No serious harm was observed during the trial.
Limitations:  This trial was a single-centre trial, and treatment was carried out by one orthodontist.
Conclusions:  Fluoride-containing resin adhesive does not have the desired preventive effect to
prevent demineralization and WSL formation, during orthodontic treatment with fixed appliance.

© The Author 2017. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
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M. Alabdullah et al. 635

Registration and Protocol: This randomized trial was not registered, and the protocol was not
published before patient recruitment.
Funding:  The University of Damascus funded this trial.

Introduction The current non-inferiority randomized controlled clinical trial,

evaluated fluoride-releasing resin (in vivo), to assess its ability to
Enamel demineralization during orthodontic treatment is a severe
prevent demineralization and WSL formation during orthodon-

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complication. Encouraged by carious demineralization, white spot
tic treatment with fixed appliances, by using visual inspection, a
lesions (WSLs) can occur on the flat area of a tooth; these are milky-
DIAGNOdent Pen and photographic images.
white opaque spots; zones of spongy external enamel (1). White
spot lesions are more common in patients with fixed orthodontic
appliances, than in those without such appliances. While they infre-
quently result in the advancement to caries, they can cause aesthetic Methods
problems, even years after the end of treatment (2). Trial design and any changes after trial
The increased danger of developing WSLs throughout orthodon- commencement
tic treatment is the result of an increased accumulation of plaque This was a two-arm split-mouth, randomized, active-controlled trial
around the brackets (3). The WSLs can be stopped by thorough and with a 1:1 allocation ratio.
habitual methods of maintaining good oral care, dropping dietary
carbohydrate consumption, and by using fluoride-containing den-
Participants, eligibility criteria and setting
tal care materials. The benefit of fluoride usage has been adequately
Consecutive patients were recruited at the orthodontic department
verified, and there are numerous means of its application, such as
from 4 January 2014 to 30 April 2014. Patients were eligible if they
oral rinses, gels, pastes and varnishes (4–6). These approaches, how-
had a Class  I  malocclusion in the permanent dentition, with full
ever, need a high level of patient vigilance to be effective (7). Both
eruption of posterior teeth. Patients were excluded if they had poor
patients and orthodontists have the same observations of WSLs; it
adequate oral hygiene and any of the following characteristics: miss-
is considered that patients are primarily responsible for their com-
ing teeth, active caries; enamel demineralization; fluorosis staining,
mencement (8), due to the patients’ failure to practice adequate oral
heavy restorations; periodontal diseases, abnormal oral conditions;
hygiene, particularly in these areas (9). Improvement of WSLs after
craniofacial syndromes; clefts; and general diseases (such as cardiac
orthodontic treatment was found to be associated with several fac-
pacemakers or mouth drying). Patients were also excluded if they
tors including age of patient, duration of orthodontic treatment,
had previous orthodontic treatment or extractions, bleaching or
tooth type, and frequency of brushing (10).
topical fluoridation, severe crowding >6 mm, severely rotated teeth
Although multibracket appliances are crucial for difficult tooth
(limiting the appearance of buccal surfaces), poor dental health pre-
movements, they also impede oral hygiene; as their components, like
cluding comprehensive orthodontic treatment with fixed appliances,
brackets, bands, elastomeric, archwires (and other parts), cause food
or if they were smokers. If the patient was eligible, we explained the
to gather around them and biofilms to develop (2, 11, 12). Long-
study and invited them to participate, after which we obtained their
term orthodontic treatment causes aggregate risk of WSL forma-
informed consent before finalizing their recruitment.
tion (11) by way of these factors, seriously risking dental health.
Orthodontists need to inhibit this progress by offering complete,
robust and sound advice and encouragement on oral hygiene. The Interventions
hazard of WSLs can be reduced in patients who adhere to a precise Before their orthodontic treatment, all patients attended a spe-
timetable of brushing their teeth several times every day. cialized scaling, debridement (and polishing appointment), and
A number of preventative tools exist for this purpose: fluoride- received oral hygiene instructions. All patients were given a medium
containing mouthwashes, for instance, have been recommended for tooth brush, an interdental brush and toothpaste (not containing
everyday use (13, 14). These tools, however, have to be used properly fluoride). Patients practiced a high level of oral care for two weeks,
to exploit their effect. One alternative approach to prevent WSL for- during which time they were examined for oral hygiene, and their
mation is the use of dental varnishes, in addition to the preventive plaque gingivitis index. The patients were divided into two groups
effect of adhesive which had investigated in vitro (15–18) and in vivo in accordance with the half-split mouth technique. The first group
(19, 20) studies. This method does not require full compliance from was the control; upon whom brackets were fixed with non–fluoride-
the patient and is known to efficiently and effectively reduce WSL containing adhesive resin (Transbond XT™, 3M Unitek, USA). The
formation (21–25). By way of simply releasing fluoride ions, these second group was the intervention group; brackets were fixed with
resources can, temporarily, protect teeth from WSLs, but they can- fluoride-containing adhesive resin (Light Bond™). All patients were
not guarantee long-term defence from caries, nor can they stimulate treated by one orthodontist using the MBT™ prescription (Victory,
remineralization when demineralization has occurred (19, 26). 3M, USA) 0.022” prescription (maxillary and mandibular pre-
The investigation of WSLs may depend on different methods such adjusted edgewise fixed appliances), with a standardized archwire
as clinical or visual inspection, photographic images, or may be per- sequence. The archwires were ligated to the brackets with stainless
formed with some devices such as DIAGNOdent and Quantitative steel ligature 0.010”, to minimize plaque accumulation related to
Light-induced Fluorescent (QLF) devices. For in vitro studies, few elastomeric rings. Before bonding took place, teeth were cleaned
methods can also be used such as scanning electron microscope with a pumice stone and a brush, attached to a low-speed micromo-
muCT scans (27). tor hand-piece.
636 European Journal of Orthodontics, 2017, Vol. 39, No. 6

A blind, split-mouth study was carried out. The resins’ tubes power of 80%). Our calculations assumed 2.25 odds ratio (40%
were labelled ‘A’ and ‘B’. The patients were randomly assigned using proportions of WSLs in control group and 60% proportions in inter-
a computer-generated random number table to one of the two inter- vention group) as described by Bailey et al. (29); this indicates that
vention groups (two types according to the applied resin), using con- 100 teeth required per treatment group (assuming teeth are inde-
secutive, opaque, sealed envelopes that included the randomization pendent). After accounting for clustering of lesions within patients,
sequence. This was generated by an assistant (who was not involved it was estimated that 280 teeth (28 patients) were needed in each
in the study) and comprised the following: type I  (resin A  was group, considering the number of teeth is being inflated by the clus-
applied in quadrants 1 and 3, and resin B was applied in quadrants tering design of 2.8 (29). To account for an expected dropout rate of
2 and 4); and type II (resin A was applied in quadrants 2 and 4, and approximately 20%, we required 34 patients per treatment group.
resin B was applied in quadrants 1 and 3). In half of the sample

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patients the resin Light Bond™ adhesive was used in quadrants 1 Blinding
and 3, while the Transbond XT™ adhesive was used in quadrants 2 The blinding of patients, outcome assessor and therapist were
and 4. In the other half of the sample patients, the treatments were achieved throughout the trials. To help with maintaining blinding,
reversed. Opposing quadrants were selected in order to reduce any both the control and study resin’ tubes were covered with opaque
bias that may occur due to handedness, which can affect the regular- black tape (by an external person), in this way, no connection could
ity of cleaning accuracy. be made between the tubes and the types of bonding. Furthermore,
The condition of the patients’ teeth was followed for twelve blinding of the data analysist was achieved by labelling treatment
months, during which time they were checked every three months. groups as ‘group 1’ and ‘group 2’, without providing further details
During checkups, the degree of enamel mineralization of all teeth was about nature of the intervention in each intervention group.
detected by visual inspection, and measured with a DIAGNOdent Pen
2190 (KaVo, Biberachan der Riss, Germany). Readings of between 0 Statistical analysis
and 13 indicated healthy enamel, between 14 and 20 suggested ini- All measurements from the digital images, visual inspections and
tial demineralization, between 21 and 29 meant considerable demin- the DIAGNOdent examinations, were logged and run through the
eralization, and greater than 30 indicated dental caries (these values Statistical Package for Social Sciences (SPSS; IBM, Armonk, NY) and
correspond to a degree of visual inspection: 0, 1, 2 and 3, respec- the Statistical Analysis System (SAS; SAS Institute Inc.) version 9.2.
tively). Furthermore, after cleaning and drying the teeth, the KaVo Intraclass correlation coefficient tests were used to detect the meas-
DIAGNOdent laser was calibrated for each patient (according to the urement accuracy of first and second records on the digital images,
manufacturer’s instructions) and readings were set at four buccal posi- with the 1-month distance between two records. The effect of the
tions on the enamel (gingival, occlusal, mesial and distal), as recom- intervention was tested in SAS; odds ratios (OR) were computed
mended by Banks and Richmond (28). Zero values were documented using mixed modelling technique, with intervention as a fixed effect
in the patients’ records. After bonding the brackets, in follow–up vis- and patient as a random effect, to compensate for the clustered
its, the mineralization of surface enamel was measured within about nature of the data (WSL frequencies on photographic images, and
1mm distance around the bracket. The laser was recalibrated after degree of WSLs in visual inspections and DIGNOdent exams). Also,
every 10 teeth measured. The measurements above were taken every a simultaneous analysis of all time points was conducted including
three months from the onset of the twelve months of treatment. intervention, time, and interaction effects into the model (as fixed
For photographic images measurements, periodic and repeatable effects) with patient as a random effect. An independent sample
photographic images were captured by a digital camera under stand- t-test was used to compare the areas of WSLs on digital images.
ardized conditions (Nikon D80 (used on manual mode): 60-mm lens; Odds ratios with 95% confidence intervals (CI) were reported, and
magnification ratio 2:1). The images were captured perpendicular level of significance was set at P < 0.05.
to the vestibular surfaces of teeth and saved to computer as JPEGs.
They were then examined for the following characteristics: frequen-
cies (evaluation of frequency of WSLs formed on tooth surfaces); area Results
of WSLs (after 1  year of treatment these were detected and calcu- Patient flow and baseline data
lated, using AutoCAD: Autodesk 2013 software, by an external and The study sample consisted of 34 patients, though four patients
blinded assessor); and examination of WSL area, using AutoCAD dropped out during the two-week phase of the oral hygiene evalua-
(WSLs areas were calculated related to the total buccal surface of the tion (before the start of the trial), due to having poor oral hygiene.
teeth, using Polyline icon, the program then calculates the square of The remaining sample size was one of 30 patients (13 males, 17
WSLs: WSL Square = WSL area / total buccal surface area × 100). females), aged between 13 and 25  years-old, with a mean age of
17.6  ±  3.55. Collectively, the patients had 600 teeth, between the
Outcomes, stopping guidelines and changes after second premolars on each side. The flow of patients in the study is
trials’ commencement displayed in Figure 1.
The primary outcome measure in this study was the formation of
WSLs evaluated by visual inspection. The secondary outcomes were Visual inspection
the degree of demineralization in DIAGNOdent examinations, fre- Results of the mixed modelling analyses showed that there was no
quencies of WSLs detected on digital photographic images, and area effect of the adhesive type on degree of WSLs formation by visual
of WSLs on photographic images after one year of treatment. No inspection (OR 0.79; 95% CI 0.52, 1.21), and no presence of inter-
interim analyses were planned, and no outcome changes or stopping action between time and treatment group (P = 0.17) (see Table 1).
guidelines were experienced. The odds ratio was not statistically significant at all follow-up peri-
ods (see Table 2): the third month (OR 0.66; 95% CI 0.43, 1.02), the
Sample size calculation sixth month (OR 1.08; 95% CI 0.78, 1.50), the ninth month (OR
The sample size was calculated using G*Power 3.1.3 statistical 1.15; 95% CI 0.87, 1.52) and the twelfth month (OR 1.07; 95% CI
software, with proportional two independent groups (α = 0.05 and 0.82, 1.39).
M. Alabdullah et al. 637

DIAGNOdent measurements study group (after 1  year of treatment), and without a significant
The results showed that there was no effect of the adhesive type on difference between groups according to the independent t-test (see
the degree of demineralization of enamel measured by DIAGNOdent Table 5).
pen (OR 0.68; 95% CI 0.43, 1.06), and no presence of interaction
between time and treatment group (P = 0.09) (see Table 1). The odds Harms
ratio was not statistically significant in any of the follow-up periods Other than the WSLs formation, no serious harm to the teeth and
(see Table  3): the third month (OR 0.68; 95% CI 0.43, 1.07), the gingival tissue was observed during the trial.
sixth month (OR 0.85; 95% CI 0.59, 1.22), the ninth month (OR
1.10; 95% CI 0.83, 1.45) and the twelfth month (OR 1.05; 95% CI
0.81, 1.37). Discussion

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Since the appearance of WSLs at the end of orthodontic treatment
Photographic images measurements is an aesthetics issue, the application of new, non-compliance pre-
The results showed that there was a high correlation between first ventive materials or methods, is considered necessary to resolve this
and second assessment of WSLs areas on photographic images problem. In our study, Light Bond™ resin was used as a preventive
(intraclass  coefficient correlation, 0.998; P  ≤  0.001). Accordingly, material, with Transbond XT™ resin being used as the control. The
only one assessment was considered for the analysis. For ‘frequen- study design was a blinded randomized control trial, where none of
cies’, the count of affected teeth had increased in both groups during the patients, the operator or the assessor of the WSLs during follow-
treatment with no significant difference between the two groups (OR ups, had knowledge of which material was used as a bonding adhe-
0.72; 0.46, 1.11) (see Tables 1 and 4). The odds ratio was only statis- sive (whether the resin contained fluoride or not). Furthermore, the
tically significant at the third month (OR 0.62; 95% CI 0.39, 0.98). interventions were applied according to half-split mouth technique,
For ‘area of WSLs’, the mean area of formed WSLs was in order to minimize the risk of confounding factors, such as the
1.87  ±  1.71 in the control group, compared to 1.56  ±  1.51 in the naturally predominant side of patients brushing habits and the dif-
ferences between patients related to food regime and preferred chew-
ing side (aside from the difference pertaining to when patients used
a non–fluoride-containing tooth paste, and when they did not use
fluoride mouthwash during follow-up periods), to detect the effect
of the adhesive itself.
While no significant differences were found after 3, 6, 9 and
12 months of treatment, WSL frequencies increased during the treat-
ment, in both groups that used the fluoride and non–fluoride-con-
taining adhesive. There were no significant differences in frequencies
or demineralization degrees between the fluoride and non-fluoride
resins, during the follow-ups periods of treatment, however, in either
the visual inspections or the DIAGNOdent examinations. Results
of evaluating photographic images showed that the frequency
of affected teeth with WSLs had increased from 18/7 teeth at the
third month, to 46/51 teeth at the twelfth month, in the control and
intervention groups, respectively. There was a significant difference
for the third month in frequencies, probably due to the weak and
short-lasting preventive effect of fluoride-containing resin compos-
ite, which did not last more than three months in our study. On the
other hand, the area of WSLs after 1 year of treatment was similar
in both groups, with no significant difference detected between the
groups. The potential explanations for the non-significant preventive
effect of the fluoride-containing resin, include the following factors:
a small amount of adhesive was used to bond the bracket, (not of
adequate quantity to contain enough fluoride ions), the hydrophobic
condition of resin composite; which does not allow for the interac-
tions between saliva and resin to occur; and the light curing mode of
Figure 1.  Enrolment and randomization of patients in the study. resin composite, which shortens the ability to release fluoride ions.

Table 1.  Simultaneous analysis of all time points including intervention, time, and interaction effects into the model (as fixed effects) with
patient as a random effect. Ratio is 3M to Reliance.

Odds ratio* for Treatment effect Time effect Time effect Interaction effect
treatment effect (95% CI) P value estimate P value (P value)

Visual inspection 0.79 (0.52, 1.21) 0.28 −0.32 (−0.42, −0.22)  < 0.0001 0.17
DIAGNOdent examination 0.68 (0.43, 1.06) 0.09 −0.36 (−0.47, −0.25)  < 0.0001 0.09
Photographic images 0.72 (0.46, 1.11) 0.14 −0.36 (−0.47, −0.26)  < 0.0001 0.08

*For visual inspection and DIAGNOdent this is a proportional odds ratio; for photographic images it is a simple odds ratio.
638 European Journal of Orthodontics, 2017, Vol. 39, No. 6

Table 2.  Degree of white spot lesion formation in visual inspection.

Time point 3M count 0/1/2 Reliance count 0/1/2 Proportional odds ratio (95% CI) P value

T1 (3 months) 281/8/11 291/4/5 0.66 (0.43, 1.02) 0.06

T2 (6 months) 273/4/23 271/9/20 1.08 (0.78, 1.50) 0.65
T3 (9 months) 264/10/26 256/12/32 1.15 (0.87, 1.52) 0.32
T4 (12 months) 255/13/22 251/13/36 1.07 (0.82, 1.39) 0.61

Table 3.  Degree of demineralization of DIAGNOdent examination.

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Time point 3M count 1/2/3 Reliance count 1/2/3 Proportional odds ratio (95% CI) P value

T1 (3 months) 283/7/10 292/4/4 0.68 (0.43, 1.07) 0.09

T2 (6 months) 274/5/21 281/3/16 0.85 (0.59, 1.22) 0.38
T3 (9 months) 264/10/26 257/18/25 1.10 (0.83, 1.45) 0.52
T4 (12 months) 257/13/30 253/18/29 1.05 (0.81, 1.37) 0.72

Table 4.  Frequency of white spot lesions on photographic images.

Time point 3M count 1/2 Reliance count 1/2 Odds ratio (95% CI) P value

T1 (3 months) 282/18 293/7 0.62 (0.39, 0.98) 0.04

T2 (6 months) 274/26 274/26 1.05 (0.75, 1.49) 0.76
T3 (9 months) 263/37 255/45 1.17 (0.88, 1.54) 0.28
T4 (12 months) 254/46 249/51 1.09 (0.84, 1.42) 0.51

Table 5.  Area of white spot lesions on photographic images.


3M Reliance Total Diff. 95% CI P value

WSL area, No. 46 51 97 0.307 (−0.82, 1.44) 0.58

Mean (SD) 1.87 (1.71) 1.56 (1.51) 1.72 (1.60)

The maintenance of a constant low-dose source of fluoride ions, the interpretations from the DIAGNOdent device into categories,
has been identified to have a cariostatic influence (26, 30). To benefit depending on the magnitude of the caries lesions for easier clarifica-
from this effect, fluorides have been added to adhesive resins. Light tion. The validity and reproducibility of the DIAGNOdent devices,
Bond™ (Reliance Orthodontic Products, Itasca, IL, USA), a light- for revealing dental caries on different dental surfaces, have been
curing resin with a high filler content, has the sufficient adhesive examined and proven (40, 41). The conventional DIAGNOdent and
strength for bracket-bonding and is, consequently, appropriate for the DIAGNOdent Pen (DP; KaVo) exhibited excellent agreement in
both the attachment of the brackets and the sealing at the enamel the quantification of caries (42).
surfaces (31). Visual inspection to detect WSLs is the most frequently The in vitro studies findings signify that the Light Bond™ resin
employed method for this purpose, due to the simplicity of its sub- did not have the ability to release fluoride ions for more than one
mission and the convenience of the technique in different clinical month. These results agree with those from a study by Banks et al.
and research facilities (32). Concerning the development of caries, (43), which compared a fluoride-releasing composite with a non–
detection and quantification methods have led to the improvement fluoride-releasing composite in 50 patients, using split-mouth mode
of devices, which enable the measurement of the degree of caries for 25 months. In this study, no significant differences were found
lesions, and the screening of their occurrence (33). between groups. These further agreed with a study by Turner (44),
The frequency of WSLs in orthodontic treatment has been stated which did not find any significant differences in WSL formation
to be 38% and 46% after 6  months and 12  months, respectively, between fluoride-containing and non–fluoride-containing resins, by
paralleled with 11% in the control group (34). Rosenbloom and using the half split-mouth design in 22 patients, during 12–14 months
Tinanoff (9) and Schlagenhauf et al. (35) found that fixed orthodon- of follow-up. Also, Mitchell’s study (45), which investigated the
tic appliances were related to considerably augmented concentra- WSLs using both visual inspection and photographic images, did not
tions of Streptococcus mutans pathogens at the end of treatment, find any preventive effect of fluoride-containing resin. The inability
compared with those present on commencement. Reduced oral of fluoride-releasing composite to protect teeth from demineraliza-
hygiene can cause increased plaque accumulation around braces tion or WSL formation, might be a result of fluoride-release stopping
(36), which can cause demineralization within a few weeks (37). after a short period following bonding, (after only 4 weeks in some
The KaVo DIAGNOdent is a movable laser fluorescence device studies). This may be explained by the light curing, hydrophobic
that releases light from a diode laser, and can discriminate between properties of the resin composites, and the small amount of resin
healthy and carious tooth surfaces and how these surfaces can used to adhere the bracket onto the tooth, which, in turn, does not
absorb the fluorescent laser (38). Published studies (39, 40) classified contain enough fluoride ions to release or to be recharged. Thus, this
M. Alabdullah et al. 639

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venting demineralization and WSLs. However, our trial had some
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limitations. First, the study did not evaluate any means of fluoride
mutans levels in patients before, during, and after orthodontic treatment.
recharging. Furthermore, the lens used in our study was 60 mm in
American Journal of Orthodontics and Dentofacial Orthopedics, 100,
length; the 105  mm length lens is a better lens use in such trials 35–37.
for intraoral imaging with, however, this was not available during 10. Kim, S., Katchooi, M., Bayiri, B., Sarikaya, M., Korpak, A.M. and Huang,
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ences; future randomized trials should consider having a smaller OR 625–633.
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Finally, the generalizability of our findings might be limited because spot formation after bonding and banding. American Journal of Ortho-
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one orthodontist.
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Conflict of Interest 18. Vorhies, A.B., Donly, K.J., Staley, R.N. and Wefel, J.S. (1998) Enamel dem-
None to declare. ineralization adjacent to orthodontic brackets bonded with hybrid glass
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