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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 50-57

Remineralization effect of diode laser, Nanoseal®, and Zamzam water on initial enamel carious lesions induced around orthodontic brackets


1 Department of Orthodontic, Faculty of Oral and Dental Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Department of Operative Dentistry, Faculty of Dental Medicine for Girls, Al-Azhar University, Cairo, Egypt
3 Department of Pedodontic, Faculty of Dental Medicine for Girls, Al-Azhar University, Cairo, Egypt

Date of Submission07-Oct-2020
Date of Decision11-Nov-2020
Date of Acceptance30-Nov-2020
Date of Web Publication06-Jan-2021

Correspondence Address:
Sara Mohamed Hosny Elkabbany
Department of Orthodontic, Faculty of Oral and Dental Medicine for Girls, Al-Azhar University, Youssef Abbass Street, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_125_20

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  Abstract 


Purpose: This in vitro study was conducted to evaluate the remineralization effect of laser, Nanoseal®, and Zamzam water on initial enamel carious lesions of premolar induced around orthodontic brackets. Materials and Methods: A total of 40 premolars divided randomly into four groups were submitted to three phases: (1) placement of orthodontic brackets; (2) demineralizing solution; and (3) remineralization (Group L; teeth were irradiated with 980 nm diode laser for 30 s, Group N; Nanoseal® was applied to teeth according to manufacturer's instructions, Group Z; teeth were immersed in Zamzam water for 3 days then rinsed with deionized water, and Group C; control with no treatment). In each phase, elemental analysis (calcium and phosphorus) was measured using a scanning electron microscope/energy dispersive X-ray analysis. The data were tested using the Bonferroni test and Tukey's test. Results: There was a decrease in calcium ion content in Groups C and L in the third phase (−1.62% and − 0.1%, respectively) than the first one. On the other hand, an increase in calcium ion was shown in Groups Z and N (1.1 and 1.6%, respectively). An increase in phosphorus ion was obvious in all experimental groups ranging from 0.6% to 3.7%, with Group N having the highest increase of phosphorus ion from the first to the third phase. Conclusions: Using Nanoseal® and Zamzam water proved to be better than a diode laser for the treatment of initial carious lesions. The use of diode laser helps to remineralize enamel but in a lower percentage than other tested agents.

Keywords: Brackets, demineralization, laser, Nanoseal®, Zamzam water


How to cite this article:
Hosny Elkabbany SM, Mosleh AA, Metwally NI. Remineralization effect of diode laser, Nanoseal®, and Zamzam water on initial enamel carious lesions induced around orthodontic brackets. J Nat Sci Med 2021;4:50-7

How to cite this URL:
Hosny Elkabbany SM, Mosleh AA, Metwally NI. Remineralization effect of diode laser, Nanoseal®, and Zamzam water on initial enamel carious lesions induced around orthodontic brackets. J Nat Sci Med [serial online] 2021 [cited 2021 Jan 22];4:50-7. Available from: https://www.jnsmonline.org/text.asp?2021/4/1/50/306258




  Introduction Top


Development of white spot lesions (WSLs) on enamel surface is the most important iatrogenic effect of the fixed orthodontic appliances. WSLs are enamel subsurface porosities with an opaque milky-white appearance. Previous studies estimated the incidence of these lesions ranging from 50% to 70%.[1] A recent meta-analysis demonstrated that in the 14 studies evaluated for WSLs, the incidence of new carious lesions formed during orthodontic treatment was 45.8% and the prevalence of lesions was 68.4%.[2]

The WSL is an active carious lesion and may progress to an incipient lesion, but the time required is not exactly known. However, the time required for dental caries to develop from the incipient phase to a clinical enamel lesion is well reported and averages 3–4 years in permanent teeth.[3]

Common interventions during or after orthodontic procedures include fluoride and calcium phosphate-based remineralizing agents. However, improving oral hygiene, restriction of cariogenic diet, and other antimicrobials are also part of the comprehensive packages of noninvasive care.[4] Several new methods can be used as alternatives or in combination with fluoride.[5]

The laser can reduce the rate of subsurface demineralization of enamel by altering its crystalline structure, acid solubility, and permeability. However, it should be applied at a low energy level to preserve enamel integrity.[6],[7],[8] Low-power lasers (diode lasers) appear to be an alternative for caries inhibition. However, there are only few studies regarding the effect of low-level lasers for the management of dental caries.[9],[10],[11],[12],[13],[14]

The caries preventive effect of fluoride is well documented.[5] Recent studies investigated the effect of Nanoseal® (a fluoride-containing aluminocalciumsilicate nanoparticle glass dispersed aqueous solution) on enamel and dentin, under the hypothesis that this material can form insoluble mineral deposits that provide acid resistance to the tooth structure and occlude open dentinal tubules.[15],[16]

Nanoseal® consists of an aqueous dispersion of calcium-fluoroaluminosilicate glass nanoparticles and phosphoric acid solution. After mixing the two liquids to acidize the glass, glass nanoparticles aggregate through the acid–base reaction. Studies concluded that the application of it resulted in the deposition of nanoparticles onto the enamel surface porosities and opened dentinal tubules on the artificial lesions. Moreover, calcium and silica incorporation into superficial enamel and dentin lesions were detected.[16]

Ultimately, these studies showed that prior coating with Nanoseal® reduced the demineralization-induced loss of enamel and dentin and suppressed the progression of root caries.[15],[16],[17]

The use of Zamzam water in remineralization of teeth was recently practiced. Zamzam well is located in the holiest city of Muslims; Makkah. It is 4000 years old, approximately 40 m deep, and surrounded by hills of igneous rocks. Zamzam water is different from natural water in terms of minerals and radiological features.[18],[19] The miracle of Zamzam is its continuous flow since 2000 BC.[20]

Recently, water quality assessment and hydrochemical characterization of Zamzam groundwater were studied. The results revealed that the water lies within acceptable limits with respect to dissolved salts, soluble cations, and anions. The computed water quality index (WQI) values reveal that 94% of the water samples were excellent for drinking (class I), and its WQIs were ranged between 28 and 41 with an average of 31.[21]

Studies have shown great potential benefits from Zamzam in fighting various human diseases and developed cancerous growth. The unique mineral composition of Zamzam water ensures several nutraceutical and functional benefits that work in synergism with other agents to impart beneficial effects or to prevent harmful effects.[22]

An important difference between Zamzam water and city water was in the quantity of calcium, sodium, potassium, and magnesium salts; the content of these was slightly higher in Zamzam water, but more significantly, the water contains fluorides that have an effective caries preventive effect.[19]

Exposure to fluoride in drinking water has been shown to be beneficial for oral and general health, especially in relation to dental caries. Ionic calcium in water is the best form to use to insure its proper absorption by the bones and teeth. Previous studies revealed that Zamzam water results in an increase in the surface microhardness of enamel, following pH-cycling, compared to sodium fluoride and casein phosphopeptide–amorphous calcium phosphate (CPP-ACP).[18],[19]

Therefore, the purpose of the present study was to evaluate and compare the remineralization potential of the diode laser, Nanoseal®, and Zamzam water on initial carious lesions in young permanent teeth enamel around orthodontic brackets.


  Materials and Methods Top


The present study was approved by the Ethics Committee of the Faculty of Dental Medicine for girls, Al-Azhar University.

Sample selection and preparation

A sample size of forty was estimated using the power calculation analysis at α = 0.05 and β = 0.20 with 80% being the power of the study using G*Power software (version 3.1.9.2, Franz Faul, Kiel University, Germany).

Forty intact maxillary first premolars, extracted for orthodontic reasons, from 12 to 18 years old patients, who were referred from Orthodontic Department, Faculty of Dental Medicine for girls, Al-Azhar University. Teeth were examined to be free from decay, defects, or cracks. They were cleaned and brushed with nonfluoride containing pumice and washed thoroughly under running tap water then were kept refrigerated at 4°C in 0.1% thymol (Merck KGaA, Frankfurter Str, Darmstadt, Germany) to inhibit microbial growth and were used within 1 month after extraction.[23]

The roots of teeth were removed using a double-faced diamond disc (BesQual Dia-Disc NY 11373, USA size: S-22 mm) in a cutting machine (DEMCO, Dental maintenance CO, Bonsall, California USA, Model E96) under water cooling. The crowns were cut mesiodistally and each buccal part was embedded in heavy body rubber base blocks (BMS 135, BMS Dental s. r. l. via M Buonarroti, Capannoli, Italy) to allow for easy handling of the sample during the application and testing procedures.[24]

Buccal surfaces were covered with adhesive tape; leaving a rectangular window (4 mm × 2 mm) at the site of bonding, which corresponds to the bracket size to ensure that acid etching was restricted only to the exposed window and to standardize the area of adhesion of the brackets.[9] The enamel surface of the windows was conditioned with 37% phosphoric acid (Etching gel, Ormco Corp, Glendora, CA, USA), and subsequently, a thin coat of Ortho Solo® primer (Ormco Corp, Glendora, California) was applied.

A total of 40 stainless steel upper premolars with 0.022” × 0.028” slot, conventional brackets, Roth prescription (OrthoPro, Pro Dent LLC, Sarasota, USA) were bonded to enamel with a light cure composite GrenGloo™ (Ormco Corp, Glendora, California) using a bracket holder. The excess resin was removed with slight pressure. Specimens were light cured for 20 s for each surface with a visible light-curing unit (LED Bluephase C5, Ivoclar, Vivadent, 500 mW/cm2) and finally, the adhesive tape was removed.[9]

Grouping and randomization

Samples were divided randomly into four groups of ten samples each and groups were assigned as follows:

Group L; samples were treated with 980 nm diode laser (Photon Plus Zolar Technology and Manufacturing Co. Inc., Mississauga, ON Canada) at 0.5 W/PW (62.2 J/cm2) in the noncontact mode for 30 s. Group N; samples were treated with Nanoseal® (OLIDENT, Podleze 653, PL– 32-003 Podleze, Poland), innovative protective varnish based on a patented silicone polymer providing adhesion to enamel and dentin without prior etching. Group Z; which was treated with Zamzam water, and finally Group C; which served as the control group that was left without treatment. All samples were subjected for baseline assessment.

Baseline recordings (phase 1)

The specimens were prepared for the first evaluation under a scanning electron microscope-energy dispersive X-ray analysis (SEM-EDX) (JSM-6510, JEOL Ltd., Tokyo, Japan), through which an enamel surface characterization was observed, and percentage analysis of mineral contents of calcium and phosphorus ions was obtained. The buccal surface of each sample was parallel to the slide base of SEM. The samples were analyzed at 15 kV and 400 magnifications.[9]

Demineralizing regimen

Each sample was immersed in a sterile test tube containing 12 ml of freshly prepared demineralizing solution (2.2 mM CaCl2, 2.2 mM NaH2PO4, 0.05M lactic acid, and 0.2 ppm fluoride). The pH was adjusted to 4.5 with 50% NaOH and kept for 72 h at 37°C.[24] Each sample was withdrawn and rinsed with running deionized water for 1 min, then immersed in artificial saliva (storage media) which replenished every day for 3 days.[25] This demineralization procedure was intended to produce an initial carious lesion.

Recording of readings after demineralization (phase 2)

The samples were evaluated for demineralization under SEM-EDX using the same parameters as in baseline.

Application of test agents (remineralization)

Samples in each group were treated with the allocated remineralizing agent following the manufacturer's instructions:

  • Group L: Diode laser was applied at 0.5W/PW (62.2 J/cm2) in the noncontact mode for 30 s/sample, with an oscillatory motion in clockwise direction around the bracket[26]
  • Group N: A thin layer of Nanoseal® was applied on the demineralized surfaces using a cotton applicator, with oscillatory movements in clockwise direction around the bracket, and then allowed to dry for 1 min before repeating the application again for three times
  • Group Z: Each sample was immersed in a 30 ml of Zamzam water for 3 days and then rinsed with deionized water for 2 min
  • Group C: Samples were left untreated.


All samples were then re-examined immediately after the ending of the remineralization procedure.

Recording of readings after remineralization (phase 3)

The samples were assessed using SEM-EDX to study the change in surface characteristics of enamel and estimate the mineral content (Ca, P) with the same parameters in phases 1 and 2.

Statistical analysis

Statistical analyses were carried out with SPSS for 20.0 Windows (SPSS Inc., Chicago, Illinois, USA). The Bonferroni test was conducted to compare mineral changes at different phases, whereas Tukey's test was carried out to compare the mean values of mineral changes for different groups.


  Results Top


The mean percentage difference values of calcium and phosphorus contents between different phases obtained from EDX analysis are shown in [Table 1].
Table 1: Mineral mean percentage difference values between different phases

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Comparison between the first and second phase

The results showed a loss of calcium ions ranging from 1.6% to 4.5%, being more pronounced in Group N. A loss of phosphorus ions was also shown in all groups ranging from 3.9% to 9.4%, being more pronounced in Group N [Table 1] and [Table 2].
Table 2: Mineral mean values

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Comparison between second and third phase

The results showed calcium ions gain in all treatment groups, from 0.17% to 6.04% with Group Z showing the highest uptake of calcium ions. Similarly, there was a gain of phosphorus ions in all groups ranging from 0.5% to 7.9%, being more pronounced in Group Z [Table 1] and [Table 2].

Comparison between first and third phase

The results showed calcium ions loss in Groups C and L in the third phase (−1.62% and −0.1%, respectively) than the first one. On the other hand, an increase in calcium ion was shown in Groups Z and N (1.01% and 1.6%, respectively) than the first phase.

An increase in phosphorus ion was obvious in all experimental groups ranging from 0.6% to 3.7%, with Group N having the highest increase of phosphorus ion from the first to the third phase [Table 1] and [Table 2].

According to the Bonferroni analysis, calcium and phosphorus content showed a statistically significant difference between the first phase and second phase in all groups [Table 3]. While calcium and phosphorus content showed a statistically significant difference between the second and third phases in experimental groups only [Table 4].
Table 3: Comparison of mean values of mineral changes for different groups

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Table 4: Concentration change of minerals in each phase of the study

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Scanning electron microscope analysis

A reference area was established with ×400 magnification to measure the calcium and phosphorus content from each sample [Figure 1]. The qualitative analysis and description of the samples' surface are shown in each phase of the study. In the first phase (at baseline), all the samples exhibited smooth enamel surfaces with no enamel prisms advent [Figure 2].
Figure 1: Bar chart showing a comparison of the mean percentage difference of calcium and phosphorus between different phases for the four groups of the study

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Figure 2: Scanning electron microscope-energy dispersive X-ray analysis images of study groups at baseline (phase 1) where (a) diode laser group, (b) Nanoseal® group, (c) Zamzam water group, and (d) control group

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After demineralization (second phase), all the samples exhibited rough surface and enamel rods became more advent due to enamel surface erosion by the action of the acidic solution [Figure 3]. After remineralization (third phase), enamel surfaces of all experimental groups showed repair of enamel surface defects which was especially more pronounced in Group Z, followed by Group N [Figure 4].
Figure 3: Scanning electron microscope-energy dispersive X-ray analysis images of study groups after demineralization (phase 2) where (a) diode laser group, (b) Nanoseal® group, (c) Zamzam water group, and (d) control group

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Figure 4: Scanning electron microscope-energy dispersive X-ray analysis images of study groups after application of tested agents (phase 3) where (a) diode laser group, (b) Nanoseal® group, (c) Zamzam water group, and (d) control group

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  Discussion Top


Demineralization of enamel leads to the dissolution of hydroxyapatite crystals (HA) and diffusion of calcium/phosphorus (Ca/P) ions toward the tooth surface unless arrested by re-mineralization. Hyper saturation of Ca/P ions on the surface results in a re-precipitation of HA forming the intact superficial layer on the enamel surface.[27]

This vision is supported by the ability to detect caries lesions at an early stage and correctly quantify the degree of mineral loss, ensuring that the correct intervention is needed.[24]

Quantitative assessment of in vitro demineralization and remineralization can be done at the microscale and nanoscale using different methods including SEMEDX, surface microhardness, polarized light microscopy, atomic force microscope, electron probe microanalysis (EPMA), and X-ray diffractometer.[28]

Forty sound premolars, extracted for orthodontic purposes, were selected for this study due to their availability and as they are the most often employed teeth in the Ph cycling models.[29] The collected teeth were extracted from the same age range to avoid large variations in their response under acidic challenge.[29] Specimens were kept in deionized water to which 0.1% thymol was added to prevent bacterial growth and then stored in artificial saliva to prevent dryness of the teeth and to simulate the circumstances in the oral cavity. This agreed with different studies[30],[31] which found that the disinfecting solution and storage medium did not influence the chemical and physical properties of human tooth substrate.

The use of artificially demineralized enamel specimens was of considerable interest as they can be compared to the earliest detectable ultrastructural change in the caries process as agreed with many studies.[24]

To produce and study in vitro enamel demineralization models, many demineralizing agents have been used such as acetic acid, lactic acid, or acidified hydroxyethylcellulose system for different time periods. In the present study, demineralization was carried out as described by a previous study[30] where the samples were kept in the demineralization solution for 72 h at 37°C, creating an initial carious lesion of approximately 150 μ widths with an intact surface simulating a WSL. The concentration of both Ca and P, in the demineralization solution, was at 50% of saturation level, causing dissolution of only enamel subsurface. The addition of fluoride prevented surface demineralization by forming fluorapatite at the surface, which simulated the naturally occurring initial carious enamel lesions having intact surface layer.[24]

In recent years, diode laser irradiation has been applied for its possible strengthening effect on tooth structure. In the current study, the laser group showed loss of calcium ions by 2.68% and loss of phosphorus ions by 6.83% after demineralization. After remineralization; the results showed calcium and phosphorus ions gain in all treatment groups with the laser group showing the lowest uptake of calcium ions by 2.58% and phosphorus ions by 4.5%.[Table 1] and [Table 2].

The results showed calcium ions reduction, in Groups C and L in the third phase (−1.62% and − 0.1%, respectively) than the first one. An increase in phosphorus ion was obvious in all experimental groups with the laser group having the lowest increase of phosphorus ion (2.34%) from the first to the third phase [Table 1] and [Table 2]. Furthermore, diode laser showed unexpected results, achieving a remineralization up to 2.58% in calcium, and a significant increase of phosphorus by 4.5%.

This result was in agreement with another study[9] which demonstrated that therapeutic laser by itself is capable of achieving favorable results, obtaining up to 1.02% remineralization of the enamel surface regarding calcium ion and a minimum but significant increase in phosphorus ions.

The current result was in contrast to another study which demonstrated that the application of 810 nm diode laser at low power mode was not effective in enhancing microhardness of initial carious lesions. This contrast may be attributed to the difference in the used wavelength.[6]

Our result was in contrast to another study which evaluated the effect of a 960 nm diode laser on the solubility of calcium in tooth enamel. The additional application of laser irradiation did not cause any significant increase or decrease in calcium solubility. It has been summarized that diode laser did not make the dental surface less susceptible to demineralization unless a fluoride agent is added.[14]

Moreover, other studies demonstrated low efficacy of diode laser by itself and recommended its use with photoabsorbing cream or in combination with other remineralizing agents such as sodium fluoride.[6],[9],[11],[12],[13] The controversy between our results and some studies may be explained by the differences in laser parameters used such as wavelength, power, frequency, pulse time, and the number of pulses. The contrast may also be attributed to the difference in sample size and study design including the type of the teeth, their composition, age of patients, storage medium, and measurement methods.

Nanoseal® group showed better results than laser group after remineralization, achieving a calcium gain up to 5.32%, and a significant increase of phosphorus 6.48%; this corroborates the findings of a previous study[15] which examined the incorporation of Ca and Si into superficial enamel and dentin with SEM-EPMA after coating them with Nanoseal®. It has been found that the application of Nanoseal® material resulted in the deposition of substances (nanoparticles) onto the enamel surface porosities on the artificial lesions. Moreover, the prior coating with Nanoseal® reduced the demineralization-induced loss of enamel and dentin.[15]

An interesting result recorded in the present study was the higher increase in calcium ion in the third phase in Group N (1.6%) than in the first phase. This can be due to the nanoparticle layer formed by the application of Nanoseal®, covered the enamel surface and supplied ions to the carious defect reducing demineralization until it retained to the same amount of ions or may exceed that of native tooth substrate.

This result was in accordance with a previous study which examined mineral loss in bovine dentin placed into an acetic acid solution. Nanoseal® application consequently suppressed mineral loss in the dentin and surpassed both fluoride varnish and a conventional desensitizer agent.[32],[33],[34]

Furthermore, our result came in accordance with an in vivo study[17] which concluded that Nanoseal® covered the region of root caries with a layer of calcium-fluoroaluminosilicate glass and other precipitates to supply ions to improve the carious lesion. Furthermore, this layer may act as a physical barrier against oral bacteria and acidic food to decrease tooth demineralization.

Zamzam water group showed also advanced results after remineralization, achieving a calcium gain up to 6.04%, and a significant increase of phosphorus 7.9%; these results came in accordance to a previous study[18] which reported an increase in microhardness of demineralized enamel surface after treatment with Zamzam water. This success in the increase of the microhardness value was attributed to the incorporation of Zamzam water elements (fluoride, magnesium, and calcium) in the appetite crystals.[18]

Another interesting result recorded in this study was the higher increase in calcium ion in the third phase in Group Z (1.1%) than in the first phase. This can be explained by Zamzam water has been shown to have additive effects in reducing caries.[19] An increase in phosphorus ion was obvious in all experimental groups ranging from 0.6% to 3.7%, with Group N having the highest increase of phosphorus ion from the first to the third phase [Table 2].

In this study, the evaluation of SEM micrographs allowed us to observe changes in the enamel structure; a visible, remarkable regeneration was observed in most samples of all groups. Zamzam water samples showed more pronounced repair of the demineralized surface under SEM and this may be due to the long period of immersion of samples in Zamzam that allowed the incorporation of Zamzam water elements (fluoride, magnesium, and calcium) in the appetite crystals increasing the repair of enamel substrate and the resistance to acid dissolution.

However, the presence of fluoride components in Zamzam water may be responsible for the chemical reaction between Zamzam water constituents and appetite crystals.

Long period of Zamzam water application was based on the recommendation of a previous study.[18] In addition, these results were in agreement with another in vitro study[19] which concluded that Zamzam water was effective in remineralization of the initial carious lesion and its effectiveness was not different from that of CPP-ACP.


  Conclusions Top


Within the limitations of this in vitro study, the following conclusions could be drawn.

  1. The tested agents (Nanoseal® and Zamzam water) and laser irradiation technique may significantly remineralize initial carious lesions and consequently the clinical WSLs. However, this effective remineralization differed according to the conditions in which they are applied
  2. Using Nanoseal® and Zamzam water proved to be better than a diode laser for the treatment of initial carious lesions. The application of a 980 nm diode laser at low power mode was the least effective strategy to increase remineralization of initial enamel carious lesions.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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