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Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 41-46

Antibacterial monomer-containing adhesive system versus conventional one in reducing demineralization of the enamel around orthodontic brackets: A split-mouth study

Department of Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Dakahlia, Egypt

Date of Submission20-Aug-2018
Date of Acceptance20-Jan-2019
Date of Web Publication12-Jul-2020

Correspondence Address:
Dr. Eqbal Nasser Aqeel
Department of Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Dakahlia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bijo.bijo_1_18

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Objective: The objective of the study was to assess the efficiency of an antibacterial monomer-containing adhesive in the reduction of white-spot lesions (WSLs) around orthodontic brackets (in vivo) in comparison to the conventional adhesive systems.
Materials and Methods: This study was conducted on twenty patients, provided that they required the extraction of the maxillary first premolars as part of their orthodontic treatment plan. This involved only on the maxillary first bicuspids (n = 40) and the left maxillary first premolars represented the control side (n = 20) where the metal brackets (3M, Unitek™ Gemini) were bonded to that side using Transbond XT light cure adhesive (3M, Unitek). Meanwhile, the right side represented the experimental one (n = 20) and the brackets were bonded to them using Clearfil SE protect (Kuraray). After 3 months, both teeth were extracted and examined by both the energy-dispersive X-ray spectroscopy to assess the calcium and phosphorus atomic percentages were assessed in the area surrounding the bracket by and the scanning electron microscopy to evaluate the morphology and crystalline structure of the tooth surfaces.
Results: A significant difference between the antibacterial monomer-containing adhesive and the conventional adhesive system in the prevention of the WSLs formation was evident in the study. Moreover, the difference in the enamel surface morphology was noted.
Conclusions: Antibacterial monomer-containing adhesive can minimize demineralization around the metal brackets (in vivo) compared to the conventional one after a period of 3 months.

Keywords: Antibacterial adhesive system, enamel demineralization, orthodontic brackets

How to cite this article:
Aqeel EN, Shamaa MS, El-Bialy AA. Antibacterial monomer-containing adhesive system versus conventional one in reducing demineralization of the enamel around orthodontic brackets: A split-mouth study. Albasar Int J Ophthalmol 2018;5:41-6

How to cite this URL:
Aqeel EN, Shamaa MS, El-Bialy AA. Antibacterial monomer-containing adhesive system versus conventional one in reducing demineralization of the enamel around orthodontic brackets: A split-mouth study. Albasar Int J Ophthalmol [serial online] 2018 [cited 2023 Sep 27];5:41-6. Available from: https://www.bijojournal.org/text.asp?2018/5/2/41/289598

  Introduction Top

White-spot lesions (WSLs) are considered one of the most prominent hazardous effects commonly associated with fixed orthodontic brackets. This complication not only compromises dental health but also affects the overall orthodontic treatment results as well as the level of patient satisfaction.[1],[2] It was proved that the accumulation of the bacterial plaque was readily increased after brackets fixation, particularly the acidogenic one (Streptococcus mutans). Along with inadequate oral hygiene, the incidence rate of WSLs ranges from 11% to 46%.[3],[4] When the fermentable carbohydrates are high enough in the meals, the bacteria will flourish and produce more acid that leads to decreasing the plaque pH. Once the pH becomes less than the threshold of re-mineralization, carious demineralization occurs. Thus, the fixed orthodontic appliances accelerate the occurrence of dental plaque and decrease the oral pH.[5],[6]

Proper oral hygiene measures together with daily gargle using fluoride mouthwash can fairly cause some degree of inhibition in decalcification.[7],[8] The cariostatic action of topical fluoride therapy comes essentially from the formation of calcium fluoride.[6] Unfortunately, these measures completely depend on patient collaboration, which is not sufficient enough in the prevention of plaque accumulation and demineralization of the enamel surface.[9]

Consequently, the need for adhesive systems decreasing the occurrence of WSLs was raised among orthodontists. Thus, the appearance of fluoride-releasing adhesive systems for the fixation of brackets attracted general attention. It was thought that wherever the fluoride delivery was proximal to the bracket–enamel interface, less need for patient cooperation was critical.[10],[11] Nonetheless, the capacity of these systems to decrease the formation of WSLs practically remained doubtful.[10],[11],[12] Although recalcification by the discharge of fluoride was important, the use of antibacterial agents was considered more crucial as a direct way in inhibition of the bacteria causing dental caries.[13] Antimicrobial agents such as chlorhexidine have been proposed to restrain demineralization produced by bacterial colonies in plaque accumulation around the orthodontic brackets at these conditions.[14],[15],[16]

Currently, bioactive adhesive systems with antibacterial actions or strong remineralization potency are regarded as an effective mean of generating superior clinical achievements.[14] Lately, an antibacterial fluoride-releasing bonding agent has been promoted by combining the physical benefits of dental-adhesive properties and the antibacterial action.[17],[18] Therefore, the aim of this study was to evaluate the effect of an antibacterial monomer-containing adhesive in reducing the enamel demineralization around the orthodontic brackets compared to the conventional adhesive systems.

  Materials and Methods Top

Twenty patients were enrolled in this study with a age range of 13–18 years old, provided that each was scheduled to have their upper first premolars extracted for orthodontic purposes. The study candidates were then informed about the study procedure and informed consent was obtained from each. They were then referred to the department of periodontology to receive the necessary oral hygiene measures and instructions to promote good oral hygiene.

Split-mouth design was used where the left maxillary first premolar of each participating candidate served as the control side. Here, the buccal surfaces of the upper left first premolars were cleaned by rubber cup and pumice, etched for 15 s, rinsed with water, and air-dried. Transbond XT primer was placed and cured for 10 s, followed by placement of the metal brackets (Gemini, 3M/Unitek) which were bonded to these teeth using Transbond XT light cure adhesive (3M Unitek). The right maxillary first premolar served as the experimental one. The buccal surfaces were also cleaned with pumice, etched for15 s, and dried with air. After that, Clearfil SE protect primer was placed and cured for 20 s, and an additional step was required: the Clearfil Bond was applied and cured for 10 s, after which the metal brackets (Gemini, 3M/Unitek) were bonded to these teeth by Clearfil SE protect (Kuraray) [Figure 1]. Oral hygiene instructions were emphasized on the patients; they were advised to brush twice daily.
Figure 1: (a) Photographs showing orthodontic procedures for bracket bonding on the right side; application of Clearfil SE Protect monomer, (b) application of Clearfil Protect bond on the right side, (c) light curing for 10 s, (d) fixing of the bracket on teeth by Transbond XT adhesive, (e) light curing for 20 s, (f) Meanwhile, on the left side, Transbond XT primer applied to the etched surfaces, (g) light curing for 10 s on the left side, (h) fixing of the bracket on teeth by Transbond XT adhesive, (i) light curing for 20 s

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After 3 months, both right and left upper first premolars were extracted, cleaned, and saved in bottles of normal saline. They were sent for assessment by scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX) (JEOL JSM 6510lv). The EDX detector system used in this study was for both qualitative and quantitative microanalyses. This detector is considered the third generation which is faster than Si (Li) conventional and does not require cooling with liquid nitrogen. It passes the X-rays through the window of radiation before entering the detector active volume and has high-resolution spectra that calculate the concentration of the main elements in weight percentage. This is the only analysis that uses this type of detector. It also uses the attached backscattered electron collector to a scanning electron microscope.

Both EDX and SEM were used in this study to measure the percentage of the calcium and phosphorus around the orthodontic brackets, the morphology, crystalline structure, and orientation of the tooth surfaces. Thus, the difference between the antibacterial and conventional adhesive systems in reducing enamel demineralization around orthodontic brackets was determined.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (Chicago: SPSS Inc; IL, USA). Qualitative data were described using numbers and percentage, while quantitative data were described using median (minimum and maximum), mean, and standard deviation. The normality of data was first tested using one-sample Kolmogorov–Smirnov test. The Mann–Whitney U-test was used for nonparametric quantitative variables to compare between thr two studied groups. Significance was determined at P < 0.05.

  Results Top

Mann–Whitney U-test was used to make comparison between the study group (Clearfil SE protect) and the control group (Transbond XT light cure adhesive) regarding the calcium and phosphorus atomic percentage. The atomic percentage is defined as the number of moles of one component divided by the number of moles of all components multiplied by 100 [Figure 2] and [Figure 3]. It showed a high statistically significant difference between study and control groups with the higher median values in the study than in control groups (P < 0.05) [Table 1] and [Table 2].
Figure 2: Percentage of the minerals around orthodontic brackets

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Figure 3: Percentage of the minerals around orthodontic brackets

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Table 1: Comparison between the median of the study and control regarding the calcium atomic % (P <0.05)

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Table 2: Comparison between the median of study and control regarding the phosphorus atomic (%) (P <0.05)

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SEM examination of enamel surfaces adjacent to orthodontic brackets at × 3000 magnification revealed an evident difference between the study and control groups. The enamel surface of the study group (Clearfil SE protect) appeared relatively regular and smooth [Figure 4], while the enamel surface of the control group (Transbond XT) appeared rough, irregular, and very small, and discontinuous depressions of different depths were found with partial removal of the aprismatic layer [Figure 5].
Figure 4: Scanning electron microscopy photograph of the enamel surface of the study group (Clearfil SE protect)

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Figure 5: Scanning electron microscopy photograph of the enamel surface of the control group (Transbond XT)

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  Discussion Top

The WSLs are one of the greatest challenges that face any orthodontist; therefore, many attempts were made to reduce demineralization and WSL development during the period of orthodontic treatment. The formation of biofilm around fixed appliances in addition to poor oral hygiene is the main cause of WSLs.[3],[4] Furthermore, after bracket bonding, the oral colonization of S. mutans was exacerbated.[19] Therefore, to prevent or minimize these lesions, the orthodontic adhesive should have a capability to inhibit the bacterial growth.[20] The incorporation of antibacterial agents, fluoride, or casein phosphopeptide–amorphous calcium phosphate with adhesive systems can reduce demineralization around the brackets.[9],[21],[22],[23]

Recently, the dental market has new self-etching adhesive system that contains fluoride and antibacterial agents.[24],[25] The attainment of an antibacterial adhesive system was done by the addition of the 12-methacryloyloxydodecylpyridinium bromide (MDPB), which is a new monomer that has a powerful bactericidal activity against oral bacteria. According to the outcomes of that study, a new single-bottled 5% MDPB-containing primer was progressing. This new adhesive agent has an antibacterial activity in addition to fluoride-releasing property, commercially it is known as Clearfil Protect Bond (Kuraray).[26]

This bond was expected to remain stable for a long time in clinical service. It was predicted that an antibacterial monomer-containing adhesive will be efficient in impeding the invasion of microbes,[26] although it requires a little more chair time for bonding the orthodontic brackets compared to the conventional systems.

The influence of several preventive materials in decreasing the demineralization of enamel was confirmed by many in vitro and in vivo studies. The in vivo study design has various advantages: the formation of caries and WSLs is evaluated in vital teeth and the adhesive agent is tested in the oral environment. In the current study, the influence of the antibacterial monomer-containing adhesive on demineralization was studied inside the patient's mouth using a split-mouth design in which one side of the mouth is a control side and the other is the study one. The number of the patients was twenty; thus, we had twenty upper right first premolars as a study group (Clearfil SE protect bond) and twenty upper lift first premolars as a control group (Transbond XT).

In the past, the cross-sectional microhardness was used to assess the mineral loss as an evaluation method, while in this study, the demineralization was evaluated using EDX that investigated the alterations in chemical composition (elements quantities) in the enamel and SEM that revealed the structural changes in the enamel surface after fixed orthodontic treatment.[27]

This research showed a highly statistically significant difference between antibacterial MDPB-containing adhesive and conventional adhesive systems regarding the calcium and phosphorus atomic percentage. The concentration of these two minerals (that perform the basic elements of tooth enamel) was higher in the study (Clearfil SE protect bond) than the control (Transbond XT) group. Thus, more demineralization was detected in the control group. This means that the antibacterial monomer-containing adhesive system was more efficient in reducing the development of the WSLs. This is in agreement with the previous studies, like Uysal et al.[26] that used microhardness analysis for comparing between Clearfil SE protect bond and Transbond XT and detected the development of a thin caries lesion around the brackets, with significant differences (P < 0.05) between the two adhesives up to the 50-μm depth of the enamel surface. Superficial lesion depths were detected around the brackets bonded with the Clearfil SE protect compared with the Transbond XT.

This study crossed over a disadvantage of the previous study that had a limited period of 1 month; thus, we increased the experimental period to 3 months to give sufficient time for evaluating the efficiency of this adhesive in reducing the formation of the WSLs.

SEM examination of enamel surfaces adjacent to the orthodontic bracket showed that there were more significant alterations in the enamel surface microstructure and morphology after fixed orthodontic treatment in the Transbond XT than that in the Clearfil SE protects. In the control group, the enamel surface appeared rough and irregular with very small, discontinuous depressions of several depths and partial removal of the layer of the aprismatic enamel layer has occurred, while the enamel surface of the study group appeared relatively smooth and regular with less depression. Thereby, the Clearfil SE protect is not only antimicrobial but also fluoride-releasing agent which renders it as more protective than Transbond XT against enamel demineralization. This was in consistency with Basdra et al.[28] who used SEM for assessment of the fluoride-releasing orthodontic agents. The results of that in vitro study showed that certain fluoride-releasing orthodontic bonding systems may provide an additional degree of safety against caries susceptibility in patients with fixed appliances for a limited period.

  Conclusions Top

The antibacterial monomer-containing adhesive has a significant effect in decreasing the enamel demineralization around fixed orthodontic appliances in vivo after 3 months in comparison with the conventional adhesive systems. The antibacterial monomer-containing adhesive (Clearfil SE protect) needs more chair time for bonding the orthodontic brackets compared to the conventional system that is less time consuming.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Bishara SE, Ostby AW. White Spot Lesions: Formation, Prevention, and Treatment. Seminars in Orthodontics. USA: Elsevier; 2008. p. 174-82.  Back to cited text no. 3
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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