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Year : 2022  |  Volume : 13  |  Issue : 4  |  Page : 117-120

Efficacy of Three Commercially Available Fluoride Releasing Varnishes in Remineralization of Artificial White Spot Lesions Evaluated by Laser Fluorescence: An In Vitro Study

1 Department of Orthodontics, College of Dentistry, University of Baghdad, Baghdad, Iraq
2 Department of Orthodontics, College of Dentistry, University of Baghdad, Iraq

Date of Submission17-Jul-2022
Date of Decision11-Aug-2022
Date of Acceptance13-Aug-2022
Date of Web Publication12-Dec-2022

Correspondence Address:
Abeer Abdul-Kareem Mohammed Hussain
Department of Orthodontics, College of Dentistry, University of Baghdad, Baghdad, Kerbala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_79_22

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Introduction This study aimed to assess the remineralization of shallow and deep artificial white spot lesion (WSL) by the application of three fluoride releasing varnishes. Methods Sixty-four extracted premolars were subjected to acid attack inducing two depths of WSLs. Using a DIAGNOdent pen, teeth were divided into two groups according to the WSL depth: shallow enamel (SE) and deep enamel (DE). Then each was subdivided into four intervention groups of eight teeth each: MI varnish, Clinpro White varnish, Clinpro XT, or control (artificial saliva). Laser fluorescence were measured via DIAGNOdent pen at baseline, demineralization stage, 24 h, 4 weeks, and 8 weeks after intervention. Results For each lesion depth, there were statistically significant differences among the agents after intervention (P < 0.01) and among time intervals for each group (P < 0.01). Conclusion MI varnish is more effective than Clinpro White varnish or Clinpro XT in remineralizing two depths of WSLs at different time points.

Keywords: Casein phosphopeptide-amorphous calcium phosphate, Clinpro XT varnish, Clinpro White varnish, deep enamel, DIAGNOdent pen, fluoride, laser fluorescence, MI varnish, shallow enamel

How to cite this article:
Hussain AKM, Rafeeq RA. Efficacy of Three Commercially Available Fluoride Releasing Varnishes in Remineralization of Artificial White Spot Lesions Evaluated by Laser Fluorescence: An In Vitro Study. Dent Hypotheses 2022;13:117-20

How to cite this URL:
Hussain AKM, Rafeeq RA. Efficacy of Three Commercially Available Fluoride Releasing Varnishes in Remineralization of Artificial White Spot Lesions Evaluated by Laser Fluorescence: An In Vitro Study. Dent Hypotheses [serial online] 2022 [cited 2023 Mar 21];13:117-20. Available from:

  Introduction Top

White spot lesion (WSL) is a common esthetic impairment associated with fixed orthodontic treatment that can be remineralized to some extent by saliva, although this is a slow process.[1] Fluoride has been demonstrated to hasten the remineralization process and the varnish is the preferable option as it is less dependent on patient compliance.[2]

Currently, some manufacturers have updated fluoride varnishes with calcium and inorganic phosphate ions in an attempt to boost effectiveness even further. Tricalcium phosphate modified by fumaric acid (fTCP) (Clinpro White varnish, containing 5% NAF), casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) (MI varnish, containing 5% NAF and 2% CPP-ACP), and resin-modified glass ionomer varnish (RMGI) (Clinpro XT varnish) are available as fluoride-containing varnishes.[3],[4] To the best of our knowledge, there was no study evaluating their remineralizing capacity for different depths. So this research aimed to assess and compare the capacity of these varnishes to remineralize shallow and deep enamel WSLs using the DIAGNOdent-pen (KaVo, Biberach, Germany).

The null hypothesis was assumed that there was no significant difference between CPP-ACFP, fTCP, and RMGI varnishes in remineralizing two depths of WSLs.

  Materials and Methods Top

The study was approved by the research ethics committee of the Baghdad University/College of Dentistry (Reference number: 616/616422). The study design was in vitro, single-blinded (the data analyst was blind to the type of intervention) with simple randomization.

Sample preparation

A sample size of 64 permanent premolars, with eight teeth per group, was required to significant difference in fluorescence among subgroups calculated based on a previous study,[5] with a power of 80% and 0.05 significance using G-power software (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany).

Sixty-four sound permanent premolars extracted for orthodontic reasons were included in the study. Teeth with any hypoplastic areas, cracks, gross irregularities, and teeth showing a DIAGNOdent score of more than 7 (as a DIAGNOdent score between 3 and 7 indicates normal enamel) were excluded. The extracted teeth after cleaning and polishing with fluoride-free pumice were sterilized with 0.5% chloramine-T solution (Kanto Chemical, Tokyo, Japan) for 1 week and then kept in normal saline at room temperature. Each tooth was poured in acryl (Kerr, Czech Republic) with the aid of a specially designed mold and covered with nail varnish (Flormar, Turkey), leaving a 6 mm x 6 mm window on the center of the buccal surface. The acrylic base was used to number each window from 1 to 64. Before each session, the device was calibrated against its own ceramic standards, as advised by the manufacturer. The type B probe was used, keeping the tip in close contact with the tooth surface and tilting it around the measurement area to gather fluorescence from all directions. The baseline fluorescence values were then recorded.

Artificial WSL induction

All teeth were then immersed in demineralizing solution (2.2 mM calcium chloride (rpicorp., USA), 2.2 mM monopotassium phosphate (rpicorp., USA), and 1 M potassium hydroxide (rpicorp., USA)) were mixed to make the demineralizing solution with the addition of 0.05 mM acetic acid (rpicorp., USA) to create an acidic medium with a pH of 5, which was changed daily till the appearance of the frosty white areas. The WSL extent was evaluated with the DIAGNOdent™ pen every single day and according to its reading, the teeth were divided into two main groups 32 teeth each, shallow enamel (SE) (DIAGNOdent™ pen value: 14–20) and deep enamel (DE) (DIAGNOdent™ pen value: 21–29).


The teeth with SE and DE WSLs were randomly ( assigned into four intervention groups including MI Varnish (GC, Japan), Clinpro White varnish (3M, Australia), Clinpro™ XT varnish (3M, Australia), and control group.

In control group teeth received no fluoride treatment and were kept in artificial saliva (Carter’s formula) which prepared by dissolving 1.2 g KCl (rpicorp., USA), 0.33 g KSCN (rpicorp., USA), 0.2 g K2HPO4 (rpicorp., USA), 1.5 g NaHCO3 (rpicorp., USA), 0.7 g NaCl (rpicorp., USA), 0.26 g Na2HPO4 (rpicorp., USA), and 0.13 g urea (rpicorp., USA) in 1000 mL deionized water, then sodium hydroxide (NaOH) (rpicorp., USA) and lactic acid (rpicorp., USA) were employed to adjust the pH to the mean human salivary pH 6.75.

Laser fluorescence were measured via DIAGNOdent pen at baseline, demineralization stage, 24 h, 4 weeks, and 8 weeks after intervention.

Statistical analysis

Data were analyzed via repeated measures ANOVA and the Tukey post hoc test using R 3.6.3 software (R Foundation for Statistical Computing, Vienna, Austria).

  Results Top

Statistically significant differences found for both SE and DE WSLs for difference intervention groups and timelines (P < 0.001) [Figure 1]. Post hoc test showed statistically significant differences for both SE and DE WSLs for different timelines (P < 0.001). Yet, different commercially available remineralizing agents showed a divers spectrum of efficacy [Figure 1], [Table 1].
Figure 1 Box and whisker plot showed results of the DIAGNOdent pen values for both shallow enamel (SE) and deep enamel (DE) artificial WSLs showing efficacy of different commercially available remineralizing agents.

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Table 1 Results of post hoc test for different commercially available remineralizing agents for both shallow enamel (SE) and deep enamel (DE) artificial white spot lesions

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  Discussion Top

Since WSLs are one of the most unfavorable side effects of fixed orthodontic treatment, it is critical to understand the effectiveness of the remineralization agents. The change in lesion fluorescence was used to determine the impact of the agents. The null hypothesis was rejected based on the findings since differences in the remineralization capabilities were seen among the investigated agents. MI varnish performed better in both shallow and deep lesions as it had the lowest mean values compared to Clinpro white varnish, Clinpro XT varnish, and AS in different time points.

There is substantial evidence to support the systematic use of conventional fluoride varnishes for the treatment of WSLs.[3],[6] Fluoride treatment intends to strengthen the mineral surface layer, by its strong affinity to hydroxyapatite, thus preventing the advancement of the mineral loss. The fluoride ion does not get into the subsurfaces if the suitable concentration and frequency of application are not considered.[6] Previous studies have shown that fluoride-containing varnishes only remain in situ for up to 24 h.[4].Therefore, a reasonable subsequent step was to remove the varnish and conduct the first measurement at 24 h. In a recent research, Sezici et al.[6] stated that Clinpro XT probably delivers a burst of fluoride released after the third week of application. Therefore, the second measurement was done at 4 weeks, and the third at 8 weeks to check for sustained release.

MI varnish superior ability in promoting remineralization could be attributed to its composition, CPP-ACP, and F which afford the enamel surface with not only fluoride ions but also calcium and phosphate ions promoting more homogeneous remineralization throughout the lesion body which has been attributed to the stabilizing properties of the CPP.[7] The findings of this study, the superiority of MI varnish, are consistent with those of Shen et al.[4] who coated human enamel slabs with one of six dental varnishes. In another study by Varma et al.,[8] the results showed that MI varnish had higher remineralizing potential as compared to the Clinpro XT varnish.

Efficacy of the Clinpro White Varnish, may be related to the fact that this varnish contains functionalized tri-calcium phosphate (F-TCP), protecting the TCP by preventing the formation of calcium fluoride or calcium phosphate complexes upon application which would negatively affect remineralization. When F-TCP is delivered to the saliva-moisturized tooth structure, the protective barrier breaks down, allowing calcium, phosphate, and fluoride ions to become free and accessible.[9] Previous researches also imply that Clinpro White as it promotes the remineralization of the surface and subsurface enamel layers.[10],[11]

Kumar et al.[12] evaluated the effectiveness of Clinpro XT utilizing DIAGNOdent, but not by a certain depth examination, and observed a substantial reduction during orthodontic treatment. This may be related to the fact that Clinpro XT varnish is a light-curable RMGI varnish that provides major glass ionomer benefits including adherence to the tooth surface and endured fluoride release.[3]

The differences in the samples of the control groups from baseline to 8th week imply that some natural remineralization occurred. A previous study indicated that the artificial saliva demonstrated remineralizing capacity for WSLs.[13]

With respect to the limitations of in vitro studies, the present of our study could not imitate the exact real-life situations. Further in situ and in vivo studies would be advantageous.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Karlinsey RL, Mackey AC, Stookey GK, Pfarrer AM. In vitro assessments of experimental NaF dentifrices containing a prospective calcium phosphate technology. Am J Dent 2009;22:180-4.  Back to cited text no. 1
Shungin D, Olsson AI, Persson M. Orthodontic treatment-related white spot lesions: a 14-year prospective quantitative follow-up, including bonding material assessment. Am J Orthod Dentofacial Orthop 2010;138:136, e1-8. Discussion 136-7.  Back to cited text no. 2
Shah M, Paramshivam G, Mehta A et al. Comparative assessment of conventional and light-curable fluoride varnish in the prevention of enamel demineralization during fixed appliance therapy: a split-mouth randomized controlled trial. Eur J Orthod 2018;40:132-9.  Back to cited text no. 3
Shen P, Bagheri R, Walker GD et al. Effect of calcium phosphate addition to fluoride containing dental varnishes on enamel demineralization. Aust Dent J 2016;61:357-65.  Back to cited text no. 4
Hussain KM, Al-Shamma MW. Effect of staining and brushing on the surface roughness of white spot lesions treated with resin infiltration technique. Ind J Public Health Res Dev 2019;10:2734.  Back to cited text no. 5
Lena Sezici Y, Yetkiner E, Aykut Yetkiner A, Eden E, Attin R. Comparative evaluation of fluoride varnishes, self-assembling peptide-based remineralization agent, and enamel matrix protein derivative on artificial enamel remineralization in vitro. Prog Orthod 2021;22:4.  Back to cited text no. 6
Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent Res 2010;89:1187-97.  Back to cited text no. 7
Varma V, Hegde KS, Bhat SS, Sargod SS, Rao HA. Comparative evaluation of remineralization potential of two varnishes containing CPP-ACP and tricalcium phosphate: an in vitro study. Int J Clin Pediatr Dent 2019;12:233-6.  Back to cited text no. 8
Vanichvatana S, Auychai P. Efficacy of two calcium phosphate pastes on the remineralization of artificial caries: a randomized controlled double-blind in situ study. Int J Oral Sci 2013;5:224-8.  Back to cited text no. 9
Patil N, Choudhari S, Kulkarni S, Joshi SR. Comparative evaluation of remineralizing potential of three agents on artificially demineralized human enamel: an in vitro study. J Conserv Dent 2013;16:116-20.  Back to cited text no. 10
[PUBMED]  [Full text]  
Damyanova D. In vitro study of the effects of fluoride releasing dental materials on re-mineralization of deciduous teeth. IOSR J Dent Med Sci 2016;15:98-101.  Back to cited text no. 11
Kumar Jena A, Pal Singh S, Kumar Utreja A. Efficacy of resin-modified glass ionomer cement varnish in the prevention of white spot lesions during comprehensive orthodontic treatment: a split-mouth study. J Orthod 2015;42:200-7.  Back to cited text no. 12
Üstün N, Aktören O. Analysis of efficacy of the self-assembling peptide based remineralization agent on artificial enamel lesions. Microsc Res Tech 2019;82:1065-72.  Back to cited text no. 13


  [Figure 1]

  [Table 1]


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