|Year : 2022 | Volume
| Issue : 2 | Page : 128-135
Effectiveness of different preventive regimens on Cariogram parameters of high caries risk patients: A randomized controlled trial
Howaida F Fouad, Amira F Elzoghbi, Rania S Mosallam, Eman A Abouauf
Conservative Dentistry Department, Faculty of Dentistry, Cairo University, Cairo, Egypt
|Date of Submission||14-Nov-2021|
|Date of Decision||23-Feb-2022|
|Date of Acceptance||26-Feb-2022|
|Date of Web Publication||26-Apr-2022|
Dr. Howaida F Fouad
Conservative Dentistry Department, Faculty of Dentistry, Cairo University, Cairo
Source of Support: None, Conflict of Interest: None
Aim: To compare the effect of different preventive regimens containing fluoride toothpaste and chlorhexidine mouthwash with or without minimally invasive (MI) varnish on Cariogram parameters of high caries risk patients. Materials and Methods: A total of 66 participants were divided into three groups according to the tested regimen, A1: fluoride toothpaste with chlorhexidine mouthwash, A2: fluoride toothpaste with chlorhexidine mouthwash and MI varnish, or A3: fluoride toothpaste only (control group). All Cariogram parameters were evaluated and recorded according to Cariogram software (Cariogram, Internet Version 2.01, April 2, 2004 Copyright: D. Bratthall, Sweden) at baseline and after 3, 6, and 12 months. Clinical oral examination was carried out for recording caries experience and plaque scores. The salivary profile was generated by recording buffer capacity, salivary flow rate, and mutans streptococci count. Fluoride program was given according to each group, while the remaining parameters were kept constant. Statistical analysis was performed with significance level set at P ≤ 0.005. Results: Regarding Cariogram sectors, the green, red, and light blue sectors showed a statistically significant difference in all groups. The MI varnish group showed the best results followed by the chlorhexidine mouthwash group and finally the control group using fluoride toothpaste only. Conclusion: MI varnish with other preventive measures could be effectively applied to reduce caries risk, especially in high caries risk patients.
Keywords: Cariogram, Chlorhexidine Mouthwash, Fluoride Toothpaste, MI Varnish
|How to cite this article:|
Fouad HF, Elzoghbi AF, Mosallam RS, Abouauf EA. Effectiveness of different preventive regimens on Cariogram parameters of high caries risk patients: A randomized controlled trial. J Int Oral Health 2022;14:128-35
|How to cite this URL:|
Fouad HF, Elzoghbi AF, Mosallam RS, Abouauf EA. Effectiveness of different preventive regimens on Cariogram parameters of high caries risk patients: A randomized controlled trial. J Int Oral Health [serial online] 2022 [cited 2022 Jun 26];14:128-35. Available from: https://www.jioh.org/text.asp?2022/14/2/128/344065
| Introduction|| |
Despite the increase in oral health awareness, dental caries is still one of the most common public health issues worldwide. Dental caries is a multifactorial disease which is caused due to interaction of cariogenic bacteria, diet rich in fermentable carbohydrates, and host factors over a period of time. Dental caries could only be prevented through addressing and changing the etiological factors. “An ounce of prevention is worth a pound of cure,” this quote by Benjamin Franklin clearly justifies the paradigm shift that occurred in treatment goals of dentistry, where prevention has gained more importance than surgical model.
Multivariate caries risk assessment models have been developed to help clinicians in fabrication of caries management protocols for each caries risk profile. Cariogram is a computer program that predicts patients’ caries risk and illustrates it graphically. It weighs each etiological factor and calculates the total risk and also suggests preventive measures to avoid formation of new caries.
Preventive measures are based on the current caries etiological paradigms. Till now, fluoride remains a key strategy to prevent dental caries. Fluoride could be used in many vehicles, with toothpaste being the most common form of caries control. However, most of the studies proved that many patients brush their teeth the wrong way or in a time that is less than the optimal time for plaque removal, that is why mouthwash has been widely used to augment mechanical plaque removal. Chlorhexidine mouthwash is still considered the gold standard for plaque control due to its potent antimicrobial effect. To further augment fluoride retention in oral cavity, varnish containing 5% sodium fluoride was used. A varnish containing fluoride and casein phosphopeptide (CPP)–amorphous calcium phosphate (ACP) proved to improve the remineralization potential due to bioactive ions.
Cariogram has been used in many studies to evaluate its effectiveness while applying different preventive programs. Karabekiro and Ünlü evaluated the effectiveness of different preventive programs on Cariogram parameters after improving oral hygiene measures with brushing using fluoride dentifrice with/without fluoride varnish or chlorhexidine varnish. They concluded that using preventive programs was effective for reducing the caries risk in young adults as demonstrated using Cariogram. This clarifies the importance of using risk-based prevention rather than routine prevention to obtain more specific and effective prevention program.
Although all these preventive agents proved to be effective in caries prevention, there is little information on their usefulness in improving caries risk of high-risk patients. Thus, the purpose of this study was to evaluate and compare the effect of different preventive regimens containing fluoride toothpaste and chlorhexidine mouthwash with or without minimally invasive (MI) varnish on Cariogram parameters of high caries risk patients. Within this context, the null hypothesis tested was that caries preventive regimen including fluoride toothpaste, chlorhexidine mouthwash, and fluoride varnish will not modify patient’s caries risk compared with fluoride toothpaste only.
| Materials and Methods|| |
Study settings and ethical approval
This randomized controlled clinical study was conducted in Faculty of Dentistry, Cairo University, Egypt. The protocol of this study was registered in clinical trials (www.clinicaltrials.gov) with unique identification number NCT04032184. Ethical approval was obtained prior to the start of the study. The study was approved by Research Ethics Committee (CREC), Faculty of Dentistry, Cairo University, Cairo, Egypt with approval number 19-7-51.
Sample size calculation
Sample size calculation was performed using G*Power 184.108.40.206, according to the results of Karabekiro and Ünlü. The predicted sample size (n) was a total of 54. Sample size was increased by 20% to account for possible dropouts during follow-up intervals to be a total of 66 cases, i.e., 22 for each group. A total of six participants dropped out of the last follow-up examination, two from each group, and were not replaced as nine cases were added to the total estimated sample size to control the attribution bias.
The materials used in this study were
- Fluoridated toothpaste: (Signal® Cavity Fighter) containing 1450 ppm fluoride with active micro-calcium with FDI approval.
- Hexitol mouthwash: the active ingredient is chlorhexidine hydrochloride (CHX) (125 mg/100 mL).
- MI varnish: 5% fluoride varnish with MI (CPP-ACP).
Patient recruitment, study design, and grouping
Patients were recruited from the outpatient clinic of Conservative Department, Faculty of Dentistry, Cairo University, Cairo, Egypt. Only eligible patients who fulfilled the eligibility criteria were included. The inclusion criteria were high caries risk patients with age range 20–50 defined according to the Cariogram caries risk assessment model with no orthodontic or prosthodontic appliance and systemically healthy. Exclusion criteria were patients on cariogenic diet and patients with a compromised medical history.
A written consent was obtained from the patients willing to participate in the trial. The participants were randomly assigned into three groups (n = 22) according to the tested preventive regimen (A), where A1 were asked to use fluoridated toothpaste and chlorhexidine mouthwash, A2 were asked to use fluoridated toothpaste and chlorhexidine mouthwash with MI varnish application, and A3 who served as control group in which participants were asked to use fluoridated toothpaste only. The change in Cariogram scores was evaluated in connection with the used regimen in relation to time (T), where T0 represents scores at baseline, T1 after 3 months from using the preventive regimen, T2 after 6 months, and T3 after 12 months.
To ensure participants’ retention, telephone numbers and address of all subjects in the study were recorded as a part of the signed consent. A phone call was given at the time of the predetermined follow updates. Also, continuous contact with all participants was done each month to collect the empty used tubes and mouthwash bottles to make sure that they are following the proper hygiene measures.
Randomization, random allocation sequence, and blinding
Simple randomization was generated using www.randomization.com. Each participant grasped an opaque sealed envelope. The name of the participant was written on the envelope that contained a code referring to either intervention or control group. This study was a triple-blinded randomized three parallel arms clinical trial with 1:1 allocation ratio.
The clinical examination was carried out by a single examiner who was trained and calibrated for data recording in the Department of Conservative Dentistry, Cairo University, Cairo, Egypt before conducting the study. Data monitoring and editing were done by a main supervisor and two co-supervisors. Oral examination of the enrolled subjects was done using a diagnostic treatment chart. Before beginning of the trial, professional oral prophylaxis was performed and all teeth that had carious lesions were restored with the most suitable restorative material. Any carious lesion that developed during the study was restored. Diet analysis including fermentable carbohydrates intake and amount was done for each participant before starting the trial according to Cariogram. Only participants on non-cariogenic diet were included in the study, and their diet included very low amount of fermentable carbohydrates and consumed maximum three meals per day including snacks. They were advised to continue on the same non-cariogenic diet and were instructed not to change their dietary habits.
All participants were instructed to refrain from additional preventive measures containing fluoride during the study period and were provided with fluoridated toothpaste (Signal® Cavity Fighter) and toothbrushes (Oral-B 3 Effect Maxi Clean toothbrush). They were instructed to locally apply a standardized amount (pea-sized quantities) of the paste to the toothbrush and brush all surfaces using modified Bass technique for 2 min, twice a day after breakfast and at night before going to bed.
The participants in the respective groups were supplied with a bottle of 0.12% chlorhexidine 100 mL (Hexitol). They were instructed to use 10 mL of chlorhexidine rinse without dilution or rinsing with water after its use. They were asked to wash and retain the mouthwash inside their mouth for 1 min before expectorating it. Such a regimen was repeated once a day 30 min after toothbrushing before going to bed, 1 week every month for 12 months.
Varnish application was carried out according to the manufacturers’ guidelines. Teeth were dried and isolated using cotton rolls. Approximately 0.1 mL of varnish was applied to all teeth and allowed to dry for 30 s. Participants were instructed not to rinse their mouth, not to eat/drink for 4 h, and not to brush till the next morning. The procedure was repeated to the respective group once every 3 months for four times during the study period.
Outcome assessment: Caries risk assessment
Caries risk assessment was done for the study participants at each of the four visits using “Cariogram” software (Cariogram, Internet Version 2.01. April 2, 2004 Copyright: D. Bratthall, Sweden). For each participant, the following 10 caries-related variables were inserted into the Cariogram software: caries experience, related general disease, diet contents and frequency, plaque amounts, fluoride program, amount of saliva secretion, amount of plaque, Streptococcus mutans count, buffering capacity, and clinical judgment. All data were scored according to a standardized protocol of Cariogram program and then entered into program to provide the pie chart.
Country/area was set at low risk as Egypt has water fluoridation regimen and the group was high caries risk for all participants. The decayed, missing, and filled index was calculated for all teeth excluding the third molar using solely clinical examination. Regarding related disease, diet content, and frequency, score 0 was given according to inclusion criteria. The plaque index was evaluated using Silness and Loe scale. Examination was done on six teeth: maxillary right first molar, maxillary right lateral incisor, maxillary left first bicuspid, mandibular left first molar, mandibular left lateral incisor, and mandibular right first bicuspid. For each tooth, the four surfaces, buccal, lingual, mesial, and distal, were scored. Then, summation of four scores for each tooth was done and divided by four to obtain the average score for each tooth. After that, the six scores for the six teeth evaluated were summed and divided by six to obtain the average score for the whole mouth. Fluoride intake scores were given according to fluoride supplements in each group. Clinical judgment was set to 1 for all the patients to avoid bias.
Unstimulated and stimulated saliva samples were obtained by asking the patient to refrain from eating, drinking, or oral hygiene procedures for at least 1 h prior to the collection. All saliva samples were collected in the morning from 10 to 11 a.m. in a plastic sealed sterile disposable graduated tube. Unstimulated saliva samples were collected to measure buffer capacity according to the Ericsson method 1959, in which 3 mL of 5 mmol/L HCl was added to 1 mL of unstimulated saliva and mixed vigorously. Then, the sample was allowed to stand for 10 min, after that the final pH was measured using a calibrated digital pH meter Adwa (AD-11) (Adwa Hungary Kft, Szeged, Hungary). Also, stimulated saliva samples were collected to measure salivary flow rate and mutans streptococci count by chewing 1 g piece of unflavored paraffin wax for 5 min. The secretion rate was then calculated by dividing the reading by 5 to obtain the secretion rate per minute. Saliva samples were cultured on Mitis Salivarius Bacitracin (MSB) agar media (HiMedia) with 1% potassium tellurite under strict aseptic conditions. MSB plates were incubated in an atmosphere of 5% CO2 using a candle jar for 48 h at 37°C. After bacterial culture, identification was done morphologically where mutans streptococci are characterized by raised, convex, undulate, opaque pale blue with frosted glass appearance, and colony-forming unit/mL (CFU/mL) was calculated.
Statistical analysis was performed with SPSS 20®13, Graph Pad Prism®14, and Microsoft Excel 201615. Quantitative data were explored for normality by using the Shapiro–Wilk normality test and presented as means and standard deviation (SD) values. Qualitative data were presented as counts and percentages. Regarding qualitative data, comparison was performed using the χ2 test. On the contrary, regarding quantitative data, comparisons were performed by using one-way analysis of variance (ANOVA) test to compare between more than two different groups followed by Tukey’s post hoc test, whereas comparison between more than two successive follow-ups was performed by using repetitive one-way ANOVA test followed by Tukey’s post hoc test. The significant level was set at P ≤ 0.05.
| Results|| |
The intragroup and intergroup comparison for red sector showed that there was statistically significant difference between the three groups at different evaluation times (P = 0.0001). After 3, 6, and 12 months, all groups showed statistically significant difference with group A3 showing the highest score, followed by group A1 and finally group A2 showing the least score. In addition, the mean value of red sector was significantly decreased at 3 months with no statistically significant difference of reduction between 6 and 12 months.
The blue sector intragroup comparison showed statistically significant difference between baseline and 3, 6, and 12 months with P-value = 0.0001, whereas there was no statistically significant difference in all groups between 3, 6, and 12 months. Regarding intergroup comparison, results showed that after 3, 6, and 12 months, all three groups showed statistically significant difference with P-value = 0.001, where group A3 showed the highest scores followed by group A1 and finally group A2 demonstrating the lowest scores. The yellow sector showed no statistically significant difference in the intergroup and intragroup comparison.
The results of green sector intragroup and intergroup comparison showed that there was statistically significant difference between the three groups at different time intervals (P-value= 0.0001). Group A2 showed the highest increase in green sector results followed by Group A1, whereas Group A3 showed the least increase in green sector results. Moreover, 6 and 12 months showed the greatest increase in green sector in all groups. Results are presented in [Figure 1] and [Table 1].
|Figure 1: Bar chart represents Cariogram sectors of all groups regarding all follow-up periods|
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|Table 1: Mean and standard deviation of Cariogram sectors of three groups and comparison between them (also comparison between different follow-up periods of all groups)|
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| Discussion|| |
Dental caries is still one of the most prevalent diseases worldwide in both industrialized and developing countries like Egypt. Therefore, every effort should be taken to help in prevention of this disease. Fluoride-containing toothpastes are by far the most common way for caries prevention being a convenient way for fluoride delivery.
Since most people perform brushing inefficiently, mouthwash could be used as a vehicle to deliver various effective agents to the oral cavity. It is considered a chemical way for plaque removal. Chlorhexidine is considered the gold standard mouthwash due to its antibacterial and antiplaque properties. Chlorhexidine mouthwash is generally used as an adjunct to toothbrushing but never to replace it.
In high caries risk patients, using other vehicles containing fluoride is preferred to elongate the contact time between teeth and fluoride, thus maximizing its preventive effect. MI varnish combines both sodium fluoride and CPP–ACP together, performing a synergistic effect. It is characterized by the bioavailability of calcium and phosphate ions together with fluoride ions at the tooth surface.
Targeting the etiology for caries development through accurate identification and treatment is predominantly the aim of every risk assessment model. Cariogram is an algorithmic computer-based software that illustrates multivariate caries factors in the form of graphical pie. Furthermore, it encourages patients to implement a preventive program that specifically targets the causative factor in each patient.
Different sectors of Cariogram were assessed between groups and within each group at different time intervals. The red sector representing bacteria is calculated as a result of data entry for the bacterial count and plaque index scores. Regarding the control group using fluoride toothpaste only, there was a significant decrease between 3 and 6 months. This improvement was due to decrease in bacterial count represented by mutans streptococci or plaque scores. Several studies evaluated the effect of fluoride toothpaste on improving plaque index scores as Biria et al. in 2017. Others, as Lorenz et al. in 2019, explained that the improvement in plaque index score was due to Hawthorne effect, in which the continuous examination of participants motivated them to change their oral hygiene habits irrespective of ingredients of toothpaste. The antibacterial effect of fluoride toothpaste was investigated by several studies such as Pukallus et al. in 2013, who found that using low-dose fluoride toothpaste for 24 months significantly reduced mutans streptococci count. This occurred mainly due to the physical effect of plaque removal by brushing twice daily rather than the effect of fluoride itself.
Both intervention groups showed the same results for the red sector where there was a statistically significant difference between baseline and 3 and 6 months, whereas there was no significant difference between 6 and 12 months. Chlorhexidine is well known for its potent antiplaque activity as it performs its action by binding one side with the bacterial cell membrane and the other side with saliva. Many studies evaluated the effect of using chlorhexidine mouthwash on plaque index as Khobragade et al., who found a significant reduction in plaque scores after using chlorhexidine. The antibacterial effect of chlorhexidine could be due to alcohol percentage included in the selected mouthwash. To be effective as germicide, it should not be less than 50%. Regarding its antibacterial property, chlorhexidine could be used either as bacteriostatic or as bactericidal depending on its concentration. The antibacterial effect of chlorhexidine mouthwash was studied at various time intervals in our study as not all people respond evenly to chlorhexidine and that its effect will eventually cease at variable time intervals. Only one study by Kamal et al. evaluated the antibacterial effect of 0.12% chlorhexidine after 1 year and found a significant increase after 9 and 12 months due to bacterial resistance after long-term use.
Regarding antibacterial effect of CPP–ACP varnish, our results were in accordance with Yadav et al., who found a significant reduction in bacterial count. They explained that CPP–ACP has higher affinity to bind with S. mutans than with calcium ions, thus increasing bioavailability of calcium in plaque. In addition, calcium has bactericidal and bacteriostatic effects and also it could have been due to high fluoride content in MI varnish. Widyarman et al. found that using CPP–ACP/F could not only reduce the cariogenic bacteria, but also enrich the healthier dental plaque microbiome. Although the results for the antibacterial effect studied by Almaz and Oba in 2020 showed significant antibacterial effect, the results after 3 months did not show improvement in bacterial scores. This could be due to applying varnish only once at the beginning of the trial.
The light blue sector represents that susceptibility occurs due to buffer capacity, saliva secretion rate, and fluoride program. All three groups proved that any one of the preventive programs used was effective in improving saliva-related factors from baseline and after 3 months, with the MI varnish group being the best followed by the chlorhexidine group. As fluoride program was different in each group, this change in itself could have contributed to the results of the light blue sector. The effect of fluoride toothpaste, chlorhexidine mouthwash, or MI varnish on saliva-related factors was not commonly investigated. A study done by Hassan et al. found no significant difference in saliva secretion rate and buffer capacity after using fluoride toothpaste, as ingredients of fluoridated toothpaste used are not directly involved in affecting pH or buffer capacity. Another study done by Velmurugan et al. attributed the effect of chlorhexidine on saliva parameters due to its substantivity. Widyarman et al. found that MI varnish showed a significant increase in saliva pH as it contains calcium and phosphate that play an important role in buffering saliva and plaque pH.
Moreover, the yellow sector indicating circumstances comprises past caries experience and related general diseases. The related general disease score was kept constant for all participants and there was no change in caries experience scores. So our results showed no significant change in the yellow sector in all the groups at all time intervals. This proved that using any preventive measure was successful in preventing occurrence of new lesions. Patel et al. found that no new caries lesions were developed during the 6-month period after using MI varnish due to the synergistic effect of adding CPP–ACP to fluoride containing varnish.
However, the dark blue sector was not investigated in this study as it resulted from diet content and frequency that were kept constant throughout the study.
There was an overall improvement in the green sector of Cariogram in all three groups, indicating the effectiveness of applying various preventive regimens on decreasing caries risk. The green sector, which is the actual chance to avoid new caries, resulted from improvement in all other remaining factors in all three groups. This proved the effectiveness of different preventive regimens applied in our study on caries-related parameters. Although there were differences between preventive programs applied in several studies, the results agreed on the effectiveness of preventive programs in improving Cariogram sectors, especially the green sector similar to that of Renuka and Pushpanjali, Karabekiro and Ünlü, and AbdAllah et al.
The results of this study suggest the rejection of the null hypothesis and confirm the effect of different caries preventive regimens on caries prevention. As this study lacks further evidence to support its findings, because most studies in the literature were of short duration, more research is necessary to confirm the long-term effect of chlorhexidine mouthwash and MI varnish on caries-related factors and whether they play a role in caries prevention.
| Conclusion|| |
Under the parameters of this study and based on the results, it could be concluded that incorporating more vehicles as chlorhexidine mouthwash or MI varnish to the preventive regimen and not just using fluoride toothpaste showed further improvement in Cariogram sectors. Also, the regular and long-term use of preventive regimens has proven to be successful in improving caries-related factors. Risk assessment is deeply correlated with preventive dentistry. If prevention is the new paradigm, then risk assessment should be applied by all dentists.
Future scope/clinical significance
Using different preventive regimens are highly recommended for the improvement of oral hygiene and subsequently caries prevention.
First, grace and foremost thanks to Allah for blessing this work. My grateful thanks and deepest appreciations to Prof. Dr. Amira Farid, Prof. Dr. Rania Mosallam and Ass. Prof. Dr. Eman Abouauf for their support and guidance.
Financial support and sponsorship
The current study is self-funded with no conflict of interest to declare.
Conflicts of interest
There are no conflicts of interest.
All authors had contributed equally and finally approved the manuscript and given consent for publication.
Ethical policy and Institutional Review Board statement
The study was approved by the Research Ethics Committee (CREC), Faculty of Dentistry, Cairo University with approval number 19-7-51 (dated July 28, 2019). The protocol of this study was registered in www.clinicaltrials.gov/ database, with unique identification number NCT04032184. All procedures performed in this study, involving human participants, were in accordance with the ethical standards of the Research Ethics Committee (CREC) of Faculty of Dentistry, Cairo University, Cairo, Egypt, with approval number 19-7-51 (dated July 28, 2019).
Patient declaration of consent
We have obtained all appropriate patient consent forms. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed, this randomized controlled clinical study was held in the Faculty of Dentistry, Cairo University, Cairo, Egypt.
Data availability statement
Data are available upon reasonable request.
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