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Table of Contents   
ORIGINAL RESEARCH  
Year : 2021  |  Volume : 32  |  Issue : 1  |  Page : 98-103
Stereomicroscopic analysis of microleakage, evaluation of shear bond strengths and adhesive remnants beneath orthodontic brackets under cyclic exposure to commonly consumed commercial “soft” drinks


1 Asst. Professor, Department of Orthodontics, DY Patil Dental School, Lohegaon, Pune, Maharashtra, India
2 Professor & Head, Department of Orthodontics, Army College of Dental Sciences, Secunderabad, Telangana, India

Click here for correspondence address and email

Date of Submission29-Dec-2018
Date of Decision20-Oct-2020
Date of Acceptance30-Nov-2020
Date of Web Publication13-Jul-2021
 

   Abstract 


Objective: This study aimed to evaluate the effects of Coca-Cola®, Sprite®, and Maaza® on Microleakage, shear bond strength (SBS) and adhesive remnants underneath orthodontic brackets. Materials and Methods: A total of 192 human premolar teeth were used in this study. The sample was divided into four groups: Artificial saliva (control) [Group 1], Coca-Cola [Group 2], Sprite [Group 3] and Maaza [Group 4]. All the samples were stored in artificial saliva and immersed in their respective testing media (except the control group) for 15 minutes 3 times a day, separated by intervals of 8 hours. The immersion cycle was repeated for 15 days. After the immersion cycle, 24 teeth from each group were tested for SBS and adhesive remnant index subsequently. The remaining 24 teeth from each group underwent dyeing with methylene blue and were analyzed stereomicroscopically to evaluate microleakage underneath the brackets. Kolmogorov-Smirnov and Shapiro normality tests were performed and homogeneity of variance was tested with the Levene test. One-way ANOVA and Kruskal-Wallis tests were carried out separately for SBS, ARI and microleakage. Statistical analyses were performed using SPSS 20 for Windows (SPSS Inc., Chicago) software. Results: Coca-Cola showed a significant reduction in SBS and microleakage (p < 0.05) compared to the other groups. ARI did not show any significant differences between any groups (p > 0.05). The mean microleakage scores were higher for the gingival side of the brackets compared to the incisal side. Both Sprite and Maaza showed significant differences compared to artificial saliva, despite the SBS not being statistically significant (p > 0.05). Conclusions: A significant reduction of SBS was observed in Coca-Cola while increased microleakage was seen in all three drinks compared to artificial saliva.

Keywords: Adhesive remnants, microleakage, orthodontics, shear bond strength, soft drinks

How to cite this article:
Pulgaonkar R, Chitra P. Stereomicroscopic analysis of microleakage, evaluation of shear bond strengths and adhesive remnants beneath orthodontic brackets under cyclic exposure to commonly consumed commercial “soft” drinks. Indian J Dent Res 2021;32:98-103

How to cite this URL:
Pulgaonkar R, Chitra P. Stereomicroscopic analysis of microleakage, evaluation of shear bond strengths and adhesive remnants beneath orthodontic brackets under cyclic exposure to commonly consumed commercial “soft” drinks. Indian J Dent Res [serial online] 2021 [cited 2021 Aug 3];32:98-103. Available from: https://www.ijdr.in/text.asp?2021/32/1/98/321391



   Introduction Top


The clinical practice of orthodontics has been revolutionized by advances in dental materials in recent years. This began with the introduction of adhesives by Buonocore[1] that permitted the direct bonding of brackets to teeth which irreversibly changed the way orthodontics is practiced. However, white spot lesions (WSLs) associated with dental erosion have been reported to form in enamel around brackets during orthodontic therapy.[2] Its prevalence is reported between 2% and 96% in patients with fixed appliances[3] which is attributed mostly to the demineralization processes occurring around and beneath the brackets due to a decrease in the salivary pH.[4]

The term “soft drinks” refers to all drinks except alcohol, mineral water, fruit juices, tea, coffee or milk-based drinks which may or may not be carbonated.[5] In a meta-analysis of 88 studies, the association between soft drink consumption and nutrition and health outcomes found clear associations of soft drink intake with increased energy intake and body weight. Soft drink intake also was associated with lower intakes of milk, calcium, and other nutrients and with an increased risk of several medical problems (e.g., diabetes).[6] Over the past 2 years, the soft drink industry has seen a value growth of 11% compound annual growth rate (CAGR) and a volume growth of 5% CAGR. In total, 1.25 billion people in the country drink 5.9 billion liters of soft drinks in a year. This makes India's per capita soft drinks consumption large, but still, this is less compared to the global statistics. In a country where more than a billion people consume soft drinks, it becomes pertinent to find out the effects of these substances on orthodontic patients.[7]

Recent literature has shown increase in the consumption of “soft drinks”[8] that are damaging to enamel not only because of the high sugar content but also because most of them have critical pH levels below the safety limit, leading eventually to enamel demineralization and dental erosion.[9],[10],[11],[12],[13] The polymerization shrinkage of the adhesive material may cause gaps between the adhesive material and enamel surface and lead to microleakage, thus facilitating the formation of WSLs under the bracket surface area.[14] Microgap formation between the adhesive material and the enamel surface contributes to microleakage, permitting the passage of bacteria and oral fluids, which may initiate WSLs under the bracket surface area.[14],[15],[16],[17]

Many authors[2],[3] have suggested that microleakage around the brackets might contribute to the formation of WSLs beneath brackets. O'Reilley and Featherstone[18] analyzed the amount of demineralization and remineralization around the fixed orthodontic appliances. They stated that demineralization did not occur due to the etching effect of acid but because of dental plaque accumulation in the mouth. The review of literature has shown that there are many conflicting data regarding the effects of consumption of Coca-Cola, however, there are no studies based on pulp-based drinks such as Maaza. The authors also found a lack of clarity in literature when it comes to quantifying and analyzing microleakage using stereomicroscope.

This study aimed to evaluate the reduction in bond strength of orthodontic brackets and the adhesive remaining on the tooth surface when intermittently exposed to three popularly consumed soft drinks: Coca-Cola, Sprite and Maaza; all the while being immersed in a remineralizing storage medium, to more accurately simulate the in-vivo scenario. The use of stereomicroscope for analyzing microleakage using image analysis tools is highlighted additionally.


   Materials and Methods Top


Sample preparation

Teeth

A total of 192 extracted human premolar teeth were collected and used in this study.

Inclusion criteria were given below:

  • Teeth free from enamel cracks
  • No caries
  • No restorations
  • Absence of fluorosis
  • No visible dental defects.


All teeth collected were stored in distilled water before the start of the study. Teeth were polished with pumice slurry and mounted on hollow metallic rings using clear acrylic [Figure 1]. Then 96 teeth were used for shear bond strength (SBS) and adhesive remnant index (ARI) testing after bracket debonding. The other 96 teeth were used for evaluation of microleakage.
Figure 1: Teeth mounted on hollow metallic rings with clear acrylic

Click here to view


Brackets

A total of 192 maxillary right first premolar brackets (0.022” MBT prescription brackets, Ortho Organizers®, USA) were used. The width of the inciso-gingival aspect of each bracket was measured by an electronic digital caliper and was 3.16 mm.

Bonding procedure

The sample teeth were etched with 37% phosphoric acid gel for 15 seconds and then rinsed with water. After rinsing, the enamel surfaces were dried with oil-free compressed air. A layer of Transbond™ XT primer was applied to the teeth, Transbond™ XT composite paste to the base of the bracket that was pressed firmly onto the teeth. The excess adhesive was removed with a sickle scaler from around the base of the bracket and the adhesive was light-cured by positioning the light guide of a LED light gun on each interproximal side for 15 seconds.

Immersion schedule

Storage of test and experimental groups

After bonding, the teeth were stored in four groups of storage media:

  • Group 1. Control group which was Artificial Saliva
  • Group 2. Coca-Cola
  • Group 3. Sprite
  • Group 4. Maaza


An artificial salivary medium was prepared with a pH of 6.75. The constitution of artificial salivary medium used was:



The teeth were immersed in artificial saliva for 15 days. Group 2 samples (n = 48) were immersed in Coca-Cola for 15 minutes three times a day for 15 days, separated by intervals of 8 hours. At other times, they were kept immersed in artificial saliva. Groups 3 and 4 samples (n = 48) were immersed in Sprite and Maaza following the same procedure as for Group 2.

Evaluation of shear bond strength

Of 192 teeth, 96 teeth were tested for SBS. Shear bond testing was done using an Instron™ Universal testing machine that gave a shearing force in Newton/mm2 to the nearest 0.01 value. The crosshead speed was set at 1 mm/minute (International Organization for Standardization, 1994). The teeth were set at the base of the machine so that the sharp end of the rod incised in the area between the base and the wings of the bracket, exerting a force parallel to the tooth surface in an occluso-apical direction. The force required to debond each bracket was registered in Newtons (N) and converted into MegaPascals (MPa) as a ratio of Newtons to the surface area of the bracket (MPa = N/mm2).

Evaluation of adhesive remnant index

Once the brackets were debonded after testing for SBS, the enamel surfaces were examined to determine the amount of residual adhesive remaining on each tooth [Figure 2]. The ARI given by Årtun and Bergland[19] was used to quantify the amount of remaining adhesive using the scale as:
Figure 2: Debonded bracket showing adhesive remaining on the tooth (left) and bracket base (right)

Click here to view


Score 0 = No adhesive remained on the tooth.

Score 1 = Less than half of the adhesive remained on the tooth.

Score 2 = More than half of the adhesive remained on the tooth.

Score 3 = All of the adhesive remained on the tooth, with distinct impression of the bracket mesh.

Evaluation of microleakage

In 192 teeth, 96 were used for microleakage testing. The teeth were dried with a dental airjet and covered with two coats of varnish, leaving 1 mm around the edges of the bracket base uncovered. The specimens were submerged in a 1% solution of methylene blue for 24 hours. To avoid penetration of the dye through the apical foramen, the teeth were placed vertically in a metallic container, fitting the roots into acrylic so that the methylene blue only covered the crown and the gingival third of the root [Figure 3]. The teeth were sectioned longitudinally in an inciso-cervical direction with a water-cooled diamond saw and examined on both the incisal and gingival sides using a stereomicroscope [Figure 4]. The stereomicroscopic image [Figure 5] was checked for the amount of microleakage for each interface by using Image Tool Software®-ITSat 10X magnification. The bracket's inciso-gingival dimension was measured using a digital vernier caliper (3.16 mm) and this value was used by the ITS to calibrate the stereomicroscopic images to find out the amount of dye penetration in millimeters. After this, microleakage was scored according to the amount of dye penetration classified according to Arhun et al.[3] as mentioned below:
Figure 3: Mounted teeth (bottom) after immersion cycle in methylene blue dyeing solution (top)

Click here to view
Figure 4: Sectioned tooth with bracket (left), stereomicroscope with camera attachment (middle), stereomicroscopic analysis of tooth-bracket sectioned specimen (right

Click here to view
Figure 5: Stereomicroscopic image of tooth specimen showing microleakage

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Score 0 = No dye penetration between the adhesive–bracket or adhesive–enamel interface.

Score 1 = Dye penetration restricted to 1 mm of the adhesive–bracket or adhesive–enamel interface.

Score 2 = Dye penetration into the inner half (2 mm) of the adhesive–bracket or adhesive–enamel interface.

Score 3 = Dye penetration into 3 mm of the adhesive–bracket or adhesive–enamel interface.

Statistical analysis

The statistical analyses were performed using SPSS 20 for Windows (SPSS Inc., Chicago, IL, USA) software. Descriptive statistics including the mean, median, mode, standard deviation, variance, range, skewness and minimum/maximum values were calculated for each of the four groups tested. Normality tests were done to analyze the distribution of data collected for each group using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Homogeneity of variance was tested with the Levene test. One-way analysis of variance (ANOVA) and the Kruskal-Wallis tests were carried out separately for SBS, ARI and microleakage to find out if any statistical difference was present between groups. After the ANOVA, multiple comparisons were performed using post-hoc tests namely Tukey's HSD and Bonferroni to determine which groups showed differences in the SBS and ARI scores. Plots for Kruskal-Wallis test were obtained for microleakage data using SPSS software separately for the gingival and incisal side scores. Two-sample Mann-Whitney U-test helped analyze significant differences in microleakage scores of the samples.


   Results Top


The statistical descriptives for the SBS data are described in [Table 1]. Data for SBS were not normally distributed and also did not show homogeneity in variances. The ANOVA showed significant differences between the groups (p < 0.05). Post-hoc tests [Table 2] showed a significant difference in SBS of Group 2 (Coca-Cola) and all the other groups (p < 0.05). The lowest mean values for SBS was seen in Group 2 (Coca-Cola) and the highest mean values were seen in Group 1 (Control- artificial saliva).
Table 1: Shear bond strength descriptives

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Table 2: Shear bond strength (Bonferroni)

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The ARI scores for all groups did not reveal any significant differences in the homogeneity of variances in between the groups. The ANOVA test did not show any significant difference between the groups (p > 0.05). Post-hoc multiple group comparisons using Tukey HSD and Bonferroni corrections also did not show significant differences in any of the four groups (p > 0.05) [Table 3].
Table 3: Adhesive remnant index

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Microleakage testing at the adhesive–bracket interface showed statistically significant differences in groups both on incisal as well as the gingival margins in both the adhesive–bracket and adhesive–enamel interfaces (p < 0.05) [[Table 4] and [Table 5], respectively]. The highest mean ranks were observed in Group 2, Coca-Cola, showing that teeth in this group showed the highest microleakage among all the groups both incisally as well as gingivally.
Table 4: Microleakage Kruskal-Wallis Test (adhesive–bracket interface)

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Table 5: Microleakage Kruskal-Wallis Test (adhesive–enamel interface)

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The mean microleakage scores were higher for the gingival side compared to the incisal side. Mann-Whitney U-test for multiple intergroup comparisons tested all pairs and showed statistically significant differences between all pairs, except Sprite versus Maaza.


   Discussion Top


There are many causes of failures related to orthodontic bracket bonding.[19],[20],[21],[22],[23] In an optimum scenario, the bond strength of an orthodontic bracket should be able to bear the forces applied during orthodontic therapy while maintaining unsullied enamel till the brackets are debonded. Also, ideally, debonding should occur at the enamel-composite interface which would make subsequent adhesive removal and polishing much easier.[24] However, these factors are affected to a degree by consumption of “soft drinks” and the best way to prevent erosive lesions is to by limiting the exposure to such exogenous acids.

Tooth enamel is a non-remodeling tissue of the human body. Hence, any changes to the enamel per se would be registered permanently.[25] Enamel demineralization underneath orthodontic brackets and subsequent loss of enamel structure, therefore, is a non-repairable process which must be dealt with carefully. A recent study in India revealed a positive co-relation between nutritional status and developmental defects in enamel.[26] Owing to vast differences in the diet of the upper and lower socio-economic strata, it becomes more relevant to investigate the effects of different soft drinks in orthodontic patients.

There is a decrease in the pH value intra-orally because of consumption of “soft drinks”. This low pH creates an environment conducive to enamel erosion. The rise in the consumption of soft drinks has made it important for orthodontists to consider the consequences of consumption of these drinks and their effects on brackets. These drinks are known to contain acidic content, especially carbonic acid in carbonated drinks,[27] which have the power to dissolve resins used to bond orthodontic brackets, leaving them vulnerable to demineralization. This eventually in turn leads to the formation of WSLs that are commonly associated with orthodontic therapy.[28],[29],[30] These WSLs are responsible for an increase in caries susceptibility and subsequent debonding of brackets.

Secilmis et al.[31] studied the effect of nine different solutions and their effect on the mineral content of stored extracted teeth. The remineralizing/buffering effect of saliva on the teeth was evaluated.[32],[33],[34] The regulated exposure to such drinks had to be maintained since consumption of soft drinks all day long is not possible.

According to Littlewood et al.,[35] bond failure can occur within the bracket, at the bracket–adhesive interface, within the adhesive or at the tooth–adhesive interface. The mean score for ARI in all the groups was in the range of 2 [Table 3], which meant that more than half of the composite remained on the tooth surface after debonding. This meant that most bond failures were at the tooth–adhesive interface, which was in agreement with the ARI percentage scores recorded microscopically by Navarro et al.[36] showing 62% of adhesive remaining on tooth surfaces in control samples (artificial saliva) and 68% in samples tested with Coca-Cola. There was no significant correlation between the SBS and ARI in any of the groups. The absence of correlation between the SBS and ARI in the study by Ulusoy et al.[37] was consistent with this study.

The method employed to measure the amount of microleakage is by direct measurements using digital calipers up to 0.5 mm as described by de Santi Alvarenga FA et al.[38] The authors used the Image Tool Software (ITS) as described by this method to objectively measure the amount of microleakage.

To evaluate the two different interfaces, namely, the adhesive–bracket and adhesive–enamel interfaces, a method similar to Navarro et al.[36] was utilized. In contrast to Navarro, who calculated the percentage of microleakage using image analysis equipment and the MIP 4 software, in our study, we used the ITS to measure microleakage in milli meters.de Santi Alvarenga FA et al.[38] showed that the visual (stereomicroscope) and digital methods (ITS) had high levels of intra and inter-examiner reproducibility when marginal microleakage was assessed. The authors used the ITS-software to analyze microleakage by using calibrated stereomicroscopic images of samples immersed in the dye after exposure to soft drinks. The amount of microleakage was obtained in millimeters and these data were used to grade microleakage according to the method described by Arhun et al.,[3] converting data into nominals for statistical evaluation.


   Conclusion Top


Orthodontic brackets showed a significant reduction in SBS when exposed to Coca-Cola in contrast to Sprite and Maaza. The ARI scores showed no significant differences between groups. At both the adhesive–bracket and adhesive–enamel interfaces, Coca-Cola showed the highest while artificial saliva showed the least microleakage. Sprite and Maaza scores were intermediate and did not show any significant difference in their microleakage scores. The mean microleakage scores were higher for the gingival side of the bracket than the incisal side. As seen in previous studies, no correlation could be established between reduction in the SBSs of the groups and adhesive remaining on the tooth on bracket debonding, differences in microleakage between the groups and reduction in SBS or demineralization of the enamel, and differences in microleakage and adhesive remaining on the tooth surface after debonding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Prasad Chitra
Professor and Head, Orthodontics, Army College of Dental Sciences, Secunderabad, Telangana - 500 087
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_936_18

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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