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Background and Objective: The objective of this study OCT or polarization-sensitive optical coherence tomogra-
was to test the hypothesis that the inhibition of deminer- phy (PS-OCT) is advantageous for imaging dental caries
alization in an in vitro simulated caries model by different [9–12] since the strong surface reflection is removed from
fluoride agents could be monitored nondestructively using the image taken in the polarization state perpendicular to
polarization-sensitive optical coherence tomography (PS- the incident polarization and the reflectivity can be
OCT) on smooth enamel surfaces peripheral to orthodontic integrated with depth to provide a measure of the lesion
brackets. severity.
Materials and Methods: Sixty human molar samples Orthodontic appliances, on the smooth surfaces can
used for this in vitro study were divided into four groups of become ‘‘plaque traps’’ increasing the risk of decalcification
fifteen. The groups consisted of a control, a fluoride around bracket bases. Maintaining oral hygiene and
releasing glass ionomer cement, an adhesive fluoride following the diet regimen are challenging during ortho-
sealant, and fluoride in solution (2-ppm fluoride). The dontic treatment. Noncompliance can lead to a higher
reflectivity from tooth surfaces was monitored using a PS- prevalence of demineralization seen when removing ortho-
OCT system at different time points after exposure to a pH dontic braces. The development of caries during orthodon-
cycling demin/remin model at 3-day intervals for 15 days. tic fixed appliance therapy is a significant concern. Early
Polarized light microscopy (PLM) was used to examine decalcification, demineralization, or ‘‘white spot lesions’’ as
lesion depth after day 15. they are often referred to, may develop and progress very
Results: PS-OCT was effective at measuring significant rapidly around brackets and bands. White spot lesions have
differences in the integrated reflectivity in depth between been shown to develop within 1 month around brackets and
the control and fluoride groups (P<0.001). The fluoride bands [13]. Such areas of decalcification are called white
sealant demonstrated a greater protective effect than the spot lesions due to the loss of translucency of the enamel in
fluoride in solution and the glass ionomer cement. that area. Typically there is no cavitation, but it may
Conclusions: These results suggest that PS-OCT is well present as a rough surface. The noncavitated surface layer
suited for the nondestructive assessment of caries inhibi- is about 40–50-mm thick, exhibits less than 20% deminer-
tion by anti-caries agents. Lasers Surg. Med. 39:422–427, alization, and subsurface layers can be up to 70%
2007. ß 2007 Wiley-Liss, Inc. demineralized. The initial appearance is chalky white,
but if mineral loss continues, subsurface lesions will result.
Key words: optical tomography; PS-OCT; dental caries; There is a possibility that white spot lesions may regress or
dental enamel; fluoride; demineralization disappear due to surface abrasion, but may still pose an
esthetic problem even 5 years post-treatment [14]. The
INTRODUCTION incidence of this demineralization after full fixed appliance
Optical coherence tomography (OCT) is a noninvasive treatment can be as high as 50% [15] or as noted
technique for creating cross-sectional images of internal elsewhere between 2% and 96% of patients [14]. If these
biological structure [1–4]. The intensity of reflected and initial lesions are detected early, they can be arrested, or
backscattered light is measured as a function of its axial even reversed, by a variety of noninvasive methods
position in the tissue. Low coherence interferometry is used
to selectively remove or gate out the component of back-
Contract grant sponsor: NIDCR; Contract grant number: R01
scattered signal that has undergone multiple scattering DE017869.
events, resulting in high resolution images of reflectivity *Correspondence to: Daniel Fried, PhD, Department of Pre-
versus depth (<15 mm). Lateral scanning of the probe beam ventive and Restorative Dental Sciences, University of California,
707 Parnassus Ave., San Francisco, CA 94143.
across the biological tissue is then used to generate a two- E-mail: daniel.fried@ucsf.edu
dimensional intensity plot, similar to ultrasound images, Accepted 21 February 2007
Published online 18 June 2007 in Wiley InterScience
called a b-scan. OCT has been used to acquire images of (www.interscience.wiley.com).
both oral soft and hard tissues [5–8]. Polarization resolved DOI 10.1002/lsm.20506
reference arm to reduce the intensity noise for shot limited 17 hours of remineralization at 3-day intervals. The
detection. The all-fiber OCDR system is described in more demineralization solution consisted of 40 ml samples
detail in reference [24]. The PS-OCT system is completely containing 2.0 mmol/L calcium, 2.0 mmol/L phosphate,
controlled using LabviewTM software (National Instru- and 0.075 mol/L acetate at a pH of 4.5 and a temperature of
ments). Acquired scans are compiled into b-scan files. 378C. The remineralization solution consisted of 20 ml
Image processing was carried out using Igor ProTM, data samples containing 1.5 mmol/L calcium, 0.9 mmol/L
analysis software (Wavemetrics, Inc., Lake Oswego, OR). phosphate, 150 mmol/L KCl, and 20 mmol/L cacodylate
In our PS-OCT system, linearly polarized light is incident buffer at a pH of 7.0 and a temperature of 378C. Progressive
on the tooth and reflected light is collected by a polarization scans at periods of 0, 3, 6 9, 12, and 15 days were taken
preserving fiber in both polarization states (k- and \-axes) during lesion development. A line profile (one point on the
and delivered to separate detectors for each polarization b-scan where the backscattering reading was taken) was
state resulting in two images for each scan called the (k- extracted from each b-scan on one side adjacent to the
axis) and (\-axis) images, respectively. The k-axis image bracket base (see Fig. 3). Comparison of all the line profiles
includes all of the reflected light from the tooth, including was used to determine the effectiveness of the PS-OCT
surface reflections, created by the air–enamel interface system in monitoring the rate of lesion development, and
[25]. This can mask surface or subsurface scattering and the efficacy of each mechanism of fluoride delivery. Each
create artifacts (spikes) in the image [25]. The (\-axis) line-profile from the PS-OCT (\-axis) b-scan scans was
image arises from light depolarized by strong light scatter- integrated over a distance from the tooth surface to a depth
ing such as that which occurs in caries lesions. It has been of 200-mm to yield the integrated reflectivity which we call
shown that PS-OCT can successfully detect artificial lesion DR and it has units of reflectivity (decibels (dB)depth
progression on occlusal surfaces and under sealants and (mm)). The background reflectivity (25 dB) was subtracted
composite restorations [26]. Defects between the sealant/ before integration. This unit is analogous to the DZ value
composite and the tooth surface can create strong reflec- used for transverse microradiography to quantify lesion
tions. The surface reflection is not strong in the perpendi- severity, namely the product of volume % mineral loss and
cular axis because the light is not depolarized with depth (Vol.%mm).
reflection at 08 incidence. For sound enamel, the perpendi-
cular axis signal in the enamel is weak due to weak Polarized Light Microscopy (PLM)
scattering and depolarization in the sound enamel. With After PS-OCT scanning tooth hemi-sections were serially
demineralization, the perpendicular axis signal is high, sectioned into sections of 200 mm thickness for polarized
similar to the parallel axis, due to the intense depolariza- light examination. Thin sections were imbibed in water and
tion by light scattering. This occurs with the increase in examined at up to 500 with a polarizing microscope
light scattering of 2–3 orders of magnitude. Therefore, the interfaced to a high-resolution digital camera. Samples
strong increase of the signal in the perpendicular axis were examined in the brightfield mode with crossed
serves to represent the severity of demineralization. polarizers and a red I plate with 500-nm retardation.
The samples were randomly assigned to one of four Demineralization due to strong scattering causes loss of
groups, each containing 15 human molar halves (n ¼ 60) birefringence in the lesion and it appears dark. Measure-
bonded with metal orthodontic brackets. All bonding ments of lesion depth were made with calibrated image
agents were used according to manufacturers specifica- analysis software that is capable of direct length and area
tions. measurements.
The four groups are:
TABLE 1. Integrated Reflectivity After Each 3-Day Period of Demineralization Mean (s.d.)
all four groups, therefore the fluoride in solution group was phy for dental structures. San Jose: SPIE; Vol. 3248, 1998.
the only fluoride group to receive two applications of pp 130–136.
10. Dicht S, Baumgartner A, Hitzenberger CK, Sattmann H,
fluoride in 15 days. However, the fluoride in solution was Robi B, Moritz A, Sperr W, Fercher AF. Polarization-
not the most effective fluoride modality, and may have been sensitive optical optical coherence tomography of dental
less effective with only one application. structures. San Jose: SPIE; Vol. 3593, 1999. pp 169–176.
The glass ionomer group showed a similar time progres- 11. Baumgartner A, Dicht S, Hitzenberger CK, Sattmann H,
Robi B, Moritz A, Sperr W, Fercher AF. Polarization-
sion of lesion development as the control group. This may sensitive optical optical coherence tomography of dental
have occurred because the line profiles were taken too far structures. Caries Res 2000;34:59–69.
away from the side of the bracket and the glass ionomer 12. Everett MJ, Colston BW, Sathyam US, Silva LBD, Fried D,
Featherstone JDB. Non-invasive diagnosis of early caries
cement is most effective in the immediate area around the with polarization sensitive optical coherence tomography
bracket base. Glass ionomer has been shown to release (PS-OCT). San Jose: SPIE; Vol. 3593, 1999. pp 177–183.
fluoride in the immediate vicinity and be a continual source 13. Ogaard B, Rezk-Lega F, Ruben J, Arends J. Cariostatic effect
and fluoride release from a visible light-curing adhesive for
of fluoride over time [13–15]. This could explain why the bonding of orthodontic brackets. Am J Orthod Dentofacial
reflectivity, even though similar to controls, was still less Orthop 1992;101(4):303–307.
for the glass ionomer group than the control group. 14. Millett DT, Nunn JH, Welbury RR, Gordon PH. Decalcifica-
The fluoride sealant group showed the least deminer- tion in relation to brackets bonded with glass ionomer cement
or a resin adhesive. Angle Orthod 1999;69(1):65–70.
alization overall. Moreover, the sealant group did not show 15. Pascotto RC, Navarro MF, Capelozza Filho L, Cury JA. In
the initial increase in demineralization seen with the vivo effect of a resin-modified glass ionomer cement on
control and glass ionomer groups. There was a marked enamel demineralization around orthodontic brackets. Am J
Orthod Dentofacial Orthop 2004;125(1):36–41.
delay in rise of reflectivity that could be anticipated, since it 16. Featherstone JDB, Glena R, Shariati M, Shields CP.
takes time for the acid to penetrate the sealant. Although, Dependence of in vitro demineralization and remineraliza-
the lesions produced under the sealant group were the least tion of dental enamel on fluoride concentration. J Dent Res
severe, it was surprising that there was measurable 1990;69:620–625.
17. Ogaard B, Duschner H, Ruben J, Arends J. Microradiography
demineralization under the sealant. Reapplication of the and confocal laser scanning microscopy applied to enamel
fluoride sealant may have provided even greater protection lesions formed in vivo with and without fluoride varnish
from the acid attack. treatment. Eur J Oral Sci 1996;104(4 (Pt. 1)):378–383.
18. Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ. Reducing
In summary, this study showed that PS-OCT system can white spot lesions in orthodontic populations with fluoride
be used to nondestructively measure the inhibition of rinsing. Am J Orthod Dentofacial Orthop 1992;101(5):403–
artificial demineralization on smooth surfaces around 407.
19. Gorton J, Featherstone JD. In vivo inhibition of deminer-
bracket bases by fluoride. PS-OCT was successful in alization around orthodontic brackets. Am J Orthod Dento-
tracking the development of white spot lesions on the facial Orthop 2003;123(1):10–14.
smooth surfaces around orthodontic brackets, and to test 20. Marcusson A, Norevall LI, Persson M. White spot reduction
the efficacy of a fluoride-releasing adhesive (glass ionomer), when using glass ionomer cement for bonding in orthodon-
tics: A longitudinal and comparative study. Eur J Orthod
a fluoride sealant, and fluoride in solution in inhibiting 1997;19(3):233–242.
decay around brackets. 21. Ogaard B, Arends J, Helseth H, Dijkman G, van der Kuijl M.
Fluoride level in saliva after bonding orthodontic brackets
with a fluoride containing adhesive. Am J Orthod Dentofacial
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