Selection Criteria Three reviewers followed the methodology outlined by the guidelines of the NHS Centre for Research and Dissemination.1 In 2008 they reviewed multiple databases (Medline, EMBASE, CINAHL, Cochrane, Web of Science, Health Technology Assessment, CDSR, ACP Journal Club, DARE, SIGLE, ISI, Conference Proceedings, Current Controlled Trials Register, and the National Research Register) and manually searched selected journals for published and unpublished material in any language. To be included in the review, studies had to meet the following inclusion criteria: (1) studies on fluoride-containing adhesives; (2) studies that included comparison groups (randomized controlled trials, clinical trials, and prospective observational studies with concurrent or historic comparison groups); and (3) studies on patients who had completed a full course of fixed orthodontic treatment. Studies that reported outcomes at both the patient and teeth level were included in the review. Data were abstracted into a data extraction sheet. Two reviewers were primarily responsible for the reviews, whereas a third investigator was used to resolve disagreements. Key Study Factor The key study factor was the use of fluoride-containing orthodontic adhesives. Main Outcome Measure The main outcome measure was the presence of decalcification (enamel demineralization/ noncavitated caries lesions) at baseline and at the end point of the studies. When possible, total numbers of white spots (noncavitated caries lesions), severity of decalcifications (demineralized lesions), and DMFT were also recorded for the start and finish of the trials for both subjects and teeth. Effect modifiers, defined as factors that may have increased or decreased a patients likelihood of developing noncavitated caries lesions, were additionally recorded when reported. Among these were the following: caries status of subjects, general health, oral hygiene, presence of an oral hygiene reinforcement program, socioeconomic status, use of topical fluoride, compliance with topical fluoride treatment, and unintentional debondings. Main Results A total of 317 publications were compiled; the first review of titles and abstracts excluded 298 of those studies. A full review of the publications excluded 9 more for a final number of 10 studies selected for inclusion in the systematic review. The 10 studies included used different methodologies and reporting strategies; therefore, no meta-analysis was conducted. All reported studies had a split-mouth design, but most other study design features were different among them. Differences were observed in the groups used for comparison (glass ionomer cement vs composite; fluoridereleasing vs conventional composite; and compomer vs composite), in the assessment of full versus partial mount, in the choice of index to quantify enamel demineralization, and in the choice of method for assessment of demineralization (clinical vs photographic). The timing of the assessment of the presence of enamel demineralization also varied among the studies, ranging from 1 week after debonding of patients to 24 months later. Only 3 of the reviewed studies reported statistically significant differences in enamel demineralization between the control and the experimental adhesives. Conclusions The authors concluded that it was not possible to make any recommendations for fluoride-containing adhesive based on the results of their review. The authors additionally concluded that there is evidence that glass ionomer cement as an orthodontic adhesive is more effective in preventing enamel demineralization during fixed appliance treatment when compared with conventional composite resins, but that the evidence is weak. Finally, the authors concluded that because of the limitations of successful bonding with glass ionomer adhesives, they could not be recommended.
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