JNatSciMed4150-7131752_194837.pdf

© 2021 Journal of Nature and Science of Medicine | Published by Wolters Kluwer - Medknow
50
Original Article
Introduction
Development of white spot lesions (WSLs) on enamel surface
is the most important iatrogenic effect of the fixed orthodontic
appliances. WSLs are enamel subsurface porosities with an
opaque milky‑white appearance. Previous studies estimated the
incidence of these lesions ranging from 50% to 70%.[1]
Arecent
meta‑analysis demonstrated that in the 14 studies evaluated
for WSLs, the incidence of new carious lesions formed during
orthodontic treatment was 45.8% and the prevalence of lesions
was 68.4%.[2]
The WSL is an active carious lesion and may progress to an
incipient lesion, but the time required is not exactly known.
However, the time required for dental caries to develop from
the incipient phase to a clinical enamel lesion is well reported
and averages 3–4 years in permanent teeth.[3]
Common interventions during or after orthodontic procedures
include fluoride and calcium phosphate‑based remineralizing
agents.However,improvingoralhygiene,restrictionofcariogenic
diet, and other antimicrobials are also part of the comprehensive
packagesofnoninvasivecare.[4]
Severalnewmethodscanbeused
as alternatives or in combination with fluoride.[5]
The laser can reduce the rate of subsurface demineralization of
enamel by altering its crystalline structure, acid solubility, and
Remineralization Effect of Diode Laser, Nanoseal®
, and
Zamzam Water on Initial Enamel Carious Lesions Induced
Around Orthodontic Brackets
Sara Mohamed Hosny Elkabbany, Asmaa A. Mosleh1
, Noha I Metwally2
Department of Orthodontic, Faculty of Oral and Dental Medicine for Girls, Al‑Azhar University, 1
Department of Operative Dentistry, Faculty of Dental Medicine for Girls,
Al‑Azhar University, 2
Department of Pedodontic, Faculty of Oral and Dental Medicine for Girls, Al‑Azhar University, Cairo, Egypt
Purpose: This in vitro study was conducted to evaluate the remineralization effect of laser, Nanoseal®
, and Zamzam water on initial enamel
carious lesions of premolar induced around orthodontic brackets. Materials and Methods:Atotal of 40 premolars divided randomly into four
groups were submitted to three phases: (1) placement of orthodontic brackets; (2) demineralizing solution; and (3) remineralization (Group
L; teeth were irradiated with 980 nm diode laser for 30 s, Group N; Nanoseal®
was applied to teeth according to manufacturer’s instructions,
Group Z; teeth were immersed in Zamzam water for 3 days then rinsed with deionized water, and Group C; control with no treatment). In each
phase, elemental analysis (calcium and phosphorus) was measured using a scanning electron microscope/energy dispersive X‑ray analysis.
The data were tested using the Bonferroni test and Tukey’s test. Results: There was a decrease in calcium ion content in Groups C and L in
the third phase (−1.62% and − 0.1%, respectively) than the first one. On the other hand, an increase in calcium ion was shown in Groups Z
and N (1.1 and 1.6%, respectively). An increase in phosphorus ion was obvious in all experimental groups ranging from 0.6% to 3.7%, with
Group N having the highest increase of phosphorus ion from the first to the third phase. Conclusions: Using Nanoseal®
and Zamzam water
proved to be better than a diode laser for the treatment of initial carious lesions. The use of diode laser helps to remineralize enamel but in a
lower percentage than other tested agents.
Keywords: Brackets, demineralization, laser, Nanoseal®
, Zamzam water
Address for correspondence: Dr. Sara Mohamed Hosny Elkabbany,
Department of Orthodontic, Faculty of Oral and Dental Medicine for Girls,
Al‑Azhar University, Youssef Abbass Street, Cairo, Egypt.
E‑mail: dr.sara1@yahoo.com
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How to cite this article: Hosny Elkabbany SM, MoslehAA, Metwally NI.
Remineralization effect of diode laser, Nanoseal®
, and Zamzam water on
initial enamel carious lesions induced around orthodontic brackets. J Nat
Sci Med 2021;4:50-7.
Abstract
Submitted: 07-10-2020 Revised: 11-11-2020
Accepted: 30-11-2020 Published: 06-01-2021
[Downloaded free from http://www.jnsmonline.org on Sunday, January 22, 2023, IP: 156.205.133.103]

Elkabbany, et al.: Zamzam water and Remineralization
Journal of Nature and Science of Medicine ¦ Volume 4 ¦ Issue 1 ¦ January-March 2021 51
permeability. However, it should be applied at a low energy
level to preserve enamel integrity.[6‑8]
Low‑power lasers (diode
lasers) appear to be an alternative for caries inhibition.
However, there are only few studies regarding the effect of
low‑level lasers for the management of dental caries.[9‑14]
The caries preventive effect of fluoride is well
documented.[5]
Recent studies investigated the effect of
Nanoseal®
(a fluoride‑containing aluminocalciumsilicate
nanoparticle glass dispersed aqueous solution) on enamel
and dentin, under the hypothesis that this material can form
insoluble mineral deposits that provide acid resistance to the
tooth structure and occlude open dentinal tubules.[15,16]
Nanoseal®
consists of an aqueous dispersion of
calcium‑fluoroaluminosilicate glass nanoparticles and
phosphoric acid solution. After mixing the two liquids to
acidize the glass, glass nanoparticles aggregate through the
acid–base reaction. Studies concluded that the application of
it resulted in the deposition of nanoparticles onto the enamel
surface porosities and opened dentinal tubules on the artificial
lesions. Moreover, calcium and silica incorporation into
superficial enamel and dentin lesions were detected.[16]
Ultimately, these studies showed that prior coating with
Nanoseal® reduced the demineralization‑induced loss of
enamel and dentin and suppressed the progression of root
caries.[15‑17]
The use of Zamzam water in remineralization of teeth was
recently practiced. Zamzam well is located in the holiest city
of Muslims; Makkah. It is 4000 years old, approximately 40
m deep, and surrounded by hills of igneous rocks. Zamzam
water is different from natural water in terms of minerals
and radiological features.[18,19]
The miracle of Zamzam is its
continuous flow since 2000 BC.[20]
Recently, water quality assessment and hydrochemical
characterization of Zamzam groundwater were studied. The
results revealed that the water lies within acceptable limits
with respect to dissolved salts, soluble cations, and anions. The
computed water quality index (WQI) values reveal that 94% of
the water samples were excellent for drinking (class I), and its
WQIs were ranged between 28 and 41 with an average of 31.[21]
Studies have shown great potential benefits from Zamzam
in fighting various human diseases and developed cancerous
growth. The unique mineral composition of Zamzam water
ensures several nutraceutical and functional benefits that work
in synergism with other agents to impart beneficial effects or
to prevent harmful effects.[22]
An important difference between Zamzam water and city
water was in the quantity of calcium, sodium, potassium, and
magnesium salts; the content of these was slightly higher in
Zamzam water, but more significantly, the water contains
fluorides that have an effective caries preventive effect.[19]
Exposure to fluoride in drinking water has been shown to be
beneficial for oral and general health, especially in relation to
dental caries. Ionic calcium in water is the best form to use to
insure its proper absorption by the bones and teeth. Previous
studies revealed that Zamzam water results in an increase in
the surface microhardness of enamel, following pH‑cycling,
compared to sodium fluoride and casein phosphopeptide–
amorphous calcium phosphate (CPP‑ACP).[18,19]
Therefore, the purpose of the present study was to evaluate
and compare the remineralization potential of the diode laser,
Nanoseal®
, and Zamzam water on initial carious lesions in
young permanent teeth enamel around orthodontic brackets.
Materials and Methods
The present study was approved by the Ethics Committee of
the Faculty of Dental Medicine for girls,Al‑Azhar University.
Sample selection and preparation
Asamplesizeoffortywasestimatedusingthepowercalculation
analysis at α = 0.05 and β = 0.20 with 80% being the power
of the study using G*Power software (version 3.1.9.2, Franz
Faul, Kiel University, Germany).
Forty intact maxillary first premolars, extracted for orthodontic
reasons, from 12 to 18 years old patients, who were referred
from Orthodontic Department, Faculty of Dental Medicine
for girls,Al‑Azhar University. Teeth were examined to be free
from decay, defects, or cracks. They were cleaned and brushed
with nonfluoride containing pumice and washed thoroughly
under running tap water then were kept refrigerated at 4°C
in 0.1% thymol (Merck KGaA, Frankfurter Str, Darmstadt,
Germany) to inhibit microbial growth and were used within 1
month after extraction.[23]
The roots of teeth were removed using a double‑faced diamond
disc (BesQual Dia‑Disc NY 11373, USA size: S‑22 mm) in a
cutting machine (DEMCO, Dental maintenance CO, Bonsall,
California USA, Model E96) under water cooling. The crowns
were cut mesiodistally and each buccal part was embedded in
heavy body rubber base blocks (BMS 135, BMS Dental s. r. l.
via M Buonarroti, Capannoli, Italy) to allow for easy handling
of the sample during the application and testing procedures.[24]
Buccal surfaces were covered with adhesive tape; leaving a
rectangular window (4 mm × 2 mm) at the site of bonding,
which corresponds to the bracket size to ensure that acid
etching was restricted only to the exposed window and to
standardize the area of adhesion of the brackets.[9]
The enamel
surface of the windows was conditioned with 37% phosphoric
acid (Etching gel, Ormco Corp, Glendora, CA, USA), and
subsequently, a thin coat of Ortho Solo®
primer (Ormco Corp,
Glendora, California) was applied.
Atotalof40stainlesssteelupperpremolarswith0.022”×0.028”
slot, conventional brackets, Roth prescription (OrthoPro, Pro
Dent LLC, Sarasota, USA) were bonded to enamel with a
light cure composite GrenGloo™ (Ormco Corp, Glendora,
California) using a bracket holder. The excess resin was
removed with slight pressure. Specimens were light cured

Journal of Nature and Science of Medicine ¦ Volume 4 ¦ Issue 1 ¦ January-March 2021
52
for 20 s for each surface with a visible light‑curing unit (LED
Bluephase C5, Ivoclar, Vivadent, 500 mW/cm2
) and finally,
the adhesive tape was removed.[9]
Grouping and randomization
Samples were divided randomly into four groups of ten
samples each and groups were assigned as follows:
Group L; samples were treated with 980 nm diode laser (Photon
Plus Zolar Technology and Manufacturing Co. Inc.,
Mississauga, ON Canada) at 0.5 W/PW (62.2 J/cm2
) in the
noncontact mode for 30 s. Group N; samples were treated with
Nanoseal®
(OLIDENT, Podleze 653, PL– 32‑003 Podleze,
Poland), innovative protective varnish based on a patented
silicone polymer providing adhesion to enamel and dentin
without prior etching. Group Z; which was treated with
Zamzam water, and finally Group C; which served as the
control group that was left without treatment. All samples
were subjected for baseline assessment.
Baseline recordings (phase 1)
The specimens were prepared for the first evaluation under
a scanning electron microscope‑energy dispersive X‑ray
analysis (SEM‑EDX) (JSM‑6510, JEOL Ltd., Tokyo, Japan),
through which an enamel surface characterization was
observed, and percentage analysis of mineral contents of
calcium and phosphorus ions was obtained. The buccal surface
of each sample was parallel to the slide base of SEM. The
samples were analyzed at 15 kV and 400 magnifications.[9]
Demineralizing regimen
Each sample was immersed in a sterile test tube containing
12 ml of freshly prepared demineralizing solution (2.2 mM
CaCl2, 2.2 mM NaH2PO4, 0.05M lactic acid, and 0.2 ppm
fluoride). The pH was adjusted to 4.5 with 50% NaOH and kept
for 72 h at 37°C.[24]
Each sample was withdrawn and rinsed
with running deionized water for 1 min, then immersed in
artificial saliva (storage media) which replenished every day
for 3 days.[25]
This demineralization procedure was intended
to produce an initial carious lesion.
Recording of readings after demineralization (phase 2)
The samples were evaluated for demineralization under
SEM‑EDX using the same parameters as in baseline.
Application of test agents (remineralization)
Samples in each group were treated with the allocated
remineralizing agent following the manufacturer’s instructions:
• Group L: Diode laser was applied at 0.5W/PW(62.2 J/cm2
)
in the noncontact mode for 30 s/sample, with an oscillatory
motion in clockwise direction around the bracket[26]
• Group N: A thin layer of Nanoseal®
was applied on the
demineralized surfaces using a cotton applicator, with
oscillatory movements in clockwise direction around the
bracket, and then allowed to dry for 1 min before repeating
the application again for three times
• Group Z: Each sample was immersed in a 30 ml of Zamzam
waterfor3daysandthenrinsedwithdeionizedwaterfor2min
• Group C: Samples were left untreated.
All samples were then re‑examined immediately after the
ending of the remineralization procedure.
Recording of readings after remineralization (phase 3)
ThesampleswereassessedusingSEM‑EDXtostudythechange
in surface characteristics of enamel and estimate the mineral
content (Ca, P) with the same parameters in phases 1 and 2.
Statistical analysis
Statistical analyses were carried out with SPSS for 20.0
Windows (SPSS Inc., Chicago, Illinois, USA). The Bonferroni
test was conducted to compare mineral changes at different
phases, whereas Tukey’s test was carried out to compare the
mean values of mineral changes for different groups.
Results
The mean percentage difference values of calcium and
phosphorus contents between different phases obtained from
EDX analysis are shown in Table 1.
Comparison between the first and second phase
The results showed a loss of calcium ions ranging from 1.6% to
4.5%, being more pronounced in Group N.Aloss of phosphorus
ions was also shown in all groups ranging from 3.9% to 9.4%,
being more pronounced in Group N [Tables 1 and 2].
Comparison between second and third phase
The results showed calcium ions gain in all treatment groups,
from 0.17% to 6.04% with Group Z showing the highest uptake
of calcium ions. Similarly, there was a gain of phosphorus
ions in all groups ranging from 0.5% to 7.9%, being more
pronounced in Group Z [Tables 1 and 2].
Comparison between first and third phase
The results showed calcium ions loss in Groups C and L in
the third phase (−1.62% and −0.1%, respectively) than the
Table 1: Mineral mean percentage difference values between different phases
Groups First phase/second phase Second/third phase Third phase/first phase
Ca P Ca P Ca P
L −2.68% (1.61) −6.83% (0.75) 2.58% (0.34) 4.5% (0.82) −0.1% (0.71) 2.34% (0.82)
N −4.50% (0.87) −9.4% (0.51) 5.32% (0.32) 6.48% (0.78) 1.61% (0.36) 3.75% (0.62)
Z −4.15% (0.33) −7.85% (0.91) 6.04% (0.57) 7.9% (1.10) 1.01% (0.24) 3.59% (1.30)
C −1.63% (0.85) −3.99% (0.45) 0.17% (0.72) 0.5% (0.25) −1.62% (0.22) 0.62% (0.55)
Data presented as mean (SD). Groups ‑ L: Laser, N: Nanoseal®
, Z: Zamzam water, C: Control, Ca: Calcium, P: Phosphorus, SD: Standard deviation

first one. On the other hand, an increase in calcium ion was
shown in Groups Z and N (1.01% and 1.6%, respectively)
than the first phase.
An increase in phosphorus ion was obvious in all experimental
groups ranging from 0.6% to 3.7%, with Group N having the
highest increase of phosphorus ion from the first to the third
phase [Tables 1 and 2].
According to the Bonferroni analysis, calcium and phosphorus
content showed a statistically significant difference between
the first phase and second phase in all groups [Table 3].
While calcium and phosphorus content showed a statistically
significant difference between the second and third phases in
experimental groups only [Table 4].
Scanning electron microscope analysis
A reference area was established with ×400 magnification
to measure the calcium and phosphorus content from each
sample [Figure 1]. The qualitative analysis and description of
the samples’ surface are shown in each phase of the study. In
the first phase (at baseline), all the samples exhibited smooth
enamel surfaces with no enamel prisms advent [Figure 2].
After demineralization (second phase), all the samples
exhibited rough surface and enamel rods became more advent
due to enamel surface erosion by the action of the acidic
solution [Figure 3]. After remineralization (third phase),
enamel surfaces of all experimental groups showed repair of
enamel surface defects which was especially more pronounced
in Group Z, followed by Group N [Figure 4].
Discussion
Demineralization of enamel leads to the dissolution of
hydroxyapatite crystals (HA) and diffusion of calcium/
phosphorus (Ca/P) ions toward the tooth surface unless arrested
Table 4: Concentration change of minerals in each phase of the study
Groups First phase/second phase P Second phase/third phase P First phase/third phase P
L
Ca 74.96 (0.63) 72.95 (0.62) 0.00* 72.95 (0.62) 74.88 (0.72) 0.001* 74.96 (0.63) 74.88 (0.72) 0.858
P 24.83 (0.47) 23.13 (0.71) 0.03* 23.13 (0.71) 24.25 (0.42) 0.001* 24.83 (0.47) 24.25 (0.42) 0.65
N
Ca 75.18 (0.38) 71.80 (0.61) 0.00* 71.80 (0.61) 76.40 (0.59) 0.00* 75.18 (0.38) 76.40 (0.59) 0.002*
P 25.09 (0.61) 22.75 (0.67) 0.00* 22.75 (0.67) 24.15 (0.57) 0.004* 25.09 (0.61) 24.15 (0.57) 0.007*
Z
Ca 76.12 (0.48) 72.95 (0.59) 0.00* 72.95 (0.59) 76.89 (0.39) 0.00* 76.12 (0.48) 76.89 (0.39) 0.012*
P 24.34 (0.73) 22.42 (1.37) 0.004* 22.42 (1.37) 24.18 (0.76) 0.010* 24.34 (0.73) 24.18 (0.76) 0.362
C
Ca 75.0 (0.86) 73.77 (0.99) 0.00* 73.77 (0.99) 73.78 (0.96) 0.832 75.0 (0.86) 73.78 (0.96) 0.000*
P 24.54 (0.85) 23.56 (0.70) 0.04* 23.56 (0.70) 23.66 (0.76) 0.35 24.54 (0.85) 23.66 (0.76) 0.067
*P values≤0.05 with Bonferroni analysis. Data presented as mean (SD). Groups ‑ L: Laser, N: Nanoseal®
, Z: Zamzam water, C: Control, Ca: Calcium,
P: Phosphorus, SD: Standard deviation
Table 2: Mineral mean values
Groups First phase Second phase Third phase
Ca P Ca P Ca P
L 74.96 (0.63) 24.83 (0.47) 72.95 (0.62) 23.13 (0.71) 74.88 (0.72) 24.25 (0.42)
N 75.18 (0.38) 25.09 (0.61) 71.80 (0.61) 22.75 (0.67) 76.40 (0.59) 24.15 (0.57)
Z 76.12 (0.48) 24.34 (0.73) 72.95 (0.59) 22.42 (1.37) 76.89 (0.39) 24.18 (0.76)
C 75.0 (0.86) 24.54 (0.85) 73.77 (0.99) 23.56 (0.70) 73.78 (0.96) 23.66 (0.76)
Data presented as mean (SD). Groups ‑ L: Laser, N: Nanoseal®
, Z: Zamzam water, C: Control, Ca: Calcium, P: Phosphorus, SD: Standard deviation
Table 3: Comparison of mean values of mineral changes for different groups
Groups First/second phase Second/third phase First/third phase
Ca P Ca P Ca P
L 2.0 (0.7)b
1.7 (0.9)a
1.93 (1.04)b
1.1 (0.5)a
−0.077 (1.2)b
0.58 (0.7)a
N 3.4 (0.6)b
2.3 (0.7)a
3.93 (0.72)a
1.63 (0.6)a
1.2 (0.7)a
0.94 (0.6)a
Z 3.2 (0.9)a
2.1 (1.3)a
4.6 (0.95)a
1.92 (1.2)a
0.76 (0.64)a
0.15 (0.4)a
C 1.2 (0.3)a
0.9 (1.2)a
0.012 (0.2)c
0.12 (0.1)b
−1.21 (0.34)c
0.88 (1.1)a
Data presented as mean (SD). Superscripts provided through multiple comparisons using Tukey HSD test. Group ‑ L: Laser, N: Nanoseal®
, Z: Zamzam
water, C: Control, Ca: Calcium, P: Phosphorus, SD: Standard deviation, HSD: Honestly significant difference

54
by re‑mineralization. Hyper saturation of Ca/P ions on the
surface results in a re‑precipitation of HA forming the intact
superficial layer on the enamel surface.[27]
This vision is supported by the ability to detect caries lesions
at an early stage and correctly quantify the degree of mineral
loss, ensuring that the correct intervention is needed.[24]
Quantitative assessment of in vitro demineralization and
remineralization can be done at the microscale and nanoscale
using different methods including SEMEDX, surface
microhardness, polarized light microscopy, atomic force
microscope, electron probe microanalysis (EPMA), and X‑ray
diffractometer.[28]
Forty sound premolars, extracted for orthodontic purposes,
were selected for this study due to their availability and as
they are the most often employed teeth in the Ph cycling
models.[29]
The collected teeth were extracted from the same
age range to avoid large variations in their response under
acidic challenge.[29]
Specimens were kept in deionized water
to which 0.1% thymol was added to prevent bacterial growth
and then stored in artificial saliva to prevent dryness of the
teeth and to simulate the circumstances in the oral cavity.
This agreed with different studies[30,31]
which found that the
disinfecting solution and storage medium did not influence
the chemical and physical properties of human tooth substrate.
The use of artificially demineralized enamel specimens was of
considerable interest as they can be compared to the earliest
detectable ultrastructural change in the caries process as agreed
with many studies.[24]
To produce and study in vitro enamel demineralization models,
many demineralizing agents have been used such as acetic
acid, lactic acid, or acidified hydroxyethylcellulose system for
different time periods. In the present study, demineralization
was carried out as described by a previous study[30]
where the
samples were kept in the demineralization solution for 72 h
at 37°C, creating an initial carious lesion of approximately
150 µ widths with an intact surface simulating a WSL. The
concentration of both Ca and P, in the demineralization
solution, was at 50% of saturation level, causing dissolution
of only enamel subsurface. The addition of fluoride prevented
surface demineralization by forming fluorapatite at the surface,
which simulated the naturally occurring initial carious enamel
lesions having intact surface layer.[24]
In recent years, diode laser irradiation has been applied for its
possible strengthening effect on tooth structure. In the current
study, the laser group showed loss of calcium ions by 2.68%
and loss of phosphorus ions by 6.83% after demineralization.
After remineralization; the results showed calcium and
phosphorus ions gain in all treatment groups with the laser
group showing the lowest uptake of calcium ions by 2.58%
and phosphorus ions by 4.5%.[Tables 1 and 2].
The results showed calcium ions reduction, in Groups C and L
in the third phase (−1.62% and − 0.1%, respectively) than the
Figure 1: Bar chart showing a comparison of the mean percentage
difference of calcium and phosphorus between different phases for the
four groups of the study
Figure 2: Scanning electron microscope‑energy dispersive X‑ray analysis images of study groups at baseline (phase 1) where (a) diode laser
group, (b) Nanoseal®
group, (c) Zamzam water group, and (d) control group
a b c d

first one. An increase in phosphorus ion was obvious in all
experimental groups with the laser group having the lowest
increase of phosphorus ion (2.34%) from the first to the third
phase [Tables 1 and 2]. Furthermore, diode laser showed
unexpected results, achieving a remineralization up to 2.58%
in calcium, and a significant increase of phosphorus by 4.5%.
This result was in agreement with another study[9]
which
demonstrated that therapeutic laser by itself is capable
of achieving favorable results, obtaining up to 1.02%
remineralization of the enamel surface regarding calcium ion
and a minimum but significant increase in phosphorus ions.
The current result was in contrast to another study which
demonstrated that the application of 810 nm diode laser at low
power mode was not effective in enhancing microhardness of
initial carious lesions. This contrast may be attributed to the
difference in the used wavelength.[6]
Our result was in contrast to another study which evaluated
the effect of a 960 nm diode laser on the solubility of calcium
in tooth enamel. The additional application of laser irradiation
did not cause any significant increase or decrease in calcium
solubility. It has been summarized that diode laser did not make
the dental surface less susceptible to demineralization unless
a fluoride agent is added.[14]
Moreover, other studies demonstrated low efficacy of diode
laser by itself and recommended its use with photoabsorbing
cream or in combination with other remineralizing agents
d h
c g
b f
a e
Figure 3: Scanning electron microscope‑energy dispersive X‑ray analysis images of study groups after demineralization (phase 2) where (a) diode
laser group, (b) Nanoseal®
a b c d
Figure 4: Scanning electron microscope‑energy dispersive X‑ray analysis images of study groups after application of tested agents (phase 3)
where (a) diode laser group, (b) Nanoseal®
a b c d

56
such as sodium fluoride.[6,9,11‑13]
The controversy between our
results and some studies may be explained by the differences
in laser parameters used such as wavelength, power, frequency,
pulse time, and the number of pulses. The contrast may also
be attributed to the difference in sample size and study design
including the type of the teeth, their composition, age of
patients, storage medium, and measurement methods.
Nanoseal®
group showed better results than laser group after
remineralization, achieving a calcium gain up to 5.32%, and
a significant increase of phosphorus 6.48%; this corroborates
the findings of a previous study[15]
which examined the
incorporation of Ca and Si into superficial enamel and dentin
with SEM‑EPMA after coating them with Nanoseal®
. It has
been found that the application of Nanoseal®
material resulted
in the deposition of substances (nanoparticles) onto the enamel
surface porosities on the artificial lesions. Moreover, the prior
coating with Nanoseal®
reduced the demineralization‑induced
loss of enamel and dentin.[15]
An interesting result recorded in the present study was
the higher increase in calcium ion in the third phase in
Group N (1.6%) than in the first phase. This can be due to the
nanoparticle layer formed by the application of Nanoseal®
,
covered the enamel surface and supplied ions to the carious
defect reducing demineralization until it retained to the same
amount of ions or may exceed that of native tooth substrate.
This result was in accordance with a previous study which
examined mineral loss in bovine dentin placed into an acetic
acid solution. Nanoseal®
application consequently suppressed
mineral loss in the dentin and surpassed both fluoride varnish
and a conventional desensitizer agent.[32-34]
Furthermore, our result came in accordance with an in vivo
study[17]
which concluded that Nanoseal®
covered the region of
rootcarieswithalayerofcalcium‑fluoroaluminosilicateglassand
other precipitates to supply ions to improve the carious lesion.
Furthermore, this layer may act as a physical barrier against
oral bacteria and acidic food to decrease tooth demineralization.
Zamzam water group showed also advanced results after
remineralization, achieving a calcium gain up to 6.04%, and a
significant increase of phosphorus 7.9%; these results came in
accordance to a previous study[18]
which reported an increase
in microhardness of demineralized enamel surface after
treatment with Zamzam water. This success in the increase of
the microhardness value was attributed to the incorporation of
Zamzam water elements (fluoride, magnesium, and calcium)
in the appetite crystals.[18]
Another interesting result recorded in this study was the higher
increase in calcium ion in the third phase in Group Z (1.1%)
than in the first phase. This can be explained by Zamzam water
has been shown to have additive effects in reducing caries.[19]
An increase in phosphorus ion was obvious in all experimental
groups ranging from 0.6% to 3.7%, with Group N having the
highest increase of phosphorus ion from the first to the third
phase [Table 2].
In this study, the evaluation of SEM micrographs allowed us to
observe changes in the enamel structure; a visible, remarkable
regeneration was observed in most samples of all groups.
Zamzam water samples showed more pronounced repair of
the demineralized surface under SEM and this may be due
to the long period of immersion of samples in Zamzam that
allowed the incorporation of Zamzam water elements (fluoride,
magnesium, and calcium) in the appetite crystals increasing the
repair of enamel substrate and the resistance to acid dissolution.
However, the presence of fluoride components in Zamzam
water may be responsible for the chemical reaction between
Zamzam water constituents and appetite crystals.
Long period of Zamzam water application was based on the
recommendation of a previous study.[18]
In addition, these
results were in agreement with another in vitro study[19]
which
concluded that Zamzam water was effective in remineralization
of the initial carious lesion and its effectiveness was not
different from that of CPP‑ACP.
Conclusions
Within the limitations of this in vitro study, the following
conclusions could be drawn.
1. The tested agents (Nanoseal®
and Zamzam water) and
laser irradiation technique may significantly remineralize
initial carious lesions and consequently the clinical
WSLs. However, this effective remineralization differed
according to the conditions in which they are applied
2. Using Nanoseal®
and Zamzam water proved to be better
than a diode laser for the treatment of initial carious
lesions. The application of a 980 nm diode laser at low
power mode was the least effective strategy to increase
remineralization of initial enamel carious lesions.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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