Remineralization Efficacy of Moringa Oleifera Varnish Vs MI Varnish in Initial Carious Lesions Over 6 Months Follow Up: a Randomized Controlled Clinical Trial

The aim of this randomized clinical trial is to evaluate the remineralization efficacy of Moringa Oleifera varnish in comparison to CPP-ACP Varnish on initial carious lesions over 6 months follow up period The null hypothesis is that there will be no difference in the remineralization effect between Moringa Oleifera varnish and CPP-ACP Varnish on incipient carious lesions after 6 months follow up.

* Study design: Randomized clinical trial. * Double-blinded (participants and outcome assessors). * Allocation ratio; 1:1 * Framework: Superiority frame.

PICOTS:

P (Population): patients (25-35 years) with active non-cavitated incipient carious lesions on the facial surface (smooth surface lesion).

I (Intervention): Moringa Oleifera-based varnish C (Comparator): CPP-ACP Varnish

O (Primary Outcome):

Outcomes Measuring device Measuring unit Primary Outcome Remineralization effect DIAGNOdent (Shalaan et al., 2023) Ordinal data (scores) Secondary Outcomes Caries lesion activity assessment Nyvad criteria (Nyvad and Baelum , 2018) Ordinal data (scores)

T (Time):

T0= Baseline T1= after 3 months T2= after 6 months S (Study design): Randomized clinical trial, parallel groups, two arms, superiority trial with 1:1 allocation ratio.

Study settings:

This clinical study will be held in the clinic of Conservative dental department-Faculty of Dentistry Cairo University, Egypt.

Inclusion criteria of participants:

* Age: 25-35 years. * Males or females. * Presentation with at least one active WSLs on the study teeth at the start of the study. * Good oral hygiene. * Co-operative patients approving to participate in the trial. * Have sufficient cognitive ability to understand consent procedures.

Exclusion criteria of participants:

* Participants with parafunctional habits or bruxism. * Participants with dry mouth. * Participants with systemic diseases or disabilities that may affect participation. * Heavy smoking. * Pregnancy. * Lack of compliance. * Severe or active periodontal disease. * Cognitive impairment

Inclusion criteria of teeth:

* Active non-cavitated initial carious lesions (ICDAS 1\&2) * DIAGNOdent score between (8-15) * Vital teeth with no signs or symptoms of irreversible pulpitis. * No signs of clinical mobility. * Teeth with healthy periodontium.

Exclusion criteria of teeth:

* DIAGNOdent score less than 8 and more than 15 * Untreated cavitated lesions or extensive restorations on the facial surfaces of the study teeth * Intrinsic or extremely heavy extrinsic staining * Periapical pathosis or signs of pulpal pathology. * Non-vital tooth. * Signs of pathological wear. * Endodontically treated tooth. * Severe periodontal affection or tooth indicated for extraction. Inclusion criteria * Active non-cavitated initial carious lesions (ICDAS 1\&2) * DIAGNOdent score between (8-15) * Vital teeth with no signs or symptoms of irreversible pulpitis. * No signs of clinical mobility. * Teeth with healthy periodontium. Exclusion criteria * DIAGNOdent score less than 8 and more than 15 * Untreated cavitated lesions or extensive restorations on the facial surfaces of the study teeth * Intrinsic or extremely heavy extrinsic staining * Periapical pathosis or signs of pulpal pathology. * Non-vital tooth. * Signs of pathological wear. * Endodontically treated tooth. * Severe periodontal affection or tooth indicated for extraction.

Examination and diagnosis:

Examination and selection of patients will be done according to inclusion and exclusion criteria. For every patient, personal data, medical and dental history will be recorded. Clinical examination of labial surfaces with active initial lesions will be done by mouth mirror and explorer with proper direct illumination after gentle dryness for 5 seconds to assess the color, texture and light reflection. To avoid intra-examiner errors, all subjects will be examined by the same examiner. After clinical inspection and DIAGNOdent examination, all patients with ICDAS score 1\&2 and with DIAGNOdent score (8-15) will be included in the study.

Informed Consent: Eligible participants will be informed with the procedure and an informed consent will be signed.

b) Moringa Oleifera-based varnish laboratory preparation: The Moringa Oleifera extract and varnish will be prepared in the National Research Centre (Giza, Egypt). Moringa Oleifera leaves will be collected, washed then dried and grinded. Afterwards, the extract of the dried powder will be prepared through extraction with 80% ethyl alcohol. The combined ethanolic extract will then be evaporated till dryness at 45 °C using rotary evaporator under reduced pressure. The obtained mark will be dissolved in water, frozen and lyophilized to obtain lyophilized dry powder then dental varnish will be prepared at a concentration of 200ml/mg. This concentration is recommended by Younis et al.,(2020) as the more the concentration of loaded Moringa Oleifera extract, the more mineral deposition and remineralization enhancement.

After preparing the varnish, it will be stored in single-use form dark bottles to avoid any possible light interactions, then the varnish will be sterilized using steam autoclave Samaha et al.,(2023).

c) Remineralizing materials application:

Teeth preparation:

Teeth with initial carious lesions will be polished with a fluoride-free prophylaxis paste. Moisture control will be done using an air syringe and high-volume suction.

Moring Oleifera Varnish application Using a disposable bond brush, the varnish will be painted on the diagnosed surfaces, then the patient will be instructed to avoid brushing or flossing and to avoid hard and sticky food or any products that may contain alcohol (oral rinses, beverages, etc.) for the next 4 hours after application.

MI Varnish application

The varnish will be applied on the clean surfaces according to manufacturer instructions as follows:

1. The foil cover of the MI Varnish unit dosage bottle will be peeled-off and MI Varnish will be stirred with the disposable brush before application. 2. The surfaces will be covered with a thin uniform layer using a disposable bond brush to avoid clumping. 3. The area will be allowed to become wet to ensure the setting of the varnish. 4. Patients will be instructed to avoid brushing or flossing and to avoid hard and sticky food or any products that may contain alcohol (oral rinses, beverages, etc.) for the next 4 hours after varnish application.

Outcomes:

Primary outcome: Remineralization efficacy The DIAGNOdent will be used to quantify objectively the white spot lesions. For every patient, measurements with the DIAGNOdent will be performed and calibrated on a sound enamel (incisal one third of the central incisor) before actual readings. The teeth will be scanned carefully with the tip held in contact with the tooth surface and tilted around the measuring site so that fluorescence could be collected from all directions. Maximum reading will be recorded Singh et al.,(2016).

DIAGNOdent scores: Shalaan et al.,(2023)

* Score 1: 0-4 (healthy tooth structure) * Score 2: 5-10 (outer half enamel caries) * Score 3: 11-20 (inner half enamel caries) * Score 4: 21+ (dentin caries).

Secondary outcome: Caries lesion activity assessment Nyvad criteria will be used to detect the carious lesion activity. The Nyvad criteria are visual tactile caries classification system which can assess the caries activity and severity. Nyvad criteria includes all stages of caries from clinically sound surfaces to non-cavitated carious lesions and microcavitated lesions in enamel up to frank cavitations in dentine Nyvad and Baelum (2018).

Lesion activity can be detected through surface topography and texture; an active lesion in enamel is rough upon probing with the tip of a ball ended probe, unlike the inactive lesion which appears to be shiny and smooth upon probing. These surface phenomena are the visual representation of the demineralization activity of the dental biofilm. Due to scattering of light, rough active non-cavitated enamel lesions appear dull to the naked eye, unlike the surfaces of inactive lesions which appears glossy due to specular reflection. Nyvad and Baelum (2018).

Patient Recruitment:

Patients will be recruited by H.T from outpatient clinic of conservative dentistry department in Faculty of Dentistry, Cairo University. Eligible patients will then be recruited to fulfill the eligibility criteria according to participant timeline.

Assignment of interventions

• Caries lesion activity assessment [Срок оценки: baseline, 3 months and 6 months]