Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Aug 2018

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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : ZC08 - ZC15 Full Version

Comparison of the Remineralisation Potential between Flaxseed Paste, Aloe Vera Gel and Fluoride Toothpaste on Artificially Created White Spot Lesions around Orthodontic Brackets: An In-vitro Study

Published: June 1, 2022 | DOI:
Rasiga Gandhi, Dilip Srinivasan, Sangeetha Duraisamy, Ravi Kannan

1. Postgraduate Student, Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India. 2. Professor, Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India. 3. Professor, Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India. 4. Professor, Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India.

Correspondence Address :
Rasiga Gandhi,
Postgraduate Student, Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India.


Introduction: White Spot Lesion (WSL) is one of the major iatrogenic effect at the end of treatment that might reduce both patient’s and orthodontist’s satisfaction in otherwise promising treatment results. Flaxseed and Aloe Vera (AV) have been used as phytotherapeutic agents because of inherent antimicrobial, anti-inflammatory, antioxidants and healing properties. They were considered in this study for their effectiveness in remineralisation of WSL.

Aim: To evaluate and compare the remineralisation potential of organic flaxseed paste, Aloe Vera gel and fluoride toothpaste on artificially created white spot lesions around orthodontic brackets using Vicker’s microhardness assessment, spectrophotometry and Scanning Electron Microscope (SEM).

Materials and Methods: This experimental in-vitro study was undertaken in Department of Orthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India, in October 2020. Forty eight extracted premolar teeth were exposed to demineralising solution for 48 hours in-vitro and randomly assigned to four groups: Group 1- untreated control, group 2- treated with flaxseed paste, group 3- treated with Aloe Vera gel and group 4-treated with fluoride toothpaste. All groups except control were treated with their respective remineralising paste for 28 days. Vicker’s Microhardness Number (VHN) and spectrophotometric values (ΔL, Δa, Δb, ΔE) were evaluated for normal enamel, WSL, remineralisation after 14 and 28 days. The surface characteristics were analysed using SEM. Statistical analysis was performed using repeated measures Analysis of Variance (ANOVA) and post hoc Bonferroni test was for pairwise comparison between groups with significance level p≤0.05.

Results: Total of 48 extracted teeth were treated and analysed in their respective groups after 28 days. Aloe Vera gel showed highest surface microhardness (SMH) (144.09±6.05 VHN) and has statistically significant difference (p<0.001) compared to flaxseed paste (125.28±3.75 VHN) and then the fluoride toothpaste (121.20±5.12 VHN). There was no significant difference (p-value=0.31) between flaxseed paste and fluoride toothpaste. Significant (p-value=0.05) ΔE changes were observed in groups treated with flaxseed paste (16.39) and fluoride toothpaste (15.08) after 28 days. SEM verified mineral gain in all three treatment groups.

Conclusion: All the three groups increased mineral gain. Aloe Vera gel showed promising results by significantly remineralising WSLs. Flaxseed paste and fluoride toothpaste had SMH recovery which was lesser than Aloe Vera gel but, these two groups significantly improved the colour of WSL.


Anticariogenic, Dental plaque, Microhardness, Plant polyphenols

White Spot Lesions (WSL) are considered as undesirable outcomes after orthodontic treatment. It has a chalky white appearance which is an optical phenomenon due to mineral loss in the subsurface and surface of enamel (1). The brackets, wires, bands, excess composite, serve as a housing for plaque and colonisation of aciduric bacteria like Streptococcus mutans over a period of time and results in active WSL. They are difficult for the patient to cleanse and are also a limitation to the self-cleansing properties of the oral musculature and saliva (2). Approximately one-third of orthodontic patients are found to have atleast one WSL (3). The extent of the risk posed by decalcification during orthodontic treatment is a wide range of 2% to 96% of tooth surfaces (4).

Traditionally fluoride toothpaste has been used for control of WSL. They maintain the plaque fluid supersaturated with fluorapatite, hence moving the balance of caries process towards remineralisation (5). High concentration fluoride application can create hypermineralised areas on the enamel surface and prevent passage of ions into the deeper affected layers, which is unaesthetic (6). There is lack of reliable evidence to support the effectiveness of remineralising agents for the treatment of post orthodontic white spot lesions. Swallowing of fluoride could be detrimental to health because of its toxicity especially in children, it could accumulate in the tissues overtime and cause adverse health effects and dental fluorosis (7).

Recently, various organic vegetables and food supplements have shown to promote oral health. Antimicrobial compounds derived from plants can be considered an alternative to chemical agents for plaque control and prevention of demineralisation (8). Newer findings show that polyphenol component in plants have potential activity in preventing oral diseases and anticariogenic properties (9).

Linum usitatissimum’- Flaxseed has minerals like calcium, magnesium, phosphorous and potassium which can help in surface remineralisation of enamel (10). The polyphenol compound called lignans in flaxseed possess antibacterial activity against cariogenic bacteria Streptococcus mutans (11).

Aloe barbadensis’ -Aloe Vera mouth rinse was found to reduce plaque and gingivitis in orthodontic patients (12). AV tooth gel was found to be effective in controlling cariogenic bacteria similar to other commercially available toothpastes (13). AV gel was also reported to have remineralising potential, abundance in essential amino acids and deposition of arginine associated to the calcium on the enamel surface was suggested as the mechanism of remineralisation (14). Polyphenols, including anthraquinones were also thought to be responsible for inducing remineralisation (15).

Till now very few studies have been conducted to evaluate the remineralising potential of natural agents which have additional benefits like anti-inflammatory and antimicrobial action (10),(14). The comparative effect of flaxseed and AV gel on WSLs is not known. Therefore, the purpose of this study is to evaluate and compare the remineralisation potential of organic flaxseed paste, Aloe Vera gel and fluoride toothpaste on artificially created WSLs around orthodontic brackets using Vicker’s microhardness assessment, spectrophotometry and Scanning Electron Microscope (SEM).

Material and Methods

This experimental in-vitro study was undertaken in Department of Orthodontics, SRM Dental College, Ramapuram in October 2020. This study was approved by Institutional Review Board and Institutional Ethical Committee: [IRB APPROVAL NUMBER:SRMDC/IRB/2018/MDS/No.106].

Inclusion criteria: Maxillary and mandibular premolar teeth, extracted for orthodontic purpose with intact crowns were included in the study.

Exclusion criteria: Teeth with restoration or decay or damage on buccal surface of tooth that was to be bonded with bracket, teeth with caries, hypocalcification, fluorosis, enamel cracks and teeth pretreated with chemical reagents were excluded from the study.

Sample size estimation: G power software with power of 95% and error of 5% was used for sample size estimation and sample size of 48 was calculated. Hence, 48 maxillary and mandibular premolar teeth were included.


The teeth were washed and stored in distilled water until the start of procedure. The buccal enamel surfaces were cleaned with non fluoridated pumice and water, etched with 37% phosphoric acid (EAZETECH, Anabond Stedman) for 30 seconds. Primer (ORTHOFIX, Anabond Stedman) was applied on the etched enamel and cured. Upper premolar brackets (3M-Unitek Gemini) were bonded using composite resin (ORTHOFIX, Anabond Stedman) and were light cured for 40 seconds after removal of excess resin around brackets. The teeth were mounted in acrylic blocks with the buccal surfaces exposed such that the surface was flat and parallel to the base (Table/Fig 1).

Development of artificial white spot lesion: Demineralising solution was prepared by mixing 0.4723 g-calcium nitrate, 0.2722 g-potassium dihydrogen phosphate, 4.5083 g-acetic acid in one litre of distilled water (16). Fifty percent NaOH was added to adjust the pH of the solution to 4-4.5. Clear acid resistant nail varnish was painted on the entire buccal surface except a 3×3 mm area of window gingival to the bracket. The 48 samples along with two additional teeth were immersed completely in the demineralising solution and placed in an incubator at 37°C for 48 hours (17). After 48 hours, WSL appearance was visually verified and then the brackets were deboned, and any residual adhesive were removed (Table/Fig 2). Two additional teeth were sectioned longitudinally and depth of the WSL measured in SEM was about 70μm (18).

The sample of forty-eight teeth with WSLs were then split into four groups.

1. Group 1 (n=12): Artificial saliva (Control) ?
2. Group 2 (n=12): Flaxseed paste ?
3. Group 3 (n=12): Aloe Vera (AV) gel ?
4. Group 4 (n=12): Fluoride toothpaste ?

Artificial saliva solution was prepared by adding 0.75 g- sodium azide, 0.804 g- potassium monohydrogen phosphate, 0.166 g- calcium chloride, 0.59 g- magnesium chloride, 1.02 g- sodium chloride, in one litre of distilled water and the pH was approximatey 7 (17). The samples in the four groups were placed in four separate containers of artificial saliva solution and placed in an incubator at 37°C to mimic oral environment (Table/Fig 3).

Remineralisation procedure: All the teeth in control group were not treated with any agents. Edible raw organic flaxseed (Nutriwish®) was ground into fine powder and mixed with deionised distilled water to make flaxseed paste with concentration of 1 gm/mL (10). Hundred percent pure AV gel extract (Cunega, India) was acquired, stored at 4°C and fresh gel was obtained every two weeks. Fluoridated toothpaste -Colgate total 12 (Colgate -Palmolive, India) was used that contained Sodium Fluoride 0.22% w/w 1000 ppm. Each block was removed from the artificial saliva solution, treated with its designated product evenly on the buccal surface using a separate toothbrush for each group to avoid contamination and placed back without rinsing. This treatment was done twice a day for three minutes and artificial saliva solution was freshly replaced after each day.

Vicker’s microhardness assessment: The Surface Microhardness (SMH) was measured using Vicker’s microhardness tester (Micro Vicker’s hardness tester, 10g-1000g, MH6, Everone) for normal enamel at baseline, after WSL, at the end of 14 days and 28 days of treatment. Three indentations about 100 μm apart were performed with a load of 100 g exercised onto the surface of the specimens in the middle third for 10 seconds and the average of three readings of Vicker’s hardness number (VHN) were taken (19).

Spectrophotometric evaluation: Digital spectrophotometer (Vita Easyshade Advance 4.0) was used to measure L*, a* and b* after grouping of the samples. L is the degree of lightness in a colour from 0- absolute black to 100- absolute white, a is the red- green chromacity; +a*-measure of redness, -a*- measure of greenness and b is the blue- yellow chromacity; +b*- measure of yellow, -b*- measure of blue (20).

The samples were placed in a uniform black background and assessment was done in an area without any light leak. The tip of the spectrophotometer was placed on the buccal surface of demineralised enamel and simultaneously adjacent normal enamel was also assessed. Similarly, spectrophotometer readings were obtained after remineralisation at the end of 14 and 28 days. Three measurements were made and average was calculated. ΔE represents the Euclidean distance between the initial and final L*, a*, and b* values calculated using the formula ΔE=[(ΔL*)2 + (Δa*)2 + (Δb*)2]1/2 (17). The ΔL, Δa, Δb and ΔE quantified the difference from normal enamel and enamel at various intervals of time including WSL, remineralised enamel at 14 days and 28 days.

Scanning Electron Microscope (SEM): On the 29th day, buccal surface sections of one random remineralised sample from each group was cleaned, dehydrated by placing in 100% ethanol for one hour and then air dried. The sections were mounted in a platform using carbon tape and placed in a sputtering machine (Emitech, SC7620 sputter coater) for gold sputtering to facilitate conduction of electricity and aid in high quality images. The sputtered sections were examined under SEM (Tescan, Vega3) with acceleration voltage standardised to 20 kV and samples were projected at 1000x magnification.

Statistical Analysis

Statistical analysis was performed using International Business Management (IBM) Statistical Package for Social Sciences (SPSS) software package version 26.0. (IBM Corp). Paired t-test was done for comparison between normal and demineralised enamel. Statistical analysis of hardness value was done within groups using repeated measures ANOVA and post hoc Bonferroni test was performed for pairwise comparison between groups. Non parametric Friedman test was performed to evaluate changes in ΔL, Δa, Δb and ΔE within groups and multiple analysis Bonferroni test was done for comparison between groups. Significance was set at the 0.05 level.


Vicker’s microhardness assessment: Paired t-test displayed statistically significant (p<0.001) difference in the mean hardness value of normal enamel (269.13±24.06) Vicker’s Pyramid Number (HV) and enamel with WSLs (45.53±15.45) HV indicating that there is a decrease in the hardness of enamel when subjected to demineralisation (Table/Fig 4). Repeated measures ANOVA showed statistically significant changes (p<0.001) in surface microhardness of normal enamel, demineralised enamel and remineralised enamel after 14 days and 28 days in all the four groups (Table/Fig 5).

Post hoc Bonferroni test was performed for multiple comparison of remineralisation values at the end of 14 and 28 days between the control and treatment groups (Table/Fig 6). During initial remineralisation (14 days), fluoride toothpaste showed the maximum SMH (69.71±9.64) HV followed by AV gel (60.90±5.86) HV and flaxseed paste (50.03±3.63) HV and all the groups showed greater SMH than control (42.56±1.95) HV. However, at 28 days, AV gel had the maximum hardness value (144.09±6.05) HV and was significantly higher than other three groups (p<0.001) (Table/Fig 5). There was no significant difference (p=0.315) between flaxseed paste (125.28±3.75) HV and fluoride toothpaste (121.20±5.12) HV and both showed similar remineralisation potential after 28 days (Table/Fig 6).

The percentage of SMH recovery (%SMHR) for all the four treatment groups at the end of remineralisation after 28 days was calculated (Table/Fig 7). Highest recovery rate was seen in AV gel with 43.18%, followed by flaxseed paste with 35.66% and fluoride toothpaste with 33.84% and least recovery rate was seen in artificial saliva with 30.71%.

Spectrophotmetric evaluation: There is a statistically significant change in the ΔL, Δa, Δb and ΔE parameters in all four groups from demineralisation, remineralisation at 14 and 28 days measured as difference from normal enamel (Table/Fig 8). All the four groups showed decrease in ΔE value at the end of 28 days (Table/Fig 9). Fluoride toothpaste showed a significant decrease in ΔE value of remineralised enamel at 14 days (p=0.003) and 28 days (p=0.005) compared to demineralised enamel (31.51±12.65). However, there was no significant difference (p=0.530) between remineralisation at 14 days (15.89±8.79) or remineralisation at 28 days (15.08±5.93) (Table/Fig 8), (Table/Fig 10).

Flaxseed paste group showed a statistically significant decrease (p=0.006) in ΔE values from demineralised enamel (27.11±6.49) to remineralisation at 14 days (22.52±8.72) and further decreased at 28 days (16.39±8.23) suggesting the remineralised enamel colour to be changing closer towards the colour of baseline normal enamel. The colour change by 28 days from demineralised enamel was not statistically significant in AV gel (p=0.937) and artificial saliva (p=0.583) [Table/Fig-8,10].

Intergroup comparison showed no significant difference (p=1.00) in ΔE between the flaxseed and fluoride groups at the end of 28 days suggesting similar decrease in ΔE values [Table/Fig-9,11].

SEM Examination

Sound enamel showed smooth, uniform surface with homogenously arranged enamel crystals and regular appearance of enamel rods (Table/Fig 12)a. The demineralised surface in artificial WSL was highly porous with loss of enamel structure and disorganised crystal arrangement (Table/Fig 12)b. In Artificial saliva, predominantly porosities were evident on the surface with faint lines of sound enamel morphology (arrows) in and around the porosities (Table/Fig 12)c. Flaxseed paste showed irregular globular structures along with porosities in-between areas of remineralisation (arrows) which were thick and more frequent (Table/Fig 12)d. In AV gel predominantly intact enamel prismatic arrangement and ideally oriented, orderly mineralisation pattern was accomplished (arrows) with very minute areas of dissolution (Table/Fig 12)e. Fluoride Toothpaste also showed oriented mineralisation pattern (arrows) with slight interprismatic core dissolution (Table/Fig 12)f.


Topical application of various remineralising agents were efficient in promoting remineralisation in the present study. WSLs are the earliest macroscopic evidence of enamel caries and has been one of the inevitable clinical problems seen in most of the patients during orthodontic treatment (21). There is constant need for preventive programs to prevent peri-bracket demineralisation. Fluoride toothpastes, mouth rinses, varnishes are the most popular methods followed until today for prevention and remineralisation of WSLs. Casein Phosphopeptide-Amorphous Calcium Phosphate Complexes (CPP-ACP), Tooth mousse, resin infiltration methods, subsurface sealants, laser therapy etc., are also some of the systems prescribed to promote remineralisation (22).

In recent times, there is preference for organic agents due to their immense bio characteristics, cost-effectiveness, availability and a wider safety margin (23). Some plant polyphenols are able to regulate the demineralisation-remineralisation cycle of enamel (24). Flaxseed and Aloe Vera gel are two such natural agents rich in polyphenols. Flaxseed extract had been used successfully for treatment of xerostomia (25) and they had been found to have antimicrobial effect on periodontal and cariogenic pathogens (11). Similarly, Aloe Vera gel has numeral benefits and had been used to promote oral health due to its antimicrobial and healing properties (26),(13). However, the studies in literature of the remineralising potential of organic ingredients are very few (10),(14),(15).

Vicker’s microhardness assessment is a simple, non destructive method and an appropriate tool to evaluate remineralisation potential. In this study, the microhardness of the teeth after demineralisation was approximately 45 which is within acceptable baseline SMH ranging from 25 to 50 VHN (27).

Though remineralisation had been extensively studied, the aesthetic changes produced by remineralising agent is not frequently studied. Increasing the translucency of opaque enamel by remineralisation at the subsurface level will allow light to be absorbed similar to sound enamel. At many instances, WSL may remineralise but the opaque nature might still prevail leading to unsightly appearance. The ΔE value aids in determination of remineralising agent that produces remineralisation which is most aesthetically similar to sound enamel. ΔE average of 3.3 was reported to be aesthetically acceptable and any difference above this limit is highly perceptible (28).

In-vitro models are the most conventional techniques in caries research and artificial caries like lesion production was first described by Featherstone JD in 1983 (29). Demineralising solution in this study was prepared as described by Featherstone pH model (16). In this study, longitudinal section showed that the depth of the white spot lesion produced was around 70 μm similar to lesion described by White DJ in 1987 (18). The time period for assessment of remineralisation was chosen in accordance with previous study as two weeks and four weeks (10).

Koulourides T et al., described inherent natural remineralisation potential of saliva (30). In this present study also, remineralisation had occurred in the artificial saliva group but it was lesser than the other three groups at 28 days. Spectrophotometer evaluation showed no improvement in the colour of the WSL and SEM images also showed very less traces of remineralisation and more porosities. This might be because the mineral gain in artificial saliva is thought to be only superficial. Cochrane NJ et al., suggested that there is requirement of supplementing the tooth with additional remineralising agents along with natural remineralisation for repair of deeper layers (31).

The samples treated with flaxseed paste showed microhardness similar to that of fluoride toothpaste at 28 days and SEM images showed more frequent areas of remineralisation than control. There are no studies mentioning about the surface microhardness or changes in surface morphology in literature. Flaxseed paste was studied only on the basis of colorimetric parameters by Raffur MA et al., (10). They observed that flaxseed paste was effective in reducing the lightness, chroma and increased hue. The exact reason is not known and they attributed the remineralisation potential to the enormous mineral content. ΔE change of remineralised enamel at 28 days (16.39±8.23) was statistically significant (p=0.005) compared to WSL.

Silva TM et al, concluded that commercially available AV tooth gel was similar to sodium fluoride toothpaste in increasing SMH (14) and Teresa Al Haddad et al., in their in-vitro study showed that AV remineralised similar to 1450 ppm fluoride toothpaste (15). Similarly, AV gel group in the present study increased the SMH significantly and was greater compared to flaxseed paste and fluoride toothpaste. The exact mechanism of action of Aloe Vera on the demineralised surface still remains unclear and the previous studies have attributed the presence of aminoacids like arginine or polyphenol components to induce remineralisation (14),(15). SEM images correlated well with the SMH showing uniform and oriented remineralisation pattern. However, Aloe Vera gel could not produce a significant change in colour similar to normal enamel in this study and there are no previous studies evaluating this parameter.

Raffur MA et al., (10) and Silva TM et al., (14) had compared the natural agents with sodium fluoride toothpaste and the same fluoride toothpaste containing 1000 ppm of sodium fluoride was used in this study. Fluoride toothpaste showed greater increase in microhardness at the end of 14 days but at the end of 28 days the microhardness was similar to flaxseed paste and was lesser than AV gel and the colour change produced was also similar to flaxseed paste. SEM images also showed uniform pattern of remineralisation with slight areas of dissolution.

Aloe Vera or flaxseed can be incorporated into mouthwash or toothpaste and a safe, effective and economical product can be introduced and clinical trials can be performed. In orthodontics, further studies can be carried out on the effect of these natural agents on prevention of peri-bracket demineralisation by means of incorporation into either varnish, primer or composite resin or by coating of brackets or elastomeric ties.


Oral environment cannot be reproduced accurately with in-vitro studies, so in-vivo studies are required for more definitive results. Further observation intervals are required to evaluate whether the agents produce remineralisation similar to sound enamel structure.


Within the limitations of this study, the authors could conclude that Aloe Vera gel significantly increased the SMH of enamel and was the highest among all groups. It produced uniform mineralisation on the surface although there was no significant improvement in colour. Flaxseed paste and fluoride toothpaste showed significant improvement in the colour of enamel compared to Aloe Vera, but the SMH recovery was lesser. Aloe Vera gel and flaxseed paste could be considered as effective natural remineralising agents. The use of natural based product as therapeutic agent against the chemical synthetic products will have equal potential while negating the unwanted side effects and are promising to human health. The natural agents largely occur and could be used at a reasonable cost in the preparation of specific remedies. The fluoride free remineralising agents will also be safer for use in young children with white spot lesions due to poor oral hygiene maintenance.


Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am. J. Orthod. 1982;81 (2):93-8. [crossref]
Guzmán-Armstrong S, Chalmers J, Warren JJ. White spot lesions: Prevention and treatment. Am J Orthod Dentofacial Orthop.2010;138 (6):690-6. [crossref] [PubMed]
Willmot D. White spot lesions after orthodontic treatment. Semin Orthod.2008;14 (3):209-219. [crossref]
Mitchell L. Decalcification during orthodontic treatment with fixed appliances--an overview. Br J Orthod. 1992;19(3):199-205. [crossref] [PubMed]
Ten Cate JM. Review on fluoride, with special emphasis on calcium fluoride mechanisms in caries prevention. Eur J Oral Sci. 1997;105(5):461-5. [crossref] [PubMed]
Bishara SE, Ostby AW. White spot lesions: formation, prevention, and treatment. Semin Orthod. 2008;14 (3):174-82. [crossref]
Ullah R, Zafar MS, Shahani N. Potential fluoride toxicity from oral medicaments: A review. Iran J Basic Med Sci. 2017;20 (8):841.
Silva app da, Goncalves RS, Borges AFS, Bedran-Russo AK, Shinohara MS. Effectiveness of plant-derived proanthocyanidins on demineralization on enamel and dentin under artificial cariogenic challenge. J. Appl. Oral Sci. 2015;23 (3):302-9. [crossref] [PubMed]
Ferrazzano GF, Amato I, Ingenito A, Zarrelli A, Pinto G, Pollio A. Plant polyphenols and their anti-cariogenic properties: a review. Molecules. 2011;16 (2):1486-507. [crossref] [PubMed]
Abd Raffur MA, Shaharuddin IM, Younis LT. The Effect of Organic Flaxseed Paste on the Colorimetric Parameters of Demineralized Tooth Surface. International journal of new technology and research. 20184(6):1-9.
Alahmad BEM, Kashmoola MA, Kumar P, Subramaniam L, Mokhtar KIB, shaban Mustafa N, et al. The antibacterial effect of flaxseed extract on selective oral pathogens-comparative in vitro study. World Journal of Pharmacy and Pharmaceutical Sciences. 2018;7(11):1-11. [crossref]
Yeturu SK, Acharya S, Urala AS, Pentapati KC. Effect of Aloe vera, chlorine dioxide, and chlorhexidine mouth rinses on plaque and gingivitis: A randomized controlled trial. J Oral Biol Craniofac Res. 2016;6(1):55-9. [crossref] [PubMed]
George D, Bhat SS, Antony B. Comparative evaluation of the antimicrobial efficacy of Aloe vera tooth gel and two popular commercial toothpastes: An in vitro study. Gen Dent. 2009;57 (3):238-41.
Silva TMD, Fonseca BMD, Sales ALLS, Holleben P, Valera MC, AraÚjo MAMD. Effects of fluoride and Aloe vera tooth gel in artificial white spot lesions in vitro. Rev Gaúch. Odontol. 2016;64(1):56-61. [crossref]
Al Haddad T, Khoury E, Mchayleh NF. Comparison of the Remineralizing Effect of Brushing with Aloe vera versus Fluoride Toothpaste. Eur J Dent. 2021;15 (01):133-8. [crossref] [PubMed]
Stookey GK. The Featherstone laboratory pH cycling model: a prospective, multi-site validation exercise. Am J Dent. 2011;24 (5):322.
Gamal M, El-Baily A, Osman MF. Assessment of the remineralization potential of recently developed nano-hydroxyapatite on the demineralized enamel around orthodontic brackets. Indian J Orthodont Dentofac Res. 2017;3 (4):218-25.
White DJ. Reactivity of fluoride dentifrices with artificial caries. Caries Res. 1987;21 (2):126-40. [crossref] [PubMed]
Chuenarrom C, Benjakul P, Daosodsai P. Effect of indentation load and time on knoop and vickers microhardness tests for enamel and dentin. Mat. Res. 2009;12(4):473-76. [crossref]
Knösel M, Reus M, Rosenberger A, Ziebolz D. A novel method for testing the veridicality of dental colour assessments. Eur. J. Orthod. 2012;34 (1):19-24. [crossref] [PubMed]
Silverstone L, Johnson N, Hardie J, Williams R. Enamel caries. Dental Caries. Springer; 1981. p. 133-61. [crossref]
Khoroushi M, Kachuie M. Prevention and treatment of white spot lesions in orthodontic patients. Contem Clin Dent. 2017;8 (1):11-19. [crossref] [PubMed]
Moghadam ET et al. Current herbal medicine as an alternative treatment in dentistry: In vitro, in vivo and clinical studies. Eur. J. Pharmacol. 2020;15:889:173665. doi: 10.1016/j.ejphar.2020.173665. [crossref] [PubMed]
Cheng L, Li J, He L, Zhou X. Natural products and caries prevention. Caries Res. 2015;49 (Suppl.1):38-45. [crossref] [PubMed]
Andersson G, Johansson G, Attström R, Edwardsson S, Glantz PO, Larsson K. Comparison of the effect of the linseed extract Salinum® and a methyl cellulose preparation on the symptoms of dry mouth. Gerodontology. 1995;12(1):12-7. [crossref] [PubMed]
Wynn RL. Aloe vera gel: Update for dentistry. Gen Dent. 2005;53 (1):6-9.
Karlinsey RL, Mackey AC, Walker TJ, Frederick KE, Blanken DD, Flaig SM, Walker ER. In vitro remineralization of human and bovine white-spot enamel lesions by NaF dentifrices: a pilot study. J Dent Oral Hyg. 2011;3(2):22-29.
Ruyter IE, Nilner K, Möller BJ. Color stability of dental composite resin materials for crown and bridge veneers. Dent Mater. 1987;3(5):246-51. [crossref]
Featherstone JD. Remineralisation of artificial carious lesions in vivo and in vitro. Demineralisation and remineralisation of the teeth. 1983:89-110.
Koulourides T, Feagin F, Pigman W. Remineralization of dental enamel by saliva in vitro. Ann N Y Acad Sci. 1965;131 (2):751-7. [crossref] [PubMed]
Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC. New approaches to enhanced remineralization of tooth enamel. J Dent Res. 2010;89(11):1187-97. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/53105.16471

Date of Submission: Oct 31, 2021
Date of Peer Review: Jan 11, 2022
Date of Acceptance: Mar 10, 2022
Date of Publishing: Jun 01 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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