human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Summary Background : Using lingual enamel surfaces for bracket placement not only has esthetic advantages , but may also be suitable in terms of reducing frequencies of enamel decalcifications . Objective : To test the null-hypothesis that there is no significant difference in enamel decalcification or cavitation incidence adjacent to and beneath bracket bases between two  lingual multi-bracket ( MB ) appliances  that are different in terms of design , material composition , and manufacturing technology ( group A : WIN , DW-LingualSystems ; group B : Incognito , 3M-Unitek ) , taking into account patient- and treatment-related variables on white spot lesion ( WSL ) formation . Methods : St and ardized , digital , top-view photographs of 630 consecutive subjects ( 16214 teeth ; n Incognito = 237/6076 teeth ; n WIN = 393/10138 teeth ; mean age : 17.47±7.8 ; m/f 43.2/56.8 % ) with completed lingual MB treatment of the upper and lower permanent teeth 1–7 were screened for decalcification or cavitation adjacent to and beneath the bracket bases before and after treatment , scored from 0 to 7 . Non-parametric ANOVA was used for main effects ‘ appliance type ’ , ‘ gender ’ , ‘ treatment complexity ’ , ‘ grouped age ’ ( ≤16/>16 years ) , and ‘ treatment duration ’ as covariable , at an α-level of 5 % . Results : About 2.57 % [ 5.94 % ] of all teeth in group A [ B ] developed decalcifications . Subject-related incidence was 9.59 % [ 16.17 % ] for upper incisors in group A [ B ] , and 12.98 % [ 25.74 % ] for all teeth 16–46 . There were significant effects by gender , age , and treatment duration . Conclusion : The null-hypothesis was rejected : sub-bracket lesions were significantly less frequent in group A , while frequencies of WSL adjacent to brackets were not significantly affected by appliance type . In view of the overall low incidences of lingual post-orthodontic white-spot lesions , the use of lingual appliances is advocated as a valid strategy for a reduction of enamel decalcifications during orthodontic treatment Background White spot lesions ( WSLs ) are a frequent side-effect of multibracket appliance treatment . The effect of local fluoridation on post-orthodontic WSL is however inconclusive . Objective Assessment of WSL changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment . Trial design R and omized , single-centre , double-blind , parallel-group , placebo-controlled study . Participants Patients with not less than 1 WSL ( modified score 1 or 2 ) on not less than 1 upper front teeth after debonding . Interventions Professional fluoride/placebo gel application during weeks 1 - 2 ; self-administered home application ( weeks 3 - 24 ) . Outcomes Photographic WSL assessment ( dimension and luminance ) of the upper front teeth ( T0-T5 ) . R and omization R and om assignment to test ( n = 23 ) or placebo group ( n = 23 ) using a sequentially numbered list ( r and om allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each ) . Recruitment The clinical study duration lasted from March 2011 to September 2013 . Blinding Unblinding was performed after complete data evaluation . Numbers analysed Intent-to-treat analysis set comprising 39 participants ( test : n = 21 , placebo : n = 18 ) . Outcome Dimensional WSL quantification showed limited reliability . Luminance improvement ( % ) of WSL , however , was seen after 6 months ( test/placebo : tooth 12 , 24.8/18.0 ; tooth 11 , 38.4/35.4 ; tooth 21 , 39.6/38.3 ; and tooth 22 , 15.2/25.0 ) . No statistically significant group difference existed . Data suggest that WSLs are difficult to measure with respect to reliability and repeatability and methods for monitoring WSLs in clinical trials require improvement/validation . Harms Similar adverse events occurred in both groups ; none was classified as possibly related to the study product . Limitations The number of dropouts was higher than expected and the socio-economic status was not assessed . Furthermore , the unknown level of compliance during the home application phase must be considered as limitation . Conclusion Based on the results of this study , no difference could be detected with respect to the development of WSL under post-orthodontic high-dose fluoride treatment . Registration The study was registered with Clinical Trials.gov ( Identifier : NCT01329731 ) . Protocol The protocol was n't published before trial commencement Orthodontic treatment with fixed appliances is considered a risk factor for the development of  white spot caries lesions ( WSL ) . Traditionally , brackets are bonded to the buccal surfaces . Lingual brackets are developing rapidly and have become more readily available . Buccal surfaces are considered to be more caries prone than lingual surfaces . Furthermore , lingual brackets are shaped to fit the morphology of the teeth and seal almost the entire surface . In the present study we tested the hypothesis that lingual brackets result in a lower caries incidence than buccal brackets . We tested this hypothesis using a split-mouth design where subjects were allocated r and omly to a group receiving either buccal or lingual brackets on the maxillary teeth and the alternative bracket type in the m and ible . The results indicate that buccal surfaces are more prone to WSL development , especially when WSL existed before treatment . The number of WSL that developed or progressed on buccal surfaces was 4.8 times higher than the number of WSL that developed or progressed on lingual surfaces . When measured using quantitative light-induced fluorescence ( QLF ) , the increase in integrated fluorescence loss was 10.6 times higher buccally than lingually . We conclude that lingual brackets make a difference when caries lesion incidence is concerned Introduction The occurrence of side-effects of fixed orthodontic therapy , such as white-spot lesions and root resorption , are known to be significantly more frequent with increasing duration of treatment . Multi-bracket treatment should be as short as possible , in order to minimize the risks of collateral damage to teeth . The aim of this non-r and omized clinical trial was to compare treatment duration with each of two types of customized lingual orthodontic appliances ( Incognito , 3 M-Unitek ; WIN , DW LingualSystems ) , taking into account treatment complexity . The null-hypothesis was that there would be no significant difference in active orthodontic treatment duration between them . Methods Of 402 potentially eligible participants , a population sample of n = 376 subjects ( nIncognito = 220 ; nWIN = 156 ; m/f 172/204 ; mean age ± SD 17.3 ± 7.7Y ) treated in one orthodontic center ( Bad Essen , Germany ) with completely customized lingual appliances in upper and lower permanent dental arches was recruited with the inclusion criterion of initiated and completed lingual multi-bracket treatment within the assessment period of April 1st 2010 – Nov 30 , 2013 , and the exclusion criterion of less than 24 bracketed teeth . We used four-factorial ANOVA to assess the impact of the following factors : initial degree of severity of malocclusion ( mild to moderate , S1 ; severe , S2 ) , appliance type ( Incognito ; WIN ) , sex , and age group ( < = 16 ; > 16 Y ) on the duration of lingual multi-bracket treatment . Results Overall , mean treatment duration was 21.7 ( SD 7.2 ) months , which was significantly shorter for WIN for both sub-groups of treatment complexity ( S1 : 17.96 mo ; S2 : 20.49 mo ) compared to Incognito ( S1 : 22.7 mo ; S2 : 29.79 mo ) . ANOVA revealed a significant influence of the main effects ‘ appliance type ’ , and ‘ severity ’ , independent of each other . Therefore , the null-hypothesis was rejected . Conclusion In terms of treatment duration , the WIN appliance performed significantly better than the Incognito appliance . Consequently , subjects treated with the WIN appliance are expected to be exposed to lower risks of the typical side-effects associated with longer multi-bracket treatment duration s , such as root resorption and enamel decalcification INTRODUCTION Dental caries , specifically decalcified white-spot lesions ( WSL ) , is a well-known side-effect of orthodontic treatment . The incidence of labial incipient caries lesions and its relationship with various patient and treatment variables was investigated in patients treated with comprehensive orthodontics .  METHODS R and omly selected orthodontic patient records ( n = 350 ) were examined to determine incipient caries lesion development . Labial surfaces on pretreatment and posttreatment photographs were scored with a st and ardized scoring system . Independent variables were collected by chart abstract ion . RESULTS The incidence of patients who developed at least 1 new WSL during treatment was 72.9 % , and this incidence was 2.3 % for cavitated lesions . Treatment duration was significantly associated with new WSL development ( P = 0.03 ) . Development of WSL and cavitated lesions increased ( both , P < 0.00 ) despite increased attention to oral hygiene during treatment . Sex , age , extraction therapy , and various fluoridation sources were not associated with WSL development , but initial oral-hygiene score was moderately associated ( P < 0.06 ) . CONCLUSIONS The incidence of WSL in patients treated with comprehensive orthodontics  was significantly high , and the preventive therapy provided appeared to be ineffective . This widespread problem is alarming and warrants significant attention from both patients and providers that should result in greatly increased emphasis on effective caries prevention SUMMARY BACKGROUND / OBJECTIVES White spot lesions ( WSLs ) are unwelcome side effects of fixed appliances that compromise the treatment outcome . Recently , infiltration of WSLs has been introduced as a viable treatment alternative . The objective was to evaluate the colour improvement of WSLs and their stability against discolouration following infiltration , fluoride , or micro-abrasion treatments in vitro . MATERIAL S/ METHODS Artificial WSLs were created in bovine enamel ( N = 96 ) using acidic buffer solution ( pH 5 , 10 days ) and were r and omly allocated to four groups . Specimens were treated with infiltration ( Icon , DMG ) , fluoride ( Elmex Caries Protection , GABA ) , and micro-abrasion ( Opalustre , Ultradent ) or remained untreated ( control ) . Groups were discoloured for 24 hours in tea or tea + citric acid . Colour components and visible colour change ( L * , a * , b * , ΔE ) were measured spectrophotometrically on following time points : baseline , after WSL formation , after treatment , and during discolouration ( 8 , 16 , and 24 hours ) . Data were analysed using Kruskal-Wallis and Mann-Whitney tests . RESULTS WSL formation increased ( L * ) in all groups . Only infiltration reduced this effect to baseline . Highest ΔE improvement was obtained by infiltration and micro-abrasion followed by fluoride . This improvement was stable only for infiltration during discolouration . L * , a * , and b * changed significantly during discolouration in all groups except infiltration . Within the same treatment group , discolouration solutions did not differ significantly . LIMITATIONS In vitro testing can not replicate the actual mode of colour improvement or stability but can be used for ranking material s and techniques . CONCLUSIONS / IMPLICATION S Infiltration and micro-abrasion treatments were capable of diminishing the whitish appearance of WSLs . Only infiltrated WSLs were stable following discolouration challenge INTRODUCTION A new , highly filled primer is currently marketed as a fluoride delivery system effective in reducing white spot lesions in orthodontic patients . However , no studies in the literature support this cl aim . The purpose of this in-vivo study was to investigate the retention and the efficacy of this primer in reducing the formation of white spot lesions . METHODS In each patient for whom premolar extraction s were planned ( n = 22 ) , 1 premolar was r and omly chosen as the experimental tooth for the application of the fluoride delivery system ( Opal Seal ; Ultradent Products , South Jordan , Utah ) , and the contralateral tooth was assigned as the control to receive the st and ard treatment ( Transbond XT ; 3 M Unitek , Monrovia , Calif ) . After the bonding procedures , separators were placed around the premolar brackets to encourage plaque retention over 8 weeks . After the extraction s , the tooth surfaces were evaluated visually and with microhardness techniques for demineralization . Primer retention was also investigated . RESULTS There were no statistically significant differences in the numbers of white spot lesions between the 2 groups . The primer retention was calculated as 50 % . CONCLUSIONS The results indicated no significant difference between the efficacies of the fluoride-releasing primer and the control primer in reducing demineralization over the duration of the study INTRODUCTION White spot lesions that form during orthodontic treatment are a problem for patients and clinicians . Lesion infiltration with low-viscosity light-cured resin has been proposed as a treatment to inhibit further demineralization . The purpose of this study was to assess the durability of assimilation of white spot lesions and sound adjacent enamel achieved over 6 months with resin infiltration . METHODS Twenty-one consecutive subjects with 231 noncavitated , unrestored white spot lesions after multibracket treatment were recruited at the Department of 
    Output:
    
agent
Conclusion Costs for repeated treatment of post-orthodontic enamel damages produced by conventional vestibular fixed appliances may easily exceed the initially higher costs associated with lingual orthodontic treatment .
Judged economically in the long term , lingual MB Tx may be considered as a more cost-effective solution for a correction of malocclusion
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Summary Background : Using lingual enamel surfaces for bracket placement not only has esthetic advantages , but may also be suitable in terms of reducing frequencies of enamel decalcifications . Objective : To test the null-hypothesis that there is no significant difference in enamel decalcification or cavitation incidence adjacent to and beneath bracket bases between two  lingual multi-bracket ( MB ) appliances  that are different in terms of design , material composition , and manufacturing technology ( group A : WIN , DW-LingualSystems ; group B : Incognito , 3M-Unitek ) , taking into account patient- and treatment-related variables on white spot lesion ( WSL ) formation . Methods : St and ardized , digital , top-view photographs of 630 consecutive subjects ( 16214 teeth ; n Incognito = 237/6076 teeth ; n WIN = 393/10138 teeth ; mean age : 17.47±7.8 ; m/f 43.2/56.8 % ) with completed lingual MB treatment of the upper and lower permanent teeth 1–7 were screened for decalcification or cavitation adjacent to and beneath the bracket bases before and after treatment , scored from 0 to 7 . Non-parametric ANOVA was used for main effects ‘ appliance type ’ , ‘ gender ’ , ‘ treatment complexity ’ , ‘ grouped age ’ ( ≤16/>16 years ) , and ‘ treatment duration ’ as covariable , at an α-level of 5 % . Results : About 2.57 % [ 5.94 % ] of all teeth in group A [ B ] developed decalcifications . Subject-related incidence was 9.59 % [ 16.17 % ] for upper incisors in group A [ B ] , and 12.98 % [ 25.74 % ] for all teeth 16–46 . There were significant effects by gender , age , and treatment duration . Conclusion : The null-hypothesis was rejected : sub-bracket lesions were significantly less frequent in group A , while frequencies of WSL adjacent to brackets were not significantly affected by appliance type . In view of the overall low incidences of lingual post-orthodontic white-spot lesions , the use of lingual appliances is advocated as a valid strategy for a reduction of enamel decalcifications during orthodontic treatment Background White spot lesions ( WSLs ) are a frequent side-effect of multibracket appliance treatment . The effect of local fluoridation on post-orthodontic WSL is however inconclusive . Objective Assessment of WSL changes in response to weekly 1.25 per cent fluoride gel application after multibracket appliance treatment . Trial design R and omized , single-centre , double-blind , parallel-group , placebo-controlled study . Participants Patients with not less than 1 WSL ( modified score 1 or 2 ) on not less than 1 upper front teeth after debonding . Interventions Professional fluoride/placebo gel application during weeks 1 - 2 ; self-administered home application ( weeks 3 - 24 ) . Outcomes Photographic WSL assessment ( dimension and luminance ) of the upper front teeth ( T0-T5 ) . R and omization R and om assignment to test ( n = 23 ) or placebo group ( n = 23 ) using a sequentially numbered list ( r and om allocation sequence generated for 50 subjects in 25 blocks of 2 subjects each ) . Recruitment The clinical study duration lasted from March 2011 to September 2013 . Blinding Unblinding was performed after complete data evaluation . Numbers analysed Intent-to-treat analysis set comprising 39 participants ( test : n = 21 , placebo : n = 18 ) . Outcome Dimensional WSL quantification showed limited reliability . Luminance improvement ( % ) of WSL , however , was seen after 6 months ( test/placebo : tooth 12 , 24.8/18.0 ; tooth 11 , 38.4/35.4 ; tooth 21 , 39.6/38.3 ; and tooth 22 , 15.2/25.0 ) . No statistically significant group difference existed . Data suggest that WSLs are difficult to measure with respect to reliability and repeatability and methods for monitoring WSLs in clinical trials require improvement/validation . Harms Similar adverse events occurred in both groups ; none was classified as possibly related to the study product . Limitations The number of dropouts was higher than expected and the socio-economic status was not assessed . Furthermore , the unknown level of compliance during the home application phase must be considered as limitation . Conclusion Based on the results of this study , no difference could be detected with respect to the development of WSL under post-orthodontic high-dose fluoride treatment . Registration The study was registered with Clinical Trials.gov ( Identifier : NCT01329731 ) . Protocol The protocol was n't published before trial commencement Orthodontic treatment with fixed appliances is considered a risk factor for the development of  white spot caries lesions ( WSL ) . Traditionally , brackets are bonded to the buccal surfaces . Lingual brackets are developing rapidly and have become more readily available . Buccal surfaces are considered to be more caries prone than lingual surfaces . Furthermore , lingual brackets are shaped to fit the morphology of the teeth and seal almost the entire surface . In the present study we tested the hypothesis that lingual brackets result in a lower caries incidence than buccal brackets . We tested this hypothesis using a split-mouth design where subjects were allocated r and omly to a group receiving either buccal or lingual brackets on the maxillary teeth and the alternative bracket type in the m and ible . The results indicate that buccal surfaces are more prone to WSL development , especially when WSL existed before treatment . The number of WSL that developed or progressed on buccal surfaces was 4.8 times higher than the number of WSL that developed or progressed on lingual surfaces . When measured using quantitative light-induced fluorescence ( QLF ) , the increase in integrated fluorescence loss was 10.6 times higher buccally than lingually . We conclude that lingual brackets make a difference when caries lesion incidence is concerned Introduction The occurrence of side-effects of fixed orthodontic therapy , such as white-spot lesions and root resorption , are known to be significantly more frequent with increasing duration of treatment . Multi-bracket treatment should be as short as possible , in order to minimize the risks of collateral damage to teeth . The aim of this non-r and omized clinical trial was to compare treatment duration with each of two types of customized lingual orthodontic appliances ( Incognito , 3 M-Unitek ; WIN , DW LingualSystems ) , taking into account treatment complexity . The null-hypothesis was that there would be no significant difference in active orthodontic treatment duration between them . Methods Of 402 potentially eligible participants , a population sample of n = 376 subjects ( nIncognito = 220 ; nWIN = 156 ; m/f 172/204 ; mean age ± SD 17.3 ± 7.7Y ) treated in one orthodontic center ( Bad Essen , Germany ) with completely customized lingual appliances in upper and lower permanent dental arches was recruited with the inclusion criterion of initiated and completed lingual multi-bracket treatment within the assessment period of April 1st 2010 – Nov 30 , 2013 , and the exclusion criterion of less than 24 bracketed teeth . We used four-factorial ANOVA to assess the impact of the following factors : initial degree of severity of malocclusion ( mild to moderate , S1 ; severe , S2 ) , appliance type ( Incognito ; WIN ) , sex , and age group ( < = 16 ; > 16 Y ) on the duration of lingual multi-bracket treatment . Results Overall , mean treatment duration was 21.7 ( SD 7.2 ) months , which was significantly shorter for WIN for both sub-groups of treatment complexity ( S1 : 17.96 mo ; S2 : 20.49 mo ) compared to Incognito ( S1 : 22.7 mo ; S2 : 29.79 mo ) . ANOVA revealed a significant influence of the main effects ‘ appliance type ’ , and ‘ severity ’ , independent of each other . Therefore , the null-hypothesis was rejected . Conclusion In terms of treatment duration , the WIN appliance performed significantly better than the Incognito appliance . Consequently , subjects treated with the WIN appliance are expected to be exposed to lower risks of the typical side-effects associated with longer multi-bracket treatment duration s , such as root resorption and enamel decalcification INTRODUCTION Dental caries , specifically decalcified white-spot lesions ( WSL ) , is a well-known side-effect of orthodontic treatment . The incidence of labial incipient caries lesions and its relationship with various patient and treatment variables was investigated in patients treated with comprehensive orthodontics .  METHODS R and omly selected orthodontic patient records ( n = 350 ) were examined to determine incipient caries lesion development . Labial surfaces on pretreatment and posttreatment photographs were scored with a st and ardized scoring system . Independent variables were collected by chart abstract ion . RESULTS The incidence of patients who developed at least 1 new WSL during treatment was 72.9 % , and this incidence was 2.3 % for cavitated lesions . Treatment duration was significantly associated with new WSL development ( P = 0.03 ) . Development of WSL and cavitated lesions increased ( both , P < 0.00 ) despite increased attention to oral hygiene during treatment . Sex , age , extraction therapy , and various fluoridation sources were not associated with WSL development , but initial oral-hygiene score was moderately associated ( P < 0.06 ) . CONCLUSIONS The incidence of WSL in patients treated with comprehensive orthodontics  was significantly high , and the preventive therapy provided appeared to be ineffective . This widespread problem is alarming and warrants significant attention from both patients and providers that should result in greatly increased emphasis on effective caries prevention SUMMARY BACKGROUND / OBJECTIVES White spot lesions ( WSLs ) are unwelcome side effects of fixed appliances that compromise the treatment outcome . Recently , infiltration of WSLs has been introduced as a viable treatment alternative . The objective was to evaluate the colour improvement of WSLs and their stability against discolouration following infiltration , fluoride , or micro-abrasion treatments in vitro . MATERIAL S/ METHODS Artificial WSLs were created in bovine enamel ( N = 96 ) using acidic buffer solution ( pH 5 , 10 days ) and were r and omly allocated to four groups . Specimens were treated with infiltration ( Icon , DMG ) , fluoride ( Elmex Caries Protection , GABA ) , and micro-abrasion ( Opalustre , Ultradent ) or remained untreated ( control ) . Groups were discoloured for 24 hours in tea or tea + citric acid . Colour components and visible colour change ( L * , a * , b * , ΔE ) were measured spectrophotometrically on following time points : baseline , after WSL formation , after treatment , and during discolouration ( 8 , 16 , and 24 hours ) . Data were analysed using Kruskal-Wallis and Mann-Whitney tests . RESULTS WSL formation increased ( L * ) in all groups . Only infiltration reduced this effect to baseline . Highest ΔE improvement was obtained by infiltration and micro-abrasion followed by fluoride . This improvement was stable only for infiltration during discolouration . L * , a * , and b * changed significantly during discolouration in all groups except infiltration . Within the same treatment group , discolouration solutions did not differ significantly . LIMITATIONS In vitro testing can not replicate the actual mode of colour improvement or stability but can be used for ranking material s and techniques . CONCLUSIONS / IMPLICATION S Infiltration and micro-abrasion treatments were capable of diminishing the whitish appearance of WSLs . Only infiltrated WSLs were stable following discolouration challenge INTRODUCTION A new , highly filled primer is currently marketed as a fluoride delivery system effective in reducing white spot lesions in orthodontic patients . However , no studies in the literature support this cl aim . The purpose of this in-vivo study was to investigate the retention and the efficacy of this primer in reducing the formation of white spot lesions . METHODS In each patient for whom premolar extraction s were planned ( n = 22 ) , 1 premolar was r and omly chosen as the experimental tooth for the application of the fluoride delivery system ( Opal Seal ; Ultradent Products , South Jordan , Utah ) , and the contralateral tooth was assigned as the control to receive the st and ard treatment ( Transbond XT ; 3 M Unitek , Monrovia , Calif ) . After the bonding procedures , separators were placed around the premolar brackets to encourage plaque retention over 8 weeks . After the extraction s , the tooth surfaces were evaluated visually and with microhardness techniques for demineralization . Primer retention was also investigated . RESULTS There were no statistically significant differences in the numbers of white spot lesions between the 2 groups . The primer retention was calculated as 50 % . CONCLUSIONS The results indicated no significant difference between the efficacies of the fluoride-releasing primer and the control primer in reducing demineralization over the duration of the study INTRODUCTION White spot lesions that form during orthodontic treatment are a problem for patients and clinicians . Lesion infiltration with low-viscosity light-cured resin has been proposed as a treatment to inhibit further demineralization . The purpose of this study was to assess the durability of assimilation of white spot lesions and sound adjacent enamel achieved over 6 months with resin infiltration . METHODS Twenty-one consecutive subjects with 231 noncavitated , unrestored white spot lesions after multibracket treatment were recruited at the Department of 
    Output:
    