The goal of this clinical trial is to learn if topical application on the all surface of 10% Povidone Iodine (Povi-One) in healthy participants in transitional or permanent dentition (10-17 y) prevents new white spot lesions in the maxillary anterior teeth at 1 year of follow-up.

Researchers will compare Povi-One to a placebo to see if Povi-One works to prevent new white spot lesions.

It will also learn about the safety of topical 10% Povidone Iodine.

The main questions it aims to answer are:

1. Does Povi-One prevent the development of any white spot lesion on the surface of maxillary anterior teeth?
2. Does Povi-One lower the probability of any International Caries Detection and Assessment System (ICDAS) score greater than 0 and mean modified Löe-Silness Gingival Index (GI) in the intervention group?

Researchers will

1. Score GI without cleaning participants teeth, then score ICDAS of maxillary and mandibular incisors after participants brush and floss their teeth and take a photograph of maxillary 6 anterior teeth
2. Apply Povi-one (or control) at the consultation appointment before placing fixed orthodontic appliances and 3, 6, and 9 months after appliance placement

Researchers will

1. Recall using Zoom 24-48 hours after the first application of Povi-One and examine the participant's mouth for oral lesions using a structured paper checklist
2. Interview the caregiver to complete a paper questionnaire on adverse effects

Researchers will

1. Score GI, and then score ICDAS of maxillary and mandibular incisors in 6, 12 months after appliance placement
2. Evaluate the development of white spot lesions on maxillary central and lateral incisors in 6, and 12 months after appliance placement

Protocol:

Efficacy and Safety Of Topical 10% Povidone-Iodine In Preventing White Spots During Orthodontic Treatment

Design:

A triple-blind randomized trial with two arms (10% Povidone Iodine, Placebo) where the primary outcome is the percentage of patients with at least one new white spot lesion on the maxillary anterior teeth at 1 year of follow-up. The secondary outcomes will utilize the ICDAS on the upper and lower anterior teeth, a modified Gingival Index, and Acceptability.

Hypothesis:

Participants treated with the test agent will be less likely to develop any enamel decalcification than participants treated with the placebo comparator. Also, the probability of any ICDAS score greater than 0 and mean modified Gingival Index will be lower in the treatment group than in the comparator.

Recruitment/Consent:

The participants will be recruited as they begin treatment. The orthodontic graduate student will briefly present the study and ask if the child/teen and caregiver (parent, guardian) are willing to talk about the study and then, if the child/teen and caregiver are willing, a research assistant will further explain participation and gain informed assent from the child/teen and consent from the parent.

Intervention:

Povi-One (10% povidone-iodine) will be applied topically by the graduate student to all tooth surfaces at the consultation appointment (baseline) before the placement of fixed appliances. Povi-one (or control) will be applied again at 3, 6, and 9 months after appliance placement by the graduate student.

Control:

The placebo (double distilled water colored to match the Povidone-Iodine solution in color and taste) application procedure is identical to that of the test product. The manufacturer will provide the placebo.

Concomitant Treatment:

No change will be made in orthodontic treatment. Any application of fluorides or other dental treatment will be recorded from the EHR. The participant and/or caregiver will be asked whether the participant is using any OTC fluoride products or had any fluoride applied by their dentist.

Management of agents (Povi-One and placebo) Povi-One and placebo will be delivered to the clinic site by the manufacturer marked with the different treatment codes. Treatment codes will be retained by the manufacturer until after analysis. Fresh products will be supplied every 6 months and stored at room temperature in locked storage in the orthodontics clinic.

Retention:

The drop-out rate of patients in the graduate orthodontic clinic once treatment begins is less than 5%

Sample size determination:

The sample size is based on recent data collected on adolescent patients in the UW graduate orthodontic clinic. Assuming a 50% incidence of any new white spot lesions, as identified by intra-oral photographs at 12 months in the placebo sample, and a reduction of 60% in the test sample, the sample size based on a two-sample chi-square test using a 0.05 significance level and 80% power is 39 participants per group (78 total) without accounting for attrition. Assuming 5% attrition at 12 months, the sample size required is 41 per group (82 total). Assuming an 80% acceptance rate and about 125 new patients in the required age range per year at the UW graduate orthodontic clinic, the sample of 80 patients can be accrued in one 1 year.

Data Management:

The demographic data, clinical evaluation data, and post-treatment reports will be recorded on paper forms precoded with the participant ID. These forms will be collected and kept in a locked file until entered into a computer database. The photographic images will be identified by participant ID and date and uploaded to a secure study computer.

Analysis:

The analysis will be based on the intention-to-treat principle. Binary outcomes will be summarized for each study arm and time point by frequency and percentage and quantitative outcomes will be summarized by mean, standard deviation, median, interquartile range, and range. A chi-square test will be used to compare the percentage of patients in each group that develop at least one new white spot lesion. A chi-square will be also used to compare the incidence of any ICDAS score greater than 0 and a two-sample test will be used to compare the mean modified Gingival Index and Acceptability. If the distribution of the modified Gingival Index or Acceptability is skewed, a non-parametric Mann-Whitney U test will be used. Log-linear regression with robust standard errors will used to compare the number of new ICDAS scores greater than 0 if sufficient numbers of participants have more than 1 new lesion (Hardin et al., 2003). If the attrition is greater than 10% at 12 months, multiple imputation methods will be used to account for the missing data and maintain the intention-to-treat analysis (Rubin et al., 1987). All analysis will be performed using R Version 4.3.0 (R Core Team, 2023).

Inclusion Criteria:

• Healthy children and teens (10-17 years old)
• Transitional or permanent dentition of at least 4 permanent anterior teeth in each arch
• Full fixed appliance orthodontic treatment is expected to last at least one year

Exclusion Criteria:

• Allergies to iodine
• Chronic prophylactic use of antibiotics
• Diagnosis of thyroid disease
• Conditions that could impair routine oral hygiene procedures.
• Pregnant at enrollment

Sharing IPD will be restricted or carefully managed to ensure participants safety. Researchers have ethical obligations to protect the participants. When individuals agree to participate in a trial, they often do so with the understanding that their personal data will remain confidential. Also, Participants may not have given explicit consent for their data to be shared beyond the scope of the specific clinical trial. Especially in this trial, participants are children and teenagers under 18 considered a vulnerable population in clinical trials, so additional precautions are taken to ensure their safety and privacy. Protecting the individual participant data of minor participants in clinical trials is crucial due to their vulnerable status, the legal requirements, and the potential for harm that could arise from breaches in privacy or confidentiality.

The manufacturer of Povi-One will provide the placebo. The products will be identical in appearance. Povi-One and placebo will be supplied every 6 months and stored at room temperature in locked storage in the orthodontics clinic. Povi-One and placebo will be delivered to the clinic site by the manufacturer marked with the different treatment codes. The study biostatistician will assign the codes and keep the key. The manufacturer will retain treatment codes until after analysis.