ORIGINAL ARTICLE

Exposure to the oral environment

enhances the corrosion of metal
orthodontic appliances caused by
fluoride-containing products:
Cytotoxicity, metal ion release, and
surface roughness
Pintu-on Chantarawaratit and Tipanan Yanisarapan
Bangkok, Thailand

Introduction: This study aimed to evaluate the metal ion release, cytotoxicity, and surface roughness of clini-
cally used metal orthodontic appliances after immersion in different fluoride product solutions compared with
those of new appliances. Methods: Used fixed appliances were debonded from 36 patients after their treatment-
was done. New appliances were as-received. Each used and new group comprised 36sets of 20 brackets and 4
tubes that were divided into 3 groups by archwire type; stainless steel, nickel-titanium, andbeta-titanium. The
samples in each group weredivided into 3 subgroups and immersed in solutionsof fluoride toothpaste, 1.23%
acidulated phosphate fluoride,or artificial saliva without fluoride as a control group. The immersion times were
estimated from the recommended time for using each fluoride product for 3 months. The samples were then
immersed in Dulbecco’s Modified Eagle’s Medium for 7 days. The cytotoxicity test was evaluated by 3-(4,5-
dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay using primary gingival fibroblasts. Chromium,
nickel, and iron ion release were detected using inductively coupled plasma mass spectroscopy. The surface
roughness of the brackets and wires was measured by a scanning electron microscope and a noncontact
optical 3-dimensional surface characterization and roughness measuring device. The data were analyzed
using the paired t test and 2-way analysis of variance. Results: Used brackets demonstrated a significantly
higher ion release, surface roughness, and cytotoxicity than the new brackets. Acidulated phosphate fluoride
significantly increased the ion release and surface roughness; however, it significantly decreased cell viability,
especially in the titanium molybdenum subgroup. Conclusions: Used brackets were significantly prone to
further corrosion. Acidulated phosphate fluoride gel should not be used in orthodontic patients with fixed metal
appliances. (Am J Orthod Dentofacial Orthop 2021;160:101-12)

O
rthodontic fixed appliances composed of metal
alloys are commonly used to treat malocclusions.
These appliances are maintained in the oral cav-
ity for several years. However, the oral environment is
Department of Orthodontics, Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Pintu-on Chantarawaratit, Department of Ortho-
dontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
10330; e-mail, pintuon@gmail.com.
Submitted, December 2019; revised, February 2020; accepted, March 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.03.035
particularly corrosive because of its varying temperature,
acidity from food and drink, bacterial products, and
enzyme activity.1-3 Therefore, orthodontic appliance
corrosion has become a major concern. Research
investigating this topic has been focused on 2
principal issues: the effects on mechanical properties
of the materials and toxicity on the surrounding tissue
and patient’s health.1-4
Previous studies have reported that corrosion com-
promises the mechanical properties of metal alloys by
increasing the surface roughness of the appliance,
increasing the friction between the archwire and
brackets, and decreasing mechanical strength.1,4-6
Biologically, metal ions released by orthodontic

101
102
appliances from corrosion cause both local and systemic
adverse effects. A previous study reported that stainless
steel (SS) brackets incubated in a cell culture medium
for 30 days released a high concentration of titanium,
chromium (Cr), manganese, nickel (Ni), and
molybdenum ions.7 These ions affect the surrounding
oral tissues by decreasing enzyme or mitochondrial ac-
tivity, carcinogenicity, and mutagenicity.7-9 Moreover,
metal ions are ingested into the gastrointestinal
system. Some ions, such as Cr and Ni ions, have the
potential to induce type IV hypersensitivity,10,11 which
can be severe in some patients.12 Orthodontic patients
have been reported to have a higher prevalence of Ni
hypersensitivity compared with nonorthodontic
patients.10,11
Fluoride toothpaste (TP) has been universally rec-
ommended for daily tooth brushing. In addition, other
professional fluoride products, such as fluoride gel or
fluoride varnish, have been used as a standard protocol
for dental caries control (CON), especially in high-risk
caries patients, such as those undergoing orthodontic
treatment.13-16 However, sodium fluoride (NaF) from
fluoride-containing products reacts with the hydrogen
ions from bacterial products, resulting in the formation
of hydrofluoric acid (HF).3,17 This acid dissolves the
protective oxide layer on the surface of the metal in
the oral cavity, allowing corrosion to occur.3,17 The
fluoride product-induced corrosion of titanium and
other dental alloys used as restorations or dental
implants has become a concern.18-20 The metal
orthodontic bracket and wires corrosion caused by
fluoride has been investigated.6,21-23 Their results
demonstrated increased surface roughness and
friction between brackets and archwires, affecting the
efficiency of orthodontic treatment.24-26 Surface
roughness induces plaque accumulation on the
appliances and adjacent tooth surfaces, leading to
caries and gingivitis.27
The previous studies concerning metal orthodontic
appliance corrosion from fluoride have used as-
received appliances.6,21-26 Currently, there is no report
on the effect of corrosion on used brackets that have
been exposed to the environment in orthodontic
patients’ oral cavity for several years. Therefore, the
purpose of our study was to evaluate the metal ion
release, cytotoxicity, surface morphology, and surface
roughness of debonded SS brackets after clinical use
and 3 different types of archwires; SS, nickel-titanium
(NT), and titanium molybdenum (TMA) exposed to a
fluoride TP or acidulated phosphate fluoride (APF) gel
July 2021  Vol 160  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chantarawaratit and Yanisarapan
and to compare the results with those of as-received
brackets.
MATERIAL AND METHODS
The study protocol was approved by the Human
Research Ethics Committee of the Faculty of Dentistry,
Chulalongkorn University, Thailand (HREC-DCU 2016-
102, 2019-052).
The experimental flow and protocol are shown in
Figure 1. The sample size was calculated from previous
studies.6,28 The new appliance group had 36 sets of
as-received brackets and tubes. Each set comprised 20
brackets and 4 tubes (Tomy International, Tokyo, Japan)
with a slot size of 0.018-in. Used appliances (Tomy In-
ternational) were obtained from 36 nonextraction or-
thodontic patients (10 males and 16 females, aged
between 15-24 years) in the Department of Orthodon-
tics, Faculty of Dentistry, Chulalongkorn University,
Thailand. Each patient had 24 fully erupted teeth from
the central incisors to the first molars that were bonded
with 20 brackets and 4 molar tubes. During treatment,
the patients repeatedly received oral hygiene instruction
and motivation. They were directed to brush their teeth
with a fluoride TP at least twice a day. No other anticar-
cinogenic product was recommended to the patients.
The appliances were removed from the patients’ teeth
after their treatment was completed. The average treat-
ment duration was 23 6 4 months. After debonding
from the enamel surfaces, the brackets and tubes were
washed with deionized water. To avoid the corrosive ef-
fect of typical sterilization techniques, the used appli-
ances were sterilized in a hot air oven (180oC,
60 minutes; Memmert, Schwabach, Germany) instead
of using an autoclave or disinfectant.29
The new and used brackets and archwires were
immersed in deionized water and cleaned in an ultra-
sonic cleaner (Biosonic UC300; Coltene, Altst€atten,
Switzerland) at 40 kHz for 15 minutes. Each set of
brackets and tubes were ligated with two 0.016-
in 3 0.022-in preformed archwires to simulate full
fixed orthodontic appliances from both dental arches.
The samples in the used and unused groups were
divided into 3 groups (n 5 12) by 3 metal types of arch-
wires SS, NT, and TMA (Ormco; Accord, Orange, Calif).
The compositions of the archwires are shown in
Table I.30 The archwires were ligated to the brackets
with 0.010-in ligature wires (Ormco; Accord). Each set
of samples was weighed on a semimicro analytical bal-
ance (New Classic MS-S; Mettler Toledo, Greifensee,
Switzerland).
Chantarawaratit and Yanisarapan
Fig 1. Sample preparation and experimental flow; x and y indicate the areas of brackets and wires
scanned by SEM.
The 12 sets of samples in each archwire group were
divided into 3 media subgroups (n 5 4); artificial saliva
(Table II) as the CON group and solutions of TP or APF
gel. The volume of the CON medium, 1 mL per 0.2 g
of the weight of the set, was calculated from
ISO10993-5.31 The TP medium was a mixture of TP con-
taining 1000 ppm of NaF (Colgate Total; Colgate-
Palmolive, Thailand) and artificial saliva at a 1:4 (w/v)
ratio. The APF medium was prepared by mixing 1.23%
APF gel (Pascal International, Bellevue, WA) and artifi-
cial saliva at a 1:1.4 (v/v) ratio.
The samples were immersed in their respective media
in an incubator shaker at 37oC and 80 rpm. The immer-
sion period was estimated from the recommended time
that each fluoride product would be clinically used for
3 months, as described in a previous study.6
1. CON groups: 12 samples were immersed in artificial
saliva without fluoride for 5 hours 36 minutes,
calculated as in no. 2.
2. TP groups: 12 samples were immersed in TP solu-
tion for 5 hours 36 minutes, simulating the total
recommended tooth brushing time for 3 months
(ie, 2 minutes per time, twice per day).15
3. APF groups: 12 samples were immersed in APF
solution for 4 minutes and dried for 30 minutes,
American Journal of Orthodontics and Dentofacial Orthopedics
103
mimicking the recommended APF gel application
time (ie, 4 minutes per time, once every
3-6 months).15
The samples were washed with deionized water and
cleaned in an ultrasonic cleaner at 40 kHz for 15 minutes.
Each set of samples was then immersed in 10 mL cell cul-
ture medium (Dulbecco’s Modified Eagle’s Medium
[DMEM]; Gibco; Thermo Fisher Scientific, Waltham,
Mass) at 5oC for 7 days.6 The DMEM was divided into
2 parts for metal ion measurement and cytotoxicity
testing.
Next, 15 mL plastic centrifuge tubes (Corning;
Sigma-Aldrich, St. Louis, Mo) were cleaned by soaking
in 10% nitric acid overnight and rinsed with deionized
water. A total of 3 mL of culture media from each sub-
group was dispensed into a tube. Ni, Cr, and iron (Fe)
ions were measured using inductively coupled plasma
mass spectroscopy (ICP-MS) (iCAP RQ ICP-MS; Thermo
Fisher Scientific, Waltham, Mass). Standard solutions
(50, 100, and 200 mg/L) of each metal were prepared
in DMEM for calibration. DMEM alone was used as a
negative CON. The mean of 3 values was calculated in
mg/L.
Primary human gingival fibroblasts were isolated
from the healthy gingiva over impacted third molars of
July 2021  Vol 160  Issue 1
104
3 young adult donors, 2 men and 1 woman, after obtain-
ing informed consent. The average donor age was
18 years 9 months (standard deviation, 1.7 years). The
isolated tissue was washed several times with DMEM
and cut into 1-2 mm3 pieces. Five explant pieces were
placed into a 35-mm 3 10-mm cell culture dish (SPL
Life Sciences, Gyeonggi-do, Korea) and incubated with
a growth medium (DMEM supplemented with 10% fetal
bovine serum, 10,000 IU/mL penicillin G sodium,
100,000 mg/mL streptomycin sulfate, 25 mg/mL ampho-
tericin B, and 1% L-glutamine) at 37 C in a 5% CO2 at-
mosphere. When the outgrown cells reached 80%
confluence, the cells were subcultured using 0.25%
trypsin- ethylenediaminetetraacetic acid solution at a
12.5:1 ratio. All experiments were performed using cells
from the third to the fifth passage. All media supple-
ments were purchased from Gibco.
The gingival fibroblasts were seeded in 24-well plates
at a concentration of 40,000 cells per well, incubated as
above for 24 hours (approximately 80% confluent),
washed twice with phosphate-buffered saline, and the
wells were divided into 2 CON groups and 9 experi-
mental groups and treated for 3 days as follows:
1. Positive CON: cells incubated with 1 mL 20%
ethanol in DMEM per well.6,32
2. Negative CON: cells incubated with 1 mL DMEM per
well.
3. Experimental groups: cells incubated with 1 mL cul-
ture media immersed with samples (SS-CON, NT-
CON, TMA-CON; SS-TP, NT-TP, TMA-TP; SS-APF,
NT-APF, and TMA-APF).
Subsequently, an MTT (3-[4, 5-dimethylthiazol-2-
yl]-2, 5-diphenyltetrazolium bromide) assay was per-
formed for cytotoxicity testing as previously described.33
Briefly, the medium was removed, the cells were washed
twice with phosphate-buffered saline and incubated
with 250 mL 1 mg/mL MTT solution (Molecular Probes,
Eugene, OR) in DMEM without phenol red for 10 mi-
nutes. The MTT solution was removed, and the precipi-
tated formazan crystals were dissolved in 500 mL
dimethyl sulfoxide. The optical density was determined
by measuring the light absorbance at 570 nm using an
Epoch Microplate Spectrophotometer (BioTek Instru-
ment, Winooski, Vermont). The background absorbance
of dimethyl sulfoxide was subtracted from the sample
absorbance, and the experiments were performed 3
times. The percent cell viability was calculated using
the following formula:
Cell viability (%) 5 (OD of the experimental group/
OD of the negative CON) 3 100
Four maxillary central incisor brackets and pieces of
the archwire that were in contact with the brackets
July 2021  Vol 160  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chantarawaratit and Yanisarapan
were randomly chosen from each experimental group.
The as-received and untreated brackets and wires were
used as a negative CON. The samples were cleaned in de-
ionized water in an ultrasonic cleaner at 40 kHz for
15 minutes, wiped and left until dry and scanned by
scanning electron microscope (SEM) (FEI, Eindhoven,
Netherlands) at 20 kV and 50003 magnification. The
bracket area near the slot was scanned at position x,
and the middle area of the wires was scanned at point
y, which was adjacent to x (Fig 1, A).
The approximately 400 3 400 mm2 area at position x
and y (Fig 1, A) on the bracket and wire surfaces were
scanned by a noncontact optical 3-dimensional surface
characterization and roughness measuring device (Infin-
ite focus SL, Alicona, Graz, Austria) to evaluate the sur-
face roughness of the samples at 50x magnification.
Each sample was scanned 3 times. The data was
analyzed by IF-MeasureSuite software (Alicona, Graz,
Austria).
Statistical analysis
The data were analyzed by the SPSS program
for Windows (version 22.0; SPSS, Chicago, IL). The
1-sample Kolmogorov-Smirnov and Levene tests were
used to test the normal distribution and homogeneity
of variance, respectively. The differences between new
and used appliances were evaluated by the paired t
test. Two-way analysis and Tamhane’s T2 post-hoc
analysis were used to analyze the differences in metal
ion release, cell viability, and surface roughness between
the groups. Values of P \0.05 were considered statisti-
cally significant.
RESULTS
The mean and standard deviation values for the
metal ion release, cell viability, and surface roughness
of the brackets and wires are presented in Table III.
In the new and used bracket groups with all types of
wires, the highest amount of Cr ions was in the APF
groups. The maximum concentration of Cr was found
in the used SS-APF groups (166.32 6 19.58 mg/L,
Table III, Fig 2, A and B). Among the used bracket
groups, significant differences in Cr were detected in
the TP and APF solutions in all archwire types compared
with their CON groups. However, in the new bracket
groups, only the APF groups had a significantly higher
amount of Cr ions than the CON groups (P \0.05, Fig
2, A). Among the wire types, the highest levels of Cr
were found in the new and used SS groups immersed
in all solutions, except in the new bracket groups in
the CON solution, in which the Cr in the TMA group
was slightly higher than those in the SS group
Chantarawaratit and Yanisarapan 105

only the SS wire presented a significant difference in Cr

Table I. Archwire alloy compositions
between the new and used groups (P \0.05, Fig 2, A
Wire and B).
alloy Composition (wt %) The highest level of Fe ions was found in the used SS-
SS 17-20 Cr, 8-12 Ni, 0.15 C, and balance mainly Fe APF groups (2236.09 6 487.50 mg/L, Table III, Fig 2, C
NT 55 Ni and 45 Ti (approximate and may contain small
amounts of Cu or other elements)
and D). In the new and used bracket groups, significantly
T-Mo 77.8 Ti, 11.3 Mo, 6.6 Zr. and 4.3 Sn higher amounts of Fe were released in all groups of arch-
wire types immersed in APF solutions; however, the dif-
C, carbon; Ti, titanium; Cu, copper; Mo, molybdenum; Zr, zirco-
ference was not significant between the immersed in TP
nium; Sn, Tin.
solution groups compared with their CON groups
(P \0.05, Fig 2, C). In the used bracket groups, SS
released the highest level of Fe in all solutions, compared
Table II. Composition of the artificial saliva used as with NT and TMA. In contrast, in the new bracket
CON groups, SS presented a significantly higher amount of
Fe only in the APF solution (P \0.05, Fig 2, D). In addi-
Ingredients Amount (g)
Potassium chloride 0.75
tion, in every solution, the SS wires with used brackets
Magnesium chloride 0.07 released significantly more Fe ions than those with
Calcium chloride 0.199 new brackets. In contrast, for the NT and TMA wires,
Dipotassium hydrogen phosphate 0.965 only the APF solutions generated significant differences
Potassium dihydrogen phosphate 0.439 in Fe between the new and used bracket groups
Sodium carboxymethylcellulose 6
Sodium benzoate 2.4
(P \0.05, Fig 2, C and D).
Deionized water 1200 (mL) APF significantly induced Ni ion release in all exper-
imental conditions compared with their CON groups;
however, TP significantly increased the Ni release only
(P \0.05, Fig 2, B). Comparing the new and used in the used TMA group (P\0.05, Fig 2, E). APF also pro-
brackets, the used APF groups with all archwire types moted significant differences in Ni between archwire
showed a significantly higher amount of ions than those types when using both new and used brackets
of the new APF groups. Significantly higher amounts of (P \0.05, Fig 2, F). Moreover, all used bracket groups
Cr ions were also found in the used TP groups with SS released significantly higher amounts of Ni than the
and NT wires compared with the new TP groups. How- new bracket groups in the same condition (P \0.05,
ever, among wire types immersed in the CON solutions, Fig 2, C and D). The maximum amount of Ni was found

Table III. Mean and standard deviation of metal ion release and cell viability
Cr (mg/L) Fe (mg/L) Ni (mg/L) Cytotoxicity(%)

Groups New Used New Used New Used New Used

SS
CON 0.84 6 0.10 35.32 6 21.70 255.13 6 11.0 756.02 6 254 5.36 6 0.07 84.02 6 11.38 90.28 6 7.19 70.29 6 5.50
TP 0.60 6 0.04 134.45 6 22.62 281.99 6 2.95 1327.1 6 251.1 5.86 6 0.41 148.37 6 62.13 83.53 6 6.09 53.71 6 9.02
APF 112.01 6 10.88 166.3 6 19.58 641.36 6 36.14 2236.1 6 487.5 62.81 6 5.85 845.32 6 138.3 67.23 6 7.08 53.71 6 5.99
( ) 0.07 6 0.02 0.07 6 0.02 233.84 6 6.00 233.84 6 6.00 0.83 6 0.10 0.83 6 0.10 97.19 6 1.8 96.4 6 2.32
(1) - - - - - - 1.91 6 0.33 1.83 6 0.38
NT
CON 0.48 6 0.02 26.60 6 13.24 271.82 6 12.61 270.61 6 16.16 7.17 6 0.42 121.02 6 138.3 81.60 6 4.32 65.97 6 7.75
TP 0.54 6 0.05 64.04 6 8.66 264.37 6 12.51 406.53 6 293.5 8.38 6 0.36 145.80 6 42.82 70.51 6 4.66 49.77 6 8.04
APF 44.38 6 4.40 105.46 6 13.53 562.02 6 26.7 1795.7 6 69.86 265.64 6 27.89 1844.8 6 249.6 53.71 6 5.99 30.54 6 6.63
( ) 0.12 6 0.07 0.12 6 0.07 243.78 6 4.53 243.78 6 4.53 0.67 6 0.09 0.67 6 0.09 100.26 6 5.94 101.19 6 4.48
(1) - - - - - - 1.50 6 0.37 1.36 6 0.49
TMA
CON 1.01 6 0.12 3.64 6 2.57 256.49 6 20.42 290.51 6 4.29 6.27 6 0.10 115.81 6 34.86 73.51 6 4.87 63.51 6 6.27
TP 0.21 6 0.02 13.45 6 10.41 297.83 6 18.83 377.6 6 164.2 3.82 6 0.35 300.02 6 78.98 53.88 6 13.56 41.38 6 8.47
APF 34.22 6 3.12 98.25 6 8.12 383.03 6 30.21 1240.0 6 111.5 121.65 6 9.69 402.79 6 80.50 9.62 6 3.76 2.77 6 0.88
( ) 0.12 6 0.02 0.12 6 0.02 237.06 6 8.90 237.06 6 8.90 0.74 6 0.04 0.74 6 0.04 96.6 6 3.95 99.4 6 2.05
(1) - - - - - - 1.63 6 0.51 1.62 6 0.53
(1) positive CON; ( ): negative CON.

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106 Chantarawaratit and Yanisarapan

Fig 2. Metal ion concentrations: A, C, and E, ion release according to the type of wire; B, D, and F, ion
release according to immersion media. An asterisk (*) indicates a significant difference between new
and used groups. Different letters indicate a significant difference between groups; P \0.05, n 5 4.

in the NT-APF group (1844.81 6 249.63 mg/L, Table III,
Fig 2, E and F).
APF significantly reduced cell viability in the new and
used brackets ligated with all types of archwire
compared with their CON groups. Moreover, TP also
significantly decreased viability in all archwire types,
except for the new SS group (P \0.05, Fig 3, A). The
highest and lowest viability among the 3 types of arch-
wires were found in the SS and TMA groups, respectively
(Fig 3, B). The lowest cell viability, as toxic as the positive
CON, was found in the used TMA-APF group, whereas
the highest cell viability was shown in new SS-CON
groups. In all experiment conditions, the used groups
had significantly lower viability than the new groups
(Fig 3, A and B).
The SEM images revealed that the used bracket sur-
faces with all archwire types were rougher than those
in the new groups (Fig 4, A-H). Most of the new bracket
surfaces showed a corrosion pattern with pits on their
surfaces (Fig 4, A, C, E, and G), whereas crevices and
cracks were present on the used bracket groups (Fig 4,
C, D, F, and H). The APF groups of the new and used
groups demonstrate more pits, fissures, and cracks
compared with their untreated groups (Fig 4, A-H).

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Chantarawaratit and Yanisarapan
Fig 3. Cell viability: A, viability according to the type of wire; B, viability according to immersion media.
An asterisk (*) indicates a significant difference between new and used groups. Different letters indicate
a significant difference among groups. (1), positive CON; ( ), negative CON; P \0.05, n 5 4.
Fig 4. Bracket surfaces scanned by SEM: A, as-received
brackets; B, untreated used brackets; C, new SS-APF;
D, used SS-APF; E, new NT-APF; F, used NT-APF;
G, new TMA-APF; H, used TMA-APF.
American Journal of Orthodontics and Dentofacial Orthopedics
107
The quantitative roughness results confirmed that
APF significantly increased brackets surface roughness
in the new and used bracket groups compared with their
CON groups (Table IV). All experimental conditions ex-
hibited that the used bracket groups had a significantly
higher bracket surface roughness than the new bracket
groups (P \0.05, Fig 5, A and B). TP significantly
increased the surface roughness in the used bracket
groups coupled with NT and TMA wires. However, in
the SS groups, only the APF groups had a significantly
higher surface roughness than their CON group
(P \0.05, Fig 5, A). In addition, the SS groups showed
the lowest bracket surface roughness in all solutions;
however, there was no significant difference between
the used SS and NT groups in the CON solutions in the
used bracket groups (P \0.05, Fig 5, B). Among the
new bracket groups, the NT groups exhibited the signif-
icantly highest surface roughness in every solution
(P \0.05). In contrast, among the used groups, the
TMA groups had the significantly highest surface rough-
ness in the CON and TP solutions; however, the bracket
surface roughness in the NT group was slightly higher
compared with the TMA group in the APF solution
(P \0.05, Fig 5, B).
The SEM images of the wire surfaces showed that the
highest and lowest surface roughness was found in the
TMA and SS groups, respectively (Fig 6, A-I). The SS
and TMA group surfaces demonstrated corrosive
grooves and fissures, including the CON groups, whereas
the corrosion on the NT surfaces was presented as poros-
ities (Fig 6, A-I). The surface roughness of all archwire
types noticeably increased after APF immersion (Fig 6,
D-I). Furthermore, after treatment with APF, cracks
were seen across the surface of the TMA wire coupled
with used brackets (Fig 6, F). In all experimental condi-
tions, the archwires combined with used brackets had
more pits and grooves than those with new brackets
(Fig 6, A-I).
July 2021  Vol 160  Issue 1
108 Chantarawaratit and Yanisarapan

Table IV. Mean and standard deviation of bracket and wire surface roughness
Bracket surface roughness(nm) Wire surface roughness(nm)

Groups New Used New Used

SS
CON 119.94 6 5.39 352.26 6 27.26 83.62 6 3.67 96.92 6 8.884
TP 134.87 6 1.74 415.88 6 45.33 84.18 6 5.56 107.90 6 3.67
APF 157.01 6 5.74 648.06 6 36.02 94.52 6 2.97 132.36 6 10.09
( ) 113.31 6 9.38 282.21 6 25.55 67.97 6 3.79 67.97 6 3.79
NT
CON 157.18 6 4.94 366.71 6 22.80 149.53 6 6.27 163.22 6 9.44
TP 166.17 6 7.20 470.72 6 27.79 146.00 6 4.84 181.42 6 17.47
APF 183.31 6 7.55 831.77 6 45.48 163.27 6 4.02 315.18 6 17.77
( ) 113.31 6 9.38 282.21 6 25.55 140.84 6 2.95 140.84 6 2.95
TMA
CON 144.05 6 4.94 436.31 6 22.80 215.57 6 7.38 268.72 6 19.61
TP 158.93 6 7.20 561.45 6 27.79 236.61 6 4.61 308.31 6 27.89
APF 177.68 6 7.55 811.35 6 45.48 264.53 6 6.07 476.14 6 21.49
( ) 113.31 6 9.38 282.21 6 25.55 183.25 6 3.39 183.25 6 3.39

( ), negative CON.

APF significantly enhanced the surface roughness of the TMA groups coupled with new and used brackets
all archwires in the new and used bracket groups, whereas compared with their CON groups (P \0.05, Fig 5, C). In
TP significantly increased the surface roughness only in all solutions, the highest and lowest surface roughness

Fig 5. Bracket and wire surface roughness from various media: A, and B, bracket surface roughness
according to wire type and immersion media, respectively. C, and D, wire surface roughness according
to wire type and immersion media, respectively. An asterisk (*) indicates a significant difference be-
tween new and used groups. Different letters indicate a significant difference between groups;
P \0.05, n 5 4.

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Chantarawaratit and Yanisarapan
Fig 6. Wire surfaces scanned by SEM: A, untreated SS wire; B, new SS-APF; C, used SS-APF;
D, untreated NT wire; E, new NT-APF; F, used NT-APF; G, untreated TMA wire; H, new TMA-APF;
I, used TMA-APF.
was found in the TMA and SS groups, respectively. Signif-
icant differences between archwire types were found in
every solution (P \0.05, Fig 5, D). In all experimental
conditions, the used bracket groups presented a signifi-
cantly higher wire surface roughness compared with the
new bracket groups (P \0.05, Fig 5, C and D).
DISCUSSION
The present study evaluated the potential of fluoride-
containing solutions to corrode metal orthodontic appli-
ances by comparing new and used brackets coupled with
3 orthodontic archwire types: SS, NT, and TMA after im-
mersion in TP and APF solutions, using artificial saliva as
a negative CON group. The new brackets were used as-
received, whereas the used brackets were obtained
from orthodontic patients after their clinical treatment
was completed. We found that used brackets were prone
to corrode much more compared with new brackets, on
the basis of ion release, cytotoxicity, and surface rough-
ness, especially after immersion in APF.
The corrosive resistance of SS and titanium-based al-
loys is based on their protective oxide layers, which are
chromium oxide (Cr2O3) and titanium oxide (Ti2O3 and
American Journal of Orthodontics and Dentofacial Orthopedics
109
TiO2), respectively. The corrosive effect of fluoride prod-
ucts on metal orthodontic appliances has been previ-
ously reported to be due to the chemical reaction
between NaF and the protective oxide layers on the
metal surface.34 The NaF from fluoride products reacts
with the hydrogen ions (H1) from bacterial products
and acidic food or drink, generating HF.34
NaF 1 H1 / HF 1 Na1
HF is one of the strongest inorganic acids and attacks
the protective oxide layers on the stainless steel and
titanium-based alloys. The chemical reactions are shown
in equation (a) and equations (b-d), respectively.3,17,34,35
Cr2O3 1 6HF / 2CrF3 1 3H2O (a)
Ti2O3 1 6HF / 2TiF4 1 3H2O (b)
TiO2 1 4HF / TiF4 1 2H2O (c)
TiO2 1 2HF / TiF2 1 H2O (d)
In both new and used bracket groups, the highest
levels of the 3 ions and surface roughness were found
in the samples immersed in APF. A possible explanation
is that the acidity of phosphoric acid (H3PO4) in APF is a
key factor in enhancing the corrosion of metal appli-
ances.19,20,36 Consequently, compared with TP, a higher
amount of HF is produced, as shown by the following
equation.17
July 2021  Vol 160  Issue 1
110
H3PO4 1 3NaF / Na3PO4 1 3HF
In contrast to APF, TP was rarely seen to generate
significantly higher amounts of metal ions than the
CON group. Although a previous study found that
neutral fluoride products with a high fluoride concentra-
tion can produce biological effects from metal corro-
sion,37 in our study, the fluoride concentration in TP
was not enough to markedly induce ion release and sur-
face roughness. These results correspond to previous
studies that reported that a low concentration of fluoride
in a neutral environment did not induce galvanic corro-
sion or increase the surface roughness of dental al-
loys.20,26 Therefore, APF, which has both a high
concentration of fluoride and a low pH, created greater
corrosive effects on metal orthodontic appliances
compared with TP.26,38
On the basis of a previous study, the amount of ions
released in our study were measured from DMEM after
incubation with treated appliances for 7 days.6 There-
fore, to compare with daily dietary intake, the results
should be divided by 7. In the present study, the esti-
mated daily release of Cr and Fe ions in every experi-
mental condition was lower than the recommended
daily dietary intake (35 mg and 8 mg, respectively).39
However, the ions released from the brackets and wires
would likely accumulate in the gingival fibroblast cells
and induced DNA damage.40 Cr was reported as a poten-
tial marker for carcinogenic substances. Moreover, free
Fe ions induce cell apoptosis by increasing lipid peroxi-
dation that can damage the mitochondrial function and
cell organelles.41,42
We found that Ni ion levels were higher than the rec-
ommended daily maximum dietary intake (162 mg) in the
used bracket NT-APF groups (1844.81 6 249.63 mg/L);
however, the levels were still lower than the Ni toxic dose
(60 mg/kg).39,43 Ni atoms are weakly bonded to form
intermetallic compounds in alloys; thus, they gradually
release from an orthodontic appliance into the patient’s
oral cavity.3 Our results confirmed that, including when
immersed in artificial saliva, the Ni released in the used
bracket groups was significantly higher than those in
the new groups. A previous study reported that urinary
Ni levels significantly increased after 2 months of ortho-
dontic treatment using fixed metal appliances.44 This
implies that Ni ingested into the gastrointestinal system
might impact other organs and systems in a patient’s
body. Ni has been reported to cause dermatitis and con-
tact stomatitis.11,45 In addition, long term exposure to
Ni-containing orthodontic appliances was reported to
induce Ni hypersensitivity.11
In this study, the groups with used brackets exhibited
significantly lower cell viability than their negative CON
groups. Moreover, after immersion in APF, the viability
July 2021  Vol 160  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chantarawaratit and Yanisarapan
in all archwire types coupled with either new or used
bracket groups was significantly decreased than those
immersed in DMEM. These findings confirmed the re-
sults of previous studies that APF significantly decreased
the cell viability of a human osteosarcoma cell line and
gingival fibroblasts.6,28 In addition, the viability of the
TMA group immersed in APF was lower than 30%, which
is considered cytotoxic according to ISO10993-5, the
biological evaluation of medical devices.31 Therefore,
APF gel should not be recommended for use by an or-
thodontic patient with fixed metal appliances, especially
when using TMA archwires.
Surface roughness is a parameter of metal surface
corrosion.5 The SEM images illustrated that the brackets
and wires exposed to APF were markedly rougher than
the untreated samples. These results correspond with
those of a previous study using 1.1% neutral and acidu-
lated fluoride gel.25 Furthermore, the NT and TMA wires
that initially had more surface roughness than the SS
wires exhibited more corrosive pits and grooves after im-
mersion in APF.25 The explanation for this finding is that
the rougher surfaces of the NT and TMA wires are more
susceptible to pitting and crevice corrosion than the SS
wire.3 Although the surface of SS wires did not notice-
ably change after being immersed in fluoride solutions,
the amount of metal ions released significantly
increased, especially in the used bracket groups. These
results might be a consequence of a uniform attack:
corrosion that occurs uniformly over the entire exposed
surface of a metal. The uniform attack is not typically
detectable by SEM before large amounts of metal have
dissolved.3 This type of corrosion also occurs on NT
and TMA surfaces; however, the surface morphologies
of pitting and crevices are more noticeable.3
We observed that the used bracket groups presented
more grooves and porosities than the new bracket
groups in the same conditions. The surfaces of the un-
treated used brackets also exhibited more cracks and
roughness than did the as-received bracket group. Inter-
estingly, the as-received archwires coupled with used
brackets presented more pits and crevices than those
treated with new brackets, especially after immersion
in the APF solution. This outcome revealed that used
brackets had a higher ability to induce new archwire
corrosion than new brackets. Moreover, ICP-MS demon-
strated that the concentrations of Cr, Fe, and Ni ions
were dramatically higher in the used bracket groups
than the new bracket groups in the same condition.
Increased surface roughness impacts several mechan-
ical properties of orthodontic appliances. With high
corrosion, and thus, high surface roughness, friction be-
tween the brackets and archwires increases and compli-
cates the orthodontic mechanics, especially when using
Chantarawaratit and Yanisarapan
sliding mechanics.5,34 Previous studies exhibited that
fluoride-containing products significantly elevated the
friction between brackets and archwires.24,34 Further-
more, fluoride was reported to decrease the unloading
force of superelasticity and shape-memory alloys, such
as NT and copper-NT archwires. Thus, the ability of
the wires to return to their original shape decreased.
Clinically, this unloading force generates orthodontic
tooth movement. Therefore, the degree of tooth
displacement was consequently decreased.25 Moreover,
rougher orthodontic appliances results in increased pla-
que accumulation that complicates the oral hygiene
control in orthodontic patients.27
The oral environment is believed to have a high po-
tential to enhance the corrosion of metals and alloys
used in dental treatment; thus, several methods have
been employed to mimic this condition in the laboratory.
Thermocycling and heat treatment were performed in
previous studies to evaluate the corrosion of used ortho-
dontic brackets.46,47 In the present study, the used
brackets in our study were exposed to the oral environ-
ment for several years; therefore, they had been corroded
by genuine temperature changes, acidity, bacterial prod-
ucts, enzyme activity, cell and tissue reactions, and fluo-
ride treatments in the oral cavity, which is a strength of
our study.3 However, in vitro experiments cannot repre-
sent the entire corrosion process that occurs in the oral
environment.3 Saliva clearance reduces the concentra-
tion of the metal ions released from orthodontic appli-
ances. Consequently, the concentrations of these ions
in orthodontic patients’ oral cavity are probably lower
than those reported in the present study. In addition,
the cell and tissue reactions from metal orthodontic
appliance corrosion could not be replicated, which are
limitations in the present study.3 Previous in vivo studies
using buccal mucosa cells found that orthodontic treat-
ment with fixed metal orthodontic appliances decreased
cell viability, induced DNA damage, and increased metal
ion concentration in the cells.9,40 However, there is no
in vivo study reporting the biological effects caused by
the corrosion of metal orthodontic appliances from
fluoride-containing products. Therefore, future clinical
studies are needed to resolve these issues.
CONCLUSIONS
Used brackets were more susceptible to corrosion
from fluoride-containing products compared with as-
received brackets. In the present study, APF gel was
the most corrosive agent that significantly increased
metal ion release, surface roughness, and decreased
cell viability. Therefore, APF gel application is not
American Journal of Orthodontics and Dentofacial Orthopedics
111
recommended during orthodontic treatment with fixed
metal orthodontic appliances, especially with the long
clinical duration that brackets are commonly used. In
contrast, fluoride TP is safer for orthodontic patients
with lower adverse effects on the biocompatibility and
mechanical properties of their metal appliances.
CREDIT AUTHORSHIP CONTRIBUTION STATEMENT
Pintu-on Chantarawaratit: Conceptualization,
Methodology, Validation, Formal analysis, Investigation,
Resources, Data curation, Writing - original draft,
Writing - review & editing, Supervision, Project admin-
istration, Funding acquisition. Tipanan Yanisarapan:
Methodology, Validation, Formal analysis, Investigation,
Data curation.
ACKNOWLEDGMENTS
This work was supported by the Faculty of Dentistry,
Chulalongkorn University (Lecturer Funding). We appre-
ciate Tomy International, Tokyo, Japan and Ormco,
Accord, Calif for providing the brackets and archwires,
respectively. In addition, the authors thank Dr Kevin
Tompkins for his valuable suggestions.
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