Efficacy of casein phosphopeptide‑amorphous calcium phosphate varnish in remineralizing white spot lesions: A systematic review and meta‑analysis

Background: This systematic review aimed to evaluate the efficacy of casein phosphopeptide‑amorphous calcium phosphate (CPP‑ACPF) varnish for remineralization of white spot lesions (WSLs) “in vitro” in human teeth. Materials and Methods: Literature search included three databases, namely Medline (via PubMed), The Cochrane Controlled Clinical Trials Register, and Google Scholar from 2010 to January 2021. The studies assessing WSL depth, calcium, phosphate ion release, and microhardness due to artificial demineralization or remineralization were considered for review. Reference articles were retrieved, and a customized risk assessment tool was used. The Cochrane risk of bias assessment tool was used to generate the risk of bias summary graph. Meta‑analysis was performed using RevMan 5.4. Heterogeneity was evaluated by Cochrane’s test, and random effects model was used to pool estimate of effect and its 95% confidence intervals (CIs) for surface microhardness. Results: Eighteen studies were selected for review based on the eligibility criteria. Four studies showed superior remineralizing effect of CPP‑ACPF compared to fluoride varnishes. Four studies involving 120 human permanent teeth samples were included in the meta‑analysis. Efficacy of CPP‑ACPF varnish was equivalent to other fluoride varnishes in improving surface microhardness after remineralization during 7‑day period (mean surface microhardness: 3.94, 95% CI [−9.08–1.21], I 2: 75%, P = 0.13). Major risks of bias associated with the studies included in the review were inadequate sample size, improper sample preparation, and unexplained blinding. Conclusion: CPP‑ACPF varnish appears to be equally effective as other fluoride varnishes in remineralizing artificially induced WSLs, but quality of evidence is low.