A comparison of cytotoxicity level, chemical and morphological changes of fake and conventional braces

The rising trend of fake braces, particularly in Southeast Asia, has raised significant health concerns. Regarded as a fashion statement, fake braces are unregulated orthodontic appliances sold through social media and online marketplaces. Unlike conventional braces, fake braces are often installed by unqualified individuals or self-applied, lacking the oversight of licensed professionals. Teenagers and young adults are drawn to fake braces because of their perceived status symbol, affordability, and potential to be customized aesthetically. However, there are serious concerns to oral health, including periodontal damage, infection, allergic reactions, and unintentional ingestion due to their poor installation and inferior grade materials. The risks are further highlighted by reports of fatalities and medical issues. According to studies, fake braces exhibit irregular surface textures encouraging the growth of bacteria and the creation of biofilms, which exacerbates oral problems like caries. Despite these risks, research on the toxicity and clinical impacts of fake braces remains sparse. This research aim is to compare the implications of fake and conventional braces in term of morphological changes, level of toxic ion released, and its cytotoxicity. It specifically aims to firstly examine the surface roughness between fake and conventional braces under immersion of different pH values of artificial saliva. Secondly is to determine the level of toxic ions released by fake and conventional braces. Thirdly is to assess the level of cytotoxicity of fake and conventional braces towards HGF cells. For objective 1 and 2, samples of fake braces (bonded and removable type) bought from Shopee and conventional braces bought from MDA-certified company were prepared in triplicates. The bracket samples were immersed in artificial saliva at pH 4.9 and pH 7.8 and kept at 37°C. The bracket samples were then extracted at 1-day and 14-days and were analysed using scanning electron microscope and surface profilometer to determine the changes in its surface roughness (Ra), and using the Inductively Coupled Plasma Optical Emission Spectroscopy (ICP-OES) to determine the levels of chromium and nickel ions released. For Objective 3, samples of fake braces bought from Shopee and conventional braces bought from MDA-certified company were immersed in Dulbecco's Modified Eagle Medium (DMEM) solution. Extracts from the immersion were then taken at 14-days and 28-days and its cytotoxicity towards HGF cells were assessed using MTT assay. Fake braces, both the bonded and removable type shows significantly higher surface roughness compared to conventional braces at pH 4.9 at T3 F (2,4) =26.085, p=0.005 and F (2,4) = 11.007, p = 0.024, respectively. Both the bonded and removable type fake braces show significantly higher Chromium ions release at T2 as compared to conventional braces in pH 7.8 of artificial saliva at (95% CI, 76.01794 to 554.0853) µg/L, p = 0.030 and (95% CI, 159.137 to 1110.577) µg/L, p= 0.029, respectively. Nickel ions released were also higher at pH 7.8 in both the bonded and removable fake braces as compared to conventional braces with (95% CI, 5542.1077 to 5893.0789) µg/L, p < 0.001 and (95% CI, 5940.539 to 6354.768) µg/L, p < 0.001, respectively. In cytotoxicity testing, there were statistically significant differences between both types of fake braces and conventional braces at both T1 (F (2, 6) =5.206, p = 0.049) and T2 (F (2,6) = 11.844, p = 0.008), with removable fake braces showing highest level of cytotoxicity. The research suggested that there were significant differences between fake and conventional braces in surface roughness, metal ions released and cytotoxicity. Both the bonded and removable type fake braces show higher surface roughness, higher levels of Chromium and Nickel ions released, and higher cytotoxicity towards HGF cells as compared to conventional braces in vitro. These may be interpreted as the low quality of alloy used in the manufacturing of fake braces and may suggests that it can pose some health risks.