White Spot Lesions: A Hygiene Perspective in the Orthodontic Practice by Miranda Valenzuela, RDH Miranda Valenzuela, RDH, graduated in 2006 with an associate degree in dental hygiene, and has received the Hu Friedy Golden Scaler award. She has worked in orthodontics in Tucson and Scottsdale, Arizona, for 17 years. She began her career as an orthodontic assistant then moved into dental hygiene in orthodontics. Valenzuela has also worked as a hygienist for community health centers. R esearch has shown that there s a 72.9 percent chance that at least one new white spot lesion (WSL) will occur during comprehensive orthodontic treatment. 1 It s fair to state that every orthodontic practice struggles with its share of patients who have poor oral hygiene or less-thanideal diet habits, which can result in the formation of WSLs. The prevention and management of this orthodontic challenge is a popular topic orthodontists and their teams can use it as a teaching moment for patients and parents. Furthermore, we can consistently treat the affected areas properly, which means that correcting these cosmetic imperfections through the promotion of remineralization can be done with less-invasive techniques. Prevention of WSL To prevent formation of WSLs, it is imperative that we discuss proper oral hygiene in depth with our patients and parents. As soon as braces and arch wires have been placed (and in some cases, before placement), Fig. 1: This patient was seen every two weeks until oral hygiene improved. thorough oral hygiene instructions need to be covered. These instructions should include proper brushing and flossing techniques, diet recommendations, and the appropriate use of fluoride/mi Paste. One of the most pivotal occasions when the orthodontist can assess a patient who may be at risk for developing decalcification is at the first adjustment. Why? Because it takes only four weeks 2, 11, 12 for WSLs to occur. If the patient is struggling with effective brushing early in treatment, then it s critical to intervene immediately. The first adjustment is an ideal opportunity to evaluate the patient s oral hygiene. You ll immediately find out if the patient understands how to brush around the braces and will be able to observe the presence of plaque accumulation around brackets and appliances (Fig. 1). One- to two-week oral hygiene appointments may be appropriate until the patient masters good brushing habits. I ve been hired specifically to work with patients and parents on nutritional counseling and proper oral hygiene. This sets the stage 16 MAY 2016 // hygienetown.com
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for patients and parents to understand that the orthodontist has a personal interest not only in straightening the teeth but also in the patient s overall health. Parents and patients have a common misconception that orthodontics is the causative agent in the development of white spot lesions. In actuality, it s a risk factor associated with orthodontia when there is prolonged plaque accumulation surrounding fixed appliances, and poor nutritional habits. Risk assessment When implementing caries-prevention medicaments, it s important to assess the patient appropriately. Patients who have fixed appliances such as bands and brackets are at a higher risk for developing WSLs, simply because of the increased difficulty of brushing properly with braces. 10 All orthodontic patients should be using some type of cariesprevention aid. To simplify the caries risk assessment, I ve established two levels of risk. Level 1: At-risk orthodontic patient. This is an above-average orthodontic patient who possesses good oral hygiene, has little to no history of dental decay, and outstanding compliance. Level 2: High-risk orthodontic patient. This patient possesses average to poor oral hygiene, many restorations, and poor-to-average compliance. An at-risk orthodontic patient A high-risk orthodontic patient Management for Level 1 Once risk-assessment levels have been established, determination of the appropriate caries prevention aid should be made. Various dosages of fluoride, casein phosphopeptide-amorphous calcuium phosphate complex (MI Paste) and functionalized beta tricalcium phosphate (Clinpro) are, in my opinion, relevant for patients in comprehensive orthodontics today. High-fluoride dentifrices (PreviDent 5000) in dosages of 5,000 ppm have been shown to reduce caries by 75 percent. 3 This dosage of fluoride therapy is appropriate for the Level 1 risk-assessment patient to ensure the inhibition of lesion formation. The high dosage of fluoride is recommended for Level 1 patients because they most likely will not develop decalcification from poor oral hygiene. However, these patients may develop decalcification through no fault of their own. For example, loose posterior molar bands can prove problematic, warranting an extra level of caries prevention. Low levels of fluoridated dentifrices in the standard dosage of 1,100 ppm will reduce caries by only 25 percent. This dosage would be insufficient protection for a Level 1 orthodontic patient. 3 Manufacturer s recommendations for Prevident 5000 are that patients should brush two times a day for two minutes, without rinsing. 18 MAY 2016 // hygienetown.com
feature \\ clinical orthodontics Management for Level 2 Risk assessment Level 2 patients should be treated differently. These patients will likely end up with WSLs at the conclusion of treatment. In fact, they may begin treatment with decalcification already present. In this case, casein phosphopeptideamorphous calcium phosphate complex (CPP-ACP, Recaldent), in the form of MI Paste Plus, or the functionalized beta-tricalcium phosphate (ftcp, Clinpro) is recommended. One way Recaldent inhibits caries is by influencing the behavior of dental plaque through binding to adhesion molecules on streptococcus mutans, thus impairing their incorporation into dental plaque. 4 Studies have shown that the active ingredient, Recaldent, works effectively as a remineralizing agent at acidic ph levels (down to 4.0) as well as in the neutral and alkaline ranges. 5 (It should be noted that patients with milk-protein allergies should not use Recaldent, although the manufacturer states that it is safe for those who are lactose intolerant.) Most Level 2 risk-assessment patients have a tendency to have a high-carbohydrate, high-sugar diet, thereby creating a highly acidic oral environment. Treatment protocols suggest brushing with MI Paste for two minutes, two times per day, without rinsing. Another delivery method of Recaldent is available in chewing gum (Trident White). The use of low-tack chewing gum with orthodontics has been shown to increase salivary flow, which raises ph levels and increases the buffer ion concentration that promotes remineralization. 7 This remedy is also popular with patients when given out chairside after adjustments. However, MI Paste Plus is a triple threat, in my opinion, because it has anticarogenic properties, promotes remineralzation and contains low levels of fluoride at approximately 900 ppm. The use of low levels of fluoride for patients who are at a higher risk for decay is worth noting. Rapid remineralization of the enamel surface in the presence of high fluoride concentration actually restricts the passage of ions into the deeper, more affected layers of enamel. 9 In these cases, high dosages of fluoride are not recommended. 8 Furthermore, high doses of fluoride may completely arrest the caries process, yet leave the lesion the same size. 9 This is ideal for posterior teeth. However, in orthodontics, the challenge tends to present itself in the maxillary aesthetic zone, requiring the 9, 10 enhancement of remineralization. Treatment protocols for arrested WSLs should include gentle pumicing, etching for three minutes, and then the application of Fig. 2: WSLs present after debonding Fig. 3: WSL improvement after three months of treatment MI Paste Plus in a custom tray for five minutes, two times a day until the patient has reached the desired result. 4 Clinical I ve used MI Paste Plus in the clinical setting. At that time, I followed the manufacturer s suggestions to help remineralize white spots. I made upper and lower custom trays for a patient to use at home under the parent s supervision. The instructions given were to use the paste in the custom trays for three minutes, two times a day over a period of three months. Results are shown in Figs. 2 and 3. In retrospect, I would have included the in-office pumice, etch and soak for five minutes, in addition to the at-home trays to see if there would have been more resolution. My results did show a decrease in the white spots, but not complete reversal. The most significant remineralization occurred hygienetown.com \\ MAY 2016 19
If the patient is struggling with effective brushing early in treatment, then it s critical to intervene immediately. The first adjustment is an ideal opportunity to evaluate the patient s oral hygiene. You ll immediately find out if the patient understands how to brush around the braces. on #8, #9 and #22 #27. The upper left lateral and cuspid eventually needed restorative treatment. Since then, there have been other clinical procedures in treating severe WSLs involving a combination of in-office pumice, etch, soak and then whitening, both in the office and at home. The manufacturer of Opalesence Tooth Whitening Systems states that whitening can blend the white spots with the rest of the tooth. It also states that the lesion may initially whiten more quickly than the unaffected enamel but after more days of whitening, it will blend. This is a helpful consideration for patients who develop decalcification. Working in the orthodontic practice as a hygienist helped me realize the need for extensive oral hygiene therapies, including education, nutrition and the implementation of anticariogenic agents. Parents and patients have a common misconception that orthodontics is the causative agent in the development of white spot lesions. In actuality, it s a risk factor associated with orthodontia when there is prolonged plaque accumulation surrounding fixed appliances, and poor nutritional habits. 13 As the technology and research evolve, our treatment modality options increase. Even with the most effective treatments, patient education should always be our first treatment of choice. n Editor s note: This author has no commercial, proprietary or financial interest in the products or companies described in this article. References 1. Richter AE, Arruda AO, Peters MC, and Sohn W. Incidence of caries lesions for patients treated with comprehensive orthodontics. J Dent Res 88 (Spec Iss A): Abstract Miami meeting, 2009. 2. Ogaard B, Rolla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop 1988;94:68-73. 3. Tavss EA, Mellberg JR, Joziak M, Gambogi RJ,Fisher SW. Relationship between dentifrice fluoride concentration and clinical caries reduction. Am J Dent 2003;16(6):369-374 4. Walsh Laurence J, Contemporary technologies for remineraization therapies: A revew. International Dentistry SA, 2009,Vol. 11, No. 6 5. Reynolds EC. Calcium phosphate-based remineralization systems: Scientific evidence? Aust Dent J. 2008;53(3):268-73. 6. Cross KJ, Hiq NL, Palamara JE, Perich JW, Reynolds EC. Physicochemical characterization of casein phosphopeptide-amorphous calcium phosphate nanocomplexes. J Biol Chem. 2005;280(15):15362-9. 7. Gray, BDS, M.M. Ferguson, BSc, MB ChB, BDS, FDSRCPS, The use of low-tack chewing gum for individuals wearing orthodontic appliances, Australian dental journal 1996. 8. Artun J, Thylstrup A. Clinical and scanning electron microscopic study of surface changes of incipient caries lesions after debonded. Scand J Dent Res 1986;94:193-201. 9. Kang Kyung-Hwa. Effects of variou s toothpastes on remineralization of white spot lesions. Korean J Orhod, 2013. 10. Gorelick L, et al. Incidence of white spot formation after bonding and banding. Am J Orthod 1982; 81 (2):93-8 11. O Reilly MM, Featherstone JDB. Demineralization and remeralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofacial Orthop 1987;92:33-40. 12. Gorton J, Featherstone JDB. In vivo inhibition of deminerlization around orthodontic brackets. Am J Othod Dentofacial Orthop 2003; 123:10-14. 13. Srivastava Kamna, Tikku Tripti, Khanna Rohit, Sachan Kiran, Risk factors and management of white spot lesions in orthodontics, Journal of Orthodontic Science Apr-Jun 2013: 2 (2):43-49 20 MAY 2016 // hygienetown.com