May, 2011
Enamel Demineralization
Dr. Kala Vani
Professor, Dept. of Orthodontics
C.K.S. Teja Institute of Dental Sciences
Tirupathi, Pradesh, India
Dr. Venkanteshwara Rao|
Assistant Professor
C.K.S. Teja Institure of Dental Sciences
Tirupathi, Pradesh, India
Dr. Kala Vani – Corresponding Author
Abstract: Enamel demineralization is one of the most common complications of fixed appliance therapy. The prevalence of this phenomenon has been reported to be very high, jeopardizing the success of orthodontic treatment outcome. It becomes mandatory for orthodontist to recognize the high risk patients, evaluate the white spot lesions, reinforce good oral hygiene measures, institute preventive fluoride regimen and manage post treatment white spot lesions to obtain optimum esthetic results.
KEY WORDS: white spot lesion, fluorides, bleaching, micro abrasions
Despite the advances in orthodontic materials & techniques in recent years, the development of enamel demineralization around the brackets remains the most undesirable and common complication of fixed appliance therapy. The overall prevalence amongst orthodontic patients ranges from 2-96%1-3. Nearly 50% of orthodontic patients exhibit clinically visible white spot lesions (WSL)2,4,5,6 These WSL are due to demineralization of the enamel by organic acids produced by cariogenic bacteria7. Orthodontic appliances make brushing and flossing difficult and increase the surface area available for accumulation of plaque and food particles.
Demineralization around brackets can be an extremely rapid process 2,6-10with visible WSL developing within four weeks after bonding. They appear most frequently on the cervical and middle third of the buccal surfaces of mandibular incisors, canines and first premolars2,11.
Evaluation of WSL:
There are macroscopic and microscopic methods used in the detection and measurement of WSL.12
1 Macroscopic methods:
a. Clinical examination: It is often difficult to distinguish white spots caused by demineralization and those that are due to other causes such as developmental hypoplasia or fluorosis. Non-fluoride opacities have a more defined shape, often located in the middle of the tooth and randomly distributed when compared to fluorotic lesions which are not well defined and have symmetrical distribution.13
b. Photographic examination:
Photographic techniques provide permanent record, can be digitized and are used extensively to assess the demineralization before, during and after treatment.14-27
c. Optical Non-fluorescent methods:
Demineralized enamel scatters light. A 100W white light can be used and the back-scatter can be measured with a densitometer or Optical Caries Monitor (OCM) described by the Ten Bosch etal.28-30
d. Optical fluorescent methods:
De Josselin de Jong et al 31,32 developed the technique of quantitative laser fluorescence for use in the mouth. Another method using laser fluorescence is an instrument called DIAGNODent (KaVo, Germany).33The most promising fluorescent method of measuring demineralization in use today is QLF (Quantitative Light Induced Fluorescence) which makes use of a small portable system for intraoral use with a new light source & filter system.34
2. Microscopic Methods:
a. Caries Models:
Orthodontic caries models have usually involved placing a band or a bracket on the tooth that is destined for extraction. Following a period in the mouth, tooth is extracted and subjected to microhardness testing, polarized light microscopy or microradiograph.35-38
b. The In Situ Caries Model:
Enamel can be placed in a removable appliance/bonded to the tooth of a volunteer or placed in a specially designed holder attached to the orthodontic archwire. 39-41
Risk Factors:
Important risk factors for enamel demineralization include the patient’s oral hygiene, diet, individual salivary flow & excess or failed bonding cement around the bracket or band. The risk factors are summarized in Table 142.
Table 1: Risk factors for enamel demineralization
| Risk factor | Description and preventive methods |
| Oral hygiene |
|
| Diet |
|
| Individual salivary characteristics |
|
| Excess bonding cement or failure of the bonding cement |
|
Prevention of Enamel demineralization
The risk of enamel demineralization during treatment can be prevented by either eliminating the plaque deposition on the enamel surface or by enhancing the enamel resistance to the microbial attacks using topical fluorides.
Prevention measures to minimize damage include: patient selection, intensive oral hygiene instruction, regular monitoring, dietary education and enhancing the enamel resistance to decalcification.
Patient Selection:
For patients with high risk of caries, orthodontic treatment should be delayed. For patients with a history of caries, treatment should be initiated only when they have been assessed over a period of time as having a good dental health, and excellent oral hygiene habits. A period of 3 months of sustained good oral hygiene is probably sufficient to evaluate a patient’s ability to confirm to meticulous oral hygiene regimen.42
Intensive Oral Hygiene Instructions:
Patients wearing fixed appliances might benefit from the use of an electric tooth brush43-45. Sonic frequency devices such as Flex care by Sonicare have been shown to be effective while not compromising bracket bond strength.46
Patients should be instructed to use the tongue cleaner at least once a day & combine it with volatile sulfur compound (vsc) neutralizing sprays to prevent staining chromogens from depositing on the teeth and / or around orthodontic brackets / bands47,48. Mechanical flosses, interdental brushes and oral irrigators used at a higher settings49 are recommended.
Diet Counseling:
Before treatment, a diet counseling session, including a 5 day detailed diet record, is recommended, particularly for patients with a history of caries.42 Bach showed an increase in decalcification following orthodontic treatment of 4.7% & 6.0% in persons with minimum & excessive carbohydrates consumption respectively.50 Patients should be advised to avoid sugar containing foods and drinks.
Regular Monitoring :
At each visit, oral hygiene and dietary education should be reinforced. Inspection of labial surface of the teeth at each appointment will identify the cases that require more intervention. If poor oral hygiene persists, the orthodontic attachments should be removed and treatment discontinued until effective oral hygiene practices are demonstrated over time.42
Enhancing The Enamel Resistance To Decalcification :.
Fluoride ions prevent plaque activity and adhesion by blocking enzyme systems, reducing enamel demineralization and promoting remineralization. Therefore it is used as a principal ingredient for preventing enamel decalcification.
1.Fluoride Mouth rinses :
A Cochrane review has recommended that orthodontic patients who are at risk of caries should use a 0.05% sodium fluoride (NaF) rinse daily during treatment , in addition to fluoridated toothpaste.51 Weekly use of 1.2% acidulated phosphate fluoride (APF) rinse has been found to reduce incidence of enamel demineralization during orthodontic treatment.9,52,53 These mouthrinses have been combined with antibacterial agents like chlorhexidine, triclosan, or zinc to improve their cariostatic effect.54
2. Fluoride Gels :
Many investigations have tried 0.4% stannous fluoride gels (SnF2) during orthodontic treatment and reported decreased enamel decalcification.54-56 Boyd compared the use of a 1100 ppm fluoride tooth paste alone or together with either a daily 0.05% NaF rinse or 0.4% SnF2 gel applied twice daily by tooth brush. He found that both provided additional protection against decalcification when compared to toothpaste alone, but neither was superior.57
3.Fluoride Dentrifices :
As orthodontic patients are at an increased caries risk, a fluoride concentration below 0.1% in dentrifices is not recommended.58
Stookey59 recommended that tooth pastes containing NaF are most effective against white spot development. On contrary Ogaard et al recommended combined use of an AmF/SnF2 toothpaste / mouth rinse daily during treatment. This combination had more inhibiting effect on white spot lesion development when compared with NaF products60.
SnF2 has a plaque inhibiting effect by interfering with the adsorption of plaque bacteria to the enamel surface.61-63 Tin atoms in stannous products also block the passage of sucrose into bacterial cells, thus inhibiting acid production. The use of fluoridated antiplaque dentifrice may reduce enamel demineralization around the brackets more than the use of a fluoridated dentifrices alone.63
4. Fluoride Varnish :
Many studies have found that fluoride varnishes are effective in preventing enamel demineralization.64-66 It has been reported that the application of a fluoride varnish resulted in 44.3% reduction in enamel demineralization in orthodontic patients while eliminating the need for patient cooperation that is required with fluoride rinses67,68
5. Fluoride containing sealants & primers:
The use of fluoride containing sealants did not affect the shear bond strength (SBS) of orthodontic adhesives but were shown to a decrease release of fluoride ions with time. Proseal, a fluoride releasing sealant was capable of releasing fluoride ions for 17 weeks.69 However, it has the ability to be recharged with fluoride ions using a foaming solution of APF; fluoride release in the first week after recharging increased to 0.354 ppm/mm2.70 While these rates of fluoride release may be low, Ten Cate suggested that even sub-ppm levels of fluoride may have a significant impact on remineralization.71
6. Luting Cement :
Fluoride releasing cements like zinc polycarboxylate & resin modified GIC demonstrated less enamel decalcification than the traditional zinc phosphate cements.72-75
7. Fluoride in Bonding Agents :
Bonding agents containing fluoride have the potential for decreasing enamel decalcification.22,76-81 Glass ionomer cements have lower SBS than RMGIC and their use for bonding orthodontic brackets became fairly limited.82-86 Because of recent improvements in the fluoride-releasing capabilities and the SBS of RMGIC, it has been suggested that these adhesives should play a greater role in bonding brackets in the future.82-87
8. Antimicrobials in Orthodontic Adhesives:
Combining chlorhexidine with the bonding primer or applying it after bonding is completed, resulted in no significant decrease in SBS.88,89 But application of chlorhexidine as a separate varnish layer during bonding, either alone or as a separate layer over the sealant before placing adhesive, resulted in significant reduction in SBS.89The use of cetyl pyridinium chloride (CPC) found no significant differences in tensile bond strength between an adhesive impregnated with 2.5% CTC & a control. Moreover, the adhesive containing 2.5% CTC was shown to inhibit bacterial growth for196 days.90
9. Fluoride containing Etchants:
The topical application of fluoride has been reported to decrease the bracket bond strength.91-94 In contrast, a study by Takashashi et al 95 reported that the application of 30% H3Po4 solution containing 0.02%NaF resulted in an increase in the fluoride content in the enamel surface without decreasing the bond strength. Other studies96 have indicated that a mixture of 37% phosphoric acid and an APF gel (50% and 66% fraction) would be used as an etchant to minimize the loss of sound enamel .
10. Fluorides in Elastomers :
Many investigations suggested that fluoride releasing modules were effective in reducing enamel decalcification around the brackets.14,97,98 Other studies concluded that short term fluoride release from these accessories did not effect the quantity of disclosed plaque around orthodontic brackets.41,99,100 In the presence of fluoridated toothpaste & mouth rinses they imbibe the fluoride and release it significantly more.101
11. Laser Irradiation:
Several authors have suggested that argon laser alters the crystalline structure of the enamel and prevents enamel decalcification.102,103 Blankenau et al103 for first time found an average of 29.1% reduction in depth of enamel decalcification with argon laser irradiation followed by many other studies.104,105 Harazaki et al106 subjected 10 orthodontic patients to a combination of Nd-YAG and APF treatment. These patients showed less number of WSL than control group.
Routine fluoride application procedures used for all patients receiving fixed appliance therapy at the Oslo University Dept of Orthodontics.107
(Fluoride content of drinking water below 0.10 ppm).
I) Before Insertion of Fixed Appliances :
1. APF gel treatment (associated with impression taking) and
2. Daily mouth rinsing with 0.05% NaF (caries prone patients should rinse twice daily).
II) Throughout Period of Active Treatment :
Daily rinsing with 0.05% NaF (caries prone patients should rinse twice daily).
III) After Removal of fixed Appliances :
a) Routine Patients: Daily rinsing with 0.05% NaF.
b) Patients having received demineralizations during treatment :
Daily rinsing with 0.2% NaF for 2-4 months followed by daily rinsing with 0.05% NaF.
In addition to fluoride mouthrinses all patients should use a fluoride dentifrice throughout treatment period.
MANAGEMENT :
Demineralized enamel can remineralize after debonding under favorable conditions.6,8,10,11 Remineralization of these WSL is a natural phenomenon resulting in the partial reversal of what is an early caries lesion108. Mellberg109 et al have shown an average remineralization of 20-30% over 2 weeks. Ogaard etal10, warned against treating visible white spot lesions on labial surfaces with concentrated fluoride agents as this arrests the lesion (hyper mineralization). Instead they advocated allowing remineralization by saliva, as this results in greater repair and less visible lesion. Lagerweij and Ten Cate found that fluoride toothpaste combined with a high concentration of fluoride gel (12,500 ppm) resulted in more remineralized lesion when compared with the use of only a fluoride tooth paste110.
Use of Casein Phosphopeptide Amorphous Calcium phosphate: (CPP-ACP)
In 1980’s, Reynolds drew attention to the fact that CPP-ACP, which is a product derived from milk casein was capable of absorbing through enamel surface & could affect the carious process.111 The CPP-ACP is a delivering system that allows freely available calcium and phosphate ions to attach to enamel & reform into calcium phosphate crystals.112 The material is marketed under the trade name “Recaldent”. Studies of the effects of CCP-ACP have shown promising dose related increase in enamel remineralization within already demineralized lesions.113,114
Chewing gum To Promote Remineralization
In nonorthodontic patients, a regimen using a sorbitol-based chewing gum chewed for 20 minutes, 5 times daily for 3 weeks, showed significant remineralization of demineralized enamel when compared with controls without chewing gum. The use of xylitol as an alternative sweetener may be superior when compared with sorbitol because of the potential anticaries properties.115-118 Beneficial effect seen with the use of chewing gum are attributable to a large measure to salivary stimulation.
Vital tooth bleaching:
If time and fluoride do not improve the esthetic concerns of the patients and clinician, post orthodontic bleaching can be beneficial. Mild whitened enamel can often be camouflaged by bleaching with standard tray-based whitening systems used over night or with hydrogen-peroxide impregnated polyethylene strips.119-123 If 2 to 4 weeks bleaching with these regimens is ineffective at camouflaging this whitened enamel, microabrasion followed by bleaching is recommended.124
Microabrasion:
Microabrasion has been shown as an effective treatment approach for the cosmetic improvement of long-standing postorthodontic demineralized enamel lesions.125-127 This procedure should be delayed atleast 3 months following debonding to allow for spontaneous improvement of the lesion & remineralization with fluoride applications.128
The white spot lesions should be abraded with 18% HCl in fine pumice under rubber dam in bursts of 30 seconds for a maximum of 10 applications. After last application tooth is washed well and a fluoride varnish is applied.125
CONCLUSION
Though many revolutionary changes in techniques & materials have marked the history of orthodontics since the time of introduction of fixed orthodontic appliances, post-orthodontic enamel demineralization unfortunately persists to be undesirable & common complication. In the light of available evidence regarding the etiology of demineralization during fixed appliance therapy, the best preventive strategy would appear to be an assessment of risk factors prior to bonding, coupled with fluoride mouth rinses, reinforcement of oral hygiene and dietary advice throughout the course of treatment.
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