Friday, November 30, 2012

Prevention and management of orthodontic decalcification

Management of white spot lesions

Decalcification is the number 1 reason that orthodontic practitioners get sued. Therefore, preventing decalcification and white spot lesions is an important aspect of management of legal risks associated with orthodontic treatment. And even more important than the legal considerations are the aesthetic implications for your patients. Improving dento-facial aesthetics is one of the primary reasons that patients seek orthodontic care. Aesthetics are severely compromised when decalcification rears its ugly head. Prevention of these problems leads to better aesthetics and, as a result, more satisfied patients. In this post, I will discuss prevention and treatment of white spot lesions. Numerous links to articles and product information are included in the post. This gives you the opportunity to learn the best techniques for prevention and treatment of this problem.

Preventing decalcification

Nothing works better than good oral hygiene. Take the time to explain and show proper brushing techniques to your patients. At each monthly visit, carefully evaluate the patient's hygiene. Continually work with the patient on brushing technique, making sure the patient is aware of areas he or she may be missing when brushing. Nightly use of a fluoride mouth rinse has been shown to be very effective at preventing decalcification.

Also, make sure the patient gets his or her teeth cleaned regularly. In my practice we schedule all orthodontic patients for prophys at 4 month intervals. This is slightly more expensive for the patient (most dental insurance covers prophylaxis at 6 month intervals, so 1 cleaning a year is usually not covered by dental insurance), but the benefits gained outweigh this small disadvantage. The method of choice for efficient cleaning of teeth with bonded and banded appliances is a prophy jet (see links below for more information).

Smooth surface sealants

These are a relatively new class of products; the results achieved in elimination of decalcification have been impressive. Smooth surface sealants can be applied to the whole facial (or buccal) surface of teeth after etching. After curing the sealant, use your preferred bracket adhesive as directed. Some clinicians prefer to place this material around the brackets after orthodontic bonding is completed. Both techniques work well.

Instructions for Use of PRO SEAL® and L.E.D. PRO SEAL® (courtesy of Reliance Orthodontic Products)

1. APPLICATION: Dispense a drop or two of PRO SEAL® onto a mixing pad. With a brush, apply a thin uniform layer on the etched enamel surface. Stroke over with the same brush to ensure a thin layer and proper coverage. If not applied in a thin layer, LED PRO SEAL® may appear yellow.

If using original PRO SEAL®, cure each tooth for 20 seconds with any corded halogen, plasma or LED curing light (390 – 440 nM). If using L.E.D. PRO SEAL®, cure each tooth for 20 seconds with any corded halogen, plasma or LED curing light (440-480 nM). The material is compatible with the majority of orthodontic adhesives.

Note: In order for PRO SEAL® to remain on a normal tooth surface, it must be applied to properly conditioned, dry enamel. Atypical enamel should be first etched and then conditioned with multiple coats of Enhance™ Adhesion Booster or Assure® Universal Bonding Resin, then lightly dried before the PRO SEAL® is applied. In order for PRO SEAL® to completely cure, a proper intensity light must be used for the prescribed time at close range.

If PRO SEAL® is cured and saliva contamination occurs, the contaminated tooth can be cleaned by dabbing lightly with Enhance™ or Assure® Sealant and dried with air.

2. REMOVAL OF SEALANT RESIN: After the adhesive paste has been removed with a Renew™ System Bur (#118S, #118L or #218), removal of PRO SEAL® sealant is easy. Use the #383 Renew™ System Point on your choice of handpiece. Lightly polish the entire tooth surface with the #383 rubber point where PRO SEAL® has been applied. Note: If patient will visit the hygienist during treatment, the enamel should not be cleaned with a prophy jet as this can remove the PRO SEAL®. Use fine pumice for cleaning.

A final note about prevention of decalcification

As dental practitioners, our most important duty when treating patients is to do no harm. Keeping this in mind, if, despite your best efforts, decalcification is occurring, the best thing to do is to stop the damage by removing the braces. In the great majority of cases, poor patient cooperation is the primary reason that decalcification occurs. Mouth rinses and sealants will often not prevent decalcification if the patient's hygiene is poor. In these cases (even though it may not seem like it at the time) the best thing you can do for the patient is to take the braces off. The teeth won't go away; orthodontic treatment may be re-initiated after hygiene improves. Following this advice will prevent a lot of problems. Logistically, early removal is a hard thing to do. Payment plans must be altered and it is not easy to convince a parent that this is the best course of action. But often it is the right thing to do, and waiting for a child to mature a little before re-treating will prevent a lot of future dental problems.

Management of white spot lesions

Despite our best efforts, decalcification does occur. It is never a good day at the office when white spot lesions are discovered when braces are removed. Fortunately, there are some new techniques that can be used to eliminate (or at least minimize) the size and scope of white spot lesions. The two best techniques are microabrasion and at home application of CPP-ACP.

Microabrasion is a technique where a combination of acid and pumice are used to remove enamel irregularities and discoloration defects. A step by step set of instructions as well as some case studies are presented in the article which can be accessed by using this link:

Studies show (see references in the article) that enamel microabrasion removes a "clinically insignificant" amount of enamel from the tooth surface. Additionally, the newly exposed enamel demonstrates a significant resistance to demineralization. For most patients 4 treatments done at 2 week intervals greatly reduce the size and discoloration of the lesions. For more information on this technique, go here  and here

The second technique which can be used to eliminate white spot lesions involves the use of casein phosphopeptide amorphous calcium phosphate (CPP-ACP). The most widely used product is called MI Paste and is distributed by by GC America. For information about this product, follow this link

MI Paste is intended for at home use. Patients apply the paste to the affected areas once a day for about a month. The material is rubbed on with either a q-tip or a finger tip. Lesion reduction is maximized if at each application the material is allowed to sit undisturbed for at least 3 minutes.

A final note
Many clinicians are reporting spectacular results in elimination of white spot lesions by using a combination of the two techniques. The Angle Orthodontist November 2012 issue contains an article describing how to combine these techniques. The article also reports results attained by doing this. You can access that article here:

I strongly encourage you to read this article. It is very well written and provides a great summary of the methodology and potential results that can be obtained by using these techniques. You will benefit your patients by offering these services.