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.

http://www.ncbi.nlm.nih.gov/pubmed/12917928

http://www.actfluoride.com/dental-professionals/act-total-care-64-oz-professional-use-dispenser/

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).

http://www.dentsplymea.com/content/cavitron%C2%AE-prophy-jet%C2%AE

http://www.dentsply.com/media/345951/dual_select_80518__r9__0512_.pdf

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.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3242403/

http://www.relianceorthodontics.com/store/product.php?productid=37



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:

http://www.dentalaegis.com/cced/2011/04/smile-restoration-through-use-of-enamel-microbrasion-associated-with-tooth-bleaching

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 http://www.youtube.com/watch?v=Zwkp5MBa9X8  and here  http://www.dentalcare.com/en-US/dental-education/continuing-education/ce1004/ce1004.aspx?ModuleName=coursecontent&PartID=2&SectionID=-1

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  http://www.breezecare.com/mediacenter/recaldent/orthomousseplus.pdf

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.
http://www.orthotechnology.com/product_literature/pdfs/B-MI_PREVENTATIVE.pdf

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: http://www.angle.org/doi/pdf/10.2319/090711.578.1

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.



61 comments:

Jannah Delfin said...


I appreciate all of the information that you have shared. Thank you for the hard work!

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Simon Adair said...

I am glad to see this kind of stuff with Coquitlam orthodontics. They always do such a great job.

Victoria Elizabeth said...

Thanks for the post! I have been looking into Coquitlam orthodontics. Your post has been helpful in searching for the place I want to go.

Elle Olsen said...

Thanks for sharing this article, it has really been a very helpful read. I've personally never had to deal with orthodontist in Edmonton, like this before. I'm really excited to see how it's all going to work out.

Hilary Kimbel said...

Thanks so much for this great information! I have actually been interested in finding out a little bit more about getting an orthodontist in Glen Ellyn, IL... Any suggestions on where I might go for that?

Layne Adams said...

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Elijah Ali said...

Thanks for this post! It is good to know these things. I have been looking for a good place that does Bedford orthodontics.

Molly Perkins said...

Great blog. I like the title a lot. My mom just got a job at Bedford orthodontics.

Booker DeWitt said...

I am looking at Bedford orthodontics, does anyone have a recommendation for a clinic?

Shelly Slader said...

I did my orthodontics in Omaha NE and am very happy with the results.

Sean Valjean said...

What this says about preventing calcification is so important. I paid close attention to this with my orthodontist in Hinsdale, IL and it has made such a difference as compared to the other people I know.

Harlin Quincy said...

I am interested on how this article was thought as written. Such a practical approach to orthodontists is odd and rare.

Jak Manson said...

I need to find a orthodontic in Gilbert az. What can someone help me find and quick? Please help me out and quick. I want to make sure that I can get rid of this pain and keep it away.

Harlin Quincy said...

What is the best form of orthodontics? If such things have such different levels, how do you know what level is the best.

Mia Hart said...

Hey there! I am looking for an office that does orthodontics in Idaho Falls, ID. Do you happen to have any recommendations? Please let me know, thanks.

Strake Davis said...

This is an interesting blog. I have seen how the Hamilton orthodontics work, and love the way they do work. Thanks for sharing!

Jak Manson said...

Where is it that I can find an orthodontic care center in Chicago? I am hoping to find one soon so that I can get this tooth taken care of.

spencer shawn said...

Thank you so much for the information! I have been thinking I was getting white spots and now I will use fluoride so that I can surprise my orthodontist in Kitchener when I next visit them! Thanks again!

tyleragent said...

This might be a shot in the dark for asking but it's worth a shot. But I've been looking for a orthodontist clinic in Bedford for my kids. And I'm not having the best of luck, so if anyone has any recommendations then that would be great.

Thiago daLuz said...

Our orthodontist in Halifax does a great job teaching us, the kids especially, the importance of preventive care.

Graham Williams said...

Great tips! I'll pass them on to my friends studying to practice orthodontics in Omaha, NE.

Mike Ross said...

Thanks for this post. I think that I need an orthodontic plate from Perth.

spencer shawn said...

I am thinking that I will need to go to Hamilton orthodontics to get my daughter's braces done. Has anyone had experience there?

Wayne Parker said...

My brother needs some braces, so he is looking for great orthodontics in gilbert az. Any suggestions? Thanks!

Lance Tankmen said...

I just went to an orthodontist Henderson NV for the first time. Wasnt bad at all!

Sampson Greenovich said...

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Konrad Jenkins said...

Very interesting article. I had no idea that going to the orthodontist could be so complicated. I've heard that John C. Matunas does the same kinds of procedures.

Charlie McPoyle said...

The last time I went to the dentist, I was informed that drinking soft drinks weaken the teeth. Soft drinks are acidic and this lowers the amount of calcium the teeth have. It's hard to cut back soft drinks but I need to take care of my teeth. http://www.perthsmiles.com.au/index.php?page=removable_appliance

DentalCare Canada said...

Every dentist always have to take care of de-calcification while practising on important aspect of management of legal risks associated with orthodontic treatment. Our dentist offer quality orthodontic treatment to the patient suffering from such issues.

Jason Strong said...
This comment has been removed by the author.
Jason Strong said...

I think taking the practical approach to orthodontics is the best way to go. I think this most important for people who are scared. I can you see you doing very well this technique.

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Seamus Lowe said...

I never knew that those white spots are where decalcification is happening. I honestly didn't know what they were, but I have noticed them on quite a few people before. I think I'm actually having that happen to me as well. I'll definitely start working on it.
-Seamus | http://www.lovemyorthodontist.com/what-we-do.html

John Howard said...

There is a lot of great stuff on this blog. I have been wondering about why people with braces get those white spots and this answered. Most of my friends have braces on right now so I'll have to explain to them about this issue. http://www.lovemyorthodontist.com

Thiago daLuz said...

I heard about decalcification just this last time I went to the dentist. It sounded intimidating at first, but the orthodontist explained it really well. I'm sure I can avoid it now. Thiago | http://www.familydentistryofwoodstock.com

Gary Puntman said...

I have heard of this happening before. Thanks for posting this information about it. My son is going to get braces soon. I will make sure he cares for his teeth the right way and uses the right products.
Gary Puntman | http://www.familydentistryofwoodstock.com

Roxanne Rook said...

My niece just got her first braces on and I remember my sister talking about decalcification. It is very important that patients form and retain good habits of oral hygiene. I'm glad orthodontists explain this to their patients.

Roxanne Rook | carlyleortho.com

Zach Thalman said...

I think one of my biggest fears is decalcification. I have met regularly with my dentist. In my family we try to practice very strict oral hygiene. My aunt is an oral hygienist and she always is talking about caring for your teeth. I know how important it is to keep you teeth clean.

Zach Thalman | http://www.lowdersmiles.com/about-orthodontics

bryan flake said...

When I had braces a few years ago, I had the issue of the sealant product being cemented on my teeth. I am glad that a few rinses of mouthwash and power toothbrush and my teeth were smooth. It was an odd sensation to have gristly material on my teeth when the braces came off. But it is all gone now, thank heavens!

http://www.auroradentalclinic.com/fort-mcmurray-orthodontics

Talmage Dangerfield said...

I never realized that decalcification was such a problem for people with braces. My grand kids are getting braces in a couple of months, so this might be important to show to my daughter, so that she's informed. I'm sure that the orthodontist has dealt with problems like these hundreds of times though. http://www.pedodonticspc.com/services.html

Gerald Vonberger said...

I remember being so embarrassed when I got my braces off when I was a teenager because of the decalcification that had happened. My orthodontist was really good and helped me fix it. Now my kids are in the same boat. Sometimes you just can't avoid it. Thanks for the post.

Gerald Vonberger | http://carlyleortho.com

Megan Jones said...

Some of my siblings had braces while we were growing up. I might have made fun of them, but justice was served because I got them later in life. Life can be funny like that.
http://www.smilespecialists.com.au

Kelsey Compars said...

I actually didn't have a huge problem with decalcification when I got my braces taken off. Of course I noticed it a little but not bad at all and my teeth went back to their normal healthy state fairly quickly. I'm sure it differs from person to person though. http://www.woosterorthodontics.com

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Sergio Freddson said...

This is a very thorough examination of preventing decalcification. I really enjoyed all the resources you provided - your thoughts are very well sourced. Thanks for sharing your knowledge with us and keep posting!

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Gerald Vonberger said...

I didn't know that could happen so easily. It's good to know that there are precautions you can take to prevent orthodontic decalcification. My son is going to get orthodontic work done in the next little while so we're researching to find out everything we can about it. http://www.seattlerainbowsmiles.com/procedures/orthodontics/

Wally West said...

This is great information and I always fear of this happening to me. I go to my orthodontist on a bi-annual basis because I don't want anything bad happening to my teeth. So far I have not had any issues and I am very thankful for that. Hopefully I can keep up the positivity and maybe nothing bad will happen to my teeth like it did my father and grandfather.

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Jackson Willis said...

When most people think about orthodontics, they think about braces. I think it's great to see a post that highlights some of the other things that orthodontists would work on. This is such a wide ranging field. It is unfair to minimize it to just one job.
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Jackson Willis said...

When most people think about orthodontics, they think about braces. I think it's great to see a post that highlights some of the other things that orthodontists would work on. This is such a wide ranging field. It is unfair to minimize it to just one job.
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Michael Williams said...

Thanks for the article! I like how you mentioned that nothing is better than personal hygiene. I have to say I agree. Ever since I was small my parents have taught me to take care of myself and especially my teeth. Now it's my turn to teach my kids how important it is to brush and floss every day, to maintain their own personal hygiene. http://www.aboutfaceortho.com.au/

Roger Pace said...

Getting braces was a hard time in my life but one that I now appreciate. As a teenager it's hard to see how good braces can actually be when it plays into how you look at that moment. When you get them off though and see those nice straight teeth, you realize that it was worth the wait.

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