Abstract
Objective: The
presence of fixed orthodontic appliances in the mouth undoubtedly predisposes
to the accumulation of plaque. Two favored sites for such accumulation are
around the cervical margins of the teeth and under the molar bands. This study was carried out to find out the
incidence and severity of white spots after a full term of orthodontic treatment
under the molar bands.
Methods:
The incidence of
white spots under the molar bands of 75 patients (300 first molars) treated by
fixed appliances in Queen Alia Hospital was recorded at the time of debonding
during the year 2005. Direct clinical examination for the presence of white
spots was made on the labial surface of the first molar teeth.
Results:
Following
debonding 93.3% of patients had at least one white spot and 50% of the examined
molars had, to some extent, a degree of decalcification. There was no
significant difference between male and female white spot distribution.
Conclusion: This study revealed that the
incidence of white spots among this sample of Jordanian patients was very high.
Of equal, if not greater, benefit would be the implementation of more stringent
and more frequent preventive measures applied prior to and throughout the
period of active treatment. Both patients and parents should be instructed and
motivated on the importance and on how to maintain the highest standards of
oral hygiene.
Key
words: Demineralization, Enamel, Molar bands
JRMS
September 2010; 17(3): 45-50
Introduction
While
the objective of orthodontic treatment is a healthy, functional and aesthetic
occlusion the presence of fixed orthodontic appliances in the mouth undoubtedly
predisposes to the accumulation of plaque. Two favored sites for such
accumulation are around the cervical margins of the teeth and under the molar bands.(1)
Enamel demineralization is the
second most common iatrogenic problem in orthodontic patients whose compliance
with oral hygiene and preventive advice is poor.(1)
Associated with fixed appliances is an extremely rapid process caused by a high
and continuous cariogenic challenge in the plaque developed around brackets and
underneath ill-fitting bands.(2) White spot lesions can
develop very quickly-within a few weeks and consist of some softening of enamel
surface with progressive mineral loss of sub-surface layer to a depth of 100
micrometers.(3) The white spot lesion is a precursor of
enamel caries that occurs due to accumulation of plaque adjacent to brackets, and
appears as a chalky white area at the cervical margin of teeth. Linear correlation between plaque accumulation and caries
has been shown in orthodontic patients.(3)
The development of white
spot lesions during fixed appliance orthodontic treatment is preventable. The
chosen method or methods for prevention will be largely dependent on individual
needs of each patient and opinion of clinician.(4) There are several methods of delivering
fluoride to teeth in patients during orthodontic treatment. These include
topical (fluoridated tooth paste, mouth rinse, gel and varnish) and adhesive (fluoride-releasing
cements and elastomeric modules and chains) methods. The aim of this study was
to establish the
incidence and severity of white spots after a full term of orthodontic
treatment under the molar bands.
Methods
This
study involved patients selected from a public sector practice and the results
reflect only the situation in that practice. The incidence of white spots under
the molar bands of 75 patients (300 first molars) treated by fixed appliances
in Queen Alia Hospital
was recorded at the time of debonding. The cement used for all bands was Zinc
phosphate cement. The average age was 16.2+3.2 years (50 females, 25 males).
Direct clinical examination using a dental mirror and explorer before and after
drying the buccal surface of the first molar teeth was made to detect the
presence of white spots and the lesions were scored according to Gorelick et
al. index(5) as follows (Fig. 1):
1.
No white spot formation
2.
Slight white spot formation
3.
Excessive white spot formation
4.
White spot formation with cavitations
Results
Of
the 75 patients evaluated, only 5 (6.7%) patients had no white spot formation
at all. Seventy (93.3%) had at least one lesion and they are distributed as
follows: 24 (32%) patients had only one first molar affected, 22 (29.3%)
patients had two first molars, 16 (21.3%) patients had three first molars and
finally 8 (10.7%) of patients had all first molars affected (Table I). With
regard to the total number of first molars (300), 150 (50%) of the first molars
examined had to some extent a degree of decalcification, 23 (7.7%) had white
spot formation with cavitations, 44 (14.7%) molars had excessive white spot formation, while the highest percentage
was 83 (27.6%) for the slight white spot formation (Table II). The
Chi-square test was used to compare the gender distribution between the affected
and non-affected patients (Table III) and no significant differences were found.
Discussion
Results of this study showed
that following orthodontic treatment there was a significant increase in the
prevalence of white spot lesions underneath banded molars. With regard to the patients
examined, the prevalence of white spot formation and severity of enamel
opacities on the maxillary and mandibular first molars is much higher than that
reported in other countries. Prevalence varies
within the published literature. Deep
and rapid demineralisation can occur in as little as four weeks,(4,6)
Mizrahi(7) found that 84% of teeth post orthodontic treatment
showed white spot lesions. Fifty percent
of patients have at least one white spot lesion after treatment and 6% have
cavitations.(6) The
maxillary lateral incisors are the teeth most susceptible to severe white spot
formation followed by the lower canine,
upper canine, lower 1st premolar and lower 1st molar.(8)
Other studies have found that the greatest prevalence
of white spot lesions is on 1st molars, canines, premolars and of
the anterior teeth lateral incisors are more affected than central incisors.(9)
The number of white spots in mandibular molars was significantly higher than
maxillary molars. This may be associated with the location of salivary glands
which results in accumulation of a greater amount of saliva around maxillary
molars causing increased mineralization of these teeth.(10)
These large variations might be the result of the difficulty in standardizing
clinical examination, the variety of detection methods, or the presence of white spots before the start of orthodontic
treatment.(11)
Ideally, the appearance of the tooth should be recorded before and
after orthodontic treatment so that the change in appearance of the tooth is
measured (incidence), not just the appearance at the end (prevalence).(12)
Orthodontic treatment may be
hazardous to the patient who has no motivation, no prophylactic program and
poor supervision. It is the clinician's responsibility to detect these lesions.
Careful inspection of the appliance at every visit and preventive fluoride
programs is therefore required.(4) Well-cemented orthodontic bands protect completely covered tooth surfaces against caries.(2) It makes though, the partly covered surfaces more susceptible to caries and destruction.
Fig. 1. Gorelick et al.
index(5): Score 1 (no white spot formation), Score 2
(slight white spot formation), Score 3 (excessive white spot formation) and
Score 4 (white spot formation with cavitations)
|
|
Table I. Number of molars affected
in each patient
|
No. of
patients
|
Affected 1st
molars
|
%
|
|
5
|
Zero
|
6.7
|
|
24
|
One 1st molar
|
32
|
|
22
|
Two 1st molars
|
29.3
|
|
16
|
Three 1st
molars
|
21.3
|
|
8
|
Four 1st molars
|
10.7
|
|
|
|
Table II. Score given for each molar No. of molars | Score | % | 150 | 1 | 50 | 83 | 2 | 27.6 | 44 | 3 | 14.7 | 23 | 4 | 7.7 |
Table III. Comparison
of gender distribution between the affected and non-affected patients
|
Gender
|
Affected
(n=70)
|
Non-affected
(n=5)
|
Total
(n=75)
|
|
Male
|
24(34%)
|
1(20%)
|
25(33%)
|
|
Female
|
46(66%)
|
4(80%)
|
50(67%)
|
|
Total
|
70
|
5
|
75
|
P-Value=0.512
|
The progression of the caries
process is retarded under a well fitting band. This is of value if caries went
undetected at the initial stage of banding.(3) Caries
development underneath orthodontic bands in the absence of fluoride is a very
rapid process caused by a high cariogenic challenge in the plaque. In the light
of available evidence regarding the aetiology of demineralization during fixed
appliance therapy, the best preventive strategy would appear to be an
assessment of risk factors prior to banding, coupled with fluoride rinse,
regular reinforcement of oral hygiene, and dietary advice throughout the
treatment.(13) Daily mouth rinsing with a neutral 0.2% NaF
solution retarded lesion development significantly. Thus fluoride applied as a
mouth rinse has a marked cariostatic effect even in poorly accessible locations
underneath orthodontic bands. However, 0.05% NaF solutions is the recommended
daily use mouthwash. The 0.2% NaF solutions is the recommended dose for
the high-risk patients.
The released fluoride influences the demineralisation and
remineralisation process of the enamel surface, resulting in more resistant
enamel underneath the bands. Once the orthodontic treatment is completed and
the appliance is removed, no further progression of lesions will occur since the
cariogenic challenge has ceased.(14)
The general belief that
these lesions disappear after removal of fixed appliances is controversial.
White spot lesions developed during orthodontic treatment have very limited
ability to improve after appliance removal(15) and in many
cases these lesions remain visible as permanent enamel scar. The cariostatic
action of topical fluoride concept is related to the fluoridation of the enamel
in the form of fluorohydroxyapatite. Visible white spots on the facial surfaces
developed during orthodontic therapy should therefore not be treated with
concentrated fluoride agents since this procedure will arrest the lesions and
prevent complete repair.(15,16) Carious lesions developed in
caries susceptible areas like proximal surfaces and the gingival part of facial
and lingual surfaces of posterior teeth should be treated topically to prevent further lesion progression.(15) Significant numbers of patients
exhibit white spot lesions after orthodontic treatment. Lesions develop quickly
and consist of enamel surface softening with progressive mineral loss of the
substrate layer. Smooth surface caries lesions of this type do remineralise
following removal of aetiological factors. Despite the preventative measures,
there will be patients with unsightly white spot lesions after debonding
presenting challenge for restorative treatment. It seems that low doses of
fluoride in mouth washes do not improve these lesions.(17)
Allowing remineralization by saliva and the use of hydrochloric
acid 10 weeks after debonding is suggested(17,18) The
procedure can be recommended as a first line treatment option in cases with
unacceptable post-orthodontic decalcification.(18) Since more than 50 per cent of
the teeth studied exhibited no white spot formation, the potential influence of
individual differences in enamel structure, composition of saliva, tooth
brushing, and other variables remain questions to be investigated.
I. Prevention:
For a better understanding of whether and which preventive measures will
be most efficacious, knowledge is required about the beginning and natural
behaviour of these orthodontic-related white spots.(16)
·
Prevention is the best cure. Good communication is essential to ensure
both patient and parent are aware of the risks of treatment.(19)
·
Begin with appropriate patient selection. Exclude patients with poor
oral hygiene and evidence of active caries
·
Diet control
·
Close monitoring of patients is essential throughout treatment. Linear
correlation between plaque accumulations and white spot formation.
·
Demineralization can be completely inhibited and/or reversed by the use
of commercially available fluoride products.(20)
·
All patients under treatment should receive instruction on tooth
brushing using fluoride containing tooth paste and to reduce daily exposure to
refined carbohydrate including acidic drink(5) in addition to
daily rinsing with a 0.05% sodium fluoride mouth rinse throughout treatment.(13,9)
·
Written and verbal information must be given. Videos serve to reinforce
this information.
·
Select proper band size and should be tightly fitted.
·
Routine checking for loose bands. Bands should be checked for retention at every visit
·
Use glass ionomer cement for banding because of fluoride release and
retentive properties.(21)
·
Obtain maximum coverage of enamel by placing a thumb on the occlusal
surface of the band so that cement is expressed gingivally.
·
The use of fluoride releasing elastomeric modules reduce but not
eliminate the incidence of decalcification.(22)
·
Light cured filled sealant (Pro Seal) can be considered as a preventive
method to reduce enamel demineralization adjacent to orthodontic attachments,
particularly in patients who exhibit poor compliance with oral hygiene and home
fluoride use.(23).
·
The use of bonded molar tubes instead of bands remains a good option
when there is no need for auxiliaries.
·
Should white spot lesions occur, these should be mentioned to the
patient/parent with an explanation of why they have occurred.
·
Removal of arch wires and bands for a visit may help oral hygiene
procedures.
·
As a last resort the appliance may be removed.
II.
Treatment:
·
Early diagnosis of white spot lesions by the clinician is a matter of
great importance. White spot lesions are an optical phenomenon due to
subsurface demineralization. The enamel surface is usually intact and acts as a
porous surface across which fluoride ions can pass. High doses of fluoride in
the form of fluoride varnish e.g. Duraphat should be avoided. This seals the
enamel surface and thus the demineralized area for life, in addition to
staining the enamel. It is best to use a low dose of fluoride in the form of
toothpaste.
·
Patients should be reassured that the appearance will improve over the
next year. They should also avoid food and drink that may stain the porous
enamel – black tea/coffee.
·
Staining persisting beyond this time may be treated by various methods
from the most conservative (acid pumice micro abrasion),(18)
to more definitive treatments for cavitations (class V composites, veneers
etc).
Generally speaking,
orthodontic treatment need not cause any
appreciable damage when accepted orthodontic principles are
followed in co-operative patients with good oral hygiene and regular fluoride
supplementation. On the other
hand, when these principles are neglected, the
damage may be considerable and the benefits from orthodontic treatment
questionable.
Conclusion
White
spot formation under molar bands is one of the risks of orthodontic treatment. This study revealed that the incidence among
this sample of Jordanian patients is very high. Of equal, if not greater,
benefit would be the implementation of
more stringent and more frequent preventive measures applied prior to and
throughout the period of active treatment. Prior to the start of active
treatment, both patients and parents should be instructed and motivated on the
importance and on the manner of maintaining the highest standards of oral
hygiene. During treatment, the use of tightly fitting and correctly adapted
bands as well as routine checking for loose bands remains the responsibility of
the orthodontist. Fluoride-containing dental cements should be used for all
cementing procedures.
References
1.
Mizrahi E. Enamel
demineralization following orthodontic treatment. Am J Orthod Dentofac
Orthop 1982; 62-67
2.
McGuinnes N. Prevention
in orthodontics-A review. Dent Update 1992; 19: 168-175.
3. Zachrisson BU. Iatrogenic damage related to orthodontic
treatment. J Clin Orthod 1978; 12: 102-113.
4. Ogaard B, Rolla G, Arends J. Orthodontic appliances and
enamel demineralisation. Part 1. Lesion development. Am J Orthd Dentofac
Orthop 1988; 94:68-73
5. Sudjalim TR, Wood MG, Manton DJ. Prevention of white lesions in orthodontic
practice: a contemporary review. Aust Dent J 2006; 51(4):284-289.
6. Gorelick L Geiger AM,
Gwinnett AJ. Incidence of white spot formation after
bonding and banding. Am J
Orthod Dentofac Orthoped 1982; 93-98.
7. Melrose CA, Appleton
J, Lovius BBJ. Ascanning electron microscope study of early cariformed in –
vivo beneath orthodontic bands. Br J Orthod 1996; 23:43-47
8. Mizrahi E. Surface distribution of enamel opacities following
orthodontic treatment. Am J Orthod Dentoac Orthop 1983; 323-331.
9. Geiger AM, Gorelick
L, Gwinnett J, Benson BJ. Reducing white spot lesions in orthodontic populations with
fluoride rinsing. Am J
Orthod Dentofac Orthop 1992; 101: 403-407.
10. Ogaard
B. Prevelance of white spot
lesions in 19-year- olds: A study on
untreated and orthodontically treated person 5 years after treatment. Am J Orthod
Dentoac Orthop 1989; 96: 432-437
11. Arbabzadeh F, Bouzari
M, Nasr H, Kharazif MJ. Distribution of white spot after debanding in orthodontic
patients. Journal of
Dentistry 2006;
3(4): 173-177.
12. Kanthathas
K, Willmot DR,
Benson PE. Differentiation of developmental and post-orthodontic white
lesions using image analysis. Eur J Orthod 2005; 27:167-172.
13. Benson
PE, Shah AA, Millett DT, Dyer F, Vine RS.
Flouride, Orthodontics and demineralization : a systematic review. J
Orthod 2005; 32:102-14.
14. Chang
HS, Walsh LJ, Freer TJ. Enamel
demineralization during orthodontic treatment. Aetiology and prevention. Aust
Dent J 1997; 42:(5):322-327.
15. Ogaard.
B, Rolla G, Arneds J, Cate
MT. Orthodontic
appliances and enamel demineralisation. part 2 Prevention and treatment of Lesions.
Am J Orthd Dentofac Orthop 1988; 94:123-128.
16. Mattousch
TJH, Veen MH, Zentner A. Caries lesions after orthodontic treatment
followed by quantitative light - induced fluorescence: a 2 –year
follow-up. Eur
J Orthod 2007; 29:
294-98.
17. Willmott
DR. White lesions after orthodontic treatment: does low fluoride make
difference? J Orthod 2004;
31:235-242.
18. Welbury
RR, Carter NE. The hydrochloric acid-pumice. Microabrasion Technique in the
treatment of post-orthodontic decalcification. Br J Orthod 1993;
20:181-185.
19. Bishara
SE, Denehy GE, Goepferd SJ. A
conservative post-orthodontic treatment of enamel stains. Am J Orthod
Dentofac Orthoped 1987; 92:2-7
20. Proffit
WR. Contemporary Orthodontics. 3rd ed, Mosby, Inc. St. Louis. USA, 2000;
1-9: p277.
21. O'Reilly
MM, Featherstone JDB. Demineralization and remineralization around
orthodontic appliances: An in vivo study. Am J Orthod Dentofac Orthop
1987; 92: 33-40.
22. Donly KJ, Istre S, Istre T. In vitro enamel
remineralization at orthodontic band margins cemented with glass ionomer
cement. Am J Orthod Dentofac Orthop 1995; 107: 461-464.
23. Mattick
CR, Mitchell L, Chadwick SM, Wright J. Fluoride releasing elastomeric
modules reduce decalcification: a randomized controlled trial. J Orthod
2001; 28:217-219.
24.
Hu W, Featherstone JDB. Prevention of enamel demineralization:
An in – vitro study using light –cured sealant. Am J Orthod Dentofac Orthop 2005; 128:592-600.