white spot lesion

1. 1 White spot lesion White spot lesion Prepared by: Prepared by: Dr. Mohammed Alruby Dr. Mohammed Alruby W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Subsurface enamel porosity from carious demineralization that present as a milky white opacity when located on smooth surface. Incidence: 49.6% in orthodontic patients compared to 24% in an untreated control Classification: (idex of Gorelick et al 1982) Grade 1: no lesion Grade 2: small lesion, --- slight white spot with line formation Grade 3: severe lesion, ----- excessive white spot formation Grade 4: cavitation. Larger lesion occurred in gingival quadrant. Sites: in fixed appliances: labially In URA: palatally Order of prevalence: Geiger et al 1992, Mizrahi 1983 U2 – L3—L4 – L6 – L5 – U3 Or: gingival third ------ Middle third -----------incisal third May be influenced by dominant hand brushing, in right hand, decalcification occurs on right side through less effective cleaning Etiology: require four elements (Kidd and Smith 1991) 1-Plaque: strep. Mutans count increase depend on fixed appliance wears 2-Substrate; -- depend on diet 3-Susceptible tooth surface ------- depend on patient’s variability 4-Time in contact with tooth surface == acidic attack, increase risk as carbonated or citrus drinks == salivary factors--- PH, flow Prevention: = appropriate patient selection, exclude patient with poor oral hygiene = monitor patients = education program: dietary advice OH advice Topical fluoride Resin sealant over labial surface = tooth brushing: manual brushing: 78% more effective Powered more effective than manual Use ultrasonic brush. = Pharmaceutical prevention: chlorhexidine reduces WSL = bonding material: resin modified glass ionomer = ligation; Self-ligation reduce plaque Wire ligation reduce plaque compared with elastics Fluoride release elastics = fluoride release from composite resin =antibacterial agents incorporated into resin = decrease flush around bracket stagnation area. W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 N: B: Fluoride: = tooth paste: 1000 – 1250 PPM reduce WSL 23% 2400 – 2800 PPM reduce WSL 36% 500> not benefit = mouth wash: daily use 0.05% (226PPM) NaF enhance prophylaxis Once daily 0.2% (900PPM) NaF effective --------------- Zero et al 1992 = acidulated phosphate fluoride: 250PPM NaF at PH5 effective as 1000 PPM at PH7 = stannous fluoride: bind g+ve bacteria prevent attachment to enamel Prevent sucrose entering cell --- prevent fermentation = fluoride varnish: as Duraphat 22600 PPm fluoride reduce WSl when used Different manufacture with different effectiveness Treatment of white spot lesion: 1-Non cavitated lesion can remineralized, significant reduction in size in first 6 to 12 months following removal of fixed appliances contraindicate use of fluoride, and acid itch surface aids diffusion and repair 2-Chewing gum: use sugar free chewing gum, use 5 /day for 3 weeks reduce WSL Micro abrasion: alteration in enamel optical properties 3-Vital tooth bleaching: non-destructive means Casein phosphopeptide: amorphous calcium phosphate Decrease strept. Mutans binding Source on nitrogen for ammonia reduce PH Promote diffusion of Ions body of lesion N:B: casein phosphopeptide = amorphous calcium phosphate (CPP—ACP) = Milk which help in remineralization and prevent dental caries --- CPP help ACP to bind with dental enamel and decrease the count of strep. Mutans = Can also block the dentinal tube and reduce sensitivity = with fluoride or alone can used as prophylactic agent before bonding orthodontic bracket. N:B: how does bleaching work: Hydrogen peroxide applied directly or via chemical reaction from carbamide peroxide, this oxidizing agent that produce free radical hydrogen ions and reactive molecules. This reactive molecule penetrates the tooth and reduce the long chained dark color Bleaching solution reach and enter into super- facial dentine Treatment of white spot lesion: by Proffit 1-Allow natural remineralization over 6 months. Pitted and porous surface have better prognosis for regaining normal enamel translucency then arrested lesion Avoid fluoride with high concentration that can arrest remineralization that lead to staining 2-After finish of natural remineralization start external bleaching to help camouflage white spot = should followed by topical fluoride because bleaching increase caries susceptibility 3-For patients with severe problems acid micro-abrasion to eliminate the external layer of the lesion may have followed by bleaching to help for normal color and luster W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 4-In some cases, restorative treatment with resin or porcelain veneer Types of bleaching: Home bleaching, Assisted bleaching, Power bleaching 1-Home bleaching: use carbamide peroxide 10% to 22% Several systems use low dose hydrogen peroxide 3% Custom trays containing the active bleaching compound are worn for several hours/ day about 2 weeks. This usually lighten the teeth by about 7 shades Advantages: a-Very little clinician time involved b-No need for rubber dam c-More economic than power and assisted d-Patients can bleach at their convenience Disadvantage: many patients wants instant results 2-Assisted bleaching: = to augment home bleaching =sits in dental chair with trays in mouth for 30 minutes with high concenteration of carbamide peroxide 35% = repeat as necessary 7 days between appointments = results achieved in shorter time = no reported increase in side effect 3-Power bleaching: = high concentration of hydrogen peroxide 30—35% = use rubber dam or resin shield with cheek and tongue retractor to protect gingiva = bleaching gel usually need activation; either chemical or light = gel applied in 1—2mm thickness = can applied on lingual surface to enhance results if using rubber dam Technique: 3 application of 10 minutes in one sitting, may involve two or more sitting separated by 7 days Advantages: a-Instant improvement ----- WOW effect b-Patient compliance not in issue c-No increase side effects compared with home type. d-No lab work required Disadvantage: a-More chair side time b-Required extra-material c-Poor isolation can lead to gingival burn Micro-abrasion: = not really destructive = highly polished enamel surface with fewer inter-prismatic spaces than normal – a glass like surface = the outer layer of prism- rich enamel is replaced with a densely compacted prism free region = less bacterial adhesion, st. Mutans colonization inhibited Technique: = the result not depend on enamel removed amount but on surface alteration W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 = too much enamel removal may actually darken the tooth due to the dentine shining through = clean teeth with pumice and water, wash and dry = isolate teeth with rubber dam = place mixture of sodium bicarbonate and water on dam behind teeth to protect patient, patient should be wear safety goggles = mix 18% hydrochloric acid with pumice = apply small amount on tooth either by wooden stick or slowly rotary rubber cup for 5 second before washing. = rubber cup should be in high torque and low speed = repeat the above steps 10 times/teeth = apply fluoride drips on the surface for 3 minutes = polish with soft –flex discs = polish with fluoridated tooth paste Another way for treatment of WSL: Restorative intervention: composite restoration / veneer or porcelain veneer In young patients: =composite resin offers satisfactory results and contraindication to use porcelain veneer due to: a-Presence of pulp horn b-Immature pulp chamber c-Immature gingival contour In older than 16: Porcelain veneer are recommended, bleaching and composite failed to produce a clinical satisfactory results N: B; fluoridated Miswaks impregnated with 0.5% sodium fluoride have a stronger remineralization effect on WSL compared with non-fluoridated Miswaks N: B: ICDAS New clinical index: international detection assessment system chewing sticks (Miswaks) are used in many countries around the world for cleaning purpose often up to 5 times /day Scores of ICDAS: Baeshen et al 2011 0: sound tooth surface, no evidence of caries Surface with developmental defects as; enamel hypoplasia, fluorosis, tooth wear, (attrition, abrasion, erosion). Extrinsic and intrinsic stain 1: first visual change in enamel, when seen wet, no change in color after prolonged drying, caries opacity is visible. 2: distinct visual change in enamel when wet discoloration in clinical appearance of sound enamel 3: localized enamel breakdown with no visible dentine after dry: caries loss surface integrity. 4: underlying dark shadow from dentine, discolored dentine through enamel surface beyond WSL 5: distinct cavity visible dentine Cavitation of opaque enamel exposed dentine 6: extensive cavity with visible dentine Loss tooth structure, dentine is clearly visible Cavity deep and wide, extensive cavity involve at least half of tooth with pulp involved W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 Histopathology: WSL: caused by change in the optical properties of enamel due to subsurface demineralization zone covered by an intact surface layer EM: deep focal micro pits and accentuated perikymata Incidence: u2 --- u,l 3--- l45--- u 67 or u2 ---l3 --- l4 ---l6 ---l5 --- u3 W White hite spot lesions spot lesions Dr. Mohammed Alruby Dr. Mohammed Alruby