White Spot Lesions, what should we do? 9 MINUTE SUMMARY

orthodontics In summary

Join me for a summary podcast exploring the topic of white spot lesions, and up-to-date research looking at how to manage lesions when they occur, when the right time is to treat the patient, and what minimally evasive options can be used in clinic. This was an excellent lecture from Gayle Glenn earlier this year at the AAO winter meeting.

Four treatment options are discussed, Fluoride, CPPACP (Mi paste), resin infiltrate and microabrasion.

Whitespot lesion background WSL
Definition - subsurface deminieralization, intact outer layer, 1st sign of carious lesions

Remineralisation – no additional agents

Most rapid repair first 6 weeks without use of additional agents

· Up to 6 months spontaneous improvement with good oral hygiene

· Recommend 3-6 months monitor after debond: BEFORE consider additional treatment

Fluoride

· Decrease enamel dissolution

· Increase reminerazation

· Formation of fluorapatite

· Products

o Fl varnish reduce WSL occuring by 44%:

§ require plaque removal and wire removal

§ Not often used in clinical practice and requires repeat application

· TREATMENT WSL

o Fluoride low dose (toothpaste)

o High Fluoride – hyperminerasied surface layer forms = seal off subsurface layer which remains demineralized. Bishara 2008

Resin infiltration Gray 2002

· Remove outer hypomineralised area with 15% HFL

o Infiltrate with low viscosity

o Improves aesthetics

o Arrest lesion – however some demineralisation may remain

o Lack long-term evidence

o Most effective in research (RR:121.50, 95%CI: 51.45-191.55 Jiang 2023)

MI paste (CPPACP) Frencken 2012

· Milk protein derived

· Stabilizes Ca PO4 – ideal of for formed WSL

· Creates Ca PO4 reservoir around bracket

· Applied:

o Brush above and below bracket or finger

o Distributed by the tongue

o Can be swallowed

o Avoid eat and drink 30-60 minutes

· Effectiveness for reminersation

o Evidence unclear – conflicting sustematic reviews AlBukaiki 2023 no difference, same year Jiang 2023, it is effective, however exceptionally large range of values (RR:49.69, 95%CI: 0.87-98.51 and although RCTs, limited to assessing premolars only and different methods of assessment and duration of treatment.

· TREATMENT FOR WSL

o Wait 3-6 months following removal of braces

o In retainer 3-5 minutes

o Rinse out

o Nothing to eat 30-60 minutes

Microabrasion

· Combination of acid and abrasive particles

· Burinsh into enamel with slow speed handpiece

· opalustre = 6% HCL + silica (low particle size, lower concentration with larger particle size than prophy paste = 12-160 particle size 1986 Krol)

o 1 mm size of use

o Burnished in using a polishing cup and slow handpiece

o 1 minute

· Not widely accepted

o Partly due to variations in protocol

o Use of rubber dam

· Microabrasion and CPP-ACP proposed idea Ardu 2007

2022 Lammert

· CPP-ACP both sides, with half of mouth also receiving 1 visit of microabrasion

· After 6 months post debonding

· Evaluate and repeat up to 8 times

· Results

o Mi paste group 9.3-8.1 size of lesion – statistically significant

o Microabrasion and Mi paste group

§ 13.2 – 4.3 and reduce to 2.1

· Most improvement immediate after microabrasion

o Compared difference of size of the initial lesion

§ 5.5 x reduction in CPPACP

§ 7.4 X reduction in microabrasion

Clinical implication

· Microabrasion = significant clinical time

o Up to 8 minutes per tooth, can be up to 1 hour

o Therefore clinical application

§ Perhaps isolated 1 or 2 teeth

Conclusions:

1. Patients with WSL are usually not great compliers, giving additional products which require significant compliance, is practising research in isolation.

2. Microabrasion takes nearly 1 hour, role in clinical practice limited to isolated areas