A Presentation presented as part of the Jordanian Orthodontic Society's Scientific Program in 2008.

1. JOS, November 2006
Post-Orthodontic Demineralization:
Recommendations for
Prevention & Clinical Management
Shadi S. Samawi
BDS, MMedSci (Orth.), MOrthRCSED.
1

2. Introduction Research Prevention Clinical Management Summary
… Clinical Success
in Orthodontics
2

3. Introduction Research Prevention Clinical Management Summary
DENTAL & FACIAL FUNCTIONAL
ESTHETICS OCCLUSION
TOTAL
PATIENT
MANAGEMENT
DENTAL
& PERIODONTAL
HEALTH
3

4. Introduction Research Prevention Clinical Management Summary
Function SUCCESS !
Esthetics =
Healthy
Dentition & Periodontium
4

5. Introduction Research Prevention Clinical Management Summary
Function FAILURE !?
Esthetics =
Post-Orthodontic Demineralization
(Precursor to Caries)
5

6. Introduction Research Prevention Clinical Management Summary
Overview
In This Presentation..
6

7. Introduction Research Prevention Clinical Management Summary
Overview
In This Presentation..
 Brief Etiology & Clinically-Relevant Research
6

8. Introduction Research Prevention Clinical Management Summary
Overview
In This Presentation..
 Brief Etiology & Clinically-Relevant Research
 Recommendations for PREVENTION:
Before..
During orthodontic treatment
6

9. Introduction Research Prevention Clinical Management Summary
Overview
In This Presentation..
 Brief Etiology & Clinically-Relevant Research
 Recommendations for PREVENTION:
Before..
During orthodontic treatment
 Recommendations for CLINICAL MANAGEMENT:
After completion of orthodontic treatment
6

10. Introduction Research Prevention Clinical Management Summary
Basics..
Bacteria Substrate
Demineralization
( Caries )
Time
7

11. Introduction Research Prevention Clinical Management Summary
Dynamics …
Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O
8

12. Introduction Research Prevention Clinical Management Summary
Dynamics …
Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O
pH
Demineralization
8

13. Introduction Research Prevention Clinical Management Summary
Dynamics …
Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O
pH
Demineralization
Remineralization
pH
8

14. Introduction Research Prevention Clinical Management Summary
The Key…
Fluoride
Best Established Remineralization Strategy
- Fluoride-enhanced precipitation of Calcium Phosphates
- Formation of Fluor-hydroxyapatite in dental tissues
9

15. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
..Prevalence reports vary widely.. %2 - %96 !
Mitchell, 1992, Br J Orth
10

16. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
..Prevalence reports vary widely.. %2 - %96 !
Mitchell, 1992, Br J Orth
..Loss of calcified tooth substance (Ca + P)
occurs as early as 4 weeks after bond-up !!
O’Reilly & Featherstone, 1987, AJODO
10

17. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
..Prevalence reports vary widely.. %2 - %96 !
Mitchell, 1992, Br J Orth
..Loss of calcified tooth substance (Ca + P)
occurs as early as 4 weeks after bond-up !!
O’Reilly & Featherstone, 1987, AJODO
..The opacity is an optical phenomenon
directly related to loss of subsurface minerals..
Gorelick et al, 1982, AJODO; Mellberg, 1988, Am J Dent
10

18. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
 Zachrisson & Zachrisson, 1971
 Zachrisson, 1977 Prevalence reports varied widely
 Mizrahi, 1982 + 1983 due to different methods of
 Gorelick et al, 1982 assessment !
 Artün & Brobakken, 1986
 Øgaard, 1989
 Mitchell, 1992
 Willmot & Brook, 1999
 Willmot, 2000
 Others …
11

19. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
 Zachrisson & Zachrisson, 1971
 Zachrisson, 1977 Prevalence reports varied widely
 Mizrahi, 1982 + 1983 due to different methods of
 Gorelick et al, 1982 assessment !
 Artün & Brobakken, 1986
 Øgaard, 1989 General agreement on increased
 Mitchell, 1992 incidence in orthodontic patients
 Willmot & Brook, 1999
 Willmot, 2000
 Others …
11

20. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
 Zachrisson & Zachrisson, 1971
 Zachrisson, 1977 Prevalence reports varied widely
 Mizrahi, 1982 + 1983 due to different methods of
 Gorelick et al, 1982 assessment !
 Artün & Brobakken, 1986
 Øgaard, 1989 General agreement on increased
 Mitchell, 1992 incidence in orthodontic patients
 Willmot & Brook, 1999
 Willmot, 2000 Fairly-good agreement on lesion
 Others … distribution, as well as tooth
groups affected
11

21. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
Localization and Distribution of White Lesions
Mizrahi,(1982 +1983)
..Opacity Index (Visual Scoring System from 0 – 3):
- Males more affected.
- Increased incidence on :
- Max. & Mand. 1st molars
- Max. lateral incisors
- Mand. Lateral incisors & Canines
- Middle & Cervical thirds of crowns most affected.
12

22. Introduction Research Prevention Clinical Management Summary
Some Relevant Research..
Localization and Distribution of White Lesions
Willmot,(2000)
Pre- & Post-treatment photographic-slide comparisons :
- In agreement with most previous reports..
- Increased incidence on :
- Upper Lateral Incisors (14.8%)
- Lower Canines (14%)
- Lower Premolars (16.2%)
- No difference between LEFT & RIGHT sides of the mouth.
13

23. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
AIM: to more accurately assess location & surface areas of PWL
on upper & lower anterior teeth..
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
14

24. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
AIM: to more accurately assess location & surface areas of PWL
on upper & lower anterior teeth..
Retrospective, Observational..Part of a wider study..
Methodology tried to overcome many problems in previous methods
of visual assessment
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
14

25. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
Digital records of (274 teeth )
 Special standardized camera setup
 Polarized white light
Pre-existing lesions excluded..
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
15

26. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
Digital records of (274 teeth )
 Special standardized camera setup
 Polarized white light
Pre-existing lesions excluded..
(Image Plus Pro, V 3.01) software:
 labial surface into 4 quadrants
 Locate + outline + measure surface
area of each lesion & quadrant
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
15

27. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
Location:
 Upper > Lower teeth..
 Ging > Occ. quadrants..
 U. lateral incisors &
Lr. canines most affected..
 No diff. between LEFT &
RIGHT sides..
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
16

28. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localization & Measurement..
Location:
 Upper > Lower teeth..
 Ging > Occ. quadrants..
 U. lateral incisors &
Lr. canines most affected..
 No diff. between LEFT &
RIGHT sides..
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
16

29. Introduction Research Prevention Clinical Management Summary
Further Attempts At Localisation & Measurment..
Surface Area:
 Upper teeth > Lower teeth lesions
(sig. diff. for centrals and laterals)..
 Gingival > Occlusal lesions..
 Sig. Diff. in lesion size between
MESIAL & DISTAL quadrants..
 No diff. between LEFT & RIGHT
sides..
Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis
S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003
( under publication )
17

30. Introduction Research Prevention Clinical Management Summary
So.. Why study PWL ??
Identify
Patterns..
Anticipate..
Target..
PREVENT
PWL ..?
18

31. Introduction Research Prevention Clinical Management Summary
So.. Why study PWL ??
A Notable Finding ..
(0.022” x 0.028”) bracket slot :
Sliding mechanics with (0.019” x 0.025”) SS posted arches
MG of Canines
DG of lateral incisors
19

32. Introduction Research Prevention Clinical Management Summary
Recommendations for Prevention
Preventive measures implemented:
 Before beginning orthodontic treatment
 During orthodontic treatment
20

33. Introduction Research Prevention Clinical Management Summary
.. Patient & Parent Education & Awareness
Before Starting Treatment are
PARAMOUNT
TO SUCCESSFUL PREVENTION..
21

34. Introduction Research Prevention Clinical Management Summary
.. Patient & Parent Education & Awareness
Before Starting Treatment are
PARAMOUNT
TO SUCCESSFUL PREVENTION..
“ Patients Don’t Know What They Want.. Until They DON’T Get It !! “
21

35. Introduction Research Prevention Clinical Management Summary
Prevention Before Orthodontic Tx
Applied
Preparation
Clinically
Instructional
(Psychological)
Preparation
22

36. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
23

37. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
Instructional (psychological) preparation :
23

38. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
Instructional (psychological) preparation :
 Emphasizing importance of strict & properly-implemented OH
measures needed throughout Tx, at the INITIAL VISIT !
23

39. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
Instructional (psychological) preparation :
 Emphasizing importance of strict & properly-implemented OH
measures needed throughout Tx, at the INITIAL VISIT !
 Letting the patient know his/her OH will be monitored closely
each and every visit !
 Providing detailed, easy-to-understand OHI at the bond-up
appointment.
23

40. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
..Detailed OHI..
1- Use “Props” for more visual instructions:
i.e: Actual toothbrushes, Bonded Typodonts,
OrthoWax, …etc...
Effective VISUAL Reinforcement !
24

41. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
..Detailed OHI..
2- How to properly use special orthodontic brushes
i.e: Ortho V-brush, Inter-dental brush
Electric toothbrush (if available), …etc..
Use the “ TELL – SHOW – DO “ technique !
25

42. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
..Detailed OHI..
3- Use PowerPoint Slide Shows or Photo-Books
for demonstration of technique or
undesirable effects of improper OH !
MORE Effective VISUAL Reinforcement !
26

43. Introduction Research Prevention Clinical Management Summary
Before Orthodontic Tx
..Detailed OHI..
4- Provide WRITTEN INSTRUCTIONS
such as Leaflets or Color Brochures
With OHI tips..
Effective Reinforcement
At Home..!
27

44. Introduction Research Prevention Clinical Management Summary
Prevention Before Orthodontic Tx
Clinical Time ?
5 Minutes ..at the Initial Exam visit !
10-15 Minutes ..OHI after the Bond-up !
1 Minute ..at beginning of each visit !
28

45. Introduction Research Prevention Clinical Management Summary
Prevention Before Orthodontic Tx
Clinically-applied Preparation :
 Patients with Very Poor OH before Tx are referred for
Professional Cleaning ( Scaling / Jet Cleaning..)
Proper Oral Hygiene RE-INSTRUCTION..
Monitored for 1-2 months before initiating orthodontic Tx..
29

46. Introduction Research Prevention Clinical Management Summary
Prevention Before Orthodontic Tx
30

47. Introduction Research Prevention Clinical Management Summary
Prevention Before Orthodontic Tx
Predictors For Potential Development Of PWL:
Pre-existing Poor Oral Hygiene
Anticipated Long Tx Time
Younger Age?
Inter-proximal Caries
Fornell & Twetman, 2004
30

48. Introduction Research Prevention Clinical Management Summary
Prevention During Orthodontic Tx
Applied
Applied
Methods
Clinically
Methods
Instructional
Patient
(Motivational)
Methods
31

49. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Instructional (Motivational) Methods :
 Constant monitoring at each subsequent visit..
 Keep parents informed about progress / Poor OH..etc..
Motivate Re-motivate WARN !
Use “ REWARD / PUNISHMENT “ techniques !
32

50. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Clinically-applied Methods :
1. Appliance System 2. Fluoride-Releasing
& Mechanics Sealants
3. Fluoride-Releasing 4. Fluoride-Releasing
Adhesives Elastomerics
33

51. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Appliance System & Mechanics :
 A more refined, less “cluttered” bracket design
 A Low – Friction system ( Reduced Tx time? )
 Simpler – yet effective - mechanics and archwires
 Less use of plaque-retaining elastomerics and Power-Chains
 Bonding rather than Banding molars..?
.. SELF - LIGATING BRACKETS ..?
34

52. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Sealants :
 Lee et al, JCO; 1973
 Acid-etching then SEALING entire labial enamel surface prior to
bonding..??
 ..Protective coating between enamel and acidic plaque environment..??
Banks & Richmond, EJO; 1994
%72 of sample suffered decalcifications !
Wenderoth et al, 1999
Results “ ..Not encouraging..”
35

53. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
New
PulpDent Corporation
Ortho-Coat™
A fluoride releasing, light-cured resin
• Patented Embrace technology: Moisture tolerant..
• Marginal integrity and ability to prevent microleakage !
www.dentalcompare.com
www.pulpdent.com
36

54. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Adhesives :
1. Composite Resins
2. Resin-modified GI
3. Hybrid Composites (Compomers)
Staley et al, 2004
Transbond XT (LC composite),
Advance (composite resin), Fuji LC (RMGI)
Fuji LC (RMGI)
37

55. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Adhesives :
Basdra et al, AJODO; 1996
In vitro comparison of :
Rely-A-Bond), Fluorobond Concise, Conventional Concise (control)
For
F. Release + Demineralization Inhibition Potential + Effects On Enamel
38

56. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Adhesives :
Basdra et al, AJODO; 1996
• Maximal
Fluoride release
period occurs
within 3-4 days..!
• After approx.
90 days,
almost no
residual F
release present !
39

57. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Adhesives :
..Removing Excess Adhesive Around Every Bracket !
40

58. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
..Strategic (Targeted) Fluoride Release..?
AROUND BRACKET MARGINS
41

59. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
Wiltshire, 1996
Promising Results..
Wiltshire, 1999
Further Clinical Trials needed!
Mattick et al, 2001
42

60. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
Wiltshire, 1996
Promising Results..
Wiltshire, 1999
Further Clinical Trials needed!
Mattick et al, 2001
PROSPECTIVE RCT
Doherty et al, 2002 “..No significant anti-cariogenic
Benefits from the use
of fluoridated ligatures..”
42

61. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
Effects on Plaque Microbiology:
“..ineffective in changing levels of
Benson et al, 2004
Streptococci or anaerobes
in plaque..”
43

62. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
LIMITATIONS
• Short-term Fluoride release
• Ligatures become SWOLLEN & lose elasticity quickly !
44

63. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Fluoride-Releasing Elastomerics:
LIMITATIONS
• Short-term Fluoride release
• Ligatures become SWOLLEN & lose elasticity quickly !
..Currently NOT a very effective measure
against decalcification !
44

64. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Patient-applied Methods :
2. Daily
1. Diet Control Tooth-brushing
(Fluoride Toothpastes)
3. Daily 4. Adjunctive
Fluoride AntiPlaque / AntiMicrobial
Mouth Rinses Agents
45

65. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Diet Control :
X
SUGARS & SWEETS
SUGARY, ACIDIC & FIZZY DRINKS
Cheese, Starchy foods (Bread & Pasta)
Fruits & Vegetables..
Water..!
46

66. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Daily Tooth brushing with Fluoride Toothpastes :
The most widely used method of delivering topical fluoride
(around 1450 ppm)
 Rinsing with water after tooth brushing greatly reduces
oral fluoride retention !
Dentifrices, mouthwashes, and remineralization/caries arrestment strategies
Indiana University School of Dentistry, Oral Health Research Institute, June 2006
47

67. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive Daily Fluoride Rinsing :
Geiger et al, 1982
Øgaard et al, 1988 + 1989
0.05% NaF (226 ppm)
And
0.2% NaF (900 ppm)
Daily / Weekly rinses:
Reduced incidence of decalcification & caries
..but NOT completely !
48

68. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive Daily Fluoride Rinsing :
49

69. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive Daily Fluoride Rinsing :
Benson et al, 2004
Systematic Review
15 Clinical trials ( > 700 patients)
CONCLUSION:
Topical fluoride / fluoride-containing bonding materials
effective
But.. Which method most effective..??
49

70. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive Daily Fluoride Rinsing :
Recommendation
Daily Fluoride Rinsing ( 0.05% NaF) ..?
Dentifrices, mouthwashes, and remineralization/caries arrestment strategies
Indiana University School of Dentistry, Oral Health Research Institute, June 2006
50

71. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive AntiPlaque / AntiMicrobial Agents :
Phenolic / Essential oil Quaternary Ammonium
Compounds Compounds
(Thymol, Eukaleptol) (Cetyl Pyridinium Chloride)
Triclosan
Dentifrices, mouthwashes, and remineralization/caries arrestment strategies
Indiana University School of Dentistry, Oral Health Research Institute, June 2006
51

72. Introduction Research Prevention Clinical Management Summary
During Orthodontic Tx
Adjunctive AntiPlaque / AntiMicrobial Agents :
Chlorhexidine
2nd line Treatment 0.2% Oral Rinse
0.05% Oral Gel
Once daily
30 sec rinse each time
Dentifrices, mouthwashes, and remineralization/caries arrestment strategies
Indiana University School of Dentistry, Oral Health Research Institute, June 2006
52

73. Introduction Research Prevention Clinical Management Summary
Recommendations for Clinical Management
Management of PWL
 After orthodontic treatment
53

74. Introduction Research Prevention Clinical Management Summary
Clinical Management
Mainly Depends On Severity :
54

75. Introduction Research Prevention Clinical Management Summary
Clinical Management
Mainly Depends On Severity :
Mild
54

76. Introduction Research Prevention Clinical Management Summary
Clinical Management
Mainly Depends On Severity :
Mild Moderate
54

77. Introduction Research Prevention Clinical Management Summary
Clinical Management
Mainly Depends On Severity :
Mild Moderate Severe
54

78. Introduction Research Prevention Clinical Management Summary
High Fluoride Concentration ??
55

79. Introduction Research Prevention Clinical Management Summary
High Fluoride Concentration ??
..The opacity is an optical phenomenon
directly related to loss of subsurface minerals..
Gorelick et al, 1982, AJODO; Mellberg, 1988, Am J Dent
55

80. Introduction Research Prevention Clinical Management Summary
Effect of High Fluoride Concentration ??
56

81. Introduction Research Prevention Clinical Management Summary
Effect of High Fluoride Concentration ??
High
Fluoride
Concentration
i.e: Fluoride
varnishes,
APF gels, etc..
56

82. Introduction Research Prevention Clinical Management Summary
Effect of High Fluoride Concentration ??
High
Fluoride • Remineralization
of Surface Layer
Concentration
• Blocks Porosities
i.e: Fluoride Leading To
varnishes, Subsurface Layers
APF gels, etc..
56

83. Introduction Research Prevention Clinical Management Summary
Effect of High Fluoride Concentration ??
High
Fluoride • Remineralization
of Surface Layer
Concentration Persistant
i.e: Fluoride
• Blocks Porosities White lesions!
Leading To
varnishes, Subsurface Layers
APF gels, etc..
56

84. Introduction Research Prevention Clinical Management Summary
Recommendation
Current Research Findings:
Lesions Remineralise Slowly Through
Normal Remineralisation Potential Of Saliva
After Debonding !
57

85. Introduction Research Prevention Clinical Management Summary
Recommendation
Current Research Findings:
Lesions Remineralise Slowly Through
Normal Remineralisation Potential Of Saliva
After Debonding !
Recommendation:
AVOID HIGH FLUORIDE CONCENTRATIONS
IMMEDIATELY & UP TO 6 MONTHS
AFTER DEBONDING !
Zachrisson, 1986 - Ogaard, 1988 – Kamp, 1989 - Willmot, 2000…
57

86. Introduction Research Prevention Clinical Management Summary
Mild White-Spot Lesions
• Small streaks..
• Not a Major
Esthetic Problem
58

87. Introduction Research Prevention Clinical Management Summary
Mild White-Spot Lesions
• Natural
Remineralization
(up to 6 months)
• Small streaks.. • Avoid High F
• Not a Major Conc.
Esthetic Problem
58

88. Introduction Research Prevention Clinical Management Summary
Mild White-Spot Lesions
• Natural
Re-assess:
Remineralization
(up to 6 months)
• Micro-Abrasion
• Small streaks.. • Avoid High F • Composite
• Not a Major Conc.
Restorations?
Esthetic Problem
58

89. Introduction Research Prevention Clinical Management Summary
Moderate White-Spot Lesions
• Larger Lesions..
• Obvious
Esthetic Problem
59

90. Introduction Research Prevention Clinical Management Summary
Moderate White-Spot Lesions
• Natural
Remineralization
(up to 6 months)
• Larger Lesions.. • Avoid High F
Conc.
• Obvious
Esthetic Problem
59

91. Introduction Research Prevention Clinical Management Summary
Moderate White-Spot Lesions
Re-assess:
• Natural
Remineralization
(up to 6 months) • Micro-Abrasion
• Composite
• Larger Lesions.. • Avoid High F Facings ?
Conc. • Porcelain
• Obvious
Veneers ?
Esthetic Problem
59

92. Introduction Research Prevention Clinical Management Summary
Severe White-Spot Lesions
• Cavitation
(Caries) !
60

93. Introduction Research Prevention Clinical Management Summary
Severe White-Spot Lesions
• Immediate Restoration
• Porcelain Veneers ?
• Fluoride Application:
• Cavitation (Wait 4-6 months first !)
(Caries) !
60

94. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
A Conservative Approach To Dealing With Mild - Moderate PWL
..Recommended to be The First Consideration for Treatment..
Croll & Bullock, JCO, 1997
61

95. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
High Torque – Low RPM application of PREMA compound
Undetectable amount of enamel (50-150 microns) uniformly
removed, along with the superficial decalcified tissue..
RESULT:
A Smooth, Polished Enamel Glaze
Resistant to Demineralization
And bacterial Colonization..
Croll & Bullock, JCO, 1997
62

96. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
Hydrochloric/Phosphoric Acid
Fine-Grit Silicon Carbide
Water-Soluble Gel
PREMA
Croll & Bullock, JCO, 1997
63

97. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
 PREMA compound to be used only with a Rubber Dam..
 Protective Eyewear for patient, clinician and staff..
 Avoid prolonged exposure of PREMA to gingival tissues !
Fluoridation is recommended after Micro-Abrasion
(4 minutes with Neutral NaF Gel)
Kamp, JCO, 1989 Croll & Bullock, JCO, 1997
64

98. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
65

99. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
Q: How much enamel
can be removed safely?
A: If concavity apparent,
Restoration is indicated!
66

100. Introduction Research Prevention Clinical Management Summary
Enamel Micro-Abrasion ( Acid-Pumice) Technique
Q: How much enamel
can be removed safely?
Q: How do we know
A: If concavity apparent,
when treatment is finished?
Restoration is indicated!
A: once wet enamel surface
shows no evidence of an opacity
after application of compound!
66

101. Introduction Research Prevention Clinical Management Summary
Summary
Post-Orthodontic Decalcification Is A Well-established &
Serious Problem In Orthodontics !
Bacteria Substrate
Demineralization
( Caries )
Time
67

102. Introduction Research Prevention Clinical Management Summary
Summary
Most Commonly-affected teeth:
 Maxillary lateral incisors
 Mandibular Premolars
 Max. + Mand. Canines
- Maxillary > Mandibular Teeth..
 Maxillary Centrals - Gingival > Incisal Quadrants..
 Mandibular 1st Molars
- Max. PWL Larger in size..
- Gingival PWL Larger in size..
68

103. Introduction Research Prevention Clinical Management Summary
Summary
Successful Prevention Of PWL
 Before Tx:
Careful Patient Selection
Proper Psychological Preparation Of Patient & Parent(s) !
Detailed, Easy-to-understand OHI:
– “Tell – Show –Do” Technique
– Visual Reinforcement
– Written OHI
69

104. Introduction Research Prevention Clinical Management Summary
Summary
Successful Prevention Of PWL
 During Tx:
“ Faster ”, Less-cluttered, More-refined Appliance System..
Simple-yet-effective Archwires & Tx Mechanics..
Fluoride Releasing Adhesives & Cements..
Adjunctive Daily Fluoride Mouth Rinses (0.05% Naf)
“Motivation / Warning” techniques..
“Reward / Punishment” techniques..
70

105. Introduction Research Prevention Clinical Management Summary
Summary
Clinical Management Of PWL
 Post - Tx:
Avoid High Fluoride Concentrations
up to 6 months Post-Debond !
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106. Introduction Research Prevention Clinical Management Summary
Summary
Clinical Management Of PWL
 Post - Tx:
Micro-Abrasion
A Conservative Approach To Dealing With Mild - Moderate PWL
1st Line Treatment
Mild PWL Natural Remineralization +/- Micro-abrasion
Moderate PWL Natural Remineralization +/- Micro-Abrasion
Severe PWL Immediate Restoration +/- Veneers?
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107. A Perfect
Treatment Plan
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108. A Perfect Sophisticated
Treatment Plan Mechanics
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109. A Perfect Sophisticated
Treatment Plan Mechanics
State-of-the-Art
Appliance Systems
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110. A Perfect Sophisticated
Treatment Plan Mechanics
State-of-the-Art
Appliance Systems
73

111. A Perfect Sophisticated
Treatment Plan Mechanics
State-of-the-Art
Appliance Systems
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112. Thank
You
For
Being..
..Good Listeners !
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