post orthodontic demineralization: recommendations for prevention and clinical management

Post-Orthodontic Demineralization:Recommendations for

Prevention & Clinical Management

Shadi S. SamawiBDS, MMedSci (Orth.), MOrthRCSED.

JOS, November 2006

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Introduction Research Prevention Clinical Management Summary

… Clinical Success in Orthodontics

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FUNCTIONALOCCLUSION

DENTAL & PERIODONTAL

HEALTH

DENTAL & FACIALESTHETICS

TOTALPATIENT

MANAGEMENT

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SUCCESS !

=Healthy

Dentition & Periodontium

Esthetics

Function

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Post-Orthodontic Demineralization(Precursor to Caries)

FAILURE !?

=Esthetics

Function

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Overview


In This Presentation..

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Overview



Brief Etiology & Clinically-Relevant Research

6

Overview




Recommendations for PREVENTION:

Before.. During orthodontic treatment

6

Overview




Recommendations for PREVENTION:

Before.. During orthodontic treatment

Recommendations for CLINICAL MANAGEMENT:

After completion of orthodontic treatment

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Substrate

Time

Bacteria

Demineralization( Caries )

Basics..


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Dynamics …


Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O

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Dynamics …


Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O

pHDemineralization

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Dynamics …


pH

Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O

pHDemineralization

Remineralization

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The Key…


- Fluoride-enhanced precipitation of Calcium Phosphates

- Formation of Fluor-hydroxyapatite in dental tissues

Fluoride

Best Established Remineralization Strategy

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Some Relevant Research..


..Prevalence reports vary widely.. %2 - %96 !

Mitchell, 1992, Br J Orth

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..Loss of calcified tooth substance (Ca + P) occurs as early as 4 weeks after bond-up !!

O’Reilly & Featherstone, 1987, AJODO



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..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



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Zachrisson & Zachrisson, 1971 Zachrisson, 1977 Mizrahi, 1982 + 1983 Gorelick et al, 1982 Artün & Brobakken, 1986 Øgaard, 1989 Mitchell, 1992 Willmot & Brook, 1999 Willmot, 2000 Others …


Prevalence reports varied widely due to different methods of assessment !


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General agreement on increased incidence in orthodontic patients


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General agreement on increased incidence in orthodontic patients

Fairly-good agreement on lesion distribution, as well as tooth groups affected


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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.

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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.

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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 AnalysisS.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003

( under publication )

Further Attempts At Localization & Measurement..

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Retrospective, Observational..Part of a wider study..Methodology tried to overcome many problems in previous methods of visual assessment


AIM: to more accurately assess location & surface areas of PWL on upper & lower anterior teeth..




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Digital records of (274 teeth )

Special standardized camera setup

Polarized white light

Pre-existing lesions excluded..




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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




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Location:

Upper > Lower teeth..

Ging > Occ. quadrants..

U. lateral incisors &

Lr. canines most affected..

No diff. between LEFT & RIGHT sides..





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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..

Further Attempts At Localisation & Measurment..



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So.. Why study PWL ??


Identify Patterns..

Anticipate..

Target..PREVENTPWL ..?

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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

DG of lateral incisors

MG of Canines

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Recommendations for Prevention

Preventive measures implemented: Before beginning orthodontic treatment During orthodontic treatment


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.. Patient & Parent Education & Awareness Before Starting Treatment are

PARAMOUNT TO SUCCESSFUL PREVENTION..


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.. 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 !! “

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Prevention Before Orthodontic Tx


Instructional(Psychological) Preparation

Clin

ical

lyApplied

Preparation

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Before Orthodontic Tx

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Instructional (psychological) preparation :



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Emphasizing importance of strict & properly-implemented OH measures needed throughout Tx, at the INITIAL VISIT !



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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.



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Effective VISUAL Reinforcement !



1- Use “Props” for more visual instructions: i.e: Actual toothbrushes, Bonded Typodonts,

OrthoWax, …etc...

..Detailed OHI..

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2- How to properly use special orthodontic brushes i.e: Ortho V-brush, Inter-dental brush

Electric toothbrush (if available), …etc..

..Detailed OHI..

Use the “ TELL – SHOW – DO “ technique !

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3- Use PowerPoint Slide Shows or Photo-Books for demonstration of technique or

undesirable effects of improper OH !

..Detailed OHI..

MORE Effective VISUAL Reinforcement !

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Effective ReinforcementAt Home..!



4- Provide WRITTEN INSTRUCTIONS such as Leaflets or Color Brochures

With OHI tips..

..Detailed OHI..

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5 Minutes ..at the Initial Exam visit !

10-15 Minutes ..OHI after the Bond-up !

1 Minute ..at beginning of each visit !

Clinical Time ?

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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..

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Predictors For Potential Development Of PWL:

Pre-existing Poor Oral HygieneAnticipated Long Tx Time

Younger Age?

Inter-proximal Caries

Fornell & Twetman, 2004

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Prevention During Orthodontic Tx

Instructional(Motivational) Methods

Clin

ical

lyApplied

MethodsPa

tient

AppliedM

ethods

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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 !

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Clinically-applied Methods :

3. Fluoride-Releasing Adhesives

4. Fluoride-Releasing Elastomerics

1. Appliance System & Mechanics

2. Fluoride-Releasing Sealants

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During Orthodontic TxAppliance 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 ..?

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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, 1999Results “ ..Not encouraging..”

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PulpDent Corporation Ortho-Coat™

A fluoride releasing, light-cured resin

• Patented Embrace technology: Moisture tolerant..

• Marginal integrity and ability to prevent microleakage !

www.dentalcompare.comwww.pulpdent.com

New

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http://www.dentalcompare.com/

http://www.dentalcompare.com/

http://www.pulpdent.com/

http://www.pulpdent.com/

1. Composite Resins2. Resin-modified GI3. Hybrid Composites (Compomers)



Fluoride-Releasing Adhesives :

Staley et al, 2004Transbond XT (LC composite),

Advance (composite resin), Fuji LC (RMGI)

Fuji LC (RMGI)

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Basdra et al, AJODO; 1996In vitro comparison of :

Rely-A-Bond), Fluorobond Concise, Conventional Concise (control)

For F. Release + Demineralization Inhibition Potential + Effects On Enamel

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Basdra et al, AJODO; 1996

• Maximal Fluoride release

period occurs within 3-4 days..!

• After approx. 90 days,

almost no residual F

release present !

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..Removing Excess Adhesive Around Every Bracket !

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..Strategic (Targeted) Fluoride Release..?

AROUND BRACKET MARGINS



Fluoride-Releasing Elastomerics:

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Wiltshire, 1996Wiltshire, 1999

Mattick et al, 2001

Promising Results..Further Clinical Trials needed!

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Wiltshire, 1996Wiltshire, 1999

Mattick et al, 2001

Promising Results..Further Clinical Trials needed!

Doherty et al, 2002

PROSPECTIVE RCT“..No significant anti-cariogenic

Benefits from the use of fluoridated ligatures..”

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Benson et al, 2004

Effects on Plaque Microbiology:“..ineffective in changing levels of

Streptococci or anaerobes in plaque..”

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LIMITATIONS• Short-term Fluoride release• Ligatures become SWOLLEN & lose elasticity quickly !

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LIMITATIONS• Short-term Fluoride release• Ligatures become SWOLLEN & lose elasticity quickly !

..Currently NOT a very effective measure against decalcification !

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Patient-applied Methods :

1. Diet Control

3. Daily Fluoride

Mouth Rinses

4. Adjunctive AntiPlaque / AntiMicrobial

Agents

2. Daily Tooth-brushing

(Fluoride Toothpastes)

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Diet Control :

Cheese, Starchy foods (Bread & Pasta)

Fruits & Vegetables..

Water..!

XSUGARS & SWEETS

SUGARY, ACIDIC & FIZZY DRINKS

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Daily Tooth brushing with Fluoride Toothpastes :

Rinsing with water after tooth brushing greatly reduces oral fluoride retention !

Dentifrices, mouthwashes, and remineralization/caries arrestment strategiesIndiana University School of Dentistry, Oral Health Research Institute, June 2006

The most widely used method of delivering topical fluoride (around 1450 ppm)

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0.05% NaF (226 ppm)And

0.2% NaF (900 ppm) Daily / Weekly rinses:

Reduced incidence of decalcification & caries..but NOT completely !



Adjunctive Daily Fluoride Rinsing :

Geiger et al, 1982Øgaard et al, 1988 + 1989

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15 Clinical trials ( > 700 patients)

CONCLUSION: Topical fluoride / fluoride-containing bonding materials

effective

But.. Which method most effective..??




Benson et al, 2004Systematic Review

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Recommendation

Daily Fluoride Rinsing ( 0.05% NaF) ..?

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Adjunctive AntiPlaque / AntiMicrobial Agents :


Triclosan

Phenolic / Essential oilCompounds

(Thymol, Eukaleptol)

Quaternary Ammonium Compounds

(Cetyl Pyridinium Chloride)

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Adjunctive AntiPlaque / AntiMicrobial Agents :


Chlorhexidine 2nd line Treatment 0.2% Oral Rinse

0.05% Oral Gel

Once daily 30 sec rinse each time

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Recommendations for Clinical Management


Management of PWL After orthodontic treatment

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Clinical Management

Mainly Depends On Severity :


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Clinical Management



Mild

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Clinical Management



Mild Moderate

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Clinical Management



Mild Moderate Severe

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High Fluoride Concentration ??


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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

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Effect of High Fluoride Concentration ??

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High Fluoride

Concentration

i.e: Fluoride varnishes,

APF gels, etc..

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High Fluoride

Concentration


APF gels, etc..

• Remineralization of Surface Layer

• Blocks Porosities Leading To

Subsurface Layers

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Persistant White lesions!



High Fluoride

Concentration


APF gels, etc..

• Remineralization of Surface Layer

• Blocks Porosities Leading To

Subsurface Layers

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Recommendation


Current Research Findings:Lesions Remineralise Slowly Through

Normal Remineralisation Potential Of SalivaAfter Debonding !

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Recommendation


Recommendation:AVOID HIGH FLUORIDE CONCENTRATIONS

IMMEDIATELY & UP TO 6 MONTHS AFTER DEBONDING !

Zachrisson, 1986 - Ogaard, 1988 – Kamp, 1989 - Willmot, 2000…

Current Research Findings:Lesions Remineralise Slowly Through

Normal Remineralisation Potential Of SalivaAfter Debonding !

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Mild White-Spot Lesions


• Small streaks..• Not a Major

Esthetic Problem

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Esthetic Problem

• Natural Remineralization

(up to 6 months)

• Avoid High F Conc.

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Esthetic Problem


(up to 6 months)


Re-assess:

• Micro-Abrasion• Composite

Restorations?

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Moderate White-Spot Lesions


• Larger Lesions..• Obvious

Esthetic Problem

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Esthetic Problem


(up to 6 months)


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Esthetic Problem


(up to 6 months)


Re-assess:

• Micro-Abrasion• Composite

Facings ?• Porcelain

Veneers ?

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Severe White-Spot Lesions


• Cavitation (Caries) !

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Severe White-Spot Lesions


• Cavitation (Caries) !

• Immediate Restoration • Porcelain Veneers ?• Fluoride Application:

(Wait 4-6 months first !)

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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

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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 DemineralizationAnd bacterial Colonization..


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Water-Soluble Gel

Fine-Grit Silicon Carbide

Hydrochloric/Phosphoric Acid

PREMA


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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

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Q: How much enamel can be removed safely?

A: If concavity apparent,Restoration is indicated!

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Q: How much enamel can be removed safely?

A: If concavity apparent,Restoration is indicated!

Q: How do we know when treatment is finished?

A: once wet enamel surface shows no evidence of an opacity after application of compound!

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Summary


Post-Orthodontic Decalcification Is A Well-established & Serious Problem In Orthodontics !

Substrate

Time

Bacteria

Demineralization( Caries )

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Summary

Most Commonly-affected teeth:

Maxillary lateral incisors Mandibular Premolars Max. + Mand. Canines Maxillary Centrals Mandibular 1st Molars


- Maxillary > Mandibular Teeth..- Gingival > Incisal Quadrants..

- Max. PWL Larger in size..- Gingival PWL Larger in size..

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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


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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..

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Summary

Clinical Management Of PWL

Post - Tx:


Avoid High Fluoride Concentrations

up to 6 months Post-Debond !

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Summary

Clinical Management Of PWL

Post - Tx:

Mild PWL Natural Remineralization +/- Micro-abrasion

Moderate PWL Natural Remineralization +/- Micro-Abrasion

Severe PWL Immediate Restoration +/- Veneers?


Micro-AbrasionA Conservative Approach To Dealing With Mild - Moderate PWL

1st Line Treatment

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A Perfect Treatment Plan

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SophisticatedMechanics

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State-of-the-ArtAppliance Systems

SophisticatedMechanics

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Thank

You

For

Being..

..Good Listeners !

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post orthodontic demineralization: recommendations for prevention and clinical management

Healthcare

brief etiology

prevalence reports varie

zachrisson zachrisson

br j orth

j dent10

2h2o ph demineralization

dental tissues

ajodo mellberg