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White Spot Lesions, what should we do? 9 MINUTE 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
View all episodes
By Farooq Ahmed
5
77 ratings
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
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