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White Spot Lesions While Wearing Braces
1. Are you seeing spots?
Preventing white spot lesions
Dr. Bryon Viechnicki, DMD, MS
October 18, 2012
2. Introduction
Hamdan, A. M., Maxfield, B. J., Tüfekçi, E., Shroff, B., & Lindauer, S. J. (2012). Preventing and treating white-spot lesions associated with
orthodontic treatment: a survey of general dentists and orthodontists. Journal of the American Dental Association (2012), 143(7), 777–783.
Chapman, et al. (2012)
3. 2012 JADA Survey
Hamdan, A. M., Maxfield, B. J., Tüfekçi, E., Shroff, B., & Lindauer, S. J. (2012). Preventing and treating white-spot lesions associated with
orthodontic treatment: a survey of general dentists and orthodontists. Journal of the American Dental Association (2012), 143(7), 777–783.
Chapman, et al. (2012)
10-20% get WSL
4. 2012 JADA Survey
Hamdan, A. M., Maxfield, B. J., Tüfekçi, E., Shroff, B., & Lindauer, S. J. (2012). Preventing and treating white-spot lesions associated with
orthodontic treatment: a survey of general dentists and orthodontists. Journal of the American Dental Association (2012), 143(7), 777–783.
Chapman, et al. (2012)
Treat with fluoride
10. Oral Hygiene and WSL
Better hygiene,
fewer WSL
Hadler-Olsen, S., Sandvik, K., El-Agroudi, M. A., & Ogaard, B. (2012). The incidence of caries and white spot lesions in orthodontically treated
adolescents with a comprehensive caries prophylactic regimen--a prospective study. European journal of orthodontics, 34(5), 633–639.
11. Oral Hygiene and WSL
Better hygiene,
fewer WSL
Hadler-Olsen, S., Sandvik, K., El-Agroudi, M. A., & Ogaard, B. (2012). The incidence of caries and white spot lesions in orthodontically treated
adolescents with a comprehensive caries prophylactic regimen--a prospective study. European journal of orthodontics, 34(5), 633–639.
12. Oral Hygiene and WSL
WATER
not soda
MEALS
not snacks
BRUSH
after eating
FLOSS
nightly
DENTIST
every 6 months
16. Oral Hygiene and WSL
Costa, M. R., Marcantonio, R. A. C., & Cirelli, J. A. (2007). Comparison of manual versus sonic and ultrasonic toothbrushes: a review. International
journal of dental hygiene, 5(2), 75–81.
Sonicare is superior in removing plaque during braces
17. Oral Hygiene and WSL
Costa, M. R., Marcantonio, R. A. C., & Cirelli, J. A. (2007). Comparison of manual versus sonic and ultrasonic toothbrushes: a review. International
journal of dental hygiene, 5(2), 75–81.
24. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 1.
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 3.
Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical
fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1.
25. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 1.
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 3.
Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical
fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1.
65,000 children
131 studies
26. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 1.
24%fewer D(M)FS when fluoride
toothpate applied daily.
27. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2003, Issue 3.
26%fewer D(M)FS when mouthrinse
applied daily (230ppm) or
weekly (900ppm).
28. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho, V. C., Higgins, J. P., Logan, S., & Sheiham, A. (2009). Fluoride gels for preventing dental caries in children and adolescents. Cochrane
Database of Systematic Reviews. John Wiley & Sons, Ltd.
28%fewer D(M)FS when APF gel
(12,300ppm) or NaF (9,050 ppm)
applied by either operator (1x-
5x/yr) or patient (4x-140x/yr) in
tray for 4 min.
29. Caries Prevention: Fluoride
• Reduces caries in kids
– Fluoride toothpaste
– Fluoride mouthrinse
– Fluoride gels
– Fluoride varnish
Marinho, V. C., Higgins, J. P., Logan, S., & Sheiham, A. (2009). Fluoride gels for preventing dental caries in children and adolescents. Cochrane
Database of Systematic Reviews. John Wiley & Sons, Ltd.
46%fewer D(M)FS when varnish
(22,600ppm) applied by
operator 2x-4x/yr.
33. WSL Prevention: Fluoride
• Fluoride releasing cement
• Fluoride ligatures
• Fluoride mouthrinse
• Fluoride toothpaste
• Fluoride varnish
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed
brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809.
Support for fluoride releasing
cements is present, but not
impressive.
34. WSL Prevention: Fluoride
• Fluoride releasing cement
• Fluoride ligatures
• Fluoride mouthrinse
• Fluoride toothpaste
• Fluoride varnish
Banks, P., Chadwick, S., Asher-McDade, C., & Wright, J. (2000). Fluoride-releasing elastomerics - a prospective controlled clinical trial. European
Journal of Orthodontics, 22(4), 401.
WSL present in both F ligatures
(31 of 49) and control
ligatures(33 of 45).
35. WSL Prevention: Fluoride
• Fluoride releasing cement
• Fluoride ligatures
• Fluoride mouthrinse
• Fluoride toothpaste
• Fluoride varnish
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed
brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809.
Geiger, A. M., Gorelick, L., Gwinnett, A. J., & Griswold, P. G. (1988). The effect of a fluoride program on white spot formation during orthodontic
treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 93(1), 29–37.
Should decrease WSL, but the
evidence is weak and sparse
because only 42% of patients
use mouthrinse daily as
directed.
36. WSL Prevention: Fluoride
• Fluoride releasing cement
• Fluoride ligatures
• Fluoride mouthrinse
• Fluoride toothpaste
• Fluoride varnish
Derks, A., Katsaros, C., Frencken, J. E., van ’t Hof, M. A., & Kuijpers-Jagtman, A. M. (2004). Caries-Inhibiting Effect of Preventive Measures
during Orthodontic Treatment with Fixed Appliances. Caries Research, 38(5), 413–420.
Stanley A. Alexander and Louis W. Ripa (2000) Effects of Self-Applied Topical Fluoride Preparations in Orthodontic Patients. The Angle
Orthodontist: December 2000, Vol. 70, No. 6, pp. 424-430.
Brushing 2x daily with 5000ppm F alone
provides greater protection than
toothbrushing with a 1000ppm paste and
rinsing with a 0.05% NaF.
37. WSL Prevention: Fluoride
• Fluoride releasing cement
• Fluoride ligatures
• Fluoride mouthrinse
• Fluoride toothpaste
• Fluoride varnish
Stecksén-Blicks, C., Renfors, G., Oscarson, N. D., Bergstrand, F., & Twetman, S. (2007). Caries-preventive effectiveness of a fluoride varnish: a
randomized controlled trial in adolescents with fixed orthodontic appliances. Caries research, 41(6), 455–459. doi:10.1159/000107932
Ivoclar Vivadent (0.1% F)
Every 6 weeks
Cotton roll isolation
Remove plaque with explorer
Minibrush applicator
Dry for 2 minutes
Avoid eating/drinking for 2 hrs
No brushing until the following day
Thick-rim
WSL
Thin-rim
WSL
Cavitation
40. Caries Prevention: CPP-ACP
• 2008 - “insufficient evidence … to make a
recommendation regarding the long-term
effectiveness … in preventing caries in vivo”
Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American
Dental Association (1939), 139(7), 915–924; quiz 994–995.
Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-
analysis. Acta Odontologica Scandinavica, 67(6), 321–332.
Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A
Randomized Trial. Journal of Dental Research, 91(9), 847–852.
41. Caries Prevention: CPP-ACP
• 2008 - “insufficient evidence … to make a
recommendation regarding the long-term
effectiveness … in preventing caries in vivo”
• 2009 – “evidence of the short-term and long-
term … use CPP-ACP for caries prevention”
Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American
Dental Association (1939), 139(7), 915–924; quiz 994–995.
Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-
analysis. Acta Odontologica Scandinavica, 67(6), 321–332.
Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A
Randomized Trial. Journal of Dental Research, 91(9), 847–852.
42. Caries Prevention: CPP-ACP
• 2008 - “insufficient evidence … to make a
recommendation regarding the long-term
effectiveness … in preventing caries in vivo”
• 2009 – “evidence of the short-term and long-
term … use CPP-ACP for caries prevention”
• 2012 – “did not detect any difference
between daily application of CPP-ACP-
containing paste”
Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American
Dental Association (1939), 139(7), 915–924; quiz 994–995.
Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-
analysis. Acta Odontologica Scandinavica, 67(6), 321–332.
Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A
Randomized Trial. Journal of Dental Research, 91(9), 847–852.
44. WSL Prevention: CPP-ACP
• ACP-containing adhesive
• Chewing gum
• Lozenge
• MI Paste
• MI Paste Plus
Behnan, S. M., Arruda, A. O., González-Cabezas, C., Sohn, W., & Peters, M. C. (2010). In-vitro evaluation of various treatments to prevent
demineralization next to orthodontic brackets. American journal of orthodontics and dentofacial orthopedics 138(6), 712.e1–7; 712–713.
Support for ACP-containing
adhesive ( Aegis-Ortho) is
present, but not impressive.
45. WSL Prevention: CPP-ACP
• ACP-containing adhesive
• Chewing gum
• Lozenge
• MI Paste
• MI Paste Plus
Cai, F., Manton, D., Walker, G., & Cross, y. r. (2007). Effect of Addition of citric acid and casein phosphopeptide-Amorphous Calcium Phosphate to
a Sugar-Free Chewing Gum on Enamel Remineralization in situ. Caries Research , 41:377-383.
Please do not encourage braces
patients to chew gum. Gum breaks
braces off teeth.
46. WSL Prevention: CPP-ACP
• ACP-containing adhesive
• Chewing gum
• Lozenge
• MI Paste
• MI Paste Plus
Cai, F., Shen P, M. M., & Reynolds. (2003). Remineralization of enamel subsurface lesions in situ by sugar-free lozenges containing casein
phoshopeptide-amorphous calcium phosphate. American Dental Journal , 4:240-243.
Insufficient evidence to recommend
47. WSL Prevention: CPP-ACP
• ACP-containing adhesive
• Chewing gum
• Lozenge
• MI Paste
• MI Paste Plus
MI Paste will help prevent WSL. And no one claims to
know how much it helps.
48. WSL Prevention: CPP-ACP
• ACP-containing adhesive
• Chewing gum
• Lozenge
• MI Paste
• MI Paste Plus
Fluoride + CPP-ACP
is better than
CPP-ACP alone
Sodium fluoride 0.2% (900ppm)
58. WSL After 6 Months of Monitoring
van der Veen, M. H., Mattousch, T., & Boersma, J. G. (2007). Longitudinal development of caries lesions after orthodontic treatment evaluated by
quantitative light-induced fluorescence. American Journal of Orthodontics and Dentofacial Orthopedics, 131(2), 223–228.
Better
Worse
59. WSL After 6 Months of Monitoring
Smaller Same
0% 20% 40% 60% 80% 100%
6 months post-debond and OH instruction
Larger
Restored
van der Veen, M. H., Mattousch, T., & Boersma, J. G. (2007). Longitudinal development of caries lesions after orthodontic treatment evaluated by
quantitative light-induced fluorescence. American Journal of Orthodontics and Dentofacial Orthopedics, 131(2), 223–228.
61. Fluoride to treat WSL
“The remineralizing capacity of
saliva in the absence of
concentrated fluoride agents is
relatively fast. Visible white spots
on the facial surfaces developed
during orthodontic therapy
should therefore not be treated
with concentrated fluoride
agents since this procedure will
arrest the lesions and prevent
complete repair”
(Ogaard, 1998)
66. Author, Year, Study
design
Intervention Control Study assessment Time of intervention Outcomes
Yengopal, 2009, meta-
analysis
CPP-ACP vs other intervention vs control
12 articles reviewed all
have controls
Varies per article Varies per article
Short term remineralization effect shown for
CPP-ACP.
Gupta, 2011, Review CPP-ACP complex in clinical studies 16 articles reviewed Varies per article Varies per article
CPP-ACP remineralized white spot lesions to
a clinically significant manor
Llena, 2009, Review CPP-ACP role in invivo and invitro studies 31 articles reviewed Varies per article Varies per article
calcium phosphate based remineralization
technologies showed effectiveness in caries
prevention and lesion reversal
Robertson 2011,
Randomized Control Trial
26 patients wear tray with CPP-ACP 3- 5
minutes after bushing, before bed for 3
months, pt checked at 4 week intervals, pt in
active orthodontic treatment
yes Enamel decalcification index 3 months
CPP-ACP decreased the number of white
spot lesions, Placebo had no preventive
effect, number of lesions increased
Uysal, 2010, Randomized
Control Trial
Topical application of CCP-ACP gel or fluoride
gel
Yes Cross-sectional microhardness 60 days
CPP-ACP and fluoride containing agents
successfully inhibited caries around
orthodontic brackets
Uysal, 2010, Randomized
Control Trial
Brackets bonded with an ACP-containing
orthodontic composite
Yes (resin-based
orthodontic composite)
Superficial-microhardness 30 days
ACP-containing orthodontic composite for
bonding orthodontic brackets successfully
inhibited demineralization in vivo
Shen 2011, Randomized
Control Trial
Slurry of product (placebo, 1000ppmF,
5000ppm F, CPP-ACP, CPP-ACP + 900ppm F,
fTCP + 950ppm F) rinsed for 60 seconds 4 times
per day for 10 days
Yes
Mineral content using transverse
microradiography
10 days
Placebo<1000 ppm F = fTMP + 950 ppm F <
5000ppm < CPP-ACP < CPP-ACP + 900 ppm F
Srinivasan 2010,
Randomized Control Trial
8 patients wearing 45 enamel samples using (
CPP-ACP, after washout period CPP-ACP + 900
ppm F)
yes Microhardness 2 days per group CPP-ACP + 900 ppm F > CPP-ACP > Saliva
Cai, 2009, Randomized
Control Trial
Chewing one of 4 gums: Trident Xtra Care
(CCP-ACP added), Orbit Professional (calcium
carbonate added), Orbit, and Extra
Yes (two sugar-free
gums: Orbit and Extra)
Mineral level determined by
microradiography
14 days per gum, 1 week
washout period between
gum type
Chewing Trident Xtra Care (contains CCP-
ACP) resulted in significantly higher
remineralization than chewing Orbit
Professional, Orbit, or Extra
Bailey, 2009, Randomized
Control Trial
Use of a remineralizing cream containing
casein phosphopeptide-amorphous calcium
phosphate
Yes
Clinical assessments using ICDAS II
criteria
12 weeks
Significantly more post-orthodontic white-
spot lesions regressed with the
remineralizing cream compared to the
placebo
Beerens 2010,
Randomized Control Trial
54 patients observed after removal of
orthodontic appliances for Caries regression
using CPP-ACFP
yes
Quantitive light induced
fluorescence
3 months
No significant difference found between
groups
Brochner 2010,
Randomized Control Trial
CPP-ACP used once daily after removal of
orthodontic appliances
yes
Quantitive light induced
fluorescence
4 weeks
No significant difference found between
groups
Ferrazzano 2011,
Randomized Control Trial
40 patients used CPP-ACP used on one side of
mouth with placebo on other side once daily
yes Scanning electron micrography 1 month
CPP-ACP able to promote remineralization of
early enamel lesions
67. Author, Year, Study
design
Intervention Control Study assessment Time of intervention Outcomes
Yengopal, 2009, meta-
analysis
CPP-ACP vs other intervention vs control
12 articles reviewed all
have controls
Varies per article Varies per article
Short term remineralization effect shown for
CPP-ACP.
Gupta, 2011, Review CPP-ACP complex in clinical studies 16 articles reviewed Varies per article Varies per article
CPP-ACP remineralized white spot lesions to
a clinically significant manor
Llena, 2009, Review CPP-ACP role in invivo and invitro studies 31 articles reviewed Varies per article Varies per article
calcium phosphate based remineralization
technologies showed effectiveness in caries
prevention and lesion reversal
Robertson 2011,
Randomized Control Trial
26 patients wear tray with CPP-ACP 3- 5
minutes after bushing, before bed for 3
months, pt checked at 4 week intervals, pt in
active orthodontic treatment
yes Enamel decalcification index 3 months
CPP-ACP decreased the number of white
spot lesions, Placebo had no preventive
effect, number of lesions increased
Uysal, 2010, Randomized
Control Trial
Topical application of CCP-ACP gel or fluoride
gel
Yes Cross-sectional microhardness 60 days
CPP-ACP and fluoride containing agents
successfully inhibited caries around
orthodontic brackets
Uysal, 2010, Randomized
Control Trial
Brackets bonded with an ACP-containing
orthodontic composite
Yes (resin-based
orthodontic composite)
Superficial-microhardness 30 days
ACP-containing orthodontic composite for
bonding orthodontic brackets successfully
inhibited demineralization in vivo
Shen 2011, Randomized
Control Trial
Slurry of product (placebo, 1000ppmF,
5000ppm F, CPP-ACP, CPP-ACP + 900ppm F,
fTCP + 950ppm F) rinsed for 60 seconds 4 times
per day for 10 days
Yes
Mineral content using transverse
microradiography
10 days
Placebo<1000 ppm F = fTMP + 950 ppm F <
5000ppm < CPP-ACP < CPP-ACP + 900 ppm F
Srinivasan 2010,
Randomized Control Trial
8 patients wearing 45 enamel samples using (
CPP-ACP, after washout period CPP-ACP + 900
ppm F)
yes Microhardness 2 days per group CPP-ACP + 900 ppm F > CPP-ACP > Saliva
Cai, 2009, Randomized
Control Trial
Chewing one of 4 gums: Trident Xtra Care
(CCP-ACP added), Orbit Professional (calcium
carbonate added), Orbit, and Extra
Yes (two sugar-free
gums: Orbit and Extra)
Mineral level determined by
microradiography
14 days per gum, 1 week
washout period between
gum type
Chewing Trident Xtra Care (contains CCP-
ACP) resulted in significantly higher
remineralization than chewing Orbit
Professional, Orbit, or Extra
Bailey, 2009, Randomized
Control Trial
Use of a remineralizing cream containing
casein phosphopeptide-amorphous calcium
phosphate
Yes
Clinical assessments using ICDAS II
criteria
12 weeks
Significantly more post-orthodontic white-
spot lesions regressed with the
remineralizing cream compared to the
placebo
Beerens 2010,
Randomized Control Trial
54 patients observed after removal of
orthodontic appliances for Caries regression
using CPP-ACFP
yes
Quantitive light induced
fluorescence
3 months
No significant difference found between
groups
Brochner 2010,
Randomized Control Trial
CPP-ACP used once daily after removal of
orthodontic appliances
yes
Quantitive light induced
fluorescence
4 weeks
No significant difference found between
groups
Ferrazzano 2011,
Randomized Control Trial
40 patients used CPP-ACP used on one side of
mouth with placebo on other side once daily
yes Scanning electron micrography 1 month
CPP-ACP able to promote remineralization of
early enamel lesions
CPP-ACP remineralizes WSL (reviews)
CPP-ACP remineralizes WSL during braces (2)
(Fluoride + CPP-ACP) remineralizes better than CPP-ACP (3)
CPP-ACP chewing gum remineralizes (1)
Twice a day remineralizes (1)
Once a day does NOT (2)
It works in a lab, too! (1)
69. CPP-ACP
• 20 s for 2 weeks, in
vitro, does little
Bailey, D. L., Adams, G. G., Tsao, C. E., Hyslop, A., Escobar, K., Manton, D. J., Reynolds, E. C., et al. (2009). Regression of Post-orthodontic Lesions
by a Remineralizing Cream. Journal of Dental Research, 88(12), 1148–1153.
70. CPP-ACP Summary
• CPP-ACP remineralizes better than placebo
– Read: It works
• CPP-ACP remineralization of WSL is unproven
in long term studies
– Read: Don’t promise a patient that it will work
74. Microabrasion
• Rubber dam
• Sweep surface with diamond bur (fine-
grit, water-cooled) for 5-10 seconds
• Apply 1 mm layer of microabrasion paste (6.6%
HCL slurry with silicon carbide micro-particles).
• Prophy cup with heavy pressure for 60 seconds.
• Suction, rinse, evaluate and repeat.
• Fluoride tray for 4-30 minutes.
75.
76. • Oral hygiene instructions
• Scaling and polishing
• Rubber dam
• Apply 3mm layer of microabrasion paste (6.6% HCL slurry with silicon carbide
micro-particles).
• Prophy cup with light pressure for 60-120 seconds.
• Suction, rinse, evaluate and repeat.
• CPP-ACP paste for 15 minutes
• Suction
• CPP-ACP twice daily for 3 months
• At home whitening as needed
85. Infiltration
Shin Kim, Eun-Young Kim, Tae-Sung Jeong, & Jung-Wook Kim. (2011). The evaluation of resin infiltration for masking labial enamel white spot
lesions. International Journal of Paediatric Dentistry, 21(4), 241–248.
86. Infiltration
11 of 18 turned out this well
Shin Kim, Eun-Young Kim, Tae-Sung Jeong, & Jung-Wook Kim. (2011). The evaluation of resin infiltration for masking labial enamel white spot
lesions. International Journal of Paediatric Dentistry, 21(4), 241–248.
87. Infiltration
• Rubber dam with separating rings
• Prophy
• 15% HCL for 120s
• Rinse 30s
• Ethanol for 30s
• Infiltrant resin for 180s (ICON-Infiltrant; DMG)
• Light cure 40s
• Infiltrant resin for 60s (ICON-Infiltrant; DMG)
• Light cure 40s
• Polish with soflex disks
88. Infiltration
WSL cut in half (mirror images)
Meyer-Lueckel, H., & Paris, S. (2008). Improved Resin Infiltration of Natural Caries Lesions. Journal of Dental Research, 87(12), 1112–1116.
DAVILA, J. M., BUONOCORE, M. G., GREELEY, C. B., & PROVENZA, D. V. (1975). Adhesive Penetration in Human Artificial and Natural White Spots.
Journal of Dental Research, 54(5), 999–1008.
89. Infiltration
6 of 18 improved some
Shin Kim, Eun-Young Kim, Tae-Sung Jeong, & Jung-Wook Kim. (2011). The evaluation of resin infiltration for masking labial enamel white spot
lesions. International Journal of Paediatric Dentistry, 21(4), 241–248.
90. Infiltration
1 of 18 showed no improvement
Shin Kim, Eun-Young Kim, Tae-Sung Jeong, & Jung-Wook Kim. (2011). The evaluation of resin infiltration for masking labial enamel white spot
lesions. International Journal of Paediatric Dentistry, 21(4), 241–248.
94. Tooth Whitening
Donly, K. J., & Sasa, I. S. (2008). Potential Remineralization of Postorthodontic Demineralized Enamel and the Use of Enamel Microabrasion and
Bleaching for Esthetics. Seminars in Orthodontics, 14(3), 220–225.
4 weeks of bleaching, 30 minutes twice per day, with a hydrogen peroxide gel
95. Tooth Whitening
Donly, K. J., & Sasa, I. S. (2008). Potential Remineralization of Postorthodontic Demineralized Enamel and the Use of Enamel Microabrasion and
Bleaching for Esthetics. Seminars in Orthodontics, 14(3), 220–225.
4 weeks of bleaching, 30 minutes twice per day, with a hydrogen peroxide gel
97. White Spot Lesions (WSL)
• Recommendations to prevent
1. Oral hygiene
Sonicare (orthodontist, free, after eating)
Plackers Orthopicks (walgreens.com, $3/24, once daily)
2. Fluoride
Varnish (dentist, $40/application, twice yearly)
Prevident 5000 Booster (pharmacy, $20/tube, three times daily)
Varnish (orthodontist, $40/application, every 6 weeks)
3. CPP-ACP
MI Paste Plus (pharmacy, $20/tube, 3 min nightly in tray)
• Recommendations to repair
1. Remineralization
Oral hygiene (orthodontist/dentist, free, salivary remineralization for 6 weeks), Fluoride
(avoid, WSL brown lesions), CPP-ACP (orthodontist/dentist, $20/tube, after 6 weeks use
MI Paste Plus for 3 months, 3 min nightly in tray), Microabrasion
(dentist, $720/application, may need up to 5 monthly applications)
2. Restoration
Resin infiltration (unknown longevity), Composite/Porcelain Veneers (last resort)
3. Cosmetic whitening (makes patients feel better about teeth)
Nearly 500 general dentists and orthodontists were surveyed (496). [The article pointed out some differences in recommendations among dentists and orthodontists. ]10-20% of patients have WSL after bracesThe median percentage of patients with WSLs after orthodontic treatment was 20 percent, according to general dentists, with a range of 1 to 100 percent. According to orthodontists, the median percentage of patients with WSLs after orthodontic treatment was 10 percent, with a range of 0 to 90 percent.70% recommended fluoride immediatelyHalf report treating WSL “sometimes”More than one-half of the general dentists surveyed (57 percent) reported that they had treated WSLs associated with braces in the previous year “sometimes.” Twenty-five percent reported having treated WSLs “rarely,” 12 percent “often” and 6 percent reported that they had “never” treated WSLs associated with braces in the previous year.Braces “rarely” removed because of POHMore than one-half of orthodontists reported that they had “rarely” (56 percent) or “never” (7 percent) removed braces because of poor oral hygiene in the previous year. However, 35 percent of orthodontists reported that they had removed braces “sometimes” and 2 percent “often” during the preceding year.The article concludes with the following statement: “to prevent the development of WSLs in patients, general dentists and orthodontists should work together.”The article concludes with the following statement: “to prevent the development of WSLs in patients, general dentists and orthodontists should work together.”
So now you know how many white spots are formed and how to treat them!
But that’s not all there is to the story. After all this was a SURVEY. So of the nearly 500 general dentists and orthodontists surveyed, the article reports their responses. It’s important to know that even though this was published, the collective hive-mind of the dental profession may not be right.After all, the percentages of WSL ranged from 1% to 100%.So, just because everyone is doing it, doesn’t make it right.
Today we are going to find out if they are right!Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
“Subjects with good compliance developed on average fewer new WSL than subjects with moderate compliance and subjects with moderate compliance developed fewer WSL than subjects with poor compliance.”
“Subjects with good compliance developed on average fewer new WSL than subjects with moderate compliance and subjects with moderate compliance developed fewer WSL than subjects with poor compliance.”80 percent of cooperative patients completely protect themselves from WSL. You are going to see, as we go through the other preventive methods, that oral hygiene is the BEST and MOST economical method to protect our braces patients from WSL.
Since oral hygiene is so important, we review this with every patient.This is what we recommend:First avoid acid that demineralizes teeth byDrinking water instead of sodaEating meals instead of snacksThen we talk to them about the importance of remove plaque:We ask them to brush after eatingAnd to Floss nightlyThen we emphasize that the dentist needs to follow up with them every 6 months.We also give them tools they need to keep things clean
We recommend the sonicare toothbrush. In our office, we’ve found that this toothbrush creates the BEST improvements in oral hygiene. In fact, it’s so good that we want all of our patients to use it. So we give one to them when they start braces.
This is our referral card – it says “every patient starting braces receives a complimentary sonicare toothbrush”. It has also had the benefit of attracting patients who are actually going to USE the toothbrush – so it’s really been a win-win
And, as you know, power toothbrushes work well.ESPECIALLY with braces patients. The Sonicare toothbrush has been shown to improve the plaque index and gingival index in orthodontic patients in 3 separate studies. So the recommendation from a 2007 study in the International journal of oral hygiene is for braces patients to use a power toothbrush, specifically the Sonicare toothbrush.Although the improvements are not necessarily significant in the general population – there is a benefit for orthodontic patients.
So the sonicare is the winner for our patientsWe also recommend another tool, from plackers
We also recommend the braces friendly floss holders. This one is called the PlackersOrthopick – and it is similar to other flossers on the market like the platypus.What we like about this kind of flosser is that it can comfortably fit behind the wire, so that patients can floss properly.The floss threaders and superfloss work, but they can be tedious to use – and we want it to be easy.
So we recommend the plackersorthopick$2 to $5 for 24 picks. You can get them online at walgreens.comNext up is encouraging patients to visit all of you to evaluate how they are doing with brushing and flossing.
Some patients need to be reminded to go and visit the dentist. This is our way of reminding patients that they need to go get a cleaning.When we see that it is about time for their cleaning – we share this card with them. It says “together with your hygienist please complete this card and return it to us for entry into a grand prize drawing”The grand prizes drawing is great! The prize is really cool! It’s usually tickets to dorney or something along those lines.And then, as you may know, the hygienist that writes their name on the winning card wins a lunch for their office!Our team really likes using the cards because it a referral into a fun game.Along those lines, the lure of a prize can really help get patients to change their behavior.
79 percent of cooperative patients completely protect themselves from WSL.
We call this our Viechnickels program and patients can win prizes
There is value in fluoride products for children and adolescents.A 2003 series of Cochrane Collaboration systematic reviews proved that fluoride toothpaste, mouthrinse, and gels reduce caries.Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 3. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1.
There is value in fluoride products for children and adolescents.A 2003 series of Cochrane Collaboration systematic reviews proved that fluoride toothpaste, mouthrinse, and gels reduce caries.Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 3. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Marinho VCC, Higgins JPT, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 1.
This review suggests that the regular and supervised use of fluoridemouthrinse by children is associated with a clear reduction incaries increment. Compared to control groups, daily and weekly/fortnightly rinse programmes result on average in 26% fewer decayed,missing, or filled permanent tooth surfaces. We found noevidence that this relative effect was dependent on baseline carieslevel or exposure to other fluoride sources, fluoride concentrationand mouthrinsing frequency, although this result should be interpretedwith caution. A higher decayed, (missing) and filled surface(D(M)FS) prevented fraction was shown with increased intensityof application (frequency times concentration). This relationshipwas dependent on the inclusion of one study with particularlypowerful effect. Unfortunately the review does not provide usefulinformation on the likelihood of significant side effects with theuse of fluoride mouthrinse, and inconclusive information on acceptability.
This review suggests that the regular and supervised use of fluoridemouthrinse by children is associated with a clear reduction incaries increment. Compared to control groups, daily and weekly/fortnightly rinse programmes result on average in 26% fewer decayed,missing, or filled permanent tooth surfaces. We found noevidence that this relative effect was dependent on baseline carieslevel or exposure to other fluoride sources, fluoride concentrationand mouthrinsing frequency, although this result should be interpretedwith caution. A higher decayed, (missing) and filled surface(D(M)FS) prevented fraction was shown with increased intensityof application (frequency times concentration). This relationshipwas dependent on the inclusion of one study with particularlypowerful effect. Unfortunately the review does not provide usefulinformation on the likelihood of significant side effects with theuse of fluoride mouthrinse, and inconclusive information on acceptability.
One study in 1967 used 140 times/ year.Acidulated phosphate fluoride (APF) gels in the concentration of 12,300 parts per million of fluoride (ppm F) are professionally-applied twice a year.The probable toxic dose (PTD) of 100 mg of fluoride for a 20 kg (5-6 year-old) child is contained in only 8 ml volumes of these gels. Approximately 5 ml of gel is used in a topical application of APF gel in a tray, representing a potential exposure of 61.5 mg of fluoride ion. There is a significant risk of over exposurewhich can result in acute toxicity (Ripa 1990).Univariatemetaregression suggested no significant association betweenestimates of D(M)FS prevented fractions and the pre-specifiedtrial characteristics: baseline levels of caries, background exposureto other fluoride sources, background exposure to fluoridatedwater, background exposure to fluoride toothpaste, gel applicationmode (operator/self ), gel application self-applied method (tray/brush), and fluoride concentration.
Fluoride varnish is cleared for marketing by the U.S. Food and Drug Administration (FDA) for the treatment of dentin hypersensitivity associated with the exposure of root surfaces or as a cavity varnish, but not for reducing cariesMarinho, V. C., Higgins, J. P., Logan, S., & Sheiham, A. (2002). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd.
Affairs, A. D. A. C. on S. (2006). Professionally applied topical fluoride Evidence-based clinical recommendations. The Journal of the American Dental Association, 137(8), 1151–1159.
Affairs, A. D. A. C. on S. (2006). Professionally applied topical fluoride Evidence-based clinical recommendations. The Journal of the American Dental Association, 137(8), 1151–1159.
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809. doi:10.1002/14651858.CD003809.pub2“there is little evidence as to which method or combination of methods to deliver the fluoride is the most effective.”Based on 2 reviews“One study (Geiger 1992) found that only 42% of patients rinsed with a sodium fluoride mouthrinse at least every other day. They also showed that those who complied least with fluoride rinsing regimens tended to have more white spots.”“There is some evidence that the use of topical fluoride or fluoride-containing bonding materials during orthodontic treatment reduces the occurrence and severity of white spot lesions”
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809. There are 10 studies worth considering with respect to choosing a fluoride-releasing cements. Composites, compomers, and glass-ionomer cements have been compared and show a trend towards reducing WSLExamined post-tx with braces
Banks, P., Chadwick, S., Asher-McDade, C., & Wright, J. (2000). Fluoride-releasing elastomerics - a prospective controlled clinical trial. European Journal of Orthodontics, 22(4), 401.Turns out that in addition to not really improving white spots that they are difficult to handle clinically – they aren’t stretchy enough for everyday orthodontics.Inclusion: no plaque deposits at start, no bleeding on probingExperiment: 2x daily brushing with conventional and inter-proximal brushes. 1x daily fluoride mouthwash.
An expert panel from the University of Iowa in 2010 corroborated the systematic reviewInclusion: no plaque deposits at start, no bleeding on probingExperiment: 2x daily brushing with conventional and inter-proximal brushes. 1x daily fluoride mouthwash.Geiger, A. M., Gorelick, L., Gwinnett, A. J., & Griswold, P. G. (1988). The effect of a fluoride program on white spot formation during orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 93(1), 29–37. doi:10.1016/0889-5406(88)90190-4
Stanley A. Alexander and Louis W. Ripa (2000) Effects of Self-Applied Topical Fluoride Preparations in Orthodontic Patients. The Angle Orthodontist: December 2000, Vol. 70, No. 6, pp. 424-430. Prevident is better, but expensive $15 per tube
Stecksén-Blicks, C., Renfors, G., Oscarson, N. D., Bergstrand, F., & Twetman, S. (2007). Caries-preventive effectiveness of a fluoride varnish: a randomized controlled trial in adolescents with fixed orthodontic appliances. Caries research, 41(6), 455–459. doi:10.1159/000107932This is the 1000ppm F varnish that evaporates to about 10,000ppm when it is dry.RCT with 273 subjects. The absolute risk reduction was 18%. Number needed to treat = 5.5I am confident recommending this in someone who just got braces and does not yet have any decalcification.Examined post-tx with braces
ACP was firstly described by Aaron S. Posner in the mid 1960s.Aggregated ACP particles readily dissolve and crystallize to form apatite.Casein phosphopeptides (CPP) contain the cluster sequence of -Ser (P)-Ser (P)-Ser (P)-Glu-Glu from casein [33,34]. Through these multiple phosphoseryl residues, CPP has a remarkable ability to stabilize clusters of ACP into CPP-ACP complexes, preventing their growth to the critical size required for nucleation, phase transformation and precipitation.Zhao, J., Liu, Y., Sun, W., & Zhang, H. (2011). Amorphous calcium phosphate and its application in dentistry. Chemistry Central Journal, 5, 40. doi:10.1186/1752-153X-5-40CPP-ACP binds well to plaque, providing a large calcium reservoir within plaque and slowing diffusion of free calcium.Rose, R. K. (2000). Binding characteristics of Streptococcus mutans for calcium and casein phosphopeptide. Caries research, 34(5), 427–431. doi:16618Plaque exposed to CPP-ACP had 2.5 times more Ca and phosphorus than control plaqueShen, P., Cai, F., Nowicki, A., Vincent, J., & Reynolds, E. C. (2001). Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Journal of dental research, 80(12), 2066–2070.
In early 2008,Azarpazhooh systemically reviewed 98 articles on the clinical efficacy of casein derivatives and concluded that there was insufficient evidence (in quantity, quality or both) in existing clinical trials to make a recommendation regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American Dental Association (1939), 139(7), 915–924; quiz 994–995.This is because most of the studies were in-situ. People would wear appliances with enamel slabs for 15 days. After the slabs were in the mouth, they would be removed and analyzed. In addition to the short time, the studies were mostly done by the group that patented CPP-ACP. So Azarpazhooh made the right call.But then, a few months after the systematic review, a long-term 24 months RCT significantly contributes to the evidence that shows a longer-term caries-preventive effect of CPP-ACP when delivered in sugar-free chewing gum (n=2720, 54 mg CPP-ACP)Morgan, M. V., Adams, G. G., Bailey, D. L., Tsao, C. E., Fischman, S. L., & Reynolds, E. C. (2008). The Anticariogenic Effect of Sugar-Free Gum Containing CPP-ACP Nanocomplexes on Approximal Caries Determined Using Digital Bitewing Radiography. Caries Research, 42(3), 171–184. doi:10.1159/000128561Starting in 2009, the next major review, this time a metaanalysis on ACP basically declared ACP as the “the in vivo randomized clinical trials provide promising results for the long-term use of CPP-ACP for caries prevention”, “this review has provided evidence of the short-term and long-term (maximum 24 months) use of CPP-ACP for caries prevention”Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. ActaOdontologicaScandinavica, 67(6), 321–332. doi:10.1080/00016350903160563Just this past June, it appears the pendulum is swinging in the other direction. Schoolchildren in Thailand who were at a high risk of caries were supervised using ACP- paste daily after toothbrusing for a period of 1 year. The result – no difference in caries progression when compared with just brushing with fluoride toothpaste.“In the present study, the pastes were applied by the children’s teachers within 10 min following the children’s toothbrushing with fluoridated toothpaste and immediately before the afternoon nap. The reason for this choice was a synergistic effect with fluoride and longer contact with the teeth. We found little evidence of beneficial effects of CPP-ACP paste, and this might be due to the strong positive effects of the fluoridated toothpaste”Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A Randomized Trial. Journal of Dental Research, 91(9), 847–852. doi:10.1177/0022034512454296
In early 2008,Azarpazhooh systemically reviewed 98 articles on the clinical efficacy of casein derivatives and concluded that there was insufficient evidence (in quantity, quality or both) in existing clinical trials to make a recommendation regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American Dental Association (1939), 139(7), 915–924; quiz 994–995.This is because most of the studies were in-situ. People would wear appliances with enamel slabs for 15 days. After the slabs were in the mouth, they would be removed and analyzed. In addition to the short time, the studies were mostly done by the group that patented CPP-ACP. So Azarpazhooh made the right call.But then, a few months after the systematic review, a long-term 24 months RCT significantly contributes to the evidence that shows a longer-term caries-preventive effect of CPP-ACP when delivered in sugar-free chewing gum (n=2720, 54 mg CPP-ACP)Morgan, M. V., Adams, G. G., Bailey, D. L., Tsao, C. E., Fischman, S. L., & Reynolds, E. C. (2008). The Anticariogenic Effect of Sugar-Free Gum Containing CPP-ACP Nanocomplexes on Approximal Caries Determined Using Digital Bitewing Radiography. Caries Research, 42(3), 171–184. doi:10.1159/000128561Starting in 2009, the next major review, this time a metaanalysis on ACP basically declared ACP as the “the in vivo randomized clinical trials provide promising results for the long-term use of CPP-ACP for caries prevention”, “this review has provided evidence of the short-term and long-term (maximum 24 months) use of CPP-ACP for caries prevention”Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. ActaOdontologicaScandinavica, 67(6), 321–332. doi:10.1080/00016350903160563Just this past June, it appears the pendulum is swinging in the other direction. Schoolchildren in Thailand who were at a high risk of caries were supervised using ACP- paste daily after toothbrusing for a period of 1 year. The result – no difference in caries progression when compared with just brushing with fluoride toothpaste.“In the present study, the pastes were applied by the children’s teachers within 10 min following the children’s toothbrushing with fluoridated toothpaste and immediately before the afternoon nap. The reason for this choice was a synergistic effect with fluoride and longer contact with the teeth. We found little evidence of beneficial effects of CPP-ACP paste, and this might be due to the strong positive effects of the fluoridated toothpaste”Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A Randomized Trial. Journal of Dental Research, 91(9), 847–852. doi:10.1177/0022034512454296
In early 2008,Azarpazhooh systemically reviewed 98 articles on the clinical efficacy of casein derivatives and concluded that there was insufficient evidence (in quantity, quality or both) in existing clinical trials to make a recommendation regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American Dental Association (1939), 139(7), 915–924; quiz 994–995.This is because most of the studies were in-situ. People would wear appliances with enamel slabs for 15 days. After the slabs were in the mouth, they would be removed and analyzed. In addition to the short time, the studies were mostly done by the group that patented CPP-ACP. So Azarpazhooh made the right call.But then, a few months after the systematic review, a long-term 24 months RCT significantly contributes to the evidence that shows a longer-term caries-preventive effect of CPP-ACP when delivered in sugar-free chewing gum (n=2720, 54 mg CPP-ACP)Morgan, M. V., Adams, G. G., Bailey, D. L., Tsao, C. E., Fischman, S. L., & Reynolds, E. C. (2008). The Anticariogenic Effect of Sugar-Free Gum Containing CPP-ACP Nanocomplexes on Approximal Caries Determined Using Digital Bitewing Radiography. Caries Research, 42(3), 171–184. doi:10.1159/000128561Starting in 2009, the next major review, this time a metaanalysis on ACP basically declared ACP as the “the in vivo randomized clinical trials provide promising results for the long-term use of CPP-ACP for caries prevention”, “this review has provided evidence of the short-term and long-term (maximum 24 months) use of CPP-ACP for caries prevention”Yengopal, V., & Mickenautsch, S. (2009). Caries preventive effect of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): a meta-analysis. ActaOdontologicaScandinavica, 67(6), 321–332. doi:10.1080/00016350903160563Just this past June, it appears the pendulum is swinging in the other direction. Schoolchildren in Thailand who were at a high risk of caries were supervised using ACP- paste daily after toothbrusing for a period of 1 year. The result – no difference in caries progression when compared with just brushing with fluoride toothpaste.“In the present study, the pastes were applied by the children’s teachers within 10 min following the children’s toothbrushing with fluoridated toothpaste and immediately before the afternoon nap. The reason for this choice was a synergistic effect with fluoride and longer contact with the teeth. We found little evidence of beneficial effects of CPP-ACP paste, and this might be due to the strong positive effects of the fluoridated toothpaste”Sitthisettapong, T., Phantumvanit, P., Huebner, C., & DeRouen, T. (2012). Effect of CPP-ACP Paste on Dental Caries in Primary Teeth: A Randomized Trial. Journal of Dental Research, 91(9), 847–852. doi:10.1177/0022034512454296
In October of 2012, there is equivocal evidence supporting the use of CPP-ACP to prevent caries. Basically, we don’t know and in areas of uncertainty we are left to our own judgement. There is probably little harm, aside from asking your patients to pay money for an unknown result when a proven equivalent, FLUORIDE, is available.
2008 study found that ACP containing adhesives
Cai published a randomized control trial titled “Remineralization of enamel subsurface lesions by chewing gum with added calcium” in 2009. Four types of sugar free gums were tested on subjects for two weeks. Chewing gums included were: (CCP-ACP added), Orbit Professional (calcium carbonate added), Orbit (2% xylitol) , and Extra (control). Comparison of groups measured Mineral levels determined by microradiography. The Study found that Chewing Trident Xtra Care (contains CCP-ACP) resulted in significantly higher remineralization than chewing Orbit Professional, Orbit, or Extra.
Cai, F., Shen P, M. M., & Reynolds. (2003). Remineralization of enamel subsurface lesions in situ by sugar-free lozenges containing casein phoshopeptide-amorphous calcium phosphate. American Dental Journal , 4:240-243.
Robertson, M. A., Kau, C. H., English, J. D., Lee, R. P., Powers, J., & Nguyen, J. T. (2011). MI Paste Plus to prevent demineralization in orthodontic patients: A prospective randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics, 140(5), 660–668. doi:10.1016/j.ajodo.2010.10.025/////////////////////ACP was firstly described by Aaron S. Posner in the mid 1960s.Aggregated ACP particles readily dissolve and crystallize to form apatite.Casein phosphopeptides (CPP) contain the cluster sequence of -Ser (P)-Ser (P)-Ser (P)-Glu-Glu from casein [33,34]. Through these multiple phosphoseryl residues, CPP has a remarkable ability to stabilize clusters of ACP into CPP-ACP complexes, preventing their growth to the critical size required for nucleation, phase transformation and precipitation.Zhao, J., Liu, Y., Sun, W., & Zhang, H. (2011). Amorphous calcium phosphate and its application in dentistry. Chemistry Central Journal, 5, 40. doi:10.1186/1752-153X-5-40CPP-ACP binds well to plaque, providing a large calcium reservoir within plaque and slowing diffusion of free calcium.Rose, R. K. (2000). Binding characteristics of Streptococcus mutans for calcium and casein phosphopeptide. Caries research, 34(5), 427–431. doi:16618Plaque exposed to CPP-ACP had 2.5 times more Ca and phosphorus than control plaqueShen, P., Cai, F., Nowicki, A., Vincent, J., & Reynolds, E. C. (2001). Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Journal of dental research, 80(12), 2066–2070.Bailey, D. L., Adams, G. G., Tsao, C. E., Hyslop, A., Escobar, K., Manton, D. J., Reynolds, E. C., et al. (2009). Regression of Post-orthodontic Lesions by a Remineralizing Cream. Journal of Dental Research, 88(12), 1148–1153.CPP-ACP and fluoride were shown to have additive effects in reducing caries experience.Reynolds EC. Calcium phosphate-based remineralization systems: scientific evidence? Aus Dent J. 2008;53:268–273. doi: 10.1111/j.1834-7819.2008.00061.x.Azarpazhooh systemically reviewed 98 articles on the clinical efficacy of casein derivatives and concluded that there was insufficient evidence (in quantity, quality or both) in existing clinical trials to make a recommendation regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American Dental Association (1939), 139(7), 915–924; quiz 994–995.In studies, ACP-containing adhesive was demonstrated with lower, but clinically satisfactory bond strength as an orthodontic adhesive because of water absorption and they slide around as curing.Dunn, W. J. (2007). Shear bond strength of an amorphous calcium-phosphate-containing orthodontic resin cement. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 131(2), 243–247. doi:10.1016/j.ajodo.2005.04.046Foster, J. A., Berzins, D. W., & Bradley, T. G. (2008). Bond strength of an amorphous calcium phosphate-containing orthodontic adhesive. The Angle orthodontist, 78(2), 339–344. doi:10.2319/020807-60Minick, G. T., Oesterle, L. J., Newman, S. M., & Shellhart, W. C. (2009). Bracket bond strengths of new adhesive systems. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 135(6), 771–776. doi:10.1016/j.ajodo.2007.06.021
Robertson, M. A., Kau, C. H., English, J. D., Lee, R. P., Powers, J., & Nguyen, J. T. (2011). MI Paste Plus to prevent demineralization in orthodontic patients: A prospective randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics, 140(5), 660–668. doi:10.1016/j.ajodo.2010.10.025/////////////////////ACP was firstly described by Aaron S. Posner in the mid 1960s.Aggregated ACP particles readily dissolve and crystallize to form apatite.Casein phosphopeptides (CPP) contain the cluster sequence of -Ser (P)-Ser (P)-Ser (P)-Glu-Glu from casein [33,34]. Through these multiple phosphoseryl residues, CPP has a remarkable ability to stabilize clusters of ACP into CPP-ACP complexes, preventing their growth to the critical size required for nucleation, phase transformation and precipitation.Zhao, J., Liu, Y., Sun, W., & Zhang, H. (2011). Amorphous calcium phosphate and its application in dentistry. Chemistry Central Journal, 5, 40. doi:10.1186/1752-153X-5-40CPP-ACP binds well to plaque, providing a large calcium reservoir within plaque and slowing diffusion of free calcium.Rose, R. K. (2000). Binding characteristics of Streptococcus mutans for calcium and casein phosphopeptide. Caries research, 34(5), 427–431. doi:16618Plaque exposed to CPP-ACP had 2.5 times more Ca and phosphorus than control plaqueShen, P., Cai, F., Nowicki, A., Vincent, J., & Reynolds, E. C. (2001). Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Journal of dental research, 80(12), 2066–2070.Bailey, D. L., Adams, G. G., Tsao, C. E., Hyslop, A., Escobar, K., Manton, D. J., Reynolds, E. C., et al. (2009). Regression of Post-orthodontic Lesions by a Remineralizing Cream. Journal of Dental Research, 88(12), 1148–1153.CPP-ACP and fluoride were shown to have additive effects in reducing caries experience.Reynolds EC. Calcium phosphate-based remineralization systems: scientific evidence? Aus Dent J. 2008;53:268–273. doi: 10.1111/j.1834-7819.2008.00061.x.Azarpazhooh systemically reviewed 98 articles on the clinical efficacy of casein derivatives and concluded that there was insufficient evidence (in quantity, quality or both) in existing clinical trials to make a recommendation regarding the long-term effectiveness of casein derivatives, specifically CPP-ACP, in preventing caries in vivo and treating dentin hypersensitivity or dry mouth.Azarpazhooh, A., & Limeback, H. (2008). Clinical efficacy of casein derivatives: a systematic review of the literature. Journal of the American Dental Association (1939), 139(7), 915–924; quiz 994–995.In studies, ACP-containing adhesive was demonstrated with lower, but clinically satisfactory bond strength as an orthodontic adhesive because of water absorption and they slide around as curing.Dunn, W. J. (2007). Shear bond strength of an amorphous calcium-phosphate-containing orthodontic resin cement. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 131(2), 243–247. doi:10.1016/j.ajodo.2005.04.046Foster, J. A., Berzins, D. W., & Bradley, T. G. (2008). Bond strength of an amorphous calcium phosphate-containing orthodontic adhesive. The Angle orthodontist, 78(2), 339–344. doi:10.2319/020807-60Minick, G. T., Oesterle, L. J., Newman, S. M., & Shellhart, W. C. (2009). Bracket bond strengths of new adhesive systems. American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 135(6), 771–776. doi:10.1016/j.ajodo.2007.06.021
Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
WSL is a caries process. We need to, at the least, arrest the progression of the lesion so it doesn’t decay further.It would also be nice to make it look better.
Study of white spots over 6 months. They looked at it under fluorescence – which is a great way to quantify the changes that occur at the surface. And over those 6 months they saw some lesions get better, and some get worse.van der Veen, M. H., Mattousch, T., & Boersma, J. G. (2007). Longitudinal development of caries lesions after orthodontic treatment evaluated by quantitative light-induced fluorescence. American Journal of Orthodontics and Dentofacial Orthopedics, 131(2), 223–228. doi:10.1016/j.ajodo.2005.07.017
Here’s a graph from that study. You can see the majority of WSL get smaller or stay the same size.About 10% get larger, and 6% need to be restored.van der Veen, M. H., Mattousch, T., & Boersma, J. G. (2007). Longitudinal development of caries lesions after orthodontic treatment evaluated by quantitative light-induced fluorescence. American Journal of Orthodontics and Dentofacial Orthopedics, 131(2), 223–228. doi:10.1016/j.ajodo.2005.07.017
Ferreira, J. M. S., Aragão, A. K. R., Rosa, A. D. B., Sampaio, F. C., & de Menezes, V. A. (2009). Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial. Brazilian Oral Research, 23(4), 446–451.Akin, M., & Basciftci, F. A. (2012). Can white spot lesions be treated effectively? The Angle Orthodontist, 82(5), 770–775. doi:10.2319/090711.578.1Does help ARREST lesion, but it does not improve the cosmetics (because of hypermineralization at surface)Øgaard, B., Rølla, G., Arends, J., & ten Cate, J. M. (1988). Orthodontic appliances and enamel demineralization Part 2. Prevention and treatment of lesions. American Journal of Orthodontics and Dentofacial Orthopedics, 94(2), 123–128. doi:10.1016/0889-5406(88)90360-5
Ferreira, J. M. S., Aragão, A. K. R., Rosa, A. D. B., Sampaio, F. C., & de Menezes, V. A. (2009). Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial. Brazilian Oral Research, 23(4), 446–451.Akin, M., & Basciftci, F. A. (2012). Can white spot lesions be treated effectively? The Angle Orthodontist, 82(5), 770–775. doi:10.2319/090711.578.1Does help ARREST lesion, but it does not improve the cosmetics (because of hypermineralizationat surface)
Ferreira, J. M. S., Aragão, A. K. R., Rosa, A. D. B., Sampaio, F. C., & de Menezes, V. A. (2009). Therapeutic effect of two fluoride varnishes on white spot lesions: a randomized clinical trial. Brazilian Oral Research, 23(4), 446–451.Akin, M., & Basciftci, F. A. (2012). Can white spot lesions be treated effectively? The Angle Orthodontist, 82(5), 770–775. doi:10.2319/090711.578.1Does help ARREST lesion, but it does not improve the cosmetics (because of hypermineralizationat surface)
Comparison
If you JUST improve oral hygiene, you win.If you add a 100ppm fluoride rinse, you win.If you apply CPP-ACP for 3 minutes daily, you win.If you microabrade the teeth, you win the most.
Shin Kim, Eun-Young Kim, Tae-Sung Jeong, & Jung-Wook Kim. (2011). The evaluation of resin infiltration for masking labial enamel white spot lesions. International Journal of Paediatric Dentistry, 21(4), 241–248. doi:10.1111/j.1365-263X.2011.01126.x
For the maximum protection of patients duringthe infiltration procedure, the patientswere made to wear the eye glasses, and rubberdam and separating rings were applied.The tooth surface was cleaned with a rubbercup and prophylaxis paste. The surface layerwas eroded by the application of 15% hydrochloricacid gel (ICON-Etch; DMG, Hamburg,Germany) for 120 s to expose the layerof lesion body. Subsequently, the etching gelwas washed away thoroughly for 30 s using awater spray and dried. The lesions were desiccatedusing ethanol (ICON-Dry; DMG) for30 s followed by air drying. An infiltrant resin(ICON-Infiltrant; DMG) was applied to thesurface and allowed to penetrate inside for3 min. Excessive material was wiped awayusing a cotton roll from the surface beforelight curing. Excessive resin in the proximalspaces was cleaned using dental floss. Afterlight curing for 40 s, the application of infiltrantresin was repeated once for 1 min andlight cured for 40 s. Finally, the roughenedenamel surface was polished using a compositeresin polishing discs (Sof-lex disk; 3MESPE, Saint Paul, MN, USA).
About half of “sealed” lesions like this continue to progress.Martignon, S., Ekstrand, K. R., & Ellwood, R. (2006). Efficacy of Sealing Proximal Early Active Lesions: An 18-Month Clinical Study Evaluated by Conventional and Subtraction Radiography. Caries Research, 40(5), 382–388. doi:10.1159/000094282The idea behind using an infiltrant is that it creates more of a barrier.One of the earliest studies on the penetration of adhesives into white spots was almost 40 years ago.DAVILA, J. M., BUONOCORE, M. G., GREELEY, C. B., & PROVENZA, D. V. (1975). Adhesive Penetration in Human Artificial and Natural White Spots. Journal of Dental Research, 54(5), 999–1008.
Thickett, E., & Cobourne, M. T. (2009). New developments in tooth whitening. The current status of external bleaching in orthodontics. Journal of Orthodontics, 36(3), 194–201. doi:10.1179/14653120723184Donly, K. J., & Swift Jr., E. J. (2005). TOOTH WHITENING IN CHILDREN AND ADOLESCENTS. Journal of Esthetic & Restorative Dentistry, 17(6), 380–383.Policy on the Use of Dental Bleaching for Child and Adolescent Patients. (2009).Pediatric Dentistry, 31(6), 59–61.
Thickett, E., & Cobourne, M. T. (2009). New developments in tooth whitening. The current status of external bleaching in orthodontics. Journal of Orthodontics, 36(3), 194–201. doi:10.1179/14653120723184Donly, K. J., & Swift Jr., E. J. (2005). TOOTH WHITENING IN CHILDREN AND ADOLESCENTS. Journal of Esthetic & Restorative Dentistry, 17(6), 380–383.Policy on the Use of Dental Bleaching for Child and Adolescent Patients. (2009).Pediatric Dentistry, 31(6), 59–61.
Thickett, E., & Cobourne, M. T. (2009). New developments in tooth whitening. The current status of external bleaching in orthodontics. Journal of Orthodontics, 36(3), 194–201. doi:10.1179/14653120723184Donly, K. J., & Swift Jr., E. J. (2005). TOOTH WHITENING IN CHILDREN AND ADOLESCENTS. Journal of Esthetic & Restorative Dentistry, 17(6), 380–383.Policy on the Use of Dental Bleaching for Child and Adolescent Patients. (2009).Pediatric Dentistry, 31(6), 59–61.
Today we are going to find out if they are right!Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Today we are going to find out if they are right!Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809. doi:10.1002/14651858.CD003809.pub2“there is little evidence as to which method or combination of methods to deliver the fluoride is the most effective.”Based on 2 reviews“One study (Geiger 1992) found that only 42% of patients rinsed with a sodium fluoride mouthrinse at least every other day. They also showed that those who complied least with fluoride rinsing regimens tended to have more white spots.”“There is some evidence that the use of topical fluoride or fluoride-containing bonding materials during orthodontic treatment reduces the occurrence and severity of white spot lesions”
Acidulated phosphate fluoride (APF) gels in the concentration of 12,300 parts per million of fluoride (ppm F) are professionally-applied twice a year.The probable toxic dose (PTD) of 100 mg of fluoride for a 20 kg (5-6 year-old) child is contained in only 8 ml volumes of these gels. Approximately 5 ml of gel is used in a topical application of APF gel in a tray, representing a potential exposure of 61.5 mg of fluoride ion. There is a significant risk of over exposurewhich can result in acute toxicity (Ripa 1990).Univariatemetaregression suggested no significant association betweenestimates of D(M)FS prevented fractions and the pre-specifiedtrial characteristics: baseline levels of caries, background exposureto other fluoride sources, background exposure to fluoridatedwater, background exposure to fluoride toothpaste, gel applicationmode (operator/self ), gel application self-applied method (tray/brush), and fluoride concentration.
A 2011 follow-up review of 25 of dentistry’s best studies proved that more fluoride is better. Higher concentrations prevent more caries. Prescription strength toothpaste prevents more caries than over-the-counter toothpaste.No amount of fluoride with supervised brushing “cured caries”.//Twenty-five studies (published between 1988 and 2006) were included: 2 RCTs, 1 cohort study, 6 case-control studies, and 16 cross-sectional surveys.Wong, M. C. M., Clarkson, J., Glenny, A.-M., Lo, E. C. M., Marinho, V. C. C., Tsang, B. W. K., Walsh, T., et al. (2011). Cochrane reviews on the benefits/risks of fluoride toothpastes. Journal of dental research, 90(5), 573–579. doi:10.1177/0022034510393346Concentrations of 440/500/550 ppm and below showed no statistically significant effect when compared with placeboDose-response – more caries prevented with higher concentrations of fluoride toothpaste
Shungin, D., Olsson, A. I., & Persson, M. (2010). Editor’s Comment and Q&A. American Journal of Orthodontics and Dentofacial Orthopedics, 138(2), 136–137. doi:10.1016/j.ajodo.2010.04.001Shungin, D., Olsson, A. I., & Persson, M. (2010). Orthodontic treatment-related white spot lesions: A 14-year prospective quantitative follow-up, including bonding material assessment. American Journal of Orthodontics and Dentofacial Orthopedics, 138(2), 136.e1–136.e8. doi:10.1016/j.ajodo.2009.05.020
Benson, P. E., Parkin, N., Millett, D. T., Dyer, F. E., Vine, S., & Shah, A. (2004). Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane database of systematic reviews (Online), (3), CD003809. doi:10.1002/14651858.CD003809.pub2“there is little evidence as to which method or combination of methods to deliver the fluoride is the most effective.”Based on 2 reviews“One study (Geiger 1992) found that only 42% of patients rinsed with a sodium fluoride mouthrinse at least every other day. They also showed that those who complied least with fluoride rinsing regimens tended to have more white spots.”“There is some evidence that the use of topical fluoride or fluoride-containing bonding materials during orthodontic treatment reduces the occurrence and severity of white spot lesions”
79 percent of cooperative patients completely protect themselves from WSL.
79 percent of cooperative patients completely protect themselves from WSL.
79 percent of cooperative patients completely protect themselves from WSL.
Today we are going to find out if they are right!Recommendations to preventFluorideToothpasteMouthrinseGelVarishGlass ionomer cementMI PasteRecommendations to repairIn-office high fluoride (does not work)Fluoride rinseMI Paste (does not work)MicroabrasionComposite/Porcelain VeneersTooth whiteningRecaldentElectric toothbrush
Gorelick L, Geiger AM, Gwinnett AJ. Incidence of whitespot formation after bonding and banding. AmericanJournal of Orthodontics 1982;81(2):93–8.
Wong, M. C. M., Clarkson, J., Glenny, A.-M., Lo, E. C. M., Marinho, V. C. C., Tsang, B. W. K., Walsh, T., et al. (2011). Cochrane reviews on the benefits/risks of fluoride toothpastes. Journal of dental research, 90(5), 573–579. doi:10.1177/0022034510393346Concentrations of 440/500/550 ppm and below showed no statistically significant effect when compared with placeboDose-response – more caries prevented with higher concentrations of fluoride toothpaste
no difference in the incidence of WSLs relative to treatment time: 12 to 16 months vs up to 36 months for banded or bonded teethno difference in WSL incidence for the right and left sidesFemale patients have been shown to have a greater interest in oral health; they have better oral health and tend to brush and floss their teeth more frequently.20-23male and female subjects had WSL incidences of 46% and 29%, respectively.3 Not only did the male subjects havea higher incidence of WSLs, but also the demineralizations tended to be more severeA younger starting age (preadolescent) was associated with a higher risk of WSL incidence in the maxillaryanterior teeth, suggesting that older patients could be more ideal candidates for fixed orthodontics treatment.Patients with fair or poor pretreatment oral hygiene examinations had 3 times the incidence of at least 1 WSL compared with patients with good pretreatment oral hygiene examinations
Affairs, A. D. A. C. on S. (2006). Professionally applied topical fluoride Evidence-based clinical recommendations. The Journal of the American Dental Association, 137(8), 1151–1159.
Or combinations of modalitiesMarinho, V. C. C. (2009). Cochrane reviews of randomized trials of fluoride therapies for preventing dental caries. European archives of paediatric dentistry: official journal of the European Academy of Paediatric Dentistry, 10(3), 183–191.
