Enamel demineralisation, usually on smooth surfaces, is unfortunately a common complication in orthodontics; figures range from 2-96% of orthodontic patients (Fig.1).2 This large variation probably arises as a result of the variety of methods used to assess and score the presence of decalcification. There is also inconsistency on whether idiopathic lucencies are included or excluded in the study design.3 The teeth most commonly affected are maxillary lateral incisors, maxillary canines and mandibular premolars.4 However, any tooth in the mouth can be affected, and often a number of anterior teeth show decal
cification. Whilst the demineralised surface remains intact, there is a possibility of remineralisation and reversal of the lesion. In severe cases, frank cavitation is seen which requires restorative intervention (Figs. 2 and 3).
Gorelick et al.5 in a study on white spot formation in children treated with fixed appliances, found that half of their patients had at least one white spot after treatment, most commonly on maxillary lateral incisors. The length of treatment did not affect the incidence or number of white spot formations, although O'Reilly and Featherstone6 and Oggard et al.7 found that demineralisation can occur rapidly, within the first month of fixed appliance treatment. This has obvious aesthetic implications and highlights the need for caries rate assessment at the beginning of treatment. Interestingly, Gorelick et al.5 found no incidence of white spot formation associated with lingual bonded retainers, which would suggest salivary buffering capacity, and flow rate have a role in protection against acid attack.
• Good oral hygiene is essential for successful orthodontic treatment
• Daily fluoride rinses may prevent and reduce decalcifications
• Care is needed when debracketing as there is the potential for enamel damage especially with ceramic brackets
Fig. 2 Cavitation at the gingival margin of the lower right canine and first premolar requiring restoration
The dominant hand may also influence the area of decalcification as brushing is more difficult on the side of the dominant hand. Whilst good oral hygiene is vital, dietary control of sugar intake is also needed in order to minimise the risk of decalcification. Fluoride mouthwash-es used throughout treatment can prevent white spot formation8 surprisingly, compliance with this is low (13%). Other fluoride release mechanisms include fluoride releasing bonding agents, elastic ligatures containing fluoride, and depot devices on upper molar bands.9
Preventive measures to minimise damage include patient selection, vigorous oral hygiene measures and dietary education. Reinforcement of oral hygiene and dietary education should be performed at each visit. Positive reinforcement even where oral hygiene is satisfactory will encourage the patient further. Inspection of the labial surfaces of the teeth at each adjustment appointment will identify cases that require more intervention and advice. It is important when examining the teeth that they are plaque-free otherwise early demineralisation may be missed. This can be done by instructing the patient to clean their teeth in the surgery with or without the wires in place, or by professional prophylaxis. The use of auxillaries such as dental health educators and hygienists is highly desirable. Removal of the appliance in cases with extreme demineralisation or poor hygiene is the last resort, but should not be discounted by the clinician.
Where demineralisation is present post treatment, fluoride application either via toothpaste, or by adjunct fluoride mouthwash (0.05% sodium fluoride daily rinse or 0.2% sodium fluoride weekly rinse), can be helpful in remineralising the lesion and reducing the unsightliness of the decalcification.10 Acid/pumice micro abrasion has also been advocated to improve the aesthetics of stabilised lesions.11,12 This procedure should be delayed at least 3 months following debond to allow for spontaneous improvement of the lesions and remineralisation with fluoride applications.13 Persistent lucencies should be abraded with 18% hydrochloric acid in fine pumice under rubber dam in bursts of 30 seconds for a maximum of 10 times. After the last application the tooth is washed well and a fluoride varnish applied.11
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