Post Orthodontic Demineralization: Recommendations for Prevention and Clinical Management
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Post Orthodontic Demineralization: Recommendations for Prevention and Clinical Management

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

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

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  • 1. JOS, November 2006Post-Orthodontic Demineralization: Recommendations for Prevention & Clinical Management Shadi S. Samawi BDS, MMedSci (Orth.), MOrthRCSED. 1
  • 2. Introduction Research Prevention Clinical Management Summary … Clinical Success in Orthodontics 2
  • 3. Introduction Research Prevention Clinical Management Summary DENTAL & FACIAL FUNCTIONAL ESTHETICS OCCLUSION TOTAL PATIENT MANAGEMENT DENTAL & PERIODONTAL HEALTH 3
  • 4. Introduction Research Prevention Clinical Management Summary Function SUCCESS ! Esthetics = Healthy Dentition & Periodontium 4
  • 5. Introduction Research Prevention Clinical Management Summary Function FAILURE !? Esthetics =Post-Orthodontic Demineralization (Precursor to Caries) 5
  • 6. Introduction Research Prevention Clinical Management Summary Overview In This Presentation.. 6
  • 7. Introduction Research Prevention Clinical Management Summary Overview In This Presentation..  Brief Etiology & Clinically-Relevant Research 6
  • 8. Introduction Research Prevention Clinical Management Summary Overview In This Presentation..  Brief Etiology & Clinically-Relevant Research  Recommendations for PREVENTION: Before.. During orthodontic treatment 6
  • 9. Introduction Research Prevention Clinical Management Summary Overview In This Presentation..  Brief Etiology & Clinically-Relevant Research  Recommendations for PREVENTION: Before.. During orthodontic treatment  Recommendations for CLINICAL MANAGEMENT: After completion of orthodontic treatment 6
  • 10. Introduction Research Prevention Clinical Management Summary Basics.. Bacteria Substrate Demineralization ( Caries ) Time 7
  • 11. Introduction Research Prevention Clinical Management Summary Dynamics …Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O 8
  • 12. Introduction Research Prevention Clinical Management Summary Dynamics …Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O pH Demineralization 8
  • 13. Introduction Research Prevention Clinical Management Summary Dynamics …Ca10(PO4)6(OH)2 + 8H+ 10Ca+2 + 6HPO4-2 + 2H2O pH Demineralization Remineralization pH 8
  • 14. Introduction Research Prevention Clinical Management Summary The Key… Fluoride Best Established Remineralization Strategy - Fluoride-enhanced precipitation of Calcium Phosphates - Formation of Fluor-hydroxyapatite in dental tissues 9
  • 15. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. ..Prevalence reports vary widely.. %2 - %96 ! Mitchell, 1992, Br J Orth 10
  • 16. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. ..Prevalence reports vary widely.. %2 - %96 ! Mitchell, 1992, Br J Orth ..Loss of calcified tooth substance (Ca + P) occurs as early as 4 weeks after bond-up !! O’Reilly & Featherstone, 1987, AJODO 10
  • 17. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. ..Prevalence reports vary widely.. %2 - %96 ! Mitchell, 1992, Br J Orth ..Loss of calcified tooth substance (Ca + P) occurs as early as 4 weeks after bond-up !! O’Reilly & Featherstone, 1987, AJODO ..The opacity is an optical phenomenon directly related to loss of subsurface minerals.. Gorelick et al, 1982, AJODO; Mellberg, 1988, Am J Dent 10
  • 18. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. Zachrisson & Zachrisson, 1971 Zachrisson, 1977 Prevalence reports varied widely Mizrahi, 1982 + 1983 due to different methods of Gorelick et al, 1982 assessment ! Artün & Brobakken, 1986 Øgaard, 1989 Mitchell, 1992 Willmot & Brook, 1999 Willmot, 2000 Others … 11
  • 19. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. Zachrisson & Zachrisson, 1971 Zachrisson, 1977 Prevalence reports varied widely Mizrahi, 1982 + 1983 due to different methods of Gorelick et al, 1982 assessment ! Artün & Brobakken, 1986 Øgaard, 1989 General agreement on increased Mitchell, 1992 incidence in orthodontic patients Willmot & Brook, 1999 Willmot, 2000 Others … 11
  • 20. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. Zachrisson & Zachrisson, 1971 Zachrisson, 1977 Prevalence reports varied widely Mizrahi, 1982 + 1983 due to different methods of Gorelick et al, 1982 assessment ! Artün & Brobakken, 1986 Øgaard, 1989 General agreement on increased Mitchell, 1992 incidence in orthodontic patients Willmot & Brook, 1999 Willmot, 2000 Fairly-good agreement on lesion Others … distribution, as well as tooth groups affected 11
  • 21. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. Localization and Distribution of White Lesions Mizrahi,(1982 +1983) ..Opacity Index (Visual Scoring System from 0 – 3): - Males more affected. - Increased incidence on : - Max. & Mand. 1st molars - Max. lateral incisors - Mand. Lateral incisors & Canines - Middle & Cervical thirds of crowns most affected. 12
  • 22. Introduction Research Prevention Clinical Management Summary Some Relevant Research.. Localization and Distribution of White Lesions Willmot,(2000) Pre- & Post-treatment photographic-slide comparisons : - In agreement with most previous reports.. - Increased incidence on : - Upper Lateral Incisors (14.8%) - Lower Canines (14%) - Lower Premolars (16.2%) - No difference between LEFT & RIGHT sides of the mouth. 13
  • 23. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. AIM: to more accurately assess location & surface areas of PWL on upper & lower anterior teeth.. Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 14
  • 24. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. AIM: to more accurately assess location & surface areas of PWL on upper & lower anterior teeth.. Retrospective, Observational..Part of a wider study.. Methodology tried to overcome many problems in previous methods of visual assessment Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 14
  • 25. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. Digital records of (274 teeth )  Special standardized camera setup  Polarized white light Pre-existing lesions excluded.. Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 15
  • 26. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. Digital records of (274 teeth )  Special standardized camera setup  Polarized white light Pre-existing lesions excluded.. (Image Plus Pro, V 3.01) software:  labial surface into 4 quadrants  Locate + outline + measure surface area of each lesion & quadrant Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 15
  • 27. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. Location:  Upper > Lower teeth..  Ging > Occ. quadrants..  U. lateral incisors & Lr. canines most affected..  No diff. between LEFT & RIGHT sides.. Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 16
  • 28. Introduction Research Prevention Clinical Management Summary Further Attempts At Localization & Measurement.. Location:  Upper > Lower teeth..  Ging > Occ. quadrants..  U. lateral incisors & Lr. canines most affected..  No diff. between LEFT & RIGHT sides.. Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 16
  • 29. Introduction Research Prevention Clinical Management Summary Further Attempts At Localisation & Measurment.. Surface Area:  Upper teeth > Lower teeth lesions (sig. diff. for centrals and laterals)..  Gingival > Occlusal lesions..  Sig. Diff. in lesion size between MESIAL & DISTAL quadrants..  No diff. between LEFT & RIGHT sides.. Localization & Surface Area Measurement of Post-Orthodontic White Lesions By Computerized Image Analysis S.S. Samawi, D.R. Willmot, School of Clinical Dentistry, University of Sheffield, 2003 ( under publication ) 17
  • 30. Introduction Research Prevention Clinical Management Summary So.. Why study PWL ?? Identify Patterns.. Anticipate.. Target.. PREVENT PWL ..? 18
  • 31. Introduction Research Prevention Clinical Management Summary So.. Why study PWL ?? A Notable Finding .. (0.022” x 0.028”) bracket slot : Sliding mechanics with (0.019” x 0.025”) SS posted arches MG of Canines DG of lateral incisors 19
  • 32. Introduction Research Prevention Clinical Management Summary Recommendations for Prevention Preventive measures implemented:  Before beginning orthodontic treatment  During orthodontic treatment 20
  • 33. Introduction Research Prevention Clinical Management Summary .. Patient & Parent Education & Awareness Before Starting Treatment are PARAMOUNT TO SUCCESSFUL PREVENTION.. 21
  • 34. Introduction Research Prevention Clinical Management Summary .. Patient & Parent Education & Awareness Before Starting Treatment are PARAMOUNT TO SUCCESSFUL PREVENTION..“ Patients Don’t Know What They Want.. Until They DON’T Get It !! “ 21
  • 35. Introduction Research Prevention Clinical Management Summary Prevention Before Orthodontic Tx Applied Preparation Clinically Instructional (Psychological) Preparation 22
  • 36. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx 23
  • 37. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx Instructional (psychological) preparation : 23
  • 38. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx Instructional (psychological) preparation :  Emphasizing importance of strict & properly-implemented OH measures needed throughout Tx, at the INITIAL VISIT ! 23
  • 39. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx Instructional (psychological) preparation :  Emphasizing importance of strict & properly-implemented OH measures needed throughout Tx, at the INITIAL VISIT !  Letting the patient know his/her OH will be monitored closely each and every visit !  Providing detailed, easy-to-understand OHI at the bond-up appointment. 23
  • 40. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx ..Detailed OHI.. 1- Use “Props” for more visual instructions: i.e: Actual toothbrushes, Bonded Typodonts, OrthoWax, …etc... Effective VISUAL Reinforcement ! 24
  • 41. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx ..Detailed OHI..2- How to properly use special orthodontic brushes i.e: Ortho V-brush, Inter-dental brush Electric toothbrush (if available), …etc.. Use the “ TELL – SHOW – DO “ technique ! 25
  • 42. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx ..Detailed OHI..3- Use PowerPoint Slide Shows or Photo-Books for demonstration of technique or undesirable effects of improper OH ! MORE Effective VISUAL Reinforcement ! 26
  • 43. Introduction Research Prevention Clinical Management Summary Before Orthodontic Tx ..Detailed OHI.. 4- Provide WRITTEN INSTRUCTIONS such as Leaflets or Color Brochures With OHI tips.. Effective Reinforcement At Home..! 27
  • 44. Introduction Research Prevention Clinical Management Summary Prevention Before Orthodontic Tx Clinical Time ? 5 Minutes ..at the Initial Exam visit ! 10-15 Minutes ..OHI after the Bond-up ! 1 Minute ..at beginning of each visit ! 28
  • 45. Introduction Research Prevention Clinical Management Summary Prevention Before Orthodontic Tx Clinically-applied Preparation :  Patients with Very Poor OH before Tx are referred for Professional Cleaning ( Scaling / Jet Cleaning..) Proper Oral Hygiene RE-INSTRUCTION.. Monitored for 1-2 months before initiating orthodontic Tx.. 29
  • 46. Introduction Research Prevention Clinical Management Summary Prevention Before Orthodontic Tx 30
  • 47. Introduction Research Prevention Clinical Management Summary Prevention Before Orthodontic Tx Predictors For Potential Development Of PWL: Pre-existing Poor Oral Hygiene Anticipated Long Tx Time Younger Age? Inter-proximal Caries Fornell & Twetman, 2004 30
  • 48. Introduction Research Prevention Clinical Management Summary Prevention During Orthodontic Tx Applied Applied Methods Clinically Methods Instructional Patient (Motivational) Methods 31
  • 49. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Instructional (Motivational) Methods :  Constant monitoring at each subsequent visit..  Keep parents informed about progress / Poor OH..etc.. Motivate Re-motivate WARN ! Use “ REWARD / PUNISHMENT “ techniques ! 32
  • 50. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Clinically-applied Methods : 1. Appliance System 2. Fluoride-Releasing & Mechanics Sealants 3. Fluoride-Releasing 4. Fluoride-Releasing Adhesives Elastomerics 33
  • 51. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Appliance System & Mechanics :  A more refined, less “cluttered” bracket design  A Low – Friction system ( Reduced Tx time? )  Simpler – yet effective - mechanics and archwires  Less use of plaque-retaining elastomerics and Power-Chains  Bonding rather than Banding molars..? .. SELF - LIGATING BRACKETS ..? 34
  • 52. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Sealants :  Lee et al, JCO; 1973  Acid-etching then SEALING entire labial enamel surface prior to bonding..??  ..Protective coating between enamel and acidic plaque environment..?? Banks & Richmond, EJO; 1994 %72 of sample suffered decalcifications ! Wenderoth et al, 1999 Results “ ..Not encouraging..” 35
  • 53. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx New PulpDent Corporation Ortho-Coat™ A fluoride releasing, light-cured resin• Patented Embrace technology: Moisture tolerant..• Marginal integrity and ability to prevent microleakage ! www.dentalcompare.com www.pulpdent.com 36
  • 54. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Adhesives : 1. Composite Resins 2. Resin-modified GI 3. Hybrid Composites (Compomers) Staley et al, 2004 Transbond XT (LC composite), Advance (composite resin), Fuji LC (RMGI) Fuji LC (RMGI) 37
  • 55. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Adhesives : Basdra et al, AJODO; 1996 In vitro comparison of : Rely-A-Bond), Fluorobond Concise, Conventional Concise (control) For F. Release + Demineralization Inhibition Potential + Effects On Enamel 38
  • 56. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Adhesives : Basdra et al, AJODO; 1996 • Maximal Fluoride release period occurs within 3-4 days..! • After approx. 90 days, almost no residual F release present ! 39
  • 57. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Adhesives : ..Removing Excess Adhesive Around Every Bracket ! 40
  • 58. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: ..Strategic (Targeted) Fluoride Release..? AROUND BRACKET MARGINS 41
  • 59. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: Wiltshire, 1996 Promising Results.. Wiltshire, 1999 Further Clinical Trials needed! Mattick et al, 2001 42
  • 60. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: Wiltshire, 1996 Promising Results.. Wiltshire, 1999 Further Clinical Trials needed! Mattick et al, 2001 PROSPECTIVE RCT Doherty et al, 2002 “..No significant anti-cariogenic Benefits from the use of fluoridated ligatures..” 42
  • 61. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: Effects on Plaque Microbiology: “..ineffective in changing levels of Benson et al, 2004 Streptococci or anaerobes in plaque..” 43
  • 62. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: LIMITATIONS • Short-term Fluoride release • Ligatures become SWOLLEN & lose elasticity quickly ! 44
  • 63. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Fluoride-Releasing Elastomerics: LIMITATIONS • Short-term Fluoride release • Ligatures become SWOLLEN & lose elasticity quickly ! ..Currently NOT a very effective measure against decalcification ! 44
  • 64. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Patient-applied Methods : 2. Daily 1. Diet Control Tooth-brushing (Fluoride Toothpastes) 3. Daily 4. Adjunctive Fluoride AntiPlaque / AntiMicrobial Mouth Rinses Agents 45
  • 65. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Diet Control : X SUGARS & SWEETS SUGARY, ACIDIC & FIZZY DRINKS Cheese, Starchy foods (Bread & Pasta) Fruits & Vegetables.. Water..! 46
  • 66. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Daily Tooth brushing with Fluoride Toothpastes : The most widely used method of delivering topical fluoride (around 1450 ppm)  Rinsing with water after tooth brushing greatly reduces oral fluoride retention ! Dentifrices, mouthwashes, and remineralization/caries arrestment strategies Indiana University School of Dentistry, Oral Health Research Institute, June 2006 47
  • 67. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive Daily Fluoride Rinsing : Geiger et al, 1982 Øgaard et al, 1988 + 1989 0.05% NaF (226 ppm) And 0.2% NaF (900 ppm) Daily / Weekly rinses: Reduced incidence of decalcification & caries ..but NOT completely ! 48
  • 68. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive Daily Fluoride Rinsing : 49
  • 69. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive Daily Fluoride Rinsing : Benson et al, 2004 Systematic Review 15 Clinical trials ( > 700 patients) CONCLUSION: Topical fluoride / fluoride-containing bonding materials effective But.. Which method most effective..?? 49
  • 70. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive Daily Fluoride Rinsing : Recommendation Daily Fluoride Rinsing ( 0.05% NaF) ..? Dentifrices, mouthwashes, and remineralization/caries arrestment strategies Indiana University School of Dentistry, Oral Health Research Institute, June 2006 50
  • 71. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive AntiPlaque / AntiMicrobial Agents : Phenolic / Essential oil Quaternary Ammonium Compounds Compounds (Thymol, Eukaleptol) (Cetyl Pyridinium Chloride) Triclosan Dentifrices, mouthwashes, and remineralization/caries arrestment strategies Indiana University School of Dentistry, Oral Health Research Institute, June 2006 51
  • 72. Introduction Research Prevention Clinical Management Summary During Orthodontic Tx Adjunctive AntiPlaque / AntiMicrobial Agents : Chlorhexidine 2nd line Treatment 0.2% Oral Rinse 0.05% Oral Gel Once daily 30 sec rinse each time Dentifrices, mouthwashes, and remineralization/caries arrestment strategies Indiana University School of Dentistry, Oral Health Research Institute, June 2006 52
  • 73. Introduction Research Prevention Clinical Management Summary Recommendations for Clinical Management Management of PWL  After orthodontic treatment 53
  • 74. Introduction Research Prevention Clinical Management Summary Clinical Management Mainly Depends On Severity : 54
  • 75. Introduction Research Prevention Clinical Management Summary Clinical Management Mainly Depends On Severity : Mild 54
  • 76. Introduction Research Prevention Clinical Management Summary Clinical Management Mainly Depends On Severity : Mild Moderate 54
  • 77. Introduction Research Prevention Clinical Management Summary Clinical Management Mainly Depends On Severity : Mild Moderate Severe 54
  • 78. Introduction Research Prevention Clinical Management Summary High Fluoride Concentration ?? 55
  • 79. Introduction Research Prevention Clinical Management Summary High Fluoride Concentration ?? ..The opacity is an optical phenomenon directly related to loss of subsurface minerals.. Gorelick et al, 1982, AJODO; Mellberg, 1988, Am J Dent 55
  • 80. Introduction Research Prevention Clinical Management Summary Effect of High Fluoride Concentration ?? 56
  • 81. Introduction Research Prevention Clinical Management Summary Effect of High Fluoride Concentration ?? High Fluoride Concentration i.e: Fluoride varnishes, APF gels, etc.. 56
  • 82. Introduction Research Prevention Clinical Management Summary Effect of High Fluoride Concentration ?? High Fluoride • Remineralization of Surface Layer Concentration • Blocks Porosities i.e: Fluoride Leading To varnishes, Subsurface Layers APF gels, etc.. 56
  • 83. Introduction Research Prevention Clinical Management Summary Effect of High Fluoride Concentration ?? High Fluoride • Remineralization of Surface Layer Concentration Persistant i.e: Fluoride • Blocks Porosities White lesions! Leading To varnishes, Subsurface Layers APF gels, etc.. 56
  • 84. Introduction Research Prevention Clinical Management Summary Recommendation Current Research Findings: Lesions Remineralise Slowly Through Normal Remineralisation Potential Of Saliva After Debonding ! 57
  • 85. Introduction Research Prevention Clinical Management Summary Recommendation Current Research Findings: Lesions Remineralise Slowly Through Normal Remineralisation Potential Of Saliva After Debonding ! Recommendation: AVOID HIGH FLUORIDE CONCENTRATIONS IMMEDIATELY & UP TO 6 MONTHS AFTER DEBONDING ! Zachrisson, 1986 - Ogaard, 1988 – Kamp, 1989 - Willmot, 2000… 57
  • 86. Introduction Research Prevention Clinical Management Summary Mild White-Spot Lesions • Small streaks.. • Not a Major Esthetic Problem 58
  • 87. Introduction Research Prevention Clinical Management Summary Mild White-Spot Lesions • Natural Remineralization (up to 6 months) • Small streaks.. • Avoid High F • Not a Major Conc. Esthetic Problem 58
  • 88. Introduction Research Prevention Clinical Management Summary Mild White-Spot Lesions • Natural Re-assess: Remineralization (up to 6 months) • Micro-Abrasion • Small streaks.. • Avoid High F • Composite • Not a Major Conc. Restorations? Esthetic Problem 58
  • 89. Introduction Research Prevention Clinical Management Summary Moderate White-Spot Lesions • Larger Lesions.. • Obvious Esthetic Problem 59
  • 90. Introduction Research Prevention Clinical Management Summary Moderate White-Spot Lesions • Natural Remineralization (up to 6 months) • Larger Lesions.. • Avoid High F Conc. • Obvious Esthetic Problem 59
  • 91. Introduction Research Prevention Clinical Management Summary Moderate White-Spot Lesions Re-assess: • Natural Remineralization (up to 6 months) • Micro-Abrasion • Composite • Larger Lesions.. • Avoid High F Facings ? Conc. • Porcelain • Obvious Veneers ? Esthetic Problem 59
  • 92. Introduction Research Prevention Clinical Management Summary Severe White-Spot Lesions • Cavitation (Caries) ! 60
  • 93. Introduction Research Prevention Clinical Management Summary Severe White-Spot Lesions • Immediate Restoration • Porcelain Veneers ? • Fluoride Application: • Cavitation (Wait 4-6 months first !) (Caries) ! 60
  • 94. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique A Conservative Approach To Dealing With Mild - Moderate PWL ..Recommended to be The First Consideration for Treatment.. Croll & Bullock, JCO, 1997 61
  • 95. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique High Torque – Low RPM application of PREMA compound Undetectable amount of enamel (50-150 microns) uniformly removed, along with the superficial decalcified tissue.. RESULT: A Smooth, Polished Enamel Glaze Resistant to Demineralization And bacterial Colonization.. Croll & Bullock, JCO, 1997 62
  • 96. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique Hydrochloric/Phosphoric Acid Fine-Grit Silicon Carbide Water-Soluble Gel PREMA Croll & Bullock, JCO, 1997 63
  • 97. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique  PREMA compound to be used only with a Rubber Dam..  Protective Eyewear for patient, clinician and staff..  Avoid prolonged exposure of PREMA to gingival tissues ! Fluoridation is recommended after Micro-Abrasion (4 minutes with Neutral NaF Gel) Kamp, JCO, 1989 Croll & Bullock, JCO, 1997 64
  • 98. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique 65
  • 99. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique Q: How much enamel can be removed safely? A: If concavity apparent, Restoration is indicated! 66
  • 100. Introduction Research Prevention Clinical Management Summary Enamel Micro-Abrasion ( Acid-Pumice) Technique Q: How much enamel can be removed safely? Q: How do we know A: If concavity apparent, when treatment is finished? Restoration is indicated! A: once wet enamel surface shows no evidence of an opacity after application of compound! 66
  • 101. Introduction Research Prevention Clinical Management Summary Summary Post-Orthodontic Decalcification Is A Well-established & Serious Problem In Orthodontics ! Bacteria Substrate Demineralization ( Caries ) Time 67
  • 102. Introduction Research Prevention Clinical Management Summary Summary Most Commonly-affected teeth:  Maxillary lateral incisors  Mandibular Premolars  Max. + Mand. Canines - Maxillary > Mandibular Teeth..  Maxillary Centrals - Gingival > Incisal Quadrants..  Mandibular 1st Molars - Max. PWL Larger in size.. - Gingival PWL Larger in size.. 68
  • 103. Introduction Research Prevention Clinical Management Summary Summary Successful Prevention Of PWL  Before Tx: Careful Patient Selection Proper Psychological Preparation Of Patient & Parent(s) ! Detailed, Easy-to-understand OHI: – “Tell – Show –Do” Technique – Visual Reinforcement – Written OHI 69
  • 104. Introduction Research Prevention Clinical Management Summary Summary Successful Prevention Of PWL  During Tx: “ Faster ”, Less-cluttered, More-refined Appliance System.. Simple-yet-effective Archwires & Tx Mechanics.. Fluoride Releasing Adhesives & Cements.. Adjunctive Daily Fluoride Mouth Rinses (0.05% Naf) “Motivation / Warning” techniques.. “Reward / Punishment” techniques.. 70
  • 105. Introduction Research Prevention Clinical Management Summary Summary Clinical Management Of PWL  Post - Tx: Avoid High Fluoride Concentrations up to 6 months Post-Debond ! 71
  • 106. Introduction Research Prevention Clinical Management Summary Summary Clinical Management Of PWL Post - Tx: Micro-Abrasion A Conservative Approach To Dealing With Mild - Moderate PWL 1st Line Treatment Mild PWL Natural Remineralization +/- Micro-abrasion Moderate PWL Natural Remineralization +/- Micro-Abrasion Severe PWL Immediate Restoration +/- Veneers? 72
  • 107. A PerfectTreatment Plan 73
  • 108. A Perfect SophisticatedTreatment Plan Mechanics 73
  • 109. A Perfect SophisticatedTreatment Plan Mechanics State-of-the-Art Appliance Systems 73
  • 110. A Perfect SophisticatedTreatment Plan Mechanics State-of-the-Art Appliance Systems 73
  • 111. A Perfect SophisticatedTreatment Plan Mechanics State-of-the-Art Appliance Systems 73
  • 112. Thank You For Being....Good Listeners ! 74