13 the white spot lesion Lama K El Banna

1. The White Spot
Lesion
Dr. Ahmed AlShawi

2.  "Dental caries is a specific and treatable bacterial infection
due to mutans streptococcus (MS) and in the later stages
to lactobacillus.”
 Currently beginning to believe that while MS is still
important, lactobacillus and other acid producing bacteria
are also initially involved.
 "The development of dental caries is a dynamic process of
demineralization of the dental hard tissues by the products of
bacterial metabolism, alternating with periods of
remineralization.”

3.  Caries is a multifactorial process (Host Factors, Specific
Bacteria, Sugar and time ) and is reversible in the early
stages.
 Pit and fissure caries is the most common.
Glass et al (Caries Res, 1983)
 Children between 6-30 months may become infected by
salivary exchange with the mother.
 Presence of caries in the mother increases risk of the child.
 Evidence indicates that not only is dental caries increasing in
the low income population but also in middle and higher
income children and teenagers.

4.  Since dental caries is an infectious disease, a review of
terms and concepts associated with the epidemiology of
infectious diseases are listed:
1. For an infectious disease to occur, it must have a source or
reservoir (person, animal, soil). In dental caries the source
may be the mother who transfers the infection to the infant.
2. Potential microorganisms may be transferred directly (by
people, insects) or indirectly (through water, air or soil). In
dental caries the transfer agent is through saliva of the
mother to the infant.
3. Pathogens must survive during transfer and successfully
establish within the host. In dental caries, this will take
several attempts and only at specified time periods.

5. 4. Colonization (multiplication of the organism) may occur
without evoking a tissue or immune response. In dental
caries this occurs. Additionally, colonization and bacterial
multiplication in dental caries is dependent upon sugar intake
and other local factors.
5. Infection indicates that colonization has occurred and the
disease process has begun as indicated by damage to the
tissue. In dental caries, there is demineralization of the tooth
surface.
6. The host response will determine if there is a manifestation
of the disease (demineralization). If the host response is
adequate, the individual may have the infection without the
clinical manifestations of the disease. He/she may thus be a
carrier, harboring the infectious agent which can be spread to
others. In dental caries, the carrier would usually be the
mother.

6.  The surface of enamel is dynamic and in a constant state of
flux depending on the microbial and chemical consistency of
saliva and plaque.
 Changes in these environments (saliva and plaque) can either
have a detrimental or beneficial affect on the enamel
surface. The detrimental affect can be identified as the early,
reversible event in dental caries, the white spot lesion.
 The early observation and clinical evaluation of white spot
lesions on the tooth surface provide the dentist with important
information about the disease process (active or inactive).

7.  1. Intact block showing enamel surface and
sub-surface

8.  2. Beginning of direct enamel surface crystal dissolution
along with subsurface dissolution
(demineralization) creates pores in the enamel.
 This results in surface roughness and loss of surface
shine (Change in optical behavior).

9.  3. Enamel demineralization alters the optical behavior of the
enamel resulting in greater visual enamel opaqueness since
porous enamel scatters the light more than does sound enamel
 (1) A lesion requiring air-drying to become visible (opaque)
has lost less mineral than a lesion which is visible without being
air-dried.
 (2) The histological examination of ground sections confirmed
a higher level of porosities and deeper penetration of the lesion
into the enamel in lesions visible without being air-dried
compared with lesions visible only after being air-dried.

10.  4. As demineralization progresses, the pores
increase and with remineralization the pores
decrease .

11.  5. As the pores enlarge bacteria may invade the
subsurface. It is somewhere during these stages of the
demineralization process that the white spot lesion will
lose its potential for remineralization.

12.  6. In the final stage, the carious process has
progressed to the point where sufficient amount
of enamel matrix has been lost and the inward
collapse of the remaining surface layer.

13. Loss of remineralization ability may be due to:
1. Destruction of the enamel matrix.
2. Alterations in the acid diffusion pattern into the subsurface
resulting in lower pH.
3. Bacterial invasion into the subsurface.

14.  The best indicators for an increased risk of dental caries
infection:
 Most consistent predictor in children is past caries experience.
 Presence of caries in the mother.
 Oral hygiene status, Fluoride intake.
 Medical conditions-- low salivary flow levels.
 MS levels are weakly predictive .

15.  Measuring the MS levels at suspected sites has use in
determining current caries activity.
-A commercially available MS test, the Dentocult SM
chair-side testing kit is available. It has limited accuracy.
 The most reliable MS test is available through
bacteriological testing labs. Levels exceeding 100,000
CFU suggest that caries is active. Knowing MS levels is
an aid for caries assessment and monitoring.
 With the white spot lesion, we observe physical changes
that occur at the tooth surface, providing information
about the status of caries activity at a specific site. Use
color and texture to access the disease state. Texture is
more reliable than color .

16.  he disappearance of white spots (WS) can be by
remineralization and surface abrasion (1).
 The repair process:
-Demonstrated by in vivo studies (2).
-Low fluoride levels enhances rate and degree of
remineralization (1,3).
-Remineralized enamel is more resistance to
caries attack (more acid insoluble) than intact
enamel (4).
-Repaired enamel has greater organic content
which helps resist acid attack (4).

17.  In a adult human study (1966) 71 WS lesions were tracked
for 7 years with the following results:
-9 lesions progressed to caries. (13%)
-25 lesions remained unchanged. (35%)
-37lesions where no longer detectable (5). (52%)
 In 12 year old children (2003) 719 WS lesions were tracked
for 36 months with the following results:
-177 lesions progressed to caries. (25%)
-397 lesions remained unchanged. (55%)
-145 lesions where no longer detectable (6). (20%)

18. Diagnosing and Differentiating Between Active and Inactive lesions.
 The white spot (WS) lesion can be active progressing to
cavitation, it may be inactive not progressing or may even be
healing
Sound
Enamel
Smooth surface intact, smooth and glossy.
Pit and fissures intact possibly with some staining.

19. Enamel
hypoplasia
Enamel
hypocalcific
ation
Enamel hypoplasia is a defect in tooth enamel matrix
formation that results in less quantity of enamel than
normal. May be pitted and rough if severe.
Enamel hypocalcification is a deficiency in mineral
content and appearing to have a normal enamel
matrix. This may be difficult at times to differentiate
from WS lesion.

20. White spot
lesion Active
caries
(chalky
surface)
Surface of enamel is whitish/yellowish opaque with loss
ofluster. It feels rough when the tip of the probe is gently
moved across the surface. No clinicallydetectable loss of
substance.
Smooth surface caries lesion typically located close to gingival
margin.
Pit and fissures have intact fissure morphology. Lesion may
extend along the walls of the fissure.
Under proper conditions, non-cavitated areas can remineralize
and converted into arrested or nonactive lesions (1).

21. White
spot
Inactive
caries
Surface of enamel is white, brown or black. It
is glossy with no loss of luster; feels smooth
and hard when the tip of the probe
is gently moved across the surface (2).
The root/dentin lesion
is hard and may be dark.

22. Cavitated lesion,
active caries.
Enamel/dentin cavity easily visible
with the naked eye;surface of
cavity feels soft or leathery on
gentle probing.
There may or may not be pulpal
involvement. The lesion is usually
moist and grayish.

23. Cavitated lesion, inactive caries
Enamel/dentin cavity easily visible
with the naked eye; surface of cavity
feels hard on gentle probing, appears
shiny and may have dark stain.

24. Classification Description
Intact
restoration.
Intact restoration.
Restoration with
active caries.
Secondary caries lesion may cavitated and/or have active
white spot lesion area adjacent to restoration. White spot area
is rough to the feel and is not glossy.
Restoration with
inactive caries.
Secondary caries lesion may cavitated and/orhave inactive
white spot lesion area adjacent to restoration. White spot
area is smooth to the feel and is glossy.

25. 1. FOR VISUAL
IDENTIFICATION OF THE
LESION

26. A. Use a good light.
B. Clean and dry the teeth.
C. Magnification helps.
D. Transillumination helps.
E. uses light to transilluminate each tooth and to instantly create a
digital images of the tooth on a computer monitor.
F. Dyes are of limited use.
G. Diagnodent :Tooth structure will fluoresce when irradiated by a
laser light of a specific wavelength. The presence of dental
caries alters the fluorescence of the tooth structure. These
fluorescence changes are measured by this instrument and are
used as an indicator of the extent of caries.

27. 2. Tactile- use of explorer?

28. 3. X-rays help especially for
proximal lesions. Use digital
x-rays.

29. STRATEGIES TO FOLLOW
FOR CARIES CONTROL:

30.  Identify the individuals at risk.
Do a risk assessment.
 Control the MS infection.
1. At the initial office visits provide 1.2% Acidulated-Phospo- Fluoride
(APF) treatment.
2. Have the patient use 1/2 oz. Chlorhexidine mouth rinse for 30 seconds
at bedtime for 2-3 weeks.
3. Apply fluoride varnish.
4. In high risk individuals also have patient use 1.1% NaF (Prevident
5000) paste.
5. Have patient use Xylitol gum, 2 pieces, 5 times per day, for 5 minutes.
6. Stress control of sugar intake.
7. Monitor oral hygiene.
8. Pit and fissure sealants may be used in the high risk patient to eliminate
sites that could harbor MS in large numbers.
9. Use hard cheese in diet. Casein presence aids in remineralization.
-Also suggested for the control of MS infection is the use of an
ozone producing device to eliminate bacteria and the use Povidone
Iodine as a topical agent on teeth.

31.  These procedures initiate measures to shift the
patient at high or moderate risk to low-risk
category. It will also aid in treating the non-
cavitated lesions to remineralize.
 Cavitated lesions are treated in the traditional
fashion.
 Monitor caries risk status of patient at recalls to
maintain-low risk category.

32.  Summary:
 Dental caries is an infectious disease caused by specific acid producing
bacteria found in the biofilm.
 Dental caries is a reversible, multifactorial process of tooth
demineralization and remineralization.
 Cavitation is the terminal, non-reversible end of the disease process.
 The cavitated lesion can only be treated by restorative means.
 The disease process begins with the concentration of MS and other acid
producing bacteria in the biofilm at specified tooth surfaces andmay lead
to white spot formation or even cavitation.
 The disease progression may be sporadic and can terminate at any point
in the process.
 The white spot is treatable by non-invasive means, can be maintained in
an inactive form or even heal, if the lesion is non-cavitated and the
cariogenic bacteria, diet factors and host factors are maintained at a low
level.