Open access peer-reviewed chapter - ONLINE FIRST
Abstract
Demineralization-induced white spot lesions (WSL) are early non-cavitated carious lesions, representing the earliest stage of tooth decay, and appear as opaque, milky, porous areas, with a depth of only 40–130 μm. They are frequently found postfixed orthodontic treatment, because of the retentive nature of brackets and wires, and the inherent difficulties in maintaining proper oral hygiene, but can be found in non-orthodontic patients, as well. The main concern is of esthetic nature, but untreated WSL may evolve in dental caries, with important structural and functional consequences. The treatment approach more often uses conservative methods such as remineralization, microabrasion, tooth whitening, and resin infiltration, but, depending on the case, resin restorations and veneers may be involved. This chapter aims to discuss their etiology, characteristics and diagnosis, prevention and treatment methods, and to present three clinical cases of demineralized induced WSL, of orthodontic and non-orthodontic origin, treated by means of a microinvasive method, namely resin infiltration.
Keywords
- white spot lesion
- WSL
- enamel
- demineralization
- remineralization
- resin infiltration
- microabrasion
- fluoridation
1. Introduction
White spot lesions (WSL) are of different etiologies and can be categorized as non-carious (due to fluorosis or developmental enamel defects such as amelogenesis imperfecta and molar incisor hypomineralization) and carious (due to localized demineralization of the enamel in non-orthodontic patients and localized areas of demineralization related to orthodontic appliances). The etiology of the WSL is of utmost importance for the treatment outcome and esthetic improvement [1].
Fluorosis results from excessive fluoride intake during tooth development and may manifest as a discoloration ranging from white spots to brown staining, accompanied by pits or cracks.
Amelogenesis imperfecta is an enamel development defect, that can be classified into three types: hypomineralized, hypomaturated, and hypoplastic.
Enamel hypoplasia is due to affected matrix formation, hypomineralization is the effect of maturation disturbance, while hypomaturation is caused by the reduced mineral deposition in the late stages of mineralization. Enamel hypoplasia appears as pits, grooves, and thin or missing enamel, hypomineralization is characterized by soft enamel, and hypomaturation by altered translucency of the entire tooth [2].
Molar incisor hypomineralization is a developmental condition that involves first or second permanent molars and permanent incisors, and appears as different-colored and demarcated enamel opacities, occasionally undergoing posteruptive breakdown [3].
These developmental enamel defects not only impair the esthetics but also exert significant effects on tooth sensitivity and function, being related to the early appearance of dental caries and malocclusion [4].
WSL of carious etiology are being associated with demineralization, and described as early non-cavitated carious lesions, representing the earliest stage of tooth decay. Demineralization related to orthodontic appliances does not represent a distinct type of caries, being the result of the earliest carious process occurring around fixed orthodontic appliances.
According to Fejerskov et al. [5], demineralization-induced WSL can be defined as the “first sign of a caries lesion on enamel that can be detected with the naked eye.” Their appearance, as white, chalky, and opaque spots, is due to the mineral loss that occurs in the surface and subsurface of the enamel, being, in fact, an optical phenomenon, and it is highlighted by drying. They are rough and porous compared with WSL of non-carious etiology, which are typically smooth and shiny. The prevalence of demineralized-induced WSL has increased lately, particularly in orthodontic patients. Left untreated, WSL can eventually develop into dental cavities [6].
Regardless of their etiology, white spot lesions may cause functional and esthetic concerns, strongly depending on their extent, depth, and color. Differential diagnosis, based on a thorough review of dental and medical history, and clinical evaluation of the location, form, symmetry, color, opacity, depth, and texture are essential in making a decision on the most appropriate type of treatment [1].
From a clinical point of view, in case of demineralization-induced WSL, preventive procedures, such as proper oral hygiene, non-cariogenic diet, and topical fluoride application are of utmost importance [2].
Treatment of WSL includes various methods, ranging from conservative to more invasive ones, such as composite restorations, veneers, and even crowns, which are mainly indicated in severe enamel discoloration or structural damage, which can be found more frequently in non-carious WSL. To fully mask the discoloration, a thicker composite layer is often needed, which may leave the tooth bulky. The esthetic outcome of veneers and crowns is definitely a good one, but they involve extensive dental tissue sacrifice, which is justified only in severe WSL cases, which cannot be treated by more conservative methods. Conservative treatment methods include remineralization, microabrasion, tooth whitening, and resin infiltration.
This chapter will further refer to
2. Etiology
WSL are the result of the bacterial acid attack of the dental biofilm. A poor oral hygiene, an insufficient salivary flow, which does not support self-cleansing, and a high-carb diet, combined with frequent exposure to fermentable carbohydrates, play their role in providing a favorable environment for developing and multiplying of cariogenic bacteria [7].
The most predisposed to WSL occurrence are highly retentive areas, which are difficult to clean and most predisposed to stagnating dental biofilm, such as neighboring areas to fixed orthodontic appliances. A total of 50% of orthodontic patients have one or more WSL, compared to 11% non-orthodontic ones [7].
Individuals exhibit different levels of caries risk, therefore a patient with an apparently acceptable dental hygiene may develop the same amount of enamel lesions as one with a poor dental hygiene. The salivary flow, the composition of the saliva, the enamel structure, the diet, as well as the genetic predisposal, are factors that may influence the individual response to acid attack [7].
Acidogenic bacteria, namely
3. Characteristics and diagnosis
The enamel demineralization-remineralization is a dynamic, continuous, simultaneous, or alternating process. Demineralization is induced by pathological factors such as acidogenic bacteria, low salivary flow, and high-carb diet, while remineralization is due to protective factors such as antibacterial agents, sufficient salivary secretion, remineralizing ions, and specific dietary nutrients. An altered balance between demineralization and remineralization results in caries initiate or arrest [5, 7].
However, when the pH is low for a longer period of time, demineralization becomes dominant, the quantity of ions that depart the enamel surface being higher than the quantity which returns. The first demineralization stage is represented by the dissolution of the interprismatic substance. The mineral loss broadly varies between 10 and 70%. The early non-cavitated carious lesion is characterized by a depth of only 40–130 μm [5].
Most WSL appear on the buccal surface of the tooth, more frequently in male population. Patients who undergo fixed orthodontic treatment show a higher prevalence of WSL, due to the retentive nature of the brackets, wires, and the inherent difficulties in maintaining proper oral hygiene. In orthodontic patients, WSL may appear as soon as 1 month after commencing the treatment, and their incidence is strongly correlated with the duration of the orthodontic therapy. Teeth with lingual brackets are less vulnerable to WLS compared to labial ones, the most important explanation being the much abundant salivary flow [10].
WSL appears as opaque, milky, porous areas, which reflect the light in a different manner when compared to natural translucent enamel. In some cases, WSL may become evident only after drying [7].
Beside visual diagnosis, quantitative light-induced fluorescence (QLF) is an efficient diagnosis method, based on the auto-fluorescence of the tooth when exposed to high-intensity blue light. Being in close relation with the mineral composition of the enamel, low fluorescence is exhibited by demineralized areas. QLF is a much more sensitive method of WSL detection, compared to visual inspection, higher WSL prevalence has been reported by studies using QLF [11].
A proper diagnosis of demineralization-induced WSL has to be carried out by making the differential diagnosis between similar conditions such as developmental enamel defects, and active or inactive carious lesions [10].
4. Prevention
Probably the best strategy is to prevent dental biofilm accumulation and improve enamel remineralization. Because of its multifactorial etiology, several approaches have been considered. However, selecting the best prevention method has to be patient-orientated.
4.1 Proper oral hygiene
Prevention must commence with educating the patient in maintaining proper oral hygiene, by explaining its importance and complications which, most probably occur in case of poor hygiene. So, detailed instructions are of utmost importance in educating patients on how to maintain adequate oral hygiene. In case of orthodontic patients, instruction should focus on how to clean around brackets. The correct brushing technique, either manual or electric must be explained, and the use of dental floss and mouthwashes must be encouraged. High fluoride concentration toothpastes are being recommended. Electric toothbrushes may represent a particular benefit to patients with higher plaque index. Antiseptic mouthwashes, particularly fluoride and chlorhexidine-based, turned out to be efficient in lowering the
4.2 Remineralization
Fluoride ions are efficient in preventing demineralization by inhibiting the enzymatic processes involved in bacterial metabolism, and thus inhibiting acid production. A decreased demineralization results in increased remineralization potential, and prevents excessive mineral loss and subsequent caries. Fluoride toothpastes and mouthwashes are meant for daily home use, while periodic topical application of fluoride varnishes, gels, and foams is mainly carried out by the dentist, more frequently in high-risk patients than in low/normal risk cases. Toothpastes with higher fluoride concentrations (1500–5000 ppm) have been shown to have a greater ability to inhibit demineralization and promote remineralization compared to conventional fluoride toothpastes (1000 ppm) [13].
Because the availability of calcium and phosphate ions limits the fluoride accumulation and the remineralization potential of saliva, the preventive efficacy of fluoride alone is questionable. The research toward caries prevention has led to the introduction of CPP-ACP, which is an amorphous form of calcium phosphate (ACP) stabilized by a phosphopeptide from the milk-protein casein (CPP). CPP-ACP has the potential to both prevent demineralization and promote enamel remineralization, by binding to the bacterial wall and, in case of an acid attack, it releases calcium and phosphate ions and maintains a saturation state of the enamel. The presence of CPP at the tooth surface has a certain role in reducing the adhesion of
4.3 Diet
A high-carb diet and frequent exposure to fermentable and refined carbohydrates, including sugared beverages, result in a higher risk of developing WSL. This type of beverage not only acts as a nourishing source to acidogenic bacteria but also carries an acid pH of 2–3. As demineralization begins to occur when the pH drops below 5.5, the combination of high sugar content and low pH promotes WSL appearance [15].
Probiotics have shown a great potential to positively impact the oral environment, by reducing the acidogenic microflora and replacing it with non-cariogenic bacterial types [16].
Polyol carbohydrates, such as xylitol, which are non-cariogenic, as they cannot be metabolized by
5. Treatment
In demineralization-induced WSL, conservative treatment methods such as remineralization, microabrasion, tooth whitening, and resin infiltration are being considered as the first choice. Depending on the case, other therapeutic choices, such as resin restorations and veneers may be necessary, or combined therapy may be attempted.
5.1 Remineralization
Remineralization is a non-invasive treatment method, carried out by using fluoride, calcium, and phosphate products. Fluoride, besides caries prevention, and enamel strengthening is also effective in reversing initial, non-cavitated lesions. Applied as varnish or other product forms, fluoride does not show immediate esthetic results, and it needs repeated applications for a certain period of time.
CPP-ACP, combined or not with fluoride, has shown to be effective in preventing and treating WSL. CPP-ACP products also help managing tooth sensitivity [6].
Self-assembling peptides (SAP) are involved in biomimetic enamel remineralization. They are involved in saliva-mediated hydroxyapatite regeneration, by providing additional nucleation sites for the crystallization of salivary calcium and phosphate ions. The most frequently used product is SAP P11-4 (Curodont Repair, Credentis), which has been proven to be effective in treating WSL, alone or associated with fluoride. The SAP P11-4 monomeric solution diffuses into the body of the lesion, and, by promoting new hydroxyapatite formation below the porous mineralized surface, it results in reducing the size of the WSL [18, 19, 20].
5.2 Microabrasion
Microabrasion is usually carried out by combining chemical erosion, using acid solutions such as HCl, and mechanical abrasion using pumice stones or brushes. HCl action consists of the decontamination and removal of the affected enamel areas and enhances the subsequent mechanical treatment. This method is considered to be safe and effective, especially in small WSL (˂ 0.2 mm diameter), and in combination with tooth whitening [21].
5.3 Tooth whitening
Tooth whitening is a minimally invasive technique, widely used in treating tooth discolorations. In case of WSL, after whitening, their milky appearance blends with the enhanced luminosity of the bleached unaffected tooth substance. The shade difference between the WSL and the sound enamel usually decreases, however, sometimes, the result may not be the expected one, and the WSL may look even worse after whitening. Whitening is especially indicated in old, inactive WSL [19, 22].
5.4 Resin infiltration
Resin infiltration is a microinvasive treatment option, an alternative to microabrasion, and it involves pretreating the WSL by using HCl, followed by subsequent infiltration with a low-viscosity light-cured resin, without mechanical removal of the surface layer. The acid leaves the tubules open, prepared for resin infiltration [23].
The white, chalky appearance of WSL is due to an optical phenomenon, caused by the difference between the refraction indexes of sound enamel and the porous, demineralized lesion. Because of hydroxyapatite dissolution, microspaces full of liquid and air were left behind. The idea was of filling these voids with a low-viscosity resin, capable of penetrating the microporosities of the etched enamel. As the infiltrating resin has a similar refraction index to hydroxyapatite, the human eye will perceive the tooth as being sound. Resin infiltration results in immediate improved esthetics and does not limit other dental treatments [22].
Resin microinfiltration results in increased microhardness, when compared to untreated or remineralized WSL, which leads to better fracture and abrasion resistance, comprehensive strength, and elasticity. This feature is due to the fact that the low-viscosity resin fills the pores and creates a diffusion barrier at the surface and within the inner part of the lesion. Thus, a re-hardening of the demineralized tooth structure takes place [24].
Regarding penetration efficiency, opposite opinions may be found in the literature. Some studies claim that the depth penetration is good, while other studies argue that the hypermineralized surface layer of early carious lesions may prevent the proper penetration of the infiltrating resin, despite the initial surface treatment using 15% HCl, questioning its efficacy and restricting it to the enamel surface [25, 26, 27, 28].
6. WSL treatment using resin infiltration: some case reports
The most frequently used and efficient resin infiltration product, widely studied since its release on the market, is the ICON kit (DMG, Hamburg, Germany) [29].
Resin infiltration treatment of WSL by using the ICON kit (Infiltration CONcept) is a microinvasive, well-tolerated method, with immediate results. ICON is recognized as effective in enhancing esthetics and reducing the risk of caries progression, thus avoiding or postponing the necessity for more extensive restorative approaches, thus having a protective-preventive role [30, 31].
The enamel structure is characterized by the presence of microporosities, which allows the low-viscosity resin to penetrate the depth of the affected enamel, filling all the voids, and resulting in the modification of its refraction index, as the resin has the same optic properties as sound enamel [30].
The system is based on three components (Figure 1): ICON-Etch (HCl 15%), ICON-Dry (ethanol), and ICON-Infiltrant (TEGDMA-based, low-viscosity light-cured resin). Its indication extends to treating incipient caries in both adults and children, being patient-friendly, as it does not involve rotary instrumentation or anesthesia [31, 32]. As it works on the infiltration principle, a dry field is necessary, and using rubber dam is required. The rubber dam also protects the soft tissues from the action of HCl, which may cause chemical burns. In order to gain a dry environment, ICON-dry (ethanol) is used to enable water evaporation from the porosities [31].
Figure 1.
The ICON kit (DMG (Hamburg, Germany)).
The technique involves etching with HCl 15%, 2 minutes, washing, drying with an air syringe, 30 seconds, ethanol application, injecting the resin, followed by light-curing. The process should be closely monitorized, as the ICON-dry application outlines if the enamel area to be infiltrated has been properly demineralized. If the enamel discoloration does not show significant improvement after one application of ICON-etch and ICON-dry, the manufacturer advises repetition, up to a maximum of three applications [32].
This is the case of hypermineralized enamel, where more than one ICON-Etch and ICON-Dry application is frequently necessary, in the attempt to penetrate the superficial layer and reach the underlying area, which still displays microporosities, and thus being characterized by a different refraction index compared with sound surrounding areas [31].
In order to illustrate the immediate esthetic outcome of ICON in treating WSL, three cases of different etiology and age were selected.
6.1 Case 1
Case 1: WSL due to fixed orthodontic treatment, which appeared 1.5 years prior to ICON treatment. WSL were localized on 1.1, 1.2, 1.3, 2.1, 2.2, and 2.3 labial side (Figure 2). In this case, three applications (which is the maximum prescribed by the manufacturer) of ICON-Etch and ICON-Dry were carried out.
Figure 2.
Case 1, WSL localized at 1.1, 1.2, 1.3, 2.1, 2.2, 2.3.
The treatment results are visible and may be described as follows: 1.1-complete blur of 80% of the area (Figures 3 and 4); 1.2-complete blur of 95% of the area (Figure 4); 1.3-complete blur of 50% of the area, the rest being partially blurred (Figure 4); 2.1-mesial WSL-partial blur of the entire area; distal WSL-almost complete blur of 90% of the area (Figures 3 and 5); 2.2-complete blur of 70% of the area (Figure 5); 2.3-no improvement (Figure 5).
Figure 3.
Case 1, 1.1 and 2.1 before and after treatment.
Figure 4.
Case 1, 1.1, 1.2, and 1.3 before and after treatment.
Figure 5.
Case 1, 2.1, 2.2, and 2.3 before and after treatment.
6.2 Case 2
Case 2: WSL due to fixed orthodontic treatment, relatively new (appeared several months prior to ICON treatment). The orthodontic device was removed 1 week prior to ICON treatment. WSL were localized in the upper part of the labial surface of 1.1, 1.2, 2.1, 2.2, 2.3 (Figure 6). Only one application of ICON-Etch and ICON-Dry was carried out. In case of 1.1, 2.1 there’s complete resolution, 1.2 shows 80% complete blur, and 2.2, 2.3 show 90% complete blur (Figure 7).
Figure 6.
Case 2, WSL localized at 1.1, 1.2, 2.1, 2.2, 2.3.
Figure 7.
Case 2, Posttreatment image.
6.3 Case 3
Case 3: non-orthodontic patient, with past neglected oral hygiene. After the occurrence of WSL, 2 years prior ICON treatment, the patient had improved oral hygiene, but there was no change. WSL were localized in the central part of the labial side of 1.1, 1.2 (Figure 8), and three applications of ICON-Etch and ICON-Dry were carried out. After treatment a complete blur of 75% of the area was seen in 1.1, and 50% in 2.1 (Figure 8).
Figure 8.
Case 3, before and after treatment.
Despite the fact that the post-treatment images of the three cases illustrated still show signs of milky areas, the patients were completely satisfied with the outcome, as their entourage no longer observes the issue.
7. Discussion
When referring to which is the most effective or the most frequently used treatment for WSL, the data found in the literature are quite controversial.
According to Saito, the most frequent treatment for WSL is fluoride, namely prescription of 5000 ppm toothpaste, followed by fluoride varnish and mouthwash [33]. Weiland also states that fluoride is the first choice of therapy in orthodontic patients, after bracket removal, followed by resin infiltration, microabrasion, resin fillings, veneers, no therapy, and tooth whitening [7]. According to Guzman, no treatment in the first 6 months after debonding may allow natural remineralization to take place, without any intervention. If this is not the case, the extent of the lesion and the urge for esthetic rehabilitation should be considered when deciding the treatment [34]. Sonnenson states that natural remineralization and tooth brushing twice a day with fluoride toothpaste may be the first option after debonding, followed by close monitoring for 3–6 months [35].
Despite the fact that fluoride is the most frequently prescribed for WSL treatment, systematic reviews by Sardana [36], Hu [37], and Sonesson [35] concluded that there’s no reliable information to support the effectiveness of topical remineralizing agents (fluoride and CPP-ACP) in treating post-orthodontic WSL. According to Sonnenson, fluoride in high concentrations (fluoride varnishes) may interfere with natural remineralization, due to surface hypermineralization, and result in permanent brown staining, with esthetic consequences [35]. On the other hand, SAPs are being mentioned as having promising results in both demineralization prevention and enamel remineralization. Using SAP P11-4 in combination with fluoride was shown to be more effective than fluoride alone [18, 38, 39, 40].
Akin compared the outcome of microabrasion with HCl and pumice to tooth brushing and concluded that microabrasion had a better outcome over a 6-month period [41]. Gu compared the esthetic effect of microabrasion and resin infiltration, over a 12-months period, and concluded that both showed sufficient durability, with a better outcome in case of resin infiltration [42]. According to Sonnensen, microabrasion and resin infiltration are efficient in more severe cases of post-orthodontic WSLs, but their disadvantage is being technique-sensitive. Microabrasion has to be repeated several times, while resin infiltration is a single-appointment treatment, but up to three rounds of etching may be needed [35].
Resin infiltration is an alternative to both prevent the WSL progression, with subsequent cavity formation and improvement of the esthetic appearance. The esthetic results in the case of anterior WSL may not be perfect, but resin infiltration has shown immediately improved esthetical appearance, when compared to untreated lesions, as well as good durability in short or long-term follow-ups. A study by Knosel considers that, after a 20-month follow-up, the assimilation of resin-infiltrated WSL to the color of adjacent teeth is suitable for a long-term esthetic improvement [43]. A meta-analysis conducted by Bouroni states that resin infiltration shows better esthetic results compared to fluoride varnish, much more, the effect of fluoride shows after several regular applications, which may take up to 6 months [26]. A recent study by Ibrahim concluded that both fluoride and resin infiltration improve the esthetic appearance of WSL, but resin infiltration lasts longer [27]. According to several systematic reviews, resin infiltration of WSL is effective in inhibiting further caries progression, in both primary and permanent teeth. Resin infiltration has proven to be more effective than the no-treatment approach and non-invasive methods such as fluoride varnish application, or hygiene instruction [25, 44]. A study by Urquhart states that the combination of resin infiltration and 5% sodium fluoride varnish is 5 times more efficient in WSL treatment, compared to no treatment [45]. Several systematic and umbrella reviews confirm the ability of resin infiltration to inhibit WSL and non-cavitated proximal enamel lesions progression, the relative risk of subsequent caries development being substantially diminished [25, 29, 44, 45, 46]. According to Cebula [29], long-term monitoring of lesion progression was confirmed by recent studies, follow-ups being usually carried out at 12–48 months, depending on the study [47, 48, 49, 50], or even at 7 years in a study conducted by Paris [30].
The 3 cases described in Section 6 are of different etiology and age. Two cases (Case 1 and 2) were of post-orthodontic treatment WSL and one of a non-orthodontic patient (case 3), with past neglected oral hygiene. The WSL of case 2 were quite new (several months prior ICON treatment), while the WSL of case 1 and 3 were older (more than 1 year prior treatment). In Case 2, only one application of ICON-Etch and ICON-Dry was necessary, while in Cases 1 and 3, the maximum of three applications of ICON-Etch and ICON-Dry were needed. In Case 2, out of the five WSL, two showed complete resolution, one showed 80% complete blur, and two showed 90% complete blur. In Cases 1 and 3, which exhibited older WSL, out of a total of eight lesions, one showed no improvement, six showed complete blur of 50–95% of the area, one was only partially blurred, and one showed complete blur of 50% of the area, the rest is partially blurred.
The better immediate esthetic outcome, with almost complete resolution of the WSL after only one application, has been observed in case of more recent lesions (Case 2). This may be explained by the still present large structural porosities, which allow the resin to penetrate the depth of the affected enamel, thus filling all the voids, and resulting in the modification of the refraction index. In case of older and deeper WSL, three ICON-Etch and ICON-Dry applications were necessary, in the attempt to penetrate the superficial remineralized enamel layer, and to reach the underlying area, which still displays voids, and thus being characterized by a different refraction index compared with sound surrounding areas. In cases of older lesions, no complete resolution was obtained, but the esthetic results were still encouraging and the patients were completely satisfied with the treatment outcome. This result is in line with previously published articles, which state that new, shallow lesions needed only one infiltration step, with good esthetic outcome, while older and deeper lesions were only partially masked after several applications [31, 51].
8. Conclusion
The treatment method in case of demineralization-induced WSL depends on the extent and esthetic gravity of the lesion and should be selected only after attempting the no treatment and at-home care options, in cases where these show to be inefficient. The resin infiltration method has good immediate results, and according to recent studies, has been proven to be not only esthetically suitable but also efficient in preventing the lesion progression, with long-term promising results.
Acknowledgments
The authors wish to express their thanks to Dr. Gloria Golban for her valuable contribution.
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