Presented by

Mutyala jhansi (JR-2)

Pediatric and preventive dentistry
It is common to look at dental caries as a multifactorial disease.

In 1980’s by thylstrup and bruun suggested that to look at dental

caries as a localised disease caused by undisturbed accumulation of
natural oral bacteria.
 The sign of the disease can be arranged on a line, illustrating principal
loss of mineral in relation to time.

The first sign of caries can only be seen through an electron microscope
at ultra-structual level. With no intervention caries will progress over
time to visible stage: white spot, cavity formation, and total destruction
Early caries lesions usually look whitish opaque, which yielded their
name as ‘white spot lesions’.

This whitish appearance is caused by localized light scattering whit in

lesion body.

In contrast to sound enamel, which is relatively translucent, in white

spot lesions the light scattered between the enamel crytstals and
porosites. (With different refractive indices)
The greater difference in RI between the pore medium and the
remaining enamel crystals ,the more the light will be scattered.

This is why dry lesions look more whitish compared with wet lesions.

“first sign of a caries lesion on enamel that can be detected with the
nakedeye.”

Fejerskov O N B, Kidd E. Dental caries: the diseasand its clinical management.2nd ed.
Copenhagen: Blackwell Munksgaard; 2003.
 In non cavitated enamel
carious lesions the
porous lesion body is
covered by a pseudo
Intact surface layer.

This highly mineralised

zone is of
approximately 20 to
40 um in thickness.

Pitts NB. Background level care. in: pitts NB(ed). Detection, assessment, diagnosis and
monitoring of caries. Basel: karger, 2009: 144-148.
Aside from the white spot lesion being the key for the early diagnosis
of caries lesions, the intact surface layer has been a confusing aspect
in the confirmation of demineralisation.

The reason behind the presence of intact surface layer is because of:

But, the calcium and phosphate

no doubt bacterial acids
ions produced from subsurface
dissolves the surface as well
dissolution diffuse outward
as the subsurface enamel
towards the surface

reprecipitation on the
surface, making the
enamel surface unaltered.
 Hence, the surface enamel is in type of equilibrium with mineral
being lost into plaque due to low pH, but being remineralised from
the ions diffusing out from subsurface lesion.

If the cariogenic environment continues, eventually the rate of

transfer from the surface enamel into plaque becomes greater than
the rate of precipitation, and the surface enamel collapse lead to
frank cavitations.

Moreno E.C. and Zahradnik R.T.: chemistry of enamel subsurface demineralization in

vitro. J. Dent. Res. 53:226, 1974.
Smooth surface caries can occur on any surface of the primary and
permanent teeth.

Most frequently in primary

dentition distal surface of
1st molar and mesial
surface of 2nd molar

In children with poor oral hygiene these smooth surface caries can
occur on

Buccal surfaces of
maxillary teeth and on
lingual surfaces of
mandibular teeth
One of the most clinically significant factors of WSL is the potential
for rapid formation, with clinically visible lesions developing in as
little as 4 weeks.

In contrast to pit and fissure caries, non rampent smooth surface lesions
appear to require at least 1 to 2 yrs of exposure to the cariogenic
environment before they can progress to cavitation.

Ogaard B, Rolla G, Arends J, ten Cate J M. Orthodontic appliances and enamel

demineralization. Part2. Prevention and treatment of lesions. Am J Orthod Dento facial
Orthop 1988; 94(2): 123–8.

Text book of Pediatric dentistry: total patient care, 1st edition stephen H.Y. Wei.
EPIDEMOLOGY:

The prevalence of WSL’s has been reported to range from 2% to 96%.

This wide range is likely due to the inconsistent operational definitions
of a WSL’s among different studies.

The sensitivity in the discrimination of a WSL’s depends on the method

of detection.

Studies employing quantitative light-induced fluorescence(QLF) report

higher prevalence of lesions than studies where these lesions are
defined by a visual inspection.

Boersma JG, van der Veen MH, lagerweij MD, et al. caries prevalence measured with QLF
After treatment with fixed orthodontic appliances: influencing factors. Caries Res
2005;39(1):41-7.
ETIOLOGY:

White spot lesions are area of demineralised enamel that usually

develop because of prolonged plaque accumulation.

This encourages the colonization of aciduric bacteria; over time, this

results in active white spot lesion and if not treated, a cavitated
carious lesion can develop.
 RISK FACTORS

 Inadequate oral hygiene .

 Inappropriate diet (refined sugar, frequent snacks)
 History of recent caries lesions or high DMFS.
 Lack of adjunctive preventive measures ( fluoride or
antibacterial exposure , xylitol , calcium – derived supplements ) .
 Orthodontic treatment time( fixed appliances) > 36 months
 ZONES OF INITIAL SMOOTH SURFACE ENAMEL CARIES
Polarized light microscopy has revealed that there are at least four
distinct zones to the Initial smooth surface lesions.
SUPERFICIAL ZONE:
Which is directly beneath the plaque and it is the least
demineralized zone.
This surface zone is 20 to 100 um thick and is estimated to have
approximately 1% to 10% mineral loss.

BODY OF THE LESION:

Where the greatest destruction to the enamel has occurred and it
occupies the largest proportion of the carious lesion.
Approximately a 25% reduction of mineral loss occurs in this zone
compared with sound enamel.
DARK ZONE:
Is found below the body of the lesion and it has approximatly 6%
mineral loss
This zone is thought to be an area of demineralization as well as
remineralization.

TRANSLUCENT ZONE:
The advancing front of the white spot lesion is most often referred
to as the translucent zone and generally has about 1% mineral loss.
 DIFFERENCIAL DIAGNOSIS OF WSL’S

Carious vs Non carious Lesions

Carious lesions : appear Rough ,Opaque ,and Porous

WHITE SPOT LESIONS ( WSL’s ): Subsurface enamel porosity from

carious demineralization manifesting as a milky white opacity on the
enamel.
.
EARLY CHILDHOOD CARIES INITIAL LESIONS : white decalcification
with beginning of enamel breakdown affecting the primary teeth

White spot lesion: prevention and treatment: Am J Orthod Dentofacial Orthop

2010;138:690-6
 Noncarious lesions : appear Smooth & Shiny

Dental Fluorosis
Enamel opacities
Enamel Hypomineralization

DENTAL FLUOROSIS: Associated with cumulative fluoride intake

during enamel development . Affected teeth are less susceptible to
dental caries .

Characteristics:
White / yellowish lesion
 Not well defined
Symmetrical distribution
 ENAMEL OPACITIES :

 More defined in shape.

 Well differentiated from surrounding enamel.
 Often located in the middle of the crown.
 Randomly distributed .

ENAMEL HYPOMINERALIZATION:
Well demarcated opacities on the labial surface, due to
injury or infection of the deciduous teeth, which has
affected mineralization of the permanent teeth .

White spot lesion: prevention and treatment: Am J Orthod Dentofacial Orthop

2010;138:690-6
 DIAGNOSTIC METHODS

 Visual examination

 Optical Non-Fluorescent Methods

Light Scattering
 Fluorescence methods
Fluorescent dye
Ultraviolet
Laser
DIAGNODent
QLF (quantitative light fluorescence)
Infra-red Fluorescence
Transillumination
 Electrical Conductance – ECM
Digital Radiography – DDR
 Diagnosis and clinical assessment of white spot lesions is a great
challenge for researchers.

International Caries Detection and Assessment System II (ICDAS II)

criteria was developed by an International team of caries researchers
to integrate several new criteria systems into one standard system for
caries detection and assessment .

It determines the potential histological depth as well as surface

changes of carious lesions by observing surface characteristics.

International Caries Detection and Assessment System Coordinating Committee.

Available at: https://www.icdas.org.
Mizrahi E. Surface distribution of enamel opacities following orthodontic treatment.
Am J Ortho Dentofac Orthop. 1983; 84:323–31.
Codes for detection and classification of carious lesions on the smooth
surfaces according to ICDAS II criteria are as follows:

Code 0: Sound tooth surface

Code 1: First visual change in enamel
Code 2: Distinct visual change in enamel when viewed wet
Code 3: Localized enamel breakdown due to caries with no visible
dentin
Code 4: Underlying dark shadow from dentin with or without
localized enamel breakdown.
VISUAL EXAMINATION:

Prior to examination, scaling of the teeth will be done to remove any

plaque and debris and all tooth surfaces were polished with pumice
and prophylaxis cup.

The visual diagnosis of WSL is the Identification of existing non

developmental WSL prior to orthodontic treatment is an important
part of the risk-assessment process.

The presence of such lesions in a patient

without a history of orthodontic appliances
should be noted in the dental history and
automatically increases the risk category
of the individual.
Individual caries risk is multifactorial.

It can be puzzling to see a patient with oral hygiene that appears

to be acceptable still develop WSL, where as one who has
extremely poor hygiene may develop none.

Individual host factors including salivary flow and composition,

enamel solubility, immune response, genetic susceptibility, diet,
and medication history are all important determinants of over all
caries risk.
Advantages

Simple and inexpensive : no expensive or complex equipment is

required.

Disadvantages

Validity : it is often difficult to clinically distinguish white spots caused

by demineralization and those that are due to other causes, such as
developmental hypoplasia or fluorosis.
OPTICAL NON-FLUORESCENT METHODS

LIGHT SCATTERING:

Light scattering, which can be measured using the Optical Caries

Monitor (OCM)

They used a 100 watt white light as a light source and measured
backscatter with a densitometer.

Ten Bosch JJ, Borsboom PC, ten Cate JM. A nondestructive method for monitoring de and
remineralization of enamel . Caries Res 1980;14:90-95.
Borsboom PCF, Ten Bosch JJ. Fiber-optic scattering monitor for use with bulk opaque
material. Applied Optics 1982;21:3531-3535.
Advantages

The optical caries monitor which enables a convenient and non

destructive quantification of enamel demineralisation.
It can be applied in the clinical environment and has been correlated
with established methods of studying mineral loss.

Disadvantage

It is particularly technique sensitive and results can vary with the

degree of wetness or drying of the tooth.
 OPTICAL FLUORESCENT METHODS

FLUORESCENT DYE:
fluorescent dye uptake various dyes fluorescent and non-fluorescent
have been used to highlight carious enamel .
Once the fluorescent dye has been applied the specimen is examined
under a suitable light source.

The disadvantage of these dyes is that slight procedural variations can

result in widely different degrees of dye uptake. They are mainly used
for the detection and removal of carious dentine.

Rawls HR, Owen WD. Demonstration of dye-uptake as a potential aid in early diagnosis
of incipient caries . Caries Res 1978;12:69-75.
45. Hosoya Y, Taguchi T, Tay FR. Evaluation of a new caries detecting dye for primary and
permanent carious dentin . J Dent 2007;35:137-143
 ULTRAVIOLET:

Early studies used an ultraviolet (UV) light for the early detection of
carious lesions on the smooth surfaces.

Special precautions are required to protect the patient and

operator because UV radiation, which has a wavelength shorter
than visible light (<400nm) is harmful to the eyes
and skin.

Safer methods using light sources with a longer wavelength have

been developed.

Shrestha BM. Use of ultraviolet light in early detection of smooth surface carious
lesions in rats . Caries Res 1980;14:448-451.
 LASER:
Josselin et al used an argon-ion laser producing light in the blue-green
range of the electromagnetic spectrum (440 to 570nm).

A yellow high-pass filter was used on the detection equipment to cut

off light with a wavelength less than 520nm (the blue and lower green
range).

De Josselin de Jong E, Sundstrom F, Westerling H, et al. A new method for in vivo quantification
of changes in initial enamel caries with laser fluorescence . Caries Res 1995;29:2-7.
Al-Khateeb S, Forsberg CM, de Josselin de Jong E, et al. A longitudinal laser fluorescence study
of white spot lesions in orthodontic patients . Am J Orthod Dentofacial Orthop 1998;113:595-
602.
This ensured that tooth scattered blue laser light did not reach the
detection apparatus, but allowed fluorescence in the yellow region
(wavelength 565-590nm) to be measured.

As with all fluorescence techniques the demineralised lesions appear

as dark areas (decreased fluorescence or absorption).

The equipment was calibrated to calculate the difference in

fluorescence between the demineralised area and the surrounding
sound enamel and thereby quantify mineral loss and lesion size.
 DIAGNODENT:

The technology of the DIAGNOdent, uses a 655 nm diode laser or the

red end of the electromagnetic spectrum for detection of
noncavitated, occlusal pit-and-fissure tooth decay, in addition to
smooth surface caries at an earlier stages .

The DIAGNOdent measures laser fluorescence within the mineral

structure of the tooth. As the incident laser light is disseminated into
the site, two-way handpiece optics allows the unit to simultaneously
quantify the reflected laser light energy

Lussi A. Clinical performance of the laser fluorescence system DIAGNOdent for detection
of occlusal caries (in German). Acta Med Dent Helv 2000; 5:15-19.
 Healthy tooth structure exhibits little or no fluorescence, resulting
in very low scale readings on the display.

Decayed tooth structure will exhibit fluorescence, proportionate to

the degree of lost tooth structure, resulting in elevated scale
readings on the display of the diagnodent.

Pinelli C, Campos Serra M, de Castro Monteiro Loffredo L. Validity and Reproducibility of a Laser
Fluorescence System for Detecting the Activity of White-Spot Lesions on Free Smooth Surfaces
in vivo Caries Res 2002;36:19–24
Sanchez-Figueras A. Laser Fluorescence Detection of Occlusal Caries. Clinical
utilization of the KaVo DIAGNOdent.
Recommendations for treatment are:
values between
10–15
no active care or Value between 15–30
treatment preventative or operative
care, depending on the
patient’s caries risk
values of 30+
operative and
preventative care.
One study compared the accuracy and repeatability of three
diagnostic systems (DIAGNOdent, visual and radiographic) for occlusal
caries diagnosis in primary molars. The DIAGNOdent was the most
accurate system in the study for the detection of occlusal dentinal
decay in primary molars.

Attrill DC, Ashley PF. Occlusal caries detection in primary teeth: a comparison of
DIAGNOdent with conventional methods. Br Dent J. 2001 Apr 28; 190(8):440-3.
 QLF (QUANTITATIVE LIGHT FLUORESCENCE):

QLF is a diagnostic method that relies on the autofluorescence of

teeth when they are exposed to high-intensity blue light.

The fluorescence of the tooth is closely related to the mineral

content of the enamel, with demineralization showing less
fluorescence.

This relationship allows for the quantification of demineralization or

remineralisation at one time point or overtime.

Heinrich-Weltzien R, Kuhnisch J, vander Veen M,et al. Quantitative light-induced

fluorescence (QLF)-a potential method for the dental practitioner. Quintessence Int
2003;34(3):181–8.

Khateeb S, et al: A longitudinal laser fluorescence study of white spot lesions in

orthodontic patients: Am J Orthod Dentofacial Orthop 1998;113:595-602
QLF is a highly sensitive diagnostic test, with the most promising
fluorescent method of measuring demineralisation in use today.

It is usefull in monitoring of mineral changes in incipient enamel lesions,

and for the evaluation of preventive measures in caries prone persons,
such as orthodontic patients.

Khateeb S, et al: A longitudinal laser fluorescence study of white spot lesions in

orthodontic patients: Am J Orthod Dentofacial Orthop 1998;113:595-602
 TRANSILLUMINATION
A new fiberoptic diagnostic tool enabling dentists to identify early
caries lesions with greater sensitivity and specificity is the fibre-
optics-based confocal imaging system which can record axial profiles
through caries lesions using single-mode optical fibers.

Digital Imaging Fiber-Optic Trans-Illumination (DIFOTI), did not

measure the depth, could only detect surface changes associated
with early demineralization as early as 2 weeks.

Rousseau C, Poland S, Girkin JM, Hall AF, Whitters CJ. Development of fi bre-optic confocal
microscopy for detection and diagnosis of dental caries. Caries Res 2007;41:245-51.
 DIGITAL RADIOGRAPHY

The X-ray micro-tomography is aimed to characterise the mineral

density (MD) of enamel white spot lesions (WSLs) calibrated with
different density hydroxyapatite phantoms.

X-ray micro-tomography is a sensitive in vitro technique capable of

characterising and quantifying MD of small non-cavitated WSLs. This
method has a promising potential for future carious and quantitative
remineralisation studies.

Tiffany T.Y. Huang, et al Characterisation of enamel white spot lesions using X-ray
micro-tomograph, J. Dent September 2007, volume 35, issue 9: Pages 737-743
 MANAGAMENT OF WHITE SPOT LESIONS

These lesions cover a range of different treatment options:

Non-invasive or non-operative treatments

Regular plaque removal
Dietary control
Fluoride
Other measures which include: Chlorhexidine
Xylitol
Carbamide peroxide
Micro invasive techniques
Resin Infiltration/sealing
Microabrasion
Whitening

Invasive or minimally invasive techniques

Resin Restorations/Indirect Restorations
 Non-invasive or non-operative treatments
These measures aim to influence etiological factors of the caries process ,
therefore not only prevent lesion formation(primary prevention) but also
accomplish arrest and remineralization of caries lesion(secondary
prevention)

Regular plaque removal:

Dental plaque is composed primarily of bacteria and ability of certain
bacteria to become attached to enamel and to proliferate while localized
there determines formation of smooth surface plaque.

The no. of micro-organisms available for attachment is one factor shown to

be important for attachment and spread of s.Mutans.

Saliva concentration of s. Muans exceeding 10 4/ml are needed to obtain

implantation or spread.

Van Houte J and green D.B:relationship between the concentation of bacteria in saliva
and the colonization of teeth in humans. Infect. Immunol, 1974, 9:624,
 Regular removal/ distrurbance of the carigenic plaque covering the lesion is
the only way to arrest further lesion progression.

Although it might seem challenging for a parent/ child to arrest progressing

lesions by plaque removal , it is important to understand that total
elimination of plaque is not necessary.

Thus, partial removal/disturbance of the cariogenic biomass is sufficient to

suppress bacterial activity and hence caries development.

Holmen L, Mejare I, Malmgren B, Thylsturp A. the effect of regular professional plaque

removal on dental caries in vivo. Caries Res 1988;22:250-256
 Fluorides:
since 1940s fluoride has been a cornerstone in caries prevention.

The effect of fluoride is predominantly a post-eruptive effect, by reducing

mineral loss from lesions beneath undisturbed plaque, which means a
reduced progression rate.

The easiest application measure is the use of fluoridated dentrifrice.

Fluoridated dentifrice combines mechanical removal and disturbance of

plaque with an appropriate delivery of fluoride and this has an effect at
the highest evidence level

Holm A-K, Axelsson S, Dahlgren H, et al. preventing dental caries. A systematic review.
2002
 The effect are dose related, i.e., Dentifrice with a 1500ppm concentration of
fluoride yield a better effect than dentifrice with 1000ppm.

Children with active caries lesion should generally be recommended to use a

high conc. of F- dentifrice i.e., 1450-1500ppm.

However, children under the age of 7-8 still have permanent teeth to be
mineralised, and therefore the risk of fluorosis should be minimized by
taking the age/weight of the child and other fluoride sources, eg: drinking
water.

Holm A-K, Axelsson S, Dahlgren H, et al. preventing dental caries. A systematic review.
2002
The mechanisam of action of applying high conc. of topical fluorides, like 2%
sodium fluoride or fluoride varnish is the formation of calcium fluoride in the
active lesion.

Calcium fluoride will serve as an reservoir of fluoride in the lesion and when
cariogenic plaque cover the lesion again, fluoride will be released and there
by decelerate the progression rate.

Bruun C, givskov H. formation of CaF2 on sound enamel and caries like enamel lesions
After different forms of fluoride application in vitro caries Res 1991;25:9-100
 Amorphous calcium phosphate (ACP) is thought to have the potential to
prevent and resolve enamel demineralization in patients with high caries
risk.

MI Paste is a product that contains casein phosphopeptide ACP, a milk-

derived protein that helps to promote high rates of enamel
remineralisation. MI Paste Plus is the same product, but also contains
900ppm of fluoride.

A recent randomized controlled trial demonstrated that orthodontic

patients who applied MI Paste Plus nightly via a fluoride delivery tray for 3
to 5 minutes following brushing showed fewer and less severe WSL than
controls.

Robertson M A, Kau C H, English J D,et al.MI Paste Plus to prevent demineralization in

orthodontic patients: a prospective randomized controlled trial. Am J Orthod Dentofacial
Orthop2011;140(5):660–8.
Dietary control:

Sugar intake plays an essential role in caries etiology.

A more strict dietary counselling of the individual child should be restricted

to children with very fast progression rates and for cases with limited effect of
the first choice procedure i.e., education and training in conjunction with
professional plaque removal and fluoride.

Gustafsson BE, Quensel CE,Lanke LS, et al . The vipeholm dental caries study. The effects of
different carbohydrate intake on caries activity in 436 individuals observed for five years.
Acta Odontol Scand 1954;11:232-264.
 Xylitol

A polyol carbohydrate, xylitol is not metabolizable by S.mutans and therefore

non cariogenic. It also appears to have antimicrobial properties that help to
prevent S.mutans attachment to tooth surfaces.

It has been demonstrated that the use of xylitol chewing gum can reduce the
risk of caries compared with gums containing sucrose or sorbitol, and
chewing gum also has been shown to increase the production of stimulated
saliva, which has higher phosphate and calcium concentrations than non
stimulated saliva.

High-risk patients may benefit from chewing xylitol gum 3 to 5 times per day
for a minimum of 10 minutes.

Dawes C, Macpherson L M. Effects of nine different chewing-gums and lozenges on

salivary flow rate and pH. Caries Res 1992;26(3):176–82
Makinen K K, Bennett C A, Hujoel P P, et al. Xylitol chewing gums and caries rates: a 40-
month cohort study. J Dent Res 1995;74(12):1904–13.
 Chlorhexidine

Chlorhexidine rinses may be used in conjunction with a fluoride

regimen to reduce the numbers of cariogenic pathogens and further
inhibits demineralization.

These rinses are recommended to be used in a 2-week regimen, with

the patients wishing for 30 seconds prior to bed time. As with all
chlorhexidine products, there is a tendency for extrinsic staining of
teeth, which patients should be informed of.

MI Paste, MI Paste Plus, or similar products may also be used as part of

a more intense regimen to increase remineralization.
Lundstrom F, Krasse B. Caries incidence in orthodontic patients with high levels of
Streptococcusmutans. Eur J Orthod 1987;9(2):117–21.
Derks A, Katsaros C, Frencken J E, et al. Caries-inhibiting effect of preventive measures
during orthodontic treatment with fixed appliances. A systematic review. Caries Res
2004;38(5):413–20.
 Carbamide Peroxide

There is evidence that salivary and plaque pH are increased by urea, which
is a component of carbamide peroxide.
This increase in pH along with the antimicrobial effect of hydrogen peroxide
may suppress plaque formation.

Patient compliance with periodic use of carbamide peroxide whitening

agents during orthodontic treatment may be enhanced because of the
perceived added benefits of tooth whitening on the part of the patient.

There is currently no published evidence of the use of carbamide peroxide

products preventing WSL in orthodontic patients, but it would seem that
this approach may have promising potential.

Lazarchik D A, Haywood V B. Use of tray-applied 10 percent carbamide peroxide gels for

improvingoral health in patients with special-care needs. J Am Dent Assoc2010;141(6):639–46.
MICRO INVASIVE TECHNIQUES

Resin Infiltration/sealing

Resin infiltration is to penetrate the porosities of the lesion body

with low viscosity light curing resin, so called infiltrants.

The fragile crystal network of the lesion body is stabilized by the

resin matrix and cavitation might be avoided.

The resin just has to be applied onto the lesion surface and the
material soaks up into the lesion body driven by capillary forces.

The aim of caries infiltration is to occlude the pores within the lesion
body in that way, diffusion pathway for cariogenic acids are blocked
and the lesion is arrested and stabilized.
 PREREQUISTIES FOR CARIES INFILTRATION

 Erosion of the surface layer

 Desiccation of the lesion
 Use of special resin(infiltrants)
 Sufficient application time
Erosion of surface layer
In non cavitated enamel caries lesion the porous lesion body is covered
by a pseudo Intact surface layer.

This highly mineralized zone is impermeable for the resin, thus to allow
infiltrants penetration the surface layer has to be removed or
perforated

This can be achieved by acid erosion Hydrochloric acid gel is applied for
120 seconds using the foil applicator. Subsequently, the gel is washed
with air water spray and the lesion is carefully dried for 15sec using
compressed air

Desiccation of the lesion

to enhance the desiccation, ethanol is applied for 15 sec and
evaporated with compressed air for 15 sec.
Use of special resin (infiltrants)

Now the infiltrant is applied with a new foil applicator.

After 3 minutes, excess resin is blown away with compressed air, the
applicator is removed and the contact area is cleared of from surplus
resin using floss.

Then the resin is light cured for of 40 sec from all the aspects.

The resin should be applied a second time for atleast 1 minute, after
removing excess resin and light curing the rubber dam can be
removed.

Infiltrant is not radiopaque, it cannot be detected on radiographs.

Sufficient application time

Sufficient time is needed for infiltrate to penetrate a porous network

because capillary penetration is a time dependent process.

It has to penetrate several hundreds of micrometers along the enamel

prisms, which are about 7um in diameter.

When the lesion pores are infiltrated with a resin that has a refractive
index close to enamel (infiltrate RI 1.52), the light scattering within
the lesion is reduced and lesions are camouflaged.
 Microabrasion

WSL of a developmental origin as well as those related to orthodontic

treatment have been successfully treated with microabrasion.

This technique involves using a slurry of pumice or silicon carbide

particles and hydrochloric acid to create surface dissolution of enamel,
and it is effective in removing superficial stains or defects.

Successful removal of WSL by this technique is possible if the lesion

does not exceed 0.2 to 0.3 mm in depth.

Croll T P. Enamel microabrasion for removal of superficial dysmineralization and

decalcification defects. J Am Dent Assoc 1990;120(4):411–5.
Heymann H O, Swift E J, Ritter A V. Sturdevant’s art and science of operativedentistry.
6th ed. 2013.
 Whitening

Vital bleaching of teeth with inactive WSL is a commonly suggested

approach in improving the appearance of affected teeth, but does it
work ?
It has been demonstrated that whitening can be successful, but both
the WSL and unaffected enamel become lighter. The good news is that
unaffected enamel appears to increase in lightness significantly more
than the WSL, which may often result in less contrast between the
lesion and the surrounding unaffected enamel.

Knosel M,Bojes M, Jung K, Ziebolz D. Increased susceptibility for white spot lesions by
surplus orthodontic etching exceeding bracket base area. Am J Orthod Dentofacial
Orthop 2012;141(5):574–82.
INVASIVE OR MINIMALLY INVASIVE TECHNIQUES

Resin Restorations/ Indirect Restorations

Patients with cavitated lesions, or more severe WSL who have already
attempted more conservative esthetic treatments without significant
improvement may benefit from the preparation of the affected tooth
surfaces and restoration with either direct resin restorations or indirect
porcelain restorations.
 MEASURES FOR PREVENTION

Normal/ low risk

 Tooth brushing (modified technique) with 1,000-ppm

fluoride tooth paste 2 to 3 times daily.

 Prophylaxis every 4 months

 Fluoride varnish every 4 months

 0.5% NaFI rinse daily at bedtime.

Heymann,,Durham. A Contemporary Review of White Spot Lesions in Orthodontics.

Journal of Esthetic and Restorative Dentistry 2013;25(2):85–95.
High risk

 Tooth brushing (modified technique 2–3times daily): 5,000-ppm

fluoride tooth paste before bed time and 1,000-ppm all other times
using mechanical brush

 Prophylaxis every 3 months

 Fluoride varnis every 3 months

 Xylitol chewing gum 3 to 5 pieces per day for at least 10 minutes per
chew

 Chlorhexidine rinse (2-week regimen) 30-second rinse daily after

brushing before bedtime.
Intratreatment management
Toothbrushing (modified technique 2–3 times daily) with 5,000ppm at
bedtime and 1,000ppm all other times
Prophylaxis every 3 months
Fluoride varnish every 3months
MI Paste Plus application nightly after brushing teeth
Xylitol chewing gum 3 to 5 pieces per day for at least 10 minutes per
chew)

If above techniques have been utilized and still have progression of WSL
and poor compliance, then proceed with EARLY APPLIANCE REMOVAL.
Post orthodontic treatment options for WSL

No treatment/ monitoring with natural resolution

 Tooth whitening
 Resin infiltration technique
Microabrasion / macroabrasion tooth preparation and restoration
(direct resin or indirect veneers)
CONCLUSION
Children are a very special risk group for caries initiation and
progression because of continuously changing eruption periods and
therefore they need professional care.

It is an obligation of dental professionals to find appropriate strategies

with the ultimate objective of producing sound tooth without
resorting to operative methods.
1) Model of demineralization and remineralization of white spot
lesion was given by

a. Miller
b. Moreno
c. Martin
d. Massler

2) An exchange of minerals between saliva and enamel is

a. Unimportant in tooth maintenance

b. Responsible for remineralization
c. Disrupted by fluoride
d. This exchange does not occur
Organic acids that are usually involved in demineralization are
a. Acetic acid
b. Pyruvic acid
c. Lactic acid
d. Both a and b
e. All of the above

Outer surface enamel is far more resistant to demineralization by

acids than deeper portion of enamel. Hence, the greatest amount of
demineralization occurs 10-15 microns beneath the enamel surface.
a. Both the statements are false
b. Both the statements are true
c. First statement is true and second is false
d. First statement is false and second is true
5) Microorganisms primarily associated with smooth surface caries is
a. Lactobacilli
b. Mutans streptococci(streptococcus sobrinus)
c. Actinomyces
d. Streptococcu pyogenes