White Spot Lesions (Tufekci)

Question 1

What is the cause of white spot lesions in orthodontics?

Answer 1

It is difficult for the patient to brush and floss with fixed appliances

Question 2

Where is the location of white spot lesions in orthodontics?

Answer 2

Buccal surface between bracket and gingival margins

Question 3

What are the 2 most common acidogenic bacteria found in plaque during orthodontic therapy?

Answer 3

1. Streptococcus mutans

2. Lactobacilli

Question 4

How does the bacterial fermentation of carbohydrates lead to white spot lesions?

Answer 4

Acid produced by fermentation drops the pH and causes flow of minerals out of the enamel and into the oral environment

Question 5

Why is there a constant ionic exchange between the dental tissues and the oral environment?

Answer 5

It is an attempt to reach ionic equilibrium

Question 6

What are the ions that preventative therapy seeks to keep in order to prevent net loss of ions within the crystalline structure of enamel?

Answer 6

1. Free fluoride
2. Calcium
3. Phosphate

Question 7

What is the critical pH that causes the release of calcium and phosphate from the enamel that leads to demineralization?

Answer 7

Approximately 5.5

Question 8

What does saliva have to offer to combat demineralization?

Answer 8

Buffering action which increases oral pH leading to teeth to incorporate calcium, phosphate, and fluoride free ions to remineralize

Question 9

Demineralization is a cycle of what factors?

Answer 9

Bacteria + fermentable carbohydrates demineralizationtooth decay

Question 10

Remineralization is a cycle of what factors?

Answer 10

Calcium + phosphate + fluoride  remineralization tooth repair

Question 11

What goes out and what goes into the tooth during demineralization?

Answer 11

Acid goes in and calcium (Ca++) and phosphate (PO43-)

Question 12

The oral environment will have a dynamic stability, and the goal to prevent white spot lesions during ortho is to keep that dynamic stability favoring what?

Answer 12

Higher pH

Question 13

What will be the pH of the oral environment if oral hygiene is poor?

Answer 13

pH will be lower and demineralization will occur

Question 14

Why do white spot lesions look white?

Answer 14

Enamel is more porous allowing more air into the enamel making it more opaque and increasing the defraction index

Question 15

Is a white spot lesion as strong as or softer than the surrounding enamel?

Answer 15

Softer

Question 16

How long after placement of a fixed appliance can significant demineralization occur?

Answer 16

Within 4 weeks (O’Reilly and Featherstone and Ogaard studies say within first month)

Question 17

White spot lesions beyond what depth cannot be remineralized?

Answer 17

75 microns (um) or deeper

Question 18

If less than ____ mm deep, there is a high chance the tooth will remineralize?

Answer 18

Less than 60 microns (um)

Question 19

What is the variation of prevalence of white spot lesions among orthodontically treated patients?

Answer 19

2-96%

Question 20

In the Gorelick study percentage of patients reported to have at least one white spot lesion after treatment?

Answer 20

50%

Question 21

What are 4 things to consider to minimized demineralization during orthodontic treatment?

Answer 21

1. Patient selection
2. Oral hygiene
3. Diet
4. Fluoride delivery

Question 22

Is a patient a good candidate for ortho if they have poor oral hygiene prior to placement of fixed appliances?

Answer 22

No

Question 23

What should be done for a pt who is already retaining plaque prior to the placement of fixed appliances?

Answer 23

Do not start orthodontic therapy. Place on rigorous oral hygiene regime and reevaluate after 3 months

Question 24

What is the problem with the target demographic for orthodontics dietary habit?

Answer 24

Diet contributes to demineralization because it is a carbohydrate-rich cariogenic diet

Question 25

What are the requirements for a patient before fixed appliance placement to decrease the risk of demineralization to the patient's teeth?

Answer 25

1. Have an acceptable level of oral hygiene 2. Understand the caries process including the role of the diet 3. Accept responsibility for maintaining a certain level of oral hygiene under difficult circumstances of having braces

Question 26

What should be documented at each visit during orthodontic treatment?

Answer 26

1. Patient’s oral hygiene | 2. Attempts made to educate patient and parents

Question 27

What is the prophylaxis schedule a patient in ortho should be placed on?

Answer 27

3 month recalls

Question 28

True or False. Despite preventative measures, there will always be a proportion of patients whose ability to clean their teeth decreases as treatment progresses?

Answer 28

True

Question 29

What is the biggest reason for patient dissatisfaction at the completion of orthodontic therapy?

Answer 29

White Spot Lesions

Question 30

What is the best defense against white spot lesions?

Answer 30

Good oral hygiene (fluoride toothpaste, fluoride mouth rinse, compliance

Question 31

What is a good defense against white spot lesions that DOES NOT require compliance?

Answer 31

Fluoride varnish

Question 32

The Schmit study showed what was the quality of fluoride varnish application: slow decrease or rapid decrease?

Answer 32

Rapid decrease

Question 33

Due to the rapid decrease in fluoride varnishes after application, how many applications are recommended?

Answer 33

Several applications (3 / month or 2 / year)

Question 34

The Todd, Schmit, and Nalbantgil in vitro studies of fluoride varnishes show how much reduction in white spot lesion depth?

Answer 34

35-50%, the studies were for 4 weeks

Question 35

The Farhadian 3 month study on the fluoride varnish application and its affect on white spot lesions showed what percentage of decrease in lesion depth in those who received the varnish?

Answer 35

40%

Question 36

The Stecksen-Blicks study of fluoride varnish applied every 6 weeks showed what percentage had white spot lesions?

Answer 36

7% had white spot lesions | 25% had no white spot lesion

Question 37

What are 3 factors to consider for multiple fluoride applications to combat white spot lesions during orthodontics?

Answer 37

1. Need multiple applications 2. Increased chair time and cost 3. Temporary discolored teeth and gingiva

Question 38

Pro-seal is what dental material?

Answer 38

High filled fluoride releasing light cure sealant with glass ionomer

Question 39

What is the importance of the highly-filled nature of Pro-Seal?

Answer 39

Makes it durable against brushing and mastication

Question 40

What does Pro-Seal have that allows for easy monitoring of sealant coverage?

Answer 40

Fluorescing agent so it shows up under blacklight

Question 41

How is Pro-Seal placed in orthodontics?

Answer 41

Entire buccal surface sealed, light-cured, then bracket is bonded on top

Question 42

What does the literature show about the preventative effects of placing Pro-Seal before placing brackets?

Answer 42

Ortho literature says No significant preventative effect. A paper in 2011 said there was in vivo preventative effect

Question 43

Is opal seal, a fluoride releasing, highly filled bonding primer supported in the literature?

Answer 43

No

Question 44

What was the big deal with the Pennella Opal Seal study?

Answer 44

Done by a VCU resident in 2011

Question 45

What was the design of the Pennella Opal seal study?

Answer 45

22 pts, split mouth design, all pts would have premolars extracted, one premolar was control, one premolar had Opal Seal placed on it

Question 46

What was done to the planned-for-extraction premolars to ensure they collected plaque to test the white spot lesion prevention ability of Opal Seal?

Answer 46

Blue band placed over bracket to trap plaque

Question 47

What did the results show after extraction, view under blacklight, and hardness tests of the premolars in the Pennella Opal Seal study?

Answer 47

29% Opal Sealed teeth had white spot lesions 46% control teeth had white spot lesions Overall 38% had white spot lesions No significant difference

Question 48

What was a significant finding in the Pennella study?

Answer 48

Showed that if tooth in mouth greater than 90 days, 58% would have white spot lesions

Question 49

What is the significance of 90 days?

Answer 49

Fluoride breaks down at 90 days

Question 50

What was found in the Panella study with respect to hardness?

Answer 50

As depth go deeper (beyond 25 microns) the enamel was harder. Upper level softness attributed to etching, therefore, only etch area to be bonded

Question 51

What did the Farah (a VCU resident) study show about the fluoride recharging capability of ortho materials?

Answer 51

After 2 weeks, any fluoride material is depleted of its fluoride

Question 52

What was the significant time period the Farah study showed to be significant, and the one that the material company kept citing in their advertisements?

Answer 52

What at 24 hrs there was a recharging

Question 53

What part-per-million (ppm) of fluoride needed to prevent mineral loss?

Answer 53

1 ppm

Question 54

What is the ppm of fluoride needed in saliva to have a remineralization effect?

Answer 54

0.08 ppm

Question 55

What ppm did Opal Seal offer?

Answer 55

0.0442 ppm

Question 56

What ppm did ProSeal offer?

Answer 56

0.0186 ppm

Question 57

What ppm did Transbond offer?

Answer 57

0.0159 ppm

Question 58

What was the average ppm of the 3 above fluoride releasing bonding agents?

Answer 58

0.0262 ppm

Question 59

How long does the recharge of these materials last according to the Farah study?

Answer 59

6 weeks

Question 60

What is an alternative to Fluoride sealants?

Answer 60

Glass ionomer cements

Question 61

What is the character of the fluoride release of glass ionomer cements?

Answer 61

High fluoride release on first day, sharp decrease the second day, gradual decrease to undetectable levels in about 3 months

Question 62

Do glass ionomer cements have a high or low bond strength?

Answer 62

Low

Question 63

What do the controversial reports say about the fluoride recharging capability of glass ionomer cements?

Answer 63

They recharge better than sealants

Question 64

What is the fluoride release of glass ionomer cements in the first week of placement?

Answer 64

0.07 ppm/mm2

Question 65

What is the fluoride release of glass ionomer cements 17 weeks after placement?

Answer 65

0.01 ppm / mm2

Question 66

What is the optimal ppm for remineralization?

Answer 66

0.08 ppm

Question 67

What is the ppm needed for remineralization to start?

Answer 67

0.03 ppm

Question 68

What does ten Cate (?) say about using the glass ionomer cements?

Answer 68

Use them because even low ppm fluoride can keep the dynamic stability in favor of no white spot lesions / favor the remineralization process

Question 69

Can OTC fluoridated toothpastes recharge fluoride releasing dental materials?

Answer 69

Yes, you want a continuous exogenous source of fluoride

Question 70

The Benson study in 2005 showed there was evidence that glass ionomers and resin modified glass ionomers reduce prevalence and severity of white spot lesions coupled with evidence that fluoride mouthrinses and fluoride gels in children and adolescents reduce dental caries. What is the problem dental material in this comparison and why?

Answer 70

Mouthrinse because it requires compliance.

Question 71

What is compliance with mouth rinse?

Answer 71

15%

Question 72

If there is a white spot lesion after ortho treatment, should it be remineralized, either by saliva or by application of fluoride and why?

Answer 72

o. Because it will only remineralized the most superficial layer of enamel but will leave deeper enamel crystals unaffected

Question 73

How long should you wait after debanding to prescribe high concentration fluoride?

Answer 73

3 months (from Ogaard study)

Question 74

What is the problem with thinking remineralization of white spot lesions will occur naturally from saliva?

Answer 74

Results vary from patient to patient from site to site in the mouth

Question 75

When brackets are removed, should high concentration fluoride toothpaste be prescribed?

Answer 75

No. Have the patient use normal toothpaste and flossing because there is a drastic improvement in their oral hygiene simply because the brackets are off?

Question 76

What is the term for repeated applications of pumice and 18% hydrochloric acid slurry to the demineralized tooth surface whose goal is to remove the discolored enamel and leave the tooth surface smooth and lustrous?

Answer 76

Microabrasion

Question 77

Should microabrasion be done immediately after brackets are removed?

Answer 77

No. Wait at least 3 months to allow initial remineralization.

Question 78

Are there any therapeutic effects to micro abrasion?

Answer 78

No. Only esthetics.

Question 79

What must be placed prior to performing microabrasion?

Answer 79

Rubber dam

Question 80

Success of micro abrasion depends chiefly on what?

Answer 80

How deeply the lesion extends into enamel (Pliska study)

Question 81

Magic elixir that contains the active compound recaldent (CPP-ACP) which is derived from the milk protein Casein Phosphopeptide (CPP)?

Answer 81

MI paste

Question 82

What does the milk protein Casein Phosphopeptide (CPP) carry?

Answer 82

Calcium and phosphate ions in the form of amorphous calcium phosphate (ACP)

Question 83

MI-Paste with its CPP-ACP is contraindicated in which patients?

Answer 83

Patients with milk allergy

Question 84

What are the results of studies of MI Paste (Beerens study, Huang study, Robertson study, Akin and Basciftici)?

Answer 84

Beerens and Huang found no clinical efficacy of MI paste plus. Robertseon, Akin and Saciftici found reduction in white spot lesions.

Question 85

What does VCU ortho think of MI paste?

Answer 85

Skeptical of results. Don't give it out much anymore.

Question 86

What is the refraction index of normal enamel?

Answer 86

1.62

Question 87

Does enamel with a white spot lesion have a higher or lower refraction index?

Answer 87

Lower

Question 88

What is the refraction index of watery medium?

Answer 88

1.33

Question 89

Another method that is NOT THERAPEUTIC, but seeks only to improve the esthetics of a demineralized tooth?

Answer 89

Resin infiltration

Question 90

What are the steps for masking white spot lesions with resin infiltration

Answer 90

1. Etch surface with 15% HCl 2. Occlude mircoporosities with low viscosity light curing resin (5 mins) 3. Apply resin again to minimize enamel porosity 4. Polish with disks and silicone polishers

Question 91

What does Resin infiltration do to the enamel?

Answer 91

Fills in microporosities to increase refraction index back towards sound enamel?

Question 92

What is the low viscosity light curing resin used to accomplish resin infiltration?

Answer 92

Icon by DMG America

Question 93

What is the best prevention of enamel decalcification during ortho treatment?

Answer 93

Good oral hygiene

Question 94

What products are indicated if the patient has poor oral hygiene while in brackets to reduce the risk of white spot lesions?

Answer 94

Products that do not require compliance

Question 95

What are the products indicated for less-compliant patients?

Answer 95

Bonding systems that have continuous release of fluoride, fluoride-containing sealants and varnishes

Question 96

Why did the teeth in the Pannella study show a difference based on 90 days (those in oral environment less than 90 days had fewer white spot lesions than those in oral environment greater than 90 days)?

Answer 96

Fluoride breaks down at 90 days