Manon Isabelle Weyland, Paul‑Georg Jost‑Brinkmann, Theodosia Bartzela
What did the authors aim to do in this study?
The primary purpose of this study is to survey the current strategies present against enamel demineralization during multibracket therapy (MBT) and guide a prevention concept based on an existing scientifc evidence.
How did the authors evaluate?
This cross sectional study was conducted by creating a multiple choice questionnaire, which was designed to address the methods and materials, that were used to prevent demineralization at the start of, during, and after multibracket therapy. It also helped to analyze the fluoride release of bracket bonding material based on the manufacturer’s report, the patient's compliance with oral hygiene regimens and appointment keeping. Apart from this, it also helped to study the participant's experience with the WSL formation & the need for a guideline to prevent demineralization during multibracket therapy. From October 2020 to December 2020, all persons contacted received an email with an information letter and access to the online survey. Completed questionnaires were entered on an Excel spreadsheet and were assessed for statistical data analysis. The analysis involved descriptive statistics using the chi-square test.
What did the authors find?
Oral hygiene status registration and a prevention protocol were carried out by 80.6% of the participants at the beginning of multibracket therapy. Most of the participants (73.5%) consistently implement oral hygiene instructions during multibracket therapy. Flossing is more often recommended than an electric toothbrush. Multibracket therapy is started by 68.7% of the participants only when patient compliance with oral hygiene is achieved. In case of oral hygiene deterioration, 21.1% responded that they consistently interrupt the multibracket therapy.
Less than a quarter of the participants regularly applied topical fluoride (gel or varnish) during MBT. According to the respondent's assessment, the prevalence of WSL during MBT is 11.6%, mainly observed in 12 to 15-year old male patients. Orthodontists graduating after 2000, tended to recommend and apply fluoride-containing materials more often than their senior colleagues. Participants from private practices applied fluoride varnish or gel more frequently than those from university clinics. Fluoridation was the most common (70.7%) treatment for WSL after MBT, followed by resin infiltration. Slightly more than half of the participants (57.5%) are more attentive to patients with high caries risk. Generally, these patients receive dental check-ups every 2 to 3 months, including fuoride gel or varnish treatment. Fluoridation is the therapy of choice for WSL in patients with multibracket appliances after debonding, followed by resin infiltration.
Fig 1. Frequencies of recommended therapies for white spot lesions after multibracket therapy
Poor oral hygiene in orthodontic patients is frequently observed and associated with swollen gingiva or plaque accumulation by 54.6% and 43.9% of the orthodontists, respectively. WSL are noticed routinely by 3.4% of the participants and frequently by 11.5%. More than half of the participants stated that the WSL occur more often within the first 9 months of multibracket therapy. Adolescents, especially 12- to 15 year olds, are more likely to miss dental appointments than adults. Additionally, according to 66.5% of the participants, male patients more often failed to attend their orthodontic appointments than female patients. Modern and innovative re-motivation methods are seldom adopted. Only a few participants implement reminder methods (text messages) to increase oral hygiene compliance. Hardly anyone used mobile apps for motivation.The majority of the participants favoured a guideline for preventing WSL's.
What did the authors conclude?
The WSL prevention during multibracket therapy is challenging for orthodontists.
Males in puberty are predominantly affected.
The results show that the available scientific evidence is not integrated into the routine management of WSL.
Younger orthodontists incorporate more than their senior peer's prevention strategies for WSL during multibracket appliance treatment.
Prevention before the intervention, dental health care experience reports, and a practice protocol are recommended.
What do we think about it?
The White spot lesions (WSL) are chalky, opaque areas on the tooth surface that develop over months and correspond to the earliest clinical signs of dental caries formation. The WSL's, as an initial sign of this imbalance, have a microscopic structure of two zones: a surface zone (30 µm) and the lesion body. As the surface zone is in direct contact with saliva, remineralization by calcium, inorganic phosphate, and fluoride from saliva can occur more quickly, allowing the minerals to reincorporate into the enamel. However, the lesion body is the most demineralized zone and has a 5 to 25% pore volume. The lesion can progress further in this zone, resulting in additional lesions in the surface zone, allowing the acids to diffuse more quickly into the enamel. If the demineralization process continues, a cavitated enamel surface appears.
Beyond the primary focus on oral functional improvement, the orthodontic treatment also aims to improve aesthetics, which increases the self-confidence and general well-being of a patient. However, as fixed orthodontic appliances facilitate plaque accumulation and complicate tooth cleaning, such treatments pose a risk of provoking WSL's and its associated negative aesthetic, financial, and health implications. Numerous studies were conducted to analyze the effect of WSL's and how to prevent them. This study compiles this data from a clinicians point of view, which is the site of practical application of all the studies, methods & data. Although there are drawbacks such as the study had a very low response rate, which risks that different perspectives did not become apparent. But inspite of these, the role of all the oral health care providers is to achieve an overall improvement in oral care. Therefore, all efforts should be made to avoid side effects, such as caries, during orthodontic treatment and this study helps us understand all these effects ideally in a manner to benifit the patients.
Weyland MI, Jost-Brinkmann PG, Bartzela T. Management of white spot lesions induced during orthodontic treatment with multibracket appliance: a national-based survey. Clin Oral Investig. 2022 Jul;26(7):4871-4883.
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