White spots on enamel: treatment protocol by superficial or deep infiltration (part 2)

Comparative evaluation of four treatments for postorthodontic white spot lesions: a randomized controlled trial

OBJECTIVES

To evaluate the treatment efficacy of fluoride toothpaste alone and those of adjunctive use of resin infiltration, sodium fluoride varnish, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) on white spot lesions (WSLs).

MATERIALS AND METHODS

Seventy-nine patients (356 teeth) with WSLs after orthodontic treatment were randomly allocated into four groups. The WSLs of the participants received resin infiltration only at baseline, and the other groups received fluoride varnish, CPP-ACP mousse, and placebo treatment every 6 months, respectively. A toothpaste containing 1400 ppm fluoride and toothbrushes were distributed to all participants, and oral hygiene instructions were provided. Photos of the teeth with WSL were taken to compare the change between groups which was measured by ImageJ software.

RESULTS

Twelve months later, different degrees of reduction in the area of WSLs were observed in all groups. The percentage of lesion area reduction in WSLs in the resin infiltration group was 46.6%, which was significantly higher than that in fluoride varnish group (26.6%), CPP-ACP group (28.6%), and control group (29.8%), and the differences were statistically significant (p < 0.001).

CONCLUSIONS

This study shows that after 1-year follow-up, the use of fluoride toothpaste, with or without the use of fluoride varnish or CPP-ACP, can reduce the area of WSLs. While resin infiltration can immediately improve dental aesthetics and continuously improved in 12 months, resin infiltration group showed much better results than other groups.

TRIAL REGISTRATION

Clinical Trials Registration Number: ChiCTR2000032516.

CLINICAL SIGNIFICANCE

The use of fluoride toothpaste, with or without adjunctive use of fluoride varnish and CPP-ACP, can reduce the area of WSLs, while resin infiltration treatment has additional effect and can immediately improve dental aesthetics.

Management of Enamel Defects with Resin Infiltration Techniques: Two Years Follow Up Retrospective Study

Background: Developmental Defects of Enamel (DDE) represent an aesthetic, functional, and often psychological problem, especially in young patients. Infiltrative treatment with resin (Icon-DMG, Hamburg, Germany) is a minimally invasive technique based on the infiltration of high viscosity resin inside the hypomineralized enamel, modifying its optical properties. The aim of this paper is to evaluate the clinical efficacy of superficial infiltration in the treatment of white enamel defects of the anterior sector with pre-eruptive etiology and its stability over time. Methods: Thirty-three patients affected by DDE associated with mild and moderate Molar Incisor Hypomineralization (MIH), mild and moderate fluorosis, and post-traumatic hypomineralization treated with resin infiltration were retrospectively retrieved. Results: In all cases an improvement in aesthetic appearance was achieved, and the 24-month follow-up confirmed the stability of the results. However, in the cases of traumatic hypomineralization the results were not completely satisfactory. Conclusions: The superficial infiltration technique can be considered a valid minimally invasive alternative to traditional treatment of mild or moderate fluorosis and mild MIH.

Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH): an updated European Academy of Paediatric Dentistry policy document

AIM

To update the existing European Academy of Paediatric Dentistry (EAPD) 2010 policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with Molar-Incisor-Hypomineralisation (MIH).'

METHODS

Experts, assigned the EAPD, worked on two different topics: (A) Aetiological factors involved in MIH, and (B) Treatment options for the clinical management of MIH. The group prepared two detailed systematic reviews of the existing literature relevant to the topics and following a consensus process produced the updated EAPD policy document on the 'Best Clinical Practice guidance for clinicians dealing with children presenting with molar-incisor-hypomineralisation (MIH).' The GRADE system was used to assess the quality of evidence regarding aetiology and treatment which was judged as HIGH, MODERATE, LOW or VERY LOW, while the GRADE criteria were used to indicate the strength of recommendation regarding treatment options as STRONG or WEAK/CONDITIONAL.

RESULTS

(A) Regarding aetiology, it is confirmed that MIH has a multifactorial aetiology with the duration, strength and timing of occurrence of the aetiological factors being responsible for the variable clinical characteristics of the defect. Perinatal hypoxia, prematurity and other hypoxia related perinatal problems, including caesarean section, appear to increase the risk of having MIH, while certain infant and childhood illnesses are also linked with MIH. In addition, genetic predisposition and the role of epigenetic influences are becoming clearer following twin studies and genome and single-nucleotide polymorphisms analyses in patients and families. Missing genetic information might be the final key to truly understand MIH aetiology. (B) Regarding treatment options, composite restorations, preformed metal crowns and laboratory indirect restorations provide high success rates for the posterior teeth in appropriate cases, while scheduled extractions provide an established alternative option in severe cases. There is great need for further clinical and laboratory studies evaluating new materials and non-invasive/micro-invasive techniques for anterior teeth, especially when aesthetic and oral health related quality of life (OHRQoL) issues are concerned.

CONCLUSIONS

MIH has been studied more extensively in the last decade. Its aetiology follows the multifactorial model, involving systemic medical and genetic factors. Further focused laboratory research and prospective clinical studies are needed to elucidate any additional factors and refine the model. Successful preventive and treatment options have been studied and established. The appropriate choice depends on the severity of the defects and the age of the patient. EAPD encourages the use of all available treatment options, whilst in severe cases, scheduled extractions should be considered.

Hypersensitivity in Molar Incisor Hypomineralization: Superficial Infiltration Treatment

To date, there are no standardized protocols available in the literature for hypersensitivity treatment in molar incisor hypomineralization (MIH) patients. The aim of this study was to evaluate the efficacy of erosion–infiltration treatments with resin in children with a strong hypersensitivity and also to develop a minimally invasive diagnostic–therapeutic pathway for young MIH patients. Patients with clinical signs of MIH were enrolled according to international guidelines. A total of 42 patients (8–14 years old) with sensitivity of at least one molar and patients with post eruptive enamel fractures, but without dentin involvement or cavitated carious lesions were selected. A single superficial infiltration treatment with ICON (DMG, Germany) was performed with a modified etching technique. Sensitivity was tested with the Schiff Scale and Wong Baker Face Scale and was repeated at 12 months follow-up. All patients reported lower sensitivity values at the end of the treatment. Significant differences of sensitivity according to the Schiff scale were reported between T0 and all subsequent follow-ups, p < 0.05. The treatment of erosion infiltration with ICON resin is a minimally invasive preventive treatment that significantly improves the problem of hypersensitivity in permanent molars with MIH.

Erosion Infiltration in the Management of Molar-Incisor Hypomineralization (MIH) Defects

White spot lesions caused by enamel demineralization are frequently encountered in dental practice. Their management has always been an important issue in modern dentistry. However, the real dilemma was treating aesthetic demands with noninvasive or minimally invasive techniques preserving the natural tissues. The introduction of resin infiltration technique seems to provide an intermediary treatment modality between prevention and restorative therapy. This case report is aimed at reporting the management of MIH opacities in anterior teeth with resin infiltration technique.

Diagnosis and treatment options for anterior white spot lesions

White spot lesions on teeth present as white opacities due to enamel surface and/or subsurface demineralisation. Unfortunately, dentistry has seen a marked jump in prevalence and severity of white spot lesions over the past decade. In response to the rise in white spot lesions, the dental industry has been pushed to create less invasive alternatives for the removal of these lesions, particularly when located anteriorly. There are numerous different causes of white spot lesions that influence how the enamel substructure is affected and which treatment option is selected. Once, the only treatment option for white spot lesions was drilling the defects away, but with a better understanding of the science and the aetiology, we have now been able to create minimally invasive, preventive alternatives. It is vital that the cause, size and depth of the white spot lesions are ascertained before providing treatment options to a patient, as treatment results will vary depending on the enamel substructure available. This paper will explore the main causes of white spot lesions and the recommended treatments for them.

A Combined Approach for the Aesthetic Management of Stained Enamel Opacities: External Bleaching Followed by Resin Infiltration

Stained enamel opacities are frequently encountered in dental practice. However, due to the risk of unaesthetic outcome, managing such lesions by resin infiltration techniques alone is not advised. Therefore, performing external bleaching before resin infiltration procedure is mandatory to eliminate stains from the hypomineralized lesions in order to aesthetically infiltrate them. In this work, we describe clinical cases in which external bleaching and resin infiltration techniques were used for managing stained enamel hypomineralized lesions related to traumatic dental injuries and molar incisor hypomineralization. Despite the fact that this approach has some limitations, it could be concluded that external bleaching associated with the resin infiltration technique shows promising results to aesthetically manage stained enamel opacities when the stain is totally removed after bleaching.

Different applicabilities of the etch-bleach-seal technique for treating opacities on permanent incisor damage by molar incisor hypomineralisation in three young patients

Enamel opacity on anterior teeth can be prejudicial for the aesthetic appearance of affected patients. Patients with molar incisor hypomineralisation, for example, present opacities that can range from discrete white mottling to extensive yellow-brown discolourations. They can request a treatment to improve their aesthetic conditions. Many techniques have been considered to manage this condition. Wright developed a technique called etch-bleach-seal, which showed promising results for the management of anterior enamel opacities. The aims of this report are to present this technique and to analyse its benefits and inconveniences.

Enamel microabrasion: An overview of clinical and scientific considerations

Superficial stains and irregularities of the enamel are generally what prompt patients to seek dental intervention to improve their smile. These stains or defects may be due to hypoplasia, amelogenesis imperfecta, mineralized white spots, or fluorosis, for which enamel microabrasion is primarily indicated. Enamel microabrasion involves the use of acidic and abrasive agents, such as with 37% phosphoric acid and pumice or 6% hydrochloric acid and silica, applied to the altered enamel surface with mechanical pressure from a rubber cup coupled to a rotatory mandrel of a low-rotation micromotor. If necessary, this treatment can be safely combined with bleaching for better esthetic results. Recent studies show that microabrasion is a conservative treatment when the enamel wear is minimal and clinically imperceptible. The most important factor contributing to the success of enamel microabrasion is the depth of the defect, as deeper, opaque stains, such as those resulting from hypoplasia, cannot be resolved with microabrasion, and require a restorative approach. Surface enamel alterations that result from microabrasion, such as roughness and microhardness, are easily restored by saliva. Clinical studies support the efficacy and longevity of this safe and minimally invasive treatment. The present article presents the clinical and scientific aspects concerning the microabrasion technique, and discusses the indications for and effects of the treatment, including recent works describing microscopic and clinical evaluations.