Enamel lesions in Orthodontics Dr. Ashok Jena and Dr.

Ritu Duggal abstract The formation of white lesions or enamel demineralization around orthodontic fixed appliances , is a very common complication during therapy or orthodontic treatment. The literature shows that this problem is preventable , where the need for good hygiene during treatment is suggested , same to be explained; prevention programs should emphasize and should suggest different ways to prevent this situation. Keywords : Injury White and opaque enamel demineralization , Prevention , Fluor. introduction The decalcification of enamel , also called white opaque lesions around orthodontic appliances , are very common during fixed orthodontic treatment , decalcification almost always goes hand in hand with the accumulation of dental plaque or food debris retained in the equipment or in the material adhesion . [1,2,3] Usually, what happens is acid production resulting from the decomposition of the bacteria which cause demineralization of the enamel surface . [3 ] Subsequently , if this process continues, the formation of dental caries is caused. [5,6] It has been clinically shown to the formation of white opaque spots around braces can occur within 4 weeks of starting treatment [7 ] and the prevalence of the same appears in about 2 - 96 % . [ 8,9,10 ] The lip -gingival area of the lateral incisors is that this entity has increased , while the maxillary posterior segment hardly suffers . [7 ] However , the incidence of the formation of these white spots on the enamel are largely attributed to poor hygiene and is more common in men than in women. [ 8,11 ] The presence of these white spots at the end of orthodontic treatment greatly compromises the aesthetic results of the same , and although there are several ways to prevent it currently remains a major problem in orthodontics . The main purpose of this article is to provide updated points of the various factors that cause this disease during orthodontic treatment and how we can prevent the development of demineralization. etiology The presence of white and opaque lesions during orthodontic treatment is caused by multiple factors , such as bacterial plaque , FERMENTATION OF CARBOHYDRATE , LOW SURFACE DENTAL AND SUFFICIENT TIME FOR ACTION , which has been shown to propagate the development of decalcification. microbial factors It has been documented that the initiation and progression of weakness or enamel surface dental caries is associated directly with Streptococcus mutans and its prevalence is related to the complexity of it . [ 12,13 ] This means that Streptococcus mutans colonize areas prefer retaining solid surfaces and their presence at a high level in these areas increases the risk of caries. [14 ] After the initiation of the carious lesion progression in caused by Lactobacillus, [15 ] and the more Lactobacillus increased production of cavities [15 ] which indicates that in patients with fixed orthodontic and poor hygiene is common to observe new sites colonized by plaque around the appliances and therefore further development of Streptococcus mutans and Lactobacillus and then start the decay process characterized by the presence of white opaque spots, which also is related to the

duration of treatment orthodontic and with the number of orthodontic attachments to carry the patient. [18] Salivary factors Saliva plays an important role at the interface of the dynamism of the loss and storage of minerals in the enamel surface - plate . The amount of enamel demineralization and softening degree is influenced by factors such as salivary pH , the degree of damping of the same . [19] The exposure of the enamel against the carbohydrate , the pH of the microbial plaque and dental plaque composition that are regulated by the saliva. Saliva also acts as a vehicle to carry fluorine ions to tooth enamel and protect . The enamel surface is more exposed to dietary carbohydrates and less exposure to saliva are those who suffer most from demineralization. And so the places with the highest incidence of decalcification in patients with orthodontic appliances occurs in the maxillary anterior teeth . [9 ] (Figure 1. And 2 . ) While the lingual surface of the lower incisors is more prevalent for the formation of calculation which indicates the presence of minerals. [10] which suggests that an adequate amount of saliva acts as a vehicle for the prevention of demineralization. Some evidence shows that saliva can influence both the risk of caries and caries activity itself. [20 ] Now, an adequate level of saliva helps maintain clean teeth surface controlling the attack balancing carbohydrates and anti- microbial activities . As this is considered as an important prevention and management of enamel demineralization factor . [21] Enamel demineralization is caused by a decrease in pH of the plaque and the same acidic pH which is offset by the ability of alkalinity to produce saliva. Both pH and buffer capacity of saliva, is maintained by the amount of salivary secretion present . [22] However, an environment with low pH is conducive to the colonization of bacteria particularly cryogenic Streptococcus mutans , a high level while maintaining a high pH buffer capacity of the saliva , so there is a negative correlation between the buffer capacity of the saliva and the frequency of caries. [23] Oral hygiene The presence of orthodontic appliances oral hygiene more difficult and therefore there is a greater accumulation of plaque on the tooth surface . These same devices restricts the self-cleaning of the tongue , lips and cheeks to remove food debris from the tooth surface , and therefore this causes the fermentation of carbohydrates by increasing the risk cryogenic bacteria like Streptococcus mutans and Lactobacillus . Furthermore it has been shown by published studies that there are specific sites affected by this disease such as: the area of the gingival margin and the edges of orthodontic bands with lactobacillus increased during active orthodontic treatment. [24] diet During fixed orthodontic treatment , the frequency of ingestion of carbohydrate increases the risk of demineralization due to fermentation , wherein transforming acids as well as the pH buffering capacity of the saliva occurs. With the increase of this process the enamel surface is exposed to these acid attacks resulting in a major loss its mineral over time. Fixed appliances in Orthodontics

The placement of orthodontic appliances on the tooth surface creates a new environment of dental plaque retention , these irregular surfaces of orthodontic attachments complicate even more the self-cleaning of the tongue, lips and cheeks , so the presence of carbohydrates , reduces production salivary , lowering the pH and creating an environment for the colonization of Streptococcus mutans and Lactobacilli . [ 16,17,18 ], [ 24,25,26,27,28 ] Found an increased deposition of plaque around the resins in the enamel itself, [29 ] and likewise more on the gingival area brackets , [30 ] which indicates that the presence of orthodontic appliances within the oral cavity transforms all normal microbial ecology in a system more susceptible to diseases . Both arches as orthodontic leagues have been evaluated for descaling, [ 28,31,32 ] and it is known that teeth are more linked to Alasticks presence of microorganisms cryogenic those associated with metal teeth , [ 28,31 ] although recent studies have shown an equal number of Streptococcus mutans accumulation around either backets Alasticks or ligature wires [33,34] Other studies argue that there is a transformation of salivary production during orthodontic treatment. [35 ] and since it increases both the salivary pH and buffer through increased saliva, there is a tendency to arrest demineralization process [ 22] and this could be one of the reasons why some patients are forming spots white around orthodontic appliances . When you start orthodontic treatment, it is logical to think of the possibility of enamel demineralization in certain patients , several authors recommend that you should take into account some factors to avoid this situation if possible . [ 16,19,21 ] between these factors include : the amount of salivary torrent , the story of the presence of caries in enamel caries incidence in the past year, the presence of dental plaque, the test activity caries, the dietary pattern of the patient and the presence of fluoride or fluoridated water in their communities. pathogenesis The appearance of white opaque surface lesions of enamel demineralization supports which results in a porosity and changes in the properties of the enamel. The porosity of the enamel usually has the appearance of a white tizoso and is associated with an erosion of the surface itself . The lesions appear after a series of losses of minerals in combination with the presence of dental plaque and salivary acidity makes it impossible for the average oral environment to repair injuries and fluctuating changes in pH are directly related to the diffusion of calcium and the phosphate ions out of the enamel . When an enamel surface remains porous there is much possibility that this injury is reversible , this often occurs spontaneously recalcification by combining the action of minerals from saliva and fluoride or therapeutic procedures. When the pH is kept low for a long period of time , becomes a vehicle so that the loss of minerals can occur continuously with remineralization few periods which results in a repair of the damaged area will not occur and gradually the carious lesion appears . Management and Prevention The risk of enamel demineralization during orthodontic treatment can be prevented by eliminating the presence of dento- bacterial plaque by improving oral hygiene [2 ] or by the more resistant to microbial attack enamel by topical application of fluoride [36 37 ] However, the frequent maintenance of optimal

hygiene is often difficult , so the application of agents with fluorine is the main weapon to prevent demineralization during active orthodontic treatment . It has been found that fluoride not only inhibits the development of white spots [ 3,38 ] but also reduces the size of the same [39 ] offering a remineralization of enamel during orthodontic treatment [ 3,38 ] the effect cariostatic of fluorine is mainly due to the formation of calcium fluoride [38 ] it has been documented that a high concentration of fluoride in the enamel is not as important as it is a moderate concentration of fluoride in the oral fluids [40 ] for maximum inhibition caries , require the presence of fluoride , albeit in lower concentrations in either saliva or plaque. [41 ] An optimal oral hygiene in combination with daily use of fluoride agents is sufficient to reduce decalcification . [9 ] The use of agents with fluoride at home depends entirely on the patient. [ 6,42,43 ] and as a result in orthodontic patients has implemented the use of cements release fluoride. Mouthwashes with Fluor Sodium Fluoride rinses have been studied enough and has shown that they can remove white spots on the enamel and thus are recommended for all patients with orthodontics. [ 3,43,44 ] The Sodium Fluoride mouthwashes ( 0.05 % or 0.2 %) and Fluor acidulated phosphate ( 1.2 % ) frequently used has been shown to reduce the incidence of enamel demineralization during active treatment orthodontics. [ 3.38 ] After a systematic review , it is recommended that the greatest method against demineralization during active orthodontic treatment is the daily use of Sodium Fluoride 0.05% in rinse. [45 ] However, Hirschfield , mentions that the topical fluoride application during orthodontic treatment more resistant against enamel decalcification. [46] Geiger et . Al reported a 25% reduction in the number of white spot lesions using fluoride rinses . [47] Also it has been found that the use of two weeks Sodium fluoride rinses with a daily frequency fluorine concentration increases significantly in the saliva. [ 48 ] Gel with Fluor Many researchers have used Stannous Fluoride gels ( 0.4 % ) during orthodontic treatment and have reported a decrease of enamel decalcification . [ 49,50 ] Recently, Boyd compared the daily use of 1100ppm of fluoride in toothpastes mouthwashes together with sodium fluoride 0.05% stannous fluoride gels or 0.4% applied twice daily with toothbrush. [51 ] and found that both gels as well as mouthwashes provide additional protection against demineralization , it mentions that if there is significant relative to the use only of toothbrushing difference , but among them none were greater; these results are very similar to which I find Hastreite in their studies. [52] toothpastes Using toothpaste is the most common recommendation given by the orthodontist , but has been shown to be not very efficient to avoid the white spots around orthodontic appliances [ 53,54,55 ] however, recommends using Stookey of sodium fluoride toothpastes as these if help or prevent the development thereof . [ 56 ] Fluoride varnish Fluorinated using protecting agents such as nail varnish containing 0.7 % of difluorsalino has been shown to reduce the formation of white spots under molar bands . [57 ] There are studies showing that much these varnishes are also effective in preventing enamel demineralization . [ 58,59,60 ] It is postulated that its

application during orthodontic treatment , at present has also suggested the application of chlorhexidine varnish to reduce the accumulation of dental- plaque and therefore decalcification. [ 61 ] Pit and fissure sealants Frazier and colleagues placed pit and fissure sealants on the labial surface of the enamel around orthodontic appliances and found that these prevent demineralization without requiring patient cooperation [62 ] But the biggest problem of this approach is its complexity and also that there is a chemical breakdown of the sealant layer which can generate a sealant demineralization below . Cementos integrated fluorine Kaswiner recommends applying fluorine containing cements [63] Similarly, it has been shown that the use of glass ionomer reduce demineralization , [ 64 ] and which when compared with zinc phosphate and zinc polyacrylate , the glass ionomer offer better results. [ 65 ] In another study, free fluor cements such as: zinc polycarboxylate modified glass ionomer resins have proven to be more efficient in preventing the demineralization zinc phosphate cements . [66 ] Millett and colleagues found less decalcification around the brackets when using glass ionomer with composite resin, but the difference was not statistically significant. [67] Bonding agents with fluoride The bonding agents containing fluorine have the potential to reduce enamel decalcification . [ 68,69,70,71 ] Similarly, it has been found less white by comparing the use of fluorine resins , with conventional stains. [ 72,73 ] The use of glass ionomer cements for bracket positioning significantly reduces enamel decalcification around the brackets . [ 74 ] Recently, the application of resins suggested modified glass ionomer and protecting the enamel . [ 75 ] It has been concluded that the fluorine released by the resins modified glass ionomer is greater and more prolonged as compared with conventional resins . [ 76 ] Corry et al conclude that the resin modified glass ionomer , as well as resins to which fluorine is added to them have a similar cariostatic effect , so that inhibition of the white spots can be removed with the use of modified glass ionomer resins with more use of topical fluoride applications . [77 ] which makes clear that the glass ionomer is more efficient for the prevention of enamel lesions manifested by the presence of conventional resins which white patches. Elastomers with Fluor Several commercial firms are producing and promoting elastomeric ligatures and chains with fluorine. Many researchers suggest that fluoride released from these additions are effective in reducing the accumulation of dental palca and enamel decalcification around the brackets . [ 78,79,80 ] Recently, however, Shah and Campbell have concluded that fluoride elastomers have a significant effectiveness against the accumulation of plaque . [81 ] Joseph , Grobler and Rossouw report that Fluor released from the elastic chains was higher in the first week and then decreased considerably. [82 ] However, to achieve optimum results in the release of fluoride is necessary to change these elastic weekly, although these elastomers anticariogenic offer significant benefits for orthodontic treatment. [83 ] In an in vitro study by Whiltshire release fluorine elastomers for more than six months showed , also was found in an in vivo comparison that the fluoride

release was seven times during the period of week [ 84,85 ] likewise the presence of pastes and mouthwashes with fluoride significantly increases the release of fluoro elastomers . [ 85 ] The Argon laser The mode of action of the argon laser for preventing enamel decalcification is due to the alteration of the crystalline structure of the enamel as suggested . [ 86,87 ] Blankenau et . al. For the first time , found an average reduction of 29.1 % in the deep enamel demineralization using Argon Laser [87] Other studies report a significant reduction of injury to the enamel irradiated with this laser . [ 88,89 ] so that this process can be considered as an effective method in reducing enamel decalcification during orthodontic treatment . Mechanical Control Board Since it is known that plaque is the main cause demineralization, mechanical control has been the most effective and important method to eliminate or prevent . It has been found that brushing is the most practical for the control of dental plaque , [ 90 ] it is suggested own methods of special techniques for brushing during orthodontic treatment [ 92 ] It has been suggested a modification to the brushing technique for the patients with fixed orthodontic treatment [91 ] the use of solutions or disclosing tablets plaque are very useful for monitoring the effectiveness of oral hygiene , [ 91,92 ] the use of automatic toothbrushes are also recommended in combination with irrigation water pressure because they are very effective in reducing plaque compared to manual brushing . Orthodontic appliances favors the possibility of demineralization due to the difficulty to maintain optimum hygiene [90 ] flossing is very important for interproximal cleaning, [63 ] the ensaltadores floss is recommended for patients who can pass the under the arches of wires, [92 ] likewise , the interproximal stimulator which consists of a rubber interdental gives a massage to the gum in his interproximal area . [ 91 ] Enamel lesions Many studies have reported that demineralization stops when removing orthodontic appliances [ 93,94 ] this may be due to the physical removal as well as the change of acid produced by plaque and improvement of salivary flow . The demineralized areas have an appearance of white spots that may disappear enamel remineralization as a result of enamel mineral deposit . [ 95,96 ] and Fitzpatrick Way showed that after the application of acid recorder everything returns to normal due to the placement of fill material and not by the removal of acid itself . [97 ] Some researchers suggest this is due to the apathetic nature of enamel with a small amount of impurities [ 96,98 ] also some evidence suggests that the clinical improvement in some lesions are not fully compatible with demineralization , but rather to abrasion of the enamel surface , suggesting the final correction of the same due to the irregularity of the enamel as a result the presence of enamel crystals giving it a harder and thicker clinical appearance . [ 93 ] Importantly enamel remineralization occurs thanks to the presence of fluorine , so routine mouthwashes with fluoride are recommended during and after treatment [99 ] It has been suggested that lesions that develop in a high fluoride environment during orthodontic treatment usually do not progress as a barrier is formed on the surface through a combination of minerals from saliva , while in the areas

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