White spot lesions during multibracket appliance treatment – a challenge for clinical excellence Inaugural-Dissertation zur Erlangung des Grades eines Doktors der Zahnmedizin des Fachbereichs Medizin der Justus-Liebig-Universität Gießen vorgelegt von: Enaia, Mahmoud aus: Abu Dhabi Gießen 2010 Aus dem Medizinischen Zentrum für Zahn-, Mund- und Kieferheilkunde Poliklinik für Kieferorthopädie Direktorin: Prof. Dr. Sabine Ruf des Fachbereichs Medizin der Justus-Liebig-Universität Gießen Gutachter: Prof. Dr. Sabine Ruf Gutachter: Prof. Dr. Dr. Howaldt Tag der Disputation:30.05.2011 Dedication Dedication This thesis would be incomplete without mentioning my great father Naeem Enaia and my wonderful mother Nagbegah, who have supported me all the way since the beginning of my studies. It dedicates to my brother Mohamed Enaia and my three sisters Reham, Rana, Role. It is also dedicated to Hannah and everyone, who has been a source of moti- vation and inspiration. Declaration Declaration „Ich erkläre: ich habe die vorgelegte Dissertation selbständig, ohne unerlaubte fremde Hilfe und nur mit den Hilfen angefertigt, die ich in der Dissertation angegeben habe. Alle Textstellen, die wörtlich oder sinngemäß aus veröffentlichten oder nicht veröffent- lichten Schriften entnommen sind, und alle Angaben, die auf mündlichen Auskünften beruhen, sind als solche kenntlich gemacht. Bei den von mir durchgeführten und in der Dissertation erwähnten Untersuchungen habe ich die Grundsätze guter wissenschaftli- cher Praxis, wie sie in der „Satzung der Justus-Liebig-Universität-Giessen zur Siche- rung guter wissenschaftlicher Praxis“ niedergelegt sind, eingehalten.“ Table of contents Table of contents 1 INTRODUCTION ............................................................................................................. 1 2 AIM..................................................................................................................................... 4 3 MATERIALS UND METHODS ..................................................................................... 5 4 RESULTS......................................................................................................................... 21 5 DISCUSSION .................................................................................................................. 77 6 CONCLUSION ................................................................................................................ 92 7 SUMMARY ..................................................................................................................... 93 8 ZUSAMMENFASSUNG ................................................................................................ 95 9 REFERENCES ................................................................................................................ 97 10 ATTACHMENT ............................................................................................................ 107 11 PUBLICATION............................................................................................................. 108 12 ACKNOWLEDGEMENT ............................................................................................ 113 13 CV ................................................................................................................................... 114 Introduction 1 INTRODUCTION Labial surface demineralisations (“White Spots”) are one of the most undesired iatrogenic side effects during orthodontic treatments using multibracket appliances (MB) (Figure 1.1) that have been reported to occur in 2-96% of the MB-patients (Gorelick et al., 1982; Mizrahi, 1982; Artun und Brobakken, 1986; Geiger et al., 1988; Mitchell, 1992; Wenderoth et al., 1999; Pancherz et al.,1997; Fornell et al., 2002; Lovrov et al., 2007). Thus, patients receiving MB-treatment are significantly more susceptible to the development of WSL than untreated patients (Øgaard, 1989). Figure 1.1 White Spot Lesions specially on the upper incisors after removal of a multibracket appliance. The presence of brackets, bands and archwires impairs oral hygiene measures and increases the plaque retention sites (Mizrahi, 1982; Gorelick et al., 1982; Årtun and Thylstrup, 1989; Chang et al., 1997; Øgaard et al., 1988; Øgaard, 2001). As a result of increased plaque ac- cumulation the level of caries inducing bacteria in the oral cavity such as S. mutans will be elevated (Balenseifien and Madonia, 1970; Diamandi-Kiopioti et al., 1987; Boyar et al., 1 Introduction 1989). The consequently lower pH of the retained plaque on the enamel surface adjacent to orthodontic brackets hinders the remineralization process and decalcification can occur (Chat- terjee and Kleinberg, 1979; Gwinnett and Ceen, 1979). Initial enamel decalcifications can be seen as early as 4 weeks after the beginning of a MB-treatment (O'Reilly and Featherstone, 1987; Øgaard et al., 1988). In the early stages, caries appears as opaque milky white stripes or spots and may increase in severity presenting cavitation (Fehr et al., 1970; Gorelick et al., 1982; Artun and Thylstrup, 1986). The opaque white spot appearance is caused by changes in the optical properties of the enamel due to subsurface demineralization (Fehr et al., 1970). White spot lesions may stop its development after removal of MB-appliances because the cariogenic challenge has ceased (Artun and Thylstrup, 1986). In addition, such inactive incipient carious lesions may regress and become less prominent (Backer Dirks, 1966; Fehr et al., 1970; Artun and Thylstrup, 1986). However, they may remain esthetically unpleasant particularly if they are extensive (Artun and Thylstrup, 1986). Nevertheless, not every white discoloration on an enamel surface has to be a carious WSL, it can also occur as a result of dental fluorosis or traumatic lesions. An accurate differential di- agnosis of the different types of white tooth discolorations can be sometimes challenging. Dental fluorosis can be differentiated from other nonfluoride opacities as they are white/yellowish lesions not well defined and having symmetrical distribution in the mouth, which is independent from the localization of orthodontic brackets. Nonfluoride traumatic opacities have a more defined shape, random distribution and are often located in the middle of the tooth (Russell, 1961). On the other hand, WSL are milky white opacities that are mostly seen around the periphery of the bracket base or directly underneath the archwire (Summitt, 2006). Although it is generally accepted, that fluoride reduces the rate of demineralization. Fluoride treatment has a limited effect under bacterially produced lower pH conditions (Rølla and Øgaard, 1993) as they occur in MB-patients compared to untreated individuals (Chatterjee and Kleinberg, 1979) as a result of the above mentioned plaque retentive properties of MB- appliances. 2 Introduction Many prophylactic measures have been introduced in the last decades aiming at the preven- tion of WSL during MB-treatment. Among the most common and effective measures are spe- cial oral hygiene instructions including a recommendation for the use of high fluoride tooth- paste (D’Agostino et al., 1988; Alexander and Ripa, 2000), fluoride mouthrinse and high fluo- ride content products. The demineralization-inhibiting tendency of a daily use of fluoride rinse has been shown during MB-therapy (Benson et al., 2004; Shafi, 2008). While specific orthodontic efforts like the use of fluoride releasing bonding materials seem to have minimal or no positive effect (Derks et al., 2004). The above mentioned general prophylactic measures have been in use in the Department of Orthodontics at the University of Giessen since 1996. It is thus, the aim to assess the preva- lence and incidence of WSL in MB-patients under standard instructive and general fluoride prophylactic measure condition in order to generate a baseline dataset for future comparison. 3 Aim 2 AIM This study aimed to investigate the incidence and further course of white spot lesions during multibracket appliance treatment and its relation with gingival inflammation. 4 Materials and Methods 3 MATERIALS AND METHODS 3.1 Study Population Ethic approval for the present study was granted by the Ethical Committee of Medical Faculty of the Justus-Liebig-University, Giessen (approval number 112/09). The treatment records of all patients that had completed a MB-appliance treatment (Figure 3.1.1) within the period 1996 – 2006 at the Department of Orthodontics of the Justus-Liebig-University in Giessen were retrospectively screened for inclusion. Figure 3.1.1 Intraoral frontal view of a patient with full upper and lower jaw MB-appliance. The following inclusion criteria were applied: 1. no previous MB-treatment, 2. all four upper front teeth (UFT = any tooth present in the area 12-22) should be fully erupted and fully visible before the start of treatment, 3. no dental structural abnormalities or frontal fillings, veneers or other type of recon- structions present on the four UFT neither before nor after treatment, 4. at least four brackets bonded to the UFT, 5