|Year : 2016 | Volume
| Issue : 2 | Page : 117-120
Minimally invasive treatment of white spot lesions
Kanika Yadav, Ida de Noronha de Ataide, Marina Fernandes, Rajan Lambor
Department of Conservative Dentistry and Endodontics, Goa Dental College and Hospital, Bambolim, Goa, India
|Date of Web Publication||19-Dec-2016|
RZF/68-A, Street No. 3, Mahavir Enclave, New Delhi - 110 045
Source of Support: None, Conflict of Interest: None
This case report elaborates the management of white spot lesion (WSL) using air microabrasion as minimally invasive treatment modality. Air microabrasion can remove the outermost layer of enamel to manage superficial discolorations and incipient carious lesions. A WSL on the maxillary left incisor was treated conservatively with air microabrasion technique. This technique might be an alternative to chemical microabrasion, macroabrasion, and invasive restorative treatments for the management of WSLs.
Keywords: Air microabrasion, demineralization, white spot
|How to cite this article:|
Yadav K, de Ataide Id, Fernandes M, Lambor R. Minimally invasive treatment of white spot lesions. Indian J Oral Health Res 2016;2:117-20
|How to cite this URL:|
Yadav K, de Ataide Id, Fernandes M, Lambor R. Minimally invasive treatment of white spot lesions. Indian J Oral Health Res [serial online] 2016 [cited 2019 Jun 15];2:117-20. Available from: http://www.ijohr.org/text.asp?2016/2/2/117/196158
| Introduction|| |
White spot lesions (WSLs) are incipient carious lesions characterized by subsurface demineralization with an intact enamel surface. It results due to dissolution of hydroxyapatite from the enamel prisms by acidogenic microflora.  Predisposing factors are inadequate oral hygiene, plaque accumulation, and frequent ingestion of fermentable carbohydrates. White spots may also be seen after removal of orthodontic bands and brackets.  Incipient carious lesions may vary in clinical appearance ranging from opaque white to yellow brown discolorations. Opaque white appearance of such lesions is due to the internal porosities created by the loss of mineral which alters the refractive index of enamel. 
| Case report|| |
A 19-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of localized discoloration of the upper left central incisor. The patient's medical and dental history was noncontributory. On intraoral examination, a WSL on incisal third of the maxillary left central incisor was evident. Lesion was opaque, chalky, matte in appearance, had yellow brown discoloration at the center, and was rough on probing. Incisal edge of the tooth was chipped off due to demineralized defect [Figure 1]. Tooth responded normally to electric pulp test and cold test. Lesion was diagnosed as incipient carious lesion (WSL) after clinical and radiographic examination. After discussing different treatment modalities with the patient, minimally invasive treatment was adopted. Treatment plan outlined was conservative tooth preparation using air microabrasion to remove the WSL.
The tooth #21 was cleaned with a rubber cup and prophylaxis paste. Following this, tooth was isolated with rubber dam application. Impression putty was used to further isolate the lesion to prevent the abrasion of adjacent sound tooth structure [Figure 2]. Air abrasion unit (Microetcher II Ea Danville Materials, CA, USA) was assembled by connecting the abrasive reservoir containing aluminum oxide particles to the handpiece and tubing to the airline of the dental unit [Figure 3]. The tip of the air abrasion handpiece was positioned at a distance of 2 mm from the lesion, and a stream of aluminum oxide particles was directed towards the lesion [Figure 4]. Complete removal of the WSL revealed a more extensive involvement [Figure 5]. Therefore, a composite resin restoration was placed in the cavity prepared by air abrasion. Cavity was etched with 37% phosphoric acid (Conditioner 36, Dentsply DeTrey, Konstanz, Germany) for 15 s and rinsed with distilled water. The cavity was blot dried and total etch adhesive (Prime and Bond NT, Dentsply Caulk, Milford, DE, USA) was applied with the applicator tip. Excess primer was removed with a gentle air stream and light cured for 20 s with a halogen curing light (Woodpecker LED Curing Light; Guilin Woodpecker Medical Instrument Co, Ltd, Guangxi, China). Nanofilled composite (Ceram X, Dentsply DeTrey) was used to restore the defect. Finishing and polishing of the restoration were carried out [Figure 6]. Three month follow-up shows intact restoration and no progression of WSL [Figure 7].
|Figure 2: Isolation of white spot lesion using rubber dam and putty impression material|
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|Figure 4: Intraoperative photograph showing abrasion of white spot lesion|
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| Discussion|| |
WSLs are incipient carious lesions with subsurface demineralization and a relatively intact enamel surface. These lesions are also called "surface-softened defects." Clinically, lesions are opaque white in appearance initially which may turn yellow brown with the progression of the lesion. On probing, lesions are softer than the adjacent sound enamel. WSLs can be active or inactive (arrested). Active lesions have rough, chalky surface and may progress to caries under acid attack, whereas arrested lesions are smooth and shiny which remains constant or may remineralize under favorable oral conditions.  In this case, lesion was dull/matte in appearance and rough, chalky on tactile examination indicating an active lesion. These lesions should be distinguished from fluorosed teeth. Fluorosis is more generalized and diffuse in outline unlike WSL which is localized and well defined. 
Early diagnosis of incipient lesions is important to institute preventive measures for caries control. Traditional diagnostic methods such as visual, tactile, and radiographic examination are inaccurate to detect incipient lesions. Recent methods for caries detection such as DIAGNOdent, quantitative laser fluorescence, optical coherence tomography, and digital imaging fiberoptic transillumination are more accurate and reliable for diagnosing early carious lesions. 
Air abrasion dentistry has evolved over a period as a means of providing a truly conservative preparation for preservation of a maximal sound tooth structure. Air abrasion removes the tooth structure using a stream of aluminum oxide particles generated from compressed air. Air abrasion preparations are comfortable and usually can be done without use of local anesthesia. Tooth structure removal with air abrasion unit depends on various parameters such as the air pressure, abrading particle size, particles flow rate, nozzle diameter of the handpiece, nozzle angulation, distance from tooth, and time of exposure. 
Air pressure ranges from 40 to 160 pounds/square inch. The recommended levels are at 100 psi for cutting and 80 psi for surface etching. The most common particle sizes are 27 or 50 μm in diameter, with an approximate flow rate of 2.5 g/min. The speed of the abrasive particles when they hit the tooth depends on gas pressure, nozzle diameter, particle size, and distance from the surface. Typical operating distances from the tooth range from 0.5 to 2 mm. It is best to hold the nozzle tip at a 30° to 60° angle to deflect the flow of particles away from the field instead of deflecting back into the oncoming stream. 
Various air abrasion systems such as PrepMaster or EtchMaster (Groman Inc, Florida, US), PrepStart and PrepAir (Danville Engineering, CA, USA), or CrystalMark (CrystalMark Inc, CA, US) work on the same principle. Recently, bioactive glass has been tried and evaluated as an alternative to aluminum oxide particles for ultraconservative cavity preparation. 
Various applications of air microabrasion are as follows:
- Removal of superficial enamel defects
- Cleaning fissures and surface preparation for sealant
- Preparation for preventive resin restorations
- Removal and repair of composite, glass ionomer cement, porcelain restorations
- Small cavity preparations
- Surface preparation for abfraction and abrasion
- Removal of pits and fissure surface stain
- Cleaning and preparation of castings
- Detection of pits and fissure caries.
Air microabrasion has several advantages over conventional cavity preparation such as no discomfort due to vibration, lesser need for local anesthesia, and conservation of the tooth structure. Limitations to its use are as follows: it cannot be used to remove amalgam restorations, not effective for removal of gross caries, cannot be used in conjunction with magnification devices as rebound particles could damage the lenses, and does not obviate the need for acid etching. Air microabrasion is contraindicated in patients with allergy to dust, asthma, and chronic pulmonary disease. 
Resurgence of air abrasive technology with newer restorative materials has given a new dimension to "minimally invasive dentistry." This case report highlights the management of WSL with minimally invasive treatment option. Furthermore, it provides a brief review of etiology, clinical features, diagnosis, and various treatment options for incipient carious lesions.
| Conclusion|| |
The dynamic balance between remineralization and demineralization determines the progression of WSLs. Prompt diagnosis and treatment of such lesions arrest its progression to caries. With an increase in demand for minimally invasive and less expensive treatment for esthetic cases, air microabrasion may be considered a suitable treatment option.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Toumba DC. Diagnosis and prevention of dental caries. In: Welbury R, Duggal MS, Hosey MT, editors. Paediatric Dentistry. 3 rd
ed. UK: Oxford University Press; 2005. p. 109.
Kidd EA, Fejerskov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res 2004;83:C35-8.
Staudt CB, Lussi A, Jacquet J, Kiliaridis S. White spot lesions around brackets: In vitro
detection by laser fluorescence. Eur J Oral Sci 2004;112:237-43.
Roopa KB, Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent 2015;3:1-7.
Soares R, Ataide I, Fernandes M, Lambor R. Esthetic management of white spot lesions - A minimally invasive approach. J Adv Med Dent Sci Res 2014;2:105-10.
Carounanidy U, Sathyanarayanan R. Dental caries: A complete changeover (Part II)-Changeover in the diagnosis and prognosis. J Conserv Dent 2009;12:87-100.
White JM, Eakle WS. Rationale and treatment approach in minimally invasive dentistry. J Am Dent Assoc 2000;131:13S-9S.
Hegde VS, Khatavkar RA. A new dimension to conservative dentistry: Air abrasion. J Conserv Dent 2010;13:4-8.
Tan MH, Hill RG, Anderson P. Comparing the air abrasion cutting efficacy of dentine using a fluoride-containing bioactive glass versus an alumina abrasive: An in vitro
study. Int J Dent 2015;2015:521901.
Wright GZ, Hatibovic-Kofman S, Millenaar DW, Braverman I. The safety and efficacy of treatment with air abrasion technology. Int J Paediatr Dent 1999;9:133-40.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]