A Simple and Effective Treatment for White Spots

INTRODUCTION
White spots on teeth have always created a dilemma for us in clinical dentistry. We commonly see many of these cases in our day-to-day operations and wonder whether or not to treat them. If we decide to treat the patient, it may be difficult to discern whether it should be done more invasively or not. Noninvasive treatments include using differing pastes available to dentists;,while invasive procedures can range from composite filling materials, to a veneer, to a full-coverage crown. With an increasing emphasis on minimally invasive dentistry, we now think about approaching many procedures much more conservatively. This concept has been extremely satisfying to us and to our patients because they truly appreciate and value our ability to solve aesthetic dilemmas in the simplest and least destructive manner.

Before Image. Preoperative full-face photo of our 19-year-old patient.	After Image. Postoperative full-face photo.

White spots on patients can certainly vary in intensity and number. Patient responses to these spots vary considerably as some patients do not mind the largest of spots, while others can be critical of the smallest spot on their tooth. Treating white spots with a minimally invasive form of dentistry has never been easier and a more rewarding experience.

BACKGROUND ON WHITE SPOT LESIONS
Etiology
What causes white spots and why do they form? White spots are signs of demineralization underneath intact enamel. Bacteria produce acids which break down apatite to calcium and phosphate ions.1 When these ions are not replaced in the natural remineralization process, porosities are created within the enamel. This usually results in the underlying porosity becoming fluid-filled, developing the classic whitish discoloration associated with demineralization. This discoloration is the result of the difference in refraction of light through healthy enamel and fluid filled porosity.² White spots can appear in primary or secondary teeth with differing intensities. Most commonly, white spot lesions are seen after orthodontic bands and brackets are removed. Some of the other causes of white spot lesions include fluorosis, hypocalcification, erosion, hypoplasia, xerostomia, tetracycline staining, and trauma. They can also be the result of arrested incipient decay that stopped progressing and remineralized.

Treatments
In the past, the primary approach to the treatment of white spots is remineralization using pastes, creams, and topical treatments. Some of these include fluoride therapy or some form of calcium phosphate paste. Teeth whitening may also be used as an option to alleviate the appearance of these white lesions but usually requires variable amounts of time. These modalities all have unpredictable degrees of success based upon published literature. Other more invasive approaches to dealing with white spot lesions include microabrasion, composite restorations, and veneers or crowns.

Diagnosis
In order to provide a good treatment plan, a proper diagnosis must be made. We have come to depend on visual examination as a primary diagnostic tool, along with probing of suspected surfaces in order to determine the location of areas of concern. Color, hardness, translucency, and opacity all play a role in diagnosing the presence of lesions.
The best way to do a visual analysis is to dry the teeth and then examine them under good lighting with high magnification. While hypocalcifications are visible wet or dry, incipient caries lesions are often visible only when enamel is dry. (Typically carious lesions are visible when dry but disappear when rewetted.) Also, the surface of an inactive white spot lesion is usually smooth and shiny, while a rough, chalky, and dull lesion can indicate an active caries lesion.

Figure 1. Smile, nonretracted.	Figure 2. Retracted smile.
Figure 3. Acid etch was applied.	Figure 4. After acid etching.
Figure 5. After placement of ICON-Infiltrant.	Figure 6. Postoperative photo retracted.

The modern practice has a growing number of caries detection technologies from which to choose: digital radiography, quantitative laser fluorescence, laser fluorescence, and several more emerging technologies. The important consideration is that we recognize that earlier diagnosis and treatment of caries lesions is the first and most important step in early minimally invasive treatment.

MINIMALLY INVASIVE APPROACH
As we continue our search for minimally invasive techniques, a product called Infiltration Concept (ICON) was introduced in the United States in 2009 by DMG America. Designed to arrest the progression of incipient carious lesions, Icon gives us a great solution for treating white spot lesions with a simple technique as well. This is a great treatment for stopping early caries and removing opaque lesions, all without any drilling or need for local anesthesia. There is no shade matching necessary as this material blends with the tooth shade and eliminates the white lesions. This procedure has worked well repeatedly in our office. The procedure is simple and can even be done by auxiliary members (check your state dental practice laws).
This product fills and reinforces the pores of these lesions with a light-cured resin material. A very low-viscosity infiltrating resin (Icon-Infiltrant [DMG America]) is pulled deep into the pores of a lesion by way of capillary action. This resin fills the tooth and replaces the lost structure within the pores. The progression of caries is stopped as no further nutrients are allowed into the pores. Icon accomplishes this without changing the shade of the tooth or altering its shape. This procedure is ideally suited for patients with a history of orthodontic therapy, high acid exposure, and/or poor oral hygiene.
Icon is not indicated for patients with fluorosis, hypocalcification, erosion, tetracycline stain or trauma to the teeth. It is indicated for those lesions, both proximal and smooth surface, that are clearly the result of cariogenic bacteria. Simply put, it is indicated for lesions that are the result of acid demineralization of tooth structure.

CASE REPORT
My patient, a 19-year-old male who had braces from the age of 12 to 14 years, is also my nephew. He had been complaining of his white spots from the day his braces were removed. The older he got, the more important it was for him to minimize or eliminate these spots.
It is extremely important to take a thorough history of the patient to confirm that the white spots are the type indicated (as discussed above) for this minimally invasive treatment. In this case, it was easy as I have known my nephew and treated him since he was a child (Before Image). We treated teeth Nos. 6 to 11 (Figures 1 and 2).

The Technique
A rubber dam (or other isolation device such as Optragate [Ivoclar Vivadent]) or liquid dam is recommended for the treatment. A prophylaxis was performed and the teeth were rinsed clean. The Icon-Etch (DMG America), a 15% hydrochloric acid, was used first and applied in a controlled manner: approximately 1.0 mm in depth and 2.0 mm from the visible margin of the lesion for 2 minutes (Figure 3). Next, the acid etch was rinsed off with water for at least 30 seconds and then dried with oil- and water-free air (Figure 4). The lesion was then etched a second time for 2 minutes (following the previous instructions). The purpose of the etching step is to gain complete access to the subsurface pores in the body of the lesion. Next, Icon-Dry (DMG America), made of 99% ethanol, was applied and left for 30 seconds, and then dried with air. Upon applying the Icon-Dry, we have an opportunity to confirm that we have etched the surface enough and truly gained access to the lesion porosities. The spots should almost disappear while wet with the ethanol. If so, we continue on to the infiltrating step; if not, we would go back to the etching step.
Upon being satisfied with the preview, we applied the Icon-Infiltrant to the teeth and left it alone for 3 minutes (Figure 5). After the 3 minutes, any excess material was removed from the teeth. Then, both sides of the teeth were flossed and the lesion was light-cured for 40 seconds. A second layer of Icon-Infiltrant was applied and allowed to sit on the surface for an additional minute. Once again, excess was removed, and the teeth were light-cured for 40 seconds. The shade of the infiltrated lesion is balanced with the rest of the tooth. Polishing cups were used at the end of the procedure to provide a smooth surface luster (Figure 6 and After Image).
One of the best features of this procedure is the fact that there is no discomfort to the patient during/after the procedure. The procedure typically takes about 15 minutes per tooth, and multiple teeth can be treated at the same time. It should be noted that the teeth may look desiccated during treatment and lighter right after completion. The patient is instructed to drink liquids and hydrate the teeth for the next few hours after treatment.
My nephew was astonished at his result and left the office wanting to have all of his white spots treated with this minimally invasive procedure.

IN SUMMARY
Caries infiltration is an excellent procedure in our quest for microinvasive dentistry. For the patient, it is a quick procedure that requires no anesthetic or drilling. Infiltration is indicated for any age patient due to its conservative nature.
It stops progressing lesions and keeps them from more expensive and invasive procedures. For the doctor, it allows us to expand our treatment modalities with a procedure that is conservative and simple, yet produces great results in short period of time. It gives an option beyond the simple first stage of fluoride or remineralization therapies. It is a minimally invasive technique that allows clinicians to treat lesions that are not advanced enough for more invasive procedures. This technique has allowed many of my patients, conscious of their white spots, to fully smile again.

References

1. Vick VX, Goldie MP, Shay K. Part III. Patient assessment. In: Daniel SJ, Harfst SA, Wilder RS, eds. Mosby’s Dental Hygiene: Concepts, Cases, and Competencies. 2nd ed. St. Louis, MO: Mosby; 2007:350.
2. Choo-Smith LP, Dong CC, Cleghorn B, et al. Shedding new light on early caries detection. J Can Dent Assoc. 2008;74:913-918.

Dr. Halabo is a graduate of Boston University’s School of Graduate Dentistry and is well known for his involvement in the continuing dental education of professionals. He is a true believer in practicing what he preaches, sharing his knowledge and giving back to the dental community. He is the former clinical director of the University of California at San Diego homeless clinic. His emphasis is on CAD/CAM dentistry, recession proofing, and working in the ideal practice. He is a member of the ADA, AGD, California Dental Association, San Diego County Dental Association, and the American Academy of Cosmetic Dentistry. He has been a clinical research associate evaluator for more than 14 years. Dr. Halabo has published a number of articles for dental professionals as well as his local community. He enjoys providing dental care at his private practice in San Diego, Calif. He can be reached at (619) 427-0810, at sam@samhalabodmd.com or at smilesbydrsam.com.

Disclosure: Dr. Halabo reports no disclosures.