Clinical Case Summary: ‘Minimally invasive treatment of white spot lesions’
A summary of: Victoria Sampson. 2020. Minimally invasive treatment of white spot lesions. DMG Connect. Date Reviewed: 13.12.2020.
White spot lesions are white opacities seen on teeth after the subsurface layer of the on enamel on the tooth becomes demineralised. The decalcified inner enamel remains trapped underneath remineralised surface enamel. The inner demineralised enamel scatters the light due to its irregular microstructure and this results in an opaque white appearance of the tooth. These white spot lesions are not cavitated.
According to US Oral Health Surveys there has been a marked increase in prevalence of white spot lesions between 1986 and 2012. With this statistic in consideration, and with the rise in social media engagement, many patients wish to not only preserve their dentition but to enhance it. White spot lesions can occur for a variety of reasons, each with a different characteristic, which may affect their prognosis. Therefore, it is important that the treatment options available are reflective of this.
There are 5 main causes of white spot lesions:
- Dental fluorosis – symmetrical, white lines, snow capping, snow flaking on enamel
- Demineralisation – faint white lesions around orthodontic brackets
- Molar incisal hypomineralisation – hypomineralised permanent first molars +/- incisors. Yellowing, mottling, post eruptive breakdown of molars
- Trauma – asymmetrical punctiform lesion on incisal third of the tooth
- Natural – isolated white spots with diameter less than 0.5mm in incisors (naturally occurring)
Through advancement in science and better understanding of the mechanisms and causes of white spot lesions, increasingly less invasive alternatives for removal of these white spots have been developed. Whereas previously, the least invasive alternative to white spots was their removal through drilling, it is now possible to treat them without the need removal of tooth tissue or application of anaesthetics. This is where ICON comes in.
The ICON (Infiltration CONcept), a low viscosity unfilled resin, was designed and developed by the company DMG (Germany) as a minimally invasive resin infiltration system for treating incipient caries in patients of all ages. ICON can arrest progression of early enamel lesions, without the need for tooth tissue removal. Aesthetically, ICON camouflages white spots by means of optical manipulation.
The clear resin flows into the demineralised enamel and has similar optical properties/refractive index (RI of resin = 1.475) to the enamel (RI = 1.65), therefore reflecting light to match the tooth’s natural shade.
Before offering ICON as the treatment of choice it is important to determine the patient’s main complaint, and whether the lesions are carious. The cause of the white spot lesions should be determined based on lesion characteristics and the patient’s medical, dental, and family history. ICON is a good treatment option in the case of orthodontically caused demineralisation, dental fluorosis, and some trauma-induced white lesions.
The resin infiltration is performed under rubber dam as part of a three-part technique: ICON-Etch, ICON-Dry and ICON-Infiltrant. This cycle is repeated until the spot is removed. This is followed by polishing to remove any surface roughness. Tooth whitening may also be offered prior to ICON treatment, but patients need to be made aware of the risk of the white lesions being exacerbated with whitening.
ICON resin treatment is an effective treatment option for patients with traumatic hypomineralised lesions in some cases, achieving excellent aesthetic results. However, since the depth and morphology of the lesions cannot be clinically distinguished, it is important to brief the patient on the possibility of unsuccessful treatment with resin infiltration. Nevertheless, since the treatment is atraumatic and painless, it should be attempted before opting for more invasive treatment options such as direct or indirect restorations.
Although, long term clinical data on this product is limited in literature, use of this technique is a step forward in providing access to atraumatic aesthetic treatments to patients of all ages.
Mobina Bohloli BDS4