Q & A

Kokich: This was an in-vitro study. Please explain the advantages and disadvantages of performing this study in vivo with patients.

Peters: A well-designed and sufficiently powered controlled clinical trial to compare the new bonding material to another effective management protocol is certainly needed. However, the many clinical parameters involved, including the large variability in natural white spot lesions, introduce confounding factors and make it difficult to determine clinical comparative effectiveness in vivo. Therefore, more economical in-vitro studies with controlled variables might provide insight in the important variables to achieve efficacy before large and costly clinical studies.

Kokich: What about the contraindications to having these chemicals in the oral cavity of children? Will we regret using these agents in the future?

Peters: Calcium and phosphate ions are natural components of hard tooth tissues and healthy saliva. They play an important role in the ion exchange during the physiologic, naturally occurring demineralization and remineralization processes in the mouth. There is no additional risk associated with this bonding material beyond the normal risks of routine orthodontic care. ACP slowly releases calcium and phosphate ions. This release self-activates in a low pH oral environment and returns to a dormant state when the pH level has returned to normal. Supersaturation of calcium and phosphate ions near the enamel-plaque interface significantly accelerates the tooth’s own calcium phosphate remineralization process and prevents demineralization. Therefore, this material might have the beneficial ability to enhance the tooth’s natural repair mechanism and reduce the detrimental effects of orthodontic brackets in a noncompliant patient. This might actually give Mother Nature a helping hand in keeping teeth healthy in harsh times.

Kokich: You learned a lot about the research in this area. What will be the future directions in research to counteract enamel decalcification?

Peters: It would help a lot if there was a remedy to prevent and remineralize white spot lesions without depending on the patient’s compliance. More research is warranted to develop a bioactive bonding agent with a remineralization boost to counteract the demineralization triggered by an acidic biofilm environment.

Kokich: If you were treating your own child who had poor oral hygiene, which method described in your research would you use to prevent decalcification?

Peters: Based on current best evidence, I would insist on repeated professional application of a fluoride varnish. Fluoride varnish doesn’t need much compliance—only some chair time and a dental professional (hygienist or auxiliary) to apply the varnish. With fluoride varnish, white spot lesions are almost entirely preventable. It is a shame that such a well-known and relatively low-cost prevention isn’t included as the standard of care in orthodontics to prevent the astoundingly high prevalence of white spot lesions as an iatrogenic side effect of orthodontic treatment with fixed or bonded appliances.

I would also try to improve oral hygiene by communication techniques like motivational interviewing and explaining what goes on in the mouth, how the mechanism of demineralization works, and why a white spot lesion can’t easily be remediated once it’s there. I would make very clear that, if poor oral hygiene continues, the brackets would need to be removed and treatment halted, since I have a professional and ethical responsibility. Personally, as a medical professional, I feel responsible to prevent starting caries disease in my patients as a result of the treatment I am providing.