Assessment of Iranian orthodontists' practice with regard to the prevention and treatment of white spot lesions.

INTRODUCTION: White spot lesions (WSLs) are common adverse effect of orthodontic treatment, which can be prevented and treated by orthodontists. This study was conducted to assess Iranian orthodontists' practice regarding the prevention and treatment of WSLs in their patients.
METHODS: In this cross-sectional study, 109 Iranian orthodontists were selected from the Iranian Association of Orthodontists' directory by cluster sampling. For data collection, a questionnaire was designed and its validity and reliability was confirmed (Cronbach's α =0.85). The questionnaire included eight general questions and eight questions about practice with regard to the prevention and treatment of WSL. Data were analyzed by descriptive tests, ANOVA test, and t-test in SPSS 20 software. P < 0.05 was considered statistically significant.
RESULTS: The mean score of orthodontists' practice was 7.62 (range: 0-8), and 94.4% of the participants were rated as good, while 3.7% and 1.9% were rated as moderate and weak, respectively. Women's score was significantly higher than that of men (P = 0.001). With increasing participants' age, their practice has been improved (P = 0.001), but there was no significant relation between years of experience and their practice (P = 0.230). Nearly 94.4% of the orthodontists prescribed fluoride products. Toothpastes and fluoride mouth rinses were the most common prescribed products (34%).
CONCLUSIONS: With regard to Iranian orthodontists' practice, it was fortunate to note that majority of the respondents were taking care of their patients with regarding to the prevention and treatment of WSLs. For enhancing their competencies, it is recommended to plan educational courses which are useful for promoting their knowledge and practice about new products and procedures used for the prevention and treatment of WSLs.

Introduction

During fixed orthodontic treatment and in the absence of adequate oral health care, fixed orthodontic appliances induce accumulation of dental plaque around orthodontic brackets. Dental plaque causes pH decrease. As the pH drops below the remineralization threshold, carious decalcification occurs.[123] White spot lesions (WSLs) are the first clinical evidence of demineralization, which can form within 4 weeks.[45] WSLs are subsurface porosities which are caused by demineralization.[6] The milky white appearance is due to changes in light scattering of the decalcified enamel.[7]

WSLs are more prevalent in orthodontic patients than others.[8] About 50% of patients receiving orthodontic treatment develop one or more WSLs during treatment, compared with 11%–24% of untreated control participants.[9] Richter et al.[10] reported that 72.9% of orthodontic patients had developed at least one WSL during orthodontic treatment, of which 2.3% of them were cavitated.

Appropriate oral health care such as toothbrushing and using fluoridated dentifrice (0.1% or more) can prevent WSLs. Using fluoridated dentifrice alone is ineffective for patients who are not compliant, and dentists should encourage these patients to use fluoride mouth rinse daily.[111213] O’Reilly and Featherstone[13] and Geiger et al.[14] reported that using fluoride mouth rinses significantly reduces the number of WSLs. However, <15% of orthodontic patients have rinsed daily, as instructed.

Consequently, more sustained fluoride supplementation is needed. Fluoride varnish is more independent of patients’ cooperation.[12] It decreases the amount of enamel demineralization in orthodontic patients.[1516] Bonding fixed orthodontic appliances with glass ionomer cements provides sustained fluoride release.[7] Hallgren et al.[17] found elevated fluoride concentrations in dental plaque adjacent to brackets bonded with glass ionomer compared with brackets bonded with resin composite.

Although fluoride supplementations are the most effective method for WSLs prevention,[1819] there is no common approach for treating this lesion.[20] Recently, using fluoride and remineralization with calcium phosphate has demonstrated good results. More studies are needed for evaluating its clinical effects.[2122]

Since orthodontists play an important role in preventing and treating WSLs which is an important clinical complication in orthodontic patients and due to the paucity of research about orthodontists’ practice in preventing and treating WSLs, this study evaluates Iranian orthodontists’ practice toward WSLs in their patients.

Methods

This cross-sectional study was conducted on Iranian orthodontists in 2015 after obtaining approval by the Ethical Committee at Isfahan University of Medical Sciences, Faculty of Dentistry. The sample size was 120, which were selected by multistage sampling from five large cities of Iran as the clusters; Tehran, Isfahan, Shiraz, Tabriz, and Mashhad. Orthodontists in these cities were randomly selected from the Iranian Association of Orthodontists directory. The orthodontists who have no clinical practice were excluded from the study. By referring to the orthodontists’ offices, data collection was done. Data collection was conducted by a questionnaire. The questionnaire was designed using literature.[71420] Questionnaire validity was confirmed by a specialist team (four orthodontists and an operative dentistry specialist and an oral health specialist) and then it was given to ten orthodontists for checking face validity and their comments were applied. The reliability of questionnaire was tested in a pilot study by 25 orthodontists (Cronbach's α = 0.85).

The final questionnaire consisted of two parts; demographic part (three questions) and the second part with 13 questions about oral health care in orthodontic clinics. There were eight key questions which assessed orthodontists’ practice regarding the prevention and treatment of WSLs. If six questions were answered true, the practice was evaluated good, if four were true, it was fair, and lower than four, it was weak.

For data analysis, SPSS 20 software (IBM Company, Armonk, NY, U.S.A) was used by applying t-test and ANOVA tests with the significant level of 0.05.

Results

From 120 orthodontists who were participants in this study, 109 orthodontists had filled questionnaires completely, so the response rate was 91%. The group consisted of 63 (59.4%) females and 43 (40.6%) males. The average age was 42.6 ± 8.7 years. The average years of experience were 10.1 ± 6.2 years. Table 1 shows orthodontists’ demographic characteristics.

Table 1

Demographic profile of participants

For the second part of the questionnaire about orthodontists’ practice regarding prevention and treatment of WSLs, 94.4% of orthodontists were categorized in good practice subgroup (6–8 score) [Table 2].

Table 2

Orthodontist's practice regarding prevention and treatment of white spot lesions

The relationship between practice score and gender, age, and years of practice was analyzed by t-test and ANOVA [Table 3].

Table 3

Mean score of orthodontists’ practice among different genders, ages, and years of experience

The average practice score in women was significantly higher than that of men. In addition, the score in orthodontists aged over 50 years was significantly higher than the orthodontists under the age of 50 years. There was no relation between the years of practice and the practice score.

Nearly 98.2% of the orthodontists instructed oral health care to their patients by themselves or by their staff [Figure 1].

Figure 1

Persons who instructed oral health care in orthodontic clinics

Almost 94.4% of orthodontists had used fluoride products for their patients. Nearly 22.9% used only one type of fluoride product; others had used two or more types simultaneously to prevent dental caries. The most commonly prescribed fluoride product was toothpaste (77%) and the least was professional fluoride therapy (8.3) [Figure 2].

Figure 2

Frequency of fluoride products prescription by orthodontists

Nearly 95.4% of orthodontists used to examine their patient's teeth for dental caries and the presence of WSLs at the beginning of the orthodontic treatment and 90% of them continue checking tooth caries during treatments [Table 4].

Table 4

Frequency of patient dental checking for the presence of white spot lesions and treatment methods used by orthodontists

Nearly half of the orthodontists referred their patients to general practitioners for treating WSLs (40%) [Table 4].

Discussion

WSLs are common complications of orthodontic treatment,[45] and nearly half of the orthodontic patients have one or more WSLs during treatment.[9] Orthodontists have an important role to prevent and manage this problem by instructing oral health care to their patients.[23] According to results of this study, 94.4% of orthodontists had good practice. Women's practice score was significantly higher than that of men. Researchers have found females to engage in better oral hygiene behavioral measures, possess a greater interest in oral health, and perceive their oral health to be good to a higher degree than males,[24] so maybe, it is the reason that they pay more attention to patients’ oral hygiene.

In 79% of cases, orthodontists or their staff instructed oral health care to their patients to prevent oral disease during the treatment. Hence, it shows that patient training and increasing patient's motivation regarding prevention of WSLs is a common practice in Iranian orthodontists.

Rubak et al.[25] conducted a meta-analysis and they found that instructions to increase the patient's motivation to implement and maintain good oral health care habits are common among orthodontists. This is the same as the result of the present study.

Ogaard et al.[26] reported that visible white spots on the facial surfaces of teeth increase during orthodontic therapy. In this study, nearly 60% of orthodontists reported that they had observed WSLs on patients’ teeth during treatment, which is similar with Ogaard's study.

In another study, Ogaard[27] recommended that clinicians provide a more continuous fluoride supplementation independent of patient cooperation, which would decrease the risk of fixed orthodontic appliances’ cariogenic effects. In this study, 94.4% of orthodontists used fluoride products to prevent and treat WSLs which demonstrated responsible practice of these orthodontists.

There are various methods for preventing and treating WSLs. Benson et al.[28] reported that daily usage of fluoride mouth rinse significantly decreases WSLs in orthodontic patients. In this study, 57% of orthodontists prescribed fluoride mouth rinses for preventing WSLs. Fluoridated toothpastes and fluoride mouth rinses were the most common prescribed products by orthodontists. According to Bergstrand and Twetman's[29] review study, fluoride varnish is the best product for preventing WSLs. It seems that using varnish fluoride is not routine because patients are more familial with using toothpaste or mouth rinse and also patients have to pay more for varnish fluoride.

Bishara et al.[11] recommended that clinicians must document all WSLs by obtaining intraoral photographs before beginning treatment. In this study, 95.4% of orthodontists evaluated WSLs before starting treatment and 92.7% checked the presence of WSLs during treatment and 61% checked WSLs at every visit.

Tufekci et al.[23] reported at least one WSL in 38% of orthodontic patients during the first 6 months and in 46% of them during the first 12 months of treatment. In this study, orthodontists were checking the presence of WSLs 3 months after starting treatment procedures. Nearly 62% observed few WSLs and 28% observed WSLs among half of their patients. The different period of time for evaluating WSLs between two studies could be the reason of these differences.

The survey showed significant relation between age of orthodontists and the practice score. Orthodontists with age of 50 years or above had better practice. The reason could be due to the role of age in preventing complications and orthodontists’ tendency to do perfectly. However, Charalambous et al.[30] did not find any significant relation between the age of dentists and their efficiency. This can be due to different elements which were assessed in these studies.

This research clarified that orthodontists do their responsibility in the prevention of WSLs. Hence, it is recommended to assess other possible factors in producing tooth caries in these patients.

Conclusions

Iranian orthodontists had good practice regarding the prevention and treatment of WSLs. Women's practice was significantly better than that of men. The most common method for preventing WSLs was in-home instructions. The most common prescribed product is fluoride-containing toothpastes. Against orthodontists’ good performance with regard to caries prevention, WSL is still the common problem in orthodontic patients. Hence, it is recommended to assess other possible factors in producing tooth caries in these patients.

Financial support and sponsorship

This study was financially supported by Isfahan University of Medical Sciences as a thesis.

Conflicts of interest

There are no conflicts of interest.