Shahreen Zahid Khan  ( Army Medical College, National University of Medical Sciences )
Muhammad Kaleem  ( Army Medical College, National University of Medical Sciences )
Shahab ud din  ( Shaheed Zulfiqar Ali Bhutto Medical University, PIMS, Islamabad )
Haroon Ahmed Khan  ( Department of Electrical Engineering, COMSATS Institute of Information Technology )
Saba Waqar Qureshi  ( Margalla Institute of Health Sciences, Rawalpindi )

To find the best option to treat White Spot Lesion in existing caries treatments, and to identify the selected articles discussing etiology of caries along with White spot lesion. Null hypothesis was that "Only anticariogenic agent can cure White Spot Lesion". PRISMA guidelines were used to conduct the systematic analysis. An electronic customized search was performed using mesh terminologies on PubMed database based on inclusion criteria that included studies with; any treatment option that can treat or prevent WSL; and minimally invasive treatment options that may be altered to treat WSL. While exclusion criteria comprised studies with treatment of rampant caries, severe early childhood caries and root caries. Inclusion criteria for etiological factors incorporated studies with factors that lead to white spot lesion or carious lesion. Finally, therapeutic agents of dental caries were analyzed. Only the use of anti-cariogenic agent cannot cure White Spot Lesion. Hence study fails to prove the null hypothesis. Although combination of anti-cariogenic agents with a re-mineralizing agent can provide additional options for the treatment or prevention of WSL.

Keywords: White spot lesion, Fluoride, Caries, Treatment. DOI:10.5455/JPMA.281716

Introduction

Dental caries is a disease affecting people of all ages.¹ Carious lesion has the ability to hurt the quality of life if left untreated. ² Treatment of such lesions at the earliest possible stage with minimally invasive options is the utmost requirement. Trend from drilling of carious lesion is moving towards reversal of early form of caries. Preservation of tooth structure is forming the basis of the latest treatment options. ^3-6 There is a fine line to differentiate between the White Spot Lesion (WSL) and caries lesion. This study seeks to present a systematic analysis on the current trends of minimal to non-invasive treatments of dental caries. Noninvasive options of treating caries may add to or provide an alternative to re-mineralising agents that are currently being investigated for the treatment of WSL.^7-9 WSL is considered the first step in the formation of carious lesion. PubMed medical subject heading (MeSH) terminology explains WSL tooth de-mineralisation separately from carious lesion even though it can lead to carious lesion. Considering de-mineralisation or WSL as a separate entity will clearly isolate the treatment options of WSL from dental caries. Available non-invasive options in use for the treatment of WSL include fluoride gel application and desensitizing agents. ⁹  While treatment options at dental clinic include filling or coating with veneers using porcelain or composite, bonding agent to correct flaw or decay, crowns or inlays and vital tooth crowning. Non-invasive treatment options in use are mostly symptomatic. On the other hand, invasive treatment options are not attractive as it involves removal of vital tooth structure.^7,10 Latest treatment options in literature focus on remineralising the WSL.^9,11 A visible change in trend over 50 years can be seen in literature (Figure-1)



which is an evidence of increasing number of research studies in this related field. Considering that present research on treating WSL is fixated on re-mineralising agents, there was a possibility of finding additional treatment options in latest research on prevention and treatment of dental caries. The current systematic review was planned to put on emphasis on the current trends in minimal to non-invasive anti-cariogenic agents that can be used to treat WSL.

Methodology

The PubMed database in conjunction MeSH terminologies was used to harvest articles most relevant to the search. The search string formulated after 'key word' optimization for maximum relevant search results was: ((((("Tooth Demineralization"[Mesh]) AND "Dental Caries"[Mesh]) AND "Dental Caries/etiology"[Mesh]) AND ("Dental Caries/therapy"[Mesh])) AND "Tooth Demineralization/etiology"[Mesh]). The initial run of search yielded 2374 articles pertaining to the topic. After search term optimisation, 86(3.62%) articles were short-listed. This was the first level of automatic filtering applied to the search engines using Boolean Logic. The search result was further refined by introducing various filters, like availability of full text, free access and publication history (last 20 years to last 5 years) etc. Each of the filters provided a sharper focus towards the current trends in research. After reducing the time span to 5 years (January 1, 2010, to January 1, 2015), the total number of studies left was 68(2.84%)(3.62%).

Inclusion Criteria

1. Any treatment option that can treat WSL.

2. Any preventive anti-cariogenic treatment that may also prevent WSL.

3. Minimally invasive treatment options that may be altered to treat WSL.

4. Factors that may lead to WSL or carious lesion.

Exclusion Criteria

1. Treatment of rampant caries and severe early childhood caries.

2. Treatment of root caries.

On the basis of the above criteria, the study rejected 38(1.6%) studies. Of the 30(1.26%) articles identified, 26(87%) pertained to therapeutic agents of dental caries that may be effective in treating or preventing WSL, and 6(20%) covered aetiological factors of caries and WSL. The search was done using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Figure-2).



Result

Of the studies selected, 11(%) were in vitro studies and 2(%) were in situ. Besides, 6(%) studies were in vivo; 3(%) of which were randomised clinical trials (RCTs), 1(%) was non-RCT, 1(%) cross-sectional and 1(%) animal study. Also, 7(%) were reviews that were included in order to investigate more treatment options. Aetiological factors of the selected studies were noted (Table-1)



and so was the case with characteristics, citations, reason for inclusion and summary of results that highlighted the therapeutic agents with potential to treat WSL (Table-2).



Discussion

After combining the results of therapeutic agents used in minimal invasive treatment options, viability of specific agents to be used as definitive treatment option can be analysed.

 

Aetiological factors related to

demineralization and dental caries

Different aetiological factors were found in studies. General causes included free sugar intake, sweetened beverages, orthodontic treatment, bad oral hygiene, diet, tobacco, stress and alcohol. Specific aetiologies covered in these studies were presence of specific gene, anaerobe bacteria especially streptococcus mutans (SM), frequent reduction in potential of hydrogen (pH), surface adhesive properties of bacteria, biofilm formation and production of organic acid. Most of the studies were related to eradication of cause (Table-2). And a few additional factors were also noted (Table-1). Method and mechanism of these aetiology-specific treatments may help in treating WSL.

Various treatment options

The various options to treat WSL found in literature were further classified under following headings. Their potential is also explained.

1: Established therapies

There are various options used in clinics that treat caries with minimal invasion. Considering these for treating WSL may have certain issues. Use of Pit and fissure sealants by covering WSL was found to be controversial.^12,13 Triclosan and chlorhexidine that act against SM needs better alternative to resolve WSL.¹⁴ Fluoride-containing therapies.^15-17make enamel more resistant to de-mineralisation but does not re-mineralise WSL. Xylitol wipes were only tested for deciduous teeth. These issues may be resolved by combining different treatment options.

2: Antibacterial / anti-cariogenic agents of

plant origin

Extracts of various plants have been tested for their anticariogenic ability.^18-24 In view of these antibacterial agents, Psidium Cattleianum leave extracts (PCLE) showed interesting results. PCLE increased the hardness of enamel but use of surfactant in the study may act as confounder. Hence, further studies are required for testing its use in the treatment of WSL. Most of these agents target the cariogenic bacteria, specifically SM. WSL that are caused by bleaching or by etching does not result from cariogenic bacteria or formation of biofilm. Hence, antibacterial agents of plant origin cannot solely resolve de-mineralisation.

3: Changing the oral habitat

Changing oral habitat by use of probiotics, ²⁵ mutants of SM²⁶  or alkali-producing bacteria²⁷ are at initial stages of research. These reduce the cariogenic bacteria and their activity. Mode of action is reversal of acidic pH or reducing bacterial adhesion in oral cavity.^25-27 Further research is required to establish its use in the treatment of WSL.

4: Vaccination against cariogenic bacteria

DNA vaccine that can be used via nasal cavity against SM is at initial stages of development. This might prevent SM activity but still cannot prevent de-mineralisation of tooth surface resulting due to reasons other than SM.²⁸

5: Nano-emulsion

It acts as disinfectant and reduces surface energy. It protects the surface of enamel.^29,30 It might be considered a preventive option for WSL, but on the contrary it may hinder the etching or bleaching process. Thus its use may be controversial in certain situations.

6: Novel composite with antibacterial
properties as well as re-mineralising efficiency

Combination of antimicrobial properties and the ability to re-mineralise may be effectively used during orthodontic treatment to prevent WSL. Further research is required in this field to establish its use for bonding or banding during orthodontic treatment.³¹

Conclusion

Most of the treatment options found in literature related to treatment of anti-cariogenic agents fail to provide a complete cure of WSL. The possible treatment option may be further explored. Further research in combining anticariogenic agents with a re-mineralising agent may effectively treat or prevent a WSL.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

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