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Enamel demineralixation following

orthodontic treatment
I3 Mizrahi

Eliakim Mizrahi, B.D.S., DipOrth., F.D.S., MSc., Ph.D.*

Johannesburg, South Africa

A cross-sectional study was carried out to determine the prevalence and severity of enamel opacities in patients
before and after orthodontic treatment. The sample consisted of 527 patients examined prior to and 269 patients
examined after completion of multibanded orthodontic treatment. The results showed that there was a significant
increase in both the prevalence (before, 72.3 per cent; after, 84.0 per cent) and severity (Opacity Index: before,
0.125; after, 0.200) following completion of orthodontic treatment. hAale patients experienced a significantly higher
increase in the severity of enamel opacities following orthodontic treatment. There was no significant sex
differential in the prevalence of enamel opacities either before or after orthodontic treatment. This study showed
that orthodontic treatment with multibanded appliances contributed to the development of new areas of enamel
demineralization and to an increase in the severity of enamel opacities as measured by the Opacity Index.

Key words: Enamel, opacities, demineralization, orthodontics, mottling

T he presence of clinically detectable areas

of enamel demineralization, often referred to as decal-
alone in a self-cleansing area of enamel would result in
a clinically detectable opacity. However, if such etched
cification, following the removal of orthodontic bands enamel was present under an orthodontic band and be-
has for many years been accepted as one of the hazards came the site of plaque accumulation, then it is conceiv-
of orthodontic treatment. i ’ 2 Demineralized surface able that a clinically detectable white opacity might
enamel is considered to be the precursor, or early le- develop.
sion, of enamel caries3 and is due primarily to the ac- The presence of fixed orthodontic appliances in the
tion of acids which, during orthodontic treatment, may mouth undoubtedly predisposes to the accumulation of
come from two sources, namely, the cement used for plaque. Two favored sites for such accumulation are
retaining the orthodontic bands and the breakdown around the cervical margins of the teeth and under the
products of food debris. bands in areas where the cementing medium has been
The liquid portion of zinc phosphate cement con- washed out.
tains 40 to 50 percent free phosphoric acid,4 so that 3 A number of workers have documented significant
minutes after the start of mixing, the pH of zinc phos- increases in oral bacteria during orthodontic treat-
phate cement is approximately 3.5.” The high acid con- ment.‘** l3 They believed that orthodontic therapy made
tent of dental cements led Letkowitz and BodeckeF to good oral hygiene more difficult, modified the oral en-
suggest that these cements had a demineralizing effect vironment, and increased caries activity as measured by
on the enamel surface under orthodontic bands. This increased salivary concentrations of lactobaccili, which
view, particularly with regard to a thin cement mix, has they considered a source of acid for enamel demineral-
since been supported by further studies.7’ * In contrast, ization.
zinc phosphate cement used in a medium-consistency In studies that I conducted to determine the preva-
mix has been shown not to have a decalcifying action lence of enamel opacities in school pupils who had
on enamel.7. g Studies on the deleterious effect of acid not received any orthodontic treatment,14 the results
etching on dental enamel have shown this to be negli- showed that 83 to 85 percent of the pupils had some
gible.‘“, ” In view of these reports, it seems unlikely evidence of enamel opacities.‘“, l6 These results are in
that the etching or demineralizing action of the cement general agreement with the findings of Hutmel and
Murray and Shaw. ‘a The opinion often held by dentists
and the general public that “orthodontic treatment re-
*Research Fellow, Dental Research Institute, MRCiUnivenity of the Wit-
sults in decalcification” is based on a purely subjective
watersrand; Specialist Orthodontist, Department of Orthodontics, Faculty of assessment of the presence of white areas of opaque
Dentistry, University of the Witwatersrand. enamel. In the light of the results reported above, the
62 0002-9416/82/070062+06$00.60/0 0 1982 The C V. Mosby Co.
Volume 82 Enamel demineralization following orthodontic treatment 63
Number 1

validity of such a statement becomes suspect. A cross- toothpaste containing fluoride compounds. The water
sectional study was, therefore, carried out to determine supply to the city and its environs contained 0.2 ppm
the prevalence and severity of enamel opacities in a fluoride (mean yearly average). All bands were ce-
group of patients prior to starting and after receiving mented with polycarboxylate cements.
orthodontic treatment.
Data on the distribution of enamel opacities in rela- Assessment
tion to different surfaces of the dentition and to indi- The opacities considered in this study were defined
vidual teeth will be presented in a subsequent publi- as any discrete area of white opaque enamel, including
cation. a line or a patch occurring on either the vestibular or
lingual surface of the crown.
RATIONALE For the purpose of this study, the scoring system
Following an approach similar to that used by was required to provide information on the location, ex-
Bach,lg, 2o it was considered essential to determine first tent, and prevalence of the lesion. Thus, the vestibular
the prevalence of enamel opacities in a sample of the and lingual surface of each tooth was divided into cervi-
general population of schoolchildren drawn from the cal, middle, and incisal (occlusal) thirds. No attempt
same geographic area and having a similar socioeco- was made to examine the interproximal surfaces.‘4-‘6
nomic background as the group of patients who were The severity of the opacity was based on its surface
referred for and who received orthodontic treatment. area and was scored from 0 to 3, similar to the system
The results recorded for the selected sample of the used by Curzon and Spector22 in 1977. The opacity was
general population have been reported.14-l6 scored for each third of the vestibular and lingual sur-
It was not the object of this study to assess the faces of each tooth as follows:
opacities on an etiologic basis. The criteria for record- 0 = No enamel opacity. An opacity of less than an
ing the condition were defined, and the assessments estimated 1 mm. in length or diameter was considered
were made on the basis of the definition as recom- absent.
mended by Al-Alousi and associates2i and not on the 1 = An opacity covering up to one-third of the sur-
basis of a presumed etiology. By comparing the preva- face area.
lence and severity of enamel opacities in samples that 2 = An opacity covering from one-third to hvo-
had not undergone orthodontic treatment with those thirds of the surface area.
that had, it was possible to determine the effect of 3 = An opacity covering from two-thirds to the full
orthodontic treatment on these parameters. surface area.
With the vestibular and lingual surfaces each con-
MATERIALS AND METHODS tributing a maximum score of 9, the total possible score
This study involved patients selected from my pri- for any one tooth was 18. It is accepted that, in a
vate practice and the results reflect only the situation in subjective assessment of this nature, variations in the
that practice. The cross-sectional study comprised a scoring of location and severity of certain lesions do
total of 796 patients divided into two groups. Group 1, occur. This type of error is common to all clinical sur-
consisting of 527 pretreatment patients (10,126 teeth), veys of this nature and can be compensated for only by
was made up of all patients referred for consultation adoption of a strict level of significance for the rejection
and possible treatment (mean age, 11.8 & 2.2 years). of the null hypothesis and continual monitoring of ex-
Group 2, totaling 269 patients (5,758 teeth), was made aminer reliability.
up of all patients who had completed treatment (mean The team for this study consisted of one examiner
age, 15.4 ? 1.6 years). All patients in Group 2 had and one chairside assistant. Special forms were de-
received comprehensive multiband orthodontic treat- signed for recording the data at clinical examination
ment with the Begg light-wire appliance. Before start- and to facilitate the subsequent transfer of the data onto
ing treatment, patients were required to have all neces- computer punch cards.
sary general dentistry completed and a topical fluoride Intra-examiner reliability was monitored by re-
application. After the bands were cemented, the pa- examining approximately 10 percent of the sample
tients were instructed concerning the importance of (seventy-five patients) within an 8-week period of the
good oral hygiene, good dietary habits, and correct initial examination.23
toothbrushing technique. These instructions were sup-
ported in the relevant booklets handed to the patient. Data analysis
No supplementary fluoride was administered during The recorded data were processed in an IBM 270/
treatment. However, patients were required to use a 158 computer using standard programs, including the
Table I. The numbers and percentages of Table II. The Opacity Index (median) and
patients with and without enamel opacities interquartile range for enamel opacities
in Groups 1 and 2 recorded for patients in Groups I and 2
/ Graup.s Groups
2 I 2

With opacities 381 (72.3%) 226 (84%) Including 0 .scorc.~

Without opacities 146 (27.7%) 43 (16%) 25% 0 0.083
Median 0.125 0.200
Chi-square tests with 1 degree of freedom: 15% 0.292 0.400
Group 1 vs. Group 2 x' = 12.85 p <O.OOl. E.rcluding 0 scores
25% 0.091 0.130
Median 0.200 0.239
Statistical Package for the Social Sciences.‘4 The data 75% 0.375 0.458
provided information on the prevalence of enamel
Median test with 1 degree of freedom:
opacities for Groups 1 and 2. The severity of the condi-
Including 0 scores Group 1 vs. Group 2 ,$ = 9.95 p ( 0.01.
tion was reflected by the Opacity Index calculated for Excluding 0 scores Group 1 vs. Group 2 x2 = 2.13 N.S.
Groups 1 and 2. In order to calculate the Opacity Index
for the sample, it was necessary first to calculate the
Opacity Index for each patient. For example, condition for the two groups. The chi-square tests be-
tween the groups (based on actual numbers) showed
Total surface score
= Opacity Index for patient that the prevalence of enamel opacities was signifi-
Number of surfaces
cantly higher (p < 0.001) in Group 2 than in Group 1.
The Opacity Indices for all patients were ranked and the The severity of the lesions as reflected by the Opac-
median value was taken as the Opacity Index for the ity Index, together with the interquartile range, is given
sample. Because of the skewed distribution of the data, in Table II. The concentration of the sample was in-
the median values, rather than the mean, were chosen creased by eliminating all subjects with 0 scores. The
as the measure of central tendency. Furthermore, this Opacity Index for this reduced sample is also given in
distribution of data required the use of nonparametric Table II. The median test indicated that the Opacity
tests for evaluating comparisons between different Index for Group 2 was significantly higher than that
groups of data. For this study, the level of statistical calculated for Group 1 (p < 0.01). The difference be-
significance chosen was p < 0.01. tween the groups did not reach significant levels when 0
scores were excluded.
Intra-examiner reproducibility Sex distribution
Three tests were used for the assessment of the An analysis of the numbers and percentages of teeth
differences between the data recorded on the first and with and without enamel opacities recorded in male and
second examinations: (1) Student’s t test for paired sam- female patients for Groups 1 and 2 showed no sex
ples = No significant difference. (2) Wilcoxon matched differential, (prevalence: Group 1 males, 71.7 percent;
pairs signed ranks test = No significant difference. (3) Group 1 females, 73.0 percent; Group 2 males, 83.0
Modified percentage reproducibility as described by percent; Group 2 females, 84.6 percent. x2 = 0.04.
Shaw and Murray2” = 95 percent. Not significant.)
The World Health Organizationz9 stated that it was The Opacity Index showed no significant sex dif-
not possible to give a precise definition of acceptable ferential in the severity of the opacities in Group 1; in
consistency; however, examiners should attempt to Group 2, however, the males recorded a significantly
achieve at least 80 percent agreement between the re- higher Opacity Index (p < 0.02), particularly when
sults of duplicate examinations. only the patients with scores above 0 were considered
(p < 0.01).
Over-all prevalence and severity
An analysis of the numbers and percentages of pa- DlSCUSSlON
tients with and without enamel opacities is presented in Over-all prevalence and severity
Table 1. The percentage of subjects with enamel opaci- The significantly higher prevalence of enamel opac-
ties (72.3 percent of Group 1 and 84.0 percent of Group ities in Group 2 (84.0 percent) as compared to Group 1
2) was considered to represent the prevalence of the (72.3 percent) suggested that orthodontic treatment re-
Volume 82 Enamel demineralization following orthodontic treatment 65
Number 1

sulted in the development of a significant number of

new areas of enamel opacities (11.7 percent increase). O/o100 c
BachzOshowed an increase in decalcification following
orthodontic treatment of 4.7 and 6.0 percent in persons
with minimum and excessive carbohydrate consump-
tion , respectively.
From the data in Table II, it is apparent that the
severity of the opacities in Group 2 (Opacity In-
dex = 0.200) was significantly greater than that re-
corded in Group 1 (Opacity Index = 0.125). The aver-
age number of teeth in Group 1 was 19.2 per patient,
and in Group 2 there were 21.5 per patient. This dis-
crepancy was due to the eruption of premolar and
canine teeth during the course of treatment. If the con-
dition were not progressive, then the Opacity Index in
Group 2 should have been lower than in Group 1, be-
cause of the increase in the number of teeth. The in-
crease in prevalence and severity of enamel opacities 1 2 PRIMARY HIGH
reflected the development of new areas of enamel de-
mineralization following orthodontic treatment. These GROUPS SCHOOLS
areas of new enamel opacities were the result of extrin- Fig. 1. The prevalence of enamel opacities recorded for pa-
sic factors, such as demineralizing acids. tients in Groups 1 and 2 as well as for primaly and high school
In spite of the statistical significance of these re- pupils.
sults, the clinical importance with regard to the over-all
health of the dentition is uncertain. In the studies on applications during orthodontic treatment as used by
enamel opacities reviewed by Small and Murray,*‘j al- Zachrisson and Zachrisson27, 3o is to be recommended.
though the opacities were assessed on a clinical basis, It was interesting to compare the prevalence of
no attempts were made to assessthe calculated statisti- enamel opacities in Group 1 and 2 with the values
cal changes in relation to the clinical importance of recorded for primary and high school children who had
these changes. not been referred for orthodontic treatrnent,14, I6 Pa-
Zachrisson and Zachrissot?’ did note that some tients in Group 1 had a significantly lower prevalence
demineralizations were mild and hardly noticeable un- of enamel opacities than an age-matched (12.3 2 0.7
less the teeth were dried and examined closely. Fur- years) group of 204 primary school subjects (p <
thermore, the demineralizations corresponding to their 0.01). By contrast, there was no significant difference
Caries Index score of 1 generally remineralized within between the prevalence of enamel opacities recorded
2 to 4 months after removal of the appliances. for patients in Group 2 and a slightly older (17.5 t 0.5
In the context of the present study, a score of 1 in a years) group of 222 high school subjects who had re-
subject with twenty-one teeth was represented by an ceived no orthodontic treatment (Fig. 1).
Opacity Index value of 0.048, the difference in the Whereas the primary school subjects that I selected
Opacity Index values between Groups 1 and 2 was 0.075 for examination14, l6 may be considered as a represen-
(that is, a change in score value of approximately 1.5). tative sample of the population for that age group, the
By definition, a score of 1 represented on opacity patients comprising Group 1 in the present study must
covering up to one third of the surface area of a particu- be considered as a select group. By accepting referral to
lar zone and the total possible score for any one tooth an orthodontist in private practice, these subjects or
was 18. their parents have shown a higher degree of dental
When a change in score of 1.5 is considered in awareness than the general population. Acceptance
relation to a dentition of twenty-one teeth, then the of the financial commitment required for orthodontic
clinical importance of the change in severity of the treatment was further evidence of their dental motiva-
opacity becomes questionable. tion. This view is supported by the findings of Savara
In view of the ample evidence available suggesting and Suher,31 who reported that parents with high edu-
that small areas of superficial enamel demineralization cation had fewer children needing dental attention. On
may be remineralized by the topical application of the basis of these assumptions, it would be reasonable
fluoride compounds, 28, 2s the use of periodic fluoride to conclude that the standard of oral hygiene practiced
by the patients in Group 1 was higher than that prac- scores recorded in males was higher than in female
ticed by the general population of comparable age. The patients.
relationship of poor oral hygiene and the accumulation The results of the present study. together with the
of plaque to the prevalence of dental caries and gingival work of Zachrisson and Zachrisson.“” support the
diseases has been the subject of many studies. A theory that female patients take greater pains with their
lengthy discussion of the many opinions on this subject oral hygiene during orthodontic treatment than their
is not considered pertinent to this study; at present there male counterparts.
is evidence to suggest that the accumulation of plaque
is associated with an increase in dental caries and gin- CONCLUSIONS
gival disease.:” The results of this study indicated that orthodontic
The higher prevalence of enamel opacities recorded treatment with multiband appliances contributed to the
for primary school subjects compared to that recorded development of new areas of enamel demineralization
for patients in Group 1 may be the result of the different and contributed to an increase in the severity of enamel
standards of oral hygiene practiced by the two groups. opacities as measured by the Opacity Index. However,
This assumption would further support the theory that a the prevalence of enamel opacities in patients who had
certain percentage of enamel opacities recorded in epi- completed orthodontic treatment was similar to that re-
demiologic studies on enamel mottling and enamel corded for a matched group of subjects considered to
opacities were due to environmental factors producing represent the general population.
surface enamel demineralization. Furthermore, the results also showed that there was
The absence of a difference in prevalence in enamel an increase in the severity of enamel opacities in male
opacities between patients in Group 2 and high school patients following orthodontic treatment. This increase
pupils, together with the results of the present study, was due to enamel demineralization associated with
indicated that, although orthodontic treatment contrib- lower oral hygiene standards in males as compared to
uted to an increase in prevalence of enamel opacities, female patients.
the prevalence of the condition in patients who had I would like to thank Professor P. Cleaton-Jones, Dr. P.
completed treatment was similar to the prevalence for Fatti, and Mr. H. Gilbert for their guidance and assistance
the general population of a comparable group who had and Mrs. J. Long for typing the manuscript. This project was
not received any orthodontic treatment. This was pos- supported financially by Elida Gibbs (S.A.).
sible because patients referred for orthodontic treatment
started with a lower prevalence of enamel opacities
than that recorded for the general population. 1. Angle, E. H.: Treatment of malocclusion of the teeth-angle’s
system, ed. 7, Philadelphia, 1907, S. S. White Dental Mfg. Co.
Sex distribution 2. Ackerman J. L., and Proffit, W. R.: Diagnosis and planning
The results of this study indicated that prior to orth- treatment in orthodontics. In Graber, T. M., and Swain, B. F.
(editors): Current orthodontic concepts and techniques, Phitadel-
odontic treatment there was no significant difference
phia, 1975, W. B. Saunders Company, pp. 1-l 10.
between the sexes with regard to the prevalence and the 3. Darling, A. I.: Studies of the early lesion of enamel caries with
extent of enamel opacities. These results are in accor- transmitted light, polarised light and radiography. Parts I and 11,
dance with the findings on the prevalence and severity Br. Dent. J. 101: 289-297, 329-341, 1956.
of opacities in primary school pupils.14-‘6 Following 4. Paffenbarger, G. C., Sweeney, W. T., and Isaacs, A.: A pre-
liminary report on the zinc phosphate cements, J. Am. Dent.
orthodontic treatment there was still no difference be-
Assoc. 20: 1960-1982, 1933.
tween the sexes with regard to prevalence; however, 5. Phillips. R. W.: Skinner’s science of dental materials, ed. 7,
there was a difference in severity of the opacities, par- Philadelphia, 1973, W. B. Saunders Company.
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Dent. Res. 17: 453-463, 1938.
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I. Docking, A. R., andNewbury, C. R.: The effect oforthodontic
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Zachrisson and Zachrisson,so in a study on oral 8. Seniff, R. W.: Enamel surface change caused by oxyphosphate
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Volume 82 Enamel deminerulizution following orthodontic treatment 67
Number 1

11. Wei, S. H. Y.: Remineralization of enamel and dentine: A re- 22. Curzon, M. E. J., and Spector, P. C.: Enamel mottling in a high
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