Prevalence of White Spot Lesions in 3-year-old Children Visiting a Private Dental College: An Observational Study

INTRODUCTION

Early childhood caries (ECC) is one of the ubiquitous chronic diseases affecting young children. It significantly affects both well developed and industrial nations.¹ According to the American Academy of Pediatric Dentistry, ECC may be defined as the presence of one or more decayed (cavitated and non-cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary teeth in a child 71 months of age or younger.² Early childhood caries is a universal and multifactorial disease with over 1.76 billion cases.³ Even though the decay-missing-filled-teeth (DMFT) count had been downsliding over the past years, its prevalence has not.⁴ In India, the prevalence figure is 44% in 8–48 months old children.⁵ In rural South India, the prevalence rate among 0–3 years old is 40.6%. Of these, 50.3% were associated with non-cavitated lesions and 49.7% showed cavitated surfaces.⁶ The prevalence of ECC in Tamil Nadu, India was 15.9% as of 2015.⁷

Due to its rapid development, young enamel is often thin and has less organized structure.⁸ Hence, acids are able to demineralize deciduous enamel in an unrestrained manner resulting in ECC.⁹ This collides with the quality of life of children as it may lead to pain, swelling, infection, and other symptoms.^10,11

The initial stage of demineralization results in white chalky appearance on the teeth, these are called white-spot lesions (or) incipient lesions (or) surface softened defect.^12,13 White spot lesion implies that there is a subsurface area with mineral loss beneath a relatively intact enamel surface.¹⁴ Clinically, early caries lesion is seen as a white opaque spot, characterized by being softer than the adjacent enamel and increasingly whiter when dried with air. It affects all parts of the tooth including the smooth surface. They are usually found along the gumline. White spot lesions can be actively demineralizing or remineralizing or arrested.¹⁵

It is acknowledged that the subsurface damage may be due to acid formed from plaque on the tooth surface.¹⁶ The organic acids produced by bacteria enter the interprismatic spaces of enamel and cause dissolution of apatite crystals, calcium and phosphate ions, and demineralization.¹⁷ These white spot lesions inevitably develop into lesions with cavitations if the mineral loss continues.¹⁸ However, according to the caries balance concept,¹⁹ the factors of demineralization can be counteracted by the factors of remineralization of which saliva and its components play a major role. Recently, biomarkers present in saliva can help detect the formation of caries.²⁰

Conversely, ECC is a multifactorial disease which is substantially associated with parental attitude toward dental caries in primary dentition.²¹ Management and maintenance of the advanced lesions mainly include operative methods.^22–28 Prophylactic methods are obligatory in order to control and overcome the consequences of the disease.^29–31

Minimum literature is available on white spot lesions in primary dentition. Only one other study attempted to determine the prevalence of white spots by evaluating the contribution of biological and socioeconomic variables.³² Because ECC is considered as a public health problem, the need to know its prevalence is justified. However, it must include information about all stages of formation and occurrence in different populations.³³

Therefore, the aim of this study is to assess the presence of white spot lesions in 3-year-old children visiting a private dental institution and those belonging to the Chennai population.

MATERIALS AND METHODS

The observational study was conducted in the Department of Pediatric and Preventive Dentistry in a private Dental Institute in Chennai during the period of June 2019 to March 2020. The ethical approval for this preliminary study was obtained from the Institutional Ethical committee (SDC/SIHEC/2020/DIASDATA/0619-0320). Written informed consent was obtained from the parents of the participating children after explaining to them the need of the study.

Healthy children of 3 years of age visiting the pediatric dental department were included in the study. In order to avoid sampling bias, the recruitment of the children was performed through simple randomization. Children with preexisting medical conditions and those with special needs were excluded from the study.

The children participating in the study were seated on the dental chair and supragingival scaling was carried out to remove plaque and debris. Post-scaling, photographs of their dentition were taken to assess the white spot lesions. A digital camera namely Canon 1500D with Tamron 90 mm macro lens, specifications of 1/200 shutter speed, and iOS 100 f-20 was used for this purpose. After adequate drying of the teeth and placement of cheek retractor, photographs were taken from different angles namely intraoral frontal, intraoral right, and intraoral left. Superior and inferior angles were taken using pedo-sized intraoral mirror. All photographs were taken under a single light source, so that the detection and appearance of white spot lesions would be uniform.

The data verification, collection, and analysis were carried out by two persons by reviewing 86,000 case sheets. Of which, records pertaining to 3-year-old children were obtained for the purpose of this study. The data were extracted by analyzing the photographs of the study participants. Five angles of the photograph were available for a single individual. The presence of white spot lesions was observed exclusively on the anterior teeth of the maxillary and mandibular arch by reviewing from various angles. They were detected according to International Caries Detection and Assessment System (ICDAS) II criteria, code 1: first visual change in enamel. Any dispute over detection was analyzed and resolved by a third reviewer. The internal validity was high as it was a representative sample and the external validity was high as the study results may be generalized to the Chennai population.

The collected data were tabulated into Excel Sheet and imported to Statistical Package for Social Sciences software by IBM for data analysis. A total of 165 study participants and 990 teeth were assessed for white spot lesions. Descriptive statistical analysis was performed and the results were tabulated graphically based on the presence and absence of white spots and carious lesions on each of the upper and lower anterior teeth of the primary dentition. Chi-square test was performed to associate the relationship between the presence of white spot lesions and gender.

RESULTS

The study was performed to evaluate the prevalence of white spot lesions in anterior teeth of 3-year-old children. A total of 165 participants were included and 990 teeth were assessed. The participants included 79 boys (47.6%) and 86 girls (52.4%) (Fig. 1). Of the 990 teeth assessed, the presence of white spot lesions in maxillary arch was 11 and 18.9% in right and left central incisors, 39 and 37.2% in right and left lateral incisors, and 78 and 67.7% in right and left canines. In the mandibular arch, 5.5 and 9.2% in right and left central incisors, 13.4 and 14% in right and left lateral incisors, 52.4 and 54.9% in right and left canines (Table 1). The lesions were highly prevalent in the maxillary canines in females (Fig. 2) followed by mandibular canines (Fig. 3) and the least were observed in mandibular central incisors (Fig. 4).

DISCUSSION

White spot lesions are characterized by subsurface demineralization with an intact surface layer of enamel. Enamel defects and white lesions in deciduous incisors and molars may be attributed to coeliac disease (or) molar incisor hypoplasia.³⁴

When the demineralization–remineralization cycle is tipped off due to extrinsic factors associated with environment or intrinsic factors associated with the host,³⁴ there is disruption in the maintenance of a neutral pH in the oral cavity resulting in early lesion formation (white spots) leading to cavitations and total destruction if unintervened.

Histopathologically, the enamel lesions are characterized by four histopathological zones namely two demineralization zones, such as translucent zones and body of the lesion, and two remineralization zones namely the dark zone and the surface zone.³⁵ The translucent zone is the advancing front of the lesion with the dark zone superficial to it. The surface zone is the intact surface above the body of the lesion zone which lies 15–20 μm beneath the intact enamel.³⁶ The reason for the surface to remain intact is because the calcium and the phosphate ions produced from subsurface dissolution move outward and reprecipitate on the surface.³⁷

Since formation of dental caries in children proceeds in a short and rampant fashion even as early as 4 weeks due to the structural morphology of the primary tooth, there is no dark zone formation. Its prime function is to act as a barrier to the caries progression toward the dentin and subsequently to the pulp. Hence, a heavily demineralized body of lesion and a surface zone with minimal thickness is formed.³³ Such a lesion becomes clinically detectable as white spots. The enamel is porous in the body of the lesion due to loss of minerals in the body of the lesion. Hence, there is an alteration of the refractive index in-between the translucent enamel crystals and the porous enamel resulting in a greater visual enamel opacity.^17,38

In our study, assessment of white spot lesions was carried out through photographic analysis. Many studies have assessed enamel defects through this method and hence this was followed as a reliable method.^39,40 Photographic methods can be advantageous for epidemiological studies. In addition, it allows for blinded assessment to avoid examiners bias.⁴¹

The 165 study participants included 47.6% of males and females 52.4% of 3 years of age. Among the 990 teeth assessed for white spot lesions, the prevalence in descending order is maxillary canines > mandibular canines > maxillary lateral incisors > maxillary central incisors > mandibular incisors.

Maxillary canines (78 and 67.7%) showed the maximum white spot lesions and mandibular central incisors (9.2 and 5.5%) showed the least lesions. This can be made concurrent with the development of ECC lesions which is highest in maxillary anteriors and the lowest in the mandibular incisors.⁴² The caries lesion is generally first seen on the primary maxillary incisors and the four maxillary anteriors are often involved concurrently.⁴³ This is evident in our study where cavitations had already occurred in maxillary central incisors at the time of assessment (64.6 and 40.2%).

According to a study by Ramos-Gomez et al., the boys were significantly more affected than the girls.⁴⁴ This was contradicting in our study as females showed a slightly greater prevalence of white spot lesions. At the specified age group, high prevalence of white spots was observed in accordance to a study by Tiano et al.³² Previous literature reveals higher prevalence figures of subsequent ECC for 3-year olds which ranges from 36 to 85%.^45,46

The prevalence of white spot lesions has been reported to range from 2 to 96%.⁴⁷ However, no studies were found in literature regarding the prevalence of white spot lesions in preschool children in the Indian population.

Every study presents itself with certain limitations. Similarly, the current study was a preliminary attempt on evaluating the prevalence of white spots in the primary teeth only through photographic evaluation whereas direct observation and assessment of lesions was not carried out. The results were not compared with other diagnostic methods, such as dyes, fluorescent methods, and DIAGNOdent. Also, no association was made with diet, oral hygiene practices, socioeconomic status, and fluoride exposure.

The scope of the study focuses on the arena that early detection of such lesions by clinicians helps to provide parental education and awareness on the progress of the lesions. It can also lead to utilization of preventive and interventional materials and methods.

CONCLUSION

Within the limits of the study, it can be concluded that the prevalence of white spot lesions was maximum in maxillary canines and the least was observed in mandibular incisors in 3-year-old children visiting a private dental college in Chennai. Early detection and intervention of white spot lesions can minimize the symptoms associated with ECC, thereby halting its progression and other financial and psychological outcomes associated with it.

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