manage white spot lesions

White spot lesions (WSL) are common during or after orthodontic treatment. Managing these lesions is a challenge. The following are best practices recommendations based on current research.

Most studies report the incidence of new clinically visible WSL occurring during orthodontic treatment to range between 30 to 70 percent of patients. Upper anterior teeth, especially maxillary laterals, are most commonly affected.

Prevention is key

Remineralization and restorative treatments for WSL are possible; but they either result in less than ideal cosmetic outcomes or they are too aggressive. Therefore, it is better to rely on prevention as the primary management strategy.

1. Identify risk 

The following conditions indicate that patients are at high-risk:

  • Existing WSL
  • Poor oral hygiene and/or diet
  • High DMFT
  • New lesions that start during treatment

2. Plaque control

Effective motivation techniques tailored to the patient, use of disclosing solution and using an electric toothbrush are helpful in improving plaque control.

3. Fluorides and other adjuncts

  • Prescribe 15000ppm Fl toothpaste. Compliance is better than fluoride rinse.
  • Application of Fl varnish as frequent as every six-weeks. This is effective in preventing and reversing early demineralization.
  • Prophylaxis every three months
  • MI Paste: Before going to bed smear over teeth with help of a brush or apply with a fluoride delivery tray.
  • Xylitol: Chew on xylitol gum three to four times a day. It increases salivation, which helps in reminerlization, and it causes reduction in the level of S.mutans.
  • Chlorhexidine rinse: Once a day rinse for a week, repeated every month. It helps reduce the level of caries producing and pH reducing bacteria in the mouth.

4. New methods

The following emerging adjunctive therapies have shown promising results (more independent research is needed):

  • Probiotics: They help shift the oral microflora balance towards higher pH producing caries free bacteria.
  • CariFree: A proprietary product that claims to help restore the pH balance in the oral environment.
  • Carbamide peroxide: Applying this has shown to improve the pH of the oral environment. Also an added benefit is whiter teeth, which would get easy acceptance with patients.
  • Resin sealants: A proprietary resin material, Pro Seal is applied on the enamel before bonding brackets. Protects it from demineralization effect. For high-risk patients this can be used, especially for upper anterior teeth. It is a bit cumbersome to clean off and polish the teeth after de-bonding though.

References

1. A Review on Prevention and Treatment of Post-Orthodontic White Spot Lesions – Evidence-Based Methods and Emerging Technologies. Bergstrand F, Twetman S. Open Dent J. 2011;5:158–62.

2. A contemporary review of White Spot Lesions in orthodontics. Heymann GC, Grauer D. J Esthet Restor Dent. 2013 Apr

3. White-Spot Lesions in Orthodontics: Incidence and Prevention. Airton O. Arruda, Scott M. Behnan and Amy Richter

Vivek Mehta DMD, FAGD, Visiting Faculty, Spear Education. Follow him on Twitter @Mehta_DMD.   


Comments

Sarat Ummethala
June 14th, 2013
I have used another technique to treat these lesions,that gave me good results some time. I would like your opinion on this. I etch the tooth for about 2 mins covering about 1mm beyond the white spot lesion, rinse , dry, apply gluma or optibond, and cure. If these are superficial lesions, this technique using unfilled resin makes the white spots go away or at least fade. Patient acceptance is usually good. Thank you for your input.
Frank Godino
June 14th, 2013
Sarat, Sounds like, whether you realize it or no, you are performing a technique similar to the product Icon Infiltrant, by the company DMG. You can look up their website. The more superficial the white lesion the more successful you will be. Frank
Vivek Mehta
June 15th, 2013
I agree with Frank's comment. When prevention has not worked, treating these lesions with conservative steps like remineralization or resin infiltration is a great choice. Review of all treatment options can make a good topic for another post. Sarat, Frank thank you for sharing your thoughts here. I appreciate it.
Jerry Rinehart
July 15th, 2013
I think it's important to identify the source/etiology of the "white spots" lesions. In the photo used in the article, it looks to me like the majority of the incisal white lesions shown in the photos may more likely be fluorosis type white lesions, not decalcification. Maybe that's just semantics, but you don't need F on a flourosis lesions. I appreciate the research on the best practices to manage decalcification. Thank You.
Vivek Mehta
July 17th, 2013
Dr. Rinehart : Thank you for your comment. You make a good point and I agree. I could have selected a better picture for this article. The "white lesions" shown in this picture are not the classic "WSL" we talk about in the article. I appreciate your input very much.
James Noble
August 5th, 2013
Thanks for your posts and the comments. If visible white spot lesions are detected when the braces are removed, they should not be treated immediately with concentrated fluoride agents. This is because subsurface soft lesions take longer to remineralize then outer lesions. The presence of excess fluoride would cause a precipitate of calcium phosphate to form on the enamel surface (creating an unsightly white opaque appearance), which would in turn block the surface pores and limit remineralization of the inner surface. This may arrest the lesion but prevent its normal repair, leading to unesthetic, opaque white spot lesions on the surface of the enamel. White spot lesions observed after debonding should therefore be treated with 2 to 3 months of good oral hygiene (the fluoride within saliva permitting a more controlled degree of remineralization), followed by professional application of topical fluoride during regular 6-month recall appointments at the dentist’s office. My two cents for what it's worth. James Noble Orthodontist
Vivek Mehta
August 5th, 2013
Dr.Noble: Thank you for your detailed comment. The info you have presented has sound reasoning and I agree with the rationale presented. I am wondering if the initial 2-3 month period of controlled reminerlization could be further helped by adding MI paste application at bed time. In other words control the fluoride exposure but bathe the surface with plenty of Ca PO4.
Cynthia
August 19th, 2013
Hello Vivek, Great article. I'm responding from Canada. I have called two pharmacies to inquire about the 15000ppm Fl toothpaste. This is currently unavailable. I'm curious to know if you are from the US? What is the name/brand of toothpaste you prescribe that contains 15000ppm Fl? Thank you.
Steve
February 19th, 2014
I agree with all Dr. Spear wrote but for my treatment planning it is "step up treatment" until desired result is reached: prophy /polish, fluoride/MI Paste Plus, Opal Lustre 30-60 sec, whitening, composite, veneer.
Sue Kash
February 20th, 2014
What would be the best treatment for fluorosis type white lesions? Cosmetic bonding or Veneers?
Dr. Mohsen S. Ozaibo
February 25th, 2014
Great article and really unique and informative. Well in regards to this post I was asking permission to repost this article on my own dental blog in which I will complete and fully give credits to your website My website is www.ozident.com