white spot lesion - prevention and management

White Spot Lesion
Prevention And Treatment
By
Ashok kumar A
Department of Orthodontics
1Dr.Ashok

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• Introduction
• Classification of White Lesions on Enamel
• Classification of WSL
• Prevalence and distribution of WSLs
• Aetiopathogenesis of WSLs
• Histopathology of WSL
• Risk factors & Risk Assesment of WSL
• Detection of white spot lesions
• Prevention & management of WSL
• Conclusion
• Reference
2Dr.Ashok

White spot lesions
• WSL has been defined as 'subsurface enamel porosity from carious demineralisation'
that presents itself as 'a milky white opacity when located on smooth surface .
• WSLs appear white because of reduced enamel mineral content leading to increased
permeability of enamel causing backscatter of light by dentin.
• The difference in the refractive index between
decalcified and adjacent healthy enamel defines
the white spot lesion.
•They need to be differentiated from idiopathic
white opacities of the enamel and fluorosis.
3
Introduction
Dr.Ashok

Classification of White Lesions on Enamel
Nonfluoride Opacities WSLsDental Flurosis
White/yellowish lesions
Not well defined
Symmetrical distribution
More defined shape,
Well differentiated
Randomly distributed
WSLs are often seen under
Loose bands, around the
periphery of the bracket base
4Dr.Ashok

Prevalence and distribution of WSLs
• WSLs after fixed orthodontic treatment widely varies in the literature between 2% and 96% .
• Using conventional visual methods of detection, the prevalence of at least one WSL in
orthodontic patients was 49 .60% compared to 24% in an untreated control group
• Light induced fluorescence (QLF) shows that - larger percentage of patients are affected.
Maxillary incisors (gingival third) are particularly susceptible – Geiger et.al
Canines and molars (cervical & middle 1/3rd)are more frequently affected- van der Veen et.al
Distogingival quadrants are more affected than the mucogingival quadrants.
Orthodontics, current principles and techniques by Graber & Vanarsdall -6th edition 5Dr.Ashok

Aetiopathogenesis of WSLs
Fixed Orthodontic Appliances
Brackets,bands,wire
Additional lowering of pH
Acid by-products
Low pH
Increased cariogenic risk of S.mutants
Rapid increase in dental plaque
Inhibition of Remineralisation &
consequent Decalcificationof Enamel
Progressive colonisation in the Bioflim
Gingivitis & progressive PDL disease
Development of white spots has been
reported to occur within 4 weeks of starting
treatment
Mineral loss around
Fixed appliances > Traditional caries process,
with demineralization being clinically
apparent within 6 months of starting treatment
6Dr.Ashok

Histopathology of WSL
Two zones of demineralization are present:
1. The translucent zone (1% pore volume)
along the advancing front of the lesion; and
2. The body of the lesion (>5-25% pore
volume) representing the majority of the lesion
and situated approximately 15-30 μm beneath
the overlying intact enamel surface
Two zones of remineralization are alsopresent:
1. The dark zone (2-4% pore volume)
situated just superficial to the translucent
zone; and
2. The surface zone (1 to <5% pore volume)
forming the intact surface overlying the lesion.
7Dr.Ashok

Risk factors
• Young age (preadolescent) at the start of treatment.
• Inadequate oral hygiene at the initial pretreatment examination.
• Number of poor hygiene citations during treatment.
• Inappropriate diet .
• Unfavorable clinical outcome score.
• Longer treatment time .
Chapman et al (2010). Risk factors for incidence and severity of white spot lesions during treatment with
fixed orthodontic appliances. AJODO 138: 188–194
8Dr.Ashok

9
Risk
Assessment for
Development
of WSLs
Dr.Ashok

Classification of WSL according to Gorelick and coworkers
Incidence of white spot formation after bonding & banding
Gorelick et al AJODO 1982
10Dr.Ashok

12
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Dr.Ashok

Detection of white spot lesions
• The WSLs chalky appearance is an optical phenomenon caused by mineral
loss in the subsurface & surface of enamel
• Alteration of enamel refractive index is the consequences of
-Surface roughness & loss of surface shine
-Alteration of the internal reflection
• Porous enamel scatters more light than sound enamel
Orthodontics, current principles and techniques by Graber & Vanarsdall -6th edition
13
Dr.Ashok

Evaluation
Demineralization is
present or not
Measure the severity
of the lesion
Macroscopically - The area and the
relative difference in the whiteness of
the lesion is compared with the
surrounding sound enamel
Microscopically by the amount
of mineral loss or lesion depth
The method of assessment should determine that
the white spot is caused by mineral loss from
enamel by acid demineralization during
orthodontic treatment, rather than an opacity
that may have been present before the appliance
was placed, the causes of which are numerous
14Dr.Ashok

Macroscopic Methods - Clinical Examination
Disadvantages
• Validity—it is often difficult clinically
to distinguish white spots caused by
demineralization and those that are due
to other causes, such as developmental
hypoplasia or fluorosis.
Advantages
• Simple and inexpensive
• Clinically valid—what the examiner
sees and measures is likely to be the
patient’s perceived problem.
Clinically, visual detection is quite satisfactorily performed by the clinician and has
significant validity as this is what would also be visible to the patient.
Evaluation of White Spot Lesions on Teeth with Orthodontic Brackets
Philip Benson SEM ORTHO 2008 15Dr.Ashok

Photographic Examination
Study the prevalence of enamel opacities and early investigations into the mechanisms
of enamel demineralization before, during, or after orthodontic treatment .
Philip Benson SEM ORTHO 2008 16Dr.Ashok

Optical Nonfluorescent Methods
Light Scattering
• Demineralization leads to more scattering of the light entering enamel.
• The scattering results in a sideward displacement of the light, which can be measured using
the Optical Caries Monitor (OCM) -Ten Bosch et al .
• They used a 100-W white light as a source and measured backscatter with a densitometer.
Philip Benson SEM ORTHO 2008
Advantage - Enables a convenient and nondestructive
quantification of enamel demineralization.
Disadvantage - Technique sensitive and results can vary with
the degree of wetness or drying of the tooth .
17Dr.Ashok

Optical Fluorescent Methods
• A material that absorbs light will be more fluorescent than a material that reflects light.
• As previously explained, demineralization leads to more backscatter of light, hence
less absorption and a lower intensity of fluorescence.
• Carious enamel will therefore show up as a dark area with fluorescent techniques.
Fluorescent Dye Uptake
Dye applied on Specimen
Examined under light source.
Disadvantage
Different degrees of dye uptake.
UV radiation
which has a wavelength
shorter than visible light
(400 nm)
Harmful to the eyes and skin.
LASER
Argon-ion laser blue-green
range (440-570 nm).
DIAGNODent
Portable system, which emits
light of wavelength 655 nm
18Dr.Ashok

Quantitative light-induced fluorescence (QLF)
• Principle - Enamel will undergo autofluorescence .
• Demineralized enamel will fluorescene less , detected
• The teeth under investigation are illuminated from a
lamp with a peak intensity of 370 nm.
• A yellow high-pass filter (520 nm) is placed in front of a
microcamera, which captures the tooth image.
• A live image of the tooth is displayed on a personal
computer (PC) screen and can be stored for analysis.

Quantitative Light-Induced Fluorescence Digital - Biluminator
Cost – Approx 14000 US Dollor /10.5 L Indian Rupee (Exclusice of GST)
20Dr.Ashok

Microscopic Methods
Transverse microradiography (TMR)
• This technique is destructive, requiring extraction or cuts to be made to the enamel or
dentine and microsamples to be removed for analysis.
• Tooth is removed from the mouth and destroyed (caries model) or
a small enamel sample attached to the appliance (in situ method)
• The basis of TMR is the measurement of x-ray absorption
by a tooth section, compared with absorption by a
simultaneously exposed standard . (microradiograph)

Preventing the loss of mineral from enamel (demineralization)
Promoting the uptake of mineral into enamel (remineralization)
Featherstone JD. Remineralization, the natural caries repair process—the need for new approaches. Adv Dent Res 2009
22
Dr.Ashok

Fluoride
• Topical fluoride-reservoir of
CaF2 in plaque-Attack Caries
Arneberg & coworker
• Plaque pH-Upper incisors-Low
• Effect of fluoride-neutralised at
pH below 4.5 owing to a reduced
conc. of both fluorapatite and
hydroxyapatite in the plaque
White Spot Lesions During Orthodontic Treatment: Mechanisms and Fluoride Preventive Aspects Bjørn Øgaard-2008
23
Dr.Ashok

• Toothpaste contains fluorides in various forms such as sodium fluoride,
monofluorophosphate , stannous fluoride or amine fluoride.
• A dose of at least more than 0.1 % fluoride is recommended for orthodontic patients.
However, a few studies have shown that toothpaste alone is inadequate for effective
prevention
• It is recommended that all orthodontic patients should use additional fluoride
mouthwash in the concentration of 0.05% NaF in addition to using a fluoridated
toothpaste.
24Dr.Ashok

• Bioactive glass ceramic materials composed of calcium, phosphorous,
sodium and silica have claimed to remineralise the WSLs.
• NovaMin (toothpaste) which contains calcium sodium phosphosilicate.
Orthodontics – Diagnosis and mangement of malocclusion and dentofacial abnormalities-OPK-3Ed 25Dr.Ashok

• For patients who are at high risk of WSL and those uncooperative in the maintenance of
oral hygiene, additional use of professional application of fluoride varnishes is
recommended at each appointment.
• Fluoride varnish (7700 ppm wet) has shown therapeutic benefits even in the presence of
plaque
Slow-Release Devices
Elastomeric Ligatures
Chewing Gums-xylitol
Copolymer Membrane
Glass Beads
Martin et al Fluoridated elastomers:
effect on the microbiology of plaque.
AJODO 2004
Prevention of demineralization during
orthodontic treatment with fluoride-containing
materials or CPP-ACP
Benson et al -2011 26
Fluor-I-Ties Glass bead
Dr.Ashok

Bonding Materials
• Adding fluoride to the material that bonds the attachment to the tooth would seem to be
an ideal means of delivering fluoride where it is needed.
• GIC(Low intitial SBS) > RMGIC > COMPOMER(Low sustained release-Fluoride)
• 4–6 % photosensitive composite resin was added to GIC (RMGIC)
• Applying 5.25 % sodium hypochlorite for 1 min, prior to phosphoric acid etching, so
temporary elimination of the acquired pellicle from the enamel surface occurs.
• This in turn allows the phosphoric acid to etch the enamel surface more effectively
creating better etching patterns which increase bracket SBS .
27Dr.Ashok

Antimicrobials
• The use of antimicrobials alone or in addition to fluoride is another attempt to
modifi the biofilm.
• Chlorhexidine(+) can damage microbial cell walls(-) within 20 s and can then
permeate the cell & attack the cytoplasmic membrane leading to cell death.
• Though chlorhexidine is effective in bacterial control for 48 h post use, its effect on
the reduction of WSL is questionable ( generally suppress caries nerver eliminate)
• An additional disadvantage of chlorhexidine is its tendency to stain composite and
glass ionomer.
Effects of combined application of antimicobial & fluoride varnishes in orthodontic patients
Ogaard et .al ALODO 2001 28Dr.Ashok

Dietary Advice
• Limited evidence submits that fluoride in the diet or added to foods, such as milk or salt, is
effective at preventing DWLs in orthodontic patients or in the general population.
• Diets like sticky and tough foodstuffs and habits such as nail-biting , pen-chewing &
consumption of excessive carbonated drinks and fruit juices,with poor oral hygiene, will
increase the risk of white spot lesions
• Dietary control is important in order to reduce the risk of demineralisation and caries,
as well as the likelihood of breakages.
• Probiotics which are live microbial feed consumed in the diet or applied locally in
dentifrices have proved to be effective against cariogenic bacteria in orthodontic patients.

Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)
• A product of milk casein has demonstrated effective remineralisation due to its
absorption through the enamel surface.
• Freely available calcium and phosphate ions move out of the CPP-ACP (RECALDENT )
into the enamel rods and reform as apatite crystals.
Management of post-orthodontic white spot lesions: an updated systematic review
Mikael Sonesson et al .EJO 2017
30
From 700 Rs range From 300 Rs range
Dr.Ashok

Nanotechnology in WSL
• Calcium nanophosphate crystals, which are less than 100nm, organised in
crystalline form of hydroxyapatite have been developed recently. They have
increased surface area and wettability and thus, increased bioactivity.
• This leads to release of calcium, phosphate and fluoride ions on the demineralised
surface of tooth & enchance remineralisation .
• In a comparative study by Carvalho et al. in 2013- on the effect of calcium
nanophosphate & CCP-APP paste, it was concluded that Ca nanophosphate is a
better remineralizing agent for eroded enamel surfaces.Thus, calcium it could be
used as a remineralizing agent after debonding of orthodontic brackets
31Dr.Ashok

Lasers
• Recently, it was shown that treatment with lasers reduced subsurface demineralization.
• Laser beams increase enamel micro-hardness and resistance to acid attack. In preventive
dentistry argon lasers, CO2, Nd-YAG, and erbium YAG are used .
• Exposure to laser beams micro-spaces form within the enamel, the released ions trap into
these micro-spaces and act as re-mineralization sites within the enamel surface.
• Samar et .al 2020 -The combined use of Er,Cr:YSGG Laser and CPP–ACP was the best
preventive measure against WSL formation evidenced by a significantly lesser lesion depth
compared to all other control groups.
32
Combined effect of Er,Cr:YSGG laser and casein phosphopeptideamorphous calcium phosphate on the prevention of
enamel demineralization:An in-vitro study Samar et.al (Angle Orthod. 2020;90:369–375.)Dr.Ashok

• Enamel surface is altered during etching and resin tag formation, & damages
during debonding and clean up procedures.
• Enamel cleanup is a critical phase as all resin needs to be removed and this is
believed to be about 50 µm but with minimal damage to enamel.
• Excessive removal of enamel lead to the fluoride rich superficial enamel being
removed leaving enamel prisms open and susceptible to caries & discoluration.
• Most of the abrasives used are harder than enamel and remove enamel
aggressively and leave behind a rough surface.
33
Procedure during Debonding
Dr.Ashok

• A recent systematic review compared several methods of enamel cleanup and
concluded that tungsten carbide burs in a contra-angle hand piece are the most
efficient in resin removal and cause less damage than Arkansas stones, green stones,
diamond burs, steel burs and lasers.
• As they leave a rough surface behind, they should
be followed up by multistep Sof-lex discs and pumice slurry.
• Stainbuster burs are composite finishing burs,
which also can be used for polishing the enamel
surface after composite clean-up.
Effect of orthodontic debonding & adhesive removal on enamel – current knowledge & future perspective – A systematic
review Tandecka et al . 34Dr.Ashok

Natural Remineralisation
• Milder forms of white soot lesions are likely to become less noticeable over a
period of a year or so because of the natural remineralisation that takes place due
to the calcium and phosphates and other trace elements present in the saliva.
• Ogaard and co-workers have cautioned against high conc fluoride as this
arrests both demineralisation & remineralisation by surface hypermineralisation.
• Instead, they advocate natural remineralisation & low dose fluorides as this
results in better repair and a less visible lesion.
Orthodontic appliances & enamel demineralisation –part-2 prevention & treatment of lesion .
Ogaard et al .AJODO 1988 35Dr.Ashok

• Vital tooth bleaching with hydrogen peroxide or carbamide peroxide increases
the whiteness of the surrounding enamel to match that of the WSL, thus
camouflaging the WSL without affecting its size or depth.
• Bleaching is a non invasive procedure that patients are happy to adopt as it lightens the
shade of the teeth.
• Microabrasion - which involves using a slurry of pumice or silicon carbide
particles and HCL acid to create surface dissolution of enamel and is effective in
removing superficial stains or defects which do not exceed 0.2-0.3 mm in depth.
Prevention & treatment of demineralisation during fixed appliances therapy: A review of current
method & future application Stewart et al . Br Dent J 2013 36Dr.Ashok

• Resin infiltration (Icon,DMG-America) is a relatively new technique, which is based on
the porous nature of demineralised enamel allow a low-viscosity resin to permeate into the
enamel matrix and fill in the voids previously filled with air or water.
• Technique produces a refractory index comparable to healthy enamel, studies have also
shown that this provides an immediate improvement in the appearance of the lesion.
• Restorations - Patients with cavitated lesions or more severe WSL who have already
attempted more conservative aesthetic treatments without significant improvement may have
to resort to restorations .
Management of post-orthodontic white
spot lesions: an updated systematic review
Mikael Sonesson et al .EJO 2017
37
1 Patient Kit:
1 x 0.30ml Syringe Icon-Etch
1 x 0.45ml Syringe Icon-Dry
1 x 0.45ml Syringe Icon-Infiltrant
6 x Smooth Surface Tips
6500 Rs range
Dr.Ashok

• Moderate evidence that regular professionally applied fluoride varnish/foam or home use of
high conc. fluoride toothpaste reduces the incidence of demineralized lesions during
orthodontic treatment with fixed appliances.
(Stecksen‐Blicks et al. 2007; Jiang et al. 2013; Sonesson et al. 2014).
• Low evidence for other fluoride interventions .
(Luther et al. 2005; van derKaaij etal.2015).
39
Key Findings
Dr.Ashok

Summary
“The first sign of a caries lesion on enamel that can be detected With the naked eye.”
- Fejerskov and colleagues
The milky white appearance is caused by an increased scattering of light that is attributable to
the loss of crystal structure and is exaggerated when the enamel is dried –Ten bosch et al
The severity of WSLs can be classified numerically using a 4-point scale (Gorelick’s scale) in
which # 1 shows no enamel demineralization, # 2 slight, # 3 severe, and # 4 cavitation
The reported proportion of patients with DWLs after fixed orthodontic treatment widely
varies in the literature between 2% and 96%.
40Dr.Ashok

Detection
Macroscopic method
Visual Examination
Photographic Examination
Optical Nonfluorescent Methods
QLFluorescent Methods
Transverse microradiography
-Caries model
-In –situ method
Microscopic method
41
Risk assesment
Low riskHigh risk
Dr.Ashok

Prevention & Treatment protocols
42Dr.Ashok

Conclusion
• The dynamic balance between demineralization and remineralization determines the
progression of white spot lesion.
• WSLs are in the face of more attention demanding clinical issues.
• A recent survey has shown orthodontists do not implement the available evidence in
order to prevent enamel demineralizations during fixed-appliance treatment
• So to prevent WSLs orthodontist should assess each patients’s risk factors before &
during treatment for better results .
44Dr.Ashok

Reference
• Orthodontics, current principles and techniques by Graber & Vanarsdall -6th edition
• Orthodontic appliances & enamel demineralisation –part-2 prevention & treatment of lesion . Ogaard
et al .AJODO 1988
• White Spot Lesions During Orthodontic Treatment: Mechanisms and Fluoride Preventive Aspects
Bjørn Øgaard-2008
• Enamel sealants: a clinical evaluation of their value during fixed appliance therapy Richmond et al
EJO 1994
• Effects of combined application of antimicobial & fluoride varnishes in orthodontic patients
Ogaard et .al ALODO 2001
• Evaluation of WSLs on Teeth with Orthodontic Brackets Philip Benson SEM ORTHO 2008
45Dr.Ashok

white spot lesion - prevention and management

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