This presentation is intended to give the GP dentists as well as specialists some essential information regarding " white spot lesions" ,which can be considered as one of the most common side effect of orthodontic treatment with fixed appliances.

1. White Spot Lesions (WSLs)
Dr.Marwan Mouakeh , Consultant Orthodontist
Academic Adviser & Head of Department ,Al-Hokail Polclinic
Khobar-Saudi Arabia

2. White spot lesions (WSLs)
Definition :
• Decalcification of the enamel surface adjacent to
fixed orthodontic appliances .

3.  White spot lesions ( WSLs )
• A Prevalent iatrogenic effect of orthodontic therapy
• Incipient carious lesions develop around brackets
and bands usually near the gingival margin .

4.  Classifications of White Lesions on Enamel
• Dental Fluorosis
• Opacities
• White Spot Lesions

5. • Dental Fluorosis
 White / yellowish lesion
 Not well defined
 Symmetrical distribution
 Associated with cumulative
fluoride intake during enamel
development .
 Characteristics

6.  Dental Fluorosis
 Mild Fluorosis
 Severe Fluorosis
• Affected teeth are less
susceptible to dental caries .

7. • Enamel opacities (VS , Fluorosis)
 More defined shape.
 Well differentiated from
surrounding enamel.
 Often located in the middle of
the crown.
 Randomly distributed .

8.  Enamel Hypomineralization
 Well demarcated opacities
on the labial surface, due to
injury or infection of the
deciduous teeth, which has
affected mineralization of the
permanent teeth .

9. White spot lesions ( WSLs )
• Subsurface enamel
porosity from carious
demineralization .
• Manifesting as a milky
white opacity on the
enamel.

10.  Initial lesions :
• white decalcification with
beginning enamel breakdown
• affecting the primary teeth , not
associated with orthodontic
treatment .
 Early Childhood Caries
 White spot lesions (WSLs)
to be differentiated from

11. • A small lesion (score 2), severe lesion (score 3), and cavitation
(score 4). No lesion is recorded as score 1.
 Classification of WSLs according to Gorelick and coworkers

12. • Overall prevalence of WSLs related to fixed appliance
treatment ranges widely from 2 % - 96 %
• Significant increase in prevalence with orthodontic
treatment (72 % - 84 %)
 Prevalence of WSLs
• 49.6 % in orthodontic patients
( Ogaard et al AJO-O 1989)
• 24 % in an untreated controls
( Gorelick et al AJO-O 1982)
•Increased with Age and Treatment duration .

13.  Etiopathogenesis of WSLs
• Areas of Demineralized Enamel developed due to
prolonged plaque accumulation .

14.  Factors Necessary for Caries Development

15.  Formation of WSLs
Fixed orthodontic appliance
Rapid increase in dental plaque
Low pH
Increased cariogenic risk of S.mutans
Acid by-products
Additional lowering of pH
Decalcification of enamel

16. Development of WSLs
Plaque accumulation
Low pH adjacent to
orthodontic brackets
Inhibition of remineralization
and consequently decalcification
Streptococcus mutans

17. •Etiopathogenesis of WSLs

18.  Risk Factors
• Inadequate oral hygiene .
• Inappropriate diet (refined sugar, frequent snacks)
• History of recent caries lesions or high DMFS.
• Lack of adjunctive preventive measures ( fluoride or
antibacterial exposure , xylitol , calcium – derived
supplements ) .
• Orthodontic treatment time( fixed appliances) > 36 months

19. Diagnostic Methods

20. External
(outer)
surface
Internal
loss of
minerals
 The WSL’S chalky appearance is an optical phenomenon
caused by mineral loss in the subsurface and the surface
of the enamel

21. • Alteration of the enamel refractive index is the
consequence of both :
- surface roughness & loss of surface shine , plus
- alteration of the internal reflection
•Porous enamel scatters more light than
sound enamel .
• Visual Enamel Opacity ??

22. Wet
Dry
•Porous enamel scatters more
light than sound enamel .

23.  Fluorescence methods
– QLF
– Infra-red Fluorescence
 Transillumination
 Electrical Conductance
– ECM
 Digital Radiography
– DDR
• Diagnostic Methods

24. •Fluorescence Example
White Spot
Reflections obscuring image

25.  Location of WSL
 High prevalence on the cervical and middle thirds of the
crowns :
 1st Molars
 maxillary lateral incisors
 mandibular incisors and canines.
 Mainly on the vestibular surfaces

26. • The highest incidence of WSLs at the labio – gingival area of the
maxillary lateral incisors .
• A strong relationship between resistance to WSL formation and
the rate of salivary flow .
 Location of WSLs

27.  Differential Diagnosis of WSLs
- Carious , vs , Non carious Lesions
 Procedure :
 Clean & dry the teeth
 Carefully evaluate the lesion ( magnification &
lightning )

28.  Differential Diagnosis of WSLs
Carious , vs , Non carious Lesions
 Carious lesions : appear Rough ,Opaque ,and Porous
 Noncarious lesions : Smooth & Shiny appearance

29.  Evolution of WSLs
• WSL left untreated after removal
of a fixed appliance will naturally
reduce in size with no intervention .
• About 75 % of the small lesions
will regress during 6 months after
debonding provided the application
of caries – preventive program .

30. • Remineralization that could occur a few weeks following the
completion of orthodontic treatment ,it is the result of improved
oral hygiene and from the available minerals in saliva, fluoridated
toothpaste ….

31. • Discoloration of white
spot lesions .
• Evolution of WSLs
• Cavitation due to white
spot lesions .

32. Prevention & Treatment of WSLs

33.  Decalcification of enamel
 Prevention
• Oral hygiene
• Dentifrices
• Mouth rinses
• Varnishes

34. • Decalcification of enamel
 Prevention
• Good Oral hygiene
• Mouth rinses

35.  White Spot Lesions…
Can be Remineralized with
• Changes in diet
• Fluoride varnish
• Daily brushing with fluoride toothpaste.

36.  Fluoride
• Inhibits demineralization
• Enhances remineralization
• Inhibits plaque bacteria
• Prevention of WSLs

37. Demineralization <------------ > Remineralization
•Frequent carbohydrate intake
•Frequent exposure to acids
•Plaque presence
•Decreased salivary flow
•Exposure to fluoride
•Removal of plaque
•Balanced diet
•Limited exposure to carbohydrates

38. • Ways to Obtain Fluoride: Topical
 Fluoride Toothpaste
 Fluoride Varnish
 Fluoride Mouthrinses

39. Decalcification of enamel
 Prevention :
 F . Dentifrices
 Sodium Fluoride
Amine Fluoride
Monofluorophosphate
Stannous Fluoride ( +
Plaque inhibiting effect )

40. •Decalcification of enamel
 Prevention :
 F. Dentifrices
• Fluoride concentration ,
0.11% - 0.15% twice daily :
 Reduce demineralization and
 Enhance remineralization

41. • Fluoridated mouth rinses ( Na.F 0.05 %) :
An improved cariostatic effect if combined with Antibacterial
agents :
- Chlorhexidine : inhibits plaque formation
( - ) : Tooth discoloration , metallic taste
- Triclosan ( with Zinc ) : antibacterial + anti- inflammatory
effects .
• Prevention of WSLs

42.  Highly concentrated topical fluoride
treatment (22,600 ppm)
 Can reverse early white spot lesions.
• Temporary discoloration of teeth
and gingival tissue
• Decrease enamel decalcification
44.3 %
• Varnishes
• Prevention of WSLs

43. Fluoridated Sealants , Primers and Adhesives
• G.I Cements: Sustained F. Release in plaque around
brackets .
• Prevention of WSLs

44. Fluoridated Sealants , Primers and Adhesives
• Resin reinforced GIC = Better bond strength
• Prevention of WSLs

45. • Complicated designed appliances make oral hygiene difficult to carry out.
• Prevention of WSLs

46. • Use of S.S ligatures > Elastic modules
• Coil spring traction > Elastic chains …
• Prevention of WSLs

47. • Self-ligating Brackets …..
• Prevention of WSLs

48. • Use of Bondable Buccal Tubes …..
• Prevention of WSLs

49. •Excess bonding material retains plaque.
• Prevention of WSLs

50. • Indirect Bonding and / or Light-cure Technique…..
• Prevention of WSLs

51. Treatment protocols for
WSLs
•First , Allow Natural
Remineralization.

52.  Treatment of WSLs
• Avoid high concentration of F agents since they arrest
enamel remineralization .
• Allow Remineralization of enamel by Saliva (less
visible lesions) .

53.  Treatment of WSLs
• Shows a lower right canine, which had an orthodontic white
spot lesion that was treated at debond with strong fluoride
varnish. The lesion has not regressed and has stained brown.

54.  Treatment of WSLs
• Low doses of F applications (50 – ppm F. mouth rinses).
• Tooth Whitening “ Bleaching “
• Use of CPP –ACP “ Casein derivates “
• Enamel Microabrasion
• Cosmetic Restorations ( Veneers ) .

55.  Treatment methods
• F. mouth rinses : 0.05% Na F + Chlorhexidine .
• Topical F. gel or varnishes application

56. Topical Application of Titanium Tetrafluoride ( solution ) :
the mechanism of interaction with the enamel
 Strong Ti-O-Ti chains on the
enamel surface .
 A titanium-rich , glaze –like coating
formed on the enamel surface following
the application of Ti. Tetra F.
 Treatment of WSLs

57. • Chlorhexidine mouthwash
• Antimicrobial therapy .
• To achieve a shift from :
Unfavorably biofilm favorably biofilm
• Maybe used as a complement to F. therapy.
 Drawback : the tendency to stain the teeth

58. • Casein Phosphopeptide Amorphous
Calcium Phosphate (CPP-ACP )
 Treatment of WSLs

59. • Casein Phosphopeptide Amorphous Calcium
Phosphate (CPP-ACP )
• Trade name : Recaldent
• Derived from milk caseine
• Enhances formation of calcium phosphate crystals

60.  Recaldent CPP-ACP :
• Natural milk derived product containing casein phosphopeptides
CPP and amorphous calcium phosphates ACP

61.  Treatment of post-orthodontic white spot lesions with
casein phosphopeptide-stabilised amorphous calcium
phosphate .
Brochner et al, Clin Oral Invest, April 2010
 The mean area of the WS lesions
decreased by 58% in the CPP- ACP
group and 26% in the fluoride group .

62. • Casein Phosphopeptide Amorphous Calcium Phosphate (CPP-ACP )
7 days
4 weeks 12 weeks

63.  Recaldent CPP-ACP
Chewing Gum :
This gum contains the active CPP-ACP .
 Recaldent also contains Xylitol, which is
a natural sweetener shown to help control
mouth bacteria and improve saliva quality.
•The in vivo studies of the remineralization
properties of Recaldent (CPP-ACP) Gum
have shown subsurface mineral gain can
occur by chewing the gum for periods of 15
minutes for 2 weeks.

64. • Vital Tooth Bleaching
 Treatment of WSLs

65. •Vital Tooth Bleaching
•View of the same maxillary
anterior teeth following 4 weeks
of overnight vital bleaching with
10% carbamide peroxide
delivered in a custom tray.
 Treatment of WSLs

66. • View of the same maxillary
anterior teeth following 4
weeks of bleaching , 30 minutes
twice per day, with a hydrogen
peroxide gel impregnated on
polyethylene strips.
•Vital Tooth Bleaching

67. Microabrasion of the enamel
 Treatment of WSLs

68.  Microabrasion
• A technique to remove the superficial non- carious
superficial enamel defects as well as WSL .
• Topical application of an 18 % hydrochloric acid and
pumice , 1 – 2 minutes .

69.  Microabrasion
• 5 to 10 applications of the microabrasion compound
should be effective .
• The abraded enamel surface is less susceptible to
demineralization than natural enamel .
• Following the microabrasion technique , a 4-minute 2 % Na F
treatment is recommended .

70. • Cosmetic Restorations
in Severe Cases
 Treatment of WSLs

71.  Decalcification restored with composite resin
.
• Cosmetic Restorations
 ( ICon ): Caries Infiltration with light-curable
resin for non-cavitated lesions

72. • Patient who needed composite
buildups on the maxillary anterior
teeth to esthetically improve areas
of severe decalcification following
orthodontic treatment .
• Cosmetic Restorations

73. Clinical Test …..

74.  How Do You Proceed ?
 Problem : Inadequate oral hygiene, generalized
gingivitis, plaque accumulation, and white spot
lesions at the bucco-cervical surfaces.

75.  Discuss with the patient the risk factors,
 Make recommendations according to the problems (eg, diet
and oral hygiene behavioral assessment),
 Prescribe high-fluoride (5000 ppm) toothpaste and 0.12%
chlorhexidine rinses, and
 Reevaluate in few months to assess whether patient has
been compliant and able to proceed with orthodontic
treatment .
 How Do You Proceed ?

76.  What do you recommend?
Reevaluate the risk factors
Reinforce oral hygiene instructions,
Prescribe high-fluoride toothpaste and chlorhexidine rinses,
Apply fluoride varnish at least 2 or 3 times a year, and also
Recommend frequent use of xylitol or sugar-free gum.

77.  Problem : at the debonding appointment , you
note white spot lesions and areas of cavitation on
the patient.
What do you do?

78.  Summary : Treatment protocols for WSLs
• First , allow natural remineralization.
• Low doses of F applications (50 – ppm F. mouth rinses).
•Use of CPP –ACP “ Casein derivates “
• If the lesions persist , professional bleaching is
indicated.
• If the effect of bleaching is inadequate , Microabrasion
is an option.
• Lastly , direct or indirect Veneers could be considered.

79.  Conclusions :
• To prevent development of white spot lesions, orthodontists
should assess each patient’s risk factors before and during
treatment.
• Oral hygiene instructions are important, but patients
might need to be assisted with additional measures, including
fluoride varnish, chlorhexidine , dietary modification,
or calcium-containing remineralization products that can
help prevent enamel demineralization, enhance remineralization,
and modify patient and biofilm factors.

80.  Conclusions :
• Restorative treatment for established white spot
lesions can range from the most conservative
(remineralization with fluoride, calcium, and
phosphate) to the most aggressive (tooth reduction
and porcelain veneers).

81.  Conclusions :
It is crucial to establish a caries risk
assessment and recommendation
protocol for patients before, during, and
after treatment to be able to provide
overall successful orthodontic
treatments for them.

82. Thank You … Dr.Marwan Mouakeh
Syria –Aleppo, the public park