White Spot Lesions (WSL)
WSL can always be blamed on the patient, bad habits and poor dental hygiene. Hopefully the orthodontist has some practices in place to take on some of the responsibility to avoid this complication.
Article in 'Veritas'(1)(summer 2014) by Dr Abdullah Aldress:
Demineralized "White Spot" Lesions in Orthodontic Practice: Prevention and Management
Caries development in the form of white spot lesions (WSLs) on the labial surfaces is a serious side effect of
orthodontic treatment with fixed appliances. The reported prevalence of WSLs in patients treated with fixed
orthodontic appliances ranges from 2 to 96 per cent...
Fixed orthodontic appliances create stagnation areas for plaque and make tooth cleaning difficult, and that
leads to the colonization of abider bacteria resulting in active caries lesions over time...
One of the strategies which can be implemented to help prevent the development of WSLs aim to increase
exposure to low dose fluoride. Ionic fluoride can be taken up by enamel to form fluoridhydrowyapatite or
calcium fluoride that forms on the outermost layer of enamel when the fluoride concentration is low and the
environment acidic. Fluorohydroxyapatite is very resistant to dissolution, protecting against further
demineralization.
The author relates several studies and the fact that the American Dental Association Council on Scientific Affairs made recommendations in 2013 based on 71 English trials. He mentions that there are fluoride-containing fixtures. Some more studies are cited and the final conclusion is:
In view of the previously presented systematic review, the available evidence supports the following
interventions - in addition to regular tooth brushing with fluoridate toothpaste (1,000 ppm), or high sodium
fluoride toothpaste (5,000 ppm) in high risk patients - to prevent the development of white spot lesions
during orthodontic treatment:
* Six-weekly, professional application of varnish containing a high concentration of fluoride (e.g.
FluorProtector®, Ivoclar Vivadent AG, Schann, Lichtenstein).
* Daily use of 0.05% sodium fluoride mouthrinse or weekly prescription-strength 0.2% sodium fluoride
mouthrinse.
Caries development in the form of white spot lesions (WSLs) on the labial surfaces is a serious side effect of
orthodontic treatment with fixed appliances. The reported prevalence of WSLs in patients treated with fixed
orthodontic appliances ranges from 2 to 96 per cent...
Fixed orthodontic appliances create stagnation areas for plaque and make tooth cleaning difficult, and that
leads to the colonization of abider bacteria resulting in active caries lesions over time...
One of the strategies which can be implemented to help prevent the development of WSLs aim to increase
exposure to low dose fluoride. Ionic fluoride can be taken up by enamel to form fluoridhydrowyapatite or
calcium fluoride that forms on the outermost layer of enamel when the fluoride concentration is low and the
environment acidic. Fluorohydroxyapatite is very resistant to dissolution, protecting against further
demineralization.
The author relates several studies and the fact that the American Dental Association Council on Scientific Affairs made recommendations in 2013 based on 71 English trials. He mentions that there are fluoride-containing fixtures. Some more studies are cited and the final conclusion is:
In view of the previously presented systematic review, the available evidence supports the following
interventions - in addition to regular tooth brushing with fluoridate toothpaste (1,000 ppm), or high sodium
fluoride toothpaste (5,000 ppm) in high risk patients - to prevent the development of white spot lesions
during orthodontic treatment:
* Six-weekly, professional application of varnish containing a high concentration of fluoride (e.g.
FluorProtector®, Ivoclar Vivadent AG, Schann, Lichtenstein).
* Daily use of 0.05% sodium fluoride mouthrinse or weekly prescription-strength 0.2% sodium fluoride
mouthrinse.
This is written on the subject by Dr Jorgensen on gregjorgensen.com:
White spot lesions...are subsurface porosities caused by dental plaque. The white, chalky marks on the teeth
appear when acids created by the plaque remove minerals from the tooth surface and change the way it
reflects light. The most common area for the white spot lesions is between the gums and the brackets where
brushing is most difficult....University studies have found that white spot lesions occur in 24% of adolescents
who have never had braces. This number jumpws to as high as 50% in teenagers with braces!
On how to protect the teeth the author writes:
There is no question that fluoride strengthens the teeth and makes them more resistant to demineralization.
The question is how much is enough? For years we have been told (and sold) that prescription fluoride
application (at home and in the dental office), fluoride rinses, and fluoride varnishes painted on the teeth can
prevent decay. Controlled studies however have failed to show that these expensive products give any better
results than just the daily use of fluoridated toothpaste. Brushing the teeth just before bed, spitting out the
foam, and leaving the residue on the teeth has been shown to be just as effective as prescription fluoride. For
this reason I do not dispense or prescribe additional fluoride products to patients in my practice. There is also
a lot of interest in sealants that prevent the plaque from contacting the enamel during treatment. While we
are hopeful that effective products will be developed, those currently available lose efficacy fairly quickly and
their long-term benefits have yet to be proven.
Treatment
I haven't found anything conclusive, nothing evidence-based, not enough data, need for more studies...as often it seems up to the individual practitioner to give some kind of recommendation or to frankly say that there is nothing that has been sufficiently proven to be efficient. Whatever the dental professional thinks, it is probably easier to send the patient home with fluoride, have them come for treatments, say things might improve with time.
So things have been tried, are still ongoing, or are more recent:
- MI PASTE
- RESIN INJECTION
White spot lesions...are subsurface porosities caused by dental plaque. The white, chalky marks on the teeth
appear when acids created by the plaque remove minerals from the tooth surface and change the way it
reflects light. The most common area for the white spot lesions is between the gums and the brackets where
brushing is most difficult....University studies have found that white spot lesions occur in 24% of adolescents
who have never had braces. This number jumpws to as high as 50% in teenagers with braces!
On how to protect the teeth the author writes:
There is no question that fluoride strengthens the teeth and makes them more resistant to demineralization.
The question is how much is enough? For years we have been told (and sold) that prescription fluoride
application (at home and in the dental office), fluoride rinses, and fluoride varnishes painted on the teeth can
prevent decay. Controlled studies however have failed to show that these expensive products give any better
results than just the daily use of fluoridated toothpaste. Brushing the teeth just before bed, spitting out the
foam, and leaving the residue on the teeth has been shown to be just as effective as prescription fluoride. For
this reason I do not dispense or prescribe additional fluoride products to patients in my practice. There is also
a lot of interest in sealants that prevent the plaque from contacting the enamel during treatment. While we
are hopeful that effective products will be developed, those currently available lose efficacy fairly quickly and
their long-term benefits have yet to be proven.
Treatment
I haven't found anything conclusive, nothing evidence-based, not enough data, need for more studies...as often it seems up to the individual practitioner to give some kind of recommendation or to frankly say that there is nothing that has been sufficiently proven to be efficient. Whatever the dental professional thinks, it is probably easier to send the patient home with fluoride, have them come for treatments, say things might improve with time.
So things have been tried, are still ongoing, or are more recent:
- MI PASTE
- RESIN INJECTION
(1) 'The Harvard Society for the Advancement of Orthodontics's newsletter that is produced twice a year and
online: hsao-online.org
(2) Dr Abdullah Aldress. Demineralized "White Spot" Lesions in Orthodontic Practice: Prevention and
Management
(3) Amely Eckstein, Hans-Joachim Helms, and Michael Knösel (2015) Camouflage effects following resin
infiltration of postorthodontic white-spot lesions in vivo: One-year follow-up. The Angle Orthodontist: May
2015, Vol. 85, No. 3, pp. 374-380.
online: hsao-online.org
(2) Dr Abdullah Aldress. Demineralized "White Spot" Lesions in Orthodontic Practice: Prevention and
Management
(3) Amely Eckstein, Hans-Joachim Helms, and Michael Knösel (2015) Camouflage effects following resin
infiltration of postorthodontic white-spot lesions in vivo: One-year follow-up. The Angle Orthodontist: May
2015, Vol. 85, No. 3, pp. 374-380.