White spot lesion from orthodontics

The white spot lesion and orthodontics

White spot lesions are extremely common.  They are the start of a cavity the never quit form.  The enamel has become demineralized and you get a chalky look to your teeth.  Many people will get them naturally, but one of the biggest causes I see is braces.  Post orthodontic treatment studies show up to 50% patients will have white spot lesions after their braces come off.  They often are seen as a ring around where the bracket was.  This area was the hardest to keep clean when wearing braces.  Plaque accumulats around the bracket causes the spot to form.  While prevention is ideal and can be done, few people will likely be reading this except those looking to fix white spot lesions that they already have.  Thus the following information will have treatment options first and preventative information later.

white spot lesion

Options for treatment

There are several methods that attempt to remineralize or hide the areas that are non-invasive.  They don’t work well or consistently enough to be considered useful to me.  Kalha’s lit review below agrees.  I discuss all the literature supported options anyway.

If they are large we prefer to treat them with removal via microabrasion or traditional removal as seen below. If there are a lot of white spots then a more realistic option to eliminate them is porcelain dental veneers or white composite fillings.

White spot of tooth fixed with composite.
Fixing a single white spot with dental composite.

Research on the topic

Resin infiltration creates more natural color than sodium fluoride (NaF) and casein phosphopeptide amorphous calcium phosphate (CPP-ACP or commercially MI paste).  Yuan Angle Ortho 2014   I have no doubt this is true as the NaF and CPP-ACP are more preventive in nature.  However, take this fact with a grain of salt as few dentists provide this service.  We find the technique to be  unpredictable.

Casein phosphopeptide-amorphous calcium phosphate products appear to benefit regression of white spot lesions.  EDB 2016 Hani  Bergstrand 2011

Effectiveness of remineralizing agents for the treatment of post orthodontic white spot lesions lacks evidence.  EBD 2013 Kalha
6 monthly treatments of 5% sodium fluoride varnish do reduce white spot lesions post orthodontic more than placebo He Am J Ortho DEnt 2016

Whitening teeth with a white spot lesion

You may notice that when bleaching your teeth the spots get VERY WHITE.  This is due to dehydration of the area.  Once the area rehydrates they will look “normal” again.  Normal meaning the area of the tooth will look the same as it did before you whitened it.  You can not whiten your natural teeth enough to hide these lesion.  Whitening will help a little if you have stain or yellow teeth.

Prevention of the lesions

Factors include home care, topical fluoride regimens, and diet.

Daily use of the higher dose fluoride toothpaste of 5000 ppm, compared to standard adult strength of 1450 ppm fluoride, does reduce number of white spot lesions from 27% of patients to 18%.  Sonesson Eur J Ortho 2014

6 week fluoride varnish treatment appears to decrease risk systemic review Cheng JADA Sept 15

Along the same lines Fernandez-Ferrer JADA 2018 systemic review found 5% sodium fluoride varnish is the only thing that improves white spot lesions after orthodontics.

While fluoride varnish does decrease amount of lesions in most people, those with excellent oral hygiene have no statistical benefit.  Perrini 2016 AJO-DO

CPP-ACP topical cream and fluoride products all are effective at prevention of WSLs. Pithon 2019