A review on prevention and treatment of post-orthodontic white spot lesions - evidence-based methods and emerging technologies.
ABSTRACT The aim of this paper was to update the evidence for primary and secondary prevention (treatment) of white spot lesions (WSL) adjacent to fixed orthodontic appliances.
A search for relevant human clinical trials published in English between 2004 and March 2011 retrieved 25 publications that fulfilled the inclusion criteria. The papers were assessed for prevented fraction and/or absolute risk reduction when possible.
The findings consolidated the use of topical fluorides in addition to fluoride toothpaste as the best evidence-based way to avoid WSL. The mean prevented fraction based on 6 trials was 42.5% with a range from -4% to 73%. The recent papers provided the strongest support for regular professional applications of fluoride varnish around the bracket base during the course of orthodontic treatment. For the treatment of post-orthodontic WSL, home-care applications of a remineralizing cream, based on casein phosphopeptide-stabilized amorphous calcium phosphate, as adjunct to fluoride toothpaste could be beneficial but the findings were equivocal. For emerging technologies such as sugar alcohols and probiotics, still only studies with surrogate endpoints are available. Thus, further well-designed studies with standardized regimes and endpoints are needed before guidelines on the non-fluoride technologies can be recommended.
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ABSTRACT: The development of incipient caries, or white spot lesions (WSLs), is a significant clinical problem in orthodontics. The purpose of this study was to retrospectively determine the incidence and severity of WSLs by examining pretreatment and posttreatment digital photographs. A total of 332 consecutive finished patients from a university graduate orthodontic clinic were evaluated. Initial and final digital images were compared to assess WSLs. The facial surfaces of the anterior 8 maxillary teeth were analyzed. The percentage area of WSL per total facial tooth surface was calculated to control for magnification differences. Reliability of the method was assessed by comparison with direct clinical examination data. Patient and operator factors, and treatment complexity and outcomes were evaluated as predictors of WSL incidence and severity. Agreement between direct clinical examination and digital photo data was excellent, with an intraclass correlation coefficient 0.88 and a 0.3% average difference between methods. The incidence of at least 1 WSL on the labial surface of the anterior 8 maxillary teeth was 36%. The order of incidence was lateral incisor (34%), canine (31%), premolar (28%), and central incisor (17%). Risk factors for the development of incipient caries during orthodontic treatment were young age (preadolescent) at the start of treatment, number of poor hygiene citations during treatment, unfavorable clinical outcome score, white ethnic group, and inadequate oral hygiene at the initial pretreatment examination. The use of computer software to evaluate digital photos retrospectively is a valid method for assessing the incidence and severity of WSLs on the maxillary anterior incisors, canines, and premolars.American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 08/2010; 138(2):188-94. · 1.33 Impact Factor
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ABSTRACT: INTRODUCTION: White spots (WS) related to orthodontic treatment are severe cariologic and cosmetic complications, but they are shown to be partially reduced by remineralization or abrasion in short-term follow-ups. In this prospective study, we quantitatively analyzed changes in WS in general and in treatment-related white spot lesions (WSL) during orthodontic treatment and at a 12-year follow-up after treatment. In addition, we quantitatively compared the effects of an acrylic bonding material vs a glass ionomer cement (GIC) on WSL. METHODS: Sum areas of WS and WSL were calculated on scans of standardized photos of the vestibular surfaces of 4 teeth in consecutive orthodontic patients (median treatment time, 1.7 years) bonded with the 2 materials in a split-mouth design. Comparisons were made in 59 patients before treatment (BF), at debonding (T0), at 1 year (T1), and at 2 years (T2), and in 30 patients at a 12-year follow-up (T3) with the Friedman test followed by pairwise comparisons with the Wilcoxon matched-pairs signed rank test. Differences of the effects of acrylic vs GIC on the sum areas of WSL were tested for each observation period with the Mann-Whitney U test. RESULTS: Increases in the sum areas of WS and WSL from BF to T0 (P <0.001) were followed by significant decreases at T1 (P <0.001) and T2 (P <0.01 for WS; P <0.001 for WSL). Significant changes were also found in the sum areas for WS at T3 compared with T2 (P <0.01), but not for WSL (P = 0.328). The sum areas of WS and WSL at T3 did not return to BF levels (P <0.001). Sum areas of WSL were higher for surfaces bonded with acrylic compared with GIC for each observation period from BF to T2 (P >0.001), and from T2 to T3 (P >0.05). CONCLUSIONS: Although significantly reduced during the 12-year follow-up and significantly lower with the GIC than the acrylic material at bonding, WSL are a cariologic and cosmetic problem for many orthodontic patients.American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 08/2010; 138(2):136-137. · 1.33 Impact Factor
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ABSTRACT: Dental caries, specifically decalcified white-spot lesions (WSL), is a well-known side-effect of orthodontic treatment. The incidence of labial incipient caries lesions and its relationship with various patient and treatment variables was investigated in patients treated with comprehensive orthodontics. Randomly selected orthodontic patient records (n = 350) were examined to determine incipient caries lesion development. Labial surfaces on pretreatment and posttreatment photographs were scored with a standardized scoring system. Independent variables were collected by chart abstraction. The incidence of patients who developed at least 1 new WSL during treatment was 72.9%, and this incidence was 2.3% for cavitated lesions. Treatment duration was significantly associated with new WSL development (P = 0.03). Development of WSL and cavitated lesions increased (both, P <0.00) despite increased attention to oral hygiene during treatment. Sex, age, extraction therapy, and various fluoridation sources were not associated with WSL development, but initial oral-hygiene score was moderately associated (P <0.06). The incidence of WSL in patients treated with comprehensive orthodontics was significantly high, and the preventive therapy provided appeared to be ineffective. This widespread problem is alarming and warrants significant attention from both patients and providers that should result in greatly increased emphasis on effective caries prevention.American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 05/2011; 139(5):657-64. · 1.33 Impact Factor
158 The Open Dentistry Journal, 2011, 5, 158-162
1874-2106/11 2011 Bentham Open
A Review on Prevention and Treatment of Post-Orthodontic White Spot
Lesions – Evidence-Based Methods and Emerging Technologies
Fredrik Bergstrand1 and Svante Twetman2,3*
1Private Practice, Stockholm, Sweden
2Department of Odontology, Section for Cariology, Endodontics and Pediatric Dentistry, Faculty of Health Sciences,
University of Copenhagen, Copenhagen, Denmark
3Maxillofacial Unit, Halland Hospital, Halmstad, Sweden
Abstract: Objective: The aim of this paper was to update the evidence for primary and secondary prevention (treatment)
of white spot lesions (WSL) adjacent to fixed orthodontic appliances.
Material and methods: A search for relevant human clinical trials published in English between 2004 and March 2011
retrieved 25 publications that fulfilled the inclusion criteria. The papers were assessed for prevented fraction and/or abso-
lute risk reduction when possible.
Results and conclusions: The findings consolidated the use of topical fluorides in addition to fluoride toothpaste as
the best evidence-based way to avoid WSL. The mean prevented fraction based on 6 trials was 42.5% with a range
from -4% to 73%. The recent papers provided the strongest support for regular professional applications of fluoride
varnish around the bracket base during the course of orthodontic treatment. For the treatment of post-orthodontic WSL,
home-care applications of a remineralizing cream, based on casein phosphopeptide-stabilized amorphous calcium
phosphate, as adjunct to fluoride toothpaste could be beneficial but the findings were equivocal. For emerging
technologies such as sugar alcohols and probiotics, still only studies with surrogate endpoints are available. Thus, further
well-designed studies with standardized regimes and endpoints are needed before guidelines on the non-fluoride
technologies can be recommended.
Keywords: Decalcification, fixed appliances, fluoride, orthodontics.
Despite extensive research in various preventive
technologies over the years, white spot lesion (WSL) devel-
opment in association with orthodontic treatment with fixed
appliances remains an unwanted clinical problem [1-3]. Such
lesions developing during orthodontic treatment have very
limited ability to improve after appliance removal . A
number of recent narrative and systematic reviews have
failed to present sufficient evidence for most preventive
measures, with topical applications of fluoride-containing
products as the only exception, and the need of new
approaches and further well designed clinical trials is em-
phasized [5-9]. Traditionally, most research has addressed
the primary prevention of WSL but in recent years, also the
secondary prevention, that is the control and treatment of
existing WSL’s after debonding, has gained interest .
The aim of this paper was to review and update the evidence
of current methods and emerging technologies to prevent and
reverse post-orthodontic WSL and to discuss the various
mechanisms of action.
*Address correspondence to this author at the Department of Odontology
Faculty of Health Sciences, University of Copenhagen, Nørre Allé 20
DK-2200 Copenhagen N, Denmark; Tel: 004535326810;
Fax: 004535326505; E-mail: firstname.lastname@example.org
A search for relevant clinical papers published in English
between January 2004 and March 2011 was conducted on
Medline/PubMed and the Cochrane Library with “orthodon-
tics”, “fixed appliances”, “caries”, “white spot lesions”,
“demineralization” and “decalcification” as principle search
terms. Only human controlled in vivo studies of topical tech-
nologies with white spot lesions incidence/reversals or other
relevant surrogate endpoints were accepted. Studies on ex-
tracted teeth as well as papers dealing with lingual orthodon-
tics and various fluoride-releasing bonding materials were
excluded since a very recent systematic review was available
on this topic . Likewise, double publications, sole ab-
stracts and case reports were discarded. The initial search
revealed 161 papers but after independent reading of the
abstracts by two examiners, 38 papers were retrieved in full
length and 25 were accepted for this report [12-36].
However, no formal quality grading was done. Data on de-
sign, performance and outcome was extracted. The prevented
WSL fraction was calculated as the difference in mean WSL
increment between the intervention and control groups, ex-
pressed as percentage of the increment in the control group.
For WSL reversals, the absolute risk reduction (ARR%) was
calculated when possible.
Prevention and Management of WSL The Open Dentistry Journal, 2011, Volume 5 159
Of the included papers, 9 dealt with primary prevention,
8 with WSL reversals and 6 utilized a surrogate measure
such as bacterial counts, plaque amount or pH-values. The
most common intervention was fluoride (9 papers) followed
by antibacterial agents (5 papers), remineralization with ca-
sein phosphopeptide-stabilized amorphous calcium phos-
phate (CPP-ACP) (5 papers), and various other methods (6
Primary Prevention of WSL Adjacent to Fixed
In the Cochrane review , it was concluded that there
was some evidence that daily NaF mouth rinses could reduce
the occurrence and severity of WSL during orthodontic
treatment albeit more high quality research was required.
The recent publications are compiled in Table 1. The mean
prevented fraction was 42.5% with a range from -4% to
73%. Seven out of nine papers were assessing a fluoride in-
tervention, while the remaining evaluated the impact of seal-
ants and ozone. Four papers dealt with fluoride varnish ap-
plications but three of them were small split-mouth studies.
Thus, the only large placebo-controlled trial with parallel
groups was most interesting . This was a fully powered
double-blind randomized controlled trial with fluoride var-
nish (Fluor Protector, Ivoclar-Vivadent) containing 0.1%
fluoride in a homogeneous solution but the concentration is
approximately 10 times higher after the varnish has dried.
The result immediately after debonding displayed a pre-
vented fraction of 70% when the varnishes were applied
around the bracket base every 6th week at the regular, sched-
uled follow-ups. The results of the three smaller split-mouth
studies pointed in the same direction, albeit with various
endpoints. In two papers, fluoride mouth rinses and/or fluo-
ride toothpaste was tested against another positive fluoride
control [12, 13]. No significant differences were found indi-
cating that the presence of fluoride per se in the oral envi-
ronment might be more important than the actual formula-
tion. The concentration of fluoride in toothpaste may how-
ever play a role. A recent study by Al-Mulla et al. 
showed that high sodium fluoride toothpaste (5,000 ppm),
available on prescription in some countries, had a greater
anti-caries potential than standard 1,450 ppm formula in pa-
tients with orthodontic bands.
The impact of non-fluoride measures was reported in two
trials, one on resin sealants  and one on ozone . Im-
pregnation of the buccal surfaces with resin sealants seemed
to effectively prevent the development of WSL in compari-
son with no treatment while the use of ozone was inferior to
chlorhexidine varnish in controlling the microflora and pre-
vent lesions. Both studies were however limited in size but
the sealant approach merits to be repeated in a larger setting.
To date, only case reports are available.
Secondary Prevention (Treatment) of Post-Orthodontic
WSL After Debonding
As mentioned earlier, the interest in secondary preven-
tion of WSL has increased. Eight new papers were identified
of which five publications investigated the novel casein
phosphopeptides-amorphous calcium phosphate (CPP-ACP)
system (Table 2). Collectively, the CPP-ACP studies with
Tooth Mousse? (GC) or similar products retrieved clinical
evidence that daily applications of the remineralizing cream
could reverse the severity and visual appearance of post-
orthodontic WSL more effective than, or at least as good as,
fluoride toothpaste [21-25]. One study displayed reduced
demineralization when ACP was incorporated in the ortho-
dontic composite . The reversals were assessed with
clinical scoring and/or laser fluorescence and the mean ARR
was estimated to 14%. It should however be noted that all
the CPP-ACP protocols were supplements to regular use of
fluoride toothpaste and that two of the studies could not dis-
play any clear clinical benefits of daily applications of the
Table 1. Clinical Trials for Primary Prevention of WSL Adjacent to Fixed Orthodontic Appliances Published in English between
2004 and March 2011
First Author [ref no.] Design/n Intervention vs. Control
Øgaard  RCT/115 AmF/SnF2-tp+rinse vs. NaF-tp+rinse 4/7 43% (NS)
de Moura  RCT/14 F-tp vs. anti-plaque/F-tp NR NR
Vivaldi-Rodrigues  SM/10 F-varnish vs. no treatment 0.34/0.51* 33% (S)
Gontijo  SM/16 F-varnish vs. no treatment NR NR
Stecksén-Blicks  RCT/273 F-varnish vs. placebo 7/26 70% (S)
Farhadian  SM/15 F-varnish vs. no treatment 57/93§ 40% (S)
Benham  SM/60 buccal sealants vs. no treatment 10/7 73% (S)
Kronenberg  SM/20 Ozone vs. CHX+F-varnish 3.2/0.7 -4% (NS)
Al-Mulla  RCT/20 F-tp (5000 ppm) vs. F-tp (1450 ppm)
?F -10/-15.8 NR
* decalcification index
§ lesion depth, micrometer
Abbreviations: PF=prevented fraction; RCT = randomized controlled trial; SM = split-mouth; S = statistically significant difference between groups; NS = no statistically significant
difference; NR = data not reported; F-tp = fluoride toothpaste; ?F = change in fluorescence
160 The Open Dentistry Journal, 2011, Volume 5 Bergstrand and Twetman
remineralizing paste [23, 25]. Furthermore, Willmot 
failed to demonstrate an additional effect of sodium fluoride
mouth rinses compared with no rinses which indicates that
remineralization of WSL with normal oral hygiene proce-
dures and fluoride toothpaste after debonding may be con-
sidered “good clinical practice” in cases with normal salivary
function. A recent study suggested that weekly applications
of fluoride varnish (Duraphat) during the first month after
debonding were effective in bringing post-orthodontic WSL
lesions to an inactive state .
The remaining papers on WSL treatment were not ad-
dressing the biologic repair process. Instead, a cosmetic im-
provement of the lesions through bleaching or micro-
abrasion was suggested [27, 28]. As expected, both tech-
niques did obviously improve the aesthetic appearance of
WSL and should be included in the therapeutic toolbox as
“plan B” in non-responders to the available biological strate-
gies. Recently, an infiltration technique has been suggested
that fills the non-cavitated pores of an incipient lesion with a
low-viscosity resin by capillary action, creating a barrier that
blocks further bacterial diffusion and lesion development.
This micro-invasive method eliminates opaqueness and may
blend existing WSL with surrounding natural teeth .
The recent literature has suggested that daily consump-
tion lozenges containing the sugar-substitute xylitol may
have a beneficial impact on the ecological environment adja-
cent to fixed orthodontic brackets [31, 32]. Other antibacte-
rial measures investigated are topical applications of chlor-
hexidine-varnish , essential oils , ozone , amor-
phous calcium phosphate  and probiotics . Although
the findings definitely are promising, all studies except one
 were reporting surrogate or intermediate endpoints such
as mutans streptococci reductions, plaque acidogenicity or
pH-recovery. As such endpoints do not allow either evi-
dence-based conclusions or treatment recommendations,
further research of the antibacterial strategies for WSL pre-
vention and control in orthodontic patients are needed.
It was somewhat disappointing to find that most of the
recent studies dealing with prevention and treatment of WSL
adjacent to fixed orthodontic still were of mixed quality.
Most studies were limited in size, few were double-blind and
placebo-controlled with parallel arms and the minority were
reporting endpoints of true relevance for the patient. Indeed,
statistically significant differences concerning surrogate
endpoints may not necessarily be of clinical significance or
importance for the patient. Furthermore, no paper provided
data on the health-economic aspects of the various interven-
tions. Thus, the need for more high quality research, as
firmly stated in previous reviews, is unchanged. However,
the tested interventions seemed to be well accepted by the
patients with few dropouts and no side-effects or severe ad-
verse events were reported for any intervention. It must also
be mentioned that lingual orthodontics represents a totally
different concept for reducing WSL in connection with or-
thodontic treatments .
The findings of the present review reinforced the use of
topical fluorides in addition to fluoride toothpaste as the
most effective way to reduce the incidence of WSL in pa-
tients undergoing orthodontic treatment with fixed appli-
ances. The novel information was that regular topical appli-
cations of fluoride varnish around the bracket base have
emerged as the most effective topical method. Fluoride var-
nish programs have the advantage of being independent of
patient compliance through its quick and simple professional
applications. Moreover, applications of fluoride varnish dur-
ing the first 4 weeks after debonding seemed to be an option
to create lesion inactivity . Concerns have been raised
against the use of highly concentrated fluoride to assist
remineralization since it may lead to unsightly staining .
Table 2. Clinical Trials for Secondary Prevention (Treatment) of Post-Orthodontic WSL Published in English Between 2004 and
First Author, [ref no.] Design/n Treatment vs. Control Endpoint Test/Control ARR
Andersson  RCT/26 CPP-ACP vs. NaF-rinse regression 55%/18% 37%
Bailey  RCT/45 CPP-ACP vs. placebo regression 72%/59% 13%
Uysal  RCT/14 CPP-ACP vs. composite micro hardness -- S
Beerens  RCT/54 CPP-ACP vs. NaF QLF decreased NS
Bröcher  RCT/60 CPP-ACP vs. NaF-paste regression 33%/38% -4% (NS)
Willmot  RCT/26 NaF-rinse vs. placebo regression 54%/66% NS
Knösel  NT/10 bleaching color improved NA
Murphy  NT/8 microabrasion regression 83%/NA NA
Du  RCT/110 F-varnish vs. saline LF scores -7.6/-3.1 S
Abbreviations: RCT=randomized controlled trial; NT = non-randomized, non-controlled trial; S = significant difference between groups; NS = not statistically different; NA = not
applicable; QLF = Quantitative light-induced fluorescence; LF score = laser fluorescence measurements (DIAGNOdent)
Prevention and Management of WSL The Open Dentistry Journal, 2011, Volume 5 161
There were unfortunately no recent trials available that could
either confirm or reject this important research question.
Due to its paramount role in WSL prevention, it could be
of interest to examine the mechanisms of action for fluoride
in combination with the other measures in the light of the
ecological plaque hypothesis. Dental plaque is an example of
a biofilm and biofilms with a diverse and stable microbial
community are generally associated with oral health .
Demineralization of enamel is a result of an adaption of the
biofilm to environmental pH-stress. Prolonged low pH con-
ditions promotes the growth of aciduric bacteria resulting in
a reduced diversity and a selection of species associated with
a cariogenic environment, such as mutans streptococci, lac-
tobacilli, actinomyces and veillonella. A WSL will occur
when the local demineralization is larger than remineraliza-
tion over time. Consequently, any intervention that counter-
act the acidic conditions in the oral environment and in the
oral biofilm is likely beneficial for the caries balance. It is
well known that very low fluoride concentrations in the
plaque fluid (0.03 ppm) can reduce demineralization and
enhance remineralization . In higher concentrations, such
as those achieved with fluoride varnish (22,500 ppm), fluo-
ride may also hamper bacterial metabolism and acid produc-
tion through interference with the enzyme enolase .
Likewise, xylitol is a microbial metabolic inhibitor that
counteracts the pH-drop in the biofilm and reduces the selec-
tion of aciduric bacteria . CPP-ACP agents may, on top
of the remineralizing properties, improve the salivary buffer
capacity and thereby elevate pH more rapidly after food in-
take . The rationale behind a daily intake of health-
promoting probiotic bacteria is that probiotic (health-
promoting) bacteria may address the biofilm imbalance, lo-
cally by competitive inhibition of pathogens and systemi-
cally by regulating the host immune response via the guts
. Consequently, all the preventive strategies mentioned
above can contribute to maintain the stability of the oral
biofilm in various ways during the low-pH challenge caused
by fixed orthodontic appliances.
The recent clinical trials on WSL prevention provided the
strongest support for regular topical applications of fluoride
varnish around the bracket base during treatment with fixed
appliances. For the treatment of post-orthodontic WSL, a re-
mineralizing cream with casein phosphopeptide-stabilized
amorphous calcium phosphate as adjunct to fluoride tooth-
paste seemed to be beneficial with some mineral and aes-
thetic improvements. Conflicting results were however re-
ported and along with emerging technologies such as sugar
alcohols, antibacterial peptides and probiotics, further high-
quality clinical trials with standardized regimes and end-
points are needed.
ACKNOWLEDGEMENT & CONFLICTS OF INTER-
Dr. Bergstrand is a consultant for 3M-Unitek, Stockholm,
Sweden. The authors report no conflicts of interest.
Chapman JA, Roberts WE, Eckert GJ, Kula KS, González-Cabezas
C. Risk factors for incidence and severity of white spot lesions dur-
ing treatment with fixed orthodontic appliances. Am J Orthod Den-
tofacial Orthop 2010; 138: 188-9.
Shungin D, Olsson AI, Persson M. Orthodontic treatment-related
white spot lesions: a 14-year prospective quantitative follow-up,
including bonding material assessment. Am J Orthod Dentofacial
Orthop 2010; 138: 136.e1-8.
Richter AE, Arruda AO, Peters MC, Sohn W. Incidence of caries
lesions among patients treated with comprehensive orthodontics.
Am J Orthod Dentofacial Orthop 2011; 139: 657-64.
Mattousch TJ, van der Veen MH, Zentner A. Caries lesions after
orthodontic treatment followed by quantitative light-induced fluo-
rescence: a 2-year follow-up. Eur J Orthod 2007; 29: 294-8.
Bergstrand F, Twetman S. Evidence for the efficacy of various
methods of treating white-spot lesions after debonding of fixed or-
thodontic appliances. J Clin Orthod 2003; 37:19-21.
Derks A, Katsaros C, Frencken JE, van't Hof MA, Kuijpers-
Jagtman AM. Caries-inhibiting effect of preventive measures dur-
ing orthodontic treatment with fixed appliances. a systematic re-
view. Caries Res 2004; 38: 413-20.
Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A.
Fluorides for the prevention of white spots on teeth during fixed
brace treatment. Cochrane Database Syst Rev 2004 (3): CD003809
Chadwick BL, Roy J, Knox J, Treasure ET. The effect of topical
fluorides on decalcification in patients with fixed orthodontic ap-
pliances: a systematic review. Am J Orthod Dentofacial Orthop
2005; 128: 601-6.
Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot
lesions in orthodontic practice: a contemporary review. Aust Dent J
2006; 51: 284-9.
Willmot D. White spot lesions after orthodontic treatment. Semin
Orthodont 2008; 14: 209-19.
Rogers S, Chadwick B, Treasure E. Fluoride-containing adhesives
and decalcification in patients with fixed appliances: A Systematic
review. Am J Orthod Dentofacial Orthop 2010; 138: 390.e1-8
Øgaard B, Alm AA, Larsson E, Adolfsson U. A prospective, ran-
domized clinical study on the effects of an amine fluoride/stannous
fluoride toothpaste/mouthrinse on plaque, gingivitis and initial car-
ies lesion development in orthodontic patients. Eur J Orthod 2006;
deMoura MS, de Melo Simplício AH, Cury JA. In-vivo effects of
fluoridated antiplaque dentifrice and bonding material on enamel
demineralization adjacent to orthodontic appliances. Am J Orthod
Dentofacial Orthop 2006; 130: 357-63.
Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The
effectiveness of a fluoride varnish in preventing the development of
white spot lesions. World J Orthod 2006; 7: 138-44.
Gontijo L, Cruz Rde A, Brandão PR. Dental enamel around fixed
orthodontic appliances after fluoride varnish application. Braz Dent
J 2007; 18: 49-53.
Stecksén-Blicks C, Renfors G, Oscarson ND, Bergstrand F,
Twetman S. Caries-preventive effectiveness of a fluoride varnish: a
randomized controlled trial in adolescents with fixed orthodontic
appliances. Caries Res 2007; 41: 455-9.
Farhadian N, Miresmaeili A, Eslami B, Mehrabi S. Effect of fluo-
ride varnish on enamel demineralization around brackets. an in-
vivo study. Am J Orthod Dentofacial Orthop 2008; 133: S95-S98.
Benham AW, Campbell PM, Buschang PH. Effectiveness of pit
and fissure sealants in reducing white spot lesions during orthodon-
tic treatment: A Pilot study. Angle Orthod 2009; 79: 338-45.
Kronenberg O, Lussi A, Ruf S. Preventive effect of ozone on the
development of white spot lesions during multibracket appliance
therapy. Angle Orthod 2009; 79: 64-9.
Al-Mulla A, Karlsson L, Kharsa S, Kjellberg H, Birkhed D.
Combination of high-fluoride toothpaste and no post-brushing wa-
ter rinsing on enamel demineralization using an in-situ caries
model with orthodontic bands. Acta Odontol Scand 2010; 68: 323-
Andersson A, Sköld-Larsson K, Hallgren A, Petersson LG,
Twetman S. Effect of a dental cream containing amorphous cream
phosphate complexes on white spot lesion regression assessed by
laser fluorescence. Oral Health Prev Dent 2007; 5: 229-33.
Bailey DL, Adams GG, Tsao CE, et al. Regression of post-
orthodontic lesions by a remineralizing cream. J Dent Res 2009;
Uysal T, Amasyali M, Ozcan S, Koyuturk AE, Akyol M, Sagdic D.
In vivo effects of amorphous calcium phosphate-containing ortho-
162 The Open Dentistry Journal, 2011, Volume 5 Bergstrand and Twetman
dontic composite on enamel demineralization around orthodontic
brackets. Aust Dent J 2010; 55: 285-91.
Beerens MW, van der Veen MH, van Beek H, ten Cate JM. Effects
of casein phosphopeptide amorphous calcium fluoride phosphate
paste on white spot lesions and dental plaque after orthodontic
treatment: a 3-month follow-up. Eur J Oral Sci 2010; 118: 610-7.
Bröchner A, Christensen C, Twetman S, et al. Treatment of white
spot lesions with casein-phosphopeptide-stabilized amorphous cal-
cium phosphate. Clin Oral Invest 2011; 15: 369-73.
Willmot DR. White lesions after orthodontic treatment: does low
fluoride make a difference? J Orthod 2004; 31: 235-42.
Knösel M, Attin R, Becker K, Attin T. External bleaching effect on
the color and luminosity of inactive white-spot lesions after fixed
orthodontic appliances. Angle Orthod 2007; 77: 646-52.
Murphy TC, Willmot DR, Rodd HD. Management of postortho-
dontic demineralized white lesions with microabrasion: a quantita-
tive assessment. Am J Orthod Dentofacial Orthop 2007; 131: 27-
Du M, Cheng N, Tai B, Jiang H, Li J, Bian Z. Randomized con-
trolled trial on fluoride varnish application for treatment of white
spot lesion after fixed orthodontic treatment. Clin Oral Investig
2011 [Epub ahead of print].
Kugel G, Arsenault P, Papas A. Treatment modalities for caries
management, including a new resin infiltration system. Compend
Contin Educ Dent 2009; 30 (Spec No 3):1-10.
Stecksén-Blicks C, Lif Holgerson P, Olsson M, et al. Effect of
xylitol on mutans streptococci and lactic acid formation in saliva
and plaque from adolescents and young adults with fixed orthodon-
tic appliances. Eur J Oral Sci 2004; 112: 244-8.
Sengun A, Sari Z, Ramoglu SI, Malkoç S, Duran I. Evaluation of
the dental plaque pH recovery effect of a xylitol lozenge on pa-
tients with fixed orthodontic appliances. Angle Orthod 2004; 74:
Derks A, Frencken J, Bronkhorst E, Kuijpers-Jagtman AM, Katsa-
ros C. Effect of chlorhexidine varnish application on mutans strep-
tococci counts in orthodontic patients. Am J Orthod Dentofacial
Orthop 2008; 133: 435-9.
Tufekci E, Casagrande ZA, Lindauer SJ, Fowler CE, Williams KT.
Effectiveness of an essential oil mouth rinse in improving oral
health in orthodontic patients. Angle Orthod 2008; 78: 294-8.
Marchisio O, Esposito MR, Genovesi A. Salivary pH level and
bacterial plaque evaluation in orthodontic patients treated with Re-
caldent products. Int J Dent Hyg 2010; 8: 232-6.
Cildir SK, Germec D, Sandalli N, et al. Reduction of salivary mu-
tans streptococci in orthodontic patients during daily consumption
of yoghurt containing probiotic bacteria. Eur J Orthod 2009; 31:
van der Veen MH, Attin R, Schwestka-Polly R, Wiechmann D.
Caries outcomes after orthodontic treatment with fixed appliances:
do lingual brackets make a difference? Eur J Oral Sci 2010; 118:
Marsh PD. Microbiology of dental plaque biofilms and their role in
oral health and caries. Dent Clin North Am 2010; 54: 441-54.
ten Cate JM. Fluorides in caries prevention and control: empiricism
or science. Caries Res 2004; 38: 254-7.
Marquis RE. Antimicrobial actions of fluoride for oral bacteria.
Can J Microbiol 1995; 41: 955-64.
Reynolds EC. Casein phosphopeptide-amorphous calcium phos-
phate: the scientific evidence. Adv Dent Res 2009; 21: 25-9.
Twetman S, Stecksén-Blicks C. Probiotics and oral health effects in
children. Int J Paediatr Dent 2008; 18: 3-10.
Received: May 26, 2011 Revised: July 10, 2011 Accepted: July 12, 2011
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