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: Background/Objectives:White spot lesions (WSLs) are unwelcome side effects of fixed appliances that compromise the treatment outcome. Recently, infiltration of WSLs has been introduced as a viable treatment alternative. The objective was to evaluate the colour improvement of WSLs and their stability against discolouration following infiltration, fluoride, or micro-abrasion treatments in vitro.Materials/Methods:Artificial WSLs were created in bovine enamel (N = 96) using acidic buffer solution (pH 5, 10 days) and were randomly allocated to four groups. Specimens were treated with infiltration (Icon, DMG), fluoride (Elmex Caries Protection, GABA), and micro-abrasion (Opalustre, Ultradent) or remained untreated (control). Groups were discoloured for 24 hours in tea or tea + citric acid. Colour components and visible colour change (L*, a*, b*, ΔE) were measured spectrophotometrically on following time points: baseline, after WSL formation, after treatment, and during discolouration (8, 16, and 24 hours). Data were analysed using Kruskal-Wallis and Mann-Whitney tests.Results:WSL formation increased (L*) in all groups. Only infiltration reduced this effect to baseline. Highest ΔE improvement was obtained by infiltration and micro-abrasion followed by fluoride. This improvement was stable only for infiltration during discolouration. L*, a*, and b* changed significantly during discolouration in all groups except infiltration. Within the same treatment group, discolouration solutions did not differ significantly.Limitations: In vitro testing cannot replicate the actual mode of colour improvement or stability but can be used for ranking materials and techniques.Conclusions/Implications:Infiltration and micro-abrasion treatments were capable of diminishing the whitish appearance of WSLs. Only infiltrated WSLs were stable following discolouration challenge.The European Journal of Orthodontics 01/2014; · 1.08 Impact Factor
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ABSTRACT: Abstract Objective. This study investigated the efficacy of ozone on microflora of patients with fixed orthodontic appliances. Materials and methods. Ten subjects undergoing fixed appliance therapy were enrolled in the study. Before any application, two elastic ligatures were removed with the aid of a sterile probe from the premolar brackets on the upper right and lower left jaws for baseline bacteriological counts. Then ozone gas was applied for 180 s by running the device on prophylaxis mode with included mouth tray according to the manufacturer's recommendations on all brackets. After the ozone application, two other elastic ligatures were removed from the opposite sides of the mouth of the patients. One week after the application two more elastic samples, which were not changed in the previous session, were collected from the upper right and lower left premolar brackets. The elastic ligatures were immersed in transfer solutions and cultured to determine the Streptococcus mutans and Lactobacillus acidophilus. Statistical analysis of the data was obtained by paired Student's t-tests. Results. The ozone treatment reduced the S. mutans and L. acidophilus immediately after the application and these reductions were found to be statistically significant (p = 0.038 and p = 0.020). Both the S. mutans and L. acidophilus values increased by the 1-week period and the S. mutans values were significantly higher than the baseline values (p = 0.01). Conclusion. It can be concluded that the ozone treatment may have an instantaneous lethal effect on S. mutans and L. acidophilus; however, within the limitations of this study, a long-term preventive effect could not be observed.Acta odontologica Scandinavica 04/2013; · 1.41 Impact Factor
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ABSTRACT: Abstract Objective. To test the stability of two conventional adhesives when combined with a low-viscosity caries infiltrant used for sealing sound enamel against toothbrush abrasion and acid challenge in vitro. Materials and methods. Bovine enamel discs (Ø = 3 mm) randomly assigned to three groups (n = 10/group) were etched with 37% phosphoric acid for 30 s and treated with resins of different monomer contents forming three test groups: (1) Untreated specimens (Control); (2) Infiltrant (Icon, DMG) + conventional enamel bonding adhesive (Heliobond, Ivoclar Vivadent); and (3) Infiltrant + conventional orthodontic adhesive (Transbond XT Primer, 3M Unitek). All specimens were immersed in hydrochloric acid (pH 2.6) for up to 9 days, during which they were exposed to 1825 toothbrush-strokes per day. Calcium dissolution was assessed using Arsenazo III method at 24-h intervals. Data were analyzed by Kruskal-Wallis and Wilcoxon signed ranks tests. Results. Cumulative calcium dissolution for the untreated specimens (39.75 ± 7.32 μmol/ml) exceeded the sealed groups (Icon + Heliobond: 23.44 ± 7.03 μmol/ml; Icon + Transbond XT Primer: 22.17 ± 5.34 μmol/ml). Untreated specimens presented a relatively constant calcium dissolution rate throughout the experimental period, whereas the sealed groups presented a gradual increase indicating weakening of the seal by toothbrush abrasion. Both sealed groups presented significantly lower daily calcium dissolution at all time points compared to the control, except for Group 2 on the last measurement day. Conclusions. Low-viscosity caries infiltrant application on sound enamel prior to conventional resin application provided a protective effect against enamel demineralization, but this effect was not stable when challenged mechanically by toothbrush abrasion.Acta odontologica Scandinavica. 05/2014;
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: email@example.com
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.
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Received: May 26, 2011 Revised: July 10, 2011 Accepted: July 12, 2011
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