Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Book Review
Case Report
Case Series
Clinical Article
Clinical Innovation
Clinical Pearl
Clinical Pearls
Clinical Showcase
Clinical Technique
Critical Review
Expert Corner
Experts Corner
Featured Case Report
Guest Editorial
Original Article
Original Research
Review Article
Special Article
Special Feature
Systematic Review
The Experts Corner
View/Download PDF

Translate this page into:

4 (
); 148-150

Spot on orthodontics! Pun intended: The impact of white spot lesions on 21st century orthodontics

Department of Orthodontics, YMT Dental College and Hospital, Mumbai, Maharashtra, India
Address for correspondence: Prof. Nikhilesh R. Vaid, Department of Orthodontics, YMT Dental College and Hospital, Mumbai, Maharashtra, India. E-mail:
This article was originally published by Wolters Kluwer and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.

How to cite this article: Vaid NR, Chandani S, Mihir M, Meghna V. Spot on orthodontics! Pun intended: The impact of white spot lesions on 21st century orthodontics. APOS Trends Orthod 2014;4:148-50.

Enamel decalcification or white spot lesion (WSL) development of the enamel surface is the most important iatrogenic effect of fixed orthodontic appliance therapy.[1] Individuals with malocclusions often have many plaque retention sites due to tooth malpositions. A cause-effect relationship and incidence statistics of WSLs in such individuals sometimes question the very logic of multibanded/bonded fixed appliance therapy. Orthodontic treatment with multibanded appliance imposes a significant risk for development of WSL. Bands and brackets increase the retention of plaque and food on smooth tooth surfaces that encourage the formation of WSLs. Despite intensive efforts to educate patients about effective oral hygiene procedures, enamel demineralization associated with fixed orthodontic appliances remains a significant clinical problem.[2,3] Formation of these spots after the completion of orthodontic treatment can lead to patient dissatisfaction and legal complications.[4] From a holistic care perspective, formation of WSLs is discouraging to a specialty whose goal is to improve aesthetics. The need of the hour is to be proactive and take active responsibility toward prevention of WSLs by educating patients about the importance of maintaining an excellent dietary compliance and oral hygiene regime.


The term WSL was defined as “the first sign of a caries lesion on enamel that can be detected with the naked eye.”[5]

The WSL has also been defined as a “subsurface enamel porosity from carious demineralization’ that presents itself as “a milky white opacity when located on smooth surfaces.”[6]


Literature reports in this regard irrespective of differences in methodology of data collection are alarming! Orthodontic patients have significantly more WSLs than nonorthodontic patients, and these WSLs may present esthetic problems years after treatment.[3,7] A recent review of literature[8] showed variations ranging from 2% to 97%, for WSL prevalence associated with orthodontic treatment.[3,7,9-13] This high prevalence is attributed to the difficulties in performing oral hygiene procedures on bonded dental arches along with a long-time accumulation and easier retention of bacterial plaque on tooth surfaces around fixed orthodontic appliances.

Depending on the examination technique used, the prevalence of WSLs varies. Gorelick et al.,[10] in their study using the visual examination technique, reported that 50% of patients had one or more WSLs at the end of treatment. Boersma et al.,[8] using quantitative light fluoroscopy, investigated the prevalence of WSLs at the end of orthodontic treatment and reported that 97% of subjects had one or more lesions.

In the literature, conflicting reports have described the distribution of WSLs. Gorelick et al.[10] reported that the tooth most commonly affected was the maxillary lateral incisor. On the other hand, Mizrahi[14] concluded that the maxillary and mandibular first molars were the teeth most commonly affected. In a later study, Ogaard[7] agreed with Mizrahi’s conclusions. In contrast, Geiger et al.[11] reported that lesions occurred most frequently on maxillary lateral incisors and canines. Tufekci et al.,[15] however, found no significant differences among teeth in the distribution of WSLs at 6-month, at 12-month, or on the day of bonding (control).

A more recent study by Boersma[8] found that 40% of the buccal surfaces in males had demineralization compared with 22% in females. One possible explanation for these results is that females are generally more compliant orthodontic patients.


Fixed appliances serve as plaque retention sites and in the absence of good oral hygiene, plaque accumulates and acidogenic bacteria cause marked demineralization. Detecting WSLs during active treatment can be challenging for the clinician. The clinical crown must be free from plaque and debris, and the presence of excess gingival tissue can make visualization of WSLs difficult. A thorough examination of each patient should be done at each appointment, and each patient should receive a customized oral hygiene treatment regimen to halt the progression of any demineralization.

The high prevalence of WSLs at 6-month into active orthodontic treatment suggests that demineralization can quickly become a concern in the presence of fixed appliances when oral hygiene is poor. According to Ogaard et al.,[2] these lesions can become noticeable around the brackets within 1-month of bonding. So even patients who otherwise practice good oral hygiene, cannot afford to slacken up between any consecutive appointments. It’s critical that orthodontists reiterate this fact to their patients regularly. It’s also important for the clinician to recognize inadequate oral hygiene early, so that preventive measures can be implemented before the development of WSLs. Length of treatment is also directly proportional to the causation of the Lesions. The prevalence of WSLs was 38% in a 6-month group, whereas it was 46% in a12-month group as reported by Tüfekçi et al.[15]


White spot lesions are generally considered to be the precursors of frank enamel carious lesions. It is, therefore, necessary to universally promote the need to maintain a high standard of oral hygiene and to reduce daily exposure to refined carbohydrates throughout the treatment period. In addition, the continuous presence of fluoride in both saliva and plaque, even in low concentrations, is necessary for maximum caries inhibition. This would, at first, involve daily exposure to fluoridated water[16,17] (where available) and the use of a fluoride-containing toothpaste.[18] The need to prescribe an additional topical fluoride will be dependent upon the needs of the individual patient and clinical judgment. The performance of currently available fluoride releasing bonding cements[19-22] and elastomeric modules and chains[23,24] makes their use both difficult and impractical. Studies of the effects of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) have so far shown promising dose-related increases in enamel remineralization within already demineralized enamel lesions.[25-27] The ability of CPP-ACP to prevent WSL formation has not, as yet, been proven. A Recent introduction of a novel technology based on Arginine and an insoluble calcium compound with fluoride in toothpaste does show promise for prevention and early intervention of WSLs.[28,29]


If WSLs occur during treatment, it is advisable first to allow the teeth to remineralize naturally. Nearly half of the original lesions would have remineralized after 6-month with no specific additional treatment. Fluoride must not be used in high concentrations because it can arrest remineralization and lead to staining. Low concentrations of fluoride might assist remineralization

If the lesions persist, professional bleaching of the teeth to diminish the contrast between the WSL and the rest of the enamel surface should be considered. Bleaching therapy can camouflage WSLs after removal of orthodontic brackets.[30] If bleaching therapy is used to mask decalcified areas, it must be considered that the microhardness of sound enamel surfaces and demineralized enamel surfaces after bleaching might be reduced.

For severe cases, acid micro abrasion is recommended when the esthetic results after external bleaching therapy are not satisfactory.[31] Finally, aggressive restorative treatment such as a direct or an indirect veneer can be considered if the patient still sees the need for further esthetic improvement when WSLs cannot be totally removed.


Debonds are the most exciting time for Orthodontic Patients, Parents, Orthodontists, and Staff. White Spots do detract from the quality of results and bring about disappointments for all of the above and the referring dental professional. Patients are increasingly getting aware of this menace associated with orthodontic therapy and Definitive protocols for their prevention and management are the need of the hour.[32] Appliances that do not affect the labial surfaces, accelerated orthodontics, targeted mechanics are all possible preventive modalities; but none can replace motivational techniques and due diligence during therapy. From a professional excellence standpoint, to motivate orthodontists to pay attention toward the prevention of WSLs, the degree and occurrence of WSLs need to be quantified and evaluated in pre and postorthodontic records, with their absence, also being a criterion for scoring during evaluation of cases for Examinations and Peer Review Boards.

A concerted effort to focus on the Evaluation, Quantification, Prevention, Identification of Risk Groups and Protocols for treating WSLs is imperative for preventing this “spot on” Orthodontic Care, and also for Orthodontics to be “Spot on”!

Nikhilesh R. Vaid, Shah Chandani, Mehra Mihir, Vandekar Meghna

Department of Orthodontics, YMT Dental College and Hospital, Mumbai, Maharashtra, India

Address for correspondence: Prof. Nikhilesh R. Vaid, Department of Orthodontics, YMT Dental College and Hospital, Mumbai, Maharashtra, India. E-mail:

Source of Support:


Conflict of Interest:

None declared.


  1. , . Demineralization and remineralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofacial Orthop. 1987;92:33-40.
    [Google Scholar]
  2. , , . Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop. 1988;94:68-73.
    [Google Scholar]
  3. . A posttreatment evaluation of direct bonding in orthodontics. Am J Orthod. 1977;71:173-89.
    [Google Scholar]
  4. . Legal aspects of orthodontic practice: Risk management concepts. Oral hygiene assessment: Plaque accumulation, gingival inflammation, decalcification, and caries. Am J Orthod Dentofacial Orthop. 1991;100:93-4.
    [Google Scholar]
  5. , , . Clinical and histological manifestations of dental caries In: , , eds. Dental Caries: The Disease and its Clinical Management. Copenhagen, Den-Mark: Blackwell Munksgaard; . p. 71-99.
    [Google Scholar]
  6. , , . Fundamentals of Operative Dentistry: A Contemporary Approach (3rd ed). Hanover Park, IL: Quintessence Publishing; . p. 2-4.
  7. . Prevalence of white spot lesions in 19-year-olds: A study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop. 1989;96:423-7.
    [Google Scholar]
  8. , , , , . Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: Influencing factors. Caries Res. 2005;39:41-7.
    [Google Scholar]
  9. . Decalcification during orthodontic treatment with fixed appliances — An overview. Br J Orthod. 1992;19:199-205.
    [Google Scholar]
  10. , , . Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81:93-8.
    [Google Scholar]
  11. , , , . The effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod Dentofacial Orthop. 1988;93:29-37.
    [Google Scholar]
  12. , , , . Fluoride-releasing elastomerics — A prospective controlled clinical trial. Eur J Orthod. 2000;22:401-7.
    [Google Scholar]
  13. , . Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod. 1986;8:229-34.
    [Google Scholar]
  14. . Surface distribution of enamel opacities following orthodontic treatment. Am J Orthod. 1983;84:323-31.
    [Google Scholar]
  15. , , , . Prevalence of white spot lesions during orthodontic treatment with fixed appliances. Angle Orthod. 2011;81:206-10.
    [Google Scholar]
  16. . Efficiency of fluoride programs in the light of reduced caries levels in young populations. Acta Odontol Scand. 1999;57:348-51.
    [Google Scholar]
  17. . Prevention and reversal of dental caries: Role of low level fluoride. Community Dent Oral Epidemiol. 1999;27:31-40.
    [Google Scholar]
  18. , , . Combined effects of a fluoride dentifrice and mouthrinse on the incidence of dental caries. Community Dent Oral Epidemiol. 1983;11:7-11.
    [Google Scholar]
  19. , . Bond strength of various fluoride-releasing orthodontic bonding systems. Experimental study. J Orofac Orthop. 2000;61:191-8.
    [Google Scholar]
  20. , . In vivo inhibition of demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop. 2003;123:10-4.
    [Google Scholar]
  21. , , , . Fluoride release from new light-cured orthodontic bonding agents. Am J Orthod Dentofacial Orthop. 2001;120:392-7.
    [Google Scholar]
  22. , , , , . Effect of fluoride exposure on cariostatic potential of orthodontic bonding agents: An in vitro evaluation. J Orthod. 2003;30:323-9.
    [Google Scholar]
  23. , , . Characteristics of a fluoride-releasing elastomeric chain. Angle Orthod. 1994;64:199-209.
    [Google Scholar]
  24. . Determination of fluoride from fluoride-releasing elastomeric ligature ties. Am J Orthod Dentofacial Orthop. 1996;110:383-7.
    [Google Scholar]
  25. . Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res. 1997;76:1587-95.
    [Google Scholar]
  26. , , , , . Remineralization of enamel subsurface lesions by sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. J Dent Res. 2001;80:2066-70.
    [Google Scholar]
  27. , , , . Retention in plaque and remineralization of enamel lesions by various forms of calcium in a mouthrinse or sugar-free chewing gum. J Dent Res. 2003;82:206-11.
    [Google Scholar]
  28. . Dental caries: A disease which remains a public health concern in the 21st century: The exploration of a breakthrough technology for caries prevention. J Clin Dent. 2013;24(A):A1-14.
    [Google Scholar]
  29. , , , , , , et al. Two-year caries clinical study of the efficacy of novel dentifrices containing 1.5% arginine, an insoluble calcium compound and 1,450 ppm fluoride. Caries Res. 2013;47:582-90.
    [Google Scholar]
  30. , , , . External bleaching effect on the color and luminosity of inactive white-spot lesions after fixed orthodontic appliances. Angle Orthod. 2007;77:646-52.
    [Google Scholar]
  31. . White spot lesions after orthodontic treatment. Semin Orthod. 2008;14:209-19.
    [Google Scholar]
  32. , , , , , . Development of white spot lesions during orthodontic treatment: Perception of parents, parents, orthodontists and general dentists. Am J Orthod Dentofacial Orthop. 2012;141:337-44.
    [Google Scholar]
Show Sections