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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 172-180

White spot lesions in orthodontic patients: An expert opinion


1 Smile Care, Mumbai, Maharashtra, India
2 Smiles n Faces Orthodontic and Face Clinic, Mumbai, Maharashtra, India
3 Department of Orthodontics and Dentofacial Orthopedics, Sri Balaji Dental College, Hyderabad, Telangana, India
4 Orthodontic Clinic, Pune, Maharashtra, India
5 Gupta Dental Centre, Delhi, India

Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. Ashok Karad
Smile Care-India, I/C 3-3, 2, Sujata Niwas, S. V. Road, Bandra (W), Mumbai 400050, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_129_19

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  Abstract 

Formation of white spot lesions (WSLs) has remained a common occurrence during fixed orthodontic treatments, particularly in patients with poor oral hygiene. Such lesions, if not addressed, may progress to caries, thereby leading to poor aesthetics and patient dissatisfaction. Given the complexities and the alarming rise in the prevalence of WSLs in orthodontic patients, there is a need to develop a set of recommendations based on the Indian scenario to address unmet patient needs in managing WSLs. This paper is an outcome of expert group discussion convened with the primary objective to discuss the knowledge–practice gaps in the field of orthodontics, to understand the prevailing clinical practice patterns in managing WSLs in Indian settings, and to facilitate information exchange among subject matter experts. In brief, patient education and motivation regarding the importance of maintaining good dietary compliance and excellent oral hygiene are the cornerstones for the prevention and management of WSLs. Moreover, identification and management of various risk factors could prove beneficial. Noninvasive treatment of early or active WSLs by means of remineralizing agents could ensure better prognosis and could help prevent WSL progression.

Keywords: Calcium Sucrose Phosphate, Expert Opinion, Fixed Orthodontic Treatment, Remineralization, Remineralizing Agents, White Spot Lesions


How to cite this article:
Karad A, Dhole P, Juvvadi SR, Joshi S, Gupta A. White spot lesions in orthodontic patients: An expert opinion. J Int Oral Health 2019;11:172-80

How to cite this URL:
Karad A, Dhole P, Juvvadi SR, Joshi S, Gupta A. White spot lesions in orthodontic patients: An expert opinion. J Int Oral Health [serial online] 2019 [cited 2019 Aug 23];11:172-80. Available from: http://www.jioh.org/text.asp?2019/11/4/172/264425


  Introduction Top


The term “white spot lesion” (WSL) can be defined as the earliest evidence of demineralization on smooth enamel surfaces that can be detected with the naked eye. Given that the objective of orthodontic treatment is to improve facial and dental aesthetics, the presence of WSLs at the time of debonding hampers the quality of treatment outcome and serves as a cosmetic challenge and a source of disappointment for the orthodontist as well as the patient. Such lesions are commonly observed during fixed orthodontic treatment despite vast improvements in preventive dental care and procedures.[1],[2],[3],[4]

During orthodontic treatment, challenges in performing oral hygiene procedures on bonded dental arches contribute to prolonged plaque accumulation on tooth surfaces. Moreover, irregular surfaces of brackets, bands, wires, and other attachments limit natural self-cleansing mechanisms. Subsequently, acidic by-products produced by the bacteria in plaque are accountable for decline in pH; this tips the demineralization–remineralization balance toward mineral loss, which, in turn, promotes WSL development and eventually leads to cavitation.[2] There are two initial stages of enamel demineralization. The first stage includes surface softening, characterized by preferential loss of the interprismatic substance, causing pronounced mineral loss at the enamel surface. The second stage involves subsurface lesions marked by dissolution, primarily confined to deeper areas of the enamel; nevertheless, the body of the lesion is still covered by a porous, mineral-rich layer.[2] These so called active lesions display better prognosis than arrested lesions due to the fact that active lesions being porous allow easy infiltration of calcium and phosphate ions into the enamel promoting remineralization. On the contrary, arrested lesions are white and shiny but sometimes have a brown surface indicating outer remineralized layer.[3]

Epidemiological studies have revealed that the overall prevalence rate of WSLs is as high as 50%–96%.[4] These statistics are indeed a cause of concern in the Indian patient population as well, owing to the presence of WSLs in 75.6% of patients undergoing orthodontic treatment.[5] The remarkably high and alarming incidence and prevalence rates of WSLs in patients receiving orthodontic treatment necessitate the attention of both patients as well as dentists in terms of implementing an early preventive regimen. A multifactorial approach is required to manage WSLs by preventing demineralization and biofilm formation, along with the use of methodologies that promote remineralization of lesions.[4]


  Rationale and Methodology Top


Given the complexities and the alarming rise in the prevalence of WSLs in orthodontic patients, there is a need to develop a certain set of recommendations based on the Indian scenario to address the unmet patient needs in managing WSL. An expert meeting was convened in April 2018, with the primary objective to discuss the knowledge–practice gaps in the field of orthodontics, to understand the prevailing clinical practice patterns in managing WSLs in Indian settings, and to facilitate information exchange among subject matter experts. The meeting also aimed at discussing measures to improve treatment outcomes including prevention or management of WSLs using various remineralizing agents with a special focus on calcium sucrose phosphate (CaSP). The panel comprised five practicing orthodontists having more than 20 years of experience in the field of orthodontics, which led to the conception of this article. On the basis of experts’ discussion and literature review, the article was formulated. Experts reviewed the content and shared their comments or suggestions and the draft was revised accordingly. [Table 1] summarizes literature search strategy used in this article.
Table 1: Literature search strategy

Click here to view



  Epidemiological Data on White Spot Lesions Top


Literature evidence

Epidemiological data suggest that the incidence rate of WSLs developed during orthodontic treatment was 45.8% and the prevalence rate was 50%–96% in patients undergoing orthodontic treatment, indicating that incidence and prevalence rates of WSLs are quite alarming in orthodontic patients and thus warrant timely intervention.[2]

WSLs are known to develop within four weeks after initiating treatment in the presence of poor oral hygiene, but progression to carious lesions usually occurs in approximately six months.[4],[5] Evidence suggests that decalcifications are found in 30%‒70% of patients undergoing orthodontic treatment compared with 15.5%‒40% of patients before treatment.[4]

Reportedly, adolescents are more likely to develop WSLs compared with adults. As age increases, WSL development was found to decrease by 0.59 lesions per age group with increase in age. Moreover, WSLs more commonly affect male patients, which may be attributed to better oral hygiene standards maintained by female patients.[2],[4] Commonly affected sites are gingival margins of teeth on the buccal surface, with the labiogingival region of lateral incisors being the most common one and maxillary posterior segments being the least common site for WSL development.[4],[5]

Taking zonal variations into account, studies have revealed higher prevalence of dental caries in certain north Indian states such as Punjab, Chandigarh, and Himachal Pradesh compared with average caries experienced across the country.[6] High incidence of caries in these states might correspond to higher incidence of WSLs as well.[2],[3]

Moreover, studies have attested the impact of treatment duration on the formation of WSLs and deduced that with increase in treatment duration from 24 to 36 months, the likelihood of WSL formation simultaneously increases by 3.65 times;[7] which could be due to increased exposure of teeth to cariogenic challenges accounting to increased plaque accumulation.[2]

Expert opinion

Experts in the field opined that the frequency of WSLs usually increases following orthodontic treatment, possibly because of increased area for plaque accumulation and compromised oral hygiene measures. According to certain clinicians, approximately 10%–15% of patients have WSLs before initiating orthodontic treatment, whereas others have reported this frequency to be as high as 40%–50%. In routine clinical practice, some experts observed that as treatment progresses, the incidence of WSLs further increases to almost twice as that before treatment. In fact, the reported prevalence can vary owing to numerous factors, for example, in an exclusive orthodontic practice, the presence of WSLs usually goes unnoticed as the focus of orthodontist is to correct the malocclusion or the relation between the two arches, whereas in a multispecialty or referral practice, such lesions are noticed more often. Moreover, experts believed that the prevalence of WSLs may vary depending on the diagnostic measures used and it could be higher when appropriate screening techniques for WSLs are used. The experts also considered a definite possibility of zonal variations in the prevalence of WSLs.

Furthermore, according to experts, neglecting oral hygiene in orthodontic patients is the primary reason for increasing prevalence of WSLs. Prevention begins by educating and motivating patients for compliance and maintaining good oral hygiene because effective oral hygiene is the primary prophylactic measure to prevent WSLs in orthodontic patients each follow-up visit. In particular, the importance of oral hygiene should be emphasized at every follow-up visit in orthodontic patients because plaque retention occurs primarily around malaligned teeth and orthodontic appliances.


  Risk Factors Contributing to Development of White Spot Lesions Top


Literature evidence

Numerous factors contribute to WSL formation on the enamel surface during fixed orthodontic treatment. Coexistence of the four factors, namely bacterial plaque, fermentable carbohydrates, a susceptible tooth surface, and a sufficient time are indispensable for the development of WSLs.[1] Poor oral hygiene is one of the most significant contributing factors in WSL formation. A study established a positive correlation between oral hygiene status of an individual and the corresponding incidence of WSLs. In patients with good oral hygiene, treatment-related WSLs were observed in only 17% of patients compared with those in 24% of patients who had fair and 38% of patients who showed poor initial oral hygiene.[8]

Moreover, salivary factors such as salivary flow and composition have an impact on the incidence of WSLs because saliva has natural remineralization potential.[9] WSLs are more common in the upper anterior teeth, probably owing to decreased salivary flow in this region of the oral cavity.[2] On the contrary, xerostomia induced by several antihypertensive drugs suppresses the salivary secretion and makes teeth more susceptible to WSLs.[10] Systemic factors such as vitamin D3 deficiency may also be linked to WSL development. [Figure 1] summarizes factors that increase the risk of WSL development.
Figure 1: Factors affecting development of white spot lesions (adapted from References[3],[4],[8],[11],[12])

Click here to view


Expert opinion

Experts unanimously agreed on certain risk factors that contribute to the development of WSLs in orthodontic patients. Poor oral hygiene is the most significant risk factor that increases plaque accumulation on teeth and orthodontic appliances, which subsequently increases acid production by bacteria, which, in turn, causes rapid demineralization of the enamel surface.

Lack of awareness regarding consequences of poor oral hygiene among younger patients may also be responsible for the increased risk of WSLs in this population. To reinforce good oral hygiene practices, such patients must be educated regarding regular follow-ups, use of plaque disclosing agents to reveal plaque present on tooth surfaces, and sequelae of plaque accumulation.

Patients should also be screened for other risk factors such as reduced salivary flow and use of drugs that decrease salivary flow, and vitamin D3 deficiency, if present, such factors must be adequately managed.


  Effects of Multibracket Appliances Top


Literature evidence

Taking into account the type of bracket or braces used, certain studies have revealed that self-ligating brackets have fewer bacteria in plaque compared with elastomeric ligated brackets.[8] On the contrary, other studies have reported no differences in terms of WSL formation between conventional straight wire and self-ligating brackets; according to these studies, WSL formation essentially depends on patients’ oral hygiene status and not on the type of bracket or ligation used.[1],[8] Contradictory to previous reports of enamel decalcification after conventional labial multibracket treatment, a study showed that the incidence of WSL was distinctly reduced with lingual appliances.[13] Additional large-scale studies are required to arrive at a definite conclusion.

Reports regarding incidence of WSL with clear-aligner therapy are scarce. A study conducted in 25 orthodontic patients treated with clear-aligner therapy protocol revealed that the overall incidence of new WSLs was 2.85%, and 28% of patients were affected by at least one new WSL. The study concluded that orthodontic treatment with clear-aligner therapy was associated with a low incidence of newly developed WSLs.[14]

Expert opinion

The demand for aesthetic dentistry has encouraged the use of ceramic brackets and lingual brackets; however, in India, use of clear aligners is still at a very nascent stage. According to experts’ opinion, lingual braces are associated with the least incidence of WSLs. Self-ligating brackets have minimal plaque retention corresponding to minimal incidence of WSLs, whereas metal brackets, which are most commonly used in clinical practice, are associated with a higher incidence of WSLs. There was an opinion that substandard brackets, with inferior finish and inferior quality of metal, could be associated with higher WSL formation because they are likely to attract more plaque. Experts unanimously agreed that remineralizing agents might have a better role to play in patients with aligners versus multibracket appliances owing to the reduced self-cleansing action of saliva in aligners. However, if oral hygiene is adequately maintained, which is possible in case of aligners, WSL formation can be reduced.


  Prevention Strategies for White Spot Lesions Top


Literature evidence

Early prevention of WSLs is one of the objectives of modern orthodontic treatment owing to challenges associated with treating patients once WSLs start progressing. Complete resolution of lesions may not be achieved, and this eventually influences aesthetics as well as treatment satisfaction. Overall management of WSLs involves both preventing demineralization and encouraging remineralization of existing lesions. Successful preventive strategies incorporate patient education, patient compliance, oral health promotion, and regular professional oral hygiene visits.[2]

Patient education using various motivational techniques has shown to effectively promote oral hygiene during orthodontic treatment with fixed appliances.[15],[16] Moreover, in a survey conducted among patients, parents, and clinicians, patients regarded themselves responsible for prevention of WSLs, making patient education a priority.[17] Cariogenic diet (e.g., sticky foods and overconsumption of carbohydrate-rich foods) and excessive intake of acidic beverages increase the probability of demineralization.[18] Fluoride treatment during orthodontic procedures has proven beneficial in reducing the incidence of WSLs.[19],[20] In addition, interdental cleaning with flossing, interdental brushing, tooth cleaning sticks and stimulators, or oral irrigators is effective in prevention and control of dental plaque and dental caries and also helps disrupt microbial biofilm formation.[20],[21],[22] Oral prophylaxis (scaling) should be performed as required, and oral hygiene instructions should be reinforced in noncompliant patients at every visit. An evidence-based protocol for the prevention of dental caries among high-risk children and adolescents recommends topical fluoride in the form of varnishes at 6-month intervals in noncompliant/high-risk patients.[23] Moreover, as active lesions are more amenable to remineralization, remineralizing agents such as CaSP, which is commonly known as “anticay,” has shown to inhibit demineralization and promote remineralization.

Expert opinion

Experts opined that prevention begins by educating and motivating patients to maintain adequate oral hygiene and compliance because effective oral hygiene is the foundation of prophylactic measures in patients with fixed orthodontic appliances. Avoidance of cariogenic diet and excessive intake of acidic beverages is another important measure. Moreover, mechanical plaque control through appropriate toothbrushing at least twice daily, and additionally after every meal, with a fluoride-containing toothpaste and fluoride mouthwash is strongly recommended. Furthermore, patients should be motivated for maintaining oral hygiene during recall visits, and if required, be provided professional prophylaxis with written instructions.


  Treatment of White Spot Lesions: Management Approach Top


Literature evidence

Essential strategies to manage WSLs include preventing demineralization and biofilm formation and enhancing remineralization by using remineralizing agents and various procedures such as microabrasion, erosion-infiltration, adhesive composite resin restorations, and bonded facets.[4] The goal of modern dentistry is to manage non-cavitated carious lesions noninvasively through remineralization by using various available remineralizing agents depending on the severity of a lesion.[24],[25] Studies have shown the effectiveness of several remineralizing agents in the regression of WSLs.[26],[27],[28],[29]

Most commonly used remineralizing agents are the following:

  • CaSP


  • Fluorides: various forms of topical fluoride (toothpaste, mouth rinse, gels, varnishes, fluoride-releasing cements, and fluoride-releasing elastomers)


  • Casein phosphopeptide–amorphous calcium phosphate (CPP-ACP)


  • Casein phosphopeptide–amorphous calcium fluoride phosphate (CPP-ACFP)


  • Bioactive glass


  • Functionalized tricalcium phosphate (fTCP)


  • Xylitol[23]


  • A couple of systematic review and meta-analyses have evaluated remineralization potential of various remineralizing agents. In a meta-analysis of 20 randomized trials that included a total of 942 patients, remineralizing effect of adjunct treatment with CPP-ACP creams, external tooth bleaching, low- or high-concentration fluoride gels, films, varnishes, mouth rinses, miswak chewing sticks, resin infiltration, and bioactive glass toothpaste was compared to no adjunct treatment (i.e., conventional oral hygiene). The study showed that the monthly use of fluoride varnish reduces the WSL area (mean difference in the reduction: −0.80mm2, 95% confidence interval [CI]: −1.10, −0.50mm2; P < 0.05) and improves enamel fluorescence (mean difference in the reduction: –0.92%, 95% CI = –1.32, –0.52; P < 0.05).[27] Similarly, Sonesson et al.[28] have shown favorable results with sodium fluoride varnish. On the contrary, another systematic review has remained inconclusive for most suitable therapy for WSLs.[29]

    Expert opinion

    Therapeutic intervention of WSLs requires a multifactorial approach. Education and motivation of patients and reinforcement of oral hygiene maintenance at every visit to prevent formation and progression of WSLs are paramount. Natural remineralization of WSLs may also occur through saliva during the initial 3–4 months in certain cases. Experts opined that the commonly used fluoride mouthwashes help in the prevention of WSLs owing to their cariostatic properties, but fluoride does not have a definitive role in the management of WSLs. Hence, to prevent disease progression and to improve aesthetics, strength, and function, fluoride application should be performed at the time of treatment and after debonding. Moreover, patients should be advised to use fluoride mouth rinses from the beginning of treatment. Furthermore, remineralizing agents should be started twice daily from treatment initiation and should be continued after treatment for at least two months. [Figure 2] shows proposed steps for the overall management of patients with WSLs.
    Figure 2: Steps for management of white spot lesions in orthodontic patients

    Click here to view



      Calcium Sucrose Phosphate in Managing White Spot Lesions Top


    A calcium sucrose phosphate-calcium orthophosphate complex is commonly known as “anticay.” It provides freely available calcium and phosphate ions at concentrations significantly higher than those normally present in the saliva at pH values found in the oral cavity.[30]

    Mechanism of action

    CaSP acts as a cariostatic agent through different mechanisms and prevents development of WSLs:

  • CaSP reduces the rate of demineralization of enamel and calcium and phosphate ions that are released into the saliva, increase the rate of remineralization owing to the common ion effect


  • Moreover, sucrose phosphate ions adsorb onto the enamel surface and further reduce the rate of acid dissolution, thereby inhibiting demineralization


  • Furthermore, it actively neutralizes plaque acids[31],[32]


  • It has complementary mechanism of action to that of fluoride. The solubility of enamel in acids is reduced due to the formation of fluorapatite, which is aided by the release of high concentration of calcium and phosphate ions from CaSP


  • Literature evidence

    A summary of in vitro evidence of CaSP is as presented in [Table 2]. In brief, numerous studies have been conducted to evaluate the remineralization potential of CaSP. Den Besten and Giambro[34] conducted a scanning electron microscope (SEM) study to confirm the efficacy of CaSP. Enamel surfaces of teeth were treated with 5.25% sodium hypochlorite, followed by a CaSP paste. SEM imaging of CaSP-treated enamel surfaces showed that porous enamel surfaces were filled with the CaSP treatment. In addition, CaSP application was shown to restore the color of WSLs to that of normal enamel based on the L* values of fluorotic enamel (L* value is an indicator for the color gradient from white to black).[34]
    Table 2: A summary of in vitro evidence on efficacy of calcium sucrose phosphate

    Click here to view


    Kaur et al.[38] further confirmed the promising prospects of CaSP in improving microhardness. According to this study, both CaSP and CPP-ACP increased the microhardness of bleached enamel; however, CaSP tooth cream was a better agent for increasing microhardness.[38] Rani et al.[42] also showed that mean surface microhardness recovery with CaSP was remarkably higher compared to that with CPP-ACP; thus, the CaSP paste showed a better efficacy profile in remineralizing early enamel lesions.

    Similarly, Sargod et al.[40] reported that twice-daily application of a CaSP toothpaste significantly reduced the depth of enamel lesions produced by subsequent acidic challenges. Enhanced surface smoothness of the enamel was also observed following two weeks of brushing with a CaSP tooth cream.[31] The efficacy of CaSP was further confirmed by George et al.[37] and Gade,[35] who reported significantly increased enamel microhardness in samples treated with CaSP. Compared to other agents, CaSP-containing dentifrices showed higher microhardness values compared with CPP-ACP and calcium sodium phosphosilicate (CSPS).[44]

    On account of its remineralization potential, CaSP application led to greater remineralization compared with CPP-ACPF (amorphous calcium phosphate with fluoride).[39] In another study, enamel surfaces treated with a CaSP paste showed the least lesion depths, followed by enamel surfaces treated with NovaMin (CSPS) toothpaste.[33] Taking this notion a step further, an in vitro study was conducted to assess remineralization and bond strengths of remineralizing agents with or without laser. Results revealed that the bond strength of CaSP cream with laser treatment was higher compared with that of CPP-ACP paste with and without laser.[41]

    Another study evaluated remineralization efficacy of stannous fluoride (SnF2), CPP-ACPF, and CaSP. Although all remineralizing agents showed improved surface remineralization, CaSP showed greater potential for remineralization compared to CPP-ACPF.[36]

    Expert opinion

    According to experts, CaSP has been found to be an effective remineralizing agent compared with other agents in a majority of studies; however, these studies were conducted in vitro. Therefore, well-designed clinical studies in orthodontic patients are required to fill the gaps between research and clinical applications of CaSP.


      Conclusion Top


    The occurrence of WSLs around fixed orthodontic appliances is a major challenge for orthodontists given that the goal of treatment is to enhance facial and dental aesthetics. Managing such lesions requires a multifactorial approach, and patient education and motivation on oral hygiene practice are essential components central to prevention and management of WSLs. Composite interpretation of aforementioned data suggests that the burden of WSLs can be reduced through evidence-based use of remineralizing agents such as topical fluorides and other non-fluoride agents such as CaSP. Substantial in vitro evidence supports the remineralization potential of CaSP, and hence, it could be considered as an important component of the therapeutic armamentarium for remineralization during orthodontic treatment.

    Ethical policy and institutional review board statement

    Not applicable

    Acknowledgement

    We would like to thank CBCC Global Research for assisting in manuscript development.

    Financial support and sponsorship

    The expert group discussion was organized in association with Abbott Healthcare Pvt. Ltd.

    Conflicts of interest

    This article is based on the views expressed during the expert group discussion. The views expressed in the discussion are solely of the panel members.

     
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    Abstract
    Introduction
    Rationale and Me...
    Epidemiological ...
    Risk Factors Con...
    Effects of Multi...
    Prevention Strat...
    Treatment of Whi...
    Calcium Sucrose ...
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