White spot lesions (WSLs) are decalcifications of enamel adjacent to orthodontic appliances, prevalent during orthodontic treatment and associated with plaque accumulation and factors such as poor oral hygiene and diet. The document outlines the classification, prevalence, etiology, and prevention strategies for WSLs, emphasizing the importance of maintaining oral hygiene and using fluoride. It also discusses treatment options ranging from natural remineralization to more aggressive interventions like microabrasion or cosmetic restorations for established lesions.

1. White Spot Lesions (WSLs)
Dr.Marwan Mouakeh , Consultant Orthodontist
Academic Adviser & Head of Department ,Al-Hokail Polclinic
Khobar-Saudi Arabia

2. White spot lesions (WSLs)
Definition :
• Decalcification of the enamel surface adjacent to
fixed orthodontic appliances .

3.  White spot lesions ( WSLs )
• A Prevalent iatrogenic effect of orthodontic therapy
• Incipient carious lesions develop around brackets
and bands usually near the gingival margin .

4.  Classifications of White Lesions on Enamel
• Dental Fluorosis
• Opacities
• White Spot Lesions

5. • Dental Fluorosis
 White / yellowish lesion
 Not well defined
 Symmetrical distribution
 Associated with cumulative
fluoride intake during enamel
development .
 Characteristics

6.  Dental Fluorosis
 Mild Fluorosis
 Severe Fluorosis
• Affected teeth are less
susceptible to dental caries .

7. • Enamel opacities (VS , Fluorosis)
 More defined shape.
 Well differentiated from
surrounding enamel.
 Often located in the middle of
the crown.
 Randomly distributed .

8.  Enamel Hypomineralization
 Well demarcated opacities
on the labial surface, due to
injury or infection of the
deciduous teeth, which has
affected mineralization of the
permanent teeth .

9. White spot lesions ( WSLs )
• Subsurface enamel
porosity from carious
demineralization .
• Manifesting as a milky
white opacity on the
enamel.

10.  Initial lesions :
• white decalcification with
beginning enamel breakdown
• affecting the primary teeth , not
associated with orthodontic
treatment .
 Early Childhood Caries
 White spot lesions (WSLs)
to be differentiated from

11. • A small lesion (score 2), severe lesion (score 3), and cavitation
(score 4). No lesion is recorded as score 1.
 Classification of WSLs according to Gorelick and coworkers

12. • Overall prevalence of WSLs related to fixed appliance
treatment ranges widely from 2 % - 96 %
• Significant increase in prevalence with orthodontic
treatment (72 % - 84 %)
 Prevalence of WSLs
• 49.6 % in orthodontic patients
( Ogaard et al AJO-O 1989)
• 24 % in an untreated controls
( Gorelick et al AJO-O 1982)
•Increased with Age and Treatment duration .

13.  Etiopathogenesis of WSLs
• Areas of Demineralized Enamel developed due to
prolonged plaque accumulation .

14.  Factors Necessary for Caries Development

15.  Formation of WSLs
Fixed orthodontic appliance
Rapid increase in dental plaque
Low pH
Increased cariogenic risk of S.mutans
Acid by-products
Additional lowering of pH
Decalcification of enamel

16. Development of WSLs
Plaque accumulation
Low pH adjacent to
orthodontic brackets
Inhibition of remineralization
and consequently decalcification
Streptococcus mutans

17. •Etiopathogenesis of WSLs

18.  Risk Factors
• Inadequate oral hygiene .
• Inappropriate diet (refined sugar, frequent snacks)
• History of recent caries lesions or high DMFS.
• Lack of adjunctive preventive measures ( fluoride or
antibacterial exposure , xylitol , calcium – derived
supplements ) .
• Orthodontic treatment time( fixed appliances) > 36 months

19. Diagnostic Methods

20. External
(outer)
surface
Internal
loss of
minerals
 The WSL’S chalky appearance is an optical phenomenon
caused by mineral loss in the subsurface and the surface
of the enamel

21. • Alteration of the enamel refractive index is the
consequence of both :
- surface roughness & loss of surface shine , plus
- alteration of the internal reflection
•Porous enamel scatters more light than
sound enamel .
• Visual Enamel Opacity ??

22. Wet
Dry
•Porous enamel scatters more
light than sound enamel .

23.  Fluorescence methods
– QLF
– Infra-red Fluorescence
 Transillumination
 Electrical Conductance
– ECM
 Digital Radiography
– DDR
• Diagnostic Methods

24. •Fluorescence Example
White Spot
Reflections obscuring image

25.  Location of WSL
 High prevalence on the cervical and middle thirds of the
crowns :
 1st Molars
 maxillary lateral incisors
 mandibular incisors and canines.
 Mainly on the vestibular surfaces

26. • The highest incidence of WSLs at the labio – gingival area of the
maxillary lateral incisors .
• A strong relationship between resistance to WSL formation and
the rate of salivary flow .
 Location of WSLs

27.  Differential Diagnosis of WSLs
- Carious , vs , Non carious Lesions
 Procedure :
 Clean & dry the teeth
 Carefully evaluate the lesion ( magnification &
lightning )

28.  Differential Diagnosis of WSLs
Carious , vs , Non carious Lesions
 Carious lesions : appear Rough ,Opaque ,and Porous
 Noncarious lesions : Smooth & Shiny appearance

29.  Evolution of WSLs
• WSL left untreated after removal
of a fixed appliance will naturally
reduce in size with no intervention .
• About 75 % of the small lesions
will regress during 6 months after
debonding provided the application
of caries – preventive program .

30. • Remineralization that could occur a few weeks following the
completion of orthodontic treatment ,it is the result of improved
oral hygiene and from the available minerals in saliva, fluoridated
toothpaste ….

31. • Discoloration of white
spot lesions .
• Evolution of WSLs
• Cavitation due to white
spot lesions .

32. Prevention & Treatment of WSLs

33.  Decalcification of enamel
 Prevention
• Oral hygiene
• Dentifrices
• Mouth rinses
• Varnishes

34. • Decalcification of enamel
 Prevention
• Good Oral hygiene
• Mouth rinses

35.  White Spot Lesions…
Can be Remineralized with
• Changes in diet
• Fluoride varnish
• Daily brushing with fluoride toothpaste.

36.  Fluoride
• Inhibits demineralization
• Enhances remineralization
• Inhibits plaque bacteria
• Prevention of WSLs

37. Demineralization <------------ > Remineralization
•Frequent carbohydrate intake
•Frequent exposure to acids
•Plaque presence
•Decreased salivary flow
•Exposure to fluoride
•Removal of plaque
•Balanced diet
•Limited exposure to carbohydrates

38. • Ways to Obtain Fluoride: Topical
 Fluoride Toothpaste
 Fluoride Varnish
 Fluoride Mouthrinses

39. Decalcification of enamel
 Prevention :
 F . Dentifrices
 Sodium Fluoride
Amine Fluoride
Monofluorophosphate
Stannous Fluoride ( +
Plaque inhibiting effect )

40. •Decalcification of enamel
 Prevention :
 F. Dentifrices
• Fluoride concentration ,
0.11% - 0.15% twice daily :
 Reduce demineralization and
 Enhance remineralization

41. • Fluoridated mouth rinses ( Na.F 0.05 %) :
An improved cariostatic effect if combined with Antibacterial
agents :
- Chlorhexidine : inhibits plaque formation
( - ) : Tooth discoloration , metallic taste
- Triclosan ( with Zinc ) : antibacterial + anti- inflammatory
effects .
• Prevention of WSLs

42.  Highly concentrated topical fluoride
treatment (22,600 ppm)
 Can reverse early white spot lesions.
• Temporary discoloration of teeth
and gingival tissue
• Decrease enamel decalcification
44.3 %
• Varnishes
• Prevention of WSLs

43. Fluoridated Sealants , Primers and Adhesives
• G.I Cements: Sustained F. Release in plaque around
brackets .
• Prevention of WSLs

44. Fluoridated Sealants , Primers and Adhesives
• Resin reinforced GIC = Better bond strength
• Prevention of WSLs

45. • Complicated designed appliances make oral hygiene difficult to carry out.
• Prevention of WSLs

46. • Use of S.S ligatures > Elastic modules
• Coil spring traction > Elastic chains …
• Prevention of WSLs

47. • Self-ligating Brackets …..
• Prevention of WSLs

48. • Use of Bondable Buccal Tubes …..
• Prevention of WSLs

49. •Excess bonding material retains plaque.
• Prevention of WSLs

50. • Indirect Bonding and / or Light-cure Technique…..
• Prevention of WSLs

51. Treatment protocols for
WSLs
•First , Allow Natural
Remineralization.

52.  Treatment of WSLs
• Avoid high concentration of F agents since they arrest
enamel remineralization .
• Allow Remineralization of enamel by Saliva (less
visible lesions) .

53.  Treatment of WSLs
• Shows a lower right canine, which had an orthodontic white
spot lesion that was treated at debond with strong fluoride
varnish. The lesion has not regressed and has stained brown.

54.  Treatment of WSLs
• Low doses of F applications (50 – ppm F. mouth rinses).
• Tooth Whitening “ Bleaching “
• Use of CPP –ACP “ Casein derivates “
• Enamel Microabrasion
• Cosmetic Restorations ( Veneers ) .

55.  Treatment methods
• F. mouth rinses : 0.05% Na F + Chlorhexidine .
• Topical F. gel or varnishes application

56. Topical Application of Titanium Tetrafluoride ( solution ) :
the mechanism of interaction with the enamel
 Strong Ti-O-Ti chains on the
enamel surface .
 A titanium-rich , glaze –like coating
formed on the enamel surface following
the application of Ti. Tetra F.
 Treatment of WSLs

57. • Chlorhexidine mouthwash
• Antimicrobial therapy .
• To achieve a shift from :
Unfavorably biofilm favorably biofilm
• Maybe used as a complement to F. therapy.
 Drawback : the tendency to stain the teeth

58. • Casein Phosphopeptide Amorphous
Calcium Phosphate (CPP-ACP )
 Treatment of WSLs

59. • Casein Phosphopeptide Amorphous Calcium
Phosphate (CPP-ACP )
• Trade name : Recaldent
• Derived from milk caseine
• Enhances formation of calcium phosphate crystals

60.  Recaldent CPP-ACP :
• Natural milk derived product containing casein phosphopeptides
CPP and amorphous calcium phosphates ACP

61.  Treatment of post-orthodontic white spot lesions with
casein phosphopeptide-stabilised amorphous calcium
phosphate .
Brochner et al, Clin Oral Invest, April 2010
 The mean area of the WS lesions
decreased by 58% in the CPP- ACP
group and 26% in the fluoride group .

62. • Casein Phosphopeptide Amorphous Calcium Phosphate (CPP-ACP )
7 days
4 weeks 12 weeks

63.  Recaldent CPP-ACP
Chewing Gum :
This gum contains the active CPP-ACP .
 Recaldent also contains Xylitol, which is
a natural sweetener shown to help control
mouth bacteria and improve saliva quality.
•The in vivo studies of the remineralization
properties of Recaldent (CPP-ACP) Gum
have shown subsurface mineral gain can
occur by chewing the gum for periods of 15
minutes for 2 weeks.

64. • Vital Tooth Bleaching
 Treatment of WSLs

65. •Vital Tooth Bleaching
•View of the same maxillary
anterior teeth following 4 weeks
of overnight vital bleaching with
10% carbamide peroxide
delivered in a custom tray.
 Treatment of WSLs

66. • View of the same maxillary
anterior teeth following 4
weeks of bleaching , 30 minutes
twice per day, with a hydrogen
peroxide gel impregnated on
polyethylene strips.
•Vital Tooth Bleaching

67. Microabrasion of the enamel
 Treatment of WSLs

68.  Microabrasion
• A technique to remove the superficial non- carious
superficial enamel defects as well as WSL .
• Topical application of an 18 % hydrochloric acid and
pumice , 1 – 2 minutes .

69.  Microabrasion
• 5 to 10 applications of the microabrasion compound
should be effective .
• The abraded enamel surface is less susceptible to
demineralization than natural enamel .
• Following the microabrasion technique , a 4-minute 2 % Na F
treatment is recommended .

70. • Cosmetic Restorations
in Severe Cases
 Treatment of WSLs

71.  Decalcification restored with composite resin
.
• Cosmetic Restorations
 ( ICon ): Caries Infiltration with light-curable
resin for non-cavitated lesions

72. • Patient who needed composite
buildups on the maxillary anterior
teeth to esthetically improve areas
of severe decalcification following
orthodontic treatment .
• Cosmetic Restorations

73. Clinical Test …..

74.  How Do You Proceed ?
 Problem : Inadequate oral hygiene, generalized
gingivitis, plaque accumulation, and white spot
lesions at the bucco-cervical surfaces.

75.  Discuss with the patient the risk factors,
 Make recommendations according to the problems (eg, diet
and oral hygiene behavioral assessment),
 Prescribe high-fluoride (5000 ppm) toothpaste and 0.12%
chlorhexidine rinses, and
 Reevaluate in few months to assess whether patient has
been compliant and able to proceed with orthodontic
treatment .
 How Do You Proceed ?

76.  What do you recommend?
Reevaluate the risk factors
Reinforce oral hygiene instructions,
Prescribe high-fluoride toothpaste and chlorhexidine rinses,
Apply fluoride varnish at least 2 or 3 times a year, and also
Recommend frequent use of xylitol or sugar-free gum.

77.  Problem : at the debonding appointment , you
note white spot lesions and areas of cavitation on
the patient.
What do you do?

78.  Summary : Treatment protocols for WSLs
• First , allow natural remineralization.
• Low doses of F applications (50 – ppm F. mouth rinses).
•Use of CPP –ACP “ Casein derivates “
• If the lesions persist , professional bleaching is
indicated.
• If the effect of bleaching is inadequate , Microabrasion
is an option.
• Lastly , direct or indirect Veneers could be considered.

79.  Conclusions :
• To prevent development of white spot lesions, orthodontists
should assess each patient’s risk factors before and during
treatment.
• Oral hygiene instructions are important, but patients
might need to be assisted with additional measures, including
fluoride varnish, chlorhexidine , dietary modification,
or calcium-containing remineralization products that can
help prevent enamel demineralization, enhance remineralization,
and modify patient and biofilm factors.

80.  Conclusions :
• Restorative treatment for established white spot
lesions can range from the most conservative
(remineralization with fluoride, calcium, and
phosphate) to the most aggressive (tooth reduction
and porcelain veneers).

81.  Conclusions :
It is crucial to establish a caries risk
assessment and recommendation
protocol for patients before, during, and
after treatment to be able to provide
overall successful orthodontic
treatments for them.

82. Thank You … Dr.Marwan Mouakeh
Syria –Aleppo, the public park