Intervention of White Spot Lesions. A Contemporary Review of 20 years
Keywords:WSLs, Demineralisation, Remineralisation, Microinvasive treatment
White spot lesion is incipient caries and it manifests as white opacity lesion on the demineralised enamel surface. White spot lesions are a common adverse effect among post orthodontic patients. The prevalence of white spot lesions in post orthodontic patients varies from 2% to 97%. Therefore, it is imperative for dental practitioners to be able to manage white spot lesions. Thus, this article is a contemporary review on the management of white spot lesions. After reviewing this article, it comes to a consensus that non- invasive treatments should be the first line management of white spot lesions. Non-invasive treatments such as patient education, motivation, oral hygiene reinforcement, and attempts to remineralise with various forms of fluoride preparation should be prioritised in the treatment plan. If the white spot lesions fail to respond more invasive treatment options might be considered.
The Glossary of Prosthodontic Terms: Ninth Edition. Journal of Prosthetic Dentistry. 2017;117(5S):e1-e105.
Featherstone. The continuum of dental caries--evidence for a dynamic disease process. J Dent Res. 2004;83 Spec No C:C39-42.
Kidd EA, Fejerskov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. Journal of Dental Research. 2004;83 Spec No C:C35-8.
Applebaum E. Incipient Dental Caries. Journal of Dental Research. 1932;12(4):619-27.
Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. American Journal of Orthodontics and Dentofacial Orthopedics. 1982;81(2):93-8.
Boersma JG, van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B. Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Research. 2005;39(1):41-7.
Ogaard B. Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 1989;96(5):423-7.
Fejerskov O, Manji F. Risk assessment in dental caries. Risk Assessment in Dentistry Chapel Hill, University of North Carolina Dental Ecology. 1990:215-7.
Shungin D, Olsson AI, Persson M. Orthodontic treatment-related white spot lesions: a 14-year prospective quantitative follow-up, including bonding material assessment. American Journal of Orthodontics and Dentofacial Orthopedics. 2010;138(2):e1-8.
Arends J, Ten Cate J. Tooth enamel remineralization. Journal of Crystal Growth. 1981;53(1):135-47.
Jon Å, Thylstrup A. Clinical and scanning electron microscopic study of surface changes of incipient caries lesions after debonding. European Journal of Oral Sciences. 1986;94(3):193-201.
Mattousch T, Van Der Veen M, Zentner A. Caries lesions after orthodontic treatment followed by quantitative light-induced fluorescence: a 2-year follow-up. The European Journal of Orthodontics. 2007;29(3):294-8.
Heymann GC, Grauer D. A contemporary review of white spot lesions in orthodontics. Journal of Esthetic and Restorative Dentistry. 2013;25(2):85-95.
Holmen L, Thylstrup A, Artun J. Surface changes during the arrest of active enamel carious lesions in vivo: a scanning electron microscope study. Acta Odontologica Scandinavica. 1987;45(6):383-90.
van der Veen MH, Mattousch T, Boersma JG. Longitudinal development of caries lesions after orthodontic treatment evaluated by quantitative light-induced fluorescence. Am J Orthod Dentofacial Orthop. 2007;131(2):223-8.
Kühnisch J, Ekstrand K, Pretty I, Twetman S, Van Loveren C, Gizani S, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. European Archives of Paediatric Dentistry. 2016;17(1):3-12.
Ganss C, Schlueter N, Preiss S, Klimek J. Tooth brushing habits in uninstructed adults—frequency, technique, duration and force. Clinical Oral Investigations. 2008;13(2):203.
Featherstone. Prevention and reversal of dental caries: role of low level fluoride. Community dentistry and oral epidemiology. 1999;27(1):31.
Cate JMt. Current concepts on the theories of the mechanism of action of fluoride. Acta Odontologica Scandinavica. 1999;57(6):325-9.
Willmot D. White Spot Lesions After Orthodontic Treatment. Seminars in Orthodontics. 2008;14(3):209-19.
Bishara SE, Ostby AW. White Spot Lesions: Formation, Prevention, and Treatment. Seminars in Orthodontics. 2008;14(3):174-82.
O'Mullane D, Baez R, Jones S, Lennon M, Petersen PE, Rugg-Gunn A, et al. Fluoride and oral health. Community Dental Health. 2016;33(2):69-99.
Duckworth R, Morgan S. Oral fluoride retention after use of fluoride dentifrices. Caries Research. 1991;25(2):123-9.
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. European Journal of Oral Sciences. 2010;118(6):610-7.
Huang, Roloff-Chiang B, Mills BE, Shalchi S, Spiekerman C, Korpak AM, et al. Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. American Journal of Orthodontics and Dentofacial Orthopedics. 2013;143(1):31-41.
Singh S, Singh SP, Goyal A, Utreja AK, Jena AK. Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial. Progress in Orthodontics. 2016;17(1):25.
Agarwal A, Pandey H, Pandey L, Choudhary G. Effect of fluoridated toothpaste on white spot lesions in postorthodontic patients. International Journal of Clinical Pediatric Dentistry. 2013;6(2):85.
Chen L, Al-Bayatee S, Khurshid Z, Shavandi A, Brunton P, Ratnayake J. Hydroxyapatite in Oral Care Products-A Review. Materials (Basel). 2021;14(17).
Deveci C, Çınar Ç, Tirali RE. Management of White Spot Lesions. Dental Caries - Diagnosis, Prevention and Management2018.
Sharma A, Agarwal N, Anand A, Jabin Z. To compare the effectiveness of different mouthrinses on Streptococcus mutans count in caries active children. Journal of Oral Biology and Craniofacial Research. 2018;8(2):113-7.
Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA, et al. Topical fluoride for caries prevention. The Journal of the American Dental Association. 2013;144(11):1279-91.
Roveri N, Battistella E, Foltran I, Foresti E, Iafisco M, Lelli M, et al., editors. Synthetic biomimetic carbonate-hydroxyapatite nanocrystals for enamel remineralization. Advanced materials research; 2008: Trans Tech Publ.
Palmieri C, Magi G, Orsini G, Putignano A, Facinelli B. Antibiofilm activity of zinc-carbonate hydroxyapatite nanocrystals against Streptococcus mutans and mitis group streptococci. Current microbiology. 2013;67(6):679-81.
Hannig C, Basche S, Burghardt T, Al-Ahmad A, Hannig M. Influence of a mouthwash containing hydroxyapatite microclusters on bacterial adherence in situ. Clinical oral investigations. 2013;17(3):805-14.
Roveri N, Battistella E, Bianchi CL, Foltran I, Foresti E, Iafisco M, et al. Surface enamel remineralization: biomimetic apatite nanocrystals and fluoride ions different effects. Journal of Nanomaterials. 2009;2009.
Ardu S, Castioni NV, Benbachir N, Krejci I. Minimally invasive treatment of white spot enamel lesions. Quintessence Int. 2007;38(8):633-6.
Hegazy SA, Salama RI. Antiplaque and remineralizing effects of Biorepair mouthwash: A comparative clinical trial. Pediatric Dental Journal. 2016;26(3):89-94.
Du M, Cheng N, Tai B, Jiang H, Li J, Bian Z. Randomized controlled trial on fluoride varnish application for treatment of white spot lesion after fixed orthodontic treatment. Clinical Oral Investigations. 2012;16(2):463-8.
Sudjalim T, Woods M, Manton D. Prevention of white spot lesions in orthodontic practice: a contemporary review. Australian dental journal. 2006;51(4):284-9.
Chen H, Liu X, Dai J, Jiang Z, Guo T, Ding Y. Effect of remineralizing agents on white spot lesions after orthodontic treatment: a systematic review. American Journal of Orthodontics and Dentofacial Orthopedics. 2013;143(3):376-82 e3.
Llena C, Leyda A, Forner L. CPP-ACP and CPP-ACFP versus fluoride varnish in remineralisation of early caries lesions. A prospective study. European Journal of Paediatric Dentistry. 2015;16(3):181-6.
Perrini F, Lombardo L, Arreghini A, Medori S, Siciliani G. Caries prevention during orthodontic treatment: In-vivo assessment of high-fluoride varnish to prevent white spot lesions. American Journal of Orthodontics and Dentofacial Orthopedics. 2016;149(2):238-43.
Sonesson M, Brechter A, Abdulraheem S, Lindman R, Twetman S. Fluoride varnish for the prevention of white spot lesions during orthodontic treatment with fixed appliances: a randomized controlled trial. European Journal of Orthodontics. 2020;42(3):326-30.
Jamil WE, El Sharkawy DA. Effectiveness of Ginger-Honey Mixture and Rosemary on Remineralization and Prevention of Enamel White Spot Lesions Measured by Color Change. Al-Azhar Dental Journal for Girls. 2022;9(3):391-8.
Amaechi BT. Remineralisation–the buzzword for early MI caries management. British dental journal. 2017;223(3):173-82.
Wei S, Chik F. Fluoride retention following topical fluoride foam and gel application. Pediatric dentistry. 1990;12(6):368-74.
Molaasadollah F, Asnaashari M, Mashhadi Abbas F, Jafary M. In Vitro Comparison Of Fluoride Gel Alone and in Combination With Er,Cr:YSGG Laser on Reducing White Spot Lesions in Primary Teeth. J Lasers Med Sci. 2017;8(4):160-5.
Reynolds. Remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. Journal of Dental Research. 1997;76(9):1587-95.
Reynolds. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. Special Care in Dentistry. 1998;18(1):8-16.
Rahiotis C, Vougiouklakis G, Eliades G. Characterization of oral films formed in the presence of a CPP-ACP agent: an in situ study. Journal of Dentistry. 2008;36(4):272-80.
Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Research. 2004;38(6):551-6.
Bailey, Adams GG, Tsao CE, Hyslop A, Escobar K, Manton DJ, et al. Regression of post-orthodontic lesions by a remineralizing cream. Journal of Dental Research. 2009;88(12):1148-53.
Indrapriyadharshini K, Kumar PM, Sharma K, Iyer K. Remineralizing potential of CPP-ACP in white spot lesions–A systematic review. Indian Journal of Dental Research. 2018;29(4):487.
Karabekiroglu S, Unlu N, Kucukyilmaz E, Sener S, Botsali MS, Malkoc S. Treatment of post-orthodontic white spot lesions with CPP-ACP paste: A three year follow up study. Dent Mater J. 2017;36(6):791-7.
Imani MM, Safaei M, Afnaniesfandabad A, Moradpoor H, Sadeghi M, Golshah A, et al. Efficacy of CPP-ACP and CPP-ACPF for Prevention and Remineralization of White Spot Lesions in Orthodontic Patients: a Systematic Review of Randomized Controlled Clinical Trials. Acta Inform Med. 2019;27(3):199-204.
Trahan L, Mouton C. Selection for Streptococcus mutans with an altered xylitol transport capacity in chronic xylitol consumers. Journal of dental research. 1987;66(5):982-8.
Maguire A, Rugg-Gunn A. Xylitol and caries prevention—is it a magic bullet? British dental journal. 2003;194(8):429-36.
Scheinin A, Mäkinen KK. Turku sugar studies: An overview. Acta Odontologica Scandinavica. 1976;34(6):405-8.
Cocco F, Carta G, Cagetti MG, Strohmenger L, Lingström P, Campus G. The caries preventive effect of 1-year use of low-dose xylitol chewing gum. A randomized placebo-controlled clinical trial in high-caries-risk adults. Clinical Oral Investigations. 2017;21(9):2733-40.
Janakiram C, Antony B, Joseph J, Ramanrayanan V. Prevalence of Dental Caries in India among the WHO Index Age Groups: A Meta-Analysis. Journal of Clinical & Diagnostic Research. 2018;Volume. 12 (Issue 8):p8-13.
Sanders ME. Probiotics: definition, sources, selection, and uses. Clinical infectious diseases. 2008;46(Supplement_2):S58-S61.
Laleman I, Detailleur V, Slot DE, Slomka V, Quirynen M, Teughels W. Probiotics reduce mutans streptococci counts in humans: a systematic review and meta-analysis. Clinical oral investigations. 2014;18(6):1539-52.
Twetman S, Jørgensen M, Keller M. Fifteen years of probiotic therapy in the dental context: what has been achieved. J Calif Dent Assoc. 2017;45(10):539-45.
Gizani S, Petsi G, Twetman S, Caroni C, Makou M, Papagianoulis L. Effect of the probiotic bacterium Lactobacillus reuteri on white spot lesion development in orthodontic patients. European Journal of Orthodontics. 2016;38(1):85-9.
Poorni S, Srinivasan MR, Nivedhitha MS. Probiotic Streptococcus strains in caries prevention: A systematic review. J Conserv Dent. 2019;22(2):123-8.
Zaura E, Twetman S. Critical Appraisal of Oral Pre- and Probiotics for Caries Prevention and Care. Caries Research. 2019;53(5):514-26.
Hadj-Hamou R, Senok AC, Athanasiou AE, Kaklamanos EG. Do probiotics promote oral health during orthodontic treatment with fixed appliances? A systematic review. BMC Oral Health. 2020;20(1):1-9.
Pietri FK, Rossouw PE, Javed F, Michelogiannakis D. Role of probiotics in oral health maintenance among patients undergoing fixed orthodontic therapy: a systematic review of randomized controlled clinical trials. Probiotics and Antimicrobial Proteins. 2020;12(4):1349-59.
Olivi G, Genovese M, Caprioglio C. Evidence-based dentistry on laser paediatric dentistry: review and outlook. European journal of paediatric dentistry. 2009;10(1):29.
Verma SK, Maheshwari S, Singh RK, Chaudhari PK. Laser in dentistry: An innovative tool in modern dental practice. National journal of maxillofacial surgery. 2012;3(2):124.
Poosti M, Ahrari F, Moosavi H, Najjaran H. The effect of fractional CO 2 laser irradiation on remineralization of enamel white spot lesions. Lasers in medical science. 2014;29(4):1349-55.
Yassaei S, Motallaei MN. The Effect of the Er:YAG Laser and MI Paste Plus on the Treatment of White Spot Lesions. J Lasers Med Sci. 2020;11(1):50-5.
Mahmoudzadeh M, Alijani S, Soufi LR, Farhadian M, Namdar F, Karami S. Effect of CO2 Laser on the Prevention of White Spot Lesions During Fixed Orthodontic Treatment: A Randomized Clinical Trial. Turk J Orthod. 2019;32(3):165-71.
Grootveld M, Baysan A, Sidiiqui N, Sim J, Silwood C, Lynch E. History of the clinical applications of ozone. Ozone: the revolution in dentistry London: Quintessence Publishing Co. 2004:23-30.
Celiberti P, Pazera P, Lussi A. The impact of ozone treatment on enamel physical properties. American journal of dentistry. 2006;19(1):67.
Holmes J, Lynch E. Evidenced based research into ozone treatment in dentistry. An overview–2004. 2004.
Margolis H, Moreno E, Murphy B. Basic biological sciences importance of high pka acids in cariogenic potential of plaque. Journal of dental research. 1985;64(5):786-92.
Azarpazhooh A, Limeback H. The application of ozone in dentistry: A systematic review of literature. Journal of Dentistry. 2008;36(2):104-16.
Makeeva IM, Turkina AY, Margaryan EG, Paramonov YO, Polyakova MA. [Assessment of antibacterial efficacy of ozone therapy in treatment of caries at the white spot stage]. Stomatologiia (Mosk). 2017;96(4):7-10.
Attin T, Schmidlin PR, Wegehaupt F, Wiegand A. Influence of study design on the impact of bleaching agents on dental enamel microhardness: a review. Dental Materials. 2009;25(2):143-57.
Basting R, Rodrigues A, Serra M. The effect of 10% carbamide peroxide bleaching material on microhardness of sound and demineralized enamel and dentin in situ. Operative dentistry. 2001;26(6):531-9.
Berger SB, Pavan S, Santos PHd, Giannini M, Bedran-Russo AKB. Effect of bleaching on sound enamel and with early artificial caries lesions using confocal laser microscopy. Brazilian dental journal. 2012;23:110-5.
Kim Y, Son H, Yi K, Ahn J, Chang J. Bleaching effects on color, chemical, and mechanical properties of white spot lesions. Operative dentistry. 2016;41(3):318-26.
Choi Y-Y, Lee D-Y, Kim Y-J. Colorimetric evaluation of white spot lesions following external bleaching with fluoridation: An in-vitro study. Korean journal of orthodontics. 2018;48(6):377.
Kielbassa AM, Mueller J, Gernhardt CR. Closing the gap between oral hygiene and minimally invasive dentistry: a review on the resin infiltration technique of incipient (proximal) enamel lesions. Quintessence international. 2009;40(8).
Paris S, Meyer-Lueckel H, Coelfen H, Kielbassa AM. Resin infiltration of artificial enamel caries lesions with experimental light curing resins. Dental materials journal. 2007;26(4):582-8.
Arnold W, Haddad B, Schaper K, Hagemann K, Lippold C, Danesh G. Enamel surface alterations after repeated conditioning with HCl. Head & face medicine. 2015;11(1):32.
Kielbassa AM, Ulrich I, Werth VD, Schüller C, Frank W, Schmidl R. External and internal resin infiltration of natural proximal subsurface caries lesions: A valuable enhancement of the internal tunnel restoration. Quintessence International. 2017;48(5).
Perdigão J. Resin infiltration of enamel white spot lesions: An ultramorphological analysis. Journal of Esthetic and Restorative Dentistry. 2020;32(3):317-24.
Meyer-Lueckel, Paris. Improved resin infiltration of natural caries lesions. Journal of dental research. 2008;87(12):1112-6.
Feng, Liu, Zhao, Chu. Effect of infiltration resin on the color masking of labial enamel white spot lesions. West China Journal of Stomatology. 2013;31(6):597-9.
Feng, Chu. Efficacy of one year treatment of icon infiltration resin on post-orthodontic white spots. Journal of Peking University (Health Sciences). 2013;45(1):40-3.
Yetkiner E, Wegehaupt F, Wiegand A, Attin R, Attin T. Colour improvement and stability of white spot lesions following infiltration, micro-abrasion, or fluoride treatments in vitro. European Journal of Orthodontics. 2014;36(5):595-602.
Knösel M, Eckstein A, Helms H-J. Long-term follow-up of camouflage effects following resin infiltration of post orthodontic white-spot lesions in vivo. The Angle Orthodontist. 2018;89(1):33-9.
Bourouni S, Dritsas K, Kloukos D, Wierichs RJ. Efficacy of resin infiltration to mask post-orthodontic or non-post-orthodontic white spot lesions or fluorosis — a systematic review and meta-analysis. Clinical Oral Investigations. 2021.
Khoroushi M, Kachuie M. Prevention and treatment of white spot lesions in orthodontic patients. Contemporary clinical dentistry. 2017;8(1):11.
Sundfeld RH, Croll TP, Briso AF, de Alexandre RS, Neto DS. Considerations about enamel microabrasion after 18 years. American Journal of Dentistry. 2007;20(2):67.
Donly KJ, O'Neill M, Croll TP. Enamel microabrasion: a microscopic evaluation of the" abrosion effect". Quintessence international. 1992;23(3).
Rodrigues MC, Mondelli RFL, Oliveira GU, Franco EB, Baseggio W, Wang L. Minimal alterations on the enamel surface by micro-abrasion: in vitro roughness and wear assessments. Journal of Applied Oral Science. 2013;21(2):112-7.
Segura A, Donly KJ, Wefel JS. The effects of microabrasion on demineralization inhibition of enamel surfaces. Quintessence International. 1997;28(7).
Gu X, Yang L, Yang D, Gao Y, Duan X, Zhu X, et al. Esthetic improvements of postorthodontic white-spot lesions treated with resin infiltration and microabrasion: A split-mouth, randomized clinical trial. The Angle Orthodontist. 2019;89(3):372-7.
Shan D, He Y, Gao M, Liu H, Zhu Y, Liao L, et al. A comparison of resin infiltration and microabrasion for postorthodontic white spot lesion. American Journal of Orthodontics and Dentofacial Orthopedics. 2021;160(4):516-22.
Heymann H, Swift E, Ritter A. Sturdevant's Art and Science of Operative Dentistry. 2013. Mosby, St Louis: pp. 2013;300(2).
Copyright (c) 2023 Annals of Dentistry University of Malaya
This work is licensed under a Creative Commons Attribution 4.0 International License.
- The Faculty of Dentistry, Universiti Malaya holds the copyright of the published manuscript including all its components such as supplementary information, graphical contents and raw data without any restrictions.
- The author grant the Faculty of Dentistry, University of Malaya assignable and sub-licensable right, unlimited in time and territory, to copy-edit, reproduce, publish, distribute, transmit, make available and store the Article, including abstracts thereof, in all forms of media of expression now known or developed in the future, including pre- and reprints, translations, photographic reproductions and extensions.
- After acceptance for publication in Ann Dent UM, the author(s) have the right to use any of its components in whole or in part for academic purposes such as, presentation in scientific conferences and seminars.