White spot lesions are one of the common complications of fixed orthodontic treatment. The responsibility of an orthodontist is to minimize the risk of the patient having decalcification as a consequence of orthodontic treatment by educating and motivating the patients for excellent oral hygiene practice. Prophylaxis with topical fluoride application should be implemented: high-fluoride toothpastes, fluoride mouthwashes, gels and varnishes during and after the orthodontic treatment, especially for patients at high risk of caries.

White spot lesions may develop as a result of prolonged plaque accumulation as a result of dietary carbohydrate and saliva modified bacterial infection; result in an imbalance between demineralization and remineralization of the enamel on the affected surface, commonly due to inadequate oral hygiene. It is generally accepted that the insertion of fixed orthodontic appliances creates stagnation areas for plaque and makes tooth cleaning more difficult. The irregular surfaces of brackets, bands, wires and other fixed orthodontic appliances may reduce the oral hygiene capabilities of orthodontic patients to suboptimal levels. In turn, this may predispose the enamel surfaces, in particular the area between the bracket and gingival margin, to the increased accumulation of bacterial plaque. Once active orthodontic treatment has been completed, the demineralization process is normally expected to decelerate due to a change in local environmental factors. Some white spot lesions may remineralize and return either to normal or at least to a visually acceptable appearance. However, white spot lesions may also persist, resulting in an aesthetically unacceptable result. In severe cases, restorative treatment may be required. It has been reported that there is a significant association between poor compliance with home care preventive procedures and the formation of white spot lesions.

Prevention of White Spot Lesions:
1. Patient education: Good oral hygiene is thus more important in orthodontic patients treated with fixed appliances than in non-treated individuals. Mechanical plaque control by proper tooth brushing is of paramount importance. A modification of the standard toothbrush, use of disclosing solutions, and use of floss can help patients in attaining good oral hygiene. Use of a power toothbrush or daily water irrigation in combination with manual tooth brushing may be a more effective method in reducing plaque accumulation than manual tooth brushing alone.
2. Professional oral hygiene instruction and regular professional prophylaxis has been shown to be effective in reducing decalcification.
3. Fluoride Administration:
(A) Water fluoridation and community-based fluoride distribution program
(B) Fluoride toothpaste, Fluoride Mouth Rinse, and Fluoride gel
(C) Fluoride varnish
(D) Fluoride in orthodontic Bonding agents and Fluoride in Elastomers (ties used in orthodontic treatment)

The development of white spot lesions during fixed appliance orthodontic treatment is preventable. The chosen method or methods for prevention will be largely dependent on the individual needs of each patient and the opinion of the clinician. White spot lesions are generally considered to be the precursors of 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 and the use of a fluoride containing toothpaste. The need to prescribe an additional topical fluoride will be dependent upon the needs of the individual patient and clinical judgment. Overall management of white spot lesions involves consideration of methods of preventing demineralization and also methods of encouraging remineralization of existing lesions. Preventive measures take precedence, due to the challenging nature of treating patients who do develop significant numbers of white spot lesions.

Written by,
Dr. Prathima Adusumilli DMD, MS Orthodontist
Coral Orthodontics
11332 Wiles rd, Coral Springs Fl 33076