Love & Orthodontics
Love & Orthodontics
Dr Chris Baker is Past President of the American Orthodontic Society, a pediatric dentist and faculty member of three dental schools. She practices in Abu Dhabi, UAE, and Texas, USA. Dr Chris writes about orthodontics, pediatric dentistry and life.
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White Spot Lesions: Three Factors of Interplay

White Spot Lesions: Three Factors of Interplay

5/21/2018 5:06:42 AM   |   Comments: 0   |   Views: 96
White spot lesions on teeth result from acid-producing pathogenic bacteria that demineralize the tooth surface.

This begins the process of tooth decay. While these lesions occur in patients without any orthodontic or other dental intervention, they also occur during orthodontic treatment.  The tooth damage results from the bacterial acids etching and eating away at the tooth structure. There is something you can do to greatly reduce the risk - more on that below.

The interplay between three areas will determine the risk and actuality of damage during orthodontic treatment: These are the orthodontic treatment (medical intervention); secondly, the complex human body existing in its environment, nature, including the trillions of microbes we call the microbiome; and third, the patients’ and parents’ degree of participation in care of that body.

Which of these areas can you impact to reduce the risk of damage?  How can you provide that impact?  The answers to these questions are important to all of us who offer and provide orthodontic treatment to transform lives.

To address these, we examine the aforementioned three factors of interplay:
  1. The Medical Intervention
  3. The Human Body Existing in its Environment, Nature
  5. The patient’s (and, for a child patient, the parents’) degree of participation.
Our ability to reduce the risk lies almost completely in the first area of the medical intervention, the orthodontic treatment.

The health of the human body and its microbiome is almost completely out of our purview, except that we can encourage the patient/parent to be aware of healthful practices that strengthen, not weaken, the microbiome.

The degree of participation of the patient/parent is again, almost completely out of our purview.  But, we can encourage the oral health care practices (regular dental care, excellent oral hygiene and related) and the proper participation in orthodontic therapy. This includes wearing elastics and appliances and controlling oral hygiene so as to reduce the time of the orthodontic appliances being in situ (on the teeth).

The area of medical intervention is the area where we have some ways to mitigate the risk of white spot lesions. Unfortunately, this amounts to only one-third of the total factors at play. Remember that each human body is part of the complexity of nature and has its risks of harm, both with and without medical intervention.

Remember, there are two other huge factors at play. Even with your best efforts and knowledge, you cannot absolutely prevent white spot lesions. Fortunately, you can mitigate the risks.First, identify your patients who are most at-risk and consider the following.

Mitigate the risk:
  • ProSeal (Reliance Orthodontic Products, Inc.)1 
ProSeal is a fine way to support patient efforts to reduce white spot lesion risk. Use this with EVERY ORTHODONTIC PATIENT on every tooth to be bracketed.

ProSeal is a smooth surface sealant that sets completely without an oxygen-inhibited layer.  This creates a smooth hard surface that protects the enamel.  It resists toothbrush abrasion and can be used under any bracketing system.  After using ProSeal/LED ProSeal with all orthodontic patients for many years and after seeing the results, including with extremely high-risk decay patients, I would not provide orthodontic treatment without it.  With ProSeal usage, white spot lesion incidence is minimized.  And, the sealant contains a UV fluorescing agent for easy monitoring of its presence over treatment times, so you can reapply as needed. This provides significant protection against acidic damage to the enamel surface.

  • Fluorides  Some of these may be placed by your office or by the patient’s regular dentist. Most require patient participation and compliance. The patient must go for the office treatments, for the instructions, and/or utilize the recommended fluorides at home The fluorides may include, both in-office and home products.  Fluoride agents like stannous fluoride and titanium fluoride deposit reservoirs on the tooth surface that may resist even low pH and severe decay challenges.  Because it is critical that the patient maintain regular preventive and evaluative care, it is best to have the pediatric dentist or GP dentist provide the in-office fluorides, every 3-6 months, whether varnish or other preparation.  Fluoride toothpastes, including Cari-Free, which claims to restore pH balance are at-home preparations.
  • Other adjuncts. These include     
    • Caseine treatments, like MI paste, which can be used at home daily,2 
    • Carbamide peroxide to restore pH balance3
    • Xylitol gum.  Be sure to recommend one that is bio-effective such as Xlear, and does not have other harmful ingredients such as artificial sweeteners that may interfere with the healthy microbiome.
    • Probiotic supplements to work to maintain/restore the healthy microbiome.
  • As Short-As-Feasible treatment time, to reduce the time over which the damage occurs. Although, it is important to know that the demineralization typically presents within the first six months of orthodontic bracket presence, and continues slowly over the next months.4
  • Communication with patient/parent 5
  • Communication with the patient’s Pedo/GP dentist 5
  • Awareness of the Risk, and Refer, Refer, Refer
It is important to communicate to the patient/parent the importance of regular evaluative and preventive care.  A big part of your job is to communicate and refer!

Because white spot lesions appear much more frequently in males than in females, (the Tufekci study showed 76% of patients with such damage were male) observation with appropriate referral to Pediatric Dentist or GP for regular evaluative and preventive care is especially important in boys, and appropriate encouragement of adjunctive therapies, as above, should be considered especially in boys with higher plaque levels. 6

That’s what you can do in your Medical Intervention of Orthodontic Treatment!

The Second Factor: The Human Body Existing in its Environment, Nature

Our human bodies are not capable of regulating themselves, like  “physiologic islands,” but each body rather, exists and is regulated - or not -  in tandem with trillions of microorganisms, hosted by the body.  As science discovers and reports this amazing interplay of bacterial life and the human body, we begin to be awed and quite frankly, stymied by how to best reduce risks and control the “bad bugs,” and allow the “good bugs” to flourish. If they do not, the human body does not survive.  You have heard the idea of ingesting “good bugs” called “probiotics,” which are micro-organisms that keep us healthy and alive.

The National Institute for Health, NIH, Human Microbiome Project defined normal bacterial makeup of the body, and reported that microbes inhabit almost every part of the human body, including the skin, the GI tract and respiratory tract.  Most of the time these bacteria live in harmony with the body and provide necessary functions for human survival, including major immune and anti-inflammation functions.

These microbes outnumber human cells in your body by ten times. Remember, there are trillions of them in your body, though the microbes are much smaller than human cells, so they are only about 1-3 percent of your body weight - about as much as your brain.  In a 200 pound man, that would be 2-6 pounds of weight of bacteria.

The project calculated that more than 10,000 different microbial species are in human bodies, and the researchers believe they have identified 81-99 percent of those microbes.

What do the friendly bugs do for us? They provide enzymes so we can digest our own food, and absorb what we need. They produce vitamins and anti-inflammatories that we cannot.  They help pregnant women prepare for birth, changing the vaginal microbial population to a healthy one for the baby to pass through, and provide the baby with its first dose of microbes that the baby will need.  The friendly bugs help your body deal with the unfriendly bugs.

Researchers found that almost everyone routinely carries pathogens or “bad bugs.”  In healthy people, they cause no disease, and just co-exist with the body (their host) and its total microbiome. However, these pathogens are etiologic in disease states such as infections, heart disease and cancers.

Additionally, nutrition and diet are critical parts of the body’s interaction with its environment, as frequent snacking and high carbohydrates and sugars help the pathogens overtake the friendly microbes.

In dentistry we are most aware of the potential pathologic bacteria-host interactions that cause gingivitis, decay, periodontal disease and other oral pathology. This is a factor about which you, as the doctor, can contribute little to reduce the risk of white spot lesions.  The most healthful lifestyles and habits are up to the patient.  Your encouragement might be helpful - but often the lifestyles and habits do not change.

Finally, the third factor which is the patient’s (and, for a child patient, the parents’) degree of participation, again, offer your encouragement. But expend your energy on the medical intervention - your treatment - and consider terminating treatment if it is appropriate to help the patient whose participation is inadequate.  A word about prevention - if before treatment is begun, a parent says to you, “My child won’t…” - the parent is right.  Save yourself the headache, save the parent and child the angst, and don’t start treatment.

As you consider the interplay between these three areas that determine the risk and actuality of damage during orthodontic treatment, you can know where you can impact the risks and how you can do so. Once you determine these, you can then happily provide orthodontic treatment that transforms lives, including your own, and help people have beautiful smiles, the best possible self-view, and the most comfortable and functional occlusion possible.

  3. Lapenaite E, Lopatiene K, Ragauskaite A. Prevention and treatment of white spot lesions during orthodontic treatment: A systematic literature review Stomatologija, Baltic Dental and Maxillofacial Journal, 18: 3-8, 2016,
  7. Tufekci E, Dixon JS, Gunsolley JC, Lindauer SJ.Prevalence of white spot lesions during orthodontic treatment with fixed appliances.Angle Orthod. 2011 Mar; 81(2):206-10. doi: 10.2319/051710-262.1.
  9. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer SJ. Development of white spot lesions during orthodontic treatment: Perceptions of patients, parents, orthodontists, and general dentists. March 2012. V 141: (3), 337–44.
  11. Tufekci E, Dixon JS, GunsolleyJC, and Lindauer SJ.Prevalence of white spot lesions during orthodontic treatment with fixed appliances. The Angle Orthodontist: March 2011, Vol. 81, No. 2, pp. 206-210.

Photo and text © 2018 by Dr Chris Baker
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