Few events are as exciting for you, your parents, and your orthodontist as the day your braces come off. Few things can ruin that celebration like discovering white spot lesions on the teeth at the end of an otherwise well-treated orthodontic case. Do braces cause white spot lesions? Can they be prevented? Can they be fixed after they appear? These are the questions I hope to answer in this article.
White spot lesions (also called decalcification or demineralization) are subsurface porosities caused by dental plaque (the same thing that causes cavities). The white, chalky marks on the teeth appear when acids created by the plaque remove minerals from the tooth surface and change the way it reflects light. The most common area for white spot lesions is between the gums and the brackets where brushing is most difficult. Many times white spots develop under swollen gum tissue making their detection difficult until after the braces are removed and swelling subsides. University studies have found that white spot lesions occur in 24% of adolescents who have never had braces (again caused by plaque left on the teeth). This number jumps to as high as 50% in teenagers with braces! Although braces DO NOT cause white spots on the teeth, they do complicate the removal of the plaque which is responsible.
Can white spot lesions be prevented? Yes. Current approaches can be grouped into three categories: 1) plaque removal, 2) hardening the enamel surface, and 3) protecting the enamel with a coating. Plaque removal is the ONLY sure way to prevent white spot lesions. In my office we begin oral hygiene coaching at the very first appointment. We provide a brushing chart and a list of the foods and drinks that should be avoided during treatment (including an emphasis on reducing the amount of acidic soda). We explain the importance of removing plaque, show the patients a picture of severe decalcification, and let the patients and parents know that white spots are a possibility if plaque is not removed (this is specifically spelled out on our consent form). We encourage the use of fluoridated toothpaste and provide special toothbrushes and floss threaders at every appointment. During treatment we reward good brushers with contest points and give additional instruction to patients who are struggling. When we notice that white spots are developing, we point them out to the family. We have even removed braces early in some patients with severe problems. The bottom line is that if plaque is regularly removed from the teeth, white spot lesions cannot form.
Orthodontists would love to find a way to prevent decalcification without relying on patient cooperation. There is no question that fluoride strengthens the teeth and makes them more resistant to demineralization. The question is how much is enough? For years we have been told (and sold) that prescription fluoride application (at home and in the dental office), fluoride rinses, and fluoride varnishes painted on the teeth can prevent decay. Controlled studies however have failed to show that these expensive products give any better results than just the daily use of fluoridated toothpaste. Brushing the teeth right before bed, spitting out the foam, and leaving the residue on the teeth has been shown to be just as effective as prescription fluoride. For this reason I do not dispense or prescribe additional fluoride products to patients in my practice. There is also a lot of interest in sealants that prevent the plaque from contacting the enamel during treatment. While we are hopeful that effective products will be developed, those currently available lose efficacy fairly quickly and their long-term benefits have yet to be proven. Neither fluoride nor sealants can replace good oral hygiene when it comes to preventing white spot lesions.
What can be done if you have white spots on your teeth after your braces come off? The first step is just to keep your teeth clean and let your enamel be bathed in your normal oral fluids for at least six months after appliance removal. All white spots improve some with time and minor ones may disappear altogether. Experts advise AGAINST applying extra fluoride during this healing period as it may seal the surface of the lesion and prevent remineralization below the surface. After six months, low concentration over-the-counter fluoride rinses and remineralization pastes (like Recaldent and MI Paste) can then be applied. Bleaching has been shown to lighten the enamel surrounding white spot lesions and reopen the “pores” overlying subsurface porosities. White spots then blend in better and actually improve as the effects of the bleaching wear off. One fairly new procedure that works well for mild to moderate white spots is resin infiltration (products like Icon resin). The resin infiltration reopens porosities and replaces lost tooth structure with a material that has optical properties closer to natural enamel. For more severe problems, your dentist may perform microabrasion (removing superficial white spots), cosmetic bonding (replacing damaged enamel), or place porcelain veneers (covering badly damaged surfaces).
In the end, white spot lesions are caused by plaque. Coating your teeth with extra fluoride or sealing your teeth with the newest products may help some, but the best solution is the daily, methodical removal of plaque with a regular toothbursh. Keep dental plaque off of your teeth and white spot lesions will never ruin your deband celebration!
NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.