Key messages:
- Despite advancements in orthodontic techniques and diagnostics, client compliance and consistent oral self-care are crucial in preventing demineralization around orthodontic brackets.
- Oral health practitioners play a vital role in motivating clients to maintain oral hygiene and use remineralizing agents to manage white spot lesions effectively.
- A comprehensive understanding of white spot lesion formation and progression is essential for developing preventive measures and minimally invasive treatments to enhance orthodontic outcomes and oral health.
Introduction
Decalcification or demineralization refers to the loss of calcified tooth substance. Enamel demineralization, alternately referred to as early carious lesions, manifests clinically as white spot lesions (WSLs) produced by changes in optical characteristics induced by subsurface mineral loss. WSLs are a prevalent complication of fixed orthodontic therapy and pose a significant aesthetic concern during and after treatment.
WSLs result primarily from inadequate oral hygiene. During orthodontic therapy, fixed orthodontic components (e.g., brackets) increase the potential for higher biofilm deposition. Consequently, individuals with a highly cariogenic diet and inadequate oral hygiene have a tendency to form WSLs, underscoring the importance of implementing preventive measures to minimize WSL development.
Aim
This narrative review explored the etiology, formation, risk factors, and treatment approaches of WSLs induced by fixed orthodontic appliances to improve oral health outcomes.
Methods
An electronic search of PubMed and ScienceDirect databases was conducted, with 172 studies from 2013 to 2023 identified and 39 selected for this narrative review.
Discussion
Fixed orthodontic therapy provides retentive sites for dental biofilm accumulation. Clients receiving orthodontic treatment had significantly higher levels of Streptococcus mutans and Lactobacillus bacteria and a decreased resting biofilm pH. Excessive material near orthodontic brackets also promoted bacterial growth.
Several factors were associated with WSLs, including:
- Age at the start of therapy as clients ≤16 years had significantly increased WSLs compared to those >16 years.
- Sex as males had significantly higher WSLs.
- Poor oral hygiene. Brushing ≥2 times a day was associated with WSL improvement.
- Salivary changes, such as a considerable drop in salivary pH.
- Rise in DMFT and plaque index scores.
- Lingual appliances significantly reduced WSLs.
- Longer time since appliance removal and longer length of orthodontic treatment were associated with decreased WSL improvement, suggesting most improvement occurs shortly after appliance removal.
Various treatment approaches were identified for managing WSLs, including frequent recare visits, improved oral self-care, and the use of antiseptics (e.g., chlorhexidine), fluorides (e.g., dentifrices, mouthrinse, varnish), remineralizing agents (e.g., casein phosphopeptides amorphous calcium phosphate [CPP-ACP]), biomimetic self-assembling peptides, lasers, bleaching, microabrasion, and resin infiltration.
Conclusions
Enamel decalcification is a common consequence of fixed orthodontic therapy, as it raises demineralization risk by increasing cariogenic bacteria deposits and complicating plaque removal. Clients should receive education on proper oral hygiene and dietary measures to control WSLs. Although numerous studies address various treatment modalities for managing WSLs, long-term evidence-based studies are lacking, highlighting the need for further controlled clinical trials to establish best clinical practice.
