Hello everyone, and welcome to Hatcher and Frey Orthodontics CE Radio. Today we are going to be covering an interesting topic: white spot lesions, specifically those that occur during orthodontic treatment, and hopefully we can provide you with some great insight into how these develop, and some strategies for how to prevent them and treat them after they do.
Most people are probably unaware that about 40 to 50% of orthodontically treated patients with fixed appliances like braces are going to develop at least one white spot lesion during the course of that treatment. Now, these may be varyingly visible. You know, some are less visible, some are more visible. But about half patients with braces will have a white spot lesion develop on their teeth, and about a quarter of these are going to be on anterior teeth, where they’re upper lower, and one out of seven are going to be on those upper anterior teeth, where they’re kind of most visible.
Many people believe that they’ll develop, and honestly they’ll heal on their own, but the studies show that that’s not necessarily the case. Only about one out of every five white spot lesions showed any improvement after about a two-year monitoring period. And essentially, if you see those localized demineralization six months after braces removal, those ones that are present at that point are going to continue to be present in the mouth going forward. So we want to make sure that we understand this problem, how it develops, and then what we can do about it.
Scott Frey 1:40
Now, most of the focus is going to be on hygiene, and certainly we want to prevent the patients from having a lot of cariogenic bacteria around their brackets and in the mouth because it’s just going to be generally unhealthy to strip minerals out in that fashion, but when we talk about the relationship of hygiene to white spot lesions directly, the correlation is not necessarily super clear. Only about 7% of patients with poor hygiene actually develop white spot lesions, and in fact, most of these patients have good or fair hygiene, and part of that is because when you deal with a very thick kind of biofilm, the mineral exchange that’s going to pull the calcium and pull those minerals out of the tooth and cause that white spot lesion isn’t necessarily going to get down to the level of the tooth. So you’ll have really puffy gums, substantial gingival inflammation, but not necessarily white spot lesions. It’s those thinner biofilms where they have particularly poor quality of bacteria, but apparently good hygiene, where you’re going to see white spot lesions more readily develop.
And interestingly enough, we see that adolescents and specifically adolescent females are much more predisposed to the development of white spot lesions, which is an interesting little bit of information because we want to understand why would this be, you know, something independent of hygiene, but really, really specific towards certain age groups and certain genders? So there’s got to be a host factor at play here that’s driving the formation of these white spot lesions, both during orthodontic treatment and just in general.
So when we look at the distribution of white spot lesions within the mouth, what we find is that almost all of them are in the upper anterior tooth region and the lower posterior tooth region on the buccal surfaces. Now, patients don’t simply develop a handicap to be able to clean these areas when braces go on, so there’s something other than simple hygiene that’s causing this process to be driven forward.
And what that is, is relative sugar concentrations and relative differences in salivary flow throughout the mouth that kind of come into play after meals and the introduction of sugars and carbohydrates, the highest sugar concentrations and lowest saliva clearance of those sugars happens in exactly those same areas where we see those white spot lesions develop, the upper anterior tooth region and lower posterior regions.
Scott Frey 4:33
So, what’s happening is there’s a failure to clear these sugars after meals, and that is what’s causing those white spot lesions to develop in those areas.
Furthermore, children and adolescents have a higher critical pH of demineralization because there’s simply less calcium in their saliva, about a third of that of an adult, and females because of increased calcium demands in general and a lower salivary flow rate will have a higher propensity for white spot lesions. So when we look at the patients that are most at risk, even though our adolescent female patients are really in tune and generally good brushers. Those are going to be the patients who are at highest risk of developing white spot lesions during the course of treatment with braces.
So when we apply braces in order to go ahead and get a healthy bond onto the tooth, a secure bond on the tooth.What we first need to do is kind of make sure we dissolve off the pellicle, dry, and expose the tooth surface, so that way we can place a primer and adhesive on that area, so we get a really secure bond with the bracket, so they don’t pop off. You know, obviously patients are going to eat some crunchy stuff from time to time, or knock them with their teeth, but we want to get a secure bond as possible. But in that process, what we’re doing is kind of eradicating all of the existing bacteria that are in that area, and now providing some additional housing with the bracket, the wire, and the glue, and all that on the surface of the tooth, for now bacteria to come back in and kind of reestablish themselves in and around that area, and what’s happening is there’s a cariogenic shift from normal bacteria to more aggressive, more virulent bacteria because of the appliances being in the mouth.
So if you look at the overall timeline I’ve put up here, you’ve got the native microflora being removed, more retentive surfaces. There’s a little bit of an increase in salivary flow because there’s something in the mouth. There’s decreased sugar clearance because of the appliances. There’s an impairment of hygiene, and there’s also increased residual saliva after swallowing, which known to pool sugars and cause the formation of cavities and white spots, that first kind of several month period, you’re going to have more intensive growth, a favorable environment for acidogenic bacteria to go ahead and take residence in and around the bracket, and you’re going to have a drop in the buffering capacity of the saliva. So a lot of the minerals that are in saliva are going to get sucked into these biofilms that are established in themselves and make them more vulnerable to changes in pH.
Scott Frey 7:30
By about five-six months in, patients are kind of adapted better. In terms of hygiene, certainly the teeth have now become a little bit straighter, so it does make hygiene a little easier for them. But by that six-month mark, most of the white spot lesions that are going to be forming, if any, are going to be starting right at that initial period. So they happen quick, and then they’re just simply going to get larger and more visible with time, and as if the braces go on for a lot longer, that will continue unless we kind of interrupt these processes.
What’s driving all of this is the sugars that are retained in and around the brackets after each meal, and that is the biggest risk factor here, and why we see this kind of pattern with braces, because we have existing kind of vulnerabilities in our adolescent patients because of the nature of growth and where that calcium is going, other than being in the saliva to kind of buffer things, but now we go ahead and introduce an environment where we’re going to make sugars more present for a longer period in areas where we know there’s some vulnerabilities, and it’s actually about like 6 to 10 minutes longer that these sugars will be present because of the brackets and wires being in the mouth, and that’s an eternity for bacteria.
Scott Frey 08:53
The cariogenic bacteria are going to suck up these sugars very quickly store them and build pretty resistant, resilient biofilms that are going to continue to produce sugar for hours afterwards. So we need to go ahead and kind of combat this big factor.
We also have increased residual saliva after swallowing, which is a known risk factor for the development of cavities. And if we have that in and around brackets, the same process generally applies.
And then also the metal ions, different things within the adhesive that are present there from the brackets themselves, favor the growth of things like Strep. mutans which are going to produce demineralization in and around those brackets. So now that we’ve got this big reservoir on the brackets of these nasty bacteria, we want to make sure that we’re doing our best to kind of control these kind of big factors.
Some people will recommend using these goofy sealants. In theory and in the lab, it works great. Unfortunately, when they’ve actually taken this into the mouth, what happens is they find that the sealants themselves are not very effective. Basically the way that the sealants are constructed, the bacteria actually eats them, and even with reapplication throughout, they have found no difference when you’ve actually taken in vivo studies rather than just in the lab. They found no difference in terms of the actual development of white spot lesions with those enamel sealants. You’ll actually kind of feel them with the scaler. It creates more retention of plaque. It kind of irritates the gums, so it’s not really a good strategy.
Scott Frey 10:39
Some people have considered lingual braces thinking that maybe we put the plaque harboring structures in an area that doesn’t necessarily have the same sugar clearance problems. But I mean, biomechanically, there’s issues with these braces. These have been around for a while, but they’re simply not as effective as labial braces. Without getting into too much detail about the biomechanics as the buccal braces, and they actually produce much much more gingival inflammation because they’re so so hard to clean on the backside of the teeth, and they harbor a lot more bacteria overall. They just happen to be an area that’s not necessarily going to have as much sugar right after meals because it’s on the lingual side of the teeth.
Scott Frey 11:26
You know, really, the best solution is going to be prevention, and that’s what we need to look at and focus on as dental professionals is how we can use the knowledge of how these processes are occurring, so that way we can prevent them from happening or at least limit the problems. So, a couple things: using brackets and appliances that are going to retain less bacteria is key.
One of the things that we use in our practice is a self-ligating bracket. You can see it on the right, as compared to the traditionally ligated brackets on the left. On the left, the wire is retained by those little rubbery, kind of elastics to hold the wire in. They’re a little less effective than a stable door, but they also provide almost like a sponge for these really nasty critters to kind of get soaked up, we have the option of not having to put those on with the self-litigating brackets. And with patients with poor hygiene, we will not really decorate the brackets with colors, and that makes things a lot more clean. And there’s been multiple studies showing that less bacteria is present. The phenomenon known as braces breath is less significant with the self ligating brackets versus the ones that are traditionally ligated.
So that is helpful, but we want to make sure that we’re individualizing our interventions because no two patients are alike. Some people are at high caries risk already, and we know this before treatment based on their dental history and what we’re looking at. But we also want to utilize some of these things that we know to our advantage. So, if the sugar clearance is being impaired by the presence of braces, if we provide favorable sugars like xylitol, we provide probiotics in the mouth, that will have a beneficial effect and will prevent more virulent bacteria from forming.
Scott Frey 13:26
We also want to increase available calcium, so the calcium-rich toothpastes are fantastic, and then we want to facilitate quick rinsing after meals. So using an alkaline-based mouthwash, or could just do baking soda and water, simple water to flush things out will be helpful. One of the things that I recommend for patients is there’s little like diabetic chewables of probiotics that people can use. You get basically a two-month supply, and you’re able to go ahead and just kind of chew them up, let them rub around on the braces, and that will, because there’s xylitol in them, help drive the growth of non-cariogenic bacteria. Yogurts like probiotic yogurts, especially Stonyfield, are an excellent choice as well. All you really need is about eight ounces, like one little cup of the yogurt a day to reduce the acidity of the biofilm around brackets, and they validated that in several studies.
Scott Frey 14:31
We want to make sure we’re facilitating better hygiene, so things like a water pick, little tools that we can use to get in and around the braces to remove the plaque as much as possible is essential, and that’s something we’ve always done. I mean, every orthodontist is giving out things to kind of care for the braces, but we need to focus more on increasing available calcium. You know, cheeses, other things within the diet. If they can tolerate yogurts, and then xylitol is super helpful. And then obviously we recommend more frequent dental cleanings, about every three to four months, especially when they’re in braces so we can both stay on top of things.
Scott Frey 15:11
But there is the option of being able to kind of sidestep all of these issues, and one of the reasons why we’ve gotten some comfortable with clear liner therapy is it does not suffer the same problems as the braces, so it has a much much lower propensity for white spot lesions.
And in fact, in a teenage sample, only less than 1% of all teeth in teenage patients developed white spot lesions when they were in Invisalign treatment. Now, certainly, somebody if they’re swishing around with Mountain Dew and different things, and keeping that like in their mouth with really sugary drinks is not great, and it kind of defeats the purpose. But the reason why there’s this huge difference between something like Invisalign and braces in the terms of development of white spot lesions is because there is no appliance that’s harboring this bacteria for an additional 10 minutes. But if you are drinking very sugary, very acidic drinks with the aligners in, and this goes for like occlusal splints. This goes for lots of other appliances that will retain sugary liquids or acidic liquids. You can see kind of erosive lesions develop because you’re just kind of holding that up against the teeth. So if somebody is having a sugary drink, a little sip of something with the aligners in, they can take them out, but that kind of sacrifices wear time. So we’ll have them use a straw or flush out with water to make sure that everything is getting cleared. We want to bring their attention to that, so that way they don’t have some issues. It’s really rare that we’ll ever see something like this, but it certainly is possible. And if someone had braces, you’d see similar lesions that they were basically drinking Mountain Dew all the time, but they would look a little different than these erosive lesions that you’ll see by just having it sit underneath an aligner or a splint.
Scott Frey 17:09
So when we’re talking about best practices with clear aligner therapy, we want to limit eating while wearing the aligners. Maintain good overall hygiene, so that way there’s not just fuzzy teeth sitting under these trays all the time. We want to regularly clean the aligners, and that’s something that we go over with patients. The aligners themselves can actually be used to deliver chemotherapeutics to the teeth. So, I mean, they’re a great bleaching tray. You can bleach when the attachments are on. It goes down and underneath.
Scott Frey 17:40
They’ve shown this in several studies that you’re not going to get like leopard spots by doing it throughout Invisalign treatment. But you can also use it to deliver MI paste, like a thin coating to help remineralize in a similar way that we would want to do in office, and then selecting attachment materials that reduce adherence of cariogenic bacteria. Tetric has been shown the EvoCeram is a great material. That one has been shown to kind of have less adherence to a lot of these cariogenic bacterias as compared to other attachment options. So those are the kind of things and best practices to follow during clear aligner therapy.
Scott Frey 18:23
Now, what happens if we do all these things right, and we’re on the other side of treatment? We’ve got some white spot lesions, and we want to fix them. What are the best current solutions on the market for treating these lesions after the fact?
Well, the studies have shown that resin infiltration systems like Icon are very effective and they can conceal white spot lesions.
But being able to combine those resin infiltration systems with these special remineralizing peptides like Curodont, will allow us to get the maximum benefit from these remineralization therapies. There’s ones out there where they’re using almost like acid abrasion or mechanical abrasion to kind of buff out the lesion itself. But the reason the Curodont is so fantastic is because it’s not trying to buff out the lesion. It’s actually remineralizing from the inside out. So it uses a special peptide. It’s called P11- 4, and what that does is you paint it on the tooth, and leave it there for about five minutes, and then over the next several months, it is going to continue to draw in more calcium, more phosphate ions to start remineralizing from the base of those lesions. So once you have that benefit, now that lesion itself is going to be far more treatable with a resin infiltration system to go ahead and mask the lesion that’s present. If they’re really, really severe, I mean, you’re almost talking about a restoration. But for small ones, this approach is excellent and it works quite well.
Scott Frey 20:08
So I hope everyone had a really great time on this quick little talk that we had about white spot lesions. Obviously, if you have any questions. Don’t hesitate to reach out to our practice. We can provide some additional clarity. But I’m hoping that this was some really useful information for everybody that we work with here in the area. Have a great day. Thanks.
