White-spot lesions. - The earliest visible sign of tooth decay.

Why they form. / Where they occur- Near the gum line, Around dental braces. / Pictures / Prevention / Treatment

1) What are white-spot lesions?

White-spots are an early stage of tooth decay formation. They're the first one that can actually be visualized.

White-spot lesions on teeth.

a) What do they look like?

True to their name, these lesions have an opaque, chalky-white appearance. The affected areas have a lighter color than the normal tooth enamel that surrounds them.

b) Where do they form?

Since they're caused by the decay process, you can expect to find white spot lesions in those areas where dental plaque has been allowed to accumulate. As examples:

  • It's very common to see them form right at a tooth's gum line, a location people often miss when brushing. (See picture above.)
  • Since dental braces can be hard to clean around, they sometimes form next to where a person's orthodontic brackets have been bonded to their teeth. (See picture, as well as more discussion about white-spot risks with braces, below.)

c) What causes white spot lesions to form?

They're caused by tooth demineralization. (The process that causes cavities.)

The demineralization process results in the loss of mineral content from tooth enamel. And as a result, it undergoes a visible change in appearance. It looses its gloss and shine and takes on a lighter chalky-white, more opaque, coloration.


2) Concerns about white spot formation when dental braces are worn.

The formation of white-spot lesions can be especially troublesome for dental patients who wear conventional bracket-and-wire (fixed) braces.

White spot lesions form around braces where dental plaque is allowed to accumulate.

White spot lesions that have formed around orthodontic brackets.

a) What's the basis of this concern?

Having fixed appliances makes it exceedingly difficult for a person to clean their teeth.

And if dental plaque is allowed to persistently accumulate around their brackets (the part that's bonded directly to their teeth), white-spot lesions may form.

However, the tooth enamel that lies underneath the bracket will remain unchanged. When the braces are taken off, the color difference between the damaged and undamaged enamel can be very obvious.

b) The appearance of the teeth may be spoiled.

As bad as it is to have white spots form, this situation is complicated by the fact that the teeth involved frequently occupy a very visible position in the mouth. And that means the white outlines, showing the original positioning of the orthodontic brackets, will be obvious to all.

Incidence rates.

Arruda (2012) and Dixon (2009) [page references] reviewed studies that had evaluated the prevalence of white spot lesions among orthodontic patients.

White spot lesions resulting from dental braces.

White spot lesions resulting from poor home care while wearing braces.

  • On a whole, rates ranging from 2 to 96% were found to have been reported.
  • A much cited study from 1982 placed the rate at 50%, whereas more recent investigations (2009 and 2007) placed it in the 73 to 95% range.
  • The patient's teeth that are most affected are typically the upper front ones (15%).
  • The teeth most commonly affected are the upper lateral incisors (23%). (The tooth with the largest white spot in our picture is a lateral.)

    Then, in descending order, the canines (eyeteeth), 1st premolars, 2nd premolars and then the central incisors. (Bourzgui 2012)

How quickly do they form?

While the time needed for formation will vary with the local conditions at each specific site, studies suggest that white spot lesions can form in as little as a month. (Arruda 2012)


3) How do you prevent white spots from forming?

a) Better brushing.

Since these discolorations are an early stage of cavity formation, the first line of defense in preventing them is to practice effective oral home care.

Of course, doing so may be easier said than done, either from a standpoint of motivation or technical ability. (The use of an electric toothbrush may help with both.) But bottom line, if no plaque is present or else is removed in a timely fashion, a white spot lesion cannot form.

 

b) Fluoride.

Because the presence of fluoride in saliva assists the remineralization process (the action that helps to reverse the damage caused by tooth decay), making sure you have an appropriate exposure of it can help to reduce your risk for these lesions.

Toothpaste, Oral Rinse

The use of a fluoridated toothpaste can help. In higher risk patients, the use of fluoride mouth rinse (like 0.05% sodium fluoride rinse, available over-the-counter) can be an effective adjunct too.

Of course patient compliance is an important factor. One study investigating this point found only 15% of orthodontic patients rinsed daily as instructed. (Dixon 2009) (Fluoride products must be used appropriately. Their recommendations and directions must be followed.)

Fluoride varnish.

A way of avoiding the need for patient compliance with high risk patients is the application of fluoride varnish. For example, some studies have evaluated its use with patient wearing dental braces.

  • One found a 7.4% incidence rate for white spot formation when the varnish was applied every 6 weeks vs. a 25.3% rate for the placebo group.
  • Another study found a 44.3% reduction in lesions in a group receiving regular applications.

Detracting from this approach is its cost (of materials, for regular application visits). It also causes a temporary discoloration of the teeth and gums (the varnish has a slight tan color).

c) ACP/CPP-ACP products.

Products that contain amorphous calcium phosphate (ACP), frequently stabilized with casein phosphopeptide (CPP), release both calcium and phosphate ions that may then aid in the remineralization process of tooth enamel. If so, their use may help to inhibit the formation of white spot lesions. This theory is not, however, fully supported by research.

d) Consume xylitol products.

Studies have shown that introducing xylitol (a natural table sugar substitute derived from birch trees) into your diet can create a substantial anti-cavity effect.


4) Treating white-spot lesions.

(Only an examination by your dentist can lead to a decision that any particular white-spot lesion should be treated or not.)

a) Some areas may not require any treatment.

White-spot lesions represent a very early stage of cavity formation. One where possibly only a minimal amount of tooth damage has occurred.

How your dentist checks.

One gauge of how much damage has taken place is to see if the tooth's surface is still hard and intact.

  • Your dentist will inspect the white spot with a metal tool. As they do, they will scrape and probe its surface to see if it's still hard and smooth.
  • If it is, tooth remineralization, on its own, may be able to repair the damage that's occurred.
  • However, even if it can, the appearance of the area will still remain chalky-white.
You'll need to change your habits.

Keep in mind that this type of natural repair can only take place if you change the conditions that allowed the white spot to form initially. (Remember: Cavities are usually caused by some combination of ineffective brushing and flossing, and inappropriate sugar consumption.)

Monitoring will be required.

Since they represent an area that at least historically has been difficult for you to keep clean, any and all untreated white-spot lesions should be monitored by your dentist during regular checkups.

b) Unsightly lesions.

While some white spot lesions may not require repair, their appearance may still be objectionable. If so, there are two relatively less-invasive remedies that may be attempted.

  • It may be possible to use teeth-whitening treatments to mask their appearance. As the tooth's color is lightened, it's lesion becomes less noticeable.
  • Microabrasion offers another possible remedy. This is a process where the surface of the tooth is worn down and polished using a hydrochloric acid and pumice mixture.

    One study determined that on average this technique was able to reduce the size of white spots by 83% (Dixon 2007).

Neither approach may give perfect results. But if passable, they can help to avoid the need for an outright repair and the long-term maintenance it will require.

c) Some lesions will require repair.

If the white spot's surface has lost its integrity (it's rough, pitted or possibly has even developed a hole), some type of repair is indicated. If so:

  • A filling (dental amalgam or tooth bonding, depending on the location) is frequently the type of restoration placed.
  • In more severe cases (on front teeth), a porcelain veneer may be needed to fully mask the damage.
 

 
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