An occasionally irregular blog about orthodontics

Oh no, we have white spot lesions on debond: What should we do?

Oh no, we have  white spot lesions on debond: What should we do?

Oh no, we have white spot lesions on debond: What should we do?

Unfortunately, we are all familiar with the problem of white spot lesions when we debond patients. Over the years I have tried many techniques and treatments to attempt to treat them, with mixed success.  This new clinical trial provides us with useful information about applying topical Fluoride to reduce white spot lesions (WSL).

1024px-Sodium-fluoride-unit-cell-3DComparative assessment of fluoride varnish and fluoride film for remineralization of postorthodontic white spot lesions in adolescents and adults over a 6-month period: A single-center, randomized controlled clinical trial

T.He et al

AJO-DDO 2016: 149: 810-819.  Doi: 10.1016/j.ajodo.2015.12.010

When a WSL occurs the most logical management strategy involves methods to encourage remineralisation. This is commonly done by applying a Fluoride varnish.  The authors suggest that there is a lack of reliable evidence to support the effectiveness of remineralising agents. However, they did not reference a Cochrane review that was published in 2013 (see this post). This concluded that the application of Fluoride varnish was an effective measure in reducing WSLs.  Nevertheless, this new study does add to the knowledge on this important issue.

What did they do?

They carried out a really nice RCT in which they screened 382 patients who had recently completed a course of orthodontic treatment.  They identified those who had at least one maxillary anterior tooth with a WSL.  This resulted in a sample of 240 patients who were randomly allocated to one of three interventions. These were were applied monthly at the clinic.

  • Duraphat varnish
  • A Fluoride film
  • A placebo toothpaste that did not contain any Fluoride.

They examined the participants at baseline, 3 and 6 months and took quantitative light-induced fluorescence (QLF) images of the anterior teeth.

The primary outcome was the volume of the decalcified lesion. They presented data on other measurements, but as I want to be brief, I will only discuss this variable.

They carried out a sample size calculation and blinding, concealment of allocation and randomisation was good. They also carried out a detailed and relevant multivariate statistical analysis.

What did they find?

They reported that

  1. There were no differences between the groups at baseline
  2. 29 (12%) of participants were lost to follow up
  3. The WSL in all the groups improved with time
  4. The application of Fluoride varnish and film resulted in a reduction in decalcification compared to the control.
  5. The varnish was more effective than the film.

What did I think?

This was a well carried out and reported trial.   It was clear that they detected differences in the effectiveness of the interventions.  While these differences were statistically significant, I was not sure on whether they were clinically significant. The authors mentioned this in the discussion and they pointed out that they were unable to relate the QLF measurement to changes that could be seen with the naked eye.  I think that this would have provided us with useful information and it is a shame that they could not do this.  However, if we put this aside I still feel that the study provides us with useful data.

There were also problems with the drop out rate. But this was not considerable and it was distributed evenly across the groups. This means that the risk of bias is somewhat reduced.

In summary, this was a useful and well carried out study. If we combine the results of this with the earlier Cochrane systematic review, we can conclude that when a patient has white spot lesions we should treat this with a monthly application of Fluoride, either in varnish or film form. I will certainly be doing this the next time that one of my patients has a WSL.

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There Are 15 Comments

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  1. Nice blog. Do we have an objective measure for how bad it has to be before we are justified in ending the treatment early? Or obliged to?

  2. Polly Muir says:

    This would be supported by the evidence for Fluoride varnish application in general coal-face dentistry, with the regular application of Fluoride recommended at check up intervals. The role of regular Fluoride mouthwash has not been mentioned here, nor has Tooth Mousse with Fluoride. The interval of one month is interesting as most patients might attend every 6-8 weeks. We also have discovered recently, from one of our vigilant Mums, that varnish has a small amount of alcohol in it. We have been reassured that this is not a problem for Muslims. Caution is also advised with asthmatics. I always understood that, whilst the Fluoride will remineralise the lesion/s, the white appearance remains. Has anyone used the recent product that is designed to disguise white spot lesions? I understood that if Fluoride products were used to strengthen & re-mineralise lesions, the white appearance could not then be reversed.

  3. Clemens says:

    Best method I have used is ICON. But beware, you have to have perfect and deep etching and good infiltration at the first time, otherwise the surface (and a little below the surface) is blocked with composite for future treatments.

    Did only use it several times (some with exellent result, other with moderate result), but I don’t use it anymore because I can’t charge any of my cost to the patiënt. This stuf is too expensive and time consuming to do it for free. I do transfer severe patients to their regular dentist, they can apply it as well and also charge for it.

  4. Ashley Smith says:

    What about using Tooth Mousse?

  5. David M Lebsack says:

    What about resin infiltration?

  6. Andrew L. Sonis says:

    The effects of fluoride varnish did result in significant reminerialization. However, these authors did not look at the clinical appearance of the white spot lesion. Several previous studies have demonstrated that arresting the white spot lesion with fluoride varnish results in a persistent esthetic problem. Additionally, several studies have shown allowing ~8 weeks post debonding without intervention will result in a clinical improvement in the appearance of the lesion. Consequently, as long as the surface enamel is intact, deferring the application of fluoride varnish for 8 weeks post debonding maybe the best approach.
    Obviously the absolute best approach is to prevent WSL in the first place. I would suggest that fluoride varnish be applied at each adjustment visit. This takes little chair time and cost is minimal.

  7. Andrew Adey says:

    Interesting. Has anyone used the Duraphat 2800 toothpastes for this?

  8. This is interesting and contradicts what I understood, which is that additional fluoride should be avoided post-debond as it helps with remineralisation but can turn the demineralised areas brown. My current recommendation is tooth mousse without fluoride, based on a study presented at the BOC a few years ago. I’d like to see more studies on this, especially if they were to focus on the clinical appearance.

  9. John Daskalogiannakis says:

    What about products like MI Paste that are milk protein derivatives that claim to achieve re-calcification? I did a quick search on the blog and could not find any research review of such products.
    Thanks for the great blog!

  10. Scott Bingham, DMD, MPH says:

    Has any studies been done using MI Paste for its effectiveness in remineralizing white spot lesions?

  11. Helen says:

    I am concerned that one group had no fluoride in their toothpaste. Given that they had white spot lesions it is possible that they have a cariogenic diet and not using a fluoride toothpaste for several months would out them at risk of developing new lesions.
    I would have liked to have seen a group included who used a regular 1500ppm fluoride toothpaste.

  12. Polly Muir says:

    May I just remind fellow ‘Posters’ that at the BOC September 2015, there was a presenter who said that he used to promote and sell GI Mousse: he now gives it away, as he felt it was ineffectual. I fail to remember the clinical grounds and the evidence base for this. Perhaps someone can jog my memory. This product has been advocated by the Paedodontists for, in particular, hypoplastic teeth and remineralisation of early carious lesions. As previous bloggers have commented, it works without sustaining the poor aesthetic appearance associated with WSL and application of Fluoride.
    What evidence do the australians have? It’s an Aussie product!!!
    The cost of applying Fluoride regularly? It may be worth it for the high risk patient.

  13. Philip Benson says:

    It is extraordinary that, for what is a relatively common side effect, we have so little evidence about how to prevent and treat demineralisation occurring during fixed appliance treatment (although I think there is also an issue of the closer you look the more you find).

    After carrying out a systematic review into the most effective way of increasing the availability of fluoride for prevention during treatment, I have used RM-GIC for bonding on all my patients. We are just analysing the results of an RCT, comparing it with composite and have found that bond failure rates are very similar. We hope to have data about demineralisation soon. The RCT was carried out in 6 centres, 4 of which were specialist practices.

    Whenever I give a talk about this now, I say that we could answer these questions (and many others) quite quickly if academics and clinicians team up to undertake more trials and collect more data in specialist practice. After all this is where most patients are treated.

  14. Kevin, Thank you for a nice information.
    I also want to start a monthly application of Fluoride to my patient with WSL.

  15. Kevin, thank you for a nice information.
    I aslo want to start a monthly application of Fluoride to my patient with WSL.

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