An occasionally irregular blog about orthodontics

Oh no! More white spot lesions..what can we do? A new trial….

By on October 17, 2016 in Clinical Research, Recent posts with 9 Comments
Oh no! More white spot lesions..what can we do? A new trial….

Oh no more white spot lesions..what can we do: A new trial!

We all know that white spot lesions (WSL) are one of the disappointing  adverse effects of orthodontic treatment. Unfortunately, we do not know much about methods of reducing the size of these lesions.  This post is about a trial that provides us with some more information.

I have posted about this problem previously.  In these posts I concluded that the application of Fluoride had a small effect on reducing the size of WSL.  This new trial has been published recently in the European Journal of Orthodontics.

Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months—a randomized placebo-controlled clinical trial.

Niko Bok et al

European Journal of Orthodontics, 2016, 1–10


A team from Giessen, Germany did this study.  They published the study in two parts.  I thought that there was a large amount of repetition between the two papers. I have, therefore, combined them into one post.

What did they do?

They did this study to find out if applying high concentration Fluoride reduced white spot lesions.

The team ran a single centre placebo controlled double blind RCT. The PICO was

Participants: Patients with a least 1 WSL on debond

Intervention: Professionally applied Fluoride paste

Comparison: Placebo gel

Outcomes:  Size of WSL (Part 1), modified white spot index

They carried out a good allocation sequence generation, concealment, blinding and sample size calculation..

Trained operators applied the high dose Fluoride (1.25%F) gel or the placebo to the teeth that were affected by the WSL.  They did this at 1, 2, 6, 12 and 24 weeks after debond.

At each visit they took records and a large amount of data.

What did they find?

The enrolled 46 patients into the trial and they divided these equally between the two interventions. At the end of the study they had 21 in the Fluoride and 18 in the placebo group.

There were no differences between the groups at the start of the treatment.

In paper 1, they did not find any differences between the groups in the size of the WSL.

They reported mostly on the use of a WSL index in paper 2.  I thought that the results in this paper were difficult to understand because they presented a large amount of data on many variables (WSL index, plaque index, DMFT, salivary flow etc).  In any case, they concluded that the application of high dose Fluoride had no effect on anything that they measured.

What did I think?

I felt that this was a good study.  Nevertheless, I found it difficult to interpret because they published it in two parts. This meant that there was a large amount of duplication of information between the papers.

In earlier blog posts I pointed out that there was a small effect of the application of Fluoride on WSLs. Several people joined in the discussions and mentioned that the investigators had not looked at the visible extent of the lesions. The authors of this paper have rectified this issue.

There have now been several studies on this problem and I have to say that I am disappointed with the results. This is because I can only conclude that the application of Fluoride varnish does not result in the resolution of white spot lesions.

As a result, the only useful clinical recommendation that I can make is that we need to go back to the basics and try to prevent the problem.  This, of course, is easier said than done!

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There Are 9 Comments

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  1. Ross Hobson says:

    Prevention is the best cure : possibly part of the problem is that the ‘incidence’ papers (usually reporting around 33% of patients affected) are now rather old and in a time when poor oral hygiene was tolerated. We audited our clinics for visible WSL (as after all that is what the general public worries about) and it was less than 5%.
    I wonder is WSL ‘management’ a solution now looking for a problem?

  2. David M Lebsack says:

    Could you please investigate resin infiltration. A product called Icon has been on the market for some time now.

  3. Tony Kilcoyne says:

    Dear Kevin,

    One of the big advantages of providing ‘Fast’ Orthodontics treatment times, is of course the reduction in time/opportunity for demineralisation of teeth (amongst other side-effects that increase exponentially once treatment extends beyond 12 months) and their health and/or cosmetic sequelae!

    It’s all part of the fully informed consent process I guess, but totally agree about prevention/reduction being the best option we have.

    Yours Optimally,

    Tony Kilcoyne.

  4. Scott Arbit says:

    Kevin, Thank you for another excellent report!
    Ross, Please share some tips to help improve oral hygiene in our practices.

  5. Is there any information to say that if the patient has braces, will the varnish prevent the lesions from becoming worse? Thank you. Love your blog.

  6. In one part of the blog post it says the title was

    Changes in white spot lesions following post-orthodontic weekly application of 1.25 per cent fluoride gel over 6 months—a randomized placebo-controlled clinical trial.

    Niko Bok et al

    and later on it says Fluoride was applied ” at 1, 2, 6, 12 and 24 weeks after debond.” Which isn’t weekly.

    I agree with Ross’ comment about prevention is the best cure, and by that measure I probably do “tolerate” bad oral hygiene, depending on the definition of “tolerate”. I tell patients to brush their teeth, then tell them what happens if they don’t. And when they don’t I repeat this process, but I don’t remove the braces for bad oral hygiene alone – do we have an objective measure, or even a shared measure amongst orthodontist for when we can do this without repercussion when the ortho isn’t finished?

  7. joel levin says:

    I have no way of proving this, but my long time of experience leads me to think that the most critical time is the first two weeks after the anterior brackets are placed. If the hygeine is good then there is a reasonable chance that it will remain so for the rest of treatment.If it is not good from the start, by the next visit decal has already started.
    we use LED Proseal(Reliance) which is a good protective layer before bonding the brackets.there is also Plaque HD which is fluoride toothpaste with a disclosing agent. Prevention is definitely the key

  8. noel Stimson - editor Cranio UK journal says:

    So far as I am aware, topical fluoride is intended primarily to increase resistance to demineralisation, so there is not a lot of sense in applying it after the WSL have occurred. The word ‘prevention’ has been mentioned several times in this blog, so why not try applying fluoride before the brackets are placed? If so, what lead time would be effective?

    Although I am not a great fan of fluoride for ecological and health reasons, at least this would be a more logical application of the preventive principle.

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