Can’t Stop Seeing White Spots? Focus on Prevention

After a year or more of braces, brackets or aligners, patients get anxious to see their new, beautiful, straight smile. However, one unanticipated result can throw a wrench in the works: white spot lesions. These milky white splotches on the teeth are not only esthetically upsetting but are also a sign of damaged tooth structure.

What are white spot lesions?

In the simplest terms, white spot lesions (WSLs) are an early sign of decay. The milky white discoloration is where enamel has demineralized, usually due to prolonged plaque accumulation and acid attack. While WSLs can occur on any tooth surface in the mouth, orthodontic treatment can exacerbate the issue. In fact, the odds of new, clinically visible WSLs during orthodontic treatment are very high, ranging from 40-70%.^1,2 Why? Unfortunately, fixed orthodontic appliances create areas that are difficult to clean and hinder the mouth’s ability to self-cleanse with mineral-rich saliva. This means plaque and food debris can accumulate easily, and over time, cause white spot lesions. And compared to the length of typical orthodontic treatment, WSLs can develop quickly. Thirty-eight percent of patients will experience at least one white spot lesion within the first six months of treatment, and that number balloons to 46% after only one year.³ While all teeth are potentially at risk, patients may particularly notice WSLs on maxillary lateral incisors, canines, premolars and central incisors.⁴ WSLs are non-cavitated carious lesions – which means, if left untreated, these white spots have the potential to progress to a more advanced stage and cause real damage. This puts patients receiving orthodontic treatment at moderate to high risk for caries, as classified by the American Dental Association, and in need of extra attention and advanced care.⁵

What about clear aligners?

Clear aligners aren’t necessarily in the clear

While clear aligner patients experience fewer overall white spot lesions (up to 25% fewer than traditional orthodontics), they’re still at risk.^6,7 Wearing aligners 22 hours per day, as recommended, limits the natural cleansing and neutralizing effects of saliva. Due to the unique fit of aligners, these WSLs tend to occur in posterior areas or on incisal edges.^6,7

Assessing white spot lesions

Assessment of WSLs should happen before, during and after treatment. It can be a challenge, but is critical to preventing, halting and reversing early lesions – and to setting your patients up for better long-term oral health. To begin, standard risk assessment strategies can help uncover underlying problems. Patients who have poor oral hygiene, partake in frequent snacking (this includes food and drink), currently have caries or have had restorative treatment previously are considered particularly high risk. Age is also important to take into account. Traditional orthodontic patients are tweens and teens who may not yet have developed effective hygiene routines or be motivated to take oral hygiene seriously. It’s also important to remember that orthodontic patient demographics have changed dramatically over the years. More and more adults are receiving orthodontic treatment and adults come with their own history of risk factors, including existing conditions that could exacerbate white spot lesions. From here, you can address specific orthodontic risks. The main contributors to this condition are:

• Orthodontic treatment time of 36 months or more
• Poor oral hygiene prior to treatment
• Changes in home care during treatment
• Existing white spot lesions prior to treatment

Helping patients make a change

How do you help educate and empower patients to improve oral hygiene? Start by recognizing and respecting the unique circumstances that can not only impact patients’ oral health, but also their drive for change. When you understand their perspective, you can help guide them to a better path. Dentists and orthodontists both have a tendency to tell the patient to “brush better,” but this doesn’t convey why the patient should care or how they can overcome their specific challenges. Plus, it puts all the burden on the patient – which can be daunting and actually discourage compliance. So how do you get patients to change? It starts with effective, open communication: Provide a safe environment for the patient to share: For many patients, visits to the dentist’s office can cause anxiety – but there are ways to build trust and help them feel safe and comfortable during their appointments. Make sure that your entire team is on the same page in helping your patients feel welcome and supported every step of the way. Practice active listening: The more patients feel heard, the more willing they’ll be to open up and share. Stay engaged in the conversation, pay attention, and show that you’re listening with open body language, eye contact and verbal and nonverbal feedback. It’s important to note that patients don’t just communicate with words, but also with body language and tone. Watch for signs of anxiety like fidgeting or speaking rapidly, so you can help relieve or reassure them. Use accessible, respectful language and tone: Patients don’t want to feel judged, patronized, or scolded for their habits. They want to know you’re there to work with them for their health. Engage with patients as an equal partner by having a conversation rather than giving a lecture. Make sure to use language and vocabulary that the patient can understand and verify patient understanding when discussing complex concepts or treatments. Above all, don’t frighten patients. While there are consequences to poor oral health, going into long-term health effects can be especially scary for teens and might make them shy away from orthodontic treatment altogether. Approach these topics carefully, and lead with the positive – a healthy, beautiful smile. Use open ended questions: Open-ended questions allow you to explore what the patient already knows and helps them reflect on the possibility for and value of change – before you even offer treatment options. Instead of lecturing, ask questions and invite collaboration: “Tell me more about how you take care of your teeth. If you could change one thing, what would it be?” The focus is on figuring out together what will work for the patient as an individual. Repeating or rephrasing can help you and your patient get on the same page. For example, “What I’m hearing is…,” “You’d like to… is that right?”, or “So what you’re experiencing is…” This both demonstrates that you’re listening and helps you get to the heart of the issue. From there, you can offer advice or recommendations from a collaborative, informed position that doesn’t feel judgmental or unsolicited. Identify the patient’s readiness to change: Through the questions you ask, you can gauge where the patient is in terms of change. Some patients will be ready to follow your advice, while others may resist it or doubt their ability to change. Some may not recognize the value in modifying their habits at all. If you can find where they are on this spectrum, you can better address their situation. Enable the patient to create their own goals: Rather than overwhelming your patients with a laundry list of behaviors to change, work together with them to select one or two behaviors to focus on first. Help them set measurable, achievable goals between appointments – and make sure to celebrate small successes, even if the patient has trouble achieving them. And the more successes they have under their belt, the more confident they’ll be working toward additional goals. Get them involved and active in their own care: Give your patients tools to help them review skills (such as how-to videos or pamphlets) and track their experience and progress (such as with intraoral photos, calendars or worksheets). This can help them pinpoint specific behaviors, actively see change and motivate them to continue improving. Keep in mind that open communication takes practice – and it isn’t the same for every patient. Regardless of your mastery, taking a CE course designed to help you develop and improve your communication skill could help improve patient acceptance, loyalty and confidence.

In-office and at-home therapies: a winning combination

Getting a patient to change their routine isn’t easy. That’s why it’s important to use a combination of in-office treatments – that take the responsibility out of the patient’s hands – and easy-to-use, at-home products that fit into patients’ daily routines.

In-office

When you have vulnerable patients in the chair, it’s important to give them a boost of caries protection wherever you can. It’s recommended that patients at moderate to high risk for caries receive a professional, in-office fluoride treatment four times per year. In addition, special protective coatings can be applied around traditional orthodontic brackets to protect the tooth where it is most vulnerable.

Home

Instead of blaming the patient for not taking care of their teeth well enough, give them the tools to overcome the problem. Using a prescription-strength fluoride toothpaste every day, in place of regular toothpaste, can help halt or reverse early lesions. In addition, utilizing over the counter fluoride rinses can help boost fluoride exposure to the tooth surface – and is likely something that patients can easily incorporate into their routine. Patient Risk Assessment Form, (PDF, 405 KB) Fluoride Treatment Protocols Based on Patient Risk Assessment, (PDF, 801 KB)

Home care routines matter

Orthodontic appliances are difficult for patients to keep clean. But home care routines make all the difference. Poor pre-treatment homecare doubles the risk of white spot lesions, and poor homecare during treatment triples the risk.⁸ While these statistics alone may help patients understand the importance of establishing and maintaining a routine, they may need help understanding how to keep their teeth clean and healthy during treatment. Some tools that may help you help your patient include:

• Taking a plaque index to find out a baseline and compare status over time
• Disclosing agents that help patients see problem areas
• Intraoral photos to document and demonstrate areas of concern—or areas of success

The tell-show-do method is an effective way to assess and retrain patient toothbrushing and interdental cleaning routines. First, tell the patient what you’d like them to do. Then show them how you would like them to do it – and finally, let them do it in front of you to demonstrate their understanding.

Changing mentalities, changing smiles

While dentists know that WSLs are early decay, orthodontists don’t always think of them in those terms. All too often, each type of practice assumes the other will take charge of white spot lesions – in effect, making it the patient’s responsibility to pursue a solution. The reality is that white spot lesions are a problem for everyone involved. Both dental and orthodontic practices should look at white spot lesions in a new light: as part of the patient’s experience and long-term oral health. After all, these are your lifelong patients and we’re all on the same team! Dental professionals, dentists and orthodontists alike can help take the burden off patients by offering proven in-office treatments, equipping patients with effective, easy to use products at home, and keeping each other informed of their patients’ challenges and treatment progress. By working together and empowering our patients, we can ensure healthier smiles.

Conclusion

White spot lesions can affect the esthetics and the long-term health of the tooth. You can set your patients up for success by helping them with their home care routines and using a combination of in-office and at home therapies to help your patients achieve the best long-term results.