Post-orthodontic white spot lesions – lack of reliable evidence for management strategies


White spot lesions (WSL) are common side effects of orthodontic treatment with fixed appliances with prevalence being reported to be as high as 70%.

The aim of this review was to examine the current evidence of effectiveness for clinical methods using remineralizing agents or minimal-invasive techniques to manage post-orthodontic WSLs.


Searches were conducted in the PubMed, The Cochrane Library, Citation Trip and Clinical databases for original studies and ongoing research.English language controlled clinical trials (randomised or non-randomised) involving more than 20 patients and with a minimum follow up period of 8 weeks were considered.

Two reviewers extracted data and assessed study quality independently. The Cochrane risk of bias and AMSTAR tools were used to assess study quality. No pooling of results was possible due to study heterogeneity.


  • 7 publications describing 8 clinical trials were included
  • 5 involved remineralising agents, 2 resin infiltration and I microabrasion. One study involved both remineralising agents and microabrasion.
  • 6 of the trials were considered to be at high risk of bias and 2 at low risk
  • All WSL management strategies including ‘no treatment’ seems to result in lesion regression or visual masking of the lesions however the quality of evidence for all technologies was graded as very low.


The authors concluded

There is a lack of reliable evidence to support remineralising or camouflaging strategies to manage post- orthodontic WSLs. Since daily use of fluoride toothpaste cannot be withdrawn for ethical reasons, this must be considered as best clinical practice. Further well-conducted controlled clinical trials with extended long-term follow-up are needed to establish best clinical practice.


This review is an update of 2011 review of this topic by the same research group, which focuses on the post orthodontic treatment of WSLs. While all the included studies have been published since that earlier review all but 2 are considered to be at high risk of bias. In addition they are all of short duration (max 6 months) and relatively small in size with the largest including 95 patients.

The 2013 Cochrane review by Benson et al (Dental Elf – 27th Jan 2014) considered interventions to prevent WSLs during treatment. That review only included 3 studies finding moderate evidence from a single study that fluoride varnish applied every six weeks at the time of during treatment is effective.   At present these reviews highlight that we currently have little reliable evidence regarding the best way of prevention and management of WSLs and that there is a need for high quality studies of appropriate size and duration to clarify the evidence.


Primary paper

Sonesson M, Bergstrand F, Gizani S, Twetman S. Management of post-orthodontic white spot lesions: an updated systematic review. Eur J Orthod. 2016 Mar 30. pii: cjw023. [Epub ahead of print] Review. PubMed PMID: 27030284.

 Other references

Dental Elf – 27th Jan 2014 – Moderate evidence that fluoride varnish applied regularly during orthodontic visits reduces enamel demineralisation

Dental Elf – 18th Feb 2014 – Study finds that high-fluoride toothpaste can reduce white lesions around orthodontic brackets

Dental Elf – 18th Jul 2013 – Sealant use had a small preventive effect on white spot lesions following orthodontic treatment

Dental Elf – 8th Mar 2013 – Lack of reliable evidence for the effectiveness of remineralizing agents for the treatment of post-orthodontic white spot lesions

Dental Elf- 18th Jan 2013 – Trial suggests that regular brushing as effective as MI paste or fluoride varnish in reducing white spot lesions post orthodontic treatment

Dental Elf – 9th Nov 2011 – MI Paste Plus helped prevent the development of new white spot lesions during orthodontic treatment


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