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Introduction: The purpose of this literature review is to provide scientific evidence on the characteristics of white spot lesions (WSL) during orthodontic treatment, their incidence, prevalence, risk factors related to their development, progression, and regression, as well as explain the most used diagnostic methods. Materials and methods: An exhaustive search was carried out in the databases of Pubmed, Scopus, Science Direct and Embase up to the date of November 30, 2022. Cross-sectional studies that evaluated white spot lesions before and after orthodontic treatments were included. Two researchers carefully selected the articles evaluated and analyzed different key topics on the subject. Results: It was found that the prevalence and incidence of white spots during orthodontic treatment varies widely depending on the diagnostic method used, the type of orthodontic technique used and the time of orthodontic treatment. The incidence of white spot lesions is highest in patients treated with conventional braces, followed by those who used self-ligating braces, and was lowest in patients who used aligners. The most affected teeth are the upper lateral incisors and upper maxillary canines at the level of the gingival third. Conclusions: The incidence of white spots is associated with orthodontic treatment, being closely related to the treatment technique used and the treatment time. There is a regression of the LMB during the first year after removal of the appliance.

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Abstract The aims of this clinical study were to evaluate the Color change - ΔE (based on spectrophotometry and visual analysis) and luminosity - L* (based on spectrophotometry) of dental enamel surface (after orthodontic treatment) around the area where orthodontic brackets were fixed, based on different cementing materials such as a resin (R group) and resin-modified glass ionomer cement (RMGIC group). The split-mouth study initially comprised 14 patients. Orthodontic brackets were fixed to the upper central incisors with resin or RMGIC. The color of the buccal surface of each tooth was measured through spectrophotometry and visual examination before the bracket-fixation process. Four individuals were excluded during the follow-up; thus 10 patients were evaluated (n=10). Brackets were removed after 12 months of orthodontic treatment, tooth color measurement and visual examination were performed again, and Adhesive Remaining Index (ARI) was also measured. ΔE and L* results were subjected to Student's t-test and by repeated-measures analysis of variance, respectively (α=0.05). ARI data were analyzed in percentages. There was statistically significant difference in ΔE between groups; the R group showed statistically higher values of L* after orthodontic treatment. ARI of 2 and 3 prevailed in the RMGIC group, whereas the R group presented 0 and 1. After orthodontic treatment, the RMGIC group presented smaller changes in ΔE, and the increase in the white scale was observed on the enamel surface around the area where brackets were fixed in the R group. The visual analysis did not show color change on the evaluated teeth.

Resumo Os objetivos deste estudo clínico foram avaliar a alteração de cor - ΔE (baseada em espectrofotometria e análise visual) e luminosidade - L* (baseada em espectrofotometria) da superfície do esmalte dentário (após tratamento ortodôntico) ao redor da área onde os braquetes ortodônticos foram fixados, com base em diferentes materiais de cimentação, como resina (grupo R) e cimento de ionômero de vidro modificado por resina (grupo RMGIC). Estudo boca dividida foi inicialmente composto por 14 pacientes. Os braquetes ortodônticos foram fixados nos incisivos centrais superiores com resina ou RMGIC. A cor da superfície vestibular de cada dente foi mensurada por espectrofotometria e avaliada por exame visual antes do processo de fixação dos braquetes. Quatro indivíduos foram excluídos durante o acompanhamento; assim, 10 pacientes foram avaliados (n=10). Os braquetes foram removidos após 12 meses de tratamento ortodôntico, a mensuração da cor do dente e o exame visual foram realizados novamente, e o Índice de Remanescente do Adesivo (IRA) também foi mensurado. Os resultados ΔE e L* foram submetidos ao teste t de Student e à análise de variância para medidas repetidas, respectivamente (α=0.05). Os dados do ARI foram analisados em porcentagens. Houve diferença estatisticamente significativa no ΔE entre os grupos; o grupo R apresentou valores estatisticamente maiores de L* após o tratamento ortodôntico. O IRA 2 e 3 prevaleceu no grupo RMGIC, enquanto o grupo R apresentou 0 e 1. Após o tratamento ortodôntico, o grupo RMGIC apresentou menores alterações no ΔE e o aumento da escala branca foi observado na superfície do esmalte ao redor da área onde os braquetes foram fixados no grupo R. A análise visual não mostrou mudança de cor nos dentes avaliados.

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BACKGROUND: The first clinically detectable stage of caries lesion is a non-cavitated white spot lesion (WSL). The detection of early stages of caries lesions allows non-invasive management by fluoride usage, oral hygiene and diet control. There is a lack of information in the literature regarding the prevalence of these caries lesions in preschool children, which is important especially for public health strategies. OBJECTIVE: The aim of this study was to conduct a systematic review with meta-analysis to verify the WSLs prevalence in primary teeth of preschool children. METHODS: A literature search with MEDLINE/PubMed, Scopus, Web of Science, and Open Gray databases was conducted. Included studies fulfilled the eligibility criteria. Meta-analyses were performed using random effects model, for prevalence of pooled WSLs and subgroups analyses. RESULTS: The search strategy identified 4922 potentially relevant articles, with final inclusion of 16 studies. The pooled prevalence of WSLs in primary teeth was 14.0% (95% CI: 8.0-24.0), without publication bias (p=0.2668). For subgroup analyses, an increase in WSLs prevalence for children of low-income economy (24.0%; 95% CI: 20.0-28.0), for age >31 months (22.0%; 95% CI: 12.0-37.0), for validated visual criteria assessment (20.0%; 95% CI: 11.0-33.0), and for tactile assessment with ball-ended probe (26.0%; 95% CI: 11-50.0) were detected. CONCLUSION: It is suggested that the prevalence of WSLs in primary teeth of preschool children increases in countries with low income economy, with age greater than 31 months or texture assessment with visual validated criteria or ball-ended probe. PROSPERO Registration: Protocol number #CDR42017078434.

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Objective: To comparatively evaluate the effect of resin infiltration, bleaching and bleaching followed by resin infiltration on the surface roughness and microhardness of human enamel with induced white spot lesions (WSLs) and their resistance to acidic challenge. Material and Methods: Sixty human specimens were randomly divided into three groups (n=20) according to the treatment modality applied; group I Icon® resin infiltration, group II bleaching and group III bleaching followed by Icon® resin infiltration. For each treatment modality, 10 specimens were tested for surface roughness and another 10 for microhardness. WSLs were artificially induced in all specimens and after treatment, all specimens were subjected to acidic challenge. Surface roughness was measured by the tapping mode of the atomic force microscope (AFM) and microhardness was measured by digital Vickers hardness tester at baseline, after induction of WSLs, after treatment and after acidic challenge. Results: Groups I and III showed significant reduction in surface roughness after treatment, while group II showed significant increase. Groups I and III showed significant increase in the microhardness after treatment, while group II showed insignificant increase. The three tested groups showed significant increase in surface roughness values and significant reduction in microhardness after acidic challenge. Conclusion: Resin infiltration and bleaching followed by resin infiltration reduced the surface roughness and enhanced the microhardness of the WSLs. The three treatment modalities failed to resist acidic challenge resulting in increasing surface roughness and reducing microhardness. (AU)

Objetivo: Avaliar comparativamente o efeito do infiltrante resinoso, clareamento e clareamento seguido de infiltração resinosa sobre a rugosidade e microdureza superficial do esmalte humano com lesões de manchas brancas induzidas (WSLs) e sua resistência ao desafio erosivo. Material e Métodos: Sessenta espécimes humanos foram divididos aleatoriamente em três grupos (n = 20) de acordo com a modalidade de tratamento aplicada; grupo I infiltrante resinoso Icon®, grupo II clareamento e grupo III clareamento seguido de infiltração resinosa Icon®. Para cada modalidade de tratamento, 10 corpos-de-prova foram testados para rugosidade superficial e outros 10 para microdureza. WSLs foram artificialmente induzidos em todas as amostras e, após o tratamento, todas as amostras foram submetidas ao desafio erosivo. A rugosidade de superfície foi medida por microscopia de força atômica em modo de contato intermitente (AFM) e a microdureza Vickers foi medida inicialmente, após a indução de WSLs, após o tratamento e após o desafio ácido. Resultados: Os grupos I e III apresentaram redução significativa da rugosidade superficial após o tratamento, enquanto o grupo II apresentou aumento significativo. Os grupos I e III apresentaram aumento significativo na microdureza após o tratamento, enquanto o grupo II apresentou aumento insignificante. Os três grupos testados mostraram aumento significativo nos valores de rugosidade superficial e redução significativa na microdureza após o desafio erosivo. Conclusão: O infiltrante resinoso e o clareamento seguido de infiltração resinosa reduziram a rugosidade de superfície e aumentaram a microdureza dos WSLs. As três modalidades de tratamento falharam em resistir ao desafio erosivo, resultando em aumento da rugosidade de superfície e redução da microdureza.(AU)

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Objective: To compare optical, morphological, chemical, and physical aspects of the sound enamel and white spot lesions (WSL) classified as ICDAS 2. Material and Methods: Seventeen human molars with one surface presenting WSL and a sound surface (2 x 2 mm window) were characterized by Quantitative light-induced fluorescence (QLF ®), Optical coherence tomography (OCT), microhardness, and Raman spectroscopy. The ANOVA and Tukey's test were used at 5% significance level. Results: The QLF comparison between distinct substrates yielded decreased ∆Q (integrated fluorescence loss) of -15,37%mm2 and -11,68% ∆F (fluorescence loss) for WSL. The OCT detected mean lesion depth of 174,43 µm. ANOVA could not detect differences in the optical attenuation coefficient between the substrates (p>0.05). Lower microhardness measures were observed in WSL than on sound enamel (p<0.05). The Raman spectra showed four vibrational phosphate bands (v1, v2, v3, v4), where the highest peak was at 960.3 cm-1(v1) for both substrates. However, a 40% decrease in phosphate (v1) was detected in WSL. The peak at 1071 cm-1 was higher for sound enamel, indicating the presence of a phosphate band instead of the B-type carbonate. The spectra showed higher intensity of the organic composition at 1295 cm-1 and 1450 cm -1 for WSL. Conclusion: Non-invasive QLF, OCT and Raman spectroscopy were able to distinguish differences in fluorescence, optical properties, and organic/inorganic components, respectively, between sound enamel and WSL, validated by the destructive microhardness analysis. (AU)

Objetivo: Comparar os aspectos ópticos, morfológicos, químicos e físicos do esmalte sadio e das lesões de mancha branca naturais, classificada como ICDAS 2. Material e métodos: Dezessete molares humanos com uma face apresentando uma lesão de mancha branca natural e outra face o esmalte hígido (2 x 2 mm) foram caracterizados utilizando a Fluorescência quantitativa induzida pela luz (QLF ®), Tomografia de coerência óptica (OCT), Microdureza e Espectroscopia Raman. A ANOVA e o teste de Tukey foram utilizados ao nível de significância de 5%. Resultados: A comparação entre os substratos distintos, utilizando o QLF ® demonstrou uma diminuição no ∆Q (perda de fluorescência integrada) de -15,37%mm2 e -11,68% de ∆F (Perda de fluorescência) para a lesão de mancha branca. O OCT detectou uma profundidade média de lesão de 174,43µm. A ANOVA não detectou diferenças no coeficiente de atenuação óptica entre os substratos (>0,05). Microdureza significantemente menor foi detectada nas lesões de mancha branca do que no esmalte sadio (p<0,05). Os espectros Raman mostraram quatro bandas vibracionais do fosfato (v1,v2,v3,v4), onde o maior pico foi em 960,3cm-1para ambos os substratos. No entanto, uma diminuição de 40% no fosfato (v1) foi detectada na lesão. O pico em 1071cm-1foi maior para o esmalte hígido, demonstrando tratar-se da banda do fosfato, ao invés do carbonato tipo B. Os espectros apresentaram maior intensidade da composição orgânica em 1295cm-1e 1450 cm-1para a lesão de mancha branca. Conclusão:Os métodos não invasivos QLF, OCT e espectroscopia Raman foram capazes dediferenciar a fluorescência, propriedades ópticas e conteúdo orgânico/inorgânico do esmalte sadio comparado com esmalte com lesões de mancha branca, sendo validado pela análise de microdureza. (AU)

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ABSTRACT: Orthodontic appliances in the oral cavity may cause problems such as white spot lesions, dental plaque, periodontal disease and root resorption. The aim of this study was to investigate the association between orthodontic treatment and oral health parameters including visible dental plaque, gingival recession and white spot lesions (WSLs). A total of 170 patients (86 females, 84 males) were randomly selected to determine visible dental plaque, gingival recession and white spot lesions by using pre-treatment and post-treatment oral photographs. Except of previously extracted teeth, maxillary and mandibular incisors, canine, 1st and 2nd premolars and 1st molar were evaluated. There was a significant difference between the T0 (before treatment) and T1 (after treatment) groups in visible plaque (P< 0.001). The distribution of gingival recession frequencies according to Miller classification before treatment did not differ from the after treatment (P=082). A statistically significant increase in the severity of WSL was detected between the two time points (P< 0.001). Males have been shown to have higher WSL incidence after treatment. In conclusion, the present study showed that visible dental plaque and white spot lesions significant increase after orthodontic treatment. Considering the relationship between oral health and orthodontic treatment, clinicians and patients should know the risks and take precautions.

RESUMEN: Los aparatos de ortodoncia en la cavidad oral puede causar problemas como lesiones de mancha blanca, placa dental, enfermedad periodontal y reabsorción radicular. El objetivo de este estudio fue investigar la asociación entre el tratamiento de ortodoncia y los parámetros de salud bucal, incluida la placa dental visible, la recesión gingival y las lesiones de mancha blanca (LMB). Un total de 170 pacientes (86 mujeres, 84 hombres) fueron seleccionados al azar para determinar la placa dental visible, la recesión gingival y las lesiones de manchas blancas mediante el uso de fotografías orales antes y después del tratamiento. Excepto los dientes extraídos previamente, se evaluaron incisivos maxilares y mandibulares, caninos, premolares y primeros molares. Hubo una diferencia significativa entre los grupos T0 (antes del tratamiento) y T1 (después del tratamiento) en la placa visible (P<0.001). La distribución de las frecuencias de recesión gingival según la clasificación de Miller antes del tratamiento no mostraron diferencias significativas con respecto al postratamiento (P=0.082). Se detectó un aumento estadísticamente significativo en la gravedad de LMB entre los dos puntos de tiempo (P<0.001). Se ha demostrado que los hombres tienen una mayor incidencia de LMB después del tratamiento. En conclusión, el presente estudio mostró que la placa dental visible y las lesiones de manchas blancas aumentaron significativamente durante el tratamiento de ortodoncia. Teniendo en cuenta la relación entre la salud bucal y el tratamiento de ortodoncia, los médicos y los pacientes deben conocer los riesgos y tomar precauciones.

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ABSTRACT Objective: To qualitatively and quantitatively assess the color changes effect and the color stability of the resin infiltrant on white spot lesions (WSLs), in comparison with nano-hydroxyapatite (nano-HA) toothpaste and microabrasion. Methods: WSLs were artificially created on sixty human premolars enamel surfaces and randomly assigned to equal four groups (n = 15 each): nano-HA toothpaste, microabrasion (Opalusture), resin infiltrant (Icon) treatment, or artificial saliva (control group). The color change (ΔE) of each specimen was measured by dental spectrophotometer (Vita Easyshade) at different time points: baseline, after WSLs' creation, after application of treatments, one month, three and six months after treatments application. Results: The ΔE value did not differ significantly for the four groups at baseline measurement before treatment (p> 0.05). Icon resin infiltrant improved the color of WSLs significantly immediately after its application, giving the lowest ΔE value (3.00 ± 0.59), when compared to other treatments (p< 0.001). There were no significant changes in ΔE (p> 0.05) for all groups during the follow up intervals (one month, three and six months after treatments application). Conclusion: Resin infiltrant can improve the color of WSLs and restore the natural appearance of enamel better than nano-HA toothpaste and microabrasion.

RESUMO Objetivo: avaliar qualitativamente e quantitativamente os efeitos nas mudanças e estabilidade da cor de lesões de mancha branca (LMBs), após tratamento com infiltração de resina, em comparação aos tratamentos com pasta de dentes com nanopartículas de hidroxiapatita (Nano-HA) e com microabrasão. Métodos: As LMBs foram criadas artificialmente em 60 superfícies de esmalte dentário de pré-molares humanos e aleatoriamente divididas em quatro grupos (n=15, cada): pasta de dentes Nano-HA, microabrasão (Opalusture), tratamento com infiltração de resina (Icon) e saliva artificial (grupo controle). A mudança de cor (ΔE) de cada espécime foi aferida com um espectrofotômetro odontológico (Vita Easyshade) em diferentes tempos: início do estudo, após a criação das LMBs, após a aplicação dos tratamentos, um mês, três meses e seis meses após a aplicação dos tratamentos. Resultados: Os valores de ΔE não diferiram significativamente entre os quatro grupos ao início do estudo (p > 0,05). A infiltração com resina Icon melhorou significativamente a coloração das LMBs imediatamente após a sua aplicação, com o menor valor de ΔE (3,00 ± 0,59), quando comparada às outras modalidades de tratamento (p < 0,001). Não houve mudanças significativas nos valores de ΔE (p > 0,05) em qualquer um dos grupos durante os intervalos de acompanhamento (um mês, três meses e seis meses após a aplicação do tratamento). Conclusão: A infiltração de resina é capaz de melhorar a coloração das LMBs e restaurar a aparência natural do esmalte de forma superior à pasta de dentes com Nano-HA e à microabrasão.

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The purpose of the present systematic review was to evaluate the effectiveness of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)-containing products in the prevention and treatment of active white spot lesions (WSL) in orthodontic patients. Searched the Scopus, PubMed, Web of Science, Cochrane, Virtual Health Language, ClinicalTrials, and Open Gray databases without limitations on the year or language of publication. We included controlled clinical trials with patients with fixed orthodontic appliances under the use of CPP-ACP-containing products compared to control, placebo, or other interventions in the prevention and treatment of WSL around orthodontic braces. Case reports, editorials, in vitro studies, annals of congress, and reviews were excluded. To assess the risk of bias, the revised version of the Cochrane tool for randomized trials (RoB 2.0) and Risk Of Bias In Non-randomized Studies for non-randomized trials were used. The biases were graded low, moderate, and high according to the tools used. Of the 599 articles found, 11 met the inclusion criteria. Of these, nine were randomized, controlled clinical trials and two were non-randomized. Two studies were considered to have moderate bias risk, and the most-used CPP-ACP presented form was a cream for topical applications. Although CPP-ACP-containing products did not differ from other fluoride products, they were able to reduce WSL and neutralize the pH around the orthodontic braces. Products containing CPP-ACP are effective in preventing and treating WSL around the braces. However, further studies with the same measurement method and periods of use, and other forms of presentation of CPP-ACP are needed.

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Resumen Introducción y objetivo: La aparatología de ortodoncia correctiva es un factor de riesgo para caries dental, facilitar su diagnóstico, prevención y control debe ser parte de la formación en esta especialidad. El propósito de este estudio fue evaluar la prevalencia de manchas blancas antes y después del tratamiento de ortodoncia en pacientes entre 10 y 22 años mediante fotografías digitales. Materiales y métodos: Se evaluaron fotografías iniciales y finales de 87 pacientes seleccionados, y modelos finales de 59 pacientes. La información recolectada fue: edad, sexo, tamaño de corona clínica, y presencia de manchas blancas en los 12 dientes anteriores; se utilizaron los criterios ICDAS para determinar la prevalencia de lesiones de mancha blanca (d2) y microcavidad en el esmalte (d3). Resultados: El 26,4% de los pacientes desarrolló lesiones de mancha blanca durante el tratamiento de ortodoncia, no hubo diferencias significativas en la distribución por cuadrantes ni por género, la prevalencia de manchas blancas fue mayor en el tercio gingival, en el canino superior derecho y en los dientes con tamaño de corona clínica más grande. Conclusión: La prevalencia de mancha blanca tuvo un aumento importante durante el tratamiento de ortodoncia con una distribución homogénea según sexo. El ortodoncista debe estar atento y orientar estrategias preventivas en sus pacientes.

Abstract Introduction and objective: Orthodontic fixed appliances are a risk factor for dental caries, and thus the understanding its prevention, diagnosis and treatment should be an integral part of specialty training in orthodontics. The purpose of this study was to evaluate the prevalence of white spot lesions before and after orthodontic treatment in patients between 10 and 22 years of age using digital photographs. Materials and methods: Initial and final photographs of 87 patients and final casts of 59 patients were evaluated. Chart information included: Age, sex, clinical crown size, and presence of white spot lesions in all 12 anterior teeth; ICDAS criteria was used to determine the prevalence of white spot lesions (d2) and enamel micro cavity (d3). Results: 26.4% of patients developed white spot lesions during orthodontic treatment; there was no significant difference in the distribution by quadrants or gender; the prevalence of white spot lesions was higher in gingival third, upper right canine and teeth with greater clinical crown size. Conclusion: Prevalence of white spot lesions increased during the orthodontic treatment with a homogenous distribution by sex. Orthodontists must to be alert and develop preventive strategies in these patients.

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Introducción: el tratamiento de lesiones interproximales de caries temprana representa un reto en la concepción moderna de la cariología y la operatoria. Como respuesta, además del diagnóstico temprano, emergen nuevos materiales para controlar laprogresión de la caries temprana. El objetivo de este estudio fue evaluar in vitro el grado de penetración de tres adhesivos: Excite (Ivoclar-Vivadent), Prime & Bond NT (Dentsply) y Single Bond (3M-ESPE), en el sellado de lesiones interproximales no cavitacionales de mancha blanca.Métodos: 117 premolares humanos extraídos con lesión interproximal de mancha blanca I CDAS-II 2 montados enyeso, simulando la situación en cavidad oral, fueron asignados aleatoriamente a uno de los tres grupos; se sellaron las lesiones con cadamaterial previamente mezclado con azul de metileno; se obtuvieron secciones longitudinales de 250 μm y se analizaron en fotografíasobtenidas bajo estereomicroscopía. Se valoró cubrimiento total de la lesión, profundidad histológica de la lesión en zonas y en micrómetros y, penetración máxima del adhesivo. Resultados: se analizaron 116 dientes. Se encontró cubrimiento total de la lesión en52,5%; 75% se ubicaron en la mitad interna del esmalte, con profundidad promedio de 854 ± 493 μm. La máxima penetración promedio del adhesivoen la lesión fue de 697 ± 412 μm. No hubo diferencias estadísticamente significativas entre grupos para las variables (Kruskal Wallis y correlación de Spearman; p > 0,05). Conclusión:estos tres adhesivos de baja viscosidad, con alto contenido de TEGDMA y HEMA,lograron el cubrimiento y la penetración de material para el sellado de lesiones tempranas de caries interproximal.

Introduction: the treatment of early proximal carious lesions represents a challenge to modern conceptions of cariology and operative dentistry. The possible solutions include, besides an early diagnosis, development of new materials to control early cariesprogression. The objective of this in vitro study was to evaluate the degree of penetration of three adhesives: Excite (Ivoclar-Vivadent), Prime & Bond NT (Dentsply), and Single Bond (3M-ESPE), in the process of sealing white-spot non-cavitated proximal lesions. Methods: 117 extracted human premolars with ICDAS 2 white-spot non-cavitated proximal lesions mounted on plaster, to simulate oral cavityconditions, were randomly sorted out in each of the three groups. The lesions were sealed with each of the materials previously mixed with methylene blue; longitudinal sections of 250 μm were obtained, and they were later analyzed on photographs taken with a stereomicroscope. These variables were evaluated: total lesion coating, lesion’s histologic depth (in micrometers), and the adhesive’s maximum penetration.Results: a total of 116 teeth were analyzed. Entire lesion coating was found in 52.5% of the cases; 75% were located in the enamel’s internal half, with an average depth of 854 ± 493 μm. The adhesive’s maximum average lesion penetration was 697 ± 412 μm. No statistical significant differences were found among the groups (Kruskal Wallis and Spearman correlation; p > 0.05). Conclusion: these three low-viscosity adhesives with high amounts of TEGDMA and HEMA effectively achieved covering and penetrating of the material for sealing early proximal carious lesions.

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