The effect of a fluoride program on white spot
formation during otihodontic treatment
Arnold M. Geiger,* Leonard Gorelick,** A. John Gwinnett,*** and Peter G. Griswold****
New York City, New Hyde Park, and Stony Brook, N.Y.
W hite spot formation (decalcification) of
the labial enamel surface subsequent to orthodontic
treatment has been recognized as a problem. This has
been reported as a clinical observation”* and quanti-
tative studies on the incidence and prevention of de-
calcification have been reported.3-i0 Equal susceptibility
to white spot formation has been reported whether teeth
are banded or bonded.g There has been general agree-
ment that the development of white spots seems to be
related to (1) the retention of plaque on the gingival
side of brackets or bands, (2) oral hygiene efficiency,
and (3) the inherent resistance of the individual.
Studies have documented the beneficial effect of
preventive fluoride programs during multibanded ortho-
dontic treatment. Such studies have reported on office-
applied and self-administered programs.5*7 However, no
studies have reported on the effect of a preventive
fluoride protocol during orthodontic treatment with
bonded appliances; nor have there been studies report-
ing on the severity and prevention of white spot for-
mation on all individual teeth.
This article presents the results of a clinical study
in which an experimental preventive fluoride program
was routinely used in the orthodontic offices of the
authors. The study was designed to provide answers to
the following questions.
1. Was the preventive fluoride program benefi-
cial in reducing the incidence and severity of
white spots after full-term bonded orthodontic
treatment?
2. Will such preventive efforts reduce the white
*Associate Clinical Professor, School of Dental and Oral Surgery, Columbia
University, New York, N.Y.
**SW Orthodontist, Long Island Jewish/Hillside Medical Center; Associate
Clinical Professor, Department of Children’s Dentistry (Olthodontics), School
of Dental Medicine, State University of New York at Stony Brook.
***Professor, Depxtment of Oral Biology and Pathology, School of Dental
Medicine, State University of New York at Stony Brook.
****Research Assistant, Department of Pediatric Cardiology, Long Island Jew-
ish/Hillside Medical Center, New Hyde Park, New York, N.Y.
spot formation for all teeth that have been
bonded?
3. What degree of cooperation (compliance) can be
expected from patients?
4. How does the degree of compliance with the
fluoride program affect white spot formation?
MATERIAL AND METHOD
In a previous study of patients from the private
practices of the authors, the incidence and severity of
white spot formation following orthodontic treatment
were reported. In that study population, it was found
that the presence of nondevelopmental white spots can
be clinically differentiated from developmental opaci-
ties (congenital); white spots were found in only 3.6%
of teeth before total orthodontic treatment. Of these,
the vast majority were congenital and not acquired.
The present study of the effect of a fluoride protocol
on white spot formation was derived from the same
practices in a common fluoridated-water supply area.
Patient selection, bonding technique, and scoring for
white spots on debonding were identical to that used
in the previous study.
For these reasons, it was concluded that the previous
study provided a baseline from which comparisons
might be made in assessing the effect of a fluoride
program on nondevelopmental white spot formation.
The fluoride program was initiated for all patients
receiving bonded brackets in the practices of the authors
(L.G. and A.G.). The fluoride application was both an
office and a home care procedure. In the office, acid-
ulated phosphate gel* was applied about 3 minutes after
brackets were bonded. The gel remained on these teeth
for 3 to 5 minutes while the teeth were isolated from
saliva. This was followed by a spray or rinse with a
0.05% solution of sodium fluoride. The patient was
advised not to eat or rinse for ‘/z hour.
The home care procedure consisted of the use of a
0.05% fluoride solution as a rinse after brushing with
*Fluoride, 1.21, in Ml10 phosphoric acid gel, pH 3.2.
29
30 Geiger et al.

Table I. Frequency of occurrence of white spots

in subjects

of all teeth bonded (%)

1 .o-10.0 9 26.5
10. I-20.0 6 17.6
20.1-30.0 10 29.4
30.1-40.0 5 14.7
40. I-50.0 2 5.9
so. 1 -t
I‘OTAL

TW Il. Ordered frequency of occurrence of

white spots by segments
Percentage
of

(f3
Segment teeth &ected

Maxillary canines and incisors 63 11.6

Mandibular molars and premolars 32 11.1
Mandibular canines and incisors 17 3.3

,o
Maxiltary molars and premolars 5 2.3
TOTAL/AVERAGE iii 7.5

Table 111.Frequency of occurrence of white

spots by segments-Right and left sides

4 Z Segment

Maxillary molars and premolars

Right

3.7
(%I Lefr

0.9
fW

Maxillary canines and incisors 11.0 12.1

Mandibular molars and premolars 12.6 9.7
Fig. 1. Diagrammatic repre$erttation of method used to score Mandibular canines and iucisors 3.9 2.1
the severity of the acquired white spots. AVERAGE 7.8 6.4

a fluoridated toothpaste. This was to be done just before
retiring at night and was not diluted by subsequent
eating or rinsing. Introduction of the home care regimen
in one office (L.G.) was presented orally to both patient
and parent. In the other office (A.G.), a letter was sent
to each parent; the patient was instructed verbally and
given printed home care directions and general cau-
tions. At irregular intervals, especially when oral hy-
giene was inadequate, patients were urged to improve
their hygiene and to use the rinse to prevent decalcifi-
cation and caries.
On the 1,567 bonded teeth that comprised the study
sample, 1,284 were bonded with u sealant-composite
combination in which the sealant covered the entire
labial surface and the composite was restricted as much
as possible to the bracket base. The remaining 283 teeth
were bonded with a one-step procedure (liquid-paste
material). The bonding method and date of application
were recorded on each patient’s record card. Charts
were designed for computer analysis to provide the
following information: patient’s age and sex, office
identification, method of bonding, length of time teeth
were bonded, and the presence and severity of any white
spot formation found on debonding. Clinical exatni-
nation of the state of the entire labial cervical enamel
was done at the debonding visit with the area to be
examined in an illuminated and relatively dry field. The
following scoring was used (Fig. 1):
1 = No white spot formation
2 = Slight white spot fonnation
3 = Severe white spot formation
4 = Excessive white spot formation (cavitation)
Volume 93 Effect of fluoride program on white spot formation 31
N11mher 1

20
Left Maxilla Righ,

2o Left Mandible Right

Fig.2. Histograms displaying the percentage of white spots according to arch and tooth in the maxilla
(A) and mandible (8).

To evaluate the patient’s compliance with the rinse
program at home, a simple questionnaire was devel-
oped. The questionnaire sought information as to how
often bottles of fluoride rinse were purchased, nights
per week the rinse was used, and whether the rinse
instructions were followed. The questions provided
some check on the accuracy of the respondent’s an-
swers, which was further reinforced by the information
given by patient and parent. It was possible for the
investigators to make generalizations of the degree of
32 Geiger et al.

X
X
X

Fig. 3. Graph showing the percentage bcsidence of white spots in subjects over time.

compliance for each patient. These were scored as poor, ined, 117 (7.5%) had some white spots. Study of the
partial, or excellent. subjects for the frequency of occurrence of white spots
All data were compiled in a Northstar microcom- indicated a rather ~~xw-Jdistribution, suggesting no un-
puter. Comparisons were done by two-way tables and due influence of susce@bi&ty in certain patients, which
the application of chi-square or linear regression anal- might be suspected if most of the teeth that developed
ysis wherever applicable. white spots occurred in a small group of patients (Ta-
The study population of 101 subjects was divided ble I).
between the two offices (55 patients from L.G. and 46 Of the 117 teeth with white spots, 101(6.4% of the
patients from A.G.). There were 39 nr& and 62 female entire sam@e) had scores of 2 or slight white spot fw-
subjects in the entire group. The age distribution was mation. The lSt&thwi&ascoreof3
as follows: 24% up to age 11 years, 60% up to age 14 (severe) and with a score indicating cav-
years, and 16% older than 14 years. itation. Therefore, those teeth with scores of 3 and 4
Gf the 1,567 teeth bonded, 60% were from patients were combined in f the data. This group was
of L.G. and 49% from A.G. Chi-square analysis of the l.l%ofthetee&
study sample showed no age and/or sex differences
between the two office groups.
Because 12% of the teeth were bonded with a one- as with the iacidmrce of
step material (liquid-paste) and the remainder with a white spots. l%ere was, however, a significant increase
sealant-composite combination, the study sample was in the more severe and cavitate white spots in persons
divided to seek differences between these groups. No less than 13 years of age (chi-sqnare, P < 0.001).
statistical differences were found in the incidence or wasdivided into the two of&e gl-o#&ps
sew&y of white spots. Neither were them any dif&r- in thie irmi-
ewes found in the length of time brackets were in Sex.
position or the compliance of the persons involved. For
these reasons, the sample was treated thereafter as a
single entity. As shown in the bar graphs (Fig. 2, A and B), there
is a selective d&t&&on in the (bccwpence of white
IWWLTS spots for indiv
Of the 101 cases, 34 (33.8%) had one or more teeth and canines were mo
with white spot formation. Gf the 1,567 teeth exam- 12.28, respectiveiy);
Volume 93
Number I
Table IV. Frequency of occurrence of white
spots in subjects by compliance
0 44 59.4 23 85.2
O-20 13 17.6 2 7.4
20+ !2- 23.0 2 7.4
TOT4L 74 100.0 -5 100.0
was affected 13.6% and the first molar 9.7%. The dis-
tribution is highly significant (chi-square, P < 0.001).
When studied by severiry, the distribution of severe and
excessive white spots (scores of 3 and 4) shows an
unexpected susceptibility of the mandibular canine to
more serious white spots. Also, there appears to be a
fairly consistent pattern of more severe white spots on
the left side of the dentition as compared with the right.
As shown in Fig. 2, the maxillary lateral incisors are
the teeth most susceptible to more severe white spot
formation.
WHITE SPOTS BY SEGMENT
For analysis by segments, each arch was divided
into an anterior segment from canine to canine, and a
posterior segment of premolars and molars. As shown
in Table II, the maxillary anterior segments and the
mandibular posterior segments were the most frequently
affected (chi-square, P < 0.001).
Comparison of white spots by right and left sides
showed that 7.8% of teeth on the right side and 6.4%
of teeth on the left side had white spots. The difference
was statistically significant (chi-square, P < 0.001).
The distribution in percentage of teeth affected is shown
in Table III.
Although the incidence of total white spots was
greater on the right side, the presence of more severe
lesions was similar in all segments except for the max-
illary canine-incisor region where more severe white
spots were found on the left side.
WHITE SPOTS RELATED TO DURATION OF BOND
Since the time interval from bonding to debonding
had been recorded for each tooth, the duration of bond
could be correlated with the incidence and severity of
white spots. The sample was divided using 6-month
increments of time and correlated with the percentage
incidence of white spots of bonded teeth in subjects. A
statistically significant correlation was found (r =
Effect of fluoride program on white spot formation 33
Table V. Number of subjects with and without
white spots by compliance
Compliance
Poor Partial Excellent Total
(no.) (no.) (no.) (no.)
White spots 21 9 4 34
No spots 32 rz 23 67
TOTAL 53 21 27 101
0.9415) and a consistent pattern is shown in the graph
in Fig. 3.
When the data were studied for the relationship of
the time the brackets were in place to severity of white
spots, it was found that all moderate and severe white
spots (scores 3 and 4) occurred when brackets were
bonded for more than 24 months, with the relationship
being statistically significant (r = 0.8665).
COMPLIANCE
Among the 101 patients, the degree of compliance
with the home care preventive protocol was judged to
be poor in 52.5%; 20.8% complied partially and 26.7%
were rated excellent. The distribution of compliance
among the male and female subjects showed no statis-
tically significant differences. When compliance was
analyzed by age, no consistent pattern was found. The
distribution of compliance by patients, as well as sex
and age comparisons, were studied for each of the two
office groups. No differences were found.
WHITE SPOTS AND COMPLIANCE
Among the 34 patients with white spot formation,
64.7% had a poor record of compliance; only 11.8%
had excellent compliance. The frequency of occurrence
of white spots in subjects was compared with compli-
ance (Table IV). Poor compliance was found in patients
having white spots in more than 20% of their bonded
teeth.
The study of the effect of compliance in all patients
(those with white spots and those with no white spot
formation) showed a significant association between
poor compliance and the formation of white spots
(chi-square, P < 0.05) (Table V). To study the effect
of compliance on the incidence of white spots for in-
dividual teeth, the sample was divided into two cate-
gories-those who had poor compliance and those
whose cooperation was partial to excellent. The inci-
dence of white spots for many individual teeth showed
a marked decrease in white spots where there was pos-
itive compliance. The maxillary lateral incisors and ca-
34 Geiger et al.

Cofrl~~flce Poor

654321 123456
30
31
tn 1 I

g20

f 10
#
0
654321 123456
0A Tooth Ntmbw

22
Jt 20
aa
g 10
*
0
654321 123456

Fig. 4, A and 8. Histograms displaying the percentage of white spots by arch and tooth according to
subject compliance. Note the dram&c increase in incidence in certein teeth where compliance is poor.

nines exhibited the largest reduction in white spots
where there was good compliance (Fig. 4, A and B).
DIE-
Some general observations can be made from the
data. There were no significant differences between the
two office samples. The complete study sample offered
a wide range of ages and is probably typical of ortho-
dontic practices. Review of the frequency of occurrence
of white spots in individual patients confirms that very
few patients were excessively susceptible to decalcifi-
cation. In our previous study,’ 49.6% of patients 6x-
perienced some white spot formation associated with
orthodontic treatment. This is similar to the findings of
Volume 93 Effect of fluoride program on white spot formation 35
Number 1

Table VI. Frequency of occurrence of white Table VII. Frequency of occurrence of white
spots of individual teeth in no-fluoride* and spots for individual teeth by compliance
fluoride samples

H
k
Maxillary canine 16.4 7.8
Maxillary lateral incisor 26.9 6.7
Maxillary lateral incisor 23.0 17.5 Maxillary central incisor 7.7 2.2
Mandibular canine 18.0 7.7 Mandibular second premolar 11.8 7.0
Mandibular first premolar 17.5 13.6 Mandibular first premolar 15.8 11.4
Mandibular first molar 14.5 9.7 Mandibular canine 9.7 5.8
Mandibular second premolar 14.1 9.3
Maxillary canine 11.2 12.2
Maxillary first premolar 9.6 1.2
Table VIII. Comparison of incidence of white
Maxillary central incisor 8.4 5.2
Mandibular lateral incisor 8.0 3.2 spots after application of acidulated phosphate
Maxillary second premolar 3.0 5.2 gel* with a no-fluoride group
Mandibular central incisor 2.5 0.0
Maxillary first molar 1.0 1.7

*From an earlier study of white spots of teeth bonded.’

-1

Maxillary canine 16.4 11.2

Stratemann and Shannon3 and Magness, Shannon, and Maxillary lateral incisor 26.9 23.0
West,6 who reported decalcification in their control Maxillary central incisor 7.7 8.4
groups of orthodontic patients to be 58% and 64%, Mandibular second premolar 11.8 14.1
respectively. Mandibular first premolar 15.8 17.5
Mandibular canine 9.7 18.0
In this study, of the entire sample of 101 cases,
one third had one or more teeth with acquired white *This group comprised noncompliant subjects (no fluoride rinse) with
spots. This compares favorably with decalcifications one-time application of acidulated phosphate fluoride gel followed
found in our previous report and other control groups by a fluoride rinse immediately after bonding.
in that it represents a 30% reduction in the number of tIncidence of white spots after debonding reported February 19849
with no fluoride applied and no rinse.
patients affected.
Of the 1,567 teeth examined, 7.5% had white spots
of varying degrees. This represents a 25% reduction of white spot formation in all segments under the flu-
in the incidence of white spots when compared with the oride protocol showed a 37% reduction from that ex-
10.8% of teeth affected that did not have the benefit of perienced in our previous study of bonded teeth with
a fluoride program.’ no fluoride.
Of those teeth that developed white spots (117), The severity of white spots is an additional impor-
only one tooth showed cavitation; in our previous tant measure of the potential effect of a preventive flu-
study,’ the most severe effect of decalcification was four oride program. In our present study, only one tooth was
times this amount. Study of the incidence of white spots recorded as having had an excessive white spot (cavi-
on individual teeth affirms the susceptibility of the max- tation). Cavitation occurred in 0.06% of the teeth
illary lateral incisors and canines, and the mandibular bonded as compared with 0.3% in our earlier study.
first premolar and molar. This is in agreement with the When the distribution of the more severe white spots
findings of Mizrahi (1983)” on banded teeth and our was studied, the mandibular canine showed a greater
earlier work on bonded teeth’ with no fluoride preven- susceptibility than expected and as compared with our
tive program. However, the incidence of white spots previous work. Although in the segment analysis there
on these more susceptible teeth decreased by about 25% were significantly more white spots on the right side of
in the entire sample exposed to the fluoride protocol. the dentition, when analyzed by severity, the left side
This supports the findings of Hirschfield’ in his study had more severe lesions.
of banded maxillary lateral incisors subjected to a Phos- Although in our earlier study,’ we found no cor-
Flur preventive rinse program (Table VI). When the relation between white spot formation and the duration
study sample was analyzed by segments, the incidence of time that teeth were bonded during orthodontic treat-
 36 Geiger et al.
ment, in this study there was a positive correlation
between both the incidence and severity of white spots
and the duration of the bond. Indeed, all moderate and
severe white spots occurred in teeth that had been
bonded for more than 24 months. In retrospect, our
earlier data may have suffered from the use of averages
in studying time and incidence, thus obscuring more
subtle shifts in the data. This has been avoided in our
current effort.
Compliance with the preventive protocol was sur-
prisingly poor in light of the educational efforts ex-
pended. Because more than half the patients had poor
compliance, it may be speculated that the reduction in
white spot formation would have been greater if com-
pliance were improved. This is substantiated by the data
when analyzed by dividing the sample into two
groups-the noncompliers and those who complied par-
tially or fully. A significant association between white
spot formation and compliance was found among sub-
jects and teeth.
Because the fluoride rinse was a nonprescriptive
drug, it was readily available to all patients. Apparently,
the written and oral instructions to the patients and
parents were insufficient to achieve greater than 12%
excellent compliance. More than 50% of the patients
complied very little or not at all.
The difficulties in changing patient behavior have
been experienced in both dentistry and medicine. Cor-
bett and Shannon8 in a clinical trial with self-admin-
istered fluorides, found that 29 of 110 orthodontic pa-
tients in a rigidly controlled study admitted to very poor
compliance. In a recent report on compliance with a
maintenance therapy program after extensive periodon-
tal therapy, only 16% of 961 patients exhibited good
compliance and 34% did not return for follow-up treat-
ment.” Even patients faced with life-threatening dis-
ease have frequently failed to change their behavior as
directed by their physicians.“,”
As discussed previously, compliance with the flu-
oride rinse program had a significant relationship with
reduced incidence of white spot formation (Fig. 4) and
this is visualized more clearly for selected teeth in Ta-
ble VII. However, the contribution of the one-time ap-
plication of acidulated phosphate fluoride gel, imme-
diately followed by a fluoride rinse to these results, has
not yet been addressed.
To isolate those persons who had only a potential
influence from the one-time fluoride application at the
time of bonding, all the noncompliers with the rinse
program were studied as a group. The incidence of
white spots in these subjects was then to be compared
with that experienced by a comparable group, free of
any type of fluoride application. Because no such group
exists in this study population, we used data from an
earlier study of white spot formation.14 These appear
in Table VIII as the “no fluoride group.”
When these two groups were compared for the in-
cidence of white spot for selected individual teeth, there
was a generally similar incidence, with differences that
showed no trend and were inconsistent from tooth to
tooth. Studies mapping plaque patterns have shown sig-
nificant accumulation of plaque on the gingival side of
bonded orthodontic brackets, frequently extending up
into the embrasure regions. I4 Such sites are potentially
more vuhterable to the pathogenicity of plaque. White
spots associated with bonded brackets frequently follow
these preferred sites of plaque accumulation. ” Fluoride
therapy can reduce enamel solubility, control plaque
activity through blocking bacterial enzyme systems,
and assist in enamel remineralization. Therefore, as a
caries preventive measure, fluoride provides an un-
equivocal benefit to the dental health of the patient. The
importance of a sustained fluoride program is well es-
tablished since fluoride is depleted from enamel during
ionic exchanges with plaque. It is necessary to replenish
such losses if benefit is to be sustained. Daily admin-
istration of topical fluoride and the use of fluoridated
toothpaste is one method of providing a continuous
reservoir of fluoride ions necessary for enamel protec-
tion against white spot formation.
Findings of the beneficial effect of fluoride preven-
tive programs have been reported for 0.4% stannous
fluoride gel as a daily self-brush application3 and acid-
ulated phosphate fluoride solution (0.3 1% fluoride; 0.1
molar phosphate; pH 4.0) applied at each office visit
during orthodontic therapy. These studies and our own
data clearly indicate the importance of the frequent and
consistent application of the fluoride as critical to the
success of a preventive program.
In addition, the data strongly suggest that the one-
time preventive procedure at the time of bonding had
little or no beneficial effect in reducing white spot for-
mation. although this conclusion could have been
strengthened by having had a control group in this
study. However, the reduced incidence and severity of
white spot formation does support the regular and re-
peated use of the low concentration of sodium fluoride
(0.05%) as a mouthwash.
1. Decalcification of the labial (buccal) surfaces of
teeth during orthodontic therapy can be significantly
reduced by the consistent use of a 0.05% sodium flu-
oride rinse during treatment.
Volume 93 Effect of fluoride program on white spot formation 37
Number 1

2. The incidence and severity of white spot for- 6. Magness WS, Shannon IL, West DC. Office-applied fluoride
mation are related to the length of time teeth are brack- treatments for orthodontic patients. J Dent Res 1979;58(4):1427.
7. Shannon IL, West DC. Prevention of decalcification in ortho-
eted. This suggests the need for a preventive fluoride dontic patients by daily self-treatment with 0.4% Sp, gel. Pediatr
rinse used continuously during treatment. Dent 1979;2:101-3.
3. Despite efforts to educate patients and parents, 8. Corbett JA, Shannon IL. Prevention of decalcification in ortho-
poor compliance with a preventive fluoride rinse pro- dontic patients: a preliminary clinical trial with a mixture of
gram occurred in 50% of patients. This suggests the fluorides. J Co10 Dent Assoc 1980;58(4):16-7.
9. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot
need for more effective methods to change behavior formation after bonding and banding. AM J ORTHOD 1982;
patterns. 81:93-S.
4. The one-time topical application of acidulated 10. Mizrahi E. Surface distribution of enamel opacities following
phosphate fluoride gel immediately after bonding ap- orthodontic treatment. AM J ORTHOD 1983;84:323-31.
pears to be ‘of little benefit in reducing the incidence of 11. Wilson TG Jr, Glover ME, Schoen J, et al. Compliance with
maintenance therapy in a private periodontal practice. J Peri-
white spots.
odontol 1984;55:468-73.
12. Clyne CA, Arch PJ, Carpenter D, et al. Smoking, ignorance and
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