Original  

Article

Investigation of the Esthetic Outcomes of White Spot Lesion Treatments

J Lee, LO Okoye1, PP Lima2, PT Gakunga, BT Amaechi2

Departments of Objective: The present study compared the ability of bleaching, resin infiltration

Abstract
Developmental Dentistry
and 2Comprehensive
and microabrasion to restore the appearance of existing white spot lesions (WSL)
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Dentistry, School of
Dentistry, University of
Texas Health San Antonio,
Texas, USA, 1Department
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on tooth surfaces as close as possible to that of the original healthy enamel.
Materials and Methods: Sixty extracted human teeth with WSL were randomly
assigned to three treatment groups (20/group). Prior to treatment, the colour of
the surrounding healthy enamel and the WSL were measured as the baseline and

of Restorative Dentistry, pre-treatment (PreRX) colours respectively using spectrophotometer based on CIE
Faculty of Dentistry, College
of Medicine, University of
L*A*B. The L-value was used for the statistical comparison. WSLs in each group
Nigeria, Enugu, Nigeria were treated respectively by bleaching, infiltration or microabrasion following the
manufacturer’s instructions. Colour measurement was repeated after treatment.
Both intragroup and intergroup comparisons were performed using ANOVA
followed by Tukey’s multiple comparison test (α=0.05). Result: In all groups
the mean L-values were significantly higher in PreRX WSL (P < 0.01; Tukey)
compared to baseline (sound enamel). After treatment the difference in mean
L-value between baseline and WSL increased significantly (P < 0.01, Tukey) in
Bleaching and Microabrasion groups by 1.4% and 1% respectively, but decreased
Received: in Infiltration group by 3.4%. Thus resin infiltration decreased the L-value of the
08-Mar-2020; WSL, bringing it closer to the L-value of the sound enamel while bleaching and
Revision: microabrasion increased the L-value. Conclusions: Among the three treatment
13-Apr-2020; modalities investigated in this study, resin infiltration was the most effective in
Accepted: masking the WSLs.
28-May-2020;
Published: Keywords: Bleaching, microabrasion, resin infiltration, spectrophotometer, white
10-Sep-2020 spot lesion

Introduction The ideal solution to WSL is prevention of formation

P atients often seek orthodontic treatment for esthetic
reasons. During orthodontic treatment, patients are
often placed at risk of enamel demineralization adjacent
to the orthodontic appliances due to poor oral hygiene
with retained plaque. Acidogenic bacteria such as
Streptococcus mutans that are harbored in dental plaque
metabolize fermentable carbohydrates in our diet, and
their byproducts of organic acids cause demineralization
of tooth enamel, which manifests as white spot
lesion  (noncavitated caries lesion). If the white spot
lesion  (WSL) remains untreated, it may progress to
cavitated caries lesion.[1,2] Clinically, formation of WSL
around orthodontic appliances can occur within 4 weeks
into orthodontic treatment, and prevalence among
orthodontic patients ranges from 2%–96%.[1]
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of the lesions in the first place. Prevention of
WSLs begins by implementing a good oral hygiene
regimen including proper and frequent tooth
brushing technique along with use of a fluoridated
dentifrice.[3,4] Additional sources of fluoride such as
mouth rinses, gels or varnishes may be beneficial
for those patients at high caries risk and should be
considered by the clinician as part of the oral hygiene
and preventive regimen.[4,5] The use of fluoride
Address for correspondence: Dr. LO Okoye,
Department of Restorative Dentistry, Faculty of Dentistry, College
of Medicine, University of Nigeria Teaching Hospital, Ituku
Ozalla, Enugu State, Nigeria.
E‑mail: linda.okoye@unn.edu.ng
This is an open access journal, and articles are distributed under the terms of the
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For reprints contact: reprints@medknow.com

DOI: 10.4103/njcp.njcp_119_20

How to cite this article: Lee J, Okoye LO, Lima PP, Gakunga PT, Amaechi BT.
PMID: ******* Investigation of the esthetic outcomes of white spot lesion treatments.
Niger J Clin Pract 2020;23:1312-7.

1312 © 2020 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow

 Lee, et al.: Esthetic outcomes of white spot lesion treatment
slows down the caries process and increases the rate
of remineralization of WSLs.[2] Other prevention
modalities against WSLs formation include the use of
surface sealants, particularly the antimicrobial and/or
fluoride‑releasing sealants.[6,7] Surface sealants offer
physical barrier against acid demineralization of tooth
surface; however, the antimicrobial sealant has the
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additional benefit of preventing plaque formation.[6,7]
Despite efforts to prevent WSLs, a number of
patients still require treatment for WSLs after
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orthodontic treatment.[8,9] The conventional approach
for treating WSLs is restorative treatment; however,
this technique has the disadvantage of being
invasive.[10] Current noninvasive treatment options
include lesion remineralization using fluoride varnish,[11]
tooth‑whitening  (bleaching),[12] microabrasion,[13] resin
infiltration,[14] or in combination.[15] Fluoride varnish
has been reported to cause 44.3% reduction in enamel
demineralization in orthodontic patients,[3] while
bleaching has successfully camouflaged WSLs.[12,16,17]
Caries lesion infiltration with resin has been claimed to
mask WSLs and restore enamel surface to its original
appearance.[14,15] Microabrasion improves esthetics by
physical removal of the discolored enamel resulting in a
smooth and lustrous surface sheen.[13]
Presently, there is no known quantitative study
that compared the ability of these WSL treatment
modalities to restore the appearance of white spot
lesion to that of the original healthy enamel. Therefore,
the main objective of the present in vitro study was to
compare the ability of microabrasion, bleaching, and
resin infiltration to restore the appearance of existing
WSLs on tooth surface as close as possible to that of
the original healthy enamel. The most effective method
is the technique that will restore the white spot lesion
most closely to the color of the healthy immediate
surrounding enamel. We hypothesized that among the
tested treatment modalities, bleaching will restore white
spot area most closely to the appearance of the original
healthy enamel as measured by Spectrophotometer.
Materials and Methods
Teeth preparation and experimental grouping
Extracted human maxillary incisor teeth were
collected from various clinics of the school of
dentistry of the University of Texas Health San
Antonio  (UTHSA), and were stored in 0.1% thymol
solution prior to use. Maxillary incisors were chosen
because the Spectrophotometer  (5  mm diameter) used
for color measurement requires flat enamel surface,
thus canines and premolars were not suitable. Only
teeth with WSLs were selected and cleaned of debris
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and stains. The selected teeth were sterilized in an
autoclave. Following sterilization, the teeth were
randomly assigned to three treatment groups (20 teeth/
group). A three‑sided die was used to determine which
treatment group a selected tooth should be assigned.
To be included in the study, tooth should have a
preexisting WSL with a minimum size of at least
1  mm  ×  1  mm  (or 1  mm diameter). Approval of the
Institutional Review Board of University of Texas
Health San Antonio was obtained (IRB Approval #:
HSC20080233N) was obtained on April 3, 2019.
Pretreatment color measurement
Prior to any treatment, the color of each tooth was
measured at two points as follows.  (1) Measurement of
the color of the sound enamel surface area adjacent to
the WSL. This color served as the baseline shade of the
tooth enamel prior to white spot development. This is
the reference against which all posttreatment data were
compared for closeness.  (2) Measurement of the color of
the WSL on the selected tooth. The tooth surface color
was assessed using a ShadeEye Spectrophotometer (Shofu
Inc., Japan) in Analyze Mode.[18] Prior to taking readings,
the spectrophotometer was calibrated using a “Standard”
provided by the manufacturer. The sensor was placed
directly in contact with the tooth surface for each reading.
Three readings were taken on each tooth surface, and each
reading was taken twice to confirm the same value and to
ensure accuracy. Samples were dried with absorbent paper,
and not desiccated, before reading. For WSLs, reading was
taken at the center of the lesion. The measurement system
used to measure color in this study was CIE L*A*B.[17]
The L‑value corresponds to the degree of lightness in the
Munsell system, whereas the a‑values and the b‑values
give the position on red or green  (+a  =  red,  ‑a  =  green)
and yellow or blue (+b = yellow, ‑b = blue) axes. During
shade measurement, the Spectrophotometer described the
tooth shade with three values, Hue, Value, and Chroma.
Value is the most important characteristic of shade.[17,19] In
our study, we measured the L‑value of each tooth, which
represents the Value component in shade description.
Treatment procedures
Bleaching group: A  bleaching gel containing 10%
carbamide peroxide with potassium nitrate and
fluoride  (Ultradent Inc., Jordan, Utah, USA) was used.
Each tooth was bleached for 8  h per day for 14  days in
accordance with the manufacturer’s instruction. A  thin
layer of less than 1  mm in thickness of the bleaching
gel was applied to the WSL and the surrounding healthy
enamel where baseline reading was taken.
Infiltration group: Resin infiltration of each WSL was
carried out using Icon™  (DMG, New Jersey, USA) as
follows. Icon‑Etch (15% HCL) was applied on the WSL
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for 2  min. Tooth was rinsed with water for 30 s and
dried. Then, Icon Dry  (95% ethanol) was applied onto
the WSL for 30 s and dried with oil‑free and water‑free
air. This was followed with applying the Icon‑Infiltrant
on the WSL for 3 min and light‑cured for 40 s. A second
layer of the Icon‑Infiltrant was placed for 1  min and
light cured for 40 s.
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enamel) and WSL pretreatment  (natural WSL),
thus indicating that groups were comparable at
baseline and WSL before treatment. However,
in all groups, the mean values of L‑value were
significantly higher in PreRX WSL  (P  <  0.01;
Tukey) compared to baseline  (sound enamel).
After treatment  (WSL PostRX), the mean values

Microabrasion group: Microabrasion was performed using of the L‑value increased in both Bleaching
Opalustre Enamel Microabrasion Slurry  (Ultradent Inc., and Microabrasion groups and decreased in
Jordan, Utah, USA), and following the manufacturer’s Infiltration group, but these changes were not
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instructions as follows. Approximately 1.0  mm thick
layer of Opalustre was applied over the WSL. Using a
rubber prophy cup at rotation speed of approximately
500 RPM, the tooth surface was polished using medium
to heavy pressure for 60 s at a time. The tooth surface
was then rinsed. The procedure was repeated twice.
Following each treatment, the color measurements were
repeated as described at the pretreatment stage, and
were taken at the same two sites that were measured at
pretreatment, i.e., sound enamel surface adjacent to the
WSL and the center of the WSL.
Data was analyzed statistically using SPSS (version 14.0,
Chicago Illinois) with the level of significance  (α)
prechosen at 0.05. Both intragroup time points (Baseline,
Pretreatment and posttreatment) comparisons and
intergroup comparisons were performed using ANOVA
followed by Tukey’s multiple comparison test.
Results
Table  1 shows the three treatment modalities
and their mean L‑values at baseline,
WSL pretreatment  (PreRX), and WSL
posttreatment (PostRX). There was no significant
difference among the three treatment modalities
in the mean values of L‑value at baseline  (sound
statistically significant in any group when
compared with WSL PreRX. However, when
compared with baseline, the changes were
significant  (P  <  0.01, Tukey) only in Bleaching
and Microabrasion groups but not in Infiltration
group. The mean difference between infiltration
and the other two treatments groups was
statistically significant  (P  <  0.005, Tukey).
Thus, following treatment, the difference
in mean values of L‑value between sound
enamel  (baseline) and WSL  (PreRX) increased
in Bleaching and Microabrasion groups from
8.5% and 6.9% to 9.9% and 7.9%, respectively,
but decreased in Infiltration group from 6.2%
to 2.8%  [Table  1]. Thus, Table  1 clearly
demonstrates that resin infiltration decreased
the L‑value of the WSL, bringing it closer to
the L‑value of the sound enamel while bleaching
and microabrasion increased the L‑value, taking
the tooth shade farther away from the shade of
the natural enamel.
Discussion
Enamel demineralization  (WSL) around orthodontic
fixed appliances presents both clinical and esthetic
problems to the patient. Therefore, in orthodontics,
WSL prevention is of particular importance.

Table 1: Means (Standard deviation) values of L‑value for Sound enamel and White spot
lesions (Pretreatment (PreRX) and Posttreatment (PostRX))
Treatment Baseline WSL WSL Difference in Difference Change in Percentage Percentage
Methods (Sound Enamel) PreRX PostRX Color between in Color WSL Color difference in difference in
Baseline and between between color between color between
WSL PreRX Baseline and PreRX and Baseline and Baseline and
WSL PostRX PostRX WSL PreRX WSL PostRX
Bleaching 68.6±7.7a,x 73.8±6.5b,y 75.4±5.4y 5.8 6.8 1.6ᵆ 8.5% 9.9%
Resin 67.6±5.3 a,x
71.8±6.4b,y 69.5±6.2y 4.2 1.9 ‑2.3* 6.2% 2.8%
Infiltration
Microabrasion 66.9±4.1a,x 71.5±6.0b,y 72.2±5.4y 4.6 5.3 0.7ᵆ 6.9% 7.9%
*Negative value indicates decrease in L‑Value toward the baseline signifying increase closeness to sound enamel shade. ᵆPositive value
indicates increase in L‑Value toward the baseline signifying decrease closeness to sound enamel shade. a,bVertically, similar letters indicates
nonsignificant difference. x,y Horizontally, similar letters indicates nonsignificant difference and nonsimilar letters indicates significant
difference

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 Lee, et al.: Esthetic outcomes of white spot lesion treatment
Unfortunately, most available preventive methods
demand patients’ compliance. Noncompliance with
the thorough oral hygiene regimen required during
orthodontic treatment with fixed appliances is the
main cause of WSL development; thus, a number
of patients still require treatment for WSLs after
orthodontic treatment.[8,9] The most popular noninvasive
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treatment options, among others, are tooth bleaching,[12]
microabrasion,[13] and resin infiltration.[14] Thus, the
present study investigated and compared the ability of
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tooth bleaching, microabrasion, and resin infiltration to
restore the appearance of WSL to that of the original
sound enamel. An effective WSL treatment should
restore the WSL as close as possible to the shade of
the immediate surrounding sound enamel.
In the present study, the bleaching group started with a
baseline shade of 68.6, which correlates with a VitaPan
Classical shade of D2. As bleaching progressed, the final
shade of the entire tooth surface was brought to a mean
L‑value of 74, which correlates with a VitaPan Classical
shade of ~A1. In terms of clinical observations, the teeth
were significantly whiter. This would correlate to a shade
increase of approximately five shades. This amount of
change may not be necessary for every patient. The
manufacturer suggests monitoring whitening every 1 to
3 days to treat each patient according to their individual
needs. On average, bleaching WSLs with 10% carbamide
peroxide increased shade approximately 1.7 units in
L‑value, indicating an increase in brightness. The final
difference between baseline and posttreatment WSL
was approximately an L‑value of 7 units  (equivalent to
six shades, on the Vita classic shade guide). Only 25%
of the teeth in the bleaching group were successfully
masked. Overall, bleaching was able to produce teeth
which appeared, on average, 10% different in shade
discrepancy from the baseline value  (natural enamel
shade). It is worth noting that bleaching often whitens
the whole tooth, thereby increasing the overall baseline
shade, and thus masked the WSL by increasing baseline
shade. However, strictly from comparing bleaching to the
original baseline shade, bleaching was a valid method
of camouflaging white spot lesions in only 25% of the
sample size. Compared with other bleaching studies,
patients typically achieve two shades of whitening
after bleaching for 2  weeks.[5,16,17] The ADA has also
defined whitening as efficient if two shades of whitening
are achieved.[20] It is possible to say from the present
study that bleaching should be able to camouflage the
WSLs after the removal of the orthodontic appliances.
However, it has been reported in a previous study that
some bleaching agents have the potential to damage the
surface finish of microhybrid and microfilled composite
restorations,[21] thus care should be taken in selection of
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bleaching materials for patients with such restorations.
Unfortunately, the present study did not assess the
effects of the used bleaching material and microabrasion
on the surface roughness properties of the investigated
teeth.
Consistent with other studies,[14,15] in the present study,
resin infiltration worked very well for some lesions and
not as well for deeper lesions. On average, the amount
of color change in L‑value with infiltration was 2.4
units, which would correlate with approximately four
to five shades. Some lesions were so well‑camouflaged
that it was difficult to discern the previous location of
the WSL. These lesions were typically observed to be
shallow lesions. On severe lesions, infiltration was
not able to mask the lesion. Severe lesions improved
slightly, but the WSL was still apparent and appeared
to have a shiny surface sheen to it. It is believed that
the strong acid of the etchant  (15% HCL) etches off
the demineralized tissue  (WSL) and replaces the tissue
with the clear resin. The etching‑off is complete in
shallow lesions and partial in deeper lesions, thus the
incomplete masking of the deeper lesions. Despite not
working on all lesions, on average, infiltration was
able to correct pretreatment WSL with an average of
negative 2.4 units in L‑value. The negative value in
this measurement implies that after treatment, the lesion
reduced in lightness than before, thus bringing the shade
of the lesion surface closer to the baseline value (normal
enamel shade). On the CIE Lab scale, zero represents
the color black, and one hundred represents the color
white, so any shift toward zero indicates a decrease
in lightness. Infiltration was the only method that was
able to lower posttreatment WSL toward baseline
values [Table  1]. On average, infiltration produced
lesions which were only different from baseline values
by 2.8%. Therefore, based on this in vitro study, we
considered infiltration as a valid option for addressing
white spot lesions. Thus, the result of the present study
rejected our hypothesis that among the tested treatment
modalities, bleaching will restore white spot area most
closely to the appearance of the original healthy enamel.
It is conceivable that the better treatment outcome with
Resin Infiltration treatment is attributable to the fact that
strong acid of the etchant etches off the demineralized
tissue  (WSL) and replaces the tissue with resin that has
translucency very close to that of enamel. The slight
difference in shade (2.8%), particularly in deeper lesion,
is believed to be due to the original enamel (baseline
value) having a dentin base underneath, while the resin
has a residual demineralized tissue  (WSL) underneath.
Thus, the near similar translucency of enamel and resin
may explain the better treatment outcome with Resin
Infiltration.
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Of all the treatment methods, microabrasion appeared to
be the messiest during application. The slurry would often
splatter, and thus, the use of a rubber dam application
was a must as stated by the manufacturer. During data
collection, microabrasion slurry seemed to make the
entire tooth surface lighter in color. One explanation
is that the acid in the slurry  (6.6% hydrochloric acid)
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etches the enamel surface, producing a whitish frosty
appearance, which is traditionally seen in enamel etching
procedures. It is also possible that microabrasion removed
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the surface layer, and exposed a deeper and perhaps
even more prominent portion of the WSL in some teeth.
After removing the slurry, we also observed the luster as
described in other studies.[13] Microabrasion was only able
to change the pretreatment WSL by 0.7 units in terms of
L‑value. This change in shade was considered clinically
insignificant. At this point, it is pertinent to mention
that prior to actual study assessments, multiple readings
of a sample test tooth were performed to observe the
differences in taking repeated readings at the same site to
reveal any errors that may have arisen from measurement
error. We found differences only varied by at most one
unit after multiple readings. Because multiple readings
had a tolerance of one unit, we concluded any changes
equal to or less than one unit should be classified as
insignificant or negligible because it could have been
attributed to instrument measurement error. Statistical
analysis also confirmed nonsignificance of this change.
The positive L‑value also indicates the WSL became
whiter. This was consistent with visual observation that
WSL appeared to be unchanged or even whiter, after two
applications of microabrasion. We, therefore, considered
it that using microabrasion did not improve WSL
significantly in this study.
Of the three investigated methods, bleaching and
infiltration seemed the most promising. Resin infiltration
was able to mask WSL the most by lowering the color
difference in value from pretreatment to posttreatment
by a negative 2.4 units. This was the only method
to mask and lower the value of the WSL relative to
baseline. Other methods increased the whiteness of the
WSL, which was expected for bleaching at 1.7 units,
but were surprising for microabrasion at 0.7 units.
Thus, our hypothesis that among the tested treatment
modalities, bleaching will restore white spot area most
closely to the appearance of the original sound enamel
was rejected. With regards to a no treatment option,
WSL will presumably remain on the teeth indefinitely.
On average the difference between a baseline reading
and a WSL with no treatment, in this study ranged from
4.2 to 5.1 in L‑value [Table 1]. In order of effectiveness,
resin infiltration was most effective in masking WSL,
followed by bleaching and microabrasion.
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The mechanisms by which white spot masking
occurs vary. Microabrasion was the application of an
acidic and abrasive compound to the surface of the
enamel and removes on average 12 μm on the first
application and 26 μm on subsequent applications.[13]
Caries infiltration exploits capillary forces to transport
resins with high penetration coefficients into enamel
porosities.[22] After polymerization, the infiltrant blocks
pathways for cariogenic acids to diffuse into and dissolve
the tooth tissue,[23,24] thus preventing further progression
of the caries lesion. For bleaching, there was a great
controversy regarding the effect of bleaching agents on
mineral contents of enamel. Some in situ studies have
been performed to verify the interaction of bleaching
agents with saliva, soft tissues, and dental structures;
however, further evaluations regarding this matter were
needed.[25] The mechanism by which teeth are whitened
by oxidizing materials such as hydrogen peroxide and
carbamide peroxide is currently not fully understood.[26]
Although the present study achieved its objective of
determining the treatment modality that can restore the
appearance of an existing white spot lesion as close as
possible to that of the immediate surrounding healthy
enamel, it has some limitations. The study did not assess
the effects of the bleaching and microabrasion on the
surface roughness properties and mineral contents of the
enamel surface, which may affect the clinicians’ decision
on the use of these techniques. Furthermore, photographs
of the treated teeth would have helped the readership
to appreciate the reported outcome of the treatments.
Finally, the use of only the L value of the CIE L*A*B
measurement system for assessing the outcome of the
study is another limitation of this study. Future studies in
this area should put these points into consideration.
Conclusions
Among the three investigated treatment modalities in
this in vitro study, resin infiltration was able to mask
WSLs the most. On average, lesions treated by resin
infiltration improved by two to three units in L‑Value.
Bleaching was able to mask approximately 25% of the
samples in this experiment and should be considered.
Last was microabrasion, which has been successful in
other studies, but did not appear to produce a significant
improvement in this study. Further research involving a
clinical trial is needed to evaluate the long‑term effects
of resin infiltration. We recommend a future study on
resin infiltration and a comparison with remineralization.
Financial support and   sponsorship
Nil.
 
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Month 2020
2020
 Lee, et al.: Esthetic outcomes of white spot lesion treatment
Conflicts of   interest
There are no conflicts of interest.
References
1. Bishara  SE, Ostby  AW. White spot lesions: Formation,
prevention, and treatment. Semin Orthod 2008;14:174-82.
2. Ogaard  B. Oral microbiological changes, long-term enamel
Downloaded from http://journals.lww.com/njcp by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
alterations due to decalcification, and caries prophylactic aspects.
Orthod Mater Sci Clin Asp 2001:123-42.
3. Staley RN. Effect of fluoride varnish on demineralization around
orthodontic brackets. Semin Orthod 2008;14:194-9.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 06/10/2023
4. Chen  H, Liu  X, Dai  J, Jiang  Z, Guo  T, Ding  Y. Effect of
remineralizing agents on white spot lesions after orthodontic
treatment: A systematic review. Am J Orthod Dentofacial Orthop
2013;143:376-82.e3.
5. Guzmán-Armstrong  S, Chalmers  J, Warren  JJ. White spot
lesions: Prevention and treatment. Am J Orthod Dentofacial
Orthop 2010;138:690-6.
6. Tran P, Hamood A, Mosley T, Gray T, Jarvis C, Webster D, et al.
Organo-selenium-containing dental sealant inhibits bacterial
biofilm. J Dent Res 2013;92:461-6.
7. Amaechi  BT, Najibfard  K, Chedjieu  IP, Okoye  LO. Do products
preventing demineralization around orthodontic brackets affect
adhesive bond strength? Open Dent J 2018;12:1029-35.
8. Lucchese A, Gherlone E. Prevalence of white-spot lesions before
and during orthodontic treatment with fixed appliances. Eur J
Orthod 2013;35:664-8.
9. Julien  KC, Buschang  PH, Campbell  PM. Prevalence of white
spot lesion formation during orthodontic treatment. Angle Orthod
2013;83:641-7.
10. Maltured  MI. Minimally invasive restorative dentistry:
A  biomimetic approach. Pract Proced Aesthet Dent
2006;18:409-14.
11. Bailey  DL, Adams  GG, Tsao  CE, Hyslop  A, Escobar  K,
Manton  DJ, et al. Regression of post-orthodontic lesions by a
remineralizing cream. J Dent Res 2009;88:1148-53.
12. Bussadori SK, do Rego MA, da Silva PE, Pinto MM, Pinto AC.
Esthetic alternative for fluorosis blemishes with the usage of a
dual bleaching system based on hydrogen peroxide at 35%.
J Clin Pediatr Dent 2004;28:143-6.
Nigerian
Nigerian
Journal
Journal
of of
Clinical
Clinical
13. Murphy TC, Willmot DR, Rodd HD. Management of postorthodontic
demineralized white lesions with microabrasion: A  quantitative
assessment. Am J Orthod Dentofacial Orthop 2007;131:27-33.
14. Kim  S, Kim  EY, Jeong  TS, Kim  JW. The evaluation of resin
infiltration for masking labial enamel white spot lesions. Int J
Paediatr Dent 2011;21:241-8.
15. Torres  C, Borges  A, Torres  L. Effect of caries infiltration
technique and fluoride therapy on the colour masking of white
spot lesions. J Dent 2011;39:202-7.
16. Knösel M, Attin  R, Becker  K, Attin T. External bleaching effect
on the color and luminosity of inactive white-spot lesions after
fixed orthodontic appliances. Angle Orthod 2007;77:646-52.
17. Knösel M, Attin  R, Becker  K, Attin  T. A  randomized CIE-lab
evaluation of external bleaching therapy effects on fluorotic
enamel stains. Quintessence Int 2008;39:391-9.
18. Amaechi B, Higham SM. Development of a quantitative method
to monitor the effect of a tooth whitening agent. J  Clin Dent
2002;13:100-3.
19. Johnston  WM, Kao  EC. Assessments of appearance match
by visual observation and clinical colorimetry. J  Dent Res
1989;68:819-22.
20. Council on Dental Therapeutics. Guidelines for the acceptance
of peroxide-containing oral hygiene products. Am Dent Assoc
1994;125:1140-2.
21. Qasim S, Ramakrishnaiah R, Alkheriaf AA, Zafar MS. Influence
of various bleaching regimes on surface roughness of resin
composite and ceramic dental biomaterials. Technol Health Care
2016;24:153-61.
22. Meyer-Lueckel  H, Paris  S. Improved resin infiltration of natural
caries lesions. J Dent Res 2008;87:1112-6.
23. Paris  S, Meye-Leuckel  H. Inhibition of caries progression by
resin infiltration in situ. Caries Res 2010;44:47-54.
24. Meyer-Lueckel H, Paris S. Progression of artificial enamel caries
lesions after infiltration with experimental light curing resins.
Caries Res 2008;42:117-24.
25. Tong  LS, Pang  MK, Mok  NY, King  NM, Wei  SH. The effects
of etching, micro-abrasion, and bleaching on surface enamel.
J Dent Res 1993;72:67-71.
26. Rodrigues  JA, Marchi  GM, Ambrosano  GM, Heymann  HO,
Pimenta  LA. Microhardness evaluation of in situ vital bleaching
on human dental enamel using a novel study design. Dent Mater
2005;21:1059-67.
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