ORIGINAL ARTICLE

Development of white spot lesions during orthodontic treatment: Perceptions of patients, parents, orthodontists, and general dentists
€ Blake J. Maxfield,a Ahmad M. Hamdan,b Eser Tufekci,c Bhavna Shroff,d Al M. Best,e and Steven J. Lindauerf ¸ Salt Lake City, Utah, Amman, Jordan, and Richmond, Va Introduction: Despite the many advances to improve the practice of orthodontics, white spot lesions, or decalcifications, remain a common complication in patients with poor oral hygiene. The purpose of this study was to assess the perceptions and level of awareness of patients, parents, orthodontists, and general dentists toward the development of white spot lesions during orthodontic treatment. Methods: This was a prospective epidemiologic survey of the perceptions of orthodontic patients (n 5 315), parents (n 5 279), orthodontists (n 5 305), and general dentists (n 5 191) regarding the significance, prevention, and treatment of white spot lesions. Results: All surveyed groups indicated that white spot lesions detracted from the overall appearance of straight teeth, attributed primary responsibility for the prevention of white spot lesions to the patients themselves, and thought that the general dentist should be responsible for treating white spot lesions. Patients regarded themselves as ultimately responsible for the prevention of white spot lesions (P \0.05). Conclusions: The patients, parents, orthodontists, and general dentists had similar perceptions regarding the significance, prevention, and treatment of white spot lesions. All groups indicated that patients were the most responsible for the prevention of white spot lesions. Communication among patients, parents, orthodontists, and general dentists needs to improve to decrease the incidence of white spot lesions in the orthodontic population. (Am J Orthod Dentofacial Orthop 2012;141:337-44)

D
a b

espite the many advances to improve the practice of orthodontics, enamel decalcifications, or white spot lesions, are the most frequent complication with fixed appliance therapy.1 The debonding appointment is generally an exciting time for the patient, parents, orthodontist, and staff. White spot lesions, however, can detract from the quality of the

Private practice, Salt Lake City, Utah. Associate professor, Department of Child Dental Health and Orthodontics, Faculty of Dentistry, University of Jordan, Amman, Jordan. c Associate professor, Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, Richmond. d Professor, Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, Richmond. e Associate professor, Department of Orthodontics, School of Periodontics, Virginia Commonwealth University, Richmond. f Professor and chair, Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, Richmond. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Supported in part by the Medical College of Virginia Orthodontic Education and Research Foundation. Reprint requests to: Steven J. Lindauer, Department of Orthodontics, School of Dentistry, Virginia Commonwealth University, PO Box 980566, Richmond, VA 23298-0566; e-mail, sjlindau@vcu.edu. Submitted, April 2011; revised and accepted, August 2011. 0889-5406/$36.00 Copyright Ó 2012 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2011.08.024

treatment results and cause disappointment among patients, parents, and dental professionals. White spot lesions are defined as “subsurface enamel porosities from carious demineralization” with “a milky white opacity . . . when located on smooth surfaces.”2 Changes in light scattering of the decalcified, porous enamel causes the white appearance. These white spot lesions rarely progress to significant cavitations and are generally not registered as caries requiring restorative treatment in the decayed, missing due to caries, filled teeth (DMFT) index.3 White spot lesions can form within 4 weeks, which is typically within the time frame between subsequent orthodontic appointments. Orthodontic attachments in the oral cavity make the mechanical removal of plaque somewhat difficult.4,5 In addition, lack of compliance in maintaining adequate oral hygiene can predispose orthodontic patients to white spot lesions.6 To prevent decalcification and formation of white spot lesions, a good oral-hygiene regimen must be implemented, including proper toothbrushing with a fluoridated dentifrice.7 Fluoride concentrations below 0.1% should not be recommended for orthodontic patients.3 For less compliant patients, the use of a fluoridated dentifrice alone is ineffective in preventing the development
337

Reexamination of 40 subjects who had participated in a randomized controlled clinical study on the effect of a cariespreventive program 6 years after debonding showed that about 75% of the small white spot lesions had regressed during that period. Surveys were therefore mailed successfully to 587 orthodontists and 495 general dentists. but the teeth in photograph B showed visible white spot lesions. The total number of surveys distributed to the 7 offices was 700 (350 to each group of patients and parents. Orthodontic patients develop significantly more white spot lesions than nonorthodontic patients. regardless of the treatment approach. parents. The American Dental Association provided the names and addresses of 500 general dentists under the age of 60 randomly chosen from Virginia. The purpose of this study was to assess the perceptions and levels of awareness of patients. Patients and parents were asked several additional multiple-choice questions.3 Patients respond differently to white spot lesions. Maryland. patients and orthodontists should work together to help prevent white spot lesions from developing during treatment. The American Association of Orthodontists provided the names and addresses of all member orthodontists under the age of 60 practicing in Virginia. these preventive measures depend on patient compliance. and general dentists toward the development of white spot lesions during orthodontic treatment.15 Twenty-five percent of the most severe lesions remained visible on the surfaces. Geiger et al9 reported that less than 15% of orthodontic patients rinsed daily as instructed. and these white spot lesions can cause esthetic problems years after treatment. and 4 identical questions were asked so that responses could be compared directly. The American Association of Orthodontists and the American Dental Association granted permission to conduct the study. respectively). Four analogous surveys were designed to assess the perceptions and levels of awareness of patients. so the answers were anonymous.3% showed cavitations. orthodontists. parents. Five offices were located in Virginia and 2 in North Carolina. Richter et al14 reported that an alarming 72. and North Carolina. A follow-up survey was sent to those who did not return the questionnaire. and general dentists toward the development of white spot lesions during orthodontic treatment.11 Gorelick et al12 found that the incidence of at least 1 white spot lesion was 50% in patients who had treatment with fixed orthodontic appliances compared with only 24% in untreated controls. of which 2. thus.9 Unfortunately. what they did to March 2012  Vol 141  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . The surveys were also pretested before implementation to improve the design and thereby increase the response rate. The teeth in photograph A had no visible white spot lesions. Ideally. and 50 were to be completed by parents of patients receiving active orthodontic treatment. Maryland. and the receptionist at each office asked patients and parents to participate in the study. The front page of each survey explained the purpose of the study and included 2 color intraoral photographs of the right side of a well-aligned dentition (Fig). 608 orthodontists).05% sodium fluoride) daily in addition to fluoride toothpaste. All questions were multiple choice.8 Orthodontic patients are therefore requested to use a fluoride mouth rinse (0. Similarly. MATERIAL AND METHODS Virginia Commonwealth University in Richmond granted institutional review board approval to conduct this study.3 Fluoride rinses have been shown to significantly reduce white spot lesions during orthodontic therapy. White spot lesions are difficult to treat and are often permanent. the recommended course of treatment should be unique to each patient.9% of patients developed at least 1 white spot lesion during orthodontic treatment. Wilson et al10 showed that only 16% of patients who received extensive periodontal therapy complied with the recommended maintenance schedules.338 Maxfield et al of carious lesions. orthodontists. These questions were (1) how much do white spots make straight teeth look worse? (2) who do you think is responsible for the prevention of white spots from braces? (3) who do you think is most responsible for the prevention of white spots from braces? and (4) who should treat white spots on teeth from braces? No identifying information was requested. Patients were asked how long they had been wearing braces. Each office was given 100 surveys. Fifty surveys were to be completed by active orthodontic patients in full fixed appliances.8. Patient and parent participants were recruited from 7 orthodontic offices that voluntarily participated in this study. Sandvik et al13 found that about 50% of patients receiving orthodontic treatment developed at least 1 white spot lesion during treatment compared with 11% in untreated controls. Twenty-one addresses from the American Association of Orthodontists and 5 from the American Dental Association were not recognized by the post office as deliverable addresses. In a more recent study. Poor patient compliance is a well-documented problem in the dental and medical literature. The envelopes were numerically coded to identify nonrespondents. and included an addressed postage-paid return envelope. and North Carolina (total. The survey distributed to patients is given in the Appendix.

teeth with white spot lesions. and 41% of parents who completed a survey were male. SAS Institute. More than 1 response was acceptable. 191 general dentists (39%).. The latter analyses were performed with a statistical package (version 19. and 279 parents (80%). 41% for more than 1 but less than 2 years.0 for Windows 2010. Most orthodontists (82%) American Journal of Orthodontics and Dentofacial Orthopedics March 2012  Vol 141  Issue 3 . Nearly all respondents indicated that patients were responsible for the prevention of white spot lesions. and whether they were instructed on how to prevent white spot lesions. which examined the perceived significance of white spot lesions among the groups. methods of taking care of teeth.05). 40% of patients. Somers. The ages in the patient group ranged from 7 to 69 years. All groups indicated joint responsibility among patients.05). Responses to question 3: once the teeth are straightened with braces. Chi-square analyses were used to determine differences in responses among the 4 groups. These included responses from 305 orthodontists (52%). 77% of general dentists. 72% of parents held themselves responsible for white spot lesions prevention. IBM SPSS. Five patients were not wearing braces and were excluded from the study. B. Overall.2. Statistical analysis Table I. Only 17% of the patients thought that prevention of white spot lesions was their parents’ responsibility (P \0.05).0. orthodontists. Seventy-six percent of orthodontists. parents. Postorthodontic treatment intraoral photographs of 2 patients: A. RESULTS A total of 1090 surveys (61%) were returned. time wearing braces.” Similar proportions of patients. take care of their teeth during treatment with braces.Maxfield et al 339 Fig. which examined the perceived responsibility for the prevention of white spot lesions. P \0.585 responses (2. and general dentists perceived that white spot lesions would make the teeth look either “a little worse” or "a lot worse” (P . Cary NC) was used for these analyses.05). NY). JMP statistical software (version 8. Parents were also asked whether they thought their child needed more instruction on white spot lesions. Table I illustrates the responses to question 3.0. 269 of 10. 315 patients (90%). Multinomial logistic regression was used to investigate the relationships between perceptions. Both patients and parents were asked why they thought people get white spot lesions on their teeth from braces. if their child had white spot lesions.5%) were discarded. and instruction on preventing white spot lesions). Reference was made to the colored photos in the Figure. However. Table II shows the responses to question 4. would they recommend treatment with braces to a friend. how much do white spots make the teeth look worse? (circle one) Group Patients Parents Orthodontists General dentists Total No worse 25 (8%) 17 (6%) 2 (1%) 2 (1%) 46 (4%) A little worse 140 (46%) 122 (45%) 117 (40%) 95 (51%) 474 (45%) A lot worse 142 (46%) 134 (49%) 175 (60%)* 90 (48%) 541 (51%) Total 307 273 294 187 1061 *Significant difference between orthodontists and other groups (P \0.0. Patterns in the differences were identified by large-cell chi-square values. The analysis showed that use of a fluoride rinse was the only factor associated with patient perceptions (P \0. whether they were worried that their child would have white spot lesions at the end of treatment with braces. parents. and 19% for more than 2 years. prevention and treatment of white spot lesions (dependent variables). including the patients themselves. However. and general dentists. a greater proportion of orthodontists (60%) indicated that white spot lesions made the teeth look “a lot worse” compared with the other groups (Table I. Multi-nomial logistic regression was used to determine whether patient factors (independent variables) were predictive of the perceived significance of white spot lesions (dependent variable). and patient variables (age. A small percentage of respondents from all groups perceived that white spot lesions made the teeth look “no worse. Unanswered questions and questions requiring 1 response with more than 1 response were omitted. teeth without white spot lesions. and.05). 39% had been wearing braces for less than a year.

Multinomial logistic regression indicated that receiving instructions on how to prevent white spot lesions and going to the general dentist for cleanings were predictors of patient perceptions (P \0. In addition. Response to question 5: who do you think is most responsible for the prevention of white spots from braces? (circle one) Responses Group Patients Parents Orthodontists General dentists Total Patients 264 (87%)* 183 (77%) 223 (78%) 118 (66%) 778 (78%) Parents 5 (2%)* 27 (11%) 42 (15%) 31 (17%) 105 (10%) Orthodontists 28 (9%) 25 (11%) 21 (7%) 31 (17%)* 105 (10%) Dentists 5 (2%) 3 (1%) 1 (0%) 0 (0%) 9 (1%) Total 302 238 287 180 1007 *Differences significant compared with other groups (P \0. ySignificant differences between laypeople (patients and parents) and dental professionals (P \0.” Most respondents indicated that the dentist should treat white spot lesions caused by braces. Multi-nomial logistic regression showed that age and time wearing braces were associated with patient perceptions of who was the most responsible for preventing white spot lesions (P \0. Table III.05). 81% of parents would still recommend treatment with braces even if their child had white spot lesions after treatment. 2% would not. and 17% said that they might not recommend braces to a friend if their child developed white spot lesions. Patient and parent surveys included the additional answer choice: “white spots from braces cannot be removed from teeth. more than 1 answer is acceptable) Responses Group Patients Parents Orthodontists General dentists Total Patients 291 (94%) 251 (92%) 299 (98%) 182 (95%) 1023 (95%) Parents 54 (17%)* 197 (72%) 275 (90%) 162 (85%) 688 (64%) Orthodontists 97 (31%)y 150 (55%)y 262 (86%) 157 (82%) 666 (62%) Dentists 89 (29%)y 106 (39%)y 194 (64%) 132 (69%) 521 (48%) Total 310 274 304 191 1079 *Significant difference between patients and other groups (P \0.05). 23% of the patients and 16% of the parents perceived that white spot lesions were permanent and could not be removed (Table IV). Only 9 respondents (1%) indicated that dentists were the most responsible for the prevention of white spot lesions (Table III). About a fifth (21%) of parents were “not at all worried. March 2012  Vol 141  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . Patients indicated that they themselves were the most responsible more often than the other groups (P \0. However. However.05). 55% of the parents thought that they or their child needed more instruction on preventing white spots from braces. Table II). Table III illustrates the responses to question 5.05. The majority of subjects in all 4 groups selected patients as most responsible for the prevention of white spot lesions from braces. 99% of the patients responded that they brushed their teeth.05).05). 62% said that they flossed. Conversely. which investigated perceptions of who was the most responsible for the prevention of white spot lesions from braces. Patients and parents indicated less often than orthodontists and general dentists that dental professionals were responsible for preventing white spot lesions (P \0. When asked what they did to take care of their teeth during treatment. and 52% used a fluoride rinse. Table IV shows the responses to question 6. Over half (58%) said that they went to the general dentist for cleanings as part of taking care of their teeth during treatment.05). most general dentists (82%) perceived that orthodontists were responsible for the prevention of white spot lesions. Seventy-two percent of the patients indicated that they had been given instructions on how to prevent white spots from braces. regarded themselves responsible for prevention of white spot lesions.” Furthermore. which determined the perceptions of who should treat white spot lesions. Most parents were “very worried” (7%) or “somewhat worried” (71%) that their child would have white spots from braces at the end of treatment. Response to question 4: who do you think is responsible for the prevention of white spots from braces? (circle all that apply.340 Maxfield et al Table II.

prevention. parents indicated that they were responsible for the prevention of white spot lesions at a much higher rate (72%). orthodontists might feel frustrated because they cannot prevent the development of white spot lesions. and treatment of white spot lesions. orthodontists expressed a strong sense of responsibility for the prevention of these lesions. most thought that the main reasons were “not brushing and flossing often enough” and “not brushing and flossing properly” (Table V). and parents. As the clinician providing treatment and aspiring to provide patients with a perfect result. especially in uncooperative patients. Patients themselves were less likely to attribute responsibility to the other groups for the prevention of white spot lesions. and general dentists (Table II). Only 17% of the patients indicated that their parents were responsible for preventing white spot lesions. When asked to identify who was responsible for the prevention of white spot lesions. and type 2 diabetes). high blood pressure. This might have been because patients and parents viewed the orthodontists’ job as involving only treatment with braces and that all other dental treatments should be carried out by general dentists. Eighty-six percent of orthodontists indicated that they were responsible to some degree for the prevention of white spot lesions (Table II). On average. Furthermore. and to present the various treatment options. A medical study documented that physicians and nurses perceive the patient to be ultimately responsible for lifestyle-related decisions dealing with certain diseases (ie. Reasons given for why people get white spots from braces (more than 1 answer was possible) Patients Parents Not brushing and flossing often enough 205 (66%) 139 (52%) Not brushing and flossing properly 187 (60%) 169 (63%) Not using fluoride rinse 86 (28%) 50 (19%) Some people are prone to get white spots 16 (5%) 40 (15%) from braces Braces cause white spots 26 (8%) 31 (12%) In this study.05). A higher percentage of orthodontists indicated that white spot lesions made the teeth look “a lot worse” (60%) compared with all other groups (P \0. the 4 groups of participants had similar perceptions regarding the significance. However. and thus parents are likely to play an integral role in the prevention and management of white spot lesions. Most orthodontic patients are adolescents. parents. Fewer patients and parents thought that “braces caused white spots” (8% of patients and 12% of parents. parents. going to the general dentist for cleanings American Journal of Orthodontics and Dentofacial Orthopedics March 2012  Vol 141  Issue 3 . we gathered information regarding the perceived significance of white spot lesions on the overall appearance of straight teeth as viewed by orthodontists. how serious it is. all groups indicated joint responsibility among patients. Furthermore. attributed primary responsibility for the prevention of white spot lesions to the patients themselves (Tables II and III). patients. orthodontists. Most patients in this study did not blame their parents for the consequences of their own inactions.17 Most respondents in all 4 groups indicated that the general dentist should be responsible for treating white spot lesions. Overall.Maxfield et al 341 Table IV. and thought that the general dentist should be responsible for treating white spot lesions (Table IV). Responses to question 6: who should treat white spots on teeth from braces? (circle one) Responses Group Patients Parents Orthodontists General dentists Total Orthodontist 69 (23%) 93 (37%) 78 (27%) 24 (13%) 264 (25%) Dentist 165 (55%) 120 (55%) 214 (73%) 165 (87%) 664 (64%) Cannot remove white spot lesions 68 (23%) 40 (16%) Total 302 253 292 189 1036 108 (10%) When patients and parents were asked why they thought people got white spots from braces.16 In our study. general dentists.05). orthodontists might be disappointed if there are white spot lesions after treatment that detract from the overall result. DISCUSSION Table V. all groups indicated that white spot lesions detracted from the overall appearance of a finished orthodontic patient (Table I). Table V). orthodontists. Most patients. “Not using a fluoride rinse” was given as a reason by 28% of the patients and 19% of the parents. and general dentists indicated that patients were the most responsible for the prevention of white spot lesions (Table III). The medical literature documents that physicians have a responsibility to inform the patient what is wrong. dyslipidemia. Age and time wearing braces were significantly associated with patient perceptions (P\0. Most participants agreed that white spot lesions made the appearance of teeth worse. how it came about.

Bishara SE. Differences in responses among the groups could be helpful in identifying areas of communication needing greater emphasis. CONCLUSIONS Patients. all groups indicated that white spot lesions detracted from the overall appearance of a finished orthodontic patient. Schwartz RS. Motivating patients and training them to implement good oral-hygiene habits might be more important than all of the advice and preventive measures combined.14:174-82. The opinions expressed in our study were those of a sample derived from 3 states on the east coast of the United States. Zachrisson BU. Contemporary treatment of dentofacial deformity. Fundamentals of operative dentistry: a contemporary approach. Ostby AW.05). Am J Orthod Dentofacial Orthop 1993. and responsibility for the prevention and treatment of white spot lesions are encouraging for their future control due to orthodontic treatment. Zachrisson S. 2006. Semin Orthod 2008. orthodontists. 3rd ed. V. 7. Seventy-eight percent of parents with children undergoing orthodontic treatment were either worried or very worried that their child would develop white spot lesions during orthodontic treatment. it is not unreasonable to assume that subjects from other parts of the United States could have similar responses. etiology. 4. White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. 5.79:394-401. White spot lesions: formation. p. Part 1. and it is important for patients and parents to know that some treatment options are available to improve. Orthodontic appliances and enamel demineralization.05). Hanover Park. and treatment. 681. Rolla G. Caries incidence and oral hygiene during orthodontic treatment. p. Sarver DM. In this study. the lesions. prevention. parents. Furthermore. 6.342 Maxfield et al and receiving instructions on how to prevent white spot lesions were significantly associated with patient assessments of who was responsible for treatment of white spot lesions (P \0. 2003. This warrants further investigation. This finding reenforces the need for continued instruction and follow-up of patients’ oral hygiene during orthodontic treatment. In this sense. REFERENCES 1. however.14: 183-93. Proffit WR. Patients regarded themselves as ultimately responsible for the prevention of white spot lesions more often than any other group (P \0. attributed primary responsibility for the prevention of white spot lesions to the patients themselves.11 Although most patients indicated that they had received proper instructions regarding the process of white spot lesion development. March 2012  Vol 141  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . Scand J Dent Res 1971. Most patients and parents indicated that white spot lesions developed because of inadequate or improper brushing and flossing (Table V). Most parents were concerned that their child would develop white spot lesions during treatment. 2. Most patients and parents were aware that white spot lesions were caused by inadequate or improper brushing and flossing during orthodontic treatment. 3. Without intervention. Alexander SA. Nineteen percent of the parents indicated that they would not or might not recommend braces to a friend if their child had white spot lesions after orthodontic treatment. Robbins JW.05) and indicated that their parents were responsible less often than any other group (P \0. Arends J. White RP. St Louis: C. On average. A meta-analysis of client-centered motivational interviewing found that strategies used to increase the patient’s intrinsic motivation so that change arises from within rather than being imposed from without outperformed traditional advice-giving strategies in 80% of the studies. and indicated that the general dentist should be responsible for treating white spot lesions. and treatment of white spot lesions. 2-4.94:68-73. but simply reminding patients might not be sufficient to decrease the incidence of white spot lesions. and general dentists regarding the significance. although one must be cautious not to generalize these findings. Summitt JB. and general dentists participating in this study had similar perceptions regarding the significance. This indicated that these parents perceived an overall negative outcome of orthodontics when white spot lesions form during treatment. prevention.18 The common opinions expressed by patients. parents and general dentists can play important roles along with the orthodontist in helping patients to prevent the development of white spot lesions during orthodontic treatment. 55% of the parents indicated that their child could have used more instruction on the prevention of white spot lesions. parents. Am J Orthod Dentofacial Orthop 1988.103:45-7. Ill: Quintessence. 23% of patients and 16% of parents thought that white spot lesions could not be removed. indicates a need for reassessment of the protocols for their prevention. The current frequency of development of white spot lesions in orthodontic patients. or at least mask. however. orthodontists. a substantial proportion (28%) did not recall receiving such instruction. Lesion development. Advice from dental professionals to maintain proper oral hygiene is necessary. Mosby. Ogaard B. Semin Orthod 2008. most indicated that they would still recommend braces even if their child had white spot lesions after treatment. it is rare for white spot lesions to go away completely. Ogaard B. The effect of fixed and functional appliances on enamel decalcifications in early Class II treatment.

14. 16. Jallinoja P. Gorelick L. Richter AE. 15. Jacobs T. 17.101:403-7. Peters MC.Maxfield et al 343 8. Compliance with maintenance therapy in a private periodontal practice. Ogaard B. Motivational interviewing: a systematic review and meta-analysis. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Seeking a balance: patient responsibilities in institutional health care. Featherstone JDB. Geiger AM. 12. Demineralization and remineralization around orthodontic appliances: an in vivo study. Wilson TG Jr. Schoen J. Baus C.3:183-95. El-Agroudi M. Talja M. Rubak S.55:468-73. Am J Orthod Dentofacial Orthop 1992.55:305-12. Bishara SE. 18. Caries and white spot lesions in orthodontically treated adolescents—a prospective study [abstract]. Kuronen R. Am J Orthod Dentofacial Orthop 2011.92:33-40. Lauritzen T. Nissinen A. Henriksson T. Geiger AM. Incidence of white spot formation after bonding and banding. 11. The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses. Gorelick L. Uutela A. Birkhed D. Gwinnett AJ. Benson BJ. 10. Absetz P.120: 28-35. American Journal of Orthodontics and Dentofacial Orthopedics March 2012  Vol 141  Issue 3 . Scand J Prim Health Care 2007. 9.28:e258. Arruda AO. Am J Orthod Dentofacial Orthop 1987. Hadler-Olsen S. et al. Am J Orthod Dentofacial Orthop 1989. Eur J Orthod 2006. Sandbaek A. Wilson CL. Reducing white spot lesions in orthodontic populations with fluoride rinsing. Ogaard B.96:423-7. Gwinnett AJ. O’Reilly MM.81:93-8. Glover ME. Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. Larsson E. Sohn W.25:244-9.139: 657-64. Br J Gen Pract 2005. Med Law Int 1998. Ogaard B. Incidence of caries lesions among patients treated with comprehensive orthodontics. 13. Am J Orthod Dentofacial Orthop 2001. Sandvik K. Am J Orthod 1982. J Periodontol 1984. Christensen B.

Orthodontist d. how much do white spots make the straight teeth look worse? (see photos on other side) (circle one) a.344 Maxfield et al APPENDIX Survey to orthodontic patients 1. White spots from braces cannot be removed from teeth 7. Orthodontist b. Orthodontist d. Dentist 6. Patient b. Dentist 5. Female 3. More than 2 years d. Once teeth are straightened with braces. Some people are just prone to getting white spots from braces e. Dentist c. Brush b. Not brushing and flossing often enough b. A lot worse—white spots make teeth look much worse 4. Parents c. Not using fluoride rinses d. Who do you think is responsible for the prevention of white spots from braces? (circle all that apply) a. Yes b. Patient b. Braces cause white spots March 2012  Vol 141  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics . Go to the general dentist for cleanings 9. Did you get instruction on how to prevent white spots from braces? (circle one) a. A little worse—white spots make teeth look a little worse c. Current age: ________ years 2. Male b. How long have you been wearing braces? (circle one) a. What do you do to take care of your teeth during the time when you have braces? (circle all that apply) a. No 10. Less than 1 year b. Who can best remove white spots on teeth from braces? (circle one) a. Floss c. No braces right now (please return survey if you don’t have braces) 8. Parents c. More than 1 year but less than 2 years c. Not brushing and flossing properly c. Why do you think people get white spots on their teeth from braces? (circle all that apply) a. No worse—white spots do not make teeth look worse b. Who do you think is most responsible for the prevention of white spots from braces? (circle one) a. Gender: a. Fluoride rinse d.

Sign up to vote on this title
UsefulNot useful