Orthodontic Scars and How to Avoid Them
Braces themselves do not stain or scar teeth, however an unfortunately common negative outcome seen at the end of braces is scars or white spots found around the braces. The reported percentage of people impacted varies significantly depending on who you ask and what studies you read. Most reports support around 60% of patients will develop a white spot lesion during orthodontics! 60% is high! This includes very small spots that remineralize and go away but it also includes those permanent scars. These are avoidable so I try to educate my patients on how to avoid these permanent scars so their final smile is as beautiful as it can be.
Where do these scars come from? What causes them? How do you avoid them? We will answer these questions and more in the following paragraphs.
The simple answer is white spots are a change to the teeth’s mineral make-up in response to plaque buildup sitting on the teeth for an extended period of time. You avoid white spot scars by brushing and flossing well to remove all buildup daily so the plaque can’t develop enough to harm the teeth. Braces, also known as fixed orthodontic appliances because they are glued to the teeth, if not well cleaned, create the perfect place for plaque to accumulate on the front surfaces of teeth which are normally self-cleansing due to their shape and constant exposure to saliva (spit). Braces create a more difficult to clean shelf for bacteria to sit on. Since bacteria sitting on the tooth for a long time causes white spots this explains why wearing braces increases your risk of white spot lesions. The rest of this post is packed with microbiology, science and is admittedly a little boring. So if you want to know more and nerd out with me keep reading, otherwise go brush your teeth!
Smaller, more superficial white spot lesions will remineralize naturally fading away in the weeks after braces are removed. More intense white spots that infiltrate deeper layers will not fully remineralize. The good news is they will remineralize and fade a little once the braces are removed but there will be a persistent white scar on the tooth surface. There are some promising remineralization agents which can help these deeper white spots.
The dreaded White Spot Lesions: What is it?
The term “white spot” is used in dentistry to describe an area of chalky enamel that has become demineralized usually as a result of prolonged exposure to plaque. The chalk-like white opaque appearance is caused by the loss of mineral at the surface and subsurface of the enamel creating more porous enamel altering the pattern of reflective light scatter. Altered light scatter impacts how our eyes see color - this is true for any surface including teeth. This is why they appear whiter than the surrounding tooth.
Plaque is simply microbial biofilm accumulation. Biofilm just means a layer of bacteria. When this plaque accumulation forms around orthodontic braces the microbes actually change the environment of the mouth into a more acidic place which promotes and supports harmful aciduric bacteria to thrive.
What bacteria make up Plaque?
The primary colonizers, primarily gram positive cocci, initiate biofilm formation by adherence directly to the tooth surface and by attracting the same species (autoaggregation) and different species (coaggregation). The structure and design of the biofilm is not only important to it’s survival it is also pretty amazing! The innermost layer of the biofilm is made up of microorganisms arranged in an extracellular polysaccharide matrix which is like a scaffolding that is capable of housing bacteria that would otherwise be unable to survive in the oral cavity. This matrix scaffolding is protected by the outermost layer of the biofilm made up of bacteria that are less harmful and able to survive in the oral cavity. The outer layer shields the more harmful bacteria inside. If the biofilm is not disrupted or removed fully by brushing and flossing for 3 days the bacterial make-up changes to more harmful bacteria. Even if you brush every day, if you are not fully disrupting the biofilm it will mature into a more harmful biofilm.
Plaque likes to hide and mature between the braces and the gums! After about 3 days the biofilm shifts to house filament and fusiform bacteria which need an acidic environment to thrive and they further create a more acidic environment raising the pH allowing demineralization to occur.
Demineralization is what it sounds like; removal of the minerals that make teeth strong, calcium, fluoride and phosphorous. Phosphate and calcium are important in the structure of teeth. These elements also naturally balance acids so in response to a more acidic surrounding these minerals leave the tooth enamel in an attempt to balance the biofilms acidity and protect the tooth and body. This exodus of minerals from the teeth result in demineralization white spots. It is this demineralization that causes the permanent white spot lesion scars on the teeth. The white spots are permanent changes to the teeth. Although white spots are not cavities, it is often the first warning sign that if things don’t improve a cavity may be next.
Back to the science for another paragraph:
If the biofilm is allowed to continue to mature undisturbed for 7 days the environment reaches an acidity level that allows for the most harmful plaque bacteria to survive and thrive. For my fellow nerds… these bacteria are vibrios, spirochetes and gram-negative microorganisms that create an acidic pH by metabolizing carbohydrates and releasing acidic by-products. If the surface pH is lowered to below enamels critical pH level of 5.5 the balance of dental remineralization and demineralization shifts to demineralization alone. This is science-talk to say that as long as the mouth stays above a pH of 5.5 the teeth are in a balance of remineralization. Acidic things such as soda and bad bacteria lower the pH, if it is lowered long enough bad things happen to the teeth because the balance is off. If this imbalance is allowed to persist white spot lesions develop and cavities can occur.
Don’t panic. Not everyone with braces will develop white spot lesions. Brushing habits and oral hygiene are large factors but they are not the only factors. Other factors include: diet, levels of minerals such as fluoride, calcium, phosphate and bicarbonate in saliva, medications and genetic susceptibility. Your best line of defense is to not allow the plaque to sit on the teeth for extended periods of time. Plaque builds up on everyones teeth, the trick is to remove it before it can develop into a harmful biofilm.
Wearing braces increases your risk of developing white spot lesions when compared to teeth that never had braces. This is not because braces cause white spots it is simply harder to clean around braces. Biofilm can form on teeth without braces, however you can imagine it is much more difficult for the biofilm to sit undisturbed for the 3-7 days required to harm teeth on smooth enamel.
It makes sense that the sites most susceptible to plaque buildup are those sites that are harder to keep clean. Notably the part of the tooth between the braces and the gums, especially on the lower incisors and all premolars as well as under the arch wire if you don’t floss. These areas are more difficult to get good contact with the toothbrush bristles. With proper technique, the teeth and gums can be kept very clean and white spots can be avoided. See the image below, who brushed twice a day, but unfortunately didn’t have ideal technique so wer can see the build-up in a few sites.
Throughout a normal day all teeth progress through a dynamic process of demineralization and remineralization of the outer enamel. This is constant and luckily doesn’t progress to white spot lesions due to protective stuff found in your spit that helps maintain and stabilize the integrity of the tooth surface until remineralization occurs. Based on what we know, it is the change in pH (acidity) and not the concentration of minerals that is the driving force behind de-and-remineralization. Meaning even if you have plenty of calcium, phosphorous and fluoride in your mouth if there is an acidic environment and the teeth are covered in a biofilm there is still the risk of white spot lesions to form. Silver lining: due to this natural ability of teeth to remineralize (up to a certain point) it seems possible that white spot lesions have the potential for remineralization. Currently this is a focus in orthodontic research. While there are some helpful remineralization agents on the market none of them are perfect and the best line of defense remains prevention!
Treatment of white spot lesions ranges from very conservative, allowing them to remineralize on their own or with the aid of pastes with calcium, phosphorous and fluoride, to more aggressive treatments including removing tooth structure similar to a cavity to place tooth colored material or veneers.
Bottom line: White spot lesions are the worst. I hate them every time I see them. They are avoidable. Let’s avoid them together.
