White Spot Lesions in Orthodontics: Causes, Prevention, and Treatment Options

White spot lesions (WSLs) are a common clinical challenge during and after orthodontic treatment with fixed appliances. They are early indicators of enamel demineralization and can significantly affect the esthetic outcomes of orthodontic care.

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This article explores the definition, characteristics, etiology, prevention, and treatment options for WSLs based on the most recent scientific literature.

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✅ Definition and Characteristics
White spot lesions are defined as subsurface enamel porosities caused by the demineralization of hydroxyapatite crystals, which appear as opaque, chalky white areas on the smooth surfaces of teeth (Gorelick et al., 1982). Unlike caries cavities, WSLs represent a non-cavitated stage of enamel decay that is often reversible with timely intervention (Featherstone, 2004).
These lesions are typically seen on the buccal surfaces of anterior teeth, especially around orthodontic brackets, and can become permanent esthetic defects if left untreated.

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✅ Etiology and Risk Factors
WSLs develop when dental plaque accumulates around orthodontic brackets and is not effectively removed. The cariogenic bacteria, particularly Streptococcus mutans and Lactobacillus, metabolize dietary sugars and produce acids that lower the pH in the biofilm, leading to enamel demineralization (ten Cate, 2001).

➤ Risk factors include:
° Poor oral hygiene during orthodontic treatment
° High carbohydrate/sugar diet
° Salivary flow or composition abnormalities
° Prolonged treatment time
° Lack of fluoride exposure

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✅ Prevention Strategies
Effective prevention is crucial since early WSLs are reversible but can rapidly progress without intervention. Strategies include:

1. Oral Hygiene Education
Patient education remains the cornerstone. Brushing twice daily with fluoride toothpaste, interdental brushes, and electric toothbrushes has shown significant benefit (Derks et al., 2004).
2. Fluoride Use
Fluoride varnishes, mouth rinses, and high-fluoride toothpaste strengthen enamel and reduce WSL incidence. A randomized controlled trial found that 5% sodium fluoride varnish applied every 6 weeks significantly lowered WSL formation (Øgaard, 1994).
3. Sealants and Coatings
Resin sealants and glass ionomer coatings applied to tooth surfaces or brackets can form a physical barrier against plaque accumulation (Julien et al., 2006).
4. Diet Counseling
Minimizing acidic and sugary food intake is essential. Xylitol gum may also reduce bacterial load and stimulate salivary flow.

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✅ Treatment Approaches
Once WSLs appear, timely and appropriate treatment can improve esthetics and prevent progression.

1. Remineralization Agents
° Fluoride therapies: High-fluoride toothpaste, varnishes, and gels promote remineralization.
° CPP-ACP (casein phosphopeptide–amorphous calcium phosphate): Enhances calcium and phosphate delivery to enamel (Bailey et al., 2009).
° Nano-hydroxyapatite: Biomimetic agent that integrates into enamel matrix (Huang et al., 2011).
2. Microabrasion
A minimally invasive technique using acidic and abrasive compounds to remove superficial enamel and improve lesion appearance (Croll, 1990).
3. Resin Infiltration (Icon®)
A novel approach using low-viscosity resin to infiltrate and mask lesions, improving esthetics and halting progression. Clinical studies report high patient satisfaction and long-term effectiveness (Paris et al., 2010).
4. Restorative Techniques
In advanced cases, composite resin restoration or veneers may be required to restore function and esthetics.

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💬 Discussion
WSLs are a frequent but preventable side effect of fixed orthodontic appliances. The use of preventive strategies, such as patient education, fluoride application, and professional monitoring, is essential in reducing incidence. Emerging technologies like resin infiltration provide minimally invasive alternatives with promising results.
Current research focuses on biomimetic remineralizing agents and nanotechnology to enhance enamel repair. However, long-term studies are needed to validate their effectiveness in different populations and orthodontic conditions.

💡 Conclusion
White spot lesions represent a significant clinical concern in orthodontics. Through early diagnosis, preventive strategies, and minimally invasive treatments, dental professionals can mitigate their impact. Collaboration between orthodontists, general dentists, and patients is key to preserving enamel integrity and esthetic outcomes.

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✅ Recommendations

° Reinforce oral hygiene at every orthodontic visit.
° Prescribe fluoride varnishes or high-fluoride toothpaste for at-risk patients.
° Consider applying sealants on high-risk teeth before bracket bonding.
° Introduce resin infiltration early for cosmetic management.
° Promote regular follow-up appointments post-debonding to monitor lesion progression.

📚 References

✔ Bailey, D. L., Adams, G. G., Tsao, C. E., Hyslop, A., Escobar, K., Manton, D. J., ... & Reynolds, E. C. (2009). Regression of post-orthodontic lesions by a remineralizing cream. Journal of Dental Research, 88(12), 1148-1153. https://doi.org/10.1177/0022034509347163

✔ Croll, T. P. (1990). Enamel microabrasion: observations after 10 years. Journal of the American Dental Association, 121(5), 548-550. https://doi.org/10.14219/jada.archive.1990.0172

✔ Derks, A., Katsaros, C., Frencken, J. E., van't Hof, M. A., Kuijpers-Jagtman, A. M. (2004). Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances: a systematic review. Caries Research, 38(5), 413-420. https://doi.org/10.1159/000079623

✔ Featherstone, J. D. B. (2004). The continuum of dental caries—evidence for a dynamic disease process. Journal of Dental Research, 83(Spec No C), C39-C42. https://doi.org/10.1177/154405910408301s08

✔ Gorelick, L., Geiger, A. M., & Gwinnett, A. J. (1982). Incidence of white spot formation after bonding and banding. American Journal of Orthodontics, 81(2), 93–98. https://doi.org/10.1016/0002-9416(82)90032-X

✔ Huang, S. B., Gao, S. S., Yu, H. Y. (2011). Effect of nano-hydroxyapatite concentration on remineralization of initial enamel lesion in vitro. Biomedical Materials, 4(3), 034104. https://doi.org/10.1088/1748-6041/4/3/034104

✔ Julien, K. C., Buschang, P. H., & Campbell, P. M. (2006). Prevalence of white spot lesion formation during orthodontic treatment. The Angle Orthodontist, 76(6), 1045–1050. https://doi.org/10.1043/0003-3219(2006)076[1045:POWSLF]2.0.CO;2

✔ Øgaard, B. (1994). Effectiveness of a fluoride-releasing orthodontic bonding material in the prevention of white spot lesions: a 9-month clinical study. American Journal of Orthodontics and Dentofacial Orthopedics, 106(6), 583–591. https://doi.org/10.1016/S0889-5406(94)70002-5

✔ Paris, S., Meyer-Lueckel, H., Mueller, J., Hummel, M., Kielbassa, A. M. (2010). Progression of sealed initial caries lesions: a randomized controlled clinical trial. Caries Research, 44(1), 67–71. https://doi.org/10.1159/000279324

✔ ten Cate, J. M. (2001). Review on fluoride, with special emphasis on calcium fluoride mechanisms in caries prevention. European Journal of Oral Sciences, 109(2), 207-212. https://doi.org/10.1034/j.1600-0722.2001.00006.x

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Fluoride Varnish for Adults: Benefits, Mechanism of Action, and Application Guidelines

While fluoride varnish is widely recognized as a preventive tool in pediatric dentistry, growing scientific evidence supports its use in adult patients, especially those at increased risk of caries, tooth sensitivity, gingival recession, or xerostomia.

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The American Dental Association (ADA) and the Academy of General Dentistry (AGD) recommend the use of professional topical fluoride as part of comprehensive preventive care throughout life.

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Fluoride varnish is a highly concentrated fluoride treatment applied directly to the teeth. It offers long-lasting protection, promoting enamel remineralization and reducing demineralization caused by acid attacks.

✅ Benefits of Fluoride Varnish in Adults

° Prevention of root and coronal caries: Particularly effective for older adults or those with exposed root surfaces due to gum recession.
° Reduction of tooth sensitivity: Helps seal exposed dentin tubules, reducing pain triggered by thermal, tactile, or chemical stimuli.
° Enamel remineralization: Rebuilds early demineralized enamel before it progresses to cavitation.
° Adjunct to periodontal and orthodontic care: Protects vulnerable surfaces during gum therapy or while wearing braces.
° Management of dry mouth: Offers extra protection in patients with xerostomia, including cancer survivors or those on multiple medications.

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✅ Mechanism of Action
The most commonly used fluoride varnish contains 5% sodium fluoride (NaF), which provides 22,600 ppm fluoride. When applied to tooth surfaces, fluoride varnish acts via several mechanisms:

° Formation of calcium fluoride (CaF₂): In the presence of saliva, fluoride reacts with calcium ions to form CaF₂ reservoirs on enamel and dentin. These serve as a slow-release fluoride source.
° Conversion to fluorapatite: Fluoride integrates into enamel crystals, transforming hydroxyapatite into fluorapatite, a mineral highly resistant to acid demineralization.
° Bacterial inhibition: Fluoride disrupts the metabolism of cariogenic bacteria like Streptococcus mutans, reducing acid production and plaque biofilm formation.

This multifaceted mechanism strengthens enamel, controls decay, and alleviates sensitivity in at-risk adult populations.

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✅ Clinical Application Protocol
The clinical application of fluoride varnish in adults should follow evidence-based steps:

1. Risk assessment: Identify risk factors like active caries, root exposure, post-periodontal therapy, or hyposalivation.
2. Tooth preparation: Perform a gentle prophylaxis if needed; varnish may also be applied without prior cleaning depending on the manufacturer's instructions.
3. Application: Use a disposable brush to apply a thin, even layer to the teeth, focusing on high-risk surfaces.
4. Post-care instructions: Advise patients to avoid brushing, eating hard foods, or drinking hot liquids for at least 4–6 hours.

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✅ Recommended Application Frequency
Application frequency depends on the individual's caries risk level:

° Low risk: Every 6 months
° Moderate risk: Every 4 months
° High risk: Every 3 months, especially for patients with multiple restorations, periodontal disease, or dry mouth

Multiple clinical studies confirm that routine fluoride varnish applications reduce caries incidence, especially in root surfaces and enamel weakened by erosion or acid attacks.

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✅ Scientific Evidence
A systematic review by Weyant et al. (2013) published in The Journal of the American Dental Association demonstrated that fluoride varnish effectively reduces caries in adult populations. Similarly, a Cochrane meta-analysis (Marinho et al., 2013) found strong evidence supporting the efficacy of fluoride varnish in reducing both coronal and root caries in adults at risk.

💡 Conclusion
Fluoride varnish is not exclusive to children. In adults, it provides a safe, effective, and evidence-based approach to preventing tooth decay, reducing sensitivity, and strengthening weakened enamel. Incorporating fluoride varnish into preventive protocols for adults, particularly those with elevated risk factors, significantly improves long-term oral health and reduces the need for restorative procedures.

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📚 References

✔ American Dental Association (ADA). (2013). Clinical Recommendations: Topical Fluoride for Caries Prevention. Retrieved from https://www.ada.org

✔ Weyant, R. J., Tracy, S. L., Anselmo, T. T., Beltrán-Aguilar, E. D., Donly, K. J., Frese, W. A., ... & Zero, D. T. (2013). Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. Journal of the American Dental Association, 144(11), 1279–1291. https://doi.org/10.14219/jada.archive.2013.0057

✔ Marinho, V. C. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7), CD002279. https://doi.org/10.1002/14651858.CD002279.pub2

✔ National Institute for Health and Care Excellence (NICE). (2020). Dental checks: intervals between oral health reviews. Retrieved from https://www.nice.org.uk/guidance/cg19

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Fluoride Varnish in Pediatric Dentistry: Benefits, Indications, Mechanism, and Application Protocol

Dental caries remains one of the most prevalent chronic diseases in childhood worldwide. According to the World Health Organization (WHO), up to 60–90% of school-aged children are affected by dental caries, significantly impacting their health and quality of life. In this context, fluoride varnish has emerged as a highly effective preventive strategy in pediatric dentistry, endorsed by major health organizations globally.

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Fluoride varnish is a topical treatment used to prevent, slow down, or even reverse the early stages of dental caries in children. Due to its ease of application, safety, and efficacy, it has become an essential part of caries management in clinical pediatric practice.

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✅ Benefits of Fluoride Varnish in Children
The use of fluoride varnish offers multiple benefits in the pediatric population:

🛡️ Caries prevention: Enhances enamel resistance to acid attacks by increasing fluoride availability on the tooth surface.
🦷 Enamel remineralization: Promotes the repair of early carious lesions (white spots), avoiding invasive treatments.
👶 Safe for young children: Due to its quick setting time and minimal ingestion risk, it is ideal for toddlers and young patients.
⏱️ Fast and non-invasive: Application is completed within minutes and causes minimal discomfort.
📈 Cost-effective: Reduces the need for restorative treatments and associated healthcare costs.

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✅ Clinical Indications in Pediatric Dentistry
Fluoride varnish is recommended in various clinical situations, including:

➤ Children at high risk of dental caries, particularly those with poor oral hygiene, high sugar intake, or socioeconomic barriers to dental care.
➤ Children undergoing orthodontic treatment, where plaque retention increases caries risk.
➤ Patients with enamel hypoplasia or demineralization.
➤ Children with special healthcare needs, who may have difficulties with standard oral hygiene routines.
➤ As a preventive adjunct during routine dental check-ups, typically every 3 to 6 months.

The American Dental Association (ADA) and the American Academy of Pediatric Dentistry (AAPD) both support the use of fluoride varnish as a routine preventive intervention in children beginning at the eruption of the first primary tooth.

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✅ Mechanism of Action
Fluoride varnish functions by:

➤ Enhancing enamel remineralization: When applied to teeth, the varnish delivers a high concentration of fluoride ions that interact with calcium and phosphate in saliva, forming fluorapatite — a more acid-resistant mineral than hydroxyapatite.
➤ Inhibiting demineralization: Fluoride ions integrate into the enamel matrix, making it less soluble under acidic conditions.
➤ Antimicrobial effect: Fluoride can inhibit the enzymatic activity of cariogenic bacteria, such as Streptococcus mutans, thereby reducing acid production.

Typically, the varnish contains 5% sodium fluoride (NaF), equivalent to 22,600 ppm of fluoride, suspended in a resin or alcohol-based solution that hardens upon contact with saliva, ensuring prolonged fluoride contact with the enamel surface.

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✅ Frequency of Application
The recommended frequency depends on the child’s caries risk:

➤ Low caries risk: Every 6 months.
➤ Moderate to high caries risk: Every 3 to 4 months.

These intervals are supported by clinical trials demonstrating that repeated applications significantly reduce caries incidence in primary and permanent teeth. Importantly, fluoride varnish is safe to use even in children under the age of six, as ingestion is minimal due to the rapid setting time and small quantity used.

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✅ Conclusion
Fluoride varnish is a cornerstone of modern pediatric preventive dentistry. Its proven efficacy in caries prevention, ease of application, and safety profile make it an indispensable tool for dental professionals. Early and regular use, especially in high-risk children, not only improves oral health outcomes but also reduces the need for restorative interventions, promoting a lifetime of healthy smiles.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Guideline on Fluoride Therapy. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry. Retrieved from https://www.aapd.org/research/oral-health-policies--recommendations/fluoride-therapy/

✔ Centers for Disease Control and Prevention. (2022). Use of Fluoride in the Prevention of Dental Caries in the Primary Care Setting. MMWR Recommendations and Reports. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm

✔ Weyant, R. J., Tracy, S. L., Anselmo, T. T., Beltrán-Aguilar, E. D., Donly, K. J., Frese, W. A., ... & Zero, D. T. (2013). Topical fluoride for caries prevention: Executive summary of the updated clinical recommendations and supporting systematic review. Journal of the American Dental Association, 144(11), 1279–1291. https://doi.org/10.14219/jada.archive.2013.0057

✔ Marinho, V. C. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7). https://doi.org/10.1002/14651858.CD002279.pub2

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Silver Diamine Fluoride in Pediatric Dentistry: Clinical Guide 2025

Silver Diamine Fluoride (SDF) at 38% concentration has become an effective, safe, and minimally invasive alternative for the prevention and treatment of dental caries in pediatric patients.

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Its topical application allows the arrest of carious lesions without the need for invasive procedures, making it especially useful in children with high caries risk, behavioral challenges, or limited access to dental care.

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✅ 1. Scientific Basis
SDF combines the antibacterial properties of silver with the remineralizing effect of fluoride. Its mechanism of action includes:

° Bacterial inhibition: Silver ions denature bacterial proteins and enzymes, inhibiting their proliferation.
° Remineralization: Fluoride promotes the formation of fluorohydroxyapatite, strengthening enamel.
° Tubule occlusion: Helps reduce sensitivity and prevent further caries progression.

Recent studies have demonstrated the effectiveness of SDF in arresting active caries, with success rates exceeding 80% in primary dentition.

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✅ 2. Indications

° Active carious lesions in primary and young permanent teeth
° Children with high caries risk (e.g., severe early childhood caries)
° Patients with behavioral or medical challenges
Situations where conventional restorative treatment is not feasible

✅ 3. Contraindications

° Known allergy to silver, ammonium, or fluoride
° Oral ulcerative lesions, stomatitis, or mucositis
° Carious lesions with pulpal involvement or symptoms of irreversible pulpitis

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✅ 4. Application Protocol

➤ Required materials:
° 38% SDF solution
° Disposable microbrushes
° Sterile gauze
° Gloves and eye protection

➤ Procedure:
1. Clinical assessment: Identify active carious lesions visually and radiographically if needed.
2. Isolation: Dry the affected area with gauze (rubber dam is not necessary).
3. Application: Use a microbrush to apply a small amount of SDF directly to the lesion for 1–3 minutes.
4. Drying: Allow the area to air dry; avoid rinsing immediately.
5. Follow-up: Reassess in 2–4 weeks to determine lesion arrest.

➤ Frequency:
° In high-risk patients or those with poor oral hygiene, reapplication is recommended every 6 months.
° In low-risk patients, annual application may be sufficient.

✅ 5. Side Effects and Aesthetic Considerations

The main side effect is permanent black staining of the treated lesion, indicating caries arrest. While safe, this discoloration can be esthetically undesirable, especially on anterior teeth. To mitigate this, potassium iodide may be applied immediately after SDF to reduce staining intensity.

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✅ 6. Parental Acceptance

Parental acceptance of SDF depends on lesion location, the child’s behavior, and prior information provided. It is crucial to explain the benefits and possible esthetic outcomes to obtain informed consent.

✅ 7. Conclusions

38% SDF is a valuable tool in modern pediatric dentistry, offering an effective and non-invasive option for treating dental caries in children. Its simple, safe, and well-tolerated application is especially beneficial for vulnerable populations or those with limited access to care. Standardized protocols and proper parental education are essential to maximize its benefits.

📚 References

✔ Juarez Lopez, M. L. A., Marin Miranda, M., & Murrieta Pruneda, F. (2021). Silver Diamine Fluoride as a minimally invasive alternative in pediatric dental care: Narrative review. Revista de Odontopediatría Latinoamericana, 11(Suppl). https://doi.org/10.47990/alop.v11iSuplemento.482
✔ Sotillo, V., Limongi, I., Medina, A. C., & Martínez Vásquez, M. G. (2023). Silver Diamine Fluoride as therapy to inactivate cavitated caries lesions in primary teeth. Revista Científica CMDLT, 16. https://doi.org/10.55361/cmdlt.v16i1.71
✔ Pariona-Minaya, M. C. (2024). Use of Silver Diamine Fluoride for treating active carious lesions. Odontología Activa Revista Científica, 5(3). https://doi.org/10.31984/oactiva.v5i3.499
✔ Sabbagh, H., Othman, M., & Yaseen Abdulgader, A. A. (2020). Parental Acceptance of Silver Diamine Fluoride Application on Primary Dentition: a Systematic Review and Meta-analysis. BMC Oral Health, 20(227):1-12. https://www.siicsalud.com/dato/resiic.php/165298
✔ Chimbo Sánchez, K. D. (2024). Uses of Silver Diamine Fluoride and its application in pediatric dentistry. Systematic review. Repositorio Digital Uniandes. https://dspace.uniandes.edu.ec/handle/123456789/17914

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Use of Silver Diamine Fluoride (SDF) - General Guide on its application

Silver diamine fluoride (SDF) is a topical medicine that is used to stop the advance of caries and in cases of dentin hypersensitivity. It can be used in both primary and permanent dentition.

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Article PDF 🔽 Fluoride Varnish in the Prevention of Dental Caries in Children and Adolescents: A Systematic Review ... Fluoride varnish is easy to apply, offers greater absorption of minerals on the teeth, and is very safe, unlike other topical fluoride treatments (gels and rinses).

It offers several advantages such as its easy application, low cost, it avoids the use of dental anesthetics, and it can be applied in places that do not have dental equipment.

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We share a complete guide on the benefits, advantages, and procedure for the application of Silver Diamino fluoride (SDF) in the treatment of cavities and dental sensitivity.

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Fluoride Varnish in the Prevention of Dental Caries in Children and Adolescents: A Systematic Review

The application of fluoride varnish is an effective method against tooth decay that can appear in the primary or permanent dentition. It is also effective in treatments against tooth sensitivity.

Fluoride varnish is easy to apply, offers greater absorption of minerals on the teeth, and is very safe, unlike other topical fluoride treatments (gels and rinses).

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We share an article that reviews the literature and develops a protocol for the use of fluoride varnish as a caries preventive agent in children and adolescents.

RECOMMENDED ARTICLE
Fluoride varnish application in children

👉 Read and download the full article in PDF👈

Amir Azarpazhooh , DDS, MSc / Patricia A. Main, BDS, DDS, DDPH, MSc, FRCD(C) JCDA Vol. 74, No. 1 ISSN: 1488-2159 February 2008

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What are the causes of white spots on teeth?

The white spots have the appearance of intense white clouds on the enamel surface, which affects aesthetics and in some cases shows poor oral hygiene.

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It can occur in both primary and permanent dentition, and a professional evaluation is necessary to determine what is the cause of the white spots and perform an appropriate treatment.

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We share a video from the CariFree channel, which explains what causes the presence of white spots on teeth.

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Source: Youtube/ CariFree