**2. Etiology of demineralization**

#### **2.1 Oral hygiene**

The presence of orthodontic attachments in the mouth paves the way for plaque formation on the tooth surface and makes tooth cleaning more difficult [3]. The plaque develops as a result of bacterial infection, modified from dietary carbohydrates and saliva. In the presence of carbohydrates, demineralization begins when the pH of the mouth drops below 5.5 and creates white spot lesions. *Streptococcus mutans* and lactobacilli bacteria are mainly effective in colonization and also caries development [4]. The plaque on the tooth surfaces prevents the remineralization of the enamel layer with calcium and phosphate ions. In addition, it facilitates the production of acid from the sugar taken with food. It is observed that the amount of decalcification is also higher in the brackets and near the gingiva, where plaque accumulation is greater in orthodontic patients [5].

#### **2.2 Diet**

It has been stated that frequent consumption of carbohydrate-rich, sugary foods and beverages facilitates the formation of caries. During 20 minutes following sugar intake, the pH of the plaque drops below the critical level of 5.5°. In addition, another factor is the difficulty in removing food residues from the teeth due to orthodontic attachments [6].

#### **2.3 Appliance type and design**

The larger the area covered by orthodontic attachments on the enamel surface, the more difficult it is to clean the remaining tooth surface. Archwire design also affects the accumulation of plaque and food debris [7].

In a study evaluating the difference in white spot lesion (WSL) formation between conventional bracket treatments and aligner treatments, it was reported that approximately 1.2% of aligner patients developed WSL compared to 26% of conventionally treated patients. The number of developing WSL is also significantly (*P* < 0.001) less in aligner patients. In patients treated with conventional braces, moderate or poor pretreatment oral hygiene, worsening of hygiene during treatment, preexisting WSL, and longer duration of treatment (*P* < 0.05) significantly increased the risk of developing WSL during the treatment [8].

In a randomized prospective controlled study, aligner and conventional bracket treatments were compared with quantitative light-induced fluorescence. According *Preventive Methods and Treatments of White Spot Lesions in Orthodontics DOI: http://dx.doi.org/10.5772/intechopen.102064*

**Figure 1.**

*Different appliance designs used in orthodontic treatment. (1) Traditional buccal metallic brackets, (2) transpalatal arch appliance, (3) clear aligner, and (4) lingual brackets.*

to the results, WSL formation was observed in both treatments. In aligner treatments, the lesions are shallower and cover a larger area. Traditional braces had deeper lesions, but their area was smaller. Plaque accumulation is also greater with conventional brackets [9].

According to a study examining the difference in WSL between lingual brackets and labial conventional brackets, patients treated with lingual brackets had significantly less development of WSL [10].

**Figure 1** shows different orthodontic appliances.

#### **2.4 Bonding technique**

Composite resin remaining around orthodontic attachments prepares the ground for plaque accumulation. Therefore, the composite resin around the bracket must be cleaned [7, 11].
