White Spots on Teeth: Types, Causes, and Treatment Options

White spots on teeth are visible when areas of the teeth are either whiter or reflect light differently than the normal enamel, appearing chalky or dull. This can be the result of demineralization or altered enamel composition.

The demineralization of the tooth enamel (1) is caused by acidic foods or bacterial waste. White lesions caused by altered enamel formation usually are a result of ingesting substances or trauma during tooth development.

Types of White Lesions

White spots or lesions on teeth can be classified based on their size and severity:

• Class 1 No lesion present
• Class 2 Mild spotting present
• Class 3 Severe white spot or spots present
• Class 4 White lesion has created a defect or cavity in the enamel structure

Causes of White Spots or Lesions on Teeth

White spots or lesions on teeth can be caused by the following.

1. Fluoride ingestion

Fluorosis (2) is the most common example of white lesions. It is caused by swallowing excessive amounts of fluoride.

The topical use of fluoride toothpaste or mouthwash is safe, but using excessive amounts, being unable to completely spit it out, or swallowing them is harmful. You may be advised to give up such a substance entirely or limit its use.

2. Enamel hypoplasia

Also known as Turner’s tooth, (3) enamel hypoplasia often occurs when a primary tooth is infected or damaged. This affects the development of the permanent tooth, resulting in thin enamel.

Enamel hypoplasia can also occur when developmental or system disorders occur. These include neonatal issues, malnutrition, infection, low birth weight, premature birth, and weaning.

Underlying systemic disorders might include rickets, tuberculosis, congenital syphilis, chronic candidiasis, seizure, and endocrine disorders.

3. Poor oral hygiene

Inadequate oral hygiene is one of the most common reasons that white lesions develop. (4) They are also the easiest to stop or arrest before it becomes visible or needs treatment.

The development of cavities is a high-risk factor for white lesions. These are generally caused by high sugar intake, especially at night in liquid form. (4) They can also occur when inadequate oral hygiene is performed.

Three things are needed to create or avoid producing a cavity: tooth structure, bacteria, and sugars or acids.

a. Tooth structure

Every day, a certain amount of enamel is removed from the tooth structure, but every day, your body rebuilds it.

White spots or cavities can be removed by extractions, covered with sealants and restorations, or hardened with fluoride. Many restorations allow the fluoride to leach into the enamel and thereby strengthen the decalcified enamel.

The factors that can result in repeated enamel malformation include:

• Fluoride ingestion in large quantities
• Defective enamel caused by antibiotic or heavy metal consumption, resulting in an improper enamel finish
• System/genetic anomalies that display as a morphologic enamel malformation and include amelogenesis imperfecta (enamel matrix malformations), (5) dentinogenesis imperfecta (dentin matrix malformations), (6) osteogenesis imperfecta, (7) dysmorphological features (changes in the shape of developing teeth), rickets (vitamin D deficiency), elevated corticosteroids, and hyperparathyroid disease (stops calcium absorption).

b. Bacteria

Colonies of bacteria live in your mouth and digestive cavity. When Streptococcus mutans and Lactobacillus become prominent in the mouth, they adhere to the tooth structure and break down any fermentable carbohydrate present on the surface.

This results in the excretion of acids and oxygen as by-products. Both of these substances further facilitate the growth of bacteria.

Unless one of the tooth structure anomalies exists, there is no such thing as soft teeth. Caries, against most belief, is a contagious disease rather than a genetic one. (8)

As more tooth structure becomes available with the eruption of primary teeth, bacteria are able to colonize the oral cavity of the child. The greatest increase is at the age of 2–2½ years of age when the second primary molars erupt.

The following tips can help decrease bacterial colonization:

• Since mothers often transmit caries to their children, they need to practice good oral care.
• Brush two times a day and for 2–3 minutes each brushing to decrease the number of bacteria in the oral cavity.
• You can use fluoride-based toothpaste as it acts as a topical antibiotic. (9) It also changes the tooth components, so more acid is needed to increase the porosity of the enamel.
• Use chlorhexidine mouthwash as it has been shown to reduce oral bacteria. (10)
• Soft tissue is very porous, so it is advisable to brush the tongue and the soft tissue around the tooth.
• Floss as it also helps remove bacteria in the sulcus.

c. Sugar

Sugars stay on the teeth for longer and are digested by bacteria to produce acids and allow reproduction. The simpler the sugar, the easier it can be broken down and cause demineralization of the tooth. (11)

You may be consuming excessive sugar in the form of:

Drinks: These get in between teeth and can dry in direct contact with the tooth. They can reach most tooth surfaces of the dentition in the shortest amount of time.

Liquids are the easiest to remove; even just consuming water or brushing reduces the effects of sugary drinks.

• It is advised to limit your intake of juices – Sugar in liquid form is already partially broken down. Fructose is a naturally occurring sugar, not bound to any complex structures, and is thus easily digestible by the bacteria and absorbed into the tooth.
• Sports drinks and sodas – These are worse than juices and contain more added sugar and acid.
• Milk – Milk, be it breast, cow, goat, or soy, has carbohydrates. The sugars break down quickly into acid and other by-products and allow bacteria to regenerate.
• Smoothies, lattes, protein drinks, and shakes – Again, they are all-natural but still full of a lot of sugar.

Solid foods: When looking at the risk of decay and what foods might lead to problems, it becomes necessary to look into not only the complexity of the carbohydrate but also the chewiness of the food.

Sweets, treats, sugars, candies, and sweeteners are all things that parents should try to avoid themselves as well as limit a child’s intake.

• Candies, gummy candies, hard candies, caramels, filled candies, and dried fruit dissolve quickly and become sticky even to the touch.
• Chocolates, frosting, ice creams, sprinkles, and sorbets are made of simple sugars bound up in the candy matrix, which slows down their full breakdown.
• Snacks and chips often contain hidden sugars as oils laden with sugar or other sweeteners. Many of these snacks also seem to stick to the occlusal surfaces of teeth.
• Fruits, nuts, grains, and starchy vegetables are all very complex carbohydrates. Unfortunately, people tend to bake them, sweeten them, or alter their makeup to release more sugar.

However, some foods have been shown to stop caries formation, such as peanuts and xylitol. (12)

Medical Treatment

Your dentist may use one of the following procedures to treat the white lesions on your teeth:

1. Icon resin infiltration

The newest and least invasive form of treatment for white spots is resin infiltration. A low-viscosity resin is used to fill in a porous, smooth tissue lesion, making it smoother and more reflective.

2. Microabrasion

This technique uses chemicals and polishing devices to smooth the enamel surface and reduce the difference between the lesion and the areas around it. Usually, a form of acidic gel and pumice are employed.

3. Vital bleaching

When the white lesions are localized and have not altered the structure of the enamel, vital bleaching can be employed. Calcium and phosphates are polished or used to seal the tooth structure.

4. Full-coverage or extensive restorations

Fillings, veneers, or crowns might be necessary if the lesion has resulted in a deep carious lesion, the tooth is weakened, or the tooth is prone to fracture.

5. Chin traps

The doctor may suggest chin straps if you sleep with your mouth open.  

Dental Checkups and Diagnosis

It is important to get routine dental checkups. All dentists can diagnose and advise you when a white spot is visible on clinical examination. The earlier it is detected, the less invasive is the treatment.

If you have a low risk of decay, checkups should occur at 6-month intervals. If you or your child has a higher risk for oral pathology, then visits should be more frequent, every 3 or 4 months.

Overall outcomes are always improved by earlier and less invasive treatments.

Preventive Measures

Prevention is the first and best defense for stopping white spots. Avoiding large amounts of bacteria and sugar in the mouth is the simplest way to protect against the most common cause of these lesions.

If you or your child are prone to cavities, then you have a higher level of bacteria present and need less sugar to form a cavity.

With each pregnancy, your bacteria levels go up, so both you and your next child will be more prone to decay.

Preventive measures such as mouth guards are also recommended to stop damage to a single tooth or a few teeth. The local assault can damage a secondary tooth or lead to abscesses.

Final Word

The most common factors that can be avoided or controlled to prevent white lesions on teeth are oral hygiene, precarious lesions, ingestion of fluoride, infection, trauma, and nutrition.

If you develop white lesions on teeth, medical care is necessary, after which improved hygiene and home care are needed to prevent further or repeated damage.