Open Access

Prevalence of white spot lesions during clear aligner therapy: a systematic review


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Figure 1.

The PRISMA Flow Chart shows the process for article selection.
The PRISMA Flow Chart shows the process for article selection.

Computerized search terms on the electronic sources.

Database Search strategy
Web of Knowledge, PubMed, PubMed Central, Medline (“Clear Aligner” Or “Aligner” Or “Invisalign” Or “Clear Appliances” Or “Clear Plaque Therapy” OR “Removable Thermoplastic Aligners”) And (“Demineralization” OR “White Spot Lesion” OR “Decalcification” OR “Tooth Demineralization” OR “Early Caries Lesions”)
Google Scholar Clear Aligner + White Spot Lesion
Invisalign + White Spot Lesion
Clear Aligner + Demineralization
Invisalign + Demineralization

I nclusion and exclusion criteria.

Inclusion criteria Exclusion criteria
Prospective and retrospective original studies on human subjects with permanent dentition Case reports
Studies on orthodontic treatment with clear aligners Reviews
Studies that included clear descriptions of materials and applied technique Abstracts
Studies with adequate statistical analysis Author debates
Summary articles
Studies in vitro
Studies with surgical orthodontic techniques

Characteristics of included studies.

Authors Journal Methods Participants Age Inclusion criteria Exclusion criteria Setting Interventions Outcomes
Azeem and Hamid (2017)21 journal of World Federation Orthodontist CCT 25 Randomized (12 Male, 13 Female) Mean age, 16.17 ± 1.76 years 1. Comprehensive clear aligner treatment of upper and lower arches2. Age 14-18 years at the start of aligner therapy3. No previous orthodontic therapy4. No hypodontia. 1. Patients with any systemic disease, clefts, general dental problems, taking daily fluoride supplements or on ongoing medications for a chronic disease2. Patients with WSL, hypoplastic or fluorotic enamel Not reported Tooth groups used in the current studyGroup 1: n=4 (22-12) Maxillary incisors: 22, 21, 11, 12Group 2: n=20 (15-45) Maxillary and mandibular incisors, canines, first and second premolars: 11-15, 21-25, 31-35, 41-45Group 3: n=24 (16-46) Maxillary and mandibular incisors, canines, first and second premolars, and first molars ** Definition by World Dental Federation numbering system 1. The overall incidence of new WSLs2. Tooth related WSL formation in tooth groups All measurements were made before and at the end of the treatment.
Albhaisi et al. (2020)18 American Journal of Orthodontics and Dento facial Orthopedics RCT 49Randomized (39 female, 10 male)Group 1 : n=l 9Group 2: n=23* In total, 42 of the 49 participants recruited completed the study 21.25 ± 3 yearsGroup 1 : 21.2 years.Group 2: 21.3 years. 1. Healthy patients of both sexes between the ages of 17-242. Classi malocclusion with mild-to-moderate crowding (≤5 mm)3. Nonextraction treatment plan4. Optimum oral hygien 1 .Patients with poor oral hygiene, defective enamel, extensive restorations, and salivary glands diseases Orthodontic clinic at Jordan University of Science and Technology The patients were divided into two groups by drawing lots.Group 1 : Treated with clear alignerGroup 2: Fixed orthodontic treatment*Quantitative light-induced fluorescence (QLF) images were taken before treatment (TO) and 3 months later (Tl). The QLF images were then analyzed to assess the research outcomes. 1. Plaque measurements2. Changes in white spot lesion parameters3. Preexisting white spot lesions vs newly developed ones All measures before treatment and3 months after the start of treatment
Buschang et al. (2019)14 Angle Orthodontist CCT 450RandomizedGroup 1: n=244Group 2: n=206*Gender not reported Group 1: 30.4 years.Group 2: 29.2 years 1. Patients in late mixed or permanent dentition with only high-quality digital photographs of pre- and post-treatment2. All malocclusion, provided that the gingival one-third of the anterior teeth is visible in the photographs Not reported Private practice and at the Department of Orthodontics, Texas A&M University College of Dentistry Patients were chosen consecutively, starting with the most recently completed cases.Group 1: Treated with clear alignerGroup 2: Fixed orthodontic treatment Initial and final intraoral photographs were retrieved from the Dolphin Imaging System, placed side by side on a computer monitor, enlarged, and evaluated in a darkened room. 1. Oral Hygiene Status2. The incidence of WSLs All measurements were made before and at the end of the treatment.
Alshatti (2017)19 Master of Dental Science at the University of Connecticut, 2017 RCT 59RandomizedGroup 1 : n=24Group 2: n=l 6Group 3: n=l 9*Gender not reported Group 1 : 21.44 yearsGroup 2: 1 4.83 yearsGroup 3: 1 4.47 years 1 .Nonextraction treatment plan.2. There should be less than 8mm of anterior crowding.3. Patients should have all permanent teeth present, except third molars.4. Demonstrable ability to maintain adequate ora hygiene.5. Show optimum denta health without immediate need for restorations. 1 .Skeletal anterior posterior discrepancies between the maxilla and mandible (ANB > 5°).2. Centric relation (CR)- Centric occlusion (CO) discrepancies of greater than 3 mm.3. Anterior or posterior open bites.4. Patients who are pregnant, diabetic or using mouth rinses or interacting medications, including antibiotic therapy. 5. Presence of impacted teeth.6. Presence of pre-treatment white spot lesions.7. Presence of active periodontal disease as evidenced by attachment loss. Division of Orthodontics, Department of Craniofacia Sciences, University of Connecticut Health Center. Randomization sequence was generated by using a PC based software “Random Allocation Software”.Group 1 : Patients receiving treatment with clear semi-elastic polyurethane aligners.Group 2: Patients receiving treatment with self-ligating brackets.Group 3: Patients receiving treatment with conventional pre-adjusted edge wise brackets. 1 : Measuring the incidence of WSLs2. Measuring the severity (surface area) of wsls3. Measuring the correlation between gingival, plaque and bleeding ndices and white spot lesionsAll measurements were pre-treatment and (TO) 1 8 months after treatment initiation. (T2) done
Tuncay et al. (2013)20 Journal of Clinical Orthodontist RCT 62Randomized*Gender not reported Participants were under 18 years old 1.Patients with class I or mild class II occlusion 1. Active caries2. Periodontal disease3. Patients unsuitable for aligner Michigan, New Jersey, Oklahoma, and Pennsylvania 62 patients were treated by clinicians.It was recommended to use at least 21 hours a day.Of the 62 patients who began the study, 42 completed treatment. 1. Gingival-index measurements2. Decalcification index3. Patient Satisfaction All measurements were collected in the first 24 months

Quality assessment of the studies based on checklist of Downs and Black.

Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Azeem and Hamid (2017)21 1 1 1 1 1 1 1 1 0 1 0 0 0 0 1 0 0 1 1 1 0 0 0 0 0 0 1
Albhaisi et al. (2020)18 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 1 1
Buschang et al. (2019)14 1 1 1 1 1 1 1 1 0 1 0 0 0 0 0 0 0 1 1 1 1 0 0 0 0 0 0
Alshatti (2017)19 1 1 1 1 1 1 1 1 0 1 0 0 0 0 1 0 1 1 1 1 1 0 1 0 0 0 1
Tuncay et al. (2013)20 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 1 0

Risk of bias summary.

Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other bias
Azeem and Hamid (2017) + + + + + +
Albhaisi et al. (2020) + + - + + +
Buschang et al. (2019) - - ? + + +
Alshatti (2017) + + + ? + +
Tuncay et al. (2013) - + - + + +
High Risk: - Unclear Risk:? Low risk: +
eISSN:
2207-7480
Language:
English
Publication timeframe:
Volume Open
Journal Subjects:
Medicine, Basic Medical Science, other