1 Omar Alkadhi et al, 2021;5(5):001–006.

International Journal of Medicine in Developing Countries

2 https://doi.org/10.24911/IJMDC.51-1619642194

REVIEW ARTICLE

3 Frequency of white spot lesion with clear

4 aligner: a systematic review
5
Omar Alkadhi1, Abrar Alqadhibi2*, Meisam Alburaiki2

6 ABSTRACT
7 The aim of this systematic review was to evaluate the incidence of white spot lesion with clear aligners.
8 Decalcification or white spot lesion is white opacity seen on smooth surface because of retention of bacterial
9 plaque. Recently, there has been increase in the number of adults seeking orthodontic treatment that is both
10 more esthetic and more comfortable. Clear aligner treatment provides various advantages in maintaining oral
11 hygiene; therefore, this systematic review was conducted of all studies that reported the frequency of white
12 spot lesion with clear aligner therapy. Literature research was conducted on different databases electronically
13 by using specific inclusion and exclusion criteria, two independent investigators performed data extraction and
14 analysis. Total 9,949 records were identified. However, only three articles met the criteria that were included
15 in this systematic review. The quality assessment for included studies showed that all three studies had low
16 quality. It was concluded that there is a change of demineralization in clear aligner according to the available
17 evidences.
18 Keywords: Clear aligner, white spot lesion, invisalign, demineralization, systematic review.

19 Introduction

20 White spot lesions (WSL) are white opacities seen on fourth week of orthodontic treatment [9]. Patients treated 47
21 smooth surfaces of enamel as a result of bacterial plaque with fixed orthodontic appliances have higher risk of 48
22 retention for prolonged periods [1,2]. Patients with WSL due to retentive sites around the components of 49
23 malocclusions usually have many plaque retention sites fixed appliances such as brackets, bands, and wires that 50
24 due to the irregularities of their teeth [3,4]. However limit salivary self-cleansing potential [3,11]. Thereby, 51
25 slivery flow, fluoridated toothpastes, and mouthwashes posing the patient toward the increased risk for the 52
26 reduce the presence of WSL around orthodontic brackets, development of gingivitis, dental caries, and WSL both 53
27 otherwise further treatment is needed for an esthetic during and after the therapy [3]. 54
28 problem [4,5]. Unlike fixed orthodontic appliances, clear aligner 55
29 Prevalence of WSL in a recent study using cast score treatment provides various advantages in maintaining 56
30 was 54.57%, whereas in International Caries Detection the oral hygiene [3]. Recently due to the increase in 57
31 and Assessment System II (ICDAS-II) index code 1 the number of adults seeking orthodontic treatment, 58
32 prevalence was 48.07% and code 2 prevalence was there has been an increase in demand for appliances 59
33 53.06% [6]. According to the prevalence of WSLs that are both more esthetic and more comfortable than 60
34 developed after fixed orthodontic appliances was 74.1% conventional fixed orthodontic appliances [2]. Clear 61
35 of the patients [7]. While previous research studies aligners made by polymer materials to move the teeth 62
36 reported that only 32% patients had WSLs and 23% had in the planned position using a software program. 63
37 an increase of at least one WSL during the treatment [1]. These aligners cover all teeth surfaces in addition to the 64
38 Another study reported enamel demineralization mean
39 of 55.93 µm for metal brackets [8]. These variations are
Correspondence to: Abrar Alqadhibi
40 possibly due to the techniques used to detect WSLs. The
*BDS, Intern Riyadh ELM University, Riyadh, Saudi
41 more sensitive the techniques, the higher the prevalence
Arabia.
42 rate of WSLs [9]. Usually, 15.5%-40% of the patients Email: abrar.ibrahim.alqadhibi@gmail.com
43 had decalcifications before orthodontic treatment and Full list of author information is available at the end of
44 in 30%-70% during the treatment [9]. WSL is common the article.
45 negative sequel of orthodontic treatment in the absence Received: 28 April 2021 | Accepted: 27 May 2021
46 of proper oral hygiene [10] that rapidly manifest on the

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 White spot lesion with clear aligner

65 marginal gingival tissues, and should be worn 20 to 22 Data extraction 104

66 hours per day and removed only for eating, drinking,
67 and tooth brushing or flossing [3]. Although increased Two reviewers (AIA and MJA) independently obtained 105
68 number of patients are undergoing orthodontic fixed any related data in a pre-designed collection form. A 106
69 appliance therapy, there are few studies reporting the consultation with the third author (OHA) was done for 107
70 prevalence of WSL in clear aligners. This systematic a final consensus to be achieved. Articles in the current 108
71 review aimed to assess the scientific literature on the study investigated the patients that came for orthodontic 109
72 prevalence of WSLs. treatment and conducted pre- and post-treatment 110
examination. 111
73 Materials and Methods
Results 112
74 This systematic review was reported following preferred
75 reporting items for systematic reviews and meta-analysis Literature flow 113
76 (PRISMA) guidelines.
Initially, 9,949 records were identified (9,938 by 114
77 Data sources and search strategy electronic searching of databases and 11 were identified 115
through manual searching). Almost 650 duplicates 116
78 An electronic search was conducted in the following were then removed and a total of 9,299 titles remained. 117
79 databases: PubMed Central, PubMed, Medline, Cochrane, Screening of titles and abstracts resulted in 9,267 118
80 Lilacs, Clinicaltrials.gov, WHO clinical trials, Embase, articles being excluded. The remaining 32 articles 119
81 NLM, and Web of Science for studies published up to were fully read and assessed; another 29 articles were 120
82 May 2019. The search strategy suitably adjusted for each excluded; therefore, three articles were included in 121
83 individual database. The references of retrieved articles this study. The process of identification, screening, 122
84 were also manually reviewed. All articles that meet the and selection of studies is shown through the PRISMA 123
85 inclusion criteria were included regardless of publication diagram (Figure 1). 124
86 year, language, or status. “gray literature” (i.e., materials
87 that cannot be found easily through conventional All included articles were prospective cohort studies. 125

88 channels) was included in the present research. When The limitations of the three selected studies were also 126

89 further information was required, authors were contacted. identified (Table 2). 127

90 One author was contacted with various questions, and Furthermore, the characteristics of the three selected 128
91 unfortunately did not respond. The Boolean operator studies were also summarized (Table 3). 129
92 (AND) was used to confine the search to relevant studies. Quality assessment of selected studies 130
93 The used keywords were “Aligner,” “Invisalign,”
94 “Aligner AND Demineralization,” “Invisalign AND The quality of included studies was assessed using an 131
95 Demineralization,” “Aligner AND White spot lesion,” adopted method from Antczak et al. [12]; Jadad et al. 132
96 “Invisalign AND White spot lesion,” and “WSL.” [13], where it is characterized as low for (0-5 points), 133
medium for (6-8 points), or high for (9 or 10 points). In 134
97 Study selection summary, a study can maximally score 10. The score for 135
included studies was low (Table 4). 136
98 Titles, abstracts, and full-text articles were screened by
99 two reviewers [Abrar I. Alqhadibi (AIA) and Maisam J. Risk of bias 137
100 Alburaiki (MJA)] separately. Consultation with the third
author [Omar H. Alkadhi (OHA)] resolve any dispute. This risk of bias was found to be high in all included 138
101
studies since no blinding or allocation concealment were 139
Eligibility criteria implemented. 140
102
103 Eligibility criteria depends upon the inclusion and Discussion 141
exclusion criteria of the study (Table 1).
It is clear that there is a lack of high-quality studies 142
on the effect of clear aligners on WSL. All included 143
studies were approved by institutional review boards/ 144
154 Table 1. Inclusion and exclusion criteria.
committees, and only one study [14] obtained written 145
Inclusion criteria Exclusion criteria informed consents from participants and performed a 146
Cohort studies Case series sample size calculation. 147
Articles investigating Case reports
Different methods of WSL measurement were used in the 148
WSL in patients un- Unsupported opinion of expert
dergoing clear aligner Editor’s choices included studies where one study [14] used quantitative 149
treatment Books’ abstracts light-induced fluorescence (QLF) image at the 150
Conference abstracts beginning and immediately after treatment by the same 151
Cross-sectional surveys operator. QLF is reported to be reliable and consistent 152
Systematic reviews measurement tool [15]. While in another study [16], 153

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 White spot lesion with clear aligner

Figure 1. PRISMA flow diagram of the literature search process.

155 Table 2. Limitations of the included research articles.

Limitation Study 1 by Buschang et al. [16]
1-No long term -Treatment duration was catego-
follow up rized as either less than 2 years
or greater than 2 years.
-Before and final photographs
were taken immediately after de-
banding and composite removal.
2-Incomplete data 1-NO gender were mentioned.a
2-Methods that has been used
not sensitive enough.
3-Possiblty of baiest.
Study 2 by Azeem et al. [14]
QLF images were taken before and
directly after clear aligner treatment by
the same operator using an Inspektor
Pro system (Inspektor Research Sys-
tems, Amsterdam, The Netherlands). I.
-Mean treatment duration was 18.11-
5.12 months (minimum, 8.12 months;
maximum, 26.23 months).
Limited sample size.
Lack of blinding.
Lack of control group.
Lack of comparison with fixed appli-
ances.
Study 3 by Tuncay et al. [17]
-The duration of treatment was 8 to
42 months.
-Scores were recorded at the initial
treatment appointment, at each
subsequent visit (every 3 months),
and at the end of treatment (or after
24 months).
1-Methods of measuring WSL were
not mentioned.
2-No gender mention.
3-No instruction for oral hygiene
(OH) before orthodontic treatment.

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 White spot lesion with clear aligner

156 Table 3. Characteristics of the included research articles.

Number of Number of Patients with WSL Teeth with WSL
Study Age
patients teeth after treatment (%) after treatment (%)
Azeem et al. [14] Incidence of
Sample:
WSL during orthodontic clear 25 1125 28 2.85
16.17 ± 1.76 years
aligner therapy.
Tuncay et al. [17] Aligner treat- Sample:
42 336 Not reported 0.90
ment in the teenage patient. 18 ≥ years old
Buschang et al. [16] Incidence Clear aligner group:
of WSL among patients treated Sample: (30.4 ± 14
with clear aligners and traditional years)
braces. 244 N\A 1.20 Not reported

Traditional group:
(29.2 ± 11.5 years)

157 Table 4. Quality evaluation of included studies.

Ade- Valid Use of Confound-
Study Adequate Blinding Adequate
quate meas- method ers
Study title de- selection in meas- statistics
sample urement error included
sign description urement provided
size methods analysis in analysis
1-Incidence of WSL during ortho- 1 1 1 1 0 0 1 5 points
dontic clear aligner therapy (low)
2-Aligner treatment 1 0 0 1 0 0 1 2 points
in the teenage patient (low)
3-Incidence of WSL among pa- 1 0 0 1 1 0 1 3 points
tients treated with clear aligners (low)
and traditional braces
158 Study design (RCT = 3; prospective study = 1; retrospective study = 0) adequate sample size = 1; Adequate selection description = 1; Valid measurement
159 methods = 1; Use of method error analysis = 1; Blinding in measurement = 1; Adequate statistics provided = 1; Confounders included = 1.

160 digital photographs were taken both pre-treatment and treatment had been treated longer than aligner patient, 185
161 post-treatment and were evaluated by two independent whereas 2 years or more would increase WSL 1.6 times 186
162 investigators for only aggravated and new WSL. Digital [16]. Pretreatment OH had statistically significant effect 187
163 photography was found to be more reliable and accurate on WSL development. Fixed orthodontic patient had 188
164 than QLF [12]. Another study implemented a method of different variation in pretreatment OH, on other hand 189
165 clinical scoring of decalcification by the orthodontists at patient able to remove the clear aligner, so there was 190
166 first and final appointment as well as every 3 months. reduction of plaque accumulation and OH improvement. 191
167 Out of 62 participants, only 42 completed the treatment It was also stated that WSLs were more frequent in 192
168 due to early poor cooperation with aligner wear, failure maxillary than in mandibular teeth [16], whereas the 193
169 to return regularly for data collection, and decisions to highest prevalent was in maxillary canine (7.3%) followed 194
170 terminate treatment [14]. by lateral incisors (6%) then central incisors (2.9%). 195
171 The main reason behind periodontal disease and caries In mandible, canine prevalence was (7.1%), followed 196
172 is accumulated plaque [17]. The plaque index in clear by lateral incisors (2.6%) and the lowest incidence in 197
173 aligner patient was reduced in both maxilla (15.1%) central incisors (2.2%) [16]. However, on the other hand, 198
174 and mandible (16.6%) as the most plaque accumulation another study reported most of WSL cases in maxillary 199
175 were in maxillary molars [19]. Poor oral hygiene, young lateral incisor [14]. 200
176 patients, male patient, and the extent of the treatment are Development of WSLs in a study [16] were 1.2% in 201
177 factors that identified to increase the present of WSL [4]. patient with clear aligner compared to traditional patient 202
178 According to the two included studies in the current review where it was 25.7% while in another study [13] it was 203
179 [14,16], the prevalence of WSL was not statistically reported 2.85% WSL in clear aligner patient and at 204
180 significant in different age groups and gender. Moreover, least 28% of the patient had new WSL. Furthermore, 205
181 the duration of the treatment had significant impact on teeth of clear aligner patient (75.6%) were free of WSL, 206
182 WSL formation as the mean treatment duration was 18.11 according to another study [19]. 207
183 ± 5.12 months and the most effected tooth group was 12 The main limitation of this review was the lack of 208
184 to 22 [14]. However, patient under fixed orthodontic randomized clinical trials. Only poor-quality articles were 209

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210 found due to the lack of methodological accuracy and Dent. 2015;5(6):433–9. https://doi.org/10.4103/2231- 262
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6. Dogra S, Gupta A, Nagpal M. Comparative evaluation 269
217 Conclusion of prevalence of incipient white spot lesions in visually 270
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218 In this systematic review, it was concluded that there is Assessment Spectrum and Treatment (CAST) criteria and 272
219 change of demineralization in clear aligner according to International Caries Detection and Assessment System II 273
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221 List of abbreviations
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222 AIA Abrar I. Alqhadibi (Second author)
Harrison JE. Factors affecting demineralization during 277
223 ICDAS-II International Caries Detection and Assessment
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224 System II Am J Orthodont Dentofacial Orthop. 2011;139(2):181– 279
225 MJA Maisam J. Alburaiki (Third author) 91. https://doi.org/10.1016/j.ajodo.2009.08.028 280
226 OH Oral hygiene
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227 OHA Omar H. Alkadhi (First author)
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228 PRISMA Preferred reporting items for systematic reviews in vitro study. Clin Cosmet Investig Dent. 2019;11:37–43. 283
229 and meta-analysis https://doi.org/10.2147/CCIDE.S190893 284
230 QLF Quantitative light-induced fluorescenceo
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231 WSL White spot lesion
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232 Conflict of interests Clin Dent. 2017;8(1):11–9. https://doi.org/10.4103/ccd. 287
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235 Funding management during the orthodontic treatment. 291
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237 Consent for publication prilozi-2014-0021 294
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239 Ethical approval effects of fixed orthodontic treatment period on white 296
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