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Title Clear Aligner Therapy Presents a Reduced Risk for White Spot Lesion Development Compared to Traditional Orthodontic Therapy
Clinical Question For a patient undergoing comprehensive orthodontic treatment, would clear aligner therapy as compared to traditional orthodontic therapy reduce the risk of white spot lesion development?
Clinical Bottom Line For patients completing comprehensive orthodontic treatment with clear aligner therapy there is reduced incidence and decreased magnitude of demineralization of white spot lesions, compared to white spot lesion development from traditional orthodontic therapy. This is supported by a retrospective cohort study, randomized clinical trial, and systematic review, all of which report the same conclusion that patients treated with clear aligner therapy experienced less white spot lesions at the end of treatment compared to patients treated with traditional orthodontic treatment. The clinical decision to treat patients presenting with poor oral hygiene and high risk of white spot lesions with clear aligner therapy rather than traditional orthodontic therapy to reduce the risk of white spot lesions is supported by the evidence.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 30556747Buschang/2019450 total patients from one private orthodontic practiceRetrospective Cohort Study
Key resultsOf the 244 observed patients treated with clear aligners, 1.2% developed white spot lesions. Comparatively, of the 206 observed patients treated with traditional orthodontic therapy, 26% developed white spot lesions. Three total white spot lesions were observed in the clear aligner therapy group, while 174 white spot lesions were observed in the traditional orthodontics group. Several variables significantly (P <.05) contributed to development of white spot lesions including: pretreatment OH status, deterioration of OH during treatment, preexisting white spot lesions, and treatment duration. The reported incidence of new white spot lesions for each group supports the conclusion that “patients treated with aligners have less risk of developing WSLs than do patients treated with traditional braces.”
#2) 32354432Albhaisi/202049 participants: 39 female, 10 male from orthodontic department in JordanRandomized Controlled Trial
Key resultsAfter randomly assigning participants into two groups (clear aligner therapy and traditional orthodontic therapy) using a coin toss by each patient, treatment was carried out according to the group assigned. White spot lesion development was assessed primarily through quantitative light-induced fluorescence and secondarily through assessing surface area of white spot lesions, the deepest point of the lesion, and incidence. Mean fluorescence (mineral) loss in patients treated with clear aligners was 0.4%, compared to 1.2% for the traditional orthodontic group. Surface area of clear aligner white spot lesions was observed at 82.2 pixels, while white spot lesions in traditional orthodontic patients was observed at 9.3 pixels. Lastly, the clear aligner therapy group experienced 6 new white spot lesions compared to the 8.25 new white spot lesions developed in the traditional orthodontic group. These results support that the traditional orthodontic patients developed more white spot lesions that were “greater severity, but smaller in area” than white spot lesions developed in the clear aligner group.
#3) 35754408Bisht/20225 studies/584 total patientsScoping review
Key resultsDatabase search through four different databases resulted in 22 total articles. Of the 22 articles, 17 unique articles were screened using the author’s generated eligibility criteria, resulting in 5 studies ultimately included in this review. Upon evaluation of the results of each study, the review suggests that “patients treated with aligners showed less incidence and risk of developing WSLs,” but “patient education and motivation on oral hygiene practice are essential components” to the incidence of white spot lesions. This review emphasizes that further clinical studies are required to confirm this conclusion.
Evidence Search “Invisalign and white spot lesions” ("orthodontic appliances, removable"[MeSH Terms] OR ("orthodontic"[All Fields] AND "appliances"[All Fields] AND "removable"[All Fields]) OR "removable orthodontic appliances"[All Fields] OR "invisalign"[All Fields]) AND ("whites"[MeSH Terms] OR "whites"[All Fields] OR "white"[All Fields]) AND "spot"[All Fields] AND ("lesion"[All Fields] OR "lesion s"[All Fields] OR "lesional"[All Fields] OR "lesions"[All Fields])
Comments on
The Evidence
Validity of the randomized clinical trial was strong, focusing on the differences of white spot lesion development in clear aligners versus traditional orthodontic therapy. While the patient population was simply randomized, the study groups were not matched. Fortunately, the various methods of white spot lesion assessment were accurate and reliable to characterize white spot lesions, which helped make clinically applicable and important conclusions. Validity of the retrospective cohort was similarly strong with a clearly focused issue and examiners who were calibrated in their assessment of white spot lesions. The patient population in the study were under the care of one private practicing orthodontist, all with appropriate follow-up. Most importantly, the authors identified important confounding factors that affect the results and suggest further studies that need to be conducted on this issue. Confidence in the validity of the systematic review: The main question is stated clearly and addressed. All relevant studies were included after a comprehensive database search using multiple databases and MESH terms on this novel topic. The exclusionary criteria was appropriate to include the most valid studies that addressed the main question, and the results of the studies were homogeneous. While the evidence presented by the review and its included studies were strong, the authors discussed the need for greater clinical evidence with more studies and controlling for confounding variables to increase confidence in the findings.
Applicability In any patient, the risk of developing white spot lesions increases with introduction of orthodontic appliances in the oral cavity. Patients present to the practitioner for orthodontic therapy with differing oral hygiene education, oral hygiene habits, and preexisting WSLs. Patients with a higher risk of developing white spot lesions due to inadequacy in these variables may benefit from the intervention of clear aligner therapy to accomplish their orthodontic goals. Clear aligner therapy often increases oral hygiene success, results in less treatment duration, and reduces plaque accumulation, all reducing the risk for new development of white spot lesions. However, factors such as (1) treatment complexity that cannot be addressed with clear aligners and (2) patient compliance may limit applicability and suggest traditional orthodontic therapy.
Specialty/Discipline (General Dentistry) (Orthodontics)
Keywords Invisalign, clear aligners, traditional orthodontic therapy, white spot lesions
ID# 3511
Date of submission: 11/29/2022spacer
E-mail Nguyenj16@livemail.uthscsa.edu
Author Jason Nguyen, DDS
Co-author(s) Claire Miles, DMD
Co-author(s) e-mail milesc@uthscsa.edu
Faculty mentor/Co-author Maria Karakousoglou
Faculty mentor/Co-author e-mail karakousoglo@uthscsa.edu
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