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Journal of the World Federation of Orthodontists 6 (2017) 127e130

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Journal of the World Federation of Orthodontists


journal homepage: www.jwfo.org

Original Research

Incidence of white spot lesions during orthodontic clear aligner


therapy
Muhammad Azeem a, *, Waheed Ul Hamid b
a
Assistant Professor, Orthodontics, Health Department Government of Punjab, Lahore / Faisalabad Medical University, Pakistan
b
Dean and Professor, Head of Orthodontics, de’Montmorency College of Dentistry, Lahore, Pakistan

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: There are many studies available regarding the incidence of while spot lesion (WSL)
Received 23 June 2017 development during fixed appliance therapy, but there is not enough equivalent information concerning
Received in revised form incidence of WSL with clear aligner therapy. Therefore, the aim of present study was to assess the
21 July 2017
incidence of WSL formation in subjects treated with clear aligner therapy.
Accepted 26 July 2017
Methods: This study was conducted on pretreatment and posttreatment quantitative light-induced
fluorescence images of 25 orthodontic patients (12 boys, 13 girls; mean age, 16.17  1.76 years)
treated with clear aligner therapy protocol. The records included each patient’s age, sex, and time points
Keywords:
Adolescents
of start and end of clear aligner therapy. The primary outcome measures were sound enamel and the
Clear aligners numbers of WSLs. Nonparametric analysis of variance was performed, taking into account the patients’
Invisalign grouped ages, sexes, and treatment timings. The Statistical Package for the Social Sciences (version 20.0)
White spot lesions was used for data analysis. P < 0.05 indicated statistical significance.
Results: The overall incidence of new WSLs was 2.85% for all the assessed teeth. Twenty-eight percent of
the patients were affected by at least one new WSL, when all the accessed teeth were considered. Fre-
quencies of WSLs were not significantly different in different age and gender groups; however, treatment
time had a significant impact on WSL formation in maxillary incisors.
Conclusion: Orthodontic treatment with clear aligner therapy showed a low incidence of newly devel-
oped WSLs.
Ó 2017 World Federation of Orthodontists.

1. Introduction [8e10]. Overall incidence of 72.9% has been found for maxillary and
mandibular teeth, including the first molars [11]. Many studies have
White spot lesions (WSLs) are clinically defined as opaque, been done to determine the best prevention and treatment of WSLs.
white areas caused by the subsurface loss of enamel minerals [1]. Most studies aimed at the prevention and treatment of WSLs by
Orthodontic patients with fixed appliance therapy are more sus- using topical fluoride toothpastes and mouthwashes, antibacterial
ceptible to the development of WSLs, than untreated patients orthodontic adhesives, fluoride varnishes or gels, and more recently
because of impaired oral hygiene and increased plaque retention laser irradiation and resin infiltration [1,12e16].
sites [2]. The introduction of removable clear aligners meant a step Many orthodontic patients adopt clear aligner therapy instead of
forward in the treatment of orthodontic conditions. Several fixed appliance treatment for social reasons. Clear aligner trays are
approaches are available for diagnosis of WSLs, including fiberoptic usually prescribed to be worn approximately 22 hours per day for
transillumination [3], ultraviolet light [4], fluorescent dye uptake optimal results. However, by covering teeth, flow of saliva is limited,
[5], laser fluorescence [6], and photographic images [7]. and self-cleansing activities of orofacial soft tissues is interrupted,
Estimates of the WSLs arising during fixed appliance therapy allowing further entrapment and development of plaque under the
showed an incidence of at least one new WSL of 46% within 1 year, aligners [17]. Additionally, many patients drink acidic beverages
14 or 36% for upper and lower incisors, and 61% for upper incisors with aligners in place, which allows further entrapment beneath
the aligners. Birdsall and Robinson [18] described a former ortho-
dontic patient with a lower vacuum-formed retainer who
* Corresponding author: Orthodontic Department, Health Department Govern-
consumed five or six soft drinks per day and demonstrated signif-
ment of Punjab, Lahore / Faisalabad Medical University, Pakistan 54000. icant decalcification and caries in normally self-cleansing areas,
E-mail address: dental.concepts@hotmail.com (M. Azeem). such as cusp tips and incisal edges. Sheridan and colleagues [19]

2212-4438/$ e see front matter Ó 2017 World Federation of Orthodontists.


http://dx.doi.org/10.1016/j.ejwf.2017.07.001
128 M. Azeem, W. Ul Hamid / Journal of the World Federation of Orthodontists 6 (2017) 127e130

reported a patient whose incisal edges had demineralised due to Table 1


frequent consumption of soft drinks while wearing a plastic sur- Tooth groups used in the current study

gical splint. A recent study demonstrated that treatment with Tooth group No. of Definition by World Dental Federation
removable aligners was associated with improved periodontal teeth numbering system
status [20]. Moshiri et al. [17] recommended that aligner patients 12e22 4 Maxillary incisors: 22, 21, 11, 12
with poor oral hygiene should be monitored for the development of 15e45 20 Maxillary and mandibular incisors, canines, first
and second premolars:
WSLs.
11e15, 21e25, 31e35, 41e45
The general assumption is that aligners are hygienic by design, 16e46 24 Maxillary and mandibular incisors, canines, first
but following the previously described rationale, it could be spec- and second premolars, and first molars:
ulated that clear aligner therapy can also lead to development of 11e16, 21e26, 31e36, 41e46
new WSLs. There are many studies available regarding the inci-
dence of WSL formation during fixed appliance therapy, but there is
not enough equivalent information concerning incidence of WSLs 16 to 46 (Table 1). The features of the 25 patients, such as treatment
during clear aligner therapy. Therefore, the aim of the present study time and age distribution, were descriptively analyzed. Nonpara-
was to assess the incidence of WSL formation in subjects treated metric, multifactorial analysis of covariance (ANCOVA) was used for
with clear aligner therapy. statistical analysis to assess the impact of the factors “sex” (female,
0; male, 1) and “age group” (16, 0; >16, 1), adjusted by the
2. Materials and methods covariable “treatment time” on the incidence of WSLs. Overall
fluorescence loss was presented as mean and range and differences
This prospective study was approved by the ethics committee of between the tooth groups were analyzed. The Statistical Package for
our institute. Written informed consents were obtained from the the Social Sciences (version 20.0; IBM SPSS Statistics, Chicago, IL)
patients for the publication of this article and any accompanying was used for data analysis. P < 0.05 indicated statistical
images. To calculate estimated sample size, power analysis was significance.
performed using G*-power (version 3.0.10; Franz Faul Universitat,
Kiel, Germany), to reach a power of 0.85, 16 orthodontic subjects
were required, but to allow for dropouts during clear aligner 3. Results
treatment, the minimum inclusion was set at 25 orthodontic sub-
jects [21,22]. All patients were considered to be free from WSLs on the smooth
In selecting the sample, we used the following criteria: (1) surfaces at baseline, as determined by QLF images. Mean treatment
comprehensive clear aligner treatment of upper and lower arches, duration was 18.11  5.12 months (minimum, 8.12 months;
(2) age 14 to 18 years at the start of aligner therapy, (3) no previous maximum, 26.23 months).
orthodontic therapy, and (4) no hypodontia. Patients with any The overall incidence of new WSLs was 2.85% for all the assessed
systemic disease, clefts, generalized dental problems, on a daily teeth; 28% of the patients were affected by at least one new WSL,
supplemental fluoride regimen, or ongoing medication for a when all the accessed teeth were considered (Table 2). The patient-
chronic disease were excluded from the study. Patients who already related incidence was 28% for tooth group 16 to 46, or 8% when
had WSLs, hypoplastic, or fluorotic enamel in their initial quanti- considering the maxillary incisors separately (Table 3).
tative light-induced fluorescence (QLF) images taken before the Table 4 shows the results of the ANCOVA of tooth-related WSL
start of the orthodontic treatment were excluded from the study. formation in the tooth groups. Frequencies of WSLs were not
Following this, 25 orthodontic patients (12 boys, 13 girls; mean age, significantly different in different age and gender groups; however,
16.17  1.76 years) treated with clear aligner therapy were selected. treatment time had a significant impact on WSL formation in tooth
All the patients received identical, standardized oral hygiene group 12 to 22. Overall fluorescence loss was 5.43%.mm2 (range
instructions, including the advice to brush and floss their teeth at 0e39.8%.mm2) with insignificant differences between the tooth
least three times daily with typical commercially available groups (P ¼ 0.8). Upper lateral incisors were most affected by WSLs
1450-ppm toothpastes; otherwise, oral hygiene, nutrition status, in the present study.
additional fluoride exposure, and saliva differences were not
considered as cofactors in current study. No additional fluoride
applications were given. 4. Discussion
The records included each subject’s age, sex, and time points of
start and end of clear aligner therapy. The primary outcome mea- Several approaches are available for diagnosis of WSLs [3e7] but
sures were sound enamel and the numbers of WSLs. For the WSL the QLF method was chosen in our study because of its proven
assessments, QLF images were taken before and directly after clear sensitivity and efficiency [21,23,24]. We did not use photographs for
aligner treatment by the same operator using an Inspektor Pro determining the WSL because lighting, angulations, and magnifi-
system (Inspektor Research Systems, Amsterdam, The cation may vary at different time points [25]. Subjects undergoing
Netherlands). Immediately before image capture, the whole quad- clear aligner therapy but already with WSLs on their smooth sur-
rant was dried. One investigator, who was blinded to the study, faces before the start of treatment, as detected by QLF images, were
evaluated each image with image-capturing software (C3 v1.20; excluded from the study, as existing WSLs at baseline seems to be
Inspektor Research Systems) for signs of decalcification, which indicative of increased development of new WSLs.
appears as dark areas surrounded by bright green fluorescing sound
tooth tissue, and images were also analyzed for fluorescence loss.
Table 2
Tooth-related incidences of white spot lesions
2.1. Statistical analysis
Tooth group No. of teeth Incidence, n (% all/male/female)

Both tooth-related and patient-related incidences of WSLs were 12e22 90 3 (3.33/3.12/3.76)


15e45 475 11 (2.31/2.12/2.87)
calculated. Incidence of WSLs was assessed separately for the 16e46 560 16 (2.85/2.34/2.65)
maxillary incisors [1,12e21], as well as for tooth groups 15 to 45 and
M. Azeem, W. Ul Hamid / Journal of the World Federation of Orthodontists 6 (2017) 127e130 129

Table 3 Our results showed that treatment time had a significant impact
Patient-related incidences of white spot lesions on WSL formation, especially at the maxillary front teeth. Findings
Tooth group No. patients Incidence, n (% all/male/female) are in contrast with studies of Chapman et al. [9], Akin et al. [27],
12e22 25 2 (8/10.33/8.89) and Al Maaitah et al. [40], but in agreement with findings of Tufekci
15e45 25 5 (20/22.87/20.09) et al. [8], Khalaf [38], and Julien et al. [39], who showed that greater
16e46 25 7 (28/29.17/26.88) treatment lengths do serve as a risk factor for WSL formation.
Regarding treatment length with aligner therapy, our results
showed that orthodontic treatment using the aligner is comparable
The overall incidence of new WSLs was 2.85% for all the assessed to buccal fixed appliance therapy in terms of treatment length
teeth; 28% of the patients were affected by at least one new WSL (18.11  5.12 months).
when all the accessed teeth were considered. In comparison with When comparing the results of the current study with fixed
studies on buccal fixed appliance therapy, Enaia et al. [10] found lingual appliance orthodontic therapy, Wiechmann et al. [41]
incidence of WSLs to be 60.9%, Gorelick et al. [26] found the inci- showed that 41.95% (28% in current study) developed at least one
dence to be 50%, Akin et al. [27] found it to be 55%, and Tufekci et al. new WSL when all teeth were considered, and this incidence was
[8] found it to be 46%. Therefore, the current study showed that 4.74% for the maxillary incisors. Of all teeth under consideration,
aligner therapy makes a difference when WSL incidence is con- 3.19% (2.85% in current study) developed a WSL during treatment.
cerned. Development of WSLs with aligner therapy can be related to The patient-related incidence in our study was 8% when consid-
findings of Tuncay et al. [28], who demonstrated that aligner pa- ering the maxillary incisors separately, whereas it was 10.5% in
tients may experience accumulation of plaque and mild papillary study by Wiechmann et al. [41].
bleeding; furthermore, a recent study found that a significant The variation in WSL incidence among studies could be attrib-
amount of bacterial plaque remained on the surfaces of aligners uted to differences in the number of teeth examined, the methods
even when proper oral hygiene was performed [29]. Another study and standardizations of the examinations, the location of the study
noted that aligner attachments offer further areas of plaque sample, initial age, treatment duration, type of orthodontic therapy,
retention [30]. Results of recent studies showed favorable conse- supplemental fluoride application, and orthodontic materials.
quences for periodontal health in patients with aligner therapy Despite the cost factor that must be weighed against the costs of
compared with fixed appliance treatment [20,28,31,32]. However, prevention or treatment of WSLs, aligner therapy may provide a
oral hygiene was not considered as a cofactor in the current study. fruitful option to patients and orthodontists. The following are
The patient-related incidence was 8% when considering the suggestions for WSL prevention during aligner therapy [17]:
maxillary incisors separately. In comparison with studies on buccal
fixed appliance therapy, Enaia et al. [10] reported patient-related  Avoid meals with aligners in mouth
WSL incidence of 57% in same tooth group and Tufekci et al. [8]  Brush teeth, and inside of aligner, after every meal
reported it to be 46% for 13 to 23 tooth group. In the literature,  At night, supplement the normal brushing routine with flossing
conflicting reports have described the distribution of WSLs. Gor- and a fluoride mouthwash rinse
elick et al. [26] and Geiger et al. [33] reported that the tooth most  Use an ultrasonic bath or Cleaning System
commonly affected was the maxillary lateral incisor, whereas  Follow-up for professional cleanings and examinations
Mizrahi [34] and Øgaard [35] found that the first molars were the
teeth most commonly affected. The present study, however, found Limitations of the current study are limited sample size, lack of
no significant differences among teeth in the distribution of WSLs blinding, lack of control group and lack of comparison with fixed
between tooth groups. appliances. Regardless of these limitations, this study provided data
Frequencies of WSLs were not significantly different between for incidence of new WSLs during clear aligner therapy. We intend
boys and girls, which is in agreement with studies of Mizrahi [36], to use results from the present study to design a future comparative
Sagarika et al. [37], and Akin et al. [27], but in contrast with findings study with increased sample size.
of Richter et al. [11], Gorelick et al. [26], Tufekci et al. [8], Boersma
et al. [21], Khalaf [38], and Julien et al. [39], in which gender dif- 5. Conclusion
ferences were found in development of new WSLs during ortho-
dontic therapy. No gender difference in the present study may be Orthodontic treatment with clear aligner therapy showed a low
related to the equal oral hygiene standards in both genders. Simi- incidence of newly developed WSLs. Our suggestion is that clear
larly, frequencies of WSLs were not significantly different in the two aligner therapy should be preferred in orthodontic patients at high
age groups, which is in agreement with studies of Sagarika et al. risk of developing WSLs.
[37], but in contrast to findings of Richter et al. [11], Akin et al. [27],
and Khalaf [38], who showed that age at the start of treatment was
a significant factor in WSL development. References

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