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Inconclusive evidence regarding post-orthodontic white spot remineralization

Sawsan Tabbaa DDS., MS., ORTHO., ABO.; Abdul Fattah Hanoun DDS, MS; Elizabeth M. Stellrecht M.L.S. .


Systematic Review Conclusion

Lack of reliable evidence exists to indicate the effectiveness of remineralizing agents for post-orthodontics white spot lesions (POWSLs).

Critical Summary Assessment

This well-conducted systematic review showed that there is no reliable evidence to support or refute the use of remineralizing agent for the treatment of POWSLs.

Evidence Quality Rating

Limited Evidence

Structured Abstract

Clinical Questions:

Are remineralizing agents effective in reducing enamel white spot lesions following orthodontic treatment?

Review Methods:

The authors searched four electronic databases without language restrictions for articles published up to July 2012 for three of the databases and up to November 2011 for the remaining database. References of the selected articles were hand searched as well. Inclusion criteria comprised randomized controlled trials (RCTs) of post-orthodontic patients who had at least one visible white-spot lesion (WSL) after brackets have been removed. These patients were treated with remineralizing agents. The primary outcome was the change in severity of the WSL between experimental and control groups. The authors selected studies comparing remineralizing agents to each other or against a control group. Only one author examined the titles and abstracts, but two authors independently evaluated the full texts. Opinion of a third reviewer was sought in case of disagreement.

Main Results:

Only seven RCTs met the eligibility criteria. Three evaluated fluoride preparations while four considered casein phosphate variations. The follow-up period ranged from 1.5 months to 12 months and the number of participants ranged from 13 to 55. Six studies had a high risk of bias due to problems associated with assessment methods and/or inadequate design. Allocation concealment was unclear in six studies. Blinding was not present in two studies and loss to follow-up was not described in most of the studies. Five out of seven studies, including the only study with moderate risk of bias, found no significant difference in the severity of WSLs between treated and untreated groups. Three studies did not use the clinically relevant outcome of interest (visual evaluation), but instead based results on a light-induced fluorescence reading. Heterogeneity between studies precluded meta-analysis.


There is lack of reliable evidence to support or refute the clinical effectiveness of remineralizing agents for POWSLs treatment.

Source of Funding:

No source of funding is identified.


Importance and Context:

The presence of WSLs as result of fixed orthodontic treatment may leave a negative perception of the orthodontist's work.[1] Effective and aesthetic remineralization treatment of POWSLs is a major concern for orthodontists and affected patients. There is some evidence to support the claim that the appearance of WSLs may slowly disappear, but full remineralization cannot be assumed.[2] A question of interest is the effectiveness of remineralizing agents for WSL treatment when compared with spontaneous remineralization.

Strengths and Weaknesses of the Systematic Review:

This is a well-conducted SR, which followed accepted methodological guidelines. The authors searched four electronic databases without limitations. They also hand searched the references of the selected articles for missing studies. Lack of methodological similarity amongst the included studies did not allow the authors to run a meta-analysis, but only qualitative assessments. The authors provided a detailed description of included articles covering results. The initial search and evaluation of titles and abstract by one researcher could be a source of possible selection bias.

Strengths and Weaknesses of the Evidence:

Only seven RCTs fulfilled the selection criteria, and there was no common outcome or treatment. The authors found a high risk of bias in six studies, and a medium risk of bias in one study. Three studies used light-induced fluorescence assessment, which may not reflect the actual visibility of the lesion (patients’ outcome of interest). In those cases the statistical significance may not necessarily be clinically significant for a patient. Only one study examined the pre-orthodontic records to exclude any pre-orthodontic WSLs. All the included studies had methodological problems such as unclear randomization and blinding procedures, small sample sizes, and/or improper statistical analysis. Quantitative synthesis of study findings was not possible as diverse interventions were used and different outcomes were measured. Future research is still needed in this field with better eligibility criteria, randomization, and blinding.

Implications for Dental Practice:

There is limited evidence to determine the effectiveness of remineralizing agents in the treatment of POWSLs. Clinicians should exercise caution when offering these procedures to patients to reduce or eliminate POWSLs as the outcome is unpredictable. Finally, clinicians should understand the differences between a professional and a layperson's determination of a clinically beneficial outcome. References: 1. Hamdan AM, Maxfield BJ, Tufekci E, Shroff B, Lindauer SJ. Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists. J Am Dent Assoc 2012; 143 (7):777-83. 2. Graber LW, Vanarsdall RL, Vig KWL. Orthodontics : current principles & techniques. Philadelphia, PA: Elsevier/Mosby; 2012.

Critical Summary Publication Date:


These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association © 2019