Labial White Spot Lesions and Proximal Caries Development in Orthodontic Patients Using Clear Aligners Versus Traditional Braces.

Background and Purpose While orthodontic treatments like traditional braces and clear aligners successfully straighten teeth, they introduce a significant challenge: they make it harder to keep teeth clean. Orthodontic appliances create new areas for dental plaque and bacteria to hide, which can rapidly lead to early tooth decay. This decay typically takes two forms: white spot lesions (WSLs), which are chalky, white marks that form on the visible front surfaces of the teeth, and proximal caries, which is hidden decay that develops in the tight spaces between adjacent teeth.

Historically, it was assumed that clear aligners were a "safer" alternative to braces regarding tooth decay because they can be removed for brushing and flossing. However, clear aligners cover the teeth for 22 hours a day, preventing natural saliva from washing away food and neutralizing acids. Because of this, the actual risk of developing both visible and hidden decay associated with the two treatments required rigorous investigation.

The primary purpose of this 6-month randomized clinical trial was to directly compare the risk, incidence, and behavior of early tooth decay in patients treated with conventional fixed braces versus those treated with clear aligners.

Study Design and Participants

This study was designed as a prospective, randomized clinical trial. A total of 24 eligible adult and adolescent participants who required orthodontic treatment were randomly assigned to one of two groups:

• Group 1: Fixed Appliances (traditional brackets and wires).
• Group 2: Clear Aligners (removable transparent trays). What Did the Researchers Measure?

To gain a complete picture of the patients' oral health, the research team tracked three major outcomes:

• Visible Decay (White Spot Lesions) and Lesion Behavior: Researchers visually examined the front surfaces of the teeth to detect new white spot lesions. Uniquely, the study did not just count the lesions at the end of treatment; it tracked their dynamic behavior. By evaluating the teeth at 3 months and 6 months, researchers could see exactly when a lesion formed and whether it worsened, stabilized, or healed (remineralized) over time.
• Hidden Decay (Proximal Caries) Using Advanced Optical Scanning: Detecting decay between the teeth usually requires X-rays, which expose patients to radiation and often miss the earliest stages of disease. To avoid unnecessary radiation and catch decay at its earliest optical phase, this study utilized Near-Infrared Imaging (NIRI). This cutting-edge, radiation-free scanner shines a safe, near-infrared light through the teeth (specifically focusing on the premolar teeth) to make hidden, early-stage decay glow brilliantly white on a digital screen.
• Oral Hygiene Burden and Professional Cleaning Procedures: The study tracked how difficult it was for patients to maintain their oral hygiene. Instead of just asking patients how well they brushed, the researchers objectively measured the "hygiene burden" by recording how often patients in each group required Professional Mechanical Plaque Removal (PMPR)-or professional dental cleaning-during their routine orthodontic visits.

Study Timeline

• Baseline (Start of Treatment): Patients received a thorough clinical examination, an assessment of their past cavity history, and a baseline NIRI optical scan to ensure no hidden decay was present before the appliances were placed.
• 3-Month Check: A visual examination was conducted specifically to catch the rapid, early onset of visible white spot lesions as patients adapted to their new appliances.
• 6-Month Check: A full examination was conducted, including a visual check for white spot lesions and a second NIRI optical scan to detect any new hidden decay that formed between the teeth over the first six months of treatment.

Why This Study Matters This study provides highly valuable, real-world evidence for both patients and healthcare providers. By demonstrating that neither appliance is completely cavity-free, it helps orthodontists provide highly accurate, evidence-based informed consent to their patients. It reveals that while clear aligners may protect the front of the teeth better and require fewer professional cleaning procedures, they still carry a significant risk for hidden decay between the teeth. Ultimately, this study emphasizes that regardless of the appliance chosen, highly personalized, strict oral hygiene routines are mandatory to protect the teeth during orthodontic treatment.

Inclusion criteria

• Demographics: Patients aged 13-45 years, possessing fully erupted permanent dentition (excluding third molars).
• Malocclusion Severity: Skeletal class I according to an ANB angle of 2-4 degrees (Steiner, 1953), moderate lower malalignment of 4-9 mm based on Little's Irregularity Index, and a class I incisor relationship (British Standards Institute, 1983).
• Treatment Protocol: Comprehensive, dual-arch orthodontic treatment strictly on a non-extraction basis.
• Handover form from their referring dentist confirming absence of caries requiring restorations and that all indicated restorative therapies have been completed, in addition to no active periodontal disease or pathologic probing depths.
• No prior history of orthodontic treatment.
• No full coverage restorations (crowns/veneers) on anterior teeth or premolars.

Exclusion criteria

• Inability to maintain adequate oral hygiene prior to treatment initiation.
• Dental Anomalies and Missing Teeth: Congenitally missing teeth, presence of dental implants, or impacted teeth (excluding third molars).
• Structural Enamel Defects: Presence of developmental enamel defects that mimic or obscure demineralization, including enamel hypoplasia, fluorosis, or amelogenesis imperfecta.
• Fluoride Supplementation: Patients currently utilizing a prescribed, daily supplemental fluoride regimen beyond standard over-the-counter fluoridated toothpaste.
• Adjunctive Appliances: Treatment plans requiring the use of plaque-retentive adjunct intraoral appliances (e.g., expanders, distalizers).
• Contraindications to Therapy: Any existing biological contraindications to comprehensive orthodontic tooth movement (e.g., advanced root resorption).