Prevalence, Incidence and Risk Factors of White Spot Lesions Associated With Orthodontic Treatment – A Systematic Review and Meta‐Analysis

The primary objective was to systematically assess the prevalence, incidence and risk factors of WSLs with orthodontic treatment. The secondary objective was to compare the prevalence of WSLs between conventional fixed appliances (CFA) and other appliances, as well as with no treatment. PubMed, Scopus, Web of Science, LILACs, Virtual Health Library and Cochrane CENTRAL were searched. Risk of bias was assessed using RoB-2, ROBINS-I tool and the Joanna Briggs Institute Critical Appraisal Checklist. Random-effects meta-analyses of pooled proportions and odds ratios (OR) with 95% confidence intervals (CIs) were conducted, followed by meta-regressions, sensitivity analyses, and an assessment of the quality of evidence using GRADE. Trial Sequential Analysis (TSA) was performed to determine the conclusiveness of the evidence. Fifty-seven studies involving 9101 patients (mean age of 16.4 years, 33.5% male) were included. Among orthodontic patients, the pooled prevalence of WSLs was 55.06% (95% CI: 47.7%, 63.6%: 42 studies), incidence was 34.2% (95% CI: 27.6%, 40.6%: 44 studies) and surface prevalence was 26.9% (6 studies; 95% CI: 13.8%, 39.8%). Among non-treated patients, the pooled prevalence of WSLs was 29.1% (95% CI: 17.2%, 41.1%; 21 studies). The odds of WSLs were significantly higher, with CFA being 4.73 times greater compared to other appliances (OR = 4.7, 95% CI: 1, 19.2, p = 0.05) and seven times higher compared to no treatment (OR = 7, 95% CI: 2.6, 18.5, p = 0.001). Prevalence of WSLs increased with longer treatment duration (p < 0.001), varied with ethnicity, being highest in Africans and lowest in Americans (p < 0.05), and method of detection (p < 00.1). TSA confirmed that CFA leads to more WSLs than other appliances or no treatment, with future studies unlikely to alter the direction of the outcomes. Orthodontic treatment increases WSL prevalence, influenced by various factors. Clinicians should carefully consider the development of WSLs during orthodontic treatment and adjust treatment plans accordingly, choose appliances wisely and monitor with effective detection tools. Since one-third of untreated cases already have WSLs, proper documentation at treatment start is essential. Trail Registration: CRD42023478065.