Non-Cochrane · intervention · PM32051965
Is Bleaching Effective in Managing Post-orthodontic White-spot Lesions? A Systematic Review.
Gizani Sotiria, Kloukos Dimitrios, Papadimitriou Aikaterini, et al. · Oral health & preventive dentistry · 2020 · PubMed · doi:10.3290/j.ohpd.a44113
Oral HealthDental cariesEsthetic dentistryOrthodonticsAMSTAR 2: Low / Critically Low (extractors disagree)
Full textEvery question was extracted from the full text, figures and supplements by two independent LLM extractors, disagreements adjudicated. Rows cite where in the review the value comes from.
Questions
9
current version
GRADE rated
0
No studies
0
Included studies
15
linked below
No studies 0 · 0%Ungraded 9 · 100%Very low 0 · 0%Low 0 · 0%Moderate 0 · 0%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Permanent teeth with post-orthodontic white spot lesions; only studies with more than 10 patients or teeth; animal, bovine and fluorotic teeth and interproximal/occlusal/pit-and-fissure lesions excluded, as were case series and case reports | 1 RCT in orthodontic patients (n=19) and 8 in vitro studies on human tooth enamel (9 studies total) |
| Intervention | Bleaching (tooth whitening) to treat or alleviate post-orthodontic white spot lesions | Home and/or in-office bleaching with carbamide peroxide (3-22%) or hydrogen peroxide (35-40%), with or without laser/light activation or added fluoride/calcium/CPP-ACP |
| Comparison | Not explicitly restricted (any study design eligible, including single-arm in vitro studies); implicit comparator is no bleaching | No bleaching / untreated or pH-cycling controls; bleaching alone (for remineralising-agent comparisons); conventional bleaching (for laser comparisons) |
| Outcomes | Efficacy of bleaching for managing white spot lesions (colour/aesthetic change) and the effect of bleaching on enamel (demineralisation, microhardness, caries susceptibility) | Colour change/camouflage (3 studies addressing the primary question; very low certainty); patient satisfaction (n=1); caries susceptibility/demineralisation/microhardness (n=5); enamel mineral loss with added fluoride/calcium/CPP-ACP (n=4); whitening efficacy with remineralising agents (n=3); laser vs conventional bleaching (n=2) |
| Study designs | Any setting; in vivo and in vitro studies | One clinical study (Germany) and eight in vitro laboratory studies (Iran, South Korea, India, Brazil x3, USA, England) |
| Timing | All follow-up time points recorded; the most commonly reported time point among included studies was used | Follow-up ranged from not stated to 28 days (Knösel RCT: 28 days; in vitro assessments up to 21 days) |
Search date: 2018-07-01. Databases: MEDLINE (Ovid and PubMed); EMBASE (Ovid); Cochrane Oral Health Group's Trials Register; CENTRAL; ClinicalTrials.gov; National Research Register; ProQuest Dissertation Abstracts and Thesis database; hand-searching of reference lists
Questions and results
Tooth bleaching (carbamide or hydrogen peroxide; home and/or in-office) vs No bleaching (untreated control)
Population: Permanent teeth with post-orthodontic white spot lesions (orthodontic patients and in vitro enamel specimens)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Colour change / camouflage of white spot lesions (reduction of colour disparity between carious and sound enamel) Bleaching may diminish colour disparities and camouflage post-orthodontic white spot lesions, but the certainty of the evidence is very low; the findings could neither support nor refute bleaching. Source: Abstract; Results (Descriptive Results: Clinical trial and Laboratory studies); Discussion; Conclusion · same question in other reviews | The results showed that bleaching of WSL can diminish colour disparities between carious and non-affected areas, but the certainty of the evidence was very low. | 3 studies | Ungraded Downgraded: risk of bias, inconsistency, indirectness |
Colour disparity between carious and non-affected enamel Varied; 28 days in the RCT Population: Permanent teeth with post-orthodontic or artificial white spot lesions Bleaching may diminish colour disparities between carious and non-affected areas (very low certainty). Source: Results, Laboratory studies; Discussion · same question in other reviews | no estimate extracted | 3 studies | Ungraded Downgraded: risk of bias |
Patient satisfaction with aesthetic outcome 28 days Population: Orthodontic patients with post-orthodontic white spot lesions (permanent teeth) In the single RCT, all bleached patients were satisfied with the aesthetic outcome, though the trial was at high risk of bias (ungraded). Source: Results (Descriptive Results: Clinical trial); Table 1b (Knösel 2007) · same question in other reviews | All patients in the bleaching group were satisfied with the outcome; the patients were pleased with the aesthetic outcome of bleaching (Knösel 2007). | 1 study · 10 participants | Ungraded |
Tooth bleaching (carbamide or hydrogen peroxide; home or in-office) vs No bleaching (untreated or pH-cycling control)
Population: Permanent teeth / enamel specimens (in vitro)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Enamel demineralisation and susceptibility to caries or acid erosion (microhardness, mineral loss) Low-quality in vitro evidence suggests that bleaching of permanent teeth does not increase susceptibility to caries, demineralisation or erosion (ungraded); the clinical question could not be answered because only in vitro studies were available. Source: Results (Descriptive Results: Laboratory studies); Discussion · same question in other reviews | Four studies at high risk of bias and one study at moderate risk reached the overall conclusion that neither home- nor in-office bleaching of permanent teeth was associated with an increased susceptibility to… | 5 studies | Ungraded |
Mineral loss, lesion depth, or enamel microhardness Varied or not stated Population: Extracted human teeth with artificial white spot lesions Low-quality in vitro evidence suggests remineralising additives may reduce mineral loss, but no firm conclusion can be drawn. Source: Results, Laboratory studies; Discussion · same question in other reviews | no estimate extracted | 4 studies | Ungraded |
Bleaching gel with added remineralising agent (fluoride, calcium, or CPP-ACP) vs Bleaching alone (no remineralising agent)
Population: Demineralised / white-spot-lesion enamel (in vitro specimens)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Whitening (bleaching) efficacy Low-quality in vitro evidence indicates that adding fluoride or other remineralising agents does not impair the whitening/bleaching effect (ungraded). Source: Results (Descriptive Results: Laboratory studies); Discussion · same question in other reviews | Low-quality in vitro data indicated that the presence of fluoride or any other remineralising agent did not impair the whitening effect. | 3 studies | Ungraded |
Caries susceptibility, enamel demineralisation, erosion, or microhardness Varied or not stated Population: Permanent teeth or extracted human teeth with artificial lesions The laboratory studies did not find increased susceptibility to caries or enamel demineralisation, but no firm conclusions can be drawn because of high risk of bias. Source: Results, Laboratory studies; Discussion · same question in other reviews | no estimate extracted | 5 studies | Ungraded |
Enamel mineral loss / remineralisation Low-quality in vitro evidence indicates that adding fluoride, calcium or CPP-ACP to bleaching agents can reduce enamel mineral loss (ungraded). Source: Results (Descriptive Results: Laboratory studies); Discussion · same question in other reviews | Inconclusive: F/Ca/CPP-ACP additives reduced mineral loss on SOUND enamel (refs 8,10,16) but not verified for artificial caries lesions (ref 35) | 4 studies | Ungraded |
Laser/light-activated bleaching vs Conventional (non-laser) bleaching with hydrogen or carbamide peroxide
Population: Permanent teeth enamel (in vitro specimens)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Enamel microhardness / caries susceptibility Low-quality in vitro evidence found no support for adding lasers to in-office bleaching; laser-activated bleaching did not appear to affect enamel microhardness or caries risk versus conventional bleaching (ungraded). Source: Results (Descriptive Results: Laboratory studies); Discussion · same question in other reviews | In two studies having high risk of bias, laser-activated bleaching did not seem to affect enamel microhardness or caries risk when compared to conventional bleaching with hydrogen or carbamide peroxide. | 2 studies | Ungraded |
AMSTAR 2 appraisal
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | No | no |
| 2Protocol established before the reviewcritical | Partial Yes | No | no |
| 3Choice of study designs explained | Yes | No | no |
| 4Comprehensive literature searchcritical | Yes | Partial Yes | no |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Yes | Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Partial Yes | NRSI: N/A · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: N/A · NRSI: N/A | NRSI: N/A · RCT: N/A | no |
| 12Impact of risk of bias on the pooled results | N/A | N/A | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | N/A | N/A | yes |
| 16Conflicts of interest reported | No | No | yes |
| Overall | Low | Critically Low | no |
Included primary studies 15
Open as a trial list| Study | Also included by | Outcomes it informs here | Trial PICO | Results |
|---|---|---|---|---|
| Alves 2007 Susceptibility to carieslike lesions after dental bleaching with different techniques. PMID:17694204 | this review only | Mineral loss, lesion depth, or enamel microhardness | not extracted yet | not extracted yet |
| Ashnagar 2017 Evaluation of the Effect of Different Laser Activated Bleaching Methods on Enamel Susceptibility to Caries; An In Vitro Mode. PMID:29071038 | this review only | Enamel microhardness / caries susceptibility | not extracted yet | not extracted yet |
| Bollineni 2014 Role of fluoridated carbamide peroxide whitening gel in the remineralization of demineralized enamel: An in vitro study. PMID:25254197 | this review only | Enamel mineral loss / remineralisation | not extracted yet | not extracted yet |
| Cavalli 2011 Effects of the Addition of Fluoride and Calcium to Low-Concentrated Carbamide Peroxide Agents on the Enamel Surface and Subsurface DOI:10.1089/pho.2010.2797 | this review only | Enamel mineral loss / remineralisation | not extracted yet | not extracted yet |
| Cavalli 2011 Effects of the addition of fluoride and calcium to low-concentrated carbamide peroxide agents on the enamel surface and subsurface. PMID:21204703 | this review only | not stated | not extracted yet | not extracted yet |
| Gladwell 2006 Remineralization Potential of a Fluoridated Carbamide Peroxide Whitening Gel DOI:10.1111/j.1708-8240.2006.00021_1.x | this review only | Enamel mineral loss / remineralisation | not extracted yet | not extracted yet |
| Gladwell 2006 Remineralization potential of a fluoridated carbamide peroxide whitening gel. PMID:16911422 | this review only | not stated | not extracted yet | not extracted yet |
| Kim 2016 Bleaching Effects on Color, Chemical, and Mechanical Properties of White Spot Lesions DOI:10.2341/15-015-l | this review only | Colour disparity between carious and non-affected enamel | not extracted yet | not extracted yet |
| Kim 2016 Bleaching Effects on Color, Chemical, and Mechanical Properties of White Spot Lesions. PMID:26669503 | this review only | not stated | not extracted yet | not extracted yet |
| Knösel 2007 External Bleaching Effect on the Color and Luminosity of Inactive White-Spot Lesions after Fixed Orthodontic Appliances DOI:10.2319/060106-224 | this review only | Colour disparity between carious and non-affected enamel | not extracted yet | not extracted yet |
| Knösel 2007 External bleaching effect on the color and luminosity of inactive white-spot lesions after fixed orthodontic appliances. PMID:17605483 | this review only | not stated | not extracted yet | not extracted yet |
| Pinto 2009 Effect of 10% carbamide peroxide bleaching on sound and artificial enamel carious lesions DOI:10.1590/s0103-64402009000100008 | this review only | Mineral loss, lesion depth, or enamel microhardness | not extracted yet | not extracted yet |
| Pinto 2009 Effect of 10% carbamide peroxide bleaching on sound and artificial enamel carious lesions. PMID:19466231 | this review only | not stated | not extracted yet | not extracted yet |
| Pretty 2005 The effect of bleaching on enamel susceptibility to acid erosion and demineralisation DOI:10.1038/sj.bdj.4812126 | this review only | Mineral loss, lesion depth, or enamel microhardness | not extracted yet | not extracted yet |
| Pretty 2005 The effect of bleaching on enamel susceptibility to acid erosion and demineralisation. PMID:15870755 | this review only | not stated | not extracted yet | not extracted yet |