Fluorides for preventing early tooth decay during fixed brace treatment

Wearing a fixed brace makes it harder for people to keep their teeth clean and may also cause pain. Pain can make it more difficult for people to brush their teeth. This can lead to a build-up of dental plaque around the brackets that attach the fixed brace to the teeth. If the plaque stays on the tooth for long enough, it will cause early tooth decay, which looks like white or brown marks (demineralised lesions, also known as white spot lesions). People often wear braces for 18 months or longer and if the decay is left to progress, it can cause holes, which are sometimes bad enough to need fillings to be done in the teeth.

Fluoride helps the tooth to heal, reducing tooth decay in people who are at risk of developing it. People receiving fixed brace treatment may be given different forms of fluoride treatment. It is important to think about how the fluoride gets to the teeth. Does the fluoride need to be placed by a dentist or dental nurse, or can people having treatment with braces apply the fluoride to their own teeth?

What was the research?

A systematic review to examine how well fluorides help to prevent early tooth decay during fixed brace treatment and to find out the best way to get fluoride to the teeth.

Who conducted the research?

The research was conducted by a team led by Philip E. Benson of the University of Sheffield School of Clinical Dentistry on behalf of Cochrane Oral Health. Nicola Parkin, Fiona Dyer, Declan T. Millett and Peter Germain were also on the team.

What evidence was included in the review?

This review is up-to-date as of 1 February 2019. The review includes 10 randomised controlled trials but we could only use the information from nine studies involving 1,798 randomised people. We have asked for more information about one of the studies. The review looks at eight different ways of applying fluoride to the teeth. People taking part in the studies were all having treatment with fixed braces. The number of people with new decay on the teeth at the end of fixed brace treatment, as well as the amount of decay in each person, were measured and counted.

We compared the following treatments:
– dentist or nurse-applied fluoride e.g. varnish, gel or foam,
– patient-applied/used fluoride e.g. toothpaste, mouthwash, gel or foam, and
– materials that release fluoride over time e.g. glues, elastic bands.

What did the evidence say?

One study showed that when the dentist applies a foam with a high level of fluoride in it onto the teeth every time the patient is seen, this might reduce the risk of new decay. Another study found that if patients use a toothpaste with a higher level of fluoride than normal, then this might also reduce the risk of new marks on their teeth.

No studies have shown that other ways of giving the teeth extra fluoride reduced the number and/or size of new decay on teeth in people wearing fixed braces. Harmful effects of the different ways of giving the teeth more fluoride were not reported in any of the included studies.

How good was the evidence?

The level of certainty for these findings is low, due to the lack of studies testing the same fluorides and showing the same results. We suggest that more, well-conducted studies should be done in this area.

What are the implications for dentists and the general public?

We do not have enough evidence from clinical trials to decide the best way to get fluoride to teeth in people having treatment with fixed braces.

What should researchers look at in the future?

There is a need for more clinical trials looking at how to deliver fluoride to the teeth, and these should have enough people participating in them to make the results meaningful. Pictures should be taken of the tooth before and after treatment so that the progress of dental decay can be measured. More than one dentist should check for tooth decay to avoid bias in the results of the trial.


Benson PE, Parkin N, Dyer F, Millett DT, Germain P. Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment. Cochrane Database of Systematic Reviews 2019 , Issue 11 . Art. No.: CD003809. DOI: 10.1002/14651858.CD003809.pub4.

This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at the Cochrane Oral Health Editorial Base.

1 thought on “Fluorides for preventing early tooth decay during fixed brace treatment

  1. Pingback: White spot lesions: Topical fluoride for prevention during fixed orthodontic treatment - National Elf Service

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