Fluorides for preventing early tooth decay (demineralised lesions) during fixed brace treatment

Philip E. Benson, Nicola Parkin, Fiona Dyer, Declan T. Millett, Peter Germain

Review question

Ugly white or brown marks sometimes appear on the teeth during treatment with braces to straighten teeth. These are due to early tooth decay and usually occur with fixed, glued‐on 'train track', braces, which make it more difficult to clean the teeth.

We know that fluoride in toothpaste helps to prevent tooth decay and think that if extra fluoride is given to people wearing fixed braces, it will protect them from getting these marks. The aim of this Cochrane Oral Health's review was to look at 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.


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, and 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?

Study characteristics

This review is up‐to‐date as of 1 February 2019. The review includes 10 studies but we could only use the information from nine studies involving 1798 randomised people. We have asked for more information about one study. 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 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.

Key results

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.

Certainty of the evidence

The level of belief we have in 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.

Read the full review

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.