Demineralized white lesions – what’s the best way to prevent them during orthodontic treatment?


Adjusting the braces… Should orthodontists be applying fluoride varnish at every visit?

The orthodontists working with the Cochrane Oral Health Group have been busy over the last few months. Another brand new review update has been published in the Cochrane Library!

Ugly white marks (demineralised white lesions) sometimes appear on the teeth during treatment with braces or other orthodontic devices. These are caused by early tooth decay and usually occur with fixed (glued on) braces. Fluoride in toothpaste helps to prevent dental decay, but is there evidence that giving people having orthodontic treatment extra fluoride will prevent these lesions? This review looks at the evidence.

What was the research?

A systematic review of the evidence to assess the effectiveness of fluorides in preventing early tooth decay during orthodontic treatment.

Who conducted the research?         

The research was conducted by a team led by Philip E. Benson from the University of Sheffield, on behalf of the Cochrane Oral Health Group. Nicola Parkin, Fiona Dyer, Declan T. Millet, Susan Furness and Peter Germain were also on the team.

What evidence was included in the review?

Data was extracted from 3 randomised controlled trials. A total of 458 people undergoing orthodontic treatment participated in the trials. These different ways of applying fluoride were assessed:

  1. Topical fluorides (eg mouthrinse, toothpaste, varnish, gel)
  2. Fluoride releasing devices attached to the braces

Control groups did not receive additional fluoride, or they received a placebo or they had a different form of fluoride.

What did the evidence say?

One study showed that fluoride varnish painted around the teeth and brace every time the brace is adjusted reduces demineralized white lesions by 70%. However, further well-designed trials are needed to confirm this finding.

How good was the evidence?

Only one of the studies included in this review was at low risk of bias. The design and reporting of trials on fluorides for preventing demineralized white lesions in orthodontics was generally poor. The methods used in the trials were inadequately reported, and few studies provided a flow diagram to show withdrawals and drop outs.

What are the implications for dentists and the general public?

Six-weekly application of fluoride varnish by a dental professional could reduce the risk of developing demineralized white lesions during orthodontic treatment. The evidence for using intraoral fluoride releasing devices is insufficient, and there was no direct evidence that fluoride mouthrinses in addition to fluoride toothpastes were effective.

What should researchers look at in the future?

More evidence is required before the most effective way of delivering fluoride to the orthodontic patient can be determined. Double-blind placebo controlled trials are needed, which look at more long-term orthodontic treatment.


Benson PE, Parkin N, Millett DT, Dyer F, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003809. DOI: 10.1002/14651858.CD003809.pub2.