White spots on teeth are sometimes occurring naturally or may result from the use of certain products such as fluoride. Too much fluoride can cause dental fluorosis, which is characterized by the appearance of spots on the teeth. Although fixed orthodontic appliances (braces) are a source of food and dental plaque retention, it is possible to keep the teeth and appliances clean during orthodontic treatment with good dental hygiene and by following certain basic rules.

Some facts about oral hygiene and orthodontics: Bacteria found in dental plaque accumulating on the teeth cause caries and tooth decalcification. The bacteria produce acid, which progressively dissolves the tooth surface. This can lead to decalcification (surface staining) and eventually to caries. Although a certain individual variation in susceptibility to caries exists, the best way to avoid caries and stains is to have an impeccable oral hygiene and to follow the hygiene instructions given to you at the beginning of treatment. Proper oral hygiene techniques will be demonstrated to you to make sure that you understand them. Orthodontic appliances as such do not cause caries, decalcification or gum disease but they may be a factor in retaining food particles and dental plaque. Caries and decalcification spots are due to the action of bacteria in dental plaque that accumulates on teeth. Unless these debris are removed completely, there may be problems occurring such as decalcification or discoloration of teeth and gum infections. Decalcification spots, which appear as white spots on teeth, can grow up to become caries if oral hygiene is not improved. Although some variation may exist in individual susceptibility to caries, the best way to prevent cavities and stains on teeth is to faithfully follow the oral hygiene instructions we will give you. At the beginning of treatment, we give very precise oral hygiene and brushing instructions by demonstrating the proper techniques you must use. You will receive various types of toothbrushes so that you have all the necessary tools to have an impeccable oral hygiene. We recommend and insist that you continue to visit your general dentist regularly during your orthodontic treatment. To know more on oral examination to the dentist.

Dental plaque bacteria adhering to tooth surface and causing dental caries.

Regardless of how well we clean and prepare your teeth before we put your braces on, only adequate oral hygiene during the whole duration of treatment will keep them clean. We will straighten your teeth but taking care of them and of your appliances is your responsibility! Brush well, have good oral hygiene and you will be able to participate in our hygiene contests and may win prizes while keeping your teeth and mouth healthy!

• Furthermore, the metabolism of the bacteria produces acid that attacks tooth enamel by dissolving its surface and removing minerals, causing tooth decay. If plaque stays on the tooth surface long enough, it may incorporate minerals present in saliva and become very hard. It is then called dental tartar or calculus.
• At this stage, the mineralized plaque (tartar) cannot be removed by simple tooth brushing and it will require a more aggressive means such as a mechanical or ultrasonic scaling by the dentist.
• Click on the button of the above video to see live bacteria in dental plaque under the microscope. This is even more impressive if you view it in full screen! Appetizing isn’t it? This may be what is crawling on your teeth…

Not only teeth, gums too!

The bacteria in dental plaque and tartar which are close to the gingiva will gradually cause gum inflammation (which is visible by redness and bleeding) which will progressively cause gingival loss (receding gums, gingival recession) and may affect the bone that supports the teeth (periodontal diseases). The best way to avoid these problems is to break the chain reaction of bacterial infection as soon as possible with good oral hygiene habits.

Hygiene and brushing technique Teeth must be brushed thoroughly after each meal or snack. A good brushing technique requires time and practice to master (brushing duration should be approximately 2 minutes). We recommend the use of a brush with a small head and with soft bristles because they damage gum less. Although “orthodontic” brushes exist, any soft-bristled toothbrush that is small enough will be adequate. It is important to apply enough pressure while brushing to feel the bristles of the brush against the gum tissue. In certain cases, an electric toothbrush may be very useful. Many models exist on the market but some perform better than others. If you wish to use an electric toothbrush, we recommend the use of an ultrasonic brush like Sonicare for which the ultrasounds generated by the high vibration rate get into areas that are more difficult to reach. Ask us if you would like to have more information on electric ultrasonic brushes or to try one. Hygiene aids: Certain products can make maintenance of your teeth easier. Braces floss threader: see the pictures below in this page or consult the FlossFish site to see a video demo on the use of this product. Interproximal toothbrush: we will provide you with little orthodontic brushes to access the areas between the brackets and under the wires (proxabrush). If your gums are sore or bleed easily while brushing, tell us so that we can evaluate the cause.

Brush or floss?

The basis of good oral hygiene is toothbrushing but we also encourage you to use dental floss. It is obviously more difficult to use dental floss with braces but we can provide you with threaders which can facilitate this task. Dental floss should be a complement to a good brushing technique but cannot replace it. Here is the reason why we do not insist on using dental floss with orthodontic appliances (braces) even if we strongly encourage it:

• People spend some time maintaining their teeth and orthodontic appliances, which is normal.
• However, whether they use the brush, floss or any other hygiene means, they will rarely spend more time completing these tasks than if they simply brushed their teeth.
• Unless people are very meticulous and take the time to brush correctly, followed (or preceded) by using dental floss, the result is often that brushing is quicker and floss is used incompletely, which decreases quality of the maintenance, because good, complete and meticulous brushing is the basis of oral hygiene.
• We are not against using dental floss and other hygiene aids but, if they are used, time spent on oral hygiene will have to be increased consequently to get the maximum back from these complementary methods.

In conclusion, a good dental floss session will not replace nor compensate for inadequate brushing but it can be beneficial! Remember… it is not necessary to brush all your teeth… only those you wish to keep!!

The “real” causes… and the solutions! It is not rocket science, most people having oral hygiene problems, whether they wear braces or not, can blame them on three main reasons: 1- Bad technique: the brushing technique is deficient or inadequate. They brush long enough (brushing duration) but they do not reach the critical zones on the edge of the gum, behind the wires and around the brackets, to remove plaque and food debris. It is important to press the bristles of the brush on the gum to massage it well during brushing. Do gentle rotation movements on every surface of the tooth. Perform a vertical movement of the brush from the gum toward the tooth. Avoid brushing horizontally in a back and forth movement to minimize chances of wearing the tooth and gums. It is preferable and less damaging for the gum to use a soft-bristled brush. In case of doubt, use a small brush head rather than one that is too big. Electric brushes can be used, but the same basic principles apply (access to plaque areas and brushing duration). Brushing pressure: studies have shown that the optimal brushing pressure is about 150 grams (5 oz) which is equivalent to the weight of an orange. Brushing with too much pressure can damage the gum and teeth. 2- Brushing duration that is too short In certain cases, the brushing technique is good, but the brushing duration is too short to “cover all” the dentition! Most experts agree that an adequate brushing session must last for at least 2 minutes. 3- Insufficient brushing frequency Someone may have a good brushing technique (as described previously), have an adequate brushing duration, but does not do it regularly enough. What is worse is if brushing is done irregularly using a bad technique and a duration that is too short. Brush your teeth after each meal and particularly before going to sleep. Ensure that you have a good technique and brush long enough and regularly to minimize the chances of having decalcification, dental caries and gum problems.

When you brush, clean each tooth surface, go around the brackets and brush behind the wires.

The little flexible interproximal toothbrushes allow you to reach between the orthodontic appliances components to remove plaque and food debris.

Aids like threaders allow the use of dental floss during your orthodontic treatment.

Severe dental wearing due to excessive brushing

Which toothbrush to use?

There are a multitude of toothbrushes on the market, each having their particular characteristics said by the manufacturers to be unique, efficient, revolutionary and justifying an important variation in the price range!

The “regular” (manual) brushes are available in a variety of sizes, lengths, shapes and ergonomic designs, with soft bristles, rigid bristles, grouped in tuft, etc. How can you get your bearings among all these products?

We believe that the most important factors to consider are the size of the brush head and how soft the bristles are.

• Choose a soft-bristled brush; this will minimize the chances of damaging the gum or the tooth enamel if your brushing technique is too “aggressive” (see illustration).
• The size of the brush head must allow you to reach easily every area of the mouth. It is thus easier to use a small brush than a bigger one.
• Adults can easily use for kids toothbrushes, but the opposite is not true.

If you wish to use a “mechanical” or “electric” brush, we recommend an ultrasonic brush like the Sonicare brush.

However, the brushing technique and the regularity in doing it are probably more important than the choice of the toothbrush per say.

Good oral hygiene

Examples of excellent dental hygiene

All these people have a practically impeccable hygiene and will not have inflammation, decalcification or caries problems during their orthodontic treatment. Everyone can end up with such a result with a good brushing technique.

Problems to avoid

Examples of hygiene problems to avoid…

Overlapping and misaligned teeth are harder to clean and facilitate accumulation of dental plaque and formation of tartar.

The presence of stains and accumulation of plaque on this dentition is a sign of bad oral hygiene and is a reason not to start an orthodontic treatment. To avoid caries and decalcification problems, hygiene must be impeccable when wearing orthodontic appliances.

Accumulation of dental plaque and food debris on teeth. The gums are inflamed in some areas and bleed easily. Dental hygiene must be significantly improved before starting an orthodontic treatment.

Smokers must be particularly careful with hygiene because nicotine even accumulates in areas where there are no braces or attachments and creates tough stains. Coffee, red wine and certain foods can also contribute to the formation of dark stains on teeth and appliances.

This 14-year-old girl’s dentition presents a lot of gingival redness (inflammation) around the anterior teeth. The brushing technique is deficient and will have to be improved before thinking about starting an orthodontic treatment.

➡ See other examples of unacceptable oral hygiene before starting an orthodontic treatment.

When there is a will… there is a way!

• During her first visit, this 15-year-old patient did not have good oral hygiene. We can see several stains and debris on the teeth near the gums. We told her that her hygiene had to be greatly improved before starting an orthodontic treatment.
• Improvement of her brushing technique and of her oral hygiene are also a good sign for us and her parents of her motivation to start a treatment that will necessitate continued cooperation.
• Although hygiene is not perfect, the significant improvement observed in a few weeks is sufficient to show the patient’s motivation and she can now start her treatment.

(A) Bad oral hygiene; stains and residues on the teeth and gingival inflammation (redness). (B) After only a few weeks, hygiene is significantly improved and the stains have almost all disappeared.

Consequences!

Examples of dental decalcification that appeared when hygiene was inadequate during an orthodontic treatment.

(A) Inadequate hygiene causes accumulation of plaque and food debris. This causes gingival inflammation (redness) and tooth decalcification (stains). (B) Examples of light decalcification affecting a few teeth. (C) Moderate decalcification on certain teeth.

(A) “Non existent” oral hygiene causing an important accumulation of plaque. (B) Moderate decalcification stains affecting a few teeth. (C) Moderate to severe decalcification stains affecting all the teeth. These problems can be avoided with a good brushing technique.

Example of damage to the teeth during an orthodontic treatment due to deficient oral hygiene. (C) Decalcification has progressed to the stage of carie (arrow).

Picture above:

• (A) Patient showing areas of decalcification before the treatment (arrows). Hygiene, without being perfect, is only average.
• (B) During the treatment, the situation worsens; hygiene (brushing) is problematic, plaque accumulates around the brackets and the gum becomes red and inflamed.
• (C) At the end of treatment, when the appliances are removed, several areas of severe decalcification are visible in both arches. An important carie is even visible on a lateral incisor (arrow). The gum is swollen and has an irregular outline (inflammation). Papillas have thickened. Several decalcification white stains affect several teeth.
• (D) The patient started repairing the caries on a few upper incisors. Several other teeth must also be repaired. Hygiene has now improved and the gum gets back to a more regular outline and a normal color. The papillas are less swollen.

(A) Although occlusion is good, this teenager’s dentition presents generalized decalcification stains. We can guess the shape of the brackets that were on the teeth and around which dental plaque was accumulating, causing these white stains. (B) Several teeth even have lesions that have evolved into caries and which will have to be repaired.

Damages to teeth necessitating several expensive repairs could have been avoided with an impeccable oral hygiene during the orthodontic treatment.

Visits to your dentist during the orthodontic treatment

Severe decalcifications can become dental caries or breaking of the tooth enamel (arrows).

➡To know more on dental caries and orthodontics.

• Not all stains on teeth are decalcifications. They can appear naturally or be the result of taking certain medication or products. See examples of dental fluorosis.

• Extreme enlargement of a tooth!

Although enamel is the hardest tissue in the human body and despite the fact that it looks very smooth, a microscopic evaluation reveals how the enamel surface can be porous and fragile. Look at this exceptional video that reveals the irregular enamel surface when enlarged thousands and millions of times.