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Improving oral hygiene in fixed appliance patients

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  Posted by: The Probe      21st October 2021

In recent times, there has been a significant increase in the volume of patients embarking on orthodontic treatment later in life, with the British Orthodontic Society reporting that 84% of orthodontists have noted an increase in adult patients. [i] This trajectory highlights the growing importance for clinicians to understand and be mindful of the challenges associated with these treatments, such as oral hygiene, which they can share with their patients to ensure a safe and successful outcome.

In this article, we provide a reminder of the risks to oral hygiene for fixed appliance wearers, the clinical considerations, how patients can take steps to improve their homecare, and what tools could support them in doing so.

The impact on oral hygiene in fixed appliance patients

Treatment with fixed appliances causes the patient to be reliant on a rigorous routine to sufficiently clean around both the brackets and fixed archwires. Therefore, fixed appliances have been shown to present increased plaque accumulation, particularly around the brackets and hard to clean areas. [ii]

The composition of the oral microbiota is unique to each individual, though it is also influenced by a number of factors, including orthodontic appliances. [iii] Dysbiosis of the microbiota can be linked with caries, white spot lesions, and areas of demineralisation due to an increase in cariogenic bacteria such as Streptococcus mutansand Lactobacillus concentrating around the orthodontic brackets. [iv] This is particularly common in people with poor oral hygiene. [v]

Additionally, it has been demonstrated that biofilm accumulates on the bonded resin or orthodontic brackets more so than on the enamel surface, leading to more acidic by-products that cause enamel demineralisation and formation of white spot lesions. iv A study by Sundararaj, et al. (2015) concluded that a notable 68.4% of orthodontic patients developed varying degrees of white spot lesions.

The aetiology of periodontal disease is multifaceted and includes poor plaque control as a contributing factor. A change in the periodontopathic bacteria also presents a risk for increased gingival inflammation and periodontal disease. [vi] Increased plaque accumulation is often noted due to the challenges of cleaning around fixed orthodontic appliances. This also leads to increased gingival inflammation and can result in a change in the composition of the oral microbiota and in the physiology of the patient.

Steps to improve oral hygiene in fixed appliance patients 

As illustrated by the oral health issues outlined, close consideration should be given to the potential challenges of conducting effective oral hygiene and the retention of plaque in fixed appliance patients.

The application of fluoride varnish by the clinician can help to prevent demineralisation and – regardless of changes in the number of cariogenic bacteria – could be considered best practice. [vii] However, this is only carried out by 8.3% of clinicians. [viii]  

Oral hygiene instructions should be viewed as an imperative step and be reiterated during each appointment to ensure oral health is maintained by the patient. [ix] It can be useful to mention the wide range of products available to patients that can support them in looking after their oral hygiene at home. For example, the use of an oscillating rotating electric toothbrush has been shown to reduce plaque accumulation around fixed appliances, [x] especially when accompanied with a fluoride toothpaste. viii

The Waterpik® Water Flosser coupled with the Waterpik® Orthodontic Tip can further support orthodontic in protecting their oral health at home. Clinically proven to remove up to three times as much plaque as dental floss,[xi] the Orthodontic Tip is specially designed to improve gum health for orthodontic patients. The innovative tapered head allows water to flow gently, effectively removing plaque from around orthodontic brackets and wires. The device also helps to flush out the bacteria and food debris from around teeth and below the gumline, ensuring a healthy mouth.It should be noted that some suggest patients who are deemed at risk of periodontal disease may consider treatment with clear orthodontic aligners, rather than fixed appliances, to support oral hygiene. [xii] It is always important to acknowledge that some results are better achieved with the use of fixed appliances. [xiii] Further high-quality research comparing the composition of the oral microbiota in individuals wearing fixed appliances or clear orthodontic aligners would to beneficial to achieve definitive guidance for clinicians.

Working together

Maintaining a healthy oral status for orthodontic patients requires a collaborative relationship between patient and dental team. By working together – with the dentist, dental hygienist or therapist advising on good practises and the patient committing to incorporating good behaviours into their daily lives – there is no doubt that a high level of oral hygiene can be achieved and maintained.

Dental hygienist and therapist Michayla Morris, graduated from the University of Sheffield in 2010. Alongside working full time as a dental hygiene/therapist in central London, she also works for waterpik as a professional educator. She has recently completed a BSc in Dental studies at the University of Central Lancashire and is due to start a MSc in Global health and development later in the year. 


For more information on Waterpik® Water Flosser products visit Waterpik® products are available from Amazon, Costco UK, Argos, Boots, Superdrug and Tesco online and in stores across the UK and Ireland.


Join the 3,000+ dental teams who have already benefitted from a professional Waterpik® Lunch & Learn. Book your free session for 1 hour of verifiable CPD and a free Waterpik® Water Flosser – available either face to face or as a webinar – at 


[i] British Orthodontic Society. ‘The Zoom Boom’ BOS stats reveal a surge in demand for orthodontics during the pandemic’. Available at: [Last accessed 21.07.2021].

[ii] Mei, L. 2017. Factors affecting dental biofilm in patients wearing fixed orthodontic appliances. . 18(1), p.4. Available at: [Last accessed 21.07.2021].

[iii] Hall, M.W., Singh, N., Ng, K.F., Lam, D.K., Goldberg, M.B., Tenenbaum, H.C., Neufeld, J.D., Beiko, R.G. and Senadheera, D.B. 2017. Inter-personal diversity and temporal dynamics of dental, tongue, and salivary microbiota in the healthy oral cavity. . 3, pp.1–7. Available from: [Last accessed 21.07.2021].

[iv] Srivastava, K., Tikku, T., Khanna, R. and Sachan, K. 2013. Risk factors and management of white spot lesions in orthodontics. . 2(2), pp.43–49.

[v] Justus, R. 2018. Prevention of white spot lesions during orthodontic treatment. . 2(1), pp.1–10 ; Khoroushi, M. and Kachuie, M. 2017. Prevention and treatment of white spot lesions in orthodontic patients. . 8(1), p.11-19.

[vi] Madariaga, A.C.P., Bucci, R., Rongo, R., Simeon, V., D’Antò, V. and Valletta, R. 2020. Impact of Fixed Orthodontic Appliance and Clear Aligners on the Periodontal Health: A Prospective Clinical Study. . 8(1), p.4.

[vii] Chakraborty, S., Kidiyoor, H. and Patil, A.K. 2020. Effect of Light-Curable Fluoride Varnish and Conventional Topical Fluoride Varnish on Prevention of Enamel Demineralization Adjacent to Orthodontic Brackets: A Comparative Study. . 54(1), pp.14–23. Available at: [Last accessed 21.07.2021].

[viii] Eslamipour, F., Shahmoradi, M. and Farhadi, V. 2017. Assessment of Iranian orthodontists’ practice with regard to the prevention and treatment of white spot lesions. . 6. Available at: [Last accessed 21.07.2021].

[ix] Bergamo, A.Z.N., Holanda, de O., Katharina,Morant, Matsumoto, M.A.N., do Nascimento, C., Romano, F.L., Bezerra, da S., Raquel,Assed, Bezerra, da S., Lea,Assed and Nelson-Filho, P. 2019. Orthodontic appliances did not increase risk of dental caries and periodontal disease under preventive protocol. . 89(1), pp.25–32.

[x] Shukla, C., Maurya, R., Singh, V. and Tijare, M. 2017a. Evaluation of role of fixed orthodontics in changing oral ecological flora of opportunistic microbes in children and adolescent. . 35(1), pp.34–40.

[xi] Waterpik. Waterpik® Orthodontic Tip. Available at: [Last accessed 14.07.2021].

[xii] Jiang, Q., Li, J., Mei, L., Du, J., Levrini, L., Abbate, G.M. and Li, H. 2018. Periodontal health during orthodontic treatment with clear aligners and fixed appliances: A meta-analysis. . 149(8), pp.712-720. e12.

[xiii] Ke, Y., Zhu, Y. and Zhu, M. 2019. A comparison of treatment effectiveness between clear aligner and fixed appliance therapies. . 19(1), p.24.

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