Braces and tooth decay: What needs to be treated before getting braces?

Before braces are fitted, the health of the teeth and gums must be evaluated, and any active cavities must be treated, as orthodontic treatment can make oral hygiene more challenging and may worsen existing dental problems.

Diagnosis and treatment planning are carried out by a multidisciplinary team, including specialists in Orthodontics and Dentofacial Orthopedics, Periodontology, and Oral Surgery, based on a comprehensive set of imaging examinations (panoramic X-rays and CT scans) and clinical photographs.

For children and adolescents, a pediatric dentist is responsible for providing all necessary dental treatments before orthodontic treatment begins.

In short, what does the preparation for orthodontic treatment involve:

• professional cleaning and scaling;
• treatment of all carious lesions;
• endodontic treatment;
• extraction of irrecoverable teeth or root remnants;
• extraction of wisdom teeth, where necessary;
• extraction of supernumerary teeth or persistent deciduous teeth in the dental arch, in the case of children;
• treatment of periodontal conditions: gingival inflammation, gingival hyperplasia/hypertrophy, gingivitis, periodontal abscess;
• replacement of existing fillings or dental crowns showing damage or secondary caries;
• long-lasting temporary crowns for teeth that have undergone root canal treatment and are at increased risk of fracture.

No, regardless of the type of dental appliance, it is not recommended that it be fitted to teeth with caries at various stages.  

Before orthodontic treatment, active caries lesions/cavities and any other dental problems that may compromise the health of the teeth or the orthodontic treatment must be identified and managed.  

H3 Types of dental caries

“Early non-cavitary lesions may, in certain situations, be managed non-invasively and monitored. Not every white spot necessarily needs to be treated with a dental filling, nor do all fillings need to be replaced – if they have been correctly placed – simply because orthodontic treatment is due.” – Dr Valeria Nechita, specialist in Orthodontics and Dentofacial Orthopaedics.

If there is already an active cavity, the decay process continues in an environment where oral hygiene becomes more difficult. Furthermore, treating cavities whilst wearing braces, particularly fixed braces, can be more difficult.

Untreated caries can progress during orthodontic treatment

An early-stage, superficial cavity can develop into a carious lesion. Similarly, a non-carious lesion can become carious.  

This is because braces create more areas that are difficult to reach when cleaning, and tooth decay can progress more quickly.  

Fixed braces can make oral hygiene more difficult  

Wearing fixed braces requires extra attention to oral hygiene, as the brackets and orthodontic wires create areas where bacterial plaque and food debris can accumulate more easily.  

Another risk associated with poor oral hygiene is the appearance of white spots caused by enamel demineralisation, which are particularly visible around the brackets. To prevent these problems, thorough brushing, the use of interdental brushes and following your orthodontist’s advice on oral hygiene and regular check-ups are essential.

Dental problems can affect the course of orthodontic treatment  

A cavity that progresses towards the dental nerve causes pain, carries a risk of dental infection and may even lead to fracture when there is no longer sufficient healthy tooth structure to support the tooth.  

“Depending on the position of the tooth and the treatment required, the orthodontist may need to temporarily remove a bracket or a wire, or modify the treatment plan. These interventions prolong the duration of orthodontic treatment and also increase the cost of treatment.” – Dr Valeria Nechita. 

A consultation with an orthodontist is the first step towards orthodontic treatment. During the consultation, the orthodontist carries out a clinical examination of:

• Type of dentition: primary (milk teeth)/mixed (milk and permanent teeth)/permanent;
• The condition of the teeth: incipient/active/secondary caries;
• Periodontal health;
• Analysis of the occlusion (bite).

The standard investigations recommended for a definitive diagnosis and to draw up a treatment plan are as follows:

• Panoramic X-ray;
• Lateral cephalometric radiograph;
• Extraoral photographs;
• Intraoral photographs;
• Study model

Additional investigations, recommended depending on the patient’s clinical condition:

• Full bimaxillary CT scan;
• CT scan of the temporomandibular joint;
• 4D dynamic occlusion analysis – Modjaw

Gingivitis and periodontal disease  

Gingival inflammation must be controlled before starting orthodontic treatment because orthodontic tooth movement is achieved through the remodelling of the bone and periodontal ligament, and these tissues must be in a stable condition before orthodontic forces are applied.  

Otherwise, tooth movement in the presence of active inflammation may compromise periodontal stability, leading to bone and gingival recession.

Gingivitis is reversible, but persistent inflammation can progress to periodontitis, with destruction of the supporting tissues and the alveolar bone.  

“Orthodontic treatment can also be carried out on patients with periodontal disease. These patients require periodontal treatment prior to orthodontic treatment and appropriate maintenance therapy throughout the course of treatment.” – Dr Valeria Nechita.

Dental infections and problems requiring root canal treatment  

If orthodontic treatment is started whilst an active endodontic infection is present:

• The microbial source remains untreated, which may lead to the spread of apical inflammation (from the root tip) from the root canal to the periapical tissues (surrounding the root) and may result in bone destruction.
• The periapical lesion may persist or progress to a granuloma, cyst, abscess or bone destruction.
• In the case of an abscess, the situation may become urgent. A necrotic tooth (with a dead nerve), with an acute apical abscess, may present with pain, swelling and, in severe cases, the spread of infection.

To avoid such problems, any active endodontic focus or tooth with an unfavourable endodontic prognosis must be assessed and treated by an endodontist.  

Teeth requiring extraction  

The surgical stage, as part of preparing the oral cavity prior to the start of orthodontic treatment, involves the extraction of certain teeth:

• with a severe periodontal prognosis;
• with significant loss of attachment/alveolar bone (loose teeth);
• with persistent endodontic lesions and a poor endodontic prognosis;
• that are beyond restoration or have severe coronal/root destruction (root remnants);
• with severe root resorption;
• vertically fractured;
• with other pathologies that compromise the long-term prognosis.

Special cases requiring surgical intervention:

• Impacted canine: surgical exposure and guidance into the dental arch
• Supernumerary teeth: these prevent eruption or alignment, or cause other problems with the remaining teeth
• Ectopic teeth: extraction may be indicated if the tooth cannot be aligned or has a poor prognosis.
• Persistent deciduous teeth: these may require extraction to allow the permanent tooth to erupt.
• Wisdom teeth: These are not automatically extracted prior to orthodontic treatment. The indication depends on position, space, pathology, the relationship with the second molars and the orthodontic treatment plan.

Extraction for orthodontic purposes is an individualised orthodontic decision, based on facial and dental diagnosis, available space, facial profile, occlusion, periodontal status and the prognosis for each tooth. 

Yes, a professional dental clean is recommended prior to orthodontic treatment. The objectives are as follows:

• Control of bacterial plaque;
• Removal of dental calculus;
• Assessment of gum health;
• Achieving stable periodontal health;
• Providing personalised hygiene recommendations before treatment begins

No, braces do not directly ‘cause’ tooth decay, but they can contribute to its development. Fixed braces, in particular, increase the risk of tooth decay and demineralisation lesions if oral hygiene and sugar intake are not properly managed.  

Metal brackets, wires and ligatures:  

• create areas where bacterial plaque can accumulate;
• create areas that are difficult for a toothbrush to reach;
• make brushing more difficult;
• promote the build-up of bacterial plaque.

Orthodontic treatment will be completed without any tooth decay developing if the following recommendations are followed:

• brushing at least twice a day, ideally after every meal
• brush using a technique suitable for braces
• use of additional hygiene aids: mouthwash, interdental brushes, dental floss
• products with a high fluoride content (as recommended by your dentist) applied in the surgery or at home
• low intake and infrequent consumption of sugars (avoid sweetened juices, fresh fruit drinks, sweets and jellies)
• after consuming foods or drinks high in sugar, it is recommended to drink water or rinse your mouth with water
• regular dental check-ups
• professional dental cleaning at the intervals recommended by your dentist:  
• every 3 months – for patients at high risk of tooth decay, with poor oral hygiene or with pre-existing demineralisation lesions.
• every 4–5 months – patients at moderate risk of tooth decay, with satisfactory oral hygiene
• Every 6 months – patients at low risk of tooth decay, with adequate oral hygiene and no pre-existing demineralisation lesions. 

Collaboration between the orthodontist and the patient’s dentist is essential. If the orthodontist notices an early-stage lesion, they will advise the patient to book an appointment with their dentist.

Depending on the situation, the orthodontist may temporarily suspend the activation of the braces in that area, but it is not necessary to interrupt the entire treatment.

“Prevention is very important. Whilst wearing fixed braces, the risk of tooth decay and demineralisation increases due to plaque build-up around the brackets. It is important to brush thoroughly, use fluoride toothpaste and, where appropriate, additional fluoride products recommended by your dentist.” – Dr Valeria Nechita

The steps involved at DENT ESTET in the process of fitting braces are as follows:

• Orthodontic consultation and recommendation of necessary investigations;
• Orthodontic treatment plan and setting of treatment objectives;
• Determination of the necessary treatments prior to fitting the braces;
• Professional dental cleaning, consultation with a general dentist;
• Specialist consultations: periodontology, endodontics, surgery, depending on each clinical case;
• Digital planning and selection of the appropriate type of braces for each clinical case;
• Regular monitoring of orthodontic treatment, as well as of general dental health. 

1. “Oral hygiene tips during orthodontic treatment” – American Association of Orthodontists (AAO)
2. American Academy of Periodontology 
3. American Association of Endodontists (AAE)