Clinical Oral Investigations

, Volume 18, Issue 7, pp 1711–1718 | Cite as

Orthodontic treatment with fixed appliances and biofilm formation—a potential public health threat?

  • Yijin RenEmail author
  • Marije A. Jongsma
  • Li Mei
  • Henny C. van der Mei
  • Henk J. Busscher



Orthodontic treatment is highly popular for restoring functional and facial esthetics in juveniles and adults. As a downside, prevalence of biofilm-related complications is high. Objectives of this review are to (1) identify special features of biofilm formation in orthodontic patients and (2) emphasize the need for strong concerted action to prevent biofilm-related complications during orthodontic treatment.

Materials and methods

Literature on biofilm formation in the oral cavity is reviewed to identify special features of biofilm formation in orthodontic patients. Estimates are made of juvenile and adult orthodontic patient population sizes, and biofilm-related complication rates are used to indicate the costs and clinical workload resulting from biofilm-related complications.


Biofilm formation in orthodontic patients is governed by similar mechanisms as common in the oral cavity. However, orthodontic appliances hamper the maintenance of oral hygiene and provide numerous additional surfaces, with properties alien to the oral cavity, to which bacteria can adhere and form a biofilm. Biofilm formation may lead to gingivitis and white spot lesions, compromising facial esthetics. Whereas gingivitis after orthodontic treatment is often transient, white spot lesions may turn into cavities requiring professional restoration. Complications requiring professional care develop in 15 % of all orthodontic patients, implying an annual cost of over US$500,000,000 and a workload of 1,000 full-time dentists in the USA alone.


Improved preventive measures and antimicrobial materials are urgently required to prevent biofilm-related complications of orthodontic treatment from overshadowing its functional and esthetic advantages.

Clinical relevance

High treatment demand and occurrence of biofilm-related complications requiring professional care make orthodontic treatment a potential public health threat.


Public health Orthodontics Biofilm White spot lesions 



This study has been supported by the Departments of Orthodontics and BioMedical Engineering, University Medical Centre Groningen, University of Groningen, the Netherlands.

Conflict of Interest

H.J. Busscher is also director of a consulting company, SASA BV (GN Schutterlaan 4, 9797 PC Thesinge, The Netherlands). The authors declare no potential conflicts of interest with respect to authorship and/or publication of this article. Opinions and assertions contained herein are those of the authors and are not construed as necessarily representing views of the funding organizations or their respective employers.


  1. 1.
    American Association of Orthodontists (2012) AAO patient census surveys 1989-2010. Bull Am Assoc OrthodGoogle Scholar
  2. 2.
    U.S. Government Printing Office. Washington, DC (2011) America’s children: key national indicators of well-being. Federal Interagency Forum on Child and Family StatisticsGoogle Scholar
  3. 3.
    Christopherson EA, Briskie D, Inglehart MR (2009) Objective, subjective, and self-assessment of preadolescent orthodontic treatment need? A function of age, gender, and ethnic/racial background? J Public Health Dent 69:9–17PubMedCrossRefGoogle Scholar
  4. 4.
    Van der Weijden GA, Echeverria JJ, Sanz M, Lindhe J (2008) Mechanical supragingival plaque control. In: Lindhe J, Lang NP, Karring T (eds) Clinical Periodontology and Implant Dentistry, 5th edn. Blackwell Munskgaard, Copenhagen, pp 705–733Google Scholar
  5. 5.
    Marsh PD (2010) Microbiology of dental plaque biofilms and their role in oral health and caries. Dent Clin North Am 54:441–454PubMedCrossRefGoogle Scholar
  6. 6.
    Flemming HC, Wingender J (2010) The biofilm matrix. Nat Rev Microbiol 8:623–633PubMedGoogle Scholar
  7. 7.
    Filoche S, Wong L, Sissons CH (2010) Oral biofilms: emerging concepts in microbial ecology. J Dent Res 89:8–18PubMedCrossRefGoogle Scholar
  8. 8.
    Subramani K, Jung RE, Molenberg A, Hammerle CH (2009) Biofilm on dental implants: a review of the literature. Int J Oral Maxillofac Implants 24:616–626PubMedGoogle Scholar
  9. 9.
    Al Mulla AH, Kharsa SA, Kjellberg H, Birkhed D (2009) Caries risk profiles in orthodontic patients at follow-up using Cariogram. Angle Orthod 79:323–330PubMedCrossRefGoogle Scholar
  10. 10.
    Liu Y, Zhang Y, Wang L, Guo Y, Xiao S (2013) Prevalence of Porphyromonas gingivalis four rag locus genotypes in patients of orthodontic gingivitis and periodontitis. PLoS One 8:e61028PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Øgaard B (2008) White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. Semin Orthod 14:183–193CrossRefGoogle Scholar
  12. 12.
    Demling A, Heuer W, Elter C, Heidenblut T, Bach F, Schwestka-Polly R, Stiesch-Scholz M (2009) Analysis of supra- and subgingival long-term biofilm formation on orthodontic bands. Eur J Orthod 31:202–206PubMedCrossRefGoogle Scholar
  13. 13.
    Sukontapatipark W, El‐Agroudi MA, Selliseth NJ, Thunold K, Selvig KA (2001) Bacterial colonization associated with fixed orthodontic appliances. A scanning electron microscopy study. Eur J Orthod 23:475–484PubMedCrossRefGoogle Scholar
  14. 14.
    Mei L, Busscher HJ, Van der Mei HC, Chen Y, De Vries J, Ren Y (2009) Oral bacterial adhesion forces to biomaterial surfaces constituting the bracket-adhesive-enamel junction in orthodontic treatment. Eur J Oral Sci 117:419–426PubMedCrossRefGoogle Scholar
  15. 15.
    Ahn SJ, Lee SJ, Lim BS, Nahm DS (2007) Quantitative determination of adhesion patterns of cariogenic streptococci to various orthodontic brackets. Am J Orthod Dentofac Orthop 132:815–821CrossRefGoogle Scholar
  16. 16.
    Van der Veen MH, Attin R, Schwestka-Polly R, Wiechmann D (2010) Caries outcomes after orthodontic treatment with fixed appliances: do lingual brackets make a difference? Eur J Oral Sci 118:298–303PubMedCrossRefGoogle Scholar
  17. 17.
    Van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C (2007) Influence of bracket design on microbial and periodontal parameters in vivo. J Clin Periodontol 34:423–431PubMedCrossRefGoogle Scholar
  18. 18.
    Pandis N, Vlachopoulos K, Polychronopoulou A, Madianos P, Eliades T (2008) Periodontal condition of the mandibular anterior dentition in patients with conventional and self-ligating brackets. Orthod Craniof Res 11:211–215CrossRefGoogle Scholar
  19. 19.
    Pellegrini P, Sauerwein R, Finlayson T, McLeod J, Covell DA Jr, Maier T, Machida CA (2009) Editor’s summary, Q & A, reviewer’s critique: plaque retention by self-ligating vs elastomeric orthodontic brackets: quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven bioluminescence. Am J Orthod Dentofac Orthop 135:426–427CrossRefGoogle Scholar
  20. 20.
    Batoni G, Pardini M, Giannotti A, Ota F, Rita Giuca M, Gabriele M, Campa M, Senesi S (2001) Effect of removable orthodontic appliances on oral colonisation by mutans streptococci in children. Eur J Oral Sci 109:388–392PubMedCrossRefGoogle Scholar
  21. 21.
    Levin L, Samorodnitzky-Naveh GR, Machtei EE (2008) The association of orthodontic treatment and fixed retainers with gingival health. J Periodontol 79:2087–2092PubMedCrossRefGoogle Scholar
  22. 22.
    Jongsma MA, Pelser FD, Van der Mei HC, Atema-Smit J, Van de Belt-Gritter B, Busscher HJ, Ren Y (2013) Biofilm formation on stainless steel and gold wires for bonded retainers in vitro and in vivo and their susceptibility to oral antimicrobials. Clin Oral Investig 17:1209–1218PubMedCrossRefGoogle Scholar
  23. 23.
    Cochrane NJ, Cai F, Huq NL, Burrow MF, Reynolds EC (2010) New approaches to enhanced remineralization of tooth enamel. J Dent Res 89:1187–1197PubMedCrossRefGoogle Scholar
  24. 24.
    Murphy TC, Willmot DR, Rodd HD (2007) Management of postorthodontic demineralized white lesions with microabrasion: a quantitative assessment. Am J Orthod Dentofac Orthop 131:27–33CrossRefGoogle Scholar
  25. 25.
    Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T (2003) Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod Dentofac Orthop 124:373–378CrossRefGoogle Scholar
  26. 26.
    Kravitz ND, Kusnoto B (2007) Risks and complications of orthodontic miniscrews. Am J Orthod Dentofac Orthop 131:S43–S51CrossRefGoogle Scholar
  27. 27.
    Erverdi N, Biren S, Kadir T, Acar A (2000) Investigation of bacteremia following orthodontic debanding. Angle Orthod 70:11–14PubMedGoogle Scholar
  28. 28.
    Gürel HG, Basciftci FA, Arslan U (2009) Transient bacteremia after removal of a bonded maxillary expansion appliance. Am J Orthod Dentofac Orthop 135:190–193CrossRefGoogle Scholar
  29. 29.
    Beyth N, Bahir R, Matalon S, Domb AJ, Weiss EI (2008) Streptococcus mutans biofilm changes surface-topography of resin composites. Dent Mater 24:732–736PubMedCrossRefGoogle Scholar
  30. 30.
    Busscher HJ, Rinastiti M, Siswomihardjo W, Van der Mei HC (2010) Biofilm formation on dental restorative and implant materials. J Dent Res 89:657–665PubMedCrossRefGoogle Scholar
  31. 31.
    Eliades T, Bourauel C (2005) Intraoral aging of orthodontic materials: the picture we miss and its clinical relevance. Am J Orthod Dentofac Orthop 127:403–412CrossRefGoogle Scholar
  32. 32.
    Ogaard B (1989) Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofac Orthop 96:423–427CrossRefGoogle Scholar
  33. 33.
    Enaia M, Bock N, Ruf S (2011) White-spot lesions during multibracket appliance treatment: a challenge for clinical excellence. Am J Orthod Dentofac Orthop 140:e17–e24CrossRefGoogle Scholar
  34. 34.
    Hadler-Olsen S, Sandvik K, El-Agroudi MA, Ogaard B (2012) The incidence of caries and white spot lesions in orthodontically treated adolescents with a comprehensive caries prophylactic regimen—a prospective study. Eur J Orthod 34:633–639PubMedCrossRefGoogle Scholar
  35. 35.
    Bollen A, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP (2008) The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence. J Am Dent Assoc 139:413–422PubMedCrossRefGoogle Scholar
  36. 36.
    Renkema AA, Dusseldorp JK, Middel B, Ren Y (2010) Enlargement of the gingiva during treatment with fixed orthodontic appliances. Ned Tijdschr Tandheelkd 117:507–512PubMedCrossRefGoogle Scholar
  37. 37.
    Tariefbeschikking Tandheelkundige zorg. Nederlandse Zorg Autoriteit.
  38. 38.
    Rafe Z, Vardimon A, Ashkenazi M (2006) Comparative study of 3 types of toothbrushes in patients with fixed orthodontic appliances. Am J Orthod Dentofac Orthop 130:92–95CrossRefGoogle Scholar
  39. 39.
    Schätzle M, Sener B, Schmidlin PR, Imfeld T, Attin T (2010) In vitro tooth cleaning efficacy of electric toothbrushes around brackets. Eur J Orthod 32:481–489PubMedCrossRefGoogle Scholar
  40. 40.
    Schmidt JC, Zaugg C, Weiger R, Walter C (2013) Brushing without brushing?—a review of the efficacy of powered toothbrushes in noncontact biofilm removal. Clin Oral Investig 17:687–709PubMedCrossRefGoogle Scholar
  41. 41.
    Busscher HJ, Jager D, Finger G, Schaefer N, Van der Mei HC (2010) Energy transfer, volumetric expansion, and removal of oral biofilms by non-contact brushing. Eur J Oral Sci 118:177–182PubMedCrossRefGoogle Scholar
  42. 42.
    Sari E, Birinci I (2007) Microbiological evaluation of 0.2 % chlorhexidine gluconate mouth rinse in orthodontic patients. Angle Orthod 77:881–884PubMedCrossRefGoogle Scholar
  43. 43.
    Wiegand A, Bichsel D, Magalhães AC, Becker K, Attin T (2009) Effect of sodium, amine and stannous fluoride at the same concentration and different pH on in vitro erosion. J Dent 37:591–595PubMedCrossRefGoogle Scholar
  44. 44.
    Noel L, Rebellato J, Sheats RD (2003) The effect of argon laser irradiation on demineralization resistance of human enamel adjacent to orthodontic brackets: an in vitro study. Angle Orthod 73:249–258PubMedGoogle Scholar
  45. 45.
    Otten MP, Busscher HJ, Van der Mei HC, Abbas F, Van Hoogmoed CG (2010) Retention of antimicrobial activity in plaque and saliva following mouthrinse use in vivo. Caries Res 44:459–464PubMedCrossRefGoogle Scholar
  46. 46.
    Chin MYH, Sandham A, Rumachik EN, Ruben JL, Huysmans MDNJM (2009) Fluoride release and cariostatic potential of orthodontic adhesives with and without daily fluoride rinsing. Am J Orthod Dentofac Orthop 136:547–553CrossRefGoogle Scholar
  47. 47.
    Lee S, Kim H, Kong Y, Kim H, Lee S, Chang Y (2005) Fluoride coatings on orthodontic wire for controlled release of fluorine ion. J Biomed Mater Res B Appl Biomater 75B:200–204CrossRefGoogle Scholar
  48. 48.
    Banks P, Chadwick S, Asher-McDade C, Wright J (2000) Fluoride-releasing elastomerics—a prospective controlled clinical trial. Eur J Orthod 22:401–407PubMedCrossRefGoogle Scholar
  49. 49.
    Benson PE, Douglas CWI, Martin MV (2004) Fluoridated elastomers: effect on the microbiology of plaque. Am J Orthod Dentofac Orthop 126:325–330CrossRefGoogle Scholar
  50. 50.
    Sehgal V, Shetty VS, Mogra S, Bhat G, Eipe M, Jacob S, Prabu L (2007) Evaluation of antimicrobial and physical properties of orthodontic composite resin modified by addition of antimicrobial agents—an in vitro study. Am J Orthod Dentofac Orthop 131:525–529CrossRefGoogle Scholar
  51. 51.
    Mei L, Ren Y, Loontjens TJ, Van der Mei HC, Busscher HJ (2012) Contact-killing of adhering streptococci by a quaternary ammonium compound incorporated in an acrylic resin. Int J Artif Organs 35:854–863PubMedGoogle Scholar
  52. 52.
    Demling A, Elter C, Heidenblut T, Bach F, Hahn A, Schwestka-Polly R, Stiesch M, Heuer W (2010) Reduction of biofilm on orthodontic brackets with the use of a polytetrafluoroethylene coating. Eur J Orthod 32:414–418PubMedCrossRefGoogle Scholar
  53. 53.
    Roosjen A, De Vries J, Van der Mei HC, Norde W, Busscher HJ (2005) Stability and effectiveness against bacterial adhesion of poly (ethylene oxide) coatings in biological fluids. J Biomed Mater Res B Appl Biomater 73B:347–354CrossRefGoogle Scholar
  54. 54.
    Chun MJ, Shim E, Kho EH, Park KJ, Jung J, Kim JM, Kim B, Lee KH, Cho DL, Bai DH, Lee SI, Hwang HS, Ohk SH (2007) Surface modification of orthodontic wires with photocatalytic titanium oxide for its antiadherent and antibacterial properties. Angle Orthod 77:483–488PubMedCrossRefGoogle Scholar
  55. 55.
    Tiller JC, Liao C, Lewis K, Klibanov AM (2001) Designing surfaces that kill bacteria on contact. Proc Natl Acad Sci 98:5981–5985PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    Beyth N, Yudovin-Farber I, Perez-Davidi M, Domb AJ, Weiss EI (2010) Polyethyleneimine nanoparticles incorporated into resin composite cause cell death and trigger biofilm stress in vivo. Proc Natl Acad Sci 107:22038–22043PubMedCentralPubMedCrossRefGoogle Scholar
  57. 57.
    Gorelick L, Geiger AM, Gwinnett AJ (1982) Incidence of white spot formation after bonding and banding. Am J Orthod 81:93–98PubMedCrossRefGoogle Scholar
  58. 58.
    Mizrahi E (1982) Enamel demineralization following orthodontic treatment. Am J Orthod 82:62–67PubMedCrossRefGoogle Scholar
  59. 59.
    Årtun J, Brobakken BO (1986) Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod 8:229–234PubMedCrossRefGoogle Scholar
  60. 60.
    Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG (1988) The effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod Dentofac Orthop 93:29–37CrossRefGoogle Scholar
  61. 61.
    Boersma JG, Van der Veen MH, Lagerweij MD, Bokhout B, Prahl-Andersen B (2005) Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors. Caries Res 39:41–47PubMedCrossRefGoogle Scholar
  62. 62.
    Lovrov S, Hertrich K, Hirschfelder U (2007) Enamel demineralization during fixed orthodontic treatment—incidence and correlation to various oral-hygiene parameters. J Orofac Orthop 68:353–363PubMedCrossRefGoogle Scholar
  63. 63.
    Chapman JA, Roberts WE, Eckert GJ, Kula KS, González-Cabezas C (2010) Risk factors for incidence and severity of white spot lesions during treatment with fixed orthodontic appliances. Am J Orthod Dentofac Orthop 138:188–194CrossRefGoogle Scholar
  64. 64.
    Tufekci E, Dixon JS, Gunsolley JC, Lindauer SJ (2011) Prevalence of white spot lesions during orthodontic treatment with fixed appliances. Angle Orthod 81:206–210PubMedCrossRefGoogle Scholar
  65. 65.
    Lucchese A, Gherlone E (2012) Prevalence of white spot lesions before and during orthodontic treatment with fixed appliances. Eur J Orthod. doi: 10.1093/ejo/cjs070 PubMedGoogle Scholar
  66. 66.
    Julien KC, Buschang PH, Campbell PM (2013) Prevalence of white spot lesion formation during orthodontic treatment. Angle Orthod 83:641–647PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Yijin Ren
    • 1
    Email author
  • Marije A. Jongsma
    • 1
  • Li Mei
    • 2
  • Henny C. van der Mei
    • 2
  • Henk J. Busscher
    • 2
  1. 1.Department of OrthodonticsUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
  2. 2.Department of Biomedical EngineeringUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands

Personalised recommendations