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Associated Topics

Inconclusive evidence on decalcification associated with use of fluoride-containing orthodontic adhesives

Priyanshi Ritwik BDS, MS .


Systematic Review Conclusion

There is conflicting evidence on decalcification adjacent to orthodontic brackets, with 1 study showing decreased decalcification around glass ionomer cement (GIC) adhesives, while 2 studies showing no difference; however, the bracket debond rate also was higher with GIC adhesives.

Critical Summary Assessment

Although there is conflicting evidence that GIC adhesives may prevented decalcification, whereas other fluoride-containing adhesives did not, the decision of which type of orthodontic adhesive to use should take into account the higher bracket debond rate associated GIC.

Evidence Quality Rating

Poor Evidence

Structured Abstract

Clinical Questions:

Does the use of fluoride containing-orthodontic adhesives reduce decalcification in patients receiving fixed orthodontic treatment?

Review Methods:

The authors searched five databases and gray literature published in all languages up to October 2008. They included studies that compared decalcification around fluoride containing orthodontic adhesives with conventional orthodontic adhesives. They included randomized controlled trials, clinical trials and prospective observational studies with concurrent or historical controls. The review was restricted to clinical studies which were comprised of patients who completed fixed orthodontic treatment and the outcome measure was decalcification.

Main Results:

From a total of 317 records, 10 studies were included in this review, five of which were randomized controlled trials and five were clinical trials. The 10 included studies utilized different methodologies, reporting strategies and different orthodontic adhesives. All of the studies used a split-mouth design to compare the fluoride containing adhesive with the conventional adhesive. Among the 10 studies, there were seven different indices used to measure decalcification. Three studies measured decalcification by direct visualization and seven used photography. Seven studies measured decalcification as the number of affected teeth three documented the number of patients. Due to the wide variation in materials used and methodologies employed, the authors of this systematic review performed a qualitative analysis rather than a meta analysis. Only three studies reported a statistically significant difference in decalcification between experimental and control adhesives, two of which compared GIC adhesives with controls. In the GIC group, 119 test teeth versus 134 control teeth had decalcification at the end point. In the fluoride containing composite group, 104 test teeth had decalcification at the end point versus 159 control teeth. The authors found a higher bracket debond rate in two studies comparing GIC adhesives with composite adhesives. The percentage of teeth exhibiting debonding in the GIC group was 17.5 percent versus 3.4 percent in the fluoride containing composite group.


Due to the heterogeneity of the included studies, clinical recommendations cannot be made. A qualitative analysis showed two trials with GIC adhesives to result in lower decalcification, although they also are associated with a higher bracket debond rate. Statistical analysis has not been performed to indicate whether any fluoride-containing adhesive prevents decalcification around orthodontic brackets.

Source of Funding:

None stated


Importance and Context:

Orthodontic treatment is usually an elective and cosmetic procedure which carries with it the inherent risk of decalcification or white spots around the bands and brackets. These unaesthetic and precarious white lesions are iatrogenic lesions and therefore any means available to reduce their incidence is of interest in clinical practice. Fluoride is commonly used in dental care for its caries preventive effect. It is of interest to assess if fluoride incorporated in orthodontic adhesives can prevent decalcification around orthodontic brackets.

Strengths and Weaknesses of the Systematic Review:

The authors reviewed five databases and gray literature and did not limit their search by language. They used specific predefined inclusion and exclusion criteria to select the studies for this systematic review. They used decalcification measured at baseline versus at the end of orthodontic treatment as the primary outcome, but also documented influential factors such as exposure to fluoridated water, oral hygiene, caries status, socioeconomic status and bracket debond rates. All data was documented in a pre-designed data extraction sheet. Review of articles and data extraction was performed by 2 authors. They resolved any disagreement by discussion and by consulting a third author, if necessary.

Strengths and Weaknesses of the Evidence:

Although all 10 included studies used a split-mouth design, there was a wide variation in their methodology. They used different indices and visualization methods to measure decalcification. Each of the 10 studies used a different test orthodontic adhesive. Due to variability of data and heterogeneity of used dental adhesives, the authors chose not to perform a meta-analysis; instead they performed a qualitative assessment of the data. The results showed that one fluoride-containing adhesive (Flur Ever) demonstrated significantly less decalcification than a non-fluoride containing composite adhesive (Aurafill). Two studies evaluating GIC orthodontic adhesives (Aquachem and Fuji Ortho LC) also showed significantly less decalcification. There were no differences in the bracket debond rates of compomers and fluoride containing composite adhesives compared to non-fluoride-containing composite adhesives. However, two studies showed GIC adhesives (Ketac Cem and Fuji Ortho) had higher bracket debond rates than composite adhesives.

Implications for Dental Practice:

There is poor evidence to support that any one fluoride-containing orthodontic adhesive prevents decalcification when compared to non-fluoride containing orthodontic adhesive. Although two studies showed that GIC adhesives prevented decalcification, one study did not show this effect. Further, the decision to use them in clinical practice also should take into account the higher bracket debond rate associated with their use.

Critical Summary Publication Date:


These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association © 2019