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Every orthodontist and general dentist knows the sinking feeling of removing brackets after 18 months of complex treatment, only to reveal demineralized enamel and white spot lesions (WSLs). It is the ultimate anti-climax: straight teeth, but compromised enamel.
For decades, we have handed our patients a standard “ortho kit” and told them to brush diligently. But is that actually enough?
A new 2025 Randomized Clinical Trial published in the Journal of EvidenceBased Dental Practice challenges the efficacy of our standard instructions. It suggests that asking patients to rely on manual brushing alone—even with fluoride toothpaste—is a losing battle against Streptococcus mutans.
To truly protect enamel during fixed appliance therapy, we need to shift our protocol from “maintenance” to “active reduction.” This is where Chlorhexidine (CHX) becomes non-negotiable.
The study set out to answer a simple but critical question: Which oral hygiene protocol actually controls bacterial colonization in adult orthodontic patients?
Researchers tracked 27 patients with fixed appliances, dividing them into three distinct hygiene protocols to measure the viable counts of S. mutans (theprimary culprit for caries and WSLs) before bonding and one month after.
The results revealed a stark “hierarchy of hygiene” that every clinician should consider when prescribing home care regimens:
Based on this evidence, our preventive strategy for orthodontic patients needs an update. We can no longer view mouthwashes as “optional extras.”
1. Abandon “Brushing Only” Advice
The data is clear: manual brushing alone is the least effective protocol. It does not just fail to improve hygiene; it allows bacterial counts to rise significantly post-bonding.
2. Prescribe Mechanical Access
Interdental brushes are essential, not optional. They are the baseline requirement to simply “hold the line” and prevent bacterial overgrowth.
3. The Chlorhexidine Advantage
To actually lower the caries risk and reduce the S. mutans load below baseline levels, chemical control is required. The addition of Chlorhexidine transforms the home care regimen from a defensive struggle into an effective offensive strategy against biofilm.
Fixed appliances change the ecology of the mouth. Your hygiene protocol must change to match it.
If your goal is merely to hold steady, interdental aids are sufficient. But if you want to actively reduce the cariogenic burden and ensure your patients finish treatment with healthy, intact enamel, the data supports a triple-threat approach: Brush + Interdental Clean + Chlorhexidine.
Elbanna MA, Elbanna SA, Abdelsayed F, Abd-El-Ghafour M. WHICH ORAL HYGIENE PROTOCOL SHOULD BE FOLLOWED BY PATIENTS WITH FIXED ORTHODONTIC APPLIANCES? A RANDOMIZED CLINICAL TRIAL. J Evid Based Dent Pract. 2025 Dec;25(4):102192.
