Brushing with braces: the spots children miss

Quick answer: With fixed braces, plaque gets left behind in three places: around the brackets, under the wire and along the gumline. A normal brushing motion does not reach those places. First pass an interdental brush under the wire, then brush for two minutes along each bracket, from above and from below. Twice a day.

There is a moment that comes back in almost every family with braces. Quarter past nine, your child is already at the stairs, and you ask whether they have really brushed. Yes, of course. And you are not sure.

Clashing over this does not mean you are too strict. Brushing with fixed braces genuinely has become harder, and most children do not brush badly because they do not want to, but because they use the wrong motion. Below you can read where the plaque stays behind and what an evening brushing routine that actually works looks like.

Fixed braces consist of brackets bonded onto the teeth, with a springy wire running through them. For a toothbrush, the smooth surface of the tooth suddenly becomes an obstacle course.

Dental plaque is the soft, whitish layer of bacteria that forms again every day. Plaque prefers to stick where a brush does not reach and nothing rubs past. Braces add exactly those kinds of places: the edge around each bracket, the space under the wire, and the narrow strip between the bracket and the gum.

A normal, horizontal brushing motion glides over the brackets. The front of the bracket shines, the edges around it do not, and to your child that feels like the job is done. Let them feel it for themselves: run the tongue over the tooth just above a bracket. That rough layer is the plaque.

In the practice we keep seeing the same four spots:

1. The edge above and below each bracket. Especially the top edge, against the gum. The brush needs to go there at an angle, not straight over it.
2. Under the wire. A normal brush cannot get here. This is the territory of the interdental brush.
3. The back molars and the bands around them. Far back, hard to see, quickly rushed.
4. The inside, on the tongue side. It gets skipped because you cannot see any of it.

A simple habit helps here: let your child start on a different side each time. Whatever comes last often gets the least attention.

The Dutch advice on preventing tooth decay names children with braces separately as a group to keep an eye on. Two things go wrong, at different speeds.

Inflamed gums, within days to weeks. If plaque stays along the gumline, the gums become irritated: red, slightly swollen, and they start to bleed when brushing. There is a trap in this, because many children avoid that very spot precisely because it bleeds. The good news: at this stage the gums usually recover as soon as everything is brushed thoroughly again.

White decalcification spots, over weeks to months. Bacteria in the plaque produce acid, and that acid dissolves minerals from the enamel. Where the plaque was, a dull, chalky white spot appears. Decalcification like this is an early stage of a cavity, but that is not what makes the biggest impression. The point is this: those white edges stand out around the places where the brackets were, and they are still there on the day the braces come off.

That is usually the only argument that really gets through to a teenager. Not cavities in ten years' time, but spots you will soon see when you smile.

We cannot give a guarantee, so we do not give one. Good brushing does make the chance of this damage a lot smaller, and it is by far the most important factor you have in your own hands. What else orthodontic treatment involves is explained on our page about risks and inconveniences.

The generally accepted dental guideline is to brush twice a day for two minutes with fluoride toothpaste. In addition, the Dutch orthodontic guideline has a set brushing routine for people wearing braces, and it does not start with the toothbrush.

1. Rinse your mouth with water. This gets rid of the larger bits of food.
2. First pass the interdental brush under the wire. Slide it under the wire, move from one bracket to the next, each time from the gum towards the edge of the tooth. All teeth and molars, top and bottom.
3. Brush the upper jaw in three directions. Place the brush above the wire and move towards the gum. Then above the wire again, but now towards the wire. Then below the wire, also towards the wire. Stay in the same spot on each tooth for a count of about ten.
4. Do the lower jaw in exactly the same way.
5. Then brush the inside and the chewing surfaces. Include the gumline as you go. If it bleeds, that is actually a reason to keep brushing there carefully.
6. Spit out the toothpaste. Whether you rinse with water afterwards is up to you: the Dutch advice on preventing tooth decay leaves that choice open.
7. Check with your tongue. If a tooth still feels rough around a bracket, there is still plaque there.

We deliberately do not name any brands, because the technique matters more than the product.

• A toothbrush with a small head and soft bristles. It gets between the parts of the braces more easily.
• Interdental brushes (small brushes for between the teeth) in the right size. The most important extra tool with fixed braces. Too thin reaches nothing, too thick does not fit. Ask at your check-up which size is right.
• A water flosser comes on top of brushing, not instead of it. The Dutch advice on preventing tooth decay mentions a water flosser as one of the ways to clean between the teeth and molars every day, alongside brushing twice a day. Around brackets and under the wire, an interdental brush gets a better grip on plaque that is stuck.

Research shows that the interdental brush in particular is the weak link. In a Dutch study of 393 teenagers with fixed braces, 88 per cent brushed for long enough, but only just over half used an interdental brush.

In addition to brushing, the orthodontic guideline advises people wearing braces to use either a fluoride mouthwash once a day, or a toothpaste with a higher fluoride content. What suits your child is something to discuss with your dentist or during a check-up with us.

• Make the evening brush the one that counts. Saliva production drops at night, so whatever stays behind stays there the longest.
• Show rather than repeat. Disclosing tablets that colour the plaque, or a photo taken with your phone, work better than asking for the tenth time whether they have brushed.
• Watch for ten seconds, not two minutes. The Dutch advice is for parents to go over their children's teeth again in the evening throughout the primary school years. With teenagers, a quick check without comment works better than supervision.
• Accept that it causes friction. It does in almost every family, for a while.

Our practice is in central Amsterdam, on Teniersstraat close to Museumplein. Lotte Meereboer is a dentist specialising in orthodontics (Drs. MSc Orthodontics) and treats children, teenagers and adults.

Because we see patients with braces at regular intervals, at every check-up we also look at the gums and the enamel, not just at the position of the teeth. If we see plaque or early inflammation, we show you there and then how to get that spot clean. Without judgement, because almost everyone needs that explanation at some point. You can read what an appointment involves on the pages about our consultations and about the clinic.

How often and for how long should my child brush with braces?

The general dental guideline is still twice a day for two minutes with fluoride toothpaste. With fixed braces, the interdental brush is added, usually once a day. Brushing after every meal is not necessary, but brushing thoroughly is.

My child's gums bleed when brushing. Should they brush more gently?

With braces, bleeding is usually caused by plaque along the gumline, not by brushing too hard. Cleaning that very spot carefully and thoroughly is the solution. If it continues after two weeks of good brushing, have it checked.

Do white spots go away once the braces are off?

Usually not completely. Very early decalcification can partly recover, but a clear white spot generally stays visible. There are treatments that make them less noticeable, although prevention is simpler.

Is a water flosser enough instead of interdental brushes?

Not as a replacement for brushing. The Dutch advice does mention a water flosser for daily cleaning between the teeth, alongside brushing. Around brackets and under the wire, an interdental brush remains the tool with the most grip.

Is an electric toothbrush better with braces?

Not automatically. Both work, as long as the technique is right and your child brushes for long enough. Do choose a small head and soft bristles.

Would you like to know more or request a no-obligation consultation? Get in touch with our practice in Amsterdam.