Isotretinoin (Roaccutane) and Orthodontic Treatment

What is isotretinoin and how does it work?

Isotretinoin is a synthetic retinoid — a derivative of vitamin A — that reduces sebum production, normalises skin cell turnover, and has anti-inflammatory effects in sebaceous glands. It is the most effective medical treatment for severe nodular or cystic acne and for acne that has not responded to antibiotics and topical treatments. In the UK it is prescribed under strict monitoring because of its teratogenicity (it causes severe fetal abnormalities) and its effects on mood. A standard course lasts four to six months. The mechanism relevant to orthodontics is its effect on bone metabolism: retinoids influence osteoblast and osteoclast activity, and isotretinoin in particular has been associated with altered bone remodelling — the very process upon which orthodontic tooth movement depends.

Root resorption: the key concern

Orthodontic tooth movement involves controlled bone resorption on the pressure side of a tooth root and bone deposition on the tension side. Root resorption — shortening of the tooth root — is a known side effect of orthodontic treatment, occurring to a minor degree in most patients and to a clinically significant degree in a smaller proportion. Case reports and small studies have raised concerns that isotretinoin use during active orthodontic treatment may increase the severity of root resorption. The proposed mechanism involves retinoid-induced alteration of osteoblast differentiation and activity, potentially disrupting the balance of resorption and repair around the root apex. While large-scale prospective evidence is limited, the biological plausibility of the interaction and the case reports in the literature mean that most orthodontists adopt a cautious approach when a patient is taking isotretinoin concurrently with active tooth movement.

Effects on the oral mucosa and bracket comfort

Isotretinoin causes dryness and fragility of all mucous membranes, not only the skin. The lips, cheeks, and gingival tissues become dry, thin, and more easily traumatised. For patients wearing fixed braces, this means that bracket edges, wire ends, and the general roughness of orthodontic appliances cause significantly more mucosal irritation than in a patient not on isotretinoin. Ulceration at the junction of the cheek and brace is more common. Orthodontic wax, silicone covers, and soft wax provide some relief but many patients find the course of treatment considerably more uncomfortable while taking isotretinoin. Clear aligner patients are less affected by this issue because aligners are smooth, but they too experience dry and fragile lip tissue, making aligner insertion and removal more uncomfortable.

Adhesive tape, perioral skin, and IPR

Isotretinoin causes increased photosensitivity and fragility of the perioral skin. Adhesive tape used during orthodontic procedures — such as cheek retractors for bonding or tape used around impressions — can cause skin stripping or irritation. Clinicians performing orthodontic bonding or other procedures involving adhesive tape on the face should be aware of this. Interproximal reduction (IPR) strips, which contact the gingival papillae and embrasure soft tissues, may cause greater than usual mucosal abrasion in patients on isotretinoin.

Dry mouth and caries risk with fixed braces

Fixed orthodontic appliances already increase the risk of dental caries by creating plaque-retentive areas around brackets and under wires that are difficult to clean. Isotretinoin reduces saliva production — one of its less-publicised effects. Saliva has a critical protective role: buffering acid, remineralising enamel, washing away food debris, and containing antimicrobial proteins. Reduced salivary flow while wearing fixed braces significantly increases the risk of white spot lesions (early enamel demineralisation) and frank caries. Patients on isotretinoin during orthodontic treatment should be on a high-fluoride toothpaste (2800 or 5000 ppm fluoride), use interdental brushes consistently, and consider a fluoride mouthwash. More frequent hygiene appointments are advisable.

Should orthodontic treatment be paused during an isotretinoin course?

There is no formal UK national guideline mandating a pause in orthodontic treatment during isotretinoin use, but many orthodontists consider pausing active tooth movement — particularly in patients with existing root resorption risk factors such as short, blunt, or pipette-shaped roots — during the four-to-six-month course. Reducing wire forces to very light levels or placing passive archwires to hold position without active movement is a more conservative approach that avoids stopping treatment entirely. The decision should be made in discussion with the patient, the prescribing dermatologist, and the orthodontist, weighing up the root resorption risk against the cost of delaying treatment completion. A one-month washout period after completing the isotretinoin course — by which time systemic levels have reduced significantly — is often recommended before resuming heavy forces or commencing surgical procedures.

Communicating with the prescribing dermatologist

UK dermatologists prescribing isotretinoin under the MHRA's Pregnancy Prevention Programme are accustomed to coordinating care with other specialties. Orthodontists should feel confident writing to the dermatologist to flag the concurrent orthodontic treatment and request discussion of timing. Similarly, patients who are about to start a course of isotretinoin should inform their orthodontist at the earliest opportunity. In some cases, deferring the isotretinoin course until after orthodontic treatment is completed — if the acne severity allows — may be the simplest solution. Where acne is severe and cannot wait, a modified orthodontic approach during the course is a reasonable middle ground.

Useful related pages

This guide is for general information only. It is not a diagnosis, treatment plan, or substitute for advice from a registered dentist or orthodontist.