Sir, I am writing to express my concern regarding your recent BDJ paper regarding prevention and treatment of demineralisation during fixed appliance therapy (BDJ 2013; 215: 505–511).

The body of the article correctly associates orthodontic fixed appliance systems as a risk factor in the development of enamel demineralisation. I further support their view that disregard of the aetiology and development of this process in orthodontic patients leaves clinicians at risk of being clinically negligent and the subject of litigation.

It was with some surprise therefore that I read Figure 1 showing a patient who has enamel demineralisation 'caused' by fixed appliances. This demineralisation has not been caused by the fixed appliance. It is associated with the process and is a risk factor in its progression but it is not a causative agent and there is not a cause-effect relationship between the two.

This misunderstanding of the relationship between orthodontic appliances and enamel demineralisation sets a concerning precedent with the ever-growing threat of litigation from the legal profession. May I suggest an amendment to the paper to reflect an association rather than a causative effect between these two variables?

Mr Colin Chambers, the corresponding author of the article, responds: Many thanks for your concerns regarding Figure 1 in our article. I would be more than happy to amend the Figure 1 legend to 'Demineralisation associated with fixed appliance treatment'.

However, the article does clearly explain the disease process that results in enamel demineralisation and should not result in any misunderstandings.

1. Sunderland