Document Type : Original Article


1 Assistant Professor, Department of Orthodontics, Dental Research Center, Faculty of Dentistry, Mazandaran University of Medical Sciences, Sari, Iran.

2 Dentist, Mazandaran University of Medical Sciences, Sari, Iran.

3 PhD in Biostatics, Department of Biostatics, Faculty of Dentistry, Mazandaran University of Medical Sciences, Sari, Iran.

4 PhD in Clinical Biochemistry, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.

5 Department of Periodontics, Dental Research Center, Faculty of Dentistry, Mazandaran University of Medical Sciences, Sari.

6 Associate Professor, Department of Oral and Maxillofacial Pathology, Dental Research Center, Faculty of Dentistry, Mazandaran University of Medical Sciences, Sari, Iran.


Aim: This study aimed to compare the incidence of mucosal lesions and pain during orthodontic treatment with fixed versus removable orthodontic appliances.
Methods: This cross-sectional study involved 58 patients with fixed orthodontic appliances and 58 patients with removable orthodontic appliances, all aged between 15 and 30 years. The presence and location of lesions were recorded at two time points: two weeks and four weeks after the start of the study. Additionally, the level of pain experienced by the patients was quantified at these same time points using a Visual Analog Scale (VAS). The Chi-square test was used to compare the frequency of oral lesions between the two groups at the onset of treatment. The Kruskal-Wallis test was used to compare the pain score at the onset of treatment between the two groups. The level of significance was set at 0.05.
Results: The frequency of traumatic lesions at two and four weeks was significantly higher in the fixed group (P<0.050). The frequency of traumatic and allergic lesions increased with time in both groups (P<0.050). Lichenoid reactions, candidiasis, and exophytic lesions were only detected in the removable treatment group. At two and four weeks, the frequency of lesions in the buccal mucosa was significantly higher than in other areas in the fixed group (P<0.050). At four weeks, the pain score of patients was higher in the fixed treatment group (P<0.050).
Conclusion: At four weeks, the frequency of lesions was higher in the fixed group. Buccal mucosa was the most common location of lesions in both groups. Pain in the fixed group was higher than the removable group at four weeks.


Main Subjects

  1. al-Emran S, Wisth PJ, Böe OE. Prevalence of malocclusion and need for orthodontic treatment in Saudi Arabia. Community Dent Oral Epidemiol. 1990;18(5):253-5. doi: 10.1111/j.1600-0528.1990.tb00070.x. PMID: 2249408.
  2. Haralur SB, Addas MK, Othman HI, Shah FK, El-Malki AI, Al-Qahtani MA. Prevalence of malocclusion, its association with occlusal interferences and temporomandibular disorders among the Saudi sub-population. Oral Health Dent Manag. 2014;13(2):164-9. PMID: 24984617.
  3. Amini F, Rakhshan V, Mesgarzadeh N. Effects of long-term fixed orthodontic treatment on salivary nickel and chromium levels: a 1-year prospective cohort study. Biol Trace Elem Res. 2012;150(1-3):15-20. doi: 10.1007/s12011-012-9457-y. PMID: 22644664.
  4. Doll GM, Zentner A, Klages U, Sergl HG. Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy. J Orofac Orthop. 2000;61(6):398-413. English, German. doi: 10.1007/pl00001908. PMID: 11126015.
  5. Jawaid M, Qadeer TA. Assessment of the changes in the oral health related quality of life 24 hours following insertion of fixed orthodontic appliance components - An observational cross-sectional study conducted at Bahria University Medical and Dental College Karachi. J Pak Med Assoc. 2019;69(5):677-683. PMID: 31105287.
  6. Mansor N, Saub R, Othman SA. Changes in the oral health-related quality of life 24 h following insertion of fixed orthodontic appliances. J Orthod Sci. 2012;1(4):98-102. doi: 10.4103/2278-0203.105880.  PMID: 24987635.
  7. Krishnan V. Orthodontic pain: from causes to management--a review. Eur J Orthod. 2007;29(2):170-9. doi: 10.1093/ejo/cjl081. PMID: 17488999.
  8. Bergius M, Berggren U, Kiliaridis S. Experience of pain during an orthodontic procedure. Eur J Oral Sci. 2002;110(2):92-8. doi: 10.1034/j.1600-0722.2002.11193.x.  PMID: 12013568.
  9. Xiaoting L, Yin T, Yangxi C. Interventions for pain during fixed orthodontic appliance therapy. A systematic review. Angle Orthod. 2010;80(5):925-32. doi: 10.2319/010410-10.1. PMID: 20578865
  10. Sandhu SS, Sandhu J. Orthodontic pain: an interaction between age and sex in early and middle adolescence. Angle Orthod. 2013;83(6):966-72. doi: 10.2319/030113-174.1.  PMID: 23705940.
  11. Kvam E, Bondevik O, Gjerdet NR. Traumatic ulcers and pain in adults during orthodontic treatment. Community Dent Oral Epidemiol. 1989;17(3):154-7. doi: 10.1111/j.1600-0528.1989.tb00012.x.  PMID: 2736897.
  12. Profit WR. Orthodontic treatment planning: Limitations, controversies and special problems. Contemporary orthodontics. 2007.
  13. Shiva A, Sobouti F. Comparative study of histopathological reports and clinical diagnosis of oral biopsies. Journal of Mazandaran University of Medical Sciences. [in persian].2017;26(144):57-64.
  14. Shiva A, Nosrati K. A calcifying odontogenic cyst associated with complex odontoma: a case report. [in persian].Journal of Babol University of Medical Sciences. 2015;17(2):57-61.
  15. Campos LA, Santos-Pinto A, Marôco J, Campos J. Pain perception in orthodontic patients: A model considering psychosocial and behavioral aspects. Orthodontics & craniofacial research. 2019;22(3):213-21. doi: 10.1111/ocr.12315.
  16. Story RI. Psychological issues in orthodontic practice. Am J Orthod. 1966;52(8):584-98. doi: 10.1016/0002-9416(66)90139-4.  PMID: 5220745.
  17. Rakhshan H, Rakhshan V. Pain and discomfort perceived during the initial stage of active fixed orthodontic treatment. Saudi Dent J. 2015;27(2):81-7. doi: 10.1016/j.sdentj.2014.11.002.  PMID: 26082574.
  18. Fujita K. New orthodontic treatment with lingual bracket mushroom archwire appliance. Am J Orthod. 1979;76(6):657-75. doi: 10.1016/0002-9416(79)90211-2.  PMID: 293135.
  19. Sinclair PM, Cannito MF, Goates LJ, Solomos LF, Alexander CM. Patient responses to lingual appliances. J Clin Orthod. 1986;20(6):396-404. PMID: 3461002.
  20. Miyawaki S, Yasuhara M, Koh Y. Discomfort caused by bonded lingual orthodontic appliances in adult patients as examined by retrospective questionnaire. Am J Orthod Dentofacial Orthop. 1999;115(1):83-8. doi: 10.1016/s0889-5406(99)70320-3. PMID: 9878962.
  21. Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop. 1989;96(1):47-53. doi: 10.1016/0889-5406(89)90228-x.  PMID: 2750720.
  22. Impellizzeri A, Samà R, Di Giorgio R, Barbato E, Galluccio G. Control of oral hygiene in the orthodontic patient: comparison between public facility and private practice. Annali di Stomatologia. 2018;9(1):43-52. doi: 10.59987/ads/2018.1.43-52.
  23. Baricevic M, Mravak-Stipetic M, Majstorovic M, Baranovic M, Baricevic D, Loncar B. Oral mucosal lesions during orthodontic treatment. Int J Paediatr Dent. 2011;21(2):96-102. doi: 10.1111/j.1365-263X.2010.01078.x. PMID: 21121986.
  24. Baranović M, Stipetić MM, Baričević D, Baranović M, Čimić A, Blažević A. Oral Mucosa Status of Patients Undergoing Orthodontic Treatment. Acta Stomatologica Croatica. 2009;43(2).
  25. Mainali A. Occurrence of oral ulcerations in patients undergoing orthodontic treatment: A comparative study. Orthodontic Journal of Nepal. 2013;3(2):32-5. doi: 10.3126/ojn.v3i2.10075.
  26. Rashidi MF, Omrani A, Aliyari L, Sarrafzadeh H. Prevalence of Oral Mucosal Lesions in Patients Undergoing Fixed Orthodontic Treatment in The Orthodontic Department of Faculty of Dentistry, Islamic Azad University Isfahan (Khorasgan) Branch During 2010-11.[in persian]. Journal of Isfahan Dental School. 2017;12(4):349-57.
  27. Rodríguez-Rentería M, Márquez-Preciado R, Ortiz-Magdaleno M, Bermeo-Escalona J, Sánchez-Vargas LO. Frequency of Pathogenic Microorganisms in Removable Orthodontic Appliances and Oral Mucosa in Children. J Clin Pediatr Dent. 2021;45(2):135-139. doi: 10.17796/1053-4625-45.2.11.  PMID: 33951170.
  28. Gupta R, Mahajan N, Jandial S, Kotwal B, Kaur S, Kharyal S. Incidence of oral ulcers in patients undergoing orthodontic treatment. International Journal of Preventive and Public Health Sciences. 2017;3(2):31-4.
  29. Baseer MA, Almayah NA, Alqahtani KM, Alshaye MI, Aldhahri MM. Oral Impacts Experienced by Orthodontic Patients Undergoing Fixed or Removable Appliances Therapy in Saudi Arabia: A Cross-Sectional Study. Patient Prefer Adherence. 2021;15:2683-2691. doi: 10.2147/PPA.S343084.  PMID: 34880603.
  30. Travess H, Roberts-Harry D, Sandy J. Orthodontics. Part 6: Risks in orthodontic treatment. Br Dent J. 2004;196(2):71-7. doi: 10.1038/sj.bdj.4810891.  PMID: 14739957.
  31. Alajmi S, Shaban A, Al-Azemi R. Comparison of Short-Term Oral Impacts Experienced by Patients Treated with Invisalign or Conventional Fixed Orthodontic Appliances. Med Princ Pract. 2020;29(4):382-388. doi: 10.1159/000505459. PMID: 31842018.
  32. Wiedel AP, Bondemark L. A randomized controlled trial of self-perceived pain, discomfort, and impairment of jaw function in children undergoing orthodontic treatment with fixed or removable appliances. Angle Orthod. 2016;86(2):324-30. doi: 10.2319/040215-219.1. PMID: 26185899.
  33. Bahrami R, Pourhajibagher M, Parker S, Esmaeili D, Bahador A. Anti-biofilm and bystander effects of antimicrobial photo-sonodynamic therapy against polymicrobial periopathogenic biofilms formed on coated orthodontic mini-screws with zinc oxide nanoparticles. Photodiagnosis Photodyn Ther. 2023;41:103288. doi: 10.1016/j.pdpdt.2023.103288. PMID: 36640857.
  34. Poppolo Deus F, Ouanounou A. Chlorhexidine in Dentistry: Pharmacology, Uses, and Adverse Effects. Int Dent J. 2022;72(3):269-277. doi: 10.1016/j.identj.2022.01.005.  PMID: 35287956.
  35. Cieplik F, Aparicio C, Kreth J, Schmalz G. Development of standard protocols for biofilm-biomaterial interface testing. JADA Foundational Science. 2022;1:100008. doi: 10.1016/j.jfscie.2022.100008.
  36. Pourhajibagher M, Bahrami R, Bazarjani F, Bahador A. Anti-multispecies microbial biofilms and anti-inflammatory effects of antimicrobial photo-sonodynamic therapy based on acrylic resin containing nano-resveratrol. Photodiagnosis Photodyn Ther. 2023;43:103669. doi: 10.1016/j.pdpdt.2023.103669.  PMID: 37356699.
  37. Al-Thobity AM, Gad MM. Effect of silicon dioxide nanoparticles on the flexural strength of heat-polymerized acrylic denture base material: A systematic review and meta-analysis. Saudi Dent J. 2021;33(8):775-783. doi: 10.1016/j.sdentj.2021.08.008. PMID: 34938017.
  38. Pourhajibagher M, Bahador A. Antimicrobial properties, anti-virulence activities, and physico-mechanical characteristics of orthodontic adhesive containing C-phycocyanin: a promising application of natural products. Folia Med (Plovdiv). 2021;63(1):113-121. doi: 10.3897/folmed.63.e52756.  PMID: 33650404.
  39. Tandra E, Wahyuningtyas E, Sugiatno E. The effect of nanoparticles TiO2 on the flexural strength of acrylic resin denture plate. Padjadjaran Journal of Dentistry. 2018;30(1):35-40. doi: 10.24198/pjd.vol30no1.16110.
  40. Pourhajibagher M, Ahmadi H, Roshan Z, Bahador A. Streptococcus mutans bystander-induced bioeffects following sonodynamic antimicrobial chemotherapy through sonocatalytic performance of Curcumin-Poly (Lactic-co-Glycolic Acid) on off-target cells. Photodiagnosis Photodyn Ther. 2020;32:102022. doi: 10.1016/j.pdpdt.2020.102022.  PMID: 33038486.