1072 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000.2025.1072 http://dentistry3000.pitt.edu Oral Mucosal Lesions Associated with Fixed Orthodontic Appliances Maha Mohammed Abd Ali1, Omar Abdul Jabbar Abdul Qader2, Ahmed M.A. Haider3, Basim Mohammed Khashman4 1Al Hadi University, Iraq 2College of Den8stry, University of Al Mashreq, Malaysia 3College of Den8stry, University of Baghdad, Iraq 4Na8onal Cancer Research Center, University of Baghdad, Iraq Abstract Objec;ve: To determine the prevalence and types of oral mucosal lesions associated with fixed metal orthodonNc appliances and assess their correlaNon with paNent demographics and treatment duraNon. Materials and Methods: A cross-secNonal study of 235 paNents (aged 11-39 years) undergoing fixed orthodonNc treatment was conducted in Baghdad, Iraq (September 2024-March 2025). Clinical examinaNons were performed by two specialists, and data were analyzed using SPSS version 22.0. Results: Among 235 parNcipants (63.4% females, 80% aged <25 years), gingiviNs was most prevalent (61.3%), followed by ulceraNve lesions (29.4%), white lesions (3.4%), fibroma (2.6%), infecNon (1.3%), and periodonNNs (1.3%). Or- thodonNc treatment duraNon >1 year was significantly associated with increased lesion prev- alence (p=0.002). No significant gender-based differences were observed (p>0.05). Conclu- sion: Fixed orthodonNc appliances are associated with high prevalence of oral mucosal lesions, parNcularly gingiviNs and ulcers. These findings emphasize the need for prevenNve strategies and comprehen- sive oral hygiene protocols in orthodon- Nc care. Open Access Cita%on: Ali MMA, et al. (2025) Oral Mucosal Lesions As- sociated with Fixed Orthodon%c Appliances. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.1072 Received: October 12, 2025 Accepted: October 15, 2025 Published: November 10, 2025 Copyright: ©2025 Ali MMA, et al. This is an open access ar%cle licensed under a Crea%ve Commons ARribu%on Work 4.0 United States License. Email: dromarqader@gmail.com Introduc)on Orthodontic treatment with /ixed appliances has become increasingly common world- wide, with growing numbers of both adoles- cents and adults seeking dental correction [1,2]. While these appliances effectively cor- rect malocclusions, they can create condi- tions conducive to plaque accumulation, me- chanical trauma, and subsequent develop- ment of oral mucosal lesions [3,4]. Malocclusion ranks as the third most preva- lent oral pathology globally after dental car- ies and periodontal disease [5]. Studies show prevalence rates vary signi/icantly by region: 47.92% in China, 45.9% in Italy, 70% in In- dia, and 83.7% in Iran [6,7]. The most com- mon classi/ication is Angle Class I (53.3%), followed by Class II and III variations. Common oral complications associated with orthodontic appliances include traumatic ul- cers, recurrent aphthous stomatitis (RAS), gingivitis, gingival hyperplasia, frictional keratosis, and reactive /ibromas [8,9]. Ap- proximately 95% of orthodontic patients re- port pain during treatment, often related to mucosal trauma from appliance components [10]. Gingival in/lammation affects a signi/i- cant proportion of patients, with severity correlating to oral hygiene status and treat- ment duration [11,12]. Despite documented associations between orthodontic appliances and oral lesions, lim- ited data exist from Middle Eastern popula- tions. This study investigated the prevalence and distribution of oral mucosal lesions in Iraqi patients undergoing /ixed orthodontic treatment and examines correlations with demographic factors and treatment dura- tion. Materials and Methods This cross-sectional study was conducted at orthodontic clinics in Baghdad, Iraq, from September 2024 to March 2025. Ethical ap- proval was obtained from the institutional review board, and informed consent was se- cured from all participants. Of 333 orthodontic patients initially screened, 235 met inclusion criteria and were enrolled. Participants were aged 11-39 years, undergoing /ixed metal orthodontic treatment, free from systemic diseases af- fecting oral health, and presented with oral mucosal changes at examination. Patients using removable appliances or headgear, those with systemic diseases Oral Mucosal Lesions Associated with Fixed OrthodonNc Appliances Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.1072 http://dentistry3000.pitt.edu 2 affecting oral health, and patients who missed scheduled appointments during the study period were not included in the study. Demographic data were collected via online questionnaire. Two specialist clinicians per- formed clinical examinations, and diagnoses were based on clinical presentation. Oral le- sions were classi/ied as: gingivitis, ulcerative lesions (traumatic ulcer and RAS), white le- sions (frictional keratosis), /ibroma, infec- tion, periodontitis, caries, and trauma. Data were analyzed using SPSS version 22.0. The Kolmogorov-Smirnov test assessed dis- tribution normality. Chi-square and bino- mial tests compared categorical variables. Contingency coef/icients and odds ratios evaluated associations between lesion types and demographic variables. Statistical signif- icance was set at p<0.05. Results Table 1 presents the demographic character- istics of the study population. Of 235 partici- pants, 149 (63.4%) were females and 86 (36.6%) were males (p=0.016). The mean age was 21.54±4.5 years, with 188 (80%) pa- tients aged ≤25 years and 47 (20%) aged >25 years (p=0.016). Treatment duration ex- ceeded one year in 142 (60.4%) patients and was less than one year in 93 (39.6%) pa- tients (mean duration: 0.4±0.49 years, p=0.002). Table 2 shows the distribution of oral muco- sal lesions among study participants. Gingi- vitis was the most prevalent lesion, affecting 144 patients (61.3%), followed by ulcerative lesions in 69 patients (29.4%). Other lesions occurred less frequently: white lesions (3.4%), /ibroma (2.6%), infection (1.3%), periodontitis (1.3%), caries (0.4%), and trauma (0.4%). The distribution showed sig- ni/icant differences among lesion types (Kol- mogorov-Smirnov test: K.S.=0.656, p<0.001). Table 3 presents the distribution of oral le- sion types according to patient gender. No signi/icant associations were found between any lesion type and patient gender (p>0.05 for all comparisons). Male-to-female ratios were approximately equal for most lesions: gingivitis (1:1.14), ulcer (1:1.12), and perio- dontitis (1:1.17). Fibroma showed female predominance (1:3) while white lesions and infections were slightly more common in males (3:1 and 3.5:1, respectively), though none of these differences reached statistical signi/icance. Table 4 summarizes the distribution of oral lesion types according to age groups. Weak, non-signi/icant relationships were observed between lesion types and age groups (p>0.05 for all comparisons). Most lesions occurred predominantly in patients ≤25 years old. Notably, ulcerative lesions showed a trend toward higher prevalence in patients >25 years (40.4%) compared to younger pa- tients (26.6%), with an odds ratio of 1.87, though this did not reach statistical signi/i- cance (p=0.063). Treatment duration exceeding one year was signi/icantly associated with increased over- all prevalence of oral lesions (p=0.002). The mean treatment duration was 0.4±0.49 years, with 60.4% of patients receiving treat- ment for more than one year showing higher rates of oral mucosal complications com- pared to those treated for shorter durations. Discussion This study demonstrates a high prevalence of oral mucosal lesions in Iraqi patients un- dergoing /ixed orthodontic treatment, with gingivitis (61.3%) and ulcerative lesions (29.4%) being most common. These /indings align with previous research showing that orthodontic appliances signi/icantly in- creased risk of mucosal pathology [13]. The 29.4% prevalence of ulcerative lesions in our study is comparable to rates reported by Chang et al. (2024) at 26.06% and Liu et al. (2023) at 22.24% [14,15]. Most traumatic ulcers result from direct contact between oral soft tissues and orthodontic brackets, particularly during initial treatment stages [16,17]. Studies indicate that 60-80% of oral ulcers are traumatic, while 8-30% are aph- thous ulcers [18]. Treatment duration >1 year and infrequent tooth brushing (≤1 time daily) have been identi/ied as risk factors for oral ulcers [15], consistent with our /inding of signi/icant as- sociation between treatment duration and lesion prevalence. The high prevalence of gingivitis (61.3%) re- /lects the challenge of maintaining adequate oral hygiene with /ixed appliances. Baricevic et al. (2011) [13] found that gingival in/lam- mation severity correlated directly with oral hygiene status in orthodontic patients. Ab- dullah et al. (2024) [12] and Alasadi et al. (2018) [19] reported that prolonged ortho- dontic treatment increases plaque retention and gingivitis severity, with signi/icant in- creases in gingival index occurring within two weeks of appliance placement. Gingival hyperplasia results from multiple factors including plaque-induced in/lamma- tion, chemical irritation from bonding mate- rials, food impaction, and mechanical irrita- tion from orthodontic devices [20]. Iraqi studies have documented signi/icant histo- pathological and cytomorphological changes in oral mucosal epithelium of orthodontic patients, including cellular hypertrophy, bi- nucleation, micronuclei formation, and in- /lammatory cell in/iltration [21,22]. Several mechanisms contribute to oral le- sions in orthodontic patients: 1. Mechanical trauma: Direct con- tact and friction between appliances and oral mucosa 2. Plaque accumulation: Appliances create retention areas dif/icult to clean 3. Metal ion release: Nickel and chromium ions from appliances exhibit cyto- toxic and genotoxic effects [23-25] 4. pH alterations: Metal braces cause more pronounced decreases in salivary pH compared to ceramic braces and aligners [26] 5. Corrosion: pH /luctuations from food and beverages facilitate appliance cor- rosion and ion release [27] The predominance of female patients (63.4%) and younger age groups (<25 years: 80%) in our study re/lects typical orthodon- tic treatment-seeking patterns. Vincent- Bugnas et al. (2021) reported highest gingi- val enlargement prevalence in 13–19-year- olds (49.2%) [28], followed by patients >20 years (43.5%). Young patients in mixed and early permanent dentition stages require special periodontal considerations due to unique developmental features and typically less consistent oral hygiene habits [29]. Our /inding of no signi/icant gender differ- ences in lesion distribution differs from some studies reporting gender-based varia- tions, possibly re/lecting population-speci/ic factors or treatment protocols. These /indings emphasize several critical as- pects of orthodontic care: 1. Preventive strategies: Compre- hensive oral hygiene education before and during treatment 2. Regular monitoring: Frequent ex- amination for early detection of mucosal le- sions 3. Appliance management: Ensur- ing proper /it and smoothing sharp edges 4. Multidisciplinary approach: Col- laboration with periodontists and oral medi- cine specialists 5. Patient education: Clear instruc- tions on oral hygiene maintenance and signs requiring immediate attention Failure to comprehensively assess periodon- tal health alongside tooth movement may re- sult in misjudgments regarding treatment progress and could lead to excessive ortho- dontic forces that exacerbate tissue damage [9,29]. This study has several limitations. The cross- sectional design prevents assessment of temporal relationships and lesion progres- sion. The relatively small sample size and single geographic location may limit general- izability. Additionally, oral hygiene practices, dietary factors, and speci/ic appliance types were not systematically evaluated, all of which could in/luence lesion development. Oral Mucosal Lesions Associated with Fixed OrthodonNc Appliances Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.1072 http://dentistry3000.pitt.edu 3 Conclusion Fixed metal orthodontic appliances are asso- ciated with a high prevalence of oral mucosal lesions, particularly gingivitis (61.3%) and ulcerative lesions (29.4%), predominantly affecting female patients under 25 years of age. Treatment duration exceeding one year signi/icantly increases lesion risk. These /indings underscore the critical importance of: 1. Comprehensive pretreatment oral health assessment and patient education 2. Regular monitoring throughout or- thodontic treatment 3. Prompt intervention when lesions develop 4. Multidisciplinary collaboration be- tween orthodontists, periodontists, and oral medicine specialists 5. Development of preventive proto- cols tailored to high-risk patients Future prospective studies with larger sam- ple sizes, multiple geographic locations, and systematic evaluation of risk factors are needed to better understand the etiology and prevention of orthodontic appliance-as- sociated oral lesions. Acknoledgements The authors thank all participating patients and orthodontic practitioners who contrib- uted to this study. Conflict of Interest None. References 1. Hung M, Lipsky MS, Moffat R, et al. (2023). Trends in adult orthodontic treatment in the United States. Ameri- can Journal of Orthodontics and Den- tofacial Orthopedics, 163(5), 621-629. doi: 10.1016/j.ajodo.2022.10.015 2. Wall A, Morgan MZ, Torgerson D, et al. (2024). Orthodontic treatment provi- sion in the United Kingdom: Current trends and future challenges. British Orthodontic Journal, 51(2), 134-142. 3. Baricevic M, Mravak-Stipetic M, Knezevic M, et al. (2020). 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Variable Category n % Mean ± SD p-value Gender Male 86 36.6 - 0.016 Female 149 63.4 - Age (years) ≤25 years 188 80.0 21.54 ± 4.50 0.016 >25 years 47 20.0 Treatment Duration <1 year 93 39.6 0.40 ± 0.49 0.002 ≥1 year 142 60.4 Table 2. Prevalence and distribution of oral mucosal lesion types (N=235). Lesion Type n % 95% CI Gingivitis 144 61.3 54.9-67.4 Ulcerative lesions 69 29.4 23.6-35.6 White lesions 8 3.4 1.5-6.6 Fibroma 6 2.6 0.9-5.5 Infection 3 1.3 0.3-3.7 Periodontitis 3 1.3 0.3-3.7 Caries 1 0.4 0.0-2.3 Trauma 1 0.4 0.0-2.3 Kolmogorov-Smirnov test: K.S. = 0.656, p<0.001 Table 3. Distribution of oral lesion types by gender (N=235). Lesion Type Male (n=86) Female (n=149) Total (n=235) M:F Ratio OR (95% CI) p-value Gingivitis 51 (59.3%) 93 (62.4%) 144 (61.3%) 1:1.14 0.88 (0.51-1.51) 0.637 Ulcer 24 (27.9%) 45 (30.2%) 69 (29.4%) 1:1.12 0.9 (0.5-1.6) 0.71 White Lesion 5 (5.8%) 3 (2%) 8 (3.4%) 3:1 3.0 (0.69-13.03) 0.122 Fibroma 1 (1.2%) 5 (3.4%) 6 (2.6%) 1:3 0.34 (0.04-2.94) 0.305 Infection 2 (2.3%) 1 (0.7%) 3 (1.3%) 3.5:1 3.52 (0.31-39.8) 0.276 Periodontitis 1 (1.2%) 2 (1.3%) 3 (1.3%) 1:1.17 0.87 (0.08-9.68) 0.906 Caries 1 (1.2%) 0 (0%) 1 (0.4%) - - 0.187 Trauma 1 (1.2%) 0 (0%) 1 (0.4%) - - 0.187 OR: Odds Ratio; CI: Con/idence Interval; All comparisons: p>0.05 (not signi/icant) Table 4. Distribution of oral lesion types by age groups (N=235). Lesion Type ≤25 years (n=188) >25 years (n=47) Total (n=235) OR (95% CI) p-value Gingivitis 119 (63.3%) 25 (53.2%) 144 (61.3%) 1.52 (0.8-2.89) 0.203 Ulcer 50 (26.6%) 19 (40.4%) 69 (29.4%) 0.53 (0.28-1.03) 0.063 White Lesion 6 (3.2%) 2 (4.3%) 8 (3.4%) 0.74 (0.15-3.78) 0.719 Fibroma 6 (3.2%) 0 (0%) 6 (2.6%) - 0.215 Infection 3 (1.6%) 0 (0%) 3 (1.3%) - 0.383 Periodontitis 2 (1.1%) 1 (2.1%) 3 (1.3%) 0.5 (0.04-5.58) 0.561 Caries 1 (0.5%) 0 (0%) 1 (0.4%) - 0.616 Trauma 1 (0.5%) 0 (0%) 1 (0.4%) - 0.616 OR: Odds Ratio (≤25 years: >25 years); CI: Con/idence Interval; All comparisons: p>0.05 (not signi/icant)