Case Report

Wulandari RW et.al. Journal of Syiah Kuala Dentistry Society

Effectiveness of online education about actions of 3G motions
Journal of Syiah Kuala Dentistry Society
Original Research

e-ISSN 2502-0412
www.jurnal.unsyiah.ac.id/JDS

Treatment of traumatic ulcer induced by fixed orthodontic

appliance: a case report

Yuli Fatzia OSSA1, Khairiyah ULFAH2,, Rizki Rachmayani SİTİNJAK3

1Department Oral Medicine, Faculty of Dentistry, Universitas Syiah Kuala, Darussalam, Banda Aceh, Aceh, Indonesia
2Department of Orthodontic, Faculty of Dentistry Universitas Syiah Kuala, Darussalam, Banda Aceh, Aceh, Indonesia
3Dental Student Faculty of Dentistry Universitas Syiah Kuala, Darussalam, Banda Aceh, Aceh, Indonesia

Corresponding Author Email: yulifatziaossa@unsyiah.ac.id

Received; February 22, 2022, Revised; April 19, 2022, Accepted; June 5, 2022

ABSTRACT Orthodontic treatment aims to improve the oral health of the patient. Still, orthodontic treatment can
also cause problems in the oral cavity, such as the appearance of traumatic ulcers caused by the use of orthodontic
appliances. The following describes a chronic traumatic ulcer in a patient using fixed orthodontic appliances. Case
Report: A female patient aged 22 years complained of thrush after using braces. Clinical examination revealed a
single ulcerated lesion on the right buccal mucosa of the upper molar region adjacent to the buccal tube of the
orthodontic appliance. The patient was then treated with topical corticosteroids and chlorhexidine gluconate. The
patient was also consulted by an orthodontic specialist for further treatment using orthodontic wax to help protect
against friction between the wires and the mucosa. The lesions healed on the third visit.: Orthodontic treatment
often causes injuries to the oral mucosa. It is because the orthodontic appliances used can rub against the oral
mucosa so that they are very susceptible to causing traumatic ulcers. Traumatic ulcers arising from orthodontic
treatment are generally chronic, requiring comprehensive treatment to reduce patient complaints. Conclusion:
Treatment of chronic traumatic ulcers due to the use of fixed orthodontic appliances should be carried out
comprehensively by involving an oral medicine specialist and an orthodontist to provide maximum treatment for
traumatic ulcers and reduce patient complaints.

KEYWORDS: Traumatic Ulcer, Orthodontic Appliance, Treatment

INTRODUCTION
Orthodontic treatment aims to improve oral
health, function, appearance, and patient confidence.
However, orthodontic treatment has risks and
complications for soft and hard tissues like other
treatments.1 Soft tissue irritation can occur indirectly
due to allergies to orthodontic appliance materials
or directly from components of fixed and removable
orthodontic appliances.1,2 Fixed orthodontic
appliances consist of brackets, wires, bands, tubes,
hooks, and other elements that can rub against the
mucosa.3 Irritation caused by orthodontic appliances
is called traumatic ulceration.3,4
Traumatic ulceration is a soft tissue lesion of
the mouth caused by acute or chronic physical,
mechanical, thermal, or chemical trauma. Clinically,
the lesion is an ulcer covered by a yellowish-white
fibrinopurulent layer and surrounded by
erythematous areas and hyperkeratotic tissue.5
Treatment for traumatic ulcers caused by
orthodontic treatment can be done in various ways
and comprehensively by involving orthodontists
and oral medicine specialists. In this case report, we
describe the treatment of a case of chronic traumatic
ulcer triggered by the use of fixed orthodontic
braces.

CASE REPORT
A 21-year-old female patient came to the Dental seven days ago. At first, the thrush was small but
and Oral Hospital, Faculty of Dentistry, Syiah Kuala grew bigger and caused pain when eating and
University, complaining of thrush in the mouth talking on the VAS 7 scale. The thrush had never

How to cite this article: Ossa et.al. Treatment of traumatic ulcer induced by fixed orthodontic appliance: case report. JDS. 2022; 7(1): 69-72

© 2020 Syiah Kuala University Press

e-ISSN 2502-0412
69
Ossa et.al.
Treatment of traumatic ulcer induced by fixed orthodontic appliance
been treated, and the patient said that the initial
appearance of thrush was due to braces. The history
of repeated thrush was denied, and the family
history of canker sores was also rejected. Extraoral
examination, lymph nodes were not abnormal, and
Figure 1. First visit, ulcerative lesion on right buccal mucosa
The patient denied any systemic disease and
had a history of allergies. At visit 1, the patient was
given a topical corticosteroid on the lesion and
educated to visit an orthodontist. On the second
visit, one week after the first visit, thrush still exists
in the oral cavity, and the pain is slightly reduced.
Clinical examination, the nodule was still visible
with ulceration in the healing process, oval in shape,
the same color as the surrounding tissue, in front of
Figure 2. On the second visit, the ulcer has not shown significant changes
On the 3rd visit, two weeks after the second
visit, the patient stated that the healing of thrush
was getting better, and the pain was no longer a
complaint. Clinical examination showed complete
70
Journal of Syiah Kuala Dentistry Society
Case Report
intra-oral examination revealed a nodule
accompanied by irregular ulceration with a size of
4x2 mm on the right buccal mucosa of region 17
(Figure 1) adjacent to the central Stensen duct.
the white nodule, measuring 4x2 mm, getting
smaller back 4x1 mm with ulcer 1x1 mm, location on
the right buccal mucosa near tooth 17, well-defined,
symptomatic. (Figure 2) at the second visit,
treatment was supplemented by administration of
0.2% Chlorhexidine gluconate, compressed twice a
day after meals, and using ortho wax to cover the
sharp ends of orthodontic wires.
ulcer healing. At this visit, the patient was instructed
to discontinue topical medications and continue
using orthodontic waxes. (Figure 3).
JDS 2022; 7(1): 69-72
Ossa et.al.
Treatment of traumatic ulcer induced by fixed orthodontic appliance
Figure 3. On the third visit, healing lesions
DISCUSSION
Traumatic ulcers can be caused by physical,
thermal, or chemical trauma. This traumatic ulcer
is a prevalent lesion found in daily practice.
Accidentally biting while eating sharp food causes
an acute traumatic ulcer that can heal in a few days
without complications. A traumatic ulcer caused
by sharp tooth edges, poor restoration, ill-fitting
dentures, and fixed orthodontic appliances can
cause chronic traumatic ulcers.
Chronic traumatic ulcers commonly occur on
the lateral margin of the tongue, buccal mucosa,
and lips. Clinically, chronic traumatic ulcers are
seen as superficial or deep solitary lesions
accompanied by varying degrees of loss of
integrity of the epithelial layer, the base of the
ulcer being covered by a yellowish-white fibrin
layer. Ulcers caused by repeated trauma may be
symptomatic or asymptomatic, often showing a
high margin and firm on palpation. When the
cause of the trauma is removed, the lesion can heal
with or without scarring.
Oral mucosal lesions associated with
orthodontic appliances are caused by trauma,
infection, or reactiveness. Traumatic pathologies
cause various clinical forms of lesions depending
on the type of orthodontic appliance used.
Brackets are associated with the appearance
of erosive and keratotic areas caused by friction on
the adjacent mucosa. Arches are often associated
with ulcers caused by hooks piercing the oral
mucosa. The mini screw is often associated with
erythema and erosion.6,7,8
In this case report, an ulcerated lesion
occurred in a patient using fixed orthodontic
appliances. Orthodontic treatment can increase the
risk of soft tissue irritation due to fixed or
removable appliance components.8 Ulceration is
one of the most common problems experienced by
most patients undergoing fixed orthodontic
treatment. Previous studies showed that 75.8% of
Journal of Syiah Kuala Dentistry Society
Case Report
fixed orthodontic appliance wearers had minor
ulcerations, and 2.5% had severe ulcerations.9,10
Fixed orthodontic appliance components
irritate brackets, bracket hooks, bands, tubes,
lingual arches, trans-palatal arch, and wires,
especially the distal part of the wire.3,4 Irritation of
the mucosa occurs due to friction between the
mucosa and the components of the orthodontic
appliance.4 Unpredictable movements of the cheek
and tongue muscles can also exacerbate ulceration.
Brackets can cause erosion and desquamation of
the mucosa, whereas wires can cause
ulceration.11,12
The epithelium damaged by the lesion
exposes nerve endings to the sensation of pain.
Previous studies have focused more on pain
caused by tooth movement than the pain caused
by lesions.12 Characteristics of mucosal pain are
stinging, stinging, or burning, and patients can
usually pinpoint the cause of the pain.13
The location of ulcers caused by the use of
orthodontic appliances is the buccal and vestibular
mucosa. In a study by Gupta et al., as many as
56.6% of traumatic ulcer lesions were found on the
buccal mucosa. Research conducted by Baricevic et
al. and Travess et al. stated that ulcers that occur in
patients using fixed orthodontic appliances are
caused by friction of the archwire and bond or
wire resting on the mucosa. 4.14
Treatment of traumatic ulceration consists of
preventive and definitive therapy.15 Treatments
commonly used in traumatic ulcer lesions caused
by fixed orthodontic appliances are chlorhexidine
gluconate (CHx), topical corticosteroids,
hyaluronic acid, and orthodontic wax used as an
interceptive element.16 The easiest way to treat
traumatic ulcerations is to identify and eliminate
the cause. In fixed orthodontic treatment, it is not
possible to remove the bracket. Therefore, a barrier
is made between the source of irritation
JDS 2022; 7(1): 69-72
71
Ossa et.al.
Treatment of traumatic ulcer induced by fixed orthodontic appliance
and the adjacent mucosa to reduce friction.
Orthodontists commonly use waxes without
medication to cover frames or other components
that cause ulceration.13,15 Research has shown that
waxes containing benzocaine are more effective at
reducing pain than waxes without medication.13
CONCLUSION
Orthodontic treatment can cause traumatic
ulcers anywhere in the oral cavity. Traumatic
ulcers caused by orthodontic appliances are
chronic, so healing takes longer. Treatment for
REFERENCES
[1]. Ellis PE, Benson PE. Potential hazards of
orthodontic treatment--what your patient
should know. Dent Update. 2002;29(10):492–6.
[2]. Lau PY-L, Wong RW-K. Risks and
complications in orthodontic treatment. Hong
Kong Dent J. 2006;3(1):15–22.
[3]. Akbari G, Dewi TS, Malik I. Traumatic ulcer
distribution of patiens with removable
orthodontic appliance in Orthodontics Clinics
of Dental Specialist Program. Padjadjaran J
Dent. 2014;26(1):81–6.
[4]. Gupta R, Mahajan N, Jandial S, Kotwal B,
Kaur S, Kharyal S. Incidence of Oral Ulcers in
Patients undergoing Orthodontic Treatment.
Int J Prev Public Heal Sci. 2017;3(2):31–4.
[5]. Anura A. Traumatic oral mucosal lesions; a
mini review and clinical update. OHDM. 2014
(13); 254-259
[6]. Mehrotra, R. et al. Prevalence of oral soft
tissue lesions in Vidisha. BMC Res. Notes
2010;3:23
[7]. Wang Z, Zhang D, Liu Y, Zhao Z. Buccal
mucosal lesions caused by the interradicular
miniscrew: A preliminary report. Int J Oral
Maxillofac Implants 2010;25(6):1183-1188
[8]. Sicard L, et al. Orthodontics and oral mucosal
lesions in children and teenagers. J
Dentofacial Anom Orthod. 2018;21:1-13
[9]. Baricevic M, Mravak-Stipetic M, Majstorovic
M, Baranovic M, Baricevic D, Loncar B, et al.
Oral mucosal lesions during orthodontic
treatment. Int J Paediatr Dent 2011;21:96-102.
72
Journal of Syiah Kuala Dentistry Society
Case Report
Another way is to remove sensitive parts of the
components. The abrupt end of the wire at the
distal buccal tube is cut or bent towards the
gingiva. The ligature wire is tilted under the wire
or bracket to avoid irritation.13.16
traumatic ulcers is carried out comprehensively by
involving an orthodontist and an oral medicine
specialist to produce a more optimal treatment.
[10]. Kvam E, Bondevik O, Gjerdet NR. Traumatic
ulcers and pain in adults during orthodontic
treatment. Community Dent Oral Epidemiol.
1989;17(3):154–7.
[11]. AlDahash F, AlShamali D, AlBander W,
Bakhsh R, AlMadhi W, AlSenani S. Oral
mucosal ulceration during orthodontic
treatment: The perception of patients and
knowledge and attitude of the orthodontic
practitioners. J Fam Med Prim Care.
2020;9(11):5537–41.
[12]. 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.
[13]. Kluemper GT, Hiser DG, Rayens K, Jay MJ.
Efficacy of a wax containing benzocaine in the
relief of oral mucosal pain caused by
orthodontic appliances. Am J Orthod
Dentofac Orthop. 2002;122(4):359–65.
[14]. Travess H, Roberts-Harry D, Sandy J.
Orthodontics. Part 6: Risks in orthodontic
treatment. Br Dent J 2004;196:71-7
[15]. Mainali A. Occurrence of Oral Ulcerations in
Patients undergoing Orthodontic Treatment :
A Comparative study. Orthod J Nepal.
2013;3(2):32–5.
[16]. Leiva-Cala C, et al. Clinical efficacy of an aloe
vera gel versus a 0.12% chlorhexidine gel in
preventing traumatic ulcer in patients with
fixed orthodontic appliance; a double-blind
randomize clinical trial. Odontology.2020;
108: 470-478.