Mouth Ulcers During Orthodontic Treatment

Two types of ulcer during orthodontic treatment

Patients with braces experience two distinct types of mouth ulcer and it is useful to know the difference. Traumatic ulcers arise when a sharp bracket edge, wire end, or bracket tie rubs repeatedly against the soft tissue of the lips, cheeks, or tongue, creating a small wound that becomes an ulcer. These ulcers are typically located directly opposite an appliance component, are painful when touched, and resolve once the source of trauma is covered or removed. Aphthous ulcers — also called recurrent aphthous stomatitis — are a separate condition unrelated to direct trauma. They are immune-mediated, triggered by stress, hormonal changes, nutritional deficiencies, or unknown systemic factors. Orthodontic treatment can act as a trigger for aphthous ulcers in susceptible individuals. Aphthous ulcers have a characteristic round or oval shape with a grey-white base and a red halo, and can appear anywhere on the oral mucosa, not only at appliance contact points.

How to distinguish traumatic from aphthous ulcers

Location is the most useful distinguishing factor. A traumatic ulcer will be precisely at the point where a bracket or wire is rubbing — typically on the inside of the lower lip, the cheeks opposite the molars, or the tip of the tongue if a lower lingual wire is present. Covering the offending component with orthodontic wax should reduce the pain noticeably within hours and allow healing within several days. An aphthous ulcer by contrast is not associated with a specific appliance contact point — it may appear on the floor of the mouth, the inner surface of the lips, or the soft palate. It does not improve when wax is applied because there is no mechanical cause to address. Aphthous ulcers also have a more distinctive clinical appearance — a well-defined oval base with a red margin — compared with traumatic ulcers, which are often more irregular and superficial.

Treatment options for orthodontic ulcers

For traumatic ulcers, the first step is applying orthodontic wax to cover the offending bracket or wire end. This removes the source of trauma and allows the tissue to heal. Over-the-counter products can speed healing and reduce pain. Bonjela (choline salicylate gel) provides local anaesthesia and mild anti-inflammatory action; it should not be used continuously or in very young patients. Difflam (benzydamine) mouthwash or spray provides topical anaesthetic action and is particularly effective for larger or more painful ulcers. Corsodyl (chlorhexidine gluconate) mouthwash reduces secondary bacterial colonisation of ulcers and may shorten healing time. Saltwater rinses — a teaspoon of salt in a glass of warm water — are a safe and effective first-line remedy that patients can use multiple times per day. Adcortyl in Orabase is a topical corticosteroid paste that can be applied to aphthous ulcers and reduces inflammation; it is available from pharmacies or on prescription.

Orthodontic wax application technique

Orthodontic wax is an effective and immediate remedy for traumatic ulcers. To apply it correctly: ensure the area around the bracket is as dry as possible — blotting with a tissue or cotton wool helps significantly. Pinch off a small piece of wax (roughly the size of a pea), warm it briefly between fingers until it becomes pliable, then press it firmly over the bracket or wire end causing the irritation, moulding it to create a smooth rounded surface. The wax should stay in place for several hours. It will soften while eating and may need to be reapplied after meals. Wax is safe to swallow in small amounts. It should be replaced when it becomes discoloured or comes loose. Some patients prefer silicone-based alternatives to wax, which adhere more reliably to wet surfaces.

When do ulcers during orthodontic treatment indicate an emergency?

Most orthodontic-related ulcers are benign and self-limiting. However, some situations warrant prompt clinical attention. If an ulcer persists for more than 10 to 14 days without signs of healing, it should be assessed by a dentist or orthodontist — persistent non-healing ulcers can occasionally indicate serious pathology and should not be ignored. Multiple rapidly spreading ulcers, ulcers associated with fever or systemic symptoms, or very large ulcers (greater than 1 cm) are also reasons to seek same-day or next-day clinical review. A broken wire end that is lacrating the cheek or tongue and cannot be managed with wax should be addressed by the orthodontic practice as an emergency, as ongoing deep tissue injury can cause significant pain and infection risk.

Prevention strategies for ulcers during treatment

For traumatic ulcers, using orthodontic wax proactively on any bracket that feels sharp — before an ulcer forms — is the most effective prevention strategy. Wax is routinely provided at the bonding appointment and is inexpensive to purchase over the counter. Maintaining good oral hygiene reduces bacterial load in the mouth and supports faster healing if ulcers do occur. For aphthous ulcers, identifying and managing personal triggers helps — common triggers include poor sleep, high stress, acidic foods such as citrus and tomatoes, SLS-containing toothpastes (switching to an SLS-free toothpaste can reduce frequency), and nutritional deficiencies in iron, folate, or vitamin B12. If aphthous ulcers are frequent and severe, a GP or dental review to check for underlying nutritional or systemic causes is worthwhile.

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.