Orthodontic braces are not inherently bad, but they do carry a real list of side effects and risks that patients rarely hear about in full before treatment begins. Pain affects roughly 90% of patients, and about 30% consider quitting treatment because of it.1Frontiers in Pain Research. Nociceptor mechanisms underlying pain and bone remodeling via orthodontic forces: toward no pain, big gain Beyond discomfort, braces can damage tooth roots, change the bacterial landscape in your mouth, weaken enamel, and trigger gum inflammation. Most of these issues are manageable or reversible, but a few are not, and the distinction matters when you are deciding whether to commit to a treatment that typically lasts one to three years.
Pain and Its Impact on Daily Life
The single most common complaint about braces is pain. It tends to peak within the first day or two after brackets are placed or adjusted, then gradually fades over the following week. One study tracking patients from the first day through two weeks found that pain levels were significantly higher with fixed braces than with clear aligners on days one, two, four, and five, and that the impact on daily quality of life was also worse in the fixed-appliance group at one day, one week, and two weeks.2European Journal of Orthodontics. Comparison of pain perception, anxiety, and impacts on oral health-related quality of life between patients receiving clear aligners and fixed appliances during the initial stage of orthodontic treatment Another study found that a week after braces were placed, about 68% of patients reported discomfort while eating and 67% had a sore jaw. At one month, those numbers had dropped significantly, though they had not returned to where they were before treatment.3Journal of Dental Sciences. Oral health-related quality of life in orthodontic patients during initial therapy with conventional brackets or self-ligating brackets
The pain is not just an annoyance. It affects eating, sleep, mood, and even work or school performance. Overall quality of life scores deteriorated by about 44% in the first week of treatment, improving to about a 14% decline at one month relative to baseline.3Journal of Dental Sciences. Oral health-related quality of life in orthodontic patients during initial therapy with conventional brackets or self-ligating brackets This pattern repeats with each adjustment appointment, though most patients say the intensity drops as treatment progresses. Over-the-counter pain relievers and orthodontic wax help, but the reality is that you will be dealing with recurring bouts of soreness for the entire treatment period.
Root Resorption
One of the less visible risks of braces is external apical root resorption, which means the tips of your tooth roots get shorter. This happens because the forces that move teeth through bone also trigger the body’s cells to break down small amounts of root structure. It is considered one of the most common side effects of orthodontic treatment and cannot be completely avoided or predicted.4PubMed Central. External apical root resorption in orthodontic tooth movement: the risk factors and clinical suggestions from experts’ consensus In most patients, the shortening is minor and has no practical consequences. But in a small percentage of cases, root loss can be severe enough to compromise the tooth’s long-term stability.
Who gets significant resorption and who does not involves a mix of factors. Treatment-related variables include the type and magnitude of force applied, the duration of treatment, and the distance teeth need to move. Patient-related variables are harder to control: some people appear to have a genetic predisposition that makes their roots more vulnerable, sometimes overshadowing the treatment factors entirely.5PubMed Central. External apical root resorption in orthodontic patients: molecular and genetic basis Teeth that already have blunted or unusually shaped roots before treatment are at higher risk. Upper front teeth tend to be the most affected. Orthodontists typically monitor root length with periodic X-rays during treatment, and can modify the plan if resorption is progressing faster than expected.6PubMed Central. Apical root resorption caused by orthodontic forces: A brief review and a long-term observation
White Spot Lesions and Enamel Damage
If you have ever seen someone get their braces off and noticed chalky white patches on the teeth where the brackets used to be, those are white spot lesions. They represent early-stage enamel demineralization caused by acid-producing bacteria that thrive around brackets and wires. Teeth with bonded or banded orthodontic attachments show a significantly higher rate of these lesions compared to untreated teeth, because the hardware creates sheltered niches where bacterial biofilm accumulates and is difficult to clean away.7PubMed Central. Prevention and Treatment of White Spot Lesions in Orthodontic Patients White spot lesions are one of the most common complications of fixed orthodontic treatment and can undermine the cosmetic result of an otherwise successful case.8PubMed Central. Risk factors and management of white spot lesions in orthodontics
The good news is that mild white spots can partially remineralize over time with fluoride exposure and good oral hygiene. The bad news is that more pronounced lesions often persist and may need cosmetic treatment such as resin infiltration or microabrasion after braces come off. Prevention is far more effective than treatment: fluoride varnishes applied by the orthodontist, prescription-strength fluoride toothpaste, and careful brushing around every bracket all reduce the risk. Patients with poor oral hygiene habits, high sugar intake, or low salivary flow are the most vulnerable.
Gum Health and the Oral Microbiome
Braces change the ecology of your mouth. The brackets, bands, and wires create surfaces that bacteria colonize readily, and they make it harder to brush and floss effectively. A retrospective study of patients treated with fixed appliances found significant increases in visible plaque, gum inflammation, and gum recession after treatment.9PubMed Central. Relationship between orthodontic treatment and gingival health: A retrospective study These changes are not just cosmetic: gum recession, once established, does not reverse on its own.
The bacterial shifts go deeper than surface plaque. Research on patients with fixed appliances has found that bacteria linked to periodontal disease, including species of Prevotella, Porphyromonas, and Selenomonas, become significantly more abundant after braces are placed. Most of the bacteria that increase are obligate anaerobes, the kinds that thrive in the oxygen-poor pockets created by orthodontic hardware.10Scientific Reports. The impact of fixed orthodontic appliances on oral microbiome dynamics in Japanese patients A systematic review comparing braces to clear aligners confirmed this pattern: fixed appliances showed increases in pathogenic bacteria and worse periodontal indices, while clear aligners maintained a less harmful microbial balance.11PubMed Central. Changes in the Oral Microbiota with the Use of Aligners vs. Braces: A Systematic Review
For most patients, these microbiome shifts are temporary and resolve after braces are removed, especially with consistent hygiene. But patients who already have periodontal disease, compromised immunity, or difficulty maintaining oral hygiene face a higher risk of lasting damage. Interdental brushes, water flossers, and more frequent dental cleanings during treatment all help keep things in check.
A Transient Inflammatory Response Beyond the Mouth
Braces do not just inflame the gums. At least one study has documented a brief whole-body inflammatory response after fixed appliances are placed. White blood cell counts rose by about 12% and high-sensitivity C-reactive protein (an inflammation marker) rose by about 18% within the first month. By six months, both measures had largely returned to baseline, though the inflammation marker remained slightly elevated.12PubMed Central. Impact of Fixed Orthodontic Appliances on Blood Count and High-Sensitivity C-Reactive Protein Levels This is a modest, self-resolving effect, but it is worth knowing about if you have a condition where even small inflammatory spikes matter.
What Happens When Brackets Come Off
Removing brackets is not risk-free either. The bonding material that glues brackets to enamel has to be cracked loose, and that process can leave tiny enamel microcracks. A meta-analysis of lab studies found strong evidence that the number of enamel microcracks increases after debonding, and weaker evidence that the cracks also grow in length.13European Journal of Orthodontics. Enamel microcracks in the form of tooth damage during orthodontic debonding: a systematic review and meta-analysis of in vitro studies An in-vivo study examining actual patients’ teeth confirmed that visible microcracks in premolars increased after metal brackets were removed, with cracks recorded in at least a quarter of evaluated teeth.14PubMed. In vivo examination of enamel microcracks after orthodontic debonding: Is there a need for detailed analysis?
Whether these microcracks cause any real problems is a separate question. Enamel is already full of microscopic imperfections before treatment, and most debonding-related cracks appear to be superficial. There is no strong evidence linking them to tooth fractures or decay later in life. Still, aggressive removal techniques carry a higher risk, and ceramic brackets tend to be harder to remove cleanly than metal ones. If you are concerned, ask your orthodontist about their debonding protocol.
Allergic Reactions to Orthodontic Materials
Some people develop allergic reactions to the metals in their braces, and nickel is the usual culprit. Nickel is present in many stainless steel components used in orthodontics, and an allergy to it can cause mouth sores, gum swelling, and a burning sensation. The reaction is more common in women, likely because prior contact with nickel-containing jewelry serves as a sensitizing exposure.15PubMed Central. Allergy and orthodontics If you already know you react to costume jewelry or belt buckles, mention it before treatment starts. Nickel-free and titanium alternatives exist for nearly every orthodontic component, though they tend to be more expensive.
The Jaw Joint Question
A persistent worry is whether braces cause or worsen temporomandibular disorders, the collection of problems that produce jaw clicking, pain, and limited opening. A systematic review and meta-analysis found a statistically significant association between orthodontic treatment and the occurrence of TMD symptoms, with roughly 84% higher odds compared to no treatment.16PubMed Central. Association between orthodontic treatment and the occurrence of temporomandibular disorders: A systematic review and meta-analysis That sounds alarming, but the picture is complicated. TMD is extremely common in the general population, it often develops in the same age range when people are undergoing orthodontic treatment, and the relationship between bite alignment and jaw joint symptoms is still debated. Some patients find that correcting their bite actually reduces TMD symptoms, while others develop them for the first time during treatment. If you have a history of jaw pain or clicking, a thorough TMD evaluation before starting braces is a sensible step.
The Extraction and Airway Debate
In cases of severe crowding or protruding teeth, orthodontists sometimes extract premolars to create space for alignment. A concern that surfaces regularly online is whether pulling teeth and retracting the front teeth backward narrows the airway and raises the risk of sleep-disordered breathing. One study on adolescents with protruding upper and lower jaws found that after extraction of four premolars, airway dimensions in several regions did become narrower and the hyoid bone shifted backward and downward.17PubMed Central. Effects of first premolar extraction on airway dimensions in young adolescents: A retrospective cephalometric appraisal
However, other studies reach different conclusions. A study looking at extraction of second premolars in adult women found a significant increase in vertical airway length but no significant changes in other airway measurements.18The Saudi Dental Journal. Evaluation of the airway space changes after extraction of four second premolars and orthodontic space closure in adult female patients with bimaxillary protrusion – A retrospective study And a study that integrated both imaging and subjective sleep quality assessments concluded that extraction treatment and incisor retraction did not affect pharyngeal airway dimensions and did not worsen patients’ sleep quality or their risk of obstructive sleep apnea.19Scientific Reports. Evaluation of pharyngeal airway space after orthodontic extraction treatment in class II malocclusion integrating with the subjective sleep quality assessment The evidence here is genuinely mixed, and the answer probably depends on the patient’s anatomy, which teeth are extracted, and how much retraction is planned. If airway health is a concern for you, discuss it with your orthodontist and consider a sleep screening before treatment.
Swallowed or Inhaled Appliance Parts
It sounds dramatic, but patients occasionally swallow brackets, bands, or small pieces of wire that come loose during treatment. Most swallowed components pass through the digestive tract without incident, but an evidence-based review of case reports found that roughly 10% to 20% of ingested orthodontic materials lacerate the oral, throat, or gastrointestinal lining, causing pain and bleeding that may require endoscopic or surgical retrieval.20Journal of Indian Orthodontic Society. Effects of Accidental Swallowing of Orthodontic Appliance on Gastrointestinal Tract and Airway: An Evidence-Based Review of Case Reports Aspiration into the airway is rarer but more dangerous. The majority of ingestion incidents involve components that had visibly fractured or detached during treatment.21PubMed Central. Ingestion of orthodontic appliances: A literature review If something breaks loose in your mouth during an appointment, tell the orthodontist immediately rather than assuming it is harmless.
Time, Money, and the Burden of Treatment
Even if you set health risks aside, braces impose a substantial practical burden. Treatment with traditional brackets typically spans 18 to 30 months, requires adjustment appointments every few weeks, and demands a level of daily oral hygiene effort that many patients underestimate. In one survey, about 72% of respondents felt orthodontic treatment takes too long, and 51% wished it could be completed in under six months.22PubMed Central. Young Adults’ Preferences and Willingness to Pay for Invasive and Non-invasive Accelerated Orthodontic Treatment: A Comparative Study
Cost is another barrier. Orthodox treatment runs into the thousands of dollars in most countries, and cases requiring jaw surgery multiply the expense further. A systematic review of the socioeconomic burden of orthodontics found that families with lower socioeconomic status are more likely to discontinue treatment, likely due to financial constraints and the cumulative time cost of frequent clinic visits.23PubMed Central. Socioeconomic burden of orthodontic treatment: a systematic review Treatment that combines orthodontics with surgical correction is especially demanding, requiring visits to dental specialists every one to two months and frequent absences from work or school.24European Journal of Orthodontics. Costs and duration of orthodontic-surgical treatment with mandibular advancement surgery For adults balancing jobs and families, the logistical load is a real downside that deserves honest discussion upfront.
Clear Aligners as an Alternative
For patients spooked by the risks above, clear aligners are an obvious question. They are not a universal substitute for fixed braces, since some complex movements still require brackets, but where they are an option, they do perform better on several of the downsides discussed here. A meta-analysis found that clear aligners produced significantly better periodontal outcomes than fixed appliances across plaque levels, gum inflammation, and probing depth.25PubMed. Periodontal health during orthodontic treatment with clear aligners and fixed appliances: A meta-analysis Pain and quality-of-life scores are also consistently better in the aligner group during the initial weeks of treatment.2European Journal of Orthodontics. Comparison of pain perception, anxiety, and impacts on oral health-related quality of life between patients receiving clear aligners and fixed appliances during the initial stage of orthodontic treatment Because aligners are removable, there is no hardware trapping plaque against enamel all day, which reduces the risk of white spot lesions and the microbiome shifts associated with fixed appliances.
That said, aligners have their own set of limitations. They require discipline, since you need to wear them 20-plus hours per day for the prescribed duration. They are generally more expensive than traditional braces for equivalent complexity. Root resorption can still occur with aligner treatment, because it is driven by the forces on teeth, not the delivery mechanism. And for cases involving significant skeletal discrepancy, impacted teeth, or complex three-dimensional tooth movements, fixed braces remain the more reliable tool.
Facial Changes After Treatment
One dimension that patients rarely think of as a “risk” but sometimes experience as one is the change in facial appearance that comes with orthodontic treatment. Moving teeth repositions the lips and soft tissue profile, and the result is not always what the patient expected. A retrospective study evaluating facial attractiveness ratings before and after orthodontic treatment found that profile ratings improved by an average of about 0.86 points on a 10-point scale, and overall ratings improved by about 0.71 points. Frontal attractiveness also improved, though by a smaller margin.26PubMed Central. Impact of orthodontic-induced facial morphology changes on aesthetic evaluation: a retrospective study In the profile view, the most prominent changes were inward retraction of the lips and slight chin protrusion.
For patients with protrusive teeth, this lip retraction is usually considered an improvement. But some patients, particularly those who did not start with prominent lips, feel that post-treatment retraction made their face look flatter or their nose appear larger by comparison. These perceptions are subjective and hard to predict. It is worth asking your orthodontist to show you digital simulations or cephalometric predictions before agreeing to a treatment plan that involves significant retraction, especially if extractions are part of the picture. The teeth may end up perfectly aligned while the face looks different from what you imagined.
Why Crowding Happens in the First Place
Understanding why so many people need braces in the first place puts the risk-benefit calculation in perspective. Dental crowding is not just genetic bad luck. Research in anthropology and developmental biology has found that as human populations shifted from hunter-gatherer lifestyles to agricultural and modern diets, jaws consistently became shorter and broader. The soft, processed foods we eat today require less chewing force, and that reduced mechanical demand during childhood appears to lead to underdeveloped jaws that cannot accommodate all the teeth they are genetically programmed to grow.27PubMed Central. Asynchronous dentofacial development and dental crowding: a cross-sectional study in a contemporary sample of children in France In other words, the mismatch is partly environmental. This has fueled interest in myofunctional therapy, early palatal expansion in children, and encouraging harder food textures during jaw development as potential preventive strategies, though none of these have the evidence base to replace orthodontic treatment once crowding has already set in.