Orthodontic Appliance Type and Oral Malodor Burden: Cross-Sectional Comparison of Clear Aligners, Fixed Braces, and Untreated Controls.

Background and

Objectives

Halitosis can impair psychosocial well-being, and orthodontic appliances may modify plaque retention and oral ecology. We compared patient-perceived halitosis burden, clinician-rated malodor, and oral health-related quality of life (OHRQoL) among clear aligner users, fixed-brace patients, and untreated controls, and explored oral and salivary correlates of worse malodor severity.

Methods

This cross-sectional study (March 2024-November 2025) enrolled 184 participants aged 15-35 years (aligners n = 62; fixed braces n = 64; controls n = 58). Outcomes were HALT (0-100), organoleptic score (0-5), and OHIP-14 (0-56). Plaque index, gingival inflammation, tongue coating, and unstimulated salivary flow were recorded; low flow was defined as <0.25 mL/min. Organoleptic score ≥ 2 was used descriptively for clinically relevant malodor prevalence, whereas organoleptic score ≥3 defined a moderate-to-severe malodor phenotype for secondary exploratory internal modeling. Multivariable robust linear models (HALT) and proportional-odds ordinal logistic regression (organoleptic severity) were used.

Results

Fixed braces showed higher HALT (53.7 ± 6.2) than controls (46.3 ± 6.4) and aligners (41.7 ± 7.4) (p < 0.001), higher organoleptic scores (2.9 ± 0.4 vs. 2.4 ± 0.6 vs. 2.2 ± 0.6; p < 0.001), and worse OHIP-14 (18.6 ± 4.7 vs. 15.9 ± 4.3 vs. 13.8 ± 4.8; p < 0.001). Clinically relevant malodor prevalence (organoleptic ≥ 2) was 96.9% in fixed braces, 79.3% in controls, and 66.1% in aligners (p < 0.001); because ≥2 was used as a broad descriptive threshold, these values should be interpreted as descriptive rather than diagnostic prevalence estimates. In adjusted models, greater tongue coating, higher plaque, and low salivary flow were associated with worse organoleptic severity, whereas appliance category did not remain independently associated with HALT once concurrent clinical correlates were included.

Conclusions

Fixed braces showed higher unadjusted malodor burden and worse OHRQoL than aligners and untreated controls, but appliance category should be interpreted as a contextual exposure linked to plaque-retentive conditions rather than as a standalone causal determinant. Plaque accumulation, tongue coating, and lower salivary flow showed the strongest associations with worse malodor severity. These findings should be interpreted in light of the cross-sectional design, possible observer and selection bias, and residual confounding.