Pharmacological interventions for pain relief during orthodontic treatment

Personality traits, pain perception, and patient attitudes toward orthodontic treatment with fixed appliances

Background

Orthodontic pain is defined as orofacial pain induced by orthodontic tooth movement. The application of orthodontic forces activates periodontal sensory receptors, resulting in a cascade of nociceptive pain processing and transduction in both the central and peripheral nervous systems, which is eventually felt by patients. The purpose of this study was to evaluate the association between pain perception, pressure pain threshold (PPT), attitude toward orthodontic treatment, and personality traits in adolescents treated with fixed orthodontic appliances.

Methods

The study involved 60 subjects aged 16 to 18 year-olds divided into 2 groups: group 1 consisted of 30 patients undergoing orthodontic treatment with fixed orthodontic appliances, and group 2 consisted of 30 untreated subjects. The tool for data collection was a questionnaire that assessed pain experience for treated subjects, pain expectation for untreated subjects, and attitude toward treatment using a visual analog scale (VAS) marked at 10-mm intervals. The assessment of patients' personality profiles was carried out using the NEO Five-Factor Inventory (NEO-FFI). PPT was measured using a digital force algometer. The results were subjected to statistical analysis. The significance threshold was established at p < 0.05.

Results

The multivariate analysis showed that treatment status was the only variable affecting patients' average attitude scores and average pain experience/expectation scores measured using a VAS, and average PPT scores (p < 0.0001). Gender and personality traits did not affect PPT scores, pain intensity, and attitude toward treatment (p > 0.05). The results of the follow-up univariate analysis demonstrated a significant difference in the patients' average attitude toward treatment (p = 0.017) and PPT scores (p < 0.0001) between the treated and untreated groups.

Conclusion

Orthodontic treatment may impact the pressure pain thresholds measured using algometry and patient attitudes toward treatment. This knowledge is essential for orthodontists and patients, as the success of orthodontic treatment largely depends on the patient's cooperation and motivation, which may be affected by patient's attitude toward treatment and pain perception. This, in turn, encourages the search for effective methods of pain reduction during orthodontic treatment and attention to communication between orthodontists and patients for a good understanding of the procedures used.

Self-reported pain during different phases of orthodontic treatment with fixed appliance: A multi-centre randomized controlled trial in adolescents with crowding

OBJECTIVES

To compare self-reported pain levels across various treatment phases using passive self-ligating (Damon) and conventional (Victory) standardized fixed appliance systems.

MATERIALS AND METHODS

Adolescents (12-17 years old) with crowding and displaced teeth, planned for non-extraction treatment, were recruited from four orthodontic clinics. They were randomized into stratified blocks (1:1 ratio) using concealed allocation to receive Damon Q™ (34 boys, 28 girls) or Victory™ (39 boys, 31 girls). Pain and analgesic intake were assessed on seven different occasions with validated self-report questionnaires using a 10-grade scale.

RESULTS

Of the 132 patients included, six were lost to follow up. Clinically relevant mean pain scores (≥4) were registered in both groups after bonding upper and lower arches and after insertion of 0.019 × 0.025 stainless steel archwire. The highest mean scores were reported on day two after bonding the upper arch (Damon 5.96, Victory 7.18, P = .011). In both groups, at least 40% reported taking analgesics during various treatment phases. The Damon group reported a lower intake of analgesics on days one and two (P = .042 and .037) after treatment initiation. In the entire sample, boys reported significantly higher mean pain scores than girls on the second and third days after bonding (P = .008 and .026, respectively).

CONCLUSIONS

Lower pain levels were reported from the Damon group after bonding. In general, boys reported higher pain than girls did. Clinicians and adolescents need to be aware that clinically relevant pain levels can be expected not only after bonding but also in later phases.

Nociceptor mechanisms underlying pain and bone remodeling via orthodontic forces: toward no pain, big gain

Orthodontic forces are strongly associated with pain, the primary complaint among patients wearing orthodontic braces. Compared to other side effects of orthodontic treatment, orthodontic pain is often overlooked, with limited clinical management. Orthodontic forces lead to inflammatory responses in the periodontium, which triggers bone remodeling and eventually induces tooth movement. Mechanical forces and subsequent inflammation in the periodontium activate and sensitize periodontal nociceptors and produce orthodontic pain. Nociceptive afferents expressing transient receptor potential vanilloid subtype 1 (TRPV1) play central roles in transducing nociceptive signals, leading to transcriptional changes in the trigeminal ganglia. Nociceptive molecules, such as TRPV1, transient receptor potential ankyrin subtype 1, acid-sensing ion channel 3, and the P2X3 receptor, are believed to mediate orthodontic pain. Neuropeptides such as calcitonin gene-related peptides and substance P can also regulate orthodontic pain. While periodontal nociceptors transmit nociceptive signals to the brain, they are also known to modulate alveolar bone remodeling in periodontitis. Therefore, periodontal nociceptors and nociceptive molecules may contribute to the modulation of orthodontic tooth movement, which currently remains undetermined. Future studies are needed to better understand the fundamental mechanisms underlying neuroskeletal interactions in orthodontics to improve orthodontic treatment by developing novel methods to reduce pain and accelerate orthodontic tooth movement-thereby achieving "big gains with no pain" in clinical orthodontics.

Comparison of the Effects of Ketorolac and Acetaminophen on RANK-L Levels in the Gingival Crevicular Fluid during Orthodontic Tooth Movement: A Pilot Study

Background: Patients usually present pain due to the release of different inflammatory mediators such as prostaglandin E2 and RANK-L. Analgesics such as acetaminophen and ketorolac can inhibit RANK-L expression and this can affect orthodontic treatment by decreasing bone remodeling and slowing orthodontic dental movement. Several studies have reported a decrease in dental movement after administering some non-steroidal anti-inflammatory drugs. Proposal: The objective was to evaluate the RANK-L levels and a possible modulation by administering acetaminophen and ketorolac in patients starting orthodontic treatment. Methodology: A double-blind, randomized clinical trial was carried out with 24 subjects divided into three study groups: calcined magnesia as a placebo, acetaminophen, and ketorolac. Gingival crevicular fluid was obtained at four time points: before pharmacological intervention, at 24 h, at 48 h, and on the 5th day. RANK-L concentrations were evaluated through ELISA analysis. Also, interproximal space generated by the elastic separator at the end of the study was recorded in the different study groups using the visual analog scale. Results: An increase in RANK-L at 24 h was observed in the placebo group compared to the ketorolac and acetaminophen groups. However, no significant differences were observed in the interproximal space at day 5 in the three study groups. Conclusion: Patients who do not take analgesics at the start of orthodontic treatment have higher levels of RANK-L. Therefore, the use of ketorolac or acetaminophen could decrease bone remodeling and interfere with orthodontic dental movement.

Nanotechnology in Orthodontics: Unveiling Pain Mechanisms, Innovations, and Future Prospects of Nanomaterials in Drug Delivery

Orthodontic pain is characterized by sensations of tingling, tooth discomfort, and intolerance. According to the oral health report, over forty percent of children and adolescents have undergone orthodontic treatment. The efficacy of orthodontic treatment involving braces can be compromised by the diverse levels of discomfort and suffering experienced by patients, leading to suboptimal treatment outcomes and reduced patient adherence. Nanotechnology has entered all areas of science and technology. This review provides an overview of nanoscience, its application in orthodontics, the underlying processes of orthodontic pain, effective treatment options, and a summary of recent research in Nano-dentistry. The uses of this technology in healthcare span a wide range, including enhanced diagnostics, biosensors, and targeted drug delivery. The reason for this is that nanomaterials possess distinct qualities that depend on their size, which can greatly enhance human well-being and contribute to better health when effectively utilized. The field of dentistry has also experienced significant advancements, particularly in the past decade, especially in the utilization of nanomaterials and technology. Over time, there has been an increase in the availability of dental nanomaterials, and a diverse array of these materials have been extensively studied for both commercial and therapeutic purposes.

Effect of chewing gum on orthodontic pain in patients receiving fixed orthodontic treatment: a systematic review and meta-analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to evaluate the effect of chewing gum on orthodontic pain and to determine the rate of bracket breakage associated with fixed orthodontic appliances.

METHODS

This review and its reporting were performed according to the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Six electronic databases were searched up to March 16, 2023, to identify relevant studies that met the inclusion and exclusion criteria. Furthermore, grey literature resources were searched. The Cochrane Collaboration Risk of Bias tool 2 was used to assess the quality of the included studies. Meta-analysis was conducted using RevMan, and sensitivity analysis and publication bias analysis were performed using STATA software. GRADE tool was used to evaluate the certainty of evidence.

RESULTS

Fifteen studies with 2116 participants were ultimately included in this review, and 14 studies were included in the meta-analysis. Compared with the blank group, chewing gum had a significant pain relieving effect at all times after fixation of the initial archwire (P ≤ 0.05). No significant difference was found between the chewing gum group and the analgesics group at any timepoints (P > 0.05). Only four studies evaluated the rate of bracket breakage and revealed that chewing gum did not increase the rate of bracket breakage. The sensitivity analysis showed that there was no significant difference in the pooled outcomes after the included studies were removed one at times, and Egger analysis revealed no significant publication bias in included studies (P > 0.05).

CONCLUSIONS

Chewing gum is a non-invasive, low-cost and convenient method that has a significant effect on relieving orthodontic pain and has no effect on the rate of bracket breakage. Therefore, chewing gum can be recommended as a suitable substitute for analgesics to reduce orthodontic pain.

High-frequency near-infrared semiconductor laser irradiation suppressed experimental tooth movement-induced inflammatory pain markers in the periodontal ligament tissues of rats

High-frequency near-infrared (NIR) semiconductor laser-irradiation has an unclear effect on nociception in the compressed lateral periodontal ligament region, a peripheral nerve region. This study aimed to investigate the effects of NIR semiconductor laser irradiation, with a power of 120 J, on inflammatory pain markers and neuropeptides induced in the compressed lateral periodontal ligament area during ETM. A NIR semiconductor laser [910 nm wavelength, 45 W maximum output power, 300 mW average output power, 30 kHz frequency, and 200 ns pulse width (Lumix 2; Fisioline, Verduno, Italy)] was used. A nickel-titanium closed coil that generated a 50-g force was applied to the maxillary left-side first molars and incisors in 7-week-old Sprague-Dawley (280-300 g) rats to induce experimental tooth movement (ETM) for 24 h. Ten rats were divided into two groups (ETM + laser, n = 5; ETM, n = 5). The right side of the ETM group (i.e., the side without induced ETM) was evaluated as the untreated group. We performed immunofluorescent histochemistry analysis to quantify the interleukin (IL)-1β, cyclooxygenase-2 (COX2), prostaglandin E2 (PGE2), and neuropeptide [calcitonin gene-related peptide (CGRP)] expression in the compressed region of the periodontal tissue. Post-hoc Tukey-Kramer tests were used to compare the groups. Compared with the ETM group, the ETM + laser group showed significant suppression in IL-1β (176.2 ± 12.3 vs. 310.8 ± 29.5; P < 0.01), PGE2 (104.4 ± 14.34 vs. 329.6 ± 36.52; P < 0.01), and CGRP (36.8 ± 4.88 vs. 78.0 ± 7.13; P < 0.01) expression. High-frequency NIR semiconductor laser irradiation exerts significant effects on ETM-induced inflammation. High-frequency NIR semiconductor laser irradiation can reduce periodontal inflammation during orthodontic tooth movement.

Altered Brain Topological Property Associated With Anxiety in Experimental Orthodontic Pain

BACKGROUND

Orthodontic pain is orofacial pain caused by tooth movement. Anxiety is a strong predictor of the severity of such pain, but little is known about the underlying neuropsychological mechanisms of such effects. The purpose of this study was to investigate the effect of orthodontic pain on brain functional networks and to define the mediating role of anxiety in orthodontic pain and brain function.

METHODS

Graph theory-based network analyses were applied to brain functional magnetic resonance imaging data from 48 healthy participants exposed to 24 h orthodontic pain stimuli and 49 healthy controls without any stimulation.

RESULTS

In the experimental orthodontic pain stimulation, brain functional networks retained a small-world organization. At the regional level, the nodal centrality of ipsilateral brain nodes to the pain stimulus was enhanced; in contrast the nodal centrality of contralateral brain areas was decreased, especially the right mid-cingulate cortex, which is involved in pain intensity coding. Furthermore, anxiety mediated the relationship between nodal efficiency of mid-cingulate cortex and pain severity.

CONCLUSION

The results illuminate the neural mechanisms of orthodontic pain by revealing unbalanced hemispherical brain function related to the unilateral pain stimulation, and reveal clinically exploitable evidence that anxiety mediates the relationship between nodal function of right mid-cingulate cortex and orthodontic pain.

Role of the general dental practitioner in managing the risks of orthodontic treatment

The aim of this article is to outline the potential risks in orthodontic treatment and the general dental practitioner's role in reducing and managing such risks. The success of orthodontic treatment largely depends on patient understanding of the risk/benefit implications of the orthodontic treatment and all of the potential consequences involved in such treatment. A perfect blend of good case selection, sound clinical judgement and, more importantly, a patient's clear understanding of the potential risks involved and the treatment implications help minimise and manage potential hazards that occur during the course of the treatment.

Chewing gum as a non-pharmacological alternative for orthodontic pain relief: A randomized clinical trial using an intention-to-treat analysis

Objective

To compare the effectiveness of ibuprofen, acetaminophen, and chewing gum for orthodontic pain relief and to assess if chewing gum can be a non-pharmacological alternative for orthodontic pain relief.

Methods

The study enrolled 106 patients of both sexes, aged ≥ 12 years, with body weight > 50 kg, and mild-to-moderate dental crowding in the upper arch. After randomization and allocation concealment, the intervention groups were either administered with ibuprofen (400 mg) or acetaminophen (500 mg) or chewed sugar-free chewing gum immediately after initial archwire placement and every 6 hours for 1 week if the pain persisted. The control group did not receive any pain relief. The pain was assessed on a 100-mm visual analog scale at rest and while biting down at T1 (2 hours), T2 (24 hours), T3 (2 days), T4 (3 days), T5 (7 days), and T6 (21 days). Statistical analyses were performed using the Kruskal–Wallis and post-hoc Mann–Whitney U tests (α = 0.05).

Results

The chewing gum group experienced more pain relief than the ibuprofen group at while biting down at T3 (p = 0.04) and at rest at T4 (p < 0.001). The chewing gum group reported more pain relief than the acetaminophen and control groups while biting down at T3 (p = 0.03 and p = 0.0006, respectively) and T4 (both p < 0.001).

Conclusions

Chewing gum can be a non-pharmacological alternative for orthodontic pain relief at 2 and 3 days after initial archwire placement.

Cortical representation of experimental periodontal pain: a functional magnetic resonance imaging study

The aim of this study was to investigate central pain representations during loading of the periodontium induced by orthodontic and occlusal stress. Nineteen healthy male volunteers (25.7 ± 2.8 years) were tested on two consecutive days: after phenotyping (questionnaires) and determination of warmth (WPT) and heat (HPT) pain thresholds, functional magnetic resonance imaging was performed as event-related paradigm including 36 tooth clenchings of 3 s duration, alternating with rest periods varying between 20–30 s. The task was performed in absence (T1) and 24 h after placement of an elastic separator between the second bicuspid and the first molar on the right side of the lower jaw (T2). No significant changes in WPT and HPT were observed but pain ratings were significantly elevated at T2. Significantly elevated activation at T2, as compared to T1, was found in bilateral sensorimotor cortex, bilateral secondary sensory cortex, supplementary motor area, right rolandic operculum, and bilateral insula. Our data show for the first time in humans that periodontal stimulation, as tested by tooth clenching in the presence of an elastic separator, goes along with specific expressions of pain at behavioral and neuronal network levels. Findings supplement the existing neuroimaging literature on odontogenic pain.

A randomized, single-blind, placebo-controlled trial to evaluate the effectiveness of verbal behavior modification and acetaminophen on orthodontic pain

OBJECTIVES

To evaluate the effectiveness of verbal behavior modification, acetaminophen, and the combined effectiveness of verbal behavior modification along with acetaminophen on orthodontic pain.

MATERIALS AND METHODS

One hundred and forty orthodontic fixed appliance patients were randomly assigned to four groups. Group A was administered acetaminophen, group B was given verbal behavior modification, group C was administered acetaminophen as well as verbal behavior modification, and group D was placebo-controlled. A visual analog scale was used to assess pain intensity after 1 week of separator placement.

RESULTS

Group A had less mean pain intensity when compared to group B at 6 hours (P < .001) and at 1 (P < .001) and 2 (P = .002) days. Group C patients encountered less mean pain intensity when compared to group B patients at 6 hours (P < .001) and at 1 (P < .001), 2 (P < .001), and 4 (P = .001) days. There was a statistically significant difference between groups A and C (group C experienced less pain intensity) after 6 hours (P = .004) and at day 4 (P = .009) after separator placement.

CONCLUSIONS

Acetaminophen is the main agent of orthodontic pain reduction after separator placement, with verbal behavior serving as an adjunct to it.