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Orthodontic Pain: From Causes To Management - A Review: Vinod Krishnan
Orthodontic Pain: From Causes To Management - A Review: Vinod Krishnan
2007. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjl081 All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.
SUMMARY Orthodontic pain, the most cited negative effect arising from orthodontic force application, is
a major concern for parents, patients, and clinicians. Studies have reported this reaction to be a major
deterrent to orthodontic treatment and an important reason for discontinuing treatment. Surprisingly this
area, which requires attention in clinical practice as well as in research, is ignored as evidenced by the
scarcity of publications on the topic in comparison with other areas of orthodontic research. This review
Introduction
provides an overview of current management strategies
Pain, which includes sensations evoked by, and reactions employed for alleviating orthodontic pain.
to, noxious stimuli, is a complex experience and often
accompanies orthodontic appointments. This, among the
Orthodontic causes of pain—what are they?
most cited negative effects of orthodontic treatment, is of
major concern to patients as well as clinicians (Oliver and It is clear from the existing literature that all orthodontic
Knapman, 1985; Kluemper et al., 2002) and is evident in procedures such as separator placement, archwire placement
recent publications (Asham and Southard, 2004; Keim, and activations, application of orthopaedic forces and
2004). Surveys performed to determine the experience of debonding produce pain in patients. It is also clear that fixed
orthodontic pain have rated it as a key deterrent to orthodontic appliances produce more pain than removable or functional
therapy and a major reason for discontinuing treatment appliances and there exists little correlation between applied
(Haynes, 1974; Oliver and Knapman, 1985; Brown and force magnitude and pain experienced.
Moerenhout, 1991; Kluemper et al., 2002). One survey rated The various discomforts experienced by patients after
pain as the greatest dislike during treatment and fourth appliance placement are often described by them as feelings
among major fears and apprehensions prior to orthodontic of pressure, tension, soreness of the teeth, and pain as such
treatment (O’Connor, 2000). (Ngan et al., 1989). Clinicians usually respond to the most
Pain is a subjective response, which shows large frequently asked question ‘Will it hurt?’ with the answer
individual variations. It is dependent upon factors such as ‘There may be some discomfort associated with all
age, gender, individual pain threshold, the magnitude of the orthodontic procedures such as placement of separators,
force applied, present emotional state and stress, cultural archwire placement and activations, elastic wear and
differences, and previous pain experiences (Ngan et al., debonding’. The two most important parts of orthodontic
1989; Brown and Moerenhout, 1991; Scheurer et al., 1996; pain—its duration and intensity are often ignored. It is
Firestone et al., 1999; Bergius et al., 2000). Surveys known that the above-mentioned procedures will cause pain
regarding the percentage of patients experiencing pain have but what is not known is ‘why they cause pain?’ It is reported
reported values ranging from 70 (Caucasian population) to 95 that orthodontic procedures will reduce the proprioceptive
(Asian population) per cent (Oliver and Knapman, 1985; Kvam and discriminating abilities of the patients for up to 4 days,
et al., 1989; Lew, 1993; Scheurer et al., 1996; Firestone which result in lowering of the pain threshold and disruption
et al., 1999). One report has even stated that 8 per cent of a of normal mechanisms associated with proprioception input
study population discontinued treatment because of pain from nerve endings in the periodontal ligament (PDL; Soltis
(Patel, 1989). Surprisingly, this important area, in clinical et al., 1971). At the same time, there will be pressure,
practice as well as research, is ignored, as evidenced by the ischaemia, inflammation, and oedema in the PDL space
scarcity of publications. This review is an attempt to (Furstman and Bernick, 1972).
organize the existing literature regarding pain, which Burstone (1962) reported an immediate and delayed
appears as part of orthodontic mechanotherapy, and attempts painful response after orthodontic force application. He
to address questions that might arise in a clinical setting attributed the initial response to compression and the
from the viewpoint of clinicians and patients/parents. It also delayed response to hyperalgaesia of the PDL. This
ORTHODONTIC PAIN 171
hyperalgaesia has been related to prostaglandins (PGEs), scores. The pain will usually last for 2–3 days and will
which make the PDL sensitive to released algogens such as gradually decrease in its intensity by fifth or sixth day (Jones
histamine, bradykinin, PGEs, serotonin, and substance P and Chan, 1992a, b).
(Ferreira et al., 1978; Polat et al., 2005). It is clear that all Comparing various archwires to determine differences in
orthodontic procedures will create tension and compression pain perception showed no statistically significant results.
zones in the PDL space resulting in a painful experience for No difference in the intensity, prevalence, or duration of
the patients. pain between different archwires was found (Jones and
Richmond, 1985; Fernandes et al., 1998; Erdinç and Dinçer,
Orthodontic separation and pain 2004). Erdinç and Dinçer (2004), in agreement with others
(Ngan et al., 1989, 1994; Scheurer et al., 1996), found that
Creating space mesially and distally to teeth, which are to
patients reported more pain experience in anterior than in
be banded, forms the initial step in fixed orthodontic
posterior teeth because of the differences in root surface
mechanotherapy. It is well-known that placement of
forces for canine retraction, stated that higher forces per muscular nature but a part of the acute inflammatory reaction
unit area increased the rate of biological response. occurring at the sutural regions.
Gianelly and Goldman (1971) argued that large forces
caused greater periodontal compression and thus more Debonding
pain. They stated that some pain accompanies every
Williams and Bishara (1992) evaluated the threshold level
orthodontic appointment. Jones and Richmond (1985)
for patient discomfort at debonding and concluded that
evaluated the relationship between initial tooth positions,
tooth mobility and force application were the two important
applied force levels, and experienced pain but observed
influencing factors. They found intrusive forces to produce
no statistically significant correlation among the three
less pain at debonding in comparison with forces applied in
parameters. Those authors suggested that the degree of
a mesial, distal, facial, lingual, or extrusive direction. They
displacement of the tooth from the archwire to indicate
suggested applying finger pressure or asking the patient to
the level of applied force and thereby discomfort
bite on a piece of cotton roll to minimize pain while
Orthopaedic forces and sutural strain What is the underlying mechanism for orthodontic
pain?
Craniofacial orthopaedics utilizes mechanical forces of a
high magnitude, which when applied are absorbed and There is no doubt that the perception of orthodontic pain is
transmitted to the craniofacial complex. These forces will part of an inflammatory reaction causing changes in blood
produce a series of reactions characterized by tissue flow following orthodontic force application. This is known
displacement, deformation, and development of internal to result in the release of various chemical mediators
stress (Mao, 2002; Mao et al., 2003). Ten Cate et al. (1977), eliciting a hyperalgaesic response. Recent research has
after exerting a sagittal expansion force in rats, observed started revealling the molecular basis of orthodontic pain
traumatic tears, exudates, death of fibroblasts, disruption with demonstration of the presence as well as elevation in
of collagen fibres, and acute inflammation. As part of levels of various neuropeptides released. Even though there
the inflammatory process, the patient perceives a painful are a number of publications, there appears to be some
sensation, which is often expressed in the whole craniofacial missing links in the pathway of pain arising as part of
region. There are reports in the literature that demonstrate orthodontic mechanotherapy, clarification of which requires
painful experiences after application of expansive force further research.
with rapid palatal expanders (Handelman, 1997; Needleman Orthodontic tooth movement is known to cause
et al., 2000; Schuster et al., 2005). Needleman et al. (2000) inflammatory reactions in the periodontium and dental pulp,
concluded that vast majority of children undergoing rapid which will stimulate release of various biochemical
palatal expansion experience pain, which occurs during the mediators causing the sensation of pain. The perception of
initial phase and diminishes thereafter. Egolf et al. (1990) orthodontic pain is due to changes in blood flow caused
found that approximately 28 per cent of patients reported by the appliances and has been correlated with the release
pain as the factor which prevented them from wearing and presence of various substances, such as substance P,
headgear or elastics. histamine, enkephalin, dopamine, serotonin, glycine,
Patients often experience discomfort after 24 hours of glutamate gamma-amino butyric acid, PGEs, leukotriens,
headgear wear and there is a sharp decline in pain after 3 and cytokines. The literature regarding the increase in the
days (Cureton, 1994; Ngan et al., 1997). Cureton (1994) levels of these mediators, which elicit hyperalgaesia response
evaluated the discomfort levels associated with combination following force application, is replete in orthodontics
therapy, headgear, and a transpalatal arch (TPA). They (Yamasaki et al., 1984; Walker et al., 1987; Davidovitch
suggested that wearing of a headgear and a TPA should et al., 1988; Nicolay et al., 1990; Davidovitch, 1991; Saito
never be started together and that headgear wear should et al., 1991b; Grieve et al., 1994; Alhashimi et al., 2001).
precede TPA wear by at least 1 week. Ngan et al. (1997), Processing of complex information arising from
who evaluated levels of masticatory muscle pain and EMG mechanical force application induces recruitment of
activity in patients treated with protraction headgear, neurons, which act by the way of chemical mediators as
concluded that protraction headgear does not induce muscle modulators of the effector response to the stimulus
pain or produce an increase in muscle activity. It is clear (Vandevska-Radunovic, 1999). Apart from the classic
that the pain associated with orthopaedic devices is not of a constituents mentioned above, peripheral nerve fibres also
ORTHODONTIC PAIN 173
participate in the inflammatory process associated with processing orofacial sensory information and an increased
tooth movement (neurogenic inflammation). This involves expression of c-Fos can be found in this nucleus after
release of neuropeptides after antidromic stimulation of orthodontic force application. On further evaluation, it was
afferent nerve endings and initiation of an inflammatory observed that the labelled neurons for c-Fos were mainly
reaction. These neuropeptides released are known to elicit a located in the superficial laminae (lamina I and II) at the
painful response (Vandevska-Radunovic, 1999). Kato et al. dorsomedial and ventral edges, predominantly near the apex
(1996) examined the distribution of nerve fibres containing and also in the transitional zone to the interpolaris. This
neurofilament protein (NFP), calcitonin gene-related peptide superficial lamina is known to contain nociceptive-specific
(CGRP), vasoactive intestinal polypeptide (VIP), and neurons (Bester et al., 1997; Jasmin et al., 1997). This was
neuropeptides Y (NPY) in the PDL of the rat first molar confirmed by the findings of a reduction in the expression of
after mechanical force application. They observed an these neurons in patients where pre-treatment morphine
increase in number of NFP and CGRP containing nerve was administered ( Aihara et al. , 1999 ). Furthermore,
line corresponding to the amount of experienced pain. This Moerenhout, 1991; Sergl et al., 1998; O’Connor, 2000). The
has been claimed to have two advantages: primary causes for poor co-operation have been attributed to
pain, functional, and aesthetic impairment caused by the
1. It provides freedom to choose the exact intensity of
appliances. This has even resulted in a discontinuation of
pain.
treatment or its early termination (Patel, 1989). Sergl et al.
2. It gives maximum opportunity for expression in an
(1998) confirmed these findings and reported a significant
individual personal response style.
correlation between patient co-operation and complaints
Another common method used in medical research, but during the 6-month period after appliance placement. Many
less explored in orthodontics, is the MPQ (Melzack, 1975). patients as well as parents consider initial lack of information
This consists of three major classes of word descriptors— about possible discomfort during treatment to be a major
sensory, affective, and evaluative—that are used by patients cause of the poor compliance exhibited. The literature
to specify subjective pain experience. It also contains an suggests that the patients’ initial attitude towards orthodontics
preferred method for pain control during orthodontics. Lack and found naproxan sodium to be more effective than
of an appropriate protocol for their administration after ibuprofen after 2 and 6 hours and even at night after archwire
orthodontic appointments is considered to be a major placement. They suggested that, in addition to the pre-
drawback requiring attention in future research. operative dose, at least one or two post-operative doses
Simmons and Brandt (1992) were the first to recommend should be administered for complete pain control after
the use of acetaminophen for managing orthodontic pain, orthodontic appointments.
while Pagenelli (1993) favoured flurbiprofen. Efforts to Apart from analgesics, other approaches have been tested
compare various drugs in managing orthodontic pain were to reduce pain from orthodontic procedures. Keim (2004)
performed by Ngan et al. (1994). They compared ibuprofen, described an anaesthetic gel ‘oraqix’, which is a combination
aspirin, and a placebo and concluded that ibuprofen of lidocaine and prilocaine in 1:1 ratio by weight. The
was the most effective analgesic in orthodontic pain findings suggest that it may be useful when performing
management. Numerous studies investigating various drugs orthodontic procedures such as band placement and
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