INFLUENCE OF THE ANTIINFLAMATORIES AND ANALGESICS USE ON THE

ORTHODONTONTIC TOOTH MOVEMENT. A REVIEW

Grecia Del Rosario De La Vega-Pachasa, Katherine Cristina Terrones-Rojasa, Luis Ernesto

Arriola-Guillén, DDS, MSc, PhDb
a
Former dental student, School of dentistry, Universidad Científica del Sur, Lima, Peru.
b
Associated professor, Division of Orthodontics, School of Dentistry, Universidad
Científica del Sur, Lima, Peru.

Corresponding author: Luis Ernesto Arriola-Guillén

School of Dentistry, Universidad Científica del Sur, Lima, Peru. Address: Av. Arequipa
4861, Miraflores, Lima. Phone number:992124507, e-mail: luchoarriola@gmail.com
INFLUENCE OF THE USE OF ANTIINFLAMATORIES AND ANALGESICS USE ON
THE ORTHODONTONTIC TOOTH MOVEMENT. A REVIEW

Abstract

The purpose of this research was to evaluate the influence of commonly used non-steroidal
anti-inflammatory drugs (NSAIDs) on tooth movement during orthodontic treatment. A
bibliographic search was carried out in the main databases of the scientific literature (Medline
via Pubmed, Scopus, Lilacs, Scielo) using the words “orthodontic tooth movement”,
“influence of anti-inflammatories”, “antiinflammatory drugs”, from the start of their time
until October 10, 2020 and without language restriction. Anti-inflammatories self -
medicated by patients and analgesic commonly prescribed by orthodontists in orthodontic
treatment were analyzed, adapting them to the needs and way of working of each of them.
The information collected allowed to identify that the frequent use of anti-inflammatory
drugs has an impact on the rate of tooth mobility during orthodontic treatment. Paracetamol
as a low-power analgesic is the appropriate medicine to relieve orthodontic pain since it does
not alter orthodontic tooth movement; however, its consumption should not exceed three
days, due to the adverse effects it presents, harming the health of the patient. Patients who
frequently consume NSAIDs due to their systemic disease have limitations in orthodontic
treatment, that is why the orthodontist should exercise caution in the treatment process to
avoid problems with the TMJ and tooth mobility is slow and difficult. It is concluded that the
use of anti-inflammatory drugs for a long time during orthodontic treatment decreases the
rate of tooth movement, on the contrary, the use of analgesics does not seem to have a greater
influence, although it is recommended not to abuse their use to avoid collateral effects.

Keywords: Antiinflamatories, Tooth movement, Orthodontic, Analgesics.

Introduction

Orthodontic treatment has increased in demand over time, due to the benefits provided to
improve aesthetics, self-esteem and occlusal stability. However, during orthodontic
treatment, unpleasant experiences can be generated in patients, one of them is pain, which
can be a consequence of the inflammatory reaction of the periodontium and dental pulp,
1-3
which can frequently cause distress and difficulty in chewing and / or bite. Due to this,
orthodontists prescribe the use of analgesics the first days of each orthodontic adjustment so
that patients if they manifest pain can resort to them, however many patients self-medicate
and make use of anti-inflammatory medications non-steroidal (NSAIDs) which provide relief
during orthodontic treatment; However, a possible inhibition of orthodontic tooth movement
(OTM) has been described that could delay treatment time. 4-6

Orthodontic dental movement is caused by physiological and biological forces that exert
prolonged pressure on the teeth, causing responses in the supporting tissue, including the
alveolar bone. These tissues will obtain macroscopic and microscopic changes when exposed
to different degrees of magnitude, frequency and duration of forces. In the initial phase of
orthodontic tooth movement, a tissue response characterized by an acute inflammation of the
periodontal vasodilation will manifest, involving a series of cellular reactions where
osteoblastic and osteoclastic activities are carried out, and the intervention of multiple factors
that modify success and expectations for orthodontic treatment. 7-8

NSAIDs are used to relieve pain. These drugs act by inhibiting the enzyme cyclooxygenase
(COX) by modulating the transformation of prostaglandins (PG) from arachidonic acid in the
cell plasma membrane. Both PGE1 and PGE2 are the main mediators of bone resorption.
Some of these NSAIDs can affect the speed of orthodontic movement, because the shortage
8,9
of certain prostaglandins reduces the rate of tooth displacement. Historically, the use of
analgesics has been a treatment option to diminish the pain of orthodontic patients, apparently
without major prejudice to the tooth movement, although its excessive use has generated
collateral effects in other organs. 10,11

Since NSAIDs have different capacities to inhibit prostaglandins, they generate different
effects on orthodontic tooth movement, so this study will have a direct focus on NSAIDs
frequently used in orthodontic patients. The objective of this study will evaluate the influence
of commonly used non-steroidal anti-inflammatory drugs (NSAIDs) on tooth movement
during orthodontic treatments. 12

Study Design

Search Strategy

This review was designed to analyze and demonstrate the importance of the consumption of
anti-inflammatory and analgesics drugs, whether prescribed by the orthodontist or self-
medicated by patients, in the control of pain during orthodontic treatment; likewise, to
evaluate how the frequent consumption of certain NSAIDs by patients suffering from
systemic diseases influences the rate of orthodontic tooth movement. The question posed was
as follows: What will be the influence of the use of anti-inflammatories on the orthodontic
tooth movement?

A bibliographic search was conducted in the main databases of the scientific literature
(Medline via PubMed, Scopus, Lilacs, Scielo) to identify relevant full-text articles in English
and Spanish which were published between August 2002 and October 2020. The following
key words were employed in the search of all the selected database: orthodontic tooth
movement, influence of anti-inflammatories on orthodontic movement, antiinflammatory
drugs, patients who take antiinflammatory drugs, antiinflamamatory on orthodontic patients
and reaction of antiinflammatory drugs. (Table.1)

Eligibility criteria

The inclusion criteria comprised randomized clinical trial that investigated the main anti-
inflammatories and analgesic drugs use in orthodontic treatment to relieve the pain, including
some systemic diseases that present problems at the level of the temporomandibular joint
and, due to the pain, patients constantly consume non-steroidal anti-inflammatory drugs.
Articles which were not related to dentistry were excluded to eliminate any bias in the testing
methods. Review articles in language other than English were excluded from the study.
Letters to the editor, personal communications, abstracts, and published theses were excluded
as well as any unpublished data. Likewise, studies in which studies in which certain non-
steroid anti-inflammatory drugs were not commonly used by orthodontic patients and those
analgesics that were not the first choice of prescription by orthodontists for pain control
during the first few days of treatment were excluded.

Results and Discussions

FREQUENTLY USED NON-STEROID ANTI-INFLAMMATORY DRUGS SELF-

MEDICATED BY ORTHODONTIC PATIENTS

Pain associated with tooth movement is one of the side effects that frequently appear in
orthodontic treatment and is the most common reason that patients do not want to start
orthodontic treatment or is the main cause of patient withdrawal during surgery. treatment.
The pain produced by orthodontic appliances begins 4 hours after having placed the fixed
orthodontic appliance, reaching its highest peak between 12 to 72 hours. Orthodontists, in
order to promote well-being and avoid cessation of treatment by patients due to tooth pain,
prescribe the use of analgesics to relieve pain. However, orthodontic patients often resort to
self-medication of NSAIDs to accelerate dental analgesia, without measuring the
consequences that these medications entail in the dental movement of orthodontic treatment.
13,14

• Ibuprofen and naproxen sodium:

They are frequently self-medicated NSAIDs by orthodontic patients to relieve OTM pain.
Ibuprofen and naproxen sodium inhibit the activity of the enzyme cyclooxygenase (COX),
which is responsible for modulating the transformation of prostaglandins (responsible for
pain and inflammation). The association between the mentioned NSAIDs and COX
inhibition; therefore, of the prostaglandins involved, they alter the rate of tooth movement
related to orthodontic forces. Among the prostaglandins is PG2, which is a protein involved
in MDO due to its high vasodilator power and participation in the osteoclastic activation
mechanism and bone resorption, being a mediator responsible for increased tooth movement.
That is why the frequent consumption of ibuprofen and naproxen sodium cause a reduction
in the speed of orthodontic tooth movement. 15,16

● Mechanism of action of NSAIDs

Non-steroidal anti-inflammatory drugs act to inhibit arachidonic acid-generating enzymes

when there is aggression at the tissue level by different agents, activating phospholipase A2;
and by means of enzymes that synthesize prostaglandins, the first enzyme being the
prostaglandin endoperoxide synthetase called fatty acid cyclooxygenase, there are two
isoforms that are COX-1 and COX-2. The first is constitutive in almost all cells and is
essential in tissue homeostasis, COX-2 is induced, expressing itself transiently, it is exclusive
in stimulated inflammatory cells promoting a rapid development of inflammation. The
mechanism of action of NSAIDs consists of suppressing the production of prostanoids
(thromboxanes, prostacyclins and PG) due to their high degree of inhibition of COX 1 in
gastrointestinal tissues and COX 2 at the site of inflammation. 8,17

NSAIDs are generally absorbed through the oral route and their metabolism is in the liver.
At the plasma level, NSAIDs bind with albumin, but this combination is easily dissociated
due to frequent interactions between them. Their absorption occurs by passive diffusion in
the stomach and at the level of the duodenum of the small intestine, since these drugs, being
weak acids, do not ionize in the acidic environment of the gastric mucosa, becoming soluble
lipids and quickly diffusing within gastric cells. The vast majority of NSAIDs are eliminated
at the renal level, as metabolites; but each drug will have a specific biotransformation
according to its chemical nature. 18

ORTHODONTIC TREATMENT IN PATIENTS WHO CONSUME ANTI-

INFLAMMATORY CONTINUOUSLY DUE TO THEIR SYSTEMIC CONDITION

In order to determine a diagnosis and choose a correct dental treatment, the general health of
the patients must be taken into account without omitting the systemic diseases that can be
detected during the anamnesis. Orthodontics works directly with medicine to carry out
orthodontic treatments, especially to patients who suffer from a systemic disease, mainly in
patients who, for such a condition, consume anti-inflammatory drugs such as lupus and
osteoarthritis to relieve inflammation or pain. They present in bones and joints. 19,20

• Systemic Lupus Erythematosus and Osteoarthritis:

Systemic lupus erythematosus (SLE) is a chronic multisystemic disease, turning individuals

who suffer from it into high-risk patients in the dental office, therefore, in orthodontic
treatment, its oral clinical manifestation being the arthritis of the temporomandibular joint.
21
Osteoarthritis is a complex syndrome that involves structural alterations in cartilage, bones,
ligaments, muscles, and in many cases affects the TMJ. The inflammation produced by these
alterations destroys the joints related to osteoarthritis causing pain, limiting their functions
and reducing the quality of life of patients suffering from the disease. 22

For both diseases, the drug treatment used to relieve pain and inflammation are certain non-
steroidal anti-inflammatory drugs, the most common being ibuprofen, naproxen, and
diclofenac (oral or topical). It is important to know the limitations presented by patients
suffering from lupus or osteoarthritis since, due to their systemic condition, they consume
anti-inflammatories, since the orthodontic treatment that will be carried out must be effective
and present the minimum risk and thus avoid problems at the TMJ level and dental mobility
is slower and more difficult. 20,23

USE OF ANALGESICS IN ORTHODONTIC TREATMENT

Analgesics are the ideal drug to be prescribed to patients when they present any pain within
the first days of activations, being administered orally or applied directly to areas where pain
occurs in the oral cavity, thus relieving pain and allows orthodontic treatment to be
comfortable and acceptable to the patient. These pain relievers are inexpensive, publicly
available, easy to use, and have no serious side effects. 24

The low-strength pain reliever frequently used by orthodontists is paracetamol. This drug
fulfills the function of inhibiting the synthesis of prostaglandins at the level of the Central
Nervous System, having a weak anti-inflammatory activity by not concentrating in the areas
of inflammation of the peripheral tissues; therefore, it has no consequence on bone resorption
associated with tooth movement in orthodontic treatment. That is why paracetamol is the
ideal analgesic to relieve pain because it does not alter the rate of tooth movement during the
orthodontic treatment process. 5

The duration of acetaminophen treatment is 1 to 2 days’ maximum because prolonged use of

this drug can cause adverse effects. Many patients believe that acetaminophen is a very safe
pain reliever; however, one of the most common poisonings is overdose. Also nausea,
vomiting, epigastric pain, drowsiness, jaundice, and liver and kidney damage have been
reported, and death may be due to the abuse of paracetamol consumption. 25,26
• Frequency of medication consumption by orthodontic patients to control pain

In a cross-sectional study, through a survey of a specific group of orthodontists and patients,

it was observed that 35.3% of orthodontists prescribe paracetamol on a regular basis, 64.7%
do not do it and 29.4% indicate it with a fixed schedule (Fig.1). In addition, some authors
have pointed out that between 95% and 97% of patients who experience pain and those who
perceive intense and persistent pain are those who self-medicate or consume more analgesics.
26

Conclusions

The use of anti-inflammatory drugs for a long time during orthodontic treatment decreases
the rate of tooth movement, on the contrary, the use of analgesics does not seem to have a
greater influence, although it is recommended not to abuse their use to avoid collateral
effects.

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