PAIN MANAGEMENT

IN ORTHODONTICS
CONTENTS
 Introduction

 Causative factors and patient compliance

 Management modalities

 Conclusion
 INTRODUCTION
 Patients may experience a considerable amount of discomfort
from orthodontic treatment, such as feelings of
 Tension,

 Pressure,

 Sensitive teeth

 Pain

 Egolf et al stated that only 15% of the patients wearing intraoral

elastics and headgear agreed that “braces aren’t painful.”

 Oliver and Knappman reported that 70% of the subjects in their

study had at least some degree of pain, regardless of the type
of appliance worn.
 Orthodontic pain arises from
 Ischemia,
 Inflammation,

 Edema in the compressed periodontal ligament.

 In an inflamed and ischemic periodontal ligament,

mediators such as histamine, bradykinin,
prostaglandins, serotonin, and substance P are
released.

 These mediators irritate the nerve ends of the

pain receptors, thus causing pain.
 Orthodontic pain usually begins at 2 hours after
force application.

 Reaches its maximum intensity at bedtime or at

24 hours.

 Lasts approximately 5 to 7 days.

 Patients treated with fixed or functional

appliances reported more tension, pressure,
sensitive teeth, or pain than the patients wearing
one or two removable plates over both short-term
and long-term courses.
CAUSATIVE FACTORS AND EFFECT
OF COMPLIANCE
 Individual psychological susceptibility is likely to be a
significant factor for the intensity of discomfort caused
by physical effects of an appliance on oral tissues.

 Pain experience, does not seem to be directly related to

the magnitude of force exerted by different arch wires
and depends rather on psychological well-being of the
individual concerned.
 Psychological research has shown that experience of
pain and discomfort is influenced by personal values
and expectations such as expectations of self-efficacy
and treatment outcome.

 Of relevance to orthodontics are -

 Patients’ attitudes toward dental esthetics,
 Perceived severity of malocclusion,
 Expectations from treatment in the sense of an
anticipated orthodontic self efficacy.
 Discomfort caused by orthodontic appliances may
significantly affect patients’ compliance with treatment.

 Pain, functional, and esthetic impairment, and

associated complaints are the primary reasons for poor
cooperation, for patients’ desire to discontinue
treatment, and for early termination of the latter by the
patient.
Initial stages of treatment

 Pain experience has been a common problem faced

by patients right from the beginning of orthodontic
treatment that is, placement of separators.

 Asiry et al. concluded that pain associated with

orthodontic separation starts and peaks within 4–
48 h from the placement of separators and starts
to decline to reach the lowest level on 5th day.
 Alterations in the periodontal ligament and surrounding
soft tissues, with intensity and prevalence varying
according to age.

 According to Campos et al. both young and adults

complain of pain after bonding and initial wire
placement.

 Various alignment wire sequences were found to have

variable pain response in patients irrespective of the
material of the wire used.

 Cioffi et al. found reduced pain response in their

patients during initial wire placement when they used
heat activated thermal nickel‑titanium (Niti) as
compared to superelastic Niti.
 Fernandes et al. compared the discomfort caused by the
initial placement of superelastic Niti wires and
conventional Niti wires.

 They found greater pain experience among patients as

a result of nitinol wires.
Intermaxillary elastics

 Intermaxillary elastics have been found to cause

pain in patients similar to wire placement.

 The pain due to elastics was not found to last as

long as the pain found after initial bonding.
Appliance activation

 Causes disruption in the periodontal ligament creating

areas of pressure and tension leading to discomfort to
the patient.

 An increase in pain 24 h after activation of appliance

was observed by Trein et al. in their patients.

 Lower forces produced less pain as compared to higher

forces with equally effective tooth movement.

 Ogura et al. compared the pain intensity among

subjects with light and heavy force application and
found that heavy forces cause greater biting pain few
hours after the force application.
Debonding of orthodontic appliances

 Debonding of fixed appliances leads to pain

experience in the patients.

 Furthermore, lower anteriors were reported to be

most painful after debonding.

 Normando et al. compared two methods of

debonding that is, a lift‑off method and ligature
cutting pliers and confirmed that lift‑off method
caused lesser pain to the patients during debonding.
Insertion of temporary anchorage devices

 Study was conducted by Chen et al. to evaluate the pain

experienced by the patients during placement of
interdental implants and was compared to the baseline
value of discomfort during premolar extractions.

 They concluded that the placement of interdental

implants did not cause pain greater than that during
traditional orthodontic treatment.
MANAGEMENT MODALITIES
Analgesics

 NSAIDs are often recommended by orthodontists to

their patients to alleviate the pain caused during
orthodontic tooth movement.

 Advised after the procedure is performed, but

preemptive administration of analgesics has been found
to be useful before procedures like separator
placement.

 Commonly prescribed are

paracetamol,ibuprofen,acetaaminophen,naproxen
sodium.
 Use of NSAIDs has been reported as the most
successful modality in orthodontic pain reduction.

 In most studies, this method has been called the

gold standard.

 NSAIDs block the formation of arachidonic acid in

the prostaglandin production cycle.

 Thereby concentration of prostaglandins, which are

important pain mediators, will be reduced.
 Paracetamol, explicitly indicated by most authors
as the safest NSAID, seems to be the drug of choice
in view of no influence on the range of tooth
movement, the risk of root resorption or other
adverse effects within oral cavity.

 Acetaminophen shows no significant effect on

prostaglandin synthesis and may be a safe choice
compared to ibuprofen for relieving pain associated
with orthodontic tooth movement
 Patel et al. evaluated the effectiveness of ibuprofen,
naproxen sodium, and acetaminophen.

 They concluded that ibuprofen was superior to the

placebo in relieving postseparator pain as measured by
the VAS pain summary scores,whereas acetaminophen
and naproxen sodium did not significantly differ from
the placebo.
 Arantes et al. evaluated an alternative drug
Tenoxicam and showed that it proved to be an
effective drug during orthodontic treatment
without affecting the tooth movement.

 Young et al. showed another drug Valecoxib to be

administered before the procedure to relieve pain
due to initial wire placement.
 In recent years, the side effects of NSAIDs such as
 thrombocytopenia,

 skin rashes,

 headaches,

 and so on, have been considered issues of

concern, leading to the opting of alternative
therapies to control pain.
Low level laser therapy

 Low‑level laser therapy has been used to relieve pain in

patients during various stages of orthodontic treatment.

 The use of local carbon dioxide laser irradiation reduces

pain without affecting the orthodontic tooth movement.

 Reduction in pain symptoms on application of low‑level

laser therapy after activation of final archwires.
 LLLT has been advocated as a collateral-free therapy, and
its application has shown considerable reduction in pain
caused by orthodontic appliance placement.

 Furthermore, LLLT has also shown nonthermal and

biostimulatory effects.

 Energy output of the device is low enough not to exceed an

irradiated tissue temperature of 36.5˚C.
 Laser irradiation can activate both local microcirculation
and cellular metabolism,and also combat pain on 2
levels:
 Pain mediation
 Stimulation of endorphin production

 LLLT produces analgesic and anti-inflammatory effects,

and accelerates tissue repair.
 LLLT penetrates deeper into tissues (ie, bone) and is
more effective than the visible laser, which is normally
used for gum and skin treatments.

 The transmission of laser through tissue is highly

wavelength specific and is optimal in the optical window
of 500 to 1200 nm.

 Lim et al used 830nm wavelength, Turhani et al used a

670-nm wavelength(Optimal Optical Window.)
 LLLT does not affect the start of pain perception
after placement of the first archwire but pain
duration and intensity is reduced.
Vibratory forces

 Vibratory stimulation, a classic noninvasive and non-

medicinal method of reducing pain, effective in orthodontic
patients.

 The orthodontic application of this method was first

investigated by Dr. Powers on a patient with a history of
painful post-adjustment episodes during closure of a wide
maxillary midline diastema with elastic chain.

 After placing a new elastic chain, Dr. Powers observed that

gentle vibration of the maxillary central incisors produced
two effects:
 The blanching of the tissue between and above the incisors
was quickly reversed,
 The previous level of pain did not occur.
 This encouraging observation was the impetus for the
commercial fabrication of a patient-controlled appliance
that could translate a vibratory effect to all the teeth.

 A small, battery operated vibrating motor with two

amplitude settings was coupled to a flexible,
detachable, soft acrylic mouthpiece for this purpose.

 Marie et al. have advised the use a vibratory apparatus

by the patients to ameliorate the pain caused by
orthodontic treatment.

 Vibratory forces are effective when used before the

development of pain as they improve and re‑establish
the blood supply in the pain‑causing ischemic areas.
Bite wafers

 Horseshoe-shaped viscoelastic bite wafers with moderate and low

toughness, respectively soft-viscoelastic and hard-viscoelastic .

 These blocks are made of polyvinyl siloxane, and they vary in

their mechanical toughness.

 Patients are instructed to chew or bit down on the bite wafers for
5 minutes at 8-hour intervals.

 Hwang et al. suggested the use of thera bite wafers in relieving

pain after orthodontic procedures.

 Mangnall et al. conducted a RCT the results of which showed a

reduction in pain during debonding procedures when the patients
were made to bite on soft acrylic wafers.
Chewing gums

 Farzanegan et al. conducted a RCT they suggested that

efficacy of chewing gums as a method to relieve pain
caused due to such orthodontic procedures was
comparable to that of analgesics.

 Benson et al. reported that the use of chewing gum

significantly decreased both the impact and pain from
the fixed appliances.

 Chewing gums can be recommended as a suitable

alternative to analgesics for pain reduction in
orthodontic patients.
 The mechanism of these methods is to-;

 Loosen the tightly grouped periodontal ligament

fibers around the nerves and blood vessels
 Restoring the normal vascular and lymphatic

circulation of the periodontal ligament.

 Thus preventing or relieving inflammation and

edema, and finally relieving pain and discomfort.
Anesthetic gels

 Anesthetic gel “Oraqix” containing a combination of lidocaine

and prilocaine in 1:1 ratio by weight.

 Such gels can be used when performing routine orthodontic

procedures to relieve the patient’s discomfort.

 Kwong et al. described the use of anesthetic gel oraqix and

for easy placement of temporary anchorage devices and
showed that it was effective in reducing the local discomfort
Medicated wax

 Wax containing slow releasing benzocaine is used to

relieve the discomfort caused by fixed orthodontic
appliances.

 The patients using medicated wax reported of less pain,

showing the analgesic properties of benzocaine
containing wax.
Behavioral therapy –TENS therapy

 A simple, chair side, non invasive technique called TENS

therapy was used to control pain associated with initial
aligning arch wires (NiTi) during orthodontic treatment.

  It is applied extraorally.

 The TENS unit comprises of pulse, amplitude knobs,

on/off switch,a pair of electrodes and conductive gel
which is applied on the site of placement.

 The electrodes are placed so that they bracket the

painful region on the corresponding cheek.
 The type of stimulation delivered by the TENS unit aims
to excite (stimulate) the sensory nerves, and by so
doing, activate specific natural pain relief mechanisms.

 There are two primary pain relief mechanisms which can

be activated :
 the Pain Gate Mechanism
 The Endogenous Opioid System

 Pain relief by means of the pain gate mechanism

involves activation of the Aβ sensory fibres and reduces
the transmission of the noxious stimulus from the ‘c’
fibres, through the spinal cord and hence on to the
higher centres.
 An alternative approach is to stimulate the Aδ
fibres which respond preferentially to a much lower
rate of stimulation, which activate the opioid
mechanisms, and provide pain relief.

 Release of an endogenous opiate (encephalin) in

the spinal cord which will reduce the activation of
the noxious sensory pathways.
ADVANTAGES

 No PG inhibition, since TENS controls pain by gate

control mechanism.

 Rapid and timely inhibition of pain at the peak

progression.

 No adverse effects of drugs.

 Non invasive.
Avoidance of hard food

 Otasevic et al compared the effects of masticatory

bite wafers and the avoidance of hard food on
initial orthodontic pain.

 They concluded that avoiding hard food in the first

week after initial archwire placement was more
effective in pain reduction than chewing on
masticatory bite wafers.
 CONCLUSION
 Orthodontic treatment is associated with a number of
side effects most common being pain.

 Orthodontists must be aware of the various factors

that might cause discomfort to the patients and
should be able to manage such episodes to improve
the compliance of patients with the orthodontic
therapy.
 By far, the most commonly used method is
administration of analgesics, and it stays to be the
most effective modality in controlling orthodontic
pain.

 However the newly developed methods also seem

promising and should be resorted to in accordance
with the indivisual need,pain perception and
compliance of the patient.
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