Pain and Discomfort After Orthodontic Appointments

Assessment of the Arabic patient-centered online information about orthodontic pain: A quality and readability assessment

BACKGROUND

This study assesses the quality and readability of Arabic online information about orthodontic pain. With the increasing reliance on the internet for health information, especially among Arabic speakers, it's critical to ensure the accuracy and comprehensiveness of available content. Our methodology involved a systematic search using the Arabic term for (Orthodontic Pain) in Google, Bing, and Yahoo. This search yielded 193,856 results, from which 74 websites were selected based on predefined criteria, excluding duplicates, scientific papers, and non-Arabic content.

MATERIALS AND METHODS

For quality assessment, we used the DISCERN instrument, the Journal of the American Medical Association (JAMA) benchmarks, and the Health on the Net (HON) code. Readability was evaluated using the Simplified Measure of Gobbledygook (SMOG), Flesch Reading Ease Score (FRES), and Flesch-Kincaid Grade Level (FKGL) scores.

RESULTS

Results indicated that none of the websites received the HONcode seal. The DISCERN assessment showed median total scores of 14.96 (± 5.65), with low overall quality ratings. In JAMA benchmarks, currency was the most achieved aspect, observed in 45 websites (60.81%), but none met all four criteria simultaneously. Readability scores suggested that the content was generally understandable, with a median FKGL score of 6.98 and a median SMOG score of 3.98, indicating middle school-level readability.

CONCLUSION

This study reveals a significant gap in the quality of Arabic online resources on orthodontic pain, highlighting the need for improved standards and reliability. Most websites failed to meet established quality criteria, underscoring the necessity for more accurate and trustworthy health information for Arabic-speaking patients.

Transdermal Patches for Pain Relief in Orthodontic Procedures: A Narrative Review

Pain relief is an integral component of any orthodontic procedure given its high association with patient compliance and treatment adherence. A transdermal drug delivery system (TDDS) is a non-invasive method of drug delivery through the skin surface that can spread the medication throughout the dermis at a predetermined rate to produce a local or systemic effect. It might be used in place of hypodermic injections and the oral medication route. A transdermal analgesic, often known as a pain reliever patch, is an adhesive patch that contains medication to treat mild-to-severe pain. Many opioids and non-steroidal anti-inflammatory drugs are currently available as patches. TDDS offers many benefits over the conventional medication delivery method. The non-invasive transdermal route or therapy has features such as excellent bioavailability, stable medication plasma concentration, and no first-pass metabolism effect. This review aims to explore the available evidence on the use of transdermal patches for pain relief in orthodontic procedures and possibly suggest recommendations based on the findings.

Comparative analysis of periodontal pain and quality of life in patients with fixed multibracket appliances and aligners (Invisalign®): longitudinal clinical study

BACKGROUNDS

The aim of this longitudinal clinical study is to analyse and compare according to location, degree and type, the pain presented by patients during their first year of treatment, as well as the quality of oral life after the placement of two types of orthodontic appliances: conventional brackets and removable Invisalign ® aligners.

METHODS

The sample consisted of 140 patients grouped into 2 study groups of 70 patients each. The first group (brackets group- BG), with fixed multibracket appliances, using the MBT technique and a 0.022" slot. The second group (invisaling group- IG), in treatment with removable aligners (IG), using the Invisalign ® system. They were providen with a questionnare where they had to record the degree (mild, moderate or intense), the type and location of the pain monthly during the first year of treatment. The second form was the Spanish version of the OHIP-14, oral quality of life questionnaire, which was provided the twelfth month after the start of treatment.

RESULTS

In both groups, we found that the most frequent location of pain occurred during the first phase: mandibular for the IG group and maxillary in the BG group. Throughout the whole analysis, the intensity was mild-moderate with lower values in the conventional brackets' group. The BG group reported acute pain while the IG group reported sensitive pain during the first month; later both reported sensitive pain.

CONCLUSIONS

There are differences in terms of periodontal pain in its degree, location, and type according to the different orthodontic techniques used.

TRIAL REGISTRATION

The study was approved by the bioethics committee of the University of Salamanca (USAL_20/516).

Effect of Mini-implant assisted Micro-osteoperforation on the rate of orthodontic tooth movement-A randomized clinical trial

OBJECTIVE

To evaluate the effectiveness of micro-osteoperforation (MOP) over a 56-day period and to determine the influence of number of perforations on the rate of canine retraction. In addition, the amount of pain and discomfort caused by the MOP was evaluated.

TRIAL DESIGN

A single-center, split-mouth, triple-blind, randomized, controlled trial.

METHODS

22 patients (18-30 years) who need fixed orthodontic treatment were recruited and randomly assigned to MOP1 and MOP2 groups. The recruited patients were divided into two groups with 1:1 allocation ratio. Randomization for the determination of experimental side and number of perforations was done using sealed envelopes. On each patient, the other side of mouth worked as control side with no MOPs. 4 months after first premolar extraction, patients in MOP1 received 3MOPs on the buccal surface of alveolar bone, whereas patients in MOP2 received three buccal and three palatal MOPs in the experimental side. The amount of canine retraction was measured every 28 days at two intervals on both sides of mouth. Pain perception was measured after 1 hr, 24 hr, 72 hr, 7 days, and 28 days of procedure.

RESULTS

Result of the intra-examiner reliability using ICC is more than 0.97 (P < 0.001), indicating excellent repeatability and reliability of the measurements. The baseline characteristics between groups were similar (P > 0.05). A statistically significant difference in the rate of canine retraction on the MOP side was observed at the end of 56 days, amounting to two folds more than that of the control side. No significant difference was seen between MOP1 and MOP2 groups (P > 0.05). Mild-to-moderate pain was experienced only in first 72 hours of procedure.

CONCLUSION

The study recommends that MOP procedure has substantial potential to be used as an adjunct to the routine mechanotherapy for accelerating tooth movement, as it may reduce treatment time by half in the first four weeks after the MOP procedure.

TRIAL REGISTRATION

Clinical trial registry of India (CTRI/2022/12/048181).

A Comparative Assessment of Acceptance of Different Types of Functional Appliances

Background Modern clinical orthodontics' functional appliances, a well-established modality of treatment, exhibit an amazing diversity of design. Clinical findings show that people have difficulty adjusting to these devices due to their size and unfixed positioning inside the mouth and that patient adaptation may vary based on the type of orthodontic functional appliance employed. Despite the fact that they appear to inflict more pain and soreness than, for example, removable plates, the effects of various orthodontic functional appliances on patients' acclimation have not yet been researched. Aim The current study's goal was to assess how different functional appliances' shapes and designs affected patients' willingness to accept them. Materials and methods About 20 adult volunteers (10 males and 10 females, age 18-32 years) with marked Class II division 1 malocclusion and not familiar with orthodontic appliances were selected as test subjects. Impressions for working casts were taken, and construction bites were prepared for the fabrication of eight functional appliances of various designs for each individual test subject. These appliances had eight design variations. There were three tests: one for speech effects, one for initial acceptance, and one for final acceptance after wearing different scales. Results Overall, the correlation between the quality of speech and pronunciation after wearing the appliance and the type of functional appliance was statistically significant. The quality of speech and pronunciation after wearing the appliance was maximum in frequency range 1 (FR1), while it was minimum in the medium-size activator. The difference was statistically significant (p=0.001). Overall, the correlation between the comfort and acceptability of functional appliances after wearing them and the type of functional appliance was statistically significant. The acceptance of functional appliances after wearing was maximum in FR1, while it was minimum in the medium-size activator. The difference was statistically significant (p=0.001). Overall, the correlation between the type of functional appliance and initial acceptance was significant statistically, with the maximum initial acceptance in medium-sized activators and the minimum initial acceptance in small bionators (p=0.001). Conclusion The study's findings show that patient acceptance of various kinds of functional appliances varies significantly.

Leveling the curve of Spee using different sized archwires: a randomized clinical trial of blood flow changes

OBJECTIVES

To compare blood flow (BF) changes of teeth subjected to orthodontic forces during curve of Spee (COS) leveling using different archwires (AW).

MATERIAL AND METHODS

Thirty subjects with COS > 5 mm were randomly assigned (1:1:1) into three groups based on the AW used: group 1: 0.017 × 0.025-inch stainless-steel (SS)AW, group 2: 0.019 × 0.025-inch SSAW, and group 3: 0.021 × 0.025-inch β-titanium (TMA)AW. In the 3 groups, a 5 mm-depth reverse COS was placed in the AWs. A laser Doppler flowmeter was used to measure BF at different time intervals (T0-T4).

RESULTS

In the 3 AWs group, BF of all measured teeth was reduced 20 min after force application. Afterwards, the BF values started to increase until the baseline values were almost restored within 1 week. Differences in BF changes between the extrusion and intrusion subgroups were observed within groups 1 and 3 during the first 20 min of force application (P < 0.05). Similar BF changes were recorded using the 3 different AWs. BF changes were associated with tooth type and the amount of COS depth change.

CONCLUSIONS

During CoS leveling, similar BF changes were recorded using the 3 different AWs. Tooth type and the amount of COS depth change were associated with BF changes within the first 20 min of force application. Greater BF reduction was found in premolars compared to incisors during the first 20 min of AW placement.

CLINICAL RELEVANCE

It is important to select a type of applied forces that minimally affect the BF. Intrusive forces appeared to have lower negative effects on the BF of teeth during COS leveling.

TRIAL REGISTRATION

ClinicalTrial.gov (# NCT04549948).

The effects of orthodontic treatment type, depression, and treatment need on perceived pain intensity

Objectives:

The objectives of this study were to evaluate how orthodontic treatment type, treatment need, and depression affect perceived pain intensity (PPI).

Material and Methods:

This prospective study included 172 patients (80 girls and 92 boys, mean age 14.32 ± 1.57 years) treated at the Sivas Cumhuriyet University Faculty of Dentistry, Department of Orthodontics. The patients were divided into three groups: the first group was treated with fixed orthodontic appliances, the second group was treated with twin blocks, and the third group was treated with rapid maxillary expansion and reverse headgear (RME/RH). Data were collected and classified with the Index of Orthodontic Treatment Need-Dental Health Component (DHC), Children’s Depression Scale, and Visual Analog Scale. PPI was recorded in the 1st week (T0), 2nd week (T1), the 1st month (T2), 2nd month (T3), 3rd month (T4), and the 6th month (T5).

Results:

PPI was higher in boys at T1 (P = 0.005) compared with girls. There was a significant difference of PPI between the treatment groups at T2 (P = 0.036), T3 (P = 0.012), T4 (P = 0.000), and T5 (P = 0.006). A statistically significant positive correlation was found between DHC and PPI at T3 (r = 0.182; P = 0.000), T4 (r = 0.161; P = 0.03), and T5 (r = 0.189; P = 0.000) time periods. There was no significant correlation between depression and PPI.

Conclusion:

Girls were more resistant to pain than boys. The type of treatment and the need for treatment both had an effect on PPI. Further studies are needed to investigate the effects of psychological states on PPI during orthodontic treatment.

Analysis of the patient’s experiences on the related instagram posts about the orthodontic treatment

Objectives:

The study aimed to comparatively evaluate the patients’ experiences with these treatments by analyzing the contents of the posts shared by the patients with clear aligner and fixed orthodontic treatment (FOT).

Material and Methods:

To reach the treatment methods, the hashtags “braces” for FOT and “aligner” for clear aligner treatment (CAT) were used in the Instagram search engine. To reach objective patient evaluations, clinicians’ posts, company posts, and influencers’ posts containing advertisements and collaborations were eliminated and direct patient posts were considered. Seventy-nine posts were included in the FOT group and 52 posts in the CAT group. The posts were evaluated comparatively in terms of the number of likes, followers of the profiles, comments and content, the gender of the patients, and the treatment stage.

Results:

According to the results of the analysis, although the number of followers, likes, comments, and positive and neutral comments were higher in favor of the aligner group between the FOT and CAT groups, the rate of likes/followers was found to be higher in favor of the fixed treatment group (P < 0.05).

Conclusion:

Considering the literature, although studies on CATs on social media are limited, this media is seen as an effective factor in the treatment decision-making process of patients. While the most negative comments of individuals in fixed treatment were psychological effects, the most criticized issue in CAT was treatment fees.

Response of masticatory muscles to treatment with orthodontic aligners: a preliminary prospective longitudinal study

INTRODUCTION

The emergence of orthodontic aligners has provided an aesthetic and comfortable option for orthodontic treatment. However, the encapsulated design of the aligners can influence the masticatory muscles, and might compromise safe treatment.

OBJECTIVE

This preliminary longitudinal study aimed to investigate whether the use of orthodontic aligners affects the biting force and myoelectric activity of the superficial masseter and anterior temporal muscles.

METHODS

Ten subjects participated in the study and underwent treatment during an 8-month follow-up period. The root mean square (RMS), the median power frequency (MPF) of the surface electromyography (sEMG) signals, and the biting force (kgf) were recorded and normalized relative to the pretreatment condition. The data were analyzed by repeated-measure analysis of variance (ANOVA), with the significance level set at 5%.

RESULTS

Both the superficial masseter and the anterior temporal muscles presented an increase in sEMG signal activity during the treatment, with a marked increase in the latter compared to the former (p<0.05). Moreover, a significant decrease in bite force was evidenced (p<0.05).

CONCLUSIONS

This preliminary study observed that the orthodontic aligners affected the muscle recruitment pattern of masticatory muscles, and reduced biting performance during the 8-month follow-up period.

Effect of Chewing Gum on Pain Following Orthodontic Elastomeric Separators Placement: A Randomized Controlled Trial

AIM: The aim of the study was to investigate whether chewing gum (CG) can reduce pain as compared to non-CG (NG) after orthodontic elastomeric separators placement. MATERIALS AND METHODS: Sixty patients were randomly allocated in a ratio of 1:1 to CG group (mean age = 21.82 ± 0.87 years) and NG group (mean age = 22.31 ± 1.09 years). Patients in the CG group were instructed to chew sugar-free gum for 10 min immediately after separators placement and then at 8-h intervals for 1 week, while the patients in the NG group were instructed not to chew any type of gum for the duration of the study. Patients in the two groups were asked not to use any type of analgesics. The patients were asked to register their pain level using a 10-cm horizontal line visual analog scale at 2 h, 6 h, bedtime, 24 h, and then daily for 1 week after separators placement. RESULTS: The data from 53 patients (27 in the NG group and 26 in the CG group) were analyzed. The pain scores were significantly lower in CG as compared to NG at 2 h, 6 h, bedtime, 24 h, and 2 days after separators placement. From day 3 to the end of the week duration of the study, the pain scores stayed lower in the CG group, but the difference was not statistically significant. CONCLUSION: CG significantly reduced pain resulting from orthodontic elastomeric separators placement as compared to non-CG controls.

Comparative Analysis of Periodontal Pain According to the Type of Precision Orthodontic Appliances: Vestibular, Lingual and Aligners. A Prospective Clinical Study

The objective of this prospective clinical study was to analyze the pain (intensity, location and type) that patients presented after the placement of different types of orthodontic appliances: conventional, low friction, lingual and aligners. The sample consisted of 120 patients divided into four groups: conventional (CON), low friction (LF), lingual (LO) and aligners (INV). The participants were given the Short-Form McGill Pain Questionnaire (Ortho-SF-MPQ), where they had to record the pain intensity (no pain, mild, moderate or intense) and the periodontal location at different time points, from the first 4 h to 7 days after the start of treatment. In all the study groups, the most frequent location was both anterior arches, with maximum values between 56.7% (CON group at 24 h) and 30% (LO group at 4 h). The "whole mouth" and "complete lower arch" locations were indicated only by the patients in the lingual group. Regarding pain intensity, the patients reported a higher percentage of mild-moderate pain during the first 3 days of treatment (96.7% in LO at 4 h, 86.7% in CON, 83.3% in LF and 90% in INV at 24 h); later, the reported pain decreased to no pain/mild pain, especially in the lingual group, until reaching values close to zero at 7 days post-treatment. The most frequent type of pain was acute in the low friction and lingual groups (with maxima of 60% and 46.7% at 24 h, respectively). On the contrary, in the conventional (36.7% at 4 h) and Invisalign (40% at 24 h) groups, the sensitive type was the most frequent. There are differences regarding periodontal pain in its intensity, location and type according to the use of different orthodontic techniques.

Comparative Evaluation of Different Numerical Pain Scales Used for Pain Estimation during Debonding of Orthodontic Brackets

Introduction

Patients experience various levels of discomfort during orthodontic treatment, i.e., after placement of separators, orthodontic implant placement, and archwire placement and during debonding. Various pain control methods have been developed to relive pain during debonding, i.e., finger pressure (FP), elastomeric wafer (EW), and stress relief (SR).

Aim

To analyse various pain scales commonly used to determine the effect of different pain control methods during debonding of orthodontic brackets. Study Design. A comparative cross-sectional study performed on a sample of 60 patients (n = 60) including 14 males and 46 females who were ready for debonding and who were divided into three groups, i.e., finger pressure (FP), elastomeric wafer (EW), and stress relief (SR).

Materials and Methods

A 100 mm Visual Analog Scale (VAS) was used to record the pain intensity for each tooth. Another scale known as Pain Catastrophizing Scale (PCS) was used to evaluate the patient's general attitude towards pain perception. The armamentarium and operator were kept same for all the patients. Statistical analysis used was the Kruskal-Wallis test, used for intergroup and intragroup comparison of pain scores.

Results

Lowest total pain score was recorded in the FP group (P=0.043) on intergroup comparison, while on intragroup comparison, higher pain scores were recorded in lower anterior region (P=0.02) in all three groups. There was no significant difference between the pain scores reported by the male and female subjects.

Conclusion

FP is an effective method of pain control. And teeth in the anterior region of lower and upper arches are more sensitive to pain. In terms of cognitive-affective constructs, although the VAS has been widely used in previous studies, the PCS has been detailed to show the most reliable association with physical discomfort and emotional distress.

Comparison of Rate of Canine Retraction and Secondary Outcomes Associated With Conventional Fixed Orthodontic Treatment and Minimally Invasive Techniques (MOPs): A Randomized Control Trial

Introduction:

The objective of the study was to assess the rate of canine retraction and secondary outcomes associated with conventional fixed orthodontic treatment (CFO) and CFO with micro-osteoperforation (CFO + MOP), that is, anchorage loss, root resorption, vitality of tooth, pain and discomfort level during the procedure.

Methods:

A total of 16 patients with Class II Division 1 malocclusion who required upper first premolar extraction with lower non-extraction/single incisor extraction were divided into the test group (MOP) and positive control group (CFO + MOP) for a split-mouth study. Both maxillary canines were retracted with nickel–titanium (NiTi) closed coil springs. Patients were reviewed after 24 hours, 7 days, 28 days, and 4, 8, and 16 weeks to assess the rate of tooth movement, anchorage loss, root resorption, vitality of tooth, pain and discomfort level.

Results:

There was a statistically significant difference in the rate of tooth movement between the CFO and CFO + MOP groups after the first 4 weeks ( P-value = .026), whereas no statistically significant difference was observed at 8, 12, and 16 weeks ( P-value = .33, .99, and .08, respectively). In the CFO group, there was no statistically significant difference in tooth movement between different time intervals ( P-value > .05). There was no significant difference in root resorption between the groups. The pain level was higher in the MOP group in the first 24 hours ( P-value < .05) after the procedure. Later on, the difference in pain level between the groups was not significant ( P-value > .05). The vitality of retracted canines in both groups was healthy.

Conclusion:

The study recommends that the CFO + MOP procedure has substantial potential to be used as an adjunct to the routine mechanotherapy for faster tooth movement, as it may reduce the treatment time by half in the first 4 weeks after the MOP procedure. There are no potential differences in anchorage loss, tipping, vitality, and apical and lateral root resorption between the CFO and CFO + MOP groups. This trial was registered at Clinical Trial Registry, India.

Dental anxiety and the effectiveness of local anesthesia

Aim: The successful anesthesia is an essential factor for dental treatment. This study aimed at determining the effectiveness of local anesthesia and it’s relationship with dental Anxiety. Methods: This cross-sectional study was carried out on 256 dental patients, in 2017. Dental Anesthesia was administered after completing the Modified Dental Anxiety Scale by the patients. The level of anesthesia was recorded in one of three states (successful, difficult, and failed). Collected data was analyzed using SPSS version 22 and tests of, Chi-square, independent t-test, analysis of variance, and logistic regression model.  Results: About 60.5% subjects had moderate-severe dental anxiety. The mean of dental anxiety significantly was lower in the successful anesthesia group (P<0.01). Patients with elementary education had a significantly higher level of dental anxiety (P<0.01). Dental anxiety was significantly higher in the age group of ≥59 years, compared to the other age groups, except for 49-58 years (P<0.05). Subjects with a significantly higher level of dental anxiety more delayed their visits to the dentist. The logistic regression model showed that the dental anxiety (high anxiety) and literacy level (elementary) were the most important predictors of failed or difficult anesthesia. Conclusion: Informing patients about dental treatment procedures, regular and periodic visits to the dentist, using psychotherapeutic techniques to reduce dental anxiety before anesthesia, could play an important role in the success of anesthesia.

Pain and Oral-Health-Related Quality of Life in Orthodontic Patients During Initial Therapy with Conventional, Low-Friction, and Lingual Brackets and Aligners (Invisalign): A Prospective Clinical Study

The aim of this study was to compare pain and its relationship with the oral quality of life of patients with different types of orthodontic appliances: conventional and conventional low-friction brackets, lingual brackets, and aligners. A prospective clinical study was carried out with a sample size of 120 patients (54 men, 66 women) divided into 4 groups of 30 patients each. The modified McGill questionnaire was used to measure pain at 4, 8, and 24 h and 2, 3, 4, 5, 6, and 7 days after the start of treatment, and the Oral Health Impact Profile-14 (OHIP-14) questionnaire was used to measure the oral-health-related quality of life (OHRQoL) in the first month of treatment. The maximum peak of pain was obtained between 24 and 48 h of treatment. It was found that patients in the lingual orthodontic group described lower levels of pain at all times analyzed, and their scores in the total OHIP-14 indicated less impact on their oral quality of life (1.3 ± 1.2, p < 0.01) compared with the other groups analyzed. There was little difference with the aligners group (Invisalign) (1.7 ± 1.9, p < 0.01). The technique used influences the pain and quality of life of patients at the start of orthodontic treatment.

Impact of catastrophizing on pain during orthodontic treatment

Objective:

This study proposed to investigate the influence of catastrophizing and others factors related to pain during orthodontic treatment.

Methods:

27 patients with 0.022 x 0.028-in Straight-wire brackets were evaluated during alignment and leveling phase with nickel-titanium wires. Visual Analog Scales measured the intensity of orthodontic pain at six moments after a clinical appointment: 6 first hours; 1, 2, 3, 5, and 7 days. Multiple linear regression and stepwise approach assessed the influence of the following variables on pain: catastrophizing, sex, age, duration of treatment, clinical appointment time (morning or afternoon), and wire diameter.

Results:

The highest pain intensity was reported 24 hours after activation. These data were used to analyze factors associated with pain level. Age (r = 0.062, p= 0.7586), sex (p= 0.28), catastrophizing (r = -0.268, p= 0.1765), and orthodontic wire diameter (r = 0.0245, p= 0.2181) were not correlated with orthodontic pain in the univariate statistics. Catastrophizing was included in the multiple regression model because it was of great interest. Duration of orthodontic treatment (r = 0.6045, p= 0.0008) and the time when orthodontic appliance was activated (p= 0.0106) showed statistical significant associations with pain, and were also included in the multivariate regression, which showed that about 32% of orthodontic pain could be explained by the duration of treatment (R²= 0.32, p= 0.0475). Catastrophizing (R²= 0.0006, p= 0.8881) and clinical appointment time were not significantly associated with pain (R²= 0.037, p= 0.2710).

Conclusions:

Pain after activation of fixed orthodontic appliance is not associated with catastrophizing as well as age, sex, orthodontic wire diameter, and period of activation.

Pain level between clear aligners and fixed appliances: a systematic review

OBJECTIVES

To assess if there is any difference in pain levels between orthodontic treatment with clear aligners or fixed appliances.

MATERIALS AND METHODS

An electronic search was completed in PubMed, The Cochrane Database, Web of Science, Scopus, Lilacs, Google Scholar, Clinical Trials, and OpenGrey databases without any restrictions until February 2019. All comparative study types contrasting pain levels between clear aligners and fixed appliances were included. The risk of bias (RoB) was assessed using the Newcastle-Ottawa Scale, ROBINS-I-Tool, or ROB 2.0 according to the study design. The level of evidence was assessed through the GRADE tool.

RESULTS

After removal of duplicates, exclusion by title and abstract, and reading the full text, only seven articles were included. Five were prospective non-randomized clinical trials (CCT), one was a cross-sectional study, and one was a randomized clinical trial (RCT). Two studies presented a high RoB, three a moderate RoB, and two a low RoB (including the RCT). A meta-analysis was not performed because of clinical, statistical, and methodological heterogeneity. Most of the studies found that pain levels in patients treated with Invisalign were lower than those treated with conventional fixed appliances during the first days of treatment. Differences disappeared thereafter. No evidence was identified for other brands of clear aligners.

CONCLUSIONS

Based on a moderate level of certainty, orthodontic patients treated with Invisalign appear to feel lower levels of pain than those treated with fixed appliances during the first few days of treatment. Thereafter (up to 3 months), differences were not noted. Malocclusion complexity level among included studies was mild. Pain is one of many considerations and predictability and technical outcome are more important, mainly considering that the difference does not seem to occur after the first months of the orthodontic treatment.

Low-level laser-aided orthodontic treatment of periodontally compromised patients: a randomised controlled trial

Low-level laser irradiation (LLLI) shows effects in orthodontic pain relief and periodontal inflammation control. The aim of this article is to investigate the analgesic and inflammation-modulatory effects of low-level laser irradiation among orthodontic patients with compromised periodontium. A randomised controlled trial with split-mouth design was conducted in 27 adults with treated and controlled chronic periodontitis over 6 months. One side of the dental arch underwent repeated treatment under a 940-nm diode laser (EZlase; Biolase Technology Inc.) with a beam size of 2.8 cm² for 60 seconds at 8.6 J/cm², whilst the other side received pseudo-laser treatment. Laser irradiation was applied repeatedly for 8 times during the first 6 weeks after bracket bonding and monthly thereafter until the end of orthodontic treatment. Subjective pain (assessed by visual analogue scale in pain diary and by chairside archwire activation), periodontal status (assessed by periodontal clinical parameters), cytokines in gingival crevicular fluid (interleukin 1β, prostaglandin E₂, substance P) and periodontopathic bacteria (Porphyromonas gingivalis and Treponema denticola) in supragingival plaque were assessed. The intensity of pain was lower on the laser-irradiated side at multiple follow-up visits (P < 0.05). The pain subsided 1 day earlier on the laser side, with a lower peak value during the first week after initial archwire placement (P < 0.05). The laser side exhibited a smaller reduction in bite force during the first month (mean difference = 3.17, 95% CI: 2.36-3.98, P < 0.05 at 1-week interval; mean difference = 3.09, 95% CI: 1.87-4.32, P < 0.05 at 1-month interval). A smaller increase was observed in the plaque index scores on the laser side at 1-month (mean difference = 0.19, 95% CI: 0.13-0.24, P < 0.05) and in the gingival index scores at the 3-month follow-up visit (mean difference = 0.18, 95% CI: 0.14-0.21, P < 0.05). Laser irradiation inhibited the elevation of interleukin-1β, prostaglandin E₂ and substance P levels during the first month (P < 0.05). However, no intergroup difference was detected in the bacteria levels. Low-level laser irradiation exhibits benefits in pain relief and inflammation control during the early stage of adjunctive orthodontic treatment in periodontally compromised individuals.

Effects of low-level laser therapy and mechanical vibration on orthodontic pain caused by initial archwire

INTRODUCTION

The aim of this study was to evaluate the effects of mechanical vibration and low-level laser therapy on orthodontic pain after placement of the initial archwire.

METHODS

Sixty subjects with 3-6 mm maxillary dental crowding, a nonextraction fixed treatment plan, and no medical history were included in this study. The subjects were randomly divided into 3 groups, equally distributed by sex. In each subject, preadjusted edgewise appliances were placed in the maxillary arch from the left first molar to the right first molar, and a 0.014-inch round nickel-titanium archwire was fully engaged with elastomeric ties and cut at the end of first molar bondable tube. In group 1 (mean age 13.98 ± 2.68 y), mechanical vibration was performed 3 times: immediately, 24 hours, and 48 hours after engagement of the initial archwire. In group 2 (mean age 14.86 ± 2.06 y), low-level laser therapy was applied once: immediately after the insertion of the initial archwire. Group 3 (mean age 14.41 ± 1.78 y) served as the control group. Pain scores were determined with the use of a visual analog scale (VAS).

RESULTS

Although no statistically significant differences were found among the groups (P >0.05), the mean VAS scores for the mechanical vibration group were consistently lower than those of the control and low-level laser therapy groups at all measured time points.

CONCLUSIONS

The mechanical vibration group had lower, though nonsignificant, VAS scores for all measured time points. Additional clinical trials are recommended for more definitive conclusions.

Valid consent and orthodontic treatment

Valid patient consent is a legal and ethical principle that is fundamental to healthcare provision. Oral health practitioners (OHPs) must understand the principles that need to be addressed to ensure that the consent given by a patient is valid. Failure to obtain consent may result in a negligence claim or a complaint of professional misconduct against the OHP. Orthodontic treatment is mostly elective but is not without risk to the patient. Obtaining and maintaining valid consent for orthodontic treatment presents additional challenges in comparison with other dental procedures as the treatment lasts over a longer time and is most commonly performed in adolescents. In addition, prospective patients need to be informed regarding ‘lifelong’ management in the retention phase to minimise the risk of relapse. The present paper outlines the principles of valid consent with particular regard to orthodontic treatment in the adolescent patient. OHPs must ensure that they are satisfied that the competent patient has the capacity to voluntarily consent. Clinicians must also recognise that valid consent is not a one-off ‘tick the box’ procedural exercise but an ongoing process of effective information sharing in light of changing laws and an ever-changing scientific evidence base within a patient-centred model of healthcare.

Evaluating low-level laser therapy effect on reducing orthodontic pain using two laser energy values: a split-mouth randomized placebo-controlled trial

Background

No randomized controlled trial before has evaluated the role of low-level laser energy in its analgesic effects in orthodontics.

Objective

To evaluate the effect of single application of low-level laser with 4-Joule or 16-Joule energy on pain reduction following elastomeric separators placement.

Trial design

A two-arm parallel-group single-blind placebo-controlled randomized controlled trial, with implementation of split-mouth technique in each group.

Materials and methods

Twenty-six patients in need of orthodontic treatment with a fixed orthodontic appliance were enrolled and randomly allocated to either the 4-Joule or the 16-Joule laser energy group. Elastomeric separators were applied for the mandibular first molars. For each patient one molar received a single low-level laser dose using an 830-nm Ga-Al-As laser device with either 4-Joule or 16-Joule laser beam energy, while the other molar received a placebo treatment by applying the laser device in the same method and parameters as the counterpart molar without emitting the laser beam. The molar to be irradiated was also randomly chosen using simple randomization technique. Allocation was concealed and patients were blinded to which side would receive the laser irradiation. Main outcome measure was the degree of pain scored during mastication for each mandibular first molar after 1, 6, 12, 24, 48, and 72 hours of both laser and placebo treatments application. A questionnaire with an 100-mm Visual Analogue Scale (VAS) was used for pain assessment.

Results

Thirty-six patients were evaluated for eligibility, 10 of them were excluded making the final randomized number 26 patients. One patient dropped out later for not completing the questionnaire. Accordingly, the results of 25 patients were statistically analysed. No statistical significance was found for both low-level laser energy values in comparison to the corresponding placebo treatments. No harms were encountered.

Limitations

Intervention provider was not blinded to the intervention.

Conclusion

Low-level laser therapy, applied at two different laser energy values, is ineffective in relieving elastomeric separators induced orthodontic pain.

Trial registration

This trial was not registered.

Funding

No funding to be declared.

Effect of 5% benzocaine gel on relieving pain caused by fixed orthodontic appliance activation. A double-blind randomized controlled trial

AIM

To compare the effectiveness of 5% benzocaine gel and placebo gel on reducing pain caused by fixed orthodontic appliance activation.

SETTING AND SAMPLE POPULATION

Thirty subjects (15-25 years) undergoing fixed orthodontics.

METHODS AND MATERIALS

A randomized, double-blind, placebo-controlled and cross-over clinical trial study was conducted. Subjects were asked to apply a placebo gel and 5% benzocaine gel, exchangeable in two consecutive appointments, twice a day for 3 days and mark their level of pain on a VAS scale. The pain severity was evaluated by means of Mann-Whitney U-test for comparing two gel groups, Kruskal-Wallis nonparametric test for overall differences and post hoc test of Dunnett for paired multiple comparisons. p-value was assigned <0.05.

RESULTS

The overall mean value of pain intensity for benzocaine and placebo gels was 0.89 and 1.15, respectively. The Mann-Whitney U-test indicated that there was no significant difference between overall pain in both groups (mean difference = 0.258 p ˂ 0.21). For both groups, pain intensity was significantly lower at 2, 6 and 24 h compared with pain experienced at days 2, 3 and 7.

CONCLUSION

Benzocaine gel caused a decrease in pain perception at 2 h compared with placebo gel. Peak pain intensity was at 2 h for placebo gel and at 6 h for benzocaine gel, followed by a decline in pain perception from that point to day 7 for both gels.

Efficacy of different methods to reduce pain during debonding of orthodontic brackets

OBJECTIVE

To determine pain during debonding and the effects of different pain control methods, gender, and personal traits on the pain experience.

MATERIALS AND METHODS

Patients who had fixed orthodontic treatment with metal brackets, but no surgical treatment or craniofacial deformity, were included. Sixty-three patients (32 female, aged 17.2 ± 2.9 years; 31 male aged, 17.2 ± 2.5 years) were allocated to three groups (n = 21) according to the pain control method: finger pressure, elastomeric wafer, or stress relief. Pain experience for each tooth was scored on a visual analogue scale (VAS), and general responses of participants to pain were evaluated by Pain Catastrophizing Scale (PCS). Multiple linear regression analysis, the Mann Whitney U-test, and Spearman's rank correlation coefficient analysis were used to analyze the data.

RESULTS

When the VAS scores were adjusted, finger pressure caused a 47% reduction overall, 56% in lower elastomer wafer total, 59% in lower right arch, 62% in lower left, and 62% in lower anterior compared with the elastomeric wafer. In the elastomer wafer group, upper and lower anterior scores were higher than posterior scores, respectively. Females had higher VAS (lower left and anterior) and total PCS scores than males. Regardless of the pain control method, total PCS scores were correlated with total (r = .254), upper total (r = .290), right (r = .258), left (r = .244), and posterior (r = .278) VAS scores.

CONCLUSIONS

The stress relief method showed no difference when compared with the other groups. Finger pressure was more effective than the elastomeric wafer in the lower jaw. Higher pain levels were recorded for the anterior regions with the elastomeric wafer. Females and pain catastrophizers gave higher VAS scores.

Insight into orthodontic appliance induced pain: Mechanism, duration and management

Most of the orthodontic patients experience pain during treatment and this significantly influences their attitudes and the approach towards treatment. A number of factors that influence pain response include age, gender, personal pain threshold, mood and stress level of the person, cultural differences and types of orthodontic treatment. Pain is a often overlooked subject by orthodontists, it is nevertheless important to understand the source and mechanism of the pain that occurs during treatment, as well as the methods for managing and controlling this pain. This review attempts to overview the mechanism, duration and current management strategies of orthodontic treatment.

Evaluation of the use of low-level laser therapy in pain control in orthodontic patients: A randomized split-mouth clinical trial

OBJECTIVE

To evaluate the effect of using low-level laser therapy (LLLT) to control pain and discomfort during orthodontic treatment.

MATERIALS AND METHODS

A randomized, split-mouth clinical trial was conducted with 30 volunteers in need of orthodontic treatment, of both genders, aged between 18 and 40 years, who were randomly divided into two groups. One hemiarch was considered the exposed group (EG) and the other, the placebo group (PG). Both groups had elastic separators placed mesially and distally to the first molars of the two hemiarches at different times. The EG received an AIGaAs diode LLLT (810 nm, 100 mW, 2J/cm(2)) application for 15 seconds per point (interdental papilla at the mesial, distal, and near the root apex) immediately after separator placement on the maxillary right side. The PG also had elastics placed around the maxillary right molars, but received only simulated LLLT application. The elastics were left in place for 5 days, and after a waiting period of 1 week, they were inserted on the left side in both groups; however, the order of laser application was changed. While the separator remained in place, the patient marked his degree of perceived discomfort on a Visual Analog Scale (VAS) at 5 minutes (T0), 24 hours (T1), and 120 hours (T2), after LLLT application.

RESULTS

A statistically significant difference was observed (P < .005) in reducing discomfort in the exposed group compared with the placebo group. This reduction of discomfort in the EG was observed at all time intervals.

CONCLUSIONS

A sincle AIGaAs diode LLLT application may be indicated for the control or reduction of pain in the early stages of orthodontic treatment.

A randomized controlled trial of self-perceived pain, discomfort, and impairment of jaw function in children undergoing orthodontic treatment with fixed or removable appliances

OBJECTIVE

To compare patients' perceptions of fixed and removable appliance therapy for correction of anterior crossbite in the mixed dentition, with special reference to perceived pain, discomfort, and impairment of jaw function.

MATERIAL AND METHODS

Sixty-two patients with anterior crossbite and functional shift were recruited consecutively and randomized for treatment with fixed appliances (brackets and archwires) or removable appliances (acrylic plates and protruding springs). A questionnaire, previously found to be valid and reliable, was used for evaluation at the following time points: before appliance insertion, on the evening of the day of insertion, every day/evening for 7 days after insertion, and at the first and second scheduled appointments (after 4 and 8 weeks, respectively).

RESULTS

Pain and discomfort intensity were higher for the first 3 days for the fixed appliance. Pain and discomfort scores overall peaked on day 2. Adverse effects on school and leisure activities were reported more frequently in the removable than in the fixed appliance group. The fixed appliance group reported more difficulty eating different kinds of hard and soft food, while the removable appliance group experienced more speech difficulties. No significant intergroup difference was found for self-estimated disturbance of appearance between the appliances.

CONCLUSIONS

The general levels of pain and discomfort were low to moderate in both groups. There were some statistically significant differences between the groups, but these were only minor and with minor clinical relevance. As both appliances were generally well accepted by the patients, either fixed or removable appliance therapy can be recommended.

The effectiveness of low-level diode laser therapy on orthodontic pain management: a systematic review and meta-analysis

To assess the effectiveness of diode low-level laser therapy (LLLT) for orthodontic pain control, a systematic and extensive electronic search for randomised controlled trials (RCTs) investigating the effects of diode LLLT on orthodontic pain prior to November 2014 was performed using the Cochrane Library (Issue 9, 2014), PubMed (1997), EMBASE (1947) and Web of Science (1956). The Cochrane tool for risk of bias evaluation was used to assess the bias risk in the chosen data. A meta-analysis was conducted using RevMan 5.3. Of the 186 results, 14 RCTs, with a total of 659 participants from 11 countries, were included. Except for three studies assessed as having a ‘moderate risk of bias’, the RCTs were rated as having a ‘high risk of bias’. The methodological weaknesses were mainly due to ‘blinding’ and ‘allocation concealment’. The meta-analysis showed that diode LLLT significantly reduced orthodontic pain by 39 % in comparison with placebo groups (P = 0.02). Diode LLLT was shown to significantly reduce the maximum pain intensity among parallel-design studies (P = 0.003 versus placebo groups; P = 0.000 versus control groups). However, no significant effects were shown for split-mouth-design studies (P = 0.38 versus placebo groups). It was concluded that the use of diode LLLT for orthodontic pain appears promising. However, due to methodological weaknesses, there was insufficient evidence to support or refute LLLT’s effectiveness. RCTs with better designs and appropriate sample power are required to provide stronger evidence for diode LLLT’s clinical applications.

Low-level laser therapy for orthodontic pain: a systematic review

This review aimed to evaluate the clinical outcome of different lasers management on orthodontic pain. Cochrane Library (Issue 7, 2014) and MEDLINE (1966-2014.7) were searched to collect randomized controlled trials on lasers for orthodontic pain. Studies meeting the inclusion criteria were systematically evaluated. The Cochrane Collaboration tools RevMan5.1.7 and GRADEpro 3.6 were used in this systematic review and meta-analysis. As a result, 11 randomized controlled trials (RCTs) studying on low-level laser therapy (LLLT) for orthodontic pain control were included. Meta-analysis and risk of bias assessment were implemented using RevMan5.1.7, and level of evidence assessments was measured by GRADEpro 3.6. In the outcome of the score of the most painful day, the comparison of laser versus placebo (pain associated with tooth movement) demonstrated that LLLT reduced the pain score significantly compared with placebo groups (MD = -4.39, 95% CI range -5.9--2.88, P < 0.00001). In the same way, the most painful day was significantly brought forward in laser versus control group (MD = -0.42, 95% CI range -0.74--0.10, P = 0.009). Furthermore, the outcome of the end of pain day showed a trend of pain termination earlier in laser versus control and placebo groups, but without statistical significance (MD = -1.37, 95% CI range -3.37-0.64, P = 0.18 and MD = -1.04, 95% CI range -4.22-2.15, P = 0.52). However, for the reason of downgrade factors, all the GRADE level of evidences of eight comparisons for three outcomes showed a very low quality. Therefore, for the methodological shortcomings and risk of bias of RCTs included, insufficient evidence was submitted to judge whether LLLT was effective in relieving orthodontic pain. Further and more perfect researches should be done in order to recommend LLLT as a routine method for orthodontic pain.

The effect of seat shape on the risk of pressure ulcers using discomfort and interface pressure measurements

BACKGROUND

It is clinically known that shape is important when selecting or designing a wheelchair support surface for the prevention of pressure ulcers (a £ 2 billion annual cost to the National Health Service, UK); however, the effect of different levels of shape contouring has not been adequately studied.

OBJECTIVES

To investigate the effect of seat shape on the risk of pressure ulcers using discomfort and interface pressure measurements.

STUDY DESIGN

Randomised, repeated trial.

METHODS

Thirty able-bodied participants sat with restricted movement for 30 min in three sessions to evaluate two cushion shapes against a flat baseline surface. Visual Analog Scaling and pressure mapping were used to measure surrogates for pressure ulcer risk, discomfort and interface pressures, respectively.

RESULTS

Linear regression revealed a reduction in discomfort (p < 0.05) on the custom contoured shapes. Interface pressures measured were also lower (p < 0.05) on the custom contoured shapes, and a negative Pearson's correlation (p < 0.05) indicated an association between smaller hip widths and increased discomfort for the commercially shaped cushion.

CONCLUSIONS

The results of this study confirm that custom contoured shapes were effective at reducing pressure ulcer surrogate measures in the participants of this study and therefore suggests that the contribution of a cushion's three-dimensional contours on pressure ulcer risk should be further researched.

CLINICAL RELEVANCE

The measurement of seat shape, discomfort and interface pressure in surrogate participants can help inform the design of wheelchair seating for individuals who are insensate or otherwise at risk of developing pressure ulcers. This knowledge can now be implemented using modern three-dimensional shape acquisition, analysis and fabrication technologies.

Effects of various analgesics on the level of prostaglandin E2 during orthodontic tooth movement

AIM

The aim of this double-blind, randomized, placebo-controlled clinical study was to evaluate the analgesic effects of preoperative/postoperative ibuprofen and acetaminophen use after bonding and to find a relation between the pain level and the amount of prostaglandin released.

MATERIALS AND METHODS

Forty-eight patients were included and randomly divided to three equal groups that received either ibuprofen, acetaminophen or placebo for pain relief. The pain levels were measured before bonding, after bonding, at first, second, third, and seventh days on a 100 mm visual analogue scale (VAS) and gingival crevicular fluid (GCF) samples were collected at the same time intervals to measure the amount of prostaglandin E2 (PGE2) released. PGE2 levels were determined with ELISA test. The results were evaluated with Wilcoxon and Kruskal–Wallis tests with Bonferroni correction.

RESULTS

Acetaminophen and placebo groups showed similar pain levels during the first 2 days, whereas ibuprofen group showed lower pain levels during the first day after bonding. PGE2 levels did not show statistically significant difference in time within the analgesic groups. No significant relation between the pain perceived and PGE2 released was found.

LIMITATIONS

The biggest limitation of this study is the subjective nature of pain and its method of evaluation.

CONCLUSIONS

The perception of pain by patients taking ibuprofen and acetaminophen at pre/post appliance placement was not different from patients taking placebo. No time-related differences in PGE2 level were found between the groups and no significant correlation was found between the perception of pain and PGE2 levels.

The effect of two phototherapy protocols on pain control in orthodontic procedure--a preliminary clinical study

Phototherapy with low-level coherent light (laser) has been reported as an analgesic and anti-inflammatory as well as having a positive effect in tissue repair in orthodontics. However, there are few clinical studies using low-level LED therapy (non-coherent light). The aim of the present study was to analyze the pain symptoms after orthodontic tooth movement associated with and not associated with coherent and non-coherent phototherapy. Fifty-five volunteers (mean age = 24.1 ± 8.1 years) were randomly divided into four groups: G1 (control), G2 (placebo), G3 (protocol 1: laser, InGaAlP, 660 nm, 4 J/cm(2), 0.03 W, 25 s), G4 (protocol 2: LED, GaAlAs, 640 nm with 40 nm full-bandwidth at half-maximum, 4 J/cm(2), 0.10 W, 70 s). Separators were used to induce orthodontic pain and the volunteers pain levels were scored with the visual analog scale (VAS) after the separator placement, after the therapy (placebo, laser, or LED), and after 2, 24, 48, 72, 96, and 120 h. The laser group did not have statistically significant results in the reduction of pain level compared to the LED group. The LED group had a significant reduction in pain levels between 2 and 120 h compared to the control and the laser groups. The LED therapy showed a significant reduction in pain sensitivity (an average of 56%), after the orthodontic tooth movement when compared to the control group.

Self-reported pain associated with the use of intermaxillary elastics compared to pain experienced after initial archwire placement

OBJECTIVE

To evaluate the pain during the use of intermaxillary elastics and to compare it with that of initial archwire placement.

MATERIALS AND METHODS

Sixteen orthodontic patients who underwent initial bonding (7 girls, 13 boys; mean age 16.75 ± 2.61 years) and 19 patients who would be using intermaxillary elastics for the first time (13 girls, 7 boys; mean age 16.21 ± 3.01 years) were enrolled in this prospective study. A visual analog scale form was given to each patient to measure the pain levels, and these were measured by the same investigator using a digital caliper. Data were evaluated using Mann Whitney U-test.

RESULTS

The pain started to increase 2 hours after the application of elastics. The highest levels were achieved at the sixth hour and the same night. The pain levels started to decrease at day 2. Although the pain levels of the elastic group started to decrease after the second day, the pain levels of the initial bonding group were still significantly high.

CONCLUSIONS

Intermaxillary elastics cause similar amounts of pain compared with initial archwire placement, but the pain of the elastics did not last as long as the pain felt after initial bonding.

Adverse effects of orthodontic treatment: A clinical perspective

Orthodontic treatment is associated with a number of adverse effects, such as root resorption, pain, pulpal changes, periodontal disease, and temporomandibular dysfunction (TMD). Orthodontists should be aware of these effects and associated risk factors. Risk factors linked to root resorption include the duration of treatment, length, and shape of the root, trauma history, habits, and genetic predisposition.