The correlations between health-related quality of life changes and pain and anxiety in orthodontic patients in the initial stage of treatment

A longitudinal pilot study examining the influence of the orthodontic system chosen in adult patients (brackets versus aligners) on oral health-related quality of life and anxiety

BACKGROUND

In recent years, the demand for orthodontic treatment with aligners has increased, led by patient need, as aligners typically provide them with improved aesthetics and less physical discomfort. In deciding with the patient on an appropriate orthodontic system, it is important to take into account the potential discomfort and the perceptions that patients have in relation to their treatment. The objective of this study was to analyze the influence of brackets or aligners on oral health-related quality of life (OHRQoL) and anxiety levels in a sample of adult patients during the first month of treatment.

METHODS

The pilot study was carried out at the Dental Clinic of the University of Salamanca between November 2023 and February 2024. Eighty adult patients who initiated orthodontic treatment were selected and divided into two groups: the brackets group (Victory®; 3 M Unitek, California, USA) (n = 40) and the aligners group (Invisalign®; Align Technology, California, USA) (n = 40). OHRQoL was analyzed using the Oral Health Impact Profile-14 (OHIP-14) questionnaire, and anxiety was analyzed using the State-Trait Anxiety Inventory (STAI). The follow-up time was one month, with scores recorded at the beginning (T0) and one month after starting treatment (T1).

RESULTS

The mean patient age was 33.70 (± 5.45) years old. The total sample (n = 80) consisted of 66.2% men and 33.8% women. In the brackets group, one month after starting treatment, the dimension with the highest impact was that of physical pain (5.62 ± 1.51). In the aligners group, where the dimension of psychological disability had the highest score (4.22 ± 1.02). In the brackets group the total OHIP score was higher at one month (T1) (33.98 ± 6.81) than at the start of treatment (T0) (21.80 ± 3.34); this greater impact on OHRQoL one month after starting treatment was not observed in the aligners group (T1 = 27.33 ± 6.83; T0 = 27.33 ± 6.22). The orthodontic system used did not influence participants' anxiety (p > 0.05). Age and sex were not influential factors in either OHRQoL or anxiety.

CONCLUSIONS

The bracket system significantly influenced patients' OHRQoL. In the sample studied, no influence of the orthodontic system (brackets versus aligners) on anxiety was observed.

Effect of aligners on patients' oral health-related quality of life and anxiety: a prospective pilot study

BACKGROUND

This prospective study explored the impact of aligners on the oral health-related quality of life and anxiety of patients during the first month of orthodontic treatment and the first month of the retention phase.

METHODS

A total of 23 male and female patients (median age 25 y) treated with clear aligners were included. The OHRQoL questionnaire was used at certain time points during treatment (T1: placement of the first aligner; T2: after one day of use; T3: after seven days; T4: after one month; and T5: after one month in the retention phase). The State-Trait Anxiety Inventory (STAI) was also self-administered to assess state and trait anxiety (Y1 and Y2 subscales, respectively) at the T1, T4 and T5 time points. A population average generalized estimating equations logistic regression model was fit to assess the effect of time on the responses, and the Wald test was used to examine the overall effect of time.

RESULTS

Overall time was a significant predictor for most of the questions. However, time was marginally significant for the OHRQoL questions evaluating oral symptoms such as bad taste/smell, sores, and food accumulation. Tooth discolouration did not differ between time points. The general activity disturbance was significantly lower in the retention phase. Higher depression and anxiety scores were reported at the initial appointment and decreased thereafter.

CONCLUSIONS

CAT has a negative impact on quality of life and psychological status during the initial days of treatment. These impairments ameliorate at later treatment stages.

Comparison of anxiety, pain, and quality of life in individuals with mild or moderate malocclusion between conventional fixed orthodontic treatment versus Invisalign: a randomised clinical trial

BACKGROUND

We evaluated anxiety, pain, and oral-health-related quality of life in individuals treated with conventional fixed appliances (Group A) and clear aligners (Group B) for moderate malocclusion during the initial phase of orthodontic treatment.

METHODS

Sixty individuals, separated into Group A (n = 30) and Group B (n = 30), were included in the study. They completed the Anxiety Levels, Oral Health Impact Profile-14, and Oral Health Related Quality of Life - United Kingdom/Surveys after the application of attachments on days 0 (T1), 10 (T10), and 20 (T20). Their pain levels were evaluated with the Visual Analogue Scale on days 0, 2, and 6 in the 2nd and 6th hours and on the 1st, 3rd, 7th, 14th, and 21st days.

RESULTS

Per the VAS questionnaire, pain levels in the 2nd hour, 6th hour, 1st day, and 3rd day were significantly lower in Group B than in Group A. In the OHIP-14 survey results, the comparison between Group A and Group B showed a significant difference only on the 1st day. The STAI and OHRQoL-UK survey results did not differ significantly between the groups.

CONCLUSIONS

We found no significant difference between the two groups in terms of anxiety levels, and pain among individuals in Group A was higher than in Group B only at the beginning of the treatment. No significant differences were observed in terms of individuals' quality of life.

TRIAL REGISTRATION

NCT06133296 (retrospectively registered)- Registration Date:15/11/2023.

Orthodontic pain is related to oral health-related quality of life in orthodontic patients

INTRODUCTION

Orthodontic pain (OP) is a subjective experience induced by prolonged force on the teeth in fixed orthodontic treatment. OP acts as a predictor of aspects related to oral health-related quality of life (OHRQOL). It is important to understand the extent of the impact of OP on a patient's daily life, especially on stomatognathic function and social impact.

OBJECTIVE

To assess the correlation between OP and OHRQOL in fixed orthodontic treatment patients.

MATERIAL AND METHODS

The comparative pain rating scale is used to assess pain intensity, while the oral health impact profile-14 (OHIP-14) assesses the impact of OP severity on OHRQOL of 57 patients undergoing fixed orthodontic treatment in the early stages of treatment (1-3 months of treatment) at the Dental Hospital, Universitas Airlangga. Gender, age, and malocclusion classifications were also analyzed for their influence. The data were analyzed using Spearman correlation and two-way analysis of variance (ANOVA).

RESULTS

In the initial phase of treatment, most of the patients (53%) experienced mild OP and moderate OP (39%), and OP was reduced over a week. The overall OHRQOL score was 17.4 ± 8, which indicates a negative impact on OHRQOL. There were also positive correlation dimensions of OHRQOL, which include the dimensions of physical limitations, psychological discomfort, and psychological limitations (r > 0.50). There was a significant difference between age groups in OP perception and OHRQOL (P < 0.05).

CONCLUSIONS

There was a positive correlation between OP intensity and OHRQOL experienced by fixed orthodontic patients at the Dental Hospital, Universitas Airlangga.

Automated Machine Learning Analysis of Patients With Chronic Skin Disease Using a Medical Smartphone App: Retrospective Study

BACKGROUND

Rapid digitalization in health care has led to the adoption of digital technologies; however, limited trust in internet-based health decisions and the need for technical personnel hinder the use of smartphones and machine learning applications. To address this, automated machine learning (AutoML) is a promising tool that can empower health care professionals to enhance the effectiveness of mobile health apps.

OBJECTIVE

We used AutoML to analyze data from clinical studies involving patients with chronic hand and/or foot eczema or psoriasis vulgaris who used a smartphone monitoring app. The analysis focused on itching, pain, Dermatology Life Quality Index (DLQI) development, and app use.

METHODS

After extensive data set preparation, which consisted of combining 3 primary data sets by extracting common features and by computing new features, a new pseudonymized secondary data set with a total of 368 patients was created. Next, multiple machine learning classification models were built during AutoML processing, with the most accurate models ultimately selected for further data set analysis.

RESULTS

Itching development for 6 months was accurately modeled using the light gradient boosted trees classifier model (log loss: 0.9302 for validation, 1.0193 for cross-validation, and 0.9167 for holdout). Pain development for 6 months was assessed using the random forest classifier model (log loss: 1.1799 for validation, 1.1561 for cross-validation, and 1.0976 for holdout). Then, the random forest classifier model (log loss: 1.3670 for validation, 1.4354 for cross-validation, and 1.3974 for holdout) was used again to estimate the DLQI development for 6 months. Finally, app use was analyzed using an elastic net blender model (area under the curve: 0.6567 for validation, 0.6207 for cross-validation, and 0.7232 for holdout). Influential feature correlations were identified, including BMI, age, disease activity, DLQI, and Hospital Anxiety and Depression Scale-Anxiety scores at follow-up. App use increased with BMI >35, was less common in patients aged >47 years and those aged 23 to 31 years, and was more common in those with higher disease activity. A Hospital Anxiety and Depression Scale-Anxiety score >8 had a slightly positive effect on app use.

CONCLUSIONS

This study provides valuable insights into the relationship between data characteristics and targeted outcomes in patients with chronic eczema or psoriasis, highlighting the potential of smartphone and AutoML techniques in improving chronic disease management and patient care.

Orthodontic Patients with Poor Oral Health-Related Quality of Life are More Likely to Have Emotional Distress: A Cross-Sectional Study

Objective

This study aims to investigate the relationship between oral health-related quality of life (OHRQoL) and emotional distress (ED), including anxiety and depression, in orthodontic patients.

Methods

A cross-sectional study was conducted involving 603 orthodontic patients, consisting of 401 females (66.5%) with a mean age of 24.15 ± 7.72 and 202 males (33.5%) with a mean age of 24.16 ± 7.72. A questionnaire containing questions of demographic information, the Oral Health Impact Profile (OHIP-14) and the Huaxi emotional-distress index (HEI) was employed to assess OHRQoL and ED. According to the HEI score, the respondents were divided into ED group (HEI > 8) and non-ED group (HEI ≤ 8). Data were analyzed using Kolmogorov-Smirnov test, Mann-Whitney test and logistic regression analysis with the significance level set at p < 0.05.

Results

The prevalence of poor OHRQoL and ED of the study sample was 28.4% and 19.57%, respectively. There was a significantly higher prevalence of ED among poor OHRQoL patients (35.67%) compared to those with good OHRQoL (13.19%) (p < 0.001). Poor OHRQoL and risky drinking behavior addressed higher significant correlation with ED patients than non-ED patients (p < 0.05). There were no statistical differences in other factors such as gender, age, and appliance type (p > 0.05). Poor OHRQoL orthodontic patients were at a higher risk of suffering from anxiety and depression compared to those with good OHRQoL (age-risky drinking behavior-sex-adjusted: OR = 4.00; all p < 0.001).

Conclusion

Oral health-related quality of life (OHRQoL) is related to emotional stress. Namely, patients with poor OHRQoL are more likely to experience anxiety and depression. As a result, orthodontists should consistently assess the emotional well-being and OHROoL of patients over the treatment course for better treatment outcomes.

Oral-Health-Related Quality of Life and Anxiety in Orthodontic Patients with Conventional Brackets

The aim of this study was to evaluate the oral-health-related quality of life (OHRQoL) and anxiety levels of adult patients undergoing orthodontic treatment with fixed multibracket appliances.

MATERIALS AND METHODS

The study was carried out at the Dental Clinic of the University of Salamanca in 2021. It included 120 adult patients between 19 and 45 years of age undergoing orthodontic treatment with conventional metal brackets. The data collection instruments chosen were the state-trait anxiety inventory (STAI) to assess anxiety levels and the OHIP-14 questionnaire to measure the OHRQoL. Anxiety levels and OHRQoL were analyzed one month after starting treatment.

RESULTS

The mean age was 31.7 years ± 6.5 years; 68 patients were women (56.7%) and 52 were men (43.3%). Psychological disability was the dimension of the OHIP-14 questionnaire that was found to have the greatest impact (3.20 ± 1.08) on patients, as compared to the dimension of disability, which had the lowest impact on the oral-health quality of life (0.37 ± 0.56). The mean total score of the OHIP-14 questionnaire was 11.93 (±2.19). There was no statistically significant influence from either sex or age on the anxiety and oral-health quality of life of the participants; however, there was a significant relationship between the dimensions of physical disability and anxiety traits.

CONCLUSIONS

The physical disability dimension of the OHIP-14 questionnaire increased the anxiety level of adult patients treated with conventional brackets. The impact of orthodontic treatment on adult patients may negatively influence their levels of anxiety.

Predicting patient experience of Invisalign treatment: An analysis using artificial neural network

Objective

Poor experience with Invisalign treatment affects patient compliance and, thus, treatment outcome. Knowing the potential discomfort level in advance can help orthodontists better prepare the patient to overcome the difficult stage. This study aimed to construct artificial neural networks (ANNs) to predict patient experience in the early stages of Invisalign treatment.

Methods

In total, 196 patients were enrolled. Data collection included questionnaires on pain, anxiety, and quality of life (QoL). A four-layer fully connected multilayer perception with three backpropagations was constructed to predict patient experience of the treatment. The input data comprised 17 clinical features. The partial derivative method was used to calculate the relative contributions of each input in the ANNs.

Results

The predictive success rates for pain, anxiety, and QoL were 87.7%, 93.4%, and 92.4%, respectively. ANNs for predicting pain, anxiety, and QoL yielded areas under the curve of 0.963, 0.992, and 0.982, respectively. The number of teeth with lingual attachments was the most important factor affecting the outcome of negative experience, followed by the number of lingual buttons and upper incisors with attachments.

Conclusions

The constructed ANNs in this preliminary study show good accuracy in predicting patient experience (i.e., pain, anxiety, and QoL) of Invisalign treatment. Artificial intelligence system developed for predicting patient comfort has potential for clinical application to enhance patient compliance.

Altered Brain Topological Property Associated With Anxiety in Experimental Orthodontic Pain

Background

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

Methods

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

Results

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

Conclusion

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

Effect of experimental orthodontic pain on gray and white matter functional connectivity

AIM

Over 90% of patients receiving orthodontic treatment experience clinically significant pain. However, little is known about the neural correlates of orthodontic pain and which has therefore been investigated in the present study of healthy subjects using an experimental paradigm.

METHODS

Resting-state functional magnetic resonance imaging (rsfMRI) was performed in 44 healthy subjects 24 hours after an elastic separator had been introduced between the first and the second molar on the right side of the lower jaw and in 49 age- and sex-matched healthy control (HC) subjects. A K-means clustering algorithm was used to identify functional gray matter (GM) and white matter (WM) resting-state networks, and differences in functional connectivity (FC) of GM and WM between the group of subjects with experimental orthodontic pain and HC were analyzed.

RESULTS

Twelve GM networks and 14 WM networks with high stability were identified. Compared with HC, subjects with orthodontic pain showed significantly increased FC between WM12, which includes posterior thalamic radiation and posterior cingulum bundle, and most GM networks. Besides, the WM12 network showed significant differences in FC with three GM-WM loops involving the default mode network, dorsal attention network, and salience network, respectively.

CONCLUSIONS

Orthodontic pain is shown to produce an alteration of FC in networks relevant to pain processing, which may be mediated by a WM network relevant to emotion perception and cognitive processing.

Efficacy of Photobiomodulation Therapy for Orthodontic Pain Control Following the Placement of Elastomeric Separators: A Randomized Clinical Trial

Introduction: Controlling pain in orthodontic patients has gained special attention. This study assessed the efficacy of photobiomodulation therapy (PBMT) for pain control following the placement of elastomeric separators. Methods: This split-mouth single-blind randomized clinical trial evaluated 30 orthodontic patients who required posterior elastomeric separators. The two maxillary quadrants were randomized into the laser and control groups. In the laser quadrant, an 808 nm diode laser (400 mW, 15.60 J/cm² , 11 seconds, continuous-wave, contact mode) was irradiated to the cervical third of the maxillary first molar roots 24 hours prior to the placement of separators. The control quadrant received placebo radiation by a light-curing unit. The patients received the second laser cycle right before the placement of separators 24 hours later. The level of self-perceived pain was recorded at 0, 2, 6, 24, and 72 hours and 5 days after the intervention in the laser and control quadrants using a visual analog scale (VAS). Data were analyzed using the analysis of variance (ANOVA) and paired-samples t test. Results: The trend of change in the pain score was similar in both groups. The pain score was significantly lower in the laser group than the control group at all-time points (P <0.05) except at time 0. The pain score increased in the first 6 hours and reached its maximum level in 24 hours in both groups. Conclusion: PBMT by an 808 nm diode laser can effectively decrease pain following the placement of elastomeric separators.

Fixed orthodontic appliance impact on oral health-related quality of life during initial stages of treatment

Aims

Our study aimed to assess the oral health-related quality of life (OHRQoL) changes during the initial stage of fixed orthodontic appliance therapy and determined the impact of various orthodontic therapy needs on the OHRQoL of Saudi patients seeking orthodontic treatment.

Materials and Methods

Forty-two patients aged 14-24 years (69% females) were recruited from the orthodontic clinics. OHRQoL was quantified by a self-administered short version of oral health impact profile (OHIP-14) questionnaire used before treatment (T0) and following bonding of fixed appliance on days 1 (T1), 7 (T2), 14 (T3), and 30 (T4). The higher the OHIP-14 score, the poorer the OHRQoL. The dental health component (DHC) of the index of orthodontic treatment needs (IOTN) was used to assess malocclusion severity. The missing, overjet, crossbite, displacement, overbite (MOCDO) hierarchical scale was used to categorize the most severe feature in each patient and determine the grade of orthodontic treatment need. Changes of OHRQoL over time were compared using the Friedman test.

Result

Overall OHIP-14 score significantly increased following orthodontic appliance bonding at T1 and T2 compared to T0 (P < 0.001). The functional limitation domains in OHIP-14 pain and discomfort, physical disability, psychological disability, and psychological discomfort were affected at T1 compared to T0 (P < 0.05). Grade 4 IOTN-DHC (definite treatment needs) significantly influenced most OHIP-14 domains compared to other grades.

Conclusion

With the growing therapeutic and cosmetic demands of orthodontic treatment and the focus on OHRQoL, the study findings can be used to enhance patients' cooperation, expectation, and adherence to orthodontic treatment.

Pain and Oral Health Related Quality of Life among Patients Undergoing Fixed Orthodontic Treatment: A Descriptive Cross-sectional Study

Introduction:

Fixed orthodontic procedures such as separator placement, archwire placement and activations, application of orthopaedic forces, and debonding of brackets produce pain in patients. This study was conducted to assess pain and oral health-related quality of life among patients undergoing orthodontic treatment.

Methods:

This descriptive cross-sectional study was conducted among 152 orthodontic patients of a teritary care center from January 2019 to October 2019 after receiving ethical approval from the Institutional Review Committee (Ref. no. 2311201813). Convenience sampling method was done to select the participants. Oral health-related quality of life using "Oral Health Impact Profile-14" and pain experienced during the first month of fixed orthodontic treatment were assessed. Data analysis for calculation of frequency and proportion was done in Statistical Package of Social Sciences.

Results:

Mean pain score of the study participants was 5.05±2.07 and their mean oral health impact was 12.71±7.27. Most of the study participants 86 (56.58%), had experienced moderate pain due to orthodontic treatment. Out of the reported impacts, 134 (88.2%) had painful aching in mouth and 127 (83.6%) had difficulty during eating. Least impact was seen in alteration of taste 35 (23%).

Conclusions:

The pain intensity experienced by patients was variable. Most participants had moderate pain but few patients perceived no pain at all. The participants had at least one or other oral health impacts due to fixed orthodontic treatment. Orthodontists should counsel the patients regarding possible discomfort so that there is no discontinuation of treatment due to pain.

Current advances in orthodontic pain

Orthodontic pain is an inflammatory pain that is initiated by orthodontic force-induced vascular occlusion followed by a cascade of inflammatory responses, including vascular changes, the recruitment of inflammatory and immune cells, and the release of neurogenic and pro-inflammatory mediators. Ultimately, endogenous analgesic mechanisms check the inflammatory response and the sensation of pain subsides. The orthodontic pain signal, once received by periodontal sensory endings, reaches the sensory cortex for pain perception through three-order neurons: the trigeminal neuron at the trigeminal ganglia, the trigeminal nucleus caudalis at the medulla oblongata and the ventroposterior nucleus at the thalamus. Many brain areas participate in the emotion, cognition and memory of orthodontic pain, including the insular cortex, amygdala, hippocampus, locus coeruleus and hypothalamus. A built-in analgesic neural pathway—periaqueductal grey and dorsal raphe—has an important role in alleviating orthodontic pain. Currently, several treatment modalities have been applied for the relief of orthodontic pain, including pharmacological, mechanical and behavioural approaches and low-level laser therapy. The effectiveness of nonsteroidal anti-inflammatory drugs for pain relief has been validated, but its effects on tooth movement are controversial. However, more studies are needed to verify the effectiveness of other modalities. Furthermore, gene therapy is a novel, viable and promising modality for alleviating orthodontic pain in the future.

Prediction of pain in orthodontic patients based on preoperative pain assessment

AIM

To investigate whether pretreatment assessment of experimental pain can predict the level of pain after archwire placement.

METHODS

One hundred and twenty-one general university students seeking orthodontic treatment were enrolled in this study. A cold pressor test was performed to estimate the pain tolerance of subjects before treatment. Self-reported pain intensity was calculated using a 10 cm visual analog scale during the 7 days after treatment. The relationship between pain tolerance and orthodontic pain was analyzed using Spearman's correlation analysis.

RESULTS

The maximum mean level of pain intensity occurred at 24 hours after bonding (53.31±16.13) and fell to normal levels at day 7. Spearman's correlation analysis found a moderate positive association between preoperative pain tolerance and self-reported pain after archwire placement (P<0.01). There was no significant difference in pain intensity between male and female patients at any time point (P>0.05).

CONCLUSION

A simple and noninvasive preoperative sensory test (the cold pressor test) was useful in predicting the risk of developing unbearable pain in patients after archwire placement. Self-reported pain after archwire placement decreased as individual pain tolerance increased.

Strong Manual Acupuncture Stimulation of "Huantiao" (GB 30) Reduces Pain-Induced Anxiety and p-ERK in the Anterior Cingulate Cortex in a Rat Model of Neuropathic Pain

Persistent neuropathic pain is associated with anxiety. The phosphorylation of extracellular signal-regulated kinase (p-ERK) in the anterior cingulate cortex (ACC) plays an important role in pain-induced anxiety. Acupuncture is widely used for pain and anxiety. However, little is known about which acupuncture technique is optimal on pain-induced anxiety and the relationship between acupuncture effect and p-ERK. The rat model was induced by L5 spinal nerve ligation (SNL). Male adult SD rats were randomly divided into control, SNL, strong manual acupuncture (sMA), mild manual acupuncture (mMA), and electroacupuncture (EA) group. Bilateral "Huantiao" (GB 30) were stimulated by sMA, mMA, and EA, respectively. The pain withdrawal thresholds (PWTs) and anxiety behavior were measured, and p-ERK protein expression and immunoreactivity cells in ACC were detected. PWTs increased significantly in both sMA and EA groups. Meanwhile, anxiety-like behavior was improved significantly in the sMA and mMA groups. Furthermore, the overexpression of p-ERK induced by SNL was downregulated by strong and mild manual acupuncture. Therefore, strong manual acupuncture on bilateral "Huantiao" (GB 30) could be a proper therapy relieving both pain and pain-induced anxiety. The effect of different acupuncture techniques on pain-induced anxiety may arise from the regulation of p-ERK in ACC.