Cognitive behavioral therapy for orthodontic pain control: a randomized trial

Effect of verbal and written information on the perception of pain and analgesic consumption, in adolescent orthodontic patients: A randomised controlled trial

OBJECTIVE

To investigate the impact of written instructions, about post-bonding pain, on patients' pain perception and analgesic consumption and to evaluate the correlation of pain with personality types.

DESIGN

Two-arm parallel randomised controlled trial.

SETTING

University Hospital Centre Zagreb, Zagreb, Croatia.

METHODS

Participants included adolescents in the permanent dentition with mild or moderate crowding.

RANDOMISATION

The participants were randomly allocated, using computer-generated random list, into two groups.

INTERVENTIONS

After bonding and archwire insertion, all participants received oral instructions on potential pain occurrence and pain control. Participants in the study group also received written information on post-bonding pain.

OUTCOMES

Pain intensity was evaluated using the Numerical Rating Scale immediately after (T0), 2 days (T1) and 7 days (T2) after the placement of the fixed orthodontic appliance. Analgesic consumption was assessed as yes or no, and personality traits were assessed using the Big Five Inventory. Operators who scored pain intensity and recorded analgesic consumption and personality traits were blinded to the group allocation. Statistical analyses included the t-test, Mann-Whitney U-test, Spearman correlations and stepwise regression analysis.

RESULTS

The highest rate of pain was recorded at T1 (P < 0.001). No statistically significant difference in pain perception between groups was observed. There was no statistically significant difference in analgesic consumption between the two groups (P = 0.81). The correlations between personality traits and pain perception were not significant.

CONCLUSION

The additional written information had little impact on pain perception, and it had no relationship to personality types. The perception of pain and analgesic consumption were not affected by the provision of additional written information (P = 0.81). Participants' personality types did not affect the impact of the information given.

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.

Nociceptor mechanisms underlying pain and bone remodeling via orthodontic forces: toward no pain, big gain

Orthodontic forces are strongly associated with pain, the primary complaint among patients wearing orthodontic braces. Compared to other side effects of orthodontic treatment, orthodontic pain is often overlooked, with limited clinical management. Orthodontic forces lead to inflammatory responses in the periodontium, which triggers bone remodeling and eventually induces tooth movement. Mechanical forces and subsequent inflammation in the periodontium activate and sensitize periodontal nociceptors and produce orthodontic pain. Nociceptive afferents expressing transient receptor potential vanilloid subtype 1 (TRPV1) play central roles in transducing nociceptive signals, leading to transcriptional changes in the trigeminal ganglia. Nociceptive molecules, such as TRPV1, transient receptor potential ankyrin subtype 1, acid-sensing ion channel 3, and the P2X3 receptor, are believed to mediate orthodontic pain. Neuropeptides such as calcitonin gene-related peptides and substance P can also regulate orthodontic pain. While periodontal nociceptors transmit nociceptive signals to the brain, they are also known to modulate alveolar bone remodeling in periodontitis. Therefore, periodontal nociceptors and nociceptive molecules may contribute to the modulation of orthodontic tooth movement, which currently remains undetermined. Future studies are needed to better understand the fundamental mechanisms underlying neuroskeletal interactions in orthodontics to improve orthodontic treatment by developing novel methods to reduce pain and accelerate orthodontic tooth movement-thereby achieving "big gains with no pain" in clinical orthodontics.

Influence of functional and esthetic expectations on orthodontic pain

OBJECTIVES

To investigate the effect of orthodontic treatment outcome (OTO) expectations on the level of pain intensity experienced after orthodontic elastomeric separation (OES).

MATERIALS AND METHODS

A total of 100 orthodontic patients (74 female and 26 male, age 14 years and above) from the Faculty of Dentistry, Mahidol University were enrolled. Before OES, questionnaires were administered to obtain patients' expectations regarding various aspects of OTO as well as OES pain expectations. Real-time self-reported pain intensity from OES at the maxillary and mandibular first permanent molars was obtained before and immediately after separator placement and at 6 h, 24 h, and then every day until day 7 after OES. Data were analyzed for the relationship between OTO expectations and OES pain intensity. The level of significance was set at 0.05.

RESULTS

The maximum OES pain intensity occurred on day 2 after OES and gradually decreased to the pretreatment level on day 7. The degree of facial, tooth alignment, masticatory function improvement expectations, and a high level of OES pain expectations were significantly associated with the severity of OES pain after separator placement.

CONCLUSION

Esthetic and functional expectations of OTO were significantly associated with OES pain intensity. Thus, knowledge about esthetic and functional expectations may help to predict patient's pain response to orthodontic treatment.

Mental and Physical Health Concerns in the Context of COVID-19: Opportunities and Applications for Behavioral Medicine

Numerous physical and mental health concerns have been documented in the context of COVID-19, and it is likely that patients, survivors, frontline health care workers, and other affected individuals will present to psychiatry for treatment. Behavioral medicine, an interdisciplinary field that is defined by a behavioral and biomedical conceptualization of clinical care, offers an opportunity for collaboration with psychiatry and other health care providers to meet the myriad needs resulting from the pandemic. This review summarizes a conceptual framework of behavioral medicine and clinical health psychology, COVID-19-related quality of life concerns that may be applicable to behavioral medicine referrals, clinical assessment directions, and intervention opportunities. The review combines both findings specific to COVID-19 and general behavioral medicine principles with an overall goal of providing a basic introduction to behavioral medicine practice, applications, and opportunities for management of medical and psychological symptoms.

Periodontal acidification contributes to tooth pain hypersensitivity during orthodontic tooth movement

Tooth movements associated with orthodontic treatment often cause tooth pain. However, the detailed mechanism remains unclear. Here, we examined the involvement of periodontal acidification caused by tooth movement in mechanical tooth pain hypersensitivity. Elastics were inserted between the first and second molars to move the teeth in Sprague-Dawley rats. Mechanical head-withdrawal reflex threshold to first molar stimulation and the pH of the gingival sulcus around the tooth were measured. The expression of acid-sensing ion channel 3 (ASIC3) in trigeminal ganglion neurons and phosphorylation of ASIC3 in the periodontal tissue were analyzed. The mechanical head-withdrawal reflex threshold to first molar stimulation and pH in the gingival sulcus decreased on day 1 after the elastic insertion. These decreases recovered to the sham level by buffering periodontal acidification. Periodontal inhibition of ASIC3 channel activity reversed the decreased mechanical head-withdrawal reflex threshold to first molar stimulation. On day 1 after elastic insertion, the tooth movement did not change the number of ASIC3 immunoreactive trigeminal ganglion neurons innervating the periodontal tissue but increased phosphorylated-ASIC3 levels in the periodontal tissue. Periodontal acidification induced by tooth movement causes phosphorylation of ASIC3, resulting in mechanical pain hypersensitivity in mechanically forced tooth.

Comparison of pain perception, anxiety, and impacts on oral health-related quality of life between patients receiving clear aligners and fixed appliances during the initial stage of orthodontic treatment

BACKGROUND AND OBJECTIVES

Clear aligner is an advanced orthodontic method with benefits of comfort, aesthetics, and convenience. This study aimed to compare pain perception, anxiety, and impacts on oral health-related quality of life (OHRQoL) between adult patients receiving clear aligners and fixed appliances during the initial stage of orthodontic treatments.

MATERIAL AND METHODS

The two groups were well matched by ages, gender, and levels of malocclusion severity. Pain perception, anxiety, and OHRQoL were assessed through visual analogue scale, state-trait anxiety inventory, and oral health impact profile-14 (OHIP-14), respectively. And the comparison of above scores was performed by two-way analysis of variance.

RESULTS

A total of 110 patients (55 pairs) were enrolled in this study. Orthodontic pain levels peaked on the first day and decreased gradually afterwards in both groups, which were significantly higher in the fixed group on the first, second, fourth, and fifth days. Likewise, anxiety levels peaked on the first day and decreased thereafter, with significant difference on the 1st, 3d, 5th, 7th, and 14th days. Moreover, the OHIP-14 scores increased and peaked on the first day and then gradually decreased for both groups, which were also significantly higher in the fixed group on the 1st, 7th, and 14th days.

LIMITATIONS

More malocclusion types should be used for group matching. The effect of exclusion of small groups should be taken into consideration in sample size calculation. Income was significantly unbalanced between two groups due to higher cost of clear aligners, and random assignment of treatment modalities was unfeasible.

CONCLUSIONS

Patients treated with clear aligners experienced lower pain levels, less anxiety, and higher OHRQoL as compared to those receiving fixed appliances.

Placebo modulation in orthodontic pain: a single-blind functional magnetic resonance study

OBJECTIVES

The mechanism of orthodontic pain modulation with a placebo remains largely unknown. This study aimed to investigate the placebo modulation of brain activity associated with orthodontic pain using functional magnetic resonance imaging (fMRI).

METHODS

This longitudinal fMRI experiment recruited 23 volunteers and a self-contrast method was used. At first time, the participants were scanned without placebo (first period), followed by a 30-day washout, the participants were scanned again with placebo administration (second period). Orthodontic pain was caused by orthodontic separators placement between the lower right molars for both two periods. 24 h after placement, the MRI scans were taken, including a bite/non-bite task fMRI and a resting-state fMRI. A generalized linear model was used to identify pain-regulating network from task fMRI. Functional connectivity analysis of pain-related brain regions was performed to study the placebo effect on connectivity of pain-regulating networks using resting-state fMRI.

RESULTS

The results of brain activation patterns were largely similar under placebo and non-placebo conditions. Under the non-placebo condition, the activities in multiple brain regions, including the pre-central gyrus, superior frontal gyrus, superior parietal lobule, and supramarginal gyrus, were significantly higher than that of the placebo condition. However, the anterior cingulate cortex (ACC) was activated under the non-placebo condition but not in the placebo one. The functional connectivities between ACC and orbitofrontal cortex, and the dorsolateral prefrontal cortex and orbitofrontal cortex were reduced under placebo condition.

CONCLUSION

Participants demonstrated similar brain activation patterns for orthodontic pain with or without placebos. With placebo, reduced activation in primary sensory cortex and decreased activation in ACC indicated that ACC could be fundamental in analgesia.

Varied temporal expression patterns of trigeminal TRPA1 and TRPV1 and the neuropeptide CGRP during orthodontic force-induced pain

OBJECTIVE

The aim of this study was to quantify the temporal changes in inflammation and TRPA1, TRPV1 and CGRP expression in the trigeminal ganglion during force-induced orthodontic pain.

DESIGN

Orthodontic force was applied to both maxillary first molars in 8-week-old Wistar rats for 12 h, 24 h, 3 d or 7 d. The rat grimace scale (RGS) score and duration of face grooming were used to measure orthodontic pain. Western blotting was performed to assess TRPA1, TRPV1 and CGRP expression in trigeminal ganglia. NF-кB levels and colocalization of TRPA1, TRPV1 and CGRP were evaluated by immunofluorescent staining.

RESULTS

Application of continuous force significantly increased pain behaviours at 1 and 3 d. NF-кB significantly increased in periodontal ligament at 12 h until 3 d. TRPV1 was significantly elevated within 1 d; TRPA1 significantly increased from 1-3 d; CGRP expression significantly increased from 12 h to 3 d. The TRPV1/TRPA1 expression ratio was highest at 12 h; the TRPA1/TRPV1 ratio peaked at 3 d. The percentages of trigeminal neurons co-expressing TRPA1/TRPV1, TRPA1/CGRP, and TRPV1/CGRP significantly increased by 12 h and peaked at 24 h. CGRP expression had a stronger positive correlation with TRPV1 than TRPA1.

CONCLUSIONS

Inflammation induced by application of orthodontic force sensitizes trigeminal TRPV1 and TRPA1; TRPV1 is primarily activated as an early response, whereas TRPA1 is activated as a late response. Activation of both nociceptors results in CGRP release. Thus, blocking both TRPV1 and TRPA1 may represent a primary therapeutic target for relief of orthodontic pain.

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.

Effects of cognitive behavioral therapy on orofacial pain conditions

Numerous studies have confirmed the effectiveness of cognitive behavioral therapy (CBT) for chronic pain, and it is generally regarded as an appropriate intervention. However, it may not be effective for some pain sites, and the duration of the effect may be limited. In addition, some studies of CBT lacked a comparison group. This review summarizes evidence for the effectiveness of CBT for orofacial pain and assists in the development of guidelines for orofacial pain management. A literature search in PubMed was performed for studies published from April 1990 through March 2020. The search keywords were "burning mouth syndrome," "temporomandibular disorders," "myofascial pain syndrome,""chronic orofacial pain conditions," "cognitive behavioral therapy," and "non-pharmacological therapy." The results indicate that CBT alone or in combination with other treatments, such as intraoral appliance, stress management, or biofeedback, is effective for the vast majority of orofacial pain cases. Therefore, dentists should consider using CBT to manage orofacial pain in their patients.

Effect of verbal and written information on pain perception in patients undergoing fixed orthodontic treatment: a randomized controlled trial

BACKGROUND

Pain can discourage patients from seeking orthodontic treatment or compromise their compliance during therapy.

OBJECTIVES

To determine the effects of verbal and written information on orthodontic pain after fixed appliance placement.

TRIAL DESIGN

Two-arm parallel design randomized controlled trial.

METHODS

Healthy adolescents with permanent dentition enrolled for orthodontic treatment were assigned to the study or control group using computer-generated random lists and allocation concealment with sealed envelopes. Participants completed baseline questionnaires to assess anxiety (State-Trait Anxiety Inventory Trait Version, Form X-2) and somatosensory amplification (Somatosensory Amplification Scale). Brackets were placed in the maxillary arch, from first molar to first molar, and an Australian archwire 0.012 inch was used for alignment. General verbal information on orthodontic treatment was given to all patients by the same clinician. Participants included in the study group received also detailed verbal instructions on orthodontic pain together with a take-home information leaflet by another clinician. Outcome included assessments of pain intensity with a Numerical Rating Scale (NRS) on the day of appliance placement (Day 1, bedtime) and twice a day for the following 6 days (Day 2 to Day 7, morning, bedtime), and analgesic consumption. Participants, statistician, and clinicians who gave general verbal information on orthodontic treatment and instructions about how to score pain intensity were blinded to group assignment.

RESULTS

Sixty patients were assigned to the study (n = 30, mean age: 15.4 ± 1.3 years) or control group (n = 30, mean age: 14.7 ± 3.2 years). At baseline, no significant between-group differences were present in terms of anxiety and somatosensory amplification. Orthodontic pain scores were significantly lower in the study group compared with the control one, at bedtime on Day 1 (P < 0.05) and in the morning of Day 2 (P < 0.01). No significant between-group differences were found in following measurements. Overall, analgesic consumption was significantly lower in study compared with the control (P < 0.01).

CONCLUSION

A combination of verbal and written information on orthodontic pain after placement of fixed appliances reduced patient's self-reported pain in the early stages.

REGISTRATION

This study was not registered.

Low-level laser therapy effectiveness in reducing initial orthodontic archwire placement pain in premolars extraction cases: a single-blind, placebo-controlled, randomized clinical trial

Background

The objective of this randomized clinical trial was to evaluate Low-Level Laser Therapy (LLLT) effectiveness in spontaneous and chewing pain reduction following initial orthodontic archwire placement.

Methods

26 patients (mean age 20.07 ± 3.13 years) with maxillary Little’s Irregularity Index (LII) of 7 mm or more that indicates first maxillary premolars extraction and no medications intake were eligible for this trial. Patients were randomly assigned with 1:1 ratio using simple randomization technique to receive either LLL or placebo treatment. Blinding was applicable for patients only. In the laser group, patients received a single LLL dose (wavelength 830 nm, energy 2 J/point) in four points (2 buccal, 2 palatal) for each maxillary anterior tooth root. Patients in the placebo group had the same laser application procedure without emitting the laser beam. Patients were asked to score spontaneous and chewing pain intensity by filling out a questionnaire with a 100-mm Visual Analogue Scale (VAS) after 1, 6, 24, 48, and 72 h of treatment application. Independent t-test was used to compare the mean pain scores between the laser and placebo groups for both spontaneous and chewing pain at each studied time point.

Results

No dropout occurred so the results of the 26 patients were statistically analyzed. Despite some clinical differences observed between the two groups, no statistical significance was found for each studied time point (p > 0.05) for both spontaneous and chewing pain except after 72 h for chewing pain with a VAS score of (18.84 ± 13.44) mm for the laser group compared to (38.15 ± 27.06) mm for the placebo group.

Conclusions

LLLT, with the suggested parameters, is not effective in pain reduction following initial orthodontic archwire placement.

Trial registration

Name of the registry:Clinicaltrials.gov

Trial registration number:NCT02568436.

Date of registration: 26 September 2015 ‘Retrospectively registered’.

Chewing gum vs. ibuprofen in the management of orthodontic pain, a multi-centre randomised controlled trial - the effect of anxiety

OBJECTIVES

Pain is a common side effect of orthodontic treatment. An objective of this study, part of a large previously reported RCT on pain and analgesic use, was to determine the effect of anxiety on perceived pain and use of analgesia.

METHODS

1000 patients aged 11-17 years, undergoing upper and lower fixed appliance treatment in nine hospital departments were recruited into this two-arm parallel design randomised controlled trial. One arm was given sugar-free chewing gum and the other arm ibuprofen for pain relief. Neither the clinicians nor patients were blinded to assignment. In addition to recording pain experience and analgesic use for 3 days following appliance placement and first archwire change, each patient recorded their level of anxiety immediately following the fitting of the appliance and the first archwire change.

RESULTS

419 chewing gum group (84%) and 407 ibuprofen group (83%) questionnaires were returned following appliance placement, and 343 chewing gum group (70%) and 341 ibuprofen group (71%) questionnaires were returned following the first archwire change. The mean anxiety scores following fitting of the appliance and first archwire change were 2.7 (SD 2.1) and 1.6 (SD 1.8), respectively. There were weak but significant positive associations between anxiety scores and pain scores. Multi-level modelling produced a coefficient for anxiety of 0.23 (95% CI 0.17-0.28) for appliance placement, suggesting a small rise (0.23) on the 11-point pain scale for a one-point increase on the corresponding anxiety scale. Following archwire change, the corresponding coefficient was 0.32 (0.24-0.39). For ibuprofen use, again simple analyses suggested a relationship with anxiety. Multi-level logistic modelling produced an odds ratio for ibuprofen use of 1.11 (95% CI 1.07-1.15) at appliance placement and 1.21 (1.10-1.33) at the first archwire change. There was a 10-20% increase in the odds of using ibuprofen for each one-point increase on the anxiety scale. No such relationship was found between anxiety and chewing gum use. There were no adverse effects or harms reported during the trial. Approvals were granted by the Research Ethics Committee (08/H0106/139), R&D and MHRA (Eudract 2008-005522-36) and the trial was registered on the ISRCTN (79884739) and NIHR (6631) portfolios. Support was provided by the British Orthodontic Society Foundation.

CONCLUSIONS

There was a weak positive correlation between anxiety reported and pain experienced following both the initial fitting of the fixed appliances and at the subsequent archwire change. Patients that were more anxious tended to take more ibuprofen for their pain relief.

Optimal management of orthodontic pain

Pain is an undesirable side effect of orthodontic tooth movement, which causes many patients to give up orthodontic treatment or avoid it altogether. The aim of this study was to investigate, through an analysis of the scientific literature, the best method for managing orthodontic pain. The methodological aspects involved careful definition of keywords and diligent search in databases of scientific articles published in the English language, without any restriction of publication date. We recovered 1281 articles. After the filtering and classification of these articles, 56 randomized clinical trials were selected. Of these, 19 evaluated the effects of different types of drugs for the control of orthodontic pain, 16 evaluated the effects of low-level laser therapy on orthodontic pain, and 21 evaluated other methods of pain control. Drugs reported as effective in orthodontic pain control included ibuprofen, paracetamol, naproxen sodium, aspirin, etoricoxib, meloxicam, piroxicam, and tenoxicam. Most studies report favorable outcomes in terms of alleviation of orthodontic pain with the use of low-level laser therapy. Nevertheless, we noticed that there is no consensus, both for the drug and for laser therapy, on the doses and clinical protocols most appropriate for orthodontic pain management. Alternative methods for orthodontic pain control can also broaden the clinician's range of options in the search for better patient care.

Pharmacological interventions for pain relief during orthodontic treatment

BACKGROUND

Pain is a common side effect of orthodontic treatment. It increases in proportion to the amount of force applied to the teeth, and the type of orthodontic appliance used can affect the intensity of the pain. Pain during orthodontic treatment has been shown to be the most common reason for people wanting to discontinue treatment, and has been ranked as the worst aspect of treatment. Although pharmacological methods of pain relief have been investigated, there remains some uncertainty among orthodontists about which painkillers are most suitable and whether pre-emptive analgesia is beneficial. We conducted this Cochrane Review to assess and summarize the international evidence relating to the effectiveness of analgesics for preventing this unwanted side effect associated with orthodontic treatment.

OBJECTIVES

The objectives of this review are to determine:- the effectiveness of drug interventions for pain relief during orthodontic treatment; and- whether there is a difference in the analgesic effect provided by different types, forms and doses of analgesia taken during orthodontic treatment.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: the Cochrane Oral Health Trials Register (to 19 June 2017), the Cochrane Central Register of Controlled Trials (CENTRAL;the Cochrane Library 2016, Issue 7), MEDLINE Ovid (1946 to 19 June 2017), Embase Ovid (1980 to 19 June 2017) and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 19 June 2017). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched on the 19 June 2017 for ongoing studies. We placed no restrictions on language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) relating to pain control during orthodontic treatment. Pain could be measured on a visual analogue scale (VAS), numerical rating scale (NRS) or categorical scale.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, agreed the studies to be included and extracted information from the included studies regarding methods, participants, interventions, outcomes, harms and results. We planned to resolve any discrepancies or disagreements through discussion. We used the Cochrane 'Risk of bias' tool to assess the risk of bias in the studies.

MAIN RESULTS

We identified 32 relevant RCTs, which included 3110 participants aged 9 to 34 years, 2348 of whom we were able to include in our analyses. Seventeen of the studies had more than two arms. We were able to use data from 12 trials in meta-analyses that compared analgesics versus control (no treatment or a placebo); nine that compared non-steroidal anti-inflammatories (NSAIDs) versus paracetamol; and two that compared pre-emptive versus post-treatment ibuprofen for pain control following orthodontic treatment. One study provided data for the comparison of NSAIDs versus local anaesthetic.We found moderate-quality evidence that analgesics effectively reduced pain following orthodontic treatment when compared to no treatment or a placebo at 2 hours (mean difference (MD) -11.66 mm on a 0 to 100 mm VAS, 95% confidence interval (CI) -16.15 to -7.17; 10 studies, 685 participants), 6 hours (MD -24.27 mm on a VAS, 95% CI -31.44 to -17.11; 9 studies, 535 participants) and 24 hours (MD -21.19 mm on a VAS, 95% CI -28.31 to -14.06; 12 studies, 1012 participants).We did not find any evidence of a difference in efficacy between NSAID and paracetamol at 2, 6 or 24 hours (at 24 hours: MD -0.51, 95% CI -8.93 to 7.92; 9 studies, 734 participants; low-quality evidence).Very low-quality evidence suggested pre-emptive ibuprofen gave better pain relief at 2 hours than ibuprofen taken post treatment (MD -11.30, 95% CI -16.27 to -6.33; one study, 41 participants), however, the difference was no longer significant at 6 or 24 hours.A single study of 48 participants compared topical NSAIDs versus local anaesthetic and showed no evidence of a difference in the effectiveness of the interventions (very low-quality evidence).Use of rescue analgesia was poorly reported. The very low-quality evidence did not show evidence of a difference between participants taking ibuprofen and participants taking paracetamol (relative risk (RR) 1.5, 95% CI 0.6 to 3.6). Nor did we find evidence of a difference between groups in likelihood of requiring rescue analgesia when ibuprofen was taken pre-emptively compared to after treatment (RR 0.8, 95% CI 0.3 to 1.9).Adverse effects were identified in one study, with one participant developing a rash that required treatment with antihistamines. This was provisionally diagnosed as a hypersensitivity to paracetamol.

AUTHORS' CONCLUSIONS

Analgesics are more effective at reducing pain following orthodontic treatment than placebo or no treatment. Low-quality evidence did not show a difference in effectiveness between systemic NSAIDs compared with paracetamol, or topical NSAIDs compared with local anaesthetic. More high-quality research is needed to investigate these comparisons, and to evaluate pre-emptive versus post-treatment administration of analgesics.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Methodologies in Orthodontic Pain Management: A Review

Introduction:

Patients experience pain and discomfort during active orthodontic treatment with fixed appliances. Pain is considered a subjective response to noxious stimuli. It can vary from person to person and is influenced by certain factors such as age, gender, previous pain experiences, stress or anxiety, and type of appliance.

Objective:

The objective of this literature review was to discuss conventional versus recently introduced treatment modalities used in pain management for orthodontic patients.

Discussion:

According to the reviewed articles, both pharmacological and non-pharmacological methods were introduced in orthodontic pain management. However, orthodontists must use their best professional judgment to assess each case individually and select an appropriate treatment modality based on pain threshold level of an individual.

Conclusion:

Nevertheless, further investigations are required in this field.

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.

Effect of somatosensory amplification and trait anxiety on experimentally induced orthodontic pain

The perception of pain varies considerably across individuals and is affected by psychological traits. This study aimed to investigate the combined effects of somatosensory amplification and trait anxiety on orthodontic pain. Five-hundred and five adults completed the State Trait Anxiety Inventory (STAI) and the Somatosensory Amplification Scale (SSAS). Individuals with combined STAI and SSAS scores below the 20th percentile (LASA group: five men and 12 women; mean age ± SD = 22.4 ± 1.3 yr) or above the 80th percentile (HASA group: 13 men and seven women; mean age ± SD = 23.7 ± 1.0 yr) were selected and filled in the Oral Behaviors Checklist (OBC). Orthodontic separators were placed for 5 d in order to induce experimental pain. Visual analog scales (VAS) were administered to collect ratings for occlusal discomfort, pain, and perceived stress. Pressure pain thresholds (PPT) were measured. A mixed regression model was used to evaluate pain and discomfort ratings over the 5-d duration of the study. At baseline, the LASA group had statistically significantly higher PPT values for the masseter muscle than did the HASA group. During the experimental procedure, the HASA group had statistically significantly higher discomfort and pain. A significant difference in pain ratings during the 5 d of the study was found for subjects in the HASA group. Higher OBC values were statistically significantly positively associated with pain. Somatosensory amplification and trait anxiety substantially affect experimentally induced orthodontic pain.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

BACKGROUND

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams.

OBJECTIVES

To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases.

METHODS

A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions.

RESULTS

The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache.

CONCLUSIONS

Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

Cognitive behavioral therapy eases orthodontic pain: EEG states and functional connectivity analysis

OBJECTIVES

To assess the effects of CBT on electroencephalogram activity in patients with orthodontic pain.

METHODS

We recruited 24 young (18-28 years), healthy individuals with matched baseline characteristics, including pain intensity, anxiety levels, personality traits, and life-quality scores. Participants were randomly assigned to either the CBT intervention group (n = 12) or the blank control group (n = 12). Multichannel continuous electroencephalogram signals and visual analog scale (VAS) scores were recorded before and after initial archwire placement for 1 week. A 1-month follow-up was conducted, when participants' daily VAS scores were recorded.

RESULTS

The overall EEG spectral power of the CBT group was lower than that of the control group, especially in the theta (4-7 Hz) and beta (14-30 Hz) bands during the treatment period. An enhanced coupling of theta and beta frequencies was observed in frontal and occipital electrodes, respectively. The EEG power in delta and theta bands correlated positively with pain intensity. Network coherence for the CBT group exhibited higher connectivity in the theta band.

CONCLUSIONS

Specific cerebral responses to CBT instructions could be detected with continuous electroencephalograms and related to orthodontic pain processing, which may provide a new insight in exploring CBT for orthodontic pain control.

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

This study aimed to assess generic health-related quality of life (HRQoL), pain intensity, and anxiety levels and the relationship between the three aspects in healthy young Chinese orthodontic patients in the early stage of orthodontic treatment. We enrolled 252 eligible participants (10–29 years old) to complete validated Chinese versions of questionnaires, including the State-Trait Anxiety Inventory (S-AI), the visual analogue scale (VAS), and the Short-Form 36-Item Health Survey (SF-36) at baseline and on days 1, 2, 3, 7, 14, and 30 after initial archwire placement (SF-36 only at baseline and day 30). The response rate was 96% (243 of 252). SF-36 had moderate reliability (Cronbach's alpha coefficient exceeding 0.7, good fit on day 30). Statistical significant changes were observed in physical function (P < 0.01), body pain (P = 0.01), and general health (P < 0.01) domains. Spearman correlation coefficients for SF-36 with S-AI were −0.131~−0.515 (P < 0.05); SF-36 with VAS were −0.141~−0.273 (P < 0.05), indicating significant but moderate negative correlations between HRQoL and pain/anxiety. Overall, the application of SF-36 in assessing HRQoL is reluctantly suitable for young Chinese orthodontic patients in the early stage of orthodontic treatment. Early treatment-related pain and anxiety are important factors in HRQoL.