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

Do different orthodontic pliers used in bracket debonding have different effects on pain and sensitivity? A prospective split-mouth study

OBJECTIVES

The assessment of whether different orthodontic pliers used in bracket debonding have different effects on pain and sensitivity experience.

MATERIALS AND METHODS

Thirty-three patients (17 females, 16 males) with metal brackets were included in the study. Compressed air and freshly melted ice water were applied to each tooth (6-6) in upper and lower arch before bracket debonding (T0), just after debonding (T1), and 1 week after debonding (T2). Bracket remover plier (BRP) and Weingart plier (WP) were used to debond brackets. A numeric rating scale (NRS) was used to assess sensitivity for each tooth at T0, T1, and T2. Tooth pain was assessed for each tooth using NRS during bracket debonding.

RESULTS

Statistically higher pain scores were found in teeth U4 (upper first premolar) (p = 0.017) and L6 (lower first molar) (p = 0.026) in Weingart plier group. No statistically significant difference was found during debonding in the other teeth between groups. Statistically high sensitivity score was found at T1 time point in tooth U3 (upper canine) by applying air stimulus in Weingart plier group (p = 0.024). There was no statistically significant difference between the sensitivity scores measured at T2 time point by applying air and cold stimuli between groups.

CONCLUSIONS

Although the debonding pain scores were statistically significant in two teeth and the sensitivity score in one tooth, there was no clinical significance between the two pliers in terms of pain and sensitivity.

CLINICAL RELEVANCE

Both debonding pliers gave clinically similar results in terms of pain and sensitivity.

The Menstrual Cycle Phase and Effect of Aromatherapy on Orthodontic Debonding Pain

Objectives: The aim of this prospective clinical study was to evaluate the effects of the menstrual cycle phases and aromatherapy on women's perception of orthodontic debonding pain. Materials and Methods: The materials of our study were consisted of randomly selected 48 female patients (mean age:19.00±3.40). Four different study groups were performed. LA+; the patients in the luteal phase and received aromatherapy(n=12), LA-; the patients in the luteal phase and did not receive aromatherapy(n=13), FA+; the patients in the follicular phase and received aromatherapy(n=11), FA-; the patients in the follicular phase and did not receive aromatherapy(n=12). Debonding was performed and the pain experience for each tooth was scored by the patient on a visual analogue scale (VAS). Also, participants' general responses to pain were assessed with the Pain Catastrophizing Scale (PCS). The aromatherapy protocol was to inhale lavender oil from approximately 30 cm for 3 minutes, 3 minutes before debonding. Results: It was found that the mean VAS scores were higher in the luteal phase than in the follicular phase, however this difference was not statistically significant. There was no statistically significant difference between the groups with and without aromatherapy in terms of VAS scores(P>0.05). The correlation between total PCS scores and total VAS scores was statistically significant (r=0.310, P

A randomized controlled trial to evaluate the effectiveness of different methods on pain management during orthodontic debonding

BACKGROUND

Orthodontic treatment procedures like separator placement, archwire placement, orthodontic force application, miniscrew placement and debonding procedure usually involve pain and discomfort. Pain perception and methods to reduce pain during debonding in regard to gender and different locations of oral cavity is still a poorly documented issue in orthodontics. The aim of this study was to evaluate the effectiveness of different methods on pain management during debonding and its association with gender and location.

MATERIALS AND METHODS

One hundred and forty orthodontic patients in the stage of debonding were randomly assigned into four groups according to different methods used during debonding; Group A: Medication group (Paracetamol given 1 h before debonding), Group B: Finger pressure group, Group C: Stress relief group and Group D: Control group. A visual analog scale (VAS) was used to assess the pain intensity just after debonding for each sextant.

RESULTS

Among 140 participants, 61 (43.57%) were males and 79 (56.43%) were females. Differences in VAS score in different areas of oral cavity among all groups were found to be significant (p < 0.05). Total VAS score was greater in control group (16.67) followed by stress relief group (13.33) and finger pressure group (10) and least in medication group (8.33). The VAS score was higher in the upper front and lower front sextants in all the groups. Females reported higher VAS score and in upper front sextant, it showed significant difference (p = 0.018). On comparison, total VAS scores were statistically significant difference in medication-stress relief arm pair (p = 0.009), medication-control arm pair (p < 0.001) and finger pressure-control arm pair (0.002). The total VAS score comparison between medication-finger pressure arm was not significant (p = 0.172).

CONCLUSIONS

Pain perceived during debonding varies in different areas of oral cavity among all the groups. Anterior area of oral cavity and female seems to be more sensitive to pain. Use of finger pressure can be used effectively for pain management during debonding.

A double-blinded randomized clinical trial of pain perception during orthodontic treatment

Abstract Introduction Orthodontic movement can cause painful symptoms, especially in the early stages of treatment. Objective This study aimed to compare the performance of chewing gum and ibuprofen in pain control during the initial period of orthodontic treatment. Material and method A randomized blind clinical trial, with an allocation ratio of 1:1, was developed with patients aged ≥18 years old. The sample size was established considering a significance level of 5% and test power of 80%, resulting in a minimum of 30 volunteers per group (n=90). Participants were paired regarding sex, age, the severity of malocclusion, defined by the Dental Health Component (DHC) of the Index of Orthodontic Treatment Need (IOTN), and crowding, determined by Little’s irregularity index. The sample was randomly allocated to three groups: Group I (control) placebo; Group II chewing gum; and Group III Ibuprofen. Pain perception was evaluated by the Visual Analog Scale (VAS) in the first 24, 36, and 48 hours after activation of the orthodontic appliance. The data were analyzed by generalized linear models for repeated measures in time. Result No statistically significant difference (p>0.05) was observed among the groups for the methods of pain therapy evaluated in 24, 36, and 48 hours post-activation. Conclusion There was no difference among the method used for pain control during the orthodontic treatment.

Is catastrophizing associated with pain perception in early phase of orthodontic treatment? a cohort study

BACKGROUND AND OBJECTIVES

This study aimed to investigate the association between pain perception and catastrophizing at the beginning of orthodontic treatment; and the association between pain during orthodontic treatment and demographic, clinical, and other psychological factors.

METHODS

A cohort study with 44 patients (28.9±15.05 years old; 25 females and 19 males) under orthodontic treatment with fixed appliances had their pain perception evaluated through a visual analog scale at baseline (before activation), 6 h, 24 h, 2^nd day, 3^rd day, 5^th day, and 7^th day after activation. The scores at each evaluation period after the first (T1), second (T2), and third (T3) appointments were compared by analysis of variance. A multivariate Poisson regression analysis verified the association between pain perception and Pain Catastrophizing Scale (PCS); and demographic (age, gender), clinical (tooth crowding, tooth loss, analgesic intake, and archwire characteristics), and other psychological (dental anxiety, and previous negative dental experiences) independent variables (p<.05).

RESULTS

Catastrophizing (RR=1.03, 95%CI 1.01 to 1.05, p=.0001) showed a weak risk of pain perception at T1. The peak of pain occurred 24 h after activation at T1, T2, and T3. Significant higher scores were observed at T1 in comparison to T2 (F_T1,T2 =11.82, p=.005) and T3 (F_T1,T3 =5.09, p=.03). Wire diameter, tooth crowding, and single arch treatment were found as risk factors for pain. Patients without tooth loss had half of the risk of pain perception, while analgesics intake and older patients were also found with a weak protective association. Dental anxiety and negative dental experience were not associated with pain perception.

CONCLUSION

Catastrophizing has a mild influence on pain perception and only after the first orthodontic activation. Patients with tooth losses, tooth crowding, and using thicker archwires are more likely to report pain after orthodontic activations.

Pain and removal force associated with bracket debonding: a clinical study

Objective:

Pain is a problem during bracket removal, and more comfortable treatment is needed. This study examined the association of pain with the removal force required for ceramic brackets, compared with metal and plastic brackets, to determine which removal method resulted in less pain and discomfort.

Methodology:

81 subjects (mean age, 25.1 years; 25 males and 56 females) were enrolled, from whom 1,235 brackets (407 ceramic, 432 plastic, and 396 metal) were removed. Measured teeth were distinguished at six segments. Pain was measured with a visual analogue scale (VAS) during the removal of each bracket. An additional grip was placed on the grips of debonding pliers with right-angled beaks; a mini loading cell sensor pinched by the grips was used to measure removal force during debonding. VAS and force values were statistically analyzed. The Kruskal–Wallis test followed by the Mann–Whitney U test with Bonferroni correction were performed for multiple comparisons; multiple regression analysis was also performed.

Results:

Forces in the upper and lower anterior segments were significantly smaller (p<0.05) than those in the other segments. Pain tended to be greater in the upper and lower anterior segments than in the posterior segments. In all segments, the removal force was greater for metal brackets than for plastic or ceramic brackets. Ceramic brackets caused significantly greater pain than plastic brackets for the upper and lower anterior segments. Debonding force was involved in the brackets, following adjustments for pain, upper left segment, age, and sex.

Conclusions

Pain and discomfort are likely to occur during bracket debonding.

Assessment of salivary stress and pain biomarkers and their relation to self-reported pain intensity during orthodontic tooth movement: a longitudinal and prospective study

PURPOSE

The aim of this prospective study was to evaluate the relationship between pain intensity and concentrations of salivary pain and stress biomarkers during orthodontic tooth movement.

METHODS

Eighteen patients (8 males, 10 females; mean age 14.57 ± 2.39 years) who needed orthodontic treatment with maxillary premolar extraction and segmental canine distalization participated in this study. Baseline samples were collected (T1), and orthodontic attachments were placed to maxillary first molars, second premolars, and canines. Then extractions were performed. After 1‑month follow-up, canine distalization started with a segmental wire (T2). Concentrations of salivary α‑amylase (sAA), cortisol, secretory immunoglobulin A (sIgA) and chromogranin A (CgA) were examined at T1, T2, and on days 4 (T3), 7 (T4), 14 (T5), and 30 (T6) after starting retraction. Participants also scored their pain on a visual analogue scale (VAS). Pain catastrophizing behavior and dental anxiety levels of the participants were evaluated by the Pain Catastrophizing Scale (PCS) and Corah's Dental Anxiety Scale (C-DAS), respectively. Repeated measure ANOVA, Mann-Whitney U test and Spearman's rank correlation coefficient analysis were used for statistical evaluations (p < 0.05).

RESULTS

The maximum values for sAA were seen at T1. Males had higher sAA levels than females with statistical differences at T1, T3, and T4. No significant differences for cortisol, sIgA, and CgA concentrations were observed. The highest mean VAS score was recorded at T3. No correlations were detected between any salivary biomarkers, VAS, C‑DAS, and PCS scores.

CONCLUSIONS

The stress of starting orthodontic treatment increased sAA levels more than the pain that was experienced during orthodontic tooth movement. Being male was a predictor of higher sAA concentrations. Orthodontic tooth movement did not cause significant alterations in salivary pain and stress biomarkers.

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 adhesive flash-free brackets on debonding pain and time: A randomized split-mouth clinical trial

OBJECTIVES

To evaluate the effects of adhesive precoated (APC) flash-free brackets on the level of pain, amount of remnant adhesive, and removal time during the debonding procedure.

MATERIALS AND METHODS

Thirty patients (20 female, 10 male) aged 12 to 18 years undergoing nonextraction fixed orthodontic treatment were included in this study. APC flash-free and conventional ceramic brackets were bonded with a split-mouth study design. Bracket types were randomly allocated to quadrants. During the removal of the brackets, the visual analogue scale (VAS) was used to assess the level of pain for each tooth. The adhesive remnant index (ARI) was used to determine the amount of adhesive remaining on the tooth surface. Adhesive removal times were calculated per quadrant. The data were analyzed using the Wilcoxon test for comparisons between groups.

RESULTS

Pain scores were generally higher for the conventional group than for the flash-free group. There were no differences in VAS scores across most tooth types during debonding. Overall, ARI results showed more adhesive remnants in the conventional bracket group (P < .001). Except for the right maxillary quadrant, the times required to remove the adhesive were significantly longer for the flash-free brackets than the conventional brackets (P ≤ .005).

CONCLUSIONS

Although removal time was slightly longer for the flash-free adhesive than for the conventional adhesive, lower pain scores were generally observed for the flash-free adhesive brackets during the debonding procedure. Both time and pain differences could be considered clinically insignificant.

Effectiveness of different debonding techniques and adjunctive methods on pain and discomfort perception during debonding fixed orthodontic appliances: a systematic review

BACKGROUND

Pain is an unpleasant side-effect that can be experienced during orthodontic procedures including debonding of fixed appliances. Pain experience can vary depending on the appliance, debonding technique, as well as adjunctive measures used.

OBJECTIVES

The primary objective of this systematic review was to assess the effectiveness of different debonding techniques and adjunctive methods on pain/discomfort perception during debonding procedure (PDP) of fixed orthodontic appliances. The secondary objective was to assess the effects of anatomic location and gender on PDP of fixed orthodontic appliances.

SEARCH METHODS

Multiple electronic databases were searched from inception to August 2018. Reference lists of the included articles were manually screened.

SELECTION CRITERIA

Randomized clinical trials (RCTs) and controlled clinical trials were included.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers according to Cochrane guidelines, with disputes resolved by a third reviewer. Clinical heterogeneity in study design and methodology prevented quantitative synthesis of the data.

RESULTS

The search yielded 198 articles after the removal of duplicates. Seven studies were included in the final review with a total of 307 participants aged 12-60 years. Of the four studies comparing different debonding instruments of labial fixed appliances, two studies showed that the lift-off debonding instrument (LODI) produced lower PDP levels than ligature cutting pliers. Three studies compared adjunctive measures to reduce PDP of labial fixed appliances. Finger pressure and bite wafers significantly reduced PDP levels. Analgesics administration (ibuprofen + paracetamol tablets) 1 hour prior to debonding also reduced PDP. PDP was significantly higher in anterior segments and in females.

LIMITATIONS

The authors acknowledge that there was clinical heterogeneity among the included studies and that the potential effect of diurnal variation on pain during debonding was not considered in any of the included trials.

CONCLUSIONS AND IMPLICATIONS

There is weak evidence indicating that using the LODI may reduce PDP of labial fixed appliances. Adjunctive measures such as an intrusive force with finger pressure, bite wafers, and preoperative analgesia may further aid PDP control. Further well-designed parallel-group RCTs taking into consideration the diurnal variation in pain are required.

REGISTRATION

PROSPERO (CRD42017084474).

FUNDING

None.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

Pain and/or Discomfort During Debracketing: A Review

The topic of bracket removal and enamel integrity has been extensively investigated. Nevertheless, bracket removal, as far as pain and/or discomfort are concerned, is poorly delineated in the orthodontic literature, i.e., the scarcity of reports in this area is conspicuous. In fact, only six studies were retrieved upon a PubMed search. These clinical studies performed with metal brackets are presented in a chronological order in the present review. Pain and/or discomfort during bracket removal are urgently in need of additional studies. The orthodontists have to be well-informed and updated to convey all the aspects of this procedure to the patient.

Evaluation of pain perception during orthodontic debonding of metallic brackets with four different techniques

Objective

The aim of this study was to evaluate patients’ pain levels during four different debonding procedures. The null hypothesis was that the pain perception of the patients undergoing four different debonding applications was not statistically significant different.

Material and Methods

One hundred and twenty orthodontic patients who underwent orthodontic debonding were included in this study. The patients were randomly divided into 4 groups according to technique used in the patients. Debonding groups were as follows: Group 1) Conventional debonding group, Group 2) Medication group (acetaminophen was given 1 hour before debonding), Group 3) Soft bite wax group, and Group 4) Soft acrylic bite wafer group. The patients’ levels of anxiety and fear of pain were evaluated before debonding, and Numerical Rating Scale (NRS) was applied to evaluate their pain perception during debonding. Mann-Whitney U and Kruskal–Wallis tests were used to evaluate non-normally distributed data. Categorical data analysis were carried by chi-square and McNemar tests. The significance level was set at p<0.05.

Results

Anxiety scores of the patients were not statistically significant between both genders and debonding groups. In the quadrants in which the patients were perceived, the highest pain level was in the left side of the mandible. The teeth in which the highest pain level was perceived were the lower left and upper right lateral incisors. Although there was no statistically significant difference among the pain scores of the patients in each group, quadrant scores of female patients showed significant differences, being the lowest scores in the soft bite wax group.

Conclusions

Majority of the patients had no fear of pain before debonding. Pain levels of the patients in the conventional debonding group were not significantly different from those of the other groups, except quadrant scores of females in the soft bite wax group. The null hypothesis was accepted.

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.