Controlling pain during orthodontic Therapy-Analyzing the role of Analgesics

Orthodontic pain is typically regarded as tooth discomfort brought on by orthodontic tooth movement and appliances used. (1)

Despite technological advances in orthodontics, considerable pain and discomfort remain associated with orthodontic therapy. (2) Orthodontic discomfort, which can occur across all orthodontic treatment procedures (like separator placement, initial wire engagement, banding, wearing elastics, rapid maxillary expansion, and debonding), affects between 72% and 100% of people and is often felt as pressure, soreness, and tension in the treated teeth. (1) The leading cause of pain and discomfort in orthodontic treatment is high-pressure levels, ischemia, inflammation, and edema related to tooth movement. (3)

Patients' increased expectations of painless orthodontic therapy and the need to limit discomfort and improve patient compliance have made good pain control a priority for dentists.

This article summarizes the role of analgesics in managing orthodontic pain while highlighting the studies supporting the same.

Effect of pain in orthodontic therapy- The pain associated with fixed orthodontic equipment frequently significantly influences the quality of life of orthodontic patients. (3)

A survey of individuals who previously had orthodontic treatment revealed that 91% suffered from pain during treatment, whereas 50% had difficulties eating and faced limits in their daily activities (2). Evidence suggests that around 25% to 45% of patients feel discomfort even after seven days of device use. (4)

A noteworthy study (5) on the Indian population revealed that 8 percent of the study population discontinued the orthodontic treatment because of pain. Pain is the leading cause of discontinuing orthodontic treatment among patients (2). It's high time that dentists focus on overcoming this challenge and providing a pain-free orthodontic experience.

Managing pain -Analysing the therapeutic potential of Analgesics

Among the pain-relieving drugs used in orthodontics, Nonsteroidal anti-inflammatory medications (NSAIDs) are the most widely used painkillers. Ibuprofen and paracetamol/acetaminophen are two medications that dentists frequently prescribe. (2)

Orthodontic tooth movement triggers dental pulp response and periodontal membrane inflammation, which induces the release of several biochemical mediators responsible for pain. One of these critical mediators is prostaglandins. (2)

NSAIDs work by preventing the synthesis of arachidonic acid, which lowers the number of prostaglandins produced during the prostaglandin synthesis cycle (2). Research in orthodontics has shifted its attention to the pre-operative or preventive administration of analgesics to lessen post-operative discomfort. The process of central sensitization is blocked by pre-emptive analgesia via inhibition of afferent nerve impulses before they enter the central nervous system. Resonating with this theory, Steen Law et al. demonstrated that pre-emptive Ibuprofen administered at 400 mg 1 hour before separator placement significantly lowered pain on chewing, even 2 hours after the procedure. (6)

Role of Acetaminophen-Acetaminophen, also known as paracetamol, became a prescription drug in the UK in 1956 and an over-the-counter drug in 1963. Since then, it has become one of the most widely used analgesics and antipyretics globally. It is frequently used in combination with other medications. Paracetamol's negligible anti-inflammatory efficacy suggests a different route of action from the traditional NSAIDs (5).

Amidst concerns that NSAIDs may decrease the osteoclastic activity required for tooth movement and delay tooth movement, Acetaminophen, owing to its unique mechanism of action and a lack of anti-inflammatory action in peripheral tissues, does not inhibit prostaglandin production and thus does not affect tooth movement. (2) Further, studies have consistently highlighted Acetaminophen to be among the safest drugs for safe and effective management of orthodontic pain (7).

Benefits of combination therapy in managing pain- Research highlights that patients undergoing orthodontic treatment may experience discomfort within 4 hours of the initial archwire or separator placements. The discomfort peaks at 24 hours and progressively subsides over a week (2,8). Considering such scenarios, combination analgesics with peak effects sustaining from as early as a few hours to 1-day post-op are best suited to help patients get over this painful phase.

Research suggests that Ibuprofen reduces pain two and six hours after intervention but not at 24 hours when the pain is at its height (3). While Ibuprofen has a long-lasting analgesic effect that peaks at 6 hours, the analgesic effect of Acetaminophen increases steadily from 2 hours through 24 hours post an orthodontic appointment (2,8). This makes the Ibuprofen- acetaminophen dual drug therapy an appropriate choice among painkillers to manage orthodontic pain at its peaks.

Experts now recommend the short-term use of low-dose analgesics to rule out the possibility of delaying tooth movement (2). A growing body of research confirms that combining Ibuprofen and Acetaminophen provides a synergistic analgesic effect exceeding their thresholds, coupled with the fact that they deliver a better peak and more consistent analgesia while minimizing the high-dose related adverse effects; this dual drug therapy has been gaining popularity rapidly. (9)

Study testimonials-

• A meta-analysis (2) aimed to assess the efficacy of analgesics in relieving pain in orthodontic treatment concluded that using analgesics is effective for patients in controlling orthodontic pain. The team affirmed that 400 mg of ibuprofen and 600 mg of acetaminophen one hour before and six hours after orthodontic therapy were optimal for pain management.
• A study compared the preoperative administration of conventional NSAIDs (ibuprofen and acetaminophen) to meloxicam. The results highlighted that acetaminophen 650 mg and ibuprofen 400 mg were equally efficient as meloxicam in controlling orthodontic pain. (3)
• Polat and Karaman et al. (10) studied several analgesics and recommended acetaminophen over naproxen sodium or aspirin. The team noted that the acetaminophen group showed similar pain scores to the other drugs but without the side effects associated with NSAIDs.
• A study by Shreena Patel et al. (4) aimed to assess the effectiveness of 3 analgesics administered before and after the placement of separators. The team concluded that administering ibuprofen before and after separator placement significantly reduced pain compared with the placebo.
• A review by Possi and Gallelli (3) described the role of ibuprofen in orthodontic pain management. The authors concluded that ibuprofen 400 mg, if taken one hour before, three hours after, and seven hours postoperatively, significantly reduced pain.

Key pointers-

• 90 to 95 percent of individuals getting orthodontic treatment experience discomfort from appliances. The most discouraging component of treatment is pain which is the primary cause for wanting to abandon orthodontic treatment.
• Optimum pain management remains a cornerstone in successful orthodontic therapy.
• Combined analgesic therapy with acetaminophen and ibuprofen has exhibited a superior efficacy and safety profile in managing orthodontic pain.
• Orthodontists must weigh the pros and cons of available painkillers before prescribing the most effective drug, depending on individual pain levels.

Take-home message- Orthodontists are positioned to use their best professional judgment to determine each patient's pain threshold level. Based on the available data, analgesics continue to be the most effective and widely used approach to orthodontic pain treatment. Furthermore, orthodontists must be aware of the pharmacological activity and pros and cons of analgesic monotherapy and combination therapy while prescribing analgesics.

Acetaminophen-ibuprofen dual therapy has cemented a firm position as the go-to analgesic therapy for pain management in orthodontic patients. Backed by years of evidence, this combination has and will continue to reign supreme in managing dental pain.

References

1. Long, H., Wang, Y., Jian, F., Liao, L. N., Yang, X., & Lai, W. L. (2016). Current advances in orthodontic pain. International journal of oral science, 8(2), 67-75.

2. Cheng, C., Xie, T., & Wang, J. (2020). The efficacy of analgesics in controlling orthodontic pain: a systematic review and meta-analysis. BMC oral health, 20(1), 1-9.

3. Hussain, A. S., Al Toubity, M. J., & Elias, W. Y. (2017). Methodologies in orthodontic pain management: a review. The open dentistry journal, 11, 492.

4. Patel, S., McGorray, S. P., Yezierski, R., Fillingim, R., Logan, H., & Wheeler, T. T. (2011). Effects of analgesics on orthodontic pain. American Journal of Orthodontics and Dentofacial Orthopedics, 139(1), e53-e58.

5. Shenoy, N., Shetty, S., Ahmed, J., & Shenoy, A. (2013). The pain management in orthodontics. Journal of clinical and diagnostic research: JCDR, 7(6), 1258.

6. Krishnan, V. (2007). Orthodontic pain: from causes to management—a review. The European Journal of Orthodontics, 29(2), 170-179.

7. Shetty et al.: Comparison of the effects of ibuprofen and acetaminophen on PGE2 levels in the GCF during orthodontic tooth movement: a human study. Progress in Orthodontics 2013 14:6.

8. Ngan P, Wilson S, Shanfeld J, Amini H. The effect of ibuprofen on the level of discomfort in patients undergoing orthodontic treatment. Am J Orthod Dentofac Orthop. 1994;106(1):88–95.

9. Derry, C. J., Derry, S., & Moore, R. A. (2013). Single dose oral ibuprofen plusparacetamol (acetaminophen) for acute postoperative pain. The Cochrane database ofsystematic reviews, 2013(6), CD010210.

10. Polat O, Karaman AI. Pain control during fixed orthodontic appliance therapy. Angle Orthod 2005;75:214-9.