Perception of pain in fixed orthodontic treatment

INTRODUCTION

Orthodontists must be able to address concerns of the patient about their treatment. Pain and discomfort are frequent side-effects of orthodontic therapy with fixed appliances. The orthodontist should be able to inform the patient about this common side-effect of treatment, especially before inserting an appliance that will cause discomfort. In most cases, the level of pre-treatment explanation seems to be generally satisfactory, but many people report not having been wellinformed (Oliver and Knapman). The mechanisms where by the application of orthodontic forces causing pain is not fully understood, but there are indications that these perceptions are due to changes in blood flow in the periodontal ligament (Burstone, White, Kvam et al,) and correlate with the presence of prostaglandins, substance P and other substances (Burstone, White, Kvam et al, Ngan et al)^1-3. The subjective perception of pain is difficult to measure and there is a wide range of individual responseeven when similar forces are applied to teeth (Burstone). Several studies have described the patients' responses to fixed orthodontic appliances. These studies report that pain begins a few hours afterapplication of an orthodontic force and lasts approximately for five days^4-6.

The aims of the present study were as follows:

1. Investigate intensity, location and duration of pain experienced by patients following insertion of fixed orthodontic appliances.

2. To examine the interaction between age, gender, kind of appliances, initial wire placed and the perception of pain respectively.

3. To investigate the pain intensity during biting, chewing, and clenching of the teeth.

4. To examine the influence of the pain experienced on daily activities. 

MATERIALS AND METHOD

The present study describes the response of patients who were at the beginning of their active orthodontic treatment. Before the insertion of a fixed appliance, 80 patients received a series of three questionnaires. The mean age of respondents was 21 years. 28 were males and 52 were females. All the subject are from the around the Raichur. The entire patients are treated in the Department of Orthodontics, Navodaya Dental College, Raichur, and Karnataka.

Appliance used:

The appliances inserted were either Begg's appliance or Pre-adjusted edgewise appliance with 0.018 slot (Roth prescription, libral Begg's metal bracket) on all teeth except first molars which was banded. The initial wires 0.016 inch Nickel titanium or 0.016 inch stainless steel (AJ Wilcock Australian wire) were inserted as initial aligning arch wires. This was in an attempt to find a co-relation between pain and time course, intensity of pain experienced and wire used.

Patient criteria

All patient in the present study required extractions of four first premolar teeth for the purpose of orthodontic treatment. There was no relevant medical history to affect the dental extraction under local anesthesia. Patient below 13 years were not included.

Description of patient questionnaire

A series of pain-discomfort questionnaires were devised in the Department of Orthodontics, Navodaya Dental College, Navodayanagar, Raichur. Patients were requested to complete the questionnaire after the first visit of insertion of fixed appliance.

RESULTS

In present study, the response rate was excellent with 80 patients (100%) reporting yes when asked did you have any discomfort or pain after fitting the braces viz Begg appliance or Preadjusted edgewise appliance Table I. Table II indicates the percentage of patients reporting start of discomfort recorded at 0 hrs., 4 hours, 8 hours, 12 hours and 24 hours. Pain intensity scores, the peak occurred at 24 hours after insertion after fixed appliance, but mean score obtained was relatively moderate. Table III. Spearman's rank correlation was constructed to examine the levels of pain intensity and duration and there existed a statistically significant correlation. Table IV. A significant (17) no of patient complained in both anterior and posterior teeth. In the soft tissue sites gums 37%, lips 32%, tongue 12.5%, cheeks 5%. However, chewing was more painful than incising at almost all the recorded intervals. For biting and chewing, there were statistically significant differences between males and females. Mann Whitney Z= 9.673, p= 0.000. The youngest patients reported a mean pain value of at least half of the VAS length for the first day, unlike the relatively lower levels reported by the 2 older groups. The correlation between gender and pain at rest and pain while biting and chewing wasanalyzed. In the present study, until day 2, the mean pain values for males and females were almost similar;however the males reported greater perception of discomfort than females for most of the intervals. The patients with pre-adjusted edgewise appliance showed slightly more pain experience than the ones with Begg's appliances. Graphs: I to IV

DISCUSSION

Pain and discomfort after insertion of initial archwire in fixed appliance therapy are common experiences among orthodontic patients. It is recognized that insertion of new orthodontic appliance may diminish cooperation by causing considerable discomfort, such as unpleasant tactile sensations, feeling of constraint in oral cavity, stretching of soft tissues, pressure of tongue, soreness of the teeth and pain.⁷

Orthodontic patients usually are informed that there may be some discomfort associated with orthodontic treatment. However, the intensity and duration of discomfort may not always be discussed. In most cases, the level of pre-treatment explanation seems to be generally satisfactory, but may people report not having well informed.^8,9,10

CONCLUSION

Initial orthodontics pain is a multifactorial phenomenon. Indeed psychological, emotional, attention, cognitive, and motivational factors all play a part in pain perception. There is diverse individual variation with attendant difference in the pain threshold; however these differences would appear to be consistent in this present study all patients usually reported relatively moderate pain within 24 hours after placement of fixed appliance^11,12,13. Majority of patients experienced start of pain within 4 hours after appliance and also experienced peak pain within 24 hours after appliance insertion.

The pain experience showed great individual variation, being severe and prolonged for some patients. However all the patients experienced relatively moderate pain receiving a fixed appliance, generally, this pain was over the first 2-3 days and gradually tailed off towards the seventh day. Generally, the pain reported after archwire placement is a mixture of periodontal pain, from pressure of the brackets, gum soreness and from soft tissue irritation. Additionally, there may be occurrence of referred pain in some patients.

The self-monitoring daily protocols evaluated in this investigation indicate that pain during mastication was the most intense pain reported by patients and it remained at elevated levels during most of the observation period. There were marked differences in the pain levels felt while biting and chewing between males and females. Clenching of the teeth also presented higher pain responses among the patients.

A highly significant association exists between the age of the patient and the post insertion pain. Greater the age, worse the pain.Gender was found to be statistically significant variable in pain response. In general, males experienced more pain than females after appliance insertion in the present study