PREDICTING FACTORS OF ORTHODONTIC PAIN – A SURVEY

Nur Liyana Hannah Binti Izham Akmal 1 and Dr. Saravana Pandian 2 . 1. Undergraduate Student Saveetha Dental College, Saveetha University, Chennai, India. 2. Reader Department of Orthodontics Saveetha Dental College, Saveetha Institute Of Medical And Technical Science, Saveetha University. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 04 February 2019 Final Accepted: 06 March 2019 Published: April 2019


204
Patients are aware of possible pain and discomfort (86%). Some are prone to react to pain (74%) although most are well informed of the whole procedure (80%). Patients are still willing to proceed with the treatment despite having pain or discomfort. Conclusion: Orthodontic pain has always been a great concern for most dentists all over the world. It is very important for every dentist to have a basic knowledge and understanding of orthodontic pain in order to overcome this condition in a clinical setting.

…………………………………………………………………………………………………….... Introduction:-
Pain and discomfort are the two common conditions experienced by most orthodontic patients, which may occur up to a certain degree during a treatment procedure. Despite the recent advancement in orthodontics, most patients still experience some pain or discomfort associated with orthodontic treatment, especially 3 to 5 days after the placement of appliances. It has been reported that about 90% of patients complained of mild to severe acute pain at some stage during their orthodontic treatment. [1,2] A report by the University of Mainz in Germany stated that patients normally begin to show adaptation to pain and discomfort with significant reduction in the number of complaints after 3 to 5 days following the placement of appliances. Patients rarely show further difference after the adaptation phase. [3] The severity of pain and discomfort in these patients are much higher in those with functional or fixed appliances compared to patients with removable appliances. Some orthodontic patients may experience less pain and fast adaptation, while others may suffer great pain and slow adaptation, following a course of orthodontic treatment. Anxious patients and those with a history of chronic pain experience greater pain as compared to those with lower anticipation for pain after the treatment. [4] Patients also complain of slurred speech, difficulty in swallowing and low self-confidence in public, mainly due to their appearance.
Various factors need to be considered in determining the main cause of orthodontic pain, which include the ability of patients to adapt after the insertion new appliances, type of appliances, degrees of pain and discomfort, patient's attitude towards the treatment and their effects on patient's compliance. [5] The type of appliances may have significant effects on the patient's speech and swallowing, while patient's expectation of a good dental treatment and better appearance can lead to feeling of oral restriction and low self-confidence in public. Patient's experience with initial pain and discomfort can contribute to the acceptance of orthodontic treatment in general. Hence, this study aims to evaluate pain and discomfort experience by patients undergoing orthodontic treatment with different appliances after insertion and factors associated with orthodontic pain.

Materials and Method:-
A questionnaire-based study was done among 100 participants who took part in the survey. The participants were divided into Group 1 consisting of 50 dental students and practitioners and Group 2 with a total of 50 dental patients coming for orthodontic treatment. All the participants were provided with a list of 10 questions related to pain during orthodontic treatment. Each group was given with different sets of questions. Data was collected and statistic analysis was done. Ideally, the sample size of the survey was calculated to be 132, which indicates 100 participants are sufficient for this study.
205 Figure 1:-Sample size calculation [6]  Are you still willing to proceed with the dental treatment despite having pain or discomfort? o Yes o No  Figure 2:-"How would you rate the probability of patients with complaints of pain or discomfort during their dental treatment?"    Figure 4:-"How would you rate the severity of pain or discomfort experienced by your patients?"            Figure 13:-"When did you start having pain or discomfort, following the placement of appliances?"  Figure 14:-"How long did it take for the pain or discomfort to subside?"  Figure 15:-"How would you rate the severity of pain you experienced during the treatment?"      Figure 19:-"Are you generally prone to react with pain, even in situations other than dentistry?"    Figure 21:-"Are you still willing to proceed with the dental treatment despite having pain or discomfort?"

Discussion:-Group 1: Dental Students and Practitioners
Based on Figure 1, 62% of the participants had chosen "moderate" as the rate of probability of patients with complaints of pain and discomfort during their dental treatment. It can be seen that 20% of them have encountered many cases of orthodontic pain as they suggested that there is a "high" probability of such problem, while 18% of them disagree with the idea by stating that the probability of patients with orthodontic pain is low. A study done in Singapore involving 203 adult Chinese patients state that 91% of the patients reported of pain after the placement of orthodontic appliances with 31% of them complaining of pain during every step of the procedure. [1] According to 52% of the participants, sensory perception of intensity and discomfort is the main component, which contributes to orthodontic pain while genetic factors or personal traits is the least associated with orthodontic pain as chosen by 2% of the participants. Psychological factors is considered as major factor of orthodontic pain by 20% of the participants, followed by 16% of them suggesting emotional influence as the principal component. The remaining factors of cognitive and environmental factors are chosen by 6% and 4% of the participants respectively. A report by Melzack R (1965) stated that orthodontic pain is commonly associated with sensory perceptions of intensity and discomfort, along with cognitive, emotional and environmental factors. [5,7,8] The cognitive factors of pain often include patient's anticipation, memory of past experiences and attention. [5,9] Various researches have been done to determine the correlation of orthodontic pain with psychological factors and personal traits, which requires substantial resources to obtain and evaluate the data from patients. [2,5,10] 44% of the participants state that patients normally experience "mild" pain or discomfort in most cases of orthodontic pain, followed by 42% of them who rate the severity of pain as "moderate and only 14% of the total participants have seen patients with complaints of "severe" orthodontic pain. It has been reported that mild-to-severe pain can be seen in approximately 90% of patients seeking orthodontic treatment [1,2] The result in Figure 4 suggests that most cases of orthodontic pain begin within 24 hours as stated by 64% of the participants. 20% of them indicate that orthodontic pain normally requires at least 2 to 3 days before it finally begins. While 12% of them suggest that it normally takes 4 to 5 days for patients to begin their complaints of orthodontic pain and the remaining 4% have had patients with orthodontic pain after 5 days of treatment. A report by Jones (1984) states that patients complain of maximum pain or discomfort begins within 24 hours after the placement of separators or arch wires. [11,12] 219 As for the relief of orthodontic pain, 45% of the participants state that it usually takes 24 hours for the pain to finally subsides, followed by approximately 22% of them indicating relief of orthodontic pain occurs within 2 to 3 days. 5% of the participants suggest that orthodontic pain may begin only after 4 to 5 days or it may require more than 5 days to subside as stated by about 12% of them. A study by Krishnan (2007) indicates that orthodontic pain generally subsides after 48 hours or approximately 2 to 3 days and further reduces to the pre-application state within 7 days. [3] However, this idea is opposed by Scheurer et al who reported of pain in 25% of the patients even after 7 days. Another study states that pain normally disappears after 1 week, which supports the report by Jones (1984) who stated that the highest analgesic intake by most patients occurs within 3 days after the treatment. [2,12] Pain sensitivity is the most selected factor to be commonly associated with orthodontic pain chosen by 44% of the participants, followed by anxiety and fear chosen by 36% of them in total. Age is also considered as a main factor of orthodontic pain by 6% of the participants. Gender, ethnicity and catastrophizing are the least common factors associated with orthodontic pain according to the participants, each with only 4% of the votes. A study by Schuerer in 1996 states that orthodontic pain is commonly associated with patients aged of 13 to 16 years old, but other studies disagree with this idea indicating that most cases of orthodontic pain are seen in older patients. [2,13] When it comes to gender differences, it has been reported that females tend to have lower pain thresholds and more complaints of pain compared to males, which is believed to be due to their greater awareness towards external threats. [14] In terms of ethnicity, A study by Woodrow and colleagues (1972) reported higher tolerance of pain in Caucasians compared to Asians who show higher tendency of pain and distress. It has been reported that anxiety and fear of dental treatment increases the tendency of orthodontic pain. [15] A study by Stewart and King (1994) states that individual's psychological health is closely related to pain or discomfort through their health state. [16] "Catastrophising" is a term used to describe "an individual's tendency to focus on and exaggerate the threat value of painful stimuli and negatively evaluate one's own ability to deal with pain". [17] A study in Canada states that the tendency of pain increases in patients with excessive focus on their pain sensations. Another study indicates that more pain are seen in catastropisers than non-catastrophisers. [18] Based on Figure 7, 52% of the participants would conduct tests on anxiety levels and dental fear to access the tendency of orthodontic pain. 22% of them suggest self-rating on oral health as the best method to determine the risk of pain. 14% with cold pressure testing and 10% of them had chosen electric pulp testing. Only 2% of the total participants would consider genetic variation tests. In a previous study, it has been proven that cold pressor test provides a valid and low-risk test that can be used to examine pain and it has been widely used for research purposes. A study in Japan reported 99% accuracy of EPT used in 396 teeth with vital pulps. [19] Despite having orthodontic pain, patient's compliance is still good as indicated by 36% of the participants. As for 48% of the participants, patient's compliance becomes moderate following their experience with orthodontic pain while the remaining 16% indicates poor patient's compliance after their encounter with pain or discomfort. By comparison, a study by Patel in 1989 suggests that 10% of patients will discontinue their treatment due to their pain experience. It is supported by another study stating that every tenth orthodontic patient tend to stop attending their treatment due to the pain they experience during the early stages. [20,21] In the treatment of orthodontic pain, 64% of the participants prefer the use of non-steroidal anti-inflammatory drugs (NSAIDs), followed by 18% with low level laser therapy, 8% with transcutaneous electrical neural stimulation and 10% chose vibratory stimulation as their preferred treatment modalities. According to Polat O and colleagues, NSAIDs is indeed the most preferred treatment modality for pain control with high rate of success. Unfortunately, many complications have been associated with the use of NSAIDs such as thrombocytopenia, skin rashes and headaches. [22] In the matter of informing the patients of the whole procedure prior to the dental treatment, 82% answered "Yes", followed by 10% with "Sometimes" and "No" by 8% of the participants. From a previous study done by Johnson J and Leventhal H, it can be seen that patients who are well-informed of the entire dental procedure required less pain medication than those who are unaware of the treatment process as patients are said to have average pain perception with proper knowledge about the procedure that they will undergo. [23] This finding supports the study by Touyz and Marchand who indicate that the risk of pain reduces as the patient acquired better understanding of the complete procedure. [24] 220

Group 2: Dental Patients
Based on Figure 1, it can be seen that most of the patients consider seeking an orthodontic treatment as important with an average score of 8. 56% of the participants rated "8" as to how important an orthodontic treatment is for them and the minimum score of "3" is selected by 2% of the participants, which indicate their low desire for orthodontic treatment. It has been previously reported by Serg et al that patients with higher demand for orthodontic correction show lower intensity of pain as they are highly motivated to receive the treatment, while another study by Berguis et al indicates prolonged pain seen in less motivated patients. [25] It can be seen that most patients normally experience pain or discomfort after 2 to 3 days of treatment as stated by 72% of them. Some may also experience pain within 24 hours as indicated by 18% of the participants, while 8% reported of pain only after 5 days or within 4 to 5 days as chosen by 2% of the participants. According to 82% of the participants, pain usually subside within 2 to 3 days after the treatment, while 14% of them suggest that the relief of orthodontic pain may occur within 24 hours. 2% of the participants indicate that pain relief only begins after 5 days or within 4 to 5 days as selected by another 2% of them.
In figure 4, most of the participants (94%) complain of moderate pain, in which they experience during their orthodontic treatment. 4% of them have only experienced mild orthodontic pain and only 2% of the participants complained of severe pain during the treatment. It has been reported previously that patient's response to orthodontic treatment varies from one individual to another, as some patients may experience severe pain while others may complain of only slight discomfort. [7,26,27] The result shown in Figure 5 states that 76% of the participants have never had a negative experience during any dental treatment before, while the remaining 24% of them showed otherwise as they have encountered such problem previously. It was reported that orthodontic pain is also commonly associated wit negative dental treatments, which may have been experienced by the patients previously. [28,29] In a study by Locker D and colleagues, 71% of the patients reported that they have had a negative dental experience related to pain with 30% of them having more than 3 of such incidents. [30] Based on Figure 6, it can be seen that most patients (78%) attend the clinic while being relaxed and calm, although 11% of the participant showed the opposite, as they are often anxious and worried prior to a dental treatment. According to Keefe FJ and colleagues, affective states such as anxiety, fear, stress, panic and depression experienced by the patients prior to a dental treatment may contribute to pain perception and expression by the patients. [4] Based on the patients' point of view, 86% of them are indeed aware of the possible pain and discomfort associated with orthodontic treatment before the procedure begins. On the contrary, 14% of the participants are unaware of this condition, which indicates their high expectation that the treatment is painless and comfortable throughout the time. A report by Bos et al states that patients who have had experiences of orthodontic treatment previously show better attitudes during the procedure as compared to those who have never experienced such treatment before. [33] Generally, 74% of the patients are prone to react with pain, even in situations other than dentistry, 22% of them indicate such behavior only in some situations and the remaining 4% of them rarely react with pain in general settings.
The result in Figure 9 indicates that 80% of the participants agree that they are well-informed of the whole procedure prior to the start of treatment, 12% of them are unsure of whether they are aware of the entire procedure and 8% of the participants state that they are not informed properly of the procedure prior to the dental treatment.
Based on Figure 10, it can be seen that 70% of the participants are still willing to proceed with the dental treatment despite having pain or discomfort, while the remaining 15% of them would rather discontinue with the treatment. A study by Bergius M and colleagues reported that 70% of patients are willing to undergo prolonged duration of treatment, along with their readiness to experience severe pain in order to attain properly arranged teeth. [27] Conclusion:-Orthodontic pain has always been a great concern for most dentists all over the world. Pain is usually related an individual's personal experience which is rarely associated with injury to the tissue strtucture. Despite the current 221 technology in orthodontics, most patients still experience some discomfort or pain in relation to orthodontic treatment with approximately 90% of patients would complain of pain during any stage of their dental treatment. Pain experienced by patient during an orthodontic treatment usually occurs along with other sensations such as anxiety and fear. 32 It is very important for every dentist to have a basic knowledge and understanding of orthodontic pain in order to overcome this condition in a clinical setting.