Pain and orthodontics

Pain andPain and
OrthodonticsOrthodontics
www.indiandentalacademy.comwww.indiandentalacademy.com

OutlineOutline
Pain physiologyPain physiology
Pain theoriesPain theories
Dual nature of painDual nature of pain
Biology of tooth movementBiology of tooth movement
Perception of pain during fixed orthodonticPerception of pain during fixed orthodontic
T/tT/t
Drugs and effects on tooth movementDrugs and effects on tooth movement
Pain control in orthodonticsPain control in orthodontics

Most commonly experienced symptoms inMost commonly experienced symptoms in
dentistrydentistry
Protective mechanismProtective mechanism
Historic significanceHistoric significance

Pain physiologyPain physiology
Nerve conduction- self propagatedNerve conduction- self propagated
passage of electrical current along nervepassage of electrical current along nerve
fibresfibres
Electrical potential that exists across nerveElectrical potential that exists across nerve
membranemembrane
Lipid layer between two layers of proteinLipid layer between two layers of protein

Resting state - Resting membraneResting state - Resting membrane
potentialpotential
-70 to -90 volts potential difference-70 to -90 volts potential difference
Relative permeability of cell membrane toRelative permeability of cell membrane to
potassium, impermeability to sodiumpotassium, impermeability to sodium
Sodium pumpSodium pump

DepolarizationDepolarization
Alteration in permeability of cellAlteration in permeability of cell
membrane- release of acetylcholinemembrane- release of acetylcholine
RepolarizationRepolarization

Pain theoriesPain theories
Specificity theorySpecificity theory
- Descartes (1644)- straight throughDescartes (1644)- straight through
channelchannel
- Muller – sensory nervesMuller – sensory nerves
- Von Frey- cutaneous receptors – painVon Frey- cutaneous receptors – pain
centrecentre

Pattern theory- Goldsheider- 1894Pattern theory- Goldsheider- 1894
- Stimulus intensityStimulus intensity
- Central summationCentral summation

Gate control theory- Melzack and WallGate control theory- Melzack and Wall
( 1965)( 1965)
- Information about injury transmitted toInformation about injury transmitted to
CNS- small peripheral nervesCNS- small peripheral nerves
- Cells in spinal cord- also stimulated byCells in spinal cord- also stimulated by
other large peripheral nervesother large peripheral nerves
- Descending control systemsDescending control systems

Peripheral nerves- A deltaPeripheral nerves- A delta
- C fibres- C fibres
Substancia GelatinosaSubstancia Gelatinosa
Large nerve fibres can modulate synapticLarge nerve fibres can modulate synaptic
transmission of small nervestransmission of small nerves
Acupuncture and TENSAcupuncture and TENS

Activation of Action systemActivation of Action system
- Sensory discriminative systemSensory discriminative system
- Motivational affective system- suffering aspect ofMotivational affective system- suffering aspect of
pain -narcotic drugspain -narcotic drugs
- Activation of motor mechanismsActivation of motor mechanisms
Descending control- ability to facilitate or inhibitDescending control- ability to facilitate or inhibit
transmissiontransmission
Activated by pharmacological or psychologicalActivated by pharmacological or psychological
factorsfactors

Receptors and stimulusReceptors and stimulus
Stimulus:Stimulus:
- BradykininBradykinin
- SerotoninSerotonin
- Potassium ionsPotassium ions
- Acetyl cholineAcetyl choline
- ProstaglandinsProstaglandins

Characteristics of painCharacteristics of pain
Threshold and intensityThreshold and intensity
AdaptationAdaptation
Localization of painLocalization of pain
Emotional accompanimentEmotional accompaniment
Influence of the rate of damage on theInfluence of the rate of damage on the
pain intensitypain intensity
First (fast) and second ( slow) painFirst (fast) and second ( slow) pain

Reactions to painReactions to pain
BehaviouralBehavioural
Muscular- benefits of massageMuscular- benefits of massage
Changes in the ANSChanges in the ANS
Reflex responseReflex response

Pain pathwayPain pathway
Trigeminal nerveTrigeminal nerve

The dual nature of painThe dual nature of pain
Pain perception – pshysioanatomical processPain perception – pshysioanatomical process
Pain reaction psychophysiological processPain reaction psychophysiological process
- Emotional statesEmotional states
- FatigueFatigue
- AgeAge
- Racial and nationality characteristicsRacial and nationality characteristics
- SexSex
- Fear and apprehensionFear and apprehension

Psychogenic painPsychogenic pain
Unpleasant sensation with no organicUnpleasant sensation with no organic
basisbasis
Should not follow anatomy of theShould not follow anatomy of the
peripheral innervationperipheral innervation
Referred painReferred pain

Neurogenic pain- sharp, burning, intense,Neurogenic pain- sharp, burning, intense,
may be constant or intermittentmay be constant or intermittent
Vascular pain- diffuse, may be referred,Vascular pain- diffuse, may be referred,
difficult to localizedifficult to localize
Muscle pain- dull, limited to area of origin,Muscle pain- dull, limited to area of origin,
movement intensifies pain.movement intensifies pain.

An unpleasant emotional experienceAn unpleasant emotional experience
usually initiated by a noxious stimulus andusually initiated by a noxious stimulus and
transmitted over a specialized neuraltransmitted over a specialized neural
network to the CNS where it isnetwork to the CNS where it is
interpretated as suchinterpretated as such

Not a pure senseNot a pure sense
Noxious stimulusNoxious stimulus
Specialized neural network with synapticSpecialized neural network with synaptic
neurotransmittersneurotransmitters
Central processing mechanisms mustCentral processing mechanisms must
identify and interpret the unpleasantidentify and interpret the unpleasant
experience as painexperience as pain

The biological basis ofThe biological basis of
orthodontic therapyorthodontic therapy
Tooth movement is aTooth movement is a
PDL phenomenonPDL phenomenon
PDL and bonePDL and bone
response to normalresponse to normal
functionfunction

Time (seconds)Time (seconds) EventEvent
< 1< 1 PDL fluid incompressible,PDL fluid incompressible,
alveolar bone bends,alveolar bone bends,
Pizeoelectric signalsPizeoelectric signals
generatedgenerated
1-21-2 PDL fluid expressed, toothPDL fluid expressed, tooth
moves in PDL spacemoves in PDL space
3-53-5 Fluid squeezed, tissueFluid squeezed, tissue
compressed, immediate paincompressed, immediate pain

PDL and bone response toPDL and bone response to
sustained orthodontic forcesustained orthodontic force
Undermining resorptionUndermining resorption
Frontal resorptionFrontal resorption
Bioelectric theoryBioelectric theory
Pressure – tension theoryPressure – tension theory

Bioelectric theory:Bioelectric theory:
- Piezoelectric signals:Piezoelectric signals:
- Quick decay rate- Quick decay rate
- Equivalent signal- Equivalent signal
- Streaming potentialStreaming potential
- Stress generated signals important forStress generated signals important for
maintenance of skeletonmaintenance of skeleton

Sustained orthodontic forces does notSustained orthodontic forces does not
produce prominent stress related signalsproduce prominent stress related signals
Bioelectric potential – bone which is notBioelectric potential – bone which is not
being stressedbeing stressed
When low voltage direct current applied toWhen low voltage direct current applied to
alveolar bone- tooth moves fasteralveolar bone- tooth moves faster
Electromagnetic fieldsElectromagnetic fields
Conclusion of bioelectric theoryConclusion of bioelectric theory

Pressure- Tension theory- Schwarz - 1932Pressure- Tension theory- Schwarz - 1932
Sustained pressure- Alteration of PDLSustained pressure- Alteration of PDL
blood flow- changes in chemicalblood flow- changes in chemical
environment- activation of cellsenvironment- activation of cells

Effects of force magnitudeEffects of force magnitude
Heavier the sustained pressure- greaterHeavier the sustained pressure- greater
the reduction in blood flowthe reduction in blood flow

Effect of force duration andEffect of force duration and
decaydecay
4-8 hours of sustained force4-8 hours of sustained force
- Continuous forceContinuous force
- Interrupted forceInterrupted force
- Intermittent forceIntermittent force

Deleterious effects ofDeleterious effects of
orthodontic forcesorthodontic forces
Effects on the pulpEffects on the pulp
- Modest and transient inflammationModest and transient inflammation
- Large abrupt movements- sever bloodLarge abrupt movements- sever blood
vesselsvessels
- Endodontically T/td teeth – more prone toEndodontically T/td teeth – more prone to
resorptionresorption

Effect on root structureEffect on root structure
- Root remodelingRoot remodeling
- Above average resorption can beAbove average resorption can be
anticipated if teeth have:anticipated if teeth have:
- Conical roots with pointed apicesConical roots with pointed apices
- Distorted root formDistorted root form
- History of traumaHistory of trauma
- Root apices in contact with cortical boneRoot apices in contact with cortical bone

Effect on alveolar bone heightEffect on alveolar bone height
- Greatest changes seen at extraction sites,Greatest changes seen at extraction sites,
not exceeding 1 mmnot exceeding 1 mm
MobilityMobility
- PDL space wideningPDL space widening
- Heavy forces- greater mobilityHeavy forces- greater mobility

Pain related to orthodontic toothPain related to orthodontic tooth
movement:movement:
- Involves individual variationInvolves individual variation
- Development of ischaemic areas in theDevelopment of ischaemic areas in the
PDL, higher the forces, more the painPDL, higher the forces, more the pain

Prostaglandins and orthodonticProstaglandins and orthodontic
tooth movementtooth movement
Chemical messengers- eicosanoids –Chemical messengers- eicosanoids –
derived from arachidonic acidderived from arachidonic acid
Enhance bone resorption, elevate bodyEnhance bone resorption, elevate body
temperature, pain, inflammationtemperature, pain, inflammation
Yamasaki et al (1980) – orthodontic forcesYamasaki et al (1980) – orthodontic forces
increase synthesis of PGs- increaseincrease synthesis of PGs- increase
osteoclastic resorptionosteoclastic resorption
Davidovitch (1988), Chumbley (AJO 86)-Davidovitch (1988), Chumbley (AJO 86)-
increased levels of PGE2 in alveolar boneincreased levels of PGE2 in alveolar bone

The effect of prostaglandins onThe effect of prostaglandins on
experimental tooth movement in monkeys-experimental tooth movement in monkeys-
Yamasaki 1982Yamasaki 1982
Bhalaji and Shetty ( JIOS 96)Bhalaji and Shetty ( JIOS 96)
Prostaglandin administration increases toothProstaglandin administration increases tooth
movementmovement
Associated with pain, frequentAssociated with pain, frequent
administration requiredadministration required

Alternatives to PGs:Alternatives to PGs:
- Administration of Misoprostol - Kehoe et al- Administration of Misoprostol - Kehoe et al
(AJO 96), Sekhavat (AJO 02)(AJO 96), Sekhavat (AJO 02)
- Calcium Gluconate with PGE2- Seiki et alCalcium Gluconate with PGE2- Seiki et al
EJO 2003EJO 2003

Etiology of Orthodontic painEtiology of Orthodontic pain
Etiology of orthodontic painEtiology of orthodontic pain
- Furstman et al (AJO 72)- periodontal pain-Furstman et al (AJO 72)- periodontal pain-
pressure, ischaemia, inflammation, edemapressure, ischaemia, inflammation, edema
- Soltis and associates- proprioceptiveSoltis and associates- proprioceptive
abilities are reduced after insertion ofabilities are reduced after insertion of
orthodontic appliancesorthodontic appliances
Patient discomfort- lowering of painPatient discomfort- lowering of pain
threshold, alteration of proprioceptivethreshold, alteration of proprioceptive
impulses from nerves of PDLimpulses from nerves of PDL

Burstone- there is wide range of individualBurstone- there is wide range of individual
responses when similar forces are appliedresponses when similar forces are applied
to teethto teeth
Immediate and delayed pain responseImmediate and delayed pain response
Immediate- compression of PDL duringImmediate- compression of PDL during
archwire placementarchwire placement
Delayed- few hours later- hyperalgesia ofDelayed- few hours later- hyperalgesia of
PDLPDL

Prostaglandins- hyperalgesiaProstaglandins- hyperalgesia
Increased sensitivity to serotonin,Increased sensitivity to serotonin,
bradykinin, substance P, histamine, acetylbradykinin, substance P, histamine, acetyl
cholinecholine

Perception of pain in patientsPerception of pain in patients
undergoing treatment (AJO 89)undergoing treatment (AJO 89)
Discomfort associated with placement of archwires orDiscomfort associated with placement of archwires or
separatorsseparators
First signs of pain- 4 hours within the placement of wiresFirst signs of pain- 4 hours within the placement of wires
or separatorsor separators
Amount of discomfort peaks about 24 hours, baseline inAmount of discomfort peaks about 24 hours, baseline in
7 days7 days
Separators- pain in posterior teeth, archwire placement-Separators- pain in posterior teeth, archwire placement-
pain in anterior teethpain in anterior teeth
Pain correlates with the presence of Substance P andPain correlates with the presence of Substance P and
Prostaglandins in the PDLProstaglandins in the PDL
Various studies- 90 % orthodontic patients experienceVarious studies- 90 % orthodontic patients experience
painpain

Pain controlPain control
Removal of the causeRemoval of the cause
Blocking the pathway of painful impulsesBlocking the pathway of painful impulses
Raising pain thresholdRaising pain threshold
Preventing pain reaction by corticalPreventing pain reaction by cortical
depressiondepression
Psychosomatic methodsPsychosomatic methods

Drug effects on the response toDrug effects on the response to
orthodontic movementsorthodontic movements
BisphosphonatesBisphosphonates
Prostaglandin inhibitorsProstaglandin inhibitors
Estrogen may be usedEstrogen may be used
Tricyclic anti depressants (Imipramine,Tricyclic anti depressants (Imipramine,
amitriptyline), anti arrhythmic (procaine),amitriptyline), anti arrhythmic (procaine),
antimalarialsantimalarials
Phenytoin decreases tooth movementsPhenytoin decreases tooth movements
Some tetracyclines act similar toSome tetracyclines act similar to
bisphosphonatesbisphosphonates

Effect of preoperative Ibuprofen andEffect of preoperative Ibuprofen and
Naproxen Sodium on orthodontic painNaproxen Sodium on orthodontic pain
Naproxen sodium (550 mg) taken one hourNaproxen sodium (550 mg) taken one hour
before archwire placement significantlybefore archwire placement significantly
decreased the severity of pain at two hours, sixdecreased the severity of pain at two hours, six
hours, and, except for pain to biting, 24 hourshours, and, except for pain to biting, 24 hours
when compared with preoperativelywhen compared with preoperatively
administrated ibuprofen (400 mg) or placebo.administrated ibuprofen (400 mg) or placebo.
As maximum pain levels are felt on the night toAs maximum pain levels are felt on the night to
24 hours after archwire adjustment, a single24 hours after archwire adjustment, a single
dose of an analgesic given preoperatively wasdose of an analgesic given preoperatively was
found insufficient to relieve pain; therefore, atfound insufficient to relieve pain; therefore, at
least one additional postoperative dose isleast one additional postoperative dose is
recommended.recommended.
- (Angle orthodontist 2004)- (Angle orthodontist 2004)www.indiandentalacademy.comwww.indiandentalacademy.com

Aspirin, Acetaminophen, and ibuprofen-Aspirin, Acetaminophen, and ibuprofen-
their effects on tooth movement ( AJO-their effects on tooth movement ( AJO-
2006)2006)
Aspirin and ibuprofen inhibit PGs andAspirin and ibuprofen inhibit PGs and
reduce tooth movementreduce tooth movement
Acetaminophen might be drug of choiceAcetaminophen might be drug of choice
for orthodontic painfor orthodontic pain

Pain control measures inPain control measures in
orthodonticsorthodontics
Don’t separate all teeth at same timeDon’t separate all teeth at same time
Force levels to be kept at low levelsForce levels to be kept at low levels
Prevent trauma from hyperocclusionPrevent trauma from hyperocclusion
In procedures suspected to cause pain-In procedures suspected to cause pain-
placing bands on unseparated teeth,placing bands on unseparated teeth,
removal of fixed expanders, arch wireremoval of fixed expanders, arch wire
placement – analgesicsplacement – analgesics
Avoiding mastication for 3 hours and hardAvoiding mastication for 3 hours and hard
foods for 7 days reduces pain (AJO 2006)foods for 7 days reduces pain (AJO 2006)

Low level laser therapy reduces pain (AJOLow level laser therapy reduces pain (AJO
1995)1995)
TENS – DebondingTENS – Debonding
Vibratory motion to teeth (JCO 2003)Vibratory motion to teeth (JCO 2003)

TMJ painTMJ pain
Home care- Jaw restHome care- Jaw rest
- Soft diet- Soft diet
- Stress reduction- Stress reduction
- heat and cold application- heat and cold application
- analgesics- analgesics

Nonsurgical T/t :Nonsurgical T/t :
- Physical therapyPhysical therapy
- Bite appliancesBite appliances
- Muscle relaxantsMuscle relaxants
- Trigger point injectionTrigger point injection

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Pain and orthodontics

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