- Email: [email protected]
Chewing gum for pain control following orthodontic separator placement
Journal of the World Federation of Orthodontists xxx (2018) 1e4
Contents lists available at ScienceDirect
Journal of the World Federation of Orthodontists journal homepage: www.jwfo.org
Chewing gum for pain control following orthodontic separator placement Muhammad Azeem a, *, Dalia Iftikhar Khan b, Furqan Jamal b, Saqib Ali c, Mehrin Fatima d, Muhammad Burhan Hayat b, Muhammad Usman Shakoor b a
Assistant Professor Orthodontics, Dental Section-Faisalabad Medical University/Punjab Medical College, Pakistan Postgraduate Trainee, de’Montmorency College of Dentistry, Lahore, Pakistan c Specialist Restorative Dentist, Tabuk Specialist Dental Centre, Tabuk, Saudi Arabia d de’Montmorency College of Dentistry, Lahore, Pakistan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 June 2018 Accepted 18 July 2018 Available online xxx
Objective: The objective was to compare the mean decrease in pain score in ibuprofen versus chewing gum groups after orthodontic separator placement. Methods: The study was conducted at the Department of Orthodontics Dental Section-Faisalabad Medical University and de'Montmorency College of Dentistry, Pakistan. A total of 120 patients were selected according to the inclusion criteria and placed into ibuprofen and chewing gum groups (60 each group) using the random number table method. Patients were asked to complete a Visual Analog Scale (VAS) performa, at baseline (i.e., before separator placement), immediately after separator placement, at 2 hours, at bedtime (i.e., 12 hours), at 24 hours, at the second day, the third day, fifth day, and seventh day, after the separator placement. For analyzing the significance of the mean decrease in VAS scores between the two groups, the t test was applied. Results: At each point of follow-up, chewing gum showed a similar decrease in mean pain score in comparison with ibuprofen (P > 0.05). Conclusion: Chewing gum can be recommended for orthodontic pain control associated with elastic separator placement and is found to be as effective as using ibuprofen. Ó 2018 World Federation of Orthodontists.
Keywords: pain chewing gum separator
1. Introduction Pain is a common experience in orthodontic patients especially after separator placement before molar banding and initial archwire placement [1,2]. Patients often rank pain as one of the worst aspects of orthodontic therapy and the major reason for discontinuing their orthodontic treatment care [3]. Some patients even reported the incidence and the severity of orthodontic pain greater than the pain of tooth extraction [4]. Many factors have been found to affect orthodontic pain, namely, amount of orthodontic forces, age, gender, the degree of malocclusion, and patient’s psychological status [5,6]. There are different theories that are suggested in the literature regarding the mechanism of orthodontic pain generation. The most acceptable theory is that orthodontic pain arises by the combination of periodontal ischemia, compression, inflammation, and edema [5]. Some
* Corresponding author: Orthodontic Department, Dental Section-Faisalabad Medical University/Punjab Medical College, Punjab, Pakistan. (M. Azeem). E-mail address: [email protected] (M. Azeem).
studies also attributed orthodontic pain to the hyperalgesia of the periodontium. Pain after orthodontic separator insertion is usually felt within a few hours and reaches maximum levels 24 hours [7]. Nonsteroidal anti-inflammatory drugs (NSAIDs) in orthodontics have been reported to be the most successful pain control method [8,9]. However, studies have shown that NSAIDs cause interference in orthodontic tooth movement by blocking the synthesis of prostaglandins, and can also result in systemic side effects, such as gastrointestinal discomfort [10e11]. Therefore, various nonpharmacological methods have been recommended for orthodontic pain control such as low-level laser therapy, transcutaneous electrical nerve stimulation, vibratory stimulation of the periodontium, chewing gum, and bite wafers [12e16]. The most reliable method for measuring the perception of pain is the Visual Analog Scale (VAS) [17,18]. VAS is a psychometric pain response scale that can be used in orthodontic questionnaires. It is a measurement instrument for subjective characters such as orthodontic pain, which cannot be measured directly. When answering to a VAS, orthodontic patients specify their intensity of pain by marking a position along a calibrated straight line [17].
2212-4438/$ e see front matter Ó 2018 World Federation of Orthodontists. https://doi.org/10.1016/j.ejwf.2018.07.002
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
2
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4
The rationale of this study was to compare a nonpharmacological option of chewing gum with ibuprofen in orthodontic pain control following separator placement. The objective of this study was to compare the effect of ibuprofen and chewing gum on pain control after separator placement in terms of mean decrease in VAS score.
2. Materials and methods After obtaining institutional ethical board approval and obtaining informed consent from patients, the study was conducted at the Department of Orthodontics Dental Section-Faisalabad Medical University and de'Montmorency College of Dentistry, Pakistan, from May 30, 2017, to May 30, 2018. The sample size was calculated after performing a power analysis, keeping in mind the past orthodontic studies on pain control. Selection criteria were as follows: 13 to 17 years of age, irrespective of gender, scheduled for separators placement for molar bands, medically fit, without temporomandibular disorders, without psychological disorders, nonsmokers, not receiving any analgesic therapy, no contraindication to the use of ibuprofen, and no oral surgery in the previous 4 weeks. The reports on the influence of age and gender on pain following orthodontic therapy are inconsistent [19,20]. Therefore to control these factors, this study was limited to the age group of 13 to 17 years and stratification based on sex was used to balance the distribution of boys and girls in both the groups. A total of 120 patients were selected according to the selection criteria and placed into ibuprofen and chewing gum groups (60 in each group) using the random number table method. In both groups, elastomeric separators (3M Unitek, Monrovia, CA) were placed using separator pliers (Dentaurum, Springen, Germany) at the mesial and distal contacts of the maxillary first molars. In the ibuprofen group, the patients received ibuprofen (400-mg tablets; Abbott Laboratories Ltd., Karachi, Pakistan) to be taken orally, 1 hour before separator placement and at 6-hour intervals. Patients in the ibuprofen group were specifically asked not to chew gum for the duration of the study. In the chewing gum group, the patients were prescribed to chew a sugar-free gum for 5 minutes (Wrigley’s Orbit Complete; Wrigley Company, Chicago, IL) immediately after separator placement and at 8-hour intervals. The patients in both the groups were instructed and encouraged not to take any additional analgesics. If an additional medication was required, patients were asked to call the primary investigator and were instructed to document the frequency, dosage, and the type of medication taken. Of the 120 patients, none had taken additional medication. The number of separators placed and the time of placement was also documented in both the groups. Patients responded to a VAS at baseline (i.e., before separator placement), immediately after separator placement, at 2 hours, at bedtime (i.e., 12 hours), at 24 hours, at the second day, the third day, fifth day, and seventh day after separator placement. When answering to VAS performa, patients were asked to specify their intensity of pain by marking a position along a calibrated straight continuous line weighted at both ends by descriptive terminology with a happy face and a sad face.
2.1. Statistical analysis The normal distribution was analyzed by the KolmogorovSmirnov test. Age and VAS scores were presented by mean SD, whereas the variable of gender was presented by frequency and percentages. Mean decrease in VAS pain score was calculated by subtracting posttreatment VAS scores at all the follow-ups from pretreatment VAS scores. For analyzing the significance of the mean decrease in VAS scores between the two groups, t test was applied. Data were analyzed using SPSS version 21.0 (IBM Corporation, Chicago, IL) with a level of significance determined at P 0.05. 3. Results Preliminary analysis was done to find out the effect of sex on the significance of the mean decrease in VAS pain scores between the two groups. There was no effect of sex on the significance of the mean decrease in VAS pain scores between the two groups; therefore, this variable was eliminated from future analyses and the subsequent analyses were conducted. There was no significant difference between the two groups, in the number of separators placed and the time of placement. Of the 120 patients, none had taken additional medication. Normal distribution of the data was confirmed by the Kolmogorov-Smirnov test. The average age at enrollment for the 60 subjects randomized to the ibuprofen group was not significantly different from that of the 60 subjects in the chewing gum group (ibuprofen, mean ¼ 15.5, SD ¼ 2.0; chewing gum, mean¼15.6, SD¼1.8) (Table 1). Gender distribution is also shown in Table 2. At each point of follow-up, the chewing gum group showed a similar decrease in mean pain score at each follow-up, in comparison with the ibuprofen group (Tables 3 and 4). 4. Discussion This study was designed to compare the effect of ibuprofen and chewing gum on orthodontic pain control by measurement of the mean decrease in VAS pain score following separator placement. A recent clinical trial showed that chewing gum use had no significant effect on the number of appliance breakages [21,22]. The results of this study show that in both the groups, the score of pain increased immediately after separator placement, lessened 2 hours later, increased at night (i.e., 12 hours), peaked at 24 hours and then decreased thereafter through 7 days after separator placement. This pain trend was similar to that seen in previous studies that reported peak pain after 24 hours of orthodontic therapy linked with the peak level of prostaglandins [23e25]. Pain following separator placement can be attributed to the combination of compression, ischemia, periodontal inflammation, and edema [15]. Orthodontic pain mainly arises due to an inflammatory reaction in the periodontium, while peak level of prostaglandins and other pain mediators in gingival crevicular fluid stimulates a pain response [15,16]. NSAIDs such as ibuprofen suppress the production of prostaglandins and thus decreases inflammatory reactions [10]. The mean decrease in VAS pain score following separator placement showed that chewing gum was as effective as ibuprofen
Table 1 Age distribution in both the groups Ibuprofen group, n ¼ 60 Age groups, y Numbers (%) Age, y, mean SD
13e15 34 (56.66)
16e17 26 (43.33) 15.50 2.00
Chewing gum group, n ¼ 60 13e15 35 (58.33)
16e17 25 (41.66) 15.60 1.80
Total, n ¼ 120 13e15 65 (54.16)
16e17 55 (45.83) 15.55 1.90
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4 Table 2 Gender distribution in both the groups Ibuprofen group, n ¼ 60
Numbers Percentage
Table 4 Comparison of mean decrease in pain scores using t test Chewing gum group, n ¼ 60
Total, n ¼ 120
Boys
Girls
Boys
Girls
Boys
Girls
33 55
27 45
24 40
36 60
54 45
66 55
in reducing pain at all follow-ups. The mechanism of chewing gum is to loosen the tightly packed periodontal ligament fibers, restoring the normal blood flow of periodontium, thus preventing the buildup of pain-causing metabolites [15,19,26]. Advantages of chewing gum are that it is a nonpharmacological method that eliminates the risk of possible systemic side effects from ibuprofen, it does not interfere in orthodontic tooth movement physiology, acts as a salivary stimulant, and can be easily used anywhere and in patients with contraindications to ibuprofen [15]. Farella et al. [27] reported that in healthy individuals, prolonged gum chewing does not necessarily result in delayed pain, soreness, or tenderness of the masticatory muscles. In a study by Benson et al. [22], patients were advised to chew gum for 10 minutes following initial archwire placement. They could observe ignificant decrease in both the impact and pain from the fixed appliances without any evidence that chewing gum increased the incidence of appliance breakages. In the present study, the patients in the chewing gum group were prescribed to chew gum for 5 minutes in accordance with the previous studies by Farzanegan et al. [15] and Hamid et al. [28]. This is the first study on the comparison of ibuprofen and chewing gum on orthodontic pain control following separator placement. The findings of the present study are in agreement with other studies on the effect of chewing gum on orthodontic pain control following initial orthodontic archwire placement [15,21,22,26]. In a recent study, Ireland et al. [21] concluded that chewing gum might help orthodontic patients to use less ibuprofen. In another study, Ireland et al. [26] concluded that patients who were more anxious tended to take more ibuprofen for their pain relief. Konno et al. [29] showed that gum chewing reduces stressrelated responses and therefore may indirectly affect pain perception and the need for analgesia, by reducing anxiety. The limitation of the present study is that it could have included a control group, as standard placebo effect in dental pain management studies is found to be 30% to 40% [30]. The present study did not have a control group, which is in accordance with the studies conceived to investigate the effect of bite wafers on pain control by orthodontic patients [16,31]. The other limitations of this study were small sample size and use of the VAS pain scoring method. We suggest conducting multicentric prospective research with a larger sample size and using objective criteria such as orthodontic pain mediators present in the gingival crevicular fluid. Table 3 Pain scores in the two groups at different time points using the t test Time point
Ibuprofen group*
Baseline Immediately 2h 12 h 24 h 2d 3d 5d 7d
0.68 3.73 2.89 6.89 7.78 3.47 2.94 2.99 0.88
*
1.55 1.53 1.55 1.16 1.00 1.12 1.68 1.29 1.10
Values are expressed as mean SD.
3
Chewing gum group* 0.67 4.15 3.16 7.51 8.11 3.94 3.73 3.54 1.02
1.56 1.15 1.16 1.11 1.18 1.17 1.11 1.10 1.31
P 0.366 0.411 0.521 0.456 0.356 0.341 0.411 0.317 0.467
Time point Baseline Baseline Baseline Baseline Baseline Baseline Baseline Baseline *
to to to to to to to to
immediately 2h 12 h 24 h 2d 3d 5 days 7d
Ibuprofen group*
Chewing gum group*
P
3.05 2.21 6.21 7.10 2.79 2.26 2.31 0.20
3.48 2.49 6.48 7.44 3.27 3.06 2.87 0.35
0.664 0.447 0.361 0.430 0.412 0.310 0.399 0.369
1.23 1.36 1.43 1.11 1.52 1.34 1.43 1.03
1.12 1.43 1.65 1.13 1.11 1.47 1.58 1.06
Values are expressed as mean SD.
5. Conclusion Chewing gum can be recommended as a nonpharmacological option instead of ibuprofen for orthodontic pain control associated with separator placement.
References [1] Shi Q, Yang S, Jia F, Xu J. Does low level laser therapy relieve the pain caused by the placement of the orthodontic separators? A meta-analysis. Head Face Med 2015;11:28. [2] Wiedel AP, Bondemark L. A randomized controlled trial of self-perceived pain, discomfort, and impairment of jaw function in children undergoing orthodontic treatment with fixed or removable appliances. Angle Orthod 2015;86:324e30. [3] Oliver RG, Knapman YM. Attitudes to orthodontic treatment. Br J Orthod 1985;12:179e88. [4] Jones ML, Chan C. Pain in the early stages of orthodontic treatment. J Clin Orthod 1992;26:311e3. [5] Gameiro GH, Schultz C, Trein MP, Mundstock KS, Weidlich P, Goularte JF. Association among pain, masticatory performance, and proinflammatory cytokines in crevicular fluid during orthodontic treatment. Am J Orthod Dentofacial Orthop 2015;148:967e73. [6] Bavbek NC, Tuncer BB, Tortop T, Celik B. Efficacy of different methods to reduce pain during debonding of orthodontic brackets. Angle Orthod 2016;86:917e24. [7] Sandhu SS, Cheema MS, Khehra HS. Comparative effectiveness of pharmacologic and nonpharmacologic interventions for orthodontic pain relief at peak pain intensity: a Bayesian network meta-analysis. Am J Orthod Dentofacial Orthop 2016;150:13e32. [8] Shetty N, Patil AK, Ganeshkar SV, Hegde S. Comparison of the effects of ibuprofen and acetaminophen on PGE 2 levels in the GCF during orthodontic tooth movement: a human study. Prog Orthod 2013;17:6. [9] Shenoy N, Shetty S, Ahmed J, Shenoy A. The pain management in orthodontics. J Clin Diagn Res 2013;7:1258. [10] Bagnoli F, Rossetti A, Messina G, Mori A, Casucci M, Tomasini B. Treatment of patent ductus arteriosus (PDA) using ibuprofen: renal side-effects in VLBW and ELBW newborns. J Matern Fetal Neonatal Med 2013;26:423e9. [11] Platts-Mills TF, Richmond NL, Hunold KM, Bowling CB. Life-threatening hyperkalemia after 2 days of ibuprofen. Am J Emerg Med 2013;31:465.e1. [12] Li FJ, Zhang JY, Zeng XT, Guo Y. Low-level laser therapy for orthodontic pain: a systematic review. Lasers Med Sci 2015;30:1789e803. [13] Kasat V, Gupta A, Ladda R, Kathariya M, Saluja H, Farooqui AA. Transcutaneous electric nerve stimulation (TENS) in dentistryda review. J Clin Exp Dent 2014;6:e562. [14] Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod 2015;86:625e30. [15] Farzanegan F, Zebarjad SM, Alizadeh S, Ahrari F. Pain reduction after initial archwire placement in orthodontic patients: a randomized clinical trial. Am J Orthod Dentofacial Orthop 2012;141:169e73. [16] Otasevic M, Naini FB, Gill DS, Lee RT. Prospective randomized clinical trial comparing the effects of a masticatory bite wafer and avoidance of hard food on pain associated with initial orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2006;130:6.e9. [17] Rausch M, Zehetleitner M. A comparison between a visual analogue scale and a four point scale as measures of conscious experience of motion. Conscious Cogn 2014;31:126e40. [18] Abend R, Dan O, Maoz K, Raz S, Bar-Haim Y. Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety. J Behav Ther Exp Psychiatry 2014;45:447e53. [19] Jones M, Chan C. The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires. Am J Orthod Dentofacial Orthop 1992;102:373e81. [20] Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:47e53.
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
4
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4
[21] Ireland AJ, Ellis P, Jordan A, et al. Comparative assessment of chewing gum and ibuprofen in the management of orthodontic pain with fixed appliances: a pragmatic multicenter randomized controlled trial. Am J Orthod Dentofacial Orthop 2016;150:220e7. [22] Benson PE, Razi RM, Al-Bloushi RJ. The effect of chewing gum on the impact, pain and breakages associated with fixed orthodontic appliances: a randomized clinical trial. Orthod Craniofac Res 2012;15:178e87. [23] Bird SE, Williams K, Kula K. Preoperative acetaminophen vs ibuprofen for control of pain after orthodontic separator placement. Am J Orthod Dentofacial Orthop 2007;132:504e10. [24] Law SL, Southard KA, Law AS, Logan HL, Jakobsen JR. An evaluation of preoperative ibuprofen for treatment of pain associated with orthodontic separator placement. Am J Orthod Dentofacial Orthop 2000;118:629e35. [25] Bernhardt MK, Southard KA, Batterson KD, Logan HL, Baker KA, Jakobsen JR. The effect of preemptive and/or postoperative ibuprofen therapy for orthodontic pain. Am J Orthod Dentofacial Orthop 2001;120:20e7.
[26] Ireland AJ, Ellis P, Jordan A, et al. Chewing gum vs. ibuprofen in the management of orthodontic pain, a multi-centre randomised controlled trialethe effect of anxiety. J Orthod 2017;44:3e7. [27] Farella M, Bakke M, Michelotti A, Martina R. Effects of prolonged gum chewing on pain and fatigue in human jaw muscles. Eur J Oral Sci 2001;109:81e5. [28] Hamid WU, Haq AUL, Mahmood S, Azeem M, Irfan S. Comparison between ibuprofen and chewing gum for orthodontic pain control. Pak Oral Dent J 2016;36:79e83. [29] Konno M, Takeda T, Kawakami Y, et al. Relationships between gum-chewing and stress. Oxygen Transport to Tissue XXXVII. New York: Springer; 2016. p. 343e9. [30] Boucher Y. Pharmacology and pain. Rev Orthop Dento Faciale 1999;33:123e41. [31] Hwang J, Tee C, Huang A, Taft L. Effectiveness of thera-bite wafers in reducing pain. J Clin Orthod 1994;5:291e2.
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
Contents lists available at ScienceDirect
Journal of the World Federation of Orthodontists journal homepage: www.jwfo.org
Chewing gum for pain control following orthodontic separator placement Muhammad Azeem a, *, Dalia Iftikhar Khan b, Furqan Jamal b, Saqib Ali c, Mehrin Fatima d, Muhammad Burhan Hayat b, Muhammad Usman Shakoor b a
Assistant Professor Orthodontics, Dental Section-Faisalabad Medical University/Punjab Medical College, Pakistan Postgraduate Trainee, de’Montmorency College of Dentistry, Lahore, Pakistan c Specialist Restorative Dentist, Tabuk Specialist Dental Centre, Tabuk, Saudi Arabia d de’Montmorency College of Dentistry, Lahore, Pakistan b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 June 2018 Accepted 18 July 2018 Available online xxx
Objective: The objective was to compare the mean decrease in pain score in ibuprofen versus chewing gum groups after orthodontic separator placement. Methods: The study was conducted at the Department of Orthodontics Dental Section-Faisalabad Medical University and de'Montmorency College of Dentistry, Pakistan. A total of 120 patients were selected according to the inclusion criteria and placed into ibuprofen and chewing gum groups (60 each group) using the random number table method. Patients were asked to complete a Visual Analog Scale (VAS) performa, at baseline (i.e., before separator placement), immediately after separator placement, at 2 hours, at bedtime (i.e., 12 hours), at 24 hours, at the second day, the third day, fifth day, and seventh day, after the separator placement. For analyzing the significance of the mean decrease in VAS scores between the two groups, the t test was applied. Results: At each point of follow-up, chewing gum showed a similar decrease in mean pain score in comparison with ibuprofen (P > 0.05). Conclusion: Chewing gum can be recommended for orthodontic pain control associated with elastic separator placement and is found to be as effective as using ibuprofen. Ó 2018 World Federation of Orthodontists.
Keywords: pain chewing gum separator
1. Introduction Pain is a common experience in orthodontic patients especially after separator placement before molar banding and initial archwire placement [1,2]. Patients often rank pain as one of the worst aspects of orthodontic therapy and the major reason for discontinuing their orthodontic treatment care [3]. Some patients even reported the incidence and the severity of orthodontic pain greater than the pain of tooth extraction [4]. Many factors have been found to affect orthodontic pain, namely, amount of orthodontic forces, age, gender, the degree of malocclusion, and patient’s psychological status [5,6]. There are different theories that are suggested in the literature regarding the mechanism of orthodontic pain generation. The most acceptable theory is that orthodontic pain arises by the combination of periodontal ischemia, compression, inflammation, and edema [5]. Some
* Corresponding author: Orthodontic Department, Dental Section-Faisalabad Medical University/Punjab Medical College, Punjab, Pakistan. (M. Azeem). E-mail address: [email protected] (M. Azeem).
studies also attributed orthodontic pain to the hyperalgesia of the periodontium. Pain after orthodontic separator insertion is usually felt within a few hours and reaches maximum levels 24 hours [7]. Nonsteroidal anti-inflammatory drugs (NSAIDs) in orthodontics have been reported to be the most successful pain control method [8,9]. However, studies have shown that NSAIDs cause interference in orthodontic tooth movement by blocking the synthesis of prostaglandins, and can also result in systemic side effects, such as gastrointestinal discomfort [10e11]. Therefore, various nonpharmacological methods have been recommended for orthodontic pain control such as low-level laser therapy, transcutaneous electrical nerve stimulation, vibratory stimulation of the periodontium, chewing gum, and bite wafers [12e16]. The most reliable method for measuring the perception of pain is the Visual Analog Scale (VAS) [17,18]. VAS is a psychometric pain response scale that can be used in orthodontic questionnaires. It is a measurement instrument for subjective characters such as orthodontic pain, which cannot be measured directly. When answering to a VAS, orthodontic patients specify their intensity of pain by marking a position along a calibrated straight line [17].
2212-4438/$ e see front matter Ó 2018 World Federation of Orthodontists. https://doi.org/10.1016/j.ejwf.2018.07.002
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
2
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4
The rationale of this study was to compare a nonpharmacological option of chewing gum with ibuprofen in orthodontic pain control following separator placement. The objective of this study was to compare the effect of ibuprofen and chewing gum on pain control after separator placement in terms of mean decrease in VAS score.
2. Materials and methods After obtaining institutional ethical board approval and obtaining informed consent from patients, the study was conducted at the Department of Orthodontics Dental Section-Faisalabad Medical University and de'Montmorency College of Dentistry, Pakistan, from May 30, 2017, to May 30, 2018. The sample size was calculated after performing a power analysis, keeping in mind the past orthodontic studies on pain control. Selection criteria were as follows: 13 to 17 years of age, irrespective of gender, scheduled for separators placement for molar bands, medically fit, without temporomandibular disorders, without psychological disorders, nonsmokers, not receiving any analgesic therapy, no contraindication to the use of ibuprofen, and no oral surgery in the previous 4 weeks. The reports on the influence of age and gender on pain following orthodontic therapy are inconsistent [19,20]. Therefore to control these factors, this study was limited to the age group of 13 to 17 years and stratification based on sex was used to balance the distribution of boys and girls in both the groups. A total of 120 patients were selected according to the selection criteria and placed into ibuprofen and chewing gum groups (60 in each group) using the random number table method. In both groups, elastomeric separators (3M Unitek, Monrovia, CA) were placed using separator pliers (Dentaurum, Springen, Germany) at the mesial and distal contacts of the maxillary first molars. In the ibuprofen group, the patients received ibuprofen (400-mg tablets; Abbott Laboratories Ltd., Karachi, Pakistan) to be taken orally, 1 hour before separator placement and at 6-hour intervals. Patients in the ibuprofen group were specifically asked not to chew gum for the duration of the study. In the chewing gum group, the patients were prescribed to chew a sugar-free gum for 5 minutes (Wrigley’s Orbit Complete; Wrigley Company, Chicago, IL) immediately after separator placement and at 8-hour intervals. The patients in both the groups were instructed and encouraged not to take any additional analgesics. If an additional medication was required, patients were asked to call the primary investigator and were instructed to document the frequency, dosage, and the type of medication taken. Of the 120 patients, none had taken additional medication. The number of separators placed and the time of placement was also documented in both the groups. Patients responded to a VAS at baseline (i.e., before separator placement), immediately after separator placement, at 2 hours, at bedtime (i.e., 12 hours), at 24 hours, at the second day, the third day, fifth day, and seventh day after separator placement. When answering to VAS performa, patients were asked to specify their intensity of pain by marking a position along a calibrated straight continuous line weighted at both ends by descriptive terminology with a happy face and a sad face.
2.1. Statistical analysis The normal distribution was analyzed by the KolmogorovSmirnov test. Age and VAS scores were presented by mean SD, whereas the variable of gender was presented by frequency and percentages. Mean decrease in VAS pain score was calculated by subtracting posttreatment VAS scores at all the follow-ups from pretreatment VAS scores. For analyzing the significance of the mean decrease in VAS scores between the two groups, t test was applied. Data were analyzed using SPSS version 21.0 (IBM Corporation, Chicago, IL) with a level of significance determined at P 0.05. 3. Results Preliminary analysis was done to find out the effect of sex on the significance of the mean decrease in VAS pain scores between the two groups. There was no effect of sex on the significance of the mean decrease in VAS pain scores between the two groups; therefore, this variable was eliminated from future analyses and the subsequent analyses were conducted. There was no significant difference between the two groups, in the number of separators placed and the time of placement. Of the 120 patients, none had taken additional medication. Normal distribution of the data was confirmed by the Kolmogorov-Smirnov test. The average age at enrollment for the 60 subjects randomized to the ibuprofen group was not significantly different from that of the 60 subjects in the chewing gum group (ibuprofen, mean ¼ 15.5, SD ¼ 2.0; chewing gum, mean¼15.6, SD¼1.8) (Table 1). Gender distribution is also shown in Table 2. At each point of follow-up, the chewing gum group showed a similar decrease in mean pain score at each follow-up, in comparison with the ibuprofen group (Tables 3 and 4). 4. Discussion This study was designed to compare the effect of ibuprofen and chewing gum on orthodontic pain control by measurement of the mean decrease in VAS pain score following separator placement. A recent clinical trial showed that chewing gum use had no significant effect on the number of appliance breakages [21,22]. The results of this study show that in both the groups, the score of pain increased immediately after separator placement, lessened 2 hours later, increased at night (i.e., 12 hours), peaked at 24 hours and then decreased thereafter through 7 days after separator placement. This pain trend was similar to that seen in previous studies that reported peak pain after 24 hours of orthodontic therapy linked with the peak level of prostaglandins [23e25]. Pain following separator placement can be attributed to the combination of compression, ischemia, periodontal inflammation, and edema [15]. Orthodontic pain mainly arises due to an inflammatory reaction in the periodontium, while peak level of prostaglandins and other pain mediators in gingival crevicular fluid stimulates a pain response [15,16]. NSAIDs such as ibuprofen suppress the production of prostaglandins and thus decreases inflammatory reactions [10]. The mean decrease in VAS pain score following separator placement showed that chewing gum was as effective as ibuprofen
Table 1 Age distribution in both the groups Ibuprofen group, n ¼ 60 Age groups, y Numbers (%) Age, y, mean SD
13e15 34 (56.66)
16e17 26 (43.33) 15.50 2.00
Chewing gum group, n ¼ 60 13e15 35 (58.33)
16e17 25 (41.66) 15.60 1.80
Total, n ¼ 120 13e15 65 (54.16)
16e17 55 (45.83) 15.55 1.90
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4 Table 2 Gender distribution in both the groups Ibuprofen group, n ¼ 60
Numbers Percentage
Table 4 Comparison of mean decrease in pain scores using t test Chewing gum group, n ¼ 60
Total, n ¼ 120
Boys
Girls
Boys
Girls
Boys
Girls
33 55
27 45
24 40
36 60
54 45
66 55
in reducing pain at all follow-ups. The mechanism of chewing gum is to loosen the tightly packed periodontal ligament fibers, restoring the normal blood flow of periodontium, thus preventing the buildup of pain-causing metabolites [15,19,26]. Advantages of chewing gum are that it is a nonpharmacological method that eliminates the risk of possible systemic side effects from ibuprofen, it does not interfere in orthodontic tooth movement physiology, acts as a salivary stimulant, and can be easily used anywhere and in patients with contraindications to ibuprofen [15]. Farella et al. [27] reported that in healthy individuals, prolonged gum chewing does not necessarily result in delayed pain, soreness, or tenderness of the masticatory muscles. In a study by Benson et al. [22], patients were advised to chew gum for 10 minutes following initial archwire placement. They could observe ignificant decrease in both the impact and pain from the fixed appliances without any evidence that chewing gum increased the incidence of appliance breakages. In the present study, the patients in the chewing gum group were prescribed to chew gum for 5 minutes in accordance with the previous studies by Farzanegan et al. [15] and Hamid et al. [28]. This is the first study on the comparison of ibuprofen and chewing gum on orthodontic pain control following separator placement. The findings of the present study are in agreement with other studies on the effect of chewing gum on orthodontic pain control following initial orthodontic archwire placement [15,21,22,26]. In a recent study, Ireland et al. [21] concluded that chewing gum might help orthodontic patients to use less ibuprofen. In another study, Ireland et al. [26] concluded that patients who were more anxious tended to take more ibuprofen for their pain relief. Konno et al. [29] showed that gum chewing reduces stressrelated responses and therefore may indirectly affect pain perception and the need for analgesia, by reducing anxiety. The limitation of the present study is that it could have included a control group, as standard placebo effect in dental pain management studies is found to be 30% to 40% [30]. The present study did not have a control group, which is in accordance with the studies conceived to investigate the effect of bite wafers on pain control by orthodontic patients [16,31]. The other limitations of this study were small sample size and use of the VAS pain scoring method. We suggest conducting multicentric prospective research with a larger sample size and using objective criteria such as orthodontic pain mediators present in the gingival crevicular fluid. Table 3 Pain scores in the two groups at different time points using the t test Time point
Ibuprofen group*
Baseline Immediately 2h 12 h 24 h 2d 3d 5d 7d
0.68 3.73 2.89 6.89 7.78 3.47 2.94 2.99 0.88
*
1.55 1.53 1.55 1.16 1.00 1.12 1.68 1.29 1.10
Values are expressed as mean SD.
3
Chewing gum group* 0.67 4.15 3.16 7.51 8.11 3.94 3.73 3.54 1.02
1.56 1.15 1.16 1.11 1.18 1.17 1.11 1.10 1.31
P 0.366 0.411 0.521 0.456 0.356 0.341 0.411 0.317 0.467
Time point Baseline Baseline Baseline Baseline Baseline Baseline Baseline Baseline *
to to to to to to to to
immediately 2h 12 h 24 h 2d 3d 5 days 7d
Ibuprofen group*
Chewing gum group*
P
3.05 2.21 6.21 7.10 2.79 2.26 2.31 0.20
3.48 2.49 6.48 7.44 3.27 3.06 2.87 0.35
0.664 0.447 0.361 0.430 0.412 0.310 0.399 0.369
1.23 1.36 1.43 1.11 1.52 1.34 1.43 1.03
1.12 1.43 1.65 1.13 1.11 1.47 1.58 1.06
Values are expressed as mean SD.
5. Conclusion Chewing gum can be recommended as a nonpharmacological option instead of ibuprofen for orthodontic pain control associated with separator placement.
References [1] Shi Q, Yang S, Jia F, Xu J. Does low level laser therapy relieve the pain caused by the placement of the orthodontic separators? A meta-analysis. Head Face Med 2015;11:28. [2] Wiedel AP, Bondemark L. A randomized controlled trial of self-perceived pain, discomfort, and impairment of jaw function in children undergoing orthodontic treatment with fixed or removable appliances. Angle Orthod 2015;86:324e30. [3] Oliver RG, Knapman YM. Attitudes to orthodontic treatment. Br J Orthod 1985;12:179e88. [4] Jones ML, Chan C. Pain in the early stages of orthodontic treatment. J Clin Orthod 1992;26:311e3. [5] Gameiro GH, Schultz C, Trein MP, Mundstock KS, Weidlich P, Goularte JF. Association among pain, masticatory performance, and proinflammatory cytokines in crevicular fluid during orthodontic treatment. Am J Orthod Dentofacial Orthop 2015;148:967e73. [6] Bavbek NC, Tuncer BB, Tortop T, Celik B. Efficacy of different methods to reduce pain during debonding of orthodontic brackets. Angle Orthod 2016;86:917e24. [7] Sandhu SS, Cheema MS, Khehra HS. Comparative effectiveness of pharmacologic and nonpharmacologic interventions for orthodontic pain relief at peak pain intensity: a Bayesian network meta-analysis. Am J Orthod Dentofacial Orthop 2016;150:13e32. [8] Shetty N, Patil AK, Ganeshkar SV, Hegde S. Comparison of the effects of ibuprofen and acetaminophen on PGE 2 levels in the GCF during orthodontic tooth movement: a human study. Prog Orthod 2013;17:6. [9] Shenoy N, Shetty S, Ahmed J, Shenoy A. The pain management in orthodontics. J Clin Diagn Res 2013;7:1258. [10] Bagnoli F, Rossetti A, Messina G, Mori A, Casucci M, Tomasini B. Treatment of patent ductus arteriosus (PDA) using ibuprofen: renal side-effects in VLBW and ELBW newborns. J Matern Fetal Neonatal Med 2013;26:423e9. [11] Platts-Mills TF, Richmond NL, Hunold KM, Bowling CB. Life-threatening hyperkalemia after 2 days of ibuprofen. Am J Emerg Med 2013;31:465.e1. [12] Li FJ, Zhang JY, Zeng XT, Guo Y. Low-level laser therapy for orthodontic pain: a systematic review. Lasers Med Sci 2015;30:1789e803. [13] Kasat V, Gupta A, Ladda R, Kathariya M, Saluja H, Farooqui AA. Transcutaneous electric nerve stimulation (TENS) in dentistryda review. J Clin Exp Dent 2014;6:e562. [14] Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod 2015;86:625e30. [15] Farzanegan F, Zebarjad SM, Alizadeh S, Ahrari F. Pain reduction after initial archwire placement in orthodontic patients: a randomized clinical trial. Am J Orthod Dentofacial Orthop 2012;141:169e73. [16] Otasevic M, Naini FB, Gill DS, Lee RT. Prospective randomized clinical trial comparing the effects of a masticatory bite wafer and avoidance of hard food on pain associated with initial orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2006;130:6.e9. [17] Rausch M, Zehetleitner M. A comparison between a visual analogue scale and a four point scale as measures of conscious experience of motion. Conscious Cogn 2014;31:126e40. [18] Abend R, Dan O, Maoz K, Raz S, Bar-Haim Y. Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety. J Behav Ther Exp Psychiatry 2014;45:447e53. [19] Jones M, Chan C. The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires. Am J Orthod Dentofacial Orthop 1992;102:373e81. [20] Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:47e53.
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002
4
M. Azeem et al. / Journal of the World Federation of Orthodontists xxx (2018) 1e4
[21] Ireland AJ, Ellis P, Jordan A, et al. Comparative assessment of chewing gum and ibuprofen in the management of orthodontic pain with fixed appliances: a pragmatic multicenter randomized controlled trial. Am J Orthod Dentofacial Orthop 2016;150:220e7. [22] Benson PE, Razi RM, Al-Bloushi RJ. The effect of chewing gum on the impact, pain and breakages associated with fixed orthodontic appliances: a randomized clinical trial. Orthod Craniofac Res 2012;15:178e87. [23] Bird SE, Williams K, Kula K. Preoperative acetaminophen vs ibuprofen for control of pain after orthodontic separator placement. Am J Orthod Dentofacial Orthop 2007;132:504e10. [24] Law SL, Southard KA, Law AS, Logan HL, Jakobsen JR. An evaluation of preoperative ibuprofen for treatment of pain associated with orthodontic separator placement. Am J Orthod Dentofacial Orthop 2000;118:629e35. [25] Bernhardt MK, Southard KA, Batterson KD, Logan HL, Baker KA, Jakobsen JR. The effect of preemptive and/or postoperative ibuprofen therapy for orthodontic pain. Am J Orthod Dentofacial Orthop 2001;120:20e7.
[26] Ireland AJ, Ellis P, Jordan A, et al. Chewing gum vs. ibuprofen in the management of orthodontic pain, a multi-centre randomised controlled trialethe effect of anxiety. J Orthod 2017;44:3e7. [27] Farella M, Bakke M, Michelotti A, Martina R. Effects of prolonged gum chewing on pain and fatigue in human jaw muscles. Eur J Oral Sci 2001;109:81e5. [28] Hamid WU, Haq AUL, Mahmood S, Azeem M, Irfan S. Comparison between ibuprofen and chewing gum for orthodontic pain control. Pak Oral Dent J 2016;36:79e83. [29] Konno M, Takeda T, Kawakami Y, et al. Relationships between gum-chewing and stress. Oxygen Transport to Tissue XXXVII. New York: Springer; 2016. p. 343e9. [30] Boucher Y. Pharmacology and pain. Rev Orthop Dento Faciale 1999;33:123e41. [31] Hwang J, Tee C, Huang A, Taft L. Effectiveness of thera-bite wafers in reducing pain. J Clin Orthod 1994;5:291e2.
Please cite this article in press as: Azeem M, et al., Chewing gum for pain control following orthodontic separator placement, Journal of the World Federation of Orthodontists (2018), https://doi.org/10.1016/j.ejwf.2018.07.002