Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2016 Dec 23;12(12):CD010263.
doi: 10.1002/14651858.CD010263.pub2.

Non-pharmacological interventions for alleviating pain during orthodontic treatment

Padhraig S Fleming  1 , Hardus Strydom  2 , Christos Katsaros  3 , Lci MacDonald  4 , Michele Curatolo  5 , Piotr Fudalej  6 , Nikolaos Pandis  3
Affiliations
Meta-Analysis

Non-pharmacological interventions for alleviating pain during orthodontic treatment

Padhraig S Fleming et al. Cochrane Database Syst Rev. .

Abstract

Background: Pain is prevalent during orthodontics, particularly during the early stages of treatment. To ensure patient comfort and compliance during treatment, the prevention or management of pain is of major importance. While pharmacological means are the first line of treatment for alleviation of orthodontic pain, a range of non-pharmacological approaches have been proposed recently as viable alternatives.

Objectives: To assess the effects of non-pharmacological interventions to alleviate pain associated with orthodontic treatment.

Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 6 October 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 9), MEDLINE Ovid (1946 to 6 October 2016), Embase Ovid (1980 to 6 October 2016) and EThOS (to 6 October 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

Selection criteria: Randomised controlled trials (RCTs) comparing a non-pharmacological orthodontic pain intervention to a placebo, no intervention or another non-pharmacological pain intervention were eligible for inclusion. We included any type of orthodontic treatment but excluded trials involving the use of pre-emptive analgesia or pain relief following orthognathic (jaw) surgery or dental extractions in combination with orthodontic treatment. We excluded split-mouth trials (in which each participant receives two or more treatments, each to a separate section of the mouth) and cross-over trials.

Data collection and analysis: At least two review authors independently assessed risk of bias and extracted data. We used the random-effects model and expressed results as mean differences (MD) with 95% confidence intervals (CI). We investigated heterogeneity with reference to both clinical and methodological factors.

Main results: We included 14 RCTs that randomised 931 participants. Interventions assessed included: low-level laser therapy (LLLT) (4 studies); vibratory devices (5 studies); chewing adjuncts (3 studies); brain wave music or cognitive behavioural therapy (1 study) and post-treatment communication in the form of a text message (1 study). Twelve studies involved self-report assessment of pain on a continuous scale and two studies used questionnaires to assess the nature, intensity and location of pain.We combined data from two studies involving 118 participants, which provided low-quality evidence that LLLT reduced pain at 24 hours by 20.27 mm (95% CI -24.50 to -16.04, P < 0.001; I² = 0%). LLLT also appeared to reduce pain at six hours, three days and seven days.Results for the other comparisons assessed are inconclusive as the quality of the evidence was very low. Vibratory devices were assessed in five studies (272 participants), four of which were at high risk of bias and one unclear. Chewing adjuncts (chewing gum or a bite wafer) were evaluated in three studies (181 participants); two studies were at high risk of bias and one was unclear. Brain wave music and cognitive behavioural therapy were evaluated in one trial (36 participants) assessed at unclear risk of bias. Post-treatment text messaging (39 participants) was evaluated in one study assessed at high risk of bias.Adverse effects were not measured in any of the studies.

Authors' conclusions: Overall, the results are inconclusive. Although available evidence suggests laser irradiation may help reduce pain during orthodontic treatment in the short term, this evidence is of low quality and therefore we cannot rely on the findings. Evidence for other non-pharmacological interventions is either very low quality or entirely lacking. Further prospective research is required to address the lack of reliable evidence concerning the effectiveness of a range of non-pharmacological interventions to manage orthodontic pain. Future studies should use prolonged follow-up and should measure costs and possible harms.

PubMed Disclaimer

Conflict of interest statement

Padhraig S Fleming: none known Nikolaos Pandis: none known Hardus Strydom: none known Christos Katsaros: none known Laura MacDonald: none known Michele Curatolo: none known Piotr Fudalej: none known

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Low‐level laser therapy versus placebo, Outcome 1 Patient‐reported pain intensity or pain relief measured on a visual analogue scale (VAS) at 6 hours, 24 hours, 3 days, 7 days.
2.1
2.1. Analysis
Comparison 2 Vibratory stimulation versus placebo or no vibration, Outcome 1 Patient‐reported pain intensity or pain relief measured on a visual analogue scale (VAS) at 6 hours, 24 hours, 3 days and 7 days.
2.2
2.2. Analysis
Comparison 2 Vibratory stimulation versus placebo or no vibration, Outcome 2 Patient‐reported pain intensity or pain relief measured on a visual analogue scale (VAS) at 1 month, 2 months, 3 months and 4 months..
2.3
2.3. Analysis
Comparison 2 Vibratory stimulation versus placebo or no vibration, Outcome 3 Patient‐reported pain intensity or pain relief measured on a visual analogue scale (VAS) after insertion of 0.018 NiTi wire.
2.4
2.4. Analysis
Comparison 2 Vibratory stimulation versus placebo or no vibration, Outcome 4 Rescue medication.
3.1
3.1. Analysis
Comparison 3 Chewing gum or wafer versus placebo or no gum, Outcome 1 Patient‐reported pain intensity or pain relief measured on chewing on a visual analogue scale (VAS) at 6 hours, 24 hours, 3 days and 7 days.
3.2
3.2. Analysis
Comparison 3 Chewing gum or wafer versus placebo or no gum, Outcome 2 Quality of life or patient satisfaction.
4.1
4.1. Analysis
Comparison 4 Brainwave therapy or cognitive behavioural therapy versus control, Outcome 1 Patient‐reported pain intensity or pain relief measured on a visual analogue scale (VAS), numerical rating scale (NRS) or any categorical scale: VAS.
5.1
5.1. Analysis
Comparison 5 Post‐treatment text message versus no text message, Outcome 1 Patient‐reported pain intensity ‐ VAS 0 to 100 mm.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010263

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

References to studies included in this review

Benson 2012 {published data only}
    1. 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. Orthodontics & Craniofacial Research 2012;15(3):178‐87. - PubMed
Farzanegan 2012 {published data only}
    1. Farzanegan F, Zebarjad SM, Alizadeh S, Ahrari F. Pain reduction after initial archwire placement in orthodontic patients: a randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 2012;141( 2 ):169‐73. - PubMed
Harazaki 1997 {published data only}
    1. Harazaki M, Isshiki Y. Soft laser irradiation effects on pain reduction in orthodontic treatment. Bulletin of Tokyo Dental College 1997;38(4):291‐5. - PubMed
Huang 2016 {published data only}
    1. Huang R, Wang J, Wu D, Long H, Yang X, Liu H, et al. The effects of customised brainwave music on orofacial pain induced by orthodontic tooth movement. Oral Diseases 2016;22(8):766‐74. - PubMed
Keith 2013 {published data only}
    1. Keith DJ, Rinchuse DJ, Kennedy M, Zullo T. Effect of text message follow‐up on patient's self‐reported level of pain and anxiety. Angle Orthodontist 2013;83(4):605‐10. - PMC - PubMed
Kim 2013 {published data only}
    1. Kim WT, Bayome M, Park JB, Park JH, Baek SH, Kook YA. Effect of frequent laser irradiation on orthodontic pain. A single‐blind randomized clinical trial. Angle Orthodontist 2013;83(4):611‐6. - PMC - PubMed
Lobre 2015 {published data only}
    1. 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 Orthodontist 2016;86(4):625‐30. [DOI: 10.2319/072115-492.1] - DOI - PMC - PubMed
Marie 2003 {published data only}
    1. Marie SS, Powers M, Sheridan JJ. Vibratory stimulation as a method of reducing pain after orthodontic appliance adjustment. Journal of Clinical Orthodontics 2003;37(4):205‐8. - PubMed
Miles 2012 {published data only}
    1. Miles P, Smith H, Weyant R, Rinchuse DJ. The effects of a vibrational appliance on tooth movement and patient discomfort: a prospective randomised clinical trial. Australian Orthodontic Journal 2012;28(2):213‐8. - PubMed
Miles 2016 {unpublished data only}
    1. Miles P, Fischer E. Assessment of the changes in arch perimeter and irregularity in the mandibular arch during initial alignment with the AcceleDent Aura appliance vs no appliance in adolescents: a single‐blind randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 2016;150(6):928‐36. - PubMed
Nobrega 2013 {published data only}
    1. Nóbrega C, Silva EM, Macedo CR. Low‐level laser therapy for treatment of pain associated with orthodontic elastomeric separator placement: a placebo‐controlled randomized double‐blind clinical trial. Photomedicine and Laser Surgery 2013;31:10‐16. - PubMed
Otasevic 2006 {published data only}
    1. 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. American Journal of Orthodontics and Dentofacial Orthopedics 2006;130(1):e9‐15. - PubMed
Turhani 2006 {published data only}
    1. Turhani D, Scheriau M, Kapral D, Benesch T, Jonke E, Bantleon HP. Pain relief by single low‐level laser irradiation in orthodontic patients undergoing fixed appliance therapy. American Journal of Orthodontics and Dentofacial Orthopedics 2006;130(3):371‐7. - PubMed
Woodhouse 2015 {published data only}
    1. Woodhouse NR, DiBiase AT, Papageorgiou SN, Johnson N, Slipper C, Grant J, et al. Supplemental vibrational force does not reduce pain experience during initial alignment with fixed orthodontic appliances: a multicenter randomized clinical trial. Scientific Reports 2015;5:17224. [DOI: 10.1038/srep17224] - DOI - PMC - PubMed

References to studies excluded from this review

Abtahi 2013 {published data only}
    1. Abtahi SM, Mousavi SA, Shafaee H, Tanbakuchi B. Effect of low‐level laser therapy on dental pain induced by separator force in orthodontic treatment. Dental Research Journal 2013;10(5):647‐51. - PMC - PubMed
Artés‐Ribas 2013 {published data only}
    1. Artés‐Ribas M, Arnabat‐Dominguez J, Puigdollers A. Analgesic effect of a low‐level laser therapy (830 nm) in early orthodontic treatment. Lasers in Medical Science 2013;28(1):335‐41. - PubMed
Bartlett 2005 {published data only}
    1. Bartlett BW, Firestone AR, Vig KW, Beck FM, Marucha PT. The influence of a structured telephone call on orthodontic pain and anxiety. American Journal of Orthodontics and Dentofacial Orthopedics 2005;128(4):435‐41. - PubMed
Bicacki 2012 {published data only}
    1. Bicakci AA, Kocoglu‐Altan B, Toker H, Mutaf I, Sumer Z. Efficiency of low‐level laser therapy in reducing pain induced by orthodontic forces. Photomedicine and Laser Surgery 2012;30(8):460‐5. - PubMed
Domínguez 2013 {published data only}
    1. Domínguez A, Velásquez SA. Effect of low‐level laser therapy on pain following activation of orthodontic final archwires: a randomized controlled clinical trial. Photomedicine and Laser Surgery 2013;31(1):36‐40. - PubMed
Doshi‐Mehta 2012 {published data only}
    1. Doshi‐Mehta G, Bhad‐Patil WA. Efficacy of low‐intensity laser therapy in reducing treatment time and orthodontic pain: a clinical investigation. American Journal of Orthodontics and Dentofacial Orthopedics 2012;141(3):289‐97. - PubMed
Eslamian 2014 {published data only}
    1. Eslamian L, Borzabadi‐Farahani A, Hassanzadeh‐Azhiri A, Badiee MR, Fekrazad R. The effect of 810‐nm low‐level laser therapy on pain caused by orthodontic elastomeric separators. Lasers in Medical Science 2014;29(2):559‐64. - PubMed
Esper 2011 {published data only}
    1. Esper MA, Nicolau RA, Arisawa EA. The effect of two phototherapy protocols on pain control in orthodontic procedure ‐ a preliminary clinical study. Lasers in Medical Science 2011;26(5):657‐63. - PubMed
Gasperini 2014 {published data only}
    1. Gasperini G, Rodrigues de Siqueira IC, Rezende Costa L. Does low‐level laser therapy decrease swelling and pain resulting from orthognathic surgery?. International Journal of Oral and Maxillofacial Surgery 2014;43( 7 ):868‐73. - PubMed
Lim 1995 {published data only}
    1. Lim HM, Lew KK, Tay DK. A clinical investigation of the efficacy of low level laser therapy in reducing orthodontic postadjustment pain. American Journal of Orthodontics and Dentofacial Orthopedics 1995;108(6):614‐22. - PubMed
Marini 2013 {published data only}
    1. Marini I, Bartolucci ML, Bortolotti F, Innocenti G, Gatto MR, Alessandri Bonetti G. The effect of diode superpulsed low‐level laser therapy on experimental orthodontic pain caused by elastomeric separators: a randomized controlled clinical trial. Lasers in Medical Science 2015;30(1):35‐41. - PubMed
Murdock 2010 {published data only}
    1. Murdock S, Phillips C, Khondker Z, Hershey HG. Treatment of pain after initial archwire placement: a noninferiority randomized clinical trial comparing over‐the‐counter analgesics and bite‐wafer use. American Journal of Orthodontics and Dentofacial Orthopedics 2010;137(3):316‐23. - PubMed
Roth 1986 {published data only}
    1. Roth PM, Thrash WJ. Effect of transcutaneous electrical nerve stimulation for controlling pain associated with orthodontic tooth movement. American Journal of Orthodontics and Dentofacial Orthopedics 1986;90(2):132‐8. - PubMed

References to studies awaiting assessment

Tortamano 2009 {published data only}
    1. Tortamano A, Lenzi DC, Haddad AC, Bottino MC, Dominguez GC, Vigorito JW. Low‐level laser therapy for pain caused by placement of the first orthodontic archwire: a randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics 2009;136(5):662‐7. - PubMed

Additional references

Atamaz 2012
    1. Atamaz FC, Durmaz B, Baydar M, Demircioglu OY, Iyiyapici A, Kuran B, et al. Comparison of the efficacy of transcutaneous electrical nerve stimulation, interferential currents, and shortwave diathermy in knee osteoarthritis: a double‐blind, randomized, controlled, multicenter study. Archives of Physical Medicine and Rehabilitation 2012;93(5):748‐56. - PubMed
Bergius 2000
    1. Bergius M, Kiliaridis S, Berggren U. Pain in orthodontics. A review and discussion of the literature. Journal of Orofacial Orthopedics 2000;61(2):125‐37. - PubMed
Bonica 1979
    1. Bonica JJ. The need of a taxonomy. Pain 1979;6(3):247‐8. - PubMed
Brown 1991
    1. Brown DF, Moerenhout RG. The pain experience and psychological adjustment to orthodontic treatment of preadolescents, adolescents, and adults. American Journal of Orthodontics and Dentofacial Orthopedics 1991;100(4):349‐56. - PubMed
Burstone 1962
    1. Burstone CJ. The biomechanics of tooth movement. In: Kraus BS, Riedel RA editor(s). Vistas in Orthodontics. Philadelphia: Lea & Febiger, 1962:197‐213.
Cruccu 2007
    1. Cruccu G, Aziz TZ, Garcia‐Larrea L, Hansson P, Jensen TS, Lefaucheur JP, et al. EFNS guidelines on neurostimulation therapy for neuropathic pain. European Journal of Neurology 2007;14(9):952‐70. - PubMed
El‐Angbawi 2015
    1. El‐Angbawi A, McIntyre GT, Fleming PS, Bearn DR. Non‐surgical adjunctive interventions for accelerating tooth movement in patients undergoing fixed orthodontic treatment. Cochrane Database of Systematic Reviews 2015, Issue 11. [DOI: 10.1002/14651858.CD010887.pub2] - DOI - PMC - PubMed
Firestone 1999
    1. Firestone AR, Scheurer PA, Burgin WB. Patients' anticipation of pain and pain‐related side effects, and their perception of pain as a result of orthodontic treatment with fixed appliances. European Journal of Orthodontics 1999;21(4):387‐96. - PubMed
Furstman 1972
    1. Furstman L, Bernick S. Clinical considerations of the periodontium. American Journal of Orthodontics 1972;61(2):138‐55. - PubMed
Guyatt 2008
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924‐6. - PMC - PubMed
Hashmi 2010
    1. Hashmi JT, Huang YY, Osmani BZ, Sharma SK, Naeser MA, Hamblin MR. Role of low‐level laser therapy in neurorehabilitation. PM & R : the Journal of Injury, Function, and Rehabilitation 2010;2(12 Suppl 2):S292‐305. - PMC - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from: www.cochrane‐handbook.org.
Jian 2013
    1. Jian F, Lai W, Furness S, McIntyre GT, Millett DT, Hickman J, et al. Initial arch wires for tooth alignment during orthodontic treatment with fixed appliances. Cochrane Database of Systematic Reviews 2013, Issue 4. [DOI: 10.1002/14651858.CD007859.pub3] - DOI - PMC - PubMed
Jones 1984
    1. Jones ML. An investigation into the initial discomfort caused by placement of an archwire. European Journal of Orthodontics 1984;6(1):48‐54. - PubMed
Jones 1985
    1. Jones ML, Richmond S. Initial tooth movement: force application and pain‐‐a relationship?. American Journal of Orthodontics 1985;88(2):111‐6. - PubMed
Kluemper 2002
    1. Kluemper GT, Hiser DG, Rayens MK, Jay MJ. Efficacy of a wax containing benzocaine in the relief of oral mucosal pain caused by orthodontic appliances. American Journal of Orthodontics and Dentofacial Orthopedics 2002;122(4):359‐65. - PubMed
Kvam 1987
    1. Kvam E, Gjerdet NR, Bondevik O. Traumatic ulcers and pain during orthodontic treatment. Community Dentistry and Oral Epidemiology 1987;15(2):104‐7. - PubMed
Litt 1996
    1. Litt MD. A model of pain and anxiety associated with acute stressors: distress in dental procedures. Behaviour Research and Therapy 1996;34(5‐6):459‐76. - PubMed
Melzack 1965
    1. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150(3699):971‐9. - PubMed
Movahedi 2006
    1. Movahedi AF, Rostami S, Salsali M, Keikhaee B, Moradi A. Effect of local refrigeration prior to venipuncture on pain related responses in school age children. Australian Journal of Advanced Nursing 2006;24(2):51‐5. - PubMed
Ngan 1989
    1. Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 1989;96(1):47‐53. - PubMed
Ngan 1994
    1. Ngan P, Wilson S, Shanfeld J, Amini H. The effect of ibuprofen on the level of discomfort in patients undergoing orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics 1994;106(1):88‐95. - PubMed
Oliver 1985
    1. Oliver RG, Knapman YM. Attitudes to orthodontic treatment. British Journal of Orthodontics 1985;12(4):179‐88. - PubMed
Paganelli 1993
    1. Paganelli C. Pharmacological support during orthodontic therapy with a topical anti‐inflammatory. Minerva Stomatologica 1993;42(6):271‐4. - PubMed
Paley 2015
    1. Paley CA, Johnson MI, Tashani OA, Bagnall AM. Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 10. [DOI: 10.1002/14651858.CD007753.pub3] - DOI - PMC - PubMed
Patel 1989
    1. Patel V. Non‐completion of Orthodontic Treatment: A Study of Patient and Parental Factors Contributing to Discontinuation in the Hospital Service and Specialist Practice [Thesis]. Cardiff (UK): University of Wales, 1989.
RevMan 2014 [Computer program]
    1. The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre: The Cochrane Collaboration, 2014.
Schreurer 1996
    1. Scheurer PA, Firestone AR, Burgin WB. Perception of pain as a result of orthodontic treatment with fixed appliances. European Journal of Orthodontics 1996;18(4):349‐57. - PubMed
Schulz 1995
    1. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273(5):408‐12. - PubMed
Schupp 2005
    1. Schupp CJ, Berbaum K, Berbaum M, Lang EV. Pain and anxiety during interventional radiologic procedures: effect of patients' state anxiety at baseline and modulation by nonpharmacologic analgesia adjuncts. Journal of Vascular and Interventional Radiology 2005;16(12):1585‐92. - PubMed
Sergl 1998
    1. Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. American Journal of Orthodontics and Dentofacial Orthopedics 1998;114(6):684‐91. - PubMed
Shin 2009
    1. Shin YS, Lim NY, Yun SC, Park KO. A randomised controlled trial of the effects of cryotherapy on pain, eyelid oedema and facial ecchymosis after craniotomy. Journal of Clinical Nursing 2009;18(21):3029‐36. - PubMed
Simmons 1992
    1. Simmons KE, Brandt M. Control of orthodontic pain. Journal IDA 1992;71(4):8‐10. - PubMed
Soltis 1971
    1. Soltis JE, Nakfoor PR, Bowman DC. Changes in ability of patients to differentiate intensity of forces applied to maxillary central incisors during orthodontic treatment. Journal of Dental Research 1971;50(3):590‐6. - PubMed
Stewart 1997
    1. Stewart FN, Kerr WJ, Taylor PJ. Appliance wear: the patient's point of view. European Journal of Orthodontics 1997;19(4):377‐82. - PubMed
Theunissen 2012
    1. Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: A systematic review and meta‐analysis of the association with chronic postsurgical pain. Clinical Journal of Pain 2012;28(9):819‐41. - PubMed
Vachiramon 2005
    1. Vachiramon A, Wang WC. Acupuncture and acupressure techniques for reducing orthodontic post‐adjustment pain. Journal of Contemporary Dental Practice 2005;6(1):163‐7. - PubMed
White 1984
    1. White LW. Pain and cooperation in orthodontic treatment. Journal of Clinical Orthodontics 1984;18(8):572‐5. - PubMed

Publication types