Non-pharmacological interventions for alleviating pain during orthodontic treatment

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.

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

Study flow diagram

2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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. 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. 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. 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. Analysis

Comparison 2 Vibratory stimulation versus placebo or no vibration, Outcome 4 Rescue medication.

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. Analysis

Comparison 3 Chewing gum or wafer versus placebo or no gum, Outcome 2 Quality of life or patient satisfaction.

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. Analysis

Comparison 5 Post‐treatment text message versus no text message, Outcome 1 Patient‐reported pain intensity ‐ VAS 0 to 100 mm.

References

References to studies included in this review Benson 2012 {published data only}

Farzanegan 2012 {published data only} Harazaki 1997 {published data only} Huang 2016 {published data only} Keith 2013 {published data only} Kim 2013 {published data only} Lobre 2015 {published data only} Marie 2003 {published data only} Miles 2012 {published data only} Miles 2016 {unpublished data only} Nobrega 2013 {published data only} Otasevic 2006 {published data only} Turhani 2006 {published data only} Woodhouse 2015 {published data only} References to studies excluded from this review Abtahi 2013 {published data only} Artés‐Ribas 2013 {published data only} Bartlett 2005 {published data only} Bicacki 2012 {published data only} Domínguez 2013 {published data only} Doshi‐Mehta 2012 {published data only} Eslamian 2014 {published data only} Esper 2011 {published data only} Gasperini 2014 {published data only} Lim 1995 {published data only} Marini 2013 {published data only} Murdock 2010 {published data only} Roth 1986 {published data only} References to studies awaiting assessment Tortamano 2009 {published data only} Additional references Atamaz 2012 Bergius 2000 Bonica 1979 Brown 1991 Burstone 1962 Cruccu 2007 El‐Angbawi 2015 Firestone 1999 Furstman 1972 Guyatt 2008 Hashmi 2010 Higgins 2011 Jian 2013 Jones 1984 Jones 1985 Kluemper 2002 Kvam 1987 Litt 1996 Melzack 1965 Movahedi 2006 Ngan 1989 Ngan 1994 Oliver 1985 Paganelli 1993 Paley 2015 Patel 1989 RevMan 2014 [Computer program] Schreurer 1996 Schulz 1995 Schupp 2005 Sergl 1998 Shin 2009 Simmons 1992 Soltis 1971 Stewart 1997 Theunissen 2012 Vachiramon 2005 White 1984