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Evidence suggests that over-the-counter analgesics are efficacious in relieving pain from fixed orthodontic appliances. Critical Summary Prepared by: James Zahrowski DMD, MS, PharmD; Arthur Jeske DMD, PhD 

OVERVIEW

  • Systematic Review Conclusion:

    Over-the counter analgesics appear to relieve pain from orthodontic appliances with some evidence suggesting their preemptive use may be appropriate.

  • Critical Summary Assessment:

    A systematic review of a few, small randomized controlled trials (RCTs) suggest that over-the-counter analgesics (acetaminophen, aspirin, naproxen and ibuprofen), prescription nonsteroidal anti-inflammatory agents (NSAIDs) and low level laser therapy (LLLT) are efficacious for relief from orthodontic-associated pain.

  • Evidence Quality Rating:

    Limited

A Critical Summary of:

Interventions for pain during fixed orthodontic appliance therapy. A systematic review

Xiaoting, L., Yin, T., Yangxi, C.. Angle Orthodontist. 2010;80(5):925-32

  • Clinical Questions:

    Do analgesics or LLLT compared to placebo, effectively relieve orthodontic pain in adolescents and adults after fixed orthodontic appliance adjustments?

  • Review Methods:

    The authors searched three electronic databases for studies published from 1966 to 2009. They followed a defined protocol including specific inclusion and exclusion criteria. Two independent reviewers, screened studies using the criteria, assessed trial quality and extracted data. They included randomized controlled trials (RCTs) with at least one orthodontic wire placed, no current analgesics, defined short-term follow-up from two hours to seven days, and pain perception measured by visual analog scale (VAS) or questionnaire.

  • Main Results:

    The authors performed a meta-analysis of six RCTs (388 subjects). Three RCTs (176 subjects) showed that ibuprofen was superior in controlling pain as compared to placebo, at six and 24 hours following arch wire placement (mean difference of -0.47 and -0.48, respectively, 95 percent confidence interval, P = 0.01). There was no difference in pain control comparing ibuprofen to acetaminophen or aspirin. Two RCTs reported that other nonsteroidal anti-inflammatory drugs (NSAIDs), tenoxicam (36 subjects) and valdecoxib (56 subjects), lowered pain perception scores from visual analog scale (VAS). One RCT (76 subjects) suggested reported LLLT is an approach to lower pain response with VAS scores of 3.30 compared to 7.25 in control group.

  • Conclusion:

    Limited evidence suggests over-the-counter analgesics (ibuprofen, naproxen, acetaminophen, and aspirin) prescription NSAIDs (tenoxicam and valdecoxib) and low level laser therapy reduce orthodontic pain without evidence showing a preferred analgesic. Preemptive use of NSAIDs may be appropriate for pain reduction.

  • Source of funding:

    Not stated

Commentary:

  • Importance and Context:

    Patients often experience pain within one to four days after orthodontic appliance adjustment to induce tooth movement. NSAIDs or acetaminophen commonly are recommended for pain control. The analgesic action of acetaminophen apparently occurs within the central nervous system. The analgesic action of NSAIDs appears to locally inhibit cyclooxygenase (COX)enzymes and the synthesis of prostaglandins at the tissue injury site. LLLT may have anti-inflammatory and regenerative effects on neurons, which may decrease the pain response. A systematic review of RCTs should evaluate common analgesics and other methods to effectively relieve acute orthodontic pain.

  • Strengths and Weaknesses of the Systematic Review:

    The authors conducted a comprehensive search using defined inclusion and exclusion criteria, and with no language restrictions. Two reviewers followed the Cochrane Oral Health Group's statistical guidelines, and independently assessed trial quality and extracted data. Methodological quality of studies was assessed. A third reviewer resolved disagreements through consensus or by consultation. The authors conducted meta-analyses with the Cochrane Collaboration’s RevMan5 software only when there were studies of similar comparisons reporting the same outcome measures. They assessed heterogeneity between studies that evaluated participants, interventions, and study outcomes.

  • Strengths and Weaknesses of the Evidence:

    The included six RCTs were of good quality. However, there was a limited amount of comparative evidence due to a small number of subjects. As a result, it is difficult to determine which type of analgesic most effectively reduces pain. Three ibuprofen studies were controlled with placebo and compared with naproxen, acetaminophen, or aspirin. Larger doses of NSAIDs were not evaluated for greater analgesia.

  • Implications for Dental Practice:

    Over-the-counter analgesics, prescription NSAIDs, and LLLT appear to reduce orthodontic pain. An increase beyond standard doses of acetaminophen may not increase pain relief and may increase side effects and toxicity.(1) NSAIDs have been extensively studied and found to be a superior analgesic compared to acetaminophen for acute soft tissue pain.(2) They also have dose-dependent analgesia (an increased dose increases pain relief, not to exceed maximum daily dose). Contraindications to the administration of NSAIDs, acetaminophen, and aspirin should be followed. Should pain be present after maximum NSAID dose administration, a standard dose of acetaminophen may be considered for concurrent administration for an increased level of analgesia.(3) Although prescription NSAIDs may be considered, they are considerably more costly for similar pain relief provided from over-the-counter NSAIDs. LLLT appears to be promising for pain relief, however it may not be clinically practical due to the high equipment cost and a total of 30-minutes of laser therapy required. 1. Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008;8(4):CD004602. 2. Ong CK, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med Res 2007;5(1):19-34. 3. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal anti-inflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.Anesth Analg. 2010 Apr 1;110(4):1170-9.

  • Critical Summary Publication Date: 7/13/2011

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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