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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 56-61

A survey of perception of pain and discomfort with elastomeric separators in patients undergoing orthodontic treatment in Western Maharashtra region


1 Intern, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India
2 Department of Orthodontics and Dentofacial Orthopaedics, School of Dental Sciences, KIMSDU, Karad, Maharashtra, India

Date of Web Publication26-Jul-2017

Correspondence Address:
Pratap Nivrutti Mane
Department of Orthodontics and Dentofacial Orthopaedics, School of Dental Sciences, KIMSDU, Karad - 415 110, Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_42_16

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  Abstract 

Aim: The aim is to determine the perception of pain and discomfort by the patient during the placement of orthodontic separators.
Materials and Methods: Elastomeric separators were placed in randomly selected 100 patients for fixed orthodontic mechanotherapy. Visual analog scale was used to register the patient's pain perception during the placement of elastomeric separators and continued subsequently on 1st, 2nd, 3rd, 4th, and 5th day.
Results: The data show 41.3% of urban and 53.7% of the rural population of the patients reported pain during the placement of separators. Until the 1st day, in the urban, 53.04% of patients and in the rural population, 48.15% of patients reported pain. In the urban population, 30.43% of patients and in the rural population, 25.93% consumed analgesics.
Conclusion: The pain associated peaks within 4–48 hr from separator placement, and then declines to reach its lowest level on the 5th day. Since pain of moderate intensity occurs during the treatment, analgesics and soft food are recommended.

Keywords: Elastomeric separators, pain perception, visual analogue scale


How to cite this article:
Kumar Bapna PA, Mane PN, Ganiger CR, Pawar RL, Phaphe SA, Ahammed YA. A survey of perception of pain and discomfort with elastomeric separators in patients undergoing orthodontic treatment in Western Maharashtra region. J Oral Res Rev 2017;9:56-61

How to cite this URL:
Kumar Bapna PA, Mane PN, Ganiger CR, Pawar RL, Phaphe SA, Ahammed YA. A survey of perception of pain and discomfort with elastomeric separators in patients undergoing orthodontic treatment in Western Maharashtra region. J Oral Res Rev [serial online] 2017 [cited 2017 Dec 11];9:56-61. Available from: http://www.jorr.org/text.asp?2017/9/2/56/211635


  Introduction Top


There has been an increasing demand for orthodontic treatment, so making the procedure as painless as possible is the duty of the dentist. Pain is defined as an unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as such.[1] Hence, the control of pain during orthodontic treatment is important to both orthodontist and patients.

Research indicates that patients rank pain as the worst aspect of orthodontic treatment and the foremost reason to discontinue treatment. When compared with the pain associated with other dental procedures, both intensity and severity of orthodontic pain seem to be greater. Hence, it is the duty of Orthodontist to inform the patients about common side-effects of treatment, especially before starting any procedural step.

Pain is the major cause for discontinuing orthodontic therapy.[2] The mechanisms whereby the application of orthodontic forces cause pain are not fully known, but there are indications that these perceptions are due to changes in blood flow in periodontal ligament and correlated with the presence of prostaglandins, substanceP and other substances.[3],[4],[5],[6] Pain is usually as a result of pressure, ischemia, inflammation, and edema occurring in periodontal ligament due to the exerted orthodontic forces.[7] Separators, arch-wires, bands, and other fixed appliances produce pressure, tension, soreness, and pain in patients.[8] It is well known fact that the placement of orthodontic separators is a painful step for the patient.[9] Bondemark et al. evaluated that pain perception to two types of separators (spring and elastomeric type), and found that there were no differences in pain effect of both types of separators.[10] The pain was mostly reported on eating by almost all patients and considered a major side effect of orthodontic treatment.[11] A correlation between pain experienced and analgesics consumption has been found.[12],[13] Drugs like ibuprofen have been studied at length for treating patients with post-operative pain after dental procedures. Recent line of Nonsteroidal anti-inflammatory drugs research has focused on the development of daily topical administration forms such as gels, toothpaste, and mouthwashes (rinses) as many of the compounds they are readily absorbed through gingival tissues and can easily penetrate into oral and gingival tissues. Hence, the current study is aimed to compare the perception of pain and discomfort due to elastomeric separators in urban and rural population. To the best of our knowledge, this is the first study to be conducted in the region of Western Maharashtra, and it deals with comparing the pain threshold among masses in urban and rural population. A proper understanding of pain and discomfort will help the dentist to schedule the appointment for the next procedure accordingly.


  Materials and Methods Top


This study was conducted in the Department of Orthodontics and Dentofacial Orthopaedics, School of Dental Sciences, KIMSDU, Karad after approval from the Institutional Ethics Committee (Ref no-KIMSDU/ICMR/STS/2015). All the patients were informed that their participation in the study was confidential and on voluntary basis. One hundred patients were randomly selected based on the following criteria:

Inclusion criteria

  1. All patients scheduled to have a fixed appliance orthodontic treatment
  2. Teeth free from pathological conditions
  3. Teeth with good gingival health
  4. Bilaterally symmetrical teeth
  5. Patients between the age group of 15 and 25 years (students).


Exclusion criteria

  1. Proximal caries
  2. Periodontally weakened teeth
  3. Missing adjacent teeth
  4. Patients with systemic diseases
  5. Patients under medications that interfere with bone metabolism and gingival tissue health
  6. Removal or loss of the separator during the procedure
  7. Patients who did not return the completed questionnaire.


In each patient, elastomeric orthodontic separators (Dentaurum, Germany) were placed on the mesial and distal aspects of the first maxillary, and mandibular molars and adequate precautions were taken such that no harm is caused to adjacent hard and soft tissues, as a procedure of their orthodontic treatment by a single Orthodontist. Immediately after separator placement, the pain sensitivity index, i.e. the degree of pain was determined through the visual analog scale (VAS) cards [Figure 1] and questionnaire forms [Table 1] thus ensuring that the result was solely based on the patient's verdict. The pain perception was measured using VAS scale from the beginning of separator placement to 6 hr after separator placement and consequently on 1st, 2nd, 3rd, 4th, and 5th day. The patients were given the prescription of analgesics (tablet diclomol 150 mg) by the Orthodontist and the patients were asked to mention whether they used analgesics or not in the questionnaire. Instructions were given to subjects to take soft diet if they experience severe pain and discomfort while having food. Patients who had accidentally lost the separators before 5th day were excluded from the study. The separators were placed for more than 24 hr according to the separation between the teeth required for the treatment.[14]
Figure 1: Visual analogue scale

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Table 1: Questionnaire

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  Results Top


The placement of separators was considered the most painful procedure in fixed mechanotherapy. The severity of pain as per VAS and nature of pain in both urban and rural population is mentioned in [Table 2], [Table 3], [Table 4], [Table 5]. The data show that 41.3% of urban population and 53.7% of the rural population of the patients reported pain during the placement of separators. Until the 1st day, in the urban population, 53.04% of patients reported with continuous pain and in the rural population, 48.15% of patients reported pain. 71.74% of patients from the urban population reported pain while eating after 6 h of placement of separators, while 56.12% of patients changed their food consistency and from the rural population, 59.26% of patients reported pain while 31.48% of patients changed their food consistency. In the urban population, 30.43% of patients consumed analgesics while in the rural population, 25.93% consumed analgesics [Figure 2].
Table 2: Pain frequency in patients from urban population

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Table 3: Nature of pain in urban population according to visual analogue scale

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Table 4: Pain frequency in patients from rural population

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Table 5: Nature of pain in rural population according to visual analogue scale

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Figure 2: Comparison between urban and rural population on basis of analgesics used and change in lifestyle

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  Discussion Top


In this study, 100 subjects were selected, of which 46 subjects belonged to the urban population and 54 subjects from the rural population. Questionnaire forms [Table 1] and VAS card was given to these patients, and the pain perception was recorded from the beginning of separator placement to 6 h after separator placement and consequently on 1st, 2nd, 3rd, 4th, and 5th day. Pain is one of the main reasons to discontinue orthodontic treatment; hence, it is vital that the procedure should be made comfortable to the patient. In the modern age, tolerance for pain is reduced among the masses. Therefore, recording pain perception after a certain procedure is important.

Patients from urban areas

During placement of separators, 41.3% of the patients reported pain. Six hours after separator placement, 60.87% of patients reported pain. 63.04% reported pain that continued up to the 1st day. There was a daily decrease in these percentages starting from the 1st day. Most of the patients felt an intermittent pain 6 hr after separator placement, increasing on the 1st day, and decreasing on following days. Thirty-three (71.74%) patients reported pain while eating after 6 hr of placement of separators that continued to the 1st day, while 56.12% of patients had to change their food consistency and then this decreased day by day. On the 1st day, 19.57% of patients were awake at night due to the pain, and 15.22% of patients stated that their daily activities were influenced. The highest consumption of analgesics (30.43% of patients) was reported after 6 h of placement of separators. There was a decrease in the number of patients reporting these effects on the following days.

Patients from rural areas

During placement of separators, 53.7% of the patients reported pain, 59.26% reported pain 6 hr after separator placement and 48.15% of patients reported pain that continued to the 1st day. There was a daily decrease in these percentages starting from the 1st day itself. Most of the patients felt an intermittent pain during and 6 hr after separator placement, 50.0% and 35.19% on the 1st and 2nd days, respectively, and then decreasing on the following days. Thirty-two (59.26%) patients reported pain while eating after 6 hr of placement of separators, while 31.48% of patients had to change their food consistency and then this decreased day by day. On the 1st day, 14.81% patients were awake at night due to the pain and 14.81% of patients stated that their daily activities were influenced. The highest consumption of analgesics (25.93% of patients) was reported after 6 hr of placement of separators and on the 1st day. There was a decrease in the number of patients reporting these effects on the following days.

Comparison between urban and rural population

  • There was significant difference in patients reporting intermittent pain and changing food habit to soft diet in urban and rural areas [Table 6]
    Table 6: Comparision between urban and rural population

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  • There was no significant difference in pain perception, patients reporting continuous pain, pain while eating, food consistency, influences on daily activities analgesic consumption and pain in the night between urban and rural populations [Figure 3].
Figure 3: Comparison between urban and rural population on nature pain experienced

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Within the limitations of the present study, it can be concluded that there was a significant difference in patients reporting intermittent pain and changing food habit to soft diet in urban and rural areas and there was no significant difference in pain perception, patients reporting continuous pain, pain while eating, food consistency, influences on daily activities analgesic consumption and pain at night between urban and rural population. According to our study, maximum level of pain was recorded 1 day after placement of separators which gradually declines until the 5th day which is similar in accordance with the results obtained by Kapoor et al.,[12] Asiry et al.,[15] Ngan et al.,[6],[7],[8] Bernhardt et al.[16] Bergius et al.[17]

Patil et al. demonstrated that diclofenac mouthwash is characterized by better efficacy in relieving pain consequent to the placement of separators.[18]

It has been reported earlier that analgesics are used fairly often by orthodontic patients.[17]

Among daily activities, eating was most affected during the separation period, and the influence on food choices was reasonably considerable since most of the patients had changed their dietary pattern to soft diet. These findings are in accordance with other previous studies.[17]

VAS was used considering the simplicity.[17] It has also been found that VAS is a useful tool when patients have to discriminate between pain/discomfort in the posterior and anterior teeth after initial placement of an archwire.[17]

On the other hand, Feinmann et al.[19] reported that pain is related to gender and social class. In addition, Unruh[20] found that females experience a higher degree of pain more frequently than males during fixed appliance treatment.

Otasevic et al.[21] found that a total of 30% of orthodontic patients discontinued their treatment because they experienced pain. Therefore, patients should be informed that the pain arises from the elastomeric separators and they should be educated on proper management by changing food consistency or using analgesics.

These conflicting results between different studies could be due to the differences in sample sizes, subject's age, and cultures.


  Conclusion Top


  1. 41.3% of urban population and 53.7% of the rural population reported pain after separator placement
  2. 60.87% of urban population and 59.26% of rural population reported continued pain for 6 hr
  3. 56.12% of urban and 31.48% of rural population had to change their food consistency
  4. The highest consumption of analgesics was reported after 6 hr in urban population and after 6 hr and on the 1st day in rural population.


Further scope of the study

The study requires more extensive research. Pain is a psychological aspect among humans and every individual has their own perception of pain threshold. Further studies can be conducted to find the variations in pain perception among an urban and rural group of the population.

Limitations of study

Despite great concern expressed by orthodontists and their patients, there is still no standard of care for controlling orthodontic discomfort and pain. Many orthodontists advise their patients to take analgesics “as needed” for postoperative pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Asiry MA, Albarakati SF, Al-Marwan MS, Al-Shammari RR. Perception of pain and discomfort from elastomeric separators in Saudi adolescents. Saudi Med J 2014;35:504-7.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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