Pain in the Separation of Molars among the Orthodontic Patients

Introduction: Pain has been the most common and foremost reason for discontinuing the orthodontic treatment. The patients usually experience the pain in Orthodontic treatment during separator placement, wire placement, headgear wear, and rapid palatal expansion. Placement of orthodontic separators (brass wire, elastomeric, spring type steel separators, and latex elastics) results in a painful experience. Therefore the purpose of the study is to assess the pain perception among the patients seeking orthodontic treatment.


I nternational Association for The Study of Pain
(IASP) has defined Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain has been the most common and foremost reason for discontinuing the orthodontic treatment. The patients usually experience the pain in Orthodontic treatment during separator placement, wire placement, headgear wear, and rapid palatal expansion. [1][2][3][4] The cause for the sensation of pain is mainly due to release of various biochemical mediators which are stimulated by inflammatory reactions in periodontium and dental pulp during the orthodontic tooth movement. The pain is due to changes in blood flow caused by the appliances which is correlated with the release and presence of various substances, such as Substance-P, Histamine, enkephalin, dopamine, serotonin, cytokines, etc. Many literatures regarding the increase in the levels of these mediators, which elicit hyperalaesia response following force application, has been published in Orthodontics. 5,6 Placement of orthodontic separators (brass wire, elastomeric, spring type steel separators, and latex elastics) results in a painful experience. Two controlled clinical trials 7, 8 performed by Ngan et al. concluded that there was discomfort associated with separator placement, which usually starts within 4 hours of insertion. The level of discomfort increases over the next 24 hours and decreases to pre-placement level within 7 days. Bondemark et al. 9 has evaluated and compared the separation effect and patient perception of pain and discomfort to two types of orthodontic separators (elastomeric and spring type) but found no statistically significant difference between the discomfort caused by the two types of separators. They reported that the worst pain was experienced at day 2 and subsided almost completely by day 5. An electromyographic (EMG) study by Michelotti et al. 10 , performed to evaluate the motor and sensory changes associated with separator placement, showed a decrease in motor output as well as pressure pain threshold in muscles of mastication.
Thus the pain assessment during the placement of separators in orthodontic procedure amongst the Nepalese patient would be necessary for the management of the pain.

MATERIALS AND METHODS
T he total number of 120 (53 male and 67 female) patients, (convenient sampling) who visited different hospitals and clinics in Kathmandu, Nepal seeking for orthodontic treatment during 4 months of period, were informed about their participation in the research and the written informed consent was obtained after getting ethical clearance from Institutional Review Committee, Maharajgunj, Nepal. On the first visit of the orthodontic treatment of the patient, the elastomeric separators were placed on the mesial and distal of the first molars. Then the patients were given a self-administered Universal pain assessment Tool ( fig. 1), with 1 to 10 markings to take home. Then the participants were asked to mark the intensity of the pain they perceived every day for next 7 days, 1 being no pain and 10 being the upmost pain. They were also asked to mark the Universal pain assessment tool for perceived pain on chewing.
The data thus obtained were analyzed at the significance level of 0.05. The data were compared between male and female and between the different age groups too. The data thus obtained were analyzed at the significance level of 0.05. The data were compared between male and female and between the different age groups too.

RESULTS
The entire self-administered Universal Assessment tool were collected from 120 participants.

RESULTS
The entire self-administered Universal Assessment tool were collected from 120 participants.

DISCUSSION
T he results obtained from the research using Universal Pain Assessment Tool for pain perception suggest the patient experiences pain during separator placement. The management of the pain can be done by the use of NSAIDS, anesthetic gel 11 , application of continuous wave low-level laser therapy 12 , and the use of vibratory stimulation. 13 The current study showed there is increased pain during eating with the separator in the teeth. Bondmark et al. 9 , and Scheurer et al. 14 also showed that eating is most affected activity during separator placement.
The pain perception pattern showed that the participant had the upmost pain for the first 3 days, Day 1 being the most and it gradually decreased after that. This result showed the agreement with the studies done by Ngan et al. 7,8 , Giannopoulou et al. 15 , and Wilson et al. 16 In contrary to that Bondmark et al. 9 and Cureton et al. 17 showed the highest pain perception on Day 1 and Day 3 respectively.
From the statistics of the study, it can be said that there is significant difference in pain perception among the genders. It shows female experiences pain more than male. This result goes in accordance with the results of research done by Abu Alhaija et al. 18 , Krishnan et al. 19 , and Berguis et al. 20 However, the study conducted by Abdullah showed no significant difference between male and female. 21 It was also shown that there was significant difference between adults and Adolescent. Adults were shown more tolerant to pain by the separators than the adults which is obvious. But the study done by Ngan et al. 7,8 disagrees with this result claiming the pain perception levels were same for adults and adolescences.

CONCLUSION
T hus it can be concluded that there is a pain due to separator placement during orthodontic treatment with maximum pain on the first day which declines after Day 3 gradually. The Adolescents and female has less tolerance to the pain than the adults and male.