May 16, 2017

Anxiety influences orthodontic pain: Is this relevant to our patients?

Anxiety influences orthodontic pain:  Is this relevant to our patients?

It is fairly well established that anxiety can increase perception of pain.  But can it influence orthodontic pain? This interesting new study tells us that it does…

Sometime ago I posted about a study that looked at the effect of chewing gum on orthodontic pain. The authors showed that when an orthodontic patient used chewing gum they took fewer analgesics to manage their pain. In this new paper they looked at additional data to measure the effect of anxiety on orthodontic pain.  A team from Bristol, in the Beautiful South of England did this study.

Chewing gum vs. ibuprofen in the management of orthodontic pain, a multi-centre randomised controlled trial – the effect of anxiety

Tony Ireland et al

Journal of Orthodontics, 44:1, 3-7, DOI: 10.1080/14653125.2016.1277317


Research has shown that when we are anxious we tend to feel more pain.  As a result, they did this study to find out if there was a relationship between anxiety and analgesic consumption in a sample of orthodontic patients.

What did they do?

This was a prospective two arm parallel design RCT.  The PICO was

Participants: Patients having orthodontic treatment

Intervention: Chewing gum

Comparator: Treatment as usual with ibuprofen (when needed).

Outcome: Analgesic intake

The patients completed a questionnaire directed at measuring their level of anxiety at the bond up appointment and following the first arch wire change.  They also recorded the number and frequency of analgesic intake.

They analysed the data blind and did the appropriate multivariate statistical analysis.

What did they find?

The enrolled 1000 children into the study. They randomised 503 to the chewing gum group and 497 to the ibuprofen group. 70% of the patients returned the anxiety questionnaires, following the first arch wire change.

When they looked at their data they found that for the patients in the ibuprofen group there was a 10-20% increase in the odds of using ibuprofen for each one point increase on the anxiety scale. They did not find this for the chewing gum group.

They concluded that there was a weak association between reported anxiety and pain at both arch wire placement and the first wire change. Interestingly, patients who were more anxious took more ibuprofen.

What did I think?

I felt that this was an interesting addition to the findings of their first paper. The strong points of the study was that it was a well carried out large randomised trial. However, we need to remember that this was a secondary outcome.  The study was not powered to detect any differences for this outcome. There was also a degree of non-response to the questionnaire, but I felt that this was within acceptable limits. Nevertheless, the findings are very interesting and logical. They are certainly supported by other research.

I was interested to see that they did not find this effect for the chewing gum group. Unfortunately,  they did not discuss this finding. Perhaps the chewing gum reduced anxiety, or it diminished the pain to a level that “wiped out” the effect of anxiety?

As with other posts, I have thought about whether these results have implications for practice.  I think that they do. Perhaps, we should encourage our patients to chew gum, which will reduce their pain.  We can then supplement this with attempts at reducing their anxiety with targeted post op information and even follow up phone calls and text messages. This may then reduce their pain experience further. This would be a simple intervention that is worth trying.

All in all, this was an interesting and clinically relevant paper.

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Have your say!

  1. I thought ibuprofen is contraindicated during orthodontics due to the negative effect on tooth movement.

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