This clinical trial was designed to evaluate the effectiveness of different methods on pain management during debonding. The effects of other important determinants like gender as well as different location on pain were also observed.
To quantify the pain intensity of the patient, various scales are commonly used like visual analog scale (VAS), numerical rating scale and verbal rating scale (VRS). Comparative studies regarding these scales showed no statistically significant difference among them [20, 21]. In this study, VAS was used because of its ease of application.
There are many methods used for debonding the bracket. Khan et al. [22] compared the ultrasonic/sonic instruments with the debonding plier and concluded that although sonic/ultrasonic based debonding technique is less painful approach but it is not recommended as a routine method as it is the most time-consuming approaches compared to debonding plier. In this study, all the patients were debonded with the same bracket removing plier to standardize the procedure. We choose bracket removing plier as the debonding instrument as it is inexpensive and most widely used in our part of the world.
Pain could be somatization of either anxiety or depression. Patient’s levels of anxiety and fear of pain were assessed at the time of participants enrollment which might affect the pain perception during debonding, so the patient who had anxiety score of ≤ 8 (evaluated by GAD-7 scoring) [19] was selected in this study to control the bias that is VAS score was less influenced by the anxiety of the participants. To control the inter-operator bias, single operator (SPG) performed all the debonding procedure with the same designated technique.
Various pain-relieving methods have tried to minimize the pain during orthodontic debonding. We advised the patient to take 500 mg of paracetamol one hour before the debonding in the medication group to control pain.
Evidence suggested that paracetamol is an effective and safe choice for the orthodontic pain at the usual therapeutic doses of 325 to 1000 mg/dose (10–15 mg/kg/dose in children) [23,24,25]. Kaur et al. tried 500 mg of paracetamol to control the separator pain and found it as effective method [26], whereas study by Priya et al. [10] concluded that use of analgesic (Paracetamol and Ibuprofen) 1 h before the debonding reduces the pain perception.
We have chosen the finger pressure method and stress relief method as it is easy, inexpensive and does not need extra armamentarium. Comparison of these methods was made with the medication and control group as well.
The results of this study revealed that medication group had least total VAS score (8.33) in comparison with finger pressure group (10), stress relief group (13.33) and control group (16.67), indicating that medication (Paracetamol) seems a better method of pain management than finger pressure and stress relief method when comparing it with the control.
There were statistically significant differences in the VAS score in different areas of oral cavity among all the groups. The median values of VAS score were highest in the lower front quadrant followed by upper front quadrant whereas least in upper and lower posterior region in all the groups, suggesting that anterior region of jaw is more sensitive to pain while debonding. The similar finding was reported by other studies [10, 11, 27,28,29,30]. It might be due to their anatomic location and root morphology. Teeth residing in the upper and lower front sextants has got single root having less surface area and housing in a thinner cortical boundary and has to bear more force than the posterior sextants that has got multirooted teeth housing in a thicker cortical boundary [11]. Debonding force per unit surface area of the root is explained by tactile sensory threshold which is 1 g in the anterior region while it is around 5 to 10 g in the posterior region of the dental arch [15].
In this study, the total VAS score for finger pressure group was 10 and for stress relief group was 13.33 which was slightly higher than the study of Karobari et al. [27] that is VAS score of 6.59 for finger pressure group and 7.49 for stress relief group. Similarly, total VAS score of this study was also higher than the study by Bavbek et al. [14] which showed VAS score of 7 for finger pressure group and 9.1 for stress relief group. It might be due to different cultural background.
In gender-wise comparison, female recorded higher VAS score and on upper front sextant, it showed significant difference. These findings are in agreement with the results of the previous studies about the impact of gender on pain perception [1, 2, 10, 14, 28,29,30,31]. In contradictory to this, other study showed no gender differences in pain perception [7].
On intergroup comparison, there were significant differences in total VAS score between medication-control group, between finger pressure-control group and medication-stress relief group while it showed no significant difference when comparing it between medication-finger pressure group, between finger pressure-stress relief group and between stress relief-control group. It suggested that finger pressure can be the equally reliable method to medication regarding pain management during debonding. In addition to this, the finger pressure method seems to be more effective than the stress relief method on the basis of total VAS score between these two groups which is in agreement with the study by Bavbek et al. who conducted the study on efficacy of different methods to reduce pain during debonding of orthodontic brackets [14]. Finger pressure can be considered as an easy and effective technique of pain control, since it is inexpensive, less time-consuming, and less technique sensitive. Finger pressure method works as it applies intrusive force on the incisal or occlusal surface of the tooth which stabilizes the tooth and counteracts the torsional and sheer/peel debonding forces applied to the periodontal ligament during debonding. Along with this, it provides proprioceptive stimulus and is believed to reduce the pain according to the gate control theory [12, 28].
The stress relief method is based on cognitive behavior therapy which is primarily directed against the psychological mechanism of pain in patients [14]. Study by Koyama et al. also noted that positive expectations result in reduced pain experience and works by altering the brain mechanism [32]. It is known that patients who trust their doctors are more comfortable during orthodontic procedure. The stress relief method along with the finger pressure method can also be tried clinically and will be the scope of further study to control the pain and discomfort during debonding as it is easy, inexpensive and does not need extra armamentarium.