JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 119-126

Comparison of Pain Perception and Discomfort with Three Types of Nickel–Titanium Arch Wires during the Initial Alignment with Fixed Orthodontic Treatment in Lower Arch: An Observational Study

1 Department of Orthodontics, RDC, PIMS (DU), Ahmednagar, Maharashtra, India
2 Department of Orthodontics, Modern Dental College and Research Centre, Indore, India
3 Private Practitioners and Consultant Orthodontist, at Bright Smile Multispeciality Dental Clinic Bilaspur, Chhattisgarh, India
4 Private Practitioners and Consultant Orthodontist, at Shwet Dental Clinic, Jabalpur, Madhya Pradesh, India

Date of Submission09-May-2020
Date of Decision27-Jun-2020
Date of Acceptance20-Jul-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Tanu Joshi
B-50, Ganesh Marg, Bapu Nagar, Jaipur, Rajasthan, 302015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_26_20

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Introduction: This observational study with the random sampling was done to locate maximum discomfort and pain experienced with three different nickel–titanium (NiTi) arch wires during the initial leveling and aligning phase of orthodontic treatment in moderate crowding in mandibular arch, and variations in pain and discomfort level associated with area, gender, and age. Materials and Methods: This observational survey was conducted on a sample of 60 orthodontic patients (20 in each group of arch wire) taking little’s irregularity (moderate 4–6 mm) crowding as criteria. The survey has started on the day of bonding along with three different types of initial arch wires (Superelastic NiTi, thermoelastic NiTi, or conventional NiTi), On the same day of bonding appointment and arch wire insertion, all participants were given the Modified Mc Gill pain questionnaire with the Visual Analog Scale and asked to fill and submit to the investigator on their next appointment positively. Results: The results were statistically insignificant in relation to the objectives of an observational study. Conclusion: Any of the three arch wires independent of age, gender, and area can be used by orthodontist during initial leveling and alignment phase of the treatment since the pain and discomfort level for all of them are same.

Keywords: Bonding, Modified MCgill Pain Questionnaire, nickel–titanium arch wires, Visual Analog Scale

How to cite this article:
Joshi T, Bhardwaj A, Toshniwal NG, Mani S, Choudhary VK, Patel S. Comparison of Pain Perception and Discomfort with Three Types of Nickel–Titanium Arch Wires during the Initial Alignment with Fixed Orthodontic Treatment in Lower Arch: An Observational Study. J Int Clin Dent Res Organ 2020;12:119-26

How to cite this URL:
Joshi T, Bhardwaj A, Toshniwal NG, Mani S, Choudhary VK, Patel S. Comparison of Pain Perception and Discomfort with Three Types of Nickel–Titanium Arch Wires during the Initial Alignment with Fixed Orthodontic Treatment in Lower Arch: An Observational Study. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Apr 21];12:119-26. Available from: https://www.jicdro.org/text.asp?2020/12/2/119/303401

   Introduction Top

The pain perception during the phase one of fixed orthodontic treatment that is alignment and leveling depends upon the appropriate selection of appliance system and the initial arch wires.[1] It is documented in the literature that 30% of patients stops the orthodontic treatment due to severe pain and discomfort experienced in the initial stages of treatment.[2] In order to lessen this consequence, many clinicians have varied the appliance prescription and the arch wire sequences. Orthodontic literature search has revealed very few studies about the same. However, no studies have been documented in the literature where different types of the nickel–titanium (NiTi) wires during the initial phase of the treatment.

Pain is mostly experienced within 24 h after first arch wire insertion which slowly declines during the 1st week in most of the cases. However, few of them they report for longer duration because of less pain threshold level.[3],[4],[5] Pain response (immediate and delayed) varies with appliance selection, initial arch wire selection, and individual variation.[6]

Soltis et al. in 1971 and Zheng et al. in 2016 stated that pain threshold of every individual differs in severity, onset, character, and timings during orthodontic treatment.[7],[8] In order to measure the pain threshold and pain perception, various measurement scales were recommended in the literature. Visual Analog Scale (VAS), Numerical Rating Scale, Verbal Rating Scale (VRS), and Faces Pain Scale-Revised[9],[10] VAS innovated by Hayes and Patterson consider to be the better reliable and more appropriate when using such type of questionnaire as a method of data collection. It is a simple, dependable means of allowing patients to convey their feelings with a high degree of resolution without resorting to cumbersome questionnaires.[11],[12],[13],[14] These scores show the qualities of ratio data and may be treated as such statistically, providing that the data are normally distributed.[15],[16]

In order to assess the pain perception through the VAS, the most appropriate questionnaire is modified Mc Gill pain which includes both Mc Gill pain questionnaire and VAS. Mc Gill pain questionnaire was developed by Melzack and Torgerson in 1971. It is a multidimensional questionnaire that permits the individuals to give their doctor a detailed description of the quality and intensity of pain that they are experiencing.[17]

Hence, none of the study in the literature has compared different types of niti wires in correcting moderate crowding in the mandibular arch. Hence, the principle objective of this observational study is to compare the pain and discomfort experienced in case of moderate crowding in mandibular arch with three different types of NiTi arch wires (Thermoelastic NiTi, superelastic NiTi, and conventional Nitinol) during the initial alignment and leveling phase. Along with that same groups have been revaluated in accordance with age, gender area where maximum pain is experienced in dental arch.[18]

   Materials and Methods Top


This observational study was conducted in the Department of Orthodontics and Dentofacial Orthopedics, Modern Dental College and Research Center, Indore. The aim and objectives of the present study were approved by the Institutional Ethical Committee of the same institute. The total sample in this observational study comprised 60 participants requiring fixed orthodontic treatment (022 slot MBT techniques) was selected on the systematic random sampling technique. The study designed was an observational cross-sectional study. The selected group of 60 was further subdivided into three groups of 20 participants each depending upon initial arch wire. Simple random sampling with the lottery method was used to divide the patients into the respective groups. The groups were matched with respect to age and gender to avoid any bias because of these factors [Table 1].
Table 1: Age and gender matching of group

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  • Group A: 20 – 014 round superelastic NiTi [Figure 1]
  • Group B: 20 – 014 round conventional NiTi [Figure 2]
  • Group C: 20 – 014 round thermoelastic NiTi [Figure 3].
Figure 1: super elastic nickel–titanium arch wire

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Figure 2: conventional nitinol arch wire

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Figure 3: thermo elastic nickel–titanium arch wire

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Informed consents from the patient/parents were obtained after the inclusion in the study. Patients having neuralgic problem, syndromic patients, disturbed mental health, and use of analgesic for medical reasons were excluded from the study. The use of drugs for pain management during the course of orthodontic treatment is strictly prohibited since it will interfere with orthodontic treatment.


At the end of bonding and arch wire insertion appointment, the selected participants were given and explained the Modified Mc Gill pain questionnaire with VAS [Annexure 1], and all the difficulties are solved regarding the understanding of the questionnaire on the same visit were asked to submit the filled questionnaire during their next 1-month follow-up visit.

This questionnaire consisted of question concerning the cause of pain, type, location, duration, intensity, initiation of pain perception as well as level of self-medication [Annexure 1]. A visual analog scale is a line, usually 10 cm in length, where the ends were considered as the limits of the pain experience; one end describes “no pain” and the other extremity as “severe pain.”

All the filled questionnaires were collected from selected participants of all groups after 1 month, and three set of each questionnaire was made. They were subjected to the necessary statistical analysis procedures on the basis of following points:

  • Set “A” prepared in three groups of A, B, and C depending upon initial arch wires of three types as discussed above
  • Set “B” is prepared as per the age of the patient in two groups

    a- Less than 16 years (n = 27)

    b- More than 16 years (n = 33).

  • Set “C” of questionnaire has been divided into two groups on the gender basis

    a- Male (n = 25)

    b- Female (n = 35).

After 1 month, area (anterior and posterior) of dental arch was analyzed in terms of maximum pain and discomfort depending on the outcome of question no. 2 of Annexure 1.

Data analysis included descriptive analysis obtained with the Statistical Package for the Social Sciences (IBM SPSS version 22 (NY, USA)). Mean, standard deviation, median, and quartiles for the pain perception were calculated. Nonparametric tests were applied for the analysis of pain perception scores since the scores were on an ordinal scale. Probability value of <0.05 has considered as statistically significant.

The pain perception was compared between the three groups (Groups A, B, and C) with the help of Chi-square test [Table 2], and the intergroup comparison between the pairs of groups was done by the Mann–Whitney test.
Table 2: Comparison of maximum pain experienced with type of material used in arch wire

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According to the response of the patient on the questionnaire regarding pain, assessment was made.

   Results Top

The demographic details of the study are given in [Table 3]. All the groups were matched with respect to age and gender [Table 1].
Table 3: Demographic details of the study population

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The mean pain score for the Set A participants included in the study was 3.91, while the mean score for Super elastic [[Figure 1], Group A], thermo elastic [[Figure 3], Group B], and conventional NiTi [[Figure 2], Group C] wire group were 4.70, 3.55, and 3.40 [Table 3] and [Table 2], respectively, which were statistically insignificant (P value more than 0.05 which is considered statistically insignificant).

Set B questionnaire depending upon the age has been tested using the Mann–Whitney test. For patients <16 years, the mean pain score was 3.70, and above 16 years, it was 4.09 [Table 4].
Table 4: Comparison of maximum pain experienced with age

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Set C which has been prepared depending upon gender and was again subjected to the Mann–Whitney test. The mean pain score for males and females was 3.64 and 4.11, respectively, which was again insignificant [Table 5].
Table 5: Comparison of maximum pain experienced according to gender

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The area of maximum pain and discomfort whether in the anterior or posterior group was again tested by using the Mann–Whitney test which shows that maximum pain was experienced in the anterior group as compared to the posterior group. This difference may be because of moderate crowding in the anterior region and variation in the root surface area [Figure 4].
Figure 4: area where maximum pain experienced by patient

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   Discussion Top

This present study examined the pain perception and discomfort after the initial placement of three different arch wires systems which have been manufactured by the same company and have 014 diameter (round wire). Initial phase of orthodontic treatment many a times becomes unpleasant and difficult for the patients (Ngan et al., 1989; Wilson et al., 1989; and Mandall et al., 2006), especially in cases of crowding where patients might experience variable discomfort and pain which can become a discouraging factor for seeking orthodontic treatment.[1] According to the WHO, pain has been defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage.[19] Pain may be due to heavy forces being applied during the treatment. Hence, incorporation of light forces is motivated which cause less trauma with a better working efficiency. Our study has utilized light forces through appropriate selection of different type of NiTi wires. This may be because of more resilient flexibility of these wires and also shows better mechanical properties mainly in the lower incisor region.[20]

This study stated that after the insertion of initial arch wires in maximum patients pain started after 1 h, reaches its peak within 24 h, and then, decline in following days and weeks which is similar to the study of Wiedel A et al in 2016 and Luppanapornlarp S et al in 2010.[21],[22] In this observational study, the results of pain experienced by the patient during initial leveling and aligning phase with three types of NiTi arch wires were statistically insignificant, but there is slightly more pain experienced by Super elastic NiTi wire than Thermo elastic NiTi and conventional Nitinol wire of same diameter. It is somewhere similar to the study of Nakano et al.[23] who observed great variation in force values with different NiTi wires of the same diameter, indicating that the wires are intrinsically different, and therefore, can be differentiated according to their characteristics. Heat-activated arch wires exert a 24% lighter force and generate a 13% longer plateau than their traditional counterparts.[24] The use of these wires is not depended on analgesic which indicates the bearable severity of pain in a range of mild to moderate.[21]

The information about the pattern of pain was gathered from the patient through the most commonly used the Visual Analog Scale (VAS), (Ngan et al., 1989; Jones and Chan, 1992; Fernandes et al., 1998; and Ertan Erdinç and Dinçer, 2004). This system is reliable and easily understood by most of the patients. This scale produces the global measure of discomfort and for different bracket designs, does not permit the participants to differentiate between different origins of discomfort, for example, associated with tooth or soft tissues.[1] Similarly, the present study indicates that the McGill Pain Questionnaire proves to be a useful tool for inspecting the extent of pain. It also provides quantitative information which can be treated statistically. This scale permits the research on pain in clinical rather than laboratory conditions. The modified Mc gill pain assessment questionnaire and VAS are introduced as the feasible basis for the invariable method of acquisition of information required to investigate the study of pain in the clinical environment.[17]

As regards to the variation in pain perception in relevance to age, our study concluded that participants above 16 years is having more pain as compared to the participants below 16 years which was statistically insignificant. Similar kind of the study has been reported by Jones (1984) with the conclusion that the pain perception was statistically significant. This difference of the result can be due to the variation in the use of rating scale. Jones used VRS and we used VAS with modified Mc gill pain questionnaire. The prevalence of reported pain after initial arch wire insertion reaches 81% among adolescent and ranges from 90% to 95% among adults. Middle age group had excessive frequency of pain.[4],[5]. Younger patients have a larger capacity to tolerate and adapts to the discomfort caused by fixed orthodontic appliance.[25]

As regard to the general discrimination, female experienced more pain intensity as compared to male which is statistically insignificant which was in agreement with previous studies which have shown that gender is not affected by the pain during orthodontic treatment (Ngan et al., 1989, Jones and Chan, 1992, Fernandes et al., 1998, and Ertan Erdinc and Dincer, 2004).[1] Scheurer et al.[4] reported that female patients reported greater pain than male patients. It has been recommended that the relationship of biological, psychological, and sociocultural factors likely contribute to these differences.[26] Mitchell et al.[27] and Riley et al. noticed sex differences, with men having greater permissiveness for pain stimuli than women.[28] It can be due to gonadal hormones which contributes to more incidents of clinical and experimental pain in female patients as compared with male patients.[29] The variation could be due to the different patient threshold which should be considered in further studies.

In this study, although higher pain scores were recorded for anterior than the posterior region, but the data show no statistically significant difference in area of pain experienced, which is similar to the results of other investigators (Ngan et al., 1989 and Scheurer et al., 1996). This could be due to active tooth movement and less bone density in anterior teeth, and their involvement during the alignment and leveling phase generates more pain. They also have smaller root surfaces than molars since they are single rooted teeth as compared to multirooted molars.[4]

Serge et al. (1998) reported that those patients who were aware of the complexities during the treatment and have control over their feelings can perceive less sensation of discomfort. Hence, the patient should be well informed before the start of treatment about the severity of malocclusion and the problem they may face during the treatment. This is a psychological way of preparing the patient, so that they can build their mind toward the adaptation of discomfort and pain during the treatment.[30]

This study have taken into account various possibilities for judging initial discomfort and pain experienced by the patient during leveling and aligning stages of orthodontic treatment, but some studies and researches are required in future which will consider more about pain threshold which can vary according to patient threshold.

   Conclusion Top

No statistically significant differences were recorded in any of the three types of NiTi arch wires (Groups A, B, and C) during initial tooth alignment. Neither gender nor age contributes in the discomfort during the initial phase of the treatment. Therefore, any of the three wires independent of age and gender can be used by orthodontist for initial leveling and alignment.

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Conflicts of interest

There are no conflicts of interest.

   Annexure 1 Top

Modified Mc Gill questionnaire

Patient name Age

Extraction yes no

7654321 1234567

7654321 1234567

Date of arch wire insertion

Type of arch wire

Please answer the following questions

Q1. What was the pain trigger?

  1. No pain
  2. Chewing
  3. Biting
  4. Cold food or liquid
  5. Hot food or liquid
  6. At rest
  7. Only during night
  8. Physical activity

Q2. Where did you perceive pain?

  1. Front tooth region
  2. Back tooth region
  3. All teeth
  4. Upper jaw
  5. Lower jaw
  6. Head

Q3. Describe the pain?

  1. Discomfort
  2. Pressure
  3. Tingling
  4. Dull
  5. Sharp
  6. Pulsating
  7. Headache

Q4. When did the pain start?

  1. Immediately after insertion of an arch wire
  2. Six hours later
  3. Twelve hours later
  4. Two days later
  5. More than 2 days later

Q5. Duration of pain?

  1. One day
  2. Two days
  3. Three days
  4. Four days
  5. Four days and longer

Has the intensity of pain decreased over time?

Have you taken any pain medication?

Visual Analog Scale

  • 0: No pain
  • 1–2: Mild pain
  • 3–5: Moderate pain
  • 6–9: Severe pain
  • 10: Unbearable pain.

On the scale of 0–10 (0 – No pain; 10 – Strongest pain you have ever experienced) please mark the pain you perceived after arch wire insertion

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

No pain mild pain moderate severe pain unbearable pain

   References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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


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