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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 608-612
Comparison of the efficacy of calcium versus acetaminophen on reduction of orthodontic pain


1 Department of Orthodontics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Department of Pharmacology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3 Postgraduate Student, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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Date of Submission20-Dec-2010
Date of Decision28-Jun-2011
Date of Acceptance22-Sep-2011
Date of Web Publication19-Feb-2013
 

   Abstract 

Background: Pain and discomfort are common during orthodontic treatment.
Aim: The aim of this single blind clinical trial was to compare the effectiveness of oral calcium versus acetaminophen in pain reduction.
Materials and Methods: In this study, the patients recorded their pain on a 100-mm visual analogue scale (VAS). Forty female patients (14-19 years old) who had passed at least 2 months of their first orthodontic archwire placement and their pain intensity was 40-100 mm (VAS) were selected and randomly assigned to two groups. Psychotic status was measured using Hospital Anxiety and Depression Scale (HADS). In group 1 calcium forte tablets (500 mg) and in group 2 acetaminophen (325 mg) tablets were prescribed to be taken one tablet per day. After consumption of all tablets (n=60), pain intensity was measured and compared with that before drug therapy.
Results: The results indicated that the difference in pain intensity before and after drug administration in the calcium group was statistically significant (P<0.001), but not significant in the acetaminophen group (P=0.468). The difference between the pain reduction in the two groups were also statistically significant (P<0.001). In the calcium group 9.5% and in the acetaminophen group 15.8% had anxiety that was not statistically significant (P=0.631). In both groups, no subject had depression.
Conclusion: Calcium is more effective than acetaminophen in long-term pain reduction during orthodontic treatment.

Keywords: Calcium, orthodontic pain, pain

How to cite this article:
Yassaei S, Vahidi A, Farahat F. Comparison of the efficacy of calcium versus acetaminophen on reduction of orthodontic pain. Indian J Dent Res 2012;23:608-12

How to cite this URL:
Yassaei S, Vahidi A, Farahat F. Comparison of the efficacy of calcium versus acetaminophen on reduction of orthodontic pain. Indian J Dent Res [serial online] 2012 [cited 2020 Jan 19];23:608-12. Available from: http://www.ijdr.in/text.asp?2012/23/5/608/107349
Pain and discomfort are common during orthodontic treatment. Approximately, 90-95% of orthodontic patients experience pain. This pain starts about 4 hours after archwire placement and peaks up after 24 hours. [1],[2],[3] The pain usually lasts for 2-3 days and the intensity of pain decreases from the fifth and or sixth day onwards. [4] It returns to normal level after 7 days. [2],[5],[6],[7] While this is not a major problem in most of the patients, approximately 10% of orthodontic patients stop their treatment due to experience of early pain. [8] In addition, in certain patients, the perception of a painful experience leads to the patient's refusal of treatment even if it is necessary. [9]

Previous studies have evaluated the effect of various drugs on pain due to orthodontic treatment. Same authors have reported the effect of acetaminophen to be similar to a placebo, [10] while others considered it to be better. [11] Similarly, some reported that the effect of acetaminophen is similar to ibuprofen. [11],[12] Some studies considered acetaminophen to be a better drug as it has no effect on tooth movement, [13],[14],[15],[16] but no one has proposed a standard protocol for this subject. Aspirin and ibuprofen can result in gastric upset, hepatic and coagulative complications. [17] They also cause a decrease in the movement of osteoclasts toward the pressure areas and result in decreased tooth movement. [13]

There are various reports concerning the effect of calcium on pain. Sato et al, [18] studied the effect of calcium phosphate paste (CPP) injections in the femoral canal on thigh pain due to total hip arthroplasty (THA). They selected 45 patients who had undergone THA. Eleven patients were injected with CPP in the femoral canal, while 34 patients in the control group were not administered CPP injection. None of the patients who had been administered CPP injection had any thigh pain, but five patients in the control group reported thigh pain. Similarly, in the group was received CPP, pain prophylaxis continued for 3 years.

Ohata et al, [19] studied seven patients who had suffered from chemical burns by hydrofluoric acid (HF) and had severe pain. In four patients, 4% calcium gluconate gel was used, while in the other three subjects, subcutaneous injections of 8.5% calcium gluconate was administered. They concluded that physicians should provide can use 4% calcium gluconate gel or subcutaneous injection of 8.5% calcium gluconate for treatment of pain due to chemical burns by hydrofluoric acid.

Ajdukiewicz et al, [20] studied the effect of calcium injections on skeletal pain in 14 primary biliary cirrhosis patients who were suffering from either back pain or pain in the arms, legs or ribs. They administered each patient diluted calcium gluconate in 5% dextrose for 12 days. All of the patients reported a reduction in pain. The pain was relieved 3-12 days after starting of injection and the relief lasted for 2-3 months.

As drugs such as acetaminophen only have a symptom relief effect which lasts up only until the patient takes the drug, the aim of this study was to compare the effect of calcium and acetaminophen tablets on pain reduction, and also to determine the intensity of reported pain after discontinuation of the drugs.


   Materials and Methods Top


This was a descriptive study done by the clinical trial and single blind method. The research was granted by the ethical committee of the research department of Shahid Sadoughi University on 11th April, 2009 via letter number P /17/1/4564 and registered at the Iranian Registry of Clinical Trials (IRCT138806282481N1). Sample selection was done by randomized controlled trial. The subjects were selected from 14 to 19-year-old female patients who have at least 2 months passed from their first orthodontic archwire placement. The intensity of their pain was estimated on the basis of Visual Analogue Scale (VAS). [21],[22] Subjects were selected if their pain intensity was between 40 and 100 mm (VAS). Orthodontic treatment was performed by one orthodontist who was main investigator.

The criteria for inclusion in the study were: (1) female patients; (2) range of age 14-19 years; (3) at least 2 months passed from first archwire placement (in first or second stage of comprehensive orthodontic treatment but no first archwire); (4) upper and lower first premolar extraction cases with bialveolar protrusion or crowding; (5) their pain intensity between 40 and 100 mm (VAS); (6) whom signed the written informed consent to participate; (7) no contraindications to the use of acetaminophen or calcium such as ventricular fibrillation, renal calculi, hypoparathyroidism and calcium supplement intake.

For sample size calculation, using previous study [23] and considering α-level of 5% and power of 80% a total of 40 subjects were included.

The degree of pain was measured on the day after manipulation and again 2 days later was measured by VAS in a pilot form on 10 patients undergoing fixed orthodontic treatment who were not included in the sample and a reliability coefficient of 0.82 was obtained. Thus, reproducibility of the examiner was considered as acceptable.

According to inclusion criteria, if the pain intensity were more than 40 mm, a questionnaire based on HAD scale would be used for measuring their anxiety levels and depression. Then, on the basis of a systematic randomized trial, patients were prescribed acetaminophen (325 mg) (Darou Pakhsh Company) or Calcium forte tablets (500 mg) (Pars Minoo Company). The patients were asked to take one tablet nightly with one glass of water. Both groups received the drugs for a period of 2 months. Active treatment continued during this study and appliance adjustment made in the 24-day interval. Pain intensity was estimated by VAS 4 days after manipulation in initial stage and final stage. After consumption of 60 tablets, the pain intensity was measured again by VAS(four days after manipulation) and registered in the questionnaire. The difference in pain intensity before and after administration of the drugs was calculated. The data was entered into a computer using SPSS software program and descriptive statistical tests like mean and standard deviation, non-parametric tests like χ2 , Mann-Whitney and Wilcoxon test were used for statistical analysis. P < 0.05 was considered significant.


   Results Top


As presented in [Table 1], the mean age of patients was 17.43 in the calcium group and 16.42 in the acetaminophen group.
Table 1: Comparison of the mean and standard deviation of depression, anxiety, HADS scores and age in the two groups under study


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The mean intensity of pain at the start of study was 66.4 mm in the calcium group and 51 mm in the acetaminophen group. The maximum intensity of reported pain was 90 mm in the calcium group and 60 mm in the acetaminophen group. The mean of pain intensity after taking drugs in the calcium and acetaminophen groups were 28.8 and 50 mm, respectively [Table 2]. Similarly, the mean rate of decrease in pain in the calcium group was 37.6 and 1 mm in the acetaminophen group. The maximum decrease in pain intensity was 60 mm in the calcium group and 15 mm in the acetaminophen group. The mean and maximum HADS was 11.28 and 19 in the calcium group. The mean and maximum HADS was 10.52 and 20 in the acetaminophen group. The minimum HADS in both groups was 2.
Table 2: Comparison of the pain intensity before and after use of drugs in the two groups

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T-test was used to initially determine whether there was any significant difference in the mean age, anxiety, depression and HADS levels of the two groups. There was no significant difference between the mean age and HAD scale of the two groups before or after intervention [Table 1]. Wilcoxon test was used to compare the intensity of pain before and after drug use. The difference in the calcium group was significant, but not in the acetaminophen group [Table 2].

Mann-Whitney test was used to compare decrease in pain intensity after use of the drugs between two groups and it was concluded that the mean and median of decrease in pain intensity in the calcium group was much more than that in the acetaminophen group and the P-value showed that this difference was significant [Table 3].
Table 3: Comparison of the rate of decrease in pain after use of the drug in the two groups

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Another evaluation which was done in this study was the study of HADS in the patients. If the patient anxiety score was more than 10, it was considered as anxiety, a score of 8-10 as borderline and a score less than 8 was considered as normal. It was the same for depression. In the calcium group, only two patients (9.5%) and in the acetaminophen group 3 patients (15.8%) had anxiety. There was no significant difference in the HAD scale of the two groups that was determined using χ2 test [Table 4].
Table 4: Comparison of the distribution of stressful persons in the two groups

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   Discussion Top


Many factors are responsible for the pain intensity reported by the patients [4] and sex is one of them. Various studies have shown that females are more inclined to discuss and report their painful experiences. [3],[8] Girls also reported more discomfort/pain than boys during fixed appliance treatment. [5],[24] Similarly, adults reported more pain than young patients. [2],[6],[25],[26],[27] Therefore, in this study, only 14-19-year-old females were included.

Another factor involved in pain intensity is the psychological status of the individual like anxiety and depression, [4] such that the physiological sensitivity of each individual plays an important role in the intensity of pain due to orthodontic treatment. [3],[8],[18],[26],[28],[29] Therefore, HAD scale was used in the present study to determine the levels of anxiety and depression. The results showed that there was no significant difference between the anxiety and depression levels in the two groups and therefore the study conditions were similar in both groups. In other words, anxiety or depression could not have been responsible for the difference in response to the two drugs.

The results of the present study showed that the mean and median decrease in pain intensity was significantly more in the calcium group compared with that of acetaminophen group. As the analgesic effect of the two drugs was studied after cessation, it can be concluded that decrease in pain due to calcium lasts for a longer period. In other words, the analgesic effect of calcium is more long lasting than that of acetaminophen. The following mechanism could be responsible for the analgesic effect of calcium. Neural messages are transferred by change in action potential. In the second stage of action potential, that is, depolarization, the walls of the nervous cells suddenly become permeable to sodium ions and a large number of sodium ions enter the axons through the voltage channels. The calcium ions attach to the outer protein of molecular surface of the sodium channels. The positive charge of the calcium ions alters the electric state of the sodium channels proteins that results in an increase in the opening threshold level of the sodium gates and therefore the nerve fibers take a longer time to be stimulated. [30]

An internet search did not reveal any similar study concerning the effect of calcium on pain in orthodontic patients. But there had been studies about the effect of calcium on reduction of pain intensity in various parts of the body.

Sato et al, [18] reported that injection of calcium phosphate paste (CPP) in the femoral canal is an appropriate technique for prevention of thigh pain following THA. Therefore, the results of the study by Sato et al, [18] were similar to the present study with respect to the analgesic effect of calcium.

Ohato et al, [19] treated seven patients who were burnt with hydrofluoric acid (HF) by calcium gluconate. This was similar to the results of the present study with respect to the analgesic effect of calcium.

In the study of Ajdukiewicz et al, [20] on primary biliary cirrhotic patients suffering from bone pain, calcium injection resulted in pain reduction in all of subjects. Therefore, the results of the study by Ajdukiewicz et al, [20] were similar to the present study with respect to the long-term analgesic effect of calcium.

Sekel [31] reported that patients with Paget's disease are relieved of their bony skeletal pain after injection of calcium. The pain reduction was observed on the third day and the analgesic effect lasted for 16 weeks. Therefore, the results of the study Sekel were in agreement with the present study with respect to the long-term analgesic effect of calcium.

In the study by Pak et al, [32] intravenous injection of calcium in idiopathic osteoporosis patients resulted in decrease of their skeletal pain. Considering the fact that the effect of calcium on pain reduction in orthodontic patients was significant in the present study, the results were similar to the results of the study by Pak et al.[32]


   Conclusion Top


Based on the results of the present study, calcium have better long-lasting analgesic effect in orthodontic patients and can be prescribed as a drug of choice in orthodontic patients who suffer from pain.

 
   References Top

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Correspondence Address:
Soghra Yassaei
Department of Orthodontics, Shahid Sadoughi University of Medical Sciences, Yazd
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.107349

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