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No Pain, No Gain?

One of the things new patients always ask about is pain.  They’ve heard that braces hurt.  Let me reassure you that the vast majority of patients are pleasantly surprised that braces hurt far less than thought it would.

Here’s what I can tell you about the discomfort of tooth movement:  

There is some inevitable discomfort associated with the start of the tooth movement process, whether the tooth movement is associated with braces, aligners, or tooth-moving retainers.  This is typically described as a dull ache that can be intermittently sharper when chewing or biting or even brushing your teeth.  Most patients report that this soreness gradually increases over several hours, peaks about a day after the tooth-moving force is applied, then lasts for 2-5 days after braces are placed, and for 1-3 days after adjustments.

For teeth to move orthodontically, we rely on the periodontal ligaments that hold the teeth in the bone, to relay the pressure from the archwires (or aligners or retainer springs) to the bone, causing bone to resorb on one side of the tooth and fresh bone to be deposited on the other side.   The pressure should be constant for this process to get under way.  Intermittent pressure from rubber bands, retainers, or aligners will just cause the bone around the teeth to get dense, and the fibers between the teeth and the bone will get tighter as the body “bucks up” to the new challenge. 

This is why it takes so much more discipline to move teeth with retainers or aligners.  But if you do try it, just remember that your teeth won’t always be as sore as they are in the first few days.  The teeth don’t stay sore the whole time they are moving.  They will keep moving throughout the entire time between adjustments even though the soreness happens in the first few days.

The tooth movement process happens most efficiently (with less overall discomfort AND faster movement) when the periodontal fibers get “stimulated” through chewing, vibration, or light pressure.  This stimulation basically pumps fresh tissue enzymes and oxygenated blood into the site while moving out the inflammation and pain mediators.  It also helps to release minor frictional binds that can occur between the wire and the brackets.  

There is a device currently being marketed, specifically to accelerate tooth movement through a light vibration, but it requires patients to sit with this device in their mouths, biting on it for 20 minutes daily.  This seems impractical to me, as well as costly.  You can get virtually the same effect with sonic toothbrush, but I don’t know who would actually brush for 20 minutes a day!

You should know that in my practice, I start braces treatment with light, flexible, archwires in an effort to minimize the discomfort and other adverse effects of tooth movement.  The gentler the tooth-moving force, the fewer pain mediators are found in the tissues.

I also give patients a rubbery “therabite” wafer to chew on periodically after braces are placed, and aligner “chewies” after delivering aligners.  However simply chewing normal foods and biting your teeth together periodically will also help.  If you notice a specific tooth that is getting particularly sore, it’s probably because it does not hit when you bite your teeth together.  So you can just take your finger and lightly press on that tooth periodically until the soreness passes. 

The key to the ligament stimulation method of managing discomfort and speeding up tooth movement is to start the stimulation before the teeth actually get sore.  If you wait until the soreness has set in, you will find it more uncomfortable to stimulate the tissues—but even then it will be more effective than no stimulation at all.

If you are still uncomfortably sore, I suggest taking the recommended dose of over-the-counter Tylenol (or generic acetomenophen).  Never take more than the recommended dose because there is not a lot of margin before Tylenol becomes dangerously toxic!

If the Tylenol hasn’t had the disired effect after an hour, try adding a dose of a NSAID such as ibuprofen (Motrin or Advil) or Alleve.  Tylenol and Motrin act in different ways, and some studies indicate that, when taken together or alternatingly, they can be just as effective as a narcotic.

An adult can actually take a prescription strength of ibuprofen using OTC pills: up to 1000 mg as a loading dose, followed by 600 mg every 6 hours or 800 mg every 8 hours.   The maximum daily dose is 3200 mg.

If you are still in a lot of pain after taking the maximum dose of Tylenol and the maximum dose of ibuprofen, especially if the discomfort does not improve over the course of a day or two, it may be a sign that a tooth has abcessed and will need a root canal treatment.

I no longer recommend starting out with a NSAID (even though they are more effective against tooth movement pain) because they have been shown to actually slow tooth movement by blocking both bone resorption and ligament and cartilage repair.  Management of tooth-movement discomfort should be managed without ibuprofen if all all possible.

In summary, follow these steps to manage your tooth movement discomfort and provide for the fastest movement:

  • Stimulate your periodontal fibers periodically before the discomfort peaks, and continue stimulating until it subsides.
    • chew normal foods (no “babying”)
    • chew gum (if you are in stiff wires)
    • bite on a therabite or aligner chewy
    • press on your tooth/teeth with your finger
    • brush with a sonic toothbrush
  • If you become too uncomfortable, take over-the-counter acetaminophen (Tylenol) at the recommended dosing—never more than the dosing recommended on the label!
  • Add in an OTC NSAID (Motrin, Advil, or Alleve) only as needed to get you through the peak discomfort.
  • If you are trying to move teeth with rubber bands or a removable aligner or retainer, it is vital that you minimize the time they are out of your mouth, at least until this initial soreness is resolved.  

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