ORIGINAL ARTICLE

Comparison of the efcacy of ibuprofen and acetaminophen in controlling pain after orthodontic tooth movement
Reza Salmassian,a Larry J. Oesterle,b W. Craig Shellhart,c and Sheldon M. Newmand Aurora, Colo Introduction: Some patients undergoing orthodontic treatment report enough discomfort to affect their compliance or request treatment termination. The purpose of this preliminary study was to test the effectiveness of ibuprofen vs acetaminophen in controlling discomfort after initial orthodontic appliance and archwire placement. Methods: A total of 60 patients (ages, 12-18 years) undergoing xed comprehensive orthodontic treatment were randomly assigned to 1 of 3 experimental groups: 600 mg of acetaminophen, 400 mg of ibuprofen, or a placebo. All subjects were instructed to take the medications orally at prescribed times after initial appliance and archwire placement. Each patients level of discomfort was assessed with a 100-mm visual analog scale immediately after placement; at 3, 7, 19, 24, 31, and 48 hours; and at 3, 4, and 7 days. Results: The results indicated that the peak level of pain was at 19 hours after placement, and the differences in scores among the 3 groups were not statistically signicant. Conclusions: Acetaminophen, ibuprofen, and placebo are equally effective in reducing discomfort after initial orthodontic appliance placement. (Am J Orthod Dentofacial Orthop 2009;135:516-21)

o matter how much progress has been made in orthodontics or how competent the practitioner is, orthodontic treatment is still associated with discomfort. One study indicated that patients rank pain as the worst aspect of orthodontic treatment and the reason for wanting to discontinue care.1 Some patients even reported that, when compared with the pain of extractions, both the incidence and the severity of orthodontic pain are greater.2 Reported pain perception from orthodontic treatment varies greatly by sex, age, type of force, and personality type.3-6 Doll et al7 found in their research on 67 patients (ages, 9-32 years) that appliance acceptance after 6 months could be predicted from their attitude toward treatment and the amount of discomfort experienced. They also found that patient compliance could be predicted from these same variables. Similarly, Sergl et al3 found that orthodontic appliance and treatFrom the Department of Orthodontics, School of Dentistry, University of Colorado at Denver and Health Sciences Center, Aurora, Colo. a Postgraduate resident. b Professor and chair. c Associate professor. d Associate professor, Department of Restorative Dentistry. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Larry Oesterle, Department of Orthodontics, School of Dentistry, University of Colorado at Denver and Health Sciences Center, Mail Stop F849, PO Box 6508, Aurora, CO 80045; e-mail, larry.oesterle@uchsc.edu. Submitted, January 2007; revised and accepted, May 2007. 0889-5406/$36.00 Copyright 2009 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.05.020

ment acceptance can be predicted by the degree of initial pain and discomfort. The more pain associated with initial orthodontic treatment, the less compliant the patient during treatment. Eighty-seven percent of patients receiving separators reported pain the rst evening after the appointment, and 27% of them used pain medication for up to 2 days after the appointment.8 Tooth movement is a complex phenomenon, and various studies have attempted to explain its mechanism. According to the pressure-tension theory, tooth movement occurs in 3 stages: alterations in blood ow associated with pressure in the periodontal ligament (PDL), formation or release of chemical messengers, and activation of cells.9 Prostaglandin (PG) E and interleukin-1 B levels increase in the PDL and the gingival crevicular uid within a short time after the application of pressure and appear to be important cellular response mediators by increasing the number of multinuclear osteoclasts, osteoclastic bone resorption, and the rate of orthodontic tooth movement.10,11 Several studies demonstrated that the application of PG E 1 or 2 resulted in increased tooth movement in both rats and humans, emphasizing its important role in the mechanism of tooth movement.10,12-14 Inammatory mediators such as PG 1 or 2 contribute to orthodontic tooth movement and are also involved in the mediation of orthodontic pain. Nonsteroidal antiinammatory drugs (NSAIDS) that block PG production are commonly given to patients for pain relief.

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The downside of NSAIDS is that they inhibit PG synthesis and therefore delay or inhibit orthodontic tooth movement. Although much has been published on this subject, it is still controversial. Mohammed et al15 found in 132 Sprague-Dawley rats a signicant inhibition of tooth movement on day 7 after injection of indomethacin, a PG synthesis inhibitor, and a leukotriene inhibitor. Similar results for indomethacin were found by Kyrkanides et al.16 Sandy and Harris17 found that animals treated with PG inhibitor urbiprofen had decreased osteoclastic activity, although no effect on tooth movement was seen. Therefore, due to their potential for slowing tooth movement, NSAIDS are not recommended during orthodontic care, at least in theory. Acetaminophen, unlike NSAIDS, is inactive as an anti-inammatory agent in peripheral tissues and does not prevent PG synthesis and tooth movement. A study by Kehoe et al18 comparing acetaminophen and ibuprofen indicate that acetaminophen is more suitable and the analgesic of choice for relief of minor orthodontic discomfort. Roche and Cisneros19 reached the same conclusion in their study of New Zealand white rabbits in which an orthodontic appliance was placed under sedation. Over a 21-day period, the rabbits received daily 1000-mg doses of Tylenol in 10-mL solutions, and, after histologic study after they were killed, the rabbits showed no adverse effects of acetaminophen on tooth movement. Like Kehoe et al,18 they recommended that an analgesic such as acetaminophen was ideal because it does not alter the inammatory response or delay tooth movement. In a more recent study, Arias and Marquez-Orozco20 made similar conclusions when they compared aspirin, acetaminophen, and ibuprofen. They found that acetaminophen did not inhibit tooth movement when injected in Wistar rats, but aspirin and ibuprofen did. They also recommended acetaminophen as the analgesic of choice for treating pain from orthodontic treatment. Even though ample research demonstrates the neutral role of acetaminophen on tooth movement, no study has compared its efcacy with other over-the-counter medications for the control of orthodontic pain. According to Bernhardt et al,21 at the present time there are no published studies that compare the effectiveness of ibuprofen and acetaminophen for the control of orthodontic pain. The purposes of this preliminary study were (1) to compare the effectiveness of ibuprofen and acetaminophen in controlling discomfort after initial orthodontic appliance and archwire placement; the null hypothesis was that acetaminophen and ibuprofen are equally effective in controlling pain after archwire placement; and (2) to determine when the peak level of pain occurs after initial appliance placement.

Table I. Group 1 2 3

Study sample size and group allocations

Medication Acetaminophen Ibuprofen Lactose Dosage 600 mg 400 mg 2 tablets Boys 9 12 10 Girls 12 7 10 Total 21 19 20

MATERIAL AND METHODS

Our subjects were patients from the Orthodontic Graduate Clinic, University of Colorado School of Dentistry, and met the following inclusion criteria: (1) scheduled to begin comprehensive orthodontic treatment (banding/bonding of at least 10 teeth in 1 arch and archwire placement in at least 1 arch); (2) extractions, if required, performed at least 2 weeks before appliance and archwire placement; (3) healthy with no signicant medical ndings; (4) no prophylactic antibiotic coverage required; (5) currently not taking antibiotics or analgesics; (6) no contraindications to the use of acetaminophen or ibuprofen; (7) no lactose intolerance; (8) minimum age of 12 years and minimum weight of 88 lbs (as required by the FDA for the use of over-the-counter pediatric dosage label guidelines); and (9) maximum age of 18 years to exclude adults. Colorado Multiple Institutional Board approval was obtained before patient recruitment (protocol #05-0887). Sixty-six patients met the inclusion criteria and were initially enrolled. Two subjects decided not to participate after archwire placement, and 4 did not return in a timely manner for follow-up appointments. The nal sample (Table I) consisted of 60 patients randomly assigned to 1 of 3 groups: group 1 (21 patients: 9 boys, 12 girls) to receive 600 mg of acetaminophen, group 2 (19 patients: 12 boys, 7 girls) to receive 400 mg of ibuprofen, and group 3 (20 patients: 10 boys, 10 girls) to receive a placebo of 2 lactose tablets. Random group allocation and coding of patients were made by a coinvestigator (W.C.S.) and the subjects and the main investigator (R.S.) were blinded to the group allocation. The ibuprofen, acetaminophen, and placebo tablets were compounded by a licensed pharmacist (Wise Pharmacy, Littleton, Colo) according to specications and were all identical in shape and color. At the treatment consultation appointment, all patients meeting the inclusion criteria were given a brief explanation of the study by the main investigator; they consented to participate and signed the necessary consent forms. Each patient was given a 12-page questionnaire, containing a 100mm visual analog scale (VAS) along with a medication case containing 18 tablets. The subjects were asked to mark their degree of discomfort (0, no pain; 10, worst

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pain imaginable) in the booklet at that moment, before appliance placement. This initial marking was the baseline (0 hour). The main investigator monitored the rst recording (baseline) to ensure each subjects full comprehension of the treatment protocols. After that, the patients had xed orthodontic appliances placed in at least 1 arch (with 10 teeth minimum) and an initial archwire placed. The subjects were then discharged and instructed to continue marking their levels of discomfort on the VAS scales at 3, 7, 19 (next morning), 24, 31 (next night after dinner), and 48 hours, and at 3, 4, and 7 days. No discrimination was made between various activities (eating, chewing, or biting). Immediately after each recording, the subjects were instructed to take 2 tablets of the medications provided. The VAS recording followed by te medication was done at each time point described above, starting at the 3-hour mark up to day 7. Excluding the baseline, each subject made 9 recordings and medication intakes during the study period. The subjects were instructed to take the medications even if they had no pain, since the side effects of the medications were extremely low to almost none at the dosages used. They were also encouraged not to take additional analgesics. However, if absolutely necessary, they were allowed to take what they usually took for pain but were required to record the exact time, dosage, and type of medication and whether it relieved the pain. No patients took additional analgesics during the study period. For younger patients (\15 years), the parents were asked to monitor the scheduled intakes, but each patient recorded his or her pain level, not the parents. The subjects were instructed to return the VAS booklet to the primary investigator once all the recordings were made. Descriptive statistics were calculated at each time interval for the experimental groups. Two-way analysis of variance (ANOVA) was used to compare differences in mean pain scores between the 3 groups. If the results of the 2-way ANOVA were signicant, then a 1-way ANOVA was carried out for each time interval. The Student t test was also used to test for differences between boys and girls. The level of statistical signicance was set at P \0.05.

In all 3 experimental groups, there was a trend for the pain to start 3 hours after archwire placement and gradually increase to a peak at 19 hours (next morning). The pain then gradually decreased to the baseline level by day 7. The highest pain level reported during the study period was with the lactose group at 19 hours, but it was only moderate (VAS score, 5.2 on a 0-10 scale). Although the data suggest that both acetaminophen and ibuprofen decreased the VAS scores more than the placebo starting at 7 hours, the differences did not rise to statistical signicance at any time.
DISCUSSION

RESULTS

The t tests showed no differences between the sexes at any time point. Therefore, the ndings were evaluated with no sex discrimination, and the data for boys and girls were combined for analysis. The mean pain values and standard deviations are shown in Table II. A graphic view of the ndings is presented in the Figure.

Several studies have shown no correlation between pain and sex.2,5,6,22 Likewise, in this study, no sex correlation was found, and therefore the sexes were combined for data analysis. A clear trend was seen for the onset of pain. In all 3 groups, the pain started 3 hours after archwire placement and reached its highest level at 19 hours (next morning). These ndings agree with those of Jones and Chan6 and Bernhardt et al.21 The ndings of Polat et al23 are also similar; they found peak levels of pain on the rst night and 24 hours after archwire placement. Ngan et al22 also observed discomfort starting 4 hours after archwire or separator placement, peaking at 24 hours, and returning to normal by day 7. The design of this study required the rst intake of medication at 3 hours after archwire placement. This allowed some discomfort to occur so that the pain-relieving effect of the medications would stand out more clearly after the rst intake. Although there appeared to be a trend of less pain with acetaminophen and ibuprofen than the placebo, this was not supported statistically. A study with a larger sample than in this preliminary study might delineate potential differences more clearly. However, Polat et al,23 in their study of naproxen vs ibuprofen, saw no statistically signicant differences between the placebo and the ibuprofen groups at any time interval studied. Likewise, Bernhardt et al21 found that ibuprofen provided signicant pain relief only at the 2-hour mark. After this time, they also found no statistically signicant difference between ibuprofen and the placebo. The nding of no statistical differences between the 3 groups can be explained by several theories. First and foremost, pain is a subjective phenomenon that is difcult to assess. Many variables come into play when one attempts to measure and quantify it.3-6 In this study, great variability was observed. Some patients reported no pain during the entire study period, even though they were in the control group, taking no analgesics.

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Table II. Group

Mean VAS scores with standard deviations for acetaminophen, ibuprofen, and placebo groups
(Baseline) 0 h Mean SD Mean SD Mean SD 0.29 0.62 0.27 0.63 0.16 0.49 3h 2.98 2.66 3.41 2.61 2.51 2.81 7h 3.60 2.73 4.25 2.71 4.40 2.50 19 h 3.75 2.77 4.79 2.54 5.23 2.68 24 h 3.59 2.77 3.63 3.01 4.07 2.75 31 h 2.96 2.48 3.00 3.01 4.22 2.12 48 h 1.70 1.85 2.05 2.53 2.72 2.14 3 days 1.25 1.60 1.90 2.58 2.13 2.29 4 days 0.65 0.83 1.38 2.10 1.56 2.21 7 days 0.28 0.47 0.63 0.87 0.43 0.54

Acetaminophen Ibuprofen Lactose

Fig. Comparison of VAS scores vs time for the acetaminophen, ibuprofen, and placebo groups.

Others, even though taking analgesics, had scores of 9 and above on the VAS scale. Therefore, the multifactorial nature of pain and the large difference in pain perception between subjects might have contributed to the lack of clear differences in the analgesic effects of the medications. Another possible explanation is that the pain associated with average, routine orthodontic treatment is so minimal for most patients that no analgesic is required. If lactose provides the same analgesic effect as ibuprofen or acetaminophen, then it is possible that orthodontically induced pain is so minimal that patients can effectively control it with nothing. Bergius et al8 found that, even though 87% of the patients receiving separators reported pain the rst evening after the appointment, only 27% of them used pain medication, indicating the low intensity of discomfort associated with orthodontic treatment. Scheurer et al24 reported an even lower percentage of patients requiring analgesics for discomfort, with analgesic demand decreasing by day 3. These studies conrm our ndings. During the entire study period, no average VAS score exceeded 5.2 on a 0 to 10 scale, conrming moderate to low pain levels associated with routine orthodontic treatment and

the minimal need for analgesics for pain control for most patients. Another explanation as to why we found no differences between the groups could be that the dosages were too low to be effective. Bernhardt et al21 speculated this in their study of the effect of preoperative and postoperative ibuprofen. Polat et al23 also recommended increasing the frequency of analgesics, since 1 preoperative dose was not adequate to control discomfort. Further research to compare the efcacy of various analgesics with increasing dosages is therefore needed to shed light on this hypothesis. Other studies comparing the efcacy of ibuprofen and acetaminophen found statistically signicant differences.25 In their study of impacted third molar removal, Dionne et al26 found that ibuprofen resulted in signicantly less reported pain than a placebo or acetaminophen taken before treatment or administration 4 and 8 hours later. Forbes et al27 also found similar results in a study of surgical removal of impacted third molars. They concluded that 400 mg of ibuprofen was superior in pain relief than acetaminophen alone or combined with codeine. Cooper28 concluded from his 5 studies on ibuprofen for postsurgical pain that ibuprofen (400 mg) is consistently more effective than aspirin (650 mg), acetaminophen (600 mg), or aspirin and acetaminophen combined. Most of these studies concluded that ibuprofen provided signicantly faster and greater relief than did acetaminophen.25-28 Although these ndings contradict our results of no statistically signicant differences between any groups, the results might simply highlight the great differences between postsurgical pain and the much less severe orthodontic pain. In this study, the highest average pain levels were 3.7, 4.8, and 5.2 for the acetaminophen, ibuprofen, and lactose groups, respectively. Even though individual patients reported higher and lower pain levels on a 0 to 10 scale, average orthodontic pain was only mild to moderate. Furthermore, a more indepth look at these studies shows that the pain levels were studied up to only 6 hours after treatment. Many studies indicate that the typical pain after orthodontic

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separator placement, for example, starts at 4 hours and peaks at 24 hours.22,29 Jones and Chan6 found that the pain score after placement of 2 types of orthodontic wires peaked the next morning and lasted for 5 or 6 days. Other authors found that signicant increases in discomfort after placement of separators or archwires occurred at 4 hours and peaked at 24 hours.5,22,30 Our study, with a 7-day time period, was the rst to compare the efcacy of acetaminophen vs ibuprofen for the control of the mild to moderate pain of orthodontic treatment. Many studies have compared the analgesic effects of medications other than acetaminophen. Polat et al23 found some promising results with naproxen sodium (550 mg) taken 1 hour before archwire placement. Valdecoxib, a COX-2 inhibitor, was another drug studied by Young et al.31 They concluded that preoperative and postoperative doses of valdecoxib are effective to minimize the discomfort of initial archwire placement. Bernhardt et al21 also looked at the use of preoperative dosages and made similar recommendations. Finally, Bartlett et al,32 in their clever study of anxiety and preappointment telephone calls, found that a simple call from the health care provider before the patients orthodontic appointment reduced anxiety and self-reported pain. Analgesic effect can be increased in several ways by increasing the dosage or the frequency of intake, or starting the analgesic before orthodontic treatment. In this study, the smallest dose recommended by the manufacturer was used and administered after the archwires were placed. Future studies might compare the analgesic effects of these medications with increasing dosages, the use of no placebo or pretreatment anxiety control, and starting analgesics before the procedure. Finally, follow-ups could be done to the study of Bartlett et al32 by comparing medication vs additional personal attention such as pretreatment and follow-up calls and the effects of each on pain perception after appliance placement. Many studies have looked at the rate of tooth movement after inhibition of PG.15-17 These studies concluded that PGs are important mediators of tooth movement, and their inhibition slows down or even prevents tooth movement. Acetaminophen does not inhibit PG synthesis and therefore had no detrimental effects on tooth movement in animal studies.18-20 Some clinicians argued that, since lower doses of these medications are used in humans and for shorter durations, in a healthy subject they are cleared by the body before tooth movement and have no effect on tooth movement. Since studies of the potential inhibition of tooth movement on humans would be not only unethical but also challeng-

ing, orthodontists should exercise caution in the use of medications that inhibit PG synthesis. Therefore, a simple, readily available, over-the-counter analgesic such as acetaminophen is recommended for the mild to moderate discomfort of routine orthodontic treatment.

CONCLUSIONS

The purpose of this preliminary study was to compare the efcacy of ibuprofen vs acetaminophen in controlling pain after initial appliance and archwire placement. The following conclusions were made. 1. No differences were found between the sexes in the levels of pain reported. Therefore, there was no correlation between sex and pain. Pain after initial archwire placement started by 3 hours and peaked at 19 hours (next morning). A gradual decrease then followed to preoperative values by day 7. The highest average VAS scores reported during this study were average to below average values, indicating the low to moderate intensity of pain associated with routine orthodontic treatment. Large individual variations in pain perception were found. No statistically signicant differences were found in pain control between any of the 3 groups. Acetaminophen, ibuprofen, and placebo are all equally effective in controlling pain after initial archwire placement. Based on these ndings, analgesics appear to be no more effective than a placebo for most routine orthodontic treatment. However, acetaminophen might be the recommended drug of choice for patients with special needs or those with a low pain threshold because of its lack of negative side effects in tooth movement physiology.

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REFERENCES 1. Oliver RG, Knapman YM. Attitudes to orthodontic treatment. Br J Orthod 1985;12:179-88. 2. Jones ML, Chan C. Pain in the early stages of orthodontic treatment. J Clin Orthod 1992;26:311-3. 3. Sergl HG, Klages U, Zentner A. Pain and discomfort during orthodontic treatment: causative factors and effects on compliance. Am J Orthod Dentofacial Orthop 1998;114:684-91. 4. Bergius M, Kiliaridis S, Berggren U. Pain in orthodontics. A review and discussion of the literature. J Orofac Orthop 2000;61: 125-37. 5. Erdinc AM, Dincer B. Perception of pain during orthodontic treatment with xed appliances. Eur J Orthod 2004;26:79-85. 6. Jones M, Chan C. The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires. Am J Orthod Dentofacial Orthop 1992; 102:373-81.

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7. Doll GM, Zentner A, Klages U, Sergl HG. Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy. J Orofac Orthop 2000;61:398-413. 8. Bergius M, Berggren U, Kiliaridis S. Experience of pain during an orthodontic procedure. Eur J Oral Sci 2002;110:92-8. 9. Proft W. Contemporary orthodontics. 3rd ed. St Louis: Mosby; 2000. p. 302-5. 10. Gurton AU, Akin E, Sagdic D, Olmez H. Effects of PGI2 and TxA2 analogs and inhibitors in orthodontic tooth movement. Angle Orthod 2004;74:526-32. 11. Grieve WG 3rd, Johnson GK, Moore RN, Reinhardt RA, Dubois LM. Prostaglandin (PGE) and interleukin-1 beta (IL-1 beta) levels in gingival crevicular uid during human orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1994;105: 369-74. 12. Sekhavat AR, Moussavizadeh K, Pakshir HR, Aslani FS. Effect of misoprostol, a prostaglandin El analog, on orthodontic tooth movement in rats. Am J Orthod Dentofacial Orthop 2002;122: 542-7. 13. Yamasaki K, Shibata Y, Fukuhara T. The effect of prostaglandins on experimental tooth movement in monkeys (Macaca fuscata). J Dent Res 1982;61:1444-6. 14. Kale S, Kocadereli I, Atilla P, Assan E. Comparison of the effects of I,25 dihydroxycholecalciferol and prostaglandin E2 on orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2004; 125:607-14. 15. Mohammed AH, Tatakis DN, Dziak R. Leukotrienes in orthodontic tooth movement. Am J Orthod Dentofacial Orthop 1989;95: 231-7. 16. Kyrkanides S, OBanion MK, Subtelny JD. Non-steroidal anti-inammatory drugs in orthodontic tooth movement: metalloproteinase activity and collagen synthesis by endothelial cells. Am J Orthod Dentofacial Orthop 2000;118:203-9. 17. Sandy JR, Harris M. Prostaglandin and tooth movement. Eur J Orthod 1984;6:175-82. 18. Kehoe MJ, Cohen SM, Zarrinia K, Cowan A. The effect of acetaminophen, ibuprofen, and misoprostol on prostaglandin E2 synthesis and the degree and rate of orthodontic tooth movement. Angle Orthod 1996;66:339-50. 19. Roche JJ, Cisneros GJ, Acs G. The effect of acetaminophen on tooth movement in rabbits. Angle Orthod 1997;67:231-6.

20. Arias O, Marquez-Orozco MC. Aspirin, acetaminophen, and ibuprofen: their effects on orthodontic tooth movement. Am J Orthod Dentofacial Orthop 2006;130:364-70. 21. Bernhardt MK, Southard KA, Batterson KD, Logan HL, Baker KA, Jakobsen JR. The effect of preemptive and/or postoperative ibuprofen therapy for orthodontic pain. Am J Orthod Dentofacial Orthop 2001;120:20-7. 22. Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am J Orthod Dentofacial Orthop 1989;96:47-53. 23. Polat O, Karaman AL, Durmus E. Effects of pre-operative ibuprofen and naproxen sodium on orthodontic pain. Angle Orthod 2005;75:791-6. 24. Scheurer P, Firestone A, Burgin W. Perception of pain as a result of orthodontic treatment with xed appliances. Eur J Orthod 1996; 18:349-57. 25. Olson NZ, Otero AM, Marrero I, Tirado S, Cooper S, Doyle G, et al. Onset of analgesia for liquigel ibuprofen 400 mg, acetaminophen 1000 mg, ketoprofen 25 mg, and placebo in the treatment of postoperative dental pain. J Clin Pharmacol 2001;41:1238-47. 26. Dionne RA, Campbell RA, Cooper SA, Hall DL, Buckingham B. Suppression of postoperative pain by preoperative administration of ibuprofen in comparison to placebo, acetaminophen, and acetaminophen plus codeine. J Clin Pharmacol 983;23:3743. 27. Forbes JA, Kehm CJ, Grodin CD, Beaver WT. Evaluation of ketorolac, ibuprofen, acetaminophen, and an acetaminophencodeine combination in postoperative oral surgery pain. Pharmacotherapy 1990;10(6 (pt2)):94S-105. 28. Cooper SA. Five studies on ibuprofen for postsurgical pain. Am J Med 1984;77(1A):70-7. 29. Wilson S, Ngan P, Kess B. Time course of the discomfort in young patients undergoing orthodontic treatment. Pediatr Dent 1989;11: 107-10. 30. Seymour RA, Simpson JM, Charlton JE, Phillips ME. An evaluation of length end-phrase of visual analogue scales in dental pain. Pain 1985;21:177-85. 31. Young AN, Taylor RW, Taylor SE, Linnebur SA, Buschang PH. Evaluation of preemptive valdecoxib therapy on initial archwire placement discomfort in adults. Angle Orthod 2006;76:251-9. 32. Bartlett BW, Firestone AR, Vig KWL, Beck FM, Marucha PT. The inuence of a structured telephone call on orthodontic pain and anxiety. Am J Orthod Dentofacial Orthop 2005;128:435-41.