THE EFFICACY OF LASER THERAPY AND IBUPROFEN ON PAIN AFTER ELASTOMERIC SEPARATOR PLACEMENT: RAPID REVIEW

Background: Separator placement is the first step in orthodontic treatment, which aims to create space between teeth before molar band placement. This procedure can cause pain for the patient. Pain management after separator placement can be done through pharmacological and non-pharmacological approaches. Method: The aim of this rapid review was to determine the efficacy of laser therapy and ibuprofen for pain management after elastomeric separator placement in orthodontic treatment. Result: Ten articles were included in this review, four articles gave laser therapy interventions and six articles gave ibuprofen therapy interventions. The result of the quality assessment using Strength of Recommendation Taxonomy (SORT) was laser therapy intervention has one good quality articles and three limited-quality articles, while ibuprofen therapy has two good quality articles and four limited-quality articles. Conclusion: The efficacy of laser therapy and the efficacy of ibuprofen on pain after separator placement is good, with the strength of the clinical recommendation of ibuprofen is better than laser therapy.


INTRODUCTION
Separators are used to create space for placement of band that later anchors the fixed orthodontic appliance. 1 The use of elastic separators is widely spread in orthodontic treatment, not only for their convenience in handling, but also due to storage, and produced significantly more space compared to the spring separators. 1,2 Placement of separator induces pain in patients. Pain usually begins at 4 hours after separator placement, increases to a peak level at 24 hours, remains bother for the next 3 days, and diminishes over the next 6-8 days. The pain experienced is due to the constant pressure, ischemia, inflammation, and edema in the periodontal ligaments of the teeth that are moved during orthodontic movements. 1,[3][4][5] Pain is a subjective response which shows large individual variation. It is affected by some factors such as age, gender, individual pain threshold, magnitude of force applied, present emotional state and stress, cultural differences and previous pain experiences. 3,[6][7][8][9] Pain due to orthodontic treatment is defined as a moderate level of pain and a tolerable mild-to-moderate jaw discomfort. 10 Pain has been the prime reason for discontinuation of orthodontic treatment. 1,10 Several methods have been invented to alleviate orthodontic pain in clinical practice, including pharmacological approaches, mechanical approaches, laser irradiation therapy and behavioural approaches. 11,12 Ibuprofen is a nonsteroidal anti-inflammatory drug that has antinociception, anti-inflammatory, and antipyretic effects. It acts as a non-selective inhibitor of the cyclo-oxygenase 1 (COX-1) and COX-2. 13 Ibuprofen is significantly effective in reducing pain. 5, [13][14][15] Laser, a highly popular technological application in recent times, is also being used as an alternative to reduce pain without affecting tooth movement. 8, 16 Laser is thought to control pain by hyperpolarization of the nerve cell membrane, which increases the patient's pain threshold. 16 The aim of this rapid review was to determine the efficacy of laser therapy and ibuprofen for pain management after elastomeric separator placement in orthodontic treatment.

LITERATURE REVIEW
The eligibility criteria were used in the selection of the articles:    Tools for randomized control trial is presented in Figure 2. The ibuprofen, paracetamol, aspirin group showed lower pain level than the placebo group during spontaneous pain, posterior occlusion, and chewing 2 hours after separator placement, significance not stated. The aspirin and ibuprofen groups showed lower pain level than the paracetamol and the placebo groups during chewing and posterior occlusion 6 hours after separator placement, significance not stated. The ibuprofen group showed lower pain level compared to the placebo group during all time evaluation, significance not stated Figure 2 The risk of subjectivity of the included studies [28] low risk, high risk, unclear risk

DISCUSSION
The heterogeneity of study designs such as differences in intervention components, study evaluation periods, comparison groups, and expectations about its effects. 32 The placebo effect was affected by expectations and closely related to emotional factors. 33,34 The analgesic effect was obtained by suggestion through patient's expectations when taking a tablet that they believe was an analgesic. 18 All articles containing ibuprofen for pain management after elastomeric separator placement gave it 1 hour prior to separator placement. Ibuprofen was rapidly and completely absorbed 1-2 hours after oral administration. 35,36 The aim of analgesics administration before treatment was to block the afferent nerve impulses before they reach to the central nervous system.
The body has enough time to absorb and distribute the drug before tissue damage and prostaglandin sequence production, and consequently would reduce inflammation reactions. 13 All included articles mentioned that the pain after separator placement peaked after 24 hours. whereas ibuprofen seemed to be a cheaper, simpler and rather cost-effective treatment option. 43 The use of an analgesic drug should only be adopted for patients with less tolerant of pain, meanwhile a single application of low level laser therapy does not seem to provide a fully effective protocol for this purpose. 45 Therefore, ibuprofen could be used for pain management after elastomeric separator placement. While, low-level laser therapy can be used as an alternative to non-pharmacological pain management in patients who have contraindications to the use of ibuprofen.

CONCLUSION
The efficacy of laser therapy and the efficacy of ibuprofen on pain after separator placement is good, with the strength of the clinical recommendation of ibuprofen is better than laser therapy.