Valsalva Maneuver in Dentistry: Clinical Guide

The Valsalva maneuver is a forced expiratory effort performed against a closed airway that produces transient increases in intrathoracic and intranasal pressure.

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Although widely used in cardiovascular and autonomic testing, the maneuver also has a specific role in oral and maxillofacial diagnosis, particularly when an oroantral communication (OAC) is suspected after procedures involving the posterior maxilla.

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In dentistry, the maneuver can help identify an abnormal connection between the oral cavity and the maxillary sinus by demonstrating air movement through the suspected communication. However, it should be regarded as a clinical adjunct rather than a definitive diagnostic test.

✅ What Is the Valsalva Maneuver?
The conventional Valsalva maneuver consists of attempting to exhale forcefully while the airway is closed. This increases intrathoracic pressure and produces predictable cardiovascular and respiratory responses. The magnitude of these responses varies according to the duration and intensity of straining, body position, lung volume, and breathing pattern.
In oral surgery, a modified and gentle form of the maneuver may be used to assess suspected communication between the oral cavity and maxillary sinus.

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✅ Valsalva Maneuver for Oroantral Communication
An oroantral communication is an abnormal connection between the oral cavity and maxillary sinus, most commonly associated with extraction of posterior maxillary teeth because of their anatomical proximity to the sinus floor. Implant surgery, sinus augmentation, trauma, and other maxillary procedures can also produce this complication.
During the clinical examination, increased pressure within the nasal and sinus cavities may cause air to pass through an OAC and emerge into the oral cavity. Clinically, this may appear as air bubbles, bleeding, fluid movement, or an audible air leak at the extraction socket or suspected communication.

Clinical Technique
The maneuver should be performed gently and only when clinically indicated:
1. Position the patient comfortably, preferably upright.
2. Keep the patient's mouth open.
3. Ask the patient to close the nostrils gently.
4. Instruct the patient to attempt a gentle exhalation against the closed nasal passages.
5. Observe the extraction socket or suspected communication for air bubbles, movement of blood or secretions, or an audible air leak.
6. Stop the maneuver immediately after obtaining a clinically meaningful response.

The objective is to generate sufficient pressure to identify air passage without producing excessive pressure within the maxillary sinus.

✅ Interpretation of the Test

Finding	Possible Interpretation
Air bubbles at the socket	Suggestive of oroantral communication
Air or blood movement through the opening	Supports the presence of communication
Audible air leakage	May indicate an oroantral defect
No detectable air movement	Does not reliably exclude a small communication
Persistent sinus-related symptoms	Requires additional clinical and radiographic evaluation

A positive response supports the clinical diagnosis, but a negative Valsalva test cannot exclude an OAC, particularly when the communication is small or partially obstructed by tissue or inflammatory material.

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✅ Diagnostic Limitations
The Valsalva maneuver should not be considered a standalone diagnostic procedure. Small communications may produce no visible clinical response, resulting in false-negative findings. Recent literature has specifically highlighted the limited sensitivity of the post-extraction Valsalva test for small OACs.
When clinical suspicion persists, additional evaluation may include periapical or panoramic radiography, while cone-beam computed tomography (CBCT) can provide three-dimensional information about the defect and the condition of the maxillary sinus.

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✅ Important Clinical Precautions
The maneuver should be performed with minimal and controlled pressure. Excessive pressure may theoretically enlarge a fresh communication or promote the displacement of oral contaminants toward the maxillary sinus. Contemporary clinical literature therefore recommends caution when using the test.
Routine aggressive probing of a suspected communication is also undesirable because instrumentation can traumatize the sinus membrane or introduce bacteria and foreign material into the sinus.

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🎯 Clinical Recommendations
▪️ Use the Valsalva maneuver as an adjunct, not as the sole method for diagnosing an oroantral communication.
▪️ Perform it gently and briefly, particularly immediately after extraction.
▪️ If clinical suspicion remains despite a negative result, consider appropriate radiographic or CBCT evaluation.
▪️ Avoid forceful pressure and unnecessary probing of a fresh extraction socket.
▪️ Document the clinical findings and evaluate the patient for symptoms or signs of maxillary sinus involvement.

💬 Discussion
The Valsalva maneuver remains a simple chairside method for detecting clinically apparent oroantral communication, particularly following posterior maxillary extraction. Its principal advantage is its immediate availability and ability to demonstrate air passage through a communication without specialized equipment.
Its principal limitation is diagnostic sensitivity. A negative test does not exclude a small defect, and excessive pressure may be undesirable in a recently created communication. Therefore, the maneuver should form part of a broader diagnostic assessment that incorporates the surgical history, intraoral findings, symptoms, and appropriate imaging.

✍️ Conclusion
The Valsalva maneuver in dentistry is a useful clinical adjunct for detecting suspected oroantral communication, particularly after posterior maxillary procedures. A positive finding can provide immediate evidence of communication, whereas a negative result does not reliably exclude a small defect. Careful technique, minimal pressure, and appropriate radiographic assessment when indicated are essential for safe and accurate clinical decision-making.

📚 References

✔ Arslanoglou, N. M., Plakogiannaki, E., Stergiou, T., Kafas, P., Lillis, T., & Dabarakis, N. (2026). Post-extraction false-negative Valsalva test in oroantral communications: Diagnostic challenges and clinical implications. European Journal of Dental and Oral Health, 7(4), 6–13. https://doi.org/10.24018/ejdent.2026.7.4.70550
✔ Khandelwal, P., & Hajira, N. (2017). Management of oro-antral communication and fistula: Various surgical options. World Journal of Plastic Surgery, 6(1), 3–8.
✔ Parvini, P., Obreja, K., Begic, A., Schwarz, F., Becker, J., & Sader, R. (2019). Decision-making in closure of oroantral communication and fistula. International Journal of Implant Dentistry, 5, 13. https://doi.org/10.1186/s40729-019-0165-7
✔ Pstras, L., Thomaseth, K., Waniewski, J., Balzani, I., & Bellavere, F. (2016). The Valsalva manoeuvre: Physiology and clinical examples. Acta Physiologica, 217(2), 103–119. https://doi.org/10.1111/apha.12639
✔ Visscher, S. H., van Minnen, B., & Bos, R. R. M. (2010). Closure of oroantral communications: A review of the literature. Journal of Oral and Maxillofacial Surgery, 68(6), 1384–1391. https://doi.org/10.1016/j.joms.2009.07.026

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Peri-Implantitis: Clinical and Radiographic Features

Peri-implantitis is a plaque-associated inflammatory disease affecting the tissues surrounding a dental implant and characterized by inflammation of the peri-implant mucosa accompanied by progressive loss of supporting bone.

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Unlike peri-implant mucositis, peri-implantitis involves radiographically detectable bone loss beyond the initial remodeling phase.

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Early identification depends on combining clinical examination, peri-implant probing, bleeding assessment, and standardized radiographic evaluation. No single clinical finding is sufficient to establish the diagnosis.

✅ Clinical Features of Peri-Implantitis
The clinical presentation is characterized primarily by signs of peri-implant inflammation and progressive changes in peri-implant tissue dimensions.

The principal findings include:
▪️ Bleeding on probing (BOP): A frequent indicator of peri-implant inflammation. Bleeding occurring shortly after gentle probing is particularly relevant.
▪️ Suppuration: May be present and indicates an inflammatory lesion, although its absence does not exclude peri-implantitis.
▪️ Increased probing depth (PD): Increasing PD compared with measurements obtained after prosthetic reconstruction is an important diagnostic finding.
▪️ Mucosal swelling and erythema: Reflect soft-tissue inflammation around the implant.
▪️ Mucosal recession: May expose the implant surface and contribute to an increased measured probing depth.
▪️ Progressive loss of peri-implant support: Represents the fundamental pathological component distinguishing peri-implantitis from peri-implant mucositis.
▪️ Implant mobility: Generally represents advanced loss of osseointegration rather than an early diagnostic feature and should be distinguished from mobility caused by prosthetic or mechanical complications.

The 2017 World Workshop consensus describes peri-implantitis sites as exhibiting inflammation, bleeding and/or suppuration, increased probing depths and/or mucosal recession, together with radiographic bone loss.

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✅ Clinical Diagnostic Criteria

Clinical Finding	Typical Finding	Diagnostic Significance
Bleeding on probing	Bleeding after gentle probing	Indicates peri-implant inflammation
Suppuration	Purulent exudate on probing	Supports the presence of active inflammation
Increased probing depth	Increase compared with baseline	Important indicator of disease progression
Erythema and swelling	Inflamed peri-implant mucosa	Supports peri-implant inflammation
Mucosal recession	Apical displacement of the mucosal margin	May accompany tissue breakdown and increase probing depth

✅ Radiographic Features of Peri-Implantitis
Radiographic assessment is essential because peri-implantitis is defined partly by progressive loss of supporting bone. The most important radiographic parameter is the change in marginal peri-implant bone level relative to an appropriate baseline examination.

1. Progressive Marginal Bone Loss
The principal radiographic feature is bone loss around the implant beyond the expected initial remodeling.
A baseline radiograph obtained after completion of the implant-supported prosthesis provides an important reference for subsequent comparisons. When previous radiographs are unavailable, the 2018 diagnostic consensus proposed that a radiographic bone level ≥3 mm, combined with BOP and probing depth ≥6 mm, is indicative of peri-implantitis.

2. Vertical and Horizontal Bone Loss
Radiographic bone destruction may present as:
▪️ Horizontal or crestal bone loss
▪️ Vertical/intrabony defects
▪️ Circumferential bone defects
Peri-implantitis lesions may have complex three-dimensional configurations that are not completely represented by conventional two-dimensional imaging.

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3. Progressive Changes on Serial Radiographs
Comparison of standardized radiographs over time is particularly valuable. Reproducible imaging geometry facilitates detection of relatively small changes in the peri-implant bone contour and level. Current radiological reviews continue to consider intraoral radiography the standard approach for routine assessment and follow-up, while CBCT is reserved for selected clinical situations.

4. CBCT Findings
Cone-beam computed tomography (CBCT) can provide additional information about the three-dimensional morphology of peri-implant defects, particularly buccal and lingual bone dimensions that may be poorly represented on periapical radiographs.
However, CBCT should not be considered a routine replacement for intraoral radiography. Metallic artifacts can obscure peri-implant structures, and the additional radiation exposure must be justified by the diagnostic question.

✅ Clinical and Radiographic Correlation

Parameter	Peri-Implant Mucositis	Peri-Implantitis
Inflammation	Present	Present
Bleeding on probing	Usually present	Usually present
Probing depth	May increase because of inflammation	Increased compared with baseline or associated with bone loss
Radiographic bone loss	Absent beyond initial remodeling	Present and progressive
Supporting bone loss	No disease-related loss	Characteristic feature

✅ Differential Diagnostic Considerations
Radiographic bone loss around an implant should not automatically be interpreted as peri-implantitis. The clinician should consider:

▪️ Initial physiological bone remodeling
▪️ Peri-implant mucositis without progressive bone loss
▪️ Mechanical complications
▪️ Implant malposition
▪️ Excessive restorative contour or plaque-retentive prosthetic design
▪️ Endodontic lesions associated with adjacent teeth
▪️ Periapical implant lesions
▪️ Occlusal or prosthetic complications

Consequently, diagnosis requires clinical–radiographic correlation, rather than interpretation of an isolated radiographic finding.

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💬 Discussion
The diagnosis of peri-implantitis is fundamentally longitudinal. The most informative assessment combines inflammation, probing findings, and changes in radiographic bone level over time. The absence of a baseline radiograph makes diagnosis more difficult, which is why baseline probing and radiographic measurements after completion of the implant-supported prosthesis are recommended.
Current evidence also supports the continued use of standardized intraoral radiographs for routine monitoring. CBCT offers valuable three-dimensional information when the morphology or extent of a peri-implant defect cannot be adequately characterized with conventional imaging, but its routine use is not supported.
Emerging technologies, including artificial intelligence applied to radiographic images, may improve detection and quantification of peri-implant bone loss. However, current AI evidence is predominantly retrospective and internally validated, with substantial methodological limitations; these technologies should therefore be considered adjunctive rather than established diagnostic standards.

✍️ Conclusion
Peri-implantitis is characterized by peri-implant inflammation combined with progressive loss of supporting bone. The principal clinical findings are bleeding on probing, increased probing depth, suppuration, mucosal inflammation, and, in some cases, recession. The principal radiographic finding is bone loss beyond the initial remodeling phase.
Accurate diagnosis requires standardized clinical and radiographic assessment, preferably supported by baseline records. Intraoral radiography remains central to routine monitoring, whereas CBCT should be used selectively when three-dimensional information is clinically necessary.

🎯 Clinical Recommendations
▪️ Establish baseline probing depths and standardized intraoral radiographs after completion of the implant-supported prosthesis.
▪️ Compare subsequent examinations with baseline measurements rather than relying exclusively on absolute probing-depth values.
▪️ Interpret bleeding on probing together with radiographic bone changes; neither finding should be considered in isolation.
▪️ When previous radiographs are unavailable, use the established diagnostic combination of bone level ≥3 mm, probing depth ≥6 mm, and bleeding on probing as a clinical reference.
▪️ Reserve CBCT for cases in which conventional radiography does not adequately characterize the suspected defect, particularly when three-dimensional morphology will influence diagnosis or treatment planning.
▪️ Distinguish disease-associated bone loss from initial remodeling, mechanical complications, and other peri-implant or adjacent-tooth pathology.
▪️ Document clinical and radiographic findings longitudinally to identify progressive disease as early as possible.

📚 References

✔ Berglundh, T., Armitage, G., Araujo, M. G., Avila-Ortiz, G., Blanco, J., Camargo, P. M., Chen, S., Cochran, D., Derks, J., Figuero, E., Hämmerle, C. H. F., Heitz-Mayfield, L. J. A., Huynh-Ba, G., Iacono, V., Koo, K.-T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S., Salvi, G. E., Schwarz, F., Tarnow, D., Tomasi, C., Wang, H.-L., & Zitzmann, N. (2018). Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Journal of Clinical Periodontology, 45(Suppl. 20), S286–S291. https://doi.org/10.1111/jcpe.12957
✔ Renvert, S., Hirooka, H., Polyzois, I., Kelekis-Cholakis, A., Wang, H.-L., & Working Group 3. (2018). Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants: Consensus report of working group 3. Journal of Clinical Periodontology, 45(Suppl. 20), S313–S318. https://doi.org/10.1111/jcpe.12957
✔ Heitz-Mayfield, L. J. A., Salvi, G. E., Mombelli, A., Faddy, M., & Lang, N. P. (2018). Peri-implant mucositis and peri-implantitis: Case definitions and diagnostic considerations. Journal of Clinical Periodontology, 45(Suppl. 20), S246–S252. https://doi.org/10.1111/jcpe.12956
✔ Schwarz, F., Derks, J., Monje, A., & Wang, H.-L. (2018). Peri-implantitis. Journal of Clinical Periodontology, 45(Suppl. 20), S246–S266. https://doi.org/10.1111/jcpe.12954
✔ Wismeijer, D., et al. (2024). Radiographic assessment of the peri-implant site. Periodontology 2000. https://doi.org/10.1111/prd.12577
✔ Jacobs, R., Vranckx, M., Vanderstuyft, T., Quirynen, M., & Salmon, B. (2018). CBCT vs other imaging modalities to assess peri-implant bone and diagnose complications: A systematic review. European Journal of Oral Implantology, 11(Suppl. 1), 77–92.
✔ Herrera, D., Berglundh, T., Schwarz, F., Chapple, I., Jepsen, S., Sculean, A., Kebschull, M., Papapanou, P. N., Tonetti, M. S., & Sanz, M. (2023). Prevention and treatment of peri-implant diseases—The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology, 50(Suppl. 26), 4–76. https://doi.org/10.1111/jcpe.13823

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Medications That Interfere With Orthodontics: Clinical Guide

Orthodontic tooth movement (OTM) is a biologically regulated process that depends on periodontal ligament responses, inflammatory mediators, osteoclast activity, and coordinated alveolar bone remodeling.

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Because several medications influence these pathways, systemic pharmacotherapy can potentially modify the rate of orthodontic tooth movement, anchorage, treatment duration, or management of orthodontic pain.

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The clinical relevance varies substantially between drug classes. Current evidence identifies nonsteroidal anti-inflammatory drugs (NSAIDs) and antiresorptive medications, particularly bisphosphonates, as the most important groups to recognize during orthodontic treatment. However, much of the available evidence remains heterogeneous, with considerable reliance on animal and experimental studies.

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🔹 How Medications Can Affect Orthodontic Tooth Movement
Orthodontic movement requires bone resorption on the pressure side and bone formation on the tension side. Medications that modify prostaglandin production, osteoclast differentiation, or systemic bone turnover may therefore alter the biological response to orthodontic forces.
The principal clinically relevant medications are summarized below.

Medication Class	Examples	Potential Effect on OTM	Clinical Relevance
NSAIDs	Ibuprofen, aspirin, diclofenac, ketorolac, meloxicam	May reduce movement by inhibiting prostaglandin-mediated bone remodeling	Most relevant with repeated or prolonged use
Bisphosphonates	Alendronate, risedronate, zoledronic acid	Reduced osteoclast activity and potentially slower OTM	Important in long-term therapy; requires individualized assessment
Other Antiresorptives	Denosumab and related agents	Potential modification of bone turnover and OTM	Clinical evidence is less established than for bisphosphonates
Corticosteroids	Prednisone, dexamethasone	May modify bone remodeling; effects are variable	Greater consideration with chronic systemic therapy
Hormonal and Bone-Metabolism Agents	Thyroid hormone, vitamin D, parathyroid hormone analogues	Potential alteration of bone turnover and OTM	Evidence is mainly experimental or heterogeneous
Other Systemic Medications	Statins, metformin, propranolol and others	Variable effects reported in experimental studies	Insufficient evidence for routine clinical modification of treatment

1. Nonsteroidal Anti-Inflammatory Drugs
NSAIDs are among the most clinically relevant medications because prostaglandins participate in the inflammatory and bone-remodeling processes associated with orthodontic movement.
Experimental and clinical evidence indicates that some NSAIDs can reduce the rate of OTM. Aspirin, diclofenac, ketorolac, and nimesulide have demonstrated inhibitory effects, whereas findings for ibuprofen, meloxicam, and celecoxib are more inconsistent and appear to depend on dose, duration, and route of administration.
Importantly, the evidence does not support avoiding NSAIDs categorically. They remain effective for orthodontic pain, and short-term use does not necessarily produce a clinically meaningful reduction in tooth movement. The 2026 systematic review of acetaminophen versus ibuprofen also confirms their role in orthodontic pain control, while the broader literature continues to show uncertainty regarding their effect on OTM.
Acetaminophen (paracetamol) differs pharmacologically from traditional NSAIDs and has generally demonstrated less interference with orthodontic tooth movement. It has therefore been extensively investigated as an alternative for orthodontic pain management.

2. Bisphosphonates and Antiresorptive Medications
Bisphosphonates inhibit osteoclast-mediated bone resorption and represent the medication group with the most consistently documented inhibitory effect on orthodontic tooth movement.
Alendronate, risedronate, and other bisphosphonates can reduce bone turnover and potentially slow orthodontic tooth movement. A 2026 umbrella review found that all included systematic reviews reported reduced OTM following bisphosphonate administration, although most of the underlying evidence was derived from animal studies. Human evidence remains limited and does not allow firm conclusions regarding the magnitude of the clinical effect.
This issue is particularly relevant in adults receiving long-term antiresorptive therapy for osteoporosis, Paget disease, or malignancy-associated bone disease. The medication history should be documented before initiating orthodontic treatment.

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3. Corticosteroids
Systemic corticosteroids can influence bone remodeling and osteoblast–osteoclast activity. However, their effect on orthodontic tooth movement is less predictable than that of NSAIDs or bisphosphonates.
Short-term and long-term corticosteroid exposure should therefore not be interpreted identically. Chronic systemic therapy may have greater implications for bone metabolism and periodontal health, but the available evidence is insufficient to establish a uniform effect on orthodontic movement.

4. Hormonal and Bone-Metabolism Medications
Medications and agents that modify systemic bone turnover—including thyroid hormones, vitamin D, parathyroid hormone analogues, and sex-hormone-related therapies—have been investigated as potential modifiers of OTM.
Some experimental studies suggest acceleration or inhibition of tooth movement depending on the agent and biological context. Nevertheless, the clinical evidence is heterogeneous, and most findings cannot currently justify changing orthodontic mechanics solely because a patient uses one of these medications.

5. Other Common Medications
Several commonly prescribed drugs—including statins, metformin, propranolol, calcium compounds, losartan, and some gastrointestinal medications—have demonstrated effects on orthodontic tooth movement in animal studies. However, the quality of evidence is generally low, and findings cannot be directly extrapolated to routine human orthodontic care.
Therefore, these medications should be considered part of the patient's pharmacological history rather than automatically classified as contraindications to orthodontic treatment.

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💬 Discussion
The relationship between medications and orthodontic tooth movement is biologically plausible but clinically complex. The strongest evidence concerns medications that directly modify inflammatory signaling or osteoclast-mediated bone resorption. NSAIDs may interfere with prostaglandin-dependent remodeling, while bisphosphonates have a more pronounced antiresorptive mechanism.
Nevertheless, the overall certainty of evidence remains limited. A 2026 systematic review included 64 studies and concluded that much of the available evidence was derived from preclinical models, with overall certainty ranging from low to very low. Consequently, laboratory findings should not automatically be translated into changes in clinical orthodontic protocols.
The practical implication is not that patients taking these medications should routinely discontinue therapy or be excluded from orthodontic treatment. Rather, medication history should be integrated into orthodontic diagnosis, treatment planning, and monitoring. Any modification or discontinuation of a systemic medication should be determined by the prescribing physician or appropriate medical specialist.

✍️ Conclusion
Several medications can potentially interfere with orthodontic tooth movement, primarily through effects on prostaglandin signaling, osteoclast activity, or systemic bone remodeling. NSAIDs and bisphosphonates have the clearest evidence of potential inhibitory effects, whereas the clinical significance of corticosteroids and other systemic medications remains less certain.
A comprehensive medication history is therefore an important component of orthodontic assessment, particularly in adults receiving chronic pharmacological therapy. Current evidence supports individualized monitoring rather than routine alteration or discontinuation of medically indicated medications.

🎯 Clinical Recommendations
▪️ Obtain a complete medication history before initiating orthodontic treatment and update it during treatment.
▪️ Identify patients receiving long-term bisphosphonate or other antiresorptive therapy and assess the indication, duration, route, and medical context.
▪️ For orthodontic pain, consider the shortest effective duration of analgesic therapy, taking the patient's general medical status into account.
▪️ Do not discontinue or alter a medically necessary medication solely to accelerate orthodontic tooth movement; coordinate such decisions with the prescribing physician.
▪️ In patients receiving medications that may alter bone remodeling, monitor tooth movement response and treatment progress rather than assuming a predictable treatment delay.
▪️ Interpret evidence from animal studies cautiously because the clinical magnitude of pharmacological effects on human OTM remains uncertain.

📚 References

▪️ Giannini, L., Macrì, F., Inchingolo, A. M., Inchingolo, F., Dipalma, G., & Maspero, C. (2026). Influence of pharmacological agents on orthodontic tooth movement: A systematic review. Bioengineering, 13(2), 224. https://doi.org/10.3390/bioengineering13020224
▪️ Amin, S., Cremona, M., & Abela, S. (2026). Effect of bisphosphonates on orthodontic tooth movement: An umbrella review. BMC Oral Health. https://doi.org/10.1186/s12903-026-08984-2
▪️ Colceriu-Șimon, I.-M., Feștilă, D., Emoke, H., Pancsur, A., Șimon, M. Ș., Olteanu, C. D., Păstrav, M., Bunta, O., & Ghergie, M. (2025). The effects of non-steroidal anti-inflammatory drugs used for orthodontic pain management on tooth movement: A comprehensive review of the literature. Journal of Clinical Medicine, 14(9), 2920. https://doi.org/10.3390/jcm14092920
▪️ Neves, N. M., Rodrigues, Á. O. L. J., Bordin, G. M., Occhi-Alexandre, I. G. P., Orsi, J. S. R., Gabardo, M. C. L., & Topolski, F. (2026). Effectiveness of acetaminophen in comparison with ibuprofen for pain control in orthodontic patients: A systematic review and meta-analysis. Korean Journal of Orthodontics, 56(3), 187–199. https://doi.org/10.4041/kjod25.273
▪️ Makrygiannakis, M. A., Kaklamanos, E. G., & Athanasiou, A. E. (2018). Does common prescription medication affect the rate of orthodontic tooth movement? A systematic review. European Journal of Orthodontics, 40(6), 649–659. https://doi.org/10.1093/ejo/cjy001
▪️ Rakhshan, V. (2017). The influence of non-steroidal anti-inflammatory drugs and paracetamol used for pain control of orthodontic tooth movement: A systematic review. Dental Press Journal of Orthodontics, 22(5), 64–72.

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Top 5 Dental Analgesics and Their Indications

Acute dental pain is commonly associated with pulpal inflammation, periapical disease, periodontal procedures, tooth extraction, endodontic treatment, and oral surgery.

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Pharmacological management should be based on the underlying diagnosis, expected pain intensity, patient-specific risk factors, and the anticipated duration of symptoms.

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Current evidence-based guidelines recommend nonopioid analgesics as first-line therapy for acute dental pain, particularly nonsteroidal anti-inflammatory drugs (NSAIDs) alone or combined with acetaminophen. NSAIDs are particularly relevant because inflammatory mediators contribute substantially to postoperative and odontogenic pain.
The following five agents represent commonly encountered options in dental practice: ibuprofen, naproxen, acetaminophen, diclofenac, and ketorolac. Their pharmacological profiles and safety considerations differ considerably.

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1. Ibuprofen
Ibuprofen is one of the most frequently used NSAIDs for acute dental pain. It inhibits cyclooxygenase (COX) enzymes and reduces prostaglandin synthesis, thereby providing both analgesic and anti-inflammatory effects.
For adolescents and adults, the 2024 ADA guideline identifies ibuprofen 400 mg as an appropriate first-line option after tooth extraction. Depending on clinical circumstances, higher therapeutic doses may be used under professional supervision.

Main indications
▪️ Postoperative dental pain
▪️ Simple or surgical tooth extraction
▪️ Endodontic pain
▪️ Acute inflammatory dental pain
▪️ Mild-to-moderate odontogenic pain
Ibuprofen can also be combined with acetaminophen, providing analgesia through complementary mechanisms. Evidence indicates that this combination can provide substantial pain relief without the adverse-effect profile associated with routine opioid use.
Important precautions: NSAIDs should be used cautiously or avoided in patients with significant gastrointestinal disease, renal impairment, certain cardiovascular conditions, NSAID hypersensitivity, or other contraindications.

2. Naproxen
Naproxen, particularly naproxen sodium, is another NSAID used for acute dental pain. Its relatively long duration of action can be clinically useful when sustained analgesia is desirable.
The ADA guideline specifically identifies naproxen sodium 440 mg as a first-line option for acute postoperative dental pain. The guideline lists a maximum daily dose of 1,100 mg of naproxen sodium for the relevant adult/adolescent recommendations.
Clinical trials involving postoperative third-molar pain have demonstrated significant analgesic efficacy with naproxen, with some evidence suggesting a longer duration of pain relief than ibuprofen at commonly used doses.

Main indications
▪️ Moderate acute dental pain
▪️ Post-extraction pain
▪️ Oral surgical procedures
▪️ Inflammatory dental pain
▪️ Situations in which longer analgesic duration is desirable
As with other NSAIDs, gastrointestinal, renal, cardiovascular, bleeding, and hypersensitivity risks should be considered before prescribing.

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3. Acetaminophen (Paracetamol)
Acetaminophen, also known as paracetamol, is an analgesic and antipyretic but has substantially weaker peripheral anti-inflammatory activity than NSAIDs.
Its clinical importance in dentistry is particularly related to its use when NSAIDs are contraindicated and as part of a combination regimen with an NSAID. The ADA guideline recommends acetaminophen alone when NSAIDs cannot be used.

Main indications
▪️ Mild-to-moderate acute dental pain
▪️ Patients with contraindications to NSAIDs
▪️ Combination therapy with ibuprofen or naproxen
▪️ Postoperative dental pain
The 2024 ADA guideline uses acetaminophen 500 mg as an example when combined with an NSAID and identifies 1,000 mg as a full therapeutic dose when acetaminophen is used alone in the relevant clinical context.
The principal safety concern is dose-dependent hepatotoxicity, particularly with excessive cumulative dosing or concurrent use of multiple acetaminophen-containing products. Patients with significant hepatic disease or substantial alcohol exposure require individualized assessment.

4. Diclofenac
Diclofenac is an NSAID with analgesic and anti-inflammatory activity. It has been investigated extensively for postoperative dental pain and may be used in some countries as an alternative to ibuprofen or naproxen.
Clinical research has demonstrated analgesic efficacy of diclofenac following third-molar extraction, including efficacy comparable with acetaminophen in some dosing regimens.

Main indications
▪️ Postoperative dental pain
▪️ Oral surgical procedures
▪️ Acute inflammatory odontogenic pain
▪️ Moderate dental pain when an NSAID is clinically appropriate
Because diclofenac is an NSAID, the same major considerations concerning gastrointestinal, renal, cardiovascular, bleeding, and hypersensitivity risks apply. It should be prescribed at the lowest effective dose for the shortest appropriate duration.

5. Ketorolac
Ketorolac is a potent NSAID generally reserved for short-term management of moderately severe acute pain. Evidence from dental studies supports its analgesic efficacy after third-molar surgery and following endodontic treatment. Recent systematic reviews have also reported beneficial effects in post-endodontic pain.
However, ketorolac has a more restrictive safety profile than commonly used NSAIDs. In the United States, the oral formulation is indicated only as continuation therapy following IV or IM ketorolac and the total duration of ketorolac therapy must not exceed 5 days.

Main indications
▪️ Short-term management of moderately severe acute pain
▪️ Selected postoperative oral surgical pain
▪️ Selected post-endodontic pain
Ketorolac should not be considered a routine first-line analgesic for uncomplicated dental pain. Its gastrointestinal and renal risks require careful patient selection, and it is contraindicated in several high-risk clinical situations.

✅ Comparison of the Top 5 Dental Analgesics

Analgesic	Class	Common Dental Indications	Key Clinical Consideration
Ibuprofen	NSAID	Acute inflammatory and postoperative dental pain	Common first-line option; can be combined with acetaminophen
Naproxen	NSAID	Moderate postoperative and inflammatory dental pain	Longer duration of action than ibuprofen in some clinical studies
Acetaminophen	Non-NSAID analgesic	Mild-to-moderate pain; NSAID contraindications	Monitor cumulative dose and hepatic risk
Diclofenac	NSAID	Postoperative and inflammatory dental pain	Consider gastrointestinal, renal, cardiovascular, and bleeding risks
Ketorolac	NSAID	Selected short-term moderate-to-severe acute pain	Restricted duration and greater safety concerns; not routine first-line therapy

✅ How Should the Analgesic Be Selected?
Analgesic selection should not depend exclusively on pain intensity. The clinician should consider the inflammatory component of the pain, expected duration, medical history, concomitant medications, renal and hepatic function, gastrointestinal risk, cardiovascular status, and previous adverse reactions.
For most adolescents and adults with acute dental pain, an NSAID such as ibuprofen or naproxen is an appropriate starting point when no contraindication exists. Combining an NSAID with acetaminophen can provide complementary analgesia and is supported by the current evidence base.
Importantly, analgesics should serve as an adjunct to definitive dental treatment, rather than replacing treatment of the underlying cause. For pulpal and periapical disease, definitive procedures such as pulpectomy, root canal treatment, drainage, or extraction may be necessary depending on the diagnosis.

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Dental Article 🔽 Diclofenac, Ibuprofen, or Acetaminophen - Which Analgesic Should Be Used in Dentistry? ... This article analyzes their mechanisms of action, pharmacological behavior, clinical indications, precautions, and comparative effectiveness in dental practice.

🎯 Clinical Recommendations
This section is more appropriate than Clinical Pearls because the topic is fundamentally pharmacological and requires direct clinical application of current evidence.
▪️ Use NSAIDs as first-line pharmacological therapy for most acute dental pain when no contraindication exists.
▪️ Consider ibuprofen or naproxen, alone or with acetaminophen, according to the expected pain level and patient-specific risk profile.
▪️ Use acetaminophen alone when NSAIDs are contraindicated, while carefully assessing hepatic risk and total daily exposure.
▪️ Reserve ketorolac for selected short-term situations because of its more restrictive safety profile and duration limitations.
▪️ Do not prescribe multiple NSAIDs concurrently; combining agents from the same NSAID class increases toxicity without providing an established therapeutic advantage.
▪️ Reassess persistent or worsening pain rather than simply escalating analgesic therapy, particularly when symptoms persist after extraction or when definitive treatment has not been completed.

💬 Discussion
The current evidence has shifted dental pain management toward nonopioid analgesia, particularly NSAIDs with or without acetaminophen. The 2024 ADA-endorsed guideline concluded that nonopioid medications provide a more favorable balance of benefits and harms than opioids for acute dental pain.
Among the agents discussed, ibuprofen and naproxen have particularly strong clinical relevance for routine acute dental pain, while acetaminophen provides an important alternative when NSAIDs cannot be used and an effective component of combination therapy. Diclofenac remains a useful NSAID in appropriate settings, whereas ketorolac requires more restrictive patient selection because of its adverse-effect profile and regulatory limitations.
Analgesic therapy should therefore be individualized rather than based on a fixed hierarchy of medications. The lowest effective dose for the shortest clinically appropriate duration remains a central principle of safe pharmacological management.

✍️ Conclusion
Dental analgesics are an important component of managing acute odontogenic and postoperative pain, but their selection should be guided by diagnosis, expected pain severity, contraindications, and patient-specific risk factors.
Current evidence supports NSAIDs as first-line therapy, with ibuprofen and naproxen representing common options. Acetaminophen is particularly useful when NSAIDs are contraindicated and as part of combination therapy. Diclofenac may be considered in selected patients, whereas ketorolac should be restricted to appropriate short-term indications.
Effective pain control ultimately depends on combining rational pharmacotherapy with timely definitive dental treatment, rather than relying on analgesics alone.

📚 References

✔ American Dental Association. (2024). Oral analgesics for acute dental pain. American Dental Association.
✔ Carrasco-Labra, A., Polk, D. E., Urquhart, O., Aghaloo, T., Claytor, J. W., Jr., Dhar, V., Dionne, R. A., Espinoza, L., Gordon, S. M., Hersh, E. V., Law, A. S., Li, B. S.-K., Schwartz, P. J., Suda, K. J., Turturro, M. A., Wright, M. L., Dawson, T., Miroshnychenko, A., Pahlke, S., ... Moore, P. A. (2024). Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. The Journal of the American Dental Association, 155(2), 102–117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
✔ Moore, P. A., & Hersh, E. V. (2013). Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice. The Journal of the American Dental Association, 144(8), 898–908. https://doi.org/10.14219/jada.archive.2013.0207
✔ Kiersch, T. A., Halladay, S. C., & Koschik, M. (1993). A double-blind, randomized study of naproxen sodium, ibuprofen, and placebo in postoperative dental pain. Clinical Therapeutics, 15(5), 845–854.
✔ Cooper, S. A., Desjardins, P., Brain, P., Paredes-Diaz, A., Troullos, E., Centofanti, R., & An, B. (2019). Longer analgesic effect with naproxen sodium than ibuprofen in post-surgical dental pain: A randomized, double-blind, placebo-controlled, single-dose trial. Current Medical Research and Opinion, 35(12), 2149–2158. https://doi.org/10.1080/03007995.2019.1655257
✔ Kiersch, T. A., Halladay, S. C., & Hormel, P. C. (1994). A single-dose, double-blind comparison of naproxen sodium, acetaminophen, and placebo in postoperative dental pain. Clinical Therapeutics, 16(3), 394–404.
✔ Green, V. G., Polk, D. E., Turturro, M. A., Moore, P. A., & Carrasco-Labra, A. (2025). Evidence-based clinical practice guidelines for the management of acute dental pain. American Journal of Emergency Medicine, 89, 247–253. https://doi.org/10.1016/j.ajem.2024.12.054
✔ Ping, R., Kang, X., Fang, R., Wang, H., & Wu, L.-A. (2026). The effectiveness of ketorolac in relieving pain associated with root canal therapy: A systematic review and meta-analysis. Clinical and Experimental Dental Research, 12(2), e70295. https://doi.org/10.1002/cre2.70295
✔ U.S. National Library of Medicine. (2026). Ketorolac tromethamine tablets, USP: Prescribing information. DailyMed.

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MBT vs Damon Brackets: Clinical Differences Explained

Choosing between MBT brackets and Damon brackets involves more than comparing conventional and self-ligating bracket designs. These systems differ in bracket mechanics, ligation, archwire engagement, and treatment philosophy, while clinical outcomes are also strongly influenced by diagnosis, treatment objectives, wire sequence, anchorage, and operator technique.

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MBT brackets are conventional preadjusted edgewise brackets that use elastomeric or metal ligatures to secure the archwire. The MBT prescription is widely used in fixed orthodontic treatment and incorporates specific bracket angulations and torque values designed to support straight-wire mechanics.

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Damon brackets, in contrast, are self-ligating brackets that use a built-in clip or sliding mechanism to secure the archwire. Damon systems have been associated with low-friction mechanics and simplified archwire engagement, although systematic reviews have not demonstrated consistent clinical superiority over conventional brackets across major treatment outcomes.
Understanding the distinction between these systems is therefore important when selecting an appliance for a specific orthodontic treatment plan.

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🔹 What Are MBT Brackets?
The MBT bracket system is a preadjusted edgewise appliance derived from modifications of the Andrews straight-wire concept. Its prescription incorporates specific values of torque, angulation, and in-out positioning for individual teeth.
Unlike self-ligating systems, conventional MBT brackets require an external ligation method. Elastomeric modules are commonly used, although stainless-steel ligatures may also be selected depending on the clinical objective.
MBT brackets can be used for a broad range of malocclusions and treatment approaches, including extraction and non-extraction treatment.

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🔹 What Are Damon Brackets?
Damon brackets are a family of self-ligating orthodontic brackets developed around a passive or low-friction bracket mechanism. The defining feature is the integrated door or clip that holds the archwire without requiring an elastomeric ligature.
The Damon approach has traditionally emphasized reduced friction, lighter orthodontic forces, and the use of specific archwire sequences. However, the clinical effects of self-ligation should not be interpreted solely from laboratory friction measurements because tooth movement in vivo involves biological, mechanical, and periodontal factors.
Clinical trials comparing Damon and conventional brackets have not consistently demonstrated shorter overall treatment times or superior occlusal outcomes.

🔹 MBT vs Damon Brackets: Key Differences

Feature	MBT Brackets	Damon Brackets
Bracket type	Conventional preadjusted	Self-ligating
Archwire retention	Elastomeric or metal ligature	Integrated clip or door
Ligation	Required	Not required
Friction	Influenced by ligature and wire-bracket interaction	Designed for low-friction engagement
Prescription	MBT prescription	Damon-specific prescription
Archwire engagement	Controlled with ligatures	Controlled by bracket mechanism
Chairside ligation	Required	Reduced
Alignment	Effective with conventional mechanics	Effective with self-ligating mechanics
Treatment time	Primarily influenced by case complexity and mechanics	No consistent overall reduction demonstrated
Pain/discomfort	Variable	Variable
Anchorage control	Depends on biomechanics and appliance configuration	Depends on biomechanics and appliance configuration
Finishing	Requires conventional finishing mechanics	Requires conventional finishing mechanics
Clinical selection	Based on prescription and treatment objectives	Based on system design and treatment objectives

🔹 Ligation and Friction
One of the most obvious differences between MBT vs Damon brackets is how the archwire is secured.
In conventional MBT brackets, elastomeric ligatures can increase resistance to sliding between the bracket and archwire. Damon brackets eliminate the need for these external ligatures by incorporating a mechanical locking mechanism.
This distinction can influence the mechanics of sliding and the time required for archwire engagement. However, lower laboratory friction does not automatically translate into faster orthodontic treatment.
A systematic review of self-ligating brackets found evidence supporting reduced chair time in some circumstances, but did not identify consistent advantages in overall treatment time or final occlusal characteristics.

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🔹 Alignment Efficiency
Orthodontic alignment is frequently cited when comparing conventional and self-ligating brackets.
Clinical evidence is mixed. A randomized clinical trial directly comparing Damon3 and MBT brackets found greater improvement in upper anterior irregularity during a four-month alignment period with Damon3 brackets. However, the difference in lower anterior alignment over the complete observation period was not statistically significant. Pain levels were also not significantly different between the groups.
Other randomized clinical research has produced different results. In one trial comparing Damon3 with conventional brackets, no significant difference in the initial rate of alignment was identified.
Therefore, Damon brackets should not automatically be considered faster for alignment in every clinical situation.

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🔹 Treatment Time
A major reason clinicians and patients may consider self-ligating brackets is the possibility of reducing total treatment time.
However, evidence does not consistently support this claim.
A randomized clinical trial involving extraction patients found no significant effect of Damon3 versus conventional brackets on overall treatment duration, number of visits, or overall occlusal improvement.
Systematic reviews have similarly reported insufficient evidence for a clinically important reduction in total treatment duration with self-ligating systems.

Treatment duration remains strongly influenced by factors such as:
▪️ Initial malocclusion severity
▪️ Extraction requirements
▪️ Anchorage demands
▪️ Space closure
▪️ Patient compliance
▪️ Missed appointments
▪️ Appliance breakages
▪️ Treatment mechanics
▪️ Finishing requirements

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🔹 Pain and Patient Comfort
Patient discomfort is another commonly discussed difference between MBT and Damon brackets.
The available evidence does not establish a consistent pain advantage for self-ligating brackets. A systematic review found no significant difference in pain between self-ligating and conventional appliances at several assessment intervals.
Similarly, the randomized Damon3-versus-MBT study found no statistically significant difference in pain experience between the two bracket groups.
Pain is therefore better considered a patient-specific response influenced by the magnitude and type of orthodontic force, archwire changes, tooth movement, and individual sensitivity.

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🔹 Arch Expansion and Transverse Changes
Damon treatment is sometimes associated with the concept of achieving greater arch development through low-friction mechanics.
However, clinical research does not support assuming that self-ligating brackets automatically produce greater transverse changes.
A multicenter randomized controlled trial comparing passive self-ligating, active self-ligating, and conventional brackets found no significant differences in maxillary transverse dimensional changes attributable to bracket type.
This distinction is clinically important. Changes in arch width should be planned according to the patient's anatomy, periodontal limits, tooth position, skeletal relationships, and treatment objectives rather than attributed solely to the bracket system.

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🔹 Biomechanical Considerations
The bracket system is only one component of orthodontic biomechanics.
With MBT brackets, elastomeric or steel ligation allows the clinician to control how the archwire is engaged. Different ligation strategies can therefore be used according to the treatment phase.
Damon brackets simplify archwire engagement through the self-ligating mechanism. Their design may reduce the need for repeated ligature placement and can be useful in situations where efficient archwire engagement is desirable.
Nevertheless, force systems are determined by the interaction between bracket prescription, archwire dimensions, material properties, bracket positioning, ligation, anchorage, and the biological response to force.
Consequently, changing from MBT to Damon does not replace the need for sound biomechanical planning.

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🔹 Clinical Comparison: MBT vs Damon
From a clinical perspective, neither system should be selected solely because of claims about reduced friction or faster treatment.

MBT may be particularly useful when:
▪️ Conventional ligation is preferred.
▪️ Detailed control of archwire engagement is required.
▪️ Specific ligation strategies are part of the treatment mechanics.
▪️ The clinician routinely uses the MBT prescription.
▪️ Conventional finishing and torque-control strategies are preferred.

Damon may be particularly useful when: ▪️ A self-ligating mechanism is preferred.
▪️ Reduced ligation time is clinically valuable.
▪️ The clinician incorporates Damon-specific mechanics into treatment.
▪️ Simplified archwire engagement is desirable.
▪️ A low-friction bracket design is preferred as part of the overall appliance strategy.
These considerations do not establish one system as universally superior. Appliance selection should be based on the malocclusion, treatment objectives, biomechanics, and clinician experience.

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🔹 Does Damon Treat Faster Than MBT?
Current evidence does not support a general statement that Damon brackets treat orthodontic cases faster than MBT brackets.
Some individual studies have reported differences during particular phases, such as initial alignment. However, randomized trials and systematic reviews have generally failed to demonstrate a consistent reduction in overall treatment duration with self-ligating brackets.
This distinction between phase-specific efficiency and overall treatment efficiency is important when interpreting claims about self-ligating appliances.

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🔹 MBT vs Damon: Which Factors Matter Most?
When comparing these systems, clinicians should consider:

1. Diagnosis: Skeletal and dental relationships determine the fundamental treatment strategy.
2. Treatment objectives: Alignment, space closure, torque control, anchorage, and finishing may require different mechanics.
3. Bracket prescription: Torque and angulation values affect tooth positioning.
4. Archwire sequence: Wire size, material, and progression influence force delivery.
5. Ligation: Conventional ligation allows different methods of archwire engagement.
6. Anchorage: Bracket selection does not eliminate the need for appropriate anchorage control.
7. Patient factors: Compliance and appointment attendance can substantially influence treatment duration.
8. Clinician technique: Bracket positioning and biomechanical execution remain critical.

🔹 Evidence-Based Clinical Perspective
The available evidence suggests that self-ligating brackets can reduce some chairside ligation procedures, but the evidence for clinically meaningful advantages in overall treatment time, pain, occlusal outcomes, or arch development is inconsistent.
A randomized clinical trial specifically comparing Damon3 and MBT brackets demonstrated that differences can occur during the alignment phase, but these findings should not be generalized to every orthodontic case.
Therefore, the most appropriate comparison is not simply "Which bracket is better?" but rather "Which bracket system fits the treatment objectives and biomechanics of this case?"

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🎯 Clinical Recommendations
▪️ Select the bracket system according to the diagnosis and treatment objectives, not marketing claims.
▪️ Do not assume that lower friction automatically means shorter overall treatment.
▪️ Consider the advantages of conventional ligation when specific archwire engagement or force control is required.
▪️ Consider self-ligating brackets when their mechanical design and reduced ligation requirements fit the clinician's workflow.
▪️ Evaluate arch expansion and tooth movement within the patient's biological and periodontal limits.
▪️ Use evidence from randomized trials and systematic reviews when evaluating claims about treatment efficiency.
▪️ Remember that bracket positioning, archwire selection, anchorage, and biomechanics can be more important than the bracket mechanism alone.

✍️ Conclusion
The comparison of MBT vs Damon brackets highlights two different approaches to fixed orthodontic appliance design. MBT brackets use conventional ligation and a preadjusted prescription, while Damon brackets incorporate a self-ligating mechanism designed to simplify archwire engagement and reduce the need for external ligatures.
Although some studies have reported differences in specific treatment phases, current evidence does not establish a consistent overall clinical advantage of Damon brackets over conventional systems in treatment duration, pain, or final occlusal outcomes.
The decision should therefore be based on the malocclusion, treatment objectives, biomechanics, archwire sequence, anchorage requirements, and clinician preference.
For orthodontists comparing bracket prescriptions and treatment philosophies, the next useful comparison is [Roth vs MBT brackets], which examines how these two conventional preadjusted prescriptions differ in torque, angulation, bracket design, and clinical application. Understanding Roth vs MBT provides an important foundation before comparing conventional systems such as MBT with self-ligating systems such as Damon.

📚 References

▪️ Jahanbin, A., Hasanzadeh, N., Khaki, S., & Shafaee, H. (2019). Comparison of self-ligating Damon3 and conventional MBT brackets regarding alignment efficiency and pain experience: A randomized clinical trial. Journal of Dental Research, Dental Clinics, Dental Prospects, 13(4), 281–288.
▪️ Chen, S. S. H., Greenlee, G. M., Kim, J. E., Smith, C. L., & Huang, G. J. (2010). Systematic review of self-ligating brackets. American Journal of Orthodontics and Dentofacial Orthopedics, 137(6), 726.e1–726.e18.
▪️ Papageorgiou, S. N., et al. (2017). Therapeutic efficacy of self-ligating brackets: A systematic review. Orthodontics & Craniofacial Research.
▪️ Fleming, P. S., Johal, A., & Pandis, N. (2013). Self-ligating brackets in orthodontics: A systematic review. Angle Orthodontist.
▪️ DiBiase, A. T., Nasr, I. H., Scott, P., & Cobourne, M. T. (2011). Duration of treatment and occlusal outcome using Damon3 self-ligated and conventional orthodontic bracket systems in extraction patients: A prospective randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics, 139(2), e111–e116.
▪️ Papageorgiou, S. N., et al. (2021). Are self-ligating brackets more efficient than conventional brackets? A meta-analysis of randomized controlled and split-mouth trials. International Orthodontics.
▪️ Fleming, P. S., et al. (2012). Systematic review on self-ligating vs. conventional brackets: Initial pain, number of visits, and treatment time.

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