comparative evaluation of orthodontic tooth movement …

www.wjpps.com │ Vol 10, Issue 7, 2021. │ ISO 9001:2015 Certified Journal │

1646

Sola Rajan et al. World Journal of Pharmacy and Pharmaceutical Sciences

COMPARATIVE EVALUATION OF ORTHODONTIC TOOTH

MOVEMENT AMONG WOMEN DURING MENSTRUATION AND

OVULATION PHASE

Sola Rajan*, Poornima R. Jnaneshwar and K. Ravi

Department of Orthodontics and Dentofacial Orthopedics, SRM Dental College,

Ramapuram Chennai- 600089.

ABSTRACT

Objective: To elucidate the difference in orthodontic tooth movement

among women during menstruation and ovulation phase. Materials

and Methods: Twenty-four women aged between 18-25 years were

divided into Menstruation group and Ovulation group. All subjects

were treated with fixed orthodontic appliance. An orthodontic force of

150 grams was given at the time of menstruation in Menstruation

group and ovulation in the Ovulation group for en-masse retraction

using module and ligature (Frictional mechanics). Orthodontic tooth

movement and levels of estrogen and progesterone were measured

during menstruation and ovulation. The blood test was done to

estimate the hormone levels and the orthodontic tooth movement was

measured using digital Vernier caliper. Results: Statistical results showed significant

difference in the orthodontic tooth movement during menstruation and ovulation phase (p

=0.01). When hormone levels decreased i.e. during menstruation, tooth movement due to

orthodontic force was accelerated when compared to the ovulation group where the hormone

levels were increased. Limitations: The sample size of 24 may not be sufficient to represent

the entire population. Therefore further studies are required with a greater sample size to

extrapolate the findings to the whole population. Blood samples were collected from all the

24 female participants which was an invasive procedure. Conclusion: Orthodontic tooth

movement was accelerated during menstruation phase (decreased hormone levels) when

compared to the ovulation group (increased hormone levels). Clinicians could seek advantage

of this concept while treating female patients to reduce the treatment duration as well as

achieve better patient acceptance.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 10, Issue 7, 1646-1660 Research Article ISSN 2278 – 4357

*Corresponding Author

Dr. Sola Rajan

Department of Orthodontics

and Dentofacial

Orthopedics, SRM Dental

College, Ramapuram

Chennai- 600089.

Article Received on

12 May 2021,

Revised on 02 June 2021,

Accepted on 22 June 2021

DOI: 10.20959/wjpps20217-19304


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KEYWORDS: Estrogen, progesterone, orthodontic tooth movement, menstruation,

ovulation.

INTRODUCTION

Orthodontic therapy is a specialized treatment in the field of dentistry that deals with the

diagnosis, prevention, and correction of irregular teeth and jaws. In recent times, a huge

number of the population undergoes orthodontic treatment to attain proper dental esthetics

along with better occlusion, improved oral function as well as pleasing facial appearance.

The total treatment duration is an important factor to be considered as to why most people

shy away from undergoing orthodontic therapy. The long-term orthodontic treatment causes

demineralization of enamel, resorption of the root, periodontal diseases and the severity of

these side effects increases as the treatment duration prolongs. Therefore, many orthodontists

have been aiming to decrease the treatment duration by accelerating the orthodontic tooth

movement. Tooth movement was successfully accelerated using various procedures like

systemic administration of Vitamin D3, Parathyroid hormone, peizocision or corticotomy but

most of them had drawbacks of being invasive or painful(1-3). This is an issue that needs to

be thoroughly investigated by all orthodontists to find a non-invasive, effective, and simpler

way to accelerate the orthodontic tooth movement.

Progesterone and estrogen are the two most vital hormones in the female body that are

accountable for various female characteristics in the body. The ovaries are a pair of ova-

producing organs that maintain the health of the reproductive system in females. In addition,

these ovaries act as an endocrine gland because of the capability to secrete hormones—

primarily estrogen and progesterone—that are important for normal reproductive

development and fertility.

In women, the menstrual cycle consists of four phases with the sex hormones varying during

the cycle and the phases are as follows

1. Menstrual phase – The sex hormone levels are the lowest (0-7days)

2. Follicular phase - Increases gradually (7-14days)

3. Ovulatory phase- Reaches its peak (14-21days)

4. Luteal phase – Decreases gradually(21-28days)


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And finally, the sex hormones decrease rapidly again during the menstrual phase. The

estrogen and progesterone level are associated with metabolism of bone therefore, the

variation in the estrogen and progesterone levels induce variations in bone remodeling.[4,5]

Increased demand for orthodontic treatment makes it necessary to have a proper

understanding of hormonal changes and their influence on the process of orthodontic

treatment. The main aim of this study was to evaluate the effects of estrogen and

progesterone on orthodontic tooth movement in adult females. In this study the null

hypothesis was stated as ―There is no statistically significant difference in the rate of tooth

movement between menstruation and ovulation group‖.

MATERIALS AND METHODOLOGY

The study was approved by the Institutional Review Board of SRM Institute of Science And

Technology. The entire subjects included in this study were patients who came and sought

orthodontic treatment in the Orthodontic and Dentofacial Orthopedic Department of SRM

Dental College, Ramapuram.

Women with good general and oral health, regular menstrual cycle (26 – 32 days each month)

and malocclusion that required bilateral first premolar extraction with no previous history of

orthodontic treatment were included in the study. Patients treated with contraceptive drugs,

female patients diagnosed with systemic disease or periodontal disease and women who were

pregnant or breastfeeding were excluded from the study.

Female patients requiring orthodontic treatment with the above-mentioned criteria were

chosen after explaining the clinical procedure involved in the study. After deciding the

treatment plan, separators were placed in the mesial and distal aspect of the first four molars

and the patients were recalled on the next day for banding procedure. Bonding procedures

were initiated using MBT prescription brackets with 0.022 slot. MBT chart was used as a

reference for bracket placement.

Brackets were bonded from right to left second premolar in the upper and lower arch and

0.014‖ NiTi archwire was inserted. This was followed by a series of archwire sequence to

complete the alignment and leveling stage.


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En-masse retraction was initiated using frictional mechanics (module and ligature) on 0.019‖

X 0.025‖ stainless steel archwire. Force of 150 grams per side was applied to initiate space

closure and the force was calibrated using Dontrix gauge.

The selected subjects were divided into two groups i.e.

Group 1:– Menstruation group (Subjects undergoing menstruation)

Group 2:– Ovulation group (Subjects undergoing ovulation)

In the menstruation group, the menstrual phase was determined at the time the subject first

noticed the bleeding. On the first day of the menstruation, en-masse retraction was initiated

using frictional mechanics (module and ligature) (first activation) (Fig 1) on 0.019‖ x 0.025‖

stainless steel archwire and the blood samples were collected to measure the estrogen and

progesterone levels. Impressions of the upper and lower arch were recorded before activation

and the study models were duplicated to determine the linear distance (mm) from the distal

surface of canine to the mesial surface of the second premolar on right and left side.

The second activation of en-masse retraction was done when the subjects had menstrual cycle

after 1 month. Impressions of the upper and lower arch were recorded and the study models

were duplicated to estimate the rate of space closure. En masse retraction was continued

using module and ligature and this procedure to determine the space closure rate was

recorded for 3 consecutive months.

In the Ovulation group, the Ovulation phase was ascertained by Ovulation Kit (I- Sure

Ovulation kit). On the first day of ovulation, en-masse retraction was initiated using frictional

mechanics (module and ligature) (first activation) (Fig 2) on 0.019‖ x 0.025‖ stainless steel

archwire and the blood samples were collected to measure the estrogen and progesterone

levels. Impressions of the upper and lower arch were recorded before activation and the study

models were duplicated to determine the linear distance (mm) from the distal surface of

canine to the mesial surface of the second premolar on right and left side.

The second activation of en-masse retraction was done when the subjects had the ovulation

phase after 1 month. Impressions of the upper and lower arch were recorded and the study

models were duplicated to estimate the range of space closure. En masse retraction was

continued using module and ligature and this procedure to determine the space closure rate

was recorded for 3 consecutive months.


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Determination of estrogen and progesterone level was done by withdrawing 5 ml of blood

(venous puncture) and then blood was collected in vacutainer tubes. Blood samples were

taken in SRM Hospital Laboratory, Ramapuram and were processed using the ELISA method

by the same technician for all the samples. To estimate the rate of space closure, alginate

impressions of the upper and lower arch were recorded and the study models were duplicated.

Digital Vernier Calliper was used to accurately determine the linear distance (mm) from the

distal surface of canine to the mesial surface of the second premolar on all four quadrants by

the same observer (measured three times per quadrant) for all the twenty-four samples.

The normality of the range of tooth movement and level of estrogen and progesterone were

assessed by the Kolmogorov Smirnov test. Since the distribution of the sample was normal,

the independent t-test was used to identify differences between range of orthodontic tooth

movement in menstruation and ovulation group and to identify the difference in estrogen and

progesterone levels in menstruation and ovulation group.

RESULTS

This study evaluated 24 female patients aged between 18 – 25 years. The collected raw data

were analyzed with IBM.SPSS statistics software 23.0 Version. In all the statistical tools the

probability value 0.05 is considered as significant level.

To find the significant difference between the estrogen and progesterone levels in

menstruation and ovulation group independent t-test was used. The independent t-test showed

significant differences in the mean progesterone and estrogen levels during menstruation and

ovulation group The mean and standard deviation of estrogen during menstruation and

ovulation was 34.97pg/ml +/- 8.1403 and 255.75pg/ml +/- 46.9993 respectively (p=.0005).

The mean and standard deviation of progesterone during menstruation and ovulation was

36.58pg/ml + /- 24.898 and 123.18pg/ml +/- 18.0733 respectively (p=.0005). The results

showed that the hormone levels decreased during menstruation and hormone levels increased

during ovulation period which was statistically significant. (Table No 1and 2)

The independent t-test was used to identify differences between the rate of tooth movement in

menstruation and ovulation group.

The mean value of the interdental space in the upper right canine and second premolar were:


1651


5.49 mm and 5.70 mm in the menstruation group and ovulation group respectively during

the first month i.e. before the commencement of retraction force.

4.51 mm and 5.07 mm in the menstruation and ovulation group respectively during the

second month i.e. one month after the retraction force.


third month.


fourth month.

The values suggest that there was a statistically significant reduction in the upper right

quadrant interdental space in the 2nd

, 3rd

and 4th

month in menstruation group (p= .044, .005,

.0005) (Table No 1&2) (Graph 1).

The mean value of the interdental space in the upper left canine and second premolar

were






third month.


fourth month.

The values suggest that there was a statistically significant reduction in the upper left

quadrant interdental space in the 3rd

and 4th

month in the menstruation group. (p= .044, .011)

and was not found to be statistically significant in the reduction of upper left quadrant

interdental space during the 2nd

month (p=.485) (Table No 1&2) (Graph 2).

The mean value of the interdental space in lower right canine and second premolar

were

4.52 mm and 5.04 mm in the ovulation group and menstruation group respectively during





1652



third month.


fourth month.

The values suggest that there was a statistically significant reduction in the lower right


, 3rd

and 4th

month in menstruation group (p= .043, .016,

.001) (Table No 1&2) (Graph 3).

The mean value of the interdental space in lower left canine and second premolar were


the first month i.e. before the commencement of the retraction force.




third month.


fourth month.

The values suggest that there was a statistically significant reduction in the lower left


, 3rd

and 4th

month in menstruation group. (p= .004, .001,.

0005) (Table No 1&2) (Graph 4).

The results of orthodontic tooth movement and hormones were compared with independent t-

test and significant differences were detected between the menstruation and ovulation group.

The mean value of the overall interdental distance in the menstruation group was 3.50 mm ±

0.79 and in the ovulation group was 4.34 mm ± 0.66. The values suggest that there was a

statistically significant acceleration in the rate of orthodontic tooth movement in menstruation

group when compared to the ovulation group i.e., statistically significant reduction in the

overall mean value of the interdental space in the menstruation group (p-value=.010) (Table

3, 4)(Graph: 5).


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Table 1: Descriptive data.

Groups N Mean Std. Deviation

UR1 M 12 5.4925 .61993

O 12 5.7092 .85281

UR2 M 12 4.5167 .62861

O 12 5.0775 .87024

UR3 M 12 3.4858 .60377

O 12 4.4275 .86511

UR4 M 12 2.4742 .63613

O 12 3.7300 .82903

UL1 M 12 5.3342 .74357

O 12 5.1533 .89872

UL2 M 12 4.3825 .75462

O 12 4.9367 .98381

UL3 M 12 3.3692 .72894

O 12 4.0308 .97913

UL4 M 12 2.4217 .74186

O 12 3.4008 .96018

LR1 M 12 4.5275 1.16496

O 12 5.0417 1.19382

LR2 M 12 3.5042 1.25007

O 12 4.3342 .87673

LR3 M 12 2.6742 1.09327

O 12 3.7183 .85846

LR4 M 12 1.8325 .90439

O 12 3.1650 .87575

LL1 M 12 4.3542 1.18796

O 12 4.9642 .88189

LL2 M 12 3.3575 1.15494

O 12 4.5683 .57630

LL3 M 12 2.5058 1.01790

O 12 3.9250 .55157

LL4 M 12 1.7500 .95737

O 12 3.3825 .52496

E M 12 34.917 8.1403

O 12 255.750 46.9993

P M 12 36.58 24.898

O 12 123.183 18.0773

ABBREVATION

UR1 – Upper right interdental space during 1st month

UR2– Upper right interdental space during 2nd

month

UR3– Upper right interdental space during 3rd

month

UR4– Upper right interdental space during 4th

month

UL1 – Upper left interdental space during 1st month


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UL2– Upper left interdental space during 2nd

month

UL3– Upper left interdental space during 3rd

month

UL4– Upper left interdental space during 4th

month

LR1– Lower right interdental space during 1st month

LR2– Lower right interdental space during 2nd

month

LR3– Lower right interdental space during 3rd

month

LR4– Lower right interdental space during 4th

month

LL1– Lower left interdental space during 1st month

LL2– Lower left interdental space during 2nd

month

LL3– Lower left interdental space during 3rd

month

LL4– Lower left interdental space during 4th

month

E - Estrogen

P - Progesterone

M - Menstruation

O - Ovulation

Table 2: Independent T. test.

UR1 .484

UR2 .044

UR3 .005

UR4 .0005

UL1 .597

UL2 .485

UL3 .044

UL4 .011

LR1 .297

LR2 .043

LR3 .016

LR4 .001

LL1 .071

LL2 .004

LL3 .001

LL4 .0005

E .0005

P .0005


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Table 3: Descriptive Data- mean difference of overall interdental distance in

Menstruation and Ovulation group.

Group N Mean Std. Deviation Std. Error Mean

Average M 12 3.50 0.79 0.23

O 12 4.34 0.66 0.19

Total M 12 55.98 12.66 3.65

O 12 69.47 10.60 3.06

Table 4: Independent T. Test – Differences between range of tooth movement in

Menstruation and Ovulation group.

Levene's

Test for

Equality of

Variances

t-test for Equality of Means

F Sig. t Df Sig. (2-

tailed)

Mean

Difference

Std. Error

Difference

95% Confidence

Interval of the

Difference

Lower Upper

Average Equal

variances

assumed

.55

8

.463 -2.8

29

22 .010 -.842

66

.297

88

-1.46

042

-.224

89

Total Equal

variances

assumed

.55

8

.463 -2.8

29

22 .010 -13.48

250

4.76

605

-23.36

668

-3.59

832

Graphs

M O

1s t

month 5.49 5.70

2n d

month 4.51 5.07

3rd

month 3.48 4.42

4t h

month 2.47 3.73

MENSTRUATION

OVULATION

Graph 1: The mean value of interdental space between the upper right Canine and

Second premolar for each month in both groups.


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M O

1s t

month

5.33 5.15

2n d

month

4.38 4.64

3rd

month

3.36 4.03

4t h

month

2.42 3.40

Graph 2: The mean value of interdental space between the upper left Canine and


M O

1s t

month 4.53 5.04

2n d

month 3.50 4.33

3rd

month 2.67 3.72

4t h

month 1.83 3.16

Graph 3: The mean value of interdental space between the lower right Canine and


M O

1s t

month 4.35 5.16

2n d

month 3.35 4.57

3rd

month 2.50 3.93

4t h

month 1.75 3.38

Graph 4: The mean value of interdental space between the lower left Canine and



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Groups Mean Std.deviation

Menstruation 3.50 0.79

Ovulation 4.34 0.66

Graph 5: The mean values of interdental distance in both groups.

Figure 1: Menstruation group – Clinical photo.

Figure 2: Ovulation group – Clinical photo.

ACKNOWLEDGEMENT: Nil

DISCUSSION

This study was done by activating orthodontic force during the peak of estrogen and

progesterone level i.e. on ovulation phase and during the lowest estrogen and progesterone


1658


level i.e. on menstruation phase. The force applied for en-masse retraction was approximately

150 grams determined by dontrix gauge. The results showed that fluctuations in estrogen and

progesterone levels during menstruation and ovulation phase can affect tooth movement due

to orthodontic force. When estrogen and progesterone levels declined i.e at the time of

menstruation, tooth movement increased, whereas when estrogen and progesterone levels

increased i.e at the time of ovulation, tooth movement decreased (p=.01). This was in

accordance with a study where they found that the estrogen levels can affect the orthodontic

tooth movement in cats. They concluded that the estrogen levels were inversely proportional

to the orthodontic tooth movement. (p=.05).[6]

According to a study done to evaluate the

effects of progesterone on orthodontic tooth movement, the increased progesterone levels

could reduce the rate of tooth movement. This study was conducted on rabbits that received

long-term, short-term and no progesterone injection and orthodontic force were applied and

they concluded that the long term administration of progesterone reduced the orthodontic

tooth movement.[7]

The levels of biomarkers of tooth movement and this correlation to female sex hormones

were evaluated in a study. They found that the biomarkers like serum TRAP, pyridinoline

that were increased during orthodontic tooth movement were inversely related to estradiol

whereas serum osteocalcin was inversely related to progesterone.[5]

This correlates with our

study where it was found that levels of estrogen were found to be higher during ovulation

phase and least in menstruation (p=0.0005) and the levels of progesterone were found to be

higher during ovulation phase and least in menstruation (p=0.0005). Orthodontic tooth

movement was found to be accelerated during the menstruation phase which was statistically

significant (p=0.010) when estrogen and progesterone levels were least and thus rejecting the

null hypothesis. This result correlates with other studies which confirm that the estrogen

levels were inversely proportional to tooth movement by orthodontic therapy in rats.[8,9]

Another study evaluated the effects of ovariectomy on orthodontic tooth movement in rats.

They found out there is a significant increase in the rate of tooth movement in the absence of

ovaries in the lag phase ( 12 – 21 days ) but there was no great difference between the two

groups up to 12 days.[10,11]

The effect of progesterone on orthodontic tooth movement was studied in pregnant rats and

they found that the progesterone was helpful in alveolar bone formation. Osteoclasts were

primarily observed 2 days after force application. But there was a decrease in the number of


1659


osteoclasts in pregnant rats 2 days after appliance insertion. This decrease in osteoclast

number may be due to the gradual increase in progesterone during pregnancy.[12]

The same

result was shown in studies which proved that estrogen and progesterone levels were also

inversely proportional to orthodontic tooth movement in rats.[11,13]

The clinical application of this study is that the sex hormone levels vary during the menstrual

cycle; the sex hormones are lowest during menstruation phase and highest during ovulation

phase. Since the low levels of these hormones are linked to cause an osteoclastic activity, an

orthodontic force during menstruation phase can accelerate the tooth movement and reduce

the treatment time.[4,5]

This study may suggest an option for orthodontists to accelerate the

tooth movement by performing activation of orthodontic force during menstruation in female

patients. This method was safer, more comfortable and the orthodontic treatment was found

to be more effective and efficient.

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piezocision in rapid canine retraction. American Journal of Orthodontics and Dentofacial

Orthopedics, 2016; 1, 149(4): 473-80.

2. Li F, Li G, Hu H, Liu R, Chen J, Zou S. Effect of parathyroid hormone on experimental

tooth movement in rats. American Journal of Orthodontics and Dentofacial Orthopedics,

2013; 1, 144(4): 523-32.

3. Yamasaki K, Shibata Y, Imai S, Tani Y, Shibasaki Y, Fukuhara T. Clinical application of

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11. Mackie MA, Momeni Danaei S, Habibagahi S, Tanide N, Dehghani Najvani A,

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progesterone on orthodontic tooth movements in pregnant rats, 1998; 16(2): 124-6.

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https://www.ncbi.nlm.nih.gov/pubmed/?term=Luo%20S%5BAuthor%5D&cauthor=true&cauthor_uid=12214412

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