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Common risk factors for postoperative pain following the extraction of wisdom teeth

Authors:

Abstract

The extraction of third molars is a common task carried out at dental/surgery clinics. Postoperative pain is one of the two most common complications of this surgery, along with dry socket. Knowledge of the frequent risk factors of this complication is useful in determining high-risk patients, planning treatment, and preparing the patients mentally. Since the risk factors for postoperative pain have never been summarized before while the risk factors for dry socket have been highly debated, this report summarizes the literature regarding the common predictors of postextraction pain. Except for surgical difficulty and the surgeon's experience, the influences of other risk factors (age, gender and oral contraceptive use) were rather inconclusive. The case of a female gender or oral contraceptive effect might mainly be associated with estrogen levels (when it comes to dry socket), which can differ considerably from case to case. Improvement in and unification of statistical and diagnostic methods seem necessary. In addition, each risk factor was actually a combination of various independent variables, which should instead be targeted in more comprehensive studies.
59
a major concern4,10,11. Besides, not all complications are rare.
There are frequent and debilitating complications as well, in-
cluding postoperative pain.
Pain is also one of the most common postoperative compli-
cations of extraction6,12-15 and might be caused by the release
of pain mediators from the injured tissues3,15. Pain is an im-
portant factor in clinical practice6,16 and could even discour-
age patients from seeking dental treatment15,17,18. It begins
after the anesthesia subsides and reaches its peak levels dur-
ing the rst postoperative day15,19,20. If dry socket or infection
occur, the onset of inammation will complicate alleviation
of postoperative pain5,15,20-26.
In the setting of elective operations, such as third molar
removal, patients demand to know the risks, benefits and
postoperative quality of life of these procedures15,1 7,27. The
knowledge of the risk factors of postsurgical complications
has clinical implications in treatment planning, patient man-
agement and prognosis15,19,21,24,28-31. This essay briey reviews
the most common risk factors of pain following third molar
removal.
I. Introduction
One of the most common procedures carried out in dental
clinics and the most frequent task done at oral and maxil-
lofacial surgery clinics is the extraction of wisdom teeth.
This procedure is frequently followed by complications in
the mandible1-3, including both iatrogenic (e.g., nerve injury,
bone fractures, etc.) and inflammatory ones, such as dry
socket, postoperative pain, delayed healing, postoperative
infection, hematoma, swelling, trismus, etc.2,4-6. Although the
overall
complication rate might be generally low, and most
complications are minor4,7-9, this surgery is so frequent that
the populations morbidity of complications may be notice-
able; thus, identifying methods to control or reduce them is
REVIEW ARTICLE
Vahid Rakhshan
#22 Behruzi Alley, Karegar St. Tehran 14188-36783, Iran
TEL: +982166929055 FAX: +982166902923
E-mail: vahid.rakhshan@gmail.com
ORCID: http://orcid.org/0000-0002-9503-3133
This is an open-access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/),
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
CC
Common risk factors for postoperative pain following
the extraction of wisdom teeth
Vahid Rakhshan1,2
1Iranian Tissue Bank and Research Center, Tehran University of Medical Sciences,
2Department of Dental Anatomy and Morphology, Dental Branch, Islamic Azad University, Tehran, Iran
Abstract (J Korean Assoc Oral Maxillofac Surg 2015;41:59-65)
The extraction of third molars is a common task carried out at dental/surgery clinics. Postoperative pain is one of the two most common complications
of this surgery, along with dry socket. Knowledge of the frequent risk factors of this complication is useful in determining high-risk patients, planning
treatment, and preparing the patients mentally. Since the risk factors for postoperative pain have never been summarized before while the risk factors
for dry socket have been highly debated, this report summarizes the literature regarding the common predictors of postextraction pain. Except for sur-
gical difculty and the surgeon’s experience, the inuences of other risk factors (age, gender and oral contraceptive use) were rather inconclusive. The
case of a female gender or oral contraceptive effect might mainly be associated with estrogen levels (when it comes to dry socket), which can differ
considerably from case to case. Improvement in and unication of statistical and diagnostic methods seem necessary. In addition, each risk factor was
actually a combination of various independent variables, which should instead be targeted in more comprehensive studies.
Key words:
Pain, Risk factors, Third molar, Extraction
[paper submitted 2014. 11. 16 / revised 1st 2014. 11. 25, 2nd 2014. 12. 4 / accepted 2014. 12. 11]
Copyright
2015 The Korean Association of Oral and Maxillofacial Surgeons. All
rights reserved.
http://dx.doi.org/10.5125/jkaoms.2015.41.2.59
pISSN 2234-7550·eISSN 2234-5930
J Korean Assoc Oral Maxillofac Surg 2015;41:59-65
60
geries leave more painful sockets. However, Benediktsdóttir
et al.29 found that simply the root morphology and level of
impaction were correlated to postoperative pain; they did not
identify any impact of the actual surgery time29. Grossi et al.38
also did not nd a signicant relationship between the elapsed
time of surgery and the level of postoperative discomfort.
Seymour et al.40 stated that the postoperative pain level might
not be dependent upon the operator or the extent of surgi-
cal trauma as estimated by operating time and radiographic
score. On the other hand, Oikarinen35, Garcia Garcia et al.36,
Haraji and Rakhshan15, and Yuasa and Sugiura37 found that
more difcult operations were more painful. The release of
more inammatory factors and proximity to the nerve might
produce more intense pain in some difcult cases. This pain
might shift to paresthesia or anesthesia in cases with direct
injury to a nerve34. It should be noted that according to recent
research, radiographic indicators alone (i.e., Winter, Pell and
Gregory, Pederson)14,41-43 cannot totally identify the extent of
the difficulty of surgery6,13,29,34,44,45. Additionally, not all the
difculty determinants are necessarily prognostic factors for
complications46. Therefore, better methods should be used to
estimate surgical difculty, or the latent variables should be
assessed independently instead31.
3. The operators expertise
An experienced surgeon might carry out a cleaner, less
traumatic and yet faster operation than someone new to the
procedure. Additionally, patients might trust experienced
clinicians more. These factors (trauma, duration of surgery
and anxiety) can play important roles in inducing complica-
tions8,12,22,28-30,47-53. Therefore, expert clinicians might obtain
better results8,12,34,48-51,54-56. However, the evidence is contro-
versial, as some authors did not denote a link between the
surgeons skill and the patients postoperative pain29. Some
of these experience levels were actually different terms of
undergraduate study and thus indicated little about the sur-
geons expertise57. A surgeons experience might reduce the
postoperative pain only within a short period after the surgery
but may have no influence on the duration or intensity of
longer pains12. This discrepancy might contribute to the con-
troversial result depending on the time at which the pain is
assessed.
4. Tobacco smoking
Smoking might increase pain by reducing blood supply in
II. Materials and Methods
The internet was searched to find relevant articles pub-
lished before July 2014 regarding the risk factors of postex-
traction pain. The search engines used were Google Scholar,
Pubmed/MEDLINE, ISI Web of Science, and Scopus. The
keywords were as follows: third molar, wisdom tooth,
wisdom teeth, extraction, removal, postoperative
pain, postsurgical pain, risk factor, prognostic factor,
and predictor.
More than 800 unique articles were initially found. All
these article titles were reviewed to narrow down the scope
of the search to more relevant articles, according to the eligi-
bility criteria of the presentation of results of original research
or short communications regarding pain perceived after the
extraction of the third molars before July 2014; the time span
was open to all articles published before this date. The ar-
ticles of interest were collected and evaluated. The reference
lists of the located articles were also consulted to identify ad-
ditional relevant reports. Each article or abstract was read at
least twice, and the proper information was aggregated. Other
more general topics were also researched for the sake of dis-
cussing the matters.
III. Results
1. Oral hygiene
The effects of hygiene maintenance on postoperative pain
have not been widely assessed except in a few English and
non-English articles. Sáez Cuesta et al.32 extracted 100 wis-
dom teeth and found that patients with poor oral hygiene be-
fore surgery experienced higher pain levels during the rst 6
postoperative hours. Peñarrocha et al.5 explored 190 impacted
third molars and found that pain increased with increasing
lack of care to hygiene. Larrazábal et al.33 asserted that pain
increases were correlated with less brushing before surgery
and also during the rst postoperative week.
2. Difficulty of the extraction procedure and trauma
An association between different aspects of surgical dif-
culty (such as the impaction level and angle, extent of bone
removal or length of surgery) and pain or paresthesia has
been assessed in most previous studies6,14,15,28,29,34-37 with a few
exceptions12,38. Lago-Méndez et al.13, Pedersen14, Baqain et
al.39, and de Santana-Santos et al.6 stated that lengthier sur-
Risk factors for postextraction pain
61
conicting results4,12,15,37,38,46,57,72,73. Capuzzi et al.12 reported a
greater extent of pain in males. Yuasa and Sugiura37 declared
that postoperative swelling and morbidity but not pain might
be greater in females. de Santana Santos et al.41 observed
signicantly more pain in females only during the rst 4 and
12 postoperative hours, but at the 24th and 48th postopera-
tive hours, the greater pain intensity in women did not reach
a level of signicance41. This controversy might be rooted in
various missing latent variables (e.g., hormonal, psychologi-
cal or genetic differences, etc.).
6. Oral contraceptives
Contraceptive consumption might be less likely to affect
or confound pain-related results4,12,38,74, although a few stud-
ies have reported on its positive role in this regard as well75.
Regardless, modern contraceptive pills contain considerably
lower doses of estrogen and therefore have a reduced role
compared with those of the past34,76.
7. Age
The production and process of sensory stimuli might be
inuenced by aging77-79. The elderly could be at higher risk
of complications, such as severe pain and sensory distur-
bances4,12,38,80,81, possibly because of this groups poorer heal-
ing potential, denser bones and completed dental roots4,28,34,82.
Some investigators have observed significant deteriorating
effects of aging on pain9,12,28,81. Blondeau and Daniel34 report-
ed increased neurosensory problems in patients older than
24 years. However, other studies have not identied such a
role29,39,83. Adeyemo et al.84 and Bui et al.4 found no signi-
cant association between age and complications. Yuasa and
Sugiura37 reported a signicant inuence of age on swelling
and collective postprocedural morbidity but not pain. Grossi
et al.38 observed a significant association between patients
older than 23 years and merely severe trismus but not pain
either reported subjectively by the patients or implied by the
number of painkillers taken. Benediktsdóttir et al.29 found no
correlation between age and discomfort, despite their find-
ing indicating that surgery could last signicantly longer in
older patients. In the study of Capuzzi et al.12, younger par-
ticipants reported less pain in the rst postextraction day, but
the number of painkillers taken was not correlated with age.
Haraji and Rakhshan15 studied younger patients and showed
that when the effects of the operation difculty, smoking and
gender were not controlled for, younger people might show
the alveolar socket33,49. Meechan et al.49 asserted that heavy
smokers have a high chance of poor lling of their extraction
sockets with blood. They also found a correlation between
this phenomenon measured immediately after the extraction
and painful sockets49. Nevertheless, to the authors knowledge,
only certain authors have found a significant link between
postoperative pain and smoking33. The only relationship that
was found was between the pains perceived on the rst post-
surgical day and with postsurgical smoking33. The same study
and many others did not correlate preoperative smoking with
postsurgical pain in their total samples4,12,15,33,38,39. In the stud-
ies of Grossi et al.38 and Heng et al.2, a greater amount of pain
perceived by females was associated with smoking2,38. Grossi
et al.38 suggested that smoking only affects the perception of
pain by females. However, Haraji and Rakhshan15 adjusted
for the role of gender while assessing the effect of smoking
on pain. In their analysis, smoking had no signicant effects
on postoperative pain on the rst or third postoperative days
or in general. They also assessed the interaction of gender
and smoking, and no signicant results appeared15.
5. Gender
Gender is a crucial variable that should be considered when
designing and analyzing the findings of studies in all areas
and at all levels of biomedical and health-related research38.
This issue has been ignored in the past and has gained popu-
larity only in the last few decades58. The association between
clinical pain and gender is not a simple one, but females have
reported more frequent pains compared to men in terms of
various anatomic regions, neuropathic conditions, chronic
musculoskeletal pains, temporomandibular pains, facial
pains, toothaches, etc.58-64. Postoperative pain studies lack
standardization and are at some points conicting; however,
in general, it could be inferred that women might experi-
ence pain more often and to a greater extent than men58,65-68.
Although the research in this regard is rather scarce in terms
of postextraction pain by gender, the aforementioned results
could imply that females might have a higher sensitivity to
pain stimuli perhaps due to psychosocial factors (mood, sex
role beliefs, pain coping strategies, and pain-related expectan-
cies), catastrophizing and sex hormones38,69,70. Also the thin-
ner mandible of women might render them more vulnerable
to pain and some complications after dental procedures6,71.
Some authors have reported more intense postsurgical
pains28,29,40, longer symptom recovery times17,47 or neuro-
sensory deficit in females34. However, many others found
J Korean Assoc Oral Maxillofac Surg 2015;41:59-65
62
tential factor might likely be a real risk factor (Table 1), the
trauma of surgery and experience of the surgeon were more
likely to be causative or risk factors of pain. High levels of
estrogen were not necessarily a risk factor for pain. Evidence
suggesting a higher incidence of postextraction pain in fe-
males was outnumbered by reports that refuted such an as-
sociation. The effect of age remained inconclusive. Although
only a few studies regarding the effect of oral hygiene on
postoperative pain exist, it was shown to be effective in that
regard as well. There were at least three obstacles for detect-
ing possible links between pain and risk factors: consumption
of painkillers and antibiotics by the patients after surgery,
which act as efficient confounders15,20,25, as well as poorer
statistical approaches, and confusion of pain caused by a
dry socket or infection with pain caused only by the surgery
and also with discomfort. Except for a few essays15, almost
signicantly greater pain. However, when these factors were
adjusted for, younger patients showed a borderline signifi-
cantly greater amount of pain only for the rst postoperative
day but not on the third postsurgical day15. The narrow range
of patient ages could mask such an effect, since third molar
extraction is usually indicated in young ages38, and debilitat-
ing effects of age might appear in older ages79. Some authors
have advocated the removal of impacted molars in young
adults to avoid severe or permanent sequelae9,34,81. Nonethe-
less, if the assumption is not confirmed, early prophylactic
extraction of wisdom teeth, which is common in Europe and
America, might not be justiable38,84,85.
IV. Conclusion
Based on the number of studies agreeing that a certain po-
Table 1. A summary of studies supporting or not supporting the role of the searched risk factors (some studies fit both criteria)
Factor Supporting study Studies failing to support the risk factor
Oral hygiene
Operation difculty, duration or trauma as
risk indicators of postoperative pain, sensory
disruption or discomfort
The expertise of the surgeon
Smoking
Gender
Age
Sáez Cuesta et al.32
Peñarrocha et al.5
Larrazábal et al.33
Lago-Méndez et al.13
Pedersen14
Baqain et al.39
de Santana-Santos et al.6
Oikarinen35
Garcia Garcia et al.36
Haraji and Rakhshan15
Yuasa and Sugiura37
Meechan et al.49
Larrazábal et al.33
Grossi et al.38
Heng et al.2
In favor of female gender
Phillips et al.28
de Santana Santos et al.41
Benediktsdóttir et al.29
Seymour et al.40
In favor of male gender
Capuzzi et al.12
Osborn et al.9
Bruce et al.81
Blondeau and Daniel34
Capuzzi et al.12
Phillips et al.28
Capuzzi et al.12
Benediktsdóttir et al.29
Grossi et al.38
Seymour et al.40
Benediktsdóttir et al.29
Capuzzi et al.12
Bui et al.4
Haraji and Rakhshan15
Larrazábal et al.33
Capuzzi et al.12
Grossi et al.38
Baqain et al.39
Eshghpour et al.57
Abu Younis and Abu Hantash72
Barbosa-Rebellato et al.73
Carvalho and do Egito Vasconcelos46
Haraji and Rakhshan15
Yuasa and Sugiura37
Bui et al.4
Grossi et al.38
Capuzzi et al.12
Akadiri et al.83
Adeyemo et al.84
Bui et al.4
Yuasa and Sugiura37
Grossi et al.38
Benediktsdóttir et al.29
Capuzzi et al.12
Haraji and Rakhshan15
Baqain et al.39
Vahid Rakhshan: Common risk factors for postoperative pain following the extraction of wisdom teeth. J Korean Assoc Oral Maxillofac Surg 2015
Risk factors for postextraction pain
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infection pain from pain caused by the surgery alone when
evaluating the risk factors for postoperative pain. Future
studies are warranted to account for each type of pain inde-
pendently. Another issue ignored in almost all studies except
a few15,28,31 is that the variables that affect pain likely interact
with each other. Therefore, analyses not accounting for the
interactions are less accurate and less useful than those that
consider a broader clinical picture31.
Conflict of Interest
No potential conict of interest relevant to this article was
reported.
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... In cases of elective dental procedures such as third molar removal, patients demand to know the risks, benefits as well as change in quality of life post-operatively [54,70]. These factors play a key role in determining the level of patient cooperation, patient anxiety as well as motivation to undergo surgery. ...
... These factors play a key role in determining the level of patient cooperation, patient anxiety as well as motivation to undergo surgery. The post-operative complications have clinical implications in treatment planning, patient management and prognosis [54,70]. The present study provides the clinicians and surgeons with a more descriptive outlook on the use of these suturing techniques for flap closure after lower third molar surgery. ...
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Background Lower third molar extraction is usually associated with multiple stigmae that deters the patients in most cases to postpone or not seek appropriate surgical care. It is also one of the most feared procedure amongst dentists and dental students. However, evidence has been reported suggesting that the choice of suturing technique can have a profound effect on post-operation complications and thereby can improve the overall outlook and comfort of the patient. In the past, multiple techniques like Mattress, Continuous etc have been compared with tissue glues, staples however, a comparative clinical study amongst the simplest and most commonly used suturing techniques have not been reported. Material and Methods Sixty patients with impacted mandibular third molars fulfilled the inclusion criteria and were randomly divided into three groups of 20 each. All patients underwent third molar extraction and sutures were placed using different techniques – Simple Interrupted (Group A), Continuous (Group B) and Figure of eight (Group C). Patients were evaluated pre-operatively as well post-operatively (at different time points) for five parameters - Pain, Swelling, Trismus, Periodontal health of second molar and Wound infection. Kruskal-Wallis (non-parametric ANOVA) with post-hoc and effect size was used for statistical analysis with P < 0.05 as statistically significant. Results Statistically significant differences were obtained in terms of pain and trismus between Groups A and C post-operatively (P < 0.05). There were also significant differences in pain between Groups B and C post-surgery (P < 0.05). No significant differences were found between groups for swelling, periodontal health of second molar and wound infection. Conclusions Figure of eight suturing presents with better patient outlook and is associated with lower pain, swelling and trismus. Continuous and simple interrupted suturing can be preferred as second-in-line techniques. Final choice of technique shall be made based on wound anatomy, patient history and surgeon’s expertise.
... As a matter of fact, for Fuster-Torres et al. (6) preventative extraction is the most common indica-tion, followed by orthodontic reasons, pericoronitis and caries. The extraction of the impacted M3 is associated with a series of immediate postoperative reactions such as pain, inflammation and trismus, and possible long-term events due to both the operative difficulty caused by the impaction of the molar and the anatomical characteristics of the operative field, affecting, thus, the patients' quality of life (7). The complication rate ranges between 2.6 and 30.9%, being the outcomes influenced by various factors such as the age and health status of patients, gender, race, weight, body mass index, the degree of impaction of the third molar, proximity to the inferior dental nerve canal, smoking habits, consumption of contraceptive drugs, level of oral hygiene, surgical technique and the operator's experience inter alia (8). ...
... However, according to Van Gool et al. (28), the severity of pain after removing the lower M3s does not seem to be related to the type of incision, the amount of ostectomy or the need for tooth sectioning. In addition, there are studies that relate the professional's little experience to increased pain, and consequent-ly to increased consumption of analgesics after surgery (14), whereas studies like those by Rakhshan et al. (7) do not find any relation between the operator's expertise and postoperative pain. Furthermore, pain and analgesic intake increased when surgical trauma increased (29). ...
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Background: Third molars are present in 96.6% of humans, although they do not always erupt completely. Between 9.5% and 73% of them remain impacted. Surgical removal of impacted third molars is the most common practice in oral and maxillofacial surgery. This procedure results in traumatism and, consequently, the postoperative phase will involve symptomatology. It is uncommon to find studies that directly relate postoperative symptomatology and the operator's experience. The aim of this study was to determine the differences regarding postoperative symp-tomatology in patients undergoing the bilateral extraction of lower impacted third molars and according to the operator's experience. Material and methods: A prospective cohort double-blind study was conducted in 50 healthy patients (100 molar extractions) to whom both lower third molars were removed by two dentists with different degree of professional experience. The extractions were randomly assigned with a split-mouth design. If an operator extracted the lower third molar on one side, the other operator extracted the contralateral one. The variables studied after four days of postoperative period were Pain (EVA scale), Inflammation and Trismus, in addition to intraoperative time and local anesthesia administered. Results: Statistically significant differences were detected in the time of intervention and in trismus, since the most experienced operator always needed less time and caused higher degree of trismus. However, this does not entail more inflammation or pain in patients, so there are no relevant differences between operators with more or less experience (p>0.05). Conclusions: The postoperative period is more favorable for the most experienced operator, although the results do not vary in a relevant manner between them. Key words:Preemptive analgesia, dental extraction, cyclooxygenases, real-time polymerase chain reaction.
... There are several factors that can affect the pain intensity after 3MS, such as the type of analgesic used postoperatively, the oral hygiene, the difficulty of the extraction procedure, and the operator's experience. 29 Therefore, the results of the pain measurement should be interpreted with caution. Finally, there are a small number of RCTs comparing some interventions, especially the top-ranking interventions. ...
Article
A variety of corticosteroids are available as an alternative to reduce inflammatory complications after mandibular third molar surgery (3MS). However, it is unclear which are the best preoperative drugs, doses, and routes of administration. A frequentist network meta-analysis was performed to assess the comparative effectiveness of corticosteroids to reduce inflammatory complications after 3MS. We searched Embase, PubMed, the Cochrane Library without language restrictions. Only randomized clinical trials (RCTs) were included. We obtained the relative effectiveness using network meta-analysis and an estimate of the relative ranking of interventions according to their effects. Our search yielded 2427, from which 61 studies involving 3561 subjects fulfilled our inclusion criteria. Five corticosteroids (dexamethasone, betamethasone, methylprednisolone, prednisolone, and triamcinolone) were compared. Dexamethasone 8mg via submucosal injection (-3.58[-6.98; -0.17]) and via pterygomandibular injection (-3.56[-6.30;-0.82]) were significantly more effective than placebo to reduce edema after 3MS. The ranking analysis showed that dexamethasone 8mg via submucosal injection and via oral tablets were the interventions with the highest probability of being the most effective methods to reduce edema after 3MS (P-Score = .71 and .75, respectively). Compared with placebo, only dexamethasone 8mg via submucosal injection effectively reduced pain in the first and second days after 3MS (-30.95[-43.41;-18.49]) and (-15.25[-23.27;-7.22]) respectively. Overall, corticosteroids reduced inflammatory complications after 3MS and did not show any serious adverse effects. Among the corticosteroids reviewed, dexamethasone 8mg was the best preoperative option to control inflammatory complications after 3MS. Further RCTs are needed to confirm the optimal route of administration.
... Platelet-rich fibrin (PRF) has been used to treat dry sockets with a study reporting an early reduction in pain levels experienced by patients with minimal need of analgesic intake [33]. Moreover, honey has also been used to treat patients with dry sockets due to a significant reduction in inflammation, discomfort, pain, and hyperemia [34,35]. Other therapies can have a significant influence on the oral environment. ...
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Introduction. Alveolar Osteitis (AO) is the most common complication faced by exodontia patients and is usually seen 24-74 hours after tooth extraction, heralded by severe throbbing pain. Nigella sativa is commonly known as a black seed known to have anti-inflammatory, antibacterial properties along with other-reparative properties that enhance bone formation. This study aimed to evaluate and compare the effect of alvogyl and a mixture of Nigella Sativa powder and oil in the treatment of dry sockets. Material and Methods. This study aimed to evaluate and compare the effect of Alvogyl and a Mixture of Nigella Sativa’s powder and oil in the treatment of dry sockets. Sixty patients above the age of 18 and below 70 years, from both genders, who underwent extraction of teeth and are clinically diagnosed with a dry socket at the clinic of College of Dentistry, Jouf University, Saudi Arabia were included in this study. Pain scores were assessed after placement of dressing at the following intervals: 5 minutes, 30 minutes, 60 minutes, 2nd Day, 4th Day, and 7th Day. Patients were randomly allocated to three groups namely Group 1 (Alvogyl), Group 2 (Mixture of Nigella Sativa’s powder and oil), Group 3 (Control). Pain relief and healing of the socket were compared between the three groups. The collected data were subjected to statistical analysis through Spearman’s correlation test, independent t-test, ANOVA, and post-hoc test. Results. A mixture of Nigella Sativa powder and oil showed a statistically significant difference in relieving pain compared to the Alvogyl group. A mixture of Nigella Sativa’s powder and oil required fewer dressings when compared to the Alvogyl group. Conclusion. A mixture of Nigella Sativa powder and oil is the more efficacious dressing material for the management of dry sockets compared to Alvogyl. It provides immediate complete pain relief and fewer numbers of repeated visits.
... Healing is defined as the recovery of damaged tissue in the body. This can occur without swelling, hematoma, pain, trismus, or any signs of inflammation or infection that delay healing and can be considered as postoperative complications (Srinivas et al., 2018) (Walter and Israel, 1987) (Rakhshan, 2015). ...
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Background and Purpose Tooth extraction is critical for dental treatment complications. One of the most discussed topics is socket healing after extraction. The Benex system allows extraction without causing unnecessary socket expansion by removing the tooth vertically, preserving both bone and soft tissue. Aim. To assess postoperative healing signs, symptoms, and complications using the Benex extraction system and compare it with conventional extraction among patients at Umm Al-Qura University. Methods. Thirty-eight patients with hopeless single-rooted teeth were included. They were divided into two equal groups: one in which teeth were extracted using the conventional method and one in which extractions were performed by Benex. The Benex system for tooth extraction was performed by drilling into the root canal, followed by screw insertion. Once the extractor was properly positioned, extraction was accomplished by turning the hand screw clockwise. At baseline, the wound size was evaluated. On days 1, 3, and 7 after extraction, telephone interviews were conducted to evaluate pain and post-extraction complications using a pain scale and questionnaire. Socket healing and wound size were evaluated after 2 and 4 weeks of extraction using the healing index and H2O2 epithelization test. Results. The Benex extraction system accelerated early soft-tissue healing and decreased pain and wound size compared with the control group. Conclusion. The Benex system is relatively safe and easy to use, but this does not eliminate the need for a degree of education and training. Proper selection of the case, knowledge of using the device, and implementation of that knowledge in the treatment planning are important factors in ensuring success with this system.
... Third molar teeth extraction is one of the most commonly carried out procedures in dental practice and most people would need surgical extraction of wisdom teeth at some point of time in life [1]. This procedure is usually associated with significant sequelae post-surgically like pain, trismus, and oedema; events that rely on several factors which can be attributed to the difficulty of the surgical procedure, the technique used, the experience of the surgeon and also the severity of the impaction [2][3][4][5][6]. ...
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Aim The present study aimed to evaluate and compare the efficacy and safety of oral bromelain, a natural enzyme complex with oral diclofenac sodium in managing pain and swelling after mandibular third molar surgery. Materials and methods A total of 40 patients were randomly divided into two groups, the bromelain group (n = 20) and the diclofenac sodium group (n = 20). Patients received either bromelain, 500 mg twice daily or diclofenac sodium, 50 mg thrice daily for five days after the surgical extraction of impacted third molars. Swelling and trismus were evaluated pre-operatively (day0) and on postoperative days 1, 2, and 7, pain on postoperative days 1, 2, and 7,also, the need for rescue medication and adverse effects were evaluated in both groups. Results There was no difference between the bromelain and diclofenac groups in VAS pain scores (day1 = 35.1 vs 33.4, p = 0.829; day2 = 22 vs 22.4, p = 0.694; day7 = 13 vs 14.3, p = 0.678). There was no difference between the groups in swelling (day0 = 270.8 vs 266.5, p = 0.256; day1 = 279.2 vs 272.8, p = 0.167; day2 = 277.3 vs 271.4, p = 0.151; day7 = 269.2 vs 266.1, p = 0.440), trismus (day0 = 50.5 vs 48.9, p = 0.542; day1 = 29.6 vs 31.7, p = 0.839; day2 = 31.7 vs 32.6, p = 0.882; day7 = 41.1 vs 37.6, p = 0.273) and the number of rescue medications (1.6vs1.9, p = 0.956). Patients in both the groups did not report any severe or serious adverse effects. Conclusions Bromelain was comparable to diclofenac in the management of postoperative pain, swelling and trismus following impacted mandibular third molar surgery.
... It can be associated with actual or potential tissue damage [3,4]. Pain is caused by the release of pain mediators from injured tissues, which reach their peak levels during the first postoperative day [5]. e treatment of choice for pain relief after teeth extraction is a nonsteroidal anti-inflammatory drug [6]. ...
Article
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Methods: The study included 60 patients according to sample size calculation, recruited from patients seeking tooth extraction at oral and maxillofacial surgery clinic at Umm Al-Qura University, Faculty of Dentistry. Patients were divided into three groups. Group Ӏ included 20 patients managed by advanced platelet-rich fibrin after extraction. Group ӀӀ included 20 patients managed by leukocyte-platelet-rich fibrin after tooth extraction. Group ӀII included 20 patients left without any addition. Each group was further subdivided into surgical and nonsurgical extraction. Afterwards, patients in each group were assessed for postextraction pain by VAS, number of analgesics, and early soft tissue healing by LWHI. Results: The study outcomes demonstrate that the use of A-PRF significantly reduces postoperative pain in the 1st and 2nd day. VAS pain scores on the first day were significantly higher in the control surgical extraction group and L-PRF nonsurgical extraction group. In early soft tissue healing. The Landry Wound Healing Index (LWHI) was used after 1 and 2 weeks of extraction to evaluate the extraction site. In first week, the A-PRF group and L-PRF group (nonsurgical extraction) had a better healing index when compared to control group, and A-PRF group (surgical extraction) had a best healing index when compared to L-PRF and control groups. In the second week, individuals in the A-PRF group (surgical and nonsurgical extraction) had a better healing index when compared to L-PRF and control groups.
... 0.007, and 0.002, respectively). Most researchers agree that women's sex hormones, psychologic and sociocultural factors, along with their thinner mandible could render them more sensitive to postoperative pain (2,3,38,39). ...
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Citation: Haghighat A, Ramezanzade S. Effectiveness of preoperative chlorhexidine mouthwash on pain after lower posterior teeth removal: a randomized, double-blind clinical trial. Avicenna J Dent Res. Abstract Background: Pain is one of the most common complications after tooth extraction and pain control is a crucial part of the procedure. The purpose of this study was to investigate the influence of 0.2% (w/v) chlorhexidine (CHX) gluconate mouth rinse on the severity of post-extraction pain. Methods: A prospective, randomized, double-blind trial was conducted among 170 subjects. Subjects were instructed to rinse with 15 mL of CHX mouth rinse (study group) or placebo (control group) 0.5 to 1 hour before extraction. Post-operative pain was evaluated considering the number of taken rescue analgesics and using a visual analog scale (VAS) that each case completed 6, 12, 24, and 48 hours after the surgery. The Mann-Whitney U test was performed in this regard. Results: There were no significant differences between the two groups regarding demographic variables (P > 0.05). The preoperative use of CHX mouth rinse showed a better performance in mitigating the perceived pain. A significant difference in the pain level (P=0.001) was found only at the 6 th hour postoperatively although there was no significant difference in the pain level between the two groups (P > 0.05) at all other times (12th, 24th, 48th hours). The total number of analgesics that were taken by the study group was significantly lower compared to the control group (P=0.042). Conclusions: The preoperative CHX mouth rinse could be a beneficial choice for reducing pain after simple tooth extractions.
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Background and purpose: Conventionally, rotary devices were used for bone surgery. Recently, new techniques have been proposed such as piezosurgery. The prevalence of impacted teeth which should be removed is high. There are different techniques for bone removal that are associated with specific complications. This study compared the postoperative complications of impacted third molar extraction between piezoelectric method and conventional surgical handpieces. Materials and methods: A cohort study was done in 40 patients (mean age: 22.05±4.13 years) including 20 men and 20 women. They were randomly assigned into two groups to receive either piezosurgery (group A) or conventional handpiece (group B). The participants were recalled after three days and pain and mouth opening were compared with those of baseline scores as well as dry socket. SPSS v. 25 was used for data analysis. Results: The mean difference in mouth opening was significantly lower in group A than group B (P<0.001). There were no significant differences in pain level between male and female patients and between the two groups (P>0.05). But, patients in piezoelectric group were more satisfied with their surgery. Dry socket was observed only in two cases of group B. Conclusion: The benefits of handpiece method is high speed in operation and lower costs. However, the piezoelectric method is newer, more convenient, and has less trismus than the handpiece method.
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Estudio del postoperatorio de lOO terceros molares mandibulares incluidos, en relación a la edad, el sexo, el tabaco u la higiene bucal Postoperatoru studu in lOO impacted mandibular third molars and his relation with age, sex. smoking and oral hugiene Resumen: La extracción del tercer molar inferior incluido provoca efectos secundarios como dolqr. inflamación y trismo. Presentamos un estudio cuyo objetivo fue relacionar la edad. el sexo. el tabaco y la higiene oral con el posto-peratorio de 100 de terceros molares inferiores incluidos. la edad. el sexo y el consumo de tabaco no influyeron significativamente en el postoperatorio. Sólo hallamos una correlación estadisticamente significativa entre la higiene oral y el dolor a las 6 horas de la exodoncia. Palabras clave: Terceros Molares llnferiores Incluidos, Cirugía Oral. Dientes Incluidos. Abstract: Surgical removal of mandibular third molars ls normally followed by an inflamatory reaction characterized by pain. swelllng, and trismus. The purpose of this study was to compare the preoperative variables !age, sex. smoking hablts and oral hygienel, with the postoperative in 100 impacted mandibular third molars. The age, the sex and smoking habits showed no signlficant difference with the postoperative pain. trismus and swelling. Significant statisticallyl us increase of the pain was found in the group of the poor oral hygiene. but not the swelling. BIBLID l1138-123X !1999l4:5; septiembre-octubre 445-5481 Sáez-Cuesta u. Peñarrocha-Dlago M. Sanchls-Bielsa JM, Gay-Escoda C. Estudio del postoperatorio de 100 terceros molares mandibulares incluidos. en rela-ción a la edad, el sexo. el tabaco y la higiene bucal.
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Aims: To assess the effects of intra-alveolar application of chlorhexidine gel on the incidence of alveolar osteitis (dry socket) and the severity of postsurgical pain. Methods: A total of 160 impacted mandibular third molars were extracted in 80 patients enrolled in this trial. In each subject, a socket was randomly selected and packed to the crest of the alveolar ridge with a gelatin sponge dressing saturated in 0.2% chlorhexidine gel. The contralateral socket was packed with a dry dressing as the placebo. None of the included patients took antibiotics or analgesics. The occurrence of dry socket and patients' pain levels were assessed at the first and third postoperative days. The data were analyzed using Spearman correlation coefficient, McNemar, Wilcoxon, and chi-square tests. Results: Chlorhexidine gel significantly reduced dry socket incidence from 32.6% to 11.3% (P ≤ .001 [McNemar and chi-square], absolute risk reduction = 21.2%, relative risk reduction = 65.4%, odds ratio = 0.263, relative risk = 0.345). It also significantly relieved postoperative pain on both sides in all the patients (P ≤ .001 [Wilcoxon]) and also in the 54 subjects who did not develop dry socket (P ≤ .001 [Wilcoxon]). Conclusions: Besides decreasing the incidence of dry socket, chlorhexidine gel can reduce postsurgical pain in patients with and without dry socket.
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Objective: This paper investigates the relationship between preoperative findings and short-term outcome in third molar surgery. Study design: A prospective study was carried out involving 80 patients who required 160 surgical extractions of impacted mandibular third molars between January 2009 and December 2010. All extractions were performed under local anesthesia by the same dental surgeon. Swelling and maximal inter-incisor distance were measured at 48 h and on the 7th day postoperatively. Mean visual analogue pain scores were determined at four different time periods. Results: One-hundred eight (67.5%) of the 160 extractions were performed on male subjects and 52 (32.5%) were performed on female subjects. Median age was 22.46 years. The amount of facial swelling varied depending on gender and operating time. Trismus varied depending on gender, operating time and tooth sectioning. The influence of age, gender and operating time varied depending on the pain evaluation period (p < 0.05). Conclusions: Short-term outcomes of third molar operations (swelling, trismus and pain) differ depending on the patients’ characteristics (age, gender and body mass index). Moreover, surgery characteristics such as operating time and tooth sectioning were also associated with postoperative variables. Key words:Third molar extraction, pain, swelling, trismus, postoperative findings, prediction.
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PURPOSE: To assess risk factors for alveolar osteitis. MATERIALS AND METHODS: A prospective nested case-control study was conducted in an urban community dental clinic in Valdivia, Chile. A cohort of 1,355 patients who underwent dental extractions was included. Eight predictor variables (risk factors), namely patient gender, hygiene, tooth location, previous surgical site infection, traumatic extraction, systemic diseases, alcohol consumption, and tobacco use, were considered in a risk factor model. A binary regression logistic analysis was performed to determine significant associations. RESULTS: In total 1,302 participants completed the follow-up. Eighty incident case patients with alveolar osteitis and 80 matched control patients were included. A statistically significant association was found between traumatic extraction (odds ratio [OR], 13.1; 95% confidence interval [CI], 5.4 to 31.7), tobacco smoking after extraction (OR, 3.5; 95% CI, 1.3 to 9.0), previous surgical site infection (OR, 3.3; 95% CI, 1.4 to 7.7), and the development of alveolar osteitis. CONCLUSIONS: Previous surgical site infection, traumatic extraction, and tobacco smoking are associated with an increased risk of alveolar osteitis.
Article
Reports on post-surgical pain are a few, controversial and flawed (by statistics and analgesic consumption). Besides, it is not known if chlorhexidine can reduce post-extraction pain adjusting for its effect on prevention of infection and dry socket (DS). We assessed these. A total of 90 impacted mandibular third molars of 45 patients were extracted. Intra-alveolar 0·2% chlorhexidine gel was applied in a split-mouth randomised design to one-half of the sockets. None of the included patients took antibiotics or analgesics afterwards. In the first and third post-operative days, DS formation and pain levels were recorded. Predictive roles of the risk factors were analysed using fixed-effects (classic) and multilevel (mixed-model) multiple linear regressions (α = 0·05, β≤0·1). In the first day, pain levels were 5·56 ± 1·53 and 4·78 ± 1·43 (out of 10), respectively. These reduced to 3·22 ± 1·41 and 2·16 ± 1·40. Pain was more intense on the control sides [both P values = 0·000 (paired t-test)]. Chlorhexidine had a significant pain-alleviating effect (P = 0·0001), excluding its effect on DS and infection. More difficult surgeries (P = 0·0201) and dry sockets were more painful (P = 0·0000). Age had a marginally significant negative role (P = 0·0994). Gender and smoking had no significant impact [P ≥ 0·7 (regression)]. The pattern of pain reduction differed between dry sockets and healthy sockets [P = 0·0102 (anova)]. Chlorhexidine can reduce pain, regardless of its infection-/DS-preventive effects. Simpler surgeries and sockets not affected by alveolar osteitis are less painful. Smoking and gender less likely affect pain. The role of age was not conclusive and needs future studies.
Article
Although dry socket (DS) is commonly investigated, many of its risk factors remain highly controversial. In addition, few studies are available to show the preventive effect of chlorhexidine gel on DS. Moreover, multivariable analyses of DS risk factors are scarce, and their interactions have not been assessed previously. Therefore, the simultaneous effect of chlorhexidine gel and 4 DS risk factors and their interactions were analyzed within a multivariable framework. Using a split-mouth randomized clinical trial design, the investigators enrolled a cohort of patients requiring extraction of 2 mandibular third molars. The primary predictor variable was extraction socket treatment status, classified as experimental or standard. Experimental treatment was the insertion of chlorhexidine gel (0.2%) into the extraction socket. Each patient had 1 third molar randomly selected as the treatment site. The contralateral third molar served as the control socket and was treated in the usual manner. The primary outcome variable was DS status, present or absent, assessed on postoperative day 3. Other study variables were categorized as demographic, smoking, and surgical difficulty according to the Pederson scale. Appropriate bivariate and multiple logistic regression statistics were used to measure the association between risk for DS and chlorhexidine gel use, age, gender, smoking, and surgical difficulty and their interactions (α = 0.05). The sample consisted of 90 bilateral extraction sockets in 45 patients (24 men; 21 smokers; mean age, 21.1 ± 2.7 yr). Regression analysis showed that when other factors and their interactions were controlled for, chlorhexidine gel application lowered the risk of DS (odds ratio [OR] = 0.05; P = .004). Increasing age (OR = 2.9; P = .030) was associated with an increased risk for DS. A similar association existed between increased difficulty level of extraction and DS risk (OR = 3.8; P = .051). The effect of gender was marginally significant (P = .091), whereas smoking did not have a significant influence (P = .4). Intra-alveolar application of chlorhexidine gel and practicing less traumatic surgeries are advocated, particularly in older patients. Smoking seems unlikely to affect DS frequency. The role of gender is inconclusive.
Article
Background Unlike passive sensitivity of implants/teeth that is assessed more, only three controversial studies have compared active tactile sensibility (ATS) of implants and teeth. PurposeWe aimed to explore the difference between the ATS of teeth and single-tooth implants. Methods The ATS of single-tooth implants and contralateral teeth was measured in 25 patients after they bit on gold and placebo foils 0- to 70-m thick, each for five times, in a random order blinded to patients and assessor, carried out at two sessions. Based on the experimental range of 0m (mock trials) to 70m, the sigmoid shape of psychometric curve was estimated to locate the 50% values as the ATS thresholds for each tooth or implant. ATS Data were analyzed using paired and unpaired t-tests and multiple linear regression (=0.05, 0.1). Also, equivalence testing approach was used to assess semi-objectively the clinical significance. ResultsAverage ATS values for teeth and implants were 21.46.55m and 30.0 +/- 7.55m, respectively (p=.0001 [paired t-test]). None of the geometric characteristics of implants nor duration of implant in function were correlated with the ATS (p>.4 [regression]). Age was positively associated with the ATS of both implants and teeth (p.019 [regression]). Tooth ATS (but not implant ATS) was significantly higher in males compared with females (p=.050 [unpaired t-test]), which contributed to a generalizable tooth-implant difference higher than 8-m clinical equivalence margin in females. The ATS was not significantly different between arches or between anterior/posterior regions (p>.6). Conclusion There was a slight but statistically significant difference between implant and tooth tactile sensitivities.
Article
Sex-related differences in the experience of both clinical and experimentally induced pain have been widely reported. Specifically, females are at greater risk for developing several chronic pain disorders, and women exhibit greater sensitivity to noxious stimuli in the laboratory compared with men. Several mechanisms have been proposed to account for these sex differences. Psychosocial factors such as sex role beliefs, pain coping strategies, mood, and pain-related expectancies may underlie these effects. In addition, there is evidence that familial factors can alter pain responses, and these intergenerational influences may differ as a function of sex. Sex hormones are also known to affect pain responses, which may mediate the sex differences. Although the magnitude of these effects has not been well characterized, there are potentially important practical implications of sex differences in pain responses. These implications are discussed, and directions for future research are delineated.