Relationship between surgical difficulty and post-op pain for wisdom teeth exo

7/30/2019 Relationship between surgical difficulty and post-op pain for wisdom teeth exo

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tions were carried out at different times. All patientswere healthy, without serious medical alterations orblood dyscrasias. No patient had acute pericoronitisor severe periodontal disease at the time of surgery.

SURGICAL PROCEDURE

All interventions were performed by postgraduate

students at the University of Santiago de Compostela.All surgeries were performed under local anesthesiaby nerve-block anesthesia of the inferior alveolarnerve, lingual nerve, and buccal nerve with 2 1.8-mLcapsules of 4% articaine with epinephrine 1:200.000(Inibsa, Barcelona, Spain).

In cases where forceps proved insufficient, a muci-periosteal flap was raised, generally by an incisiondistal to the lower second molar along the length ofthe anterior border of the ascending ramus of themandible, with another incision mesial to the samemolar. Osteotomy, coronal section, or root section

was then performed as required, and the wound wasclosed with 3/0 silk, with a piece of folded gauzeapplied to the wound to aid hemostasis. The sutureswere removed 1 week later.

All patients received an antibiotic (amoxycillin, 500mg every 8 hours for 7 days, starting the day beforesurgery), an anti-inflammatory/analgesic (ibuprofen,600 mg every 8 hours for 4 days, starting after sur-gery), and an antiseptic (chlorhexidine 0.12%, 3mouth rinses per day for 7 days, starting the day aftersurgery).

EVALUATION OF SURGICAL DIFFICULTY

Surgical difficulty was evaluated on the basis ofduration of the intervention (from the start of theexodoncy procedure to the final suture) and rating ofdifficulty on a 4-class scale: I, extraction requiringforceps only; II, extraction requiring osteotomy; III,extraction requiring osteotomy and coronal section;IV, complex extraction (root section).

EVALUATION OF POSTOPERATIVE PAIN

Postoperative pain was evaluated using a visualanalog scale (VAS)13 that the patient completed athome every day after surgery (at approximately the

same time of day as the operation) until day 6 post-surgery, at which time the sutures were removed. Onthe VAS, the leftmost end represented absence of pain(score 0); the rightmost end, the most severe painimaginable (score 100).

STATISTICAL ANALYSIS

The Kruskal-Wallis test was used to compare painevaluations between the various surgical-difficultygroups. For paired comparisons, the Mann-WhitneyUtest with Bonferroni correction was used. Spearmansrank correlation was used to investigate relationships

between continuous variables. P values less than .05were considered to indicate statistical significance. Allsignificance tests were 2-way tests. All analyses weredone using SPSS for Windows (SPSS Inc, Chicago, IL).

Results

Of the 139 patients, 50 (36%) were men and 89(64%) were women. Mean age ( standard deviation)was 27.2 8.1 years (range, 18 to 60 years). Lowerthird molar extraction was required due to inflamma-tory pathology in 29.8% of cases and for prophylacticreasons in 41.7% of cases.

The most frequent surgical difficulty classes wereIII (32.5% of interventions, n 51) and IV (30.6% ofinterventions, n 48). The mean duration of surgerywas 36.8 22.8 minutes.

Mean reported pain (as evaluated on the VAS) washighest on the day of surgery and subsequently de-

clined steadily. As shown in Figure 1, patients whounderwent more difficult extractions tended to reportmore severe pain; mean pain evaluation was signifi-cantly higher in difficulty class IV than in difficultyclass I on days 0 to 6 inclusive, significantly higher inclass III than in class I on days 0 to 6 inclusive, andsignificantly higher in class II than class I on days 0 to5 inclusive. No significant differences were observedbetween classes IV and III, IV and II, or III and II atany time in the study. In line with these findings,patients who underwent interventions of longer du-ration had significantly higher pain evaluations on

days 0 (P

.019), 5 (P

.041), and 6 (P

.032).

Discussion

Pain, inflammation, and trismus are typically ob-served in the postoperative period after mandibularthird molar extraction.4 The sensation of pain is, ofcourse, subjective, and there are no uniform criteriafor its measurement. Pain sensation depends on eachindividuals subjective pain threshold, which may beinfluenced by diverse factors including age, gender,anxiety, and surgical difficulty.6,14,15 Diverse proce-dures and scales have been proposed for pain evalu-

ation, including the semiquantitative verbal scale ofOhnahaus and Adler,16 the McGill Pain Questionnaireof Melzack,17 the VAS of Scott and Huskinsson,13 andanalgesic use.7,8 For the present study, we selectedthe VAS, which is straightforward to apply and widelyused.

Surgical difficulty likewise may be evaluated in di-verse ways. Some previous studies have evaluatedsurgical difficulty in lower third molar extraction onthe basis of surgical complications,15 but difficultygenerally has been evaluated on the basis of anatom-ical factors and the position of the molar as assessed

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main difference between the present study and pre-vious studies is in the surgeons experience; all sur-geons in the present study were postgraduate stu-dents in training, without significant surgicalexperience. This is reflected in the long durations ofsurgery and should be taken into account in ourassessment of the relationship between surgical diffi-

culty and postoperative pain.Surgical difficulty as evaluated on our 4-class scale

was positively correlated with postoperative pain.This finding was as expected, because tissue damageis generally more extensive and more severe at eachincreasing level of surgical difficulty, and pain is dueprincipally to tissue damage.31 Similar results havebeen obtained in many previous studies.5,9,33-35 Incontrast, however, other studies25,30,36 have foundthat the severity of postextraction pain can vary frompatient to patient and does not appear to be related tosurgical difficulty or the degree of tissue damage.

In the present study, the relationship between sur-gical difficulty and pain was observed from difficultyclass II (requiring the raising of a mucoperiosteal flap)onward. We have reported the affect of this proce-dure on postoperative pain in a previous study,8 al-though in that study pain was evaluated on the basisof self-reported analgesic use. Another previous studylikewise evaluated the affect of raising a mucoperios-teal flap on postoperative pain in patients subjectedto bilateral extraction of mandibular third molars,comparing the side on which the flap was raised withthe contralateral side and finding more severe discom-

fort on the flap side.

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In the present study, thedifference in pain evaluations between difficulty classII and difficulty classes III and IV was not verymarked, although some previous studies have foundmore severe pain in more complicated interventions,in whichtraction by the mucoperiosteal flap is moresevere.5

Yuasa and Sugiura37 likewise reported a relation-ship between surgical difficulty and pain; however,they evaluated the difficulty before the surgery. Asnoted earlier, the present studylike that of Bergeand Boe6 evaluated surgical difficulty after thesurgery, which is probably a more accurate ap-

proach (although, of course, for clinical purposes,predicting the difficulty before the surgery is moreuseful).

The relationship observed between duration ofsurgery and postoperative pain was statistically sig-nificant only on day 1 postsurgery, when pain wasmost severe. Despite the limited experience of thetrainee surgeons in the present study, these resultsare similar to those obtained in previous studies,which likewise reported a relationship of thistype.4,5,38,39 Oikarinen5 reported a statistically sig-nificant difference in pain evaluations depending

on the duration of surgery. In the present study, arelationship was observed on days 4, 5, and 6 post-surgery, implying slower recovery for interventionsof longer duration. Pedersen4 recorded analgesicconsumption over the first 48 hours postsurgeryand found a significant correlation between dura-tion of surgery and postoperative pain. However,

other authors have not found an association be-tween severity of pain and duration of sur-gery,25,26,40 and some have not found any relation-ship between severity of pain and degree ofsurgical trauma.25,34

In conclusion, longer interventions are typicallyassociated with more pain. Likewise, pain increaseswith increasing difficulty of surgery, notably in op-erations requiring the raising of a mucoperiostealflap. In the present study, the surgical difficulty wasevaluated after the surgery, but for clinical pur-poses, both presurgical and postsurgical evaluation

are required for optimal analgesic management.Furthermore, it should be kept in mind that painafter third molar extraction also depends on otherfactors, such as smoking, oral hygiene, and historyof pericoronitis.

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Relationship between surgical difficulty and post-op pain for wisdom teeth exo

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