Dental pain: Predicting postoperative pain prior to the procedure

While one cannot predict which dental patients will experience postoperative pain and which will not, Dr. Scott Froum distills the top five preoperative factors and patient characteristics that lead to postprocedural pain and the need for analgesics so you can better anticipate various dental pain levels and respond proactively.

Mar 6th, 2019
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While one cannot predict which dental patients will experience postoperative pain and which will not, Dr. Scott Froum distills the top five preoperative factors and patient characteristics that lead to postprocedural pain and the need for analgesics so you can better anticipate various dental pain levels and respond proactively.


PAIN AND DISCOMFORT AFTER DENTAL PROCEDURES can decrease patient satisfaction and negatively affect repeat visits and/or referrals, as well as positive patient reviews. Much attention has been given toward pain management postdental procedure, particularly as the opioid epidemic has come into national focus. Minimally invasive dentistry utilizing instruments, surgical techniques, computer-assisted anesthetic delivery systems, and nonopioid long-lasting analgesics have been invented to minimize postdental procedural discomfort.

The problem remains, however, that it is unpredictable as to which dental patients will experience postprocedural pain and which patients will not. In fact, there have been many times in my practice when a patient who had undergone an invasive surgical procedure experienced no pain, while another patient who had a minor minimally invasive procedure performed called my after-hours emergency service in agony. The intent of this article is to briefly describe the top five preoperative factors and patient characteristics that lead to postprocedural pain and the need for analgesics in an attempt to better anticipate various levels of dental pain and thus respond proactively.

Anxiety

According to numerous studies, the number one predictor of preoperative pain is anxiety prior to the dental procedure. (1) Furthermore, anxiety can be broken down into three different subsets.

• Patients who are only anxious prior to the dental procedure but in general are not anxious have a positive correlation with postoperative pain. (2) These patients may have better postoperative pain outcomes with some form of sedation.

• Patients with psychological stress who are generally nervous and tend to catastrophize (an immediate and habitual tendency toward a negative assessment of the situation). These patients think the procedure is going to hurt postoperatively despite what they are told. Distraction mechanisms (taking the patient's mind off the procedure) have been shown to positively benefit these types of patients in terms of minimizing postoperative pain.

• Patients with poor coping skills tend to have higher intensities of postprocedural pain than patients with good coping skills. Good coping skills include information-seeking behavior, emotional support systems, and religious beliefs. (3)

Preoperative pain

Patients who are already experiencing pain and/or have low pain thresholds prior to a dental procedure are more likely to have postoperative pain than patients who do not have preexisting pain. (4) In order to reduce pain, these patients may benefit from antibiotic and anti-inflammatory medication for a duration of time prior to a dental procedure.

Type and length of procedure

In general, patients who are undergoing long, invasive dental procedures experience more postoperative pain than patients undergoing shorter, minimally invasive procedures. One study suggests that if a surgical procedure can be shortened by 10 minutes, moderate to severe postoperative pain can decrease as much as 40%. (5)

Age

Many studies have found that younger patients have been correlated with higher postprocedural pain and analgesia requirements. (6) Although there is no consensus in the literature, the proposed suggestion for age-related postprocedural pain is that increases in age may blunt the peripheral nociceptive function, decreasing pain in some contexts and reducing the need for postprocedural analgesia. However, confounding variables do exist in the elderly population, and patients who are already experiencing chronic pain and/or are on pain medication may not fall into this category.

Red hair

Although the science is scarce on this topic, the literature has shown that patients with red hair are more likely to experience postoperative pain and have a diminished response to dental anesthesia when compared to patients who do not have red hair. The possible mechanism of this phenomena is that red hair is the phenotype for mutations of the melanocortin 1 receptor. Studies suggest that redheads are more sensitive to thermal pain and are resistant to the analgesic effects of subcutaneous lidocaine. Mutations of the melanocortin 1 receptor, or a consequence thereof, modulate pain sensitivity. (7)

Conclusion

Every patient is different, and pain is a multifactorial, dynamic topic that requires much more research. Personalized dentistry and DNA sequencing may solve some of the mysteries of pain management. However, in general, if an anxious, young redheaded patient who is experiencing severe tooth pain presents for treatment requiring a lengthy, invasive surgical extraction, you may want to warn that individual that the following days may not be pleasant.

References

1. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements.Pain. 1986;24(3):331-342.

2. Ye H, Chen R, Lian X, et al. Risk factors associated with postoperative pain and discomfort in oculoplastic surgery with general anesthesia: a prospective study.J Pain Res. 2018;11:407-415. doi:10.2147/JPR.S156104.

3. Perry F, Parker RK, White PF, Clifford PA. Role of psychological factors in postoperative pain control and recovery with patient-controlled analgesia.Clin J Pain. 1994;10(1):57-63.

4. Mamie C, Bernstein M, Morabia A, Klopfenstein CE, Sloutskis D, Forster A. Are there reliable predictors of postoperative pain?Acta Anaesthesiol Scand. 2004;48(2):234-242.

5. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures.J Periodontol. 2006;77(12): 2070-2079. doi:10.1902/jop.2006.050296.

6. Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.Anesthesiology. 2009;111(3):657-677. doi:10.1097/ALN.0b013e3181aae87a.

7. Liem EB, Joiner TV, Tsueda K, Sessler DI. Increased sensitivity to thermal pain and reduced subcutaneous lidocaine efficacy in redheads.Anesthesiology. 2005;102(3):509-514.

MORE CLINICAL TIPS FROM DR. SCOTT FROUM . . .

Scott Froum, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a clinical associate professor at SUNY Stony Brook School of Dental Medicine in the Department of Periodontology. He serves on the board of editorial consultants for the Academy of Osseointegration's Academy News. Contact him through his website at drscottfroum.comor (212) 751-8530.

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