Pain and Dental Implantology: Sensory Quantification and Affective Aspects. Part I: At the Private Dental Office
http://www.implantoloji.info/articles/1/1/Pain-and-Dental-Implantology-Sensory-Quantification-and-Affective-Aspects-Part-I-At-the-Private-Dental-Office/Page1.html
By JDI editor
Published on 01/2/2001
Ernesto Muller, Dr Odont,
Director, Dental Implant Center, Universidad Santa Maria, School of Dentistry, Adjunct Professor of Periodontology and Oral Biology, Goldman School of Dental Medicine, Boston University, Boston, MA, USA.
Maria del Pilar Rios Calvo, Odont, MScD
Coordinator of Prosthetics, Dental Implant Center, Universidad Santa María, School of Dentistry, Private Practice limited to Prosthetic Dentistry, Centro Profesional Tamanaco, Caracas, Venezuela.
Does dental implantology hurt? The results of this research have demonstrated that the occurrence of pain is minimal and that the possibility of the onset of pain could be associated with the amount of trauma produced during the surgical procedures. At first-phase surgery, pain during swallowing and chewing can be expected. Pain in the implanted areas is anticipated to take place at a low intensity. The pain present after surgery can be easily managed following our presurgical and postsurgical medication protocol. Pain medication is generally not needed for more that 24 hours. Edema was the most prominent sign observed in the postoperative period after first-phase surgery; especially during the first 2 days. Hematoma was the second most common occurrence. The presence and intensity of edema will vary between patients. At second-phase surgery, slight discomfort that does not reach the level of pain is to be expected. However, strong postoperative pain that required pain medication was present in all patients who received acellular dermal grafts. This pain was easily controlled with the pain relief medications as prescribed in the standard presurgical and postsurgical medication instruction sheet, but had to be taken for a longer period of time. At second-phase surgery, edema and hematoma were not usually observed.
Director, Dental Implant Center, Universidad Santa Maria, School of Dentistry, Adjunct Professor of Periodontology and Oral Biology, Goldman School of Dental Medicine, Boston University, Boston, MA, USA.
Maria del Pilar Rios Calvo, Odont, MScD
Coordinator of Prosthetics, Dental Implant Center, Universidad Santa María, School of Dentistry, Private Practice limited to Prosthetic Dentistry, Centro Profesional Tamanaco, Caracas, Venezuela.
Does dental implantology hurt? The results of this research have demonstrated that the occurrence of pain is minimal and that the possibility of the onset of pain could be associated with the amount of trauma produced during the surgical procedures. At first-phase surgery, pain during swallowing and chewing can be expected. Pain in the implanted areas is anticipated to take place at a low intensity. The pain present after surgery can be easily managed following our presurgical and postsurgical medication protocol. Pain medication is generally not needed for more that 24 hours. Edema was the most prominent sign observed in the postoperative period after first-phase surgery; especially during the first 2 days. Hematoma was the second most common occurrence. The presence and intensity of edema will vary between patients. At second-phase surgery, slight discomfort that does not reach the level of pain is to be expected. However, strong postoperative pain that required pain medication was present in all patients who received acellular dermal grafts. This pain was easily controlled with the pain relief medications as prescribed in the standard presurgical and postsurgical medication instruction sheet, but had to be taken for a longer period of time. At second-phase surgery, edema and hematoma were not usually observed.
Introduction.
Ernesto Muller, Dr Odont,
Director, Dental Implant Center, Universidad Santa Maria, School of Dentistry, Adjunct Professor of Periodontology and Oral Biology, Goldman School of Dental Medicine, Boston University, Boston, MA, USA.
Maria del Pilar Rios Calvo, Odont, MScD
Coordinator of Prosthetics, Dental Implant Center, Universidad Santa María, School of Dentistry, Private Practice limited to Prosthetic Dentistry, Centro Profesional Tamanaco, Caracas, Venezuela.
Approximately 3 years ago, 15 Venezuelan specialists in dental implantology gathered with the aim of answering the following question: How can one convince the patient who is afraid of experiencing pain during or after implant surgery, that placement of dental implants is not painful? After some pondering, several answers that could be given to the patient were expressed: The patient will be fine, because he will have received medication to prevent pain; This surgery is less painful than the extraction of a wisdom tooth; Before placement of the implants, a computerized T-scan will be taken to confirm the indication and the possibilities and to aid in the case presentation; It is just a matter of rapport between the dentist and the patient. They were also asked, based on their previous experience, whether any of the patients had complained about pain during or after the treatment. Each of the specialists indicated that all of their patients had been pleasantly surprised about how little pain and postoperative discomfort (or other symptoms) they had experienced.
Is there any scientific proof to lay the foundation to these answers? Based on previous studies, are there concrete conclusions indicating no major pain associated with dental implantology? Are we really prepared to answer this important ques tion: Does dental implantology cause pain?
A patient who comes to the dental office is concerned about the cost of treatment and longevity of the results of treatment, but the major concern is the fear of dental pain, which can increase when the patient becomes aware of the surgical procedures involved in the placement of dental implants. However, most of the answers that the clinicians give to the patient are based on thier own clinical experience. There is no clinical research reported (between 1987 and 2000) that directly addresses this topic. Until now, all of the answers that the clinicians have provided to the patient have been speculative. Because pain is an experience that cannot be shared, different individuals sensing identical noxious stimuli feel pain differently and react at different levels of suffering.
Dental-oral pain creates a physiological fear situation in which patients experience a sense of emergency and anxiety toward the dentist and the treatment. The primary motivating factors for accepting or rejecting dental implants as a restorative alternative therapy is based on previous dental experiences, the relationship between the patient and the dentist, and the personal threshold of pain. However, pain is now considered to be more than a sensation. It constitutes an experience that involves both sensation and emotion. Pain cannot be sensed in a detachable manner; it comes in combination with dislike, anxiety, fear, and urgency.
Pain is conceptualized as constituting an unpleasant sensory and emotional experience associated with actual or potential tissue damage. If the patient regards his experiences as pain it should be accepted as pain. The intensity of pain from physical injury relates to the attention given at the time to the pain. Pain does not become an issue until the consequences of the injury induce feelings of concern and anxiety that relate more to the therapy and recovery process than to the injury itself. Pain may be judged subjectively or objectively. Subjective evaluation is based on the patient’s description, whereas the objective evaluation is based on changes in vital signs. Because subjectivity in pain evaluation depends on the patients’ description at the onset, the clinician should fully understand pain intensity, temporal behavior, quality of sensation, and the painful sensation character as well as the differences between clinical versus experimental pain; acute versus chronic pain; somatic versus neurogenous pain; superficial versus deep somatic pain; primary versus secondary pain; musculoskeletal versus visceral pain; inflammatory versus noninflammatory pain; and stimulusevoked pain versus spontaneous pain.
The overall aim of this study was to assess pain
Director, Dental Implant Center, Universidad Santa Maria, School of Dentistry, Adjunct Professor of Periodontology and Oral Biology, Goldman School of Dental Medicine, Boston University, Boston, MA, USA.
Maria del Pilar Rios Calvo, Odont, MScD
Coordinator of Prosthetics, Dental Implant Center, Universidad Santa María, School of Dentistry, Private Practice limited to Prosthetic Dentistry, Centro Profesional Tamanaco, Caracas, Venezuela.
Approximately 3 years ago, 15 Venezuelan specialists in dental implantology gathered with the aim of answering the following question: How can one convince the patient who is afraid of experiencing pain during or after implant surgery, that placement of dental implants is not painful? After some pondering, several answers that could be given to the patient were expressed: The patient will be fine, because he will have received medication to prevent pain; This surgery is less painful than the extraction of a wisdom tooth; Before placement of the implants, a computerized T-scan will be taken to confirm the indication and the possibilities and to aid in the case presentation; It is just a matter of rapport between the dentist and the patient. They were also asked, based on their previous experience, whether any of the patients had complained about pain during or after the treatment. Each of the specialists indicated that all of their patients had been pleasantly surprised about how little pain and postoperative discomfort (or other symptoms) they had experienced.
Is there any scientific proof to lay the foundation to these answers? Based on previous studies, are there concrete conclusions indicating no major pain associated with dental implantology? Are we really prepared to answer this important ques tion: Does dental implantology cause pain?
A patient who comes to the dental office is concerned about the cost of treatment and longevity of the results of treatment, but the major concern is the fear of dental pain, which can increase when the patient becomes aware of the surgical procedures involved in the placement of dental implants. However, most of the answers that the clinicians give to the patient are based on thier own clinical experience. There is no clinical research reported (between 1987 and 2000) that directly addresses this topic. Until now, all of the answers that the clinicians have provided to the patient have been speculative. Because pain is an experience that cannot be shared, different individuals sensing identical noxious stimuli feel pain differently and react at different levels of suffering.
Dental-oral pain creates a physiological fear situation in which patients experience a sense of emergency and anxiety toward the dentist and the treatment. The primary motivating factors for accepting or rejecting dental implants as a restorative alternative therapy is based on previous dental experiences, the relationship between the patient and the dentist, and the personal threshold of pain. However, pain is now considered to be more than a sensation. It constitutes an experience that involves both sensation and emotion. Pain cannot be sensed in a detachable manner; it comes in combination with dislike, anxiety, fear, and urgency.
Pain is conceptualized as constituting an unpleasant sensory and emotional experience associated with actual or potential tissue damage. If the patient regards his experiences as pain it should be accepted as pain. The intensity of pain from physical injury relates to the attention given at the time to the pain. Pain does not become an issue until the consequences of the injury induce feelings of concern and anxiety that relate more to the therapy and recovery process than to the injury itself. Pain may be judged subjectively or objectively. Subjective evaluation is based on the patient’s description, whereas the objective evaluation is based on changes in vital signs. Because subjectivity in pain evaluation depends on the patients’ description at the onset, the clinician should fully understand pain intensity, temporal behavior, quality of sensation, and the painful sensation character as well as the differences between clinical versus experimental pain; acute versus chronic pain; somatic versus neurogenous pain; superficial versus deep somatic pain; primary versus secondary pain; musculoskeletal versus visceral pain; inflammatory versus noninflammatory pain; and stimulusevoked pain versus spontaneous pain.
The overall aim of this study was to assess pain
- during and after the placement of dental implants, and
- at the second-phase surgery.
Materials and methods.
Patients (middle-high or high social and economic class) were examined at a private dental office specialized in periodontology and dental implantology. They were already oriented to receiving dental implants as a replacement therapy as part of their periodontal and restorative treatments. Patients were considered who had not received any bone grafts, soft tissue grafts, sinus floor elevation, or nerve transposition procedures before implant placement in the last 3 years. In the 75 patients selected at random, a total of 221 implants had been placed.
As psychological preparation, all the patients received only the necessary explanations about dental implants. Questions, typically asked at this point, were answered by the clinicians. These questions included the following: What is an implant?, What do they look like?, How will the surgery be performed?, How many surgeries are involved?, Are they painful?, Will I have pain after surgery?, Can I work immediately after surgery?, How will my private life be affected?, Will I be able to swallow?, How and when am I going to be restored?, How am I going to look?, How long is the treatment going to take?, How much will the treatment cost? And, of course, How long are they going to last?
The use of the necessary didactic materials, the availability of printed material to read, and bringing the patients in contact with other patients who have already had the experiences were crucial aids to our explanations and to create a better understanding for the patients and to assure them about the simplicity of the procedures and the absence of pain.
Once the patient’s confidence had been established about the proposed therapy, the letter of consent was signed. Each patient was examined according to a specially designed Pain Data Sheet, following the protocol oriented to analyze the individual threshold to pain. Presurgical and postsurgical instructions were standard for all patients. The pain data sheets were filled out by two independent clinicians who evaluated all signs and symptoms. The clinicians were trained and qualified by the surgeon. They had to transform subjective data to numerical data.
Data Records.
As psychological preparation, all the patients received only the necessary explanations about dental implants. Questions, typically asked at this point, were answered by the clinicians. These questions included the following: What is an implant?, What do they look like?, How will the surgery be performed?, How many surgeries are involved?, Are they painful?, Will I have pain after surgery?, Can I work immediately after surgery?, How will my private life be affected?, Will I be able to swallow?, How and when am I going to be restored?, How am I going to look?, How long is the treatment going to take?, How much will the treatment cost? And, of course, How long are they going to last?
The use of the necessary didactic materials, the availability of printed material to read, and bringing the patients in contact with other patients who have already had the experiences were crucial aids to our explanations and to create a better understanding for the patients and to assure them about the simplicity of the procedures and the absence of pain.
Once the patient’s confidence had been established about the proposed therapy, the letter of consent was signed. Each patient was examined according to a specially designed Pain Data Sheet, following the protocol oriented to analyze the individual threshold to pain. Presurgical and postsurgical instructions were standard for all patients. The pain data sheets were filled out by two independent clinicians who evaluated all signs and symptoms. The clinicians were trained and qualified by the surgeon. They had to transform subjective data to numerical data.
Data Records.
- Phase I: 2 Days before surgery.
Recorded data included age group and gender; the fear of the dentist and the fear of implantology as measured on a scale from 1 (no fear) to 10 (maximum fear); whether the pa tient was partially or totally edentulous; the presence or absence of temporomandibular myofascial pain disorders, recorded as yes or no; and buccal opening, recorded in millimeters. Function and pain were recorded for swallowing, talking, yawning, opening, closing, lateral movements, neck pain, and back pain as present or absent. Palpation and pain for the temporomandibular joint, temporal muscles, medial and external pterygoid muscles, and masseter muscles were recorded as present or absent. Dentate areas and ridges, dental pain, edentulous areas, and implanted areas were recorded using a pain scale measuring from 0 to 8: 0, no pain; 1, discomfort that does not reach the level of pain; 2, sporadic or intermittent pain; 3, continuous pain; 4, strong persistent pain that requires pain medication; 5, pain only controllable with pain medication; 6, recurring strong pain; 7, remission pain; and 8, periodic pain.
Pain in dentate areas and edentulous areas as well as other important symptoms that the patient described at the time of examination such as ear pain, neuralgia, cephalalgia, postoperative edema, and hematoma were evaluated and recorded. Previous dental experiences were recorded as good or bad. The same presurgical medication was given to all patients according to the protocol. All of the parameters were recorded during an appointment 2 days before surgery. - Phase II: Surgery.
Surgery was performed under local anesthesia (lidocaine 2% with epinephrine 1:100,000) according to a modified Brånemark surgical protocol. Standard screw-type implants (Restore, Lifecore Biomedical) were utilized in the mandible, and cylindrical pressfit, titanium plasma-sprayed implants (Restore) were utilized in the maxilla. At first-phase surgery, alloplastic bone substitute grafts (Bio-Oss, Geistlich Biomaterials, Wolhusen, Switzerland) with resorbable collagen membranes (Bio-Gide, Geistlich Biomaterials) were used when necessary. All implants were placed by the same clinician, who was experienced in periodontology and dental implantology. All of the patients received the same postsurgical instructions and medication. Following the protocol, the data related to pain during surgery was recorded. In addition, the duration of the surgical procedure, location and number of implants, use of grafts or membranes, and surgical complications were recorded at this stage. - Phase III: 24 Hours after surgery.
Immediate recording at 24 hours was selected to have an evaluation of all signs and symptoms at the possible peak. Same data was recorded as in phase I. - Phase IV: 1 Week and 1, 2, and 3 months after surgery.
The same parameters as in phase I were recorded on the Pain Data Sheet. A second measurement of maximal opening was taken at 1 week postsurgery to evaluate possible changes of maximum opening as a result of the surgical procedures. The evaluations at 1, 2, and 3 months were selected for observations of long-term postsurgical signs and symptoms. - Phase V: Second-stage surgery.
All patients underwent the secondphase surgical procedures The 4-month time selection corresponded to the second surgery for implants placed in the mandible and to the 6-month timing that corresponded with the second-stage surgery for implants placed in the maxilla. At the time of second-phase surgery, acellular dermal grafts (AlloDerm, LifeCell, Branchburg, NJ) were utilized when insufficient attached mucosa was present. All data were again recorded as in phase I. - Phase VI: 1- and 2-Year follow up.
All data were again recorded as in phase I. The times of observation at 1 and 2 years were selected to evaluate all of the signs and symptoms during a longer period of time, which would allow us to answer some questions (repeatedly asked by the patients) in relation to implant survival and possible long-term pain.
Results.
The concept of the possibility of feeling pain during or after dental implant surgical procedures plays an important role in the everyday practice of dentistry. Therefore, the method based on a Pain Data Sheet, was designed to collect an important amount of data that could be properly analyzed. The following results are an analysis of the data gathered on 75 patients with a total of 221 dental implants.
Data Records.
Age and gender.
The population was distributed in eight age groups: 1% of the patients were 15 to 20 years old; 8% were 21 to 30 years old; 4% were 31 to 40 years old; 32% were 41 to 50 years old; 28% were 51 to 60 years old; 27% were 61 to 70 years old; 6% were 71 to 80 years old; and no patients were 81 to 90 years old. Therefore, the main concentration of patients was between 41 and 70 years of age (87%). Of the 75 patients, 63% were women and 37% were men.
Distribution by partially and totally edentulous patients.
A total of 93% of the patients were partially edentulous, and 7% were totally edentulous.
Dental implant location.
The implants were distributed as follows: 53 dental implants were located in the upper right quadrant, 43 in the upper left quadrant, 61 in the lower left quadrant, and 64 in the lower right quadrant.
Fear of dentistry.
On a scale of 1 to 10, 57% of the patients reported an answer of level 1; no patients answered level 2, 30% answered level 3, and 13% answered level 4.
Fear of dental implantology.
The results on a scale of 1 to 10 were as follows: 4% answered level 1, 25% answered level 2, 23% answered level 3, 33% answered level 4, 11% answered level five, and 4% answered level 6.
Previous dental experience.
Regarding previous dental experience, 24% of the patients reported a previous bad dental experience compared with 76% who reported having had a good previous experience.
Temporomandibular myofascial pain disorders.
Temporomandibular myofascial pain disorders at phase I: 97% did not present any signs or symptoms, whereas 3% presented positive signs or symptoms.
Maximum opening.
Before surgery (phase I), the average maximum opening was 38 mm; 1 week after surgery (phase IV), the average maximum opening was 36.5 mm. Compared with phase I, no differences were observed in phase V or VI.
Pain and function during yawning.
Patients were asked to indicate the presence of pain during yawning. Of the 75 patients, before surgery (phase I), 2% indicated presence of pain during yawning; 24 hours (phase III) postsurgery, 5% indicated presence of pain; 1 week postsurgery (phase IV), 3% indicated presence of pain; and 1 month postsurgery (phase IV), 1% indicated the presence of pain (Fig. 1).
Pain and function during opening.
Patients were asked to indicate the presence of pain during opening. In the presurgical phase (phase I), 2% of patients indicated presence of pain during opening; in the surgical phase (phase II), 2% indicated presence of pain; 24 hours postsurgery (phase III), 5% indicated presence of pain; after 1 week (phase IV), 4% indicated presence of pain; at 1 month (phase IV), 2% indicated presence of pain; at 2 months 3% indicated presence of pain; at 4 months (phase V), 4% indicated presence of pain; at 1 year (phase VI), no patients indicated presence of pain; and at 2 years (phase VI), 1% indicated presence of pain. Pain and function during swallowing. Only at 24 hours postsurgery (phase III) was a positive response indicated for 15% of the patients.
Palpation and pain of the temporomandibular joint and muscles.
At the temporomandibular joint area, 1% of patients reported the presence of pain at 1 month postsurgery (phase IV). The results of palpation of the medial pterygoid muscle and the sternocleidomastoid muscle were negative during all phases. For the lateral pterygoid muscle, 3% of the patients reported pain during the presurgical phase; at 24 hours, 1% reported pain; after 1 week, 4% reported pain; after 1 month, 1% reported pain; and no patients reported the presence of pain thereafter. For the masseter muscle, 3% the patients reported pain at the presurgical phase, at 24 hours, 1% reported pain; at 1 week, 4% reported pain; after 1 month, 1% reported pain; and no patients reported the presence of pain thereafter. No pain was present during opening, closure, and lateral movements.
Evaluation of pain on edentulous areas and ridges.
Using a pain scale of 0 to 8 (0 indicative of no pain, whereas 8 indicated maximum pain), dental pain and pain in edentulous areas were absent. Pain in implanted areas at the first phase of surgery showed positive answers ranging from 1 to 4 at 24 hours postsurgery in 100% of the patients; at 1 week, 21% of the patients reported pain; at 1 month, 5% reported pain; at 4 months, 25% reported pain; and at 6 months, 25% reported pain. At second-stage surgery (4 months), 21% of the patients reported pain that ranged from a 1 to 4 level of pain, and at the second-stage surgery (6 months), 33% of the patients reported pain that ranged from a 1 to 4 level. No pain was present thereafter.
Ear pain, neuralgia, headache, edema, and hematoma.
At the presurgical and surgical phase (phases I and II), no patients reported pain. Twenty-four hours postsurgery (phase III), headache was present in 1% of the patients, edema in 90% of the patients, and hematoma in 33% of the patients. At 1 week postsurgery (phase IV), headache was present in 1% of the patients, edema in 23% of the patients, and hematoma in 12% of the patients. At 1 and 2 months (phase V), 4 and 6 months (phase VI), and 1 and 2 years, no pain was reported.
Surgical Procedures.
All of the patients followed the presurgical and postsurgical medication protocol. All of the patients received local anesthesia. Two percent of patients also received iv sedation. At the first phase of surgery, surgical time ranged from 45 to 270 minutes, with most surgeries lasting 60 to 75 minutes. In the second phase of surgery, surgical time ranged from 15 to 60 minutes, with most surgeries lasting 30 minutes.
Bone and Soft Tissue Grafts.
During first-phase surgery, 61% of the patients received alloplastic bone grafts (Bio-Oss) with resorbable collagen membranes (Bio-Gide). At second-stage surgery (4 months for the implants placed in the mandible and 6 months for implants place in the maxilla), 11% of the patients received acellular dermal grafts (AlloDerm, LifeCell). The patients who received the acellular dermal grafts had pain that ranged from discomfort that did not reach the level of pain (level 1) to continuous pain that required pain medication (level 4) for up to 15 days after surgery.
Statistical Analysis.
The statistical analysis was performed using the SPSS (Computerized Software program for Statistical analysis of Science) applied to the data (m 5 75). A chi square and a correlation test were calculated for each dependent and interdependent variable to estimate the sensory quantification and the affective aspects of pain related to dental implantology. Data were summarized by basic descriptive statistics to analyze all the variables within a period of time.
When patients inquire about the possibility of suffering pain at phase I (2 days before surgery), phase II (at surgery), phase III, (24 hours after surgery), phase IV (1 week and 1, 2, and 3 months postsurgery), phase V (second-stage surgery), phase VI (1- and 2-year follow up), the practitioner can reply that with a standard deviation of 0.3 to 0.5 and a level of confidence of P . .001, there is no statistical significance between pain and the basic surgical dental implantology procedures at any of the phases (based on the same variables). However, there is a statistical correlation between postsurgical dental implantology and edema, hematoma, and pain as well as pain at the site of the implanted areas during chewing from 24 hours postsurgery to 1 week postsurgery (same level of confidence).
Data Records.
Age and gender.
The population was distributed in eight age groups: 1% of the patients were 15 to 20 years old; 8% were 21 to 30 years old; 4% were 31 to 40 years old; 32% were 41 to 50 years old; 28% were 51 to 60 years old; 27% were 61 to 70 years old; 6% were 71 to 80 years old; and no patients were 81 to 90 years old. Therefore, the main concentration of patients was between 41 and 70 years of age (87%). Of the 75 patients, 63% were women and 37% were men.
Distribution by partially and totally edentulous patients.
A total of 93% of the patients were partially edentulous, and 7% were totally edentulous.
Dental implant location.
The implants were distributed as follows: 53 dental implants were located in the upper right quadrant, 43 in the upper left quadrant, 61 in the lower left quadrant, and 64 in the lower right quadrant.
Fear of dentistry.
On a scale of 1 to 10, 57% of the patients reported an answer of level 1; no patients answered level 2, 30% answered level 3, and 13% answered level 4.
Fear of dental implantology.
The results on a scale of 1 to 10 were as follows: 4% answered level 1, 25% answered level 2, 23% answered level 3, 33% answered level 4, 11% answered level five, and 4% answered level 6.
Previous dental experience.
Regarding previous dental experience, 24% of the patients reported a previous bad dental experience compared with 76% who reported having had a good previous experience.
Temporomandibular myofascial pain disorders.
Temporomandibular myofascial pain disorders at phase I: 97% did not present any signs or symptoms, whereas 3% presented positive signs or symptoms.
Maximum opening.
Before surgery (phase I), the average maximum opening was 38 mm; 1 week after surgery (phase IV), the average maximum opening was 36.5 mm. Compared with phase I, no differences were observed in phase V or VI.
Pain and function during yawning.
Patients were asked to indicate the presence of pain during yawning. Of the 75 patients, before surgery (phase I), 2% indicated presence of pain during yawning; 24 hours (phase III) postsurgery, 5% indicated presence of pain; 1 week postsurgery (phase IV), 3% indicated presence of pain; and 1 month postsurgery (phase IV), 1% indicated the presence of pain (Fig. 1).
Pain and function during opening.
Patients were asked to indicate the presence of pain during opening. In the presurgical phase (phase I), 2% of patients indicated presence of pain during opening; in the surgical phase (phase II), 2% indicated presence of pain; 24 hours postsurgery (phase III), 5% indicated presence of pain; after 1 week (phase IV), 4% indicated presence of pain; at 1 month (phase IV), 2% indicated presence of pain; at 2 months 3% indicated presence of pain; at 4 months (phase V), 4% indicated presence of pain; at 1 year (phase VI), no patients indicated presence of pain; and at 2 years (phase VI), 1% indicated presence of pain. Pain and function during swallowing. Only at 24 hours postsurgery (phase III) was a positive response indicated for 15% of the patients.
Palpation and pain of the temporomandibular joint and muscles.
At the temporomandibular joint area, 1% of patients reported the presence of pain at 1 month postsurgery (phase IV). The results of palpation of the medial pterygoid muscle and the sternocleidomastoid muscle were negative during all phases. For the lateral pterygoid muscle, 3% of the patients reported pain during the presurgical phase; at 24 hours, 1% reported pain; after 1 week, 4% reported pain; after 1 month, 1% reported pain; and no patients reported the presence of pain thereafter. For the masseter muscle, 3% the patients reported pain at the presurgical phase, at 24 hours, 1% reported pain; at 1 week, 4% reported pain; after 1 month, 1% reported pain; and no patients reported the presence of pain thereafter. No pain was present during opening, closure, and lateral movements.
Evaluation of pain on edentulous areas and ridges.
Using a pain scale of 0 to 8 (0 indicative of no pain, whereas 8 indicated maximum pain), dental pain and pain in edentulous areas were absent. Pain in implanted areas at the first phase of surgery showed positive answers ranging from 1 to 4 at 24 hours postsurgery in 100% of the patients; at 1 week, 21% of the patients reported pain; at 1 month, 5% reported pain; at 4 months, 25% reported pain; and at 6 months, 25% reported pain. At second-stage surgery (4 months), 21% of the patients reported pain that ranged from a 1 to 4 level of pain, and at the second-stage surgery (6 months), 33% of the patients reported pain that ranged from a 1 to 4 level. No pain was present thereafter.
Ear pain, neuralgia, headache, edema, and hematoma.
At the presurgical and surgical phase (phases I and II), no patients reported pain. Twenty-four hours postsurgery (phase III), headache was present in 1% of the patients, edema in 90% of the patients, and hematoma in 33% of the patients. At 1 week postsurgery (phase IV), headache was present in 1% of the patients, edema in 23% of the patients, and hematoma in 12% of the patients. At 1 and 2 months (phase V), 4 and 6 months (phase VI), and 1 and 2 years, no pain was reported.
Surgical Procedures.
All of the patients followed the presurgical and postsurgical medication protocol. All of the patients received local anesthesia. Two percent of patients also received iv sedation. At the first phase of surgery, surgical time ranged from 45 to 270 minutes, with most surgeries lasting 60 to 75 minutes. In the second phase of surgery, surgical time ranged from 15 to 60 minutes, with most surgeries lasting 30 minutes.
Bone and Soft Tissue Grafts.
During first-phase surgery, 61% of the patients received alloplastic bone grafts (Bio-Oss) with resorbable collagen membranes (Bio-Gide). At second-stage surgery (4 months for the implants placed in the mandible and 6 months for implants place in the maxilla), 11% of the patients received acellular dermal grafts (AlloDerm, LifeCell). The patients who received the acellular dermal grafts had pain that ranged from discomfort that did not reach the level of pain (level 1) to continuous pain that required pain medication (level 4) for up to 15 days after surgery.
Statistical Analysis.
The statistical analysis was performed using the SPSS (Computerized Software program for Statistical analysis of Science) applied to the data (m 5 75). A chi square and a correlation test were calculated for each dependent and interdependent variable to estimate the sensory quantification and the affective aspects of pain related to dental implantology. Data were summarized by basic descriptive statistics to analyze all the variables within a period of time.
When patients inquire about the possibility of suffering pain at phase I (2 days before surgery), phase II (at surgery), phase III, (24 hours after surgery), phase IV (1 week and 1, 2, and 3 months postsurgery), phase V (second-stage surgery), phase VI (1- and 2-year follow up), the practitioner can reply that with a standard deviation of 0.3 to 0.5 and a level of confidence of P . .001, there is no statistical significance between pain and the basic surgical dental implantology procedures at any of the phases (based on the same variables). However, there is a statistical correlation between postsurgical dental implantology and edema, hematoma, and pain as well as pain at the site of the implanted areas during chewing from 24 hours postsurgery to 1 week postsurgery (same level of confidence).
Discussion - References.
DISCUSSION.
Overall, the patients who requested dental implantology treatment were between the ages of 41 to 70 years. Women outnumbered men at a ratio of 2 to 1. The majority of patients were partially edentulous (93%). (This could be related to the high socioeconomic level of the patients at the private dental clinic.) Of particular interest was the finding that the greater percentage of implants were placed in the lower left quadrant. There was no statistically significant difference between maximum jaw opening before and 1 week after surgery. Fifty-seven percent of patients responded that they had no fear toward dental treatment. However, 48% of the patients had fear toward dental implants. The latter finding might be related to lack of the correct information on dental implantology and the abundance of hearsay comments. Only one patient presented temporomandibular disorder-related symptoms in the postsurgical phase. This patient had symptoms after the surgical procedure when she had been deprived of her full-mouth dentures; it is likely that the lack of support for muscle function and the diminished vertical dimension during function were the causes of these signs and symptoms. The restitution of the denture to the patient’s mouth immediately resolved the problem. Five percent of the patients had pain during yawning and opening, which was localized to the lateral pterygoid and masseter muscles, before and after surgery. These symptoms disappeared before the first postoperative month was over. After the first-stage surgery, 15% of the patients had a positive response of pain during swallowing. This symptom disappeared after the first 24 hours and was not observed at second-stage surgery. This finding is probably due to the fact that secondstage surgery is less traumatic to the patient. Although pain is a subjective sensation, at 24 hours after firstphase surgery, 100% of the patients reported discomfort or pain in a range of 1 to 4 (on a scale of 0 to 8); 40% presented only discomfort that did not reach a level of pain, and 45% reported only sporadic or intermittent pain. At second-stage surgery, 45% of the patients reported no pain, and 55% of the patients reported pain ranging from a level 1 (discomfort that did not reach pain) to a level 4 (strong persistent pain that required medication). Pain was present in 22% of the patients who received second-phase surgery after 4 months and in 33% of the patients who received second-stage surgery after 6 months. Of these patients, in 11% of the cases, the pain was related to acellular dermal soft tissue grafts. The pain related to the acellular soft tissue grafts was of a higher level and longer duration, needing more medication for pain relief. Edema was present in 95% of the patients after first-phase surgery, and hematoma was present in 12% of the patients. Both edema and hematoma diminished gradually. After 1 week, edema was only present in 23% of the patients, and before the end of the first month, no signs remained of either edema or hematoma. Edema and hematoma were not present after second-stage surgery.
REFERENCES.
1. Ehrenfeld M, et al. Treatment of implant-induced pain conditions in the maxillofacial area. Deutshe Zhan Zeitschift. 1990;45:59–60.
2. Koling A. Neurolo, oron-nas och halslakare? Lakartidningen. 1998;95:2320–2325.
3. de Bruyn H, Collaert B, Linden U, et al. Patient’s opinion and treatment outcome of fixed rehabilitation on Brånemark implants: A 3-year follow up study in private dental practices.
4. Rozenzweig D. Des cles pour reussir au cabinet dentaire.
5. Gorsky BH. Pain, Origin and Treatment. Garden City, NY: Medical Examination Publishing; 1981.
6. Wolff HG, Wolf S. Pain, 2nd ed. Springfield, IL: Charles C Tomas; 1958.
7. Moran Peter, et al. Phychiatric problems in chronic facial pain. Alpha Omegan. 1998;91:19–23.
8. IASP Subcommittee of Taxonomy. Pain terms: A list with definitions and notes on usage. Pain. 1979;6:249–252.
9. Bell WE. Temporomandibular Disorders, Classification, Diagnosis, Management, 3rd ed. Chicago: Year Book Medical Publishers; 1990.
10. Beecher HK. The use of chemical agents in the control of pain. In: Knighton RS, Dumke PR, eds. Pain. Boston: Little Brown; 1996:221–239.
Overall, the patients who requested dental implantology treatment were between the ages of 41 to 70 years. Women outnumbered men at a ratio of 2 to 1. The majority of patients were partially edentulous (93%). (This could be related to the high socioeconomic level of the patients at the private dental clinic.) Of particular interest was the finding that the greater percentage of implants were placed in the lower left quadrant. There was no statistically significant difference between maximum jaw opening before and 1 week after surgery. Fifty-seven percent of patients responded that they had no fear toward dental treatment. However, 48% of the patients had fear toward dental implants. The latter finding might be related to lack of the correct information on dental implantology and the abundance of hearsay comments. Only one patient presented temporomandibular disorder-related symptoms in the postsurgical phase. This patient had symptoms after the surgical procedure when she had been deprived of her full-mouth dentures; it is likely that the lack of support for muscle function and the diminished vertical dimension during function were the causes of these signs and symptoms. The restitution of the denture to the patient’s mouth immediately resolved the problem. Five percent of the patients had pain during yawning and opening, which was localized to the lateral pterygoid and masseter muscles, before and after surgery. These symptoms disappeared before the first postoperative month was over. After the first-stage surgery, 15% of the patients had a positive response of pain during swallowing. This symptom disappeared after the first 24 hours and was not observed at second-stage surgery. This finding is probably due to the fact that secondstage surgery is less traumatic to the patient. Although pain is a subjective sensation, at 24 hours after firstphase surgery, 100% of the patients reported discomfort or pain in a range of 1 to 4 (on a scale of 0 to 8); 40% presented only discomfort that did not reach a level of pain, and 45% reported only sporadic or intermittent pain. At second-stage surgery, 45% of the patients reported no pain, and 55% of the patients reported pain ranging from a level 1 (discomfort that did not reach pain) to a level 4 (strong persistent pain that required medication). Pain was present in 22% of the patients who received second-phase surgery after 4 months and in 33% of the patients who received second-stage surgery after 6 months. Of these patients, in 11% of the cases, the pain was related to acellular dermal soft tissue grafts. The pain related to the acellular soft tissue grafts was of a higher level and longer duration, needing more medication for pain relief. Edema was present in 95% of the patients after first-phase surgery, and hematoma was present in 12% of the patients. Both edema and hematoma diminished gradually. After 1 week, edema was only present in 23% of the patients, and before the end of the first month, no signs remained of either edema or hematoma. Edema and hematoma were not present after second-stage surgery.
REFERENCES.
1. Ehrenfeld M, et al. Treatment of implant-induced pain conditions in the maxillofacial area. Deutshe Zhan Zeitschift. 1990;45:59–60.
2. Koling A. Neurolo, oron-nas och halslakare? Lakartidningen. 1998;95:2320–2325.
3. de Bruyn H, Collaert B, Linden U, et al. Patient’s opinion and treatment outcome of fixed rehabilitation on Brånemark implants: A 3-year follow up study in private dental practices.
4. Rozenzweig D. Des cles pour reussir au cabinet dentaire.
5. Gorsky BH. Pain, Origin and Treatment. Garden City, NY: Medical Examination Publishing; 1981.
6. Wolff HG, Wolf S. Pain, 2nd ed. Springfield, IL: Charles C Tomas; 1958.
7. Moran Peter, et al. Phychiatric problems in chronic facial pain. Alpha Omegan. 1998;91:19–23.
8. IASP Subcommittee of Taxonomy. Pain terms: A list with definitions and notes on usage. Pain. 1979;6:249–252.
9. Bell WE. Temporomandibular Disorders, Classification, Diagnosis, Management, 3rd ed. Chicago: Year Book Medical Publishers; 1990.
10. Beecher HK. The use of chemical agents in the control of pain. In: Knighton RS, Dumke PR, eds. Pain. Boston: Little Brown; 1996:221–239.