Management of Post-Surgical Pain

Post-Surgical Pain (Nociceptive Pain)

Pain caused by stimulation of peripheral nerve fibres by noxious stimuli such as mechanical, thermal or chemical stimulants. Most patients describe post-surgical pain once the effects of local and/or general anesthesia have dissipated. Post-surgical pain typically peaks at the end of the first postoperative day (24–36 h postoperatively).

Presentation

Population

Adults over 25 years old

Risk Factors

• Oral contraceptives (which may lead to dry socket)
• Smoking (which may lead to dry socket)
• Surgical trauma

Signs

• Patients appear to be in distress
• Typical pain behaviours (e.g., guarding, fear of being touched or moving, emotional fragility)
• In the event of dry socket causing the pain, there may be concomitant malodorous signs with evidence of an empty extraction socket
• Evident areas of tissue necrosis, inflammation, or ulceration

Symptoms

• Anxiety/agitation
• Insomnia
• Complaints associated with adjacent dentition or ipsilateral opposing arch
• Otalgia (ear pain)
• Latency period to development of pain frequently related to dry socket
• Variable—may be contiguous with the surgical site or referred

Investigation

1. Obtain a thorough medical and dental history.
   
   If you have not carried out the surgery, specific questions regarding the surgery should focus on perceived difficulty, length of time taken, presence of preoperative pain or other symptoms, level of pain experienced in the initial period after surgery and response to analgesics.
2. When a likely clear cause is not evident, imaging should be considered: periapical and/or panoramic X-rays are good initial choices, especially if you have not carried out the surgery.
3. Patients with symptoms and signs of a concurrent systemic illness may require medical assessment.
4. Complete extraoral and intraoral examinations to look for possible sources of pain. Frequent causes include:
   • Normal sequelae of surgery
   • Proximal-associated mucosal ulcerations following minor surgical procedures
   • Delayed healing of extraction sockets with possible dry socket
   • Wound infection
   • Secondary source or incorrect preoperative diagnosis
5. Surgical site pain must be distinguished from muscular pain as a result of local anesthetic administration (needle injury), traction or splinting secondary to disuse.
6. Pain that develops 3–4 days after an extraction should be critically evaluated for evidence of dry socket or infection.

Diagnosis

Based on clinical examination, history review and radiographic examination (if indicated), a diagnosis of post-surgical pain is determined and other possibly etiologies are excluded (e.g., exposed bone, macerated tissue, pain from previously undiagnosed pathology).

When a diagnosis cannot be established, consultation from dental and medical colleagues should be sought.

Differential Diagnosis

• Normal sequelae
• Infection
• Temporomandibular disorder
• Dry socket
• Atypical neuralgia
• Functional overlay/pain-focused behaviour
• Iatrogenic nerve injury
• Jaw fracture

Treatment

Common Initial Treatments

• Combined use of acetaminophen and NSAIDs to capitalize on their synergistic properties, where not contraindicated
• Analgesics (opioids and non-opioids)
• Cold compresses

Alternate Treatments

• Use of intra-socket medication in the case of dry socket
• Use of topical agents to address mucosal irritation from surgical procedures
• Refraining from smoking during the postoperative period

Advice

• Centrally mediated aspects of postoperative pain must always be taken into account (e.g., chemical dependence and tolerance, psychiatric conditions).
• Dentists should avoid prescribing narcotics to any patients when there is no apparent cause for the severity of the claimed postoperative pain. Drug-seeking individuals may greatly exaggerate their symptoms to obtain narcotics. A second opinion is useful in these circumstances.

THE AUTHORS

	Dr. Friedlich is in private practice as an oral and maxillofacial surgeon in Toronto and Brampton. He remains on active staff in the department of surgery at the William Osler Health Centre, is chief division of oral and maxillofacial surgery, department of surgery, York Central Hospital, and staff at the Toronto Hospital.
	Dr. Blanas is an oral and maxillofacial surgeon in the department of dentistry at the Sunnybrook Health Sciences Centre.

Correspondence to: Dr. Joseph Friedlich, Bramalea Oral Surgery, 407-18 Kensington Road, Brampton, ON  L6T 4S5. Email: jfriedlich@sympatico.ca

The authors have no declared financial interests.

This article has been peer reviewed.