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Pain Experience After Simple Tooth Extraction

Article  in  Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons · June 2008
DOI: 10.1016/j.joms.2007.12.008 · Source: PubMed

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 J Oral Maxillofac Surg
66:911-917, 2008

Pain Experience After Simple

Tooth Extraction
Taiseer Hussain Al-Khateeb, BDS, MScD, FDSRCSE, FFDRCSI,*
and Amir Alnahar, BDS, MDSc†

Purpose: To assess pain experience after simple uncomplicated tooth extraction and to see if there is
a need to prescribe analgesic drugs after such a procedure.
Patients and Methods: A random sample of patients presenting for tooth extraction at the Maxillo-
facial Unit, Jordan University of Science and Technology was included. A baseline assessment of
previously experienced general and dental pains using numeric scales was done. Subsequently, tooth
extractions were done and telephone interviews were made during evenings for a week. Pain intensity
was assessed on a numeric scale, and use of analgesic drugs and pain quality were recorded.
Results: At the evening of extraction 81.8% of patients had pain. Female gender predominance in pain
reporting was statistically significant on postextraction days 3 and 5. Chronically inflamed teeth caused
the highest mean pain intensity scores and nonsmokers showed significantly higher mean pain intensity
scores compared with smokers. Mild pain was experienced by most patients (38.6%) on the evening of
extraction. It was found that 55.3% of participants (largely females) used analgesic drugs on the evening
of extraction, and 6.8% of participants still used analgesic drugs on day 7 postextraction. There was a
significant correlation between mean pain intensity score and previous dental injection pain.
Conclusion: Patients, notably females, experienced pain of varying intensity after simple uncompli-
cated tooth extraction maximally at the evening of extraction; and greater than 50% of the patients used
analgesic drugs. We recommend offering regular analgesic drugs during the first week after tooth
extraction.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:911-917, 2008

Pain is an unpleasant sensory and emotional experi- tween patients.3 Postoperative pain is related signifi-
ence associated with actual or potential tissue dam- cantly to the amount of surgical trauma.4 Surgical
age.1 The Institute of Medicine Committee on Pain, removal of bony impactions and osseous periodontal
Disability, and Chronic Illness Behavior highlighted surgery are more traumatic and produce more intense
the complex nature of pain by noting that experience pain when compared with simple uncomplicated
of pain is more than a simple sensory process; it is a tooth extraction. Little information is available in the
complex perception involving higher levels of the literature about pain experience after simple uncom-
central nervous system, emotional states, and higher plicated tooth extraction. Most of the literature fo-
mental processes.2 cuses on postoperative pain after surgical removal of
Extraction of teeth is a common dental procedure. impacted third molars or on the effectiveness of dif-
After tooth extraction the patient may experience ferent pharmaceutical options in combating postsur-
pain, and there is a varying degree of severity be- gical pain. The aim of this study was to prospectively
assess and analyze pain experience after simple un-
complicated tooth extraction and to see if there is a
*Associate Professor, Division of Oral and Maxillofacial Surgery, need to prescribe analgesic drugs after such a proce-
Faculty of Dentistry, Jordan University of Science and Technology, dure. The effect of patient gender, age, smoking, and
Irbid, Jordan. educational level, the operators’ status, and the ex-
†Private Practice, Jerash, Jordan. tracted teeth quantity, side, and location also were
Address correspondence and reprint requests to Dr Al-Khateeb: investigated.
Jordan University of Science and Technology, Faculty of Dentistry,
Oral and Maxillofacial Surgery, JUST, PO Box 3030, Irbid 22110, Patients and Methods
Jordan; e-mail: [email protected]
© 2008 American Association of Oral and Maxillofacial Surgeons SUBJECTS
0278-2391/08/6605-0013$34.00/0 Two hundred patients (100 females, 100 males)
doi:10.1016/j.joms.2007.12.008 were selected randomly from patients undergoing

911
912 ANALGESICS USE AFTER SIMPLE TOOTH EXTRACTION

simple (intra-alveolar) tooth extraction at the oral and relation to recalling having experienced “examination
maxillofacial unit at the dental teaching clinics at with a dental probe,” “having your teeth polished,”
Jordan University of Science and Technology (JUST). “dental injection,” and “drilling.” Mean NS assess-
The following selection criteria were used for subject ments for previous general pain and dental pain were
inclusion: used for analysis.

1. The patient is medically fit and healthy, over 18 STATISTICAL ANALYSIS

years old and not on any regular medication. Simple descriptive statistics using SPSS (SPSS Inc,
2. The extraction is done using forceps and/or el- Chicago, IL) were used and differences in frequencies
evators without any surgical intervention. and proportions between groups were analyzed with
3. The teeth are asymptomatic. Pearson’s ␹2. Due to skewness in data, nonparametric
statistics (Mann-Whitney U test) were computed to
Teeth were classified into sound, mobile, grossly test significance between groups according to scale
carious, or chronically inflamed (with radiographi- assessments. To investigate the repeated pain assess-
cally evident periodontal or apical involvement). ments, a Friedman’s 2-way analysis of variance
(ANOVA) between measurements was calculated.
PROCEDURES Analysis of variance (2-way ANOVA) of pain assess-
Undergraduate and postgraduate students carried ments were computed for different variables. A non-
out the extractions but a single investigator made all parametric correlation analysis between variables was
the assessments. Approval of the Human Ethics Com- made using the Spearman rank correlation method.
mittee at JUST was obtained. After informed consent, Tukey test was used to determine which of the vari-
a semistructured baseline interview was conducted at ous tooth states had effect on mean pain intensity.
the patients’ first visit before treatment. The interview
included baseline assessments of general and dental
Results
pains experienced previously using numeric scales
(NSs). The patients received NS pain assessment A total of 180 patients agreed to participate in the
forms and separate envelopes to be used in conjunc- study; 36 (20%) failed to comply with follow-up. The
tion with telephone follow-up interviews on the remaining 144 patients were included. Sums of 12
evening of the day of the extraction, the following patients with postextraction complications were ret-
evening, and then every second evening for 1 week. rospectively excluded leaving 132 patients (72 fe-
After the initial interview, tooth extraction was car- males, 60 males) for analysis; their age and gender
ried out. distribution is shown in Figure 1.
Pain assessment was recorded during 4 telephone The preoperative diagnosis of teeth extracted was
interviews and 1 personal interview at the next ap- as follows: sound (9.8%), mobile (12.1%), grossly de-
pointment at the clinic. During each interview the
patients were asked if they have experienced any pain
and, if so, to assess the intensity of their pain on the
10-mm NS (“No pain” to “Worst pain possible”). The
assessment was then put in a separate envelope
marked for each day. The character of pain was indi-
cated (yes/no) using 4 descriptors according to the
McGill Pain Questionnaire: constant pain, shooting
pain, dull pain, and pain when chewing or biting. In
addition, each interview included a report of the use
of painkillers. The type and dosage of medication was
also noted.

INSTRUMENTS
During the initial interview each patient was asked
to make NS assessments of his/her experience of
previous general and dental pains, rated from “No
pain” to “Worst pain possible.” The proposed painful
situations included “cutting one’s finger,” “wasp- FIGURE 1. Age and gender distribution of participants included in
stings,” “spraining one’s ankle,” “having a vaccination the study (n ⫽ 132).
(IM injection),” “burning one’s finger,” and “having a Al-Khateeb and Alnahar. Analgesics Use After Simple Tooth Ex-
sore throat.” Previous dental pain was assessed in traction. J Oral Maxillofac Surg 2008.
AL-KHATEEB AND ALNAHAR 913

with the value at day 5 (Spearman ␳ ⫽ 0.783; P ⬍ .01)

but less significantly correlated with the value at day
3 (Spearman ␳ ⫽ 0.579; P ⬍ .01). There was also a
significant difference between males and females at
the evening of extraction and on days 1, 3, and 5 (P ⫽
.007, .014, .018, .012, respectively), but at day 7 there
was no significant difference (P ⫽ .128).
One-way ANOVA analysis showed that there was a
significant effect of tooth status before extraction on
the postextraction mean pain intensity scores (F ⫽
3.42, P ⫽ .019). Tukey test was used to determine
which of the various tooth states had effect on mean
pain intensity. It was found that chronically inflamed
teeth, followed by grossly decayed teeth, caused the
FIGURE 2. Frequency of pain reporting during the postextraction highest mean pain intensity scores. Nonsmokers
period. showed significantly higher mean pain intensity
Al-Khateeb and Alnahar. Analgesics Use After Simple Tooth Ex- scores compared with smokers (t test, P ⫽ .004).
traction. J Oral Maxillofac Surg 2008. The t test showed that there was no significant
effect on mean pain intensity scores either by the
operator’s level of experience (post- or undergradu-
cayed (70.4%), or chronically inflamed (7.6%). Extrac- ate) (P ⫽ .582), or the quantity (single or multiple)
tion was unilateral in 93.9% of cases, and single teeth (P ⫽ .93), side (uni- or bilateral) (P ⫽ .529), or
were extracted in 83.3% of cases. Most (93.2%) of position in relation to midline (P ⫽ .293) of teeth
teeth extracted were away from midline, and post- extracted, or patient’s educational level (P ⫽ .828).
graduate students did 82% of extractions. The age category related to the levels of pain during
the postoperative follow-up period is shown in Figure 3.
REPORTING OF POSTEXTRACTION PAIN Although subjects in their 20s, 70s, and 80s seem to
report more intense pain, especially during the initial
On the evening of extraction, 81.8% of patients
postoperative period, 1-way ANOVA analysis showed
reported feeling pain. The frequency of pain report-
that age alone, and age and gender together have no
ing dropped gradually, reaching 15.9% at day 7 pos-
significant effect on mean pain intensity scores re-
textraction (Fig 2). Generally, a higher percentage of
ported by the participants throughout the follow-up
females reported having postextraction pain through-
period (P ⫽ .49, .67, respectively).
out the postoperative period (Fig 2). This gender
difference in pain reporting was statistically signifi- CHARACTER OF PAIN
cant only on day 3 and 5 postextraction (P ⫽ .020 and
Patients who had postextraction pain described the
.039, respectively).
character of their pain as either constant when chew-
ing, shooting, or dull. The distribution of the pain
PAIN INTENSITY SCORES
The intensity of the pain (on NS) showed a similar
pattern (Fig 2). The pain intensity assessments peaked
on the evening of extraction when the mean pain
intensity score reached 4.4 for the females (range,
0-10; median, 4), and 2.8 for males (range, 0 to 10;
median, 2). There was a drop in mean pain intensity
score on each subsequent postextraction day until
day 7 when the mean pain intensity score reached 0.7
for females (range, 0 to 10; median, 0) and 0.3 for
males (range, 0 to 2; median, 0).
There was a significant correlation between the
mean pain intensity score at the extraction evening
and at day 1 postextraction (Spearman ␳ ⫽ 0.707; P ⬍
.01), whereas the correlation was lower between ex- FIGURE 3. Age distribution as related to the pain intensity during the
traction evening and days 1 and 7 postextraction postoperative period.
(Spearman ␳ ⫽ 0.264, 0.439; P ⬍ .01). The mean pain Al-Khateeb and Alnahar. Analgesics Use After Simple Tooth Ex-
intensity score at day 7 was correlated significantly traction. J Oral Maxillofac Surg 2008.
914 ANALGESICS USE AFTER SIMPLE TOOTH EXTRACTION

Table 1. PAIN CHARACTERS REPORTED BY PARTICIPANTS THROUGHOUT FOLLOW-UP PERIOD

Postextraction Day
Character Gender Evening % 1 % 3 % 5 % 7 %

Constant Male 5 3.8 0 0.0 1 0.8 0 0.0 0 0.0

Female 24 18.2 5 3.8 4 3.0 2 1.5 1 0.8
Shooting Male 4 3.0 4 3.0 1 0.8 0 0.0 0 0.0
Female 13 9.8 11 8.3 5 3.8 1 0.8 1 0.8
Mild Male 33 25.0 25 18.9 14 10.6 7 5.3 7 5.3
Female 18 13.6 21 15.9 19 14.4 17 12.9 13 9.8
When chewing Male 8 6.1 10 7.6 7 5.3 3 2.3 2 1.5
Female 3 2.3 14 10.6 12 9.1 5 3.8 5 3.8
None Male 10 7.6 21 15.9 37 28.0 50 37.9 51 38.6
Female 14 10.6 21 15.9 32 24.2 47 35.6 52 39.4
Total 132 100 132 100 132 100 132 100 132 100
Al-Khateeb and Alnahar. Analgesics Use After Simple Tooth Extraction. J Oral Maxillofac Surg 2008.

characters is shown in Table 1. Mild pain was expe- pains experienced previously were due to “burning”
rienced by the majority (38.6%) of patients on the (mean NS of 7.45) and “drilling” (mean NS of 4.77),
evening of extraction, and the percentage remained respectively. Pains caused by burns, intramuscular
relatively high (15.2%) on day 7 postextraction. injections, sprains, and cuts were scored significantly
One-way ANOVA analysis was used to explore ef- higher by females than males (P ⬍ .05), and pain from
fect of gender on the character of pain reported. drilling and dental injections were scored significantly
Participants reported different characters of pain higher by females (P ⬍ .05).
without significant differences at days 0, 1, 5, and 7 (P The effect of previous general and dental pain expe-
⫽ .23, .19, .40, .87, respectively). At day 3, there was riences on the postextraction mean pain intensity scores
a significant difference between genders (P ⫽ .010) was obtained by using the Pearson correlation test. Al-
with females reporting more throbbing pain. though there was no significant correlation between
USE OF ANALGESICS any of the previous general pains and mean NS, there
was a significant correlation between mean NS and
It was found that 55.3% of participants used anal-
previous dental injection pain at the level of 0.01.
gesic drugs at the evening of extraction. This percent-
age dropped steadily on subsequent postextraction
days until day 7 when 6.8% of participants were still
using analgesic drugs (Fig 4). To see if there were
statistical differences between females and males in
the use of analgesic drugs, univariate ANOVA was
done. It was found that females used analgesic drugs
significantly more than males throughout the fol-
low-up period (P ⬍ .05) except at day 7 (P ⫽ .112).
Most participants used either paracetamol (27.3%)
or NSAIDs (22.7%). Using the ANOVA test, it was
found that patients with high mean pain intensity
scores used a combination of more than 1 analgesic
drug type; and those taking a single type of analgesic
drug had lower mean pain intensity scores (F ⫽ 9.39,
P ⫽ .000). Participants who did not use any type of
analgesic drugs had the lowest mean pain intensity
scores of the whole sample.

PREVIOUS EXPERIENCE OF GENERAL AND

DENTAL PAIN
The strongest general and dental pains experienced FIGURE 4. Frequency of using analgesic drugs during the postextrac-
previously by males were due to “burning” (mean NS tion period.
of 5.20) and “probing” (mean NS of 3.11), respec- Al-Khateeb and Alnahar. Analgesics Use After Simple Tooth Ex-
tively. As for females, the strongest general and dental traction. J Oral Maxillofac Surg 2008.
AL-KHATEEB AND ALNAHAR 915

Discussion previous inflammation, and carious teeth with excited

nerve endings will produce more pain when ex-
It is surprising that despite being one of the most
tracted as compared with noninflamed ones where
common oral surgical procedures, the literature gives
nociceptors are not sensitized.
very little attention to pain after simple tooth extrac-
The number of teeth extracted was found in this
tion. Indeed, most previous studies focus on either
study to have no significant effect on the mean pain
postoperative pain after surgical removal of impacted intensity scores obtained. This is in contrast with
third molars, or on the effectiveness of different phar- previous studies about surgical procedures. For exam-
maceutical agents in combating postoperative se- ple, Penarrocha et al16 found that the increase in
quelae. To the best of our knowledge, this is the first number of teeth treated with periapical surgery in-
study that presents a detailed analysis of pain experi- creased pain postoperatively. The reason our results
ence after simple, uncomplicated tooth extraction. are different from those of others might be due to the
Our results showed that almost 82% of patients fact that simple tooth extraction does not incur
experienced moderate pain (with a mean pain inten- enough tissue damage to induce sensitization of no-
sity score of 3.6/10) on the evening of extraction day; ciceptors.
and up to 16% of patients continued to experience In this investigation, females reported more pain as
this postextraction pain after a week. Among the compared with males. This is in agreement with the
previous studies that superficially allude to pain after findings of most previous studies that reported that
simple tooth extraction, Cheung et al5 found that female patients experience significantly more pain
healing of normal uncomplicated extraction alveolus than males.17-19 However, Capuzzi et al20 found that
caused moderate to severe pain. Adeyemo et al6 young male patients experience significantly more
found that uncomplicated extraction socket healing pain than young females. Furthermore, other studies
was associated with mild or moderate pain up to the showed no gender differences in terms of pain expe-
third day after extraction in 9.6% of cases whereas rience.21,22 The difference between genders in pain
2.4% of patients had mild pain throughout the sev- reporting and intensity found in this investigation was
enth postextraction day. Garcia et al7 pointed out that explained by Wiesenfeld-Hallin19 who stated that gen-
pain after simple tooth extraction is less severe com- der differences are attributed mainly to differences in
pared with complicated extraction that involves bone biologic mechanisms and partly to psychologic and
removal and tooth sectioning. They also found that sociocultural factors. They suggested that normal
regardless of the type of extraction, pain declined males have a higher level of activity in the endoge-
between days 1 and 5 postsurgery. The moderate nous analgesic system compared with normal fe-
intensity of postextraction pain can be explained by males. Furthermore, pain sensitivity, tolerance, and
the little amount of tissue damage that a simple ex- threshold in women vary with the stage of menstrual
traction incurs. Previous studies8 support the opinion cycle.23
that postoperative pain reported by patients was sig- We found that there was no significant effect for
nificantly less when using minimal incisions, small the side (uni- or bilateral) on the mean pain intensity
mucoperiosteal flap reflection, or flapless surgery. score. This contrasts with the experimental work of
In the current study, it was found that the pre- Sabino et al24 who found that the activation of trigem-
extraction status of a tooth had a significant effect on inal nucleus neurons bilaterally after tooth extraction
the pain intensity perceived after extraction. The induced more pain sensation compared with ipsilat-
chronically inflamed teeth caused the highest mean eral neuron activation. The reasons why our results
pain intensity scores. Our findings are in line with differ from others is probably attributed to the small
those of other investigators9,10 who found that post- number of teeth extracted bilaterally (n ⫽ 8). Sabino
operative pain increased 3-fold in patients undergoing et al24 also found that extraction of central incisors in
surgical extraction of symptomatic third molars as the rat induced substance P receptors internalization
compared with those with asymptomatic teeth. The of both ipsilateral and contralateral neurons. On the
reason for this is probably attributed to the synergistic other hand, molar extraction induced only ipsilateral
effect of various inflammatory mediators (produced substance P receptor internalization. They suggested
by the pre-existing inflammatory condition) that pro- that structures damaged around the midline induced
duces a long-lasting increase in the activity of noci- more pain. In our study, however, there was no sig-
ceptors.11 Furthermore, it has been shown that the nificant effect for the tooth position in relation to the
expression, in dental pulpal tissue, of substance P, midline on the mean pain intensity scores. This may
vasoactive intestinal peptides, and neuropeptide Y be attributed to the lower number of extracted teeth
are all increased significantly with caries-induced pul- around the midline (n ⫽ 9).
pal inflammation.12-15 Therefore, inflamed teeth, We found that there is not a significant effect on
where the nociceptors are already sensitized due to mean pain intensity scores by the operator level of
916 ANALGESICS USE AFTER SIMPLE TOOTH EXTRACTION

experience. This contrasts with findings of Troullos that as neuronal cell death is observed in many parts
et al25 who indicated that the degree of tissue damage of the CNS in aged subjects, there will be modification
is dependent on the expertise of the operator. Morin of the circuits responsible for pain, or new circuits
et al,17 investigating implant insertion, found that se- will form, thus explaining the aging-related hyperal-
nior surgeons produced significantly less pain than gesia. It has also been hypothesized that descending
the fourth year resident. Capuzzi et al20 found that the pain inhibitory signals in aged animals will be im-
expertise of the surgeon significantly affects the level paired.37
of postoperative pain. They found that impacted third It was found in this investigation that analgesic
molar removal by surgeons with considerable or av- drugs were used most frequently during the evening
erage expertise resulted in less postoperative pain as of extraction and on day 1 postextraction. After 24
compared with surgeons with little expertise. Fagade hours there was a decline in the number of patients
and Oginni,26 investigating intraoperative pain per- requiring analgesic drugs with a decline of the mean
ception in tooth extraction, found that the attending pain intensity scores. Most analgesic drugs used were
surgeon’s status affected pain scores. Our result can paracetamol and NSAIDs. This is attributed to their
be explained by the fact that tooth extraction was availability because they are obtained easily without a
simple, using forceps or an elevator that are not ex- prescription in Jordan. In agreement with our study,
pected to cause a significant amount of tissue injury. Urquhart38 stated that the main need for analgesic
In the present investigation, it was found that there treatment was in the first 24- to 48-hour period. We
is not a significant effect of the patients’ educational also found that there were significant differences in
level on mean pain intensity scores. This contrasts analgesic drug use between males and females
with Tanwir et al,27 and Peretz and Mersel28 who throughout the follow-up period. This contrasts with
found that pain was a more frequent complaint others who found no gender differences in analgesic
among poorly educated subjects than among the ed- drug use in the postoperative period.18,22,39 Our re-
ucated. However, Maggirias and Locker29 found that sults are, however, in line with those of Liddell and
pain was more likely to be experienced by those with Locker40 who found that there were gender differ-
higher levels of education. ences in analgesic drug use due to higher levels of
Smoking has long been identified as harmful to anxiety reported by females compared with males.
health. Meechan et al30 identified smoking as a major This finding is logical and is highly related to gender
predisposing factor in occurrence of painful sockets differences in mean pain intensity scores; the females
after tooth extraction. Smoking has also been associated had higher pain intensity scores that made them use
with poorer healing after mucogingival surgery and more analgesic drugs compared with males.
with higher rates of refractory periodontitis.31 Awaw- We found a positive correlation between mean
deh et al13 found that there was an increased neu- pain intensity scores and previous dental pain expe-
ropeptide concentration, such as CGRP, in pulps of riences. Those who reported higher dental pain ex-
smokers’ teeth compared with nonsmokers’. In this perience with local anesthetic injections had higher
study, nonsmokers showed significantly higher mean mean pain intensity scores. On the other hand, there
pain intensity scores compared with smokers. This is was no significant correlation between any previous
probably related to the analgesic effect of nicotine in general pain experiences and mean pain intensity
cigarettes.32 Our findings are, however, in contrast scores. In line with our findings, Maggirias and
with Tanwir et al27 who found that postsurgical pain Locker29 found that those with high levels of previous
was significantly more in smokers compared with painful dental experience reported significantly more
nonsmokers. On the other hand, while investigating postoperative pain compared with those of a low
pain after surgical endodontics, Penarrocha et al16 level of previous painful experiences. Also in har-
found that smoking had no significant influence on mony with our findings, Maggirias and Locker29 found
postoperative pain. that previous frightening experiences did not signifi-
In our study, the age of the patients had no signif- cantly affect pain reporting and intensity. However,
icant effect on mean pain intensity scores. This is in Bergius et al41 found that there were no significant
agreement with other studies.16,27,33 On the other differences between females and males in the previ-
hand, other studies4,20,34 found that pain increased in ous dental pain experiences. Williams et al42 are of
older patients, and Maggirias and Locker29 found that the opinion that negative dental experience would be
younger patients were more likely to report pain than a risk of reporting pain from general dental treatment.
older subjects. It has been found in a rat model that Our results of positive correlation between dental
neuronal activity in the spinal dorsal horn is signifi- injection and high postoperative mean pain intensity
cantly greater in aged rats after noxious stimulation35; scores are probably attributed to fear of a dental
and the response to heat and mechanical stimulation needle that probably increased anxiety, and so in-
was higher in aged rats.36 It has been hypothesized36 creased pain reporting.
 AL-KHATEEB AND ALNAHAR 917

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