1) Odontólogo. Alumno del Máster de Cirugía e Implantología Bucal
2) Profesor Titular de Estomatología. Facultad de Medicina y Odontología. Director del Máster de Cirugía e Implantología Bucal
3) Profesor Asociado de Cirugía Bucal. Profesor del Máster de Cirugía e Implantología Bucal
4) Profesor Colaborador de Cirugía Bucal. Facultad de Medicina y Odontología. Universidad de Valencia.

Received: 22-11-2003 Accepted: 25-04-2004

INTRODUCTION

Following dental implant placement, patients present different degrees of pain and swelling as a direct consequence of surgery (1,2). A review of the literature has yielded few studies of pain and inflammation following these procedures (1-3).

The present study examines postoperative pain and swelling in patients subjected to dental implant placement, and their correlation to different clinical and surgical parameters.

MATERIAL AND METHODS

A total of 41 patients (17 males and 24 females, aged 25-69 years) received 131 threaded dental implants (Defcon^®, Impladent, Senmenat, Barcelona, Spain) in application to different types of edentulism (total and/or partial). The implants were positioned by the same surgeon (JGC) under local anesthesia (4% articaine with adrenalin 1:100.000).

The following data were recorded: patient age and sex, maxillary or mandibular location, type of edentulism (free extremes, interdental spaces or totally edentulous), implant location (anterior and posterior to the canine) and type (with or without releasing incisions), incision size (in cm), number of implants, and instrumentation (bone bed preparation with a rotary technique or manually using osteotomes). Maxillary sinus lift or bone regeneration procedures were also recorded, along with the duration of each operation.

Antibiotic medication was provided after surgery (amoxicillin 500 mg, every 8 hours for 5 days, or clindamycin 300 mg, every 8 hours for 5 days in the case of allergy to penicillin), together with antiinflammatory treatment (ibuprofen 600 mg, every 8 hours for 3 days) and analgesics upon demand (magnesium metamizol 575 mg).

The patients rated pain intensity based on a visual analog scale (VAS from 1 to 10) and verbal scale (1 = no pain, 2 = mild pain, 3 = moderate pain, 4 = intense pain), and inflammation as follows: 1 = none (absence of inflammation), 2 = mild (intraoral swelling in the surgical zone), 3 = moderate (extraoral swelling in the surgical zone), 4 = intense (extraoral swelling extending beyond the surgical zone). All scores were recorded 2, 4, 6, 12 and 24 hours after the operation, and on day 2, 3, 4, 5, 6 and 7.

The data obtained were coded and introduced in a database. The SPSS version 11.0 package was used for statistical analysis of the results. The relations of the variables pain and swelling were evaluated by the Student t-test on relating them to qualitative variables (two levels); fully randomized analysis of variance (ANOVA) on relating them to qualitative variables (three or more levels); the Pearson correlation test on relating them to quantitative variables; and ANOVA for repeated measures on examining the time course of swelling and pain. Statistical significance was accepted for p≤0.05.

RESULTS

Based on the VAS scores, peak pain intensity was recorded 6 hours after the operation in most cases (41.5% of the patients presenting scores of between 2 and 4)(Table 1). The verbal scale values likewise reported mean maximum pain 6 hours after surgery (corresponding to mild intensity pain)(Fig. 1). In turn, 48.8% of the patients developed moderate swelling – the maximum intensity of inflammation being observed after 48 hours (Table 2 and Fig. 2).

Analysis of the relation between pain 6 hours after the operation and the different study variables only showed a statistically significant correlation to the number of implants (r=0.311; p=0.048) – increased pain being recorded in the patients subjected to a larger number of dental implants (Table 3).

Analysis of the relation between inflammation 48 hours after the operation and the different study variables showed statistically significant correlations to more advanced patient age (r=0.386; p=0.013), surgery in edentulous patients and free extremes (F=7.293; p=0.002), and to surgical approaches in the posterior sector of both jaws (F=4.908; p=0.013). A significant relation was also observed between swelling and the number of implants, when an increased number of implants were placed (r=0.389; p=0.012), and with surgery involving sinus lift (t=2.522; p=0.016) or bone regeneration procedures (t=3.939; p<0.001)(Table 3).

DISCUSSION

In the series published by Muller et al. (1), involving 221 dental implants, 45% of the patients reported pain in the first 24 postoperative hours. In another series (3) of 80 patients with 226 implants, maximum pain was recorded 6 hours after the operation, and was of moderate intensity. Another study (2) comprising 70 patients and 163 implants reported peak pain after 12 hours (VAS intensity score = 3.5). In our series pain was found to be of maximum intensity after 6 hours, and was reported to be mild by 41.5% of the patients.

In one half of our patients inflammation was seen to be maximum 48 hours after surgery, and was of moderate intensity. Other studies (2,3), likewise based on a verbal assessment scale, have reported moderate intensity swelling (with a mean score of 2.4 over 4) in most patents – though peak inflammation was recorded after 24 hours.

Guarinos et al. (2) and Peñarrocha et al. (3) observed no relation between patient age and pain and inflammation after implant surgery. Some authors (4-6) consider that older patients suffer increased pain after third molar extraction; however, other investigators have found no such significant relation between age and pain intensity (7,8). In our series no relation was observed between patient age and pain – though increased inflammation was associated to older patient age.

Following third molar surgery, some investigators have recorded increased pain in males (4), while in other series increased pain corresponded to women (6). However, in coincidence with our own findings, other authors have observed no gender-based differences in pain following implant placement (2,3) or impacted molar extraction (7,8). Some studies (3) have reported increased swelling in females, though in our series and in coincidence with other investigators (2), no such significant association was recorded.

In the present study, and in coincidence with other authors (2,3), pain and swelling were reported to increase with the number of dental implants placed. In this context, it is logical to assume that more traumatic interventions will also involve more pain and inflammation. In relation to third molar extraction, authors such as Lombardía et al. (9) and Martínez et al. (8) have published a statistically significant relation between flap size, the magnitude of the osteotomy performed, and postoperative pain intensity following third molar surgery.

According to our results, implants placed at free extremes and in totally edentulous patients caused more inflammation than implants located in interdental spaces. In contrast, Guarinos et al. (2) reported lesser swelling in posterior mandibular regions. We are unable to account for these contradictory results.

Surgery involving sinus lift or bone regeneration procedures is associated to increased swelling. Guarinos et al. (2) likewise reported greater inflammation with sinus lift procedures. In agreement with the observations of other authors (2,3), we found no relation between pain and swelling and the type and magnitude of the incision made – though it would seem logical to assume that larger incisions produce more side effects. In turn, we found no relation between implant bed preparation with rotary instruments or dilators and the associated postoperative symptoms – in coincidence with other authors (2,3). Thus, apparently, osteotomy performed with one material or other exerts no influence on patient symptoms after the operation.

BIBLIOGRAFÍA        [ Links ]

2. Guarinos J, Peñarrocha M, Sanchís JM, Torrella F. Estudio del dolor y la inflamación en 70 pacientes, tras la colocación de 163 implantes (ITI^®) dentales. RCOE 1998;3:229-33.         [ Links ]

3. Peñarrocha M, Sanchis JM, Guarinos J, Soriano I, Balaguer J. Estudio comparativo entre la técnica convencional y la de los osteodilatadores para la creación del lecho implantológico. A propósito de 226 implantes (ITI^®) colocados en 80 pacientes. Periodoncia 2000 10;3:189-98.         [ Links ]

4. Capuzzi P, Montebugnoli L, Vaccaro MA. Extraction of impacted third molars. A longitudinal prospective study on factors that affect postoperative recovery. Oral Surg Oral Med Oral Pathol 1994;77:341-3.         [ Links ]

5. Fisher SE, Frame JW, Rout PG, Mc Entergart DJ. Factors affecting the onset and severity of pain following the surgical removal of unilateral impacted mandibular third molar teeth. Br Dent J 1988;164:351-4.         [ Links ]

6. Olmedo MV, Vallecillo M, Gálvez R. Relación de las variables del paciente y de la intervención con el dolor y la inflamación postoperatorios en la exodoncia de los terceros molares. Medicina oral 2002;7:360-9.         [ Links ]

7. Infante P, Espín F, Mayorga F, Hernández JM, Rendón JI, Delgado MJ. Estudio de los factores relacionados con la recuperación postoperatoria tras la exodoncia de terceros molares inferiores retenidos. Av. Odontoestomatología 1995;11:569-73.         [ Links ]

8. Martínez MA, Bermuda L, González A, Montes J, Valiente A. Evaluación de Ketorolaco, Ketoprofeno y tramadol en el dolor postoperatorio en cirugía oral ambulatoria. Av Odontoestomat 1995;11:385-8.         [ Links ]

9. Lombardía E, González M, Junquera LM. Estudio del dolor postoperatorio habido tras la extracción de terceros molares inferiores. Rev Esp Cirug Oral y Maxilofacial 1989;11:98-104.        [ Links ]