Igor Tsesis (ed.)Complications in Endodontic Surgery2014Prevention, Identification and Management10.1007/978-3-642-54218-3_12
© Springer-Verlag Berlin Heidelberg 2014
12. Pain, Swelling, and Surgical Site Infection
Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
Pain and swelling are common side effects of endodontic surgery, and their intensity depends on the degree of the surgical damage to the tissue.
The pain and swelling are associated with inflammatory responses that are part of the typical wound healing process. Infection of the surgical site may complicate the postoperative sequel, aggravate the symptoms, and may require further pharmacologic and surgical interventions.
Several possible factors may affect the risk and intensity of postsurgical side effects, including patient-related factors and the surgical technique, and this chapter will review methods to prevent and manage postoperative side effects.
Surgical procedures commonly produce side effects, and the intensity of those side effects depends on the degree of tissue damage [1–5]. Pain and swelling are common side effects following surgical endodontic treatment [6–9], and traditionally, approximately two-thirds of the patients require analgesics during the postoperative period [6–9].
Postoperative pain and swelling are related to the inflammatory response to the trauma induced during the surgery, and these reactions have several functions: defend the body organ, removal of necrotic or dying tissue, and repair and regeneration promotion . Inflammation is defined as “the cellular and vascular response of tissues to injury” . Histologically, following an injury damaged cells dispense their contents into extracellular spaces, and chemical mediators that regulate the inflammatory response are released. These mediators cause inflammatory changes such as vasodilatation and increased vascular permeability, which cause edema. All these inflammatory processes can proceed with or without concomitant surgical site infection [10, 12–14].
Surgical site infection (infection) can be defined as “invasion and proliferation of pathogenic microorganisms in body tissues following a surgical procedure and the reaction of the tissues to their presence.” These tissue reactions include also inflammatory reactions . Thus, following surgery, inflammation may occur due to the surgical tissue injury alone (noninfectious postsurgical inflammation (NIPSI)) or as a result of the tissue injury combined with infection (infectious post-surgical inflammation (IPSI)).
The traditional signs of inflammation are the following: dolor (pain), calor (heat), rubor (redness), tumor (swelling), and functio laesa (loss of function) . Infection also usually includes at least one of the following signs and symptoms: pain or tenderness, localized swelling, redness, or heat [13–15]. In addition, NIPSI may cause pathological conditions (such as edema development) that may provide favorable conditions for an ensuing contamination and infection of the surgical site with subsequent IPSI. Thus, the clinical diagnosis between NIPSI and IPSI may be difficult [8, 12–14].
The management of NIPSI is usually palliative (e.g., the use of anti-inflammatory medication protocol) and usually bares no or little long-term and systemic risks. On the other hand, IPSI may bare significant systemic risks and sometimes may require more aggressive treatment modalities (e.g., antibiotic therapy, with\without surgical drainage). Thus, the difficulty to differentially diagnose between IPSI and NIPSI presents a clinical dilemma to the practitioner [8, 10, 12–14].
This chapter would review pain swelling and infection as possible complications of endodontic surgery.
Pain and Swelling Definitions and Sequel
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage” . Pain perception is a highly subjective experience modulated by multiple physical and psychological factors [17, 18]. In addition, pain measurement is burdened with hazards and opportunities for errors [18, 19], and different scales and methods have been used to assess pain after endodontic therapy [18, 19], including visual analog scale (VAS) that is considered a valid and reliable ratio scale to measure pain [18, 19].
Swelling may begin minutes to hours after the surgical procedure and is the consequence of two processes: hemorrhage and edema. These can continue for several days, depending upon the tissue injury severity. The edema, defined as “an accumulation of fluid in a tissue ,” does not emerge equally in all directions from the site of injury . In addition, after an injury, the bleeding usually stops within several minutes because of clotting. Therefore, the swelling is usually caused by edema [1, 3, 6–10].
The maximum severity of pain is usually reported during the first 24 postoperative hours, similar to results found in studies on the extraction of impacted third molars, and between 40 and 76 % of patients present either no or moderate pain . The maximum swelling is presented between the first and second postoperative day, and between 45 and 66 % of patients present either no or moderate swelling .
Pain and Swelling Risk Factors
Several possible factors affecting the risk and\or intensity of postsurgical symptoms were reported, including the type of surgical technique (traditional versus modern surgical technique [1, 6, 9, 20]), poor oral hygiene , smoking , pre-operative medication , local anesthesia type , type of root-end filling material , and the patient’s age or gender .
The Surgical Technique
Endodontic surgery is usually performed in teeth with persistent periradicular pathosis . The traditional technique of endodontic surgery (“traditional technique”) consisted of root-end resection with a lingual to labial bevel for surgical access and visibility and root-end preparation using a round bur . In recent years, a technique (“modern technique”) that includes the use of magnification and illumination devices was introduced. The modern technique raised the success rate to above 90 % (compared to about 60 % success with the traditional technique) [19, 20, 25, 26] while allowing a more conservative and precise procedure with significantly less tissue damage [19, 20, 25, 26]. Since the modern technique results in less tissue damage during the surgery [9, 20, 26–28], a lower incidence and milder severity of postoperative pain and swelling following modern technique surgery versus the traditional technique is expected [8, 9, 29]. However, even with the modern technique, pain and swelling may occur [6–9].
Kvist and Reit  reported that on the evening after traditional endodontic surgery, almost all patients experienced pain, with 67 % requiring analgesics. Swelling was reported in all patients and reached the maximum on postoperative day 1 [6, 9]. Tsesis et al.  compared postoperative quality of life of patient receiving modern versus traditional surgical endodontic treatment and reported a high incidence of symptoms in both groups. It was also reported that patients treated by the modern technique had significantly less postoperative pain but reported more difficulty in mouth opening, mastication, and ability to speak during the immediate postoperative period .
The patient’s personal habits, such as the level of oral hygiene, and smoking habits may affect the risk and intensity of postoperative pain. Patients with poor oral hygiene may have higher maximum pain . The same was reported for surgery of impacted third molars , and patients who smoke are those who perceived greater pain .
García et al.  reported that modern endodontic surgery caused little pain and moderate swelling during the first 2 days after the intervention, and these findings were more distinct in patients with poor oral hygiene and in smokers , and they recommended that by maintaining good oral hygiene and by avoiding smoking both before and after the surgery, it is possible to minimize the postoperative symptoms .
Local Anesthetic, Root-End Filling, and Patient’s Age and Gender
The effect of the local anesthesia type, the root-end filling material, and the patients’ age or gender on the risk for postoperative symptoms seems to be insignificant. Meechan and Blair  compared postoperative pain experience after endodontic surgery using local anesthesia with lignocaine or etidocaine (long-acting local anesthetic) and found no differences in pain experience between the groups despite the much longer anesthesia for long-acting etidocaine . Chong and Pitt Ford  evaluated pain experience following root-end resection and filling with MTA or IRM and found that there was no significant difference in the pain experienced by both treatment groups. The age and gender of the patient had no statistically significant effect on any of the postoperative symptoms in endodontic surgery [1, 21]; however, some studies indicate that pain is more acute in females or in males following the extraction of impacted third molars .
In conclusion, it seems that the surgical technique characteristics directly affecting the amount of tissue injury during surgery are the most significant confounders for the risk of postoperative symptom development.
Prevention of Postoperative Pain and Swelling
Transmission of pain signals evoked by tissue damage leads to sensitization of the peripheral and central pain pathways . Inadequate pain control during the early postoperative period may contribute to the development of hyperalgesia and likelihood of stronger pain levels later. Thus, because it is easier to prevent than to eliminate pain, the concept of “pre-emptive analgesia” is to treat postoperative pain by preventing the establishment of central sensitization [30, 31].
Pre-emptive analgesia may be defined as “a treatment that is initiated before the surgical procedure in order to reduce central sensitization and ensuing excessive pain” . Thus, due to a “defensive” effect on the nociceptive system, pre-emptive analgesia has the potential to be more effective than a similar analgesic treatment initiated after surgery .
Pre-emptive analgesia includes the administration of a drug that blocks painful (nociceptive) input from entering the central nervous system before a surgical procedure in order to attenuate the development of changes that manifest as increased pain at later time points . Clinically, this strategy not only forecasts less pain during the initial postoperative period but also lowers the intensity of pain during the days after the procedure .
Studies have been published in which corticosteroids or “nonsteroidal anti-inflammatory drugs” (NSAIDs) have been used before and after surgery to control pain and swelling during the postoperative period [8, 33]. Tsesis et al.  in a case series of 82 patients treated using a modern surgical technique, premedicated all patients with a single dose of oral dexamethasone (8 mg) preoperatively and two single doses (4 mg) 1 and 2 days postoperatively. One day postoperatively, 76.4 % of the patients were completely pain free, less than 4 % had moderate pain, and 64.7 % did not report any swelling . In addition, patients with preoperative pain were more likely to have postoperative pain .
Lin et al. , in a double-blind study of 90 modern endodontic surgery patients, that were randomly premedicated with placebo or with either protocols: a single dose of oral dexamethasone, 8 mg, preoperatively and 2 single doses, of 4 mg, 1 and 2 days postoperatively; or a single dose of etodolac, 600 mg, and 2 single doses, of 600 mg, 1 and 2 days postoperatively. They reported that 1 day postoperatively, 41.8 % of the patients reported no or very mild pain, whereas after 7 days, 87.9 % reported no or very mild pain and that both etodolac and dexamethasone had a significant effect on reducing postoperative pain compared with placebo .
Surgical wounds may heal by primary intention (when the wound edges are brought together and detained in place, with minimal scar formation) or by secondary intention (in the presence of infection, when there is no proper approximation of the flap, and flap tension). Thus, the surgical procedure itself may affect the risk of postoperative pain, and a correct surgical technique may prevent postoperative excessive symptoms [34, 35]. It was reported that the type of incision for flap elevation may influence the risk for postoperative pain: 40 patients were randomly assigned to two groups. In one group a sulcular incision (SI) with complete papilla mobilization was made, and in the other group a papilla-base incision (PBI) was used. The papilla-base incision technique was better in reduction of pain levels .
In order to minimize postoperative pain and discomfort, the surgical procedure should be as atraumatic as possible , and when performing flap elevation, precautions must be taken to avoid perforation or tearing of the flap, and a tension-free primary flap closure is essential; in addition, during osteotomy the bone should be kept moist .
Management of Postoperative Pain and Swelling
The pain experienced by patients is mostly limited to the first few days after surgery, and pain and swelling are usually the chief postoperative sequelae [6, 8, 9, 35]. The patient’s attitude to development of postoperative symptoms is subjective, and patients may be forced to seek treatment only when the actual pain they are experiencing is greater than their anxiety about the expected pain . Thus, it is important to inform the patients of possible postoperative symptoms .