Postprocedural pain (PPP) is a common yet complex sequalae of dental procedures, often presenting challenges in diagnosis and management. While many dental procedures inherently involve some degree of discomfort such as local anesthesia administration or scaling and root planing—the primary goal remains to relieve pain and prevent disease progression. Effective PPP management requires a multifactorial approach, taking into account the patient’s chief complaint, age, gender, medical and psychosocial background, and drug compatibility. The use of preemptive and multimodal analgesia is of utmost importance in the effective management of PPP.
Key points
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Although dental procedures may temporarily cause pain and the ultimate goal is to alleviate procedural pain and prevent disease.
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Important concepts in optimal pain management include preemptive and multimodal analgesia.
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Persistent pain that lingers for 6 months or longer after the successful completion of root canal treatment may be suggestive of nonodontogenic pain origin.
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The concept of prompt referral to a pain management specialist should be considered if there is evidence of suboptimal pain control.
Abbreviations
| ACE | angiotensin-converting enzyme inhibitors |
| APAP | acetaminophen |
| CBT | cognitive behavioral therapy |
| COX | cyclooxygenase |
| GI | gastrointestinal |
| NSAID | nonsteroidal anti-inflammatory drug |
| OD | occlusal dysesthesia |
| POS | postoperative sensitivity |
| PPP | postprocedural pain/postprocedure pain |
| RCT | root canal treatment |
| SDS | somatic symptom disorder |
| SRP | scaling and root planning |
| SSRI | selective serotonin reuptake inhibitors |
| TMD | temporomandibular disorder |
| TMJ | temporomandibular joint |
Introduction
Odontogenic pain is the most common orofacial pain, differentiating it from nonodontogenic pain can be challenging. , Postprocedural pain (PPP) is a common sequelae of dental treatments. Factors influencing PPP include the nature of the treatment, tissues involved, and complexity of the procedure. A succinct PPP management should consider various factors such as the chief complaint, gender, age, patient’s physical, medical, and psychosocial status, and compatibility with medications, among others. This narrative review highlights the various aspects of PPP across dental specialties. The review also delves into the importance of implementing proper pain assessment protocols and patient education strategies to ensure optimal pain management outcomes.
Pain and postprocedural pain
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Table 1 summarizes the basis for the various classifications of pain and its characteristics. . ,,, PPP refers to the pain stemming from therapeutic, operative, and diagnostic procedures. Acute PPP occurs immediately after a procedure and resolves usually within 7 days (up to less than 3 months), whereas chronic PPP persists for greater than 3 months. Early recognition of factors predisposing to PPP may facilitate prevention and prompt management. Box 1 illustrates these risk factors. ,,
Table 1
Classifications and characteristics of pain
| Classification | Characteristics |
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| 1. Based on duration | |
| Acute pain | A sudden sharp pain of short duration (lesser than 3 mo) that results from a normal physiologic response to injury, illness, and/or trauma and heals once the causative factor is addressed |
| Transient pain | A brief/short term pain sensation |
| Chronic pain | Persistent pain lasting >3 mo. Continuous in nature, affecting the patient’s emotional well-being and quality of life, even without an identifiable cause |
| Persistent postsurgical/postprocedure pain | Pain that stems from therapeutic and diagnostic procedures (acute/chronic) |
| Breakthrough pain | A temporary exacerbation of pain occurring despite well-controlled baseline pain |
| 2. Based on mechanism | |
| Nociceptive pain | Pain arising from stimulation of nociceptors resulting from actual tissue damage. Classified as somatic or visceral pain |
| Neuropathic pain | Pain arising from damage or disease affecting the somatosensory nervous system and is often characterized by symptoms such as burning sensations, allodynia, or other sensory experiences |
| Nociplastic pain | Pain arising from the activation of nociceptors, in the absence of actual tissue damage |
| Mixed pain | Pain involving a combination of nociceptive, neuropathic, and/or nociplastic pain mechanisms occurring simultaneously or consecutively in the same area, with one mechanism potentially dominating at any given time. It can present as either acute or chronic pain |
| 3. Based on etiology | |
| Somatic pain | Originating from body tissues |
| Referred pain | The site (where pain is felt) and source (origin of the pain) of pain being distinct, with specific referral patterns |
| Psychogenic pain (somatic symptom disorder) | Purely originating from psychological factors |
| 4. Based on course | |
| Continuous pain | Persisting pain throughout the day without any relief |
| Incident pain | Pain arising due to a specific and preventable cause |
| Intermittent pain | Pain occurring sporadically, with periods of relief |
| Fluctuant pain | Pain which could randomly increase or decrease |
| 5. Based on intensity | |
| Mild pain | Usually, 1–3 on a visual analogue scale (0–10) |
| Moderate pain | Usually, 4–6 on a visual analogue scale (0–10) |
| Severe pain | Usually, 7–10 on a visual analogue scale (0–10) |
| 6. Based on pain description/quality | |
| Hotness: hot, burning, scalding | |
| Abrasiveness: itchy, stinging | |
| Incision: lancinating, cutting, slashing | |
| Puncture: pricking, piercing, stabbing | |
| 7. Based on location | |
| Local pain | For example: acute pulpitis |
| Diffuse pain | For example: myalgia |
| Regional pain | For example: myofascial pain |
| Global pain | For example: fibromyalgia |
| 8. Based on response to conventional treatment modalities | |
| Refractory | Clinicians usually use these terms to designate pain that is difficult to control |
| Recalcitrant | |
| Resistant | |
| Intractable | |
Box 1
Predisposing factors as related to the procedure, the patient, and biology in the development of postprocedure pain
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Procedure-related factors
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Preoperative
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Preexisting inflammation or infection
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Patient-related factors
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Type of procedure
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Lack of utilization of preemptive analgesia
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Preexisting pain (presence/absence; chronicity of pain; chronification of pain)
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Inadequate pre-op assessment (eg, anatomy, imaging evaluation)
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Intraoperative.
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Lack of profound anesthesia
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Surgical technique (eg, excessive force, poor asepsis, lack of manual dexterity)
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Tissue handling (eg, soft tissue trauma; mechanical/chemical/thermal trauma)
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Clinician’s expertise
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Duration of the procedure
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Postoperative
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Complications (eg, dry socket)
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Noncompliance with post-op instructions (eg, smoking, poor oral hygiene)
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Occlusal trauma (eg, high points following restoration)—Inadequate pain management
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Patient-related factors
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Demographics (eg, age, gender)
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Preexisting pain or chronic conditions (eg, temporomandibular disorders, neuropathic orofacial pain)
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Psychological factors (eg, anxiety and depression)
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Pain threshold and tolerance
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Socio-cultural factors
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Patient’s medical history
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Medications
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Biological factors
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Healing capacity
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Inflammatory response
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Risk of infection
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Neurophysiology/mechanism of postprocedural pain
Upon injury, nociceptors (A-delta and C-fibers) are activated due to the release of inflammatory mediators such as prostaglandins and cytokines. These mediators lower the activation threshold of nociceptors. This process, known as peripheral sensitization, leads to increased excitability and spontaneous nerve firing. These first-order neurons synapse with second-order neurons at the level of subnucleus caudalis of the spinal trigeminal nucleus. This information travels via the trigeminothalamic tract to the ventral posteromedial nucleus of the thalamus. From the thalamus, upon processing, these signals are further projected into the somatosensory cortex, where the perception of pain occurs. However, the entire “experience” of pain is robustly influenced by other involved centers such as the limbic system and descending modulatory system, among others. A process called central sensitization may occur if the constant barrage of pain signals into the higher centers. This may result in hyperalgesia, allodynia, spontaneous pain, and, in some cases, a transition to chronic pain ( Fig. 1 ). ,, An entity called the “first pain” is usually felt immediately after the injury. It is primarily a defensive mechanism mediated by A-delta fibers and characterized by intense sharp pain sensations. “Second pain” is the lower level of pain that is felt usually after a few minutes of that intense “first pain” dissipates. This second pain is primarily mediated through C-fibers, and is dull, aching, burning, and annoying. The switch from the first pain to second pain is primarily thought to be due to the activation of the descending modulatory system.
Neural pathways of pain transmission.
(Illustration by Dr. Murtaza Shapurwala, BDS.)
Psychosocial aspects of postprocedural pain
Somatic symptom disorder (SDS) is a condition characterized by emotional or psychological factors manifesting as physical symptoms, such as pain, without a clear medical explanation. This disorder involves heightened sensitivity to bodily sensations, further intensified by anxiety, excessive focus on pain, and significant time and energy spent worrying about these symptoms, to the extent that it disrupts daily functioning. In rare cases, patients may experience persistent pain or occlusal discomfort after a dental procedure, even when no identifiable clinical or radiographic abnormalities are present. Occlusal dysesthesia (OD) is a SDS arising following dental interventions, characterized by a persistent sensation of an uneven bite, despite the absence of actual occlusal discrepancies. Attempts to resolve this condition even with minor dental interventions can often worsen symptoms. , Management of OD should be driven by information and counseling in an attempt to defocus the patient’s preoccupation with their occlusion, and cognitive behavioral therapy (CBT). Occlusal splint therapy and medications may be utilized as adjunct treatments.
Another key factor influencing the development of PPP is the nocebo effect. The nocebo effect is marked by worsened symptoms, undesirable treatment outcomes, and adverse effects, as an unintended consequence of appropriate dental treatment. Negative thoughts and expectations about potential side effects related to a dental procedure can amplify the nocebo effect. Effective communication and patient education are critical in minimizing this effect and ensuring improved post-treatment outcomes. , A diagnosis of SDS can only be established after positively ruling out odontogenic and nonodontogenic causes of pain, and in collaboration with a trained psychologist or psychiatrist.
Postprocedural pain associated with dental procedures
PPP is an unintended consequence of clinical dentistry. While PPP is typically associated with more invasive procedures such as surgical extractions, it is not uncommon for patients to present to the clinician complaining of pain from a seemingly minor procedure. It is critical for dentists to recognize various clinical presentations of PPP related to common dental procedures.
Tooth Extraction
Third molar extraction is one of the most common dental surgical procedures. PPP is one of the most reported sequelae. Patients with dental anxiety or phobia may often express concerns about PPP, which can significantly impact their quality of life. ,, Most PPP complaints from third molar extractions are temporally related to a time frame of approximately 4–6 hours after the extraction. In addition, the reported peak intensity is within the first 24 hours postoperatively. , However, PPP is often attributed to factors including but not limited to clinicians’ skills, preoperative, perioperative, intraoperative, and postoperative protocols. Other factors may include gender, biological, psychosocial, and anatomic. , It is postulated that older adults have a greater tendency to experience pain following third molar extraction. , Alveolar osteitis, also known as dry socket, is a common postoperative complication characterized by pain in and around the extraction site reportedly caused by the partial or complete disintegration of the blood clot within the socket. The pain typically intensifies within the first 3 days following extraction.
Postendodontic Pain
PPP and discomfort following pulp capping procedures, is most common on the first day following the procedure. Typically, this discomfort dissipates over time. Partial pulpectomy (“coronal pulpotomy”) is a viable, time-efficient, and cost-effective alternative to root canal treatment (RCT) and postulated to have superior pain relief. However, in general both procedures result in a low frequency of severe PPP. Moderate to severe pain is more commonly reported within 2 to 3 days after completion of RCT, whereas in pulpotomy, it tends to peak within the first 36 hours. Pulpotomy consistently shows a higher incidence of pain-free outcomes and lower occurrences of mild to moderate pain than single-visit RCT. Additionally, pain intensity following pulpotomy varies depending on the material used, with calcium-enriched materials causing greater PPP intensity compared with mineral trioxide aggregate. Nevertheless, clinicians should not base their clinical decision between RCT and pulpotomy solely on PPP differences.
Pulpectomy
In young children, anxiety can significantly amplify PPP. The severity of pain is influenced by factors such as the host’s immunologic reaction, microbial invasion, and tissue injury. Postoperative inflammation of periradicular tissues immediately following pulpectomy is a common complaint. Pain typically peaks within the 48 hours postoperatively and gradually subsides over a week. Optimum mechanical instrumentation, antimicrobial irrigation, and proper obturation contribute to favorable treatment outcomes. Modified techniques utilizing rotary instruments showed less PPP compared with hand instrumentation. , This is attributed to factors such as over instrumentation beyond the apex and inadvertent extrusion of debris into the periapical tissues.
Root canal treatment
PPP after RCT is not an uncommon complaint and is influenced by several factors. There is a strong correlation between preoperative pain and PPP intensity, with most discomfort occurring after pulpectomy. Significant pain and swelling occurring within a few days after RCT may affect up to 16% of cases and can be influenced by factors such as the accuracy of working length measurement, which may irritate or injure the periapical tissues, as well as demographic factors and the patient’s general health status ( Table 2 ). Additionally, microbial and chemical factors, the pain prior to procedure, the type of tooth being treated (molar vs incisor), and the number of appointments required for the treatment may increase the likelihood of PPP. Persistent pain that lingers for 6 months or longer after successful completion of RCT may be suggestive of a nonodontogenic pain origin (eg, trigeminal neuralgia and cluster headache). The key in many of these cases is to consider the possibility that the original pain that prompted the RCT to begin with, may have been nonodontogenic in origin. Succinct attempt to delineate the temporal relationship of the “tooth ache” to other etiologies is paramount. Additionally, a known but undesirable adverse effect of RCT is pain related to deafferentation from pulpectomy that may persist and be ultimately diagnosed as post-traumatic trigeminal neuropathic pain.
Postoperative Sensitivity
Postoperative sensitivity (POS) following restorative procedures utilizing direct adhesive restorative materials is not uncommon. Patients experiencing POS after restorative treatment may present with tooth pain while chewing or sensitivity to stimuli such as cold, hot, and/or sugary substances. POS has been shown to occur more frequently in deeper cavity preparations following composite restorations. Involvement of additional tooth surfaces has also been associated with a higher incidence of POS.
Dental Implant Surgery
PPP is relatively common in dental implant surgeries. Preoperative and postoperative expectations and apprehension may predispose patients to increased PPP. The various factors that affect the pain experience following implant placement are summarized in Fig. 2 . ,,,,,, Nerve injury can occur at various stages of implant placement, potentially resulting in altered sensations such as partial or complete loss of touch, temperature, or pressure perception. In some cases, persistent pain after implant placement may indicate neuropathic pain, which may be associated with hyperesthesia, dysesthesia, paresthesia, or allodynia. ,, Anxiety stemming from a patient’s expectations about implant surgery can influence how they perceive PPP. Addressing these expectations through appropriate communication may help lower anxiety and improve patient outcomes of the treatment. ,
Predisposing factors for PPP following implant placement.
Nonsurgical Periodontal Therapy
PPP of mild to moderate intensity of inflammatory origin is anticipated after scaling and root planning (SRP). This pain is usually transient, and resolves within 3 days postprocedure, especially with judicious use of anti-inflammatory agents. However, when PPP subsequent to SRP (or dental prophylaxis with minimal SRP) persists for an extended period of time, the potential for neuropathic pain should be explored. The mechanism and clinical presentation related to “deafferentation pain” should be considered. Terms such as post-traumatic trigeminal pain, neuropathic pain, and other related terms have been used in the recent literature in an attempt to explain, diagnose, and manage these persistent pains.
Surgical Periodontal Therapy
A range of surgical periodontal therapies may be indicated for management of periodontal diseases. Postoperative complications including swelling, bleeding, delayed wound healing, infections, and flap dehiscence, may be accompanied by pain. A minimally invasive flap design has been shown to enhance postoperative healing while minimizing PPP. Guided tissue regeneration is associated with greater PPP, whereas the adjunctive use of enamel matrix derivative at the recipient site is associated with a notable reduction in PPP intensity. It has been reported that free soft tissue grafting is associated with greater PPP intensity compared with subepithelial connective tissue grafting procedures. Further, postsurgical periodontal dressings have been reported to be associated with greater PPP intensity, particularly in the first 48 hours following surgery. An explanation remains unknown, however, postulated to be attributed to an acute inflammatory response, heat generated, plaque accumulation, and bacterial proliferation under the dressing. Further studies are necessary to delineate the exact mechanisms related to certain periodontal surgical techniques and associated PPP.
Pain During/Following Orthodontic Treatments
Orthodontic treatment, involving procedures such as separator placement, arch wire insertion, appliance activation, and debonding, may be associated with varying degrees of pain. The mechanism may be a combination of orthodontic forces, ischemia, inflammation, and edema in the periodontal tissues. The onset of pain typically occurs within 4 hours of appliance placement, intensifies over the next 24 hours, and gradually subsides within a few days. Peak pain levels are observed in the first 72 hours. Interestingly, recent literature reports indicate a higher level of PPP occurring more immediately after the first and the third visit of treatment. The PPP after the first visit has been proposed to be associated with a combination of soft-tissue irritation and ulceration, and orthodontic forces. The second peak (during third visit) of pain is likely attributed to the increased orthodontic force from a larger diameter archwire. The type of appliance may impact PPP intensity. Fixed and functional appliances tend to cause greater discomfort than removable appliances, primarily due to their constant force application and mucosal irritation. Biting and chewing remain painful for an extended period, leading many patients to modify their diets to include softer foods. Pain and discomfort during mastication is a persistent symptom during orthodontic treatment, with its effects lasting beyond the acute phase of treatment.
Pain Related to Temporomandibular Disorders
Transient temporomandibular disorder (TMD) pain lasting for a few days postprocedure, is a common complaint following dental treatment involving prolonged mouth opening. , Signs and symptoms typically experienced include dull or intermittent sharp pain and stiffness localized to the TMJs and masticatory muscles, limited mouth opening, and new onset TMJ clicking, and on occasion intermittent catching and locking episodes postoperatively. The risk for developing PPP related to TMDs is greater in individuals with predisposing factors such as preexisting TMDs or orofacial symptoms, psychological conditions, pain disorders, and sleep disorders. Knowledge of these predisposing factors is critical and understandably patients may presume that their newly developed signs and symptoms are directly related to inappropriate dental care and maybe subsequently upset. Preventive measures during dental procedures, such as allowing breaks to rest the jaw, supporting the jaw with bite blocks, and minimizing the procedure duration are essential to mitigate the risk of developing PPP.
Management involves a combination of education and reassurance regarding the self-limiting nature of TMDs, self-care strategies, including applying cold or warm compresses, practicing gentle jaw exercises, and pain-free jaw functions such as adhering to a soft diet, avoiding parafunctional jaw activities such as nail biting, gum chewing, chin resting, and awake teeth clenching and jaw bracing to reduce overuse. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and if necessary short-term use of muscle relaxants may be beneficial. In cases of persistent pain, referral to an orofacial pain specialist is recommended.
Management of postprocedural pain
Effective management of PPP requires a comprehensive approach that considers multiple factors (see Box 1 ). An appropriate regimen should be planned across various stages, including preprocedure, intraprocedure, and postprocedure phases, to ensure optimal pain management. The general principles for PPP management are outlined later
Preprocedural and Intraprocedural Approach
The clinician must evaluate the patient’s medical history and dental history to aid in the assessment of their susceptibility to pain related to the procedure. , Anxiety is a crucial factor influencing the development of PPP. Managing the patient’s anxiety through education and counseling may aid in minimizing PPP. Concepts such as preemptive analgesia (having the analgesic on board before the procedure), and multimodal analgesia (combining analgesics with different modes of action) are core principles of optimal PPP management. Profound local anesthesia even in procedures performed under intravenous (IV) sedation and general anesthesia is paramount in PPP management. Table 2 provides an overview of preprocedural and intraprocedural approaches aimed at preventing or managing PPP. ,,,,,
Table 2
Preprocedural and intraprocedural approach to prevent/manage postprocedure pain
| Preprocedural and Intraprocedural Approach | Description |
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| Preemptive analgesia |
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| Multimodal analgesia |
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| Corticosteroids |
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| Management of anxiety |
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| Reducing tissue trauma |
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| Long-acting local anesthetic |
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