A clinical study was done to determine if routine operative dental procedures are followed by discomfort within 24 hours after the patient leaves the dental office. The types and frequencies of immediate postoperative discomfort are presented. The severity and duration of postoperative discomfort as a result of stimuli of cold, heat, and sweets are also presented.
Character and frequency of discomfort immediately following restorative procedures Anthony R. Silvestri, Jr., Steven N. Cohen, Jon H. Wetz,
DMD
DMD
DDS, B oston
Postoperative discomfort following routine re storative dental procedures may often be exper ienced by patients, but is seldom reported to the dentist. Consequently, he may assume that little discomfort exists. Yet even successful routine dental treatment may produce some discomfort. Empirical evidence clearly indicates that if dis comfort persists after the anesthetic has worn off, it lasts only a short time; at the next appoint ment in about a week, all discomfort is gone and usually forgotten. Therefore, this study was de signed to concentrate on immediate postopera tive discomfort within the first 24 hours after treatment.
T ra u m a and re sto rative p ro c e d u re s
Cavity preparation in the dentin and subsequent restoration is a traumatic procedure. Investiga tors have shown that inflammation of the pulp results from routine restorative procedures . 1,2 Cutting dentin with rotary instruments has been shown 3' 5 to cause damage to the odontoblastic layer. Several groups 6,7 have shown that pulpal damage results from excessive heat production
of high-speed rotary cutting instruments and dessication of dentin from excessive drying of the cavity preparation. Others have shown that pulpal damage results from the use of cavity ster ilizing agents ,2,8 and from some cavity liners and bases .3,9 Some patients experience momentary painful reaction to cold stimulus on a newly placed amal gam or composite restoration. Johnson and Brannstrom 1 have suggested that sensitivity to cold and other types of stimuli may be the result of inflammation to the pulp. Routine operative dental procedures also can cause trauma to the gingiva, deeper periodontal structures, and other related oral tissues. Pro cedures such as rubber dam placement and ad ministration of local anesthesia can cause trau matic injury. Every phase of cavity preparation and restoration has the potential to injure the dentin and even the pulp, and can result in post operative discomfort. Postoperative pain has been the subject of in vestigation in other areas of dentistry. Investi gators 10' 13 have studied the incidence and dura tion of pain following endodontic therapy, and others 14,15 have investigated the nature of pain JAD A , V ol. 95, J u ly 1977 ■ 85
following periodontal therapy. The purpose of this study was to investigate the frequency and nature of postoperative discomfort (low-grade “ pain” ) experienced by patients within the 24hour period immediately following the place ment of a dental restoration.
M e th o d s
Forty patients in need of routine operative pro cedures participated in the study. Patients were randomly selected from the patient population of the authors’ private dental practices. The oper ative procedures included Class I, II, and V amalgam restorations in posterior teeth and Class III and V composite restorations in an terior teeth. The length of dental appointments varied with each patient from Vi to lVi hours. All procedures were performed routinely without any special precautions or alterations in operating tech nique. Cavity preparations were performed with high-speed rotary cutting instruments with a wa ter and air spray as a coolant. Excavation of car ies was performed with slow-speed round burs and/or spoon excavators. Rubber dam with rub ber dam clamp and local anesthesia* were used with all patients. In teeth with cavity preparations deeper than 1.5 mm, a calcium hydroxide baset was applied to the pulpal and/or axial walls. A copal resint varnish was applied to the entire cavity prepara tion in every tooth that was to receive an amal gam restoration. For Class II amalgam restora tions, a Tofflemire type matrix, 0.015 inches thick, with a matrix retainer and wooden wedge, was used. For Class III composite resin restor ations, a clear celluloid matrix strip was used. A commercially available dispersion phase alloy§
and a composite resinll were the restorative ma terials used in this study. At the completion of the procedure, each pa tient received a standardized questionnaire per taining to postoperative discomfort (Table 1). The patients were instructed to complete the questionnaire within 24 hours after the total ef fects of the local anesthesia were no longer felt. The questionnaire was subsequently returned by mail in a self-addressed stamped envelope pro vided by the authors. The dentists completed a standardized data form immediately after each routine restorative procedure. These data included information that described the many variables encountered dur ing the restorative procedures (Table 2). The variables were selected to provide a broad data base from which to evaluate possible causes of postoperative discomfort. The patient question naires were compared with the respective data forms that the dentists completed for compilation of results and statistical analysis.
Results
Thirty-six of the 40 patients completed the stan dardized questionnaire and returned it as dir ected. Three patients did not return the question naire and one patient did not complete the ques tionnaire within the 24-hour time period. Eighteen of the 36 patients (50%) indicated that they had experienced some discomfort af ter the dental procedure, by answering affirm atively to the question, “ Did you experience any discomfort immediately after the anesthetic wore off?” An additional ten patients answered negatively the same question, yet answered pos itively one or more of the remaining questions referring to specific types of postoperative dis-
THE AU TH O R S
Drs. W etz, Silvestri, Cohen (left to right) are assistant professors of restorative dentistry at Tufts University School of Dental M edicine, 1 Kneeland Dr, Boston, 02111. Address requests for reprints to Dr. Silvestri. W ETZ
86 ■ JADA, V o l. 95, J u ly 1977
SILVESTRI
COHEN
Table 1 ■ Patient questionnaire. Nam e--------------------------------------------------------------------------------------------------------------------- Date--------------Instructions: Please com plete this questionnaire within 24 hours after leaving the dental office. Questions refer only to discom fort experienced after th e dental procedure is com pleted. Please answer questions honestly and return as soon as possible in the selfaddressed stam ped envelope provided. Thank You. Yes 1. Did you exp erience any discom fort im m ediately after the anesthetic wore off? 2. Did you exp erien ce any head, neck, or back pain follow ing the dental procedure? 3. Is your tooth sensitive to cold? If yes, how long does the sensitivity last? S e c o n d s ______ Minutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 4. Is your tooth sensitive to hot? If yes, how long does the sensitivity last? S e c o n d s ______ Minutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 5. Is your tooth sensitive to sweets? If yes, how long does the sensitivity last? S e c o n d s ______ M inutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 6. Is the restoration uncom fortable because it is “ high?” 7. Is the tooth uncom fortable to biting pressures? 8. Does your jaw hurt w hen you open your m outh w i d e l y ? 9. Is there discom fort if you palpate the area (with your finger) where the anesthetic was injected? 10. Are your gum s sore w hen you floss? 11. Is there an unusual taste in your m outh?
comfort. Therefore, 28 patients of the 36 sampled (78%) indicated that routine operative dental procedures were followed by some form of dis comfort. Table 3 lists, in order of decreasing frequency, the types of discomfort experienced by the pa tients, and shows the number and percentage of patients who reported having experienced each type of discomfort.
No
---------------------------------------------
-----------------------
-----------------------------------------------------------------_____________ ---------------------------------------------
Sensitivity to cold, hot, and sweets was further investigated with respect to severity and dura tion. Table 4 indicates the severity of discomfort experienced by patients when each stimulus was applied (by the patient) to the restored teeth. Table 5 indicates the duration of discomfort ex perienced by patients when cold, hot, and sweet stimuli were applied to the restored teeth.
Table 2 ■ Data base.
_
Date __________ I. Personal data A. N a m e _____________________ B. A g e ______ C. S e x ______ m ______ f D. Previous exp erience with d e n tis try :______ none, ______ m inim al, ______ m oderate, ______ extensive E. Length of tim e as p a t ie n t__________ F. Personality type: ______ calm , ______ stoic, ______ excitable II. Anesthesia A. T y p e __________ C o n c e n tra tio n __________ E p in e p h rin e __________ B. L o c a tio n __________ Infiltration ___________ B lo c k __________ C. N um ber of c a r p u le s __________ D. N eedle g a u g e __________ III. Rubber dam A. C lam p n u m b e r __________ B. Use of lig a tu r e :______ yes ______ no C. Traum a from placem ent with floss: ______ none, ______ m ild, ______ m oderate, ______ severe IV. Restorative procedure A. Tooth n u m b e r ______ s u rfa c e s ______ B. Restorative material: a m a lg a m ______ c o m p o s ite ______ C. History of pain prior to appointm ent: ______ yes ______ no D. Length of dental a p p o in tm e n t__________ E. O ld restoration: none______ am algam ______ gold______ com posite______ F. Tim e of procedure: ______ A.M. ______ P.M. G. Decay: none______ active______ non-active______ H. Depth of decay: beyond DEJ______ 1mm______ 2m m ______ 3mm ______ 4mm. exposure ______ I. Excavation of decay: spoon______ slow speed______ high speed______ J. High speed handpiece coolant: water______ air______ K. Base: calcium h y d ro x id e zinc o x id e ____________ o t h e r ______ L. Liner: __________ copal resin v a r n is h ____________________ M. M atrix: n o n e ______ to ffle m ir e ______ p la s tic ______ N. W ooden w edge: ______ yes ______ no
S ilv e s tri— C o h e n — W e tz: D IS C O M FO R T AFTER R ESTO R ATIVE PR O C E DU R E S ■ 87
Discussion Clinicians necessarily concern themselves with the elimination of discomfort during routine den tal procedures. Discomfort experienced by pa tients after leaving the dental office has been largely ignored by investigators since it is gen erally agreed that if it does occur it is tolerated without severe complaint. The authors found that a large number of the patients sampled (78%) experienced some form of discomfort within 24 hours following a routine operative procedure.
Table 3 ■ Types of discomfort experienced by patients. Types of discom fort
No. patients
% of total (36)
18 15 14
50* 41 38
8 7 6 6 5 2 0
22 19 16 16 13 5 0
Tooth sensitive to cold Painful w hen opening jaw widely Painful upon palpation of area where anesthetic was adm inistered Painful w hen flossing Tooth sensitive to hot D iscom fort from biting pressure Unpleasant taste High restoration Head, neck, or back discom fort Tooth sensitive to sweets
•Patients indicated m ore than one type of discom fort.
Table 4 ■ Severity of discomfort.
P o sto p e ra tiv e d iscom fort a s a resu lt o f co ld stim uli: Sensitivity to the application of cold ■
stimuli is the most frequent type of discomfort experienced by patients (50% reported it) after the placement of a routine amalgam or composite restoration. All cavity preparations in this study received a calcium hydroxide base applied to the pulpal and/or axial walls. In addition to calcium hydroxide, in teeth in which amalgam restora tions were to be placed, several thin layers of a copal resin varnish were applied to all cavity walls. Going16 suggested that calcium hydroxide with a copal varnish best fulfills all the require ments of a good liner under amalgam restora tions. Our study suggests that this combination of materials appears to be less than perfect in insulating the pulp from thermal stimuli since 50% of the patients sampled experienced dis comfort to cold. Several investigators17,18 have shown that pain can be elicited by a cold stimulus before any change in temperature has reached the pulp. The transmission of the cold stimulus most prob ably originates in the outermost cut dentinal tub ules, closest to the dentinoenamel junction, since the deeper layers are afforded protection by a relatively thick layer of calcium hydroxide. The results of this study indicate the need for a more effective method of thermal insulation to the pulp.
No. patients reporting discom fort Type of stimuli Cold Hot Sweets
No. patients 18 7 0
M ild 14 (78% ) 5 (71% ) 0
M oderate
Sev
4 (22% ) 2 (29% ) 0
( ( (
Table 5 ■ Duration of discomfort. No. patients reporting duration of discomfi Type of stim uli Cold Hot Sweets
No. patients
Fleeting (seconds)
18 7 0
17 (94% ) 6 (86% ) 0
Prolonged (minute 1 (6%) 1 (14%) 0
inhibits the ions from entering the pulp via freshly cut dentinal tubules and hence minimizes pulpal inflammation, which reduces postoperative ther mal sensitivity. The duration of discomfort to cold stimuli was uniformly fleeting, 94% of the patients reported. Only 6% of the patients reported experiencing discomfort, caused by cold stimuli, that lasted more than several seconds. This study suggests that the clinical manifes tation of the inflammatory response that results from routine operative procedures is a fleeting discomfort to cold stimuli.
■
■ P o sto p era tive discom fort fro m local a n e s thesia: Postoperative discomfort resulting from
sulting from cold stimuli was most frequently mild (78% of patients reporting). Twenty-two percent of the patients experienced moderate reaction to cold, and none experienced severe discomfort. Dachi and Stigers19 said that copal varnish minimizes the leakage of salivary ions into the microscopic space between the cavity wall and the amalgam restoration. This, in turn,
the administration of local anesthesia was the second most frequent type of discomfort exper ienced. Forty-one percent of the patients exper ienced pain during extreme jaw opening and 38% of the patients felt discomfort on digital palpa tion of the injection site and surrounding tissues. Traumatic injury by the needle to the muscle and surrounding soft and hard tissue is the most probable cause for this postoperative sensation.
S everity a n d duration o f d iscom fort a s a result o f co ld stim uli: The severity of discomfort re
88 ■ JADA, V o l. 95, J u ly 1977
However, local tissue damage from the anes thetic solution itself cannot be ruled out. ■ Other types o f postoperative discomfort: A routine operative dental appointment may result in several other types of postoperative discom fort. In addition to sensitivity to cold stimuli, the altered pulp and disturbed dentinal tubules will occasionally respond to hot stimulus (19% of the patients reported this). The introduction of re storative materials and foreign substances into the oral cavity also results in such postoperative problems as high restorations (reported by 13%) and unpleasant taste (reported by 16%). Injury to the gingiva and deeper periodontal structures also may occur. Pain during flossing (reported by 22%) and discomfort from biting pressures (reported by 16%) are discomforts re sulting from periodontal damage. The placement of the rubber dam, rubber dam clamp, matrix, matrix retainer, and wooden wedge may injure the gingiva and periodontal tissues. The finish ing of the restoration with finishing strips is yet another possible source of injury to the epithelial attachment and periodontal structures. Back and neck fatigue resulting from long ap pointments (1 to lVi hours) was not a significant postoperative problem for most patients. Only 5% of the patients reported experiencing head, neck, or back discomfort within 24 hours after leaving the dental office. Modem operatory chairs are probably responsible for this low inci dence of postoperative discomfort. N o patient reported experiencing discomfort as a result of the sweet stimulus. Improved re storative materials and the copal resin varnish apparently seal the margins of the restorations sufficiently to prevent the relatively large su crose molecule from penetrating and eliciting an irritating hyperosmotic effect on the recently cut dentinal tubules.
often fleeting (reported by 94%) and seldom pro longed (reported by 6%). The second most fre quent type of postoperative discomfort reported was associated with the administration of the lo cal anesthetic. Sensitivity to sweets does not seem to be a source of postoperative discomfort following routine operative dental procedures. W e acknow ledge the assistance and guidance of Dr. M aury Massler. *Xylocaine 2%, 1:100,000 epinephrine; or Citanest Forte, Astra Pharm aceutical Products, W orcester, Mass 01606. tD ycal, L. D. C aulk Co., M ilford, Del 19963. tC opalite, H. J. Bosworth Co., C hicago, 60605. §Dispersalloy, Johnson & Johnson, N ew Brunswick, NJ 08520. ItConcise, 3 M Co., Costa M esa, C alif 92626. 1. Johnson, G., and Brannstrom , M. Pain reaction to cold stim ulus in teeth with experim ental fillings. Acta O dontol Scand 29: 639 D ec 1971. 2. S eltzer, S.; Bender, I.B.; and Kaufman, I.J. H istologic c h ang es in dental pulps of dogs and monkeys follow ing application of pressure, drugs, and m icroorganism s on prepared cavities. Oral Surg 14:327 March 1961. 3. Jam es, V.E., and Schour, I. Early dentinal and pulpal chang es follow ing cavity preparations and filling m aterials Oral Surg 8 :1305 Dec 1955.
in
dogs.
4. W eider, S.R.; Schour, I.; and M oham m ad, C.l. R eparative dentine follow ing cavity preparation and fillings in rat molar. Oral Surg 9:221 Feb 1956. 5. Langeland, K. Tissue changes in the dental pulp; an exper imental histologic study. O dontol T 65:239 Aug 1957. 6. S eltzer, S., and Bender, I.B. M odification of operative pro cedures to avoid postoperative pulp inflam m ation. JADA 66:503 April 1963. 7. B rannstrom , M. Dentinal and pulpal response to applica tion of reduced pressure to exposed dentine. Acta O dontol Scand 18:1 M ay 1960. 8. Englander, H.R.; James, V.E.; and M assler, M. Histologic effects of silver nitrate on human dentine and pulp. JADA 57:621 Nov 1958. 9. B rannstrom , M., and Nyborg, H. D entinal and pulpal re sponse IV. Pulp reaction to zinc oxyphosphate cem ent. M or phologic study on dog and man. Odontol Rev 11:37 No. 1, 1960. 10. Clem, W .H. Post-treatm ent endo don tic pain. JADA 81:1166 Nov 1970. 11. Seltzer, S.; Bender, I.B.; and Ebrenreich, J, Incidence and duration of pain follow ing endodontic therapy. Oral Surg 14:74 Jan 1961. 12. Frank, A.L., and others. The intra-canal use of sulfathiazole in endodontics to reduce pain. JADA 77:102 July 1968. 13. Fox, J., and others. Incidence of pain follow ing one visit endodontic treatm ent. Oral Surg 30:123 July 1970. 14. G lenw right, H.D., and Strahan, J.D. Observations on pain follow ing periodontal surgery. Dent Pract Dent Rec 18:323 May
Conclusions Within 24 hours after dental treatment, discom fort was experienced by 78% of the patients ques tioned. Sensitivity to cold was the most frequent type of discomfort experienced (reported by 50% of the patients). Postoperative discomfort resulting from cold stimulus was most often mild (in 78%), occasionally moderate (in 22%), and never severe. The duration of postoperative dis comfort resulting from cold stimulus was most
1968. 15. Strahan, J.D., and G lenw right, H.D. Pain exp erien ce in periodontal surgery. J Periodont Res 2:163, 1963. 16. Going, R.E. Cavity liners and dentin treatm ent. JADA 69: 416 Oct 1964. 17. Hansel, H„ and M ann, G. Pain in human teeth caused by tem p erature variations and heat conduction. S tom a 9:76 Feb 1956. 18. Naylor, M .N. Studies on the m echanism of sensation of cold stim ulation on human dentine. In A nderson, D.J., ed. S en sory m echanism in dentine. Oxford, Pergam on Press, 1963, p 80. 19. Dachi, S.F., and Stlgers, R.W. Reduction of pulpal inflam m ation and therm al sensitivity in am algam restored teeth treated with copal varnish. JADA 74:1281 M ay 1967.
S ilv e s tri— C o h e n — W etz: D IS C O M FO R T AFTER R ESTO R ATIVE P R O C ED U R E S ■ 89
Character and frequency of discomfort immediately following restorative procedures Anthony R. Silvestri, Jr., Steven N. Cohen, Jon H. Wetz,
DMD
DMD
DDS, B oston
Postoperative discomfort following routine re storative dental procedures may often be exper ienced by patients, but is seldom reported to the dentist. Consequently, he may assume that little discomfort exists. Yet even successful routine dental treatment may produce some discomfort. Empirical evidence clearly indicates that if dis comfort persists after the anesthetic has worn off, it lasts only a short time; at the next appoint ment in about a week, all discomfort is gone and usually forgotten. Therefore, this study was de signed to concentrate on immediate postopera tive discomfort within the first 24 hours after treatment.
T ra u m a and re sto rative p ro c e d u re s
Cavity preparation in the dentin and subsequent restoration is a traumatic procedure. Investiga tors have shown that inflammation of the pulp results from routine restorative procedures . 1,2 Cutting dentin with rotary instruments has been shown 3' 5 to cause damage to the odontoblastic layer. Several groups 6,7 have shown that pulpal damage results from excessive heat production
of high-speed rotary cutting instruments and dessication of dentin from excessive drying of the cavity preparation. Others have shown that pulpal damage results from the use of cavity ster ilizing agents ,2,8 and from some cavity liners and bases .3,9 Some patients experience momentary painful reaction to cold stimulus on a newly placed amal gam or composite restoration. Johnson and Brannstrom 1 have suggested that sensitivity to cold and other types of stimuli may be the result of inflammation to the pulp. Routine operative dental procedures also can cause trauma to the gingiva, deeper periodontal structures, and other related oral tissues. Pro cedures such as rubber dam placement and ad ministration of local anesthesia can cause trau matic injury. Every phase of cavity preparation and restoration has the potential to injure the dentin and even the pulp, and can result in post operative discomfort. Postoperative pain has been the subject of in vestigation in other areas of dentistry. Investi gators 10' 13 have studied the incidence and dura tion of pain following endodontic therapy, and others 14,15 have investigated the nature of pain JAD A , V ol. 95, J u ly 1977 ■ 85
following periodontal therapy. The purpose of this study was to investigate the frequency and nature of postoperative discomfort (low-grade “ pain” ) experienced by patients within the 24hour period immediately following the place ment of a dental restoration.
M e th o d s
Forty patients in need of routine operative pro cedures participated in the study. Patients were randomly selected from the patient population of the authors’ private dental practices. The oper ative procedures included Class I, II, and V amalgam restorations in posterior teeth and Class III and V composite restorations in an terior teeth. The length of dental appointments varied with each patient from Vi to lVi hours. All procedures were performed routinely without any special precautions or alterations in operating tech nique. Cavity preparations were performed with high-speed rotary cutting instruments with a wa ter and air spray as a coolant. Excavation of car ies was performed with slow-speed round burs and/or spoon excavators. Rubber dam with rub ber dam clamp and local anesthesia* were used with all patients. In teeth with cavity preparations deeper than 1.5 mm, a calcium hydroxide baset was applied to the pulpal and/or axial walls. A copal resint varnish was applied to the entire cavity prepara tion in every tooth that was to receive an amal gam restoration. For Class II amalgam restora tions, a Tofflemire type matrix, 0.015 inches thick, with a matrix retainer and wooden wedge, was used. For Class III composite resin restor ations, a clear celluloid matrix strip was used. A commercially available dispersion phase alloy§
and a composite resinll were the restorative ma terials used in this study. At the completion of the procedure, each pa tient received a standardized questionnaire per taining to postoperative discomfort (Table 1). The patients were instructed to complete the questionnaire within 24 hours after the total ef fects of the local anesthesia were no longer felt. The questionnaire was subsequently returned by mail in a self-addressed stamped envelope pro vided by the authors. The dentists completed a standardized data form immediately after each routine restorative procedure. These data included information that described the many variables encountered dur ing the restorative procedures (Table 2). The variables were selected to provide a broad data base from which to evaluate possible causes of postoperative discomfort. The patient question naires were compared with the respective data forms that the dentists completed for compilation of results and statistical analysis.
Results
Thirty-six of the 40 patients completed the stan dardized questionnaire and returned it as dir ected. Three patients did not return the question naire and one patient did not complete the ques tionnaire within the 24-hour time period. Eighteen of the 36 patients (50%) indicated that they had experienced some discomfort af ter the dental procedure, by answering affirm atively to the question, “ Did you experience any discomfort immediately after the anesthetic wore off?” An additional ten patients answered negatively the same question, yet answered pos itively one or more of the remaining questions referring to specific types of postoperative dis-
THE AU TH O R S
Drs. W etz, Silvestri, Cohen (left to right) are assistant professors of restorative dentistry at Tufts University School of Dental M edicine, 1 Kneeland Dr, Boston, 02111. Address requests for reprints to Dr. Silvestri. W ETZ
86 ■ JADA, V o l. 95, J u ly 1977
SILVESTRI
COHEN
Table 1 ■ Patient questionnaire. Nam e--------------------------------------------------------------------------------------------------------------------- Date--------------Instructions: Please com plete this questionnaire within 24 hours after leaving the dental office. Questions refer only to discom fort experienced after th e dental procedure is com pleted. Please answer questions honestly and return as soon as possible in the selfaddressed stam ped envelope provided. Thank You. Yes 1. Did you exp erience any discom fort im m ediately after the anesthetic wore off? 2. Did you exp erien ce any head, neck, or back pain follow ing the dental procedure? 3. Is your tooth sensitive to cold? If yes, how long does the sensitivity last? S e c o n d s ______ Minutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 4. Is your tooth sensitive to hot? If yes, how long does the sensitivity last? S e c o n d s ______ Minutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 5. Is your tooth sensitive to sweets? If yes, how long does the sensitivity last? S e c o n d s ______ M inutes ______ Is the sensitivity: M i l d ______ M o d e r a te ______ S e v e r e ______ 6. Is the restoration uncom fortable because it is “ high?” 7. Is the tooth uncom fortable to biting pressures? 8. Does your jaw hurt w hen you open your m outh w i d e l y ? 9. Is there discom fort if you palpate the area (with your finger) where the anesthetic was injected? 10. Are your gum s sore w hen you floss? 11. Is there an unusual taste in your m outh?
comfort. Therefore, 28 patients of the 36 sampled (78%) indicated that routine operative dental procedures were followed by some form of dis comfort. Table 3 lists, in order of decreasing frequency, the types of discomfort experienced by the pa tients, and shows the number and percentage of patients who reported having experienced each type of discomfort.
No
---------------------------------------------
-----------------------
-----------------------------------------------------------------_____________ ---------------------------------------------
Sensitivity to cold, hot, and sweets was further investigated with respect to severity and dura tion. Table 4 indicates the severity of discomfort experienced by patients when each stimulus was applied (by the patient) to the restored teeth. Table 5 indicates the duration of discomfort ex perienced by patients when cold, hot, and sweet stimuli were applied to the restored teeth.
Table 2 ■ Data base.
_
Date __________ I. Personal data A. N a m e _____________________ B. A g e ______ C. S e x ______ m ______ f D. Previous exp erience with d e n tis try :______ none, ______ m inim al, ______ m oderate, ______ extensive E. Length of tim e as p a t ie n t__________ F. Personality type: ______ calm , ______ stoic, ______ excitable II. Anesthesia A. T y p e __________ C o n c e n tra tio n __________ E p in e p h rin e __________ B. L o c a tio n __________ Infiltration ___________ B lo c k __________ C. N um ber of c a r p u le s __________ D. N eedle g a u g e __________ III. Rubber dam A. C lam p n u m b e r __________ B. Use of lig a tu r e :______ yes ______ no C. Traum a from placem ent with floss: ______ none, ______ m ild, ______ m oderate, ______ severe IV. Restorative procedure A. Tooth n u m b e r ______ s u rfa c e s ______ B. Restorative material: a m a lg a m ______ c o m p o s ite ______ C. History of pain prior to appointm ent: ______ yes ______ no D. Length of dental a p p o in tm e n t__________ E. O ld restoration: none______ am algam ______ gold______ com posite______ F. Tim e of procedure: ______ A.M. ______ P.M. G. Decay: none______ active______ non-active______ H. Depth of decay: beyond DEJ______ 1mm______ 2m m ______ 3mm ______ 4mm. exposure ______ I. Excavation of decay: spoon______ slow speed______ high speed______ J. High speed handpiece coolant: water______ air______ K. Base: calcium h y d ro x id e zinc o x id e ____________ o t h e r ______ L. Liner: __________ copal resin v a r n is h ____________________ M. M atrix: n o n e ______ to ffle m ir e ______ p la s tic ______ N. W ooden w edge: ______ yes ______ no
S ilv e s tri— C o h e n — W e tz: D IS C O M FO R T AFTER R ESTO R ATIVE PR O C E DU R E S ■ 87
Discussion Clinicians necessarily concern themselves with the elimination of discomfort during routine den tal procedures. Discomfort experienced by pa tients after leaving the dental office has been largely ignored by investigators since it is gen erally agreed that if it does occur it is tolerated without severe complaint. The authors found that a large number of the patients sampled (78%) experienced some form of discomfort within 24 hours following a routine operative procedure.
Table 3 ■ Types of discomfort experienced by patients. Types of discom fort
No. patients
% of total (36)
18 15 14
50* 41 38
8 7 6 6 5 2 0
22 19 16 16 13 5 0
Tooth sensitive to cold Painful w hen opening jaw widely Painful upon palpation of area where anesthetic was adm inistered Painful w hen flossing Tooth sensitive to hot D iscom fort from biting pressure Unpleasant taste High restoration Head, neck, or back discom fort Tooth sensitive to sweets
•Patients indicated m ore than one type of discom fort.
Table 4 ■ Severity of discomfort.
P o sto p e ra tiv e d iscom fort a s a resu lt o f co ld stim uli: Sensitivity to the application of cold ■
stimuli is the most frequent type of discomfort experienced by patients (50% reported it) after the placement of a routine amalgam or composite restoration. All cavity preparations in this study received a calcium hydroxide base applied to the pulpal and/or axial walls. In addition to calcium hydroxide, in teeth in which amalgam restora tions were to be placed, several thin layers of a copal resin varnish were applied to all cavity walls. Going16 suggested that calcium hydroxide with a copal varnish best fulfills all the require ments of a good liner under amalgam restora tions. Our study suggests that this combination of materials appears to be less than perfect in insulating the pulp from thermal stimuli since 50% of the patients sampled experienced dis comfort to cold. Several investigators17,18 have shown that pain can be elicited by a cold stimulus before any change in temperature has reached the pulp. The transmission of the cold stimulus most prob ably originates in the outermost cut dentinal tub ules, closest to the dentinoenamel junction, since the deeper layers are afforded protection by a relatively thick layer of calcium hydroxide. The results of this study indicate the need for a more effective method of thermal insulation to the pulp.
No. patients reporting discom fort Type of stimuli Cold Hot Sweets
No. patients 18 7 0
M ild 14 (78% ) 5 (71% ) 0
M oderate
Sev
4 (22% ) 2 (29% ) 0
( ( (
Table 5 ■ Duration of discomfort. No. patients reporting duration of discomfi Type of stim uli Cold Hot Sweets
No. patients
Fleeting (seconds)
18 7 0
17 (94% ) 6 (86% ) 0
Prolonged (minute 1 (6%) 1 (14%) 0
inhibits the ions from entering the pulp via freshly cut dentinal tubules and hence minimizes pulpal inflammation, which reduces postoperative ther mal sensitivity. The duration of discomfort to cold stimuli was uniformly fleeting, 94% of the patients reported. Only 6% of the patients reported experiencing discomfort, caused by cold stimuli, that lasted more than several seconds. This study suggests that the clinical manifes tation of the inflammatory response that results from routine operative procedures is a fleeting discomfort to cold stimuli.
■
■ P o sto p era tive discom fort fro m local a n e s thesia: Postoperative discomfort resulting from
sulting from cold stimuli was most frequently mild (78% of patients reporting). Twenty-two percent of the patients experienced moderate reaction to cold, and none experienced severe discomfort. Dachi and Stigers19 said that copal varnish minimizes the leakage of salivary ions into the microscopic space between the cavity wall and the amalgam restoration. This, in turn,
the administration of local anesthesia was the second most frequent type of discomfort exper ienced. Forty-one percent of the patients exper ienced pain during extreme jaw opening and 38% of the patients felt discomfort on digital palpa tion of the injection site and surrounding tissues. Traumatic injury by the needle to the muscle and surrounding soft and hard tissue is the most probable cause for this postoperative sensation.
S everity a n d duration o f d iscom fort a s a result o f co ld stim uli: The severity of discomfort re
88 ■ JADA, V o l. 95, J u ly 1977
However, local tissue damage from the anes thetic solution itself cannot be ruled out. ■ Other types o f postoperative discomfort: A routine operative dental appointment may result in several other types of postoperative discom fort. In addition to sensitivity to cold stimuli, the altered pulp and disturbed dentinal tubules will occasionally respond to hot stimulus (19% of the patients reported this). The introduction of re storative materials and foreign substances into the oral cavity also results in such postoperative problems as high restorations (reported by 13%) and unpleasant taste (reported by 16%). Injury to the gingiva and deeper periodontal structures also may occur. Pain during flossing (reported by 22%) and discomfort from biting pressures (reported by 16%) are discomforts re sulting from periodontal damage. The placement of the rubber dam, rubber dam clamp, matrix, matrix retainer, and wooden wedge may injure the gingiva and periodontal tissues. The finish ing of the restoration with finishing strips is yet another possible source of injury to the epithelial attachment and periodontal structures. Back and neck fatigue resulting from long ap pointments (1 to lVi hours) was not a significant postoperative problem for most patients. Only 5% of the patients reported experiencing head, neck, or back discomfort within 24 hours after leaving the dental office. Modem operatory chairs are probably responsible for this low inci dence of postoperative discomfort. N o patient reported experiencing discomfort as a result of the sweet stimulus. Improved re storative materials and the copal resin varnish apparently seal the margins of the restorations sufficiently to prevent the relatively large su crose molecule from penetrating and eliciting an irritating hyperosmotic effect on the recently cut dentinal tubules.
often fleeting (reported by 94%) and seldom pro longed (reported by 6%). The second most fre quent type of postoperative discomfort reported was associated with the administration of the lo cal anesthetic. Sensitivity to sweets does not seem to be a source of postoperative discomfort following routine operative dental procedures. W e acknow ledge the assistance and guidance of Dr. M aury Massler. *Xylocaine 2%, 1:100,000 epinephrine; or Citanest Forte, Astra Pharm aceutical Products, W orcester, Mass 01606. tD ycal, L. D. C aulk Co., M ilford, Del 19963. tC opalite, H. J. Bosworth Co., C hicago, 60605. §Dispersalloy, Johnson & Johnson, N ew Brunswick, NJ 08520. ItConcise, 3 M Co., Costa M esa, C alif 92626. 1. Johnson, G., and Brannstrom , M. Pain reaction to cold stim ulus in teeth with experim ental fillings. Acta O dontol Scand 29: 639 D ec 1971. 2. S eltzer, S.; Bender, I.B.; and Kaufman, I.J. H istologic c h ang es in dental pulps of dogs and monkeys follow ing application of pressure, drugs, and m icroorganism s on prepared cavities. Oral Surg 14:327 March 1961. 3. Jam es, V.E., and Schour, I. Early dentinal and pulpal chang es follow ing cavity preparations and filling m aterials Oral Surg 8 :1305 Dec 1955.
in
dogs.
4. W eider, S.R.; Schour, I.; and M oham m ad, C.l. R eparative dentine follow ing cavity preparation and fillings in rat molar. Oral Surg 9:221 Feb 1956. 5. Langeland, K. Tissue changes in the dental pulp; an exper imental histologic study. O dontol T 65:239 Aug 1957. 6. S eltzer, S., and Bender, I.B. M odification of operative pro cedures to avoid postoperative pulp inflam m ation. JADA 66:503 April 1963. 7. B rannstrom , M. Dentinal and pulpal response to applica tion of reduced pressure to exposed dentine. Acta O dontol Scand 18:1 M ay 1960. 8. Englander, H.R.; James, V.E.; and M assler, M. Histologic effects of silver nitrate on human dentine and pulp. JADA 57:621 Nov 1958. 9. B rannstrom , M., and Nyborg, H. D entinal and pulpal re sponse IV. Pulp reaction to zinc oxyphosphate cem ent. M or phologic study on dog and man. Odontol Rev 11:37 No. 1, 1960. 10. Clem, W .H. Post-treatm ent endo don tic pain. JADA 81:1166 Nov 1970. 11. Seltzer, S.; Bender, I.B.; and Ebrenreich, J, Incidence and duration of pain follow ing endodontic therapy. Oral Surg 14:74 Jan 1961. 12. Frank, A.L., and others. The intra-canal use of sulfathiazole in endodontics to reduce pain. JADA 77:102 July 1968. 13. Fox, J., and others. Incidence of pain follow ing one visit endodontic treatm ent. Oral Surg 30:123 July 1970. 14. G lenw right, H.D., and Strahan, J.D. Observations on pain follow ing periodontal surgery. Dent Pract Dent Rec 18:323 May
Conclusions Within 24 hours after dental treatment, discom fort was experienced by 78% of the patients ques tioned. Sensitivity to cold was the most frequent type of discomfort experienced (reported by 50% of the patients). Postoperative discomfort resulting from cold stimulus was most often mild (in 78%), occasionally moderate (in 22%), and never severe. The duration of postoperative dis comfort resulting from cold stimulus was most
1968. 15. Strahan, J.D., and G lenw right, H.D. Pain exp erien ce in periodontal surgery. J Periodont Res 2:163, 1963. 16. Going, R.E. Cavity liners and dentin treatm ent. JADA 69: 416 Oct 1964. 17. Hansel, H„ and M ann, G. Pain in human teeth caused by tem p erature variations and heat conduction. S tom a 9:76 Feb 1956. 18. Naylor, M .N. Studies on the m echanism of sensation of cold stim ulation on human dentine. In A nderson, D.J., ed. S en sory m echanism in dentine. Oxford, Pergam on Press, 1963, p 80. 19. Dachi, S.F., and Stlgers, R.W. Reduction of pulpal inflam m ation and therm al sensitivity in am algam restored teeth treated with copal varnish. JADA 74:1281 M ay 1967.
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