Postoperative Pain of Two Intraosseous Anesthetic Techniques: DISCUSSION part 2

In: Anesthesia

24 Oct 2009

Postoperative Pain of Two Intraosseous Anesthetic Techniques disscus

With respect to postoperative pain, the 2 subjects who were reperforated (1 Stabident and 1 X-Tip™) could have had a small effect on postoperative pain. However, it is very unlikely that the administration of an additional 0.3 mL of anesthetic solution for the infiltration would have had an effect on postoperative pain.

Postinjection pain ratings, at the time subjective numbness wore off, were similar for the Stabident and X-Tip™ systems, with no statistical differences between the 2 techniques (Table 3). The mean VAS ratings were 18 for the Stabident technique and 31 for the X-Tip™ technique—which would be in the faint to weak pain range (Figure 3). The incidence of moderate pain was 7-15%, with no reports of severe pain (Table 3). Various authors have reported that 2-16% of subjects had moderate pain and 0-3% had severe pain at the time subjective numbness wore off after receiving Stabident IO injections. Therefore, the incidence of moderate pain is similar between the previous studies and the current study. Clinically, with both the X-Tip™ and Stabident IO systems, the likelihood of having moderate pain at the time subjective numbness wears off is 16% or less. The potential for severe pain is small. cialis super active online

For the Stabident IO injections, postinjection pain was rated as none to mild, on the first morning, in 95% of the IO injections, with 2% reporting moderate or severe pain (Table 3). Generally, the pain ratings decreased over the next 2 days, with only a couple reports of moderate and severe pain (Table 3). Stabident post-injection pain ratings, on the first morning, have been reported by a number of authors as 0-10% moderate pain and 0-5% severe pain. For postoperative day 2, moderate pain has been reported as 0-10%, with no reports of severe pain. For postoperative day 3, moderate pain decreased to 0-5%, with no reports of severe pain. The results of the previous studies are similar to the current study. Therefore, the Stabident IO injection has a 0-10% potential for moderate postinjection pain, on the first morning, with decreasing moderate pain ratings over the next 2 days. The potential for severe pain is less than 5%.

For the X-Tip™ IO injections, postinjection pain was rated as none to mild, on the first morning in 75% of the IO injections, with 25% reporting moderate or severe pain (Table 3). For postoperative day 2, moderate pain was reported as 17%, with no reports of severe pain. For postoperative day 3, moderate pain decreased to 12%, with no reports of severe pain. Statistical analysis showed that males experienced significantly more postoperative pain, starting on the first morning and continuing through day 3, with the X-Tip™ system than with the Stabident system (Table 3). The 25% incidence of moderate to severe postoperative pain on day 1 (with decreasing incidence over the next 2 days) with the X-Tip™ system in males would indicate that male patients should be informed that they may experience moderate to severe pain a quarter of the time when the X-Tip™ system is used in an apical location. Patients may have to take analgesic medication to help with their postoperative pain. cheap levitra professional

Why did males have significantly more postoperative pain with the X-Tip™ IO injection? Reviews by Unruh and Miaskowski have indicated that there are differences between males and females regarding clinical pain experiences. Unruh, in reviewing research articles examining sex differences in clinical pain experiences, reported that females generally have higher levels of pain, have pain more frequently, and have a longer duration of pain than do males. However, in the current study, males experienced more moderate levels of pain and had pain more frequently than females. Therefore, we can speculate that the results of this study are not necessarily related to sex issues but to other factors or combinations of factors. One factor was the apical location of the X-Tip™ perforation. Kingsmill and Boyde studied mineralization density of human mandibular bone and reported that the lowest density occurred in the anterior alveolar crest while one of the highest densities was found buccally in the posterior mandible. There fore, the apical site of the X-Tip™ perforation, as was used in the current study, would probably be a higher mineralized site than the coronal site of the Stabident perforation. In concert with the perforation site would be the male bone density. Kingsmill and Boyde found women had lower mandibular bone mineral content than men. Therefore, if the apical cortical bone in the posterior mandible in males is denser and more mineralized than the crestal bone, the apical perforation process may cause greater frictional heat generation. Another factor, as mentioned previously, was that the X-Tip™ perforating system diameter is larger than the Stabident perforator. Therefore, the greater surface area of the X-Tip™ system may generate more frictional heat in the osseous tissues during perforation. A controlled histological study is needed to confirm the factor of X-Tip™ perforator diameter and the role it plays in damage to osseous tissues. Additionally, the effects of the X-Tip™ perforation on postoperative pain, when used in a coronal location, are not known. viagra professional online

There was 1 Stabident subject reporting severe postoperative pain at day 1 through day 3. The perforation for this individual was rated as easy. The moderate ratings for day 1 and day 2 were from 2 separate subjects and their perforations were rated as hard. The 10 X-Tip™ subjects reporting moderate to severe postoperative pain at day 1 were the same subjects who accounted for all the moderate to severe ratings over the next 2 days. Eight perforations for these individuals were rated as easy and 2 were rated as hard. It is difficult to explain the moderate to severe postoperative pain ratings based solely on the difficulty of perforation because the majority of the perforations were rated as easy. Perhaps the factors for more postoperative pain in males, as discussed previously, would account for bone damage and still be associated with an easy perforation.

Although no animal study has investigated the effects of the Stabident or X-Tip™ IO injection systems on gingiva and bone, various authors have reported postoperative swelling and purulence at Stabident IO injection sites. Generally, the incidence in these studies has been less than 5%. These changes are likely related to gingival or bone trauma during perforation. In the current study, 2 subjects (5%) reported postinjection swelling, with no exudate, with the Stabident technique (Table 4). All resolved by the third day. Clinically the chance is less than 5% that swelling or exudate will occur postoperatively with the Stabident system. buy hydrochlorothiazide

Swelling (with no exudate) with the X-Tip™ technique occurred 20% (8 of 41) of the time (Table 4). One subject (2%) had purulent exudate associated with the swelling. Four of the 9 swellings resolved by the third postoperative day. Five of the subjects did not resolve until 1-2 weeks. Eight of 9 subjects who reported swellings were male and their postoperative pain ratings were higher than the male subjects without swellings. Although the swelling was not statistically significant (P = .07) when compared with the Stabident system, clinically, the X-Tip™ system may have a higher incidence of postoperative swelling.

Five to 15% of the subjects reported the first molar “felt high” when chewing for a few days (Table 4). There was no statistical difference between the 2 techniques. Other studies using the Stabident technique reported an incidence of 0-13%. This feeling is most likely an increased awareness to biting that results from soreness in the area caused by damage from perforation or inflammation of the bone. Clinically, with both the X-Tip™ and Stabident IO systems, the likelihood of patients reporting that their teeth would be sore to chewing would be 15% or less. cheap cialis professional

In conclusion, the apical primary X-Tip™ intraosseous technique achieved similar pain ratings for infiltration, perforation, needle insertion, solution deposition, mock or actual guide sleeve removal, and postoperative pain (at the time subjective anesthesia wore off) as the coronal primary Stabident technique. However, on postoperative days 1-3, significantly more males experienced postoperative pain with the X-Tip™ system than with the Stabident system.


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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.

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