Psychological factors influencing post-operative pain and analgesic consumption

Implications of Lingual Orthodontics Compared to Conventional Orthodontics

In orthodontics, the treatment plan and the impact of orthodontic appliances on patients' aesthetic appearance have significantly influenced patients' aesthetic demands over time. Patients considering orthodontic treatment are very concerned about the potential compromise in facial appearance that conventional orthodontic treatment could cause. Lingual orthodontics offers an aesthetically pleasing appearance compared to conventional orthodontic systems, addressing the growing demand for inconspicuous treatment options. This review examines the implications of lingual orthodontics compared to conventional orthodontics, focusing on aesthetics, oral health outcomes, and patient satisfaction. The benefit of lingual brackets is that when positioned on the teeth's lingual surfaces, they are almost undetectable. However, they are associated with increased difficulty in oral hygiene maintenance due to their placement, leading to higher plaque accumulation that causes compromised periodontal health. Conversely, studies show a lower incidence of white spot lesions on lingual surfaces compared to buccal surfaces, suggesting a reduced risk of caries. Challenges with lingual systems include increased tongue discomfort and speech difficulties. Despite these challenges, lingual orthodontics demonstrates favourable outcomes for patients prioritising aesthetics. Future advancements should focus on improving appliance designs to enhance patient comfort and oral hygiene accessibility, ensuring optimal treatment outcomes. Interdisciplinary collaboration and comprehensive oral hygiene education are essential to maximise the benefits of lingual orthodontics.

The role of psychopathological symptoms in lumbar stenosis: A prediction model of disability after lumbar decompression and fusion

Introduction

Pre-operative psychological factors may influence outcome after spine surgery. The identification of patients at risk of persisting disability may be useful for patient selection and possibly to improve treatment outcome.

Methods

Patients with neurogenic claudication associated with degenerative lumbar spinal stenosis (DLSS) performed a psychological assessment before lumbar decompression and fusion (LDF) surgery. The following tests were administrated: Visual Analogic Scale; Symptom Checklist-90 (SCL-90-R), Short Form-36 and Oswestry Disability Index (ODI). The primary outcome was ODI score lower than 20. A cross correlation matrix (CCM) was carried out with significant variables after univariate analysis and a linear logistic regression model was calculated considering the most significant variable.

Results

125 patient (61 men and 64 women) were included in the study. Seven parameters of the SCL-90-R scale showed statistical significance at the univariate analysis: obsessivity (p < 0.001), Current Symptom Index (p = 0.001), Global Severity Index (p < 0.001), depression (p < 0.001), positive Symptom Total (p = 0.002), somatization (p = 0.001) and anxiety (p = 0.036). Obsessivity was correlated with other significant parameters, except GSI (Pearson's correlation coefficient = 0.11).The ROC curve for the logistic model considering obsessivity as risk factor, has an area under the curve of 0.75.

Conclusion

Pre-operative psychopathological symptoms can predict persistence of disability after LDF for DLSS. Future studies will evaluate the possibility of modifying post operative outcome through targeted treatment for psychological features emerged during pre-operative assessment.

Less stress, better success: a scoping review on the effects of anxiety on anesthetic and analgesic consumption

Preoperative anxiety has an incidence of 11-80% in patients undergoing surgical or interventional procedures. Understanding the role of preoperative anxiety on intraoperative anesthetic requirements and postoperative analgesic consumption would allow personalized anesthesia care. Over- or under-anesthetizing patients can lead to complications such as postoperative cognitive dysfunction in elderly patients, or procedural discomfort, respectively. Our scoping review focuses on the current evidence regarding the association between preoperative anxiety and intraoperative anesthetic and/or postoperative analgesic consumption in patients undergoing elective surgical or interventional procedures. Based on 44 studies that met the inclusion criteria, we found that preoperative anxiety has a significant positive correlation effect on intraoperative propofol and postoperative opioid consumption. The analysis of the literature is limited by the heterogeneity of preoperative anxiety tools used, study designs, data analyses, and outcomes. The use of shorter, validated preoperative anxiety assessment tools may help optimize the intraoperative anesthetic and postoperative analgesic regimen. Further research to determine the most feasible and clinically relevant preoperative anxiety tool and subsequent implementation has the potential to optimize perioperative care and improve patient outcomes.

Pain perception of orthodontic treatment - A cross-sectional study

Objectives:

The objectives were to evaluate the intensity of pain perceived 24 hours following insertion of fixed orthodontic appliance components i-e separators, bands and brackets.

Methods:

This cross-sectional study conducted at a Dental College in Karachi (July 2017-March 2018) investigated the amount of pain perceived during different stages of fixed orthodontic treatment. The inclusion criteria were healthy individuals without systemic disease, age 13-26 years, fixed orthodontic treatment candidates having healthy permanent first molars. The exclusion criteria were missing permanent first molars, patients requiring brass wire separators instead of elastomeric separators and molar tubes instead of bands, ongoing or previous periodontal disease and syndromic patients. Pain intensity was assessed in ninety eight patients using a Numeric Rating scale (NRS) at baseline (T0) before insertion, and 24 hours after insertion (T1) of a component. This procedure was repeated six times, twice each for separators, bands and brackets. Scoring was done on the NRS from 0 to 10 where 0 indicated no pain and 10 indicated worst pain possible.

Results:

A significant difference in perceived pain was found between baseline and after 24 hours of placement of all components (P-value 0.000). Odds ratio indicated that males were at a greater risk to feel pain than females at baseline and after 24 hours of insertion of all components. Mann-Whitney U test showed that the most painful components at baseline were bands (Mean value=0.56) and after 24 hours were brackets (Mean value 6.25).

Conclusions:

Significant increase in pain was noted 24 hours after insertion of separators, bands and brackets. The most painful components were bands at baseline and brackets after 24 hours of insertion. There were no significant variations in pain perception based on age. However, males perceived higher pain than females both at baseline and after 24 hours.

Evaluation of Postoperative Pain after Sinonasal Surgery

Background

Pain after sinonasal surgery concerns both patients and surgeons. Factors affecting sinonasal postoperative pain have not been examined extensively.

Methods

Using a prospective survey design, sinonasal surgery patients evaluated postoperative pain (on a scale of 0–10), pain location, and medication use.

Results

One hundred twenty-seven patients consented to participate. One hundred fifteen patients returned surveys, with 100 patients appropriate for analysis over the 6-day postoperative period. Pain score and medication use were evaluated with respect to sex, primary/revision case, nasal packing, and other factors. Repeated measures analysis of variance and chi-square analysis were conducted (p < 0.05). Pain ratings and analgesic use declined significantly over the postoperative period (p < 0.05). Mean pain score on postoperative day (POD) 1 was 3.61 and on POD 6 was 1.72. Mean medication use was 1.37 tablets on POD 1 and 0.55 tablets on POD 6. Additionally, a significant interaction existed, such that narcotic medication use declined from 1.91 tablets on POD 1 to 0.52 tablets on POD 6, whereas nonnarcotic medication use remained steady (p < 0.05). Periorbital pain was most frequent (46.3%), with unilateral facial pain reported least (4.1%). A significant difference existed for distribution of pain location (p < 0.05). Finally, the difference in pain rating between primary and revision procedure for women (0.65) was less than for men (1.12); this interaction was significant (p < 0.05).

Conclusion

Multiple patient and operative factors affect pain rating and medication use after sinonasal surgery. Generally, pain level should be low with little analgesic use postoperatively.

Factors Affecting Long-Term Postoperative Narcotic Use in Discectomy Patients

BACKGROUND

Long-term narcotic use has risks and potentially life-threatening opioid-related side effects. Extended narcotic use in patients undergoing discectomy raises concerns of other underlying causes of pain or overprescription and/or abuse. The goal of this study was to determine which factors have an effect on active narcotic prescription >3 months after discectomy.

METHODS

The PearlDiver Database was used in this study. Patients 30-55 years old undergoing discectomy without fusions were queried for active narcotic drug prescription occurring >30 days and >3 months after original surgery. Medical co-diagnoses were independently analyzed for effects on long-term active narcotic prescriptions. Prior narcotic use was defined by use within 4 months before surgery.

RESULTS

Of 1321 patients undergoing discectomy, 621 had actively prescribed narcotics >3 months after surgery. Preoperative narcotic use had the largest effect on odds of postoperative prescription (odds ratio [OR] = 3.4). Medical comorbidities increasing odds of long-term narcotic prescriptions included migraines (OR = 1.4), diabetes mellitus (OR = 1.4), depression (OR = 1.6), and smoking (OR = 1.9).

CONCLUSIONS

Narcotic abuse is a serious problem rooted in overprescription of these drugs, which has ultimately led to much more caution in prescribing among physicians. Because pain management and drug prescription must be balanced, identifying patients who may be susceptible to narcotic overprescription is important. Patients with co-diagnoses increasing odds of long-term narcotic prescriptions would benefit from early and continual postsurgical follow-up to ensure accurate pain management and to determine if narcotic prescriptions are justly warranted in the later postoperative period.

Factors associated with pain and analgesic consumption following non-surgical periodontal therapy under local anaesthesia and carried out by dental students

AIM

Evaluate factors associated with pain and analgesic consumption following non-surgical periodontal therapy.

MATERIALS AND METHODS

The sample consisted of 218 patients with chronic periodontitis, submitted to non-surgical scaling and root planing under local anaesthesia at a public dental service in southern Brazil. The data collection instruments included a demographic questionnaire, as well as State-Trait Anxiety Inventory, Corah's Dental Anxiety Scale, Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale. The presence and intensity of pain were evaluated at 2, 6, 12, 24 and 48 hr after scaling and root planing.

RESULTS

A total of 52.3% of the patients reported mild intensity pain at some point during the 48 hr after scaling and root planing with local anaesthesia. Smoking (PR = 1.47; 95% CI = 1.16-1.65), severe periodontal inflammation (PR = 1.31; 95% CI = 1.09-1.58) and dental anxiety (PR = 1.24; 95% CI = 1.03-1.49) were associated with postoperative pain after adjusting for age, gender and state and trait anxiety scores. Moreover, 46.8% of the subjects used analgesics at some time during the 48-hr follow-up period and dental anxiety was the only factor associated with postoperative analgesic use.

CONCLUSIONS

Smoking, severe periodontal inflammation and dental anxiety were identified as factors associated with pain after non-surgical scaling and root planing with local anaesthesia. Dental anxiety was also a factor associated with postoperative analgesic use.

Pain and distress induced by elastomeric and spring separators in patients undergoing orthodontic treatment

Aims and Objectives:

The objective of the present investigation is to evaluate patients’ pain perception and discomfort, the duration of pain and the level of self-medication over time during tooth separation, and the effectiveness of elastomeric and spring types of orthodontic separators in Saudi population.

Materials and Methods:

The study group consisted of 30 female adolescent patients who had elastomeric/spring separators as part of their orthodontic treatment. A self-administrated questionnaire comprising 16 multiple choice questions and another with visual analog scale were used to record the patient's pain perceptions at 4 hours, 24 hours, 3 days, 5 days, and 7 days from the time of insertion. The level of pain and discomfort during these time periods were assessed by a visual analog scale. After a separation period of 7 days, the amount of separation was measured with a leaf gauge. Type and frequency of analgesic consumption was also recorded. The Statistical Package for the Social Sciences (SPSS) version 20 (IBM SPSS -Chicago, IL: SPSS Inc.,) was used for statistical analysis.

Results:

The data showed significant increase in the level of pain at 4 hours, 24 hours, and 3 days from separator placement. The elastomeric separators produced significantly more separation than the spring separators and also caused maximum pain during the first 3 days after insertion. However, there was no significant difference between the score of pain between two separators at all time intervals.

Conclusion:

Both elastomeric and spring separators showed comparative levels of pain and discomfort during the early phase of separation. Elastomeric separators were found to be more effective in tooth separation than spring separators. However, further studies are necessary to substantiate this preliminary observation.

Oral hygiene compliance in orthodontic patients: a randomized controlled study on the effects of a post-treatment communication

Background

Several studies have recently demonstrated that a post-treatment communication to explain the importance of an oral hygiene can improve the orthodontic patients’ compliance over a period of 66 days. The main goal of this study is to evaluate the effects of a structured follow-up communication after orthodontic appliance application on oral hygiene compliance after 30–40 days.

Methods

Eighty-four orthodontic participants enrolled from patients who were beginning fixed orthodontic treatment at the Orthodontic Department, Gaslini Hospital, Genova, between July and October 2014 were randomly assigned to one of three trial arms. Before the bonding, all patients underwent a session of oral hygiene aimed at obtaining an plaque index of “zero.” At the following orthodontic appointment, the plaque index was calculated for each patient in order to assess oral hygiene compliance. The first group served as control and did not receive any post-procedure communication, the second group received a structured text message giving reassurance, and the third group received a structured telephone call. Participants were blinded to group assignment and were not made aware that the text message or the telephone call was part of the study. (The research protocol was approved by the Italian Comitato Etico Regionale della Liguria-sezione 3^ c/o IRCCS-Istituto G. Gaslini 845/2014, and it is not registered in the trial’s register.)

Results

Thirty patients were randomly assigned to the control group, 28 participants to the text message group, and 26 to the telephone group.

Participants who received a post-treatment communication reported higher level of oral hygiene compliance than participants in the control group. The plaque index was 0.3 (interquartile range (Iqr), 0.60) and 0.75 (Iqr, 1.30), respectively, with a significant difference (P = 0.0205).

Conclusions

A follow-up procedure after orthodontic treatment may be an effective tool to increase oral hygiene compliance also over a short period.

Preoperative state anxiety, acute postoperative pain, and analgesic use in persons undergoing lower limb amputation

OBJECTIVES

The current study examined the relationship between preoperative anxiety and acute postoperative phantom limb pain (PLP), residual limb pain (RLP), and analgesic medication use in a sample of persons undergoing lower limb amputation.

MATERIALS AND METHODS

Participants included 69 adults admitted to a large level 1 trauma hospital for lower limb amputation. Participants' average pain and anxiety during the previous week were assessed before amputation surgery. RLP, PLP, and analgesic medication use were measured on each of the 5 days following amputation surgery.

RESULTS

Results of partial-order correlations indicated that greater preoperative anxiety was significantly associated with greater ratings of average PLP for each of the 5 days following amputation surgery, after controlling for preoperative pain ratings and daily postoperative analgesic medication use. Partial correlation values ranged from 0.30 to 0.62, indicating medium to large effects. Preoperative anxiety was also significantly associated with ratings of average RLP only on postoperative day 1, after controlling for preoperative pain ratings and daily postoperative analgesic medication use (r=0.34, P<0.05). Correlations between preoperative anxiety and daily postoperative analgesic medication dose became nonsignificant when controlling for preamputation and postamputation pain ratings.

DISCUSSION

These findings suggest that anxiety may be a risk factor for acute postamputation PLP and RLP, and indicate that further research to examine these associations is warranted. If replicated, the findings would support research to examine the extent to which modifying preoperative anxiety yields a reduction in postoperative acute PLP and RLP.

Pain experience during initial alignment with three types of nickel-titanium archwires: a prospective clinical trial

OBJECTIVE

To clinically evaluate the pain intensity during the week following initial placement of three different orthodontic aligning archwires.

MATERIALS AND METHODS

A consecutive sample of 75 patients requiring upper and lower fixed orthodontic appliances were alternately allocated into three different archwires (0.014-inch superelastic NiTi, 0.014-inch thermoelastic NiTi or 0.014-inch conventional NiTi). Assessments of pain/discomfort were made on a daily basis over the first 7-day period after bonding by means of visual analog scale and consumption of analgesics. The maximum pain score was recorded. The possible associations between age, gender, degree of crowding, and teeth irregularity and the pain intensity were also examined. Demographic and clinical differences between the three groups were compared with chi-square test or analysis of variance (ANOVA) test.

RESULTS

No statistically significant differences were found in the pain intensity when the three aligning NiTi archwires were compared (P  =  .63). No significant differences in pain perception were found in terms of gender, age, lower arch crowding, and incisor irregularity. The intake of analgesics was the least in the superelastic NiTi group.

CONCLUSION

The three forms of NiTi wires were similar in terms of pain intensity during the initial aligning stage of orthodontic fixed appliance therapy. Gender, age, and the degree of crowding have no effect on the perceived discomfort experienced by patients undergoing fixed orthodontic treatment.

Self-reported pain after orthodontic treatments: a randomized controlled study on the effects of two follow-up procedures

OBJECTIVES

To assess the effects of a follow-up text message and a telephone call after bonding on participants' self-reported level of pain.

MATERIALS AND METHODS

Eighty-four participants were randomly assigned to one of three trial arms. Randomization was performed by the Department of Epidemiology and Biostatistics of IRCCS G.Gaslini. Participants were enrolled from patients with a permanent dentition who were beginning fixed no extraction treatment at the Orthodontic Department, Gaslini Hospital. Participants completed baseline questionnaires to assess their levels of pain prior to treatment. After the initial appointment, participants were completed a pain questionnaire at the same time, daily, for 7 days. The first group, served as control, did not receive any post-procedure communication; the second group received a structured text message; and the third group received a structured telephone call. Participants were blinded to group assignment.

LIMITATIONS

A larger sample size should have been considered in order to increase the ability to generalize this study's results.

RESULTS

Participants in both the telephone call group and the text message group reported lower level of pain than participants in the control group with a larger and more consistent effect for the telephone call group. Most participants reported a higher level of pain during the first 48 hours post-bonding. The analgesic's consumption significantly correlated with the level of pain during the previous 24 hours. Female participants appeared to be more sensitive to pain than male participants.

CONCLUSIONS

A telephone follow-up after orthodontic treatment may be an effective procedure to reduce participants' level of pain.

PROTOCOL

The research protocol was approved by the Italian Comitato Etico Regionale della Liguria-sezione 3^ c/o IRCCS- Istituto G.Gaslini 845/2014.

REGISTRATION

182 Reg 2014, 16/09/2014 Comitato Etico Regione Liguria, Sez.3.

Effects of cranial electrotherapy stimulation on preoperative anxiety, pain and endocrine response

OBJECTIVES

Cranial electrotherapy stimulation (CES) is used as a treatment for depression and anxiety, and as an adjunctive intervention for pain management. This prospective study investigated whether CES could decrease preoperative anxiety, the injection pain of rocuronium, postoperative pain and stress hormone levels.

METHODS

Female patients undergoing thyroidectomy were randomly assigned to two groups, to receive either no pretreatment (control group) or CES pretreatment. Anxiety score, withdrawal response on rocuronium injection, and pain scores at 1, 4, 12 and 24 h post surgery were evaluated. Adrenocorticotrophic hormone (ACTH), cortisol and glucose levels were measured. Patients were blinded to the treatment condition.

RESULTS

Fifty patients entered the study (n = 25 per group). Anxiety score and withdrawal responses during rocuronium injection were significantly reduced in the CES group compared with the control group. Pain score was significantly lower in the CES group than in the control group, 1 h and 4 h post surgery. There were no significant differences in ACTH, cortisol and glucose levels.

CONCLUSIONS

CES pretreatment appears to reduce the level of preoperative anxiety, injection pain of rocuronium and postoperative pain. However, CES pretreatment did not affect stress hormone responses.

Evaluation of the structure of Brazilian State-Trait Anxiety Inventory using a Rasch psychometric approach

OBJECTIVE

This study evaluates the State-Trait Anxiety Inventory (STAI) structure using a Rasch psychometric approach, and a refined and shorter STAI version is proposed.

METHODS

A cross-sectional study was performed with 900 inpatients scheduled for elective surgery. Age varied from 18 to 60 years (American Society of Anesthesiologists physical status I-III). Demographic information was collected using a structured questionnaire. The measuring instrument (the STAI) was applied to all patients in the afternoon before the surgery and prior to the patients receiving preoperative sedatives.

RESULTS

Rasch analysis of the state and trait anxiety scales was performed separately. This analysis demonstrated that the original format of state and trait scales fails to show invariance across the trait-state anxiety level, which results in the unstable performance of items. The refined scale was retested in two subsequent random samples of 300 subjects each, and the results were confirmed. The performance was adequate regardless of gender. In the analysis, some items of the state scale (items 3,4,9,10,12,15, and 20) were deleted due to poor fit statistics. The remaining 13 items showed unidimensionality, local independence, and adequate index of internal consistency. Also, the original trait scale displayed several weaknesses. First, the four-point Likert response scale proved to be inadequate, and threshold disorders were found in all 20 items. Also, the original trait scale showed insufficient item-trait interaction and several individual item misfits. Following the rescoring process, and retesting in a second random sample, items were excluded (namely Items 3, 4, 11, 13, 14, 15, 18, and 19). The refined version showed local independence, unidimensionality, and adequate fit statistics.

DISCUSSION

The results indicate that the application of the Rasch model led to the refinement of the classic STAI state and trait scales. In addition, they suggest that these shorter versions have a more suitable psychometric performance and are free of threshold disorders and differential item functioning problems.

A comparison of pain experienced by patients treated with labial and lingual orthodontic appliances

SUMMARY

The aim of this prospective longitudinal study was to compare pain experiences among Chinese adult patients treated with labial and lingual orthodontic appliances. Sixty patients, 30 with labial appliances (18 females and 12 males, mean age 20.33 years, SD +/- 4.205) and 30 with lingual appliances (22 females and 8 males, mean age 21.63 years, SD +/- 2.236), rated their overall pain experience on a 100 mm visual analogue scale (VAS) at three time points: 1 week (T(1)), 1 month (T(2)), and 3 months (T(3)) after bracket placement. In addition, on a separate 100 mm VAS, they rated their pain experience at the locations of the tongue, lips, cheeks, gums, face, and jaw at T(1), T(2), and T(3). Changes in pain VAS were conducted using Friedman analysis of variance, area under the curve (AUC) analysis and the data were compared using a t-test. There was no significant difference in global ratings of pain among those treated with labial or lingual appliances (P > 0.05). Among both groups, global ratings of pain decreased over the study period (P < 0.001). Patients treated with lingual appliances reported higher ratings of tongue pain (P < 0.001), while those treated with labial appliances reported higher ratings of lip (P < 0.001) and cheek (P < 0.001) pain. The findings indicate that patients treated with labial and lingual appliances rate similarly the level of overall pain they experience during treatment. Ratings of overall pain experienced decreased for both treatment groups with time. However, ratings of pain differed at various sites with respect to the type of orthodontic appliance. These findings have implications in informing patients' treatment decision-making processes regarding labial and lingual appliances and in the management of discomfort associated with different treatment modalities.

Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia

OBJECTIVES

Postoperative pain is characterized by a wide variability of patients' pain perception and analgesic requirement. The study investigated the extent to which demographic and psychologic variables may influence postoperative pain intensity and tramadol consumption using patient-controlled analgesia (PCA) after cholecystectomy.

METHODS

Eighty patients, aged 18 to 70 years, with an American Society of Anesthesiologists physical status I or II and a body mass index between 18.5 and 24.9, undergoing laparoscopic cholecystectomy were enrolled. Self-rating anxiety scale (SAS) and self-rating questionnaire for depression (SRQ-D) were used--1 day before surgery--to assess patients' psychologic status. General anesthesia was standardized. PCA pump with intravenous tramadol was used for a 24-hour postoperative analgesia. Visual analog scale at rest (VASr) and after coughing (VASi) and tramadol consumption were registered. Pearson's and point biserial correlations, analysis of variance, and step-wise regression were used for statistical analysis.

RESULTS

Pearson r showed positive correlations between anxiety, depression, and pain indicators (P<0.05). Moreover, female patients had higher pain indicators (P<0.05). Analysis of variance showed that anxious (P<0.05) and depressed (P<0.001) patients had higher pain indicators, which significantly decreased during the postoperative 24 hours (P<0.00001). Regression analysis revealed that tramadol consumption was predicted by preoperative depression (P<0.001). VASr was predicted by sex and SRQ-D (P<0.05). VASi was predicted by sex and SAS (P<0.05).

DISCUSSION

Pain perception intensity was primarily predicted by sex with an additional role of depression and anxiety in determining VASr and VASi, respectively. Patients with high depression levels required a larger amount of tramadol.

Psychological intervention in acute dental pain: review

Acute dental pain is an unpleasant experience. This article studies acute dental pain and examines the role of psychological intervention. After identification of the psychological factors associated with dental pain we go on to assess the role of psychological interventions.

The influence of a structured telephone call on orthodontic pain and anxiety

INTRODUCTION

This purpose of this study was to examine the effects of a structured telephone call after orthodontic appliance placement on self-reported pain and anxiety.

METHODS

One hundred-fifty orthodontic patients were randomly assigned to 1 of 3 groups and matched for age, sex, and ethnicity. The subjects completed baseline questionnaires to assess their levels of pain (on a 100-mm visual analog scale) and anxiety (Spielberger's State-Trait Anxiety Inventory) before orthodontic treatment. After the initial archwires were placed, all subjects completed the pain questionnaire and state-anxiety inventory at the same time daily for 1 week. One group also received a structured telephone call demonstrating care and reassurance; the second group received an attention-only telephone call, thanking them for participating in the study; the third group served as a control.

RESULTS

Although both telephone groups reported significantly less pain (P = .005) and state-anxiety (P = .033) than the control group, there was no difference between the 2 telephone groups (P > .12 for pain; P > .81 for state-anxiety).

CONCLUSIONS

A telephone call from a health-care provider reduced patients' self-reported pain and anxiety; the content of the telephone call was not important.

Preoperative coping strategies and distress predict postoperative pain and morphine consumption in women undergoing abdominal gynecologic surgery

OBJECTIVES

The aim of the present study was to predict postoperative pain and morphine consumption based on preoperative psychosocial factors.

METHODS

One hundred and twenty-two women completed measures of distress and coping 1 week before major abdominal gynecological surgery by laparotomy. Forty-eight hours after surgery, measures of pain and negative affect (NA) were completed, and morphine consumption was recorded from a patient-controlled analgesia pump. Four weeks after surgery, measures of pain and NA were completed.

RESULTS

Multivariate analyses revealed that preoperative self-distraction coping (P=.039) positively predicted postoperative pain levels in the hospital, after accounting for the effects of age, concurrent NA, and morphine consumption. Emotional support (P=.031) and religious-based coping (P=.036) positively predicted morphine consumption in the hospital, after accounting for the effects of age, concurrent NA, and pain levels. Preoperative distress (P<.04 to .008) and behavioral disengagement (P=.034), emotional support (P=.049), and religious-based coping (P=.001) positively predicted pain levels 4 weeks after surgery, after accounting for the effects of age and concurrent NA.

CONCLUSION

The results suggest that preoperative psychosocial factors are associated with postoperative pain and morphine consumption.

[Postoperative pain relief after gynecologic surgery]

Early administration of analgesics, generally before awakening from general anesthesia is useful to improve the patient's comfort in the post-anesthesia care unit (PACU). Multimodal analgesia includes administration of several analgesics from different pharmacological classes but in almost every combination, morphine or one of its derivatives is included. In the PACU, morphine is titrated using the intravenous route to obtain adequate and rapid pain relief. Analgesics are administered orally as soon as possible and in the vast majority of cases, immediate postoperative administration can be performed orally. After minor surgery (for example: diagnostic or operative laparoscopy) often performed in out-patients, a combination of acetaminophen and of a non-steroidal anti-inflammatory drug with or without an oral preparation of morphine is efficient and safe. Intraperitoneal administration of a local anesthetic can be a useful addition. When the postoperative surgical stress is expected to be of moderate intensity (for example: hysterectomy), the same combinations can be used but are initially administered intravenously. Nefopam, which is available only by intravenous administration in France, can be safely added. Morphine is often applied using a patient-controlled analgesia device (PCA). After major surgery (especially after radical surgery for malignant disease), intrathecal or epidural analgesia, using a local anesthetic and an opioid is extremely efficient and is combined with other analgesics. Finally, because the affective dimension is extremely important after gynecologic surgery (especially in mutilating interventions), psychologic preparation, patient information and communication are essential components of care.

Preoperative emotional states in patients with breast cancer and postoperative pain

BACKGROUND

The present study examined the relationship between psychological variables, including anxiety, depression, and patient-controlled analgesia (PCA) use in patients who underwent radical mastectomy.

METHODS

Ninety-nine ASA I-II women with breast cancer between 18 and 60 years scheduled for modified radical mastectomy completed the state scale of the state-trait anxiety inventory and the Beck depression inventory before the day of surgery. Standard general anesthesia, surgery, and IV-PCA therapy was conducted. Postoperative ratings of pain intensity, opioid consumption and satisfaction with PCA were recorded for the first 24 h on the ward. The degree of pain intensity was evaluated by a visual analog scale (VAS, 1-10). Satisfaction with pain control was reported using an five-point scale from 1 (very dissatisfied) to 5 (very satisfied).

RESULTS

The pain intensity, total analgesic consumption and dose/demand ratio were significantly related to preoperative anxiety and depression (P<0.05). Degree of dissatisfaction with PCA was significantly correlated with preoperative anxiety and depression (P<0.01).

CONCLUSION

Patients with higher anxiety and depression levels had higher postoperative pain and analgesic requirements in this study.

Pain management 1: psychological and social aspects of pain

This two-part article presents psychological and social factors which affect pain perception and response and the implications of these for nursing practice. In this article, the complex interactions between neurophysiological and psychological factors are outlined and theories of pain perception and ways in which the pain experience can be modulated are presented. The role of psychological factors, attitudes, beliefs and expectations of both patient and practitioner, pain behaviours and ability to cope are discussed. In the second part, these are further elaborated with particular reference to the nurse-patient interaction. The use of psychological approaches to augment clinical practice, such as education, reduction of anxiety and improving coping ability, are suggested. Finally, the importance of communication skills in pain management is addressed.

Preoperative anxiety and postoperative pain in women undergoing hysterectomy. A repeated-measures design

OBJECTIVES

To determine whether psychological variables such as preoperative anxiety can serve as predictors for the postoperative pain response.

METHODS

The study sample included women who underwent elective abdominal hysterectomy (n=53). Two weeks prior to surgery, characteristics such as trait anxiety, coping style, and perceived stress were evaluated. Throughout the perioperative period, state anxiety, pain, as well as analgesic consumption were assessed at multiple time points. The anesthetic and surgical management were carefully controlled for and postoperative pain management was standardized.

RESULTS

Path analysis demonstrated that there are both direct and indirect effects of preoperative state anxiety on postoperative pain. Preoperative state anxiety is a significant positive predictor of the immediate postoperative pain (beta=0.30), which, in turn, is a positive predictor of pain on the wards (beta=0.54). Pain on the ward, in turn, is predictive for pain at home (beta=0.30).

CONCLUSION

The results of this study indicate that preoperative anxiety may have a critical role in the chain-of-events that controls the postoperative pain response.

Behavioural measurement of postoperative pain after oral surgery

The amount and type of postoperative analgesia prescribed depends on the clinician's judgement of the patient's need. Among other factors, this judgement is likely to be based on the patient's behaviour. The primary aim of this study was to investigate the validity of using behavioural measures to provide information about a patient's experience of pain during the early stages of recovery from oral surgery under general anaesthesia. Behavioural measures were not valid measures of acute postoperative pain, which suggests that while clinicians may build a better picture of a patient's experience of pain by including behavioural observation in their range of assessments, they should not rely on them when judging a patient's need for analgesia. The results also show differences between the sexes in their reaction to pain. Significantly more women than men showed signs of pain, despite little difference in self-rating pain scores.

Do psychological factors influence pain following a fracture of the extremities?

We studied the role of psychological factors on pain following a fracture of the extremities in older adults (n = 111) using a prospective design. Pain and psychological variables measured at baseline, postfracture anxiety and depression, and demographic variables were used to predict pain two months after the fracture. Both moderately severe and serious fractures lead to an increase in pain. Pain at baseline and postinjury anxiety were associated with pain following a fracture of the extremities.

Patient controlled analgesia in children and adolescents: a randomized controlled trial

In children, patient controlled analgesia (PCA) and continuous infusion (CI) of morphine are well established methods of relieving postoperative pain. This study was designed to assess the efficacy of PCA plus background infusion (BI) (15 microg x kg(-1) x h(-1) and bolus doses of 15 microg x kg(-1) with a lock-out interval of 10 min) with CI (20 to 40 microg x kg(-1) x h(-1)) in terms of analgesia, morphine needs and side-effects. A stratified randomized controlled trial was carried out. 47 children aged 5-18 years undergoing major elective lower/upper abdominal or spinal surgery were allocated. The magnitude of surgery was assessed by the Severity of Surgical Stress scoring (SSS) system. Pain was assessed by self-report every three h. Side-effects compatible with morphine as well as morphine consumption were recorded. Morphine consumption was significantly increased in the PCA group compared with the CI group. Moreover, morphine consumption was associated with SSS, independent of the technique of administration. There were no significant differences between groups in pain scores or in the incidence of side-effects.

Pain and discomfort experienced after placement of a conventional or a superelastic NiTi aligning archwire. A randomized clinical trial

Two nickel-titanium arch-wire types commonly used for initial tooth alignment were compared with regard to the pain/discomfort patients experience during the initial phase of tooth movement. The two arch wires used were a superelastic nickel-titanium alloy, 0.014 inch Sentalloy, Light (GAC International Inc. Central Islip, NY, USA) and a 0.014 inch Nitinol (Unitek, Monrovia, CA, USA), a conventional nickel-titanium aligning archwire. One hundred and twenty-eight consecutive patients attending an orthodontic university clinic and 2 private practices for routine placement of a fixed appliance were randomly assigned one of these 2 initial arch wires. Assessments of pain/discomfort were made daily by means of a 100 mm visual analog scale (VAS) over the first 7-day period after bonding. On the first day, recordings were made every hour for the first 11 hours. The results showed that the level of discomfort increased continuously every hour after the insertion of either a Sentalloy or a Nitinol as first arch wires, with a peak in the first night, remaining high on the second day and decreasing thereafter to baseline level after 7 days. During the first 10 hours it was apparent that the pain/discomfort experienced after placement of a Sentalloy was less than that found with the Nitinol archwire, although a significant difference could be found at 4 hours only. No significant gender-specific differences were found in either archwire group. A significant difference between the upper and lower dental arches was observed during the first 11 hours after placement of either a Sentalloy or a Nitinol arch wire, with the lower arch having the higher pain experience.

[The epideiology of postoperative pain]

Postoperative pain, as all types of pain, is a complex phenomenon including sensory, emotional and behavioural factors. The incidence and severity of postoperative pain is very variable between patients and is rather unpredictable. Patients characteristics as well as the types of surgery and anaesthesia will be of importance. Health professionals have a major role to play for improving effectiveness of pain management as well as safety.

Pattern of self-administered paracetamol and codeine analgesic consumption after mandibular third-molar surgery

Pattern of analgesic consumption after unilateral mandibular third-molar surgery was investigated in an open study in 201 patients. All patients were supplied with six analgesic tablets containing 500 mg paracetamol and 30 mg codeine. Instructions for use were given. A mean consumption of 4.9 tablets over the 1st week and 3.6 tablets the day of operation was found. Eight (4%) patients indicated inadequate or no effect of the medication. The remaining patients were able to control pain, to a level of one-third of maximum pain, by using from one to five tablets. One hundred and thirty-two (68%) patients followed instructions with regard to start of medication. No difference in mean tablet consumption was found between compliant patients and those who delayed the intake of the first analgesic dose by more than 1 h. Predictor analysis showed the most powerful predictors to be preoperative depth of the third molar and moderate or heavy smoking. Thirteen per cent explanatory power of all predictors together was found.

Patient experience of pain after elective noncardiac surgery

The purpose of this study was to examine the extent and evolution of pain after common major surgical procedures and to establish correlates of three types of pain: pain at rest, pain with movement, and maximum pain over the previous 24 h. Patients completed a preoperative questionnaire to obtain data on age, gender, narcotic use, baseline level of pain, chronicity of pain, and level of anxiety. Patients were then interviewed on Postoperative Days 1, 2, and 3 to assess their pain on a scale of 0 (none) to 10 (worst imaginable). The mean pain score at rest was 2.6 on Postoperative Day 1 and decreased to 2.3 on Postoperative Day 3 (P = 0.06). The mean pain score with movement was 4.5 on Postoperative Day 1, which decreased to 4.2 on Postoperative Day 3 (P = 0.03). The mean maximum pain score over the previous 24 h was 6.3, which decreased to 5.6 (P = 0.0001). Preoperative narcotic use and high baseline preoperative pain, defined as a score > or = 4, were significantly (P < 0.05) associated with increased pain at rest, pain with movement, and maximum pain. Epidural analgesia was the only mode of analgesia significantly associated with both decreased postoperative pain at rest and decreased pain with movement (P < 0.05). These relatively high pain scores and minimum decreases in pain from Postoperative Days 1 to 3 emphasizes the need for more effective pain management continuing into the postoperative period to facilitate mobilization and recovery.

The effect of tramadol on dento-alveolar surgical pain

The aim of the study was to assess the analgesic effect of tramadol in the relief of pain after dentoalveolar operations that involve the removal of bone and suturing. Four-hundred and fifty-two patients over the age of 18 years who were to undergo removal of impacted teeth (n = 362), removal of root (n = 79), or alveolectomy, enucleation of cysts, or removal of soft tissue (n = 11) under local anesthesia were studied. Patients were randomly allocated to receive tramadol 100 mg or 50 mg four times daily, or 50 mg twice daily, or placebo. Median pain scores on the day of operation in the three tramadol groups were similar (2 in each group, ranges 1-5, 1-4.8, and 1-5 respectively) and were all significantly lower than that in the placebo group (2.3 range 1-4.2). The median number of Paracetamol tablets taken by patients in the three tramadol groups was 2 (ranges 0-8, 0-12 and 0-8 respectively), and were all significantly less than in the placebo group (4, range 0-12). More patients given tramadol reported complete pain relief than the placebo group. The advantages of tramadol continued over the next 2 days. There were no serious or unexpected adverse effects. It is concluded that tramadol is an effective analgesic after dentoalveolar operations.

Bupivacaine for postoperative analgesia following endoscopic sinus surgery

This prospective study was conducted to examine pain after endoscopic sinus surgery (ESS). The hypothesis was that a long-acting anesthetic agent would result in patients experiencing less pain in the 24-hour postoperative period and therefore needing fewer oral analgesics. We randomized 100 patients undergoing ESS to receive either lidocaine (1% or 2%) with epinephrine or bupivacaine (0.25% or 0.5%) with epinephrine as an anesthetic and for a sphenopalatine block. Postoperative pain was assessed with a standard numeric pain assessment scale at baseline and at 2, 6, and 24 hours after surgery. The use of analgesics during this period was also documented. We compared the results between patients receiving bupivacaine and those receiving lidocaine, as well as between patients who required nasal packing and those who did not. We discovered that in general, pain after ESS was less severe than expected. We further found that the type of anesthetic used did not significantly affect postoperative pain; pain score changes and use of analgesics were similar between the two anesthesia groups. Postoperative pain was also similar between the "packing" and "no packing" groups. Although patients receiving packing had consistently lower increases in pain (and in fact many patients in this group had decreases in pain from baseline), none of the differences between group means was statistically significant.

Good patients cope with their pain: postoperative analgesia and nurses' perceptions of their patients' pain

Patients routinely receive less analgesia postoperatively than they need. Previous attempts to understand this have examined the nurses' attitudes to analgesia and their ability to assess accurately the intensity of their patients' pain. The present study examined three hypotheses derived from an alternative view that undermedication results from patients failing to disclose their difficulty in coping with pain because this would lead to disapproval by nurses: (i) that analgesic intake is related, not to pain intensity but to patients' feelings of being unable to cope with pain and to nurses' assessment of their inability to cope; (ii) that nurses specifically underestimate patients' ability to cope with their pain; and (iii) that poor coping with pain is seen by nurses as indicative of a 'bad' patient. Pain ratings were completed by 56 patients undergoing minor abdominal surgery; nurses completed similar scales to show their perception of patients' pain, as well as a specially devised scale which measured how negatively or positively they felt about their patients. Nurses were sensitive to the intensity of their patients' pain, but underestimated how well patients felt they coped with pain and how much they wanted analgesia. Patients who experienced the worst pain, or whom the nurses perceived as coping least well with their pain, were evaluated by the nurses as unpopular and demanding.

Variation in opioid use during PCA in adolescents

The objective of this investigation was to determine if the variability in the use of opioids for pain following surgery is related to variability in blood concentration of opioids used for pain relief. We measured morphine use and morphine blood concentration in a group of otherwise healthy adolescent girls following spinal surgery. There was considerable variability in morphine use and morphine blood levels as indicated by a large range of values and a moderately large standard deviation. Morphine blood concentration correlated with morphine use. Neither morphine use nor morphine concentration correlated with pain scores. The data indicate that there is considerable variability among patients in the amount of opioid needed to achieve comfort and in the blood concentration associated with comfort. The cause of this variability does not appear to be related to metabolism of opioid, but may be related to psychological differences, differences in pain tolerance and threshold, or differences in the way patients use PCA.

Pre-surgery psychological characteristics, pain response, and activities impairment in female patients with repeated periodontal surgery

This study assessed relationships between pre-surgery psychological characteristics and post-surgery pain response and impairment of life activities following each of two sessions of periodontal surgery. Forty-two female periodontal patients between the ages 26 and 67 participated. None had experienced previous peridontal surgery. Pre-surgery scores on dental anxiety, fatigue, and depression were positively associated with measures of post-surgery pain after the first surgery, and were negatively associated with positive well-being scores. A similar, though weaker pattern of associations was evident after the second surgery. Younger women reported significantly greater impairment of life activities during recovery than did the older women after both surgery episodes. The study points to the relevance of pre-surgery well-being and psychological stability as predictors of post-surgery pain and degree of impairment of life activities, as seen in the time sequence of repeated surgeries.

The pain and discomfort experienced during orthodontic treatment: a randomized controlled clinical trial of two initial aligning arch wires

A randomized controlled clinical trial was performed to compare the nature, prevalence, intensity, and duration of pain related to the use of a relatively recently developed superelastic arch wire and a more traditional multistranded steel arch wire. Other factors likely to influence the pain experience were also investigated. Forty-three subjects participated in the study, the pain response being assessed by each of the visual analogue scales, the questionnaires, and an analgesic consumption record. In 18 of the 43 subjects a standardized preliminary dental extraction procedure was used as a control. Subsequent to the random allocation of an initial arch wire in 43 patients, 22 of them underwent a second arch wire in the opposing arch, the wire again being determined by random allocation. It was found that the prevalence, intensity, and duration of pain after the insertion of the two types of wire was similar but much greater than in the postextraction control phase. The pain score peaked on the morning after the placement of the arch wire, lasting typically for 5 to 6 days. The pain and discomfort experienced after the insertion of the second arch wire was similar to that of the first, no conditioning response being evident. Overall a diurnal variation was found with a tendency to an increase in pain in the evenings and nights, although this did not greatly affect sleep. The pain response was found to be highly and consistently subjective, not related to the dental arch, crowding, sex, or social class; however, a statistically significant association was found between the age and the pain experienced.

Successful pain management by Finnish oral surgeons. A clinical follow-up study

The current practice of postoperative pain management among Finnish oral surgeons was evaluated in a two-phase study. In the first phase, a questionnaire was sent to specialist members of the Finnish Society of Oral and Maxillofacial Surgeons that concerned the routine use of analgesic drugs after surgical removal of third molar teeth. In the second phase, the clinical adequacy of pain medication was assessed in 84 patients who had the same procedure. Patients estimated the intensity of pain with a 100 mm visual analogue scale at five time points during the day of surgery and on three postoperative days. Anti-inflammatory analgesics were widely used either alone or in combination with centrally acting analgesic drugs. Tolfenamic acid, diclofenac, and ketoprofen were the most commonly used analgesic drugs. The analgesic effect of the currently used drug combinations proved to be sufficient except in a few patients during the first night after surgery.

Postoperative pain after mandibular third-molar surgery

The pain experienced after 116 operative removals of mandibular third molars was studied in a homogeneous group of patients consisting of 85 healthy university students. Pain was recorded daily on a visual analogue scale during the postoperative week. It was shown that preoperative inflammation and the difficulty and duration of the operation increased the intensity of pain.

Intravenous diclofenac sodium. Does its administration before operation suppress postoperative pain?

Intravenous diclofenac sodium was evaluated in a double-blind randomised trial relative to intramuscular diclofenac, intravenous fentanyl, and intramuscular placebo in 160 patients undergoing extraction of impacted lower third molar teeth. The test drug was administered before operation in an attempt to alleviate postoperative pain. A 10-cm visual analogue scale was used to assess pain at 30 minutes and one day after surgery, if the patients stayed overnight. Patients who received intravenous diclofenac had significantly less pain than the other groups 30 minutes after operation. They also had significantly less pain one day after surgery than the placebo or opioid groups, but not less than the intramuscular diclofenac group. Capillary bleeding time, in comparison with placebo, was significantly prolonged after the use of intramuscular diclofenac, and a similar but nonsignificant trend was observed in the intravenous diclofenac group. No problems were encountered with excessive bleeding in any group.

Pain development and consumption of analgesics after oral surgery in relation to personality characteristics

In the present study a survey has been performed of the pain development and analgesic intake in 100 patients following elective oral surgery of impacted third molars in relation to preoperative assessment of personality characteristics. Our results show that no sex differences existed preoperatively concerning personality characteristics, concerning postoperative pain development or analgesic consumption. Fourteen patients reported no pain at all and 40 patients did not use any analgesics in the postoperative period. We also found a good correlation between total sum of pain scores and analgesic intake. Patients undergoing surgery in the morning reported a lower total sum of pain scores, reported pain at fewer occasions and tended to require less analgesics than patients being subjected to surgery in the afternoon. The patients who reported a total sum of pain scores in the upper percentile during the postoperative period rated their general health worse, as rated on the General Health (GH) questionnaire, and used more analgesics than did patients in the lower percentile. Also, patients not using any analgesics reported less symptoms of distress according to the GH scale as compared to patients using analgesics. In general, however, less than 10% of the variance in postoperative pain and consumption of analgesics could be explained by the preoperative factors studied.

Reduction of postoperative pain and swelling by ultrasound treatment: a placebo effect

Ultrasound (US) therapy is used to reduce pain and inflammation and to accelerate healing after soft tissue injury. However, there is little objective evidence of its effectiveness and the mechanisms which may cause these effects are unknown. In a placebo-controlled double-blind clinical trial we examined the contribution of placebo and massage effects in ultrasound therapy following bilateral surgical extraction of lower third molars. Four to 6 h after surgery the patients (25 per group) received either no therapy, US (0.1 W/cm2), 'mock' US with massage, 'mock' US without massage, or 'self-massage' with a dummy applicator. Facial swelling, trismus, serum C-reactive protein, serum cortisol, pain and anxiety were measured 24 h postoperatively. The results showed that the beneficial analgesic and anti-inflammatory effects of US therapy were placebo-mediated, with maximum effect in the placebo ('mock' US) group without circular massaging with the applicator). Self-massage by the patient produced no significant effect. This placebo action was independent of changes in serum cortisol or patient anxiety state. US therapy can significantly reduce postoperative morbidity, but by placebo-mediated mechanisms which are unrelated to the US itself.