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J Am Dent Assoc, Vol 136, No 6, 774-778.
© 2005 American Dental Association
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CLINICAL PRACTICE

JADA Continuing Education

The influence of cryotherapy on reduction of swelling, pain and trismus after third-molar extraction

A preliminary study



JOSÉ RODRIGUES LAUREANO FILHO, D.D.S., Ph.D., EMANUEL DIAS de OLIVEIRA e SILVA, D.D.S., IGOR BATISTA CAMARGO, D.D.S. and FABIANA M. V. GOUVEIA


   ABSTRACT
TOP
 ABSTRACT
MATERIAL AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Swelling, pain and trismus are undesirable consequences of impacted mandibular third molar extraction. The authors conducted a study to evaluate the effectiveness of cryotherapy, the therapeutic use of cold, in reducing undesirable consequences after surgery.

Methods. Fourteen patients aged 20 to 28 years comprised the sample. The authors extracted two impacted mandibular third molars at different times from each patient. Immediately after surgery, the patient underwent cryotherapy on one side for 30 minutes every one and one-half hours for 48 hours when he or she was awake. The patient did not receive cryotherapy on the other side. The authors performed clinical examinations to measure trismus and swelling before surgery, immediately after surgery and 24 and 48 hours after surgery.

Results. The authors compared both sides for differences in swelling, pain and trismus in each patient. The results showed significant statistical differences in two of the five points that were used to measure the swelling (Wilcoxon nonparametric signed rank test of linear distances between the angle of the mandible to the pogonion and to the tragus). They found statistical differences between the two sides in relation to the pain; however, they found no significant differences in relation to trismus.

Conclusions. Cryotherapy was effective in reducing swelling and pain in this sample. Despite playing no role in the reduction of trismus, cryotherapy was effective in reducing swelling and pain in this sample, and the authors still recommend it be used.

Clinical Implications. Cryotherapy is helpful after third-molar extraction. Further studies need to be conducted that use larger samples of patients and other types of therapy, such as low-level laser therapy.

Key Words: Third molar extraction; cryotherapy; swelling; pain; trismus

Surgical removal of an impacted third molar often involves pain, swelling and dysfunction during the postoperative period. The many factors that contribute to these situations are complex, but they originate in an inflammatory process initiated by surgical trauma.1

The use of cryotherapy results in reduced swelling and pain after surgery.

Cyclo-oxygenase and prostaglandins play a crucial role in the development of postoperative pain and swelling during such reactions. Pain and swelling can be reduced using glucocorticoids, which have a membrane-stabilizing antiexudative effect; cyclo-oxygenase with nonsteroidal anti-inflammatory drugs; and ice (cryotherapy, cold pack therapy or ice therapy). Ice therapy is low-cost, has no side effects, is easy to apply and has a wide spectrum of action.2–10

The first physiological response of the tissues to cryotherapy is a fall in the local temperature that leads to reduced cell metabolism. This causes the cells to consume less oxygen and survive a longer period of ischemia. The main function of the ice on the circulatory system is reducing the blood flow affected by the vasoconstriction, staunching the initial intratissular hemorrhage and limiting the extent of the injury.2–4,11–17

Numerous studies in the literature report on postextraction complications, but only one study in our literature review evaluated prospectively how the use of ice can affect postoperative recovery.1

We conducted a study to analyze the side effects, such as pain, trismus and swelling, after the removal of third molars, by comparing the use or absence of cryotherapy in the reduction of these effects 24 and 48 hours after surgery. We conducted an intraindividual, self-controlled, blind study to establish whether using cryotherapy is more effective than not using cryotherapy in the treatment of side effects after third-molar extractions.


   MATERIAL AND METHODS
TOP
 ABSTRACT
 MATERIAL AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Fourteen healthy patients with two symmetrically impacted inferior third molars underwent surgery as part of a prospective, intraindividual, randomized, double-blind crossover study. The sample comprised 11 women and three men aged 20 to 28 years, with a mean age of 24 years. The patients did not have any illnesses, and they were not taking any medication that might influence the surgical procedure or postoperative wound healing. All subjects were nonsmokers. Each patient’s third molars showed the same degree of impaction on each side (either partially or fully covered by bone), and all of the patients were treated at the Surgical Clinic of the School of Dentistry of the Federal University of Pernambuco, Recife, Brazil.

Patients underwent cryotherapy on the treated side with a cold pack (blocks of ice enveloped by a band to protect the skin) for 30 minutes every one and one-half hours for 48 hours while they were awake.

A dental surgeon (I.B.C.) removed the teeth in two sessions six weeks apart. All of the patients needed a similar surgical procedure on two occasions (the surgical procedure was fully standardized), and, thus, they were able to act as their own controls in a cross-over trial; the third molars were bilaterally and symmetrically identical.

Preoperative examination. Before surgery, the surgeon recorded the patient’s maximum mouth opening from the maxillary incisive edge to the mandibular incisive edge, using a millimeter scale.18 He recorded cheek swelling with a modification of the tape measure method described by Neupert and colleagues,8 which is simple when compared with other methods in the literature such as those described by Gabka and Matsumura,13 Amin and Laskin19 and Souza and Consone.15 The surgeon measured the linear distances from the angle of the mandible to the tragus, eye angle, alar nose angle, corner of the mouth and pogonion. He drew the points for the tape measurements using a waterproof felt-tip pen (Figure 1Go).



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  		Figure 1. Measurement points. A. Facial points marked to measure the distance from the gonion to the pogonion. B. Measuring maximum mouth opening with a paquimeter.

 
Surgical technique. The patient underwent third-molar extraction while under local anesthesia without any kind of sedation (oral, nasal or venous). The local anesthetic was lidocaine in a 3 percent solution with 1:50,000 nor-epinephrine. The surgeon provided nerve block anesthesia of the inferior alveolar nerve at the mandibular foramen. He used a marginal flap in all extractions. The surgeon administered an average quantity of local anesthetic of 3.03 tubes of 1.8 milliliters. He performed an ostectomy of the contiguous bone with a round bur (carbide no. 8), and he sectioned the teeth with a fissure bur (carbide no. 702). Both procedures were performed using a low-speed straight handpiece under constant irrigation with cool sterile physiological saline solution. The surgeon sutured the flap with a 4-0 silk suture. After surgery, all of the patients received an oral nonsteroidal anti-inflammatory drug (100 milligrams of nimesulide every 12 hours for four days), an analgesic (750 mg of paracetamol every six hours in the event of pain or fever) and topical chlorhexidine digluconate for seven days.

Cryotherapy technique. In accordance with the technique described in the literature,2–7,12,13 the patients underwent cryotherapy on the treated side with a cold pack (blocks of ice enveloped by a band to protect the skin) for 30 minutes every one and one-half hours for 48 hours while they were awake. One of the authors (F.M.V.G.) supervised the entire cryotherapy technique during all of the periods studied, and she instructed the patients to use the pack as often as possible and to note the time of each application. Temperatures declined in a manner typical with this mode of cryotherapy. During the course of the 30-minute cold treatment, the patients’ body temperatures declined a little more than 8 C, whereas skin temperature declined approximately 27 C—nearly three times as much. Core temperature (40 mm under the skin) also declined slightly (2 C) (Figure 2Go).3



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  		Figure 2. Immediately after surgery, patients applied ice packs on the treated side for 30 minutes every one and one-half hours for 48 hours when he or she was awake.

 
Postoperative examination. One of the authors (I.B.C.) performed the clinical examinations 24 and 48 hours after surgery. He did not know whether he was evaluating the treated or the control side of the patient’s mouth. During the postoperative examinations, he evaluated the swelling and recorded the measurements for use in the statistical analysis. To assess the effect of the ice therapy on the extent of postoperative trismus, he measured maximal mouth opening as the maximum bite width before surgery and on the first and second days after surgery. He assessed pain clinically using a 10-centimeter, horizontal visual analog scale (VAS) one hour before the operation, and three times each day on the first, second and seventh days after surgery. He assessed pain using the VAS by adding together the three values for each day and comparing the totals.
The increase in pain was smaller on the treated side than on the control side.

Statistical analysis. We designed the prospective investigation statistically as an intraindividual, randomized, blind crossover study. We used descriptive statistics to characterize the results of the therapy. Using continuous variables (pain and maximum mouth opening), we compared both sides (treated and control) using analysis of variance of repeated measures. With categorical data (swelling), we used contingency tables with Wilcoxon rank sum test and analysis. We set the significance level at P < .05 and adopted a power of 80 percent. We evaluated the data using a statistical software package (SPSS, Version 8.0, SPSS, Chicago) in collaboration with the Department of Biometry and Medical Computing, Ageu Magalhães Research Center, Recife, Brazil. The ethics committee of the Federal University of Pernambuco examined and approved the study protocol.


   RESULTS
TOP
 ABSTRACT
 MATERIAL AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Duration of surgery. On the treated side, the average duration of the operation was 43.86 minutes (range, 20–70 minutes); on the control side, it was 41.71 minutes (range, 26–65 minutes).

Pain. We noted significant differences between the treated side and the control side in terms of pain values. In both sides, we noted a significant increase in pain values five days after surgery (P < .05), but the increase was smaller on the treated side.

Swelling. To measure the degree of intraexaminer agreement, we used the {kappa} statistic to reexamine three patients from the total sample.

Overall, we found significant differences between the control and treated sides (Wilcoxon signed rank test, P < .05) when we compared the preoperative linear distances from gonion to tragus and from gonion to pogonion with those taken 48 hours after surgery. The result of the agreement we obtained from the {kappa} statistic was a mean value of 0.93 for the gonion to tragus distance and a mean value of 0.94 for the gonion to pogonion distance. The amount of swelling (increased volume of the skin) for the gonion to tragus distance was an average of 0.13 ± 0.12 standard deviation (SD) cm on the treated side and 0.26 ± 0.24 cm on the control side, which indicated twice as much swelling on the control side (Figure 3Go). The gonion to pogonion distance presented a similar pattern of behavior, showing a mean increase of 0.16 ± 0.18 cm on the treated side and 0.44 ± 0.34 cm on the control side. We found no significant statistical differences between the other points analyzed. The power of the test for the paired groups was 59.5 percent for the gonion to tragus distance and 85.0 percent for the gonion to pogonion distance.



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  		Figure 3. Comparative volume increase between the treated and control sides of the goniontragus and gonionpogonion distances before surgery and 48 hours after surgery.

 
Maximum mouth opening. We found no differences between the control and treated sides in terms of maximum mouth opening during the times analyzed after surgery. Both sides showed a similar pattern of behavior in that there was a significant decrease in maximum mouth opening 24 hours after surgery, with a mean reduction of 1.72 cm on the treated side and a mean reduction of 1.6 cm on the control side (Figure 4Go). At 48 hours, there was a slight improvement with no statistical differences between the sides (P < .05).



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  		Figure 4. Maximum opening of the mouth before surgery and 24 and 48 hours after surgery.

 
On the treated side, the mean mouth openings were 3.01 ± 1.01 cm before surgery, 1.29 ± 0.78 cm at 24 hours and 1.49 ± 0.95 cm at 48 hours. On the control side, the corresponding values were 3.01 ± 1.19 cm, 1.41 ± 1.18 cm and 1.98 ± 1.89 cm, respectively.


   DISCUSSION
TOP
 ABSTRACT
 MATERIAL AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
The literature includes many comparative studies on side effects patients experience after extraction of third molars, but none describe the use of ice therapy.

A study on the complications after removal of impacted third molars that compared adults with patients aged 9 to 16 years (early removal of third molars) showed that such complications were more frequent in patients 24 years of age and older.20 The patients in our sample had a mean age of 24 years.

The oral surgeon’s experience is a factor that can influence the amount of side effects after third-molar extraction. A study by Capuzzi and colleagues1 comparing factors that influence recovery after surgery—sex, age, smoking habits, degree of difficulty of the extraction, use of birth control pills, experience of the surgeon, duration of surgery and antibiotic prophylaxis—concluded that sex, age and the experience of the surgeon do influence the degree of pain. The authors found that the other variables had no influence on the degree of postoperative swelling and pain. Their study is in agreement with that of Sisk and colleagues14 that found that the surgeon’s experience influences the intensity of postoperative side effects. In our study, a first-year resident (I.B.G.) operated on the patients under the supervision of a senior resident and one professor (J.R.L.F.). The surgeon did not use any form of sedation (oral, nasal or venous), which probably accounts for the long surgical duration of approximately 40 minutes seen in our results.

An evaluation of the use of antibiotics to decrease other adverse outcomes such as alveolar osteitis, trismus, pain and swelling found that there tended to be little improvement with the use of antibiotics.21 In view of this, the routine use of prophylactic antibiotics in patients undergoing removal of impacted third molars cannot be recommended.21

In a study comparing the use of ibuprofen and methylprednisolone to control the local side effects of pain and swelling after third-molar removal, the authors concluded that the combination of both medications was well-suited for treating these effects and should be used when extensive postoperative swelling of soft tissue is expected.10

The results of our study showed that there was an increase in pain values up to the fifth day after surgery on both the treated and control sides, but patients reported a smaller increase in the pain on the treated side. This may be related to the alveolar osteitis in the scar tissue that is formed on both sides. Cryotherapy can stabilize the membranes and reduced sensitive cell metabolism, leading to a local reduction in alveolar pain.2–10

This decrease in pain on the treated side may be related to psychological factors, as the patients knew which side was being treated. This influence, however, does not apply to the other factors studied, which are purely physiological.

According to Savin and Ogden,9 one-third of patients will feel a marked disinclination to socialize for at least one week after third-molar extraction, and the fact that one in five patients claimed that they would not recommend third-molar extraction suggests that more could be done to both reassure patients and address their discomfort. Our study suggests that cryotherapy could be used to make the period after surgery more comfortable.

The literature describes other methods to prevent or control the side effects after third-molar removal such as the use of a gauze drain impregnated with chlortetracycline, a lingual splint, the conventional buccal approach, or the marginal or paramarginal flap. These methods have not been shown to prevent or control pain, despite the fact that the amount of trismus is less when the lingual split technique is employed.1–16,20,22


   CONCLUSION
TOP
 ABSTRACT
 MATERIAL AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Our study shows that the use of cryotherapy results in less serious side effects, such as reduced swelling and pain, after surgery. Despite playing no role in the reduction of trismus, cryotherapy was effective in reducing swelling and pain in this sample, and we still recommend it be used to reduce postoperative swelling and pain. We also suggest that further trials using larger sample sizes and other types of postoperative therapy, such as low-level laser therapy, be conducted.


   FOOTNOTES
 

Dr. Laureano Filho is an associate professor, Oral and Maxillofacial Surgery, School of Dentistry, University of Pernambuco, Recife, Brazil, and the head, Oral and Maxillofacial Surgery, Oswaldo Cruz University Hospital, Recife, Brazil. Address reprint requests to Dr. Laureano Filho at Av. General Newton Cavalcanti, 1650, 55753-220 Camaragibe–PE, Brazil, e-mail "laureano{at}fop.upe.br".


Dr. Oliveira e Silva is a full professor and the head, Oral and Maxillofacial Surgery, School of Dentistry, University of Pernambuco, Recife, Brazil. He also is the dean, University of Pernambuco, Recife, Brazil.


Dr. Batista Camargo is a dentist and a resident, Oral and Maxillofacial Surgery, University of Pernambuco, Recife, Brazil, and Oswaldo Cruz University Hospital, Recife, Brazil.


Ms. Gouveia, is a physiotherapist, and a professor, Physiotherapeutics, Federal University of Pernambuco, Recife, Brazil.


   REFERENCES
TOP
 ABSTRACT
 MATERIAL AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Capuzzi P, Montebugnoli L, Vaccaro MA. Extraction of impacted third molars: a longitudinal prospective study on factors that affect postoperative recovery. Oral Surg Oral Med Oral Pathol 1994;77:341–3.[Medline]

  2. Guirro R, Abib C, Máximi C. Os efeitos fisiológicos da crioterapia: uma revisão. Rev Fisioterapia da USP 1999;6:164–70.

  3. Jutte LS, Merrick MA, Ingersoll CD, Edwards JE. The relationship between intramuscular temperature, skin temperature and adipose thickness during cryotherapy and rewarming. Arch Phys Med Rehabil 2001;82:845–50.[Medline]

  4. Knight KL Crioterapia no tratamento das lesões esportivas. São Paulo, Brazil: Manole; 2000:225–38.

  5. Mac Auley DC. Ice therapy: how good is the evidence? Int J Sports Med 2001;22:379–84.[Medline]

  6. Mocan A, Kisnisci R, Üçok C. Stereophotogrammetric and clinical evaluation of morbidity after removal of lower third molars by two different surgical techniques. J Oral Maxillofac Surg 1996;54:171–5.[Medline]

  7. Nelli EA, Silva JR, Pacheco G. Fisioterapia póscorreção cirúrgica da anquilose temporomandibular. Rev Brasileira de Medicina 2000;57:121–3.

  8. Neupert EA 3rd, Lee JW, Philput CB, Gordon JR. Evaluation of dexamethasone for reduction of postsurgical sequelae of third molar removal. J Oral Maxillofac Surg 1992;50:1177–83.[Medline]

  9. Savin J, Ogden GR. Third molar surgery: a preliminary report on aspects affecting quality of life in the early postoperative period. Br J Maxillofac Surg 1997;35:246–53.

  10. Schultze-Mosgau S, Schmelzeisen R, Frölich JC, Schmele H. Use of ibuprofen and methylprednisolone for prevention of pain and swelling after removal of impacted third molars. J Oral Maxillofac Surg 1995;53:2–7.[Medline]

  11. Curl WW, Smith BP, Marr A, Rosencrance E, Holden M, Smith TL. The effect of contusion and cryotherapy on skeletal muscle microcirculation. J Sports Med Phys Fitness 1997;37:279–86.[Medline]

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  15. Souza JA, Consone DP. Método para medida do edema facial em pós operatório de cirurgias bucais. RGO 1992;40:137–9.

  16. Suarez-Cunqueiro MM, Gutwald R, Reichman J, Otero-Cepeda XL, Schmelzeisen R. Marginal flap versus paramarginal flap in impacted third molar surgery: a prospective study. Oral Surg Oral Med Oral Pathol Radiol Endod 2003;95:403–8.[Medline]

  17. Thermann H, Krettek C, Hufner T, Schratt HE, Albrecht K, Tscherne H. Management of calcaneal fractures in adults: conservative versus operative treatment. Clin Orthop Relat Res 1998;353:107–24.

  18. Agerberg G. On mandibular dysfunction and mobility. UMECI University Odontological Dissertation Abstracts 1974;3:16–20.

  19. Amin MM, Laskin DM. Prophylactic use of indomethacin for prevention of postsurgical complications after removal of impacted third molars. Oral Surg Oral Med Oral Pathol 1983;55(5):448–51.[Medline]

  20. Chiapasco M, Crescentini M, Romanoni G. Germectomy or delayed removal of mandibular impacted third molars: the relationship between age and incidence of complications. J Oral Maxillofac Surg 1995;53:418–22.[Medline]

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  22. Akota I, Alvsaker B, Bjørnland T. The effect of locally applied gauze drain impregnated with chlortetracycline ointment in mandibular third-molar surgery. Acta Odontol Scand 1998;56:25–9.[Medline]





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