Exploring Non-Opioid Post-Operative Pain Management Strategies for Third Molar Surgery

Photo Credit: Maryna Auramchuk

Researchers reviewed alternative and complementary therapies for postoperative pain management in patients undergoing lower third molar surgery.

In a “How I Do It” session at the 106^th AAOMS Annual Meeting, Anisha Gupta, DDS, discussed strategies for managing pain without opioids as patients recover from third molar surgeries.

Dr. Gupta covered intraoperative protocols to reduce pain and surgical complications such as infection and alveolar osteitis. Session attendees learned how to design a “highly acceptable” patient treatment plan.

Dr. Gupta’s session focused on liposomal bupivacaine and platelet-rich fibrin, but various complementary and alternative therapies have also been investigated for reducing pain after third molar surgery.

Authors of a systematic review not affiliated with the meeting emphasized that lower third molar surgery (LTMS) is associated with the highest incidence of postoperative complications compared with other types of dental extractions.

“Oral surgeons are keenly interested in strategies to mitigate these complications, particularly postoperative pain, which ranks as the most significant issue,” Saulo Gabriel Moreira Falci, PhD, and colleagues reported in Clinical Oral Investigations. “While there have been research efforts evaluating alternative and complementary medicines after LTMS, consensus regarding their effectiveness in the acute phase of inflammation remains elusive. This systematic review aimed to assess whether alternative or complementary treatments when compared to placebo or non-treatment, can indeed reduce postoperative pain after LTMS.”

Complementary Therapies for Pain Management

The authors searched Embase, MEDLINE, Cochrane, clinicaltrials.gov, and Google Scholar to identify relevant studies. To be included in the review, the studies had to be randomized clinical trials, include a placebo/no treatment group, and report postoperative pain at 1, 2, and 7 days after surgery.

The initial search yielded 1,958 articles, of which 82 (4,575 participants) were included for qualitative analyses and 33 (1,428 participants) for network meta-analysis. There were 21 split-mouth and 12 parallel trials.

The studies examined alternative therapies, including acupuncture, lower-level laser therapy (LLLT), kinesio taping, massage, cryotherapy, heat therapy, pulsed electromagnetic field therapy, and lymph drainage. Some studies investigated ozone therapy, which is not approved for medical use in the US.

“Only six studies showed low risk of bias, four showed high risk of bias, and the other included studies showed some concerns regarding risk of bias. The most and the least researched complementary treatments were LLLT and drainage tube, respectively,” the researchers reported.

Postoperative Pain Reduced at Various Timepoints

The researchers included 17 trials with a total of 1,202 subjects in their analysis of pain after 24 hours. At this time, the drainage tube (SMD: −1.65; 95% CI, -2.24 to -1.06), kinesio taping (SMD, -0.99; 95% CI,  -1.30 to -0.68), and LLLT (SMD, -0.36; 95% CI, -0.59 to -0.12) outperformed placebo or no treatment.

The results were similar for pain after 48 hours (22 trials; n=1,303). The drainage tube (SMD, -1.89; 95% CI, -2.51 to -1.28), kinesio tape (SMD, -0.92; 95% CI, -1.31 to -0.52), and LLLT (SMD, -0.64; 95% CI, -0.91 to -0.38) provided superior pain relief compared with placebo or no treatment.

“The SUCRA [surface under the cumulative ranking curve] ranking positioned the drainage tube (98.2%) in the top spot for pain relief after 48 hours, followed by kinesio taping (83%),” the authors wrote.

After 72 hours (18 trials; n=1,335), acupuncture (SMD, -0.55; 95% CI, -0.99 to -0.11), drainage tubes (SMD, -1.75; 95% CI, -2.35 to -1.15), kinesio taping (SMD, -1.35; 95% CI, -2.16 to -0.53), and LLLT (SMD, -0.43; 95% CI, -0.74 to -0.12) were superior to placebo or no treatment. With a SUCRA rank of 96%, drainage tubes were the top-ranked complementary intervention, followed by ozone therapy (80.6%) and kinesio taping (72.8%).

When analyzing outcomes after 7 days (28 trials; n=1,840), the researchers found that compression (SMD, -0.63; 95% CI, -1.15 to -0.12), drainage tubes (SMD, -1.38; 95% CI, -1.95 to -0.82), kinesio taping (SMD, -1.17; 95% CI, -2.08 to -0.26), LLLT (SMD, -0.60; 95% CI, -0.85 to -0.36), and ozone therapy (SMD, -1.40; 95% CI, -1.80 to -1.00) performed better than placebo or no treatment.

According to the findings, “The SUCRA ranking placed ozone therapy (83.5%) in the first position, followed by drainage tube (71.4%).”

The researchers concluded that several complementary therapies showed promise for improving post-operative pain in patients undergoing LTMS. Their meta-analysis particularly highlighted drainage tubes and kinesio taping.

“However,” they wrote, “it is crucial to note that only two out of all the included RCTs evaluated [drainage tubes]. Therefore, the findings for this alternative treatment should be approached with caution.” In addition, patients were aware they were treated with drainage tubes and kinesio tape, introducing potential bias to the findings.

Nevertheless, the authors concluded that “these findings have important implications for clinical practice, as they highlight the potential benefits of incorporating these therapies into postoperative pain management plans.”