Tobias K. Boehm (November 26, 2024)
(Stock photo of woman holding an ice pack by Engin Akyurt, Pexel.com)
Why is there pain after surgery
Surgery always causes some level of tissue damage. Damaged tissue triggers inflammation as immune cells move into the surgical area to remove dead and damaged cells. While inflammation is part of normal healing after surgery, it also is the source of pain after surgery. Swelling in the tissue may apply pressure on free nerve endings which then triggers a sensation of pain. Immune cells and damaged cells release molecules that trigger pain sensation in local nerve fibers.
In addition to normal inflammation, additional more severe pain can develop if an infection sets up after surgery. Infections are caused by microbes that entered the tissue during surgery and now are growing inside the tissue. Microbes usually release irritants and cause additional tissue damage which leads to more inflammation and more pain.
What influences the pain experience after surgery?
Many factors influence the pain experience. The main local factor that influence pain experience after surgery is the level of inflammation caused by the surgery and whether an infection develops after the surgery. The level of inflammation caused by the surgery depends how much tissue damage occurred during surgery and if there is the presence of any irritating factors after surgery such as stitches (‘sutures’), staples, graft materials, implanted materials and other foreign material. Tissue damage depends on surgery length, difficulty of the surgery, type of surgery, experience of the surgeon, surgical technique, amount of tissue handling during surgery and materials/equipment used during surgery.
Pain experience after surgery is also significantly influenced by an individual’s healing ability and mental state. Quick healing after surgery reduces the pain experience, while complications like infections or wound opening worsen the pain experience. Anxiety or stress worsens pain whereas relaxation reduces pain (1,2). Pain perception differs across individuals leading to what some call high or low pain tolerance. In a study of hip and knee replacement surgeries, high pain tolerance and believing in pain control led to lower pain experience (3). It seems likely that knowing what to expect and feeling trust can reduce the pain experience.
What is normal pain after surgery?
Some level of pain after surgery is normal and part of inflammation, some of which is necessary for healing to proceed. While pain experience differs greatly between individuals and surgeries, generally normal post-surgery pain begins when the numbness (‘local anesthesia’) wears off and usually is worst the night or first day after surgery as this is when immune cells are most active in removing damaged tissue and there is the most amount of inflammation. With uncomplicated basic oral surgery procedures such as periodontal surgery, implant placement or small biopsies, pain should begin to lessen on the second day after surgery and may quickly diminish within few days. Pain might take longer to subside after tooth removal or bone grafting, but in most cases, pain should be much diminished or gone one week after the surgery.
What should I watch for after surgery?
You should consult your surgeon if numbness lasts longer than 12 hours after surgery, or if pain becomes worse several days after surgery. Numbness could indicate a surgical complication and your surgeon will likely want to evaluate immediately. Increasing pain several days after surgery usually indicates an infection.
How can I reduce post surgical pain?
Before the surgery, make sure you feel trust in your surgical team and ask any questions you want to know. Be sure to understand how you procedure is done in basic terms, learn what to expect after surgery and what to look for, risks, benefits and alternatives. Be sure that the surgery is something that you decided you want to do, and that financing has been worked out to your satisfaction. If you feel anxious about the surgery, ask your surgeon for options to manage anxiety during the surgery such as relaxation techniques, hypnosis, anxiety-reducing medications, sedation and anesthesia. Be sure to ask what medcations you have to take for and after the surgery and make arrangements to have these ready for you to use.
There is some scientific evidence that taking non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids (i.e. dexamethasone) just before the surgery can help reduce pain experience after surgery. Ask your surgeon whether you need to take medication before the surgery (4).
After surgery, take your prescribed medication as directed by your surgeon.
If you have been told to apply ice, apply ice as directed. Icing the surgery area reduces blood flow to the area, thus reducing inflammation and swelling after the surgry, which results in less pain. If applying ice on the outside of your face, apply a bag of ice or cold pack wrapped in a towel to the general surgery area for five minutes and remove it. Do not apply ice packs directly to exposed skin as it can cause frost bite and more pain. The more regularly you ice it, the more effective the pain control. Icing loses its effectiveness generally after the first day.
What medications work against post surgical pain?
Generally, NSAIDs work best for pain control after oral surgery. Opioid medication generally should not be used as first medication for post surgery pain after oral surgery unless specifically ordered by the surgeon if medical conditions prevent use of NSAIDs. Surgeons may choose to prescribe anti-inflammatory corticosteroids such as dexamethasone or prednisone to reduce inflammation and pain experience.
If your surgeon just generally advised you to take NSAIDs, but no specific directions you may try the following common over-the-counter NSAID medications:
- Ibuprofen 200 mg tablets: Take two tablets every 4 hours, no longer than 5 days. Do not take more than 16 tablets (3,200 mg) per day as higher amounts can cause severe kidney damage
- Acetaminophen 500 mg tablets: Take 1 tablet every 6 hours, no longer than 5 days. Do not take more than 8 tablets (4,000 mg) per day as higher amounts can cause severe liver damage.
- Aspirin 325 mg tablets: Take 1 tablet every 6 hours, no longer than 5 days. Aspirin can cause stomach upset and kidney failure
- Ibuprofen and Acetaminophen can be alternated for improved pain control. In the United States, there is a combination medication available that contains 250 mg Acetaminophen and 125 mg Ibuprofen per tablet, sold under the brand name Advil Dual Action. With this medication, 2 tablets are taken every 8 hours.
If you experience pain that is not relieved by any of these medications, or pain that worsens several days after surgery, consult with your surgeon as this could indicate significant complications after surgery.
About the author:
Tobias K. Boehm, DDS, PhD, MBA, PC, DABP, DICOI, FGDIA is the founder of The Dental Institute, executive director at The Defeating Epilepsy Foundation and a professor at Western University of Health Sciences where he teaches and practices a periodontal specialist.
References:
(1) Stamenkovic DM, Rancic NK, Latas MB, Neskovic V, Rondovic GM, Wu JD, Cattano D. Preoperative anxiety and implications on postoperative recovery: what can we do to change our history. Minerva Anestesiol. 2018 Nov;84(11):1307-1317. doi: 10.23736/S0375-9393.18.12520-X. Epub 2018 Apr 5. PMID: 29624026.
(2) Yuan H, Liu Q, Tang T, Qin H, Zhao L, Chen W, Guo S. Assessment of early wound healing, pain intensity, quality of life and related influencing factors during periodontal surgery: a cross-sectional study. BMC Oral Health. 2022 Dec 10;22(1):596. doi: 10.1186/s12903-022-02630-3. PMID: 36496401; PMCID: PMC9741525.
(3) Jurewicz A, Gasiorowska A, Leźnicka K, Pawlak M, Sochacka M, Machoy-Mokrzyńska A, Bohatyrewicz A, Maciejewska-Skrendo A, Pawlus G. Individual Factors Modifying Postoperative Pain Management in Elective Total Hip and Total Knee Replacement Surgery. Life (Basel). 2024 Jan 31;14(2):211. doi: 10.3390/life14020211. PMID: 38398720; PMCID: PMC10890574.
(4) Steffens JP, Santos FA, Sartori R, Pilatti GL. Preemptive dexamethasone and etoricoxib for pain and discomfort prevention after periodontal surgery: a double-masked, crossover, controlled clinical trial. J Periodontol. 2010 Aug;81(8):1153-60. doi: 10.1902/jop.2010.100059. PMID: 20367520.