ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title No Evidence to Show Benefits of Cold Therapy After Third Molar Extraction
Clinical Question In patients aged 18 to 30 who undergo impacted third molar extraction, does cold therapy reduce pain, trismus, and edema when compared to the absence of cold therapy?
Clinical Bottom Line While there is some subjective evidence showing that patients believe cold therapy increases their postoperative quality of life after third molar extraction, overwhelming statistical and objective evidence shows that there is no significant difference between patients who have been given cold therapy compared to those without cold therapy.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 26597577Keshavarz/201530 patients (7 males, 23 females) between the ages of 18-30Randomized Controlled Trial
Key resultsIn this crossover trial where patients served as their own controls, pain, trismus, swelling, and overall patient satisfaction were evaluated at 2 and 7 days after removal of a mandibular third molar. Pain was measured on a scale from 1 to 10. Mean pain scores at 2 days postoperative were 3.83 (cold therapy) and 4.43 (control) (P = 0.29); at 7 days, both groups reported 0 pain. There was no statistical difference between the groups for pain score. At the 2-day postoperative evaluation, mean reductions in mouth opening were 17.17 mm for cold therapy and 16.30 mm for control (P = 0.533); at 7 days, mean reduction was 0.53 mm (cold therapy) and 0.37 mm (control) (P = 0.168). Again, there was no statistical difference. Facial swelling was measured at 2 and 7 days postoperative as well. At 2 days, mean facial swelling was 10.57 mm (cold therapy) and 10.83 mm (control) (P = 0.872). At 7 days postoperative, mean facial swelling was measured at 0.77 mm (cold therapy) and 0.63 (control) (P = 0.536). There was not a statistically significance difference. Overall patient satisfaction was also measured on a scale from 1 to 10. Mean patient satisfaction was 7.27 for cold therapy and 7.00 for control, which equates to a non-significant P = 0.459.
#2) 15741037Roelse/200560 patients requiring extraction of bilateral, impacted third molarsRandomized Controlled Trial
Key resultsMean facial swelling of patients, measured on the day following surgery, with ice pack therapy measured to be 6.0 mm and 4.6 mm on the left and right sides respectively. Comparatively, 6.4 mm and 5.4 mm of mean swelling was recorded for the control patients on left and right sides, respectively. The difference in mean facial swelling between the control and experimental patients was not significantly significant (P > 0.05). Mouth opening was also recorded preoperatively as well as postoperatively on the morning of the first day after surgery. Postoperatively, patients with cold therapy exhibited a 41% average decrease in mouth opening while patients without cold therapy exhibited a 45% average decrease in mouth opening. While the patients with cold therapy had marginally better results, the difference was a statistically insignificant (P > 0.05). The “patient’s subjective perception of the efficacy of control of postoperative pain and discomfort,” however, was found to have a statistically significant difference (P = 0.015). Twenty-six of the patients in this study indicated their postoperative pain control to be “excellent.” Of the 26, 18 had received ice therapy while the remaining 8 had received no ice therapy. Furthermore, 19 of the 29 patients who voted their postoperative control to be “good” had been given no ice therapy. The remaining had 10 patients received ice packs.
Evidence Search ("hypothermia, induced"[MeSH Terms] OR ("hypothermia"[All Fields] AND "induced"[All Fields]) OR "induced hypothermia"[All Fields] OR ("cold"[All Fields] AND "therapy"[All Fields]) OR "cold therapy"[All Fields] OR "cryotherapy"[MeSH Terms] OR "cryotherapy"[All Fields] OR ("cold"[All Fields] AND "therapy"[All Fields])) AND ("pain"[MeSH Terms] OR "pain"[All Fields]) AND ("trismus"[MeSH Terms] OR "trismus"[All Fields]) AND ("molar, third"[MeSH Terms] OR ("molar"[All Fields] AND "third"[All Fields]) OR "third molar"[All Fields] OR ("third"[All Fields] AND "molar"[All Fields]))
Comments on
The Evidence
Validity: Due to the nature of the clinical studies, the materials and methods, as well as research incorporated within each study, I have reason to believe that the evidence presented has high values of validity. The crossover clinical trial that was conducted in the Keshavarz article incorporates advantages of the reduction of confounding factors and increases the statistical power of the study. A disadvantage of this type of study is the period effect, which is when the response to intervention differs due to treatment not being delivered simultaneously. The Roelse 2005 study's strengths include its randomization and blinding. The control group ensures that the results are attributed solely to the interventions being measured. One of the weaknesses that may have had an affect on the results was the short 24-hour follow up time. The subjective nature of pain adds a factor of variability. Because each individual has different levels of pain tolerance, measuring the results with a 100% degree of objectivity is impossible. Steps, such as a standard 1-10 pain scale, were incorporated to try and mitigate the subjectivity of the data. Perspective: Cold therapy has often been prescribed as a cost-effective, low-risk method of decreasing pain and reducing recovery time after injury. While is a lack of statistical, objective evidence supporting this for post-operative therapy for third molar extractions, I suspect a placebo effect is associated with cold therapy post-surgery. Because of the general impression tied to cold therapy, I will continue to prescribe it until there is irrefutable evidence that it causes harm.
Applicability Due to the common nature of third molar extractions in today’s society and cold therapy being one of the most easily administered therapies, this is highly applicable information. The subjects are representative of my future patients and the treatment is feasible in an outpatient and home setting. Potential benefits of cold therapy include increased quality of post-operative life and ease of recovery, while possible harms include nerve and epidermal damage due to prolonged and/or intense cold therapy.
Specialty/Discipline (General Dentistry) (Oral Surgery)
Keywords Third molar extraction, cold therapy, pain, trismus, edema
ID# 3142
Date of submission: 03/23/2017spacer
E-mail hemmatp@livemail.uthscsa.edu
Author Payam Hemmat
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Jeffery Hicks, DDS
Faculty mentor/Co-author e-mail Hicksj@uthscsa.edu
Basic Science Rationale
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