ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Pain In Subepithelial vs. Free Soft Tissue Grafts
Clinical Question In healthy adults who are being treated for gingival recession does a subepithelial connective tissue graft (SCTG) or a free soft tissue graft (FSTG)cause more postoperative pain?
Clinical Bottom Line More studies are needed to confirm this finding, but these studies show that patients who undergo a free soft tissue graft procedure are more likely to develop postoperative pain than those who receive a subepithelial connective tissue graft. (See Comments on the CAT below)
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) 17209793Griffin/2006228 Adults receiving 75 FSTG and 256 receiving SCTGCase Series/Clinical Trial
Key resultsPatients who underwent free soft tissue grafts were three times more likely to develop postoperative pain (P = 0.002) when compared to those who received a subepithelial connective tissue graft.
#2) 18315424Wessel/200823 Adults 23 receiving FSTG and 12 receiving SCTG Case Series/Clinical Trial
Key resultsPatients who underwent free soft tissue grafts were more likely to have donor site pain at 3 days (early postoperative period) when compared to those who received a subepithelial connective tissue graft (P=0.05).
Evidence Search Adult AND Pain AND Postoperative AND Gingival Recession ...view in PubMed
Comments on
The Evidence
In the first study, patients who underwent free soft tissue grafts were more likely to develop postoperative pain (P = 0.002) when compared to those who received a subepithelial connective tissue graft. In addition, the duration of surgical procedures was highly correlated with pain or swelling post-surgically (P = 0.001). Therefore, the length could influence the pain perceived by the patient more than the type of tissue graft they received. The study was designed fairly well considering the goals of the investigation. The groups were similar at the start and there was a greater than 90% completion rate. The patients generally were treated the same, receiving one of two types of connective tissue grafts. However, the operator was not obligated to use a randomized method of treatment allocation and based his treatment on the surgical goal of obtaining root coverage or increasing the width of keratinized gingiva. The study was not double-blind as the operator was not blind to the state of the patient during treatment planning. There was adequate follow up with only one patient not reporting pain status. There is also a potential for a bias in this study, because different patients have different thresholds for pain. The authors also noted that the application of dressing materials may have influenced the patients’ feelings post-operatively, and that the difference in pain might have been greater without the application of the dressing. Due to the bias and lack of randomization, this study should not be used alone to make clinical judgments. In the second study, patients who underwent free soft tissue grafts were more likely to have donor site pain at 3 days (early postoperative period) when compared to those who received a subepithelial connective tissue graft. The groups were similar at the start of the study, but there was not a completion rate of 90% or more. Three of the twenty-six subjects did not complete the study because of failure to comply with postoperative protocol. The patients in this study were not treated the same, because there were many different operators that performed the surgeries. The experience of the operator could have impacted the length of surgery and therefore the amount pain the patient experienced. Another limitation of this study is the difference in patients’ pain perceptions. The authors suggest a crossover study design where subjects have both a subepithelial connective tissue graft and a free soft tissue graft performed by the same operator at different times. More studies are needed to confirm the results presented here and the practitioner might want to incorporate their own patient experiences into the decision making process.
Applicability This information can be useful for patients who are trying to decide between subepithelial and free soft tissue grafts and want to know which one is more painful.
Specialty/Discipline (Periodontics)
Keywords Gingival recession, subepithelial connective tissue graft, free soft tissue graft, postoperative pain
ID# 581
Date of submission: 04/01/2010spacer
E-mail Lindskog@livemail.uthscsa.edu
Author Hanna Lindskog
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Archie Jones, DDS
Faculty mentor/Co-author e-mail JonesA@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
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Comments on the CAT
(FOR PRACTICING DENTISTS' and/or FACULTY COMMENTS ON PUBLISHED CATs)
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by Sathya Mahendrarajah and Shelrethia Battle-Siatita (San Antonio, TX) on 08/08/2013
After conducting a Pubmed search, we found a double-blinded randomized-controlled clinical trial published in 2010 which yielded conflicting results (PMID # 20590963 , Zucchelli, 2010). No clinically significant differences were found in post-operative pain levels between patients who received connective tissue grafts and those who received de-epithelialized (harvested as free soft tissue and de-epithelialized) gingival grafts. Reported post-operative pain in previous studies may be associated with the harvest technique employed, donor site management, case/patient selection and overall pain management protocol. Additionally, pain is highly subjective. Together with the small sample size (N=50) of this clinical trial, there is an indication for further studies to explore this topic. We would conclude that each case needs to be individually evaluated in predicting the extent and duration of post-operative discomfort when performing root coverage procedures.
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