Long-lasting Mechanical Sensitization Following Third Molar Surgery

Aims: To investigate the degree and duration of neuronal hyperex-citability due to local inflammatory trauma after surgical removal of an impacted mandibular third molar. Methods: A total of 32 healthy men (16 patients, 16 control subjects) underwent quantita-tive sensory tests (QST) at baseline (preoperatively) and 2, 7, and 30 days following surgical removal of a mandibular third molar. Thermal and mechanical QST was applied to the extraoral and intraoral regions as well as to the dominant forearm. Results: Detection thresholds for thermal and mechanical stimuli did not change over time in patients and control subjects, but pain thresh-olds (thermal, pressure, electrical) in the control group increased significantly. Patients showed significantly decreased pain pressure thresholds and pressure pain tolerance (P < .05 for both) on the operated side and absence of adaptation to the tests for up to 30 days postoperatively. Conclusion: These results indicate that even a minor surgical procedure in the orofacial region may be suffi-cient to evoke hyperexcitability in an area adjacent to the surgical wound for up to 30 days. The decreased adaptive capacity in the patient group also suggests the involvement of central pain-regula-tory mechanisms in response to the surgical trauma.

orofacial; pressure pain; sensitization; third molar

1. Marchettini P, Formaglio F, Barbieri A, Tirloni L, Lacerenza M. Pain syndromes that may develop as a result of treatment interventions. In: Proceedings of the 9th World Congress on Pain. Seattle: IASP Press, 1999:675–688.

2. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000;93:1123–1133.

3. Mikkelsen T, Werner MU, Lassen B, Kehlet H. Pain and sensory dysfunction 6 to 12 months after inguinal herniotomy. Anest Analg 2004;99:146–51.

4. Nikolajsen L, Sørensen HC, Jensen TS, Kehlet H. Chronic pain following Caesarean section. Acta Anaesthesiol Scand 2004;48:111–116.

5. Coderre TJ, Katz J. Peripheral and central hyperexcitability: Differential signs and symptoms in persistent pain. Behav Brain Sci 1997;20:404–419.

6. Koltzenburg M. The changing sensitivity in the life of the nociceptor. Pain 1999;6:93–102.

7. Jensen TS, Gottrup H, Kasch L, Nikolajsen L, Terkelsen AJ, Witting N. Has basic research contributed to chronic pain treatment? Acta Anaesthesiol Scand 2001;45: 1128–1135.

8. Woolf CJ. Dissecting out mechanisms responsible for peripheral neuropathic pain: Implications for diagnosis and therapy. Life Sci 2004;74:2605–2610.

9. Imbe H, Iwata K, Zhou QQ, Zou S, Dubner R, Ren K. Orofacial deep and cutaneous tissue inflammation and trigeminal neuronal activation. Implications for persistent temporomandibular pain. Cells Tissues Organs 2001; 169:238–247.

10. Sessle BJ. Recent insights into brainstem mechanisms underlying craniofacial pain. J Dent Educ 2002;66: 108–112.

11. Dubner R, Ren K. Brainstem mechanisms of persistent pain following injury. J Orofac Pain 2004;18:299–305.

12. Iwata K, Tsuboi Y, Shima A, et al. Central neuronal changes after nerve injury: Neuroplastic influences of injury and aging. J Orofac Pain 2004;18:293–298.

13. Koltzenburg M. Neural mechanisms of cutaneous nocicep-tive pain. Clin J Pain 2000;16:131–138.

14. Cadden SW, Orchardson R. The neural mechanisms of oral and facial pain. Dent Update 2001;28:359–367.

15. Kosek E, Ekblom J, Hansson P. Modulation of pressure pain thresholds during and following isometric contraction in patients with fibromyalgia and in healthy controls. Pain 1996;64:415–423.

16. Gottrup H, Andersen J, Arendt-Nielsen L, Jensen TS. Psychophysical examination in patients with postmastectomy pain. Pain 2000;87:275–284.

17. Svensson P, List T, Hector G. Analysis of stimulus-evoked pain in patients with myofascial temporomandibular pain disorders. Pain 2001;92:399–409.

18. Jensen TS, Baron R. Translation of symptoms and signs into mechanisms in neuropathic pain. Pain 2003;102:1–8.

19. Cruccu G, Anand P, Attal N, et al. EFNS guidelines on neuropathic pain assessment. Eur J Neurol 2004;11:153–162.

20. Eliav E, Gracely RH, Nahlieli O, Benoliel R. Quantitative sensory testing in trigeminal nerve damage assessment. J Orofac Pain 2004;18:339–344.

21. Essick GK. Psychophysical assessment of patients with posttraumatic neuropathic trigeminal pain. J Orofac Pain 2004;18:345–354.

22. Svensson P, Baad-Hansen L, Juhl GI, Thygesen T, Jensen TS. Overview on tools and methods to assess neuropathic trigeminal pain. J Orofac Pain 2004;18:332–338.

23. Byers MR, Närhi MVO. Dental injury models: Experimental tools for understanding neuro-inflammatory interactions and polymodal nociceptor functions. Crit Rev Oral Biol Med 1999;10:4–39.

24. Huang GJ, LeResche L, Critchlow CW, Martin MD, Drangsholt MT. Risk factors for diagnostic subgroups of painful temporomandibular disorders (TMD). J Dent Res 2002;81:284–288.

25. Hansson P, Ekblom A, Lindblom U, Marchettini P. Does acute intraoral pain alter cutaneous sensibility? J Neurol Neurosurg Psychiatry 1988;51:1032–1036.

26. Eliav E, Gracely RH. Sensory changes in the territory of the lingual and inferior alveolar nerves following lower third molar extraction. Pain 1998;77:191–199.

27. Ekblom A, Hansson P. Thermal sensitivity is not changed by acute pain or afferent stimulation. J Neurol Neurosurg Psychiatry 1987;50:1216–1220.

28. Juhl GI, Svensson P, Norholt SE, Jensen TS. Persistent mechanical allodynia and hyperalgesia following oral surgery [abstract]. Presented at the 4th Congress of European Federation of International Association for the Study of Pain Chapters, Prague, Czech Republic, 2–6 Sept 2003.

29. Fruhstorfer H, Gross W, Selbmann O. von Frey hairs: New materials for a new design. Eur J Pain 2001;5:341–342.

30. Norholt SE, Aagaard E, Svensson P, Sindet-Pedersen S. Evaluation of trismus, bite force, and pressure algometry after third molar surgery: A placebo-controlled study of ibuprofen. J Oral Maxillofac Surg 1998;56:420–427.

31. Sang CN, Max MBH, Gracely RH. Stability and reliability of detection thresholds for human A-beta and A-delta sensory afferents determined by cutaneous electrical stimulation. J Pain Symptom Manage 2003;25:64–73.

32. Breivik EK, Bjornsson GA, Skovlund E. A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain 2000;16:22–28.

33. Svensson P. Quantification of Argon Laser-Induced Nociception from Human Oral Mucosa and Facial Skin [thesis]. 1993. [Author: University of Aarhus?]

34. Jääskeläinen SK. Clinical neurophysiology and quantitative sensory testing in the investigation of orofacial pain and sensory function. J Orofac Pain 2004;18:85–107.

35. Graven-Nielsen T, Arendt-Nielsen L. Peripheral and central sensitization in musculoskeletal pain disorders: an experimental approach. Curr Rheumatol Rep 2002;4:313–321.

36. Eliav E, Tal M, Benoliel R. Experimental malignancy in the rat induces early hypersensitivity indicative of neuritis. Pain 2004;110:727–737.

37. Kilo S, Schmelz M, Koltzenburg M, Handwerker HO. Different patterns of hyperalgesia induced by experimental inflammation in human skin. Brain 1994;117:385–396.

38. Langemark M, Jensen K, Jensen TS, Olesen J. Pressure pain thresholds and thermal noci-ceptive thresholds in chronic tension-type headache. Pain 1989;38:203–210.

39. Svensson P, Arendt-Nielsen L, Nielsen H, Larsen JK. Effect of chronic and experimental jaw muscle pain on pain-pressure thresholds and stimulus-response curves. J Orofac Pain 1995;9:347–356.

40. Kosek E, Ordeberg G. Abnormalities of somatosensory perception in patients with painful osteoarthritis normalize following successful treatment. Eur J Pain 2000;4:229–238.

41. Sabino MAC, Honore P, Rogers SD, Mach DB, Luger NM, Mantyh PW. Tooth extraction-induced internalization of the substance P receptor in trigeminal nucleus and spinal cord neurons: Imaging the neurochemistry of dental pain. Pain 2002;95:175–186.

42. Hu JW. Is tooth extraction a good model for dental pain?Pain 2002;99:605–606.

43. Vanegas H, Schaible H. Descending control of persistent pain: Inhibitory or facilitatory? Brain Res Brain Res Rev 2004;46:295–309.

44. Suzuki R, Rygh LJ, Dickenson AH. Bad news from the brain: Descending 5-HT pathways that control spinal pain processing. Trends Pharmacol Sci 2004;25:613–617.

45. Vanegas H. To the descending pain-control system in rats, inflammation-induced primary and secondary hyperalgesia are two different things. Neurosci Lett 2004;361: 225–228.

46. Witting N, Svensson P, Arendt-Nielsen L, Jensen TS. Differential effect of painful heterotopic stimulation on capsaicin-induced pain and allodynia. Brain Res 1998;801:206–210.