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REVIEW
Key words:
cold application, cryotherapy, third molars
Correspondence to:
Mr P.Taneja
Birmingham Dental Hospital
St Chads Queensway
Birmingham
West Midlands B4 6NN
UK
Tel.: 0121 466 5156
Fax: 0121 466 5151
email: pankaj.taneja@bhamcommunity.nhs.uk
Accepted: 5 November 2014
doi:10.1111/ors.12144
Abstract
Aim: To review the literature on the different methods and application
regimes of cryotherapy, and investigate its effects with respect to the
removal of third molars.
Materials and methods: A search was conducted through PubMed, Embase
and the Cochrane electronic databases. The publications included for the
review were those that investigated any form of cryotherapy and the
removal of third molars. Additionally a manual search of the reference lists
of included articles were reviewed.
Results: The literature search resulted in 111 articles, of which 10 met the
inclusion criteria. Outcomes of interest included body temperature, efficacy
of pain control, facial swelling, neurological scores, occurrence of inflammation, pain patient, satisfaction, quality of life, trismus and wound healing.
Conclusion: The review has found that there have been a variety of cooling
methods investigated, with the effects assessed postoperatively. Cryotherapy in the form of continuous cooling was shown to have significant
effects on postoperative mouth opening, pain, swelling and improved
patient satisfaction over conventional cooling.
Introduction
The surgical removal of third molar (M3) is a
common procedure in oral surgery, involving the
handling of soft and hard tissues. These procedures
cause a local inflammatory response often accompanied by, but not limited to, morbidity including pain,
swelling and trismus1. Therefore, there is a need for
techniques to help reduce the effects of the inflammatory response, which could potentially improve
post-operative morbidity. A suggested method of
controlling the immediate inflammatory response is
cryotherapy.
As first described by Hippocrates, cryotherapy or cold
therapy (CT) is the local or systemic application of cold
for therapeutic reasons2. There have been a variety of
cooling methods described in the literature, including
the passive application of packs of gel, ice and cold comOral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Taneja et al.
Body temperature
Results
The literature search resulted in 111 articles, of which
26 were duplicates. From the remaining articles, 10
met the inclusion criteria of CT and M3 removal. There
were no any additional articles found following review
Study type
Number of
patients
Teeth removed
Cryotherapy
system used
Cryotherapy regime
Bastian et al.
RCT
107
Bilateral LM3
Cryotherapy
probe
Courage et al.
Prospective study
47
Bilateral LM3
Cold packs
Filho et al.
RCT
14
Bilateral LM3
Cold pack
Forouzanfar et al.
Forsgren et al.
RCT
RCT
100
45
Unilateral LM3
Bilateral LM3
Ice compression
Cold dressing
Gelesko et al.
Prospective study
206
All M3
Cold wrap
Osunde et al.
Rana et al.
Literature review
RCT
30
Not specied
All M3
Ice packs
i) Cold compress
ii) Continuous
cooling
Sortino et al.
Van der Westhuijzen
et al.
Literature review
RCT
60
Not specied
Bilateral LM3
Ice packs
Bilateral face ice
packs
RCT, randomised control trial; M3, third molars; LM3, lower third molar; UM3, upper third molar.
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Taneja et al.
Efcacy of
pain control
Facial
swelling
Neurological
scores
Occurrence of
inammation
Pain
Patient
Satisfaction
Quality of
life (QOL)
Trismus
Wound
healing
*Osunde et al. and Sortino et al. have not been included as they are reviews of the literature.
Facial swelling
Six studies investigated post-operative facial swelling
following LM3 removal7,9,10. Filo et al. measured swelling from linear distances from the angle of the mandible to the tragus, eye angle, alar nose angle, corner of
the mouth and pogonion. Measurements were taken
pre-operatively and at 24 and 48 h post-operatively.
Statistically significant differences (P < 0.05) were
found in pre-operative linear distances with those
taken at 48 h post-operatively from gonion to tragus
(treated side: 0.13 0.12 cm, control side: 0.26
0.24 cm) and from gonion to pogonion (treated side:
0.16 0.18 cm, control side: 0.44 0.34 cm)8.
Rana et al. used a three-dimensional optical scanner
to measure facial swelling in volume in millilitres (mL).
Three-dimensional scans were recorded at 5 points:
before surgery, directly after surgery, and postoperatively on the 2nd, 10th, and 28th days. The study
compared two forms of CT (cold compress and continuous cooling) and concluded that the continuous
cooling method had a statistically significant reduction
Oral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Neurological analysis
Neurological analysis and scores following surgery
were investigated in only one study10. This was performed by the cotton test for touch sensation, the pinprick test for sharp pain and with the use of a blunt
instrument for testing pressure. The regions of the skin
of the infraorbital, mental region and upper and lower
lip were evaluated. The neurological score was assessed
at 3 points: before surgery, and on the 2nd and
28th post-operative days. There was no statistically
significant difference between the two groups (conventional cooling with a cold compress and continuous
cooling) concerning the neurological scores at the 2nd
(P = 0.8) and 10th (P = 0.6) day post extraction. There
was however a highly significant decrease in the neurological score observed after 10 days compared with
the 2nd post-operative day for both groups (continuous cooling, 2nd day 1.2 0.6 vs. 10th day 0.07 0.3,
P < 0.001; conventional, 2nd day 1.1 0.6 vs. 10th day
0.1 0.4, P < 0.001).
Occurrence of inammation
Bastian et al. found inflammation requiring treatment
to have occurred in nine patients on the side that
received CT and 16 patients on the side not given CT2.
There was no statistical analysis calculate for this.
Pain
Eight of the 10 studies assessed pain as an
outcome2,6,7,8,9,10,11,12. This was measured by a visual
analogue scale (VAS)2,6,8,9,10, pain-line7, Likert-type scale
anchored with verbal descriptive anchors12, number of
paracetamol consumption during the investigation
period,7 the mean consumption of ibuprofen in
mg/patient per 24 h6 and pain catergorised by intensity
and duration until relief by analgesia11. Two studies
found no statistical difference (P > 0.05) in the use of CT
for the reduction of pain following removal of M37,9.
Bastian et al. reported on patients that had LM3
removed under a general anaesthetic or a local anaesthetic. This study found a significant difference following LM3 removal between moderate and severe pain
with cryotherapy than without (P < 0.01, CT:
moderate/no pain = 77 and severe pain = 30, no CT:
moderate pain = 57 and severe pain = 50)2. Filho et al.
also found a significant difference between the CT
treated side and the control side following LM3
removal. A significant increase (P < 0.05) was found in
pain values 5 days following surgery; in both sides,
however, the increase was smaller in the treated side8.
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Taneja et al.
Patient satisfaction
Rana et al. assessed satisfaction by providing patients
with a questionnaire to complete on the 10th postoperative day10. However, the article reported that the
questionnaire was in fact completed on the 2nd postoperative day and reported a statistically significant
difference (continuous cooling 1.9 0.2 and conventional 3.1 0.3, P = 0.003) was found between the
groups9. Bastian et al. also reported that the majority of
patients found CT to be better and would prefer to have
it again if given the choice over no CT (n = 57), but
there was no report on statistical significance2.
Quality of life
Forouzanfar et al. provided patients with a quality
of life questionnaire that was completed 1 week
Oral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Taneja et al.
Trismus
Filho et al. measured mouth opening from the maxillary incisive edge to the mandibular incisive edge, using
a millimetre scale8. A significant decrease (P < 0.05) in
maximum mouth opening 24 h after surgery was
found in both sides (mean reduction 1.72 cm on CT
side and 1.6 cm on control side). However, there was
no statistical significance found between the CT
and the control sides during directly after surgery and
at 48 h.
Forsgren et al. and Van der Westhuijzen et al. used a
vernier gauge to measure mouth opening from
between the upper right and lower right central incisors7,9. Both studies concluded that there was no significant difference (P > 0.05) in trismus between the
sides treated with CT and the sides not treated with CT.
Rana et al. measured mouth opening in millimetres
(mm) at 5 points: before M3 surgery, directly after
surgery, and post-operatively on the 2nd, 10th and
28th days, respectively10. The study reported a significantly greater mouth opening directly after surgery
(continuous cooling 22.8 0.7 mm and conventional
17.1 0.7 mm, P = 0.01) and on the 2nd post-operative
day (continuous cooling 25.1 2.4 mm and conventional 22.0 1.9 mm, P = 0.002) in the group receiving
continuous cooling.
Wound healing
Forsgren et al. investigated wound healing on the 7th
post-operative day7. Assessment for infection, loose
mucoperiosteal flaps and the occurrence of alveolitis
were recorded. The study reported alveolitis in six cases
after post-operative treatment with cold dressings, and
four cases after operations when no cold dressings were
used. There were two patients who developed postoperative infections that required antibiotics and one
patient with a loose mucoperiosteal flap observed
when cold dressings were not used. There were not any
conclusions that could be made regarding the benefits
of CT from the differences observed.
Discussion
The surgical removal of M3s typically results in morbidity including, but not limited to, pain, swelling and
Oral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Taneja et al.
Conclusion
The consistent outcomes of pain, swelling and dysfunction on post-operative recovery following M3
removal provides a good model for studying the efficacy of an intervention, such as cryotherapy12. This
review has found that there are limited findings in the
use of CT in reducing post-operative morbidity.
However, with the variety of CT methods that were
reviewed, it has been interesting to see that continuous
cooling has shown to have significant effects on a
number of conditions including post-operative mouth
opening, pain, swelling and improved patient satisfaction over conventional cooling. This method of CT
would also have the benefits of controlling the temperature and preventing it from falling too low or,
conversely, as seen with ice packs, from warming following contact with the facial tissues as time passes.
Continuous cooling also relies on a fixed facial mask
that would eliminate the compliance required in the
repeated changing of ice/cool packs, making it easier
for patients to sustain. In order to achieve this, specialist equipment may be required with possible training
and cost implications. In addition, further research is
required to further support these findings.
Another benefit that may require further investigation is the role of compression. As discussed, compression has shown to have a significant effect in reducing
post-operative pain following M3 removal, and further
investigations could clarify if there is a synergistic effect
with CT.
With all of the studies reviewed, CT was performed
post-operatively. If cell metabolism is reduced through
the application of cold, then it may be worth considering applying CT for a period prior to surgery, or even
during surgery (CT method permitting). In this way,
tissues will be at the ideal temperature for slowing the
biochemical reactions that lead to inflammation. In
addition, the effects of CT on vasoconstriction and
reduction of nerve velocity could be advantageous in
terms of decreased bleeding associated with the operative field for the surgeon and decreasing pain for the
patient.
The accumulated data from the review provide an
understanding of how the different modalities of CT
provide an alternate method with simple and safe
treatment of some of the post-operative symptoms following M3 removal. When one of the alternate
approaches are to simply ingest a medication, studies of
Oral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Taneja et al.
CT effects need to show a vast improvement in postoperative morbidity before it is likely to convince both
clinicians and patients.
Conflict of interest
The authors confirm that they have no conflict of
interest.
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