Hindawi

International Journal of Dentistry

Volume 2021, Article ID 4134932, 5 pages
https://doi.org/10.1155/2021/4134932

Review Article
Pain Experience after Dental Implant Placement Compared to
Tooth Extraction

Alaa W. AlQutub
Oral and Maxillofacial Surgery Department, Um AlQura University, Faculty of Dentistry, Makkah 24225, Saudi Arabia

Correspondence should be addressed to Alaa W. AlQutub; [email protected]

Received 19 May 2021; Accepted 18 August 2021; Published 31 August 2021

Academic Editor: Vincenzo Iorio Siciliano

Copyright © 2021 Alaa W. AlQutub. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. A patients’ main concern when visiting the dentist is the pain experience during the procedure and postoperatively.
Patients who are undergoing dental surgical procedures in particular may experience more concerns and higher level of anxiety
and stress that can affect their psychology and decision-making ability. A thorough discussion with the patients about the planned
surgical procedure and the expected postsurgical pain and discomfort level is crucial to reduce their fear and stress. Despite
increasing popularity of dental implants, limited data are available on pain experience related to surgical implant placement. This
review is to discuss and compare postoperative pain and discomfort level after dental implant placement procedure and tooth
extraction. The review has a clinical significance as it can be used as a reference when explaining to the patients about the
anticipated pain and discomfort level after implant placement. Conclusion. Informing patients about implant placement surgical
procedure and the anticipated postsurgical pain can reduce their anxiety level and affect postsurgical pain and discomfort. Implant
placement surgical procedure is less unpleasant than tooth extraction, with less postsurgical pain and limitation of daily activities.

1. Introduction is available on the pain experience associated with the

surgical placement of dental implants [4]. Comparing this
Fear of dental treatment has been ranked as the 4th most experience to other dental surgical experiences such as
common fear among the population [1]. The most feared dental extraction is more relevant to the patients as it can
dental procedures in dentistry ranked by the patients are help them to understand the anticipated pain after implant
drilling, anesthetic injection, and extraction. Dental fear surgery, hence influencing their decision-making process.
mostly starts in childhood in patients with previous traumatic Moreover, they should understand that there are some
dental experiences as the main causative factor. In this case, contributing factors that might increase the pain perception
the dentist’s professional behavior plays a major role in after implant placement surgery.
creating such a fear. However, for acquired fear in adult years,
the main reason is pain. Patients’ fear and pain anticipation 2. Effect of Anxiety Level on Pain Experience
towards treatment may not consistently reflect their actual
experience of treatment as they may expect a stimulus to be Patients tend to overestimate the fear of pain of the dental
more painful than what they actually perceived [2]. treatment that they have not experienced, compared to those
To manage and control patients’ fear and anxiety before a they have experienced in the past [5]. Most of the candidates
planned dental surgical procedure, a thorough discussion for surgical implant placement do not have an experience
should be attempted. Providing information to patients can with implant surgery, and subsequently, they become more
help dentally anxious individuals prepare for treatment and anxious about the associated pain which can affect their
subsequently reduce anxiety levels [3]. certainty about the treatment [4].
As dental implants acquired much popularity as a first On the other hand, the majority of these candidates may
treatment option chosen by the patients, limited information have an experience of at least one tooth extraction.
2 International Journal of Dentistry

Comparing the two surgical experiences will help the pa- One study that compared the pain experience in patients
tients to relate the anticipated pain after implant surgery who went through both tooth removal and dental implant
which can influence their decision-making on proceeding surgery was carried out by Tabrizi et al. [10]. They conducted
with the treatment providing clear and accurate information a crossover study on 40 patients and their pain severity at 12,
about expected pain during treatment which will result in 24, 48, and 72 hours after each procedure was assessed by
more reliable communication between clinicians and pa- using a visual analog scale (VAS) as self-reported. Their
tients. This will enable patients to have a more realistic results showed that the pain of dental implant surgery de-
expectation of the treatment process and reveal all risks that creased faster than tooth extraction with time, and that the
might influence or conflict with their decisions [6]. postsurgical pain with implant surgery is mild with mod-
Well-informed patients about their procedures seem to erate inflammation. They concluded that patients who had
be less anxious and more comfortable [7]. experienced both tooth extraction and a dental implant
A qualitative study of patients’ views of techniques to placement reported significantly less pain in implant surgery
reduce dental anxiety was conducted by Wang et al. [3]. Four [10].
factors were acknowledged as possible ways to reduce patients’ This finding is in line with a conclusion of a study
anxiety levels including preparedness, teamwork, reinforced conducted by Abolfazil et al. [11]. The study was cross-
trust, and tailored treatment plan. In this study, patients sectional, and the patients underwent simple tooth extrac-
preferred to be prepared for the treatment by having more tion for posterior teeth under local anesthesia and received
information about the steps of the procedure. They also in- ibuprofen (400 mg) every 6 hours for postsurgical pain
dicated that engaging them in the process of treatment plan management. Two months later, dental implant surgeries
formulation and decision-making will reduce their anxiety were carried out for all patients, and they received ibuprofen
and build up the trust with their dentists. Importantly, par- (400 mg) every 6 hours as well. Pain level was assessed by
ticipants wanted to know about the anticipated discomfort VAS immediately after procedure and in the interval time of
during and after treatment, the cost, expected treatment time, 6 hours and 1, 3, and 7 days, respectively. They stated that the
and number of appointments needed to complete the treat- level of postsurgical pain after tooth extraction was more
ment [3]. This study supports the concept that well-informed than implant surgery [11].
patients will be less anxious about the dental treatment. Pain and inflammation following the placement of
Dental anxiety has been reported as having direct in- dental implants were assessed by González-Santana et al.
fluence on pain perception in dental procedures in different [12]. They studied pain and swelling in the first-week
laboratory and clinical studies. It is closely linked to painful postimplant surgical placement reported by the patients
stimulus and increased pain perception. Therefore anxious using verbal and visual analog scale (VAS). Most of the
patients may experience more pain that lasts longer with patients reported slight pain with a peak intensity 6 hours
exaggerated memory of pain [8]. after surgery and moderate swelling with a peak intensity of
There is a positive relation between the patient’s fear and inflammation after 48 hours. Analysis of pain 6 hours
anxiety level and pain perception after dental procedures. postoperation showed a statistically significant correlation to
Croog et al. [9] assessed relationships between presurgery the number of implants, as increased pain was recorded in
psychological characteristics and postsurgery pain response the patients subjected to a large number of dental implants.
and effect on life activities following each of two sessions of They concluded that pain after implant placement is mild
periodontal surgery. Forty-two female periodontal patients with moderate inflammation [12].
with no previous surgical experience were evaluated. They Al-Khabbaz et al. [4] assessed the pain associated with
indicated that presurgical scores on dental anxiety, fatigue, surgical implant placement in a multicenter, prospective
and depression were positively associated with measures of study. Patients’ mean pain scores were evaluated with 0 to 10
postsurgical pain after the first surgery. However, a weaker scale during 24 hours and 1, 6, and 12 weeks after surgery.
pattern of associations was evident after the second surgery. They reported that pain experience following the implants’
The study points to the relevance of presurgical psycho- surgical placement was generally mild and gradually de-
logical condition as a predictor of postsurgical pain and creased with time [4].
impairment of life activities. It is indicated that postsurgical Pain experience and anxiety following dental implant
pain and discomfort can possibly be reduced by attempts to placement was investigated by Hashem et al. [13] using
control dental anxiety and emotional distress prior to sur- questionnaires by recording pain intensity interference with
gery. It also supports the perception that patients’ anxiety daily activities on a visual analog scale (VAS). They also
level is reduced with the past dental experience [9]. analyzed pain and anxiety by collecting salivary cortisol 1
week before surgery, the day of surgery, and 3 and 6 days
3. Pain Experience after Implant Surgery postoperatively. Their results stated that most patients re-
Compared to Tooth Extraction ported mild to moderate pain and interference with daily
activities after implant placement. Average pain experience
There are limited data comparing the pain experience of decreased significantly with time, and limitation of daily
dental extraction with dental implant surgery on the same activities was highest on the first postsurgical day and di-
patient. This can be advantageous as the pain experience minished to about half the maximum level by the 2nd or 3rd
reported by the same subject will be more consistent and the day. Patients scored the highest anxiety level on the day of
comparison will be more reliable. surgery; however, the salivary cortisol level did not validate
International Journal of Dentistry 3

this as no difference was presented. It is concluded that greater in patients with implants placed in the posterior
implant placement is a mild to moderately painful and versus anterior zone and in free end spaced or totally
anxiety-provoking procedure with some limitations of daily edentulous patients versus interdental spaces.
activities and symptoms are expected to occur during the González-Santana et al. [12], who studied the pain and
first 3 postsurgical days [13]. swelling in the first-week postimplant surgical placement
A comparison study conducted by Yao et al. [6] revealed reported by the patients using VAS, analyzed the relation
that surgical tooth extraction is significantly associated with between inflammation 48 hours after the operation and the
more pain and bleeding at the first day of healing. However, different study variables. Statistically significant correlations
more swelling and bruising were associated with implant were found: more advanced patient age, surgery in eden-
placement with guided bone regeneration procedure. It is tulous patients and free extremes, and surgical approaches in
reported that healing events of straightforward implants are the posterior area of maxilla and mandibula.
similar to those of simple extraction [6]. Moreover, a significant association was observed be-
The patients’ perspective, i.e., how patients perceive their tween swelling and more number of implants placed and
oral health, is being recognized recently as a significant with surgery involving sinus lift or bone regeneration
outcome in modern implant dentistry. A study was con- procedures [12]. The results of Yao et al. [6] also reported
ducted to assess how patients perceive the perisurgical stages that patients who had implant placement with guided bone
of implant placement and whether the overall perceived regeneration procedure may experience more swelling and
burden of the surgical process is related to specific stage of bruising [6].
treatment and to compare patients’ perceptions during Location of the placed implant and the proximity to vital
implant placement with tooth extraction. Considering structures is correlated with pain perception. Swelling was
treatment stages, burdens were highest for anesthesia and reported to be greater in patients with implants placed in the
lowest for side effects. The study results demonstrated that posterior versus anterior zone and in free end spaced or
even though implant placement requires basically similar totally edentulous patients versus interdental spaces [12].
surgical procedure and instruments for incision, muco- Timing of implant placement and loading are also related
periosteal flap reflection, bone drilling, and suturing, pa- to the pain experience. Immediate implants may be asso-
tients seem to perceive the procedures related to bone and ciated with more discomfort as patients’ undergo an ex-
soft tissue less burdensome than during surgical tooth ex- tensive surgical procedure of both tooth extraction and
traction. It can be concluded that implant placement was implant placement. Urban and Wenzel reported that pa-
rated as least burdensome, especially in relation to bone and tients experienced low to moderate pain with severe swelling
soft tissue manipulations such as pressure during incision or after immediate implant placement in the molar area with
vibration due to drills compared with surgical tooth ex- the regenerative procedure [17]. Immediate loading may
traction [14]. induce more postoperative pain and swelling than con-
ventional or delayed loading [18].
4. Factors Affecting Pain Experience in In terms of flap design, flapless procedure has less pain
Implant Patients intensity and duration and faster healing time than open flap
procedures. There is a relatively high probability (43%) of
Many factors are associated with the reported pain intensity experiencing no pain with no medications, and this prob-
in relation to the implant placement procedure such as ability could be increased by taking steroidal anti-inflam-
operator experience, female gender, and surgical difficulty as matory agents [19]. Khouly et al. reported that short-term
reported by Al-Khabbaz et al. [4]. use of analgesic medications, in the first 72 hours, is suffi-
The surgeon’s experience plays a role in reducing the cient for postsurgical pain management in dental implant
perisurgical and postsurgical pain [15]. Morin et al. stated surgery [20]. On the other hand, it is recommended that
that senior surgeons produced significantly less pain than analgesics should be prescribed during the first week after
juniors during the implant placement procedure. They also tooth extraction indicating that tooth extraction has a
found that pain after implant placement perceived differ- prolonged unpleasant healing process that necessitates using
ently based on the patients’ gender, with females reporting analgesics up to the 7th postextraction day. [21].
greater overall pain intensity than males. However, men are Minimally invasive procedures are always preferred to
more disturbed by the low levels of pain during healing than reduce patients’ anxiety and the pain experience and hence
women [16]. increase the treatment acceptance rate by the patient.
A number of implants placed and the related regener-
ative procedures (e.g., guided bone regeneration, sinus lift, 5. Discussion
and split ridge) are associated with increased postsurgical
pain and swelling. Moreover, pain experience is more in- It is suggested that pain intensity is higher with tooth ex-
tense in older patients and smokers [12, 13]. traction compared to the implant placement procedure. This
It is proven that the longer the duration of the procedure, can be explained as most of the extracted teeth are usually
the more swelling, pain and discomfort perceived by patients chronically inflamed or symptomatic. There is a significant
[14]. relation between pre-extraction tooth status and the pain
Location of the placed implant and the proximity to vital intensity perceived after extraction, as postextraction pain
structures is correlated with pain perception. Swelling is can increase 3 folds in patients with symptomatic teeth
4 International Journal of Dentistry

[22, 23]. The reason for such pain is most probably due to the dental implants,” Journal of Periodontology, vol. 78, no. 2,
synergistic effect of different inflammatory mediators, pp. 239–246, 2007.
produced by the pre-existing inflammatory condition that [5] A. J. Van Wijk and J. Hoogstraten, “Experience with dental
produces a long-lasting increase in the nociceptors activity pain and fear of dental pain,” Journal of Dental Research,
[24]. Therefore, inflamed teeth with triggered nociceptors vol. 84, no. 10, pp. 947–950, 2005.
[6] J. Yao, K. Lee, C. McGrath, Y. N Wu, K. Y. Li, and
and carious teeth with excited nerve endings will produce
N. Mattheos, “Comparison of patient-centered outcomes after
more pain when extracted as compared with noninflamed routine implant placement, teeth extraction, and periodontal
teeth [21]. Subsequently, it is expected that implant place- surgical procedures,” Clinical Oral Implants Research, vol. 4,
ment procedure that does not involve dealing with inflamed pp. 373–380, 2016.
teeth is more pleasant and has less postsurgical pain [7] U. Berggren and G. Meynert, “Dental fear and avoidance:
perception. causes, symptoms, and consequences,” Journal of the Amer-
Another explanation is that dental implant surgery is a ican Dental Association, vol. 109, no. 2, pp. 247–251, 1984.
more controllable and less traumatic procedure than tooth [8] M. Wong and D.-G. Kaloupek, “Coping with dental treat-
extraction. Subsequently, less pain and discomfort is ex- ment: the potential impact of situational demands,” Journal of
pected postsurgically. Behavioral Medicine, vol. 9, pp. 579–597, 1986.
More research studies should be carried out to compare [9] S. H. Croog, R. M. Baume, and J. Nalbandian, “Pre-surgery
between surgical implant placement and other oral surgical psychological characteristics, pain response, and activities
impairment in female patients with repeated periodontal
procedures on the same individuals with larger sample sizes,
surgery,” Journal of Psychosomatic Research, vol. 39, no. 1,
taking into consideration the contributing factors that might pp. 39–51, 1995.
affect the pain perception by implant candidates. [10] R. Tabrizi, H. Mohajerani, A. Nabtieh, and S. Shafiei, “Do
patients have the same experience of pain following tooth
6. Conclusion extraction and dental implants?” Annals of maxillofacial
surgery, vol. 10, no. 1, pp. 88–90, 2020.
Informing patients about the anticipated surgical procedure [11] S. Abolfazli, E. Gravand, M. Hedayatian, A. Rohani, and
of implant placement and the postsurgical pain intensity can K. Shakerian, “Comparison of pain between tooth extraction
reduce their anxiety level and subsequent postsurgical pain and implant surgery,” Journal of Research in Medical and
and discomfort. Patients can be informed that, in general, Dental Science, vol. 7, no. 3, pp. 126–131, 2019.
implant placement surgical experience is less unpleasant [12] H. González-Santana, M. Peñarrocha-Diago, J. Guarinos-
compared to tooth extraction with less postsurgical pain and Carbó, and J. Balaguer-Martı́nez, “Pain and inflammation in
limitation of daily activities. However, some factors can 41 patients following the placement of 131 dental implants,”
Medicina Oral, Patologia Oral Cirugia Bucal, vol. 10,
increase the pain intensity and discomfort level on indi-
pp. 258–263, 2005.
vidual bases.
[13] A. A. Hashem, N. M. Claffey, and B. O’Connell, “Pain and
anxiety following the placement of dental implants,” The
Abbreviations International Journal of Oral & Maxillofacial Implants, vol. 21,
no. 6, pp. 943–950, 2006.
VAS: Visual Analog Scale. [14] D. Reissmann, G. Poulopoulos, and J. Durham, “Patient
perceived burden of implant placement compared to surgical
Data Availability tooth removal and apicectomy,” Journal of Dentistry, vol. 12,
pp. 1456–1461, 2015.
The data supporting this review are from previously reported [15] I. Eli, D. Schwartz-Arad, R. Baht, and H. Ben-Tuvim, “Effect of
studies and datasets, which have been cited. anxiety on the experience of pain in implant insertion,”
Clinical Oral Implants Research, vol. 14, pp. 115–118, 2003.
Conflicts of Interest [16] C. Morin, J. P. Lund, T. Villarroel, C. M. L. Clokie, and
J. S. Feine, “Differences between the sexes in post-surgical
The author declares no conflicts of interest. pain,” Pain, vol. 85, no. 1-2, pp. 79–85, 2000.
[17] T. Urban and A. Wenzel, “Discomfort experienced after
References immediate implant placement associated with three different
regenerative techniques,” Clinical Oral Implants Research,
[1] A. N. Tanidir, M. S. Atac, and E. Karacelebi, “Information vol. 21, pp. 1271–1277, 2010.
given by multimedia: influence on anxiety about extraction of [18] T. Mundt, N. Passia, W. Att et al., “Pain and discomfort
impacted wıidom teeth,” British Journal of Oral and Maxil- following immediate and delayed loading by over dentures in
lofacial Surgery, vol. 54, no. 6, pp. 652–657, 2016. the single mandibular implant study (SMIS),” Clinical Oral
[2] U. Klages, O. Ulusoy, S. Kianifard, and H. Wehrbein, “Dental Investigations, vol. 21, no. 2, pp. 635–642, 2017.
trait anxiety and pain sensitivity as predictors of expected and [19] T. Fortin, J. L. Bosson, M. Isidori, and E. Blanchet, “Effect of
experienced pain in stressful dental procedures,” European flapless surgery on pain experienced in implant placement
Journal of Oral Sciences, vol. 112, no. 6, pp. 477–483, 2004. using an image-guided system,” The International Journal of
[3] M. C. Wang, K. Vinall-Collier, J. Csikar, and G. Douglas, “A Oral & Maxillofacial Implants, vol. 21, p. 298, 2006.
qualitative study of patients’ views of techniques to reduce [20] I. Khouly, R. S. Braun, M. Ordway et al., “Post-operative pain
dental anxiety,” Journal of Dentistry, vol. 66, pp. 45–51, 2017. management in dental implant surgery (2021) a systematic
[4] A. K. Al-Khabbaz, T. J. Griffin, and K. F. Al-Shammari, review and meta-analysis of randomized clinical trials,”
“Assessment of pain associated with the surgical placement of Clinical Oral Investigations, vol. 25, no. 5, pp. 2511–2536, 2021.
International Journal of Dentistry 5

[21] T. H. Al-Khateeb and A. Alnahar, “Pain experience after

simple tooth extraction,” Journal of Oral and Maxillofacial
Surgery, vol. 66, pp. 911–917, 2008.
[22] D. A. Ruta, E. Bissias, S. Ogston, and G. R. Ogden, “Assessing
health outcomes after extraction of third molars: the post-
operative symptom severity (PoSSe) scale,” British Journal of
Oral and Maxillofacial Surgery, vol. 38, no. 5, p. 480, 2000.
[23] G. D. Slade, S. P. Foy, D. A. Shugars, C. Phillips, and
R. P. White, “The impact of third molar symptoms, pain, and
swelling on oral health-related quality of life,” Journal of Oral
and Maxillofacial Surgery, vol. 62, p. 1118, 2004.
[24] J. Levine, “Pain and analgesia: the outlook for more rational
treatment,” Annals of Internal Medicine, vol. 100, p. 269, 1984.