Int. J. Oral Maxillofac. Surg.
2009; 38: 395–396
?available online at http://www.sciencedirect.com
Letters to the Editor
Effect of ice compression on pain after
mandibular third molar surgery: a
single-blind, randomized controlled
trial
We read the article of FOROUZANFAR
et al.1 with interest while this is a report
of a randomized clinical trial on a potential
useful treatment in our daily practice.
Although randomized clinical trials are
the golden standard in clinical research,
they are relatively scarce in our profession2.
In the article, the authors rightly con-
cluded that there was no significant extra
pain reduction when ice was added to the
compression pack. Patients were correctly
blinded for the addition of ice, as were the
surgeons. However, the conclusion that
compression itself has a significant effect
on pain reduction and quality of live is not
entirely appropriate. Although the patients
were randomized in three groups, they were
only blinded for the addition of ice. This
means that the patients in group A and B
knew that they received extra compression
therapy after surgery and the controls
(group C) knew that they were not receiv-
ing any additional therapy. Therefore, a
substantial placebo effect between the
groups (A and B versus C) could be
expected. The authors discuss the potential
placebo effect of the compression therapy
but fail to recognize that this effect is very
much embedded in the design of their
study. Moreover, because the controls were
fully aware of the fact that no treatment was
given to them, an information bias can also
be suspected which has an influence on
their assessment of pain and quality of live.
Together, both items make the outcomes of
the VAS and quality-of-live scores dubious
and difficult to interpret.
Another, minor shortcoming is the fact
that patients who underwent a removal of
a wisdom tooth in the past were not
0901-5027/040395 + 02 $36.00/0 # 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
excluded from the study. Because of the
potentially severe impact of this type of
treatment, these patients are prone to
‘‘rumination bias’’ which means that their
experiences from the past will influence
their appraisal of the complications of the
present treatment.
In conclusion, whether or not there is
any real effect of compression therapy
after removal of third molars can not be
drawn from this study and the positive
effect that was observed on pain and qual-
ity-of-live scores is possibly ‘‘only’’ a
placebo effect.
J. de Lange*
E.M. Baas
Dep. Oral & Maxillofacial Surgery,
Zwolle, The Netherlands
References
1. Forouzanfar T, Sabelis A, Ausems S,
Baart JA, van der Waal I. Effect of ice
compression on pain after mandibular third
molar surgery: a single-blind, randomized
controlled trial. Int J Oral Maxillofacial
Surg 2008: 37: 824–830.
2. Kyzas PA. Evidence-Based Oral and
Maxillofacial Surgery. J Oral Maxillofac
Surg 2008: 66: 973–986.
doi:10.1016/j.ijom.2008.12.018
Reply to letter to the editor ‘‘Effect of
ice compression on pain after mandib-
ular third molar surgery: a single-
blind, randomized controlled trial’’
We are pleased to read the comments in
the letter. Pain, pain management and pain
measurement is still a difficult subject in the
dental-medical practise. Therefore every
comment leading to improvement of any
investigation in these subjects is welcome.
According to the comments the effect of
ice compression and compression without
ice is mainly caused by the placebo effect.
Furthermore there would be a information
bias in the VAS and quality-of-life score
because the control group was fully aware of
the fact that no treatment was given to them.
Levine et al.1 clearly demonstrated that
placebo analgesia is mainly endogenous.
Endorphin production starts directly after
placebo effect1. In our study significant
pain reduction in the treatment groups
started after the third day. In the first 3
days there were no differences between
the groups. If the results are mainly a
placebo effect, one would expect that there
were also some differences in pain reduc-
tion between the groups. Therefore we
think that beside a placebo effect there
is also a physiologic effect in the treatment
groups which has resulted in the signifi-
cant pain reduction after day 3. Further we
are aware that there is an information bias,
which can be suspected in all subjective
measurements. It is not clear if this bias is
mainly the result of the fact that the
patients in the control group were aware
that they were not receiving any additional
therapy. However, because this bias did
not result in any differences between the
three groups in the first 3 days we can
conclude that the effect of the information
bias on the total result is minimal. There-
fore, the outcomes of these subjective
measures are not dubious and are not
difficult to interpret.
The patient population of our study
consisted of patients who needed a surgi-
cal removal of the third molar for the first
time. Patients with bilateral removal were
excluded.
We are aware that our study design is
not optimal and has several shortcoming.