Postoperative Pain After Dental Procedures: A National Dental PBRN Observational Study Using an mHealth Platform

Abstract

Background:

Managing postoperative dental pain is essential, but patient-reported data on pain and current medication practices are scarce. This study examined pain, functional interference, and medication use reported by patients following common dental procedures.

Methods:

In this prospective observational cohort study, 2,674 adults in a multi-center U.S. practice-based network reported pain intensity and interference via a mobile app. Outcomes were collected on days 0, 1, 3, 5, and 7 to assess trajectories across endodontic, periodontal, oral surgery, implant procedures, and multiple procedures within these four categories.

Results:

Among 2,674 participants (mean age, 49.8 years; 55.6% female), mean pain intensity decreased from 3.0 (SD, 3.5) on day 0 (pre-op), 2.2 (SD, 2.4) on day 1, and to 0.9 (SD, 1.5) on day 7. Patient-reported opioid use declined from 6.6% on day 1 to 1.8% on day 7. After adjusting for various factors, surgical extractions had the highest odds of moderate-to-severe pain, with an adjusted odds ratio (aOR) of 2.1 (95% CI, 1.3–3.5; P = .003). Multiple procedures had aOR of 2.5 (95% CI, 1.3–5.0; P=.008). Surgical extractions were also associated with increased difficulty falling asleep, with an aOR of 2.6 (95% CI, 1.2–5.6; P = .018).

Conclusions:

Postoperative pain and functional interference vary significantly by procedure. Surgical extractions and multiple procedures confer the highest risk for moderate-to-severe pain, which patients primarily managed with non-opioid analgesics.

Practical Implications:

These findings can guide patient counseling on pain trajectories and help develop procedure-specific, non-opioid pain management protocols to improve care and promote opioid stewardship.

Introduction

Acute post-operative pain is a common and expected consequence following many dental procedures, significantly impacting patients' quality of life and daily function.^1,2 Inadequately managed dental pain can impede recovery, affect eating and sleeping, lead to patient dissatisfaction, and potentially increase healthcare utilization.^3–5 Furthermore, the prescribing of analgesics, particularly opioids, occurs frequently in dentistry, making it a frontline discipline for balancing effective pain relief with public health imperatives around opioid misuse.^6–9 Procedures like surgical extractions, endodontic treatments, and implant placements can cause varying discomfort, but there's still insufficient understanding of patients' pain experiences in the first week post-treatment.^1,10–12

Current clinical understanding of the typical post-operative course is often limited by traditional pain assessment methods, which frequently rely on patient recall during intermittent clinic visits.^13,14 Such methods are susceptible to recall bias and provide only static snapshots, missing the nuances of how pain fluctuates day-to-day and affects real-time functional ability.^15–17 Significant gaps remain in the real-world evidence regarding patients' pain and functional interference outside clinical settings. There is a need for detailed data on these experiences across common dental procedures, as large-scale comparative studies are lacking but essential for refining clinical expectations and improving pain management strategies.¹⁸ Equally important is the need to understand how patient-reported pain corresponds with actual analgesic consumption patterns, including opioid and non-opioid use, an area that remains insufficiently documented in routine dental practice.¹⁹

To address these limitations, this study utilized Patient-Reported Outcomes (PROs) collected via a mobile health (mHealth) platform. PROs capture patients' perspectives on their symptoms and functional status using validated tools, ensuring data quality.^20,21 Mobile health technologies offer a robust method for collecting these PROs longitudinally, frequently, and conveniently from patients within their own environment.^22,23 By prioritizing patient-centered outcomes, we aim to enhance shared decision-making and holistic care in dentistry.²⁴

In this study, we characterize and compare post-operative pain experiences across common dental procedures using mHealth-collected patient-reported outcomes (PROs). The objectives were to: (1) describe pain intensity over the first 7 days post-surgery; (2) examine daily pain interference with activities, sleep, eating, and speaking during the same period; (3) compare pain intensity and interference among different dental procedures (Endodontics, Periodontal Surgery, Oral Surgery, Implant Dentistry, and Multiple Surgical Procedures); and (4) analyze patterns of analgesic use, including opioids and non-opioids, and their association with procedure type.

Methods

Study Design and Population

This prospective observational cohort study characterized patient-reported pain experiences following routine dental procedures known to cause clinically meaningful postoperative pain (for example, extractions, implant placement, endodontic therapy, and periodontal surgery). Non-surgical operative procedures such as direct restorations, crowns, and inlays/onlays were not included because they generally produce little or no postoperative pain. The study was conducted over a 16-month period, with data collection spanning from January 2022 to May 2024. We used the National Dental PBRN, a nationwide network of participating dental practices across the United States. This network encompasses six administrative regions and includes a diverse mix of dental providers and patient populations regarding demographics and clinical characteristics, enhancing the generalizability of the findings.²⁵ The study adhered to STROBE guidelines for observational research and was approved by the National Dental PBRN institutional review board.

Study Participants and Recruitment

Providers, including general dentists and specialists in Oral and Maxillofacial Surgery, Endodontics, and Periodontics, were recruited by PBRN regional coordinators. They enrolled eligible patients aged 18 and older, who were scheduled for painful procedures and had access to a smartphone. Informed consent was obtained verbally from all participants before enrollment.

Data Collection, Variables, and Outcomes

Data were collected from two sources: an mHealth platform (FollowApp.Care) for patient-reported outcomes (PROs) and dentists’ input procedural and prescribing data in an electronic case report form (REDCap^26,27). Additional details of the study design, sites, population, eligibility criteria, and the mHealth platform have been detailed in our published protocol.²⁸

Enrolled patients received text message prompts with brief surveys at 9:00 AM on Days 1, 3, 5, 7, 14, and 21 post-procedure. The main outcomes assessed were pain intensity and pain interference in the first seven days. Pain intensity was measured using a single item from the PROMIS^® Short Form 3a on a 0–10 numerical rating scale. Pain interference, which indicates how pain affects daily activities, was evaluated through five items from the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R), also on a scale from 0 to 10. This assessment focused on the impact of pain on activities, sleep, eating, and speaking. We use the term "interference" to stay consistent with the terminology of this validated instrument and the PROMIS "pain interference" domain. For analysis, both pain and interference scores were categorized as none (0), mild (1–3), moderate (4–7), or severe (8–10). Survey non-completion was monitored, and response rates were evaluated at each time point to assess feasibility and participant burden. Here we report on the immediate post-operative period (days 1–7).

Procedure categories (Endodontics, Periodontal Surgery, Oral Surgery, Implant Dentistry, Multiple Surgical Procedures) were assigned based on standardized dental procedure codes (CDT) from the EHR (see published protocol²⁸). For the analyses, endodontic procedures were further divided into non-surgical root canal therapy, pulp treatment (e.g., pulpotomy or pulpectomy), and endodontic surgery (e.g., apicoectomy). Periodontal surgery comprised both soft-tissue and osseous procedures, including flap surgery with or without osseous recontouring, periodontal regenerative procedures, and crown lengthening. Oral surgery procedures were categorized as simple extractions, surgical extractions, or other oral surgery (for example, alveoloplasty, tori removal, and surgical exposure of teeth). The ‘multiple procedures’ category was used when two or more of the above qualifying procedures were performed during the same visit (for example, multiple extractions, or an extraction combined with implant placement or periodontal surgery). Restorative and other non-surgical procedures performed at the same visit were not coded as separate index procedures but may have occurred in combination with these qualifying procedures. Other variables included patient-reported medication use, patient demographics (age, gender, income, insurance), pre-procedural pain, and presence of swelling. To improve data integrity, real-time data validation checks were embedded in REDCap forms, and clinics received regular reminders to complete entries within 48 hours of the procedure.

Statistical Analysis

The sample size calculation estimated recruitment of between 150 and 215 dental providers, with each provider expected to enroll an average of 21 patients for a total maximum of 3147 patients. Assuming a 40% missing data rate among enrolled patients throughout the duration of the study, including patient non-response rates as well as item non-response rates for the outcome of interest during the study period, a final sample of 1888 was estimated to be required for statistical analysis. Power analysis indicated the study had 80.7% power to detect a 2.0-unit difference in pain intensity with a significance level of 0.05 (α=0.05) and a within-cluster correlation coefficient of 0.1 (ρ=0.1).

Descriptive statistics were used to quantitatively summarize patient, procedure, and outcome variables. An analytic dataset was formed after excluding patients who withdrew, had non-qualifying dental procedures, or had no postoperative outcome data (i.e., non-response on all post-procedure surveys). For the remaining participants, we used all available outcome measurements; patients contributed data even if they missed one or more daily surveys. Because the measures of association in the hierarchical models (generalized linear mixed models-GLMMs) were calculated using maximum-likelihood estimation, they provide unbiased estimates under a missing-at-random assumption and do not require imputation of intermittently missing outcome data. Observations with truly missing covariate values were rare (<5% for each variable) and were excluded from the multivariable models. Univariate models and chi-squared test of association were used for variable selection.

To test whether there was a difference in the odds of pain intensity or pain interference between procedure groups, hierarchical linear and multinomial logistic regression models were used that adjusted for repeated measures over patient responses. Using hierarchical models adjusted for provider-level factors and minimizing patient selection bias. Adjusted models included the procedure type, medications taken, time of survey, age, gender, pre-procedural pain, income, and insurance, which limited effect modification and confounding bias due to these variables. All analyses were performed using R Statistical Software, with statistical significance set at α=0.05.

Results

Participant Flow and Characteristics

A total of 143 dental providers recruited 3,139 patients, of whom 2,674 met inclusion criteria for the final analytic sample (Figure 1). Of the 465 patients excluded, 10 withdrew from the study, 26 had non-qualifying procedures, 265 did not complete any postoperative surveys, and 164 did not respond to any question on day 0. The mean (SD) age was 49.8 (17.4) years, and 1488 (55.6%) were female (Table 1). The most common procedures were simple extractions (28.4%), surgical extractions (25.8%), and non-surgical endodontic procedures (20.2%) (Table 1). Participants were recruited from practices in all six National Dental PBRN regions, with the largest proportions from the Southwest (25.6%) and Midwest (22.4%), followed by the Northeast (17.8%), South Atlantic (12.7%), Western (12.3%), and South Central (9.2%) regions (Table 1; Supplemental Figure 1). Supplemental Table 2 shows the demographic characteristics of the general dentists and specialists who participated in the study. Response rates for the daily mHealth surveys were high, beginning at 87.0% on Day 1 and remaining at 80.0% on Day 7. Survey response rates across all time points are reported in Supplemental Table 3.

Figure 1:

Inclusion and exclusion of patients at each step of creating the final analytic dataset

Table 1:

Distribution of patient characteristics

PATIENT CHARACTERISTICS	N = 2674	%
AGE	49.8 years	SD = 17.4
GENDER
Female	1488	55.6%
Male	1171	43.8%
Other	5	0.2%
Missing	10	0.4%
RACE
African American	394	14.7%
Asian	151	5.6%
Caucasian	1843	68.9%
Native American Alaska Native	31	1.2%
Native Hawaiian Other Pacific Islander	17	0.6%
Multiple Races	73	2.7%
Prefer Not to Answer	119	4.5%
Missing	46	1.7%
ETHNICITY
Hispanic/Latino Origin	339	12.7%
Not Hispanic/Latino Origin	2270	84.9%
Prefer Not to Answer	43	1.6%
Missing	22	0.8%
INSURANCE
Private Insurance	1561	58.4%
Public/Government Insurance	489	18.3%
No Dental Insurance	436	16.3%
Prefer Not to Answer	34	1.3%
I Don’t Know	69	2.6%
Missing	85	3.2%
EDUCATION
Less than High School Diploma	95	3.6%
High School Diploma/GED	659	24.6%
Some College/ Associate's Degree	857	32.0%
Bachelor's Degree	600	22.4%
Graduate Degree	432	16.2%
Missing	31	1.2%
INCOME
Up to $25,000	291	10.9%
$25,001-$50,000	460	17.2%
$50,001-$100,000	699	26.1%
Over $100,000	714	26.7%
Prefer Not to Answer	474	17.7%
Missing	36	1.3%
NEIGHBORHOOD
Rural	487	18.2%
Suburban	1437	53.7%
Urban	704	26.3%
Missing	46	1.7%
GEOGRAPHIC REGION (UNITED STATES)
Southwest	685	25.6%
Midwest	598	22.4%
Northeast	475	17.8%
South Atlantic	339	12.7%
Western	329	12.3%
South Central	248	9.2%
HOUSEHOLD MEMBER COUNT	2.87 (med = 2)	SD=2.08
PROCEDURE TYPE
Endodontics - Non-Surgical	547	20.5%
Endodontics - Pulp Treatment	71	2.7%
Endodontics-Surgery	22	0.8%
Extractions - Simple	765	28.6%
Extractions - Surgical	689	25.8%
Implants - Surgical Procedures	179	6.7%
Multiple Procedures	207	7.7%
Oral Surgery Other	14	0.5%
Perio - Surgical	180	6.7%

Pain and Functional Interference

During the preoperative treatment period (Day 0), the overall mean (SD) pain intensity score was 3.0 (3.5). 51.8% of total respondents reported higher levels of pain intensity on Day 1 post treatment, while 34.8% reported higher pain intensity levels on Day 0, and 13.4% did not answer. Figure 2 shows the distribution of patient-reported average pain intensity (0–10 point scale) by dental procedure type across the 7 day reporting period. In the postoperative period (Days 1 through 7), the mean (SD) pain intensity score was highest on Day 1 post-procedure at 2.2 (2.4) and declined to 0.9 (1.5) by Day 7 (Supplemental Figure 3a). Accordingly, 60.9% of patients reported any pain (score ≥1) on Day 1, which decreased to 30.9% by Day 7 (Supplemental Figure 3b). On average, patient-reported pain interference with daily functions such as sleeping and eating was in the mild range (mean scores <3) across the first week (Supplemental Table 3).

Figure 2:

Distribution of average pain intensity experienced by patients by dental procedure type from the day 0 pre-operative period through the 7-day postoperative period

Postoperative Medication Use

Most patients reported using some form of analgesic medication, declining from 88.1% of respondents on Day 1 to 60.4% on Day 7. Non-opioid analgesics were the most frequently used medication type (Supplemental Figure 2). Patient-reported opioid use, decreased from 6.6% of patients on Day 1 to 1.8% on Day 7. Procedure type was significantly associated with the type of medication used across all assessment days (all P < .0001).

Adjusted Association Between Procedure Type and Outcomes

Hierarchical regression models showed that after adjusting for time, medication, pre-operative pain, and patient-relevant covariates, undergoing multiple procedures, surgical extractions, surgical implants, and periodontal surgeries were consistently associated with higher post-operative pain intensity. In contrast, non-surgical endodontic treatments (reference group) were associated with the lowest pain intensity scores.

Patients undergoing multiple surgical procedures had significantly higher odds of moderate (OR: 4.23, 95% CI: 2.11–8.48, p < 0.001) and severe pain (OR: 7.52, 95% CI: 3.06–18.47, p < 0.001) compared to non-surgical endodontics. Surgical periodontal procedures had the highest odds of mild pain (OR: 2.79, 95% CI: 1.45–5.35, p = 0.002).

Additional predictors of greater pain included female gender, presence of pre-operative pain, and household income below $25,000. Conversely, older age and time since procedure were independently associated with reduced pain intensity (Table 2).

Table 2:

Multinomial logistic regression analysis for intensity of pain experienced by patients 7 days postoperatively (Model adjusted for procedure type, day after procedure, medications, preoperative pain intensity, gender, age, insurance, income and presence of postoperative swelling)

	Pain (Mild) vs Pain (None)				Pain (Moderate) vs Pain (None)				Pain (Severe) vs Pain (None)
	Odds Ratio	P-value	95% CI		Odds Ratio	P-value	95% CI		Odds Ratio	P-value	95% CI
Procedure Types
Endodontics - Non-surgical (Baseline)
Endodontics - Pulp Treatment	0.523	0.176	0.205	1.337	0.779	0.643	0.271	2.239	1.068	0.919	0.300	3.798
Extractions - Simple	1.308	0.214	0.857	1.995	1.732	0.027	1.065	2.816	2.131	0.024	1.104	4.113
Extractions - Surgical	1.754	0.013	1.128	2.726	2.391	0.001	1.450	3.942	3.335	<0.001	1.709	6.510
Implants - Surgical Procedures	2.332	0.013	1.196	4.547	2.779	0.010	1.276	6.051	4.313	0.009	1.439	12.927
Multiple Procedures	2.603	0.003	1.395	4.857	4.237	<0.001	2.115	8.485	7.527	<0.001	3.066	18.475
Perio - Surgical	2.795	0.002	1.458	5.358	3.921	<0.001	1.871	8.218	3.649	0.028	1.151	11.573
Day after procedure
Day 1 (Baseline)
Day 3	0.284	<0.001	0.226	0.358	0.167	<0.001	0.126	0.222	0.166	<0.001	0.110	0.251
Day 5	0.121	<0.001	0.095	0.155	0.054	<0.001	0.040	0.074	0.059	<0.001	0.037	0.092
Day 7	0.056	<0.001	0.043	0.074	0.016	<0.001	0.011	0.023	0.014	<0.001	0.008	0.024
Non-opioid medication taken in 7 days
Yes	8.282	<0.001	5.432	12.627	13.791	<0.001	8.292	22.937	15.909	<0.001	8.129	31.137
Opioid medication taken in 7 days
Yes	6.570	<0.001	3.802	11.352	14.096	<0.001	7.926	25.070	28.378	<0.001	14.956	53.846
Pain intensity before procedure
No pain (Baseline)
Mild	3.451	<0.001	2.313	5.151	3.363	<0.001	2.138	5.290	1.465	0.304	0.707	3.036
Moderate	5.397	<0.001	3.374	8.634	6.058	<0.001	3.586	10.232	7.791	<0.001	3.941	15.401
Severe	4.794	<0.001	3.161	7.269	7.418	<0.001	4.687	11.743	18.070	<0.001	10.150	32.169
Gender
Female	1.040	0.798	0.772	1.400	1.804	0.001	1.289	2.525	2.447	<0.001	1.570	3.815
Age group
18–25 years old (Baseline)
26–45 years old	0.454	0.013	0.244	0.844	0.305	<0.001	0.159	0.587	0.315	0.003	0.145	0.683
46–65 years old	0.278	<0.001	0.150	0.514	0.119	<0.001	0.062	0.229	0.165	<0.001	0.076	0.357
>65 years old	0.288	<0.001	0.151	0.550	0.116	<0.001	0.058	0.232	0.113	<0.001	0.048	0.269
Insurance type
No insurance/Self-pay (Baseline)
I don’t know	2.083	0.231	0.627	6.920	3.676	0.042	1.046	12.913	7.988	0.002	2.110	30.241
Private Insurance	1.626	0.022	1.071	2.468	1.448	0.121	0.907	2.313	0.846	0.565	0.478	1.496
Public/Government Insurance	1.674	0.049	1.002	2.795	2.141	0.008	1.221	3.755	1.814	0.075	0.942	3.492
Annual Household Income
Less than $25,000 (Baseline)
$25,001-$50,000	0.907	0.727	0.525	1.568	0.744	0.322	0.414	1.337	1.076	0.829	0.553	2.093
$50,001-$100,000	0.794	0.408	0.461	1.370	0.528	0.034	0.293	0.951	0.390	0.009	0.191	0.793
Over $100,000	0.713	0.239	0.406	1.252	0.413	0.005	0.223	0.765	0.304	0.003	0.140	0.659
Presence of post-operative swelling
Yes	9.335	<0.001	6.490	13.427	18.178	<0.001	11.656	28.350	10.973	<0.001	6.136	19.621

Pain Interference with Daily Functions

As shown in Table 3, the odds of experiencing mild interference while performing activities, eating, and speaking during the 7 days post-procedure had the most statistically significant associations for all procedure types except endodontic pulp treatments and simple extractions, as compared to non-surgical endodontic treatments. With respect to sleep, patients undergoing surgical extractions and multiple procedures had higher odds of difficulty falling asleep compared with those receiving non-surgical endodontic treatment. Surgical extractions were associated with increased odds of both mild (OR, 1.57; 95% CI, 1.08–2.29, p-value=0.018) and severe (OR, 2.45; 95% CI, 1.10–5.42, p-value=0.027) interference with falling asleep, and multiple procedures showed a similar pattern (severe interference OR, 4.56; 95% CI, 1.75–11.89, p-value=0.002).

Table 3:

Multinomial logistic regression analysis for pain interference experienced by patients during the 7 days postoperatively (Model adjusted for procedure type, day after procedure, medications, preoperative pain intensity, gender, age, insurance, income and presence of postoperative swelling)

Interference Outcome Group Dental Procedure	Falling Asleep				Staying Asleep				Doing Activities				Eating Food				Saying Words
	OR	P-value	95% CI		OR	P-value	95% CI		OR	P-value	95% CI		OR	P-value	95% CI		OR	P-value	95% CI
Interference (Mild) vs (None)
Endodontics - Pulp Treatment	0.677	0.396	0.275	1.667	0.696	0.458	0.267	1.813	1.387	0.478	0.561	3.429	1.275	0.523	0.606	2.681	2.653	0.059	0.962	7.315
Extractions - Simple	1.053	0.792	0.720	1.539	0.975	0.902	0.656	1.451	1.509	0.070	0.966	2.355	1.345	0.098	0.947	1.912	1.897	0.032	1.056	3.408
Extractions - Surgical	1.573	0.018	1.080	2.291	1.267	0.240	0.854	1.881	1.915	0.004	1.236	2.967	1.746	0.004	1.195	2.551	2.859	0.000	1.628	5.021
Implants - Surgical Procedures	1.439	0.214	0.811	2.553	1.415	0.251	0.782	2.558	2.631	0.003	1.382	5.009	1.390	0.227	0.815	2.372	2.884	0.011	1.278	6.508
Multiple Procedures	1.720	0.038	1.030	2.872	1.406	0.215	0.820	2.412	2.126	0.011	1.187	3.806	1.934	0.022	1.102	3.394	3.362	0.001	1.683	6.716
Perio - Surgical	1.300	0.358	0.743	2.274	1.302	0.371	0.730	2.322	2.143	0.017	1.143	4.018	2.475	0.002	1.411	4.344	5.179	0.000	2.526	10.618
Interference (Moderate) vs (None)
Endodontics - Pulp Treatment	0.898	0.874	0.238	3.393	2.028	0.271	0.576	7.134	1.301	0.748	0.261	6.494	0.688	0.538	0.210	2.259	1.107	0.928	0.124	9.899
Extractions - Simple	0.847	0.601	0.454	1.579	0.815	0.584	0.392	1.696	1.248	0.567	0.585	2.662	1.804	0.011	1.145	2.841	2.532	0.044	1.026	6.252
Extractions - Surgical	1.381	0.285	0.764	2.496	1.502	0.243	0.759	2.969	1.214	0.616	0.568	2.596	2.275	0.001	1.415	3.657	2.286	0.076	0.918	5.697
Implants - Surgical Procedures	1.520	0.351	0.631	3.660	2.138	0.151	0.758	6.035	4.136	0.003	1.611	10.617	1.492	0.266	0.738	3.017	1.829	0.380	0.476	7.035
Multiple Procedures	1.464	0.358	0.649	3.301	3.037	0.008	1.341	6.878	3.381	0.005	1.437	7.955	2.997	0.001	1.554	5.779	4.030	0.010	1.391	11.675
Perio - Surgical	0.720	0.528	0.259	1.997	1.151	0.807	0.372	3.562	2.002	0.199	0.695	5.769	2.664	0.009	1.283	5.530	3.775	0.027	1.159	12.296
Interference (Severe) vs (None)
Endodontics - Pulp Treatment	1.649	0.506	0.377	7.200	0.603	0.533	0.123	2.957	1.476	0.740	0.149	14.663	1.691	0.352	0.559	5.113	0.000	0.975	0.000	0.000
Extractions - Simple	1.643	0.229	0.732	3.685	0.849	0.643	0.425	1.697	1.833	0.329	0.543	6.183	1.433	0.233	0.794	2.586	1.684	0.364	0.547	5.186
Extractions - Surgical	2.447	0.027	1.104	5.420	1.374	0.350	0.705	2.679	4.357	0.012	1.380	13.756	3.526	0.000	2.007	6.196	3.068	0.037	1.069	8.807
Implants - Surgical Procedures	0.880	0.878	0.173	4.482	0.780	0.716	0.205	2.967	0.000	0.986	0.000	.	1.388	0.495	0.541	3.563	1.132	0.914	0.119	10.794
Multiple Procedures	4.557	0.002	1.746	11.894	1.693	0.264	0.672	4.262	6.982	0.006	1.741	28.001	4.315	0.000	2.022	9.211	3.697	0.055	0.971	14.078
Perio - Surgical	1.949	0.283	0.576	6.591	0.833	0.767	0.248	2.793	7.124	0.013	1.503	33.760	5.254	0.000	2.345	11.772	6.492	0.009	1.600	26.334

Among all procedures, the highest odds of severe interference were experienced after periodontal surgical procedures for performing activities (OR:7.12, 95% CI=1.5– 33.76, p-value=0.013), eating (OR:5.25, 95% CI=2.34– 11.77, p-value<0.001), and speaking (OR:6.49, 95% CI=1.6– 26.33, p-value=0.009). Multiple surgical procedures, followed by surgical extraction procedures, were consistently associated with experiencing greater mild, moderate, or severe interference across all 5 outcomes during the 7-day postoperative period, which was statistically significant. Endodontic pulp treatments did not have a statistically significant association with interference experienced across any of the 5 outcomes.

Discussion

In this large prospective study, we used mHealth to analyze postoperative dental pain. Our findings indicate a predictable pain trajectory that peaks early and resolves within a week for most patients. Notably, surgical extractions and multiple procedures are linked to higher odds of moderate-to-severe pain and functional interference. Additionally, pain management primarily involved non-opioid analgesics, with low reported opioid use, reflecting current practices in National PBRN dental practices.

Our descriptive findings broadly align with other studies establishing the typical course of acute dental pain.^29–31 Our methodology provides confirmation of this pattern in a real-world setting.^32,33 We also discovered that surgical extractions and multiple surgical procedures confer a two- to three-fold higher odds of moderate-to-severe pain compared to non-surgical endodontics, while also interfering with sleep and eating, amplifying the patient's overall burden after these common dental procedures.³⁴ The elevated odds of sleep interference in these groups are clinically important, given the bidirectional relationship between sleep disruption and pain amplification documented in orofacial pain populations.^34,35

Patient- and tooth-level factors likely contributed to variability in pain intensity and duration. In endodontic cases, preoperative diagnostic features such as tooth type and the presence of swelling have been associated with greater odds of post-preparation pain and prolonged symptoms.³⁶ Parafunctional habits (e.g., bruxism) may also exacerbate postoperative discomfort, including pain in adjacent teeth following third-molar surgery.³⁶ In addition, systemic comorbidities and behavioral factors, such as arthritis, cancer, cardiovascular disease, diabetes mellitus, osteoporosis, older age with multimorbidity, smoking, and poor oral hygiene, are linked to higher rates of postoperative complications and may prolong pain recovery.³⁶ These factors can increase the risk of inflammation and infection, prolonging postoperative pain and delaying the return to normal function. In some cases, this may lead to persistent orofacial pain. Future studies should measure and adjust for additional covariates to improve risk stratification and personalize perioperative pain management.

A central finding of this study is the low rate of patient-reported opioid use, which stands in contrast to data from the preceding two decades that identified dentistry as a major gateway for opioid exposure.^8,37 This observation may reflect a successful, widespread adoption of opioid stewardship principles and adherence to clinical guidelines that champion NSAIDs as first-line therapy .^38,39 This interpretation should be viewed cautiously. The National Dental PBRN offers a diverse sample of US practitioners, but Network dentists may not fully represent all dentists due to unmeasured factors like clinical research participation. However, they exhibit similarities to the broader dentist population, as evidenced by: 1) representation in various Enrollment Questionnaire categories, 2) comparable diagnosis and treatment patterns to non-network dentists, and 3) similarities found in national survey comparisons.^40–48 The study cohort, which required smartphone ownership and tech engagement, may be more health-literate and predisposed to avoid opioids. Participation could have introduced a Hawthorne effect, affecting both provider behavior and patient reporting on sensitive topics like opioid use.

This study has notable strengths, including its large, prospective design and real-world setting. The use of an mHealth platform for high-frequency data capture is a methodological advantage, minimizing recall bias and providing longitudinal data on the patient experience.²³ The integration of validated instruments (PROMIS, APS-POQ-R) enhances reliability and comparability across studies. However, several limitations exist. The observational design, while high in external validity, precludes causal inference. Selection bias remains a concern; our cohort is, by definition, composed of smartphone users who consented to participate. As shown in Table 1, this group had higher socioeconomic status (26.7% had incomes over $100k, and 26.1% between $50k-$100k), and may be more engaged in their health, potentially leading to an underestimation of average pain intensity and opioid use compared to the broader U.S. population. Prior work in the National Dental PBRN shows that longer and more severe preoperative pain predicts higher postoperative pain and slower resolution, which may partly explain the variability we observed in time to pain relief.⁴⁹ Future studies should validate these findings in more diverse clinical settings, and consider the duration and intensity of preoperative pain. Our analyses were intentionally restricted to the acute postoperative period and did not model pain trajectories beyond the first week or evaluate the potential transition from acute to persistent postsurgical pain. As a result, this study cannot address the chronicity of dental pain after these procedures. Longer-term follow-up that incorporates both pain intensity and psychosocial factors would be valuable to characterize the small subset of patients who may develop prolonged orofacial pain. We did not assess Axis II factors, such as anxiety, depression, catastrophizing, or other psychosocial comorbidities, which are known to amplify pain reporting and increase the risk of pain chronification. Including validated measures of these constructs in future work would allow more nuanced modeling of individual differences in postoperative pain.

We recruited participants from all six National Dental PBRN regions, but did not achieve representation from every U.S. state, and some practice types, like federally qualified health centers and very small rural offices, are under-represented. This limits the generalizability of our findings to all U.S. dental settings. While self-reporting is the gold standard for pain assessment, our medication data were not verified, which may lead to inaccuracies. Additionally, this study focused only on single-visit endodontic treatments, which can underestimate the pain burden compared to multi-visit procedures.^50,51

Conclusions

This study offers insights into postoperative dental pain, highlighting a clear hierarchy of procedural risk and its impact on patient function. The findings support a tailored clinical approach where patients undergoing higher-risk procedures receive more robust, non-opioid analgesic plans and proactive counseling on functional recovery. While the observed low opioid consumption is promising, it needs further investigation for broader applicability. Future research should focus on developing tailored pain management pathways that consider procedure risk and patient factors, ideally incorporating digital tools for better monitoring and education.