Ibuprofen as a pre-emptive analgesic is as effective as rofecoxib for mandibular third molar surgery

PREEMPTIVE INTRAVENOUS IBUPROFEN AND LOCAL KETAMINE IMPROVE POSTOPERATIVE ANALGESIA FOLLOWING THIRD MOLAR SURGERY: A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED CLINICAL STUDY

OBJECTIVE

To compare the efficacy of preemptive ibuprofen, local ketamine, and their combination in managing postoperative pain and trismus following third molar surgery.

MATERIALS AND METHODS

One hundred patients were randomly divided into 4 groups. The Intrafen Group had their impacted third molars surgically removed under local anesthesia after receiving intravenous (IV) ibuprofen for preemptive effect. The Ketamine Group received an IV placebo before the surgery, and the extraction process was completed with a local anesthetic-ketamine combination. The Combined Group received preemptive IV ibuprofen before the procedure, and the surgery was performed with a local anesthetic-ketamine combination. The Control Group received an IV placebo before the procedure and then had their impacted third molars removed under local anesthesia. The Visual Analogue Scale (VAS) values, corresponding to the patients' pain levels at the 2nd and 12th postoperative hours and the total amount of analgesic dose used in the first 24 hours, were recorded, and evaluated. The maximum mouth opening of the patients was measured immediately before the procedure, and on the second and seventh postoperative days. The level of patient satisfaction in all groups was assessed during the procedure.

RESULTS

The mean VAS value corresponding to the second-hour pain level of the combined group was statistically significantly lower than the other groups (P = .003). A statistically significant difference was found in the mean VAS values corresponding to the pain levels of the groups, favoring the combined group compared to the other groups (P ≤ .001). A significant difference was observed between the VAS difference values corresponding to the pain levels of the Intrafen group and the Ketamine group, favoring the Intrafen group (P = .038). The Ketamine group consumed the most analgesic on average over the first 24 hours, whereas the Combined group consumed the least. No statistically significant difference was found between the mean trismus levels of the groups on days 0-2 (P = .528) and days 0-7 (P = .129). The intraoperative patient satisfaction level of the combined group was significantly higher than that of the other groups (P = .030).

CONCLUSION

Preemptive Intrafen is an effective regimen for postoperative pain management and is superior to the local anesthetic-ketamine regimen. The most effective method to reduce postoperative pain following third molar surgery is to use a combination of these 2 regimens. However, none of the treatment methods used in the study had a positive effect on postoperative trismus.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

The effect of pre-emptive ibuprofen on post-operative pain after removal of lower third molar teeth: a systematic review

Objective To investigate the effect of pre-emptive ibuprofen on post-operative pain after lower third molar surgery.Methods A search for randomised controlled trials was undertaken across the databases Medline, Embase, Cochrane Central and Dentistry and Oral Sciences Source. Citation searching was used to supplement the database search. Inclusion and exclusion criteria were used for independent double screening by two assessors.Results A total of five randomised controlled trials were included in the review. A risk of bias assessment identified some concerns in four of the included studies. One study was assessed as having low risk of bias. The important outcomes measured were post-operative pain intensity, total pain relief, use of rescue analgesia, time to rescue analgesia and total consumption of rescue analgesia. In two trials, pre-emptive ibuprofen was shown to significantly reduce pain intensity after lower third molar surgery compared with placebo. Two trials showed no significant difference between ibuprofen and placebo groups. Pre-emptive ibuprofen was shown to provide superior pain relief compared with placebo in the one trial measuring this outcome. Where the use of rescue medication was measured as an outcome, two trials showed that pre-emptive ibuprofen was superior to placebo, one trial showed that placebo was superior to ibuprofen and two trials found no significant difference between ibuprofen and placebo groups.Conclusion Due to the inconsistency of the results, there is insufficient evidence to support the use of pre-emptive ibuprofen for management of post-operative pain after lower third molar surgery. Further research into the effects of pre-emptive analgesia on the surgical pain pathway is required.

Pre-emptive analgesic efficacy of injected ketorolac in comparison to other agents for third molar surgical removal: a systematic review

This study aimed to evaluate and compare the pre-emptive analgesic efficacy of injected ketorolac to that of other agents for impacted third molar surgical removal in a healthy population.

PubMed, Ovid SP, Cochrane databases were filtered from 1980 to July 2020 for potential papers using relevant MeSH terms and pre-specified inclusion and exclusion criteria independently by reviewers. Studies that compared pre-emptive intramuscular or intravenous administration of ketorolac to other agents were evaluated. The outcomes sought were self-reported postoperative pain (patient-perceived pain), median duration for rescue analgesic medication, total number of analgesics consumed in the recovery period, and global assessment (overall patient satisfaction) after the recovery period.

Six studies were included in the final evaluation. The outcome of pain perception and the number of analgesics taken were significantly lower in the ketorolac group (intramuscular or intravenous) in most of the studies (n=5) than in the group of other drugs. The mean time for rescue analgesia intake was higher for the ketorolac group, and global assessment scores were also better in the ketorolac group.

Although the included studies show significantly better outcomes such as postoperative pain, median time taken for rescue medication, total number of analgesics taken, and overall patient satisfaction with injected ketorolac group in comparison to injected diclofenac, dexamethasone, and tramadol, definitive conclusions cannot be made regarding the superiority of injected Ketorolac as a pre-emptive agent. A greater number of randomized control trials with a proper protocol are needed to make definitive conclusions.

Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain, swelling, and mouth opening after surgical removal of impacted third molars: a randomized, controlled clinical trial

The objective of this study was to compare the efficacy of celecoxib and ibuprofen in reducing postoperative sequelae following the surgical removal of impacted mandibular third molars. Ninety-eight subjects who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5days after surgery: placebo (n=32), ibuprofen (n=33), or celecoxib (n=33). The primary outcome chosen was postoperative pain, which was evaluated using the visual analogue scale (VAS) score recorded by each patient. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with celecoxib and ibuprofen resulted in improvements in the primary outcome. Furthermore, when compared to the other groups, patients in the celecoxib group showed a significant reduction in postoperative pain scores at 6h (P<0.001), 12h (P=0.011), and 24h (P=0.041) after surgery. Regarding swelling and maximum mouth opening values, there were no significant differences between the groups at each follow-up session. This study demonstrated that treatment with celecoxib decreased the incidence and severity of postoperative pain following third molar surgery compared to ibuprofen and placebo.

Impact of Pre-Emptive Intravenous Ibuprofen on Perioperative Analgesia in Patients Undergoing Third Molar Extraction: A Randomised Controlled Study

Objective

The aim of the present study was to evaluate the analgesic efficacy of pre-emptive intravenous (iv) ibuprofen on pain during and after the mandibular third molar surgery.

Methods

A total of 60 patients were included in the study. They were allocated as ibuprofen 800 mg iv+dexketoprofen 50 mg (group 1), ibuprofen 800 mg iv alone (group 2) or placebo (group 3). A local anaesthetic infiltration was administered to all patients. In all patients, haemodynamic values (mean arterial pressure (MAP) and heart rate (HR)) were recorded preoperatively, and infusions were started. State-Trait Anxiety Inventory (STAI) scale was used to assess anxiety states. Surgery started 15 min after the infusion. Haemodynamic values and pain scores with visual analogue scale (VAS) were recorded. Pain scores were recorded postoperatively at rest (VASR) and swallowing (VASS).

Results

There was no significant difference in the preoperative STAI values between the groups (p>0.05). HR, MAP and VAS pain scores were significantly higher in group 3 than in groups 1 and 2 (p<0.05). VASR and VASS scores were significantly higher in group 3 than in group 1 in the first 4 h postoperatively (p<0.05). VASS scores were significantly higher in group 3 than in group 2 at 1-4 h postoperatively (p<0.05), but there was no difference in VASR and VASS scores at 48 h after surgery.

Conclusion

Ibuprofen alone or in combination with dexketoprofen provided similar analgesia in the perioperative period when administered pre-emptively.

Effect of preemptive intravenous ibuprofen on postoperative edema and trismus in third molar tooth extraction: A randomized controlled study

Background

This study aimed to evaluate the anti-inflammatory efficacy of preemptive intravenous ibuprofen on inflammatory complications such as edema and trismus in patients undergoing impacted mandibular third molar surgery.

Methods

Sixty patients were included and divided into three groups (800 mg IV ibuprofen + 50 mg dexketoprofen, 800 mg IV ibuprofen, and control). In all patients, preoperative hemodynamic values were recorded before the infusions. The operation was started at 15-min post-infusion. Evaluation of edema size on the face and mouth opening (trismus) was conducted in the preoperative period, and at postoperative 48 h and 1 week.

Results

No difference was determined among the groups in trismus and edema size in postoperative measurements (P > 0.05). There was a difference between group 2 and group 3 only in measurement value of tragus-corner of the mouth on the postoperative day 2 (P < 0.05). A difference was found between the measurement values of trismus preoperatively and at preoperative day 2, and between postoperative day 2 and 1 week in group 3 based on time (P < 0.05). In group 3, edema on the face on postoperative day 2 increased significantly compared to that in the preoperative period (P < 0.001); in addition, edema increased significantly in groups 1 and 2 in the postoperative period but was less than that in group 3 (P < 0.001).

Conclusions

In this study, intravenous ibuprofen was determined to be more effective alone or in combination in alleviating trismus and to better limit the postoperative edema.

Decreased post-operative pain using a sublingual injection of dexamethasone (8 mg) in lower third molar surgery

Background

Every patient who undergoes mandibular third molar surgery is concerned about post-operative pain. Indeed, previous researchers have used various methods to treat such pain. This study aimed to assess the effectiveness of sublingual injection of dexamethasone (8 mg) to treat post-operative pain after mandibular third molar surgery.

Method

This was a randomized, double-blind, split-mouth, clinical trial, involving 48 healthy patients who required surgical removal of two mandibular third molars with similar bilateral positions. All operations were performed by the same experienced surgeon. The patients were randomized into a study group (8 mg dexamethasone injection) and a placebo group (normal saline injection). Both interventions were injected into the sublingual space immediately after local anesthesia, 30 min before the first incision. The study group received an 8 mg dexamethasone injection, while the placebo group received a normal saline injection. The wash period between the patients' two operations was 3 to 4 weeks. Pain was assessed by recording the number of analgesic tablets (rescue drug) consumed, as well as by noting the patients' responses to the visual analog scale (VAS) on the first, second, and third days after surgery.

Results

The study group differed significantly from the placebo group in terms of VAS score and analgesic consumption.

Conclusion

Dexamethasone (8 mg), injected sublingually, significantly eased post-operative pain after surgical removal of the mandibular third molar.

Comparative Evaluation of Preemptive Analgesic Effect of Injected Intramuscular Diclofenac and Ketorolac after Third Molar Surgery- A Randomized Controlled Trial

INTRODUCTION

Analgesia pre-emptively administered effect-ively aid in management of pain. Pre-emptive analgesia is anti-nociceptive treatment which prevents altered central sensitization of afferent inputs.

AIM

To compare and evaluate the pre-emptive analgesic efficacy of preoperatively administered ketorolac and diclofenac for controlling postoperative pain after third molar surgery.

MATERIALS AND METHODS

A total of 50 patients with symmetrically impacted third molars were divided into two groups, 30mg intramuscular injection of ketorolac and 75 mg diclofenac sodium were used in the respective groups. The visual analogue scale was used to assess post operative pain for three days and the patients were also evaluated for the number of rescue analgesia.

RESULTS

The data was statistically evaluated with paired t- test. The maximum time taken for pain perception for Group A Ketoralac was 5.48 hrs and Group B Diclofenac sodium was 4.9 hrs and p=0.235 which was not significant. The mean number of tablets taken by the patients in the first three post operative days was 3.24 in Group A i.e., Ketorolac and 4.04 in Group B i.e., Diclofenac sodium. The values were compared using the paired t test. The p value = 0.004, which was significant.

CONCLUSION

Ketoralac showed better pre-emptive analgesic effect for post-operative pain management after third molar extraction. The immediate post-operative pain free period provided by both ketorolac and diclofenac by intramuscular route was same.

A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars

Pain after third molar extraction has been considered the most suitable pharmaceutical model to evaluate acute pain. This study aimed to evaluate the pre-emptive analgesic/anti-inflammatory efficacy of etoricoxib 120 mg following mandibular third molar surgery. A split-mouth, randomized, triple-blind, placebo-controlled study was conducted with patients undergoing the surgical removal of mandibular third molars. All volunteers were allocated randomly to receive either etoricoxib 120 mg or placebo 1h preoperatively, and inflammatory events were evaluated. An estimated sample of 18 surgical units per group was required based on a pilot study (95% confidence level and 80% statistical power). Rescue medication was analyzed by Kaplan-Meier method through log-rank Mantel-Cox test and Pearson linear correlation (P<0.05). Pre-emptive etoricoxib reduced postoperative pain scores significantly in comparison to placebo (P<0.001), with a pain score peak at 6h after surgery (P<0.001). The mean rescue medication consumption was lower in the etoricoxib group compared to the placebo group over the study period (P<0.05). There was no statistically significant difference between groups related to swelling and trismus. The pre-emptive administration of etoricoxib 120 mg significantly reduced the postoperative pain intensity and the need for rescue medication, but did not reduce swelling or trismus.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

Overuse of non-prescription analgesics by dental clinic patients

Background

Many patients present to dental clinics for treatment of painful conditions. Prior to seeking treatment, many of these patients will self-medicate with non-prescription analgesics (NPA), and some will unintentionally overdose on these products. The objective of this study is to describe the use of NPA among dental patients.

Methods

All adult patients presenting to an urban dental clinic during a two-week period in January and February of 2001 were approached to participate in this research project. Trained research assistants using a standardized questionnaire interviewed patients. Patient demographics and the NPA usage over the 3 days preceding the office visit were recorded. We defined a supra-therapeutic dose as any dose greater than the total recommended daily dose stated on package labeling.

Results

We approached 194 patients and 127 participated. The mean age of participants was 35.5 years, 52% were male. Analgesic use preceding the visit was reported by 99 of 127 patients, and most (81/99) used a NPA exclusively. Fifty-four percent of NPA users were taking more than one NPA. NPA users reported using ibuprofen (37%), acetaminophen (27%), acetaminophen/aspirin combination product (8%), naproxen (8%), and aspirin (4%). Sixteen patients reported supra-therapeutic use of one or more NPA (some ingested multiple products): ibuprofen (14), acetaminophen (3), and naproxen (5).

Conclusion

NPA use was common in patients presenting to a dental clinic. A significant minority of patients reported excessive dosing of NPA. Ibuprofen was the most frequently misused product, followed by naproxen and acetaminophen. Though mostly aware of the potential toxicity of NPA, many patients used supra-therapeutic dosages.

Comparison of etoricoxib vs. ketorolac in postoperative pain relief

BACKGROUND

COX-2 inhibitors have been claimed to have equal analgesic efficacy as non-selective nonsteroidal anti-inflammatory drugs, but this has been disputed in animal experiments.

METHODS

One hundred thirty-three women scheduled for ambulatory, laparoscopic gynaecological surgery were included in this randomised, double-blind study. Group E received 120 mg etoricoxib orally as premedication. Group K received 30 mg ketorolac i.v. after induction of anaesthesia. General anaesthesia was induced and maintained with propofol and remifentanil. Fentanyl 0.5 microg/kg i.v. and local wound anaesthesia was administered at the end of surgery. Postoperatively, the patients received fentanyl 0.5 microg/kg i.v. if visual analogue scale (VAS) >or=30 mm. Before discharge, Group K received 30 mg ketorolac i.v. Twenty-four hours postoperatively, Group E received 120 mg etoricoxib.

RESULTS

The first 4 h postoperatively, Group K required 83+/-65 microg and Group E required 123+/-91 microg fentanyl [mean (SD), P=0.004]. After 30 min VAS in Group K was 31.3+/-19.7 mm and 43.8+/-16.9 mm in Group E [mean (SD), P<0.001]. Discharge readiness was significantly shorter in Group K (222+/-40 min) compared with Group E (244+/-47 min) [mean (SD), P=0.004]. There were no differences in pain scores or rescue pain medication at 24 or 48 h postoperatively. Less nausea was observed in the 4-24-h period in Group E.

CONCLUSIONS

Thirty milligram ketorolac i.v. after induction of anaesthesia resulted in significantly less immediate pain and opioid consumption during the first 4 h postoperatively compared with 120 mg etoricoxib preoperatively.

Prospective, Double-Blinded, Randomized, Placebo-Controlled Comparison of Local Anesthetic and Nonsteroidal Anti-Inflammatory Drugs for Postoperative Pain Management after Laparoscopic Surgery

Compared with the open approach, laparoscopy has been shown to significantly reduce postoperative pain. Improving postoperative analgesia in laparoscopic surgery is an area of continued interest. The goal of this study was to compare the efficacy of local anesthetic infiltration with or without preoperative nonsteroidal anti-inflammatory drugs. Patients undergoing elective laparoscopic cholecystectomy were enrolled in an Institutional Review Board-approved, prospective, double-blinded, randomized, placebo-controlled comparison study. Patients were randomized into four groups: Group I, preoperative oral administration of a placebo medication and prein cision local infiltration of 40 mL of 0.5 per cent bupivicaine at trocar sites; Group II, preoperative oral administration of 50 mg of rofecoxib; Group III, preoperative oral administration of 50 mg of rofecoxib and preincision local infiltration of 40 mL of 0.5 per cent bupivicaine into skin, muscle, and peritoneum; and Group IV, preoperative oral administration of a placebo medication. Postoperative pain scores were assessed at 4 hours, 8 hours, 12 hours, and 24 hours using a visual analog scale. Postoperative analgesic use, complications, and length of stay were recorded. Statistical significance was defined as P < 0.05. Fifty-five patients (46 women and 9 men) were enrolled in this study and underwent a standardized, elective, laparoscopic cholecystectomy for mild, symptomatic cholelithiasis (96.4%) and gallbladder polyps (3.6%). No patient had pain immediately before surgery. Postoperative analgesic requests, visual analog scale results, incidence of postoperative vomiting at 4 hours, 8 hours, 12 hours, and 24 hours, in addition to length of stay, were not statistically different between the four groups. No complications occurred. The use of preoperative rofecoxib, 0.5 per cent bupivicaine infiltration, or both for postoperative analgesia did not decrease postoperative pain or decrease length of stay after laparoscopic cholecystectomy compared with placebo. Preoperative administration of an oral anti-inflammatory pain medication, infiltration of a local anesthetic, or both had no greater effect than placebo in controlling discomfort after a laparoscopic cholecystectomy. The challenge of preempting postoperative pain continues and will require further investigation.