Efficacy of oral diclofenac with or without codeine for pain control after invasive bilateral third molar extractions

Analgesics effect of local diclofenac in third molar surgery: a randomized, controlled trial

OBJECTIVES

This study aimed to evaluate the effect of locally diclofenac application on postoperative pain, sequalae, and adverse effects following mandibular third molar (MTM) surgery.

METHODS

A randomized, crossover, double-blind, controlled trial was conducted in 20 patients who required surgical removal of bilateral symmetrical impacted MTM at two separate appointments. The 40 MTMs were randomly allocated to two groups. One side was assigned 0.1% w/v diclofenac sodium as the diclofenac group. The contralateral side was assigned phosphate-buffered saline (PBS) as the control group. Postoperative pain intensity was measured by visual analogue scale (VAS), where the time when the first pain emerged, the time to first rescue medication, pain at 6 and 24 h after surgery, and the total number of analgesics consumed were recorded. Postoperative swelling and trismus were assessed on postoperative days 2 and 7. The differences of continuous outcomes between two groups were analyzed by paired t-test or Wilcoxon signed-rank test.

RESULTS

VAS scores were significantly lower when the first pain emerged and 6 h after surgery in diclofenac group (p < 0.05). The onset of pain in the diclofenac group was significantly longer than in the control group (p < 0.05). Two patients reported mild nausea and dizziness in the diclofenac group.

CONCLUSION

This study demonstrates the analgesic effectiveness of 0.1% local application of diclofenac within 6 h postoperative with few side effects.

CLINICAL RELEVANCE

Locally diclofenac application is an alternative of postoperative analgesic in MTM surgery which provides pain-free periods within 6 h.

Preemptive Analgesic Efficacy of Dexamethasone and Diclofenac in Mitigating Post-surgical Complications After Mandibular Third-Molar Surgery: A Systematic Review

Mandibular third-molar extraction is a frequently executed minor oral surgical procedure, with a subsequent recovery period lasting several days. Typically, preemptive administration of non-steroid anti-inflammatory drugs (NSAIDs) and steroids has been employed, resulting in a notable decrease in postoperative complications like pain, facial swelling, trismus, and alveolar osteitis. This systematic review's primary goal was to investigate the efficacy of preemptive analgesia with dexamethasone and diclofenac in minimizing the post-surgical complications following the surgical extraction of the mandibular third molars. The systematic search was carried out to identify relevant literature in digital databases including PubMed®, Cochrane Library, Web of Science, and Scopus, from January 1990 to January 2022. The search used specific keywords. The randomized clinical trials assessing the efficacy of dexamethasone and diclofenac or dexamethasone alone compared to diclofenac or placebo as preemptive analgesics were considered inclusion criteria for this systematic review. Case reports, literature reviews, letters to the editor, and non-English publications were not included. Two authors screened the titles and abstracts, and articles fulfilling the study criteria were included. After reading the full text and data collection, analysis was performed. The included article's bias was evaluated by the Risk of Bias 2 (RoB 2) tool. A digital database search yielded a total of 207 articles. After excluding duplicates and articles written in languages other than English, 90 were removed. Based on the title and abstract, out of 177, 95 studies were excluded. After full-text reading of 22 articles, 17 were eliminated because they did not meet the inclusion and exclusion criteria. The remaining five studies were found eligible and included in the systematic review. Four studies were of low risk, while one study had some concerns. Two studies evaluated the combination of dexamethasone with diclofenac, while three evaluated dexamethasone alone. Total samples included samples of 436 third-molar surgeries in 420 patients. There was a substantial decrease in the mean pain score and swelling measurement when diclofenac alone was compared with coadministration of diclofenac and dexamethasone. Preemptive administration of dexamethasone and diclofenac has been shown to effectively reduce pain and facial swelling, with the exception of trismus, in third-molar surgeries when compared to diclofenac alone. As a result, it is recommended to administer these drugs prior to the commencement of third-molar extraction. However, further research is mandatory, specifically good quality randomized controlled trials involving large cohorts, in order to assess any significant variations and validate these findings.

Current and emerging COX inhibitors for treating postoperative pain following oral surgery

INTRODUCTION

The numerous drugs in the NSAID class are often used to treat acute postoperative pain associated with oral surgery such as impacted third-molar extractions. These drugs are effective in this setting and dental pain studies often serve as models for acute pain relief and for registration of analgesics. With numerous cyclooxygenase (COX) inhibitors available as monotherapy, for use in combination with analgesic regimens, and in different doses and formulations, it was our aim to determine if there were clear-cut distinctions among these products and dosing regimens.

AREAS COVERED

This is a literature review of recent randomized controlled clinical trials evaluating NSAIDs for use in postoperative pain management following oral surgery. Of particular interest were head-to-head studies, which might offer some insight into comparative effectiveness.

EXPERT OPINION

Postoperative oral surgery pain is largely managed in real-world clinical practice using NSAIDs, either alone or in combination, and there is good evidence supporting their use especially in multimodal therapy. Head-to-head and comparative studies do not show a clear-cut 'optimal NSAID' in this setting, although ibuprofen, ketoprofen, dexketoprofen, and naproxen have gained most acceptance. Combination therapy with other analgesics or adjuvants is largely accepted.

Pain in Oral and Maxillofacial Surgery and Implant Dentistry: Types and Management

Over the years, the pain has been defined numerous times in several ways. In oral and maxillofacial surgery, the occurrence of pain, especially postoperatively, is anticipated. Pain arises as a combination of various processes after tissue damage. Distinct pain experiences in oral surgery were depicted in several previous studies, adding knowledge to the field. The management of these encounters has been suggested over time, improving treatment approaches in the clinical setting. This review aims to understand the pain and its types and intervention in the field of oral and maxillofacial surgery.

Pharmacological and Non-Pharmacological Methods of Postoperative Pain Control Following Oral and Maxillofacial Surgery: A Scoping Review

PURPOSE

To conduct a scoping review regarding current pharmacological and non-pharmacological methods of postoperative pain control following oral and maxillofacial surgery.

MATERIALS AND METHODS

PubMed was used to conduct research for this study. Identification criteria included surgery: patients undergoing the extraction of third molars; therapy: pharmacological or non-pharmacological methods; and outcomes: postoperative pain control. The search included full-text RCTs published after October 13, 2014, that were electronically accessible on PubMed and in the English language. After assessing quality, a scoping review was performed.

RESULTS

Thirty-five RCTs were evaluated, which included a total of 3,791 subjects. The studies evaluated patients' postoperative pain by either utilizing a visual analogue scale (VAS), measuring the time between surgery and when rescue analgesics were used, measuring the amount of rescue analgesics used, or by distributing questionnaires.

CONCLUSION

COX-2 inhibitors may provide greater analgesic effects compared to traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Additionally, although the supplementation of an opioid analgesic to a NSAID regimen provides an increase in pain control, it does not further reduce pain levels in a patient alternating between ibuprofen and acetaminophen. Other methods of postoperative pain control mentioned in this review should be further explored in studies that contain larger sample sizes and that evaluate side effects of the treatment.

Multifocal Analysis of Acute Pain After Third Molar Removal

Background: To analyze the pain modulation capacity profile in a Brazilian population, the relationship between opioid receptor (OPRM1) and Catechol-O-methyltransferase (COMT) 1polymorphisms and pain modulation capacity was determined through preoperative pain modulation tests and acute postoperative pain control evaluation, swelling, and trismus in 200 volunteers undergoing lower third molar removal.

Methods: Psychologic and clinical parameters were measured. Patient DNA was sequenced for single nucleotide polymorphisms in OPRM1 and COMT, and the salivary concentration of interleukin (IL)-2 (IL)-6, interferon (IFN)-γ and tumor necrosis factor (TNF)-α was evaluated. Primary outcomes were the influence of all predictors on the fluctuation of pain intensity using a visual analogue scale (VAS), and swelling and trismus on the 2nd and 7th postoperative days. Preoperative pain modulation capacity (CPM), pain catastrophizing scale (PCS), body mass index (BMI), and surgery duration and difficulty were evaluated.

Results: Salivary concentration of IFN-γ and IL-2 as well as the duration of surgery influenced the fluctuation of postoperative pain in the VAS, and in the sum of the differences in pain intensity test at 8, 48, and 96 h. BMI influenced swelling, while both BMI and COMT haplotype influenced trismus on the 2nd postoperative day.

Conclusion: Polymorphisms in COMT, salivary concentrations of IL-2 and IFN-γ, BMI, and duration of surgery were predictors for pain fluctuation, swelling, and trismus on the 2nd day after lower third molar extraction. This therapy was effective in controlling inflammatory symptomatology after lower third molar extraction and ibuprofen was well tolerated by patients.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03169127.

Comparative Effectiveness of the Homeopathic Preparation Traumeel S in Third Molar Extraction Surgery: A Preliminary Triple-Blind Clinical Trial

BACKGROUND AND AIM

 This preliminary study aimed to evaluate whether a homeopathic preparation (Traumeel S) might be a good option to control post-operative outcomes (pain, edema and trismus) associated with surgical removal of mandibular third molar teeth. The null hypothesis was that Traumeel S is not different from dexamethasone (gold standard) in controlling these post-operative inflammatory complications.

METHODS

 A randomized, "split-mouth", triple-blind clinical trial was conducted. Seventeen healthy patients with a mean age of 20.94 ( ± 5.83) years had their lower asymptomatic bilateral third molars removed. Patients were randomized to receive Traumeel S or dexamethasone pre-operatively by injection into the masseter muscle; each patient acted as his/her own control. At 24, 48, 72 hours and 7 days after the surgery, the pain was evaluated according to a visual analog scale, edema through linear measurements of the face, and trismus through the maximum buccal opening. Wilcoxon statistics or paired t-test were used, and a significance level of 95% was adopted.

RESULTS

 For pain, the results for Traumeel S were not different (p > 0.05) from those of dexamethasone after 24 hours, 72 hours, and 7 days. For edema, the results for Traumeel S were not different (p > 0.05) from those of dexamethasone at all post-operative evaluations. For mouth opening, the results for Traumeel S were not different (p > 0.05) from those of dexamethasone at 72 hours and 7 days after third molar extraction.

CONCLUSION

 With the exception of some early post-operative findings, the null hypothesis is not rejected. Traumeel S might be a good alternative approach to dexamethasone for controlling pain, edema and trismus after third molar removal.

CYP450 polymorphisms and clinical pharmacogenetics of ibuprofen after lower third molar extraction

PURPOSE

This study hypothesized that drugs accumulate in the bloodstream of poor-metabolizing patients and may have more adverse effects and different pain perceptions and aimed to investigate the influence of CYP450 polymorphisms on acute postoperative pain, swelling, and trismus controlled by ibuprofen (600 mg) in 200 volunteers after dental extraction. In addition, surgical outcomes can determine pain, edema, and trismus and indicate inflammatory reactions after oral surgeries.

METHODS

Genetic sequencing was performed to identify CYP450 polymorphisms and the surgical parameters evaluated: pre and postoperative swelling, trismus, and temperature; self-reported postoperative pain with visual analog scale (VAS); rescue medication consumed; and severity of adverse reactions.

RESULTS

A multiple linear regression model with independent variables [single nucleotide polymorphisms (SNPs), BMI (body mass index), duration, and difficulty of surgery] and dependent variables [postoperative pain by sum of pain intensity difference (SPID), trismus, and swelling] was used for analysis. The duration of surgery was a predictor for pain at 8 h and 96 h after surgery, and BMI was a predictor for both swelling and trismus on the 2nd postoperative day. When evaluating CYP2C8 and C9 genotyped SNPs, it was observed that normal metabolizers showed higher pain levels than the intermediate/poor metabolizers on the postoperative periods as compared with time 0 h. In another analysis, the poor metabolizers for CYP2C8 and C9 presented lower levels of postoperative pain after 8 h and used rescue medication earlier than normal metabolizers.

CONCLUSION

Ibuprofen 600 mg was very effective in controlling inflammatory pain after lower third molar surgeries, without relevant adverse reactions; although in a very subtle way, patients with poor metabolism had higher levels of pain in the first hours, and no longer after 8 h, and used pain relief medication earlier.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov ID (NCT03169127), on March 16th, 2017.

Comparison of Effectiveness of Etoricoxib and Diclofenac on Pain and Perioperative Sequelae After Surgical Avulsion of Mandibular Third Molars: A Randomized, Controlled, Clinical Trial

OBJECTIVE

The objective of this analysis was to compare the efficacy of etoricoxib and diclofenac in the management of perioperative sequelae following impacted mandibular third molar surgery.

MATERIALS AND METHODS

Ninety-seven patients who needed surgical avulsion of an impacted mandibular third molar were chosen for the study. All patients were randomly allocated to receive one of the following treatments, twice a day for 5 days after surgery: placebo (n=33), diclofenac (n=32), or etoricoxib (n=32). The primary outcome evaluated was postoperative pain, recorded by each patient and evaluated using the Visual Analogue Scale score. The secondary outcomes chosen were, compared with preoperative ones, changes in postoperative swelling and maximum mouth opening.

RESULTS

Compared with placebo, treatment with etoricoxib and diclofenac demonstrated an enhancement in the primary outcome. Furthermore, when compared with the other groups, patients who had undergone etoricoxib presented a significant median reduction in postoperative pain at 2 hours (P<0.001), 12 hours (P=0.025), and at 48 hours (P=0.018) after surgery. Moreover, the linear regression analysis showed that diclofenac and etoricoxib determined a significant influence on Visual Analogue Scale at 2, 6, 12, 24, 48 hours and at 10 days after surgery. There were no differences in swelling and maximum mouth opening values between groups.

DISCUSSION

This study demonstrated that both treatments were effective. However, treatment with etoricoxib showed a greater reduction in the incidence and severity of postoperative pain following third molar surgery compared with diclofenac and placebo.

Analysis of the Effectiveness of Lornoxicam and Flurbiprofen on Management of Pain and Sequelae Following Third Molar Surgery: A Randomized, Controlled, Clinical Trial

The aim of this study was to analyze the effectiveness of Lornoxicam and Flurbiprofen in reducing perioperative sequelae after impacted mandibular third molar surgery. Ninety-one patients 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 5 days after surgery: placebo (n = 29), Flurbiprofen (n = 31), or Lornoxicam (n = 31). The primary outcome was postoperative pain, evaluated using the visual analogue scale (VAS) score at 30 min, 2, 6, 12, 24, 48 h, 7 and 10 days following surgery. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with Flurbiprofen and Lornoxicam was characterised by an improvement in the primary outcome. Moreover, the treatment with Lornoxicam presented significantly lower median pain scores at 2 h (p < 0.001) and at 6 h (p = 0.016) compared to Flurbiprofen and at 2 h (p < 0.001), 6 h (p = 0.01), and at 24 h (p = 0.018) after surgery compared with placebo. Swelling and maximum mouth opening values were not significantly different between the groups at each follow-up session. This trial demonstrated that treatment with Lornoxicam showed a decrease in the incidence and severity of pain in the first postoperative phase following third molar surgery compared to Flurbiprofen and placebo.

Efficacy of Ketoprofen With or Without Omeprazole for Pain And Inflammation Control After Third Molar Removal

In view of the gastrointestinal problems generated by the ketoprofen use, the ketoprofen association with omeprazole is available on the market. However, this association efficacy in acute pain control has not been established. Bilateral extraction of lower third molars in similar positions is currently the most used model for the evaluation and investigation of the efficacy and pharmacological effects of new compounds for the treatment of acute postoperative pain. The randomized and crossover study consisted in evaluating the clinical efficacy of therapy performed by ketoprofen 100 mg (twice daily-b.i.d.) versus ketoprofen 200 mg + omeprazole 20 mg (once daily-q.d.) to pain, swelling and trismus control in the bilateral extraction model of lower third molars in similar positions in two different appointments, in 50 volunteers. Volunteers reported significantly less postoperative pain at various post-operative periods and consumed less rescue analgesic medication (acetaminophen 750 mg) throughout the study when they took the combination of ketoprofen 200 mg + omeprazole 20 mg (q.d.). Following administration of both study drugs, no gastrointestinal adverse reactions were reported by volunteers. Furthermore, the evaluations of the drugs in pain control by the volunteers were significantly favorable to ketoprofen 200 mg + omeprazole 20 mg (q.d.). For swelling and trismus control, the treatments presented similar results. In conclusion, when volunteers took ketoprofen 200 mg + omeprazole 20 mg (q.d.), they reported significantly less postoperative pain at various post-surgical periods and consumed less rescue analgesic medication throughout the study compared with ketoprofen 100 mg (b.i.d).

Efficacy of piroxicam for postoperative pain after lower third molar surgery associated with CYP2C8*3 and CYP2C9

Objective

Nonsteroidal anti-inflammatory drugs (NSAIDs) are metabolized by the cytochrome P450 enzymes (CYPs), predominantly CYP2C8 and CYP2C9. The aim of this study was to evaluate the possible association of polymorphisms in the CYP2C8*3 and CYP2C9 genes with the clinical efficacy of oral piroxicam (20 mg daily for 4 days) after lower third molar surgeries with regard to postoperative pain, swelling, trismus, adverse reactions, need for rescue medication and the volunteer’s overall satisfaction.

Materials and methods

For this purpose, 102 volunteers were genotyped for CYP2C8*3 and CYP2C9 polymorphisms. Briefly, genomic DNA was isolated from saliva collected from volunteers subjected to invasive lower third molar surgeries, and the preoperative, intraoperative and postoperative parameters were collected and analyzed.

Results

An equal amount of piroxicam sufficiently managed postoperative pain and inflammatory symptoms, with visual analog pain scores typically <40 mm for all genotypes investigated. Furthermore, only two out of 102 volunteers heterozygous for CYP2C8*3 and CYP2C9*3 reported adverse side effects.

Conclusion

In general, slow metabolizers of piroxicam, who were volunteers with mutant alleles, were indifferent from normal metabolizers with the wild-type alleles and therefore did not require specialized piroxicam doses to manage postoperative pain and inflammation.