A Randomized Clinical Trial Comparing 2 Ibuprofen Formulations in Patients with Acute Odontogenic Pain

Pain Reduction of Ibuprofen Sodium Dihydrate Alone and in Combination with Acetaminophen in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation

INTRODUCTION

Most pain studies have been based on a postsurgical, third molar model using ibuprofen (IBU)/acetaminophen (APAP). Studies have found quicker onset of pain relief with a newer formulation of IBU - ibuprofen sodium dihydrate (ISD). The purpose of this study was to compare pain reduction of ISD/APAP to ISD in an acute endodontic pain model of untreated patients experiencing moderate to severe pain with symptomatic apical periodontitis.

METHODS AND MATERIALS

In this double-blind randomized study, 64 adult emergency patients in acute moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and symptomatic apical periodontitis participated. Each patient randomly received either one dose of 768 mg ISD/1000 mg APAP or one dose of 768 mg ISD. Pain intensity scores were recorded every 15 minutes over 240 minutes using the Heft-Parker VAS along with time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief also recorded. The data were analyzed statistically.

RESULTS

Both ISD and ISD/APAP groups showed a progressive decrease in pain from baseline to 120 minutes after medication administration. Afterward, a relative plateau was seen in the patients' pain. There was no difference in the VAS scores between the ISD and ISD/APAP at any given time point, time to first sign of pain relief, time to meaningful pain relief, and time to 50% pain relief.

CONCLUSIONS

The addition of APAP to ISD for pain control in an untreated endodontic pain model did not differ significantly from ISD alone.

Cannabidiol as an Alternative Analgesic for Acute Dental Pain

Odontogenic pain can be debilitating, and nonopioid analgesic options are limited. This randomized placebo-controlled clinical trial aimed to assess the effectiveness and safety of cannabidiol (CBD) as an analgesic for patients with emergency acute dental pain. Sixty-one patients with moderate to severe toothache were randomized into 3 groups: CBD10 (CBD 10 mg/kg), CBD20 (CBD 20 mg/kg), and placebo. We administered a single dose of respective oral solution and monitored the subjects for 3 h. The primary outcome measure was the numerical pain differences using a visual analog scale (VAS) from baseline within and among the groups. Secondary outcome measures included ordinal pain intensity differences, the onset of significant pain relief, maximum pain relief, changes in bite force within and among the groups, psychoactive effects, mood changes, and other adverse events. Both CBD groups resulted in significant VAS pain reduction compared to their baseline and the placebo group, with a maximum median VAS pain reduction of 73% from baseline pain at the 180-min time point (P < 0.05). CBD20 experienced a faster onset of significant pain relief than CBD10 (15 versus 30 min after drug administration), and both groups reached maximum pain relief at 180-min. Number needed to treat was 3.1 for CBD10 and 2.4 for CBD20. Intragroup comparisons showed a significant increase in bite forces in both CBD groups (P < 0.05) but not in the placebo group (P > 0.05). CBD20 resulted in a significant difference in mean percent bite force change in the 90- and 180-min time points compared to the placebo group (P < 0.05). Compared to placebo, sedation, diarrhea, and abdominal pain were significantly associated with the CBD groups (P < 0.05). There were no other significant psychoactive or mood change effects. This randomized trial provides the first clinical evidence that oral CBD can be an effective and safe analgesic for dental pain.

COVID-19 Risk Management in Dental Offices: A Review Article

BACKGROUND: As all the dental staff, including nurses and practitioners, are exposed to various routes of contamination due to the novel COVID-19 virus, which is still unknown to the scientific world, developing strategies to reduce the risk of transmission and decontaminate surfaces in a dental office would be of high importance. Although there is still insufficient data on managing this virus in dental offices, several studies have suggested protocols for improving care. AIM: This study aimed to review present investigations and reach a conclusion on what we know and need to know to combat this virus. MATERIALS AND METHODS: In this review, Scopus, PubMed, and MEDLINE databases were searched using the keywords “COVID-19,” “SARS-CoV-2,” “Medical Disinfectants,” “Personal Protective Equipment’s,” and “Surface Decontamination.” Articles were reviewed, and finally, relevant articles published during 2000–2022 were included in the final paper. RESULTS: The present research concluded that using a combination of the face shield and N95 masks protected the eyes, nose, and mouth. To have more efficient protection, water-resistant long-sleeved gowns and gloves were highly suggested. To overcome aerosols, high-performance air filters and ultraviolet were found quite effective. Allowing the patient to use antiseptic mouthwash before starting the treatment could reduce oral microorganisms and the following airborne contamination. CONCLUSION: This review has gathered all available data regarding dentistry and COVID-19 in order to conclude what has been achieved yet in the prevention of this virus through dental offices; however, more investigations are needed to have a definitive protocol against the virus.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review

OBJECTIVE

To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.

SETTING/PARTICIPANTS

Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.

STUDY SELECTION

Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.

OUTCOMES

Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.

RESULTS

Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.

DISCUSSION

A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.

CONCLUSIONS

A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020210183.

Pharmacological Management of Acute Endodontic Pain

Pain associated with infections of the tooth pulp and periapical tissues is intense and often the most common reason for patients seeking emergency dental care. Effective management of acute dental pain requires a deep understanding of pain mechanisms, which enables accurate diagnosis and definitive treatment. While drugs are only used as an adjunct to definitive dental treatment, a thorough understanding of their mechanism of action and effectiveness enables clinicians to effectively control intra-operative and post-operative pain and prevent persistent pain. This review describes how pain is detected, processed, and perceived. It also provides information on evidence-based strategies on the use of different classes of drugs to effectively manage endodontic pain.

To Drill or Not to Drill: Management of Endodontic Emergencies and In-Process Patients during the COVID-19 Pandemic

Introduction

Dental professionals are at high risk of contracting coronavirus disease 2019 (COVID-19) infection because of their scope of practice with aerosol-generating procedures. Recommendation by the Centers for Disease Control and Prevention to suspend elective dental procedures and avoid aerosol-generating procedures posed significant challenges in the management of patients presenting with endodontic emergencies and uncertainty of outcomes for endodontic procedures initiated, but not completed, before shutdown. The purpose of this study was to evaluate the success of palliative care on endodontic emergencies during the COVID-19 pandemic and to evaluate the stability of teeth with long-term Ca(OH)₂ placement because of delays in treatment completion.

Methods

Patients presenting for endodontic emergencies during COVID-19 Shelter-in-Place orders received palliative care, including pharmacologic therapy and/or non–aerosol-generating procedural interventions. Part I of the study evaluated the effectiveness of palliative care, and need for aerosol-generating procedures or extractions was quantified. Part II of the study evaluated survivability and rate of adverse events for teeth that received partial or full root canal debridement and placement of calcium hydroxide before shutdown.

Results

Part I: Twenty-one patients presented with endodontic emergencies in 25 teeth during statewide shutdown. At a follow-up rate of 96%, 83% of endodontic emergencies required no further treatment or intervention after palliative care. Part II: Thirty-one teeth had received partial or full root canal debridement before statewide shutdown. Mean time to complete treatment was 13 weeks. At a recall rate of 100%, 77% of teeth did not experience any adverse events due to delays in treatment completion. The most common adverse event was a fractured provisional restoration (13%), followed by painful and/or infectious flare-up (6.4%), which were managed appropriately and therefore seemed successful. Only 1 tooth was fractured and nonrestorable (3%), leading to a failed outcome of tooth extraction. The remaining 4 outcome failures (13%) were due to patient unwillingness to undergo school-mandated COVID testing or patient unwillingness to continue treatment because of perceived risk of COVID infection.

Conclusions

Palliative care for management of endodontic emergencies is a successful option when aerosol-generating procedures are restricted. This treatment approach may be considered in an effort to reduce risk of transmission of COVID-19 infection during subsequent shutdowns. Prolonged Ca(OH)₂ medicament because of COVID-19 related delays in treatment completion appeared to have minimal effect on survival of teeth.

Biosafety for Dental Patients During Dentistry Care After COVID-19: A Review of the Literature

The world is currently changing due to coronavirus disease 2019 (COVID-19), and the field of dentistry is no stranger to this. The care of patients in the dental office involves very strict biosafety protocols, and patients must be aware of the protection barriers implemented to allow satisfactory, safe dental care. The purpose of this study was to synthesize and analyze the management of the current biosafety standards for dental patients since the arrival of the COVID-19 pandemic. A bibliographic search of the main sources of information including MEDLINE (by means of PubMed), Scopus, Science Direct, SCIELO, and Google Scholar was carried out. Articles published without language restriction, systematic reviews, literature reviews, and observational studies were included. We identified the biosafety measures that must be taken before, during, and after dental practice following the arrival of COVID-19. The main measures include telephone triage, temperature taking on arrival at the office, the organization of the waiting room, washing hands before entering the office, knowing the auxiliary radiographic exams of choice and what type of treatment can be performed, albeit with restrictions. In conclusion, dental patients must comply with all the biosafety measures established by international protection standards and implemented by dentists before, during, and after dental practice to reduce the possibility of COVID-19 infection.

Coronavirus Disease 19 (COVID-19): Implications for Clinical Dental Care

The recent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease has gripped the entire international community and caused widespread public health concerns. Despite global efforts to contain the disease spread, the outbreak is still on a rise because of the community spread pattern of this infection. This is a zoonotic infection, similar to other coronavirus infections, that is believed to have originated in bats and pangolins and later transmitted to humans. Once in the human body, this coronavirus (SARS-CoV-2) is abundantly present in nasopharyngeal and salivary secretions of affected patients, and its spread is predominantly thought to be respiratory droplet/contact in nature. Dental professionals, including endodontists, may encounter patients with suspected or confirmed SARS-CoV-2 infection and will have to act diligently not only to provide care but at the same time prevent nosocomial spread of infection. Thus, the aim of this article is to provide a brief overview of the epidemiology, symptoms, and routes of transmission of this novel infection. In addition, specific recommendations for dental practice are suggested for patient screening, infection control strategies, and patient management protocol.

Ibuprofen and Acetaminophen Versus Intranasal Ketorolac (Sprix) in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation

INTRODUCTION

Previously, ketorolac was available for primary use only via intravenous and intramuscular routes. Its availability in intranasal form offers an alternative route of administration that patients can self-administer. The purpose of this study was to compare the efficacy of intranasal ketorolac (Sprix; Egalet US Inc, Wayne, PA) with a combination of ibuprofen/acetaminophen in an acute pain model of untreated endodontic patients experiencing moderate to severe pain and symptomatic apical periodontitis.

METHODS

Seventy patients experiencing moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and a periapical diagnosis of symptomatic apical periodontitis participated. Patients were randomly divided into 2 groups and received either 31.5 mg intranasal ketorolac and placebo capsules or 1000 mg acetaminophen/600 mg ibuprofen capsules and a mock nasal spray. Patients recorded perceived pain scores on a visual analog scale every 15 minutes from drug administration up to 240 minutes. The time to 50% pain relief, the first sign of pain relief, and meaningful pain relief were recorded, and the data were analyzed.

RESULTS

A decline in reported pain was observed until 120 minutes after dosing, after which reported pain remained relatively constant. There was no significant difference between the 2 groups for the time to 50% pain relief, the first sign of pain relief, or meaningful pain relief.

CONCLUSIONS

The effectiveness of intranasal ketorolac was not significantly different from that of a 1000 mg acetaminophen/600 mg ibuprofen combination. Intranasal ketorolac provides a nonnarcotic alternative and an additional route of medication administration to practicing clinicians.