Pre-emptive analgesic effect of tramadol after mandibular third molar extraction: a pilot study

Mapping trends in preemptive analgesia related to oral surgery with the use of Ibuprofen: a comprehensive quantitative and qualitative analysis of bibliometric parameters

PURPOSE

This study aims to conduct a thorough analysis, both quantitative and qualitative, of bibliometric parameters related to preemptive analgesia (PA) in oral surgical procedures (OSP).

METHODS

Research trends on PA in OSP using ibuprofen were reviewed through bibliometric analysis of 68 journal articles published from 1991 to 2022 in the Web of Science database. Bibliometric indicators were applied to analyze the journal article data, including the annual distribution of publications and literature growth, document types, citation indicators to measure qualitative research performance, and keyword mapping to identify research trends. The results were imported into RStudio, and the Bibliometrix package was used to prepare and analyze the metadata.

RESULTS

The 68 included articles received a total of 900 citations, ranging from 1 source to 72 citations with some fluctuations. The papers on PA in OSP using ibuprofen had an average of 16.85 citations per paper. These publications were originated from 25 countries, with the highest contributions from Brazil (n = 17), the USA (n = 13), and Turkey (n = 8). The top five major contributing journals were the International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Journal of Cranio-Maxillo-Facial Surgery, Journal of Periodontology, and Acta Odontologica Scandinavica, representing more than half of all selected papers.

CONCLUSION

Papers focused on PA in OSP received numerous citations. The citation per article correlated with the number of publications at the affiliation, author, country, and journal levels. However, there is still a scarcity of studies in this field.

Efficacy and safety of parenteral and local application of tramadol in mandibular third molar extraction: a qualitative systematic review of current evidence

PURPOSE

To assess the efficacy and safety of perioperative parenteral administration or submucosal infiltration of tramadol for perioperative pain control on the basis of pain intensity or analgesics consumption and perioperative outcomes in mandibular third molar surgery.

MATERIAL-METHODS

An electronic database search was conducted up to 10 November 2022 to retrieve all randomized controlled trials (RCTs), assessing the analgesic efficacy of parenteral use of tramadol implemented as an adjunct to local anesthesia or intraoperative sedation/general anesthesia, in surgical extraction of mandibular third molars. Modified Jadad scale and Cochrane bias tool were used for the qualitative appraisal.

RESULTS

Nineteen RCTs were selected for qualitative analysis. Nine studies involved intravenous, and 5 intramuscular administration of tramadol, while 5 evaluated submucosal infiltration with tramadol. Intravenous or intramuscular tramadol provided a weaker analgesic effect compared with non-steroidal anti-inflammatory drugs (NSAIDs), while intravenous tramadol induced an enhanced analgesic effect than oral tramadol. Parenteral administration of tramadol improved the quality of postoperative analgesia versus placebo. No notable adverse effects were recorded.

CONCLUSIONS

Parenteral or submucosal infiltration of tramadol constitutes an effective and safe alternative analgesic approach in surgical extraction of mandibular third molars, yet the nociceptive effect of this analgesic modality could not supersede that of NSAIDs.

TRIAL REGISTRATION

PROSPERO No CRD42021227574.

A Systematic Review on the Role of Antibiotics and Analgesics in Systemically Ill Patients Undergoing Tooth Extraction

Antibiotics are commonly prescribed as a preventive measure, particularly post-tooth extraction, aiming to minimize the risk of infection. Preemptive analgesia functions by disrupting the nervous system's ability to encode pain stimuli, thus preventing the formation of pain memory. Dentists often recommend analgesics and antibiotics either as adjuncts or sole treatments for various dental conditions, offering both efficacy and cost-effectiveness. A comprehensive literature search was conducted across multiple databases, including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Science Direct, and Lilac, using MeSH terms relevant to the role of antibiotics and analgesics in systemically ill patients undergoing tooth extraction. Out of 178 articles screened, 83 underwent full-text assessment for eligibility, and six were selected for qualitative analysis. The review process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring methodological rigor and transparent reporting. Across diverse study populations, the role of antibiotics and analgesics consistently demonstrated a statistically significant impact. Hence, the utilization of analgesics and antibiotics plays a pivotal role in preventing infection following tooth extraction in systemically ill patients, thereby promoting optimal oral hygiene and overall health.

Efficacy of Preemptive Analgesia on Pain Perception After Simple Tooth Extraction: A Prospective Study

Background and objective This study aims to explore the concept of preemptive analgesia, which is the technique of administration of analgesic agents before the painful stimulus. This bridges the time gap between the onset of action of the analgesic agents and the wear-off of local anesthesia. Existing literature also brings up the concept of central sensitization, which is the hyper-activity of the nervous system in response to a noxious stimulus. Administration of preemptive analgesia prevents central sensitization and hence provides prolonged analgesia to the patient. For the benefit of this study, tab. Etoricoxib 90 mg was used as the analgesic agent. In addition, this study aims to investigate the effects of the administration of tab. Etoricoxib 90 mg 30 minutes before extraction of a single mandibular third molar on the effects of pain experienced by the patient after tooth extraction as compared to a placebo. Methodology This was a double-blinded, prospective, observational study. The pain experienced by 50 participants in each group was measured at 1 hour, 6 hours, 12 hours, and 24 hours postoperatively using a visual analog scale (VAS). The independent samples t-test was then conducted to evaluate the results and draw out conclusions. Results The average difference in pain experienced was maximum in the first hour after the procedure. The mean VAS score reported by patients was 3.14 in the study group but was 6.40 in the control group within the first hour. This difference was reduced in the first six hours after the procedure, with the average score being 3.82 in the study and 7.16 in the control group. The difference was the least after 12 hours, with the study group experiencing a VAS score of 4.64 and controls experiencing a VAS score of 6.14. After the first 24 hours, the mean VAS score was 3.80 in the study group and 5.60 in the control group. Conclusions Preemptive administration of tab. Etoricoxib 90 mg can reduce postextraction pain in healthy adult patients as compared to placebo tablets, with a maximum difference in pain reduction seen at the end of the first six hours (P = 0.012) and the minimum at the end of 12 hours (P = 0.0197).

Comparative evaluation of efficacy of diclofenac and ketoprofen administered using transdermal drug delivery route in management of post endodontic pain: A randomized controlled clinical trial

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used as a postoperative medication after endodontic treatment. The introduction of transdermal patches aided in reducing the discomfort caused by medication prescribed through the oral route.

Aim

This study aims to compare the efficacy of transdermal patches of diclofenac and ketoprofen for postendodontic pain control.

Materials and Methods

Thirty patients with symptomatic irreversible pulpitis in singlerooted teeth of either arch were endodontically treated by a single endodontist. Oral diclofenac for Group I and transdermal diclofenac patch for Group II and transdermal ketoprofen patch for Group III were administered as postendodontic analgesics. Visual Analog Scale chart was used to record pain intensity preoperatively and at intervals of 4, 8, and 24 h postoperatively. Paracetamol 500 mg tablets were provided as rescue medication.

Statistical Analysis

Repeated Measure ANOVA.

Results

There was a significant decrease in the postoperative pain intensity scores for both transdermal groups. The postoperative scores gradually decreased from day 1 to day 2. Six out of ten patients who had received diclofenac tablets complained of gastric discomfort.

Conclusion

Both transdermal ketoprofen and diclofenac patches were effective than oral diclofenac tablet and can be used as an alternative and effective analgesic for postendodontic pain management, especially in patients with gastric discomfort.

Effect of preoperative ibuprofen on pain after lower third molar removal: A randomized controlled trial

Aim

The aim of the study is to predict the effect of preemptive analgesics in the third molar surgery and to analyze whether the number and frequency of postoperative analgesics are reduced following the administration of preemptive analgesics.

Materials and Methods

The present study was carried out on 50 patients who reported to the Department of Oral and Maxillofacial Surgery for removal of their impacted mandibular third molar. The patients were randomly divided into two groups of 25 patients each - Group A (test group) patients receiving ibuprofen (400 mg) half an hour before the surgery and placebo half an hour after surgery and the Group B (control group) patients receiving placebo half an hour before the surgery and ibuprofen (400 mg) half an hour after surgery. Both groups of patients will be instructed to avoid any drug but those prescribed (ibuprofen 400 mg SOS and rescue medication of tramadol 50 mg SOS) and not to seek any medical help elsewhere for postoperative problems. The pain was recorded using a visual analog scale.

Results

Demographic data in the study show females (8%) and male (92%) patients. The average time taken for surgery was more in the control group (58.36 min) as compared to the test group (55.64 min) with no statistically significant difference. Values of pain score, medication score, number of rescue medication, and frequency at different time intervals (at baseline, after 3 h, 6 h, 24 h, and 7 days) are expressed in terms of mean and standard deviation, respectively, and the result shows the statistically significant difference for pain score at baseline and 7th-day time interval only. The distribution of different types of impaction and different types of elevation/odontotomy shows a significant association in test and control groups.

Conclusion

Preoperative ibuprofen decreases the frequency and intensity of the pain. We believe that since this preoperative ibuprofen seems to be beneficial without any adverse effects, it may be used routinely in the 3rd molar surgeries and even in routine extraction.

Analgesic Efficacy of COX-2 Inhibitors in Periodontal Surgery: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to evaluate the analgesic efficacy of COX-2 inhibitors versus other drugs in periodontal surgery. Two researchers searched PubMed, Google Scholar, ACM Digital, BASE, EBSCOhost, Scopus, or Web of Science for clinical trials using various combinations of words. All articles that met the selection criteria were assessed using the Cochrane Collaboration’s risk of bias tool. For data analysis, the inverse variance and mean difference statistical method was used with Review Manager 5.3 software for Windows. According to the conclusion of each study (qualitative evaluation), only one clinical trial had results in favor of a COX-2 inhibitor when compared to placebo, one clinical study informed that a COX-2 was better that an active control, four studies showed similar analgesic efficacy to active controls, and one clinical study informed the analgesic effect of one celecoxib-caffeine combination in comparison with celecoxib alone and placebo (n = 337). The COX-2 inhibitors showed a decrease in the rescue analgesic consumption (n = 138; I2 = 15%; mean difference = −0.31; 95%CIs = −0.6 to −0.01), and lower pain intensity at four hours (n = 178; I2 = 0%; mean difference = −2.25; 95%CIs = −2.94 to −1.55; p = 0.00001) when compared to active controls after periodontal surgery. In conclusion, the data indicate that COX-2 agents produce better pain relief in comparison to placebo and other drugs after periodontal surgery.

Effects of Early Weight-Bearing Treadmill Training Combined with Pre-Emptive Analgesia on Femoral Fracture Recovery

Background

The effect of pre-emptive analgesia plus early weight-bearing treadmill training (EWBTT) on healing and motor function recovery of femoral shaft fracture is not clear.

Methods

A total of 60 SD male rats were randomly allocated into 4 groups: group A (pre-emptive analgesia with EWBTT), group B (pre-emptive analgesia with delayed weight-bearing treadmill training, DWBTT), group C (pre-emptive analgesia with no weight-bearing), and group D (EWBTT with no pre-emptive analgesia). All rats were molded by internal fixation with Kirschner wire after right femoral shaft fracture. In groups A, B, and C, tramadol was intramuscularly injected 15 minutes before surgery. EWBTT was performed at day 1 postoperatively in groups A and D, and DWBTT was performed at day 14 postoperatively in group B. Oblique plate test was accomplished to assess hindlimb motor function recovery of rats in each group. Status of fracture healing was assessed through digital radiography (DR). Hematoxylin-eosin (HE) staining and immunohistochemistry of bone morphogenetic protein-2 (MBP-2) and vascular endothelial growth factor (VEGF) in callus were performed to explore fracture healing. The expression of BMP-2 and VEGF protein in quadriceps femoris muscle was detected by Western blot technique and mRNA expression of BMP-2 and VEGF in callus ascertained via reverse transcription-polymerase chain reaction (RT-PCR) technique.

Results

For oblique plate test, rats in group A outperformed those in groups B and C at all time points after operation. DR image revealed that large numbers of callus growth, blurred fracture line, and obvious continuous callus passing through the fracture line can be found in group A at day 28 postoperatively, which is the best healing status among all groups. HE staining of callus confirmed the optimal effect of healing for rats in group A. VEGF and BMP-2 expression by immunohistochemistry showed a significantly higher positive score for callus in group A while those in group C being the lowest at all time points postoperatively. Significantly higher expression level of VEGF and BMP-2 protein was detected in quadriceps femoris muscle from group A, which exceeded those in all other groups at all time points. RT-PCR testing proved the highest expression of BMP-2 and VEGF mRNA in callus of rats from group A, significantly higher than those of other groups.

Conclusions

Both pre-emptive analgesia and EWBTT can effectively invoke the expression of VEGF and BMP-2 and promote recovery of hindlimb locomotor function in rats with femoral fracture, and the combination of them leads to more superior results.

Comparison of preemptive ibuprofen, acetaminophen, and placebo administration in reducing peri- and postoperative pain in primary tooth extraction: A randomized clinical trial

Background

The management of pain resulting from anesthesia injection, tooth extraction and in the period after extraction is of great importance in pediatric dentistry.

Objective

The aim of this study was to compare the efficacy of the preemptive administration of ibuprofen or acetaminophen with placebo in reducing the pain during injection, extraction and postoperatively in children undergoing primary tooth extraction.

Material and methods

A randomized, placebo‐controlled, triple‐blinded clinical trial of cooperative children who needed primary molar extraction by local anesthesia. Sixty‐six children aged between 6 and 8 years were randomly assigned to one of three groups: (a) Acetaminophen syrup (320 mg/10 ml); (b) placebo solution; and (c) ibuprofen syrup (200 mg/10 ml). Each of the three solutions was given 30 min before administration of the local anesthetic agent. The Pain level was assessed using the Wong–Baker faces® pain rating scale after injection, extraction, and postoperatively. The Kruskal–Wallis and Mann–Whitney U test were used to evaluate the pain scores between groups at confidence level of 95%.

Results

The use of preemptive analgesics showed lower pain scores compared to placebo. Additionally, only ibuprofen significantly reduced pain scores compared to placebo at the points immediately after injection (p = 0.001), immediately after extraction (p = 0.0001) and 5 h after extraction (p = 0.002).

Conclusion

Preemptive usage of ibuprofen reduces injection pain and relieves both extraction and postoperative pain in children undergoing primary tooth extraction.

What this paper or case report adds

It adds the knowledge regarding pain relief of injection and extraction in children.

Preemptive analgesic medications have a beneficial effect on alleviating postoperative pain following tooth extraction in children.

Ibuprofen is an effective analgesic for postoperative pain relief in children undergoing primary tooth extraction.

Why this paper or case report is important to pediatric dentists

Pediatric dentists may consider preemptive ibuprofen in children before injection and extractions.

Identifies that Ibuprofen is an effective method of reducing postoperative pain.

Effect of pre-operative administration of ibuprofen in children undergoing extraction for reducing post-operative pain: a double-blind randomised controlled clinical trial

Introduction Administration of non-steroidal anti-inflammatory drugs (NSAIDs) before tooth extraction may reduce post-surgical pain, but there is a lack of research.Aims To compare pain and anxiety in paediatric tooth extraction patients receiving a pre-operative NSAID vs placebo.Design Randomised, double-blind, placebo-controlled clinical trial.Setting Princess Nourah bint Abdulrahman University's dental clinic in Riyadh, Saudi Arabia.Materials and methods Eligible paediatric tooth extraction patients were randomised to group A, which received NSAID pre-operatively, or group B, which received the placebo.Interventions A research coordinator measured participants before extraction, and then 3 hours and 24 hours post-extraction.Main outcome methods The Wong-Baker FACES scale and the Modified Child Dental Anxiety Scale (faces).Results There were 56 participants (28 in each group). Pain and anxiety scores were not statistically significantly different between the two groups before or 24 hours post-extraction. However, group A had significantly lower pain (-1.3151, p = 0.0063) and anxiety scores (-0.6071, p = 0.0081) compared to group B three hours post-extraction.Discussion Pre-operative administration of NSAIDs in paediatric dental patients was associated with significantly lower post-extraction pain and anxiety.Conclusions Clinicians should consider making NSAID administration before paediatric tooth extraction part of their clinical protocol.

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.

Comparative Evaluation of Quality of Obturation and Its Effect on Postoperative Pain between Pediatric Hand and Rotary Files: A Double-blinded Randomized Controlled Trial

Background

One of the cardinal points to be considered during endodontic procedures in children is the measure of postoperative pain.

Aim and objective

To evaluate the quality of obturation and its effect on postoperative pain with three file systems in primary mandibular molars during 1 week follow-up.

Materials and methods

The study was conducted as a double-blinded randomized controlled trial. The participants between 6 years and 9 years old requiring a pulpectomy were recruited for the trial. Forty-five primary mandibular molars were randomly allocated into 15 teeth each in Hand K-files; Kedo-SH and Kedo-SG Blue groups. Wong Baker's FACES Pain Rating Scale was used for assessing the postoperative pain in the children for 1 week. Pearson's Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test were used for analyzing the data statistically.

Results

Optimal fillings were observed more in the Kedo-SG Blue group (80.0%) compared to the other two groups (p < 0.017). On intergroup analysis, the Kedo-SG Blue group reported less postoperative pain compared to Kedo-SH group on day 1 while on day 7 no postoperative pain was experienced in either of the groups. Less postoperative pain was reported by the children in whom the canals were optimally filled compared to overfilling and underfilling.

Conclusion

Kedo-SG Blue resulted in less postoperative pain when compared to Kedo-SH and hand K-files, whereas optimally filled children experienced less postoperative pain compared to overfilling and underfilling.

Clinical significance

A felicitous pediatric dental practice includes appropriate assessment and management of postoperative pain in children. Hence, the present study is important in highlighting the affiliation of postoperative pain with quality of obturation following an endodontic intervention in children.

How to cite this article

Jeevanandan G, Govindaraju L, Subramanian EMG, et al. Comparative Evaluation of Quality of Obturation and Its Effect on Postoperative Pain between Pediatric Hand and Rotary Files: A Double-blinded Randomized Controlled Trial. Int J Clin Pediatr Dent 2021;14(1):88-96.

Tramadol versus ketorolac for pain management after third molar surgery

Objectives:

To compare the analgesic efficacy of preoperative intravenous (IV) ketorolac versus tramadol in preventing postoperative pain after mandibular third molar surgery.

Methodology:

Two hundred patients in the age group of 18–40 years with asymptomatic impacted mandibular molars were randomly allocated into one of the two groups (100 in each group) and underwent third molar surgery under local anesthesia. Group I received IV ketorolac 30 mg and Group II received IV tramadol 50 mg preoperatively. The difference in postoperative pain was assessed by five primary end points: pain intensity being measured hourly by Wong-Baker pain assessment scale for 6 h, onset of analgesia, duration of action, total number of analgesics consumed, and patient's global assessment.

Results:

Throughout the 6 h investigation period, patients reported significantly lower pain intensity scores, longer duration of action, lesser postoperative analgesic consumption, and better global assessment in ketorolac when compared to tramadol group. Patients in the ketorolac group significantly performed better than the tramadol group in terms of all parameters except onset of analgesia. All the drug-related complications were mild and did not require any investigation.

Conclusion:

The result of the present study shows that preoperative IV ketorolac 30 mg is more effective than tramadol 50 mg for postoperative pain following third molar surgery.

The effect of sonic activation of irrigant on postoperative pain after root canal treatment in primary molar teeth: a randomized, clinical study

PURPOSE

Postoperative pain following root canal treatment is a concern for pediatric patients and pediatric dentists. The purpose of this study was to evaluate the effect of using sonic activation (SA) on postoperative pain levels after root canal therapy of primary molars.

METHODS

A total of 110 patients aged 5-9 years with symptomatic irreversible pulpitis involving primary molars were included in the study and were randomly divided into two groups according to agitation methods: SA and no sonic activation (NSA). Root canal treatments were completed, and the teeth were restored permanently. Postoperative pain levels were evaluated using the five-face scale at 8, 24, 48, and 72 h and 1 week after treatment. Pain levels and frequency of analgesic intake were recorded and analyzed.

RESULTS

Postoperative pain values were lower in the SA group than in the NSA group at 8, 24, and 48 h after treatment (p < 0.05). No significant difference was observed between the groups in terms of postoperative pain values at 72 h and 1 week after treatment (p > 0.05).

CONCLUSIONS

It was determined that the use of SA reduces postoperative pain level significantly after root canal treatment in primary molar teeth.

CLINICAL RELEVANCE

The use of SA can be recommended to clinicians since it is effective in the successful management of postoperative pain of root canal treatment in primary molar teeth.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04197531.

Does the pre-emptive administration of paracetamol or ibuprofen reduce trans- and post-operative pain in primary molar extraction? A randomized placebo-controlled clinical trial

BACKGROUND

There is no consensus whether the pre-emptive administration of analgesics reduces trans- and post-operative pain in primary molar extraction.

AIM

Investigate whether the pre-emptive administration of ibuprofen and paracetamol reduces trans- and post-operative pain on primary molars extraction compared to placebo.

DESIGN

A parallel, placebo-controlled, triple-blind, randomized clinical trial was conducted. Forty-eight children who needed primary molar tooth extraction were selected and treated under local anaesthesia and pre-emptive administration of placebo or analgesics. Self-reported pain was evaluated during the anaesthesia, extraction, and 2, 6, and 24 hours of post-operative period, using a visual analogue scale (VAS). Children's baseline anxiety, behaviour during the procedure, parents' anxiety, and post-operative analgesia were also assessed. Data analysis included descriptive statistics and multiple linear regression.

RESULTS

No association was found between the use of pre-emptive analgesic and lower scores of trans- and post-operative pain compared to placebo. Children who presented negative behaviour reported greater pain during anaesthesia (P = .04) regardless of pre-emptive analgesia group. Children from the placebo group were more likely to need post-operative analgesia at 2 hours of follow-up (P = .03).

CONCLUSION

The pre-emptive administration of analgesics did not significantly reduce trans- and post-operative pain in children after primary molars extraction.

Preemptive Analgesia with a Second Dose of Pregabalin, Acetaminophen, Naproxen, and Dextromethorphan: A Comparative Clinical Trial in Major Surgeries

Background

Postoperative pain management can improve patients’ quality of life and decrease hospitalization rates. Preemptive analgesia may provide an effective approach for both pain control and opioid consumption decrease. A common approach for pain management after surgery is to relieve the pain that has already occurred.

Objectives

The aim of this clinical trial was to compare the preemptive analgesic effect of single-dose versus two-dose administration of pregabalin, acetaminophen, naproxen, and dextromethorphan (PAND) combination.

Methods

This study involved 60 patients who had undergone one surgery (including nephrectomy, cystectomy, prostatectomy, colectomy, Whipple, and RPLND). They were randomly divided into two groups: The first group received a single dose of PAND, while the other group received a second dose within 6 hours after discharge from recovery. Pain intensity was assessed by the Universal Pain Assessment Tool (UPAT) in both groups 2, 4, 6, 8, 12, 24, and 48 hours postoperatively. The postoperative morphine dose in both groups was also recorded. Data were analyzed using SPSS version 25.

Results

Mean pain scores were significantly different between the two groups at 2, 12, 24, and 48 hours after surgery (P < 0.05). There was a statistically significant difference between the two groups in terms of opioid consumption (P < 0.001). The total opioid consumption in the second group (with the second administration of PAND) was lower than the first group.

Conclusions

Preemptive analgesia with a second dose of PAND is an effective method for reducing pain and morphine consumption after surgery.

Pre-emptive and preventive opioids for postoperative pain in adults undergoing all types of surgery

BACKGROUND

Postoperative pain is a common consequence of surgery and can have deleterious effects. It has been suggested that the administration of opioid analgesia before a painful stimulus may improve pain control. This can be done in two ways. We defined 'preventive opioids' as opioids administered before incision and continued postoperatively, and 'pre-emptive opioids' as opioids given before incision but not continued postoperatively. Both pre-emptive and preventive analgesia involve the initiation of an analgesic agent prior to surgical incision with the aim of reducing intraoperative nociception and therefore postoperative pain.

OBJECTIVES

To assess the efficacy of preventive and pre-emptive opioids for reducing postoperative pain in adults undergoing all types of surgery.

SEARCH METHODS

We searched the following electronic databases: CENTRAL, MEDLINE, Embase, AMED, and CINAHL (up to 18 March 2018). In addition, we searched for unpublished studies in three clinical trial databases, conference proceedings, grey literature databases, and reference lists of retrieved articles. We did not apply any restrictions on language or date of publication.

SELECTION CRITERIA

We included parallel-group randomized controlled trials (RCTs) only. We included participants aged over 15 years old undergoing any type of surgery. We defined postincision opioids as the same intervention administered after incision whether single dose (as comparator with pre-emptive analgesia) or continued postoperatively (as comparator with preventive analgesia) (control group). We considered studies that did and did not use a double-dummy placebo (e.g. intervention group received active drug before incision and placebo after incision; control group received placebo before incision and active drug after incision).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: early acute postoperative pain (measured within six hours and reported on a 0-to-10 scale) and respiratory depression. Our secondary outcomes included: late acute postoperative pain (24 to 48 hours and reported on a 0-to-10 scale), 24-hour morphine consumption, and adverse events (intraoperative bradycardia and hypotension). We used GRADE to assess the quality of the evidence for each outcome.

MAIN RESULTS

We included 20 RCTs, including one unpublished study with 1343 participants. Two studies were awaiting classification as the full text for these studies was not available. One study evaluated pre-emptive opioids, and 19 studies evaluated preventive opioids. We considered only one study to be at low risk of bias for most domains. The surgeries and opioids used varied, although roughly half of the included studies were conducted in abdominal hysterectomy, and around a quarter used morphine as the intervention. All studies were conducted in secondary care.Pre-emptive opioids compared to postincision opioidsFor pre-emptive opioids in dental surgery, there may be a reduction in early acute postoperative pain (mean difference (MD) -1.20, 95% confidence interval (CI) -1.75 to -0.65; 40 participants; 1 study; low-quality evidence). This study did not report on adverse events (respiratory depression, bradycardia, or hypotension). There may be a reduction in late acute postoperative pain (MD -2.10, 95% CI -2.57 to -1.63; 40 participants; 1 study; low-quality evidence). This study did not report 24-hour morphine consumption.Preventive opioids compared to postincision opioidsFor preventive opioids, there was probably no reduction in early acute postoperative pain (MD 0.11, 95% CI -0.32 to 0.53; 706 participants; 10 studies; I² = 61%; moderate-quality evidence). There were no events of respiratory depression in four studies (433 participants). There was no important reduction in late acute postoperative pain (MD -0.06, 95% CI -0.13 to 0.01; 668 participants; 9 studies; I² = 0%; moderate-quality evidence). There may be a small reduction in 24-hour morphine consumption (MD -4.91 mg, 95% CI -9.39 mg to -0.44 mg; 526 participants; 11 studies; I² = 82%; very low-quality evidence). There may be similar rates of bradycardia (risk ratio (RR) 0.33, 95% CI 0.01 to 7.88; 112 participants; 2 studies; I² = 0%; low-quality evidence) and hypotension (RR 1.08, 95% CI 0.25 to 4.73; 88 participants; 2 studies; I² = 0%; low-quality evidence).

AUTHORS' CONCLUSIONS

Due to the low quality of the evidence, we are uncertain whether pre-emptive opioids reduce postoperative pain. Based on the trials conducted thus far, there was no clear evidence that preventive opioids result in reductions in pain scores. It was unclear if there was a reduction in morphine consumption due to very low-quality of evidence. Too few studies reported adverse events to be able to draw any definitive conclusions. Once assessed, the two studies awaiting classification may alter the conclusions of the review.

Comparison of intravenous tramadol versus ketorolac in the management of postoperative pain after oral and maxillofacial surgery

BACKGROUND

The aim of this study was to assess the better postoperative analgesic, tramadol, and ketorolac, in patients with maxillofacial trauma and who had undergone maxillofacial surgery, i.e., open reduction internal fixation, under general anesthesia.

MATERIALS AND METHODS

After taking ethical approval from the institution and informed consent, 46 ASA grade I-II patients were block randomized (ABAB) based on inclusion and exclusion criteria and equally divided into two groups in which one group of patients was given intravenous tramadol 100 mg and another group of patients was given intravenous ketorolac 30 mg at the time of closure of skin and was repeated after 8 and 16 h following surgery. Pain using VAS at the 2nd, 4th, 6th, 12th, and 24th postoperative was assessed, and association of results was compared using Cramer's V test SPSS (Version 22). Vital signs and side effects were recorded.

RESULTS

Although both drugs resulted in significant decrease in pain intensity from the 2nd to 24th postoperative hour, intravenous tramadol always resulted in better pain control than intravenous ketorolac at every postoperative hour (p value < 0.05) except at 2nd hour where changes are non-significant (p value > 0.05).

CONCLUSION

Apart from first 2 h where the changes are non-significant, this study clearly demonstrates the advantage of the intravenous tramadol in the management of postoperative pain and ease of administration in postoperative patient through IV cannula. The side effects of both the drugs were insignificant and did not have any effect on the result.

Comparison of Postoperative Pain Following One-Visit and Two-Visit Vital Pulpectomy in Primary Teeth: A Single-Blind Randomized Clinical Trial

Introduction:

The aim of this study was to compare post-operative pain following one-visit pulpectomy and placing stainless steel crown (SSC), with two-visit treatment (performing pulpectomy at the first visit followed by placing SSC at the next visit one week later) in vital pulp of primary molars with carious involvement.

Methods and Materials:

In this randomized clinical trial, 100 children aged 6-12 years with a carious primary molar tooth in need of pulpectomy were randomly divided into two groups of 50 each. In one-visit group, pulpectomy and placement of SSC were carried out at the same appointment. In two-visit group, pulpectomy of root canals was carried out at the first visit and placement of SSC was performed at the second visit one week after the first appointment. Post-operative pain was recorded using visual analogue scale (VAS) during one week after each treatment visit.

Results:

No significant difference was found in the mean age and gender distribution between the two groups (P˃0.05 for both comparisons). Findings revealed that in the two-visit (pulpectomy) group during first three days and 4-7 days after the first treatment appointment, pain felt by the children was significantly lower than that felt by the one-visit group at the same time period (P˂0.0001 for both comparisons). Moreover, children in two-visit (pulpectomy) group consumed significantly lower amount of analgesics than those in the one-visit group (P<0.0001).

Conclusion:

No significant difference was found between pain felt by children during the first three days following one-visit pulpectomy and placement of SSC at the same appointment. Therefore, one-visit treatment of vital primary tooth is recommended.

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.

Comparison of the analgesic efficacy of oral ketorolac versus intramuscular tramadol after third molar surgery: A parallel, double-blind, randomized, placebo-controlled clinical trial

BACKGROUND

Preemptive analgesia is considered an alternative for treating the postsurgical pain of third molar removal. The aim of this study was to evaluate the preemptive analgesic efficacy of oral ketorolac versus intramuscular tramadol after a mandibular third molar surgery.

MATERIAL AND METHODS

A parallel, double-blind, randomized, placebo-controlled clinical trial was carried out. Thirty patients were randomized into two treatment groups using a series of random numbers: Group A, oral ketorolac 10 mg plus intramuscular placebo (1 mL saline solution); or Group B, oral placebo (similar tablet to oral ketorolac) plus intramuscular tramadol 50 mg diluted in 1 mL saline solution. These treatments were given 30 min before the surgery. We evaluated the time of first analgesic rescue medication, pain intensity, total analgesic consumption and adverse effects.

RESULTS

Patients taking oral ketorolac had longer time of analgesic covering and less postoperative pain when compared with patients receiving intramuscular tramadol.

CONCLUSIONS

According to the VAS and UAC results, this study suggests that 10 mg of oral ketorolac had superior analgesic effect than 50 mg of tramadol when administered before a mandibular third molar surgery.

Preoperative analgesics for additional pain relief in children and adolescents having dental treatment

BACKGROUND

Fear of dental pain is a major barrier to treatment for children who need dental care. The use of preoperative analgesics has the potential to reduce postoperative discomfort and intraoperative pain. We reviewed the available evidence to determine whether further research is warranted and to inform the development of prescribing guidelines. This is an update of a Cochrane review published in 2012.

OBJECTIVES

To assess the effects of preoperative analgesics for intraoperative or postoperative pain relief (or both) in children and adolescents undergoing dental treatment without general anaesthesia or sedation.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 5 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 12), MEDLINE via OVID (1946 to 5 January 2016), EMBASE via OVID (1980 to 5 January 2016), LILACS via BIREME (1982 to 5 January 2016) and the ISI Web of Science (1945 to 5 January 2016). We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials to 5 January 2016. There were no restrictions regarding language or date of publication in the searches of the electronic databases. We handsearched several specialist journals dating from 2000 to 2011.We checked the reference lists of all eligible trials for additional studies. We contacted specialists in the field for any unpublished data.

SELECTION CRITERIA

Randomised controlled clinical trials of analgesics given before dental treatment versus placebo or no analgesics in children and adolescents up to 17 years of age. We excluded children and adolescents having dental treatment under sedation (including nitrous oxide/oxygen) or general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors assessed titles and abstracts of the articles obtained from the searches for eligibility, undertook data extraction and assessed the risk of bias in the included studies. We assessed the quality of the evidence using GRADE criteria.

MAIN RESULTS

We included five trials in the review, with 190 participants in total. We did not identify any new studies for inclusion from the updated search in January 2016.Three trials were related to dental treatment, i.e. restorative and extraction treatments; two trials related to orthodontic treatment. We did not judge any of the included trials to be at low risk of bias.Three of the included trials compared paracetamol with placebo, only two of which provided data for analysis (presence or absence of parent-reported postoperative pain behaviour). Meta-analysis of the two trials gave arisk ratio (RR) for postoperative pain of 0.81 (95% confidence interval (CI) 0.53 to 1.22; two trials, 100 participants; P = 0.31), which showed no evidence of a benefit in taking paracetamol preoperatively (52% reporting pain in the placebo group versus 42% in the paracetamol group). One of these trials was at unclear risk of bias, and the other was at high risk. The quality of the evidence is low. One study did not have any adverse events; the other two trials did not mention adverse events.Four of the included trials compared ibuprofen with placebo. Three of these trials provided useable data. One trial reported no statistical difference in postoperative pain experienced by the ibuprofen group and the control group for children undergoing dental treatment. We pooled the data from the other two trials, which included participants who were having orthodontic separator replacement without a general anaesthetic, to determine the effect of preoperative ibuprofen on the severity of postoperative pain. There was a statistically significant mean difference in severity of postoperative pain of -13.44 (95% CI -23.01 to -3.88; two trials, 85 participants; P = 0.006) on a visual analogue scale (0 to 100), which indicated a probable benefit for preoperative ibuprofen before this orthodontic procedure. However, both trials were at high risk of bias. The quality of the evidence is low. Only one of the trials reported adverse events (one participant from the ibuprofen group and one from the placebo group reporting a lip or cheek biting injury).

AUTHORS' CONCLUSIONS

From the available evidence, we cannot determine whether or not preoperative analgesics are of benefit in paediatric dentistry for procedures under local anaesthetic. There is probably a benefit in using preoperative analgesics prior to orthodontic separator placement. The quality of the evidence is low. Further randomised clinical trials should be completed with appropriate sample sizes and well defined outcome measures.

Comparison of the anti-inflammatory effect of dexamethasone and ketorolac in the extractions of third molars

This double-blind, split-mouth, and randomized study was aimed to compare the efficacy of dexamethasone and ketorolac tromethamine, through the evaluation of pain, edema, and limitation of mouth opening. Thirty-four individuals aged 18-26 years, having bilateral mandibular third molars, in a similar position, were selected. Two different surgical procedures were performed on the same individual by the single surgeon. For an extraction, the individual received 1 capsule of 10 mg ketorolac tromethamine 1 h before surgery and every 8 h for 2 days. For the extraction of the contralateral side, the individual received 1 capsule of 8 mg dexamethasone 1 h before surgery and 1 placebo capsule every 8 h for 2 days. Sodium metamizol, 500 mg, was given as rescue medication in postoperative. Pain was assessed by the Visual Box Scale-11 points (BS-11) at 24 h postoperative. Edema (metric measurement) and the maximum mouth opening (interincisal) were recorded in the pre-operative, 24 h, 48 h, 72 h and 7 days postoperatively. The results showed that both therapeutic treatments used were effective in the postoperative, and there were no statistically significant differences between the groups for the pain and edema variables. However, for the limitation of mouth opening, 24 h and 7 days postoperatively, the dexamethasone group had a lower limitation of mouth opening, behaving better than the ketorolac for this variable in these periods. Due also to the higher margin of safety, the use of dexamethasone as a single dose becomes a more suitable alternative for use in routine surgical extractions of third molars.

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.

Effect of submucosal application of tramadol on postoperative pain after third molar surgery

The aim of this study was to evaluate the effectiveness of submucosal application of tramadol, for acute postoperative facial pain, following the extraction of impacted third molar teeth. This prospective, double-blind, randomised placebo-controlled study included 60 ASA I-II patients undergoing impacted third molar surgery under local anaesthesia. Following the surgical procedure, patients were randomly divided into two groups; group T (1 mg/kg tramadol) and group S (2-mL saline). Treatments were applied submucosally after surgery. Pain after extraction was evaluated using a visual analogue scale (VAS) 0.5, 1, 2, 4, 6, 12, 24, and 48 h postoperatively. The time at which the first analgesic drug was taken, the total analgesic dose used, and adverse tissue reactions were also evaluated. In group T, postoperative VAS scores were significantly lower compared to that in group S (p < 0.05). This study demonstrated that post-operative submucosal application of tramadol is an effective method for reducing acute post-operative facial pain after impacted third molar surgery.

Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars

PURPOSE

In this study we assessed the clinical efficacy of sub-mucosal injection of ketamine at sub-anesthetic dose of 0.5 mg/kg on post-operative pain, swelling and trismus following surgical extraction of impacted mandibular third molars.

METHODS

Forty bilaterally symmetrical impacted mandibular third molars in 20 patients who required surgical removal were included in the study. Within the same individual, one of the sites received a test medication whereas the other site was used as control. All patients received nerve blocks with local anesthetic (2 % lignocaine hydrochloride with 1:80,000 adrenaline); the Test group received sub-mucosal infiltration of 0.5 mg/kg of ketamine hydrochloride (without preservative) around the impacted mandibular third molar and along the incision line, while the Placebo group received normal saline infiltration, 10 min before placement of the incision.

RESULTS

The pain scores on VAS at 30 min, 1, 4, 12 h and 1 day post-operatively was significantly lower in the Test group than in the Placebo group (p < .05). With respect to facial swelling and mouth opening the Test group and Placebo group showed overall no statistically significant difference (p > .05) on the 1st, 3rd and 7th post-operative days.

CONCLUSION

The sub-mucosal injection of 0.5 mg/kg ketamine administered before surgical removal of impacted mandibular third molars was found to be effective in significantly reducing post-operative pain for the first 24 h.

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.

Intraoperative local anaesthesia for reduction of postoperative pain following general anaesthesia for dental treatment in children and adolescents

BACKGROUND

Whilst carrying out dental procedures under general anaesthesia (GA), practitioners routinely give local anaesthetics (LA) intraoperatively to children. Local anaesthetics are used to help manage postoperative pain and reduce bleeding and the physiological response to procedures. Studies of effectiveness of intraoperative LA to date have reported contradictory results.

OBJECTIVES

To assess the effects of intraoperative local anaesthesia for reducing postoperative pain following general anaesthesia for dental treatment in children and young people aged 17 years or younger.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 12), MEDLINE via OVID (1946 to 02 January 2014), EMBASE via OVID (1980 to 02 January 2014) and Web of Science Conference Proceedings (1990 to 02 January 2014). We searched for ongoing trials in the US National Institutes of Health Register, the metaRegister of Controlled Trials (mRCT) and the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) Clinical Trials Portal. We did not place any restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials in which local anaesthetic was given intraoperatively under general anaesthesia for dental treatment of children and young people aged 17 years or younger.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We performed data extraction and assessment of risk of bias independently and in duplicate. We contacted authors to clarify omissions in trial reports. In the 'Summary of findings' tables, we elected to report the outcomes pain, distress, postoperative bleeding, and physiological parameters related to the general anaesthetic, as we considered these to be the outcomes of greatest importance to readers of the review.

MAIN RESULTS

We included 14 trials in this review, with 1152 randomised participants. The studies were published between 1990 and 2009 and were conducted in the United Kingdom, Egypt, Saudi Arabia, and the United States. The age of participants ranged from 2 to 40 years. Three studies were at an overall high risk of bias, seven studies were at an unclear risk of bias, and we judged four studies to be at low risk of bias. The clinical heterogeneity of the included studies precluded pooling of studies in terms of method of administration of LA (e.g., intraligamental injection, infiltration injection, or topical delivery) and variation in the use of supplementary analgesics and follow-up time.Of the seven studies where administration of LA was by infiltration injection, six studies (very low-quality body of evidence, 542 participants analysed, 1 study had overall high risk of bias, 4 studies had overall unclear risk of bias, 1 study had overall low risk of bias) measured postoperative pain. The results were equivocal. There was a decrease in bleeding and increase in soft tissue damage in the LA groups, but we did not judge this to be clinically significant.In the 2 studies where administration of LA was by intraligamental injection, there was no difference in mean pain scores, and they did not report any soft tissue damage (very low-quality body of evidence, 115 participants analysed, 1 study had overall high risk of bias, 1 study had overall unclear risk of bias).One 3-armed study (very low-quality body of evidence, 54 participants analysed, overall high risk of bias) compared the effects of intraligamental and infiltration LA injection with no treatment. There was no evidence of a mean difference in pain, distress, or postoperative anxiety among the three groups.Four studies (very low-quality body of evidence, 343 participants analysed, 2 studies had overall low risk of bias, 2 studies had overall unclear risk of bias) evaluated the effects of topical LA compared with no treatment or placebo. One study (overall unclear risk of bias) with a no-treatment comparator reported lower mean pain in the LA group; all other studies reported no difference in mean pain scores. Two studies reported on bleeding (overall unclear risk of bias): One study reported a clinically insignificant increase in bleeding with no treatment; the other reported no difference.None of the studies reported on participant or child satisfaction.

AUTHORS' CONCLUSIONS

In this review, it was difficult to reach firm conclusions as to the benefit of using local anaesthetic for dental treatment under general anaesthesia. The information reported in the included studies was comprehensive and applicable to the review question, but ultimately it was not sufficient to address the objective of the review. We were unable to pool the included studies in a meta-analysis because of substantial variation in outcome measures, interventions, and treatment types. The use of supplementary analgesia further obscured the effect of local anaesthetics.Based on the literature review and the results of this review, we recommend further randomised controlled trials that minimise bias through adequate allocation concealment and blinding of participants and assessors, and assess the effect of intraoperative local anaesthetic on the volume and type of anaesthetic used and on the cardiovascular system in participants receiving supplementary analgesics as well. Researchers should give consideration to the impact of any changes on the health and well-being of the participant and report baseline measures of pain or distress, or both, and preoperative anxiety.

Efficacy of preemptive lornoxicam on postoperative analgesia after surgical removal of mandibular third molars

OBJECTIVE

Pain is the most encountered complication following third molar surgery. Although nonsteroidal anti-inflammatory drugs are often used for pain control, the effect of preemptive lornoxicam has not been detailed. We compare the analgesic efficacy of preemptive lornoxicam versus postoperative lornoxicam.

STUDY DESIGN

Forty-three participants aged 18 to 33 years who had bilateral, symmetrical third molars were included in this double-blind, randomized, placebo-controlled study. All participants took part in each of the 2 groups for a 1-month interval (crossover design). Group Pre received lornoxicam 8 mg intravenously 25 minutes before surgery and 2 mL serum saline postoperatively. Group Post was given the opposite protocol. Pain was evaluated by visual analog scale in the first 12 hours.

RESULTS

We observed statistically significant differences in the reduction of the pain level in group Pre (P < .05). These participants felt less pain in the first 5 postoperative hours and needed fewer analgesics in the first 12 postoperative hours.

CONCLUSIONS

Preemptive lornoxicam is effective for postoperative pain control.

Comparative study of intravenous Tramadol versus Ketorolac for preventing postoperative pain after third molar surgery--a prospective randomized study

The aim of this comparative, prospective, randomized, controlled study was to evaluate two different regimens of analgesics: a preoperative intravenous dose of either Tramadol or Ketorolac given 10 min prior to surgery to assess their impact on clinical recovery after third molar surgery. Forty patients requiring surgical extraction of unilateral impacted mandibular third molars similar in position were enrolled in the study. Patients were randomly divided into two groups based on permuting the numbers. Patients in Group 1 and Group 2 were administered either Tramadol 50 mg or Ketorolac 30 mg, intravenously, 10 min prior to surgery. The difference in postoperative pain was assessed by four primary points: pain intensity as measured by a 10 mm visual analogue scale hourly for 12 h, median time to rescue analgesics, number of analgesics consumed and patient's overall 5-point global assessment scale. Throughout the 12 h investigation period, patients treated with Ketorolac reported significantly lower pain intensity scores, significantly longer time to rescue analgesics (Acetaminophen 500 mg) and less intake of postoperative analgesics. In Group 2, 40% of the patient had good overall assessment as compared to Group 1 where only 25% of patients had good overall assessment. The current study shows that pre-emptive use of Inj. Ketorolac 30 mg intravenously can reduce the severity of the postoperative sequelae of asymptomatic impacted mandibular third molar surgery.

Preemptive analgesia in third molar impaction surgery

INTRODUCTION

We have evaluated efficacy of diclofenac sodium as pre-emptive analgesia agent in a prospective triple blind placebo controlled randomized clinical trial in a patients undergoing third molar impaction surgery.

MATERIALS AND METHODS

Randomization of groups was done by randomization software and two groups were constituted one group receiving placebo pre operatively and then the drug for next five days while the other group was given diclofenac sodium pre operatively and then for five days.

RESULTS

Results were achieved with help of measurement of outcome variables like postoperative tenderness, swelling and trismus on a visual analogous scale (VAS) and other personalized scale. Collected data shows that there is a significant reduction in the score of postop tenderness in experimental group (P = 0.00), while there is a minimal difference between score of postoperative swelling and tenderness (P > 0.04).

CONCLUSION

So, we can conclude that use of diclofenac sodium as a preemptive analgesic agent is beneficial for better pain control in third molar impaction surgery.

What strategies are helpful in the operative management of third molars?

PURPOSE

The purpose of this review was to investigate and report strategies that might improve patient recovery after third molar (M3) surgery.

MATERIALS AND METHODS

This was a literature review on various topics to identify the methods of improving outcomes after M3 removal. Numerous topics were reviewed, including patient age, flap design, effect of smoking, use of antibacterial rinses, pre-emptive analgesia, and the role of antibiotics and corticosteroids in recovery.

RESULTS

Increased patient age appears to be a factor in a higher complication rate, but the literature is sparse. The results of studies on flap design are contradictory, but there is no difference in long-term periodontal health. Systematic reviews clearly show that longer periods of smoking cessation decrease surgical complications, but few studies have addressed M3 surgery. Likewise, the role of pre-emptive analgesia, although beneficial in a general surgical setting, has not been studied thoroughly with regard to M3 surgery. The use of chlorhexidine rinses to prevent alveolar osteitis and surgical site infection has been studied extensively, but meta-analyses have not convincingly proved this effect. The evidence is convincing that antibiotics decrease alveolar osteitis and surgical site infection. Similarly, it is clear that corticosteroids decrease postoperative trismus and edema; however, the role of steroids in decreasing pain is not proved.

CONCLUSION

This review found various factors associated with improving recovery and minimizing complications in M3 surgery.

Comparative evaluation of pre-emptive analgesic efficacy of intramuscular ketorolac versus tramadol following third molar surgery

Pre-emptive analgesia aims at preventing the central nervous system from reaching a hyper-excitable state known as central sensitization, in which it responds excessively to afferent inputs. The clinical implication would be more effective pain management, thereby reducing post-operative pain and analgesic requirements. This study aimed at investigating the existence of pre-emptive analgesia and to compare the pre-emptive analgesic efficacy of im ketorolac [NSAID] versus tramadol [SYNTHETIC OPIOD] for post-operative pain management following third molar surgery. Fifty patients under the age group of 16-25 years with asymptomatic, symmetrically impacted mandibular third molars were equally divided into 2 groups and underwent third molar surgery under local anesthesia. Ketorolac 30 mg and tramadol 50 mg were used in the study group, while sodium chloride 0.9 % was used in the control group. Study parameters included pain intensity scores for 12 post-operative hours, time to 1st rescue analgesia, total number of analgesics consumed during the 5 post-operative days and patients' self assessment of efficacy of the surgery with regardsto no pain. Statistically, the data are presented as the mean values with their standard deviations and a 95 % confidence interval [p is significant, if p < 0.05] for the mean are applicable. Incidences of adverse events like pain on injection of the study drug, local reactions, nausea and vomiting were noted. Patients in the study group significantly performed better than the control group in terms of all the parameters; while among the study group, ketorolac fared better than tramadol. All the drug related complications were mild and did not require any intervention. Pre-operative ketorolac or tramadol in comparison to placebo resulted in a significantly better post-operative pain management. However as against tramadol, ketorolac is a better choice as a pre-emptive analgesic agent for the post-operative pain management following third molar surgery.

Preoperative analgesics for additional pain relief in children and adolescents having dental treatment

BACKGROUND

Fear of dental pain is a major barrier to children needing dental care. The use of preoperative analgesics has the potential to reduce postoperative discomfort. In addition it might also reduce intraoperative pain. Reviewing the available evidence will determine whether further research is warranted and will inform the development of prescribing guidelines.

OBJECTIVES

To assess the effects of preoperative analgesics for pain relief in children and adolescents undergoing dental treatment.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 8 March 2012), EMBASE via OVID (1980 to 8 March 2012), LILACS via BIREME (1982 to 8 March 2012) and the ISI Web of Knowledge (1945 to 8 March 2012). There were no restrictions regarding language or date of publication.The reference lists of all eligible trials were checked for additional studies. Specialists in the field were contacted for any unpublished data.

SELECTION CRITERIA

Randomised controlled clinical trials of analgesics given before dental treatment versus placebo or no analgesics in children and adolescents aged up to 17 years. We excluded children and adolescents having dental treatment under sedation (including nitrous oxide/oxygen) or general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors assessed titles and abstracts for eligibility and undertook data extraction and assessment of risk of bias.

MAIN RESULTS

Five trials met the review's inclusion criteria with 190 participants in total. Three trials were dentally related i.e. restorative and extraction treatments; two trials related to orthodontic treatment. None of the included trials were judged to be at low risk of bias. Three trials compared paracetamol with placebo, only two of which provided data for analysis (presence or absence of parent-reported postoperative pain behaviour). The meta-analysis of the two trials showed a nonsignificant risk ratio (RR) for postoperative pain-related behaviours of 0.81 (95% confidence interval (CI) 0.53 to 1.22; P = 0.31), which showed no evidence of a benefit in taking paracetamol preoperatively (52% reporting pain in placebo versus 42% in test group). One of these trials was at unclear risk of bias, the other at high risk. Four trials compared ibuprofen with placebo. Three of these trials provided useable data. One trial reported no statistical difference in postoperative pain experienced by the ibuprofen group and the control group for children undergoing dental treatment. Data from two trials, including patients who were having orthodontic separator replacement without a general anaesthetic, were pooled to determine the effect of preoperative ibuprofen on the severity of postoperative pain. There was a statistically significant benefit, with regard to severity of postoperative pain, for giving ibuprofen preoperatively with mean difference -19.12 (95% CI -29.36 to -8.87; P = 0.0003; moderate quality evidence) on a visual analogue scale (0 to 100) indicating a probable benefit for preoperative ibuprofen before this orthodontic procedure. However, both these trials were at high risk of bias. Adverse events were only reported in one trial (one patient from the ibuprofen group and one from the placebo group reporting a lip or cheek biting injury).

AUTHORS' CONCLUSIONS

From the available evidence we cannot determine whether or not preoperative analgesics are of benefit in paediatric dentistry for procedures under local anaesthetic. There is probably a benefit in prescribing preoperative analgesics prior to orthodontic separator placement.

Comparative analysis of preemptive analgesic effect of tramadol chlorhydrate and nimesulide following third molar surgery

The aim of this prospective, randomized, controlled, paired trial was to perform a comparative analysis of the preemptive analgesic effect of nimesulide and tramadol chlorhydrate during third molar surgery. The study was carried out between March and November 2009, involving 94 operations in 47 male and female patients with bilateral impacted lower third molars in comparable positions. The sample was divided into two groups. Group A received an oral dose of 100 mg of nimesulide 1 h prior to surgery. Group B received an oral dose of 100 mg of tramadol chlorhydrate 1 h prior to surgery. The following aspects were evaluated in the postoperative period: adverse effects of the drugs; amount of rescue medication used (acetaminophen 750 mg); and pain 5, 6, 24, 36, 48, 60, 72 and 84 h after surgery using a visual analog pain scale. Peak pain occurred 5 h after surgery in both groups, with a mean pain score of 2.3 in Group A and 3.0 in Group B; this difference did not achieve statistical significance (p > 0.141). Based on the sample studied, nimesulide and tramadol chlorhydrate demonstrate similar preemptive analgesic effects when used in lower third molar surgeries.

[Review: effect of preventive analgesia on postoperative pain]

Preventive analgesia (administration of a technique or analgesic drug with the aim of reducing postoperative pain, hyperalgesia and allodynia) has shown to be effective in experimental studies. However, the results in patients have been controversial. A review has been made of the clinical trials published during the last 5 years to test the efficacy of preventive analgesia on postoperative pain. A search was made of the published literature in Medline, with the terms "pre-emptive analgesia", "preventive analgesia" and "postoperative pain", selecting prospective, controlled, randomised and double blind studies that compared analgesic regimens before and after the incision or the same or very similar postoperative conditions. A total of 27 studies were found during the period 2005-2010 that complied with the inclusion criteria. Analgesia measurement variables were analysed, such as postoperative pain, time passed until the first rescue, and total analgesic requirements. Preventive analgesia was effective in 15 of the 27 studies, with pre-incisional epidural drug administration being the most effective (local anaesthetics with or without opioids, clonidine). The possible effectiveness of preventive analgesia in humans is still controversial, partly due to the wide heterogeneity in the inclusion criteria, types of patients, or the analgesia measurement parameters analysed by the studies. More studies are required with common criteria and objectives.

Articaine versus lidocaine for third molar surgery: a randomized clinical study

OBJECTIVE

Pain reduction has been the subject of continuous research in the field of oral and maxillofacial surgery since postoperative pain with ranging of intensity and duration may affects the patient submitted in an oral surgical procedure. The aim of present study was to compare the analgesic effectiveness between two different anesthetic solutions (articaine and lidocaine) in third molar surgery.

STUDY DESIGN

A prospective, randomized and clinical study with patients submitted to third molar surgery at two distinct times. The visual analogue scale, the McGill Pain Questionnaire and the analgesic consumption record were used to measure the pain after each surgical time.

RESULTS

Duration of surgery, latency, the amount of anesthetic used and analgesic consumption showed clinical differences with highlights of articaine, though statistical significance was not observed (P<0.05). The pain scores indicated similar anesthetic efficacy with both solutions.

CONCLUSION

In the present study no significant differences were observed between lidocaine and articaine in the control of postoperative pain.

Pre-emptive analgesic effectiveness of meloxicam versus tramadol after mandibular third molar surgery: a pilot study

PURPOSE

To compare the pre-emptive analgesic effectiveness of 15 mg of meloxicam and 50 mg of tramadol after mandibular third molar surgery.

PATIENTS AND METHODS

This pilot study was a double-blind, randomized, parallel-group clinical trial. The patients were randomized into 2 treatment groups, each with 15 patients, by use of a series of random numbers: group A was administered 15 mg of meloxicam intramuscularly (IM) 50 minutes before the surgery and group B was given 50 mg of tramadol IM 50 minutes before the surgery. We evaluated pain intensity, analgesic consumption, swelling, and trismus.

RESULTS

The group receiving 15 mg of meloxicam IM showed differences in pain intensity evaluated by the area under the curve of the visual analog scale and total analgesic consumption when compared with the group receiving 50 mg of tramadol IM.

CONCLUSION

The patients receiving 15 mg of preoperative meloxicam had less pain intensity and total analgesic consumption than those receiving 50 mg of preoperative tramadol.

Comparison of pre-emptive ibuprofen, paracetamol, and placebo administration in reducing post-operative pain in primary tooth extraction

BACKGROUND

This study investigates preliminary investigations that a pre-emptive analgesia administration may reduce post-extraction pain.

AIM

This prospective, placebo-controlled, randomized, double-blind trial was planned to compare the efficacy of the pre-emptive administration of ibuprofen, paracetamol, and placebo in reducing post-extraction pain in children.

DESIGN

Forty-five children, ages 6-12, who needed primary mandibular molar tooth extraction were treated in paediatric dental clinics, with treatment preceded by local anaesthesia and analgesic drugs during the preoperative period. A five-face scale was used to evaluate pain reaction during the injection, extraction, and post-operative period. Self-report scores were recorded when the local anaesthesia had been administered in soft tissues and both before and after the extraction was completed. The Kruskal-Wallis and Mann-Whitney U tests (with Bonferroni correction paired t-test as the post hoc test) were used at a confidence level of 95%.

RESULTS

The use of pre-emptive analgesics showed lower scores compared to the placebo, irrespective of the age, weight, gender of the child, and the number of teeth extracted during the study period. Additionally, ibuprofen exhibited lower pain scores (P < 0.05) compared to paracetamol at the 15-min (P < 0.001) and 4-h (P < 0.009) periods.

CONCLUSIONS

Preoperative use of ibuprofen and paracetamol may provide a pre-emptive analgesic effect in paediatric patients who receive adequate analgesia during mandibular primary tooth extraction.

A comparitive study of diclofenac transdermal patch against oral diclofenac for pain control following removal of mandibular impacted third molars

OBJECTIVE

The objectives of this study was to evaluate subjectively the analgesic efficacy of Oral Diclofenac Sodium against Diclofenac Sodium Transdermal patch in the management of postoperative pain following surgical removal of impacted mandibular third molars.

MATERIALS AND METHODS

Twenty healthy subjects belonging to both the sexes in the age group of 18-40 years with bilateral mesioangular impactions of mandibular third molar teeth underwent surgical removal under local anaesthesia by administering an inferior alveolar nerve block on two different occasions with a minimum interval of 1 week in-between the procedures. The postoperative pain was recorded on visual analog scale, a verbal rating scale, a pain relief scale and a pain intensity scale. Readings were taken at 2 hours, 4 hours, 8 hours, 12 hours and 24 hours postoperatively, taking the time at which the surgery was completed as a reference. On the second and third days, the repeat medication was administered at that reference time and recordings taken at the same intervals for a total of 3 days. Patients received the study medication i.e. Diclofenac Sodium 100mg once a day for 3 days after performing surgery on one side and the same patients were given Diclofenac Sodium Transdermal Patch 100mg once a day for 3 days after performing surgery on the contralateral side.

RESULTS AND OBSERVATIONS

Both the statistical analysis and clinical observation showed that on the first postoperative day diclofenac sodium administered orally has slightly more significant efficacy when compared to the drug administered transdermally. However, on the second and third postoperative days there was no statistical or clinical difference in the pain control by either route of administration.

CONCLUSIONS

The study concludes that transdermal diclofenac sodium can be used as an alternative form of pain control following removal of impacted mandibular third molars, however considering that the analgesic potency might be lesser in the immediate postoperative period, it might be prudent to use oral diclofenac sodium for immediate postoperative pain relief, following which transdermal route can be used for pain control.