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

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.

Provider-directed analgesia for dental pain

INTRODUCTION

Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry.

AREAS COVERED

This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain.

EXPERT OPINION

Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

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.

Pre-emptive analgesia efficacy of piroxicam versus tramadol in oral surgery

Background

This double-blind randomized controlled trial (RCT) was conducted to evaluate the pre-emptive analgesia and anti-inflammatory efficacy of piroxicam compared with tramadol in patients undergoing oral surgery.

Methods

Seventy-eight patients who required extraction of impacted mandibular third molars were randomized into three treatment groups of 26 patients each: group I received 100 mg of tramadol, group II received 20 mg of piroxicam, and group III received a placebo. Drugs were administered intramuscularly 30 min prior to the extraction procedure.

Results

Pain intensity, time to first analgesic administration, total analgesic consumption, facial edema, and trismus were the outcomes of interest. The group receiving 20 mg of piroxicam showed significantly lower pain intensity, increased time to first analgesic, and reduced edema from preoperative to postoperative day seven than those in the tramadol and placebo groups.

Conclusion

The findings of this study showed that piroxicam had significant pain relief efficacy after third molar surgery compared with that in tramadol.

Efficacy of Preoperative Piroxicam, Diclofenac, Paracetamol With Tramadol and Placebo Tablets for Relief of Postoperative Pain After the Removal of Impacted Mandibular Third Molars: A Randomised Controlled Trial

Aim

We aimed to analyze the influence of preoperative piroxicam, diclofenac, paracetamol, tramadol, and placebo tablets as measured in the time required for rescue analgesia for postoperative pain relief after the extraction of impacted mandibular third molar.

Materials & methods

Forty-four patients who needed extraction of impacted mandibular third molar were arbitrarily categorized into four groups namely, piroxicam, diclofenac, paracetamol with tramadol, and placebo. The test medicine was given one hour preoperatively before the surgical removal. The pain was assessed using visual analog scale (VAS) and verbal rating scale (VRS) scores preoperatively and at the third and 24^th hours. The time required for escape analgesia was measured. 

Results

The mean VAS and VRS scores showed significant differences across the groups after 24 hours. The mean score was lowest for the patients taking piroxicam (1.30+1.95) and highest for patients taking tramadol + paracetamol (4.50+2.59). As far as escape analgesia is concerned piroxicam group was by far superior.

Conclusion

The pain scores and the rescue analgesic requirement suggested that piroxicam analgesic significantly reduced pain; moreover, it is a safe as well as an efficacious substitute to the conventional non-steroidal anti-inflammatory drugs (NSAIDs) for mandibular third molar impactions.

Combination of etodolac and dexamethasone improves preemptive analgesia in third molar surgery: a randomized study

OBJECTIVE

This randomized, controlled, triple-blind, crossover clinical trial aimed to investigate the use of dexamethasone (DEX) and etodolac (ETO) as preemptive analgesia before mandibular third molar extraction.

METHODS

Patients were divided into three groups (n = 20 teeth each) based on the drug administered: DEX 8 mg (DEX); DEX 8 mg plus ETO 300 mg (DEX + ETO), and ETO 300 mg (ETO). Paracetamol (750 mg) tablets were administered as rescue analgesics. Pain was evaluated using the visual analog scale (VAS) at 6, 12, 24, 48, and 72 h and 7 days postoperatively. Edema and trismus were assessed 48 and 72 h postoperatively. All data were subjected to statistical analysis, where a P value < .05 indicated statistical significance.

RESULTS

VAS scores and the number of rescue analgesics taken were lower in the DEX + ETO group than in the other groups (P < .001 and P = .014, respectively). At 48 h, trismus was similar among all groups; however, the ETO group showed the highest trismus 7 days postoperatively (P < .05). Edema was similar among all groups at all time points (P > .05).

CONCLUSION

The combined use of the anti-inflammatory drugs, DEX and ETO, resulted in better pain control and the need for fewer rescue analgesics than the use of either drug alone, which indicated their effectiveness in mandibular third molar extractions preoperatively.

CLINICAL RELEVANCE

This drug combination can lead to less pain, edema, and trismus and reduce the use of rescue analgesics in the postoperative period.

Efficacy of fentanyl transdermal patch in pain control after lower third molar surgery: A preliminary study

Background

Surgical removal of impacted lower third molars is a common oral surgical procedure, generally followed by moderate to severe postoperative pain. Transdermal drug delivery as a concept offers interesting possibilities for postoperative pain control. The aim of this study was to evaluate the efficacy of transdermal system with fentanyl in relieving pain following impacted lower third molar surgery.

Material and Methods

Seventeen patients with bilateral impacted lower third molars were included in this preliminary study. For postoperative pain control, patients randomly received a fentanyl patch plus placebo tablet after the first operation and regular (placebo) patch and an analgesic, after the second operation. Analgesia was evaluated during first 24 hours postoperatively according to patients’ reports about time of first pain appearance and additional analgesic consumption. Pain severity was rated using a 10 cm long visual analogue scale (VAS).

Results

Intensity of postoperative pain and postoperative analgesic consumption were significantly lower after the Fentanyl Transdermal System (FTS) was applied (p<0.05). Duration of postoperative analgesia was significantly higher with FTS when compared to control treatment (p<0.05).

Conclusions

Based on the results of this preliminary study, transdermal system with fentanyl significantly reduced postoperative pain after third molar surgery.

Key words:Analgesia, fentanyl, transdermal administration, third molar surgery, acute pain, postoperative care.

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.

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.

Does the Preemptive Use of Oral Nonsteroidal Anti-inflammatory Drugs Reduce Postoperative Pain in Surgical Removal of Third Molars? A Meta-analysis of Randomized Clinical Trials

The purpose of this study was to investigate the effectiveness of preemptive analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs) in third-molar surgery. A PubMed literature search was conducted for articles restricted to the English language using the following terms (DeCS/MeSH) or combinations: analgesia, third molar, and preemptive. From a total of 704 articles, 6 (n=420 subjects) were selected. All studies presented a low risk of bias (Cochrane criteria) but exhibited high heterogeneity of methods. Two studies were excluded from the meta-analysis because they did not have adequate numeric values (dichotomous data) for the calculations. Preemptive analgesia showed no significant benefit (n=298, P=.2227, odds ratio: 2.30, 0.60-8.73) in reducing postoperative pain after removal of lower impacted third molars. However, there was a probable direct relationship between the effectiveness of NSAIDs in preemptive analgesia for removal of third molars and its selectivity for the cyclooxygenase-2 (COX-2). Preemptive analgesia did not have a significant effect in reducing postoperative pain after removal of lower impacted third molars. More homogeneous and well-delineated clinical studies are necessary to determine a possible association between NSAIDs' selectivity for COX-2 and treatment effectiveness.