Preoperative nonsteroidal anti-inflammatory agents: review of the literature

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.

Comparison of Pain Levels With Postoperative Intramuscular Administration of Single-Dose Ketoprofen Versus Diclofenac Sodium in Patients Undergoing Lower Third Molar Surgery

Background Third molar surgeries are commonly performed in oral and maxillofacial surgery practice. Pain associated with this procedure is usually a frequent reason for patient apprehension and discomfort. Oral analgesics, though effective, do not provide sufficient pain relief in the immediate postoperative period.  Aim To assess the postoperative effect on pain levels of single-dose administration of ketoprofen and diclofenac sodium as an injection in patients undergoing third molar removal surgeries.  Methods This study was conducted among 30 patients divided into two groups (n=15). Patients in Group K received injection ketoprofen 100 mg and Group D included patients receiving injection diclofenac sodium 75 mg, both intramuscularly postoperatively. The intensity of pain was assessed at 30 minutes, two, six, and eight hours post-surgical removal of the impacted tooth using the visual analogue scale (VAS). The statistical data was analyzed using SPSS for Windows version 23.0 (IBM Corp., Armonk, NY, USA). The comparative statistical test adopted to compare pain scores between the two groups was the Independent samples t-test. A p-value of <0.05 was considered to be statistically significant. Results Our study results revealed that Group K patient's VAS scores after two hours, six hours, and eight hours were 3.9 ± 2.7, 4.5 ± 3.23, 2.93 ± 2.27 respectively. In Group D patient's VAS scores after two hours, six hours, and eight hours were 4.83 ± 2.82, 5.03 ± 2.9, 3.73 ± 2.91 respectively. Patients who were administered ketoprofen had lower pain levels when compared to patients who were given diclofenac but the difference was not statistically significant at any time point (p=0.172 after eight hours). Our results depicted that the pain levels uniformly reached their maximal levels six hours after the procedure and thereafter steadily declined in both groups.  Conclusion It can be concluded from the study that both the drugs ketoprofen and diclofenac sodium analyzed in this study can be used interchangeably for the reduction of pain following lower third molar surgery.

Using Intravenous Ibuprofen for Preventive Analgesia in Orthognathic Surgery

PURPOSE

Preventive analgesia aims to manage postoperative pain caused by nociceptive and central stimulation. The purpose of this study was to research the effect of a single-dose intravenous (IV) ibuprofen administration for preventive analgesia on postoperative pain management in orthognathic surgery.

MATERIALS AND METHODS

This prospective, double blind, and randomized study was performed on a total of 40 adult patients who planned to undergo bimaxillary osteotomy, between 2018 and 2019. Thirty minutes before the surgery, 800 mg of IV ibuprofen and 100 mL of saline were applied to group 1 (ibuprofen; n = 20) and group 2 (placebo; n = 20), respectively. Postoperative analgesia was maintained with tramadol infusion via a patient-controlled analgesia pump. Postoperative visual analog scale (VAS) scores at 1, 3, 6, 9, 12, and 24 hours after surgery, rescue analgesic requirement, total tramadol dose, and adverse effects were recorded.

RESULTS

VAS scores between the groups at 1, 6, 9, and 24 hours and also the average of 24-hour VAS scores were similar (P > .05). However, VAS scores at 3 hours were significantly higher in group 2 (P = 0.06). Also, rescue analgesic intake of paracetamol was significantly higher in group 2 in the third hour (P = .08). Rescue analgesic intake of paracetamol and tramadol consumption during the postoperative 24 hours were similar (P > .05).

CONCLUSIONS

Using single-dose IV ibuprofen administration just before orthognathic surgery for preventive analgesia reduced VAS scores and postoperative opioid consumption in patients. However, further studies in a large population are needed to estimate the preventive analgesia effect of ibuprofen in orthognathic surgery.

Attitudes of dental implantologists in Spain to prescribing antibiotics, analgesics and anti-inflammatories in healthy patients

Background

The implantologists frequently prescribe antibiotics, analgesics and anti-inflammatories in dental implant surgery. The aims of this study were to evaluate the attitudes of implantologists in Murcia (Spain) to prescribing antibiotics, analgesics and anti-inflammatories in healthy patients during different implant dentistry procedures, and to see how these are influenced by individual dentist’s academic level, professional experience, and ongoing training (attending courses or reading scientific literature on medication use)

Material and Methods

This cross-sectional study included a total of 200 implantologists from the Murcia area (Spain), who each completed a two-page questionnaire consisting of 26 questions.

Results

The implant procedure in which most dentists (n=97) prescribed antibiotics was multiple implant surgery with flap raising, in which 55.6% of these 97 respondents used a prophylactic antibiotic regime for 7 days after implant placement. All subjects (n=200) prescribed analgesics for eight out of the eleven procedures included in the survey and anti-inflammatories in six. Dentists with higher academic levels or longer professional experience prescribed more antibiotics, but those who underwent continuous training (attending courses or reading scientific literature) reduced antibiotic prescription.

Conclusions

Dentists often prescribed antibiotics, analgesics and anti-inflammatories in almost all implant procedures in healthy patients, but ongoing training reduced the frequency of antibiotic prescription in some procedures.

Key words:Antibiotics, analgesics, anti-inflammatories, dental implant, oral surgery.

Effect of preemptive dexamethasone and etoricoxib on postoperative period following impacted third molar surgery - a randomized clinical trial

BACKGROUND

The aim of this study was to compare the anti-inflammatory effects of dexamethasone and etoricoxib after third molar extraction.

MATERIAL AND METHODS

A prospective, randomized, controlled, split-mouth study was conducted. 19 volunteers were allocated randomly to receive 90mg etoricoxib 1 hour prior to the procedure or 4mg intramuscular dexamethasone immediately after anesthesia. Baseline measurements were obtained preoperatively, and subsequent assessments were made on immediate postoperative, at 72 hours and 7 days after surgery to measure postoperative facial swelling by use of linear measurements, interincisal mouth opening width and visual analog scale score for pain. The amount of analgesics consumed was recorded. Descriptive statistics and the independent-samples t-test were used to compare the two groups at P < 0.05.

RESULTS

Dexamethasone was effective in the control roasted edema for measurements of the mandibular angle - wing of the nose and mandibular angle - labial commissure 72 hours after surgery. And for the measurement mandibular angle - mentum, in the time of 72 hours and 7 days. There was no statistically significant difference in relation to pain and trismus.

CONCLUSIONS

Considering significant results for some measures of the variable edema for the group that used intramuscular dexamethasone and the difference without statistical significance between groups for the other variables studied, we seem to reflect the intramuscular indication of the corticosteroid in a single dosage in relation to the use of etoricoxib as pre-emptive medication.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Is dipyrone effective as a preemptive analgesic in third molar surgery? A pilot study

PURPOSE

Studies on preemptive analgesia in maxillofacial surgery have shown several controversial clinical results, mainly due to the absence of a methodological standard, besides a wide variety of studied drugs. This study intended to answer the following hypothesis: Is the administration of dipyrone preemptively capable of decreasing trans- and postoperative pain in the third molar surgical extraction?

METHODS

A pilot prospective double-blind placebo-controlled study was carried out with 25 patients submitted to the third molar surgical extraction at two moments, one side in each intervention. Dipyrone (1 g) was preemptively administered (study group) for the extraction of two third molars on the same side and, in a second surgical procedure, dipyrone (1 g) was administered in the immediate postoperative period (control group). Evaluated variables were the amount of anesthetic, pain perceived through the visual analogue scale (VAS) in transoperative and immediate postoperative periods, and over 12-h investigation period, analgesic consumption, duration of surgery, and time to rescue analgesia.

RESULTS

The results were submitted to Student's t test and statistical differences were observed in transoperative (p < 0.05) and immediate postoperative (p < 0.01) periods, while the other studied variables did not present statistical differences.

CONCLUSION

The preemptive administration of dipyrone decreased the perception of transoperative and immediate postoperative pain when compared to its use after surgery only.

A Comparison of 4 Analgesic Regimens for Acute Postoperative Pain Control in Breast Augmentation Patients

PURPOSE

Patients undergoing breast augmentation are treated with multiple combinations of medications for pain control including ketorolac, liposomal bupivacaine, bupivacaine, and intravenous and oral narcotics. There is no current consensus on the optimal combination; therefore, all are used at the discretion of the surgeon.

METHODS

This was a single-center, retrospective study. The total number of patients included was 132. Comparisons were made between 4 groups: bupivacaine only (B); bupivacaine and liposomal bupivacaine (BL); bupivacaine and liposomal bupivacaine plus intraoperative ketorolac (BLKi); and bupivacaine and liposomal bupivacaine plus postoperative ketorolac (BLKp). Average pain scores immediately postoperative and before discharge were recorded and correlated to percentage of patients who received narcotic in the post-anesthesia care unit (PACU). Additional end points noted were side effects including nausea and time spent in PACU postoperatively.

RESULTS

Those receiving intraoperative ketorolac had the lowest pain on discharge (P < 0.0001) and the lowest percentage of patients receiving narcotics (P = 0.009) out of all 4 groups. There was no significant difference between the 4 groups in terms of time spent in PACU, pain immediately after the procedure, or amount of antiemetic given. No bleeding complications were noted for those who did or did not receive ketorolac.

CONCLUSIONS

When given options for pain control in breast augmentation, intraoperative ketorolac should be considered, because its inclusion was significant in decreasing use of narcotics and pain upon discharge. Addition of other costly drugs such as liposomal bupivacaine may not provide additional benefit in the immediate postoperative setting for procedures with a short recovery period such as breast augmentation.

Efficacy of Preoperative Administration of Paracetamol-Codeine on Pain following Impacted Mandibular Third Molar Surgery: A Randomized, Split-Mouth, Placebo-Controlled, Double-Blind Clinical Trial

Objectives. The aim of this study was to determine the effectiveness of preoperative administration of single-dose of paracetamol-codeine, in the relieving of acute postoperative pain after the surgical removal of an impacted mandibular third molar. Materials and Methods. The study cohort consisted of 32 Caucasian outpatients, giving a total of 64 bilateral symmetrical impacted mandibles. Patients were randomized in two experimental groups to receive a preoperative oral dose of paracetamol-codeine (analgesic group) or a placebo (placebo group) at the first and second surgeries. Study participants were asked to record pain intensity scores during the operation and the next 2 days, the time of the first request for rescue analgesic, and the total number of postoperative-supplement paracetamol-codeine tablets. Results. The pain intensity score on the first day was significantly lower in the analgesic group than in the placebo group (p < 0.001). The time to using rescue therapy was significantly longer in the analgesic group than in the placebo group (p = 0.004). The number of paracetamol-codeine tablets used postoperatively did not differ between the analgesic and placebo groups (p = 0.104). Conclusions. Preoperative paracetamol-codeine is effective in providing immediate postoperative pain control after third molar surgery and in delaying the initial onset of pain. This trial is registered with ClinicalTrials.gov Identifier (Registration Number): NCT03049878.

Efficacy of systemic diclofenac sodium on intravitreal concentration

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs), as an alternative, are replacing corticosteroids in ocular inflammatory diseases. Diclofenac has been used mainly topically, and recent focus has been on intravitreal delivery. Both of these methods have been shown to have complications in long-term application.

PURPOSE

To assess the efficacy of slow release oral diclofenac sodium on intravitreal concentration in experimental model of chemically injured eyes.

METHODS

In an experimental double-masked clinical trial, right eyes of 24 albino rabbits were chemically injured by 1 N NaOH. One hour after chemical injury, 10 cc suspension gavage containing 100 mg slow release diclofenac sodium was administered in all cases. 2, 4, 6, 12, 24, 48 h after gavage, vitreous samples were obtained in all cases. Intravitreal concentration of diclofenac sodium was evaluated in all samples using high-performance liquid chromatography (HPLC) method.

RESULTS

Intravitreal diclofenac levels by oral intake were enhanced by the inflammation in all the measurements. In inflamed eyes, diclofenac concentration was ten times more than control eye (2.658 ± 0.344 vs. 0.242 ± 0.0279 and 1.617 ± 0.527 vs. 0.148 ± 0.095; in 2 and 4 h, respectively). After 6 h, diclofenac concentration was statistically different, although it reduced below 1 μg/ml.

CONCLUSION

Diclofenac is delivered to the inflamed eye more than healthy eye. It seems that by oral diclofenac consumption, it is possible to make a significant intravitreal concentration.

Pre-emptive analgesic effect of lornoxicam in mandibular third molar surgery: a prospective, randomized, double-blind clinical trial

The aim of this study was to establish whether the pre-emptive use of lornoxicam (16mg) in third molar surgery ensures successful postoperative analgesia and reduces rescue analgesic intake when compared to postoperative application, and in comparison with placebo. Ninety patients were split randomly into three groups: group A received lornoxicam 60min before surgery and placebo 60min after surgery; group B received placebo 60min before surgery and lornoxicam 60min after surgery; group C received placebo 60min before surgery and placebo 60min after surgery. Postoperative pain was recorded on a visual analogue scale and on a numerical rating scale at 1, 2, 4, 6, 8, 12, and 24h after surgery. The patients recorded total dose of paracetamol intake during the 24h after the procedure. The efficacy of postoperative analgesia was greater in lornoxicam groups when compared to the placebo group; there was no difference between the two lornoxicam groups (A and B). Patients in group C took their first rescue analgesic dose earlier after surgery than patients in the two lornoxicam groups. The average dose of paracetamol taken in group C was 1000mg, while it was500 mg in the lornoxicam groups.

Endodontic surgery

A better understanding of endodontic disease and the causes of treatment failure has refined the role of surgery in endodontics. The advent of newer materials, advances in surgical armamentarium and techniques have also led to an improved endodontic surgical outcome. The aim of this article is to provide a contemporary and up-to-date overview of endodontic surgery. It will focus primarily on the procedures most commonly performed in endodontic surgery.

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.

Comparison of the effect of naproxen, etodolac and diclofenac on postoperative sequels following third molar surgery: a randomised, double-blind, crossover study

Objectives: To compare the three non-steroidal anti-inflammatory agents (NSAIDs) diclofenac potassium, etodolac and naproxen sodium in relation to pain, swelling and trismus following impacted third molar surgery. Study Design: The study was a randomized and a double-blinded study which included 42 healthy young individuals with impacted third molars and bone retention. Patients were randomly assigned to 3 groups (n: 14) to which diclofenac potassium, naproxen sodium and etodolac were administered orally an hour before the operation. Impacted third molars were surgically extracted with local anaesthesia. Visual analog scales (VAS) were used to assess the pain in the 6th, 12th hours and on the 1st, 2nd, 3rd, 5th, and 7th days postoperatively. Swelling was evaluated using ultrasound (US) and mouth opening (trismus) was measured with a composing stick pre and post operatively on the 2nd and 7th days respectively. Results: Regarding pain alleviation, diclofenac potassium was better than naproxen sodium and naproxen sodium was better than etodolac but these differences were not statistically significant. US measurements showed that the swelling on postoperative 2nd day was significantly lowest with diclofenac potassium as compared to others (p= 0.027) while naproxen sodium and etodolac acted similarly (p=0.747). No difference was noted regarding trismus in any of the groups. Conclusions: NSAIDs (diclofenac, naproxen and etodolac) are somehow similarly effective for controlling pain and trismus following extraction of mandibular third molars but diclofenac potassium surpasses others in reduction of swelling.

Key words:Diclofenac potassium, naproxen sodium, etodolac, impacted third molar surgery, pain, swelling, trismus.

Effect of preoperative ibuprofen on pain and swelling after lower third molar removal: a randomized controlled trial

The aim of this study was to compare the analgesic and anti-inflammatory effects of preoperative and postoperative administration of ibuprofen after the surgical removal of impacted lower third molars. A triple-blind, randomized, placebo-controlled clinical trial of 120 patients requiring the surgical removal of lower third molars was performed. The subjects were randomized into the experimental group (patients were administered 600 mg of ibuprofen (p.o.) 1h before the surgical procedure, followed by placebo just after the end of the operation) or into the control group (subjects received the same medication but the administration sequence was reversed). Pain was assessed using visual analogue scales, and consumption of rescue analgesic. The facial swelling and trismus were evaluated by measuring facial reference distances and maximum mouth opening. There were no significant differences between the two study groups regarding postoperative pain, rescue analgesics consumption, facial swelling and trismus. There was a slightly higher need for rescue analgesics in the experimental group. The preoperative intake of ibuprofen does not seem to reduce pain, facial swelling and trismus after impacted lower third molar removal when compared to the postoperative administration of the same drug.

Steroidal and non-steroidal cyclooxygenase-2 inhibitor anti-inflammatory drugs as pre-emptive medication in patients undergoing periodontal surgery

The aim of the present study was to compare the pre-emptive use of a cyclooxygenase-2 (COX-2) inhibitor with a well established steroidal anti-inflammatory drug for pain and edema relief following periodontal surgery for crown lengthening. Thirty patients requiring periodontal surgery were randomly assigned to receive one of the following medications: selective COX-2 inhibitor or steroidal anti-inflammatory drug, 60 min before the surgical procedure. To examine patient anxiety, a Corah's dental anxiety scale was applied before surgery. Using a visual analog scale, the extent of pain/discomfort during the trans-operative period and immediately after the surgery was measured. Additionally, intensity of pain/discomfort and edema were examined 4, 8, 12 and 24 h postoperatively. With regard to anxiety, no statistical differences between the groups were observed (p>0.05). With respect to the extent of pain/discomfort during the trans-operative, immediate and late postoperative period, data demonstrated no significant differences (p>0.05) between the COX-2 inhibitor and steroidal groups. With regard to edema, intragroup analysis did not reveal any statistically significant difference (p>0.05) during the 24 h following surgery in either group. In conclusion, both anti-inflammatory drugs presented a similar potential for pain and edema relief following periodontal surgery.

Effect of preemptive topical diclofenac on postoperative pain relief after photorefractive keratectomy

PURPOSE

To assess the prophylactic effect of preoperative application of topical diclofenac on postoperative pain control in patients having photorefractive keratectomy (PRK).

SETTING

Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran.

DESIGN

Randomized masked clinical trial.

METHODS

In this paired-eye study, patients having bilateral PRK received 1 drop of diclofenac 0.1% in 1 eye and 1 drop of placebo in the fellow eye 2 hours before PRK. Postoperatively, both arms of the trial (both eyes of each patient) received topical diclofenac every 6 hours for 2 days. One day and 2 days postoperatively, patients were asked to rate the perceived pain in each eye using an 11-point verbal numerical rating scale. A trained examiner noted the eye-specific responses.

RESULTS

All 70 patients (140 eyes) completed the study and were included in the statistical analysis. Twenty-four hours after PRK, patients reported pain scores that were clinically and statistically significantly lower in the eyes pretreated with diclofenac than in the fellow eyes (0.97 versus 2.09) (P=.018). Pain scores at 2 days did not differ significantly (P=.877).

CONCLUSION

Administration of a single drop of topical diclofenac 0.1% 2 hours before PRK seemed to increase the efficacy of postoperative pain management in a clinically and statistically significant manner.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Postoperative analgesia in impacted third molar surgery: the role of preoperative diclofenac sodium, paracetamol and lornoxicam

OBJECTIVE

The aim of this study was to compare the postoperative analgesic effects of preoperative intravenous (i.v.) paracetamol, diclofenac sodium and lornoxicam (nonsteroidal anti-inflammatory drugs).

SUBJECTS AND METHODS

Sixty patients with impacted third molar who underwent surgical removal were randomly allocated into three groups: group P (n = 20), group D (n = 20) and group L (n = 20). Group P received preoperatively 1 g paracetamol i.v., group D 75 mg diclofenac sodium i.m. and group L 8 mg lornoxicam i.v. Postoperative pain intensity, additional consumption of analgesics postoperatively and postoperative complications were compared among groups.

RESULTS

The groups were comparable for pain scores (p > 0.05). Maximum pain scores were recorded in postoperative 4th h in all groups (group L 22, 14-44 mm; group P 24, 13-43 mm; group D 14, 10-24 mm, p = 0.117). Patients experienced high satisfaction scores which were comparable among groups (group L 85, 75-100 mm; group P 87, 70-95 mm; group D 84, 77-98 mm, p = 0.457).

CONCLUSION

Preoperative intramuscular diclofenac, intravenous paracetamol and lornoxicam effectively decreased the pain scores. The patients were satisfied with the three postoperative pain management regimens.

Platelet rich plasma to facilitate wound healing following tooth extraction

Following tooth removal bone formation normally takes 16 weeks and may result in less than adequate volume for the necessary reconstruction. Platelet rich plasma (PRP) has been promoted as an effective method for improving bone formation. Its use is often expensive, time consuming, or not clinically convenient for the patient and/or clinician. This study examines a simple method for obtaining a "Buffy Coat"-PRP (BC-PRP) and its effect on bone healing following the removal of bilateral mandibular 3rd molars. Subtraction digital radiography and CT scan analysis were used to track changes in radiographic density at PRP treated sites in comparison to ipsilateral non-PRP treated sites. PRP treated sites demonstrated early and significant increased radiographic density over baseline measurements following tooth removal. The greatest benefit of PRP is during the initial 2-week postoperative healing time period (P < .001). During weeks 3 though 12, BC-PRP treatment resulted in significant (P < .0001) increases in bone density compared to control, but there was no significant interaction between time and treatment (P > .05). For the entire time period (0-25 weeks) PRP treatment was significant (P < .0001) and time was significant (P < .0001) but there was no significant interaction (P > .05) between the effect of PRP treatment and time. It required 6 weeks for control extraction sites to reach comparable bone density that PRP treated sites achieved at week 1. Postoperative pain, bleeding, and numbness were not significantly affected by BC-PRP application. Results suggest that this simple technique may be of value to clinicians performing oral surgery by facilitating bone regeneration following tooth extraction.

Prescriptions of NSAIDs to patients undergoing third molar surgery : an observational, prospective, multicentre survey

BACKGROUND AND OBJECTIVES

Surgical extraction of an impacted third molar is generally followed by acute post-operative pain that has been shown to be primarily inflammatory. Thus, use of NSAIDs in this context is appropriate and has been shown to be effective. Several drugs are employed for this purpose, but no information exists on the reasons why preference is given to one rather than another. The principal objective of this study was to evaluate the pattern of administration of NSAIDs in patients undergoing surgery for impacted third molar extraction. The study also aimed to collect information on the efficacy, onset and duration of the analgesic effect of routinely prescribed NSAIDs and to assess the duration of treatment with these drugs and their tolerability.

METHODS

This was an observational, multicentre, prospective survey. A total of 616 patients (38% male and 62% female) from the Italian Stomatology Clinics of the Universities of Bologna, Brescia, Cagliari, Chieti, Pavia, Pisa, Siena and Varese and from the Department of Oral and Maxillo-Facial Surgery of Semmelweis University, Budapest, were eligible for the study. Patients were evaluated over the 7 days following surgical extraction. NSAIDs were prescribed according to the normal prescribing habits of the centre and physician involved. The main outcomes of interest in the survey were the efficacy, onset and duration of analgesic effect, duration of therapy, and tolerability of the NSAIDs prescribed.

RESULTS

Nimesulide was the most prescribed NSAID (68%), followed by diclofenac, ketoprofen and ibuprofen. Because of the low proportion of patients receiving other NSAIDs, these patients were considered a single treatment group for evaluation purposes. Nimesulide, especially when given before patients started experiencing pain after surgery, was more effective than other NSAIDs in reducing the severity of pain on the day of surgery, in delaying the time to maximum intensity of pain, in providing complete pain relief and in prolonging the duration of analgesic effect on the day of surgery. These results are consistent with the known anti-inflammatory and analgesic actions of nimesulide and with the important role of inflammation in the onset of pain after this type of surgery.

CONCLUSION

These results confirm nimesulide as an effective reference drug for the treatment of post-operative dental pain and show that it has a positive benefit/risk profile in this setting.

[Prevention and relief of pain induced by otolaryngological and cervicofacial surgery]

Pain after otolaryngological and cervicofacial surgery varies greatly because of the wide variety of procedures. Preventing this pain stems from the administration of paracetamol, nonsteroid anti-inflammatory drugs, nefopam, and systematic recourse to morphine when remifentanil is used. Postoperatively, the most painful surgical procedures are an indication for multimodal anesthesia and patient-controlled morphinic analgesic after titration in the postoperative postanesthesia care unit. Applying antalgic protocols, also including locoregional anesthesia, depending on the type of procedure and the patient, can improve the quality of care.

The use of COX-2 inhibitors for acute dental pain: A second look

BACKGROUND

On the basis of their perceived better safety profile compared with other analgesic agents, cyclo-oxygenase-2 (COX-2) inhibitors have been prescribed frequently as first-line agents to treat acute dental pain. However, recently identified cardiovascular adverse reactions associated with these drugs mandate a reappraisal of their use in dental practice. TYPES OF STUDIES REVIEWED. The authors reviewed 18 clinical studies that evaluated the efficacy of a COX-2 inhibitor for the treatment of acute dental pain. All of the studies used the widely established third-molar surgical extraction model to induce postsurgical inflammatory based pain, and all were randomized, double-blinded and placebo-controlled. However, numerous vagaries in overall study design made direct comparisons difficult.

RESULTS

None of the studies established any of the COX-2 inhibitors as clearly better than ibuprofen, the current gold standard for the treatment of surgically induced dental pain. However, in single-dosing scenarios, the COX-2 inhibitor often demonstrated a longer duration of action compared with ibuprofen.

CLINCAL IMPLICATIONS

The evidence to date fails to demonstrate any therapeutic advantage to using a COX-2 inhibitor to treat acute dental pain compared with ibuprofen. In the rare event that a COX-2 inhibitor may be appropriate, the clinician must inform the patient of the potential risks, and the drug should be used for the shortest possible time.