An evidence-based update of the use of analgesics in dentistry

ANALGESIC EFFICACY OF TRAMADOL/DEXKETOPROFEN VS IBUPROFEN AFTER IMPACTED LOWER THIRD MOLAR EXTRACTION: A RANDOMIZED CONTROLLED CLINICAL TRIAL

OBJECTIVE

Impacted third molar extraction is associated with acute moderate-to-severe pain for up to 48 hours post-surgery. This trial was designed to compare the analgesic effectiveness, swelling, and adverse events after impacted third molar surgery following multimodal therapy with 75 mg tramadol hydrochloride plus 25 mg dexketoprofen or monotherapy with 400 mg ibuprofen.

METHODS

Seventy-two patients were randomly assigned to receiving ibuprofen (n = 36) or tramadol-dexketoprofen (n = 36). Postoperative pain intensity and swelling were measured using a visual analog scale (VAS); pain relief experienced was reported using a 4-point verbal rating scale; the rescue medication requirement, adverse effects, and global impression of the medication were recorded.

RESULTS

No statistically significant between-group difference in pain intensity was observed at any time point; however, pain relief was significantly higher in the tramadol-dexketoprofen treated-group at 6 and 36 hours. Self-reported verbal rating scale assessments showed significantly lower swelling in the tramadol-dexketoprofen group at 24 hours post-surgery but not at 48 or 72 hours, and VAS-swelling scores showed no significant between-group difference. The frequency of postoperative nausea and dizziness was significantly higher in the tramadol-dexketoprofen group.

CONCLUSIONS

Multimodal therapy proved more effective to manage moderate-severe pain after impacted third molar surgery in comparison to monotherapy. However, the improvement in relief must be balanced against the increased risk of adverse effects when considering this multimodal approach.

Preemptive analgesia in dental implant surgery: A systematic review and meta-analysis of randomized controlled trials

Background

To assess the effectiveness of preemptive analgesia in dental implant surgery in randomized controlled trials (RCTs).

Material and Methods

The present study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and registered in PROSPERO database CRD42020168757. A search without restrictions regarding language or date of publication was conducted in six databases and gray literature. A random effect meta-analysis compared the efficacy of preemptive analgesia compared to placebo through pooled OR and 95%CI. The interpretation of results followed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach together with the magnitude of the effect according to GRADE guidelines.

Results

Four studies were included in the review and three were incorporated into the meta-analysis. All studies demonstrated that preemptive analgesia contributed to a significant improvement in the postoperative pain control. However, the overall pooled standard mean difference (SMD) showed that preemptive analgesia had small effects compared to placebo in reducing pain (SMD: -0.45; IC: -0.83; -0.08) with low certainty of the evidence. Our meta-analysis showed that the magnitude of the effect was bigger six to eight hours after the surgery (large effect), compared to the time of one to two hours after the surgery (small effect).

Conclusions

Preemptive analgesia may have a positive effect in reducing pain compared to not using preemptive medication, but the evidence is very uncertain.

Key words:Preemptive analgesia, postoperative pain, dental implant surgery, systematic review.

Patient-reported outcome measures and clinical outcomes following peri-implant vestibuloplasty with a free gingival graft versus xenogeneic collagen matrix: a comparative prospective clinical study

BACKGROUND

The objective of this study was to compare patient-reported outcome measures (PROMs) and clinical outcomes after augmentation with xenogeneic collagen matrix (XCM) or free gingival graft (FGG) during different postoperative phases.

METHODS

Forty-two patients (21 per group) with keratinized mucosa width (KMW) of < 2 mm at buccal implant sites in the posterior mandible were enrolled. All underwent vestibuloplasty and were allocated to either FGG (control) or XCM (test) group. Intraoperative morbidity of pain, stress, nausea, tolerance to time, and acceptance of surgery were evaluated immediately after surgery. The severity and duration of subjective pain, swelling, and bleeding were compared within a 2-week postoperative period. The willingness to retreat and satisfaction were assessed at 6 months. All PROMs were obtained using questionnaires and visual analog scales. The buccal KMW and other peri-implant parameters were also evaluated.

RESULTS

No significant between-group differences were observed in PROMs immediately after surgery, except acceptance of surgery (0, 0-30.0 vs. 30, 0-50.0, p = 0.025). At 2 weeks, pain severity (46.7 ± 25.9 vs 61.9 ± 20.2, p = 0.040) and duration (5.52 ± 3.57 vs 8.48 ± 2.80, p = 0.005) were significantly lower in the test group, and pain perception during speaking and chewing was significantly higher for FGG, with no significant between-group differences in swelling and bleeding. At 6 months, the test group showed a higher willingness to retreat (76% vs 43%, p = 0.021); however, satisfaction with treatment outcomes was similar in both groups. At 6 months, the gain of KMW was significantly higher in FGG than in XCM (XCM: 1.57 ± 1.69 mm, FGG: 2.68 ± 1.80 mm, p = 0.003). Other peri-implant parameters did not show significant differences.

CONCLUSIONS

Within the limitation of the present nonrandomized study, XCM demonstrated more positive PROMs than FGG during different postoperative phases, mainly for less pain perception during the early healing stage, but was inferior to FGG in terms of gain of KMW. For KMW augmentation in the posterior mandible, XCM may be indicated when patients can bear little pain.

CLINICAL TRIAL REGISTRATION

ChiCTR1900022575 , date of registration: 17/4/2019, retrospectively registered.

Effect of orally administered magnesium on postoperative pain level and trismus after surgical removal of the lower third molars: a randomized, double-blind, placebo-controlled trial

OBJECTIVES

Pain and trismus are the most common postoperative complications following a surgical removal of the lower third molar. This randomized, double-blind, placebo-controlled clinical trial evaluated the effect of orally administrated magnesium on postoperative pain and trismus after surgical removal of the lower third molars.

MATERIALS AND METHODS

The study was conducted on 80 participants who were divided into two groups. Each group took different oral forms of magnesium citrate. Participants in both groups had their two lower molars surgically removed. For one randomly selected third molar, participants received either magnesium citrate tablets or lozenges. For the surgical removal of the lower third molar of the opposite side, the participants received either placebo tablets or lozenges. The data were analyzed using the Wilcoxon signed-ranked test, the Mann-Whitney U test, and the Spearman rank-order correlation with the level of significance set at p < 0.05. This manuscript was written in accordance with the Consort recommendation.

RESULTS

The results show a statistically significant lower pain level at all tested times (24 h, 48 h, and 72 h postoperatively) for participants who used magnesium preparations in lozenges (p = 0.012, p = 0.013, and p ≤ 0.001) as well as in tablet form (p ≤ 0.001) compared to placebo. The results also show a statistically significant greater mouth opening ability at all tested times (24 h, 48 h, and 72 h postoperatively) between magnesium preparations and the placebo (p ≤ 0.001).

CONCLUSION

Orally administered magnesium (either lozenges or tablets) before and after a lower third molar surgical removal significantly reduces pain intensity and the degree of trismus in the postoperative period.

CLINICAL RELEVANCE

Based on the results of the study, oral magnesium could be used in the oral and maxillofacial surgery to reduce postoperative complications after surgical removal of the lower third molars.

TRIAL REGISTRATION

This study is registered on http:clinicaltrials.gov under protocol no. NCT03398382.

Selection of analgesics for the management of acute and postoperative dental pain: a mini-review

Pain management is an important part of dental practice, and dentists frequently prescribe analgesics to improve clinical outcomes. Dentists should be aware of the pharmacological characteristics of the analgesics commonly used in dentistry and should choose appropriate analgesics to treat and prevent pain associated with inflammation or surgery. In this article, we review the potential benefits and risks of the analgesics frequently used in dental practice and provide a stepwise approach for pain management.

Pattern of Opioid Analgesic Prescription for Adults by Dentists in Nova Scotia, Canada

Global consumption of prescription opioid analgesics has increased dramatically in the past 2 decades, outpacing that of illicit drugs in some countries. The increase has been partly ascribed to the widespread availability of prescription opioid analgesics and their subsequent nonmedical use, which may have contributed to the epidemic of opioid abuse, addiction, and overdose-related deaths. International studies report that dentists may be among the leading prescribers of opioid analgesics, thus adding to the societal impact of this epidemic. Between 2009 and 2011, dentists in the United States prescribed 8% to 12% of opioid analgesics dispensed. There is little information on the pattern of opioid analgesic prescription by dentists in Canada. The aim of this study was to examine the pattern of opioid analgesics prescription by dentists in Nova Scotia (NS), Canada. This retrospective observational study used the provincial prescription monitoring program's record of oral opioid analgesics and combinations dispensed to persons 16 y and older at community pharmacies that were prescribed by dentists from January 2011 to December 2015. During the study period, more than 70% of licensed dentists in NS wrote a prescription for dispensed opioid analgesics, comprising about 17% of all opioid analgesic prescribers. However, dentists were responsible for less than 4% of all prescriptions for dispensed opioid analgesics, prescribing less than 0.5% of the total morphine milligram equivalent (MMEq) of opioid analgesics dispensed over the 5 y. There was a significant downward trend in total MMEq of dispensed opioid analgesics prescribed by dentists from about 2.23 million MMEq in 2011 to 1.93 million MMEq in 2015 (r = -0.97; P = 0.006). Opioid prescription is common among dentists, but their contribution to the overall availability of opioid analgesics is low. Furthermore, there has been a downward trend in total dispensed MMEq of opioid analgesics prescribed by dentists. Knowledge Transfer Statement: This study will serve to inform dentists and policy makers on the types and dosage of opioid analgesics being prescribed by dentists. The study may prompt dentists to reflect on and adjust their practice of opioid analgesic prescription in view of the current opioid analgesic epidemic.

Analgesic efficacy of ketorolac associated with a tramadol/acetaminophen combination after third molar surgery - a randomized, triple-blind clinical trial

BACKGROUND

This study compared the efficacy of ketorolac alone versus its combination with tramadol/acetaminophen for pain control after mandibular third molar surgery.

MATERIAL AND METHODS

A randomized, triple-blind clinical trial was carried out with 52 patients divided into 2 groups: Group K+T+A (1 tablet of Ketorolac 10 mg plus and 1 capsule of Tramadol 37.5 mg/acetaminophen 325 mg) and Group K (1 tablet of Ketorolac 10 mg plus and 1 placebo capsule). The treatments were given 1 h before the surgery and was repeated 4 times per day, for 48 h. The difference in postoperative pain was assessed by 4 primary end-points: pain intensity (VAS 100mm, for 48 h), rescue medication, overall assessment and adverse effects.

RESULTS

Significant differences in pain intensity were observed in the different times (p < 0.05). The comparison of groups in each time showed significant differences only of 9 h, with lower level of pain intensity for group K+T+A (p = 0.005). The need of analgesics was higher in Group K (p < 0.001), the need of antiemetic were greater in Group K+T+A (p < 0.0001). No significant difference between groups were observed in overall assessment. The adverse effects was higher in Group K+T+A.

CONCLUSIONS

The current study showed that both ketorolac and the combination of ketorolac plus tramadol/acetaminophen showed good control of pain after the extraction of the lower third molars. Although the combination group showed lower pain at 9 h, the difference is small and not clinically relevant.

Preoperative Administration of Jidabokuippo, a Kampo Medicine, Alleviates Postoperative Pain after Tooth Extraction with Mandible Bone Removal under General Anesthesia: A Prospective, Single-Blind, Randomized Controlled Trial

OBJECTIVE

This study aimed to determine the efficacy of preoperative administration of Jidabokuippo (JDI), a Kampo medicine, in treating postoperative pain after tooth extraction with mandible bone removal.

DESIGN

This single-blind, randomized controlled study was conducted among two groups of adult patients who were scheduled to undergo tooth extraction with mandible bone removal under general anesthesia. Patients were randomly assigned to either the JDI or control group.

INTERVENTION

Before surgery, the JDI group received JDI (7.5 g), whereas the control group did not receive any treatment. Patients and the evaluator were blinded to the treatment status. At 0, 1, 3, and 24 h after anesthesia recovery, an investigator recorded the severity of postoperative pain and nausea using a numeric rating scale (0, no pain or nausea; 10, worst imaginable pain or nausea). The number of patients who requested nonsteroidal anti-inflammatory drug (NSAID) and that of additional NSAID administration within 24 h from anesthesia recovery, and the time to the first NSAID request from anesthesia recovery was also measured.

RESULTS

The severity of postoperative pain was significantly lower in the JDI group compared with the control group at 3 and 24 h after anesthesia recovery (p < 0.001 each). Both the number of patients requesting NSAID and additional NSAID administration after anesthesia recovery were significantly smaller in the JDI group than in the control group (p = 0.006, p < 0.001). The time to first NSAID request from anesthesia recovery was significantly longer in the JDI group compared with control group (p < 0.001). The severity of nausea did not differ significantly between the groups. No significant side effects related to JDI were noted during the trial.

CONCLUSIONS

JDI administration before general anesthesia effectively decreased the severity of postoperative pain after anesthesia recovery in patients who underwent tooth extraction with mandible bone removal.

New Findings on Local Tramadol Use in Oral Surgery

In modern times, all procedures in oral surgery need to be painless and management of postoperative pain needs to be adequate. The surgical extraction of the third molar or alveolectomy of the wisdom tooth is one of the most common surgical procedures carried out in oral surgery and it includes rising a flap, bone removal and suturing. These surgical procedures usually cause swelling, trismus and moderate to severe pain. Third molar surgery is often used as a model in clinical trials that are directed toward reducing postoperative pain and improving its management. Tramadol is a well-known central acting opioid analgesic that produces analgesia against multiple pain conditions such as postsurgical pain, obstetric pain, terminal cancer pain, pain of coronary origin and neuropathic pain. Tramadol is an atypical opioid. When administered locally, it has both analgesic and anesthetic properties. The aim of this paper was to present new findings on local effects of tramadol in oral surgery.

Comparison between paracetamol, piroxicam, their combination, and placebo in postoperative pain management of upper limb orthopedic surgery (a randomized double blind clinical trial)

Background:

Therapeutic superiority of a combination of Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) over either drug alone remains controversial. We evaluated the efficiency of a combination of Paracetamol and Piroxicam versus each drug alone and also placebo in the management of postoperative pain, in patients who had undergone elective upper limb orthopedic surgery under general anesthesia.

Materials and Methods:

A total of 100 patients were randomly divided into four groups to receive either intravenous (IV) infusion of Paracetamol, 15 mg/kg., intramuscular (IM) injection of Piroxicam 0.4 mg/kg., their combination or placebo. The pain scores were recorded at the first; second, fourth, sixth, twelfth, and 24 hours after Post Anesthesia Care Unit (PACU) admission. After the operation 0.1 mg/kg of morphine was administered, if the patient needed.

Result:

The means of the pain scores were 5.26 ± 1.53, 4.09 ± 0.88, 4.36 ± 1.48, and 4.11 ± 1.29, in groups A, B, C, and D, respectively, (Group A: received placebo; Group B: received both Paracetamol and Piroxicam; Group C received Piroxicam; Group D received Paracetamol). Except for differences between the mean pain scores in Groups B and D, the other differences were statistically significant (P value < 0.05). No adverse effect was reported in the four groups.

Conclusion:

IV infusion of 15 mg/kg Paracetamol used as a preventive may provide effective analgesia in comparison with IM 0.4 mg/kg Piroxicam or placebo. Addition of Piroxicam to Paracetamol has not much more benefit than Paracetamol alone, in reducing pain after upper limb orthopedic surgery.

An appraisal of innovative meloxicam mucoadhesive films for periodontal postsurgical pain control: A double-blinded, randomized clinical trial of effectiveness

Background and Objective:

Transmucosal analgesic delivery is a promising approach to periodontal postoperative pain management. The purpose of this clinical trial is to appraise the effectiveness of transmucosal drug delivery system with meloxicam films and to identify its minimum effective dosage via this route after periodontal flap surgery.

Materials and Methods:

The analgesic mucoadhesive films were formulated using meloxicam and hydroxypropyl methyl cellulose polymer by solvent casting method. The sample size consisted of 60 chronic periodontitis patients who require periodontal flap surgery. The subjects were randomized using lottery method into four groups (Group A - 45 mg; B - 30 mg; C - 20 mg; D - 10 mg meloxicam per film). After periodontal flap surgery, the respective meloxicam mucoadhesive films were placed over the surgical site and were removed on 4^th day of postsurgery. The primary outcome measure was postsurgical pain level and recorded at 1^st, 2^nd, 3^rd, 4^th, 5^th, 24^th, and 48^th h using a 0–10 mm visual analog scale with markings from 0 = no pain to 10 = extreme pain.

Results:

The postoperative pain control observed in Groups A and B was found to be effective, and the patient comfort level was very satisfactory. Whereas in Group C, it was found to be high in the first 3 h postsurgically, after which adequate pain relief was seen. Group D exhibited inadequate pain relief. No adverse reactions were noted after applying the film in any of the groups.

Conclusion:

Transmucosal delivery of meloxicam was found to be effective and safe in postsurgical pain control of periodontal flap surgery. The minimum effective dosage via this route for meloxicam was found to be with 30 mg mucoadhesive films.

Diclofenac is more effective for post-operative analgesia in patients undergoing lower abdominal gynecological surgeries: A comparative study

Aim:

The present study aimed to compare the efficacy of injectable diclofenac intramuscularly (IM), injection paracetamol intravenously (IV), or a combination of both to provide post-operative analgesia in patients undergoing lower abdominal gynecological surgeries.

Materials and Methods:

A total of 90 female patients (American Society of Anesthesiologists I and II), aged 20-50 years, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized to receive 75 mg diclofenac IM 8 hourly (Group D) or 1 g paracetamol IV 8 hourly (Group P) or a combination of both 8 hourly (Group PD) for 24 h post-operative period from the start of surgery. The primary outcome measured was the requirement of rescue analgesic (tramadol), the secondary outcomes measured included visual analog score (VAS) for pain, time until first rescue analgesic administration, patient satisfaction score and any side effects.

Results:

The requirement of rescue analgesic was significantly lower in Groups D and PD compared to Group P. Mean (standard deviation) tramadol requirement during 24 h was 56.67 (62.60) mg, 20.00 (40.68) mg and 20.00 (40.68) mg in the Groups P, D and PD respectively. Less number of patients in Groups D and PD (20% in both the groups) required rescue analgesic compared to Group P (50%). The VAS showed a significant decrease in Groups D and PD compared to Group P between 4 and 12 h post-operatively. However, Group PD showed no significant difference when compared to Group D alone.

Conclusion:

Injection diclofenac IM is more effective than paracetamol IV in terms of rescue analgesic requirement, but the combination of diclofenac IM and paracetamol IV provides no added advantage over diclofenac IM alone.

OFIRMEV: an old drug becomes new again

This was judged to be the first place winning submission for the American Dental Society of Anesthesiology Student Essay Award. Acetaminophen is an old drug that is now available in an intravenous formulation. Its advantages and disadvantages are reviewed, including its potential role in multimodal postoperative pain therapy.

Diseases of the mouth

Oral pathologic abnormality is common and can be potentially serious. There are many diseases of the mouth that medical personnel must be able to diagnose and initiate management. The most prevalent lesions can be categorized as infectious, inflammatory, and common benign and malignant lesions. This article discusses prevalence, cause, diagnosis, and management of lesions such as stomatitis, candidiasis, caries, oral cancers, and bony tori.

Antidepressants relevant to oral and maxillofacial surgical practice

Background:

Depression is commonly associated with a high-carbohydrate diet, lack of interest in proper oral hygiene and xerostomia connected to the use of antidepressants. Patients often consult their dentists as a result of changes affecting the hard dental substance and the soft-tissues.

Aim:

The aim of this study was to identify adverse drug interactions between the antidepressants and medications commonly administered in dentistry in order to give practicing dentists an overview of the scientific literature.

Objective:

The objective is to identify the adverse drug interactions between antidepressants and medication commonly administered in dentistry.

Study Design:

The literature search was performed using PubMed, Cochrane and the specific search items. The review (1984-2009) focused on medicines used in dental practice (vasoconstrictors, non-opioid analgesics, non-steroidal anti-inflammatory drugs, antibiotics, antifungals and benzodiazepines).

Results:

There are various drug interactions between antidepressants and medicines used in dentistry. When two or more drugs are co-administered, a drug interaction must always be anticipated though many of the interactions are potential problems, but do not seem to be real clinical issues.

Conclusion:

The probability of a drug interaction can be minimized by careful history-taking, skillful dose adjustment and safe administration of the therapeutic agent.

Therapeutic efficacy and tolerability of the topical treatment of inflammatory conditions of the oral cavity with a mouthwash containing diclofenac epolamine: a randomized, investigator-blind, parallel-group, controlled, phase III study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs), including diclofenac, are the mainstay of analgesic and anti-inflammatory treatment in dentistry. Diclofenac epolamine [diclofenac N-(2-hydroxyethyl)pyrrolidine; DHEP] is a diclofenac salt with greater water solubility and better cutaneous absorption properties than other commonly used forms of the drug. IBSA has recently developed a mouthwash formulation of DHEP for the topical treatment of inflammatory conditions of the oral cavity.

OBJECTIVE

The aim of this study was to compare the efficacy and tolerability of DHEP mouthwash (Osmal®) with that of a reference product (commercially available diclofenac mouthwash).

METHODS

This was a randomized, investigator-blind, parallel-group, controlled, phase III study that enrolled 80 patients with conditions affecting the oral cavity, characterized by an inflammatory component, and eligible for analgesic and anti-inflammatory treatment. Patients were randomized 1:1 to DHEP mouthwash (0.103% DHEP in aqueous solution) or to diclofenac mouthwash (0.074% free diclofenac in aqueous solution). The treatment regimen was the same in both groups: 1-minute rinse with 15 mL of mouthwash, twice daily for 7 days. Visits were scheduled at study inclusion (D0), and 3 days (D3) and 7 days (D7) after treatment initiation. During each visit assessments were made of pain severity (using a 5-point semi-quantitative scale and a 100-mm visual analogue scale [VAS]) and inflammatory signs (using a 5-point scale). The primary study endpoint was the change in pain severity scores from D0 to D3 and D7. Secondary endpoints included effects of treatment on inflammation score, quality of sleep, compliance with treatment and the safety and tolerability of treatment.

RESULTS

The two treatment arms were homogeneous in terms of patient characteristics. The most prevalent oral condition was gingivitis. Overall both topical treatments were effective in alleviating pain and inflammation, as evidenced by decreases in pain and inflammation scores within 3 days after treatment initiation. Notably, a significantly greater proportion of patients treated with DHEP were free of pain and inflammatory symptoms at D3 compared with those treated with the diclofenac mouthwash (40% vs 20% of patients; p < 0.05). Also, DHEP was associated with more marked, but not statistically significant, decreases in VAS pain scores versus baseline after 3 days' treatment. Compliance with both treatments was good and both mouthwashes were well tolerated.

CONCLUSION

DHEP mouthwash was at least as effective as diclofenac mouthwash at alleviating pain and inflammation symptoms and is well tolerated in patients with painful inflammatory conditions of the oral cavity. The potential of DHEP mouthwash deserves to be investigated in a larger patient population.