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

The use of advanced platelet-rich fibrin after surgical removal of mandibular third molars: a systematic review and meta-analysis

The objective of this systematic review was to test the hypothesis of no difference in recovery following surgical removal of mandibular third molars with the application of advanced platelet-rich fibrin (A-PRF) in the extraction socket compared with alternative biomaterials or natural wound healing. A search of MEDLINE (PubMed), Embase, Cochrane Library, and Scopus was conducted. Human randomized controlled trials published in English up until December 31, 2020 were included. Outcome measures were pain, facial swelling, trismus, soft tissue healing, alveolar osteitis, and quality of life; these were evaluated by descriptive statistics and meta-analysis including 95% confidence intervals (CI). Four studies with a low or moderate risk of bias fulfilled the inclusion criteria. A-PRF resulted in significantly lower pain scores when compared with leucocyte platelet-rich fibrin or natural wound healing after 2 days (-16.8, 95% CI -18.9 to -14.7), 3 days (-12.1, 95% CI -13.4 to -10.7), and 7 days (-1.9, 95% CI -2.9 to -0.9). A-PRF seems to have a negligible effect on facial swelling and trismus and some beneficial effect on soft tissue healing. Alveolar osteitis and quality of life were not assessed. The included studies were characterized by considerable heterogeneity and confounding variables. Thus, the level of evidence appears to be inadequate for clinical recommendations according to the focused question.

COMPARATIVE ANALGESIC EFFECTS OF SINGLE-DOSE PREOPERATIVE ADMINISTRATION OF PARACETAMOL (ACETAMINOPHEN) 500 mg PLUS CODEINE 30 mg AND IBUPROFEN 400 mg ON PAIN AFTER THIRD MOLAR SURGERY

BACKGROUND

Efficacy and rapid onset of postsurgical oral pain relief are critical to improve clinical outcomes and reduce the risk of excessive dosing with analgesic drugs.

PURPOSE

To compare analgesic effects of preoperative administration of paracetamol 500 mg plus codeine 30 mg in single-tablet and effervescent formulation to ibuprofen 400 mg, and placebo in the management of moderate to severe postoperative pain after mandibular third molar surgery.

MATERIALS AND METHODS

One hundred twenty healthy outpatients aged 15-29 years undergoing surgical removal of 1 bony impacted mandibular third molar were enrolled in this, single-center, prospective, randomized, triple-blind parallel-group, placebo-controlled, clinical trial. Study participants were randomly assigned to three treatment arms. According to the concealed allocation, each patient 30 minutes before surgery received paracetamol 500 mg plus codeine 30 mg (group APAP/COD), ibuprofen 400 mg (group IBU) or placebo (group PLA). Rescue therapy allowed in the postoperative period was paracetamol 500 mg plus codeine 30 mg in groups APAP/COD and PLA and ibuprofen 400 mg in group IBU. Patients recorded on Numerical Rating Scale-11 (NRS-11) the pain intensity, total number of postoperative-supplement medications and time of the first intake, until 12-hours after surgery and over extra 2 days, RESULTS: Over postoperative 3 days, patients in the APAP/COD group (2.33 ± 1.99) displayed significantly (P< .001) less pain intensity than IBU (3.43 ± 2.47) and placebo (3.57 ± 2.62) groups. The first-day postoperative pain was significantly (P < .001) higher in group PLA than in groups APAP/COD and IBU, but not between the latter 2 groups. However, at 2 hours postdose, the IBU group displayed average pain intensity lower than APAP/COD group (P> .05). On the next 2 days, pain intensity was significantly (P< .001) lower in group APAP/COD than in groups IBU and PLA but failed to reach statistical significance between groups IBU and PLA. Although the time to the first using rescue therapy was longer (445.88 ± 159.96 minute) in group IBU, compared to groups APAP/COD (392.67 ± 138.90 minutes) and PLA (323.00 ± 143.95 minutes), the number of supplemented tablets was significantly higher in group IBU (2.89 ± 2.13) than in groups APAP/COD (1.24 ± 1.79) (P= .001) and PLA (1.53 ± 1.67) (P = .008). No adverse events were registered for all groups.

CONCLUSIONS

Within the limits of the present study, over postoperative 3 days, a statistically significant intensity pain reduction and decreased rescue therapy consumption were recorded in the paracetamol-codeine group than to ibuprofen group. Nevertheless, lower pain intensity at 2 hours postdose and longer time using rescue therapy was found in the ibuprofen group without statistical significance. No adverse events occurred over the studied period.

Resolving Issues About Efficacy and Safety of Low-Dose Codeine in Combination Analgesic Drugs: A Systematic Review

INTRODUCTION

The objective of this systematic review is to reflect on assumptions in relation to codeine use in combination with other analgesics.

METHODS

MEDLINE was searched according to the predetermined keywords and criteria. Only English language studies were taken into consideration and the outcome data of the final studies were extracted by two reviewers independently from each other and were checked by the third reviewer. Additionally, the available codeine-related Individual Case Safety Reports (ICSRs) retrieved from EudraVigilance were reviewed.

RESULTS

Sixteen placebo-controlled studies that involved 3378 subjects suffering from acute pain were analyzed for the efficacy of low-dose codeine (≤ 30 mg) combination products. Twelve of them found low-dose codeine combinations more efficient in relieving pain than the assigned comparator. According to 20 randomized clinical trials which included at least one dose of codeine (from 30 to 240 mg daily), the vast majority of reported side-effects were mild or moderate in severity. A total of 20 ICSRs for dependence were identified in the EudraVigilance database with codeine as a suspect drug for the 10-year time period for the European region.

CONCLUSIONS

Low-dose codeine combinations are effective after a single application in treating acute pain. Codeine in doses ≤ 30 mg and higher was considered safe since only mild to moderate side-effects were observed. There is no indication in the available sources which clearly links low doses of codeine to substance use disorder in non-dependent subjects.