The effects of nonsteroidal anti-inflammatory analgesics on pain after periodontal surgery

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Effectiveness of Bromelain in the control of postoperative pain after periodontal surgery: A crossover randomized clinical trial

Background

This study aimed to compare the analgesic effects of Ibuprofen and bromelain after periodontal surgery.

Methods

A double-blinded crossover clinical trial was conducted on 22 patients needing two crown lengthening surgeries without bone surgery or with limited bone surgery on two quadrants of the maxilla, with control and test sides. Each quadrant was randomly assigned to bromelain (500 GUD) or ibuprofen (400 mg). Immediately after the surgery and 6 hours after it, the first dose of the drugs was packaged in the same capsules in A and B. Postoperative pain was evaluated during the first 8 hours and on the following day using a visual analog scale (VAS).

Results

Using the VAS, the Ibuprofen group showed significantly lower mean pain scores than the bromelain group at 4 hours (P=0.047). In contrast, there were no significant differences between the two groups at 2, 6, 8, 10, 12, 24, and 48 hours (P>0.05).

Conclusion

The effectiveness of bromelain for pain control following periodontal surgery was comparable to that of Ibuprofen. Therefore, bromelain can be an efficient replacement for ibuprofen in managing pain after periodontal surgery, especially in patients with gastric ulceration and increased bleeding tendency.

Effectiveness of ginger on pain following periodontal surgery - A randomized cross-over clinical trial

Background

Ibuprofen is one of the generally prescribed Non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative pain after periodontal surgery, but are contraindicated in certain patients. Ginger, which is the rhizome of Zingiber officinale, being a common herbal drug having anti-inflammatory as well as analgesic activities can be an efficient substitute for synthetic agents like Ibuprofen.

Objectives

To compare the effectiveness of ibuprofen and dried ginger powder on pain and gingival inflammation following open flap debridement.

Materials and methods

Ten systemically healthy individuals with chronic generalized periodontitis were selected for this single-blinded randomized cross-over clinical trial and underwent open flap debridement in at least two quadrants. Each quadrant was randomly allocated to receive either Ibuprofen (400 mg) or Ginger powder capsules (400 mg) thrice daily for three days. Subjects were requested to note down the pain score on the Visual Analogue Scale (VAS) provided in a printed format, for the first eight hours after surgery and on the following two days, and gingival inflammation was assessed after one week, using Modified Gingival Index (MGI).

Result

The difference in the VAS score and MGI between the two groups was not of statistical significance.

Conclusion

Effectiveness of ginger powder for the management of pain and gingival inflammation following open flap debridement is comparable to that of ibuprofen.

Comparison Between Dexamethasone and Ibuprofen for Postoperative Pain Prevention and Control After Surgical Implant Placement: A Double-Masked, Parallel-Group, Placebo-Controlled Randomized Clinical Trial

BACKGROUND

Postoperative pain is a potential adverse side effect of oral surgeries, and attempts should be made to prevent or minimize it. This study compares efficacy of preemptive ibuprofen and dexamethasone protocols for pain prevention or control after surgical implant placement.

METHODS

This prospective, double-masked, parallel-group, placebo-controlled, randomized clinical trial included 117 patients with planned dental implant placement. Patients were assigned to receive one of three different protocols: 1) 600 mg ibuprofen 1 hour before surgery and another 600 mg 6 hours after the first dose; 2) 4 mg dexamethasone 1 hour before surgery and another 4 mg 6 hours after the first dose; or 3) placebo. Rescue medication (1,000 mg acetaminophen) was made available to each patient, and they were instructed to take it as necessary. Pain intensity was evaluated via a 101-point numeric rating scale and a visual analog scale, and discomfort was evaluated using a four-point verbal rating scale hourly for the first 8 hours after surgery and three times daily for the following 3 days.

RESULTS

Ibuprofen and dexamethasone significantly reduced pain (Kruskal-Wallis; P <0.05) up to 3 days after surgery and discomfort (P <0.05) up to 2 days after surgery compared with placebo treatment. Both treatments reduced the number of painkillers taken and increased time before the first painkiller was taken (P <0.01).

CONCLUSION

Steroidal dexamethasone is as effective as non-steroidal ibuprofen for preventing or controlling postoperative pain and discomfort after surgical implant placement.

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.

The efficacy of acetaminophen-caffeine compared to Ibuprofen in the control of postoperative pain after periodontal surgery: a crossover pilot study

BACKGROUND

Previous studies showed that non-steroidal anti-inflammatory drugs (NSAIDs) have significant benefits in the control of pain after periodontal surgery. Acetaminophen (centrally acting NSAID) is believed to provide less analgesic efficacy than ibuprofen (centrally and peripherally acting NSAID). This study compared an alternative combination of acetaminophen, 500 mg, with caffeine, 30 mg, to ibuprofen, 400 mg, in pain management after periodontal surgeries.

METHODS

A prospective, randomized, double-masked crossover clinical trial was conducted on 15 patients. Open flap debridement was performed on two quadrants with a 3-week interval in between. Each quadrant was randomly assigned to acetaminophen, 500 mg, with caffeine, 30 mg, or ibuprofen, 400 mg, immediately after surgery and 8 hours after the first dose. Postoperative pain was assessed during the first 8 hours and on the following day using the 101-point numeric rate scale (NRS-101) and the four-point verbal rating scale (VRS-4).

RESULTS

Using the NRS-101, the acetaminophen-caffeine group showed statistically significantly lower mean pain scores than the ibuprofen group at 1 and 2 hours (P = 0.002), whereas at 6, 7, and 8 hours, the ibuprofen group showed statistically significantly lower mean pain scores (P <0.001). Using the VRS-4, there was no statistically significant difference between the two groups at all periods (P >0.05).

CONCLUSION

Acetaminophen, 500 mg, with caffeine, 30 mg, can be used efficiently in controlling postoperative pain after open flap debridement, especially in patients with gastric ulcers or bleeding tendency because acetaminophen is less hazardous than ibuprofen.

Single dose oral ibuprofen for acute postoperative pain in adults

BACKGROUND

This review updates a 1999 Cochrane review showing that ibuprofen at various doses was effective in postoperative pain in single dose studies designed to demonstrate analgesic efficacy. New studies have since been published. Ibuprofen is one of the most widely used non-steroidal anti-inflammatory (NSAID) analgesics both by prescription and as an over-the-counter medicine. Ibuprofen is used for acute and chronic painful conditions.

OBJECTIVES

To assess analgesic efficacy of ibuprofen in single oral doses for moderate and severe postoperative pain in adults.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, EMBASE and the Oxford Pain Relief Database for studies to May 2009.

SELECTION CRITERIA

Randomised, double blind, placebo-controlled trials of single dose orally administered ibuprofen (any formulation) in adults with moderate to severe acute postoperative pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Pain relief or pain intensity data were extracted and converted into the dichotomous outcome of number of participants with at least 50% pain relief over 4 to 6 hours, from which relative risk and number-needed-to-treat-to-benefit (NNT) were calculated. Numbers of participants using rescue medication over specified time periods, and time to use of rescue medication, were sought as additional measures of efficacy. Information on adverse events and withdrawals were collected.

MAIN RESULTS

Seventy-two studies compared ibuprofen and placebo (9186 participants). Studies were predominantly of high reporting quality, and the bulk of the information concerned ibuprofen 200 mg and 400 mg. For at least 50% pain relief compared with placebo the NNT for ibuprofen 200 mg (2690 participants) was 2.7 (2.5 to 3.0) and for ibuprofen 400 mg (6475 participants) it was 2.5 (2.4 to 2.6). The proportion with at least 50% pain relief was 46% with 200 mg and 54% with 400 mg. Remedication within 6 hours was less frequent with higher doses, with 48% remedicating with 200 mg and 42% with 400 mg. The median time to remedication was 4.7 hours with 200 mg and 5.4 hours with 400 mg. Sensitivity analysis indicated that pain model and ibuprofen formulation may both affect the result, with dental impaction models and soluble ibuprofen salts producing better efficacy estimates. Adverse events were uncommon, and not different from placebo.

AUTHORS' CONCLUSIONS

The very substantial amount of high quality evidence demonstrates that ibuprofen is an effective analgesic in treating postoperative pain. NNTs for 200 mg and 400 mg ibuprofen did not change significantly from the previous review even when a substantial amount of new information was added. New information is provided on remedication.

Therapeutic uses of non-steroidal anti-inflammatory drugs in dentistry

The non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of drugs for the management of acute and chronic pain in dentistry. Their therapeutic efficacy and toxicity are well-documented and provide evidence that NSAIDs generally provide an acceptable therapeutic ratio of pain relief with fewer adverse effects than the opioid-mild analgesic combination drugs that they have largely replaced for most dental applications. The great many studies done with the oral surgery model of acute pain indicate that a single dose of an NSAID is more effective than combinations of aspirin or acetaminophen plus an opioid, with fewer side-effects, thus making it preferable for ambulatory patients. The combination of an NSAID with an opioid generally results in marginal analgesic activity but with an increased incidence of side-effects, which limits its use to patients in whom the NSAID alone results in inadequate analgesia. The selective COX-2 inhibitors hold promise for clinical efficacy with less toxicity from chronic administration and may prove advantageous for the relief of chronic orofacial pain. The use of repeated doses of NSAIDs for chronic orofacial pain should be re-evaluated in light of a lack of documented efficacy and the potential for serious gastrointestinal and renal toxicity with repeated dosing.

Single dose oral ibuprofen and diclofenac for postoperative pain

BACKGROUND

Ibuprofen and diclofenac are two widely used non-steroidal anti-inflammatory (NSAID) analgesics. It is therefore important to know which drug should be recommended for postoperative pain relief. This review seeks to compare the relative efficacy of the two drugs, and also considers the issues of safety and cost.

OBJECTIVES

To assess the analgesic efficacy of ibuprofen and diclofenac in single oral doses for moderate to severe postoperative pain.

SEARCH STRATEGY

Randomised trials were identified by searching Medline (1966 to December 1996), Embase (1980 to January 1997), the Cochrane Library (Issue 3 1996), Biological Abstracts (January 1985 to December 1996) and the Oxford Pain Relief Database (1950 to 1994). Date of the most recent searches: July 1998.

SELECTION CRITERIA

The inclusion criteria used were: full journal publication, postoperative pain, postoperative oral administration, adult patients, baseline pain of moderate to severe intensity, double-blind design, and random allocation to treatment groups which compared either ibuprofen or diclofenac with placebo.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers, and trials were quality scored. Summed pain relief or pain intensity difference over four to six hours was extracted, and converted into dichotomous information yielding the number of patients with at least 50% pain relief. This was then used to calculate the relative benefit and the number-needed-to-treat (NNT) for one patient to achieve at least 50% pain relief.

MAIN RESULTS

Thirty-four trials compared ibuprofen and placebo (3,591 patients), six compared diclofenac with placebo (840 patients) and there were two direct comparisons of diclofenac 50 mg and ibuprofen 400 mg (130 patients). In postoperative pain the NNTs for ibuprofen 200 mg were 3.3 (95% confidence interval 2.8 to 4.0) compared with placebo, for ibuprofen 400 mg 2.7 (2.5 to 3.0), for ibuprofen 600 mg 2.4 (1.9 to 3.3), for diclofenac 50 mg 2.3 (2.0 to 2.7) and for diclofenac 100 mg 1.8 (1.5 to 2.1). Direct comparisons of diclofenac 50 mg with ibuprofen 400 mg showed no significant difference between the two.

REVIEWER'S CONCLUSIONS

Both drugs work well. Choosing between them is an issue of dose, safety and cost.

Analgesic dose-response relationship of ibuprofen 50, 100, 200, and 400 mg after surgical removal of third molars: a single-dose, randomized, placebo-controlled, and double-blind study of 304 patients

The purpose of this single-dose, randomized, placebo-controlled, and double-blind study was to evaluate the analgesic dose-response relationship of 50-mg, 100-mg, 200-mg, and 400-mg doses of ibuprofen after third molar surgery. Patients were instructed to take a single dose of either placebo or 50 mg, 100 mg, 200 mg, or 400 mg of ibuprofen when the postoperative pain was moderate to severe. Acetaminophen 500 mg was used as a rescue medication. Pain intensity, pain relief, and any possible adverse events were recorded on self-administered questionnaires hourly for 6 hours after intake of study medication. If rescue medication was taken, the time of intake was registered. A total of 304 patients entered the study, and 258 complied with the protocol. A positive analgesic dose-response relationship of 50-mg, 100-mg, 200-mg, and 400-mg doses of ibuprofen was observed when evaluated by pain intensity difference, sum of pain intensity difference, pain relief, total pain relief, and survival distribution of patients not taking rescue medication. Although significant pain relief was seen after a dose of 50 mg ibuprofen, ibuprofen 400 mg provided maximum pain relief and the longest duration of analgesic effect. Mild transient adverse events were reported by 6.8% of the patients. However, there was no significant difference in frequency between the placebo and 50 mg, 100 mg, 200 mg, and 400 mg ibuprofen dose groups.

Comparison of presurgical and immediate postsurgical ibuprofen on postoperative periodontal pain

Previous studies have indicated that non-steroidal anti-inflammatory drugs administered prior to oral surgery procedures are effective in reducing postoperative pain. The purpose of the present study was to compare the efficacy of medicating with ibuprofen immediately presurgically to medicating immediately postsurgically on postoperative pain associated with periodontal surgery. Sixty patients who were to undergo periodontal surgery were randomly divided into 3 groups: the I-pretreatment group received 600 mg ibuprofen immediately presurgically and placebo immediately after the surgery; the I-post-treatment group received placebo before surgery and 600 mg ibuprofen postsurgically; the placebo group received placebo at both time periods. Responses from an 8-hour pain diary completed by each subject were quantified and statistically evaluated non-parametrically. Results indicated that dosing with ibuprofen either immediately before or immediately after periodontal surgery significantly delays onset of pain as compared to placebo, with dosing after surgery demonstrating a significantly greater delay of onset of pain as compared to dosing presurgically. In addition, unlike the presurgical dosing, dosing postsurgically significantly decreases mean pain intensity for a combined 8-hour period following periodontal surgery as compared to placebo.