Pre-emptive 8 mg dexamethasone and 120 mg etoricoxib for pain prevention after periodontal surgery: A randomised controlled clinical trial

Preemptive oral analgesia with steroidal and nonsteroidal anti-inflammatory drugs in periodontal surgery: a systematic review

Introduction: Periodontal procedures can promote prolonged intense pain, particularly in clinical situations requiring surgical procedures. In this context, preemptive analgesia has also been assessed for its utility in controlling post-operative pain and discomfort in patients undergoing periodontal invasive procedures. This study assessed the efficacy and safety of preemptive oral analgesia with steroidal and non-steroidal anti-inflammatory drugs in periodontal surgeries. Methods: This systematic review performed a search in the following electronic sources: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via PubMed), EMBASE (via Ovid), Web of Science, Virtual Health Library and in clinical trials electronic databases for relevant randomized clinical trials (RCTs); published up to July 2023. Primary outcomes assessed were post-operative pain, edema and trismus. A narrative synthesis of the findings was carried out. Results: Six RCTs, involving a total of 250 participants, were included. The studies reviewed had a high risk of bias, particularly due to allocation concealment and blinding of participants and personnel. The RCTs reported only the outcome pain. The preemptive use of dexamethasone 8 mg, etoricoxib 90 mg or 120 mg and ketorolac 20 mg seems to be more effective for controlling post-operative pain than placebo. Discussion: The anti-inflammatory drugs evaluated proved to be effective for controlling post-operative pain. However, given the limitations regarding lack of studies, methodological biases, disparities in drugs and doses, report restricted the pain outcome; further RCTs confirming the effectiveness and safety of these drugs in periodontal surgical procedures are warranted.

Preemptive effects of etoricoxib, acetaminophen, nimesulide, and ibuprofen on postoperative pain management after single-implant surgery: A randomized clinical trial

BACKGROUND

There is insufficient evidence for pain control in preemptive analgesia (PA) after dental implant surgery, signaling the need for further studies. The objective of this study was to evaluate the efficacy of PA in single dental implant surgeries (SDIS), seeking to identify among the etoricoxib (ETOR), ibuprofen (IBU), nimesulide (NIME), and acetaminophen (ACETA)], which one has the higher efficacy effectiveness in relieving postoperative pain and reducing the use of rescue medication compared to placebo.

METHODS

In this triple-blind, parallel, randomized controlled clinical trial, 135 individuals with a mean age of 57.6 years (±11.7), both genders, were randomly divided into five groups according to the test drug: I-PLACEBO; II-IBU (600 mg); III-NIME (100 mg); IV-ACETA (750 mg); and V-ETOR (90 mg). The occurrence, duration, and intensity of pain were analyzed using the Chi-square, Fisher's exact and ANOVA tests, and the generalized estimating equation models, when appropriate.

RESULTS

Test drugs provided a reduction in postoperative pain scores and lower use of rescue medication when compared to placebo. The ETOR group presented significantly lower pain scores, when compared to other active treatments. The IBU group showed the highest mean number of rescue medication used.

CONCLUSIONS

All test drugs provided a beneficial preemptive effect demonstrated by the reduced postoperative pain and reduced use of rescue medication. The ETOR group presented lower pain scores, and the IBU group showed the highest mean number of rescue medication used among the test groups.

Pain management in periodontal therapy using local anesthetics and other drugs: an integrative review

Background

Surgical and non-surgical periodontal procedures often lead to postoperative pain. Clinicians use pharmacological methods such as anesthetics, anti-inflammatory drugs, and analgesics for relief. However, the multitude of options makes it challenging to select the best approach for routine dental care.

Objective

This review aimed to describe previous studies regarding the pharmacological management used for pain control during periodontal procedures as well as factors that may interfere with patients' perception of pain.

Methods

We included studies (period of 2000-2023, whose approach corresponded to the pharmacological protocols used for preoperative, trans-operative, and postoperative pain control in adult patients undergoing surgical and non-surgical periodontal therapy.

Results

A total of 32 studies were included in the analysis, of which 17 (53%) were related to anesthetic methods and 15 (47%) were related to therapeutic protocols (anti-inflammatory/analgesic agents). These studies predominantly involved nonsurgical periodontal procedures. Studies have reported that factors related to age, type of procedure, and anxiety can influence pain perception; however, only seven of these studies evaluated anxiety.

Conclusions

Numerous methods for pain control can be applied in periodontal therapy, which are accomplished through anesthetic methods and/or therapeutic protocols. Factors such as anxiety, age, and type of procedure are related to pain perception in patients. Thus, it is the responsibility of dentists to evaluate each clinical situation and define the best protocol to follow based on the literature.

Analgesic Efficacy of COX-2 Inhibitors in Periodontal Surgery: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to evaluate the analgesic efficacy of COX-2 inhibitors versus other drugs in periodontal surgery. Two researchers searched PubMed, Google Scholar, ACM Digital, BASE, EBSCOhost, Scopus, or Web of Science for clinical trials using various combinations of words. All articles that met the selection criteria were assessed using the Cochrane Collaboration’s risk of bias tool. For data analysis, the inverse variance and mean difference statistical method was used with Review Manager 5.3 software for Windows. According to the conclusion of each study (qualitative evaluation), only one clinical trial had results in favor of a COX-2 inhibitor when compared to placebo, one clinical study informed that a COX-2 was better that an active control, four studies showed similar analgesic efficacy to active controls, and one clinical study informed the analgesic effect of one celecoxib-caffeine combination in comparison with celecoxib alone and placebo (n = 337). The COX-2 inhibitors showed a decrease in the rescue analgesic consumption (n = 138; I2 = 15%; mean difference = −0.31; 95%CIs = −0.6 to −0.01), and lower pain intensity at four hours (n = 178; I2 = 0%; mean difference = −2.25; 95%CIs = −2.94 to −1.55; p = 0.00001) when compared to active controls after periodontal surgery. In conclusion, the data indicate that COX-2 agents produce better pain relief in comparison to placebo and other drugs after periodontal surgery.

Melatonin as preemptive analgesic for intraoperative pain

Several anti-inflammatory and analgesic drugs have been used to reduce pain and discomfort during periodontal surgeries. This study evaluates the efficacy of using melatonin and ketorolac for pain prevention during open-flap debridement surgery. This prospective randomized controlled trial was performed in patients who presented with chronic periodontitis after non-surgical periodontal therapy, requiring flap surgery. Group 1: Flap surgery following non-surgical periodontal therapy after one month with no oral administration of analgesic. Group 2: Flap surgery following non-surgical periodontal therapy after one month with oral administration of Ketorolac 400mg one hour prior to the surgery. Group 3: Flap surgery following non-surgical periodontal therapy after one month with oral administration of 2 mg Melatonin one hour prior to the surgery. VAS and FLACC score along with blood pressure, SPO2 and heart rate. Statistical analysis was done using SPSS software. The intragroup comparisons (control-test drug) demonstrated that melatonin and ketorolac showed positive preemptive effect which compared to the control with mean differences significantly different from zero. However, when melatonin and ketorolac were compared there was no significant difference in postoperative pain among patients. The adoption of a preemptive medication protocol using either melatonin or ketorolac may be considered effective for pain and discomfort prevention during and post open-flap debridement surgeries. Melatonin showed similar effect to gold standard ketorolac in terms of its preemptive analgesic effect additional to having anti-inflammatory effect. Further studies are required to standardize the protocol for using melatonin as preemptive analgesic for dental surgical procedures.

Analgesic Efficacy of Etoricoxib following Third Molar Surgery: A Meta-analysis

Background

The purpose of this meta-analysis was to assess the clinical efficacy of etoricoxib in comparison with traditional NSAIDs for postoperative pain after third molar surgery.

Methods

The quality of studies found in PubMed and Google Scholar was evaluated with Cochrane Collaboration's risk of bias tool. Data on total consumption of rescue analgesics, number of patients using rescue analgesics, global assessment of study treatments, and adverse effects were extracted exclusively from high-quality clinical trials. Each meta-analysis was performed with the Review Manager Software 5.3 for Windows.

Results

The qualitative analysis showed that etoricoxib has better analgesic activity when compared with ibuprofen (2 clinical trials) and diclofenac (1 clinical trial). A similar analgesic efficacy between etoricoxib and nonselective Cox-2 NSAIDs was informed in 3/8 studies (2 compared to ibuprofen and 1 to naproxen sodium). Moreover, the number of patients requiring rescue analgesics in the postoperative period showed a statistical difference in favor of etoricoxib when compared to NSAIDs.

Conclusion

Etoricoxib significantly reduces the number of patients needing rescue analgesics compared to NSAIDs after third molar surgery.

Preemptive effects of ibuprofen and nimesulide on postoperative pain control after open flap periodontal surgeries: A randomized placebo-controlled split-mouth clinical trial

BACKGROUND

Data on preemptive analgesia in periodontal surgeries are scarce and still diverse. The aim of this study was to evaluate and compare the analgesic effects of the preemptive administration of ibuprofen and nimesulide in open flap periodontal surgeries.

METHODS

The present randomized controlled clinical trial comprised 40 individuals, divided into two groups (n = 20), according to the test drug (ibuprofen and nimesulide) to be administered 1 hour preoperatively. Participants underwent bilateral periodontal surgeries at two different times, and were randomly given the test drug or placebo in a split-mouth design. Postoperative pain and rescue medication were evaluated at different times. Comparisons between ibuprofen and nimesulide were performed through a Generalized Estimation Equation model, using test drug and evaluation times, along with an interaction between these two variables as predictors.

RESULTS

In intergroup comparisons regarding pain control, ibuprofen showed better effects than placebo only at the first postoperative hour, whereas nimesulide showed better effects than placebo at 1, 6, 24, and 48 postoperative hours. In intergroup comparisons, nimesulide showed better effects than ibuprofen at 24, 48, and 72 postoperative hours, demonstrating a higher overall preemptive effect. No differences were observed in relation to the number of rescue medication.

CONCLUSION

Preemptive administration of nimesulide showed better overall preemptive effects on postoperative pain control when compared with ibuprofen.

Pharmacological management of pain after periodontal surgery: a systematic review with meta-analysis

OBJECTIVES

To assess and compare the pharmacological effect of different drugs on pain relief after periodontal surgery.

MATERIALS AND METHODS

Five databases were searched up to September 2019. The eligible studies comprised randomized clinical trials, involving only adult individuals that received any periodontal surgery and presenting two distinct groups of therapeutic regimens to control postoperative pain. Placebo groups could be included. The risk of bias was assessed with the RoB 2 Cochrane tool and the GRADE system. Meta-analyses were performed using different follow-up and drug comparisons.

RESULTS

Overall, 2398 studies were identified, of which 35 were included. Low risk of bias was determined for the majority of the studies. The meta-analyses showed that the comparison of dexamethasone or non-steroidal anti-inflammatory drugs (NSAID) versus placebo favored the use of both interventions in a follow-up of 1 to 8 h for open flap procedures (OFP). However, no statistical difference was found for the comparison between NSAID and dexamethasone for OFP.

CONCLUSIONS

Patients may benefit from several pharmacological schemes for pain relief after periodontal surgeries. However, due to the high heterogeneity among studies, no fixed pharmacological protocol could be proposed.

CLINICAL RELEVANCE

There is not enough evidence to recommend one therapeutic scheme. However, untreated pain is harmful to the patients and it is not advisable.