The efficacy of etodolac and ibuprofen, regarding gender, on pain, edema and trismus after impacted lower third molar surgery: A randomized prospective clinical split-mouth study

Pain control following impacted mandibular third molar surgery: a comparison of the effectiveness of two different protocols

The use of multimodal analgesia is a common practice in clinical settings, where a combination of drugs with different mechanisms of action is used to enhance the effectiveness of an analgesic and reduce its adverse effects. This study aimed to compare the efficacy of concurrent ibuprofen and paracetamol with alternate administration in the management of postoperative pain after the surgical removal of impacted mandibular third molars. A single-center, double-masked, parallel-group, randomized controlled clinical trial involved 56 patients undergoing scheduled surgical extraction of impacted mandibular third molars. Patients were randomly assigned to either Group A (Control), where they were instructed to take one tablet of ibuprofen 400 mg and two tablets of paracetamol 500 mg together every 8 h for 48 h, or Group B (Study), where they were instructed to take one tablet of ibuprofen 400 mg and two tablets of paracetamol 500 mg alternatively every 4 h for 48 h. The primary outcome measure was the intensity of postoperative pain, which was evaluated using a Visual Analogue Scale (VAS) ranging from 0 to 10. The secondary outcome measure was the timing of the onset of the analgesic effect, the duration of pain relief, the frequency of rescue drug administration, and the time interval between taking the recommended medication and the need for rescue medication. Investigators involved in analyzing the patients' responses were blinded to the pain control regime used by the participants. Pain intensity during the first 48 h after the extractions showed that most participants experienced "some pain," including 50% in Group A and 35.7% in Group B. The percentage of patients reporting "no pain" was higher in group B than in group A, although the difference was not statistically significant (p = 0.495). More than half of the participants (53%) in group A reported needing an extra dose in the 48-hour follow-up period, while 85% in group B reported pain relief (p = 0.002). When correlating the mean pain score to the complexity level, in patients with moderate complexity of extraction, higher pain scores were recorded in group B. The findings of this study show that the combination of Paracetamol and Ibuprofen are well-tolerated and effective option for post operative pain after surgical removal of mandibular third molars. Use of Paracetamol and Ibuprofen alternatively in the first 48 h showed a more effective pain control compared to concurrent use of these medications. However given the small sample size and patients recruited from a single center, multicenter studies with a bigger sample size and stratified complexity groups would enhance the generalizability of the findings.This trial protocol was registered with ClinicalTrials.gov (Registration No: NCT06514222 dated 23/07/2024).

A prospective split-mouth clinical study: comparison of the effect of lornoxicam and etodolac on postoperative sequels following lower third molar surgery

PURPOSE

This study aims to compare the efficacy of two non-steroidal anti-inflammatory agents (NSAIDs), namely lornoxicam and etodolac for controlling pain, edema and trismus after removal of lower impacted third molars.

MATERIALS AND METHODS

A total of 20 patients comprised of both genders with bilateral impacted lower impacted third molars (in similar positions) was included in the present study. Patients were randomly assigned either to the lornoxicam group (8 mg of lornoxicam) or to the etodolac group (400 mg of etodolac). The drugs prescribed were handed out immediately after tooth extraction. Postoperative pain was assessed using visual analog scale (VAS). Edema was evaluated using reference lines on the face. Trismus was assessed using a caliper at maximum mouth opening (mm).

RESULTS

There was no significant difference in postoperative pain, trismus, and edema between lornoxicam and etodolac group (p > 0.05).

CONCLUSIONS

Based on the results obtained in the present study, ıt has been verified that both lornoxicam and etodolac were adequately effective in the management of pain following third molar surgery. Lornoxicam and etodolac had similar impacts on pain, edema and trismus after impacted lower third molar surgical extractions.

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.

An Evaluation of the Effect of Using Irrigations at Different Temperatures on Pain, Edema, and Trismus during the Extraction of Bilateral Impacted Mandibular Third Molars: A Randomized Split-Mouth Clinical Trial

BACKGROUND AND AIM

The surgical extraction of impacted wisdom teeth is a standard practice in dentistry. Unfortunately, inflammatory reactions such as discomfort, edema, and trismus frequently jeopardize patients' well-being after the extraction of third molars. Saline solutions at room temperature (25°C) are routinely used in impacted tooth extraction. Refrigerated saline solutions were used to work with cold solutions, and as the refrigerator temperature was 4°C, this study was designed to have a cold solution temperature of 4°C. This study aimed to assess the influence of saline irrigation at various temperatures (4°C, 25°C) on postoperative edema, pain, and trismus after the extraction of impacted third molars.

MATERIALS AND METHODS

Eighteen patients with bilateral symmetrical mandibular impacted third molars were enrolled in this split-mouth, randomized, prospective, double-blind clinical trial. For each patient, one side was irrigated with a saline solution (% 0.9 isotonic sodium chloride) at 4°C (test), and the other side was irrigated with a saline solution at room temperature (25°C) (control). Pain, trismus, and facial edema were noted on the 2nd, 4th, and 7th days. A Mann-Whitney U-test was used to compare pairs, and a Wilcoxon signed-rank test was used to compare groups.

RESULTS

The two groups had no considerable differences in terms of pain levels and facial edema (P > 0.05). Regarding trismus, the maximum mouth opening for cold irrigation (4°C) was significantly higher than for room temperature irrigation (25°C) across all postoperative periods (P < 0.05).

CONCLUSION

Cold irrigation therapy (4°C) exerts beneficial effects more than room temperature (25°C) irrigation on the trismus after impacted mandibular third molar surgery.

Patterns of Third-Molar-Pericoronitis-Related Pain: A Morphometrical Observational Retrospective Study

BACKGROUND

Mandibular third molar (M3M) removal and the management of postoperative complications represent a common matter of interest in oral and maxillofacial surgery. Pain represents a great symptom for patients affected by pericoronitis and it is the most common indication for third molar removal. The aim of the present article is to search for patterns of pre-operative pain in patients before undergoing third molar surgery and to test for a relation between some patterns of symptoms, such as pain intensity, site of symptomatic tooth, and referred area of pain.

METHODS

This retrospective observational study enrolled a total of 86 patients, aged (mean ± SD) 34.54 ± 13.62 years (range 17-78 years), scheduled for outpatient third molar extraction at the Oral Surgery School, Department of Medical Biotechnologies, Policlinico "Le Scotte", University of Siena. Pericoronitis and pain were the symptoms of the patients and the indication of extraction. Inclusion criteria were the presence of partially impacted third molars, confirmed with a preoperative panoramic radiograph, and preoperative pain. Exclusion criteria were known neurological disease (such as previous trigeminal or facial nerve injuries), impaired communicative or cognitive disease, diagnosed diabetes mellitus, and oral surgical intervention within 30 days before data collection. Patients were visited and asked to answer a morphometric analytic questionnaire about their perception of pain referred to the third molar. Analyses were performed on statistical evaluation on age, age ranges, patient gender, prior third molar extraction, site of pericoronitis, pain score (1-10), and pain area. Two-tailed p values of less than 0.05 were considered significant if not otherwise specified.

RESULTS

No correlations were found between age, gender, previous extraction, tooth site (maxillar on mandible), pain score, and pain area. Patterns of third molar pericoronitis pain among 86 patients were reported. A significant correlation was found between pain score and pain area (p = 0.0111, r_s = 0.3131).

CONCLUSIONS

Pain intensity has indeed some kind of responsibility in determining the orofacial distribution of pain. The pain area referral patterns of the present article could be considered as a pain model resulting from the pericoronitis of maxillar and mandibular third molars.

Current and emerging COX inhibitors for treating postoperative pain following oral surgery

INTRODUCTION

The numerous drugs in the NSAID class are often used to treat acute postoperative pain associated with oral surgery such as impacted third-molar extractions. These drugs are effective in this setting and dental pain studies often serve as models for acute pain relief and for registration of analgesics. With numerous cyclooxygenase (COX) inhibitors available as monotherapy, for use in combination with analgesic regimens, and in different doses and formulations, it was our aim to determine if there were clear-cut distinctions among these products and dosing regimens.

AREAS COVERED

This is a literature review of recent randomized controlled clinical trials evaluating NSAIDs for use in postoperative pain management following oral surgery. Of particular interest were head-to-head studies, which might offer some insight into comparative effectiveness.

EXPERT OPINION

Postoperative oral surgery pain is largely managed in real-world clinical practice using NSAIDs, either alone or in combination, and there is good evidence supporting their use especially in multimodal therapy. Head-to-head and comparative studies do not show a clear-cut 'optimal NSAID' in this setting, although ibuprofen, ketoprofen, dexketoprofen, and naproxen have gained most acceptance. Combination therapy with other analgesics or adjuvants is largely accepted.