Assessment of preemptive analgesia with ibuprofen coadministered or not with dexamethasone in third molar surgery: a randomized double-blind controlled clinical trial

Preemptive vs preventive coadministration of ibuprofen L-arginine and dexamethasone in lower third molar surgeries: a randomized controlled trial

OBJECTIVE

To compare the effect of different preemptive and preventive analgesia strategies involving oral coadministration of ibuprofen-arginine (770 mg)-Ib-Ar and dexamethasone (8 mg)-DX, and their respective placebos (P-Ib-Ar and P-DX), four evaluation groups on inflammatory and laboratory parameters, impact on quality of life, pain catastrophizing perception and sleep quality related after lower third molar surgery.

STUDY DESIGN

A randomized split-mouth, triple-blind, controlled clinical trial was conducted with 48 volunteers. They were allocated depending on the use of Ib-Ar or DX, 1 hour before surgery or immediately postoperatively, discriminating the groups: G1 (Ib-Ar + DX), G2 (Ib-Ar + P-DX), G3 (P-Ib-Ar + DX), and G4 (P-Ib-Ar + P-DX).

RESULTS

Pain peaks occurred after 2 h (P-Ib-Ar groups) (P = .003), while the other groups showed peak pain after 4 h (P < .05). Regarding the edema: groups treated with placebos measurements significantly reduced without returning to baseline (P < .001). Regarding laboratory parameters: MPO and MDA levels, the G1 group (P < .001) was the only one showing significant reduction.

CONCLUSIONS

The use of preemptive and preventive analgesia strategies of Ib-Ar and DX showed that the combined use delayed peak pain, with no difference in edema and trismus. The benefit of coadministration of both strategies was superior to isolated use of drugs.

PREEMPTIVE INTRAVENOUS IBUPROFEN AND LOCAL KETAMINE IMPROVE POSTOPERATIVE ANALGESIA FOLLOWING THIRD MOLAR SURGERY: A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED CLINICAL STUDY

OBJECTIVE

To compare the efficacy of preemptive ibuprofen, local ketamine, and their combination in managing postoperative pain and trismus following third molar surgery.

MATERIALS AND METHODS

One hundred patients were randomly divided into 4 groups. The Intrafen Group had their impacted third molars surgically removed under local anesthesia after receiving intravenous (IV) ibuprofen for preemptive effect. The Ketamine Group received an IV placebo before the surgery, and the extraction process was completed with a local anesthetic-ketamine combination. The Combined Group received preemptive IV ibuprofen before the procedure, and the surgery was performed with a local anesthetic-ketamine combination. The Control Group received an IV placebo before the procedure and then had their impacted third molars removed under local anesthesia. The Visual Analogue Scale (VAS) values, corresponding to the patients' pain levels at the 2nd and 12th postoperative hours and the total amount of analgesic dose used in the first 24 hours, were recorded, and evaluated. The maximum mouth opening of the patients was measured immediately before the procedure, and on the second and seventh postoperative days. The level of patient satisfaction in all groups was assessed during the procedure.

RESULTS

The mean VAS value corresponding to the second-hour pain level of the combined group was statistically significantly lower than the other groups (P = .003). A statistically significant difference was found in the mean VAS values corresponding to the pain levels of the groups, favoring the combined group compared to the other groups (P ≤ .001). A significant difference was observed between the VAS difference values corresponding to the pain levels of the Intrafen group and the Ketamine group, favoring the Intrafen group (P = .038). The Ketamine group consumed the most analgesic on average over the first 24 hours, whereas the Combined group consumed the least. No statistically significant difference was found between the mean trismus levels of the groups on days 0-2 (P = .528) and days 0-7 (P = .129). The intraoperative patient satisfaction level of the combined group was significantly higher than that of the other groups (P = .030).

CONCLUSION

Preemptive Intrafen is an effective regimen for postoperative pain management and is superior to the local anesthetic-ketamine regimen. The most effective method to reduce postoperative pain following third molar surgery is to use a combination of these 2 regimens. However, none of the treatment methods used in the study had a positive effect on postoperative trismus.

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.

Photobiomodulation increases uprighting tooth movement and modulates IL-1β expression during orthodontically bone remodeling

This study investigated the effects of photobiomodulation (PBM) in acceleration of orthodontic movement of inferior molar uprighting movement. Thirty-four individuals, with indication of molar uprighting movement for oral rehabilitation, were randomly divided in two groups: verticalization + PBM (808 nm, 100 mW, 1 J per point, 10 points and 25 J/cm2 ) or verticalization + PBM simulation. Elastomeric chain ligatures were changed every 30 days for 3 months. FBM was performed immediately, 24 h, 72 h, 1 and 2 months after activation. The primary outcome was the amount of uprighting movement. Secondary outcomes were pain, amount of medication, OHIP-14 questionnaire, and cytokine IL-1β. PBM group increase uprighting movement when compared to control after 3 months and modulate IL-1β expression. For pain control, the amount of medication and OHIP-14 no difference were found. This study suggests that PBM accelerates tooth movement during molar uprighting, due to modulation of IL-1β during bone remodeling.

Corticosteroids for managing acute pain subsequent to surgical extraction of mandibular third molars: A systematic review and meta-analysis

BACKGROUND

Corticosteroids are used to manage pain after surgical tooth extractions. The authors assessed the effect of corticosteroids on acute postoperative pain in patients undergoing surgical tooth extractions of mandibular third molars.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic review and meta-analysis. The authors searched the Epistemonikos database, including MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the US clinical trials registry (ClinicalTrials.gov) from inception until April 2023. Pairs of reviewers independently screened titles and abstracts, then full texts of trials were identified as potentially eligible. After duplicate data abstraction, the authors conducted random-effects meta-analyses. Risk of bias was assessed using Version 2 of the Cochrane Risk of Bias tool and certainty of the evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Forty randomized controlled trials proved eligible. The evidence suggested that corticosteroids compared with a placebo provided a trivial reduction in pain intensity measured 6 hours (mean difference, 8.79 points lower; 95% CI, 14.8 to 2.77 points lower; low certainty) and 24 hours after surgical tooth extraction (mean difference, 8.89 points lower; 95% CI, 10.71 to 7.06 points lower; very low certainty). The authors found no important difference between corticosteroids and a placebo with regard to incidence of postoperative infection (risk difference, 0%; 95% CI, -1% to 1%; low certainty) and alveolar osteitis (risk difference, 0%; 95% CI, -3% to 4%; very low certainty).

PRACTICAL IMPLICATIONS

Low and very low certainty evidence suggests that there is a trivial difference regarding postoperative pain intensity and adverse effects of corticosteroids administered orally, submucosally, or intramuscularly compared with a placebo in patients undergoing third-molar extractions.

Is coadministration of preemptive medications an effective strategy for reducing inflammatory clinical events and the need for rescue medication after mandibular third molar surgery? A systematic review of randomized clinical trials

This study aimed to evaluate the scientific evidence on the effect of preemptive drug coadministration (PDC) for relieving inflammatory events (pain, swelling, and trismus) in mandibular third molar surgery. A PROSPERO-registered systematic review (CRD42022314546) was conducted according to the PRISMA guide. The searches were carried out in six primary databases and the gray literature. Studies not written in languages with the Latin alphabet (Roman) were excluded. Potential randomized controlled trials (RCTs) were screened for eligibility. Cochrane's Risk of Bias-2.0 (RoB) tool was assessed. A synthesis without meta-analysis (SWiM) based on a vote counting and an effect direction plot. Nine studies (low RoB) fulfilled the eligibility criteria and were included for data analysis, with a total of 484 patients. PDC mostly involved corticosteroids (Cort) and non-steroidal anti-inflammatory drugs (NSAIDs). PDC of Cort and other drugs mainly reduced pain scores (6 and 12 h postoperatively) and swelling (48 h postoperatively). PDC of NSAIDs and other drugs mainly reduced pain scores at 6, 8, and 24 h follow-up; swelling and trismus intensity ameliorated at 48 h postoperatively. The most frequently prescribed rescue medication was paracetamol, dipyrone, and paracetamol plus codeine. Results from individual studies have shown reduced consumption of ingested rescue analgesics. In summary, the available evidence from clinical trials included in this SWiM suggests that PDC may provide benefits in reducing the severity of inflammatory outcomes related to mandibular third molar surgery, especially the pain scores in the first hours after surgery, and the rescue analgesic consumption during the postoperative period.

Dexamethasone in preventive analgesia alleviates pain and complications after jaw cyst enucleation: a randomized controlled trial

Background

Dexamethasone is widely used in the prevention of postoperative complications in oral surgery and strengthening the analgesic effect after anesthesia, but the efficacy is controversial, and the relationship between postoperative complications and pain is still unclear. The purpose of this study was to evaluate the analgesic effect of dexamethasone in the treatment of jaw cyst and to explore the relationship between postoperative complications and pain.

Methods

We conducted a prospective, randomized, double-blind clinical trial. 120 patients were divided into two groups, dexamethasone group ( group D) and control group (Group C). All patients were given 0.02 mg·kg−1 of hydromorphone to relieve pain in advance at 10 min before the beginning of operation. Meanwhile, dexamethasone was injected 0.2 mg·kg−1 intravenously in group D and normal saline was injected in group C. The primary endpoint was pain intensity at 2 h, 6 h, 12 h, 24 h and 48 h after surgery. The secondary endpoints were the incidence and extent of complications after surgery, including facial swelling and trismus.

Results

Compared with group C, the visual analogue scale (VAS) scores and occurrence of painful event postoperatively in group D were significantly lower both at rest (P < 0.0001 and P = 0.0014) and during mobilization (P < 0.0001 both). The degree of facial swelling and trismus in group D were significantly lower than that in group C at 24 h (P < 0.0001 and P = 0.00022) and 48 h (P < 0.0001 and P = 0.00015) after surgery, but there was no difference at 6 h and 12 h (P = 0.137 and P = 0.083) after surgery. The C-reactive protein (CRP) level at 24 h after operation in group D was lower than group C (P = 0.012), but there was no significant difference in blood glucose concentration between the two groups (P = 0.608).

Conclusion

Dexamethasone can reduce the degree of facial swelling and trismus after jaw cyst surgery by inhibiting the production of inflammation, which alleviated the postoperative pain of patients significantly. In addition, it did not increase the risk of hyperglycemia.

Trial registration

This study was registered with the Chinese Clinical Trial Registry on May 07, 2020 (URL: http://www.chictr.org.cn/showproj.aspx?proj=53344. Registry number: ChiCTR2000032693). Registered on 07/05/2020.

The effect of pre-emptive ibuprofen on post-operative pain after removal of lower third molar teeth: a systematic review

Objective To investigate the effect of pre-emptive ibuprofen on post-operative pain after lower third molar surgery.Methods A search for randomised controlled trials was undertaken across the databases Medline, Embase, Cochrane Central and Dentistry and Oral Sciences Source. Citation searching was used to supplement the database search. Inclusion and exclusion criteria were used for independent double screening by two assessors.Results A total of five randomised controlled trials were included in the review. A risk of bias assessment identified some concerns in four of the included studies. One study was assessed as having low risk of bias. The important outcomes measured were post-operative pain intensity, total pain relief, use of rescue analgesia, time to rescue analgesia and total consumption of rescue analgesia. In two trials, pre-emptive ibuprofen was shown to significantly reduce pain intensity after lower third molar surgery compared with placebo. Two trials showed no significant difference between ibuprofen and placebo groups. Pre-emptive ibuprofen was shown to provide superior pain relief compared with placebo in the one trial measuring this outcome. Where the use of rescue medication was measured as an outcome, two trials showed that pre-emptive ibuprofen was superior to placebo, one trial showed that placebo was superior to ibuprofen and two trials found no significant difference between ibuprofen and placebo groups.Conclusion Due to the inconsistency of the results, there is insufficient evidence to support the use of pre-emptive ibuprofen for management of post-operative pain after lower third molar surgery. Further research into the effects of pre-emptive analgesia on the surgical pain pathway is required.

A triple-blind randomized clinical trial of different associations between dexamethasone and non-steroids anti-inflammatories for preemptive action in third molar extractions

The aim of this study is to evaluate the preemptive analgesic effects of dexamethasone (DEX) alone or combined with non-steroidal anti-inflammatory drugs (NSAIDs) in third molar surgeries. The subjects were divided into five groups (n = 20 teeth/group); subjects received only 8 mg of dexamethasone 1 h before the surgical procedure (DEX group), or in combination with etodolac (DEX + ETO), ketorolac (DEX + KET), ibuprofen (DEX + IBU), loxoprofen (DEX + LOX). Paracetamol 750 mg was provided as the number of rescue analgesics (NRA). Salivary PGE2 expression was measured preoperatively and at 48 h. Edema and Maximum mouth opening (MMO) were measured postoperatively at 48 h and 7 days. A visual analog scale (VAS) was performed postoperatively at 6, 12, 24, 48, 72 h, and 7 days. Salivary expression of PGE2 showed a decrease only for the DEX group. Edema and MMO and NRA consumption showed no significant differences among the groups (P > 0.05). The VAS showed a significantly lower pain perception at 6 h after the surgery for the DEX + ETO and DEX + KET groups (P < 0.05). The combination of DEX and NSAIDS should be considered for preemptive acute postsurgical pain management in third molar surgery. In some drug associations such as dexamethasone 8 mg + NSAIDS (ETO and KET) in the pre-operative time, only a few rescue analgesics are necessary.

Photobiomodulation Therapy Improves Postoperative Pain and Edema in Third Molar Surgeries: A Randomized, Comparative, Double-Blind, and Prospective Clinical Trial

PURPOSE

Laser light has biological effects that can modulate inflammatory processes. Thus, this study aimed to evaluate the effects of photobiomodulation (PBM) therapy on pain, edema, and trismus after the extraction of retained third molars.

METHODS

A split-mouth, double-blind, randomized clinical trial (RCT) was conducted in 13 patients with similar bilateral third molars who received intraoral application PBM therapy at 4 points with a diode laser at 810 nm wavelength, 6 J (100 mW, 60 seconds/point) on 1 side (the PBM side); and laser irradiation simulation on the other side (SHAM side). The pain was assessed through visual analog scale (VAS) at 0, 12, 24, 48, and 72 hours, number of analgesic-relief (NAR), and mean time of first analgesic use; edema, through VAS, and linear facial measurements at 0, 24, 48, and 72 hours; and trismus, through the mouth opening measurements at 0, 24, 48, and 72 hours. The repeated-measures analysis was applied to assess the effect of the treatment, followed by Tukey's post hoc test for multiple comparisons (P < .05).

RESULTS

Thirteen patients (61.77% male and 38.63% female) with age of 24.16 ± 2.06 participated in this research. VAS showed that PBM controlled pain better (7.56 ± 6.25) than SHAM (32.25 ± 22.78) at 24 hours (P < .001) and 48 hours (19.47 ± 9.27 and 39.87 ± 4.21, respectively) (P = .011). VAS also showed that PBM controlled edema better (19.7 ± 13.27) than SHAM (32.38 ± 15.28) at 24 hours (P = .037) and 48 hours (19.47 ± 13.11 and 39.87 ± 22.77, respectively) (P = .002).

CONCLUSION

The PBM therapy in this study resulted in pain and edema reduction after third molar surgery and may be considered as adjuvant therapy after the surgical procedure.

Effectiveness of pre-operative oral corticosteroids in reducing pain, trismus and oedema following lower third molar extractions: a systematic review

Aim To determine if a single pre-operative dose of oral corticosteroids would be effective in reducing pain, trismus and oedema following lower third molar surgical extraction. Secondary outcomes of interest were post-operative complications such as infections.Methods Searching was conducted using Embase, Medline, DOSS, CINAHL and CENTRAL for randomised controlled trials. Four studies which compared pre-operative oral corticosteroids to placebo before lower third molar surgical extractions were eligible for inclusion.Results All studies were judged to be at unclear risk of bias. All studies tested the efficacy of 8 mg dexamethasone 60-90 minutes before surgical extractions. While three studies showed improvement in pain visual analogue scale (VAS) scores in the dexamethasone groups, two were not statistically significant. One study found no improvement in pain scores on VAS. One study found no difference in either trismus or oedema. One study reported one occurrence of post-operative alveolar infection in the dexamethasone group and one occurrence of alveolar osteitis in the placebo group.Conclusion While there seems to be an improvement in pain scores on VAS, these results are not clinically significant. Post-operative analgesia plays a more important role clinically.

Preemptive use of intravenous ibuprofen to reduce postoperative pain after lower third molar surgery: a systematic review of randomized controlled trials

This study aimed to systematically review the literature to assess the effect of preemptive intravenous ibuprofen on pain reduction after lower third molar surgery. Nine databases (PubMed, Scopus, LILACS, SciELO, Embase, Web of Science, Cochrane, Open Gray, and Open Thesis) were used as sources of research, including "grey literature." The protocol was registered in PROSPERO. Only randomized clinical trials evaluating the effects of preemptive intravenous ibuprofen on pain during and immediately after the extraction of lower third molars were included, without restrictions of year and language. Two reviewers independently performed the study selection, data extraction, and assessment of the risk of bias. The "Joanna Briggs Institute for Randomized Controlled Trials" tool was used to assess the risk of bias. Each study was categorized according to the percentage of positive responses to the questions corresponding to the assessment instrument. The results were measured narratively/descriptively. The initial search resulted in 3,257 records, of which only three studies (n=150 participants) met the eligibility criteria and were included in the qualitative analysis. All studies were published in 2019. The risk of bias ranged from low to moderate. Two studies found significant pain reduction within 48 h after the procedure. In conclusion, the use of preemptive intravenous ibuprofen for extracting third molars reduces pain and analgesic consumption after the surgical procedure.

Pre-emptive analgesic efficacy of injected ketorolac in comparison to other agents for third molar surgical removal: a systematic review

This study aimed to evaluate and compare the pre-emptive analgesic efficacy of injected ketorolac to that of other agents for impacted third molar surgical removal in a healthy population.

PubMed, Ovid SP, Cochrane databases were filtered from 1980 to July 2020 for potential papers using relevant MeSH terms and pre-specified inclusion and exclusion criteria independently by reviewers. Studies that compared pre-emptive intramuscular or intravenous administration of ketorolac to other agents were evaluated. The outcomes sought were self-reported postoperative pain (patient-perceived pain), median duration for rescue analgesic medication, total number of analgesics consumed in the recovery period, and global assessment (overall patient satisfaction) after the recovery period.

Six studies were included in the final evaluation. The outcome of pain perception and the number of analgesics taken were significantly lower in the ketorolac group (intramuscular or intravenous) in most of the studies (n=5) than in the group of other drugs. The mean time for rescue analgesia intake was higher for the ketorolac group, and global assessment scores were also better in the ketorolac group.

Although the included studies show significantly better outcomes such as postoperative pain, median time taken for rescue medication, total number of analgesics taken, and overall patient satisfaction with injected ketorolac group in comparison to injected diclofenac, dexamethasone, and tramadol, definitive conclusions cannot be made regarding the superiority of injected Ketorolac as a pre-emptive agent. A greater number of randomized control trials with a proper protocol are needed to make definitive conclusions.

Postoperative pain and edema control following different protocols of preemptive analgesia in the surgical removal of impacted third molars: A triple-blind parallel randomized placebo-controlled clinical trial

This randomized controlled clinical trial aimed to evaluate the preemptive effects of acetaminophen, ibuprofen, ketoprofen, nimesulide or dexamethasone on postoperative pain and edema in the surgical removal of impacted third molars. Participants underwent bilateral surgeries at 2 different times and were randomly given the test drug or placebo (split-mouth). Postoperative pain, edema and rescue medication were evaluated at different times. Study power was >80% for the observed effect size in the crossover repeated measures design. Differences between test drug and placebo were the response variable. Generalized Estimation Equation models were adjusted for each outcome. Sample comprised 5 groups (n = 20 each). Ibuprofen and nimesulide showed higher overall effects on pain scores over time, with no differences between them (p = 0.557). Acetaminophen showed significantly lower overall effects in edema control over time, when compared to other test drugs, that showed similar effects. Lower quantity of rescue medication were also observed for ibuprofen and nimesulide, with no differences between them (p = 0.999). Ibuprofen and nimesulide showed beneficial overall preemptive effects. Hence, in the decision-making process for preemptive analgesia in impacted third molar surgeries, ibuprofen and nimesulide should be considered on a case-by-case basis as the drugs of choice.

Combination of etodolac and dexamethasone improves preemptive analgesia in third molar surgery: a randomized study

OBJECTIVE

This randomized, controlled, triple-blind, crossover clinical trial aimed to investigate the use of dexamethasone (DEX) and etodolac (ETO) as preemptive analgesia before mandibular third molar extraction.

METHODS

Patients were divided into three groups (n = 20 teeth each) based on the drug administered: DEX 8 mg (DEX); DEX 8 mg plus ETO 300 mg (DEX + ETO), and ETO 300 mg (ETO). Paracetamol (750 mg) tablets were administered as rescue analgesics. Pain was evaluated using the visual analog scale (VAS) at 6, 12, 24, 48, and 72 h and 7 days postoperatively. Edema and trismus were assessed 48 and 72 h postoperatively. All data were subjected to statistical analysis, where a P value < .05 indicated statistical significance.

RESULTS

VAS scores and the number of rescue analgesics taken were lower in the DEX + ETO group than in the other groups (P < .001 and P = .014, respectively). At 48 h, trismus was similar among all groups; however, the ETO group showed the highest trismus 7 days postoperatively (P < .05). Edema was similar among all groups at all time points (P > .05).

CONCLUSION

The combined use of the anti-inflammatory drugs, DEX and ETO, resulted in better pain control and the need for fewer rescue analgesics than the use of either drug alone, which indicated their effectiveness in mandibular third molar extractions preoperatively.

CLINICAL RELEVANCE

This drug combination can lead to less pain, edema, and trismus and reduce the use of rescue analgesics in the postoperative period.

Dexamethasone Injection Into Pterygomandibular Space Versus Sublingual Space on Post-Operative Sequalae of Lower Third Molar Intervention

Background

The surgical removal of lower third molar is still the most common surgical procedure that is done in oral and maxillofacial surgery field and creates the predictable post-operative sequelae such as pain, swelling, stiffness and difficulty in mouth opening. The purpose of this study is to compare pre-operative dexamethasone injection into pterygomandibular space (PGS) and sublingual space (SLS) in lower third molar intervention of post-operative pain, swelling, and limited mouth opening.

Methods

This study is the split-mouth, randomized crossover clinical trial in 30 healthy patients (mean age 21 years). These patients had similar bilateral lower third molar impactions. The patients were randomly divided into two groups receiving either 8-mg dexamethasone injection into SLS or PGS with the 4-week washout period intervention. Clinical assessment of facial swelling and maximum mouth opening was performed before operation and on day 2 and day 7 after operation. The post-operative pain was also measured by patients' response on pain visual analogue scale (VAS) on the first, second and third day after intervention.

Results

There is no significant difference between PGS group and SLS group in pain and swelling on the second and seventh day after operation. However, PGS group showed a greater degree of limited mouth opening than SLS group on the second day after operation.

Conclusions

This study showed that 8-mg dexamethasone injection into PGS or SLS was not different in reduction of pain, swelling, and limited mouth opening. This result suggests that dexamethasone injection into PGS or SLS is similarly effective.

Does Pre-Emptive Administration of Intravenous Ibuprofen (Caldolor) or Intravenous Acetaminophen (Ofirmev) Reduce Postoperative Pain and Subsequent Narcotic Consumption After Third Molar Surgery?

PURPOSE

Pre-emptive analgesia is known to reduce postoperative pain after third molar removal. The purpose of this study was to compare postoperative pain in patients receiving either preoperative intravenous (IV) ibuprofen or preoperative IV acetaminophen for third molar surgery.

PATIENTS AND METHODS

This study was a randomized, single-blinded clinical study conducted in patients undergoing surgical extraction of 2 or more impacted third molars under deep sedation. This study compared 2 interventions: 800 mg of IV ibuprofen (Caldolor; Cumberland Pharmaceuticals, Nashville, TN) and 1,000 mg of IV acetaminophen (Ofirmev; Mallinckrodt Pharmaceuticals, Staines-upon-Thames, United Kingdom). The primary outcome variable was postoperative pain measured on a visual analog scale at different time points. The secondary outcome variable was the amount of postoperative analgesic (narcotic and over-the-counter) medication taken in both groups. The Mann-Whitney U test was used to compare groups in terms of outcomes, the χ² test was used to assess associations between nominal variables, and Spearman correlations were used to assess associations between continuous variables. Significance was set at P < .05.

RESULTS

The study sample consisted of 58 patients (39 female and 19 male patients). A total of 41 patients (IV ibuprofen, n = 19; IV acetaminophen, n = 22) completed the study. Equal distributions of age, gender, and number of impacted teeth were noted between the groups. At 4 hours postoperatively, the pain level in the ibuprofen group was significantly lower than that in the acetaminophen group (P = .004). This trend continued at 24 hours (P = .019) and 48 hours (P = .017). The average amount of narcotic medication taken in the ibuprofen group (2.68 ± 2.26 doses) was lower than that in the acetaminophen group (7.32 ± 6.68 doses), and the result was statistically significant (P = .005).

CONCLUSIONS

Pre-emptive analgesia with IV ibuprofen is more effective than IV acetaminophen in reducing postoperative pain and opioid use for third molar surgery.

Low-level laser treatment applied at auriculotherapy points to reduce postoperative pain in third molar surgery: A randomized, controlled, single-blinded study

OBJECTIVE

Evaluate the effectiveness of LLL (Low level laser therapy) in auriculotherapy points for pain reduction following lower third molar extractions.

STUDY DESIGN

Randomized, controlled, single-blinded study.

METHODS

Eighty-four bilateral, symmetrical third molar surgeries were performed in 42 healthy patients using a split-mouth design. In the immediate postoperative period, each side was randomly treated in a single-blind method with an LLL at the auriculotherapy points or simulation of its use (contralateral side) over a 21-day interval. This protocol was repeated 24 and 48 hours after surgery. All patients used the same analgesic (paracetamol) but only in case of pain. The primary variable was postoperative pain according to the visual analogue scale, and the secondary variables were mouth opening, edema, local temperature, dysphagia, and the presence of infection (systemic temperature, lymphadenopathy). These variables were evaluated at baseline and at 24 hours, 48 hours and seven days after surgery. Adverse effects were recorded and reported.

RESULTS

There was no difference between the groups in relation to any of the evaluated parameters (p>0.05).

CONCLUSION

For this experimental model, application of a low-intensity laser at auriculotherapy points did not prevent postoperative pain following lower third molar surgery.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov; the registration number is NCT02657174 and the Unique Protocol ID number is 1.100.869. (https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=View&listmode=Edit&uid=U0002BEY&ts=11&sid=S0006026&cx=6g4wff).

Is dipyrone effective as a preemptive analgesic in third molar surgery? A pilot study

PURPOSE

Studies on preemptive analgesia in maxillofacial surgery have shown several controversial clinical results, mainly due to the absence of a methodological standard, besides a wide variety of studied drugs. This study intended to answer the following hypothesis: Is the administration of dipyrone preemptively capable of decreasing trans- and postoperative pain in the third molar surgical extraction?

METHODS

A pilot prospective double-blind placebo-controlled study was carried out with 25 patients submitted to the third molar surgical extraction at two moments, one side in each intervention. Dipyrone (1 g) was preemptively administered (study group) for the extraction of two third molars on the same side and, in a second surgical procedure, dipyrone (1 g) was administered in the immediate postoperative period (control group). Evaluated variables were the amount of anesthetic, pain perceived through the visual analogue scale (VAS) in transoperative and immediate postoperative periods, and over 12-h investigation period, analgesic consumption, duration of surgery, and time to rescue analgesia.

RESULTS

The results were submitted to Student's t test and statistical differences were observed in transoperative (p < 0.05) and immediate postoperative (p < 0.01) periods, while the other studied variables did not present statistical differences.

CONCLUSION

The preemptive administration of dipyrone decreased the perception of transoperative and immediate postoperative pain when compared to its use after surgery only.

Randomized controlled trial to compare oral analgesic requirements and patient satisfaction in using oral non-steroidal anti-inflammatory drugs versus benzydamine hydrochloride oral rinses after mandibular third molar extraction: a pilot study

Background

Third molar extraction is associated with considerable pain and discomfort, which is mostly managed with oral analgesic medication. We assessed the analgesic effect of benzydamine hydrochloride, a topical analgesic oral rinse, for controlling postoperative pain following third molar extraction.

Methods

A randomized controlled trial was conducted in 40 patients divided into two groups, for extraction of fully erupted third molar. Groups A received benzydamine hydrochloride mouthwash and group B received normal saline gargle with oral ibuprofen and paracetamol. Oral ibuprofen and paracetamol was the rescue analgesic drug in group A. Patients were evaluated on the 3^rd and 7^th post-operative days (POD) for pain using the visual analogue score (VAS), trismus, total number of analgesics consumed, and satisfaction level of patients.

Results

The VAS in groups A and B on POD3 and POD7 was 4.55 ± 2.54 and 3.95 ± 1.8, and 1.2 ± 1.64 and 0.95 ± 1.14, respectively and was statistically insignificant. The number of analgesics consumed in groups A and B on POD3 (5.25 ± 2.22 and 6.05 ± 2.43) was not statistically different from that consumed on POD7 (9.15 ± 5.93 and 10.65 ± 6.46). The p values for trismus on POD3 and POD7 were 0.609 and 0.490, respectively and those for patient satisfaction level on POD3 and POD7 were 0.283 and 0.217, respectively.

Conclusions

Benzydamine hydrochloride oral rinses do not significantly reduce intake of oral analgesics and are inadequate for pain relief following mandibular third molar extraction.

Evaluation of the Effect of Phototherapy in Patients with Mandibular Fracture on Mandibular Dynamics, Pain, Edema, and Bite Force: A Pilot Study

OBJECTIVE

The aim of this study was to evaluate the effect of phototherapy on bite force, facial swelling, mandibular movements, and pain in patients having undergone surgical treatment for mandibular fractures.

BACKGROUND

These are among the predominant types of facial fractures, and treatment involving surgical fixation with titanium plates is one of the most common procedures in oral-maxillofacial surgery. Phototherapy has been used to accelerate the muscle healing process and significantly improves muscle regeneration by inducing the formation of new muscle fibers.

METHODS

The patients were divided into two groups: Group 1-active phototherapy, and Group 2-sham phototherapy. Both groups underwent the surgical procedure by the same surgeon using the same surgical technique. Dosimetric parameters are wavelength, 660 nm; power, 108 mW; radiant energy, 21.6 J; fluency, 21.6 J/cm²; radiance, 38197 mW/cm²; exposure time, 200 sec per point, 10 points bilaterally. Photobiomodulation was performed in 15 sessions.

RESULTS

The primary variable was bite force measured with a gnathodynamometer and the secondary variables were facial swelling, mandibular movements (measured with digital calipers), and pain. The Student's t-test was used to determine intergroup differences.

CONCLUSIONS

The findings suggest improvements in the laser group in comparison with the sham group with regard to mandibular dynamics, a reduction in postoperative facial swelling, a reduction in pain, and an increase in bite force.

Comparison of paracetamol, ibuprofen, and diclofenac potassium for pain relief following dental extractions and deep cavity preparations

Objectives:

To compare the effectiveness of different oral analgesics for relieving pain and distress in adults following the extraction of teeth and deep cavity preparations under local anesthesia.

Methods:

This randomized controlled study was conducted between November 2015 and May 2016. One hundred and twenty patients were randomly allocated to 3 groups. Forty patients were in the paracetamol (1 gram) group, 40 in the ibuprofen (400 mg) group and 40 in the diclofenac potassium (50 mg) group. Evaluation of the post extraction and deep cavity preparations pain was made by patients immediately postoperatively, 2, 4 and 6 hours postoperatively on standard 100 mm visual analogue scales (VAS). Furthermore, each patient was observed preoperatively and immediately postoperatively for signs of distress by using a 5 point face scale.

Results:

There were significant decreases in mean pain VAS scores for diclofenac potassium group compared to paracetamol and ibuprofen groups at 4 hours postoperatively (one-way Analysis of Variance: p=0.0001, p=0.001) and 6 hours postoperatively (p=0.04, p=0.005). Changes in distress scores from the preoperative score to the postoperative score were made using the paired sample t-test. There were significant decreases in distress scores between the preoperative and postoperative scores (p=0.0001).

Conclusions:

Diclofenac potassium was more effective than paracetamol or ibuprofen for reducing postoperative pain associated with tooth extraction and deep cavity preparation. Patients’ distress levels can be alleviated by using preemptive analgesics.

Evaluation of low-level laser at auriculotherapy points to reduce postoperative pain in inferior third molar surgery: study protocol for a randomized controlled trial

Background

A comfortable postoperative return to daily activities has increased the need to control inflammation after third molar surgery. Anti-inflammatory drugs and analgesics are not exempt from adverse effects such as allergies and chronic gastritis, and they are not without cost. The association between low-level laser and auricular acupuncture can be an alternative when conventional drugs are contraindicated. Among its advantages, we can mention the low risk of side effects, low cost and simplicity of application. The objective of this study is to evaluate the efficiency of low-level laser at auriculotherapy points in reducing postoperative pain in lower third molar surgery.

Methods/design

Ninety bilateral, symmetrical lower third molar surgeries will be performed in 45 healthy patients. Each patient will be their own control, through a split-mouth crossover study. One side of the mouth will be randomly chosen and, immediately after surgery, will be treated with low-level laser. After 21 days, the contralateral side will be operated on with low-level laser simulation used postoperatively. This regimen (laser application or not) will be repeated at 24 and 48 h after surgery. All patients will be requested to take analgesics (acetaminophen) if they have pain, i.e. in case of pain. Neither the surgeon nor the patients will know the assigned treatment. The primary variable will be postoperative pain assessed using a Visual Analog Scale, and the secondary variables will be trismus, edema, local temperature, dysphagia, presence of infection and painkiller ingestion. These variables will be assessed at baseline, 24 h, 48 h and 7 days after surgery. Blood samples for systemic inflammatory cytokine (TNF-α, IL-1, IL-6 and IL-8) analysis will be assessed at baseline and 24 h after surgery.

Discussion

Some authors believe that using a wavelength of 633 to 670 nm is a good option for laser therapy in the field of acupuncture. This wavelength can penetrate biological tissue to a depth of about 3 mm. However, for auriculotherapy points, the stimulus (mustard seeds, needles 1 to 2.5 mm) does not penetrate so deeply. For this reason, we chose a laser wavelength of 660 nm (red wavelength).

Trial registration

ClinicalTrials.gov Identifier: NCT02657174, registered on 11 January 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1540-9) contains supplementary material, which is available to authorized users.

Comparative Assessment of the Effect of Ibuprofen and Etodolac on Edema, Trismus, and Pain in Lower Third Molar Surgery: A Randomized Clinical Trial

PURPOSE

To compare the efficacy of ibuprofen (IBU) and etodolac (ETO) for controlling pain, edema, and trismus after extraction of lower third molars.

MATERIALS AND METHODS

Twenty adolescents and adults with 2 impacted mandibular-third molars (in similar positions) were selected for the study. Patients were randomly assigned either to the IBU group (600 mg of IBU 3 times a day for 3 days) or to the ETO group (300 mg of ETO 3 times a day for 3 days). Drugs were administered immediately after dental extraction.

RESULTS

During the first 2 days after extraction, swelling was more pronounced in the IBU group than in the ETO group (P = .033). Seven days after surgery, there was no difference in the degree of edema between the groups. At the 2- and 7-day evaluation points, mouth opening was significantly more reduced in the IBU group than in the ETO group (P < .05). After the first 6 hours, the ETO group had more effective pain relief (P < .05), but after this time point, both groups reported similar degrees of relief. Compared with the IBU group, the ETO group had a lower need for administration of additional rescue analgesics.

CONCLUSIONS

After extraction of impacted lower third molars, we found that swelling, trismus, and pain were more effectively controlled with ETO than with IBU.

Postoperative pain after bupivacaine supplementation in mandibular third molar surgery: splint-mouth randomized double blind controlled clinical trial

INTRODUCTION

Efficacy of anesthetic supplementation with bupivacaine to control both pain and the number of analgesics ingested after surgery has been proposed; however, no report was found in the literature regarding supplemental use of bupivacaine. Thus, the aim of this study was to evaluate the clinical efficacy of bupivacaine in appeasing postoperative pain, when used as supplemental anesthesia at the end of surgeries to extract mandibular third molars.

METHODS

Eighty surgeries were performed in 40 healthy ASA I patients of mandibular bilateral, semi-enclosed, and symmetrical third molars, in a randomized, double-blind, placebo-controlled, and split-mouth clinical trial. Two procedures were performed. In one case, a preoperative anesthetic block was performed with bupivacaine (0.5 %) and epinephrine (1:200,000). Supplementation with the same anesthetic composition was used at the end of the surgery (test group). In the second case (control group), the procedure was identical to that used in the test group, but was supplemented in a randomized double-blind trial with saline (placebo), using the split-mouth method. Postoperative pain (measured with a visual analog scale) was the primary variable studied, and analgesic consumption was the secondary variable. Nonparametric analysis of variance (Wilcoxon test) and a two-tailed test to determine the ratio was used. P value was set at 0.05.

RESULTS

No statistically significant difference (P > 0.05) was found in the variables studied. An adverse effect related to the anesthetic under study was not observed.

CONCLUSION

There is no appreciable value to the second injection regarding pain and analgesia use, but there was a difference regarding patient acceptance in surgeries of mandibular semi-enclosed and impacted third molars.