Treatment of acute pain following removal of mandibular third molars. Use of the dental pain model in pharmacological research and development of a comparable animal model

Is Injectable Platelet-Rich Fibrin Really Effective in Reducing Expected Side Effects of Removing Impacted Third Molar Surgery?

BACKGROUND

Common side effects of third molar (M3) operations including pain, edema, and trismus have an adverse effect on patient quality of life. Injectable platelet-rich fibrin (i-PRF) may ameliorate some of the side effects of the operation.

PURPOSE

The primary purpose of this study is to measure and compare differences in pain, swelling, trismus, and quality of life between i-PRF side and a control side of subjects undergoing M3 removal.

STUDY DESIGN, SETTING AND SAMPLE

This study is a single-center, split-mouth, randomized prospective clinical trial conducted at Ordu University Faculty of Dentistry. Patients who presented between March and August 2022 for the extraction of impacted third molars due to various reasons were included in the study. The exclusion criteria were local conditions and systematic comorbidities. Additionally, patients with differences that could cause bias between the sides were excluded from the study.

PREDICTOR VARIABLE

The predictor variable is treatment i-PRF or control.

MAIN OUTCOME VARIABLE

The outcome variables of interest are the pain level and analgesic consumption values on the Visual Analog Scale, the distance between determined reference points, maximum mouth opening, and the Postoperative Symptom Severity scale data. A Postoperative Symptom Severity scale was created using questions commonly employed in the clinical evaluation of patients following the extraction of third molars. This scale was further divided into subscales corresponding to the 7 primary adverse effects identified in a prior study.

COVARIATES

Covariate variables, sex, age, and operation times.

ANALYSES

The normality of the distribution of the study data was assessed using the Kolmogorov-Smirnov test. Depending on whether the data exhibited a normal distribution or not, the data were analyzed using either the paired t-test or the Wilcoxon test. A P value < .05 was considered statistically significant.

RESULTS

The study included 35 patients with a mean age of 19.97 ± 2.07 years. The i-PRF side significant success in postoperative edema measurements. There was a statistically significant difference observed between the control side and the i-PRF side on the second day (control: 9.74 ± 0.57 mm, i-PRF: 9.46 ± 0.51 mm) and seventh day (control: 9.33 ± 0.59 mm, i-PRF: 9.12 ± 0.50 mm) in lateral canthus-angulus measurements (P: .01 and P: .04, respectively). Additionally, on the second day, there was a statistically significant difference in tragus-commisura measurements (control: 11.53 ± 0.62 mm, i-PRF: 11.31 ± 0.58 mm) with a P value of .02. There was no significant difference observed between the sides in terms of postoperative pain (P > .05). However, analgesic consumption in the i-PRF side was significantly lower at the sixth hour (control: 1.8 ± 0.58 dose, i-PRF: 1.14 ± 0.35 dose), 24th hour (control: 1.77 ± 0.54 dose, i-PRF: 1.14 ± 0.35 dose), and second day (control: 1.8 ± 0.47 dose, i-PRF: 1.4 ± 0.73 dose) postoperatively (P: .000, P: .000, and P: .012). Mouth opening was significantly lower in the i-PRF side on the second day (control: 27.88 ± 6.48 mm, i-PRF: 25.51 ± 5.56 mm) (P: .025). However, i-PRF had no significant effect on postoperative quality of life (P > .05).

CONCLUSIONS

According to the study results, i-PRF had a limited effect on the management of postoperative pain, but i-PRF was effective in reducing postoperative edema. Further studies with larger patient sides are now needed to yield more detailed findings on the subject.

Comparison of the C-Reactive Protein Level and Visual Analog Scale Scores between Piezosurgery and Rotatory Osteotomy in Mandibular Impacted Third Molar Extraction

This study aimed to compare the C-reactive protein level and visual analog scale scores of piezo- and rotatory-based surgical extraction of the third molar. As a split-mouth study, the comparative groups consisted of 25 patients, each of whom underwent surgical removal of the third molar by piezo on one side and rotatory bur on the other side. C-reactive protein levels were quantitatively assessed (enzyme-linked immunosorbent assay) before and immediately post-extraction. The immediate postoperative blood sample (baseline) C-reactive protein levels were compared with 24 h and 72 h post-op samples, both within and between the groups. Pain was assessed using the visual analog scale at 24 h and 72 h post-operatively. The C-reactive protein levels were lower in the piezo group than in the rotatory group, although the difference was not significant (p > 0.05). The visual analog scale score was significantly (p < 0.01) lower in the piezo group than in the rotatory group. The C-reactive protein levels increased in both the rotary and piezo groups from the pre-op to the immediate post-op value, but in the piezo group, the levels dropped back after 24 h. On the contrary, in the rotatory group, the C-reactive level kept increasing until 24 h; the visual analog scale score dropped significantly from 24 to 72 h for both the rotatory and piezo groups. Surgical techniques that could spare the surrounding soft tissues, such as the piezo, could aid in reducing overall postoperative morbidity.

Effects of transcutaneous electrical nerve stimulation on pain after impacted third molar surgery

Background

The aim of this study was to assess the therapeutic effects of Transcutaneous Electrical Nerve Stimulation (TENS) on pain after the impacted third molar surgery.

Material and Methods

The study was carried out on 30 patients attending the outpatient department of the oral and maxillofacial surgery. Both sides’ impacted mandibular third molars were taken into consideration, and a total of 60 impacted third molars were undergone surgical extraction. After the first surgery, patients were given analgesic, antibiotics, and mouthwash as a routine treatment procedure. Following the second surgery, TENS was applied over the painful area of the cheek for patients in addition to routine treatment procedure. Pain was evaluated with Visual Analog Scale (VAS) at the postoperative 6, 8, 24 hours and 2,3,4 and 5 days. The Student t test was applied to compare pain levels between groups. P<0.05 and p<0.001 were considered significant in all statistical analyses.

Results

The study was carried out in 30 patients 15 (50%) female and 15 (50%) male, aged between 20 and 31 years. The mean age of the patients was 24.60 ± 4.76. There was a statistically significant difference in the evaluation of VAS levels in postoperative 6, 8, 24 hours and 2, 3, 4, and 5 days between the routine treatment group and the TENS application group.

Conclusions

TENS activates a complex neuronal network to result in a reduction in pain. In conclusion, TENS application was highly effective in pain modulation following the third molar surgery. Therefore, TENS, which is one of the non-pharmacological pain control methods after such surgeries, can be used safely in reducing postoperative pain.

Key words:Impacted teeth, third molar, pain, transcutaneous electrical nerve stimulation.

Pre-emptive analgesic effect of lornoxicam in mandibular third molar surgery: a prospective, randomized, double-blind clinical trial

The aim of this study was to establish whether the pre-emptive use of lornoxicam (16mg) in third molar surgery ensures successful postoperative analgesia and reduces rescue analgesic intake when compared to postoperative application, and in comparison with placebo. Ninety patients were split randomly into three groups: group A received lornoxicam 60min before surgery and placebo 60min after surgery; group B received placebo 60min before surgery and lornoxicam 60min after surgery; group C received placebo 60min before surgery and placebo 60min after surgery. Postoperative pain was recorded on a visual analogue scale and on a numerical rating scale at 1, 2, 4, 6, 8, 12, and 24h after surgery. The patients recorded total dose of paracetamol intake during the 24h after the procedure. The efficacy of postoperative analgesia was greater in lornoxicam groups when compared to the placebo group; there was no difference between the two lornoxicam groups (A and B). Patients in group C took their first rescue analgesic dose earlier after surgery than patients in the two lornoxicam groups. The average dose of paracetamol taken in group C was 1000mg, while it was500 mg in the lornoxicam groups.

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.

The Assessment of Oral Microflora Exposed to 3% Ethanolic Extract of Brazilian Green Propolis Preparation Used for Hygiene Maintenance following Minor Oral Surgeries

The aim of this study was to investigate the influence of a topically administered hygienic preparation containing a 3% ethanolic extract of Brazilian green propolis (EEP-B) on oral microflora spectrum changes in a group of patients who underwent common oral surgery procedures. Two gel samples were compared: the tested gel containing an active ingredient, that is, a 3% EEP-B (gel GA), and a placebo as the negative control (gel GC). The collection of microbiological material included 14 patients requiring surgical extraction of wisdom molars and short endosseous implant installation. Clinical examinations were carried out as follow-up, that is, baseline and after 5-6 weeks' time. During the first and subsequent assessment, swabs were taken from the mucosal surface. The number of microorganism species was found to have increased following the application of GC gel over the period of 5-6 weeks. This mainly affected Gram-positive rods and bacilli as well as Gram-negative rods. Application of the GA gel enriched with 3% EEP-B caused a profound reduction in the amount of Neisseria spp. and Bifidobacterium spp. strains. Elimination of seven species of microorganisms was observed: Streptococcus acidominimus, Streptococcus oralis, Staphylococcus epidermidis, Veillonella parvula, Bifidobacterium breve, Bifidobacterium longum, and Lactobacillus acidophilus.

Combination paracetamol and ibuprofen for pain relief after oral surgery: a dose ranging study

PURPOSE

Combined paracetamol and ibuprofen has been shown to be more effective than either constituent alone for acute pain in adults, but the dose-response has not been confirmed. The aim of this study was to define the analgesic dose-response relationship of different potential doses of a fixed dose combination containing paracetamol and ibuprofen after third molar surgery.

METHODS

Patients aged 16 to 60 years with moderate or severe pain after the removal of at least two impacted third molars were randomised to receive double-blind study medication as two tablets every 6 h for 24 h of either of the following: two tablet, combination full dose (paracetamol 1000 mg and ibuprofen 300 mg); one tablet, combination half dose (paracetamol 500 mg and ibuprofen 150 mg); half a tablet, combination quarter dose (paracetamol 250 mg and ibuprofen 75 mg); or placebo. The primary outcome measure was the time-adjusted summed pain intensity difference over 24 h (SPID 24) calculated from the 100-mm VAS assessments collected over multiple time points for the study duration.

RESULTS

Data from 159 patients were included in the analysis. Mean (SD) time-adjusted SPID over 24 h were full-dose combination 20.1 (18.0), half dose combination 20.4 (20.8), quarter dose combination 19.3 (20.0) and placebo 6.6 (19.8). There was a significant overall effect of dose (p = 0.002) on the primary outcome. Planned pairwise comparisons showed that all combination dose groups were superior to placebo (full dose vs. placebo p = 0.004, half dose vs. placebo p = 0.002, quarter dose vs. placebo p = 0.002). The overall effect of dose was also significant for maximum VAS pain intensity score (p = 0.048), response rate (p = 0.0094), percentage of participants requiring rescue (p = 0.025) and amount of rescue (p < 0.001). No significant dose effect was found for time to peak reduction in VAS or time to meaningful pain relief. The majority of adverse events recorded were of mild (52.75%) or moderate (40.16%) severity and not related (30.7%) or unlikely related (57.5%) to the study medication.

CONCLUSION

All doses of the combination provide safe superior pain relief to placebo in adult patients following third molar removal surgery.

Medical tongue piercing - development and evaluation of a surgical protocol and the perception of procedural discomfort of the participants

BACKGROUND

A system providing disabled persons with control of various assistive devices with the tongue has been developed at Aalborg University in Denmark. The system requires an activation unit attached to the tongue with a small piercing. The aim of this study was to establish and evaluate a safe and tolerable procedure for medical tongue piercing and to evaluate the expected and perceived procedural discomfort.

METHODS

Four tetraplegic subjects volunteered for the study. A surgical protocol for a safe insertion of a tongue barbell piercing was presented using sterilized instruments and piercing parts. Moreover, post-procedural observations of participant complications such as bleeding, edema, and infection were recorded. Finally, procedural discomforts were monitored by VAS scores of pain, changes in taste and speech as well as problems related to hitting the teeth.

RESULTS

The piercings were all successfully inserted in less than 5 min and the pain level was moderate compared with oral injections. No bleeding, infection, embedding of the piercing, or tooth/gingival injuries were encountered; a moderate edema was found in one case without affecting the speech. In two cases the piercing rod later had to be replaced by a shorter rod, because participants complained that the rod hit their teeth. The replacements prevented further problems. Moreover, loosening of balls was encountered, which could be prevented with the addition of dental glue. No cases of swallowing or aspiration of the piercing parts were recorded.

CONCLUSIONS

The procedure proved simple, fast, and safe for insertion of tongue piercings for tetraplegic subjects in a clinical setting. The procedure represented several precautions in order to avoid risks in these susceptible participants with possible co-morbidity. No serious complications were encountered, and the procedure was found tolerable to the participants. The procedure may be used in future studies with tongue piercings being a prerequisite for similar systems, and this may include insertion in an out-patient setting.

Central sensitization phenomena after third molar surgery: A quantitative sensory testing study

BACKGROUND

Surgical removal of third molars may carry a risk of developing persistent orofacial pain, and central sensitization appears to play an important role in the transition from acute to chronic pain.

AIM

The aim of this study was to investigate sensitization (primarily central sensitization) after orofacial trauma using quantitative sensory testing (QST).

METHODS

A total of 32 healthy men (16 patients and 16 age-matched control subjects) underwent a battery of quantitative tests adapted to the trigeminal area at baseline and 2, 7, and 30 days following surgical removal of a lower impacted third molar.

RESULTS

Central sensitization for at least one week was indicated by significantly increased pain intensity evoked by intraoral repetitive pinprick and electrical stimulation (p<0.05) including facilitation of temporal summation mechanisms (p<0.05), extraoral repetitive electrical stimulation (p<0.001), significantly more frequent aftersensation in patients (p<0.001), extraoral hyperalgesia due to single pinprick stimulation (p<0.05) and larger pain areas due to intranasal stimulation (p<0.001). Peripheral sensitization was indicated by intraoral hyperalgesia due to single pinprick (p<0.05).

CONCLUSION

We found clear signs of sensitization of the trigeminal nociceptive system for at least one week after the surgery. Our results indicate that even a minor orofacial surgical procedure may be sufficient to evoke signs of both central and peripheral sensitization, which may play a role in the transition from acute to chronic pain in susceptible individuals.

Sublingual ketorolac and sublingual piroxicam are equally effective for postoperative pain, trismus, and swelling management in lower third molar removal

OBJECTIVE

Lower third molar removal provides a clinical model for studying analgesic drugs. The present study's aim was to compare the clinical efficacy of sublingual ketorolac and sublingual piroxicam in managing pain, trismus and swelling after lower third molar extraction in adult volunteers.

STUDY DESIGN

In this double-blinded, randomized, crossover investigation, 47 volunteers received for 4 days ketorolac sublingually (10 mg 4 times daily) and piroxicam sublingually (20 mg once daily) during 2 separate appointments after lower third molar extraction of symmetrically positioned lower third molars. A surgeon evaluated objective parameters (surgery duration, mouth opening, rescue analgesic medication, and facial swelling) and volunteers documented subjective parameters (postoperative pain and global evaluation), comparing postoperative results for a total of 7 days after surgery. The means of the objective and subjective parameters were compared for statistical significance (P < .05).

RESULTS

Volunteers reported low pain scores during the postoperative period when treated with either sublingual ketorolac or piroxicam. Also, volunteers ingested similar amounts of analgesic rescue medication (paracetamol) when they received either drug sublingually (P > .05). Additionally, values for mouth openings measured just before surgery and immediately after suture removal 7 days later were similar among volunteers (P > .05), and the type of nonsteroidal antiinflammatory drug (NSAID) used in this study showed no significant differences between swellings on the second or seventh days after surgery (P > .05).

CONCLUSIONS

Pain, trismus, and swelling after lower third molar extraction, independent of surgical difficulty, were successfully controlled by sublingual ketorolac (10 mg 4 times daily) or sublingual piroxicam (20 mg once daily), and no significant differences were observed between the NSAIDs evaluated.

Evaluation of the dose range of etoricoxib in an acute pain setting using the postoperative dental pain model

OBJECTIVE

This study was conducted to evaluate the dose range of etoricoxib in acute pain using the postoperative dental pain model further.

METHODS

This double-blind, randomized controlled study evaluated etoricoxib (90 and 120 mg), ibuprofen (600 mg), and acetaminophen (600 mg/codeine) (60 mg, (A/C)) in patients aged ≥ 18 years with moderate or severe pain after surgical extraction of ≥ 2 third molars (≥ 1 impacted). The patients reported pain intensity and pain relief over 24 hours. The primary efficacy endpoint was total pain relief over 6 hours (TOPAR6). Adverse events were evaluated throughout the study.

RESULTS

There were 588 patients randomized to placebo (n=46),etoricoxib (90 mg (n=191)), etoricoxib (120 mg (n=97)), ibuprofen(2400 mg (n=192)), and A/C (n=62). The overall analgesic effect (TOPAR6) of etoricoxib (90, 120 mg) was significantly greater than that of placebo (P ≤ 0.001), and not inferior to that of ibuprofen; no discernible difference was observed between etoricoxib 90 and 120 mg. Both etoricoxib doses were superior to A/C (P ≤ 0.001). Etoricoxib (90 and 120 mg) and ibuprofen(2400 mg) were generally well tolerated and had a similar incidence of adverse events (AEs). A/C was associated with significantly more AEs that led to discontinuation (ie, nausea and vomiting).

CONCLUSIONS

Etoricoxib (90 and 120 mg) showed similar efficacy in the postoperative dental pain model, which was noninferior to ibuprofen and superior to A/C. A higher number of tooth extractions or a higher mean impaction score may have led to a greater separation in efficacy between the 2 etoricoxib doses.

Efficacy of ibuprofen versus lornoxicam after third molar surgery: a randomized, double-blind, crossover pilot study

PURPOSE

The aim of this study is to compare the analgesic efficacy and tolerability of a pre-emptive/post-surgery 4-day regimen of oral ibuprofen 400 mg with that of lornoxicam 8 mg.

METHODS

Sixteen patients received ibuprofen or lornoxicam, respectively, before and after surgery of impacted third molars in two separate appointments, in a double-blind, randomized, and crossover design. The postoperative analgesic and rescue medication consumption was recorded and pain scores were evaluated with a visual analogue scale at 2, 6, 24, 48, and 72 h, postoperatively.

RESULTS

No statistically significant differences were found between ibuprofen 400 mg and lornoxicam 8 mg with respect to study medication (p = 0.34) or rescue analgesic consumption (p = 0.5) (SUMstudy and SUMrescue). Ibuprofen: SUMstudy median 7.5 interquartile range IQR (4.25-8), 95% CI (4.6-7.7); SUMrescue median and IQR 0, 95% CI (-0.6-4.6). Lornoxicam: SUMstudy median 7 IQR (3.75-9), 95% CI (7.7-4.9); SUMrescue median and IQR 0, 95% CI (-0.7-2.7). The area under the pain intensity curve (AUC(2-72) PI) over the 4 days of investigation did not reveal significant differences between the two medications (p = 0.32). AUC(2-72) PI ibuprofen: median 1,509.7 IQR (712.36-2,444.65); 95% CI (1,078.7-2,156.5). AUC(2-72) PI lornoxicam: median 1,166.9 IQR (783.4-2,221.2), 95% CI (1,032-2,130.6). Moreover, patient satisfaction and incidence of adverse events did not reveal any significant differences between treatment groups.

CONCLUSION

Ibuprofen 400 mg and lornoxicam 8 mg were rated as equal and effective pain treatment medication after wisdom tooth surgery. In comparison, neither of the drugs provided clinical advantages nor did side effects occur more frequently after one of the analgesics.

Superficial selective cervical plexus block following total thyroidectomy: a randomized trial

BACKGROUND

Pain after thyroid surgery is of moderate intensity and short duration. Bilaterally superficial cervical plexus block (BSCPB) may reduce analgesic requirements. However, its effectiveness in decreasing pain after thyroidectomy is debated.

METHODS

This double-blind, randomized placebo-controlled study in 100 patients undergoing total thyroidectomy evaluates the effects of BSCPB done with 20 mL of 0.75% ropivacaine. Additional parecoxib was administrated immediately postoperatively and 12 hours later.

RESULTS

Postoperative pain was assessed by visual analogue rating scale. All parameters were recorded at 0, 3, 6, 9, 12, and 24 hours after surgery. The control group had higher values than the ropivacaine group at all moments (p < .05) except H12 (p = .76). Additional analgesia was needed for 7 patients (14%) in the control group and for 8 patients (16%) in the group with ropivacaine (p = .96).

CONCLUSION

Two-point bilateral BSCPB has a major analgesic effect on patients after total thyroidectomy, with a statistically significant reduction in postoperative pain scores. However, no significant difference was noted in the proportion of patients that required additional analgesics.

Comparison of oral versus sublingual piroxicam during postoperative pain management after lower third molar extraction

In this study, 53 patients received piroxicam, administered orally or sublingually, after undergoing removal of symmetrically positioned lower third molars, during two separate appointments. This study used a randomized, blind, cross-over protocol. Objective and subjective parameters were recorded for comparison of postoperative results for 7 days after surgery. Patients treated with oral or sublingual piroxicam reported low postoperative pain scores. The patients who received piroxicam orally took a similar average amount of analgesic rescue medication compared with patients who received piroxicam sublingually (p>0.05). Patients exhibited similar values for mouth opening measured just before surgery and immediately following suture removal 7 days later (p>0.05), and showed no significant differences between routes of piroxicam administration for swelling control during the second or seventh postoperative days (p>0.05). In summary, pain, trismus and swelling after lower third molar extraction, independent of surgical difficulty, could be controlled by piroxicam 20mg administered orally or sublingually and no significant differences were observed between the route of delivery used in this study.

Analgesic efficacy of quick-release versus standard lornoxicam for pain after third molar surgery: a randomized, double-blind, placebo-controlled, single-dose trial

OBJECTIVE

The aim of this study was to evaluate the analgesic efficacy and time to onset of effect of the lornoxicam quick-release (LNX-QR) tablet compared with the standard-release tablet (LNX-ST).

METHODS

In this randomized, double-blind, single-dose trial, 200 patients with moderate pain after surgical removal of an impacted third molar were randomized to treatment with an LNX-QR 8 mg tablet (80 patients), an LNX-ST 8 mg tablet (80 patients) or placebo (40 patients). Pain intensity (PI) and pain relief (PAR) were assessed (numerical and verbal rating scales) for 6 hours, and time to onset of PAR was recorded. The cumulated sum of PI differences (SPID) and PAR (TOTPAR) were calculated. Tolerability was evaluated by occurrence of adverse events.

RESULTS

Kaplan-Meier analysis of time to onset of analgesic efficacy demonstrated a significantly faster onset with LNX-QR than placebo or LNX-ST (p < 0.0001). Median time of onset was 32 minutes (range 29-37) for LNX-QR and 46 minutes (range 37-59) for LNX-ST. The analgesic efficacy of LNX-QR and LNX-ST were superior to that of placebo, whereas paired comparisons of TOTPAR and SPID showed LNX-QR to be superior to LNX-ST (p < 0.05).

CONCLUSION

LNX-QR provided a faster onset and superior analgesic effect against pain following third molar surgery than LNX-ST.

A double-blind comparison of a supplemental interligamentary injection of fentanyl and mepivacaine with 1:200,000 epinephrine for irreversible pulpitis

The analgesic efficacy of supplemental interligamentary fentanyl injection for management of endodontic debridement patients was investigated through a randomized, double-blind study. Forty patients who presented with acute symptomatic irreversible pulpitis of the upper first molar tooth participated in the study. Patients were scheduled for endodontic debridement, for which infiltration anesthesia with 1.8 ml of 2% mepivacaine with epinephrine 1:200,000 was the standard primary anesthetic technique. Patients were randomly divided into two equal groups. The first group received supplemental interligamentary injection with 0.4 ml fentanyl 0.05 mg/ml, while the second group received supplemental interligamentary injection with 0.4 ml mepivacaine with epinephrine 1:200,000. The intraligamental-injected drug was given as 0.2 ml on the mesial and 0.2 ml on the distal aspect of the tooth. Results indicated that fentanyl provided relatively greater analgesia, yielding satisfactory relief during different stages of the procedure, including access cavity preparation, pulpotomy, and pulp extirpation. Fentanyl is effective when used in conjunction with local anesthetics to provide adequate analgesia during endodontic debridement, and this finding provides strong evidence that peripheral actions are involved in the analgesia produced by opioid drugs in inflammatory pain.

Combining paracetamol with a selective cyclooxygenase-2 inhibitor for acute pain relief after third molar surgery: a randomized, double-blind, placebo-controlled study

Severe pain after third molar surgery is often encountered and more effective treatment regimes are warranted. The objective of this study was to evaluate if the combination of paracetamol and rofecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor, improves analgesic effects following third molar surgery compared with rofecoxib alone. Paracetamol alone was also evaluated. Altogether 120 patients with moderate to severe pain after third molar surgery were given a single postoperative dose of one of the following treatments: rofecoxib + paracetamol; rofecoxib alone; paracetamol alone; or placebo. Patients assessed level of pain and pain relief every 30 min for 8 h after surgery, and made a global evaluation of the medication 4 and 8 h after surgery. Paracetamol and rofecoxib combined improved the analgesic effect compared with rofecoxib alone for the first 1.5 h. Rofecoxib alone and the combination of paracetamol and rofecoxib had a significantly better analgesic effect than paracetamol alone from 3 h onwards. The early onset of pain relief for the combination of paracetamol and rofecoxib, compared with rofecoxib alone, could be of great importance when treating acute pain after third molar surgery. After data collection for this study, rofecoxib was withdrawn from the market as a result of reported fatal cardiovascular events. Whether this is relevant for short-term use is unknown, but it has to be considered before rofecoxib may be used for pain relief following third molar surgery.

The use of COX-2 inhibitors for acute dental pain: A second look

BACKGROUND

On the basis of their perceived better safety profile compared with other analgesic agents, cyclo-oxygenase-2 (COX-2) inhibitors have been prescribed frequently as first-line agents to treat acute dental pain. However, recently identified cardiovascular adverse reactions associated with these drugs mandate a reappraisal of their use in dental practice. TYPES OF STUDIES REVIEWED. The authors reviewed 18 clinical studies that evaluated the efficacy of a COX-2 inhibitor for the treatment of acute dental pain. All of the studies used the widely established third-molar surgical extraction model to induce postsurgical inflammatory based pain, and all were randomized, double-blinded and placebo-controlled. However, numerous vagaries in overall study design made direct comparisons difficult.

RESULTS

None of the studies established any of the COX-2 inhibitors as clearly better than ibuprofen, the current gold standard for the treatment of surgically induced dental pain. However, in single-dosing scenarios, the COX-2 inhibitor often demonstrated a longer duration of action compared with ibuprofen.

CLINCAL IMPLICATIONS

The evidence to date fails to demonstrate any therapeutic advantage to using a COX-2 inhibitor to treat acute dental pain compared with ibuprofen. In the rare event that a COX-2 inhibitor may be appropriate, the clinician must inform the patient of the potential risks, and the drug should be used for the shortest possible time.

The efficacy of preoperative versus postoperative rofecoxib for preventing acute postoperative dental pain: a prospective randomized crossover study using bilateral symmetrical oral surgery

BACKGROUND

Previous data have demonstrated that rofecoxib has good analgesic efficacy for acute postoperative dental pain. However, up to half of these patients require rescue analgesics within the first 24 hours. As the timing of analgesic interventions may be an important factor in pain control, the present study tested the hypothesis that rofecoxib administered preoperatively would improve the analgesic efficacy and reduce rescue analgesic requirements within the first 24 hours compared with postoperative administration.

METHODS

This was a double-blind, randomized, crossover study where 45 patients had each of their identical impacted mandibular third molars removed under local anesthesia on 2 separate occasions. Patients acted as their own control; one side was pretreated with rofecoxib 50 mg, 2 hours before surgery, followed by placebo 15 minutes after surgery, and the contralateral side was pretreated with placebo 2 hours before surgery and posttreated with rofecoxib 50 mg 15 minutes after surgery. The difference in postoperative pain between 2 sides was assessed by 4 primary end-points: pain intensity as measured by a 100-mm visual analogue scale hourly for 12 hours, time to rescue analgesic, postoperative analgesic consumption, and patient's global assessment.

RESULTS

Patients reported significantly lower pain scores (P = 0.04), longer time to rescue analgesic (P = 0.02), lesser postoperative analgesic consumption (P = 0.008), and better global assessment (P = 0.01) in the pretreated compared with the posttreated sides. There were significantly more patients in the pretreated group who did not required rescue analgesic within the first 24 hours (80% vs. 58%, P = 0.01), and the pain scores were extremely low in both groups during the 12 hours postoperative period (9.8 +/- 5.0 mm vs. 14.3 +/- 7.4 mm).

CONCLUSION

Rofecoxib is an excellent analgesic for preventing postoperative dental pain and when given 2 hours preoperatively rendered most patients relatively pain free, requiring no rescue analgesics on the first postoperative day.

Attenuation of C-reactive protein increases after exodontia by tramadol and ibuprofen

The anti-inflammatory effects of ibuprofen and tramadol were investigated by measuring C-reactive protein concentrations after removal of an impacted lower third molar. Forty-five American Society of Anesthesiologists Class I patients were randomly categorized into 3 equal groups according to postoperative analgesic medication. The first group received tramadol (100 mg every 8 hours), the second group received ibuprofen (400 mg every 8 hours), and the last group received half doses of both drugs in combination (50 mg tramadol every 8 hours and 200 mg ibuprofen every 8 hours). C-reactive protein was measured before surgery to exclude the presence of any preexisting inflammatory condition that might interfere with the study. C-reactive protein was also determined immediately after surgery and 72 hours postoperatively. At 72 hours, C-reactive protein had increased over postsurgery baseline by 123% in the tramadol group (P < .001), 84% in the ibuprofen group (P < .001), and only 37% in the combined analgesic group (P = .078). These results suggest that tramadol may produce supra-additive anti-inflammatory effects with ibuprofen after third-molar extractions.

Comparison of rofecoxib and oxycodone plus acetaminophen in the treatment of acute pain: a randomized, double-blind, placebo-controlled study in patients with moderate to severe postoperative pain in the third molar extraction model

BACKGROUND

Opiates, acetaminophen, nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2-selective inhibitors such as rofecoxib are used in the treatment of acute pain because of their anti-inflammatory and/or analgesic properties. Rofecoxib has demonstrated an improved gastrointestinal safety profile compared with nonselective NSAIDs.

OBJECTIVE

The aim of this study was to compare the analgesic efficacy and tolerability profile of rofecoxib 50 mg with those of the centrally acting, nonsalicylate, opiate/nonopiate analgesic combination oxycodone/acetominophen 5/325 in patients with pain after dental surgery.

METHODS

In this randomized, double-blind, placebo- and active comparator-controlled study, patients experiencing moderate to severe postoperative pain after extraction of > or =2 third molars (including > or =1 mandibular impaction) received a single oral dose of rofecoxib 50 mg, oxycodone/acetaminophen 5/325 mg, or placebo. End points included total pain relief over 6 hours (TOPAR6, the primary end point) and 4 hours (TOPAR4), patient's global assessment of treatment at 6 hours (GLOBAL6) and 24 hours (GLOBAL24), summed pain intensity difference over 6 hours (SPID6), onset of analgesic effect (time to perceptible/meaningful pain relief, using a 2-stopwatch method), peak pain relief (PEAKPR), peak pain intensity difference (PEAKPID), and duration of analgesic effect (time to use of rescue analgesia).

RESULTS

Two hundred twelve patients (63% female, 37% male; 76% white, 24% other; mean [SD] age, 20.9 [4.4] years; age range, 16-41 years) were enrolled in the study and received a single oral dose of rofecoxib 50 mg (n = 90), oxycodone/acetaminophen 5/325 mg (n = 91), or placebo (n = 31). The analgesic effect of rofecoxib was significantly greater than that of oxycodone/acetaminophen at P < 0.001 for TOPAR6, TOPAR4, GLOBAL6, GLOBAL24, and SPID6; at P < 0.010 for PEAKPR and PEAKPID; and at P < 0.001 for median time to use of rescue analgesia. Significantly fewer patients in the rofecoxib group (72.2%) took rescue analgesia within 24 hours postdose compared with the oxycodone/acetaminophen group (94.5%; P < 0.001) and the placebo group (96.8%; P < 0.02). Both active treatments were similar with respect to onset of analgesic effect. Both were generally well tolerated; the overall incidence of adverse experiences in the rofecoxib, oxycodone/acetaminophen, and placebo groups was 51.1%, 64.8%, and 48.4%, respectively. Rofecoxib was associated with a significantly lower incidence of nausea (18.9% vs 39.6%; P < 0.001) and vomiting (6.7% vs 23.1%; P < 0.001) compared with oxycodone/acetaminophen.

CONCLUSIONS

In study patients with moderate to severe pain after dental surgery, rofecoxib 50 mg had a greater analgesic effect than oxycodone/acetaminophen 5/325 mg and was associated with less nausea and vomiting.

Etoricoxib in acute pain associated with dental surgery: a randomized, double-blind, placebo- and active comparator-controlled dose-ranging study

BACKGROUND

Patients experiencing acute pain after surgery, including dental surgery, often require analgesia. Ideally, the chosen analgesic should have a rapid onset and sustained effect. Etoricoxib is a new cyclooxygenase-2-selective inhibitor that has demonstrated analgesic efficacy in the treatment of acute pain with a rapid onset and long-lasting pain relief.

OBJECTIVE

The goal of this study was to determine the analgesic effect of single oral doses of etoricoxib 60, 120, 180, and 240 mg compared with placebo in the treatment of pain after dental surgery. Ibuprofen was used as an active control.

METHODS

This was a randomized, double-blind, parallel-group, single-dose, placebo- and active comparator-controlled study performed at a single center. It consisted of 3 visits (prestudy, treatment, and poststudy). Eligible patients were aged > or =16 years with moderate or severe pain after surgical extraction of > or =2 third molars, of which > or =1 was an impacted mandibular molar. Patients were assessed over 24 hours and reported pain intensity and pain relied at 14 predefined time points. Plasma samples for a pharmacokinetic/pharmacodynamic analysis were collected from a subset of patients at baseline and the 14 predefined time points. The end points included total pain relief over 8 hours (TOPAR8, the primary end point), sum of pain intensity difference over 8 hours, patient's global evaluation of treatment, median time to onset of pain relief (2-stopwatch method), peak pain relief, and duration of analgesic effect (median time to use of rescue medication). Adverse events were collected up to 14 days postdose.

RESULTS

Three hundred ninety-eight (63.1% women, 36.9% men; mean age, 21.1 years; 72.1% white, 27.9% other; mean number of third molars removed, 3.5; 65.2% experiencing moderate pain) were randomly allocated to receive etoricoxib 60 mg (n = 75), etoricoxib 120 mg (n = 76), etoricoxib 180 mg (n = 74), etoricoxib 240 mg (n = 76), ibuprofen 400 mg (n = 48), and placebo (n = 49). All active treatments had significantly greater overall analgesic effect (TOPAR8) compared with placebo (P < or 0.001). Patients who received etoricoxib 120 and 180 mg had significantly higher TOPAR8 scores than those who received etoricoxib 60 mg ( P < = 0.001) and ibuprofen (P < 0.05 etoricoxib 120 mg; P < or = 0.001 etoricoxib 180 mg). Least-squares mean TOPAR8 scores for etoricoxib 60, 120, 180, and 240 mg, ibuprofen, and placebo were 16.0, 22.0, 23.5, 20.7, 18.6, and 5.2, respectively. The median time to onset of analgesia was 24 minutes for etoricoxib 120, 180, and 240 mg, and 30 minutes for etoricoxib 60 mg and ibuprofen. There were no significant differences in the onset of analgesia between etoricoxib 120, 180, and 240 mg and ibuprofen. The duration of analgesic effect was >24 hours for etoricoxib 120, 180, and 240 mg, and 12.1 hours for etoricoxib 60 mg. The duration of effect was significantly longer with all 4 etoricoxib doses compared with ibuprofen (10.1 hours; P < 0.05 etoricoxib 60 mg; < or = 0.001etoricoxib 120, 180, and 240 mg) and compared with placebo (2.1 hours; P < = 0.001). In the pharmacokinetic/pharmacodynamic analysis (n approximately 120), there was a linear relationship between plasma etoricoxib concentrations and pain relief scores up to the maximum observed concentration, followed by a decline in plasma concentrations with persistent analgesia. The most common adverse events were postextraction alveolitis and nausea.

CONCLUSIONS

In this dose-ranging study, etoricoxib 120 mg was determined to be the minimum dose that had maximal efficacy in patients with moderate to severe acute pain associated with dental surgery. Both etoricoxib and ibuprofen were generally well tolerated.

A double-blind placebo-controlled comparison of tramadol/acetaminophen and tramadol in patients with postoperative dental pain

The objective of this study was to compare the analgesic efficacy of tramadol/acetaminophen (APAP) (total dose 75 mg/650 mg) and tramadol (total dose 100 mg) for the control of pain after oral surgery. A total of 456 patients with moderate-to-severe pain within 5 h after extraction of two or more third molars were randomized to receive two identical encapsulated tablets containing tramadol/APAP 37.5 mg/325 mg, tramadol 50 mg, or placebo. Tramadol/APAP was superior to tramadol (P < 0.001) or placebo (P < 0.001) on all efficacy measures: total pain relief (PAR) over 6 h (7.4, 2.5, and 1.5, respectively, on a scale of 0-24); sum of pain intensity differences (PIDs) (3.1, 0.6, and 0.1, respectively, on a scale of -6 to 18); and sum of PAR and PID (10.5, 3.1, and 1.6, respectively, on a scale of -6 to 42). Median times to onset of perceptible and meaningful PAR were 37.6 and 126.5 min, respectively, for the tramadol/APAP group (P < 0.001) for each, compared with tramadol and placebo arms). The most common adverse events with active treatment were nausea, dizziness, and vomiting; these events occurred more frequently in the tramadol group than in the tramadol/APAP group. This study established the superiority of tramadol/APAP 75 mg/650 mg over tramadol 100 mg in the treatment of acute pain following oral surgery.

Mechanisms of Inflammatory Pain

The study and treatment of clinical pain has historically identified particular pain syndromes and linked their etiology with disease factors. Missing in this approach is consideration of the mechanisms accounting for the pain that is experienced by the patient. The recent increase in our understanding of how peripheral and central mechanisms contribute to the perception of pain, including the identified role of prostaglandins, has led to a shift in treatment strategy to directly target these mechanisms. This article provides a brief overview of pain mechanisms, focusing on inflammatory pain, and discusses the role of cyclooxygenase (COX)-2 inhibitors as analgesic agents.

A Randomized, Double-Blind, Parallel-Group Study Comparing the Analgesic Effect of Etoricoxib to Placebo, Naproxen Sodium, and Acetaminophen With Codeine Using the Dental Impaction Pain Model

OBJECTIVE

To compare the overall analgesic effect, including time to onset, peak and duration of effect for etoricoxib 120 mg, a new COX-2 selective inhibitor, in patients with acute pain to that of placebo. Naproxen sodium 550 mg and acetaminophen/codeine 600/60 mg were the active comparators.

METHODS

A total of 201 patients with moderate to severe pain following surgical extraction of > or = 2 third molars, of which at least the mandibular tooth was impacted, were randomly allocated to receive single oral doses of placebo (n = 50), etoricoxib 120 mg (n = 50), naproxen sodium 550 mg (n = 51), or acetaminophen/codeine 600/60 mg (n = 50). The endpoints included total pain relief over 8 hours (TOPAR8, primary end point), sum of pain intensity difference over 8 hours, patient's global evaluation, onset, peak, and duration of analgesia.

RESULTS

Etoricoxib 120 mg had a significantly greater least squares (LS) mean TOPAR8 score than placebo (20.9 vs 5.4; P < 0.001) and acetaminophen/codeine 600/60 mg (20.9 vs 11.5; P < 0.001), and a similar LS mean TOPAR8 score to naproxen sodium 550 mg (20.9 vs 21.3). All three active treatments had rapid onset of analgesia, median time approximately 30 minutes. The duration of analgesic effect, defined as median time to rescue medication use, was >24 hours for etoricoxib, 20.8 hours for naproxen sodium, 3.6 hours for acetaminophen/codeine, and 1.6 hours for placebo.

DISCUSSION

Etoricoxib is a new COX-2 selective inhibitor under development for treatment of osteoarthritis, rheumatoid arthritis, and acute pain. In this study, etoricoxib 120 mg provided rapid and long-lasting pain relief to patients with moderate-to-severe postdental surgery pain. Etoricoxib was generally well tolerated.

Analgesic efficacy of a single dose of lumiracoxib compared with rofecoxib, celecoxib and placebo in the treatment of post-operative dental pain

This randomised, double-blind, placebo-controlled, parallel-group study compared the efficacy and tolerability of lumiracoxib (a novel COX-2 selective inhibitor) with rofecoxib, celecoxib and placebo in patients with moderate-to-severe post-operative dental pain. Following third molar extraction, patients received single oral doses of lumiracoxib 400 mg, rofecoxib 50 mg, celecoxib 200 mg or placebo (n = 355). Additional patients from a similar study, assigned to lumiracoxib, rofecoxib or placebo (n = 155), were included for analysis of the primary variable, Summed Pain Intensity Difference over the first 8 h post dose (SPID-8). For SPID-8, lumiracoxib was superior to rofecoxib (p < 0.05), celecoxib (p < 0.001) and placebo (p < 0.001). Lumiracoxib demonstrated the fastest onset of analgesia and the longest time to rescue medication use. Patient global evaluation of lumiracoxib was comparable to rofecoxib and superior to celecoxib and placebo. All treatments were well tolerated. Lumiracoxib 400 mg provides rapid, effective and sustained relief of post-operative dental pain, comparable or superior to rofecoxib.

Analgesic efficacy of single oral doses of lumiracoxib and ibuprofen in patients with postoperative dental pain

This randomised, double-blind study compared single dose lumiracoxib (a cyclooxygenase-2 selective inhibitor) 100 and 400 mg, ibuprofen 400 mg and placebo in patients with postoperative dental pain over 12 h. The primary efficacy variable was pain intensity difference. Lumiracoxib 400 mg and ibuprofen were superior to placebo from 1 to 12 h post dose while lumiracoxib 100 mg was superior from 1.5 to 9 h. Lumiracoxib 400 mg demonstrated the fastest median time to onset of analgesia (37.4 min) followed by ibuprofen (41.5), and lumiracoxib 100 mg (52.4; all p < or = 0.001 vs. placebo). Median time to rescue medication (h) was longer for lumiracoxib 400 mg (> or = 12), lumiracoxib 100 mg (approximately 7) and ibuprofen (approximately 8) than placebo (approximately 2; all p < or = 0.001 vs. placebo). Patients rated lumiracoxib 400 mg superior to the other active treatments (p < 0.05); lumiracoxib 100 mg was comparable with ibuprofen and superior to placebo (p < 0.001). Lumiracoxib provided rapid, effective and well-tolerated analgesia.

COX-2 selective inhibitors: a literature review of analgesic efficacy and safety in oral-maxillofacial surgery

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed analgesic agents in surgical outpatients. Major limitations of NSAIDs are their gastrointestinal (GI) adverse events (perforation, ulceration, and bleeding), impairment of hemostatic function, and renal failure (with long-term therapy). A new class of NSAIDs, the COX-2 selective inhibitors (CSIs or Coxibs), have been developed with the aim of reducing the GI adverse events of traditional NSAIDs while maintaining their effective anti-inflammatory and analgesic properties.

OBJECTIVE

This is a narrative review of the literature aimed to discuss analgesic efficacy, clinical safety and cost-benefit ratio of CSIs in the treatment of post-oral surgery pain.

METHODS

Relevant drug and clinical studies of analgesic efficacy and safety of CSIs in the management of postoperative dental pain were identified through searches of MEDLINE/PubMed, in peer-reviewed journals of medicine and dentistry. The Food and Drug Administration Web site was searched for data of tolerability. Hand-searching included several dental journals and bibliographies of relevant studies. The last electronic search was conducted in April 2003.

RESULTS

Data from well-designed, randomized, controlled trials of CSIs on the management of post-oral surgery pain indicate that these drugs are as well-effective analgesic agents as traditional NSAIDs and offer clinical advantages in terms of GI safety and unimpaired platelet function. CSIs do not offer advantages of renal safety over traditional NSAIDs.

CONCLUSION

Although CSIs display analgesic efficacy similar to that of traditional NSAIDs in the treatment of acute, post-oral surgery pain, there is reasonable evidence that these new drugs are preferable in patients who are at an increased risk of developing serious upper-GI complications, in patients who take aspirin for cardiovascular comorbid conditions, and in those allergic to aspirin. Furthermore, CSIs may be given more safely than NSAIDs in perioperative settings, because of their lack of impairment of the blood-clotting. However, the high costs of CSIs available at present limit their routine use in the short period of postoperative dental pain-in most cases 2 to 4 days after surgery-because there is not an increased risk of developing serious GI complications with the use of cost-saving NSAIDs. The GI safety advantages of CSIs may improve the tolerability of long-duration analgesic therapies, such as cases of painful temporomandibular joint disorders and chronic orofacial pain. Further studies are needed to determine the cost-benefit ratio of using CSIs for the management of acute pain.

The unresolved problem of the third molar: would people be better off without it?

BACKGROUND

Third molars are teeth that have little functional value and a relatively high rate of associated pain and disease. Their value as part of the dentition of modern people is dubious.

TYPES OF STUDIES REVIEWED

The authors review the evolution, development, morbidity and treatment of third molars. They assess the value of third molars in the 21st century and describe the risks these teeth pose when they develop in the dentition.

CONCLUSIONS

There is a mandate for the dental profession to improve health outcomes and quality of life. The prevention of third molar-related morbidity should be included in dental research efforts. The authors suggest that novel preventive methodologies be developed to alleviate the problems third molars pose. One potential methodology suggested is intentional therapeutic agenesis of this tooth.

CLINICAL IMPLICATIONS

Prevention of third molar development early in life, even before tooth bud initiation, could dramatically improve health care outcomes for millions of people.

A comparison of rofecoxib versus celecoxib in treating pain after dental surgery: a single-center, randomized, double-blind, placebo- and active-comparator-controlled, parallel-group, single-dose study using the dental impaction pain model

BACKGROUND

Rofecoxib and celecoxib, selective cyclooxygenase-2 inhibitors, have analgesic efficacy similar to that of nonselective nonsteroidal anti-inflammatory drugs.

OBJECTIVE

This study was designed to confirm earlier findings that the overall analgesic efficacy of rofecoxib 50 mg was superior to that of celecoxib 200 mg and to extend the comparison to include celecoxib 400 mg.

METHODS

In this single-center, randomized, double-blind, placebo- and active-comparator-controlled, parallel-group, single-dose study, patients who experienced moderate or severe pain after surgical extraction of at least 2 third molars received a single oral dose of either rofecoxib 50 mg, celecoxib 400 mg, celecoxib 200 mg, ibuprofen 400 mg, or placebo. Patients recorded scores of pain intensity, pain relief, and global assessment at prespecified time intervals throughout the 24-hour period after dosing. The end points were total pain relief (TOPAR) score over 8 hours (TOPAR8; primary end point), TOPAR score over 12 hours (TOPAR12), sum of pain intensity difference (SPID) over 8 and 12 hours (SPID8 and SPID12), patient's global assessment of study drug at 8 hours, time to confirmed perceptible pain relief (ie, time to onset of analgesic effect), peak pain intensity difference (PID), peak pain relief, time to first dose of rescue medication (ie, duration of analgesic effect), and percentage of patients using rescue medication.

RESULTS

A total of 482 patients (358 females, 124 males; mean age, 22.1 years) were enrolled. Rofecoxib 50 mg (n = 151 patients) demonstrated significantly greater overall analgesic efficacy compared with celecoxib 400 mg (n = 151), as measured by TOPAR8 (least squares mean [SE] 17.2 [0.8] vs 15.0 [0.8]; P < 0.05) and TOPAR12 (25.3 [1.2] vs 21.0 [1.2]; P < 0.05), as well as a significantly longer duration of analgesic effect (P < 0.05). Time to onset of analgesic effect and peak analgesic effect were similar for rofecoxib 50 mg and celecoxib 400 mg. Rofecoxib also showed significantly greater overall analgesic efficacy than did celecoxib 200 mg (n = 90), including greater TOPAR8 scores (17.2 [0.8] vs 11.5 [1.1]; P < 0.001), faster onset of analgesic effect (P < 0.001), greater peak analgesic effect (P < 0.001 for peak pain relief and peak PID), and longer duration of analgesic effect (P < 0.001). The overall analgesic efficacy of rofecoxib 50 mg was similar to that of ibuprofen 400 mg (n = 45), except that the duration of analgesic effect of rofecoxib 50 mg was significantly longer (P < 0.001). All active treatments produced significantly greater overall analgesic efficacy compared with that of placebo (P < 0.001 for all scores [TOPAR8, TOPAR12, SPID8, SPID12, and patient's global assessment] for all study drugs). The adverse-events (AE) profile was generally similar in all treatment groups. The 3 most common AEs were nausea, postextraction alveolitis, and vomiting.

CONCLUSIONS

In this study, rofecoxib 50 mg provided generally superior overall analgesic efficacy compared with that of celecoxib 400 and 200 mg, including a significantly longer duration of analgesic effect. The overall analgesic efficacy of rofecoxib 50 mg was generally similar to that of ibuprofen 400 mg, except for a significantly longer duration of analgesic effect.

Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review

The objective of this article is to harmonize descriptive definitions for the condition known as alveolar osteitis and to critically review and discuss the aetiology and pathogenesis of alveolar osteitis. In addition, the need for the identification and elimination of risk factors as well as the preventive and symptomatic management of the condition are discussed. The aim of this critical review is to provide a better basis for clinical management of the condition. A meta-analysis of data was not done.

Selective COX-2 inhibitors: a review of their therapeutic potential and safety in dentistry

Anti-inflammatory analgesics are commonly used medications in dental and medical practice. Their uses in dentistry include use as analgesics and as anti-inflammatory agents. In addition, antipyretic action accompanies the medication. The action of these groups of drugs depends on the dose provided. Analgesic and antipyretic effects occur at low dose, whereas analgesic effects occur at high dose. Among the common side effects of this class of medications are gastrointestinal irritation with potential for ulceration, increased tendency for bleeding due to antiplatelet effects, and long-term chronic dosing effects on renal function may occur. Recent developments in the anti-inflammatory group of medications include the introduction of cyclooxygenase-II inhibitors. These agents offer potentially significant advantages because of their relative lack of gastrointestinal irritation. Because of this, it is likely that these medications will be frequently used in the management of dental and medical conditions. Patients will present while on these medications, and these agents may serve as medications for management of dental pain, postsurgical pain, and for anti-inflammatory effects. The current literature indicates that COX-2 inhibitors offer substantial benefits because of their favorable gastrointestinal profiles and because of their lack of effect on platelet function.