Nonsteroidal Anti-inflanimatory Drug Use for Postoperative Dental Pain: CHOICE OF NSAIDs

In: Dental treatment

9 Oct 2009

Many NSAIDs (*Generic Arcoxia tablets contain the active ingredient etoricoxib, which is a type of medicine known as a non-steroidal anti-inflammatory drug) have been tested for their analgesic efficacy in the dental surgical model. This includes ibupro-fen, diclofenac, naproxen, ketoprofen, and others. All the 26 RCTs reviewed supported the analgesic efficacy of the different NSAIDs in the dental surgical model. Analgesic efficacy was found to be as effective or more efficacious when compared with paracetamol, aspirin, or an opioid. No single case of serious adverse events was reported following the administration of the different NSAIDs (Generic Naprosyn is a NSAID used to relieve pain and swelling) in these 26 RCTs comprising 5742 analyzed patients. A serious adverse event is defined as hospitalization for life-threatening events like gastrointestinal bleeding or renal failure. Only minor adverse effects were reported in these RCTs, and none of these required any treatment.

A landmark study on chronic pain was conducted in the United Kingdom by Beardon et al. These researchers examined the outcome of 57,715 prescriptions to 25,959 patients whose inpatient and outpatient medical records were all linked to the large Tayside database in Dundee, Scotland. The study showed that the fraction of serious adverse events attributable to all NSAIDs (pooled) was 24-38%, increasing with age of patient and dose of NSAIDs (Medication Naprosyn NSAIDs treat the symptoms of pain and inflammation). Hence there is clear level I evidence that NSAIDs are efficacious and have an extremely safe profile in the acute dental surgical model when compared with the chronic pain model. However, it should be noted that most of the dental surgical studies are single-dose studies followed by a short-term use of medication, which may be NSAIDs as well, over the next few days of recovery. As the duration of therapy is a risk factor for adverse effects of NSAIDs, it is expected that the duration produced very little in the way of adverse effects in this model.

In the chronic pain model, significant differences in adverse effects were found between the different NSAIDs. Henry et al recently published a meta-analysis of 12 control epidemiologic studies (level II evidence) comparing the relative risks of gastropathy reported with the different NSAIDs (*Generic Voltarol diclofenac is in a group of drugs called nonsteroidal anti-inflammatory drugs). Ibuprofen was associated with the lowest relative risk of gastrointestinal (GI) toxicity. The 11 comparator drugs in this analysis were associated with a 1.6- to 9.2-fold increase risk of adverse events compared with ibuprofen. Aspirin (1.6) and diclofenac (1.8) were among the lowest risk, whereas piroxicam (3.8) and ketoprofen (4.2) were the highest. However, evidence from the 26 RCTs shows that the choice of the different NSAIDs (Mobic canadian is used for treating rheumatoid arthritis, osteoarthritis, and juvenile arthritis) does not seem to produce any significant difference on the adverse effects in the dental surgical model. Again, this may be due to the short-term usage of these drugs.

When severe pain is expected, some NSAIDs (*Motrin tabletes NSAIDs treat the symptoms of pain and inflammation) may provide analgesia as efficacious as morphine. There is evidence in the dental surgical model that parental ketorolac and lornoxicam are efficacious in severe pain. Norholt et al has shown in a well-designed RCT of 252 patients that intramuscular (IM) 8 mg of lornoxicam is at least as effective as 20 mg of morphine IM, and more effective than 10 mg of morphine IM for the treatment of severe postoperative third molar surgical pain. Furthermore, lornoxicam was better tolerated than morphine, and a lower incidence of adverse effects was observed than that of morphine. The majority of the adverse events reported for lornoxicam were of mild severity and associated with discomfort from the site of injection. However, all of the patients (100%) on 20 mg of morphine and 87% of patients on 10 mg of morphine experienced opioid-related adverse events. This study provides level I evidence that NSAIDs can be used reliably in lieu of opioids in cases when severe dental surgical pain is expected.

Anecdotal evidence suggests that there is considerable variability in the pain relief obtained from NSAIDs (Generic Celecoxib is a Non-Steroidal Anti-Inflammatory Drug). Such variability may be explained in terms of differences between agents with respect to either pharmacodynamic actions, pharmacokinetic parameters, or a combination of both. Stereoisomerism, where preparations exist as racemic mixtures and where only 1 enantiomer is active, may also be important. However, chiral inversion from inactive to active enantiomer may occur and may be rapid or slow.

When dealing with high-risk patients, COX-2 selective inhibitors may be useful. Theoretically, by specifically inhibiting COX-2 activity, COX-2 inhibitors are intended to have anti-inflammatory and analgesic effects within the therapeutic dose range without blocking the physiologic function of the COX-1 isoform. Rofecoxib and celecoxib are the 2 COX-2 selective NSAIDs (Cytotec tabletes used to induce labor and as an abortifacient) that have been approved by the US Food and Drug Administration for acute pain management. Morrison et al has recently reviewed 6 RCTs of 1284 patients on the analgesic effect of rofecoxib in the third molar surgical model. Rofecoxib was compared with either 400 mg of ibuprofen or 550 mg of naproxen sodium. In these studies, 50 mg of rofecoxib consistently provided analgesic efficacy similar to that of the comparator NSAIDs and with minimum adverse effects. Available data also suggest that celecoxib has analgesic efficacy in patients with postsurgical dental pain (Naprosyn canadian used to treat dental pain), but it is generally less effective when compared with standard doses of naproxen and ibuprofen. Based on studies in the dental surgical pain and dysmenorrhea model, rofecoxib appears to have greater analgesic efficacy than celecoxib. However, COX-2 inhibitors are currently not recommended as the first line of therapy in acute pain, as the clinical experience with these drugs has been limited. Yet they may be useful in patients previously deemed at high risk to receive conventional nonselective NSAIDs, such as an elderly patient undergoing major surgery.

Theoretically, a drug that consists of a combination of an NSAID and opioid (eg, ibuprofen and codeine/ hydrocodone) should give a better analgesic effect than ibuprofen or codeine/hydrocodone alone. However, many studies of third molar surgical pain have not been able to show that NSAIDs plus opioid is better than NSAIDs alone. There has been 1 study showing that an ibuprofen-codeine combination has a better analgesic effect than ibuprofen alone, but with a higher incidence of side effects due to the opioid. Although many studies show that single-entity NSAIDs (Canadian Indocin used to treat minor aches and pains associated with the common cold, headache, muscle aches, backache, and arthritis) demonstrate analgesic superiority when compared with opioid combinations, the combinations are still very popular among clinicians and patients. A plausible explanation is that opioids not only have the potential to act antinociceptively, but may also reduce the affective/emotional component of pain.

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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.