Endodontic postoperative pain: which non-steroidal anti-inflammatory drug?

This RCT does not establish equivalence between mindfulness-based cognitive therapy and antidepressants for recurrent depression.

Endodontic treatment is carried out to remove the infected pulp and relief pain. However, post-operative pain and discomfort are not uncommon following treatment. A variety of drugs have been used to manage this post-operative pain and these often include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations of drugs.

The aim of this review was to assess the comparative efficacy of NSAIDs compared with non-narcotic analgesics or placebo in reducing postoperative endodontic pain and the incidence of adverse events’

Methods

Searches were conducted in the Medline, OldMedline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and   ClinicalTrials.gov databases. Randomised controlled trials (RCTs) in patients with endodontic pain requiring nonsurgical endodontic treatment receiving preoperative NSAIDs compared with postoperative NSAIDs or other analgesia were considered.

Two reviewers independently selected, abstracted data and assessed study quality. The Cochrane risk of bias tool was used to assess study quality. Data were extracted on treatment drugs, dosing, dosing schedules of drug administration, pain measurement, and pain severity. Meta-analyses were conducted when appropriate.

Results

  • 15 studies were included.
  • None of the studies were at low risk of bias, 8 being at high risk.
  • 12 different of drugs were evaluated in the studies.
  • The top 5 drugs in terms of greatest decrease in pain relative to placebo are found in. Ibuprofen, flurbiprofen, and ibuprofen plus acetaminophen combinations were represented in multiple trials.
  • L’Abbe plots suggest that NSAIDs are effective at relieving postoperative endodontic pain overall.
  • 5 studies were included in a meta-analysis which showed that ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively (ES [effect size] = 10.50, P = .037), and ibuprofen 600 mg + acetaminophen 1000 mg combination is more effective than placebo (ES = 34.89, P = .000) but not significantly different than ibuprofen (ES = 13.94, P = .317)
  • 7 studies reported on adverse events, 5 studies reported patients experiencing adverse events such as drowsiness, dizziness, nausea, and emesis; 2 studies reported that patients experienced no adverse events.

Conclusions

The authors concluded

A combination of ibuprofen 600 mg and acetaminophen 1000 mg is more effective than placebo but not significantly different than ibuprofen 600 mg at 6 hours postoperatively. Ibuprofen 600 mg is more effective than placebo at 6 hours postoperatively; however, there are insufficient data to recommend the most effective NSAID, dose amount, or dose interval for the relief of postoperative endodontic pain of longer duration in patients with preoperative pain.

Comments

This review has taken a good methodological approach although the quality of the studies meeting the inclusion criteria is disappointing. All but 3 of the included studies were published after the original CONSORT statement  on reporting of randomised controlled trials. In 1996.  While the quality appraisal of the included studies is clearly displayed the sample sizes of the included studies are not displayed in the summary of included studies or provided in the text. The reviews discussion clearly highlights the need for larger, well-conducted randomised trials comparing one NSAID with another to provide more definitive conclusion. Although a significant number of review of pain have already been carried out by the Cochrane Pain, Palliative and Supportive Care Group and many of their reviews use studies that use third molar extraction as the pain model and can provide information on the comparative effectiveness of NSAIDs.

Links

Primary paper

Smith EA, Marshall JG, Selph SS, Barker DR, Sedgley CM. Nonsteroidal Anti-inflammatory Drugs for Managing Postoperative Endodontic Pain in Patients Who Present with Preoperative Pain: A Systematic Review and Meta-analysis. J Endod. 2017 Jan;43(1):7-15. doi: 10.1016/j.joen.2016.09.010. Review. PubMed PMID:27939729.

Other references

Original review protocol on PROSPERO

Cochrane Pain, Palliative and Supportive Care Group Reviews

 

Dental Elf – 19th Oct 2015

Few adverse events with single dose oral analgesics for acute postoperative pain

 

Dental Elf – 21st Jan 2014

 

Ibuprofen more effective than paracetamol for postoperative pain following third molar removal

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