This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
Objective The purpose of our study was to perform a systematic review and meta-analysis of randomized, blinded, placebo-controlled studies that, following third-molar extraction, utilized either a combination of acetaminophen (600 mg) with codeine (60 mg) or ibuprofen (400 mg) for pain management. Design We searched PubMed, and the trial registry ClinicalTrials.gov databases with the keywords "molar or molars," "tooth or teeth," "extraction," and "pain." Selected studies were: (1) randomized, blinded, placebo controlled, (2) utilized either a single-dose combination acetaminophen (600 mg) with codeine (60 mg) (A/C) or ibuprofen, and (3) recorded standardized pain relief (PR) at 6 hours, or summed total pain relief over 6 hours (TOTPAR6). Of the 2,949 articles that were identified, 79 were retrieved for full-text analysis, and 20 of these studies met our inclusion criteria. Results For A/C, the weighted, standardized mean difference (SMD) for TOTPAR6 was 0.796 (95% confidence interval [CI], 0.597–0.995), P < .001, and for PR at 6 hours, the SMD was 0.0186 (0.007 to 0.378; P = .059), whereas for ibuprofen the SMD for TOTPAR6 was 3.009 (1.283 to 4.735; P = .001), and for PR at 6 hours, the SMD was 0.854 (95% CI, 0.712–0.996; P < .001). A SMD of 0.8 or larger is indicative of a large effect. Conclusions Our data indicate that single dose of ibuprofen (400 mg) is an effective pain reducer for post third molar extraction pain.
The purpose of this systematic review was to determine the analgesic efficacy and adverse effects of ibuprofen in comparison with other traditional non-opioid analgesics after third molar surgery. A total of 17 full texts were identified in PubMed and assessed using the Cochrane Collabo-ration’s risk of bias tool by two independent researchers. The sum of pain intensity differences, total pain relief, the overall evaluation, the number of patients requiring rescue analgesics, and adverse effects were collected. Data were analyzed using the Review Manager Software 5.3. for Windows. A total of 15 articles met the criteria. The qualitative and quantitative analysis showed that ibuprofen is more effective to relieve post-operative dental pain than acetaminophen, meclofenamate, aceclofenac, bromfenac, and aspirin. Moreover, ibuprofen and traditional non-steroidal anti-inflammatory drugs have a similar safety profile. In conclusion, ibuprofen 400 mg appears to have good analgesic efficacy and a safety profile similar to other traditional non-steroidal anti-inflammatory drugs after third molar surgery.
BACKGROUND: Many women experience perineal pain after childbirth, especially after having sustained perineal trauma. Perineal pain-management strategies are an important part of postnatal care. Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly-used type of medication in the management of postpartum pain, and their effectiveness and safety should be assessed. This is an update of a review first published in 2016.
OBJECTIVES: To determine the effectiveness of a single dose of an oral NSAID for relief of acute perineal pain in the early postpartum period.
SEARCH METHODS: For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 December 2019), OpenSIGLE and ProQuest Dissertations and Theses (28 February 2020), and reference lists of retrieved studies.
SELECTION CRITERIA: Randomised controlled trials (RCTs) assessing a single dose of a NSAID versus a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. We excluded quasi-RCTs and cross-over trials. We included papers in abstract format only if they had sufficient information to determine that they met the review's prespecified inclusion criteria.
DATA COLLECTION AND ANALYSIS: Two review authors (FW and VS) independently assessed all identified papers for inclusion and risks of bias, resolving any discrepancies through discussion. Two review authors independently conducted data extraction, including calculations of pain relief scores, and checked it for accuracy. We assessed the certainty of the evidence using the GRADE approach.
MAIN RESULTS: We included 35 studies examining 16 different NSAIDs and involving 5136 women (none were breastfeeding). Studies were published between 1967 and 2013. Risk of bias due to random sequence generation, allocation concealment and blinding of outcome assessors was generally unclearly to poorly reported, but participants and caregivers were blinded, and outcome data were generally complete. We downgraded the certainty of evidence due to risk of bias, suspected publication bias, and imprecision for small numbers of participants. NSAID versus placebo Compared to women who receive a placebo, more women who receive a single-dose NSAID may achieve adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23; 10 studies, 1573 women; low-certainty evidence) and at six hours (RR 1.92, 95% CI 1.69 to 2.17; 17 studies, 2079 women; very low-certainty evidence), although we are less certain about the effects at six hours. At four hours after administration, women who receive a NSAID are probably less likely to need additional analgesia compared to women who receive placebo (RR 0.39, 95% CI 0.26 to 0.58; 4 studies, 486 women; moderate-certainty evidence) and may be less likely to need additional analgesia at six hours after initial administration, although the evidence was less certain at six hours (RR 0.32, 95% CI 0.26 to 0.40; 10 studies, 1012 women; very low-certainty evidence). One study reported that no adverse events were observed at four hours post-administration (90 women). There may be little or no difference in maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70; 13 studies, 1388 women; low-certainty evidence). Fourteen maternal adverse effects were reported in the NSAID group (drowsiness (5), abdominal discomfort (2), weakness (1), dizziness (2), headache (2), moderate epigastralgia (1), not specified (1)) and eight in the placebo group (drowsiness (2), light-headedness (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. Neonatal adverse effects were not assessed in any of the studies. NSAID versus paracetamol NSAIDs may lead to more women achieving adequate pain relief at four hours, compared with paracetamol (RR 1.54, 95% CI 1.07 to 2.22; 3 studies, 342 women; low-certainty evidence). We are uncertain if there is any difference in adequate pain relief between NSAIDs and paracetamol at six hours post-administration (RR 1.82, 95% CI 0.61 to 5.47; 2 studies, 99 women; very low-certainty evidence) or in the need for additional analgesia at four hours (RR 0.55, 95% CI 0.27 to 1.13; 1 study, 73 women; very low-certainty evidence). NSAIDs may reduce the risk of requiring additional analgesia at six hours compared with paracetamol (RR 0.28, 95% CI 0.12 to 0.67; 1 study, 59 women; low-certainty evidence). One study reported that no maternal adverse effects were observed at four hours post-administration (210 women). Six hours post-administration, we are uncertain if there is any difference between groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08; 3 studies, 300 women; very low-certainty evidence), with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group. Neonatal adverse effects were not assessed in any of the included studies. Comparisons of different NSAIDs or doses did not demonstrate any differences in effectiveness for any primary outcome measures; however, few data were available on some NSAIDs. None of the included studies reported on any of this review's secondary outcomes.
AUTHORS' CONCLUSIONS: In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo or paracetamol) may provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia, but uncertainty remains, as the evidence is rated as low- or very low-certainty. The risk of bias was unclear for many studies, adverse effects were often not assessed and breastfeeding women were not included. While this review provides some indication of the likely effect, there is uncertainty in our conclusions. The main reasons for downgrading were the inclusion of studies at high risk of bias and inconsistency in the findings of individual studies. Future studies could examine NSAIDs' adverse effects, including neonatal effects and the compatibility of NSAIDs with breastfeeding, and could assess other secondary outcomes. Future research could consider women with and without perineal trauma, including perineal tears. High-quality studies could be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.
OBJECTIVES: To compare selective COX-2 inhibitors with ibuprofen in terms of analgesia, rescue medication consumption, and adverse effects after impacted third molar removal.
MATERIALS AND METHODS: Electronic databases were searched. Single dose, double-blind, randomized, and controlled clinical trials comparing the analgesic effect of a selective COX-2 inhibitor versus at least one active control group using ibuprofen after impacted third molar removal were selected.
RESULTS: Twelve studies were included for the qualitative synthesis and eight were included in the meta-analysis. No statistically significant differences were found between selective COX-2 inhibitors and ibuprofen in terms of pain relief after 6, 8, and 12 h. Rescue analgesia use after 24 h was significantly greater in the ibuprofen group than in the selective COX-2 inhibitor group. There were no statistically significant differences in the number of patients presenting one or more adverse events between the two groups, though ibuprofen intake was related with more nausea and vomiting.
CONCLUSIONS: No statistically significant differences were found in terms of pain relief 6, 8, and 12 h post-medication between selective COX-2 inhibitors and ibuprofen following totally or partially impacted third molar removal. The patients who consumed selective COX-2 inhibitors needed less rescue analgesia after 24 h. The occurrence of one or more adverse events was similar in both groups, though patients who consumed ibuprofen had more nausea and vomiting.
CLINICAL RELEVANCE: COX-2 inhibitors could be considered a suitable alternative to ibuprofen for pain relief after third molar extraction in patients at risk of developing nausea and vomiting. Also, COX-2 inhibitors seem to slightly reduce the need of rescue medication consumption.
BACKGROUND: This review updates part of an earlier Cochrane Review titled "Pregabalin for acute and chronic pain in adults", and considers only neuropathic pain (pain from damage to nervous tissue). Antiepileptic drugs have long been used in pain management. Pregabalin is an antiepileptic drug used in management of chronic pain conditions.
OBJECTIVES: To assess the analgesic efficacy and adverse effects of pregabalin for chronic neuropathic pain in adults.
SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase for randomised controlled trials from January 2009 to April 2018, online clinical trials registries, and reference lists.
SELECTION CRITERIA: We included randomised, double-blind trials of two weeks' duration or longer, comparing pregabalin (any route of administration) with placebo or another active treatment for neuropathic pain, with participant-reported pain assessment.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality and biases. Primary outcomes were: at least 30% pain intensity reduction over baseline; much or very much improved on the Patient Global Impression of Change (PGIC) Scale (moderate benefit); at least 50% pain intensity reduction; or very much improved on PGIC (substantial benefit). We calculated risk ratio (RR) and number needed to treat for an additional beneficial (NNTB) or harmful outcome (NNTH). We assessed the quality of the evidence using GRADE.
MAIN RESULTS: We included 45 studies lasting 2 to 16 weeks, with 11,906 participants - 68% from 31 new studies. Oral pregabalin doses of 150 mg, 300 mg, and 600 mg daily were compared with placebo. Postherpetic neuralgia, painful diabetic neuropathy, and mixed neuropathic pain predominated (85% of participants). High risk of bias was due mainly to small study size (nine studies), but many studies had unclear risk of bias, mainly due to incomplete outcome data, size, and allocation concealment.Postherpetic neuralgia: More participants had at least 30% pain intensity reduction with pregabalin 300 mg than with placebo (50% vs 25%; RR 2.1 (95% confidence interval (CI) 1.6 to 2.6); NNTB 3.9 (3.0 to 5.6); 3 studies, 589 participants, moderate-quality evidence), and more had at least 50% pain intensity reduction (32% vs 13%; RR 2.5 (95% CI 1.9 to 3.4); NNTB 5.3 (3.9 to 8.1); 4 studies, 713 participants, moderate-quality evidence). More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (62% vs 24%; RR 2.5 (95% CI 2.0 to 3.2); NNTB 2.7 (2.2 to 3.7); 3 studies, 537 participants, moderate-quality evidence), and more had at least 50% pain intensity reduction (41% vs 15%; RR 2.7 (95% CI 2.0 to 3.5); NNTB 3.9 (3.1 to 5.5); 4 studies, 732 participants, moderate-quality evidence). Somnolence and dizziness were more common with pregabalin than with placebo (moderate-quality evidence): somnolence 300 mg 16% versus 5.5%, 600 mg 25% versus 5.8%; dizziness 300 mg 29% versus 8.1%, 600 mg 35% versus 8.8%.Painful diabetic neuropathy: More participants had at least 30% pain intensity reduction with pregabalin 300 mg than with placebo (47% vs 42%; RR 1.1 (95% CI 1.01 to 1.2); NNTB 22 (12 to 200); 8 studies, 2320 participants, moderate-quality evidence), more had at least 50% pain intensity reduction (31% vs 24%; RR 1.3 (95% CI 1.2 to 1.5); NNTB 22 (12 to 200); 11 studies, 2931 participants, moderate-quality evidence), and more had PGIC much or very much improved (51% vs 30%; RR 1.8 (95% CI 1.5 to 2.0); NNTB 4.9 (3.8 to 6.9); 5 studies, 1050 participants, moderate-quality evidence). More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (63% vs 52%; RR 1.2 (95% CI 1.04 to 1.4); NNTB 9.6 (5.5 to 41); 2 studies, 611 participants, low-quality evidence), and more had at least 50% pain intensity reduction (41% vs 28%; RR 1.4 (95% CI 1.2 to 1.7); NNTB 7.8 (5.4 to 14); 5 studies, 1015 participants, low-quality evidence). Somnolence and dizziness were more common with pregabalin than with placebo (moderate-quality evidence): somnolence 300 mg 11% versus 3.1%, 600 mg 15% versus 4.5%; dizziness 300 mg 13% versus 3.8%, 600 mg 22% versus 4.4%.Mixed or unclassified post-traumatic neuropathic pain: More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (48% vs 36%; RR 1.2 (1.1 to 1.4); NNTB 8.2 (5.7 to 15); 4 studies, 1367 participants, low-quality evidence), and more had at least 50% pain intensity reduction (34% vs 20%; RR 1.5 (1.2 to 1.9); NNTB 7.2 (5.4 to 11); 4 studies, 1367 participants, moderate-quality evidence). Somnolence (12% vs 3.9%) and dizziness (23% vs 6.2%) were more common with pregabalin.Central neuropathic pain: More participants had at least 30% pain intensity reduction with pregabalin 600 mg than with placebo (44% vs 28%; RR 1.6 (1.3 to 2.0); NNTB 5.9 (4.1 to 11); 3 studies, 562 participants, low-quality evidence) and at least 50% pain intensity reduction (26% vs 15%; RR 1.7 (1.2 to 2.3); NNTB 9.8 (6.0 to 28); 3 studies, 562 participants, low-quality evidence). Somnolence (32% vs 11%) and dizziness (23% vs 8.6%) were more common with pregabalin.Other neuropathic pain conditions: Studies show no evidence of benefit for 600 mg pregabalin in HIV neuropathy (2 studies, 674 participants, moderate-quality evidence) and limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy.Serious adverse events, all conditions: Serious adverse events were no more common with placebo than with pregabalin 300 mg (3.1% vs 2.6%; RR 1.2 (95% CI 0.8 to 1.7); 17 studies, 4112 participants, high-quality evidence) or pregabalin 600 mg (3.4% vs 3.4%; RR 1.1 (95% CI 0.8 to 1.5); 16 studies, 3995 participants, high-quality evidence).
AUTHORS' CONCLUSIONS: Evidence shows efficacy of pregabalin in postherpetic neuralgia, painful diabetic neuralgia, and mixed or unclassified post-traumatic neuropathic pain, and absence of efficacy in HIV neuropathy; evidence of efficacy in central neuropathic pain is inadequate. Some people will derive substantial benefit with pregabalin; more will have moderate benefit, but many will have no benefit or will discontinue treatment. There were no substantial changes since the 2009 review.
خلفية: ضيق التنفس العرضي (إب) أو ضيق التنفس هو عرض مشترك مع تأثير سلبي جدا على نوعية حياة المرضى الذين يعانون من السرطان ومع الأمراض المتقدمة غير السرطانية، أساسا القلب التنفسي والعصبية. الهدف: الغرض من هذا الاستعراض غير المنهجي هو التأكد من الدور الذي تلعبه المواد الأفيونية في إدارة ضيق التنفس العرضي. الطرق: تم إجراء مراجعة غير منهجية للأدبيات في قواعد البيانات مدلين و كوكرين و داتاباس، وتم اختيار مواد ذات صرامة علمية أكبر، وبشكل رئيسي المراجعات أو الدراسات المستقبلية / التجارب السريرية العشوائية المنشورة حتى الآن (أغسطس 2015). وشملت المصطلحات المستخدمة في البحث ضيق التنفس العرضي، ضيق التنفس الحاد، ضيق التنفس العرضي، الأفيونيات، المورفين، الفنتانيل، أوكسيكودون، وضيق التنفس اختراق. الاستنتاجات: على الرغم من أن الفيزيولوجيا المرضية وآلية عمل المواد الأفيونية لإدارة ضيق التنفس، وتحديدا إب، ليست معروفة تماما، وهناك أدلة علمية، وخاصة الأدلة السريرية كبيرة، لصالح هذه الفئة المخدرات لإدارة ضيق التنفس. من المهم التفريق بين المرضى في المستشفى من المرضى الخارجيين لأن الوصول الوريدي أو تحت الجلد هو أسهل في المرضى في المستشفى، ولكن استخدام الفنتانيل المخاطية، وخاصة في الصيغ أسرع مثل تطبيق الأنف، يفتح إمكانيات جديدة لإدارة المرضى الخارجيين بسبب بداية سريعة للعمل. والمشكلة الرئيسية هي الافتقار إلى البيانات المتاحة والعدد الكبير من الأسئلة التي لم يتم الرد عليها بشأن نوع المواد الأفيونية، وطريق الإدارة، والسلامة، ومعايرة الجرعة.
الأدلة الداعمة إدارة الألم بعد العملية الجراحية باستخدام الركبه كتدخل مساعد في مختلف النماذج الألم الجراحية غير متوفرة. وكان الهدف من هذه المراجعة المنهجية إلى تقييم "نموذج محدد" الفعالية النسبية ومضار الركبه بعد بروتوكول مراجعة منهجية سبق نشرها. تم تفتيش MEDLINE، EMBASE، وسجل كوكرين المركزي للتجارب ذات الشواهد من إنشائها خلال أغسطس 2013. كما تم عرض البيانات وتم تنفيذ استخراج واحد مع تأكيد مستقل وخطر مزدوج يتمثل في تقييم التحيز. تم تقييم نوعية الأدلة (QoE) باستخدام نهج الصف. وكانت النتائج الأولية لتخفيف الآلام أثناء الراحة وعلى الحركة وانخفاض في استهلاك مسكن بعد العملية الجراحية. تم فحص ما مجموعه 1423 السجلات، وشملت 43 دراسة. أدت الركبه المحيطة بالجراحة البحث في 16 في المائة (95 في المائة الثقة الفاصل [CI [، و 9٪ -21٪) خفض استهلاك مسكن (QoE المعتدلين، 24 المحاكمات) وانخفاض طفيف في حجم الألم في جراحات يرتبط الألم pronociceptive. لكل 1000 مريض، 10 أكثر ستشهد عدم وضوح الرؤية (95٪ CI، 5-20 أكثر؛ QoE المعتدل، 17 تجربة) و 41 مزيد من التخدير (95٪ CI، 13-77 أكثر، 17 تجارب). لمنع 1 حالة من الغثيان والقيء المحيطة بالجراحة، والعدد المطلوب للعلاج هو 11 (95٪ CI: 7-28، 25 تجارب). تناول أدلة كافية نتائج الاستخلاص المعزز ومضار خطيرة. يقتصر بريغابالين فعالية مسكنة الى حد كبير العمليات الجراحية المرتبطة آليات pronociceptive. يجب أن يكون وزنه الأهمية السريرية لفوائد الركبه وحظ ضد الشكوك حول مضار خطيرة والاستخلاص المعزز للإبلاغ الاختيار الدقيق للمرضى العمليات الجراحية. ويقترح توصيات للبحوث في المستقبل.
خلفية: عدوى فيروس التهاب الكبد B (هبف) هي مصدر قلق الصحة العامة العالمية الكبرى. على الرغم من أن النتائج الأخيرة تشير إلى وجود علاقة عكسية بين عدوى فيروس التهاب الكبد الوبائي و الورم النخاعي المتعدد (مم)، لا تزال العلاقة الحقيقية بين هذين الشرطين غير واضحة. الهدف: كان الهدف الأساسي من هذا التحليل التلوي لتقييم الارتباط بين عدوى فيروس التهاب الكبد الوبائي، والمعروفة بأنها إيجابية التهاب الكبد B مستضد السطح، وحدوث مم. الطريقة: بحثنا في بوبمد / مدلين، مكتبة كوكرين، وقواعد بيانات إمباس من يناير 1975 إلى يوليو 2014 واستعرضنا القوائم المرجعية لجميع المقالات المسترجعة. تم حساب نسب الأرجحية وفواصل الثقة بنسبة 95٪ باستخدام التأثيرات الثابتة ونماذج التأثيرات العشوائية. النتائج: حددنا تسع دراسات حالة السيطرة التي تشمل 30646 مريضا مع مم و 379،837 الضوابط. لم ترتبط عدوى فيروس التهاب الكبد البائي بشكل ملحوظ مع تطور مم (نسبة الأرجحية ،، 1.3؛ 95٪ فاصل الثقة:، 0.92-1.82؛ p = 0.14). وكان هناك خطر مماثل لتطوير مم في بلدان مختلفة انتشار فيروس الالتهاب الكبدي الوبائي. ومع ذلك، لوحظ عدم التجانس كبير بين الدراسات (ع = 0.01). وقد تم الكشف عن علاقة ذات دلالة إحصائية بين عدوى فيروس التهاب الكبد البائي وزيادة خطر مم في التحليلات الفرعية تقييم الدراسات عالية الجودة وتلك التي مع الضوابط المستندة إلى المستشفى (P <0.05). الاستنتاج: قد تترافق عدوى فيروس التهاب الكبد البائي مع زيادة خطر مم. ومع ذلك، فإن تأكيد هذه العلاقة والآليات الجزيئية المحددة المشاركة في الارتباط بين عدوى فيروس التهاب الكبد الوبائي وتطوير مم تتطلب المزيد من الاستكشاف.
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
