The naturally occurring cannabis plant has played an established role in pain management throughout recorded history. However, in recent years, both natural and synthetic cannabis-based products for medicinal use (CBPM) have gained increasing worldwide attention due to growing evidence supporting their use in alleviating chronic inflammatory and neuropathic pain associated with an array of conditions. In view of these products' growing popularity in both the medical and commercial fields, we carried out a systematic review to ascertain the effects of cannabis and its synthetically derived products on orofacial pain and inflammation. The application of topical dermal cannabidiol formulation has shown positive findings such as reducing pain and improving muscle function in patients suffering from myofascial pain. Conversely, two orally-administered synthetic cannabinoid receptor agonists (AZD1940 and GW842166) failed to demonstrate significant analgesic effects following surgical third molar removal. There is a paucity of literature pertaining to the effects of cannabis-based products in the orofacial region; however, there is a wealth of high-quality evidence supporting their use for treating chronic nociceptive and neuropathic pain conditions in other areas. Further research is warranted to explore and substantiate the therapeutic role of CBPMs in the context of orofacial pain and inflammation. As evidence supporting their use expands, healthcare professionals should pay close attention to outcomes and changes to legislation that may impact and potentially benefit their patients.<ovid:br/><ovid:br/> Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.
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.
Cannabinoids, cannabis, and cannabis-based medicines (CBMs) are increasingly used to manage pain, with limited understanding of their efficacy and safety. We summarised efficacy and adverse events (AEs) of these types of drugs for treating pain using randomised controlled trials: in people of any age, with any type of pain, and for any treatment duration. Primary outcomes were 30% and 50% reduction in pain intensity, and AEs. We assessed risk of bias of included studies, and the overall quality of evidence using GRADE. Studies of <7 and >7 days treatment duration were analysed separately. We included 36 studies (7217 participants) delivering cannabinoids (8 studies), cannabis (6 studies), and CBM (22 studies); all had high and/or uncertain risk of bias. Evidence of benefit was found for cannabis <7 days (risk difference 0.33, 95% confidence interval 0.20-0.46; 2 trials, 231 patients, very low-quality evidence) and nabiximols >7 days (risk difference 0.06, 95% confidence interval 0.01-0.12; 6 trials, 1484 patients, very low-quality evidence). No other beneficial effects were found for other types of cannabinoids, cannabis, or CBM in our primary analyses; 81% of subgroup analyses were negative. Cannabis, nabiximols, and delta-9-tetrahydrocannabinol had more AEs than control. Studies in this field have unclear or high risk of bias, and outcomes had GRADE rating of low- or very low-quality evidence. We have little confidence in the estimates of effect. The evidence neither supports nor refutes claims of efficacy and safety for cannabinoids, cannabis, or CBM in the management of pain.
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.
Aim: This study aims to perform a literature review that reports on the use of opioid analgesics and their efficacy after extracting third molars, comparing them with other types of drugs. Methods: The search of articles in the PubMed database was carried out from 2006 to 2016, resulting in a total of 131 articles. Of these, 122 articles that did not report the use of opioids that were not from the Dentistry area, or that did not report the use of opioids after the extraction of third molars, were excluded. Literature reviews or non-comparative articles were also excluded. Thus, 9 articles were considered and incorporated into the review. Results: This review identified some clinical trials comparing the use of opioid analgesics with other drug options. From the trials comparing opioid analgesics with other NSAIDs (N = 3), with no drug combinations, NSAIDs proved to be more effective or, in the case of preemptive analgesia, had the same effect. Studies comparing the association of opioid analgesics with NSAIDs (N = 4) have shown that the association is more beneficial than the use of opioids alone. A single study that tested the association between opioids and corticosteroids has shown that this association is more effective than the association between opioids and NSAIDs. One study, which tested the association between opioids and paracetamol with NSAIDs concluded that the efficacy was similar between groups. Conclusion: Opioid analgesics are generally less effective than NSAIDs in controlling pain after the extraction of third molars. Its association with NSAIDs is recommended in some clinical situations. The use of opioids as the first choice seems to be restricted to patients with a contraindication to the use of NSAIDs.(AU)
Postoperative pain after root canal treatment can be reduced by applying recent advances in endodontic techniques and equipment. This systematic review includes current knowledge about pain after nonsurgical root canal treatment, including predictors, related factors, effects of recent advances, and management. A literature search was performed using the PubMed, ScienceDirect, and Cochrane Library databases for articles published between 1990 and 2016. Search keywords included postoperative pain, nonsurgical treatment, single visit, recent advances in endodontics, and management of postoperative pain with endodontic treatment. Only original research studies were included; editorials, reviews, brief notes, conference proceedings, and letters to the editor were excluded. The initial search yielded 4941 articles, which were assessed and filtered using the selection criteria. Sixty-five studies met the inclusion criteria and were included in the review. The findings showed that pain after nonsurgical root canal treatment occurred in 3-69.3% of patients. Microorganisms were identified as the primary contributors to postoperative pain, and there was no significant difference in postoperative pain between single- and multiple-visit treatments. Postoperative pain after root canal treatment ranges from mild to moderate and occurs even after optimally performed procedures. Furthermore, adequate management of postoperative pain is often considered an indicator of clinical excellence. Application of recently developed endodontic techniques and devices will reduce postoperative pain. Furthermore, a flexible, severity-based drug administration plan can be used to control and manage pain after root canal treatment. Application of the current research findings will reduce pain following root canal treatment and improve patient outcomes.
BACKGROUND: This review is an update of "Single dose oral ketoprofen and dexketoprofen for acute postoperative pain in adults" last updated in Issue 4, 2009. Ketoprofen is a non-selective nonsteroidal anti-inflammatory drug (NSAID) used to treat acute and chronic painful conditions. Dexketoprofen is the (S)-enantiomer, which is believed to confer analgesia. Theoretically dexketoprofen is expected to provide equivalent analgesia to ketoprofen at half the dose, with a consequent reduction in gastrointestinal adverse events. This review is one of a series on oral analgesics for acute postoperative pain. Individual reviews have been brought together in two overviews to provide information about the relative efficacy and harm of the different interventions.
OBJECTIVES: To assess the efficacy and safety of single dose oral ketoprofen and oral dexketoprofen compared with placebo for acute postoperative pain, using methods that permit comparison with other analgesics evaluated in the same way, and criteria of efficacy recommended by an in-depth study at the individual patient level.
SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from 2009 to 28 March 2017. We also searched the reference lists of retrieved studies and reviews, and two online clinical trial registries.
SELECTION CRITERIA: Randomised, double-blind, placebo-controlled trials of single dose orally administered ketoprofen or dexketoprofen in adults with moderate to severe acute postoperative pain.
DATA COLLECTION AND ANALYSIS: Two review authors independently considered studies for inclusion in the review, examined issues of study quality and potential bias, and extracted data. For dichotomous outcomes, we calculated risk ratio (RR) and number needed to treat for an additional beneficial outcome (NNT) or harmful outcome (NNH) with 95% confidence intervals (CI) for ketoprofen and dexketoprofen, compared with placebo, where there were sufficient data. We collected information on the number of participants with at least 50% of the maximum possible pain relief over six hours, the median time to use of rescue medication, and the proportion of participants requiring rescue medication. We also collected information on adverse events and withdrawals. We assessed the quality of the evidence using GRADE, and created 'Summary of findings' tables.
MAIN RESULTS: This updated review included 24 studies; six additional studies added 1001 participants involved in comparisons of ketoprofen or dexketoprofen and placebo, with a 12% increase in participants taking ketoprofen and a 65% increase for dexketoprofen. Most participants (70%) were women. Dental studies typically involved young participants (mean age 20 to 30 years); other types of surgery involved older participants (mean age 37 to 68 years). Overall, we judged the studies at high risk of bias only for small size, which can lead to an overestimation of benefit.Ketoprofen doses ranged between 6.5 mg and 150 mg. The proportion of participants achieving at least 50% pain relief over six hours with the usual ketoprofen oral dose of 50 mg was 57%, compared to 23% with placebo, giving an NNT of 2.9 (95% CI 2.4 to 3.7) (RR 2.5, 95% CI 2.0 to 3.1; 594 participants; 8 studies; high quality evidence). Efficacy was significantly better in dental studies (NNT 1.8) than other surgery (NNT 4.2). The proportion of participants using rescue medication within six hours was lower with ketoprofen (32%) than with placebo (75%), giving a number needed to treat to prevent use of rescue medication (NNTp) of 2.3 (95% CI 1.8 to 3.1); 263 participants; 4 studies; high quality evidence). Median time to remedication estimates were poorly reported. Reports of any adverse event were similar with ketoprofen (18%) and placebo (11%) (RR 1.6, 95% CI 0.98 to 2.8; 342 participants; 5 studies; high quality evidence). No study reported any serious adverse events (very low quality evidence).Dexketoprofen doses ranged between 5 mg and 100 mg. The proportion of participants achieving at least 50% pain relief over six hours with the usual dexketoprofen oral dose of 20 mg or 25 mg was 52%, compared to 27% with placebo, giving an NNT of 4.1 (95% CI 3.3 to 5.2) (RR 2.0, 95% CI 1.6 to 2.2; 1177 participants; 8 studies; high quality evidence). Efficacy was significantly better in dental studies (NNT 2.7) than other surgery (NNT 5.7). The proportion of participants using rescue medication within six hours was lower with ketoprofen (47%) than placebo (69%), giving an NNTp of 4.7 (95% CI 3.3 to 8.0); 445 participants; 5 studies; high quality evidence). Median time to remedication estimates were poorly reported. Reports of any adverse event were similar with dexketoprofen (14%) and placebo (10%) (RR 1.4, 95% CI 0.89 to 2.2; 536 participants, 6 studies; high quality evidence). No study reported any serious adverse events (very low quality evidence).
AUTHORS' CONCLUSIONS: Ketoprofen at doses of 25 mg to 100 mg is an effective analgesic in moderate to severe acute postoperative pain with an NNT for at least 50% pain relief of 2.9 with a 50 mg dose. This is similar to that of commonly used NSAIDs such as ibuprofen (NNT 2.5 for 400 mg dose) and diclofenac (NNT 2.7 for 50 mg dose). Dexketoprofen is also effective with an NNT of 4.1 in the dose range 10 mg to 25 mg. Differential efficacy between dental surgery and other types of surgery seen for both drugs is unusual. Both drugs were well tolerated in single doses.
BACKGROUND: Cannabinergic medications have been postulated to demonstrate efficacy in the management of pain. The aim of this systematic review was to assess the analgesic efficacy and adverse effects of cannabinoids when used for the management of acute pain.
METHODS: A systematic review was performed by searching the MEDLINE, EMBASE and CENTRAL databases, and the World Health Organization International Clinical Trials Registry Platform for human randomized controlled trials that assessed the analgesic efficacy of cannabinoids compared to placebo or active comparators. The reported outcomes for analgesic efficacy and adverse effects in included studies were qualitatively analysed.
RESULTS: Seven studies, including 611 patients were included in the systematic review. In five studies, cannabinoids were found to provide equivalent analgesia to placebo, in one study the analgesia provided by cannabinoids was superior to placebo, and in one study cannabinoids provided analgesia that was inferior to that provided by placebo. No synergistic or additive analgesic effect was observed when cannabinoids were used in combination with opioids. In five of the seven studies, certain adverse effects were more frequent with cannabinoid treatment than with placebo or active comparator.
CONCLUSION: On the basis of the available randomized controlled trial evidence, cannabinoids have no role in the management of acute pain.
Abstract Background Anti-inflammatory, analgesic, anticonvulsant, and other effects have been attributed to cannabis, and so it has been widely used to treat several diseases. Objective To assess the use and therapeutic effects of cannabinoid drugs and the cannabis plant in several diseases. Method We carried out a narrative review of the literature that has reported the use of the cannabis plant (marijuana) and cannabinoid drugs (nabilone, cannabinol and dronabinol, among others). We conducted a search in Medline, Cochrane, SciELO and other web sites. Clinical, controlled, double-blind and randomized studies were included. The route of administration and the cannabinoid drugs used were assessed too. Results Thirty-four studies were included. Nabilone was the cannabinoid drug more commonly used (12 studies), followed by delta-9-tetrahydrocannabinol (THC) (11 studies). It was also found that the marijuana plant and cannabinoid drugs were used to treat many symptoms or diseases. Two studies were reported for Gilles de la Tourette's syndrome. Discussion and conclusion Many scientific studies on the marijuana plant and cannabinoid drugs conclude that these are not as effective as conventional medications and thus their benefits should be taken with caution.
BACKGROUND: Diclofenac is a nonsteroidal anti-inflammatory drug, available as a potassium salt (immediate release) or sodium salt (enteric coated to suppress dissolution in the stomach). This review updates an earlier review published in the Cochrane Database of Systematic Reviews (Issue 2, 2009) entitled 'Single dose oral diclofenac for acute postoperative pain in adults'.
OBJECTIVES: To assess the analgesic efficacy and adverse effects of a single oral dose of diclofenac for moderate to severe postoperative pain, using methods that permit comparison with other analgesics evaluated in standardised trials using almost identical methods and outcomes.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Oxford Pain Relief Database, two clinical trial registries, and the reference lists of articles. The date of the most recent search was 9 March 2015.
SELECTION CRITERIA: Randomised, double-blind, placebo-controlled clinical trials of single dose, oral diclofenac (sodium or potassium) for acute postoperative pain in adults.
DATA COLLECTION AND ANALYSIS: Two review authors independently considered studies for inclusion in the review, assessed risk of bias, and extracted data. We used the area under the pain relief versus time curve to derive the proportion of participants with at least 50% pain relief over six hours prescribed either diclofenac or placebo. We calculated the risk ratio (RR) and number needed to treat to benefit (NNT). We used information on the use of rescue medication to calculate the proportion of participants requiring rescue medication and the weighted mean of the median time to use. We also collected information on adverse effects.
MAIN RESULTS: This update included three new studies, providing a 26% increase in participants in comparisons between diclofenac and placebo. We included 18 studies involving 3714 participants, 1902 treated with diclofenac and 1007 with placebo. This update has also changed the focus of the review, examining the effects of formulation in more detail than previously. This is a result of increased understanding of the importance of speed of onset in determining analgesic efficacy in acute pain.The largest body of information, for diclofenac potassium 50 mg, in seven studies, produced an NNT for at least 50% of maximum pain relief compared with placebo of 2.1 (95% confidence interval (CI) 1.9 to 2.5) (high quality evidence). There was a graded improvement in efficacy as doses rose from 25 mg to 100 mg, both for participants achieving at least 50% maximum pain relief, and for remedication within 6 to 8 hours. Fast-acting formulations (dispersible products, solutions, and softgel formulations) had a similar efficacy for a 50 mg dose, with an NNT of 2.4 (2.0 to 3.0). Diclofenac sodium in a small number of studies produced a lesser effect, with an NNT of 6.6 (4.1 to 17) for the 50 mg dose.Adverse event rates were low in these single dose studies, with no difference between diclofenac and placebo (moderate quality evidence).
AUTHORS' CONCLUSIONS: Diclofenac potassium provides good pain relief at 25 mg, 50 mg, and 100 mg doses. Diclofenac sodium has limited efficacy and should probably not be used in acute pain.
