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.
ANTECEDENTES:
Esta revisión actualiza una revisión Cochrane de 1999 que indicó que el ibuprofeno a diversas dosis era eficaz para los dolores posoperatorios en estudios de dosis única diseñados para demostrar la eficacia analgésica. Desde entonces se han publicado nuevos estudios. El ibuprofeno es uno de los analgésicos antiinflamatorios no esteroides (AINE) más ampliamente usados, tanto por prescripción médica como sin prescripción. El ibuprofeno se utiliza para afecciones que causan dolor agudo y crónico.
OBJETIVOS:
Evaluar la eficacia analgésica del ibuprofeno en dosis oral única para el dolor posoperatorio de moderado a grave en pacientes adultos.
ESTRATEGIA DE BÚSQUEDA:
Se hicieron búsquedas de estudios en Cochrane CENTRAL, MEDLINE, EMBASE y en la Oxford Pain Relief Database hasta mayo 2009.
CRITERIOS DE SELECCIÓN:
Ensayos controlados con placebo, doble ciego, aleatorios de dosis única de ibuprofeno administrado por vía oral (cualquier formulación) en adultos con dolor posoperatorio agudo de moderado a intenso.
RECOPILACIÓN Y ANÁLISIS DE DATOS:
Dos autores de la revisión evaluaron de forma independiente la calidad de los ensayos y extrajeron los datos. Se extrajeron datos sobre el alivio del dolor o la intensidad del dolor, y se convirtieron en resultados dicotómicos sobre el número de participantes con al menos un 50% de alivio del dolor de cuatro a seis horas, con los que se calculó el riesgo relativo y el número necesario a tratar (NNT) para que resulte en un beneficio. El número de participantes con medicación de rescate durante períodos específicos, y el momento adecuado para el uso de medicación de rescate, se buscaron como medidas adicionales de eficacia. Se recopiló información sobre los retiros y los eventos adversos.
RESULTADOS PRINCIPALES:
Setenta y dos estudios compararon ibuprofeno y placebo (9186 participantes). Los estudios eran predominantemente de alta calidad de información, y la mayor parte de la información se refería a ibuprofeno de 200 mg y 400 mg. Para el grupo de al menos un 50% de alivio del dolor en comparación con placebo, el NNT para el ibuprofeno de 200 mg (2690 participantes) era de 2,7 (2,5 a 3,0) y para el ibuprofeno de 400 mg (6475 participantes) era de 2,5 (2,4 a 2,6). La proporción con al menos el 50% de alivio del dolor era del 46% con 200 mg y del 54% con 400 mg. La necesidad de volver a medicar dentro de las seis horas fue menos frecuente con las dosis mayores, el 48% de los pacientes requirieron medicación adicional con 200 mg y el 42% con 400 mg. La mediana de tiempo transcurrido hasta la remedicación fue de 4,7 horas con 200 mg y 5,4 horas con 400 mg. El análisis de sensibilidad indicó que tanto el modelo de dolor como la formulación farmacéutica del ibuprofeno pueden afectar el resultado, ya que con modelos de implantes dentales y sales solubles de ibuprofeno se produjeron mejores estimaciones de eficacia. Los eventos adversos fueron poco frecuentes y similares a los del placebo.
CONCLUSIONES DE LOS AUTORES:
La gran cantidad de pruebas de alta calidad demuestra que el ibuprofeno es un analgésico eficaz para tratar el dolor posoperatorio. El NNT para los 200 mg y los 400 mg de ibuprofeno no varió significativamente de la revisión anterior, a pesar de haberse agregado una cantidad apreciable de nueva información. Se proporcionó nueva información sobre la remedicación.
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.
