Dental Study: Effectiveness of Non-opiate Pain Relievers vs. Oxycodone and Codeine

Tuesday, April 10, 2018
Author: 

R.L. Wynn

The appropriateness and safety of pain relievers are an issue of great concern for all prescribers, including dental professionals. A study published in 2017 sought to determine current evidence on postoperative strategies to reduce inflammatory complications such as pain, swelling, trismus, infection, and alveolar osteitis after third molar removal, comparing non-opiate pain relief options with opiates.

For pain reduction, the non-opiates acetaminophen and ibuprofen received the highest level strength of evidence for effectiveness compared to the opiates oxycodone and codeine. In addition to presenting evidence on other postoperative strategies, this study provided more data to support the use of non-opiates as the more preferred treatment of pain and swelling compared to opioids. 

The report can be accessed at: Cho, H; Lynham, AJ; Hsu, E. “Postoperative interventions to reduce inflammatory complications after third molar surgery: review of the current evidence.” Australian Dental Journal 2017; 62:412-419.

Study Methods

The study authors were from the School of Medicine, University of Queensland, and the Maxillofacial Unit, Royal Brisbane and Women’s Hospital, Queensland, Australia.

A literature search was conducted using four databases:

  1. PubMed
  2. Cochrane Library
  3. ScienceDirect
  4. Google Scholar

The review was limited to studies published from 2000 to 2016. Only postoperative interventions employed after patients’ discharge were included. Search terms included:

  • Molar
  • Third
  • Postoperative
  • Complications

Along with additional key words, including:

  • Pain
  • Swelling
  • Edema
  • Trismus
  • Infection
  • Alveolar osteitis
  • Dry socket

Results

A total of 221 papers were included in the literature review. In the past, the interventions that were frequently used postoperatively were analgesics, corticosteroids, antibiotics, and chlorhexidine mouthwash. These were evaluated according to postoperative effect, grade of recommendation, and level of evidence of the recommendation. The National Health and Medical Research Council (Australian government) body of evidence matrix and evidence hierarchy were applied to determine the grades of recommendations (A through D) and levels of evidence with I being the highest level and IV the lowest.

A summary of postoperative interventions and strength of evidence follows:

Acetaminophen – 1000 mg doses decrease pain

  • Safe and effective for the treatment of postoperative pain following third molar removal
  • Recommendation grade of A, meaning that the body of evidence can be trusted to guide practice
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Ibuprofen – 400 mg doses decrease pain

  • Recommendation grade of A, meaning that the body of evidence can be trusted to guide practice
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Codeine – 30 to 60 mg doses MAY decrease pain

  • Recommendation grade of C, meaning that the body of evidence provides some support for the recommendation, but care should be taken in its application
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Oxycodone – 5 to 10 mg doses decrease pain

  • Recommendation grade of B, meaning that the body of evidence can be trusted to guide practice in most situations
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Corticosteroids – decrease swelling and trismus and MAY reduce pain

  • Drug, route, and dosing require clarification
  • Recommendation grade of A, meaning that the body of evidence can be trusted to guide practice
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Postoperative antibiotics – should NOT be routinely prescribed

  • Recommendation grade of A, meaning that the body of evidence can be trusted to guide practice
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Chlorhexidine mouthwash – decreases risk of dry socket

  • Used on day of surgery and twice daily for 1 week
  • Recommendation grade of A, meaning that the body of evidence can be trusted to guide practice
  • Strength of evidence I (highest level), defined as “from systematic review of published randomized controlled trials”

Discussion

The authors cite specific studies uncovered in the review that provided additional information not described in the results section:

  • Acetaminophen and anti-inflammatory drugs are widely used and are the mainstay for many practitioners. The efficacy of this combination has been repeatedly demonstrated, and they are routinely recommended.
    • From Oral and Dental Expert Group. Therapeutics guidelines: oral and dental, 2nd ed. 2012; 145-155.
  • The combination of ibuprofen (400 mg) and acetaminophen (1000 mg) appeared to be more effective than the drugs taken singly when measured at 6 hours after third molar removal.
    • From Baily F. et al. Br Dent J. 2014; 216: 451-455 and Moore RA, et al. Cochrane Database Syst Rev 2015; 11: CD010794.
  • Current body of evidence for acetaminophen/codeine combination use postoperatively is not as strong as that for acetaminophen/ibuprofen.
    • From Macleod AG et al. Aust Dent J 2002; 47:147-151.
  • For corticosteriods, multiple reviews have demonstrated steroids to be safe when used as a short course, but the case for routine use to prevent inflammatory complications has not been substantiated.
    • From Kim, K, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: 630-640 and Ngeow, WC, et al. Adv Ther 2016; 33: 1105-1139.
  • Corticosteroids helped to reduce edema and trismus in the early (1-3 days) and late (> 3 days) postoperative phases. However, any effect on pain could not be determined.
    • From Markiwicz, MR, et al. J Oral Maxillofac Surg 2008; 66: 1881-1894.
  • Corticosteroids statistically decrease inflammation and trismus; the parenteral route, prior to surgery, was the most favorable in terms of reducing inflammation.
    • From Herrera-Briones, FJ, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2013; 116: e351.
  • Swelling peaks 48 to 72 hours after removal of bilateral impacted third molars. Corticosteroids, when administered, should be at a dose equivalent to 300 mg hydrocortisone (e.g., 60 mg prednisone) and be continued for 3 to 5 days for maximum benefit.
    • From Kim, K, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: 630-640.
  • For antibiotics, their role in prophylaxis is well established for specific surgical procedures, such as prevention of infective endocarditis. Their role in routine third molar surgery is not so clear. From 16 clinical trials with a total of 2932 patients, it was concluded that preoperative antibiotics reduced alveolar osteitis by 0.1 % and wound infection by 4%, with a number needed to treat of 25 patients to avoid one such complication.
    • From Ren, YF; Malstrom, HS. J Oral Maxillofac Surg 2007; 65: 1909-1921.
  • For every 21 people who receive antibiotics, a minor adverse reaction to antibiotics is likely. Thus, the routine prescription of antibiotics for healthy people undergoing extraction of third molars could not be supported.
    • From Lodi, G, et al. Cochrane Database Syst Rev 2012; 11: CD003811.
  • Mouthwashes have the benefit of acting locally at the surgical site as well as providing mechanical debridement. The gold standard is considered to be chlorhexidine for its ability to reduce plaque, broad spectrum activity against oral aerobes and anaerobes, general tolerability, and lack of bacterial resistance.
    • From Osunda, OD, et al. J Oral Maxillofac Surg 2014; 43: 649-653.
  • There is strong evidence to support the use of chlorhexidine as a rinse following third molar removal. The use of chlorhexidine mouth rinse 0.12% on the day of surgery and used for 7 days postoperatively produced a significant reduction in alveolar osteitis.
    • From Caso, A, et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 155-159.
  • If prevalence of dry socket with no intervention is 5%, then the numbers needed to treat with chlorhexidine to prevent one patient having a dry socket is 47.
    • From Daly, et al. Cochrane Database Syst Rev 2012; 12: CD006968.

Conclusion

The study reviewed the different modalities to reduce inflammatory complications after third molar removal. From the literature review, the following was be concluded:

  1. There was strong evidence for the use of acetaminophen and ibuprofen to manage postoperative pain
  2. Antibiotics reduce infection when used as surgical prophylaxis, but should not be used in healthy patients undergoing routine third molar removal
  3. Corticosteroids reduce swelling and trismus after surgery; however they should only be used in selected cases
  4. Chlorhexidine mouthwash has been proven unequivocally to be efficacious in reducing alveolar osteitis

Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.

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