An interesting article titled “Acute Postoperative Pain Due to Dental Extraction in the Adult Population: A Systematic Review and Network Meta-analysis,” written by A. Miroshnychenko and et. al appears in the 2023 edition of the Journal of Dental Research. The article seeks to conduct a systematic review and meta-analysis to assess tto compare the effectiveness of 10 different pharmacological treatments including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids, to the management of acute pain after dental tooth extractions. Further the article looked at the pain associated with pulpitis or its complications.
The authors were motived to conduct the review based on the opioid crisis occuring in North America which has been discussed before on this site, see for example the posts Assessing the Impact of Three Day Opioids Limits for Dentists, Dentists Overprescribing Opioids to Adults in the U.S., and Reducing Opioids in Oral and Maxillofacial Surgery. In this study, the authors performed searches in Medline, EMBASE, CENTRAL, and US Clinical Trials registry through November 21, 2020. The authors screened a total of 4,716 titles and abstracts, and included 85 unique randomized clinical trials that were reported in 82 articles. The majority of the studies were conducted in the United States (75%) with the number of those in the study ranging from 31 to 540.
Fifty-six trials with 9,095 participants looked at pain relief and found that the most effective were ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg, acetaminophen 650 mg plus oxycodone 10 mg, ibuprofen 400 mg, and naproxen 400 to 440 mg. Forty-four trials with 7,282 participants looked at total pain relief and found that the most effective were ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg, acetaminophen 650 mg plus oxycodone 10 mg, ibuprofen 400 mg, and naproxen 400 to 440 mg. Thirty-one trials with 6,721 participants looked at summed pain intensity difference and found that the most effective were acetaminophen 650 mg plus oxycodone 10 mg and ibuprofen 400 mg. The authors state:
“Based on moderate- and high-certainty evidence, in individuals undergoing surgical tooth extractions, the interventions classified as the most effective for pain relief were ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg, acetaminophen 650 mg plus oxycodone 10 mg, ibuprofen 400 mg, and naproxen 400 to 440 mg.”
It was found that oxycodone 5 mg or codeine 60 mg and tramadol 37.5 mg plus acetaminophen 325 mg were not any more effective than a placebo for pain relief after tooth extraction. Therefore, the authors found that except for acetaminophen 650 mg plus oxycodone 10 mg, nonsteroidal anti-inflammatory drugs with or without acetaminophen were more effective at pain releif than opioids.
The authors noted that results for ibuprofen 200 mg plus hydrocodone 5 mg and hydrocodone 5 mg plus acetaminophen 300 to 325 mg were not available and should be the foucs of future research since oral surgeons like to this combination to manage of pain after wisdom teeth extractions. The results of the current study can be used to help inform evidence-based clinical practice guidelines for the managing dental pain being devloped by the ADA’s Council on Scientific Affairs, the ADA Science & Research Institute, and the University of Pittsburgh and the University of Pennsylvania schools.