A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars
Introduction
The removal of third molar teeth in a day case setting has become popular with patients, healthcare trusts and oral surgeons. As well as alertness and rapid recovery from anaesthesia, well-controlled pain is another indication for discharging a patient home.1 Postoperative analgesia may be achieved by the use of local anaesthesia or by giving non-steroidal anti-inflammatory drugs (NSAIDS), opioids, or a combination. The pre-emptive use of a non-steroidal anti-inflammatory drug before operation may be more beneficial than its use after operation2 and opioids are also more effective if given before rather than after operation.3., 4., 5. Pre-emptive local anaesthesia has no advantages over its postoperative use.6., 7., 8. A preoperative oral COX-2-specific inhibitor, valdecoxib also provided well-tolerated and effective analgesia for mild to moderate postoperative pain.9 Pre-emptive analgesia prevents establishment of central sensitisation caused by incisional and inflammatory injuries. It starts before incision and covers both the period of operation and the initial postoperative period.10
In this randomised, double-blind, placebo-controlled trial, we wanted to find out if there was any benefit in using pre-emptive ibuprofen 600 mg, diclofenac 100 mg, paracetamol 1 g with codeine 60 mg or placebo (Vitamin C 50 mg) tablets in patients having removal of third molar teeth as day cases.
Section snippets
Method
One hundred and twenty-five patients in American Society of Anesthesiologists grades 1 and 2 who were to have third molar teeth removed under general anaesthesia were invited to participate in the study. The approval of the Regional Ethics Committee was obtained and all patients gave written informed consent to participate. They were randomly assigned immediately after consent had been obtained to be given 1 h preoperatively either ibuprofen 600 mg or diclofenac 100 mg or paracetamol 1 g + codeine
Patients
Of 125 patients, 5 (4%) withdrew from the study during the postoperative period. One patient developed bronchospasm during induction of anaesthesia and required admission to hospital overnight. He was withdrawn from the study. Of the remaining 119 patients, 31 (26%) were in the ibuprofen group, 29 (24%) were in the diclofenac group, 30 (25%) were in the paracetamol + codeine group, and 29 (24%) were in the placebo group. Thirty-three men and 86 women participated in the study. Their mean age
Discussion
Management of pain after third molar operations is important particularly as most patients are treated as day-cases. Postoperative non-steroidal anti-inflammatory drugs such as ibuprofen11., 12., 13., 14. and paracetamol with codeine14., 15. have been reported to be effective after removal of third molars. Basic scientific evidence suggests that an analgesic given before operation should produce a better outcome than the same drug given after operation. Reviews of clinical findings have been
Acknowledgements
We thank the staff of the Oral Surgery Day-case Unit at the Manchester Royal Infirmary.
References (25)
- et al.
Preoperative morphine pre-empts postoperative pain
Lancet
(1993) - et al.
Is there any clinical advantage of increasing the pre-emptive dose of morphine or combining pre-incisional with postoperative morphine administration?
Br. J. Anaesth.
(1995) - et al.
Pre-emptive analgesia using local anaesthesia: a study in bilaterally symmetrical surgery
Br. J. Anaesth.
(1997) - et al.
Balanced pre-emptive analgesia: does it work? A double-blind, controlled study in bilaterally symmetrical oral surgery
Br. J. Anaesth.
(1998) - et al.
The Comparative Efficacy of Aceclofenac and Ibuprofen in post-operative pain after third molar surgery
Br. J. Oral Maxillofac. Surg.
(1998) - et al.
Are the Pharmacokinetics of Ibuprofen important determinants for the drugs efficacy in post-operative pain after third molar surgery?
Br. J. Oral Maxillofac. Surg.
(1997) - et al.
Evaluation of oxycodone and acetaminophen in the treatment of post-operative dental pain
Oral Surg., Oral Med., Oral Pathol.
(1980) - et al.
The value of pre-emptive analgesia in the treatment of post-operative pain
Br. J. Anaesth.
(1993) - et al.
Comparison of pre-operative and post-operative diflunisal for suppression of post-operative pain
J. Oral Maxillofac. Surg.
(1989) - et al.
A comparison of pre-operative and post-operative naproxen sodium for suppression of post-operative pain
J. Oral Maxillofac. Surg.
(1990)
The absence of any pre-emptive analgesic effect for non-steroidal anti-inflammatory drugs
Br. J. Oral Maxillofac. Surg.
Anaesthesia for day case surgery
Br. J. Hosp. Med.
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