Following root canal treatment postoperative pain is not uncommon with 25-40% of patients reporting problems. Non-steroidal anti-inflammatory drugs are often used for the management of this pain either alone or in combinations.
The aim of this review was to evaluate the efficacy of non-narcotic analgesics including non- steroidal anti-inflammatory drugs (NSAIDs) and/or paracetamol in the treatment of post-operative endodontic pain.
Methods
Searches were conducted in the Medline, Cochrane Library, Scopus, Science Directs Google Scholar, Networked Digital Library of Thesis and Dissertations, and the Pro-Quest Digital Dissertation and Index to Thesis databases.
Randomised placebo-controlled trials (RCTs) in patients over 15 years of age having non-surgical root canal treatment (RoCTs) were considered. The outcome measure was post-operative pain intensity or pain relief within the first 24 hours.
Two reviewers independently selected studies. Data was abstracted and risk of bias assessed using the Cochrane tool. Standardised mean difference (SMD) was calculated and data pooled using the random-effect inverse variance approach. Meta-regression was conducted to examine the associations between effect sizes and study-level covariates.
Results
- 27 RCTs involving a total of 2188 patients were included.
- 24 RCTs used single-dose drugs, 3 used multiple doses.
- 22 RCTs used a single agent with 23 using combination agents.
- Meta-analysis showed statistically significant improvement in pain scores for NSAIDs compared with placebo at each of the post-operative time points.
| Pain scores | No. of studies | Standardised mean difference (95%CI) |
| immediately after the procedure | 8 | -0.50 (-0.70, -0.30) |
| At 6 hours | 20 | -0.76 (-0.95, -0.56) |
| At 12 hours | 15 | -1.15 (-1.52, -0.78) |
| At 24 hrs | 15 | -0.65 (-1.05, -0.26) |
Conclusions
The authors concluded: –
that the clinicians can manage post-operative endodontic pain by administration of NSAIDs and/or paracetamol. However, analgesic regimens should be considered as important determinants when prescribing a pharmacological adjuvant.
Comments
The authors of this review have conducted a broad search and included only placebo-controlled RCTs. While the selection of studies is clear described as being conducted independently by two reviewers there is less clarity regarding the data abstraction and the risk of bias assessment. Earlier this year (Dental Elf -18th Jan 2017 ) we considered a review addressing this same topic. This has slightly different inclusion criteria and included only 15 studies compared with the 27 for this review. Only 8 of the included studies are common to both reviews. IT is also interesting to note that of the 8 common studies there are differences in the risk of bias assessment even those both groups of researchers used the same Cochrane assessment tool. In general, the risk of bias assessments in this current review are more generous than in the earlier review.
Both reviews find that NSAIDs have a significant effect on post-endodontic pain and while this review focuses on pain reduction the other review focuses more on the type of NSAID. As the studies were placebo controlled trials further high quality studies directly comparing the effectiveness of different types of NSAIDs would be useful, although a large number of pain systematic review have been carried out by the Cochrane Pain, Palliative and Supportive Care Group which provide useful information on the comparative effectiveness of NSAIDs.
Links
Primary paper
Shirvani A, Shamszadeh S, Eghbal MJ, Asgary S. The efficacy of non-narcotic analgesics on post-operative endodontic pain: A systematic review and meta-analysis: The efficacy of non-steroidal anti-inflammatory drugs and/or paracetamol on post-operative endodontic pain. J Oral Rehabil. 2017 Apr 27. doi: 10.1111/joor.12519. [Epub ahead of print] Review. PubMed PMID: 28449307.
Other references
Cochrane Pain, Palliative and Supportive Care Group
Dental Elf -18th Jan 2017
Endodontic postoperative pain: which non-steroidal anti-inflammatory drug?
