Surgical removal of third molars is a very common procedure and postoperative pain is a major concern for patients. Non-steroidal anti-inflammatory drugs are (NSAIDs) frequently recommended to manage this pain.   Ibuprofen and paracetamol commonly used and recently a combination analgesic containing both paracetamol and ibuprofen has become available in the UK. The aim of this review was to compare the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth, at different doses and administered postoperatively.

The usual Cochrane approaches were taken with searches being undertaken in the Cochrane Oral Health Group’s Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Medline; Embase and the metaRegister of Controlled Trials. Only randomised controlled double-blinded clinical trials using the third molar model were included. The proportion of patients with at least 50% pain relief (based on total pain relief (TOTPAR) and summed pain intensity difference (SPID) data) was calculated for all three drugs at both two and six hours post-dosing and meta-analysed for comparison.

• 7 parallel-group studies  [involving 2241 patients] were included. (2 were at low risk of bias, 3 high risk and 2 unclear).
• Ibuprofen was found to be a superior analgesic to paracetamol at several doses
  • High quality evidence suggests that ibuprofen 400 mg is superior to 1000 mg paracetamol based on pain relief (estimated from TOTPAR data) and the use of rescue medication meta-analyses.
  • Risk ratio for at least 50% pain relief (based on TOTPAR) at six hours was 1.47 (95% confidence interval (CI) 1.28 to 1.69; five trials) favouring 400 mg ibuprofen over 1000 mg paracetamol,
  • Risk ratio for not using rescue medication (also favouring ibuprofen) was 1.50 (95% CI 1.25 to 1.79; four trials).

• The combined drug showed promising results,
  • Risk ratio for at least 50% of the maximum pain relief over six hours of 1.77 (95% CI 1.32 to 2.39) (paracetamol 1000 mg and ibuprofen 400 mg) (one trial; moderate quality evidence),
  • Risk ratio not using rescue medication 1.60 (95% CI 1.36 to 1.88) (two trials; moderate quality evidence).
• The information available regarding adverse events from the studies (including nausea, vomiting, headaches and dizziness) indicated that they were comparable between the treatment groups, but no formal analysis could be undertaken.

The authors concluded

There is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively. The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice. The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.

Comment

As the authors note in their discussion based on previous Cochrane reviews the number needed to treat (NNT) for 400 mg ibuprofen is 2.3 (95% CI, 2.2 to 2.4) compared with 3.6 (95% CI, 3.2 to 4.0) for 975 mg to 1000 mg paracetamol.  This review confirms the superiority of ibuprofen over paracetamol although the new combination drug shows promise, and as the authors note the basis for developing combination analgesics is that enhanced pain relief can potentially be achieved from two drugs with different modes of action using a lower dose and with reduced side effects.

Links

Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD004624. DOI: 10.1002/14651858.CD004624.pub2.

Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010210. DOI: 10.1002/14651858.CD010210.pub2

Dental Elf  5^th June 2012  – Taking ibuprofen before wisdom tooth removal does not appear to be more effective for controlling post operative pain