The removal of lower third molars under local anaesthesia is a commonly performed procedure. Post-operative pain is common and while some pain relief is provided by the duration of the local anaesthesia additional relief relies on the use of systemic analgesics. There is high quality evidence that ibuprofen is better than paracetamol in the management of post-operative pain and some evidence that paracetamol and ibuprofen combined is more effective than ibuprofen alone at six hours after surgery (Dental Elf – 21st Jan 2014). Theoretically pre-operative analgesia may be more effective that post-operative regimes, however, studies have shown inconsistent results.
The aim of this review was to assess the effect of pre-emptive ibuprofen on post-operative pain after lower third molar surgery.
Methods
Searches were conducted in the Medline, Embase, Cochrane Central and Dentistry and Oral Sciences Source. Independent double screening was carried out. Randomised controlled trials (RCTs) in adults having lower third molar tooth removal under local anaesthetic comparing the effect of pre-emptive ibuprofen with pre-emptive placebo and published in English were considered. RCTs involving multiple doses or additional analgesic drugs administered pre- or post-operatively were excluded. Included studies were assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. A narrative summary was presented.
Results
- 5 RCTs (2 parallel, 3 split mouth) involving a total of 324 patients and 425 surgeries were included.
- 1 study was considered to have a low risk of bias and 4 some concerns.
- 4 studies reported on pain intensity 2 studies reported a significant reduction and two no difference between the ibuprofen and placebo groups.
- 1 RCT reported that total pain relief (TOPAR) scores over 8 hours and 12 hours were significantly better in the ibuprofen group compared with placebo
- 4 studies reported on time to rescue medicine use with one reported a significantly longer time to use in the ibuprofen group compared with placebo and another a significantly shorter.
- Total consumption of rescue medication was reported in 2 RCTs with no statistically significant difference between ibuprofen and placebo groups.
- 2 studies reported on the proportion of participants requesting rescue analgesia which was greater in the placebo group.
Conclusions
The authors concluded: –
There is insufficient evidence to support the routine use of pre-emptive ibuprofen to reduce post-operative pain after lower third molar removal. Further well-designed randomised controlled trials are required to accurately assess the value of pre-emptive analgesics.
Comments
A good range of databases were searched for this review although only English language papers were considered which may have excluded some relevant studies. In addition, the review was not registered on a prospective register like PROSPERO as a result no protocol is available. The authors did not indicate that they were following the PRISMA reporting guideline and while a PRISMA flow diagram is presented there is a lack of methodological detail. Only a small number of RCTs were included and only one was considered to be of low bias the remainder having concerns related to a limited detail about randomisation and allocation concealment. Because of variations between included studies in the type and recording of outcomes no meta-analyses was possible. The direction of findings between the studies also varied so a conclusion of insufficient information was easy to draw. A good discussion of some of the challenges to measuring outcomes in this area is provided in the review and future studies would benefit from some agreement over a common outcomes set (COMET). Any new studies should be of appropriate size well designed and conducted and reported in line with SPIRIT and CONSORT guidelines .
Links
Primary Paper
Gately F, Ali K, Burns L. The effect of pre-emptive ibuprofen on post-operative pain after removal of lower third molar teeth: a systematic review. Evid Based Dent. 2022 Mar 4. doi: 10.1038/s41432-021-0211-1. Epub ahead of print. PMID: 35246613.
Other references
Dental Elf – 5th Jun 2012
Dental Elf – 21st Jan 2014
Ibuprofen more effective than paracetamol for postoperative pain following third molar removal
