Paracetamol for pain relief after surgical removal of lower wisdom teeth: Cochrane systematic review
Assessed as up to date: 2006/08/24
Paracetamol has been commonly used for the relief of postoperative pain following oral surgery. In this review we investigated the optimal dose of paracetamol and the optimal time for drug administration to provide pain relief, taking into account the side effects of different doses of the drug. This will inform dentists and their patients of the best strategy for pain relief after the surgical removal of wisdom teeth.Objectives
To assess the beneficial and harmful effects of paracetamol for pain relief after surgical removal of lower wisdom teeth, compared to placebo, at different doses and administered postoperatively.Search methods
We searched the Cochrane Oral Health Group's Trials Register; the Cochrane Pain, Palliative and Supportive Care Group's Trials Register; CENTRAL; MEDLINE; EMBASE and the Current Controlled Trials Register. Handsearching included several dental journals. We checked the bibliographies of relevant clinical trials and review articles for studies outside the handsearched journals. We wrote to authors of the identified randomised controlled trials (RCTs), to manufacturers of analgesic pharmaceuticals, we searched personal references in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied. The last electronic search was conducted on 24th August 2006.Selection criteria
Randomised, parallel group, placebo controlled, double blind clinical trials of paracetamol for acute pain, following third molar surgery.Data collection and analysis
All trials identified were scanned independently and in duplicate by two review authors, any disagreements were resolved by discussion, or if necessary a third review author was consulted. The proportion of patients with at least 50% pain relief was calculated for both paracetamol and placebo. The number of patients experiencing adverse events, and/or the total number of adverse events reported were analysed.Main results
Twenty-one trials met the inclusion criteria. A total of 2048 patients were initially enrolled in the trials (1148 received paracetamol, and 892 the placebo) and of these 1968 (96%) were included in the meta-analysis (1133 received paracetamol, and 835 the placebo). Paracetamol provided a statistically significant benefit when compared with placebo for pain relief and pain intensity at both 4 and 6 hours. Most studies were found to have moderate risk of bias, with poorly reported allocation concealment being the main problem. Risk ratio values for pain relief at 4 hours 2.85 (95% confidence interval (CI) 1.89 to 4.29), and at 6 hours 3.32 (95% CI 1.88 to 5.87). A statistically significant benefit was also found between up to 1000 mg and 1000 mg doses, the higher the dose giving greater benefit for each measure at both time points. There was no statistically significant difference between the number of patients who reported adverse events, overall this being 19% in the paracetamol group and 16% in the placebo group.Authors' conclusions
Paracetamol is a safe, effective drug for the treatment of postoperative pain following the surgical removal of lower wisdom teeth.
Weil Kiaran, Hooper Lee, Afzal Zahid, Esposito Marco, Worthington Helen V, van Wijk Arjen, Coulthard Paul
Paracetamol for pain relief after surgical removal of lower wisdom teeth
The surgical removal of wisdom teeth (third molars) is the most commonly performed surgical procedure undertaken in oral surgery practice. Postoperative complications may include swelling, bruising and limited mouth opening but patients are most often concerned about postoperative pain, which may be severe. Paracetamol is effective in relieving pain with a low incidence of adverse effects. It is one of the most commonly used analgesics and is widely available without prescription around the world. In this review we investigated the optimal dose of paracetamol and the optimal time for drug administration to provide pain relief after the surgical removal of wisdom teeth. The side effects of different doses of the drug were also explored.
Twenty-one trials (with over 2000 participants) were included. Paracetamol provided a statistically significant benefit when compared with placebo for pain relief at both 4 and 6 hours after taking the drug. It is most effective at 1000 mg dose, and can be taken at six hourly intervals without compromising safety. There was no statistically significant difference between the number of patients who reported adverse events, overall this being 19% in the paracetamol group and 16% in the placebo group. It should be noted that most of the studies were found to have some limitations mainly due to poor reporting of information. However the review concludes that paracetamol is a safe, effective drug for the treatment of postoperative pain following the surgical removal of lower wisdom teeth.
Implications for practice
Paracetamol (acetaminophen) is an effective drug to use for postoperative pain following oral surgery, and the reporting of adverse events shows it to be a safe drug (number needed to treat (to benefit) (NNT) is 3 for 1000 mg of paracetamol at 6 hours, number needed to treat to harm (NNTH) 33). It is most effective at 1000 mg dose, and can be taken at six hourly intervals without compromising safety. It could be considered more readily by dentist and patients both as a first choice analgesic, or to be taken alternately with doses of other analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDS).
Implications for research
There is a large body of research in this area, and further research, other than as a comparison seems unnecessary. However, in one trial (Moller 2000) it was found that an effervescent formulation appeared to have a faster onset of pain relief, which would be beneficial to patients who are looking for a rapid onset of relief. It may be helpful to undertake some research to confirm these findings. The use of pain relief and pain intensity difference as a measure of pain relief may be another area for further investigation. It is valuable to have NNT/NNTH as a baseline for comparison with other analgesics. Maximizing the third molar pain model population by multidisciplinary research is another area of interest highlighted by this review.Get full text at The Cochrane Library
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