Page 322 Acute Pain Management

(either alone or in combination) (Ahmad et al, 1997 Level I) and ketorolac provided better
analgesia with fewer adverse effects than pethidine (Fricke et al, 1992 Level II) or tramadol
(Ong & Tan, 2004 Level II). The combination of paracetamol 1000 mg with ketoprofen 100 mg
was more effective than either drug given alone (Akural et al, 2009 Level II).
Coxibs were of similar efficacy to nsNSAIDs in acute postoperative dental pain (Chen et al, 2004
Level I; Cicconetti et al, 2004 Level I). A single dose of celecoxib 400 mg provided similar analgesia
to ibuprofen 400 mg, however with a longer duration of action and increased time to rescue
analgesia following dental surgery (Cheung et al, 2007 Level II). A combination of oxycodone
5 mg /ibuprofen 400 mg was more effective than various other combinations of paracetamol,
ibuprofen, oxycodone or hydrocodone or placebo for analgesia following dental surgery
(Litkowski et al, 2005 Level II). Tramadol 100 mg had a similar efficacy to aspirin/opioid or
paracetamol/opioid combinations in treating acute dental pain (Moore & McQuay, 1997 Level I).
A tramadol/paracetamol combination was superior to tramadol alone with fewer adverse
effects (Edwards, McQuay et al, 2002 Level I; Fricke et al, 2004 Level II).
Perioperative steroid administration reduced swelling and trismus but not pain, following third
molar extraction (Markiewicz et al, 2008 Level I) and reduced postoperative nausea (Baxendale et
al, 1993 Level II; Schmelzeisen & Frolich, 1993 Level II).

Note: reversal of conclusion
This reverses the Level 1 conclusion in the previous edition of this
document; an earlier meta‐analysis reported an improvement in
analgesia.

A single postoperative IM injection of prednisolone combined with diclofenac reduced pain
for the first 7 hours postextraction and reduced swelling and trismus at various times up to
7 days, compared with placebo; prednisolone alone reduced pain at 7 hours and swelling on
day 2 (Buyukkurt et al, 2006 Level II). A submucosal injection of either 4 mg or 8 mg of
dexamethasone at the time of third molar extraction reduced facial swelling but not pain or
trismus compared with placebo for up to 48 hours (Grossi et al, 2007 Level II); injection of
methylprednisolone into the masseter muscle following extraction reduced pain, swelling
CHAPTER 9 and trismus (Vegas‐Bustamante et al, 2008 Level II).
Cryotherapy (ice packs) following third molar extraction did not reduce trismus but may have
reduced facial swelling and pain, although the results were conflicting (Laureano Filho et al, 2005
Level II; van der Westhuijzen et al, 2005 Level II). Facial compression reduced pain for up to 3 days,
with no additional benefit from co‐application of ice packs (Forouzanfar et al, 2008 Level II).
Acupuncture may be of benefit in reducing postprocedural dental pain but better quality trials
are required (Ernst & Pittler, 1998 Level I).
NSAIDs and emergency pulpectomy (Sutherland & Matthews, 2003 Level I) but not antibiotics
(Keenan et al, 2005 Level I) reduced pain in patients with acute apical periodontitis.
Acute pain associated with pharyngitis
Paracetamol, nsNSAIDs, coxibs and opioids, administered as monotherapy or in combination,
were effective in the treatment of pain associated with acute pharyngitis (Thomas et al, 2000
Level I; Romsing et al, 2000 Level II). Aspirin (Thomas et al, 2000 Level I; Eccles et al, 2003 Level II)
particularly when combined with caffeine (Schachtel et al, 1991 Level II) was also effective.
Topical analgesics such as benzydamine HCl 0.15% (as an anti‐inflammatory spray) (Thomas et
al, 2000 Level I) or flurbiprofen lozenges (Watson et al, 2000 Level II) provided effective analgesia
in acute sore throat, with minimal side effects.

274 Acute Pain Management: Scientific Evidence