Page 325 Acute Pain Management

Povidone‐iodine mouthwash also significantly reduced the severity of oral mucositis compared
with sterile water, however chlorhexidine was ineffective (Potting et al, 2006 Level I). Preventive
strategies for mucositis such as palifermin or oral cryotherapy, may be effective in specific
circumstances (Bensinger et al, 2008).
Several topical measures have been postulated to treat the pain of oral mucositis. Two
different formulation of 200 mcg dose transmucosal fentanyl citrate were equal in efficacy,
tolerability and side‐effects profile but no better than placebo for analgesia in radiation‐
induced mucositis (Shaiova et al, 2004 Level II). Topical morphine (Cerchietti et al, 2003 Level III‐I),
doxepin (Epstein et al, 2006 Level II) and ketamine (Slatkin & Rhiner, 2003) may also provide
analgesia, and IV ketamine ‘burst therapy’ may be effective in mucositis pain that is refractory
to opioid analgesia (Jackson et al, 2005) (see Sections 9.7, 10.8).
Oral laser light therapy reduced mucositis pain and progression (Abramoff et al, 2008 Level II;
Arora et al, 2008 Level II).
Clinical practice guidelines for the prevention and treatment of mucositis in cancer patients
have been published by the Mucositis Study Section of the Multinational Association of
Supportive Care in Cancer and the International Society for Oral Oncology (Keefe et al, 2007).

Key messages
Dental extraction
1. Paracetamol 1000 mg provides safe and effective analgesia with minimal adverse effects,
following dental extraction (N) (Level I [Cochrane Review]).
2. Non‐selective NSAIDs, coxibs, paracetamol, opioids or tramadol provide effective analgesia
after dental extraction (U) (Level I).

3. Non‐selective NSAIDs or coxibs provide better analgesia with fewer adverse effects, than
paracetamol, paracetamol/opioid, paracetamol/tramadol, tramadol or weaker opioids,
following dental extraction (U) (Level I).
4. Perioperative steroid administration reduces swelling (S) but not pain (R) (Level I) and
reduces postoperative nausea (U) (Level II), following third molar extraction.

5. The combination of paracetamol with a non‐selective NSAID provides analgesia that is
superior to each drug given alone following third molar extraction (N) (Level II).
Tonsillectomy CHAPTER 9
6. Aspirin and some NSAIDs increase the risk of perioperative bleeding after tonsillectomy (U)
except in children (N) (Level I [Cochrane Review]).
7. Peritonsillar infiltration or topical application of local anaesthetics produces a modest
reduction in acute post‐tonsillectomy pain (R) with topical application and infiltration being
equally effective (N) (Level I).
8. Intraoperative dexamethasone administration reduces acute pain (S) (Level I), nausea and
vomiting (U) (Level I) post‐tonsillectomy, although there may be an increased bleeding risk
(N) (Level II).

9. Peritonsillar infiltration with tramadol or ketamine may reduce post‐tonsillectomy pain and
analgesia requirements, but was no more effective than equivalent doses administered
parenterally (N) (Level II).

Acute pain management: scientific evidence 277