Oral analgesics after third molar surgery — a systematic review of relative efficacy

Key Points

• This paper reviews the available high quality information on analgesics commonly prescribed by dentists, including COX-2 selective inhibitors.

• Problems related to chance effects are avoided by combining multiple trials in a meta-analysis.

• There is good evidence of efficacy for most commonly-prescribed analgesics.

• Standard doses of NSAIDs and COX-2 inhibitors provide the best analgesia and lowest rate of adverse events.

Abstract

Objectives To compare the relative efficacy of analgesics after third molar extraction from systematic reviews of randomised, double blind studies.

Data sources Dental trials from systematic reviews of randomised, double-blind studies of analgesics in acute pain.

Data selection Number of patients with moderate or severe pain achieving at least half pain relief over 4 to 6 hours after a single oral dose of analgesic.

Data extraction Independently by two reviewers.

Data synthesis Use of dichotomous information from active and placebo treatments, first to calculate the statistical significance using relative risk, and then to evaluate the clinical relevance using number needed to treat (NNT). Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2) inhibitors had the lowest (best) NNTs for the outcome of at least half pain relief over 4-6 hours compared with placebo. With the best performing analgesics, 50-70 patients out of 100 had good pain relief compared with about 10 out of 100 with placebo. Only paracetamol 600/650 mg plus codeine 60 mg was associated with any significant increase in any patient experiencing an adverse event.

Conclusions NSAIDs and COX-2 inhibitors have the lowest (best) NNTs. They may also have fewer adverse effects after third molar surgery, though conclusive evidence is lacking. At least 80% of analgesic prescribing by UK dentists is in line with the best available evidence on efficacy and safety.

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