|Year : 2015 | Volume
| Issue : 4 | Page : 474-476
Pre-emptive 8 mg dexamethasone and 120 mg etoricoxib for pain prevention after periodontal surgery: A randomised controlled clinical trial
Kranti Konuganti, Mani Rangaraj, Anjana Elizabeth
Department of Periodontics, M. S. Ramaiah Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||19-Feb-2014|
|Date of Acceptance||02-Feb-2015|
|Date of Web Publication||11-Aug-2015|
Department of Periodontics, M. S. Ramaiah Dental College and Hospital, MSR Nagar, MSRIT Post, Bengaluru - 560 054, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Several anti-inflammatory drugs have been used to reduce pain and discomfort after periodontal surgeries. This study evaluates the efficacy of using etoricoxib and dexamethasone for pain prevention after open-flap debridement surgery. In this study, 60 patients who were undergoing open flap debridment surgery were randomly assigned to receive a single dose preoperative medication 1 hour prior to surgery. The patients were divided into three groups. In Group 1, 20 patients were given placebo drug orally. In Group 2, 20 patients were given 8 mg Dexamethasone orally and in Group 3, 20 patients were given 120 mg Etoricoxib orally. Patients were instructed to complete a pain diary hourly for the first 8 hours after each surgery and three times a day on the following 3 days. The four point verbal rating scale (VRS 4) and Numerical rate scale were used to assess discomfort. Post-operative Assessment of Pain and Discomfort showed that persistent discomfort and pain were found to be more in the placebo group compared to dexamethasone and etoricoxib group. The adoption of a preemptive medication protocol using either etoricoxib or dexamethasone may be considered effective for pain and discomfort prevention after open-flap debridement surgeries.
Keywords: Analgesia, dexamethasone, etoricoxib, pain
|How to cite this article:|
Konuganti K, Rangaraj M, Elizabeth A. Pre-emptive 8 mg dexamethasone and 120 mg etoricoxib for pain prevention after periodontal surgery: A randomised controlled clinical trial. J Indian Soc Periodontol 2015;19:474-6
|How to cite this URL:|
Konuganti K, Rangaraj M, Elizabeth A. Pre-emptive 8 mg dexamethasone and 120 mg etoricoxib for pain prevention after periodontal surgery: A randomised controlled clinical trial. J Indian Soc Periodontol [serial online] 2015 [cited 2021 Aug 3];19:474-6. Available from: https://www.jisponline.com/text.asp?2015/19/4/474/153475
| Introduction|| |
“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Periodontal therapy may lead to common incidence of pain. Scaling and root planning (SRP) being one of the foremost common procedures in periodontal therapy may promote pain of significant duration and magnitude, periodontal surgery also generates pain and discomfort with greater intensity than that occasioned by SRP alone., So, patients who are indicated for surgery may be treated with pre-emptive analgesia as a protocol that aims to reduce pre and postoperative pain and discomfort. Some trials, have recommended preoperative administration of various anti-inflammatory drugs for management of postoperative pain.
Etoricoxib is a non-steroidal anti-inflammatory drug (NSAID) that selectively inhibits cyclooxygenase-2 (COX-2), that has been used to prevent and control acute pain after different surgical procedures. COX-2 is an enzyme substantially induced in the presence of tissue injury or surgical trauma. It leads to the production of prostaglandins, prostacyclin's, and thromboxane's, which are important mediators in promoting pain and swelling. Dexamethasone is a steroidal anti-inflammatory drug that inhibits phospholipase A2, the enzyme responsible for the induction of arachidonic acid., An effective pain control has been reported for open flap periodontal surgeries with the use of dexamethasone, compared to the placebo group. Thus the aim of the present study was to evaluate the efficacy of 120 mg Etoricoxib or 8 mg Dexamethasone as a single – dose preemptive medication on pain prevention after open flap debridement surgery.
| Materials and methods|| |
A total of 60 patients were selected from the OPD, Department of Periodontics, and M.S Ramaiah Dental College and Hospital Bangalore. The study was approved by the ethical committee of M.S Ramaiah Dental College, Bangalore. The ages of the patient included in the study were between 18-56 years. A written informed consent was taken from the patients. The patients with moderate or severe periodontitis who were scheduled for open- flap debridement surgery were included in the study. Patients allergic to any of the formulations used in the study, patients using analgesics and anti- inflammatory drugs, patients with history of systemic disease –diabetes mellitus, hypertension or gastric ulcer, pregnant or lactating females and patients who were at risk for infective endocarditis were excluded from the study. Patient who were undergoing flap surgery were randomly assigned to receive a single dose preoperative medication 1 hour prior to surgery. The patients were divided into three groups. In Group 1, 20 patients were given placebo drug orally. In Group 2, 20 patients were given 8mg Dexamethasone orally and in Group 3, 20 patients were given 120 mg Etoricoxib orally. Patients were instructed to complete a pain diary hourly for the first 8 hours after each surgery and three times a day on the following 3 days. For ethical reasons all participants were given rescue medicine (650 mg acetaminophen) and were instructed to take it as needed. Patients were instructed that they can take the painkiller whenever considerable pain is felt, according to their judgement and to wait at least 6 hours between intakes and write in the pain diary each time the medication was used. The four point verbal rating scale (VRS 4) and Numerical rate scale were used to assess discomfort. VRS was assessed only on the first day and Numerical rating scale was assessed on three consecutive days. Statistical analysis was done using Spearman correlation coefficient, which was used to assess correlation between NRS and VRS-4. Chi Square Test was also used. For these tests, the significance level was set at 0.05 and data analysis was carried out using Statistical Package for Social Science (SPSS, V 10.5) package.
| Results|| |
All the patients in the study were allowed to take rescue pill if they felt pain. Maximum number of rescue pills were taken by placebo group (95%) followed by dexamethasone group (35%) and etoricoxib group (25%) (Graph: 1). Post-operative Assessment of Pain and Discomfort Using Verbal Rating Scale showed that persistent discomfort and pain were found to be more in the placebo group compared to dexamethasone and etoricoxib group. 45% of patients that had taken dexamethasone showed some transitory discomfort. 75% of the patients that had taken etoricoxib and55% of patients that had taken dexamethasone showed no discomfort (Graph: 2). On comparison of Post-Operative Pain Assessment Using Numerical Rating Scale on the first, second and third day, the etoricoxib group showed higher level of discomfort compared to the other two groups (Graph: 3). This could have been due to the effect of rescue pill taken which was found to be maximum in placebo followed by dexamethasone group.
| Discussion|| |
Pain and discomfort are usually expected after open-flap debridement surgery which is an efficient therapeutic approach for patients who do not respond well to non-surgical periodontal treatment., Several medication protocols were proposed to minimize these effects. The adoption of a pain model using open-flap debridement surgery was due to its frequent use in periodontal practice, the ease of recruiting patients and the possibility of a standardized surgical procedure. Pre-emptive analgesia is believed to promote improved clinical results for pain prevention than treatment initiated after surgery. Postoperative pain generally lasts for 24 hours, with greater intensity at 6 to 8 hours,,, which justifies the evaluation of an 8-hour period on the first day of surgery in this study. Waiting for pain initiation after surgery to medicate produces unnecessary discomfort and may reduce the efficacy of any posterior treatment. Etoricoxib is a novel NSAID that is highly selective for COX-2. It is rapidly absorbed, greater plasmatic levels are reached after 1-hourand its elimination half-life is 25 hours. These data support the use of this medication in the proposed protocol, which promotes analgesic coverage for enough time.
Malmstrom et al., stated that 120 mg should be the minimum dose for the best analgesic action of this drug. The advantages of etoricoxib over traditional NSAIDs include less adverse reactions related to gastrointestinal problems, the absence of platelet-aggregation inhibition, long-action duration and elimination half-life and long-lasting pain relief. Furthermore, adverse effects related to the use of COX-2–selective drugs such as kidney or cardiovascular problems were only observed with chronic use. Steroidal anti-inflammatory drugs may also be used for pain prevention. Dexamethasone (4 mg) was not an effective reducer of pain inflammatory markers after tissue injury in vivo or of pain prevention after open-flap debridement surgeries. In contrast, Baxendale et al., observed significant pain prevention with the use of an 8-mg dose after multiple extractions of third molars. Although a significant amount of the administered glucocorticoid is eliminated from the blood before 24 hours, some late anti-inflammatory effects may be observed for up to3 days, which were the time period evaluated in this study. The time needed for dexamethasone to reach a plasmatic-concentration peak varies from 1to 2 hours, and there were favourable results with its use 1 or 2 hours before surgery.,, Adverse effects of glucocorticoids include immunosuppression, which is detected after 5 days of use and may take up to 9 months for the patient to recover.
| Conclusion|| |
The results of the study indicate that use of pre-emptive medication either etoricoxib or dexamethasone can be viewed as effective medication for pain prevention after open-flap debridement surgical procedure. Furthermore longitudinal studies involving large population utilizing different modalities of periodontal surgical procedures are needed to conform the adequacy of these pre-emptive medications.
| References|| |
H Merskey The definition of Pain European Psychiatry 1991; 6:153-9.
Pihlstrom BL, Hargreaves KM, Bouwsma OJ, Myres WR, Goodale MB, Doyle M J et al
. Pain after periodontal scaling and root planing. J Am Dent Assoc 1999; 130:801-7.
Matthews DC, McCulloch CA. Evaluating patient perceptions as short-term outcomes of periodontal treatment: A comparison of surgical and non-surgical therapy. J Periodontol 1993; 64:990-7.
Canakcxi CF, Canakcxi V. Pain experienced by patients undergoing different periodontal therapies. J Am DentAssoc 2007; 138:1563-73.
Joshi A, Parra E, Macfarlane TV. A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars. Br J OralMaxillofac Surge 2004; 42:299-306.
Curtis JW Jr., McLain JB, Hutchinson RA. The incidence of complications and pain following periodontal surgery. J Periodontol 1985; 56:597-601.
Parente L, Solito E. Annexin: More than an antiphospholipase protein. Inflamm Res 2004; 53:125-32.
Steffens JP, Santos FA, Sartori R, Pilatti GL. Preemptive Dexamethasone and Etoricoxib for pain and discomfort prevention after periodontal surgery: A double-masked, crossover, controlled clinical trial. J Periodontol 2010;81:1153-60.
Minutello JS, Newell DH, Thrash WJ, Terezhalamy GT. Evaluation of preoperative diflunisal for postoperative pain following periodontal surgery. J Periodontol 1988; 59:390-3.
Seymour RA, Meechan JG, Blair GS. An investigation into post-operative pain after third molar surgery under local analgesia. Br J Oral Maxillofac Surg 1985; 23:410-18.
Shi S, Klotz U. Clinical use and pharmacological properties of selective COX-2 inhibitors. Eur J ClinPharmacol 2008; 64:233-52.
Malmstrom K, Sapre A, Couglin H, Agarwal NG, Mazenko RS, Fricke JR et al
. Etoricoxib in acute pain associated with dental surgery: A randomized, doubleblind, placebo- and active comparator-controlled dose-ranging study. Clin Ther 2004; 26:667-79.
Clarke R, Derry S, Moore RA, McQuay HJ. Single dose oral etoricoxib for acute postoperative pain in adults. Cochrane Database Syst Rev 2009.
Dionne RA, Gordon SM, Rowan J, Kent A, Brahim JS. Dexamethasone suppresses Peripheral prostanoid levels without analgesia in a clinical model of acute inflammation. J Oral Maxillofac Surg 2003; 61:997-1003.
Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia 1993; 48:961-64.
Bahn SL. Glucocorticosteroids in dentistry. J Am Dent Assoc 1982; 105:476-81.
Laureano-Filho JR, Maurette PE, Allais M, Cotinho M, Fernandes C. Clinical comparative study of the effectiveness of two dosages of dexamethasone to control postoperative swelling, trismus and pain after the surgical extraction of mandibular impacted third molars. Med Oral Patol Oral Cir Buccal 2008; 13:129-132.
Czock D, Keller F, Rasche FM, Ha¨ussler U. Pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids. Clin Pharmacokinetic 2005; 44:61-98.