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Pain control after routine dento-alveolar day surgery: a patient satisfaction survey by A Joshi, A T Snowdon, J P Rood, and H V Worthington Br Dent J 2000; 189: 439–442

Comment

This paper answers some pragmatic questions about appropriate analgesia for dentoalveolar surgery. There have been many prospective studies on pain relief for third molar surgery but the regimes and drugs chosen are mainly experimental.

In this study 147 patients were prescribed ibuprofen 400 mg TDS for 5 days and 13 patients were prescribed paracetamol 500 mg with codeine QDS for 5 days (if a contraindication to NSAIDs existed eg asthma) after dentoalveolar surgery under general anaesthesia (77.6% third molar surgery, 16% surgical extraction of other teeth and 4% apicectomy). Pain assessment was done via a 'McGill type' questionnaire with five variations of the degree of pain, answered by the patient at 1 hour after surgery, at discharge, at 24 hours and 48 hours (latter both by phone).

Of interest was that ibuprofen provided adequate relief (< 2 score) for 65% of patients and although 85% of patients reported adequate pain relief, 20% had taken supplemental analgesics including; paracetamol – 64%, Solphadeine – 10%, Tylex – 7%, Co-codamol – 7%, other paracetamol/codeine preparations – 3% and Voltarol suppositories – 1%. None of the paracetamol group took adjunctive analgesics. Pain relief with ibuprofen occurred in 83% of the patients at 24 hours and at 48 hours this had risen to 96%, compared with 100% for the paracetamol group.

Overall the paracetamol/codeine combination appeared to be a more effective analgesic than ibuprofen with a lower risk of the patient self prescribing analgesics, a practice highlighted in this study, thus avoiding the inherent dangers of drug toxicity and addiction. However 38% of these patients reported significant side effects (including drowsiness, nausea and vomiting), compared with 2% of patients taking ibuprofen (including indigestion and nausea). The side effects of codeine are generally underestimated and coincides with previous reports.1 Indeed combination analgesics are not recommended as they have not been shown to be advantageous.2

The authors confirm that communication with the patient postoperatively by phone can provide reliable information about the patient's assessment of their pain and to reinforce analgesic prescriptions and to give further advice on supplement analgesics if required.

As 94% of patients had significant low pain scores at 24 and 48 hours in this study one questions the policy of prescribing these drugs for 5 days, particularly in the current climate where cost effectiveness is continually assessed. As almost a third of the ibuprofen group had inadequate pain relief this must raise further questions about what is the optimum dosage, timing of administration and possibly route of administration for this type of surgery.