What will it be: Ibuprofen or acetaminophen for pain relief after surgical removal of lower wisdom teeth?
December 17, 2013
This summary is based on the Cochrane systematic review: Ibuprofen versus paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth
Context
- Both paracetamol and ibuprofen are commonly used analgesics for the relief of pain following the surgical removal of lower wisdom teeth (third molars).
- In 2010, a novel analgesic (marketed as Nuromol) containing both paracetamol and ibuprofen in the same tablet was launched in the United Kingdom. This drug has shown promising results to date and there is a need to compare the combined drug with the single drugs using this model.
- In this review, the optimal doses of both paracetamol and ibuprofen are investigated via comparison of both and via comparison with the novel combined drug. The side effect profile of the study drugs was taken into consideration.
- This review will help oral surgeons to decide on which analgesic to prescribe following wisdom tooth removal.
Purpose of the Review
- To compare the beneficial and harmful effects of paracetamol, ibuprofen and the novel combination of both in a single tablet for pain relief following the surgical removal of lower wisdom teeth, at different doses and administered post-operatively.
Conclusions
- There is high quality evidence that ibuprofen is superior to paracetamol at doses of 200 mg to 512 mg and 600 mg to 1000 mg respectively based on pain relief and use of rescue medication data collected at six hours postoperatively.
- The majority of this evidence (five out of six trials) compared ibuprofen 400 mg with paracetamol 1000 mg, these are the most frequently prescribed doses in clinical practice.
- The novel combination drug is showing encouraging results based on the outcomes from two trials when compared to the single drugs.
Main Results
- Seven studies were included, they were all parallel-group studies, two studies were assessed as at low risk of bias and three at high risk of bias; two were considered to have unclear bias in their methodology. A total of 2241 participants were enrolled in these trials.
- Ibuprofen was found to be a superior analgesic to paracetamol at several doses with high quality evidence suggesting that ibuprofen 400 mg is superior to 1000 mg paracetamol based on pain relief (estimated from TOTPAR data) and the use of rescue medication meta-analyses.
- The risk ratio for at least 50% pain relief (based on TOTPAR) at six hours was 1.47 (95% confidence interval (CI) 1.28 to 1.69; five trials) favouring 400 mg ibuprofen over 1000 mg paracetamol, and the risk ratio for not using rescue medication (also favouring ibuprofen) was 1.50 (95% CI 1.25 to 1.79; four trials).
- The combined drug showed promising results, with a risk ratio for at least 50% of the maximum pain relief over six hours of 1.77 (95% CI 1.32 to 2.39) (paracetamol 1000 mg and ibuprofen 400 mg) (one trial; moderate quality evidence), and risk ratio not using rescue medication 1.60 (95% CI 1.36 to 1.88) (two trials; moderate quality evidence).
- The information available regarding adverse events from the studies (including nausea, vomiting, headaches and dizziness) indicated that they were comparable between the treatment groups. However, we could not formally analyse the data as it was not possible to work out how many adverse events there were in total.
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On behalf of Dr. Pat Duronio,
It should be noted that research has shown that the best pain medication regimen for 3rd molar extraction (and by extrapolation, acute pain) is 1000 mg acetaminophen and 400 mg. ibuprofen. That is what I put my patients on. That combination has been incorporated into a tablet called Maxigesic that is available in Australia and the UK. To this day, some physicians tell patients not to combine these drugs. The reality is that one is metabolized in the liver and the other in the kidney, and they potentiate one another. I guess I was naive in thinking that this was general knowledge.
Research has shown many times that Ibuprofen in doses of 400mg q6h is superior to two Tylenol 3 tabs, and that Ibuprofen and Tylenol is superior to Ibuprofen alone. However, in treatment of significant oral pain due to surgery, or postoperative endodontic flare-up, the combination of Ibuprofen (400mg q6h) and Dexamethasone (4mg q12h) for 2- three days is optimal.
Caution should be exercised in patients with a history of gastric ulcer or diabetes, as well as renal impairment or light-chain myeloma although these are not strict contraindications. For surgeries or procedures where significant pain and inflammation is expected, pre-op loading a few hours prior to the procedure has also shown to be helpful.
Using a mild pain modulator such as ibuprofen which also has cumulative anti-inflammatory effects is an obvious choice. Choosing a steroid to complement this effect (via a different pathway) is a better option than merely using Tylenol as the latter modulates the same pain pathway as Ibuprofen, and fails to address the cause of the pain (usually inflammation).
600 mg ibuprofen and 1000 mg acetaminophen will block all of both types of pain receptors..any more is a waste. However, I do not prescribe ibuprofen anymore, but have switched to Naproxen 500 mg bid…it is far superior to ibuprofen, longer lasting, and fewer long-term side effects than ibuprofen. After being in 2 MVA’s with displaced SI joint that took 3+ years to diagnose, I can tell you from personal experience that the anti-inflammatory and pain control of Naproxen was like night and day over ibuprofen…immediate relief…
So would you then prescribe 500mg naproxen + 500mg Acetaminophen bid?
Naproxen 500mg bid + Acetaminophen 1000 mg qid