Cicconetti Andrea, Bartoli Adriano, Ripari Francesca, Ripari Andrea
Clinica Odontoiatrica, Dipartimento di Odontostomatologia, University of Rome, Italy.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Feb;97(2):139-46. doi: 10.1016/j.tripleo.2003.08.032.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed analgesic agents in surgical outpatients. Major limitations of NSAIDs are their gastrointestinal (GI) adverse events (perforation, ulceration, and bleeding), impairment of hemostatic function, and renal failure (with long-term therapy). A new class of NSAIDs, the COX-2 selective inhibitors (CSIs or Coxibs), have been developed with the aim of reducing the GI adverse events of traditional NSAIDs while maintaining their effective anti-inflammatory and analgesic properties.
This is a narrative review of the literature aimed to discuss analgesic efficacy, clinical safety and cost-benefit ratio of CSIs in the treatment of post-oral surgery pain.
Relevant drug and clinical studies of analgesic efficacy and safety of CSIs in the management of postoperative dental pain were identified through searches of MEDLINE/PubMed, in peer-reviewed journals of medicine and dentistry. The Food and Drug Administration Web site was searched for data of tolerability. Hand-searching included several dental journals and bibliographies of relevant studies. The last electronic search was conducted in April 2003.
Data from well-designed, randomized, controlled trials of CSIs on the management of post-oral surgery pain indicate that these drugs are as well-effective analgesic agents as traditional NSAIDs and offer clinical advantages in terms of GI safety and unimpaired platelet function. CSIs do not offer advantages of renal safety over traditional NSAIDs.
Although CSIs display analgesic efficacy similar to that of traditional NSAIDs in the treatment of acute, post-oral surgery pain, there is reasonable evidence that these new drugs are preferable in patients who are at an increased risk of developing serious upper-GI complications, in patients who take aspirin for cardiovascular comorbid conditions, and in those allergic to aspirin. Furthermore, CSIs may be given more safely than NSAIDs in perioperative settings, because of their lack of impairment of the blood-clotting. However, the high costs of CSIs available at present limit their routine use in the short period of postoperative dental pain-in most cases 2 to 4 days after surgery-because there is not an increased risk of developing serious GI complications with the use of cost-saving NSAIDs. The GI safety advantages of CSIs may improve the tolerability of long-duration analgesic therapies, such as cases of painful temporomandibular joint disorders and chronic orofacial pain. Further studies are needed to determine the cost-benefit ratio of using CSIs for the management of acute pain.
非甾体抗炎药（NSAIDs）是外科门诊最常用的镇痛药。NSAIDs的主要局限性在于其胃肠道（GI）不良事件（穿孔、溃疡和出血）、止血功能受损以及肾衰竭（长期治疗时）。一类新型的NSAIDs，即COX-2选择性抑制剂（CSIs或昔布类药物）已被研发出来，目的是在保持其有效的抗炎和镇痛特性的同时，减少传统NSAIDs的胃肠道不良事件。
这是一篇叙述性文献综述，旨在探讨CSIs在治疗口腔手术后疼痛中的镇痛效果、临床安全性和成本效益比。
通过检索MEDLINE/PubMed以及医学和牙科领域的同行评审期刊，确定了关于CSIs在治疗术后牙痛中的镇痛效果和安全性的相关药物及临床研究。在食品药品监督管理局网站上搜索耐受性数据。手工检索包括几本牙科期刊和相关研究的参考文献。最后一次电子检索于2003年4月进行。
关于CSIs治疗口腔手术后疼痛的精心设计的随机对照试验数据表明，这些药物作为镇痛药与传统NSAIDs一样有效，并且在胃肠道安全性和血小板功能未受损方面具有临床优势。CSIs在肾脏安全性方面并不比传统NSAIDs更具优势。
尽管CSIs在治疗急性口腔手术后疼痛时显示出与传统NSAIDs相似的镇痛效果，但有合理证据表明，对于发生严重上消化道并发症风险增加的患者、因心血管合并症而服用阿司匹林的患者以及对阿司匹林过敏的患者，这些新药更可取。此外，由于CSIs不影响血液凝固，在围手术期使用可能比NSAIDs更安全。然而，目前可用的CSIs成本高昂，限制了它们在术后短期牙痛（大多数情况下是手术后2至4天）中的常规使用，因为使用成本较低的NSAIDs发生严重胃肠道并发症的风险并未增加。CSIs的胃肠道安全性优势可能会提高长期镇痛治疗（如颞下颌关节紊乱疼痛和慢性口面部疼痛病例）的耐受性。需要进一步研究以确定使用CSIs治疗急性疼痛的成本效益比。
