Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
J Dent Res. 2023 Apr;102(4):391-401. doi: 10.1177/00220345221139230. Epub 2023 Jan 11.
This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6 h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400 mg plus acetaminophen 500 to 1,000 mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650 mg plus oxycodone 10 mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400 mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440 mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650 mg plus oxycodone 10 mg) or placebo.
本研究旨在比较药物治疗的效果，为拔牙后急性疼痛的管理制定指南。我们于 2020 年 11 月 21 日检索了 Medline、EMBASE、CENTRAL 和美国临床试验注册处，纳入了比较 10 种干预措施（包括对乙酰氨基酚、非甾体抗炎药（NSAIDs）、阿片类药物和联合用药）的参与者的随机临床试验（RCT）。在重复筛选和数据提取后，我们针对每个结局（即疼痛缓解、总疼痛缓解[TOTPAR]、总和疼痛强度差异[SPID]、总体疗效评分、解救性镇痛和不良反应）进行了贝叶斯网络荟萃分析。我们使用改良的 Cochrane RoB 2.0 工具评估偏倚风险，并使用 Grading of Recommendations, Assessment, Development, and Evaluation 方法评估证据确定性。我们在 RStudio 版本 3.5.3 中实施了分析，并按照最有益或最有害的顺序对干预措施进行分类。我们纳入了 82 项 RCT。56 项纳入 9095 名参与者的 RCT 研究发现，布洛芬 200-400mg 加对乙酰氨基酚 500-1000mg（与安慰剂相比的平均差异[MDp]，1.68；95%置信区间[CI]，1.06-2.31）、对乙酰氨基酚 650mg 加羟考酮 10mg（MDp，1.19；95%CI，0.85-1.54）、布洛芬 400mg（MDp，1.31；95%CI，1.17-1.45）和萘普生 400-440mg（MDp，1.44；95%CI，1.07-1.80）在 0-4 分疼痛量表上最有效。羟考酮 5mg、可待因 60mg 和曲马多 37.5mg 加对乙酰氨基酚 325mg 与安慰剂相比无差异。TOTPAR、SPID、总体疗效评分和解救性镇痛的结果相似。基于低和极低确定性证据，大多数干预措施被归类为与安慰剂相比对大多数不良反应没有更多的危害。基于中高度确定性证据，与阿片类药物（除了对乙酰氨基酚 650mg 加羟考酮 10mg）或安慰剂相比，含或不含对乙酰氨基酚的 NSAIDs 可带来更好的疼痛相关结局。
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