ARTICLE

PRESENTATION
Presented by
Sabeela Alangadan
Department of Oral and Maxillofacial Surgery
PRE EMPTIVE ANALGESIA IN THIRD MOLAR IMPACTION SURGERY
RAKESH SHAH, AMIT MAHAJAN, NAVIN SHAH, ASHISH P. DHADHANIA
NATIONAL JOURNAL OF MAXILLOFACIAL SURGERY VOL 3/ ISSUE 2
INTRODUCTION
Effective postoperative pain control is very important factor in
our day to day practice. Use of diclofenac sodium as
preemptive analgesic agent in third molar impaction surgery
prevents occurrence of chronic postoperative pain experience.
Various preemptive agents can be used for effective pain
control. Here we used oral tablet of diclofenac sodium in 50
mg dose one hour before surgery which is given as a
preemptive analgesic agent in experimental group. While in
control group placebo it is given one hour before surgery.
We have measured post operative tenderness, swelling and
trismus for five postoperative days.
MATERIALS AND METHODS
60 patients (both male and female).
All patients came to the department for removal of
impacted third molars.
Informed consent was obtained from all the patients.
Study comprise of two groups of 30 patients each.
The patient, the operating surgeon, and the evaluating
surgeon, all were blinded.
 CONTROL GROUP EXPERIMENTAL GROUP
30 patients. 30 patients.

Receive placebo one hour prior Receive diclofenac sodium one

to surgery. hour prior to surgery.

Receive diclofenac sodium Receive diclofenac sodium

post operatively three times post operatively three times
daily for a period of 5 days. daily for a period of 5 days.

All patients evaluated at 1 hour post operatively followed by

3rd and 5th days for swelling, tenderness, trismus and any
other complications like nerve injury, infection, etc.
 CRITERIA FOR MEASUREMENT
PAIN SWELLING TRISMUS
0 to 10 0 to 3 0 to 4

0 absence of pain 0 absence of swelling 0 no trismus

10 severe pain 1 mild swelling 1 mouth opening > 76%
2 moderate swelling 2 mouth opening < 75%
3 severe swelling 3 mouth opening > 51%
4 mouth opening < 25%
RESULTS
There was significant difference in tenderness at 3 rd
and 5th post operative day between experimental and
control group.
Trismus and swelling, at any stage, did not see any
difference between experimental and control groups.
DISCUSSION
Results of the study indicated better pain control in
experimental group.
There was highly significant difference in post operative
score of tenderness, where as no much difference in
case of trismus and swelling.
DEFINITIONS OF PRE EMPTIVE
ANALGESIA
Three different definitions used as the basis for recent
clinical trials.
Defined as treatment that :
1. Starts before surgery.
2. Prevents the establishment of central sensitization caused
by incisional injury (covers only the period of surgery).
3. Prevents the establishment of central sensitization caused
by incisional and inflammatory injuries (covers the period of
surgery and the initial post operative period).
WHY DICLOFENAC SODIUM ???
Easy availability
Economic
Effective pain control
Relatively safe drug
Minimal reported allergy
Plasma half life is 1-2 hours, so we can achieve
ideal optimal concentration if we provide it, in 1
hour preoperatively.
PREVIOUS STUDIES
SUPPORTING THE
RESULTS
ONG ET AL (2004)
Double blind, randomized, placebo controlled study .
34 patients with each of their identical impacted
mandibular third molars removed under local
anesthesia on two occasions.
Experimental group pre treated with KETOROLAC.
Lower pain intensity scores in the experimental group
throughout the 12 hour investigation period.
AOKI ET AL (2006)
Selective cyclo oxygenase 2 (COX-2) inhibitor MELOXICAM
was tested.
Patients undergoing unilateral mandibular 3 rd molar extraction
surgery allocated to 3 groups A, B and C.
Group A - premedicated with oral 10 mg MELOXICAM
Group B - premedicated with 27 mg AMPIROXICAM
Group C - placebo

Post operative pain evaluated on 1 st , 7th and 14th post operative

day.
Concluded that MELOXICAM 10 mg reduced post operative pain
comparatively.
 POZOS GUILLEN ET AL (2007)
Tested efficacy of TRAMADOL as pre emptive and post operative
analgesia.
3 groups of 20 patients each were included.

Group A - preoperative TRAMADOL 100mg IM, 1 hour before surgery.

Group B - post operative TRAMADOL 100mg IM, immediately after surgery.
Group C - saline

This study suggested TRAMADOL as a method to pre emptive analgesia

for the acute pain treatment after removal of impacted mandibular third
molar under local anesthesia.
PREVIOUS STUDIES
WITH
CONTRADICTORY
RESULTS
 SISK ET AL (1990)
Compared preoperative and post operative NAPROXEN SODIUM for
suppression of pain in dental surgery cases.

Control group - NAPROXEN SODIUM 550 mg, 30 minutes post operatively.

Pre emptive group - NAPROXEN SODIUM 550 mg, 30 minutes pre operatively.

Results not supportive for the use of pre emptive analgesia.

KACZMARZYK ET AL (2010)
Tested pre emptive effect of KETOPROFEN on post operative
pain following third molar surgery.
96 patients placed into 3 groups :

Pre-group - KETOPROFEN 60 min pre operatively.

Post-group - KETOPROFEN 60 min post operatively.
No-group - placebo

Results showed that initial onset of pain was significantly

delayed only in the post-group.
CONCLUSION
Use of DICLOFENAC SODIUM orally in 50 mg dose, one
hour pre operatively as pre emptive analgesic agent is
economical, effective, easy and safe method of post
operative pain control in mandibular third molar impaction
surgery cases.
THANK YOU