Abubakar Sheikh1 , Muhammad Atif Saleem Agwan2 , Muhammad Amin3 , Muhammad Athar Khan4 , Ismail Sheikh5 , Syed Imran Shah6
1. Assistant Professor Operative Dentistry Fatima Jinnah Dental College.
2. Assistant Professor Operative Dentistry Karachi Medical and Dental College & Abbassi Shaheed Hospital. < email@example.com >
3. Assistant Professor & Consultant, Department of Operative Dentistry, Dental section, Dow International Medical College; DUHS, Karachi.
4. Research Unit, Department of Medical Education King Saud bin Abdulaziz University Riyadh, Kingdom of Saudi Arabia. < firstname.lastname@example.org >
5. Professor, Department of Operative Dentistry, Altamash Institute of Dental Medicine, Karachi.
6. Assistant Professor, Department of Operative Dentistry Women Medical College, Abbotabad. < Imranshah_78@hotmail.com >
Corresponding author: “Dr Abubakar Sheikh ” < email@example.com >
How to CITE:
Sheikh A, Agwan MAS, Amin M, Khan MA, Sheikh I, Shah SI. Comparison of Ibuprofen And Celecoxib For Controlling Post Endodontic Pain. J Pak Dent Assoc 2014; 23(3):106-111
The objective of this study was to compare the efficacy of ibuprofen and celecoxib in controlling post endodontic pain.
A Quasi Experimental study was conducted in the Operative Dentistry Department of Altamash Institute of Dental Medicine during fourteen months study period. One hundred patients who required root canal treatment and fulfilled the criteria of the study were equally divided into two groups, A and B. Patients in group A were given Ibuprofen and those in group B were administered Celecoxib for 2 days following treatment. Patients rated their pain on a visual analog scale at initial and then 4, 8, 12, 24 and 48 hours after first visit of endodontic therapy. Data analysis was performed through SPSS version-13.0. Independent samples t-test was used with p-value <0.05 considered as significant.
There was no statistically significant difference in post endodontic pain between the groups of patients taking Ibuprofen and Celecoxib. (p value: Pre-op 0.54, 4 hrs 0.62, 8 hrs 0.86, 12 hrs 0.57, 24 hrs 0.61, 48 hrs 0.09)
Ibuprofen and Celecoxib have similar efficacy in controlling post endodontic pain.
Ibuprofen, Celecoxib, Postoperative pain, Visual Analogue Scale.
Root Canal Treatment is generally considered to be a painful process1, but with proper techniques and strategies pain can be managed effectively.
Optimal pain management includes both pharmacological and non-pharmacological treatment strategies2. Pain management strategies start from preoperative pain control which includes accurate diagnosis and anxiety reduction followed by intra-operative pain control which can be covered by effective local anesthetic and operative techniques. Finally postoperatively pain can be managed by different pharmacologic agents2.
Both pulpotomy and pulpectomy can relieve or reduce patient’s pain regardless of whether any medication is prescribed. They reduce tissue levels of inflammatory mediators and the elevated interstitial tissue pressure that stimulate peripheral terminals of nociceptors3. Clinical trials often demonstrate a significant and substantial reduction in pain by 24 hours to 36 hours after pulpectomy4. Postoperative pain following root canal treatment can occur in the range of 16 to 48.5 per cent of cases, and these symptoms can last for several hours and even up to several days (23)5. Earlier studies conducted on postoperative endodontic pain have also shown that there can be moderate to severe pain varying from 15% to 25% (24, 25)1,2.
Ibuprofen and other nonselective NSAIDs inhibit both cytoprotective COX-1 enzymes and inflammatory COX-2 enzymes. Consequently, the use of these agents is associated with possible damage of the gastrointestinal tract causing gastric erosions, ulcers and bleeding. Studies exhibit that COX-2-selective inhibitors are almost equally effective in controlling pain compared to NSAIDs with the additional benefit of having decreased side effects such as GI ulceration, inhibition of platelet aggregation, or increased bleeding time. Therefore, COX-2-selective inhibitors can be recommended for controlling post endodontic pain8.
Selective COX-2 inhibitors have been tested in some studies previously. In one study Celecoxib was found to have a slower onset of action when compared to ibuprofen7. Barden et al. found that a single dose of oral celecoxib, 200 mg, is quite effective for controlling post-operative pain and its efficacy is equivalent to aspirin 600-650 mg and paracetamol 1000mg9. In a study by Malmstrom et al., rofecoxib and celecoxib were compared to ibuprofen in patients who had undergone third molar extraction. They concluded that pain control of rofecoxib was equivalent to ibuprofen, but celecoxib showed decreased analgesic efficacy compared to both the drugs10.
Few clinical trials have been carried in dentistry to compare nonselective NSAIDs with COX-2 inhibitors. At the national level, there is hardly any such clinical trial especially in dentistry. This study was conducted with the purpose of providing dental practitioners with an option of prescribing a drug with reduced adverse effects for the management of post endodontic pain. The objective of this study was to compare the efficacy of ibuprofen and celecoxib in controlling post endodontic pain using VAS (Visual Analogue Scale).
A quasi experimental study was conducted in the operative dentistry department, Altamash Institute of Dental Medicine, Karachi. One hundred patients requiring endodontic treatment and meeting inclusion and exclusion criteria were included in the study.
The inclusion and exclusion criteria were following:
1. Patients requiring root canal treatment for pain of endodontic origin.
2. Patient reports spontaneous pain of at least 3 (0-10) in the visual analogue scale.
3. Patient reads and understands questionnaires.
4. Patient provides informed consent.
1. Younger than 15 years or older than 65 years.
2. Analgesic intake within last 12 h.
3. History of allergy to NSAIDs or local anesthetics.
4. History of gastrointestinal disorders, active asthma, decreased renal function, decreased hepatic function, hemorrhagic disorders, or poorly controlled diabetes mellitus.
5. Current use of drugs contraindicated with NSAIDs.
6. Pregnant or nursing.
Informed consent was taken from the included patients. Purpose and procedure, risks and benefits were explained to the patient. The clinical examination included a percussion test, a cold test, periodontal probing, mobility assessment and palpation. Provisional pulpal and periradicular diagnosis were determined after clinical and radiographic examination. Pulpal diagnosis was either Irreversible pulpitis or Necrosis. Periradicular diagnosis was made as Normal, Acute periradicular periodontitis, Chronic periradicular periodontitis and Acute alveolar abscess.
The included patients were allocated into two groups by using convenience sampling. Patients in Group A(N=50) were administered ibuprofen (Brufen 400mg t.d.s) and those in Group B(N=50) were administered celecoxib (Celbex 200mg b.i.d) for two days. Pain intensity was measured using a visual analogue scale before treatment and at 4, 8, 12, 24 and 48 hours after only the canal preparation visit on a proforma. First dose of the drug was administered before root canal preparation visit; remaining medication and pain proforma were explained to the patient and given along. They were asked to record their pre and post treatment pain on the proforma. The proforma containing VAS scores was collected from patients at the second visit when the canals were obturated.
Root canal treatment was performed in two visits. During first visit, local anaesthetic was administered; tooth was isolated under rubber dam and access obtained. Cleaning and shaping was done in the following manner: The canals were negotiated with k files #10, #15, #20 and till file #25 reaching 0.5-1.0 mm of estimated working length, which was determined radiographically. Gates Glidden burs #2-4 were used for coronal flaring. Sodium hypochlorite (2.5%) was used as irrigant. After completing cleaning and shaping with the Step-back technique, the canals were dried and closed with a sterile cotton pellet and cavit. Canals were not filled with and intra-canal medicament as done in previous studies on this topic.
Data analysis was performed through SPSS (Statistical package for social sciences) version-13.0. Frequencies and percentages were computed for presentation of qualitative response variables like gender, periapical and pulpal diagnosis, tooth position and tooth number and quantitative response variables like age, pain score (VAS) were presented by Mean ± Standard deviation. Independent samples t-test was applied to compare the normally distributed mean VAS (pain scores) observed on subsequent intervals between the subjects of two groups based on Ibuprofen and celecoxib drugs. Statistical significance was taken at p < 0.05.
One hundred patients requiring root canal treatment were included in the study. None of the patients dropped out from the study. Out of these, 59 (59%) were females and 41 (41%) males (F: M=1.4: 1). Among 50 patients who received Ibuprofen, 21 (42%) were males and 29 (58%) females while among 50 patients who received celecoxib, 20 (40%) were males and 30 (60%) females. The difference of gender distribution between the groups was statistically insignificant (p=0.234).
Pulpal diagnosis of Irreversible pulpitis was diagnosed in 34 (68%) patients out of 50 patients of each group, while the rest 16 (32%) patients of both groups were diagnosed as pulp necrosis (p=0.999). Periapical diagnosis of acute apical periodontitis was diagnosed in 29 (58%) patients out of 50 patients of each group, followed by chronic apical periodontitis amongst 5 (10%) while 16 (32%) patients had no periapical pathosis. Tooth position (upper and lower) was similar in both groups. Majority of the patients of both groups were of age group 15-30 years. Mean age of patients who received Ibuprofen was 34.2± 14.0 and the mean age of patients who received celecoxib was 29.4± 13.2, however the difference of mean age between two groups was statistically insignificant (p=0.083).
The mean preoperative pain score (VAS) in the patients who received ibuprofen was 5.84± 1.99 while in the group of patients who received celecoxib was 6.10± 2.25. After 4 hours post operatively, the mean VAS score in ibuprofen group was 1.66± 2.38 and 1.90± 2.38 in celecoxib group. The attenuation in pain score after 4 hours was statistically significant in both drug groups (p<0.001). The difference of mean attenuation in postoperative pain after 4 hours between the groups who received either ibuprofen or celecoxib was not statistically significant (p=0.615). ( Table 1 )
Trend of attenuation in postoperative pain (VAS) from preoperative phase till postoperative 48 hours was statistically significant within both groups however, it was insignificant between them (Figure-1). The two groups of patients based on receiving Ibuprofen and celecoxib were found statistically similar according to gender and age.
In this study, a nonselective NSAID, Ibuprofen was compared to a selective COX-2 inhibitor, Celecoxib for controlling post endodontic pain. Both the drugs provided significant relief in pain. This was shown by the reduction in pain score after 4 hours, which was statistically significant within both drug groups (p<0.001). Preoperative administration of Ibuprofen and Celecoxib, both provided significant reduction in postoperative pain in our study, however there was no difference between the groups.
The difference of mean attenuation in postoperative pain after 4 hours between the groups who received either ibuprofen or celecoxib was not statistically significant (p=0.615). Even during the follow up period (48 hours) there was still no statistically significant difference between the two groups. Celecoxib offered similar pain control compared to Ibuprofen. Thus the hypothesis of the study that there will be no significant difference between celecoxib and ibuprofen in controlling post endodontic pain was proven correct.
Cicconetti and Bartoli conducted a literature review over analgesic efficacy and safety in oral-maxillofacial surgery of Cox-2 selective inhibitors (CSIs)11. They concluded that 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. The results of this literature review were in accordance with our study.
In contrast to our results, another study comparing rofecoxib (50 mg) and celecoxib (200mg) to ibuprofen (400mg)12, showed Ibuprofen to be superior to the selective COX 2 inhibitors. The difference could be attributed to the fact that this study was done on postoperative pain following third molar extraction where the pain intensity can be higher compared to post-endodontic pain in which cases pain usually ranges from mild to moderate. Also in the oxford league table of analgesics13, ibuprofen 400mg has been rated superior to celecoxib 200mg, each having a NNT value of 2.5 and 3.5 respectively but inferior to celecoxib 400mg (NNT 2.1).
This study has been carried out using Ibuprofen 400mg three times a day as it has been evaluated in various studies to be an effective dose for controlling mild to moderate postoperative pain14. Amongst the selective COX-2 inhibitors, in Pakistan Celecoxib is the only currently available drug, so this study has been carried out using this drug with a dosage of 200mg twice daily. Other studies have evaluated doses of 100mg, 200mg and 400mg15,16.
The intensity of preoperative pain is a strong indicator of the severity of postoperative pain in endodontics. This correlation has also been tested in a study by Genet et al17. The results of their study depicted that approximately 29 per cent of patients undergoing endodontic treatment had moderate to severe postoperative pain. The majority of these patients also had moderate to intense preoperative pain, thus confirming the relationship between preoperative and postoperative pain. Therefore it can be stated that while evaluating post endodontic pain, it will be worthwhile to check the preoperative pain status of the patient. To control this variable, in our study patients were equally divided in the two groups based on the intensity of preoperative pain which is confirmed by the fact that there is statistically insignificant difference between the two groups in terms of preoperative pain score. Thus preoperative pain levels did not influence our results.
Preoperative dose of an analgesic has been effective in controlling postoperative pain18. This effect has been tested in a study in which ibuprofen (800mg) or flurbiprofen (100mg) were given preoperatively and such patients had decreased post-treatment pain19. In patients who are unable to tolerate NSAIDs, we have the option of prescribing acetaminophen (1000mg) preoperatively and it will also reduce post-treatment pain20. In our study as well, first dose of the drug was given preoperatively and it showed significant reduction in pain.
There were a few limitations in the study. Pain perception varies greatly between individuals. For some patients with low pain threshold, even mild pain can be considered as severe, on the other hand for patients with high pain threshold severe pain might just be felt as mild pain. There are other factors also which will influence the pain felt by the patient such as the emotional status, psychological factors etc. Therefore studies involving evaluation of pain will be affected by the varied response of patients. The reduction in pain can also be related to the removal of source of pain itself. Visual analogue scale (VAS) has been used in various pain measurement studies and has been proven to be quite effective and it has been used in this study as well. Although the first dose of medicine is given by the doctor preoperatively, but patient compliance to take the remaining doses at their proper timings cannot be guaranteed. Similarly their pain recording at the specified time may also not be totally accurate. Another limitation was that it was not a double blind study, which is considered as a standard for clinical trials. The operator himself was responsible for giving the medication preoperatively. There was also lack of randomization in this study.
The results of this study indicate that anti-inflammatory medicines may help in reducing postoperative endodontic pain. In patients with gastrointestinal problems or those who cannot tolerate traditional NSAIDs, selective COX II inhibitors are a reasonable alternative and they can be prescribed to decrease the chances of postoperative pain . In future further studies with randomization and blinding can be carried out to test the analgesic efficacy of selective COX-2 inhibitors in controlling dental pain and also to evaluate their risks versus benefits.
This clinical study revealed that Ibuprofen and Celecoxib had similar efficacy in controlling post endodontic pain. There was no statistically significant difference in post endodontic pain at any of the time periods.
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