Assessment of Pain Management Post Mandibular Third Molar Extraction with Piroxicam: A Retrospective Analysis Over 10 Months
Gokul Gunasekaran1, Pradeep D2*, Sri Rengalakshmi3
1 Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
2 Associate Professor, Department of Oral & Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
3 Senior Lecturer, Department of Orthodontics, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
*Corresponding Author
Pradeep D,
Associate Professor, Department of Oral & Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University,
Chennai 600077, Tamil Nadu, India.
Tel: 9789936383
E-mail: pradeep@saveetha.com
Received: July 30, 2021; Accepted: August 10, 2021; Published: August 17, 2021
Citation:Gokul Gunasekaran, Pradeep D, Sri Rengalakshmi. Assessment of Pain Management Post Mandibular Third Molar Extraction with Piroxicam: A Retrospective Analysis Over 10 Months. Int J Dentistry Oral Sci. 2021;8(8):3892-3896.doi: dx.doi.org/10.19070/2377-8075-21000796
Copyright: Pradeep D©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Surgical removal of impacted mandibular third molar is one of the most commonly performed procedures in oral and maxillofacial surgical practice. The role of postoperative medications for management of postoperative pain is important for comfortable and uneventful healing .To assess and compare the therapeutic effect of piroxicam and other NSAIDs on patients undergoing surgical removal of impacted mandibular third molar, the study was conducted among patients who reported to a dental college for surgical removal of mandibular third molar. The data was collected and tabulated in MS-Excel and was analysed using SPSS software. Patients experience less post-operative pain on administration of piroxicam in comparison to other analgesics which will help to improve the post-operative pain. Piroxicam was found to have a better analgesic action in comparison to other analgesics given and also help to increase the postoperative comfort and quality of life.
2.Introduction
3.Conclusion
4.References
Keywords
Analgesics; Third Molar; Pain; Piroxicam; Impaction.
Introduction
The surgical removal of impacted third molars is one of the most
common minor oral surgery procedures widely carried out in general
practice and also occupies an appreciable amount of clinical
time in many hospitals in oral and maxillofacial departments
[23]. The decision to remove the third molar is often difficult
because of the consequences of the surgical extraction. Patients
complain of pain, swelling, and limitation of mouth opening [50].
Frequently, this pain is moderate and temporary. Pain from lower
third molar extraction reaches its maximum intensity 2–4 h after
the end of surgery, and, in most cases, patients require analgesic
treatment. Besides pain, swelling and the limited articulation of
the temporomandibular joint associated with inflammation, there
are further who undergo surgical interventions in the oral cavity
and treatment for pain, trismus and swelling after lower third molar
surgery includes non-steroidal anti-inflammatory require analgesic
treatment [23, 7, 4]. The role of preoperative and postoperative
medications in reducing postoperative complications has
been extensively evaluated. Nonsteroidal anti-inflammatory drugs
(NSAIDs) inhibit the synthesis of prostaglandins and reduce the
inflammatory reaction and nociceptive stimuli causing reduction
in pain. Piroxicam, a NSAID with a long half-life and potent analgesic
activity similar to that of indomethacin, [55] has been developed
in a new sublingual formulation. It is easily administered
and does not have any harmful effects in the oral cavity. Although
the analgesic effect of piroxicam in several types of pain (e.g.,
postoperative pain, acute renal colic, [49] dysmenorrhea, osteoarthritis,
[36] low back pain, headache, and migraine [27] has been
investigated. Surgical trauma activates a biochemical cascade, with
the synthesis or release of prostaglandins, bradykinin, substance-
P, histamine, and other substances. They interact to produce plasma
extravasation, leading to edema. They also excite and sensitize
peripheral nerve endings, resulting in the clinical manifestation
of hyperalgesia. These substances have several other effects on peripheral nerve endings. They stimulate the release of neuropeptides
such as calcitonin gene-related peptide (CGRP) from
peripheral nerve endings, contributing to the synergistic effects
of other biochemical cascades. These substances form a positive
feedback loop that is thought to continually refuel the inflammatory
process, maintaining the clinical signs of inflammation for
days after the initial stimulus [8]. NSAIDs including piroxicam are
not completely free of adverse effects. Some individuals exhibit
allergic reactions to NSAIDs. Patients with an increased risk for
hepatic failure, peptic ulcers, and gastrointestinal inflammation
should avoid using NSAIDs, including piroxicam [24, 12]. Complications
of extraction such as dry socket can be treated with
ZOE paste [16] . In another study, Irrespective of the year of
study, majority of the students showed a negative attitude toward
HIV/AIDS patients and only a few among the interns showed a
positive approach toward treating HIV patients [37]. This present
study compares the efficacy of piroxicam versus other analgesics
in surgical extraction of mandibular third molars and assessing
the post-operative pain experience by the patients.
Previously our team has a rich experience in working on various
research projects across multiple disciplines. (Jain, 2017 [14]);
(Varghese, Ramesh and Veeraiyan, 2019 [51]); (Ashok and Ganapathy,
2019 [3]); (Padavala and Sukumaran, 2018 [29]); (Ke et al.,
2019 [17]); (Ezhilarasan, 2018 [9]); (Krishnan et al., 2018 [18]);
(Ezhilarasan, Sokal and Najimi, 2018 [9]); (Pandian, Krishnan and
Kumar, 2018 [31]); (Ramamurthy and Mg, 2018 [39]); (Gupta,
Ariga and Deogade, 2018 [13]); (Vikram et al., 2017 [54]); (Paramasivam,
Vijayashree Priyadharsini and Raghunandhakumar,
2020 [32]); (Palati et al., 2020 [30]); (Samuel, Acharya and Rao,
2020 [44]) Now the growing trend in this area motivated us to
pursue this project.
Materials And Methods
This retrospective study was conducted in the university setting.
Data chosen for evaluations were patients who reported to a dental
college for the removal of mandibular third molars. The details
of the patients were obtained from analysis of 86,000 patients
from June 2019 to March 2020 from patient dental records for
the purpose of preservation and efficient analysis of the patient’s
details including intraoral and extra oral pictures and treatments
being done, which is maintained in a confidential manner. These
serve as records for the retrospective studies. The study was conducted
after getting ethical approval from the Institutional Ethical
Committee (Ethical approval number: SDC/SIHEC/2020/
DIASDATA/0619-0320). Cross verification was done with the
help of patient dental records data. To minimize sampling bias all
data were included. The inclusion criteria included patients who
required removal of impacted mandibular third molars, prophylactic
removal of mandibular third molars and patients with acute
pericoronitis. The exclusion criteria included patients with drug
allergies, medically compromised patients and patients who are
pregnant or current lactation. Data was downloaded from the patient
dental records and imported to Excel. Data which was not
required were excluded. Excel tabulation was done and imported
to SPSS and results were obtained in the form of graphs and tables.
The advantages of the study included easy accessibility and
availability of the required data and drawback was the available
data was not location specific and belonged to different ethnicity.
Independent variables that were included in the study – age,
gender, tooth number (mandibular third molars), analgesic. The
dependent variable included post-operative pain. The correlation
and association between the variables were analysed and assessed
using this test.
Results & Discussion
A total number of 694 patients had undergone surgical extraction
of mandibular third molars. Of these 153 patients were administered
aceclofenac, 17 diclofenac, 141 paracetamol and 342
Piroxicam. Figure 1 shows better efficacy of analgesics in the
younger age group. Figure 2 shows males to have a better analgesic
effect compared to females. From Figure 3 we can conclude that piroxicam has a better efficiency to control pain post extraction,
diclofenac and paracetamol have the least efficacy in pain
control. Ketorolac and aceclofenac were found to have an intermediate
efficiency in controlling pain. Piroxicam was found to
be a better analgesic for surgical extraction comparatively. From
Figure 1, Painless extractions were highest in the age group 18-
35 years (63.91%) followed by 36-52 years (13.16%) and 53-67
years (1.49%). The extractions reported with pain were also highest
in 18-35 years (18.05%) followed by 36-52 years (2.85%) and
53-67 years (0.54%). Chi-square test was done and association
was found to be statistically insignificant. Pearson’s Chi square
value: p value: 0.524(>0.05). Hence not statistically significant. So
age is not a factor for confirming the effectiveness of piroxicam.
From Figure 2, Painless post-extraction periods were highest in
the males (46.27%) and females (32.27%). The extractions reported
with pain were also highest in males (11.87%) and females
(9.60%). Chi-square test was done and association was found to
be statistically significant .Pearson’s Chi square value: p value:
0.418(>0.05) Hence not statistically significant. So gender is not
a factor for confirming the effectiveness of piroxicam. From Figure
3, Painless post-extraction periods were highest in the Piroxicam
(48.93%), Paracetamol (12%) and Aceclofenac (12%), Ketorolac(
4.40%) and Diclofenac(1.20%). The extractions reported
with pain were also highest in Aceclofenac (9.87%), Paracetamol
(7.60%), Ketorolac(1.60%) Piroxicam (1.20%), and Diclofenac
(1.20%).Chi-square test was done and association was found to
be statistically significant .Pearson’s Chi square value: p value:
0.000(<0.05). So, proving piroxicam has a better analgesic effect
when compared to other drugs post mandibular third molar extraction.
The presence of pain during the postoperative period after third
molar extraction is the chief indicator. In this study we can compare
the efficacy of pain with the control group of drugs; Diclofenac,
Aceclofenac, Paracetamol and Ketorolac among different
age groups. Other studies deal with the swelling, trismus,
pain post third molar extraction(Shruthi, no date). A Sunshine et
al study on Piroxicam provided evidence for longer duration of
analgesic action compared to codeine or aspirin [48]. In another
study, ketorolac 10 mg is more effective than Paracetamol 500mg
as an analgesic after dental extractions [26]. Oropharyngeal airway
volume has shown the highest post-surgical reduction though
statistically insignificant [6, 2, 14]. The importance of training regarding
biomedical waste management must be emphasized as
the lack of proper and complete knowledge about it. [34] management
impacts practices of appropriate waste disposal. [20].
A standard protocol regarding the training as well as preventive
measures for surgical extractions should be formulated for the
dental students and the knowledge acquired must be transferred
into practice [45]. The etiology and pattern of maxillofacial injuries
reflect the trauma patterns within the community and can
thus provide a guide to help design programs toward prevention
and treatment [28]. In another study, buccal fat pad graft proved
to give better results as the interposition material as it has good
patient acceptance, rapid epithelization, minimal donor site morbidity
and minimal intra and postoperative complications [33, 21].
The ability to use Botox as an adjuvant and primary mode of
the treatment for various maxillofacial disorders offers exciting
treatment options for dentists and patients in the future [19, 15].
Surgical trauma activates a biochemical cascade, with the synthesis
or release of prostaglandins, bradykinin, substance-P, histamine,
and other substances. They interact to produce plasma extravasation,
leading to edema. They also excite and sensitize peripheral
nerve endings, resulting in the clinical manifestation of hyperalgesia.
These substances have several other effects on peripheral
nerve endings. They stimulate the release of neuropeptides such
as calcitonin gene-related peptide (CGRP) from peripheral nerve
endings, contributing to the synergistic effects of other biochemical
cascades. These substances form a positive feedback loop that
is thought to continually refuel the inflammatory process, maintaining
the clinical signs of inflammation for days after the initial
stimulus [8]. Acute pain serves an immediate sensory function,
and the inflammatory process is important for normal tissue healing.
However, pain and other inflammatory reactions may often
overshoot their goal and cause unnecessary sequelae. The magnitude
of postoperative pain depends on the degree of tissue
damage and on the extent of operative trauma. Reducing pain
and excessive inflammatory reactions is necessary not just for immediate
reduction of postoperative morbidity, but also to provide
prolonged benefits by preventing further worsening of pathologic
states. In another study, there was a statistically significant reduction
in pain on the postoperative days in the piroxicam group. No
rescue treatment was required by any of the subjects in both the
groups during the trial and sublingual piroxicam was effective in
the management of postoperative pain following surgical removal
of mandibular impacted third molar [25].
Our institution is passionate about high quality evidence based
research and has excelled in various fields (Pc, Marimuthu and
Devadoss, 2018 [35]; Ramesh et al., 2018 [40]; Vijayashree Priyadharsini,
Smiline Girija and Paramasivam, 2018 [53]; Ezhilarasan,
Apoorva and Ashok Vardhan, 2019 [10]; Ramadurai et al., 2019
[38]; Sridharan et al., 2019 [47]; Vijayashree Priyadharsini, 2019
[52]; Chandrasekar et al., 2020 [5]; Mathew et al., 2020 [22]; R et al., 2020 [42]; Samuel, 2021 [43] ). We hope this study adds to this
rich legacy.
Figure 1: This bar graph represents the association between age groups and the analgesic effect of drugs post mandibular third molar extraction-axis represents the age distribution and Y-axis represents the total number of patients who underwent mandibular third molar extraction(Blue: Painless , Green: Pain ). Chi-square test was done and association was found to be statistically Not significant. Pearson’s Chi square value: p value: 0.524(>0.05) Hence not statistically significant , proving age does not influence the analgesic effect of drugs post mandibular third molar extraction.
Figure 2: This bar graph represents the association between gender and the analgesic effect of drugs post mandibular third molar extraction. X-axis represents the age distribution and Y-axis represents the total number of patients who underwent mandibular third molar extraction (Blue: Painless, Green: Pain). Chi-square test was done and association was found to be statistically significant. Pearson’s Chi square value: p value: 0.418(>0.05) Hence not statistically significant , proving gender does not influences the analgesic effect of drugs post mandibular third molar extraction.
Figure 3: This bar graph represents the association between different analgesic drugs and the analgesic effect of the drugs post mandibular third molar extraction. X-axis represents the analgesic drugs and Y-axis represents the total number of patients who underwent mandibular third molar extraction (Blue: Painless, Green: Pain). Chi-square test was done and association was found to be statistically significant. Pearson’s Chi square value: p value: 0.000(<0.05) Hence, it is statistically significant, proving piroxicam has a better analgesic effect when compared to other drugs post mandibular third molar extraction.
Conclusion
Within the limitations of the study, the efficacies of piroxicam
among other NSAIDs was found to be significantly high and in
different age groups and gender were found to be not very significant
for comparison as a better analgesic when compared to
other NSAIDs. In the future studies, larger sample size with multicentered
and multiple ethnic groups should be involved to get
better results.
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