Critical Thinking

Pain site. It has a dual phase character,

Pain is the most common symptom bringing
patients to dental office 1. Despite its prevalence it’s very
challenging to manage pain in day today practice. Often the dental treatment
alone can provide a great relief from pain such as immediate reduction of pain
following an incision and drainage of an abscess or the relief that can be
accomplished by removal of an affected tooth. So the next step will be towards
managing the post-operative pain.

Surgical removal of third molar is one of the
common procedures done by oral and maxillofacial surgeons, this procedure
involves incisional and inflammatory injuries that results in pain, swelling, trismus
in the post-operative period 2. The first 12 hours following
removal of the tooth is considered as most unpleasant experience3.
 This can be reduced by use of
pre-emptive analgesia that is started before the beginning of the surgery.  It has a great impact on the patient’s pain perception
4, 5.

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During the perioperative period, there is a
flow of nociceptive signals from the operating site. It has a dual phase
character, the initial phase or the first phase results from injuries produced
by the surgical procedure, the second phase of nociceptive stimulation is due
to the inflammatory responses associated with the tissue injury.

The peripheral tissue injury provokes two
kinds of modification in the responsiveness of the nervous system: Peripheral
sensitisation, a reduction in the threshold of nociceptor afferent peripheral
terminals and Central sensitisation, an actively dependant increase in the
excitability of spinal neurons. Together these changes contribute to post
injury pain hypersensitivity state found post operatively.  This manifest as increase in response to
noxious stimuli and a decrease in pain threshold both at the site of injury and
in the surrounding uninjured tissue. The sensory signals generated by the
tissue damage during the surgery can produce an increased excitability in the
central nervous system. The role of Preemptive analgesia is that it blocks the
initiation of central sensitisation evoked by incisional and inflammatory
injuries occurring during surgery and in initial post-operative period.6
78 It leads to effective reduction in the development of Peripheral
and Central sensitisation – the reason for primary and secondary hyperalgesia.
9101112Primary hyperalgesia refers to pain sensitivity in the
surgical site, whereas secondary hyperalgesia refers to pain sensitivity in the
surrounding tissues.

Thus successful post-operative pain control
can be achieved by

·      
Blocking
the beginning of neural cascade which results to increased sensitivity produced
by noxious stimuli.6 7 8 13

·      
Efficient
analgesic agent before the onset of the unpleasant stimulus to prevent central
sensitisation and preventing painless sensation to be seen as pain (allodynia).6
78 13 

This idea of preventing pain was first
introduced by Crile in 1913, which was further developed by Wall and Woolf.
They suggested that simply changing the timing of treatment can have better
effects on post-operative pain.

Various pre-emptive agents can be used for
effective pain management among them are NSAID’S. 14 15 16 17  The Main mechanism of action of NSAIDs
are inhibition on cyclooxygenase activity as a result there is inhibition of
prostaglandins which has a proinflammatory effect.

We have compared Aceclofenac 100 mg and
Piroxicam 20 mg given orally one hour before the surgery among patients
undergoing surgical removal of impacted third molar.

With the help of our prospective randomised
double blind study we have compared the efficacy of Aceclofenac and Piroxicam
as pre-emptive analgesic for preventing postoperative pain after third molar
surgery.

Materials and Methods

Study
location:  The study was conducted among patients
reporting to the Department of Oral and Maxillofacial Surgery for surgical
removal of impacted third in a private Dental

College, Chennai, Tamil Nadu, India.

Study
Groups:

The study was conducted among 50 subjects,
who were randomly grouped into two groups- Aceclofenac group (A) and Piroxicam
group (B).

The Aceclofenac group (A) comprised of 25
individuals, who were given Aceclofenac 100mg preoperatively 1 hour before the
procedure.

The Piroxicam group (B) comprised of 25
individuals, who were given Piroxicam 25mg preoperatively 1 hour before the
procedure

All the subjects were explained about this
study in detail and the possible complications in the study and all the
patients were given informed consent.

 

 

 

 

Inclusion
criteria:

1. Healthy subjects without any systemic
disease were included in this study.

2. Subjects not under any analgesics or other
medications 24 hours prior to surgery.

3. Subjects not allergic to any medicament.

4. Patients who can report for post-operative
review.

Exclusion
criteria:

1. Subjects with systemic disease, pregnancy
or lactation were excluded.

2. Subjects reported with pericoronitis or
pericoronal abscess were excluded from the study.

3. Subjects who have taken any analgesics 24
hours prior to surgery were excluded.

4. Subjects allergic to any medicament were
excluded from the study.

The patient, the operating surgeon were all
blinded during the study process, all the patients were evaluated by one principal
investigator.

Each patient was assessed before the
procedure for any pain, if they had pain their score was recorded in the Visual
Analogue Scale, followed by 24 hours post operatively followed by 3rd
and 5th day for pain.  Patient’s mouth opening was assessed before
the procedure, followed by  3rd
and  5th day.

Criteria for measurement:

Pain measurement was done using Visual Analogue
Scale (VAS) on a scale of 0 to 10.

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