CATEGORY AUSTRALASIAN DENTIST105 CLINICAL Acumen Dental has been advocating for dental practices to prescribe and dispense themselves for 25 years. One of the most popular solutions for a practice is pain relief. There’s no getting around the fact that many dental procedures can be painful, and the more invasive the procedure, the worse the pain is and the longer it lasts.1 Unfortunately, fear and anxiety about potential pain make the pain worse,1 and pain during past dental visits contributes to a patient’s fear and anxiety.2 That’s why it’s so important that we provide our patients with effective pain relief during and after dental procedures – not just to give patients the most comfortable experience they can have, but to minimise anxiety and break the cycle of pain–fear–avoidance that can lead to patients delaying dental visits and developing more serious problems. Evidence for NSAIDs + analgesics Almost all pain in dentistry is caused by tissue inflammation, usually resulting from infection or trauma – such as a dental procedure.3 Therefore, from a mechanistic viewpoint, an anti-inflammatory drug is indicated because an analgesic alone does not address the underlying problem. A systematic review of 27 randomised clinical studies found considerable evidence for the use of nonsteroidal antiinflammatory drugs (NSAIDs) used pre- and post-procedurally to relieve dental pain.4 Several studies included in this analysis also found that the combination of an NSAID + analgesic (e.g. paracetamol) was more effective than either agent on their own.4 This is supported by evidence from animal models showing that paracetamol combined with NSAIDs produces a supraadditive or synergic analgesic effect.5 MAXIGESIC for dental pain MAXIGESIC is a fixed combination of ibuprofen and paracetamol, the two most commonly used over-the-counter medicines for pain.6 In patients undergoing dental extraction, the combination of paracetamol + ibuprofen provides more effective pain relief than either component given alone,7 and a faster onset of meaningful pain relief than paracetamol or ibuprofen alone.7 A clinical study using the Maxigesic United States formulation, which is bioequivalent to the Australian formulation, compared MAXIGESIC with paracetamol alone, ibuprofen alone or placebo in 408 patients undergoing third molar extraction, using doses of 975 mg of paracetamol, 292.5 mg of ibuprofen, 292.5 mg ibuprofen + 975 mg paracetamol (as MAXIGESIC) or placebo every 6 hours for 48 hours.7 The primary endpoint was the sum of pain intensity differences over 48 hours (SPID48) to assess pain relief throughout the treatment period. Pain intensity scores during the first 6 hours after surgery were consistently lower with MAXIGESIC compared with the other agents (Figure 1), and SPID48 showed significantly greater pain relief with MAXIGESIC throughout treatment (P<0.001). The time to meaningful pain relief was also significantly shorter with MAXIGESIC (43 minutes) than with ibuprofen (62 minutes) or paracetamol (49 minutes) (P≤0.03).7 Patients receiving MAXIGESIC also required fewer rescue analgesics (P≤0.002). there is no evidence of an increased risk of postoperative bleeding with MAXIGESIC vs placebo in comparative studies.8 Bottom line MAXIGESIC is an effective, convenient and well tolerated choice for short-term pain relief after dental procedures, providing superior pain relief than paracetamol or ibuprofen alone without any increase in the risk of side effects. X Visit our website at Acumen Dental www.acumen.dental for the support, tools and products you need to prescribe and dispense, great for your patients care, additional revenue and improved service. References 1. Tickle M, et al. Predictors of pain associated with routine procedures performed in general dental practice. Commun Dent Oral Epidemiol 2012;40:343-350. 2. Carter AE, et al. Pathways of fear and anxiety in dentistry: a review. World J Clin Cases 2014;2(11):642-653. 3. Hargreaves K, Abbott PV. Drugs for pain management in dentistry. Aust Dent J 2005;50(Suppl. 2):S14-S22. 4. Aminoshariae A, et al. Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: A systematic review of randomized controlled trials. J Am Dent Assoc 2016;147(10):826-39 5. Miranda HF, et al. Synergism between paracetamol and nonsteroidal antiinflammatory drugs in experimental acute pain. Pain 2006;122:22-28. 6. Tanner T, et al. The pharmacokinetic profile of a novel fixed-dose combination tablet of ibuprofen and paracetamol. BMC Clin Pharmacol 2010;10:10. 7. Daniels SE, et al. Analgesic efficacy of an acetaminophen/ibuprofen fixeddose combination in moderate to severe postoperative dental pain: a randomized, double-blind, parallel-group, placebocontrolled trial. Clin Ther 2018;40:1765-1776. 8. Aitken P, et al. An integrated safety analysis of combined acetaminophen and ibuprofen (MAXIGESIC®/Combogesic®) in adults. J Pain Res 2019;12:621-634. Managing dental pain: the role of MAXIGESIC By Dr Mike Ryan, Acumen Dental What about side effects? MAXIGESIC is generally well tolerated, with an adverse event rate similar to placebo in clinical trials.8 and is associated with a similar incidence of adverse events as ibuprofen or paracetamol alone.8 The most common adverse event with MAXIGESIC is mild to moderate nausea.8 Although NSAIDs may inhibit clotting, Figure 1. Pain intensity scores during the first 6 hours after removal of 2 – 4 wisdom teeth in a randomised, double blind, placebo-controlled trial.7 FDC = fixed-dose combination (MAXIGESIC). Dr Mike Ryan
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