7. Analgesic monotherapy versus combined therapy in dental practice

Analgesic monotherapy and combined therapy is shown in different clinical situations such as reducing pain in surgical procedures, periodontal and endodontic procedures which is documented also from different clinical trials. Many NSAIDs which are used in dental pain includes ibuprofen, aspirin, diflunisal, etodolac, mefenamic acid, ketoprofen, ketorolac and flubiprofen. Ibuprofen is the most commonly used in acute pain and is often prescribed as the first choice analgesic associated with its anti-inflammatory actions in the dentistry practice. Paracetamol acts in the central nervous system and it possesses analgesic and antipyretic effects. It is the first choice for patients who cannot tolerate NSAIDs. Higher doses such as 1000 mg are more favorable in the context of its efficacy and were comparable with ibuprofen.

There is strong evidence that combined analgesics therapy lead to greater efficacy and fewer adverse events compared with monotherapy of analgesics in higher doses. Different randomized controlled trials that compared combinations of several analgesics (NSAIDs and acetaminophen) revealed that the combination of acetaminophen with different NSAID drugs was more effective than either acetaminophen or individual NSAID alone [18, 91, 92].

Currently there are many combinations of paracetamol with other NSAIDs such as ibuprofen, ketoprofen and diclofenac and they have resulted in providing superior analgesia than using the drug alone. Otherwise in the patients with moderate to severe pain induced by postoperative pain, the combination of lower doses of ibuprofen with paracetamol has not shown benefits when compared with ibuprofen used alone. This is an indication that dosage choice is an important factor regarding its related combinations [93–95].

Naproxen is indicated in toothache and its pain relief efficacy is comparable with ibuprofen. It is comparable with etodolac, but less effective in swelling when compared with diclofenac when they were used in oral surgical procedures, including postoperative third molar surgery or orthodontic pain [96–98]. Diclofenac is used in moderate to severe pain following third molar extraction and it could be used in an intravenous form in risk population groups such as the elderly and renal insufficiency, postoperative anticoagulation which uses ketorolac as the only choice for the moderate to severe acute pain. Very similar effects were shown when transdermal diclofenac patches were used compared to oral administration [99, 100].

Due to safety concerns COX-2 selective inhibitors have been introduced as a safe alternative in dentistry practice with superior analgesic and inflammatory conditions in periodontal diseases and after oral surgery procedures. Etoricoxib and celecoxib groups were shown to be comparable to ibuprofen on its efficacy in the dental pulpal pain or postoperative pain relief, third molar surgery but superior toacetaminophene [101–103].

Their use is favorable in patients with upper-GI-complications, in the aspirin user for cardiovascular comorbidities, or those allergic to aspirin and perioperative settings due to their lack of properties over blood clotting. But they are limited to be used in such short periods including postoperative periods due to their cost effectiveness compared to other NSAIDs. Also, their long-term uses in the painful temporo mandibular joint disorders and chronic orofacial pain in the patients without cardiovascular risk factors could be considered as another therapeutic option [41, 104].
