Pain control after third molar surgery

Abstract

The ideal agent for use after third molar surgery should alleviate pain, reduce swelling and trismus to a minimum, promote healing and have no unwanted effects. Of course, such an agent does not exist. For relief of pain, analgesics are the obvious choice. Where possible, an analgesic with additional anti-inflammatory properties should be used. There seems little to choose between aspirin, 1000 mg; diflunisal, 500 mg; ibuprofen, 400 mg and zomepirac sodium, 50 mg. In the subject allergic to aspirin and aspirin-like compounds, then paracetamol is the poor alternative. Surprisingly, the efficacy of most of the opioids in post-operative third molar pain is poor, and these drugs alone cannot be recommended for this purpose. Long-acting local anaesthetic solutions may be of value in some situations where extreme pain is likely to be a feature in the immediate post-operative period. However, there are no strict criteria for identifying such cases pre-operatively. Recent work on the use of corticosteroids would suggest that these drugs may be of value in reducing post-operative sequelae. Their future in dentistry in this rôle appears interesting and promising, and worthy of further study. Antihistamines and enzymes have been shown to be of little value, and the fact that these agents now receive little attention is evidence in its own right. The use of locally applied antimicrobials has been shown to be of little value in third molar surgery. In any case, their use is probably contraindicated because of the risk of sensitising the patient. The studies reviewed have not pointed to the effectiveness of the routine use of systemic antimicrobials in preventing or reducing postoperative sequelae after removal of impacted third molars in normal circumstances. Particular conditions, for example in patients susceptible to infection, may benefit by the use of prophylactic antimicrobials. However, each case must be judged on its individual merits, bearing in mind the attendant risks inherent in antimicrobial therapy. Finally, whatever agent is chosen for the control of the post-operative sequelae after third molar surgery, it must be borne in mind that, if the normal post-operative course occurs, then treatment is unlikely to extend beyond 48 h. Few doses of the particular agent will hence be used during this time period and thus the incidence of unwanted effects will be minimised.