Ketoprofen Is More Effective Than Diclofenac After Oral Surgery When Used as a Preemptive Analgesic: A Pilot Study

Aim: To evaluate the preemptive analgesia of ketoprofen in comparison with diclofenac after mandibular third molar surgery. Methods: This study was a double-blind, randomized clinical trial. Forty patients were randomized into two treatment groups (each with 20 patients) by using a series of random numbers: group A received ketoprofen 100 mg and group B received diclofenac 75 mg, all intramuscularly. Surgery was done 30 minutes after analgesic treatments. The durations of analgesia, pain intensity, analgesic consumption, and side effects were evaluated. The statistical analysis was done using the chi-square, Student t, Mann-Whitney U, and Log-Rank tests. Results: The duration of analgesia was longer in the ketoprofen group when compared with the diclofenac group. The number of patients taking the first rescue analgesic at 6 hours was lower in the ketoprofen group in comparison with the diclofenac group. Patients who received ketoprofen had lower pain intensity compared with patients who received diclofenac. Conclusion: Intramuscular ketoprofen 100 mg is more effective than intramuscular diclofenac 75 mg after mandibular third molar extraction when used as a preemptive analgesic.

dental pain; diclofenac; ketoprofen; third molar surgery

1. Seymour RA, Meechan JG, Blair GS. An investigation into postoperative pain after third molar surgery under local analgesia. Br J Oral Maxillofac Surg 1985;23:410–418.

2. Ong KS, Seymour RA. Pathogenesis of postoperative oral surgical pain. Anesth Prog 2003;50:5–17.

3. Barden J, Edwards JE, McQuay HJ, Wiffen PJ, Moore RA. Relative efficacy of oral analgesics after third molar extraction. Br Dent J 2004;197:407–411.

4. Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM. Acute pain management: scientific evidence. Melbourne: Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine, 2010.

5. Roth SH. Nonsteroidal anti-inflammatory drug gastropathy: new avenues for safety. Clin Interv Aging 2011;6:125–131.

6. Gan TJ. Diclofenac: an update on its mechanism of action and safety profile. Curr Med Res Opin 2010;26:1715–1731.

7. Derry S, Wiffen PJ, Moore RA. Relative efficacy of oral analgesics after third molar extraction--a 2011 update. Br Dent J 2011; 211:419–420.

8. Levrini L, Carraro M, Rizzo S, Salgarello S, Bertelli E, Pelliccioni GA, et al. Prescriptions of NSAIDs to patients undergoing third molar surgery: an observational, prospective, multicentre survey. Clin Drug Investig 2008;28:657–668.

9. Christensen K, Daniels S, Bandy D, Ernst CC, Hamilton DA, Mermelstein FH, Wang J, Carr DB. A double-blind place-bocontrolled comparison of a novel formulation of intravenous diclofenac and ketorolac for postoperative third molar extraction pain. Anesth Prog 2011;58:73–81.

10. Heo SK, Cho J, Cheon JW, Choi MK, Im DS, Kim JJ, et al. Pharmacokinetics and pharmacodynamics of ketoprofen plasters. Biopharm Drug Dispos 2008;29:37–44.

11. Sarzi-Puttini P, Atzeni F, Lanata L, Bagnasco M, Colombo M, Fischer F, et al. Pain and ketoprofen: what is its role in clinical practice? Reumatismo. 2010;62:172–188.

12. Katz J, Clarke H, Seltzer Z. Review article: Preventive analgesia: quo vadimus? Anesth Analg 2011;113:1242–1253.

13. Davenport DL, Bowe EA, Henderson WG, Khuri SF, Mentzer RM Jr. National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists physical status classification (ASA PS) Levels. Ann Surg 2006;243:636–644.

14. Lima CJ, Silva LC, Melo MR, Santos JA, Santos T. Evaluation of the agreement by examiners according to classifications of third molars. Med Oral Patol Oral Cir Bucal 2012;17:e281–e286.

15. Akural E, Järvimäki V, Länsineva A, Niinimaa A, Alahuhta S. Effects of combination treatment with ketoprofen 100 mg + acetaminophen 1000 mg on postoperative dental pain: a sin-gle-dose, 10-hour, randomized, double-blind, active- and placebo-controlled clinical trial. Clin Ther 2009;31:560–568.

16. Leone M, Richard O, Antonini F, Rousseau S, Chabaane W, Guyot L, et al. Comparison of methylprednisolone and ketoprofen after multiple third molar extraction: a randomized controlled study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e7–e9.

17. Cooper SA, Reynolds DC, Reynolds B, Hersh EV. Analgesic efficacy and safety of (R)- ketoprofen in postoperative dental pain. J Clin Pharmacol 1998;38:11S–18S.

18. Reed KL, Smith JR, Lie T, Adams DF. A pilot study comparing ketoprofen and acetaminophen with hydrocodone for the relief of postoperative periodontal discomfort. Anesth Prog 1997; 44:49–54.

19. Mehlisch D, Frakes L, Cavaliere MB, Gelman M. Double-blind parallel comparison of single oral doses of ketoprofen, codeine, and placebo in patients with moderate to severe dental pain. J Clin Pharmacol 1984;24:486–492.

20. Tuzuner Oncul AM, Yazicioglu D, Alanoglu Z, Demiralp S, Ozturk A, Ucok C. Postoperative analgesia in impacted third molar surgery: the role of preoperative diclofenac sodium, paracetamol and lornoxicam. Med Princ Pract 2011;20:470–476.

21. Pandit MK, Godhi S, Lall AB. Preoperative intravenous tramadol versus diclofenac for preventing postoperative pain after third molar surgery: a comparative study. J Maxillofac Oral Surg 2011;10:306–309.

22. Roelofse JA, Van der Bijl P, Joubert JJ. Analgesic and anti-inflammatory efficacy of tenoxicam and diclofenac sodium after third molar surgery. Anesth Prog 1996;43:103–107.

23. Roelofse JA, van der Bijl P, Joubert JJ. An open comparative study of the analgesic effects of tenoxicam and diclofenac sodium after third molar surgery. Anesth Pain Control Dent 1993; 2:217–222.

24. Leeson RM, Harrison S, Ernst CC, Hamilton DA, Mermelstein FH, Gawarecki DG, et al. Dyloject, a novel injectable diclofenac formulation, offers greater safety and efficacy than voltarol for postoperative dental pain. Reg Anesth Pain Med 2007;32: 303–310.

25. Seymour RA, Moore U, Hawkesford J, Coulthard P, Jackson-Leech D, Thomas D, et al. An investigation into the efficacy of intravenous diclofenac in post-operative dental pain. Eur J Clin Pharmacol 2000;56:447–52.

26. Goucke CR, Keaveny JP, Kay B, Healy TE, Ryan M. The effect of diclofenac and nefopam on postoperative dental pain. Anaesthesia 1990;45:329–331.

27. Valanne J, Korttila K, Ylikorkala O. Intravenous diclofenac sodium decreases prostaglandin synthesis and postoperative symptoms after general anaesthesia in outpatients undergoing dental surgery. Acta Anaesthesiol Scand 1987;31:722–727.

28. Tai YM, Baker R. Comparison of controlled-release ketoprofen and diclofenac in the control of post-surgical dental pain. J R Soc Med 1992;85:16–18.

29. Niemi L, Tuominen M, Pitkänen M, Rosenberg PH. Comparison of parenteral diclofenac and ketoprofen for postoperative pain relief after maxillofacial surgery. Acta Anaesthesiol Scand 1995; 39:96–99.

30. Seymour RA, Kelly PJ, Hawkesford JE. The efficacy of ketoprofen and paracetamol (acetaminophen) in postoperative pain after third molar surgery. Br J Clin Pharmacol 1996;41:581–585.

31. Seymour RA, Watkinson H, Hawkesford JE, Moore U. The efficacy of buffered ketoprofen in postoperative pain after third molar surgery. Eur J Clin Pharmacol 2000;55:801–806.

32. Sunshine A, Olson NZ, Marrero I, Tirado S. Onset and duration of analgesia for low-dose ketoprofen in the treatment of post-operative dental pain. J Clin Pharmacol 1998;38:1155–1164.

33. Pozzi A, Gallelli L. Pain management for dentists: the role of ibuprofen. Ann Stomatol 2011;2:3–24.

34. Olmedo MV, Gálvez R, Vallecillo M. Double-blind parallel comparison of multiple doses of ketorolac, ketoprofen and placebo administered orally to patients with postoperative dental pain. Pain 2001;90:135–141.

35. Kubitzek F, Ziegler G, Gold MS, Liu JM, Ionescu E. Analgesic ef-ficacy of low-dose diclofenac versus paracetamol and placebo in postoperative dental pain. J Orofac Pain 2003;17:237–244.

36. Esteller-Martínez V, Paredes-García J, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Analgesic efficacy of diclofenac sodium versus ibuprofen following surgical extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal 2004;9:448–453.

37. Walton GM, Rood JP, Snowdon AT, Rickwood D. Ketorolac and diclofenac for postoperative pain relief following oral surgery. Br J Oral Maxillofac Surg 1993;31:158–160.

38. Sudarshan, Girish Rao S, Venkataraghavan K. Management of Postoperative Pain and Swelling following Mandibular third molar surgery with Newer Drugs – A Comparative Study. Int J Contemp Dent 2011;2:92–97.

39. Chunduri NS, Kollu T, Goteki VR, Mallela KK, Madasu K. Efficacy of aceclofenac and diclofenac sodium for relief of postoperative pain after third molar surgery: A randomised open label comparative study. J Pharmacol Pharmacother 2013;4:144–145.

40. Coaccioli S. Ketoprofen 2.5% gel: A clinical overview. Eur Rev Med Pharmacol Sci 2011;15:943–949.

41. Ong KS, Seymour RA. Maximizing the safety of nonsteroidal antiinflammatory drug use for postoperative dental pain: An evidence-based approach. Anesth Prog 2003;50:62–74.

42. Forrest JB, Camu F, Greer IA, Kehlet H, Abdalla M, Bonnet F, et al. Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery. Br J Anaesth 2002;88:227–233.

43. Naclério-Homem MG, Deboni MC, Rapoport A, Chin VK. Effects of ketoprofen and diclofenac potassium on blood coagulation tests after removal of third molars. Quintessence Int 2009;40:321–325.