Analgesia preemptiva em cirurgias de implantes dentais: (i) revisão sistemática e meta-análise; (ii) ensaio clínico triplo-cego, paralelo, randomizado e controlado por placebo

Abstract

There is insufficient evidence to recommend a specific analgesic regimen for pain management in preemptive analgesia after dental implant surgery, signaling the need for further studies. This research presents two studies with different objectives: (1) to evaluate the effectiveness of preemptive analgesia in dental implant surgeries through a systematic review and meta-analysis of randomized clinical trials. (2) to evaluate and compare, through a randomized clinical trial (RCT), parallel, controlled by placebo, the effectiveness of preemptive analgesia in single dental implant surgeries, seeking to identify among analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) [ eterocoxib (ETERO), ibuprofen (IBU), nimesulide (NIME) and acetaminophen (ACETA)], which is more effective in relieving postoperative pain and reducing the use of rescue medication compared to the use of placebo. The systematic review with meta-analysis was conducted by PRISMA guidelines and registered in PROSPERO (CRD42020168757). Five studies were included in the review and four were incorporated into the meta-analysis. A random-effect meta-analysis compared the effectiveness of preventive medication compared to placebo. The interpretation of the results followed the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach together with the magnitude of the effect according to the GRADE guidelines. All studies demonstrated that preemptive medication contributed to a significant improvement in postoperative pain. However, the pooled overall mean standard deviation (SMD) showed that preventive medication had a small effect compared with placebo in reducing pain (SMD: -0.43; CI: -0.71; -0.15) with low certainty of evidence. Our meta-analysis showed that the magnitude of the effect was greater six to eight hours after surgery (large effect), compared to one to two hours after surgery (small effect). It was concluded that preventive analgesia can have a positive effect in reducing pain compared to not using preemptive medication, but the evidence is still insufficient. The RCT with single dental implant insertion involved 135 individuals, with a mean age of 57.1 (±11.2), of both genders allocated into 5 groups (ETERO, IBU, NIME, ACETA and placebo). The occurrence, duration and intensity of pain were analyzed using Chi-square, Fisher's Exact, ANOVA and generalized estimating equation models when appropriate. All drugs tested provided a beneficial effect of preemptive analgesia demonstrated by reduced postoperative pain and reduced use of rescue medication. The IBU group had significantly higher pain scores than the other three test groups (ETERO, NIME and ACETA), which were equivalent to each other. Despite the occurrence of statistical significance, from the point of view of clinical relevance, the difference between the groups was small and all had low pain scores. Thus, we suggest that the decision making regarding the choice of medication should also consider the cost-benefit ratio, adverse effects and individual characteristics of patients. In addition, future studies in extensive implant dentistry surgeries (greater number of implants inserted and with bone/gingival grafts) presenting high methodological rigor are still necessary. (CAEE 83534618.5.0000.5149)