COX-2 inhibitors and dental pain control.

Celecoxib (CELEBREX) and rofecoxib (VIOXX) appear to offer the following advantages: reduced incidence of gastric ulceration during long-term administration; little or no effect on platelet aggregation; longer clinical duration of action than aspirin, acetaminophen and ibuprofen. However, in the context of the management of dental pain and inflammation, the following points and disadvantages should be considered: no greater effectiveness than conventional NSAIDs (e.g., ibuprofen) for dental pain; greater cost than conventional NSAIDs (especially those available in generic forms); not available over-the-counter; possible inadequate duration of action for postoperative dental pain (see references 6 and 7); similar contraindications and drug interactions to less expensive, equally effective conventional non-selective NSAIDs. At this time, celebrex and rofecoxib cannot be recommended over conventional, non-selective NSAIDs as first-choice drugs for pain and inflammation in dentistry. Practitioners are cautioned against selecting any new drug based on "clinical trials of one", in which both the dentist and the patient know the drug being prescribed, (as opposed to double-blind studies), usually in the context of considerable "hype" about the drug (based on comments about the fact that the agent being tried is "new") and strong placebo reinforcement based on the dentist's enthusiasm for the new product, which does not usually accompany the prescription of older, routinely prescribed drugs. Finally, such "clinical trials of one" invariably involve close follow-up about the outcome of the treatment, which is usually not done with more common, older drugs, and which only introduces further bias into the interpretation of the effectiveness of the drug by both the patient and the dentist. Anaglesic drugs should be selected on the basis of controlled, double-blind, randomized clinical trials which utilize a reasonable, dentally-related pain model. The older NSAIDs, such as ibuprofen, naproxen, diflunisal and others, remain first-choice drugs for the treatment of mild-to-moderate pain in dentistry in patients lacking the contraindications for such drugs. As proposed by this author several years ago, the major contraindications to NSAIDs can be remembered by the "SAAB Rule", an acronym which stands for "Stomach problems", Aspirin Allergy" and "Bleeding problems", in addition to pregnancy and hepatic/renal disease.