Management of post-surgical pain is a critical aspect in specific dental procedures. Reviewing, for example, the avulsion of the lower third molars in a state of inclusion, which can often require investigative maneuvers in terms of amplitude of surgical access (flap) and osteotomy, surgical procedure and postoperative course. Following procedures of this type, the progression of pain levels envisages a peak on the first day, and then potentially continues for about one week.

Conceptually, in these cases, it would be useful to extend the analgesic effect established by anesthetic administration beyond the procedure through the correct use of painkillers. Among these, the first line therapy to consider consists of nonsteroidal anti-inflammatory drugs (NSAIDs). More recently, some studies have raised some interest in other molecules, such as tramadol, a synthetic opioid, already well known to dentists because of its use in the treatment of trigeminal neuralgia.

The molecule is available as a salt (tramadol hydrochloride) for injection and, therefore, despite the fact that the reduced impact of some systemic side effects typical of opioids (respiratory depression, constipation) has been documented, the effects of local administration have been widely studied. In general surgery, for example, administration of tramadol in addition to the infiltration of local anesthetic is able to prolong the effectiveness of the latter and reduce postoperative consumption of painkillers.

In the dental field, the Iqbal and Shetty study recently assessed the efficacy of submucosal injection of tramadol in management of postoperative pain after surgery for inclusion of third molars.

The randomized clinical trial, the results of which were published at the end of 2019 in the Journal of Oral and Maxillofacial Surgery, involved a sample of 60 patients (32 men, aged 19-45 years) undergoing extractions. Each patient underwent the same antibiotic prophylaxis, surgical procedure and even local anesthesia. Namely, lower alveolar, lingual and long buccal nerve blocks, with 2% lidocaine combined with epinephrine 1: 200000. The case group also received tramadol, diluted in saline solution, at a dosage of 1 mg pro kilo immediately after suturing. The numerically equivalent control group received a placebo solely consisting of saline solution.

The pain scores, assessed on a visual analogue scale and subjected to statistical analysis by means of unpaired Student t tests, were significantly lower than 0.5, at 1, 2, 4 and 6 hours, but not for the subsequent findings, collected at 12, 24 and 48 hours.

The study therefore established the efficacy of submucosal administration of tramadol in reducing postoperative pain in the extraction surgery of lower third molar inclusions, but detected a temporal limitation. The effect is significantly expressed, in fact, up to the six (6) post-procedural hours threshold.

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