Can an intranasal NSAID offer relief for endodontic pain?

Which pain reliever do you prescribe for patients experiencing moderate to severe pain from their untreated endodontic symptoms? A new study compared the intranasal form of the nonsteroidal anti-inflammatory drug (NSAID) ketorolac with a combination of ibuprofen and acetaminophen to see which is more effective.

Ketorolac has been reported to offer pain relief similar to opioid medications in previous studies. And when researchers of the new study compared the results of ketorolac with those from the ibuprofen and acetaminophen combination in 70 patients, they found no significant difference between the patient groups for the time to 50% pain relief, the first sign of pain relief, or meaningful pain relief.

"Intranasal ketorolac provides a promising alternative for clinicians in managing preoperative and postoperative endodontic pain, as well as an additional route of administration," wrote the authors, led by Kathryn Watts, DMD, of the division of endodontics at the Ohio State University in Columbus (Journal of Endodontics, January 30, 2018).

Timely relief

Studying pain preoperatively in endodontic patients provides practical information for practitioners:

• As treatment may not be able to be offered immediately, practitioners can advise patients on pain management options.
• The efficacy of pain management treatments can be studied without the confounding factor of root canal treatment, which helps to alleviate patients' pain.

Ketorolac, known by the brand name Sprix (Egalet US), has been available for primary use only via intravenous and intramuscular routes. The intranasal form of the NSAID offers patients a self-administration option for pain relief. The researchers wanted to compare the efficacy of intranasal ketorolac with a combination of ibuprofen and acetaminophen in an acute pain model of untreated endodontic patients experiencing moderate to severe pain and symptomatic apical periodontitis.

The double-blind, randomized study included 70 patients experiencing moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and a periapical diagnosis of symptomatic apical periodontitis. Patients were randomly divided into two groups: One group received 31.5 mg of intranasal ketorolac and placebo capsules, and the other received 1,000 mg of acetaminophen and 600 mg of ibuprofen capsules and a mock nasal spray.

Patients recorded perceived pain scores on a visual analog scale every 15 minutes from drug administration up to 240 minutes. Researchers also measured the time to 50% pain relief, the first sign of pain relief, and meaningful pain relief.

The average time to meaningful pain relief was 67 minutes for the mock nasal spray group and 79 minutes for the ketorolac group. The researchers found no significant difference between the two groups for the time to 50% pain relief, the first sign of pain relief, or meaningful pain relief (see table below).

Valid options

The authors reported no study limitations, but they noted that while it was possible that participants may have guessed they were in the intranasal ketorolac group based on unwanted side effects, the participants who received acetaminophen and ibuprofen with the mock nasal spray also reported side effects.

Both intranasal ketorolac and the combination of 1,000 mg of acetaminophen and 600 mg of ibuprofen are viable pain relief regimens for endodontic patients, the study authors concluded.

"With the increase in opioid misuse/abuse and the numerous side effects associated with opioids, having multiple effective, nonopioid options with varying forms of administration is invaluable to practicing clinicians," they wrote.