Does oral Nonsteroidal Anti-inflammatory Drugs (NSAIDs) premedication in patients with irreversible pulpitis increase the success rate of inferior alveolar nerve block?

Data sources PubMed, EBSCOhost and Scopus database up till 9 September 2017 in English language. Clinical trial registry and reference lists of published systematic reviews, textbooks and selected articles were also searched. Study selection Population-based randomised clinical trials comparing effects of any single NSAID versus placebo as an oral premedication on the efficacy of IANB in achieving anaesthesia in patients ranging from age 14-68 with irreversible pulpitis who were undergoing nonsurgical root canal therapy in mandibular posterior teeth. Data extraction and synthesis Studies were selected, reviewed and extracted by two independent reviewers using a standardised extraction form. They assessed risk of bias using the revised Cochrane Risk of Bias Tool for Randomised Trials (ROB 2.0). Meta-analysis was performed using a random effects model. I 2 was used to evaluate heterogeneity. A subgroup analysis was conducted to investigate the dose-response effect of ibuprofen. Sensitivity analyses were performed by restricting studies with a low risk of bias and by using a fixed effects model (using STATA 14.1 software). Publication bias was assessed using funnel plot asymmetry and Egger regression tests. Trial Sequential Analysis (TSA) was conducted to assess the risk of random errors and to determine the required sample size, which helped to evaluate if evidence is conclusive. Quality of evidence was rated by GRADE pro GDT software. Results Thirteen randomised clinical studies that investigated the efficacy of oral premedication (30-60 minutes prior) with a single NSAID in promoting the anaesthetic success of IANBs involving 1,174 patients between the age of 14 to 68 were included. Of these, 1,034 were evaluated as a comparison to placebo while the remainder were comparisons to various medications. Among the 13 RCTs, eight showed a low risk of bias, four trials showed a high risk and the remaining one showed unclear risk. For all studies, intervention provision and outcome measurement were performed at the same visit with no follow-up periods. Of the 1,034 participants, 493 (47.6%) reported successful anaesthetic outcomes. Quantitative pooling of the results showed that the use of any NSAID significantly increased the anaesthetic success of IANB compared with placebo (RR=1.96; 95% CI, 1.63-2.35; I 2 = 6.8%). Subgroup analysis of nine trials showed that ibuprofen, diclofenac 50mg and ketorolac 10mg had a statistically significantly effect in increasing the anaesthetic success of IANBs compared with placebo (RR= 1.83, 95% CI, 1.43-2.35, I 2 = 20.8%; RR= 2.56, 95% CI, 1.46-4.50, I 2 = 44.8%; and RR= 2.07, 95% CI, 1.47-2.90, I 2 =0% respectively). While Ibuprofen >400mg was significantly more effective than placebo (RR= 1.85; 95% CI, 1.39-2.45; I 2 =26.7%), ibuprofen <400mg showed no statistical association (RR=1.78; 95% CI, 0.90-3.55; I 2 =38.70%). Funnel plot showed low publication bias. GRADE evaluation showed that the accumulated evidence for premedication with NSAIDs demonstrated high quality. I 2 results showed a low heterogeneity among trials. TSA concluded that the results of the meta-analyses showing premedication with NSAIDs increased the success rate of IANB anaesthesia were valid. Conclusions High quality evidence demonstrated that the oral premedication with NSAIDs increases the success rate of IANB in patients with irreversible pulpitis. © 2019, British Dental Association.