Analgesia peri-operatoria in chirurgia orale: revisione narrativa della letteratura e proposta di uno schema terapeutico multimodale

OBJECTIVES Pain is a common event occurring after surgical procedures, and its management can be very challenging for the clinician. Every surgical trauma leads to both local and systemic inflammatory reactions, which stimulate the pain pathways. Post-operative pain following oral surgery procedures may range from mild to severe depending on the complexity of the procedure, and the clinician has the duty to minimize its intensity and duration to improve patients’ quality of life and surgical healing. Scientific literature focusing on post-operative pain management is mainly based on unimodal treatment, with the use of a single type of anti-inflammatory/ analgesic drug. However, this method does not allow for an optimal pain reduction and may lead to a significant increase in drugs adverse effects. Therefore, the multimodal therapeutic regimen was proposed, involving the combination of different drugs. Moreover, it is essential to obtain the analgesic effect not only during the post-operative period but also before and during the surgery, and the term peri-operative analgesia appears more appropriate. The purpose of this research work is to present a narrative review of the scientific literature on the topic, and to propose an effective therapeutic regimen for the management of peri-operative pain in oral surgery procedures. MATERIALS AND METHODS This narrative literature review is based on the following question: “What are the pharmacological methods to ensure an effective peri-operative pain control in oral surgery?”. A bibliographic search was performed on PubMed, Medline, and Embase on the topic, and a manual search on pharmacology databases and anesthesiology textbooks was also performed. The results of this review are presented according to a logical flow of treatments with the aim to obtain a good peri-operative pain control. In the end, the authors propose an effective and applicable multimodal analgesic regimen for oral surgery procedures. RESULTS AND CONCLUSIONS Numerous drugs are available for the control of dental pain, including long-acting local anesthetics, steroidal and non-steroidal anti- inflammatory drugs, opioids, and nitrous oxide for conscious sedation in dentistry. It can be challenging to achieve an optimal analgesic effect with a single drug, and the use of different drugs (multimodal analgesia) allows for increased efficacy due to additive or synergistic effects, with no need to increase the dose of individual drugs, reducing possible side effects. Therefore, a tailored multimodal analgesic therapeutic regimen is proposed, differentiated according to the anticipated pain intensity that the surgical procedure may generate in the patient. In fact, oral surgery is an extremely heterogeneous branch of dentistry, ranging from simple surgical procedures, which can cause mild pain, to invasive surgeries requiring a complex analgesic scheme, and the use of multiple drugs may help to obtain a better pain management. CLINICAL SIGNIFICANCE According to the findings of this narrative review, peri-operative pain management is of primary importance. In fact, untreated pain can lead to many problems, including stress and impaired surgical healing. Multimodal analgesia allows to increase the analgesic efficacy thanks to the synergistic effects of multiple therapeutic molecules.