Dental Intervention Procedures: Challenges, Management and Role of Aceclofenac, Paracetamol and Serratiopeptidase Based Combination Treatment

Dental intervention procedures encompass a comprehensive array of treatments conducted by dental professionals to maintain oral health, address dental ailments, and enhance individuals' overall well-being. These interventions span restorative procedures like dental fillings, crowns, and bridges; endodontic therapies such as root canal treatments; orthodontic interventions including braces and clear aligners; cosmetic dentistry interventions like teeth whitening and veneers; and surgical procedures like extractions and dental implants.[1] Preventive measures like dental cleanings and regular check-ups contribute to early disease detection. Together, these procedures are tailored to individual needs, optimizing oral function & enhancing quality of life.[1]

Challenges In Dental Intervention Procedures

The utilization of dental services in India is influenced by a range of factors, including the economic status & implications, presence of dental symptoms, geographical accessibility, and availability of specialists. Economic factors, such as actual and perceived dentist fees, play a crucial role, along with the willingness to undergo preventive and treatment interventions; together, they shape accessibility to dental care.[2] Dental intervention procedures in India also encounter challenges related to patient anxiety, pain management, accessibility, cost, and treatment planning. Overcoming these issues requires enhanced patient education, improved access to care, and effective communication to improve treatment outcomes.[3,4,5,6]

Managing pain associated with dental procedures is crucial, as most patients report pain during treatment. Invasive dental procedures tend to be associated with higher chances of intraoperative pain, often described as moderate to severe, peaking about 5 to 6 hours after surgery and lasting for days to weeks. This underscores the need for effective pain management strategies beyond the immediate postoperative period. Pain management has multifaceted implications in dental care, involving physical comfort, anxiety reduction, and fear alleviation. Effective pain management is critical not only for ensuring patient comfort but also for optimizing treatment care outcomes [4,5,7,8]

Current Pain Management Strategies in Dental Intervention Procedures

Postoperative complications following dental interventions, such as pain, swelling, and trismus, reiterate the importance of effective pain management strategies to ensure patient comfort, speedy recovery, and successful treatment outcomes.[9] Some of the current pain management strategies employed include:

• Local Anaesthetics: The administration of local anesthetics numbs the specific area being treated, effectively blocking pain signals during the procedure. These include lidocaine, mepivacaine, bupivacaine, prilocaine, and articaine.[10]
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are commonly used to alleviate pain and inflammation following dental procedures. [11,12]
• Paracetamol: It is a widely used analgesic and antipyretic medication. It effectively alleviates pain and reduces fever by inhibiting the production of prostaglandins responsible for these experiences. [11,12]
• Opioids: For severe pain, opioids like codeine or hydrocodone might be used. However, their utility must be carefully monitored due to potential side effects and addiction risks.[11,12]
• Combination Therapy: Combining different pain-relief medications, such as NSAIDs and paracetamol, can enhance their overall effectiveness and provide a broader action on pain and inflammation relief.[11,12]
• Preemptive Analgesia: Administering pain relief medications before the procedure can preemptively reduce pain and discomfort.[11]
• Intraoperative Techniques: Some dental procedures incorporate techniques like nerve blocks or continuous infusions of local anesthetics for extended pain relief.[11]
• Multimodal Analgesia: Combining various pain management approaches, such as medications, local anesthetics, and non-pharmacological methods, can offer comprehensive relief.[12]

Aceclofenac, Paracetamol & Serratiopeptidase Combination Treatment

Aceclofenac was initially approved in the EU in 1990 and introduced in Spain in 1992. Since then, it has been utilized among an estimated 171 million patients. Aceclofenac primarily operates by selectively inhibiting COX-2, which produces prostaglandins responsible for inflammation, pain, and fever. Furthermore, Aceclofenac demonstrates anti-inflammatory activity by inhibiting key mediators like Interleukines( IL-1, IL-6), Tumor Necrosis Factor(TNF-α), Nitric Oxide(NO), Matrix Metalloproteases(MMP), and enhancing IL-1Ra (Interleukin-1 Receptor antagonist) production. These actions collectively attenuate inflammation and reduce Prostaglandin(PGE2) production. These mechanisms are relevant in addressing dental pain associated with inflammatory processes, as infographically represented below. [13,14]

Figure: Potential Mechanism of Action of Aceclofenac. Adapted from Anu Grover., et al. “Aceclofenac in Osteoarthritis - NSAID with Novel Mechanism of Action". Acta Scientific Orthopaedics 3.12 (2020): 02-13.

Paracetamol is a widely used medication known for its effective pain-relieving and antipyretic properties. Paracetamol's efficacy makes it valuable in addressing dental discomfort and postoperative pain.[15] Paracetamol primarily works centrally, in the brain, to reduce the perception of pain and fever. It inhibits the release of prostaglandins in the brain, which are associated with pain and fever. [13,14,15]

Serratiopeptidase, a proteolytic enzyme derived, has gained attention for its potential role in addressing dental pain. Its anti-inflammatory and wound-healing properties help reduce tissue swelling and inflammation in oral conditions, potentially relieving pain. Serratiopeptidase exerts its anti-inflammatory activity by decreasing the viscosity of accumulated fluids, facilitating efficient drainage. Additionally, it can modulate cell-surface adhesion molecules responsible for attracting inflammatory cells to their target sites. The analgesic effect of serratiopeptidase is attributed to its inhibitory action on pain-inducing substances like bradykinin and other related amines [16,17]

Combining Aceclofenac and Paracetamol with Serratiopeptidase demonstrates a synergistic effect in dental pain management. Aceclofenac and Paracetamol provide analgesia through distinct mechanisms, while Serratiopeptidase offers anti-inflammatory and wound healing properties by reducing inflammation and supporting tissue repair. This combination addresses pain and inflammation comprehensively, potentially enhancing overall therapeutic efficacy associated with dental pains for improved patient comfort.[11,12,13,14,15,16,17]

Review of Clinical Studies- Aceclofenac, Paracetamol, Serratiopeptidase

• Effectiveness of Aceclofenac in Reducing Dental Pain: In a randomised, double-blind trial by P. Pavithra et al, 85 Indian patients suffering from acute dental pain due to irreversible pulpitis were enrolled. Among the fifty eligible participants, two treatment groups were designed. Group A received 400mg Ibuprofen, while Group B was administered 100 mg Aceclofenac. Using the Visual Analog Scale (VAS) (a tool to gauge pain intensity), assessments were made at 15, 30, and 45-minute intervals. Both medications effectively alleviated pain, with Aceclofenac displaying superior analgesic efficacy compared to Ibuprofen across all time points (p<0.001). The study concluded that Aceclofenac could be a preferred option for managing dental pain.[18]
• Paracetamol Effective for Postoperative Pain Management After Dental Surgery: In a double-blind, randomised parallel study conducted by D R Mehlisch, 162 outpatients experiencing moderate to severe pain post-dental surgery were included. They were administered paracetamol (1 gm), aspirin (650 mg), or a placebo. Patients rated their pain intensity and relief at various intervals over six hours post-medication. Within this period, 135 patients required additional medication. Both paracetamol and aspirin groups reported significantly better analgesic effects (P < 0.05) than the placebo. Paracetamol outperformed aspirin in terms of maximum pain reduction (P < 0.05) and maximum pain relief (P < 0.03), specifically in patients initially experiencing severe pain. Thus, the study concluded that paracetamol is effective in managing post-operative pain.[19]
• Five-day Serratiopeptidase Treatment Effective for Reducing Postoperative Swelling After Dental Intervention Procedure: Tachibana M et al. conducted a multi-center, double-blind, placebo-controlled trial involving 174 patients undergoing Caldwell-Luc surgery (an oral surgical procedure to remove tooth roots from maxillary sinus). The study aimed to examine the efficacy of serratiopeptidase, an anti-inflammatory enzyme for managing post-operative tissue swelling. The enrolled patients were categorised into two treatment arms: one group (n=88) received 10 mg of serratiopeptidase three times before the operation, once on the night of the operation, and thrice daily for five days post-operation, while the second group (n=86) received a placebo. The serratiopeptidase-treated patients experienced significantly less buccal swelling after the procedure compared to the placebo group at all observation points up to the 5th day(P<0.001-0.005), with maximal swelling also reported significantly less than placebo. This concludes that serratiopeptidase effectively reduces postoperative swelling after a dental intervention procedure.[20]

Clinical Advantages & Recommended Dosage for Using Aceclofenac Paracetamol Serratiopeptidase Combination

• Enhanced Pain Relief: The combined action of Aceclofenac, Paracetamol, and Serratiopeptidase supports a synergistic effect and helps more effective and comprehensive pain relief.[11,12,13,14,15,16,17]
• Multimodal Approach: These three components target pain through complementary action- aceclofenac for inflammation, paracetamol for analgesia, and serratiopeptidase for wound healing and faster recovery, providing a comprehensive care approach to pain management. [12,13,14,15,16,17] Aceclofenac offers a faster onset of action for prompt dental pain relief,[12,13,14] while serratiopeptidase's pain perception modulation and wound healing action help in overall effectiveness.[16,17]
• Improved Patient Comfort: This combination approach delivers superior pain relief and overall comfort throughout recovery.[11,12,13,14,15,16,17]
• The recommended dosage of the combination Aceclofenac (100 mg), Paracetamol (325 mg), and Serratiopeptidase (15 mg) can be up to two times daily. [21]

Clinical Care Pointers

• Dental interventions encompass a wide range of treatments for maintaining oral health. Challenges in these procedures include addressing patient anxiety, managing pain, handling technical complexities, and effective communication with patients.
• To manage postoperative pain & discomfort, dental practitioners employ various pain management strategies. These include nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, local anesthetics, opioids, and combinations of these medications.
• The combination of aceclofenac, paracetamol, and serratiopeptidase is clinically valuable in addressing inflammation, alleviating pain, and promoting healing after dental interventions. This combination therapy effectively targets different facets of pain and inflammation.
• Clinical studies have demonstrated the effectiveness of aceclofenac, paracetamol, and serratiopeptidase in relieving dental pain. These studies confirm the practical application of this therapy for patients undergoing dental procedures.
• The combination therapy of aceclofenac, paracetamol, and serratiopeptidase enhances patient comfort during the recovery phase after dental interventions by effectively addressing pain and inflammation. The treated patients experience improved postoperative healing and comfort from pain. [11,12,13,14,15,16,17]

References:

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2. Ramandeep Singh Gambhir, Prabhleen Brar, Gurminder Singh, Anjali Sofat, Heena Kakar. Utilization of dental care: An Indian outlook. Journal of Natural Science, Biology and Medicine,2013;4(2). DOI:10.4103/0976-9668.116972

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7. Ruth Suzanne Maximo da Costa, Suelen do Nascimento Ribeiro, Etenildo Dantas Cabral. Determinants of painful experience during dental treatment. Rev Dor. São Paulo, 2012 oct-dec;13(4):365-70 https://www.scielo.br/j/rdor/a/Yzr9fQwdmjXxmSyb9PFx6Fx/?format=pdf&lang=en

8. Stanley F. Malamed Pain management following a dental trauma and surgical procedures Dental Traumatology. 2023;39:295–303.https://doi.org/10.1111/edt.12840

9. Osunde OD, Adebola RA, Omeje UK. Management of inflammatory complications in third molar surgery: A review of the literature. African Health Sciences,2011;11(3):530-537. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3261018/

10. Derek Decloux, Aviv Ouanounou. Local Anaesthesia in Dentistry: A Review. International Dental Journal,201;71(2):87–95. https://doi.org/10.1111/idj.12615

11. Daniel E. Becker. Pain Management: Part 1: Managing Acute and Postoperative Dental Pain.AnesthesiaProgress,2010;57(2):67–79. https://doi.org/10.2344/0003-3006-57.2.67

12. Christina M. A. P. Schuh, Bruna Benso and Sebastian Aguayo. Potential novel strategies for the treatment of dental pulp-derived pain: Pharmacological approaches and beyond.FrontiersinPharmacology,2019;10. https://doi.org/10.3389/fphar.2019.01068

13. Giovanni Iolascon, Sergio Giménez and Dorottya Mogyorósi A Review of Aceclofenac: Analgesic and Anti-Inflammatory Effects on Musculoskeletal Disorders. Journal of Pain Research,2021;14:3651–3663. https://doi.org/10.2147/JPR.S326101

14. Dilip Shah, Ananda K Pal, Gurinder Bedi, Anu Grover, Amarjit Singh, Indranil Purkait, Apurva Jawdekar and Anil Pareek. Aceclofenac in Osteoarthritis - NSAID with Novel Mechanism of Action. Acta Scientific Orthopaedics,2020;3(12):02-13. https://www.researchgate.net/publication/345404158_Acta_Scientific_Orthopaedics_ISSN_2581-8635_Aceclofenac_in_Osteoarthritis_-NSAID_with_Novel_Mechanism_of_Action

15. Weil K, Hooper L, Afzal Z, Esposito M, Worthington HV, van Wijk A, Coulthard P. Paracetamol for pain relief a, er surgical removal of lower wisdom teeth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004487. DOI: https://doi.org/10.1002/14651858.cd004487.pub2

16. Gowri Sivaramakrishnan, Kannan Sridharan. Role of Serratiopeptidase After Surgical Removal of Impacted Molar: A Systematic Review and Meta-analysis. Journal of MaxillofacialandOralSurgery,2018;17(2):122–128. https://doi.org/10.1007/s12663-017-0996-9

17. Nair, S. R., & Devi., S. Serratiopeptidase: An integrated view of Multifaceted Therapeutic Enzyme. Biomolecules,2022,12(10), 1468. https://doi.org/10.3390/biom12101468

18. P.Pavithra, M. Dhanraj, Prathap Sekhar. Analgesic Effectiveness of Ibuprofen and Aceclofenac in the Management of Acute Pulpitis - A Randomized Double-Blind Trial.Int. J. Pharm. Sci. Rev. Res., 35(2), November – December 2015; Article No. 14, Pages: 70-74 https://globalresearchonline.net/journalcontents/v35-2/14.pdf

19. D R Mehlisch, L A Frakes A controlled comparative evaluation of acetaminophen and aspirin in the treatment of postoperative pain Clinical Therapeutics,1984;7(1):89–97. https://pubmed.ncbi.nlm.nih.gov/6394131/

20. M Tachibana, O Mizukoshi, Y Harada, K Kawamoto, Y Nakai. A multi-center, double-blind study of serrapeptase versus placebo in post-antrotomy buccal swelling. Pharmatherapeutica, 1984;3(8):526–530. https://pubmed.ncbi.nlm.nih.gov/6366808/

21. Acleclofenac, Paracetamol and Serratiopeptidase tablets. Taj Life Sciences. Retrieved on 21st October 2023 from https://tajlifesciences.com/portfolio/aceclofenac-paracetamol-and-serratiopeptidase-tablets-100mg325mg15mg-2/