Int. J. Odontostomat.

,
12(3):225-227, 2018.

COX-2 Inhibitors in Dental Pain Management

Inhibidores de la COX-2 en el Tratamiento del Dolor Dental

Fatima Erendida Del Muro Casas; Karina Gómez Coronado; Nelly Alejandra Rodríguez Guajardo;
Manuel Varela-Parga; Jesús Alberto Luengo Ferreira & Juan Carlos Medrano Rodríguez

DEL MURO, C. F. E.; GÓMEZ, C. K.; RODRÍGUEZ, G. N. A.; VARELA-PARGA, M.; LUENGO, F. J. A. & MEDRANO, R. J.
C. COX-2 inhibitors in dental pain management. Int. J. Odontostomat., 12(3):225-227, 2018.

ABSTRACT: Pain is a major symptom in many dental procedures. Studies show consistently that pain, including
dental pain, is not effectively treated; management of pain is a critical and challenging component in dentistry. Improvement
and efficacy on the treatment depends on knowing which treatments are the most effective. Knowing how well an analgesic
works and its associated adverse effects is fundamental to clinical decision. The aim of this review is to provide information
to the dentistry field on the treatment of dental pain specifically with COX-2 inhibitors providing a useful guide to dentist on
controlling pain. Therefore, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed analgesic
agents in surgical outpatients. Major limitations of NSAIDs are their gastrointestinal (GI) adverse events (perforation, ulceration,
and bleeding), impairment of hemostatic function, and renal failure (with long-term therapy). A new class of NSAIDs, COX-
2 selective inhibitors (Coxibs), have been developed with the aim of reducing the GI adverse events of traditional NSAIDs
while maintaining their effective anti-inflammatory and analgesic properties.

KEY WORDS: Pharmacology, cox-2 inhibitors, dental pain.

INTRODUCTION

Pain has been described as an emotional muscles innervated by the trigeminal nerve. It is
experience and sometimes subjective stimulation described as a dull and oppressive feeling, sometimes
caused by harmfulness sensory nerve endings throbbing, burning, intense and sometimes transitory.
produced by damage, generally unpleasant, associated Often, the patient finds it difficult to identify the affected
with tissue damage. It is the most common symptom dental organ and can point to the pain as coming from
for which patients see doctors. It appears if any tissue other dental organ in one of the arcades or on face
is injured and causes the subject to react by sometimes and neck; often dental pain is confused with other
removing the stimulus, but damage has already taken backgrounds (Rodríguez Reyes et al., 2013).
place. Pain is defined as an unpleasant sensory and
emotional experience associated with actual or Oral tissue injury activates the inflammatory
potential tissue damage. It has both sensory and an process, which releases a large series of pain
affective-motivational component. The nature and mediators. Mediators such as prostaglandins and
severity of pain is a consequence of both the sensory bradykinins cause increased sensitivity and excitation
events arising from tissue damage, and the affective- of peripheral nociceptors, which usually have little
cognitive mechanisms. A study has shown that anxiety spontaneous activity under normal conditions
and stress are correlated with the reported level of pain (peripheral sensitization). With repetitive C-fiber
(Ong & Seymour, 2008). nociceptor stimulation from the periphery, excitatory
amino acids such as glutamate and aspartate, as well
Dental pain. Toothache and dental pain can originate as several peptides (including substance P) increase
from dental pulp or from periodontal ligaments. Dental and cause activation of N-methyl-D-aspartate receptors
pain is deep, somatic and presents a variety of central of the postsynaptic second-order neuron in the dorsal
excitatory effects. Referred pain includes autonomic horn. This leads to increased responsiveness of
effects, induction of spasms and trigger points in neurons in the central nervous system and to central

Autonomous University of Zacatecas, México.

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 DEL MURO, C. F. E.; GÓMEZ, C. K.; RODRÍGUEZ, G. N. A.; VARELA-PARGA, M.; LUENGO, F. J. A. & MEDRANO, R. J. C. COX-2 inhibitors in dental pain management.
Int. J. Odontostomat., 12(3):225-227, 2018.

sensitization, which is responsible for the prolonged pain constitutive COX-1. Even more, some studies suggest
after dental surgery. Some of these mediators may be that selective COX-2 inhibitor reduce the incidence of
usefully inhibited or blocked by analgesics for example; gastro intestinal side effects compared with conventional
the analgesic effect of non-steroidal anti-inflammatory NSAIDs (Chen et al., 2004; Daniels et al.; Silva et al.,
drugs is primarily the result of their inhibition of the 2011).
synthesis of prostaglandins and bradykinins through the
inactivation of cyclooxygenase (Ong & Seymour). Therefore, the aim of this review was to offer
information to the dentistry field on the treatment of
NSAID´s Drugs. All NSAIDs, including traditional dental pain, specifically with COX-2 inhibitors, providing
nonselective drugs cyclooxygenase inhibitors-1 (COX- a useful guide to dentist on controlling different types
1) and subclass of selective cyclooxygenase-2 (COX-2) of dental pain.
inhibitors, are a heterogeneous group of drugs. From
the chemical point of view are organic acids that share These type of drugs available on the market in
certain therapeutic actions and adverse effects (Grosser Mexico, concerning to selective inhibitors of COX-2 are
et al., 2011). Such drugs are the source of treatment of basically two: celecoxib and etoricoxib; and preferential
mild to moderate pain and its use is one of the bases to COX -2: meloxicam and nabumetone (Table I).
suggested by the World Health Organization (WHO). The
action of the NSAIDs are: antipyretic, anti-inflammatory
and analgesic; however, these drugs, depending on their CONCLUSION
subclass, properties and structural chemical differences,
as inhibition to COX (1 or 2) enzyme, determining its
greater capacity within the above three properties. Even It is of importance the pharmacotherapeutic
more, the particular interest on COX-2 which has the management of dental pain, particularly of severe
highest participation in the anti-inflammatory and intensity pain, which is also accompanied by
analgesic capacity (Curlin, 2004; Daniels et al., 2011). inflammation. COX-2 inhibitors are drugs that are poorly
explored and implemented in the treatment of dental
However, peri-operative use of NSAIDs has been pain, mainly due to its controversy regarding
limited because of the associated gastrointestinal, cardiovascular-type adverse effects. However, In other
coagulation, and renal side-effects. The selective COX- studies (Nissen et al., 2016) it was shown that despite
2 inhibitors (e.g. celecoxib, rofecoxib, valdecoxib, the evidence of adverse cardiovascular outcomes in a
parecoxib, etoricoxib and lumiracoxib) are specifically placebo-controlled trial, resulting in the withdrawal of
designed to inhibit the COX-2 isoenzyme, which produ- the selective COX-2 inhibitor rofecoxib in 2004.
ces the prostaglandins; almost exclusively responsible Therefore on the basis of a small number of events,
for pain, inflammation and fever, without inhibiting the the results of another trial suggested that

Table I. COX-2 inhibitors in dental pain management therapeutic guide.

Drug Dental Indications Dosage Presentation Contraindications
CELECOXIB Pain relief after Initial dose: 400 mg Capsules of 100 and 200 Patients s ensitive to the formula
(celebrex) complicated extraction in acute pain; mg. itself and even any other
or third molar surgery, maintenance dose Box with 10, 20 and 30 NSAIDs.
post-surgical and of 100-200 mg per capsules. Asthmatic patients.
alveolitis day
ETORICOXIB Pain caused by Depending on the Coated tablets with 60, Patients with hepatic dysfunction
(Arcoxia) mandibular or maxillary intensity of the pain 90 and 120 mg. Not to be used in patients with
dislocation, post- goes from 60, 90 Box with 7 and 14 tablets. cardiovascular disease and
surgica l pain treatment and up to 120 mg a patients sensitive to the formula
and pulpitis. day. itself or any other NSAID.
MELOXICAM Post-extraction tooth Oral dose of 7.5 to 7.5 and 15 mg tablets. Hypersensitivity to the formula.
(Mobic, Dolocam, pain, mandibular and / 15 mg daily. Suspension of 7.5 mg in Do not administer in combination
genérico) or maxillary dislocation Parenteral 15 mg 5 mL. with other NSAIDs.
pain and alveolitis. per day, or al Solution for injection IM Patients with asthma.
follow-up not 15 mg in 1.5 mL.
exceeding 15 mg
per day.
NABUMETONA Chronic pulpitis, post- Oral dose of 1g per 500 and 750 mg tablets . Renal failure patients.
(Naburem) extraction pain and day, being able to Do not combine with other
alveolitis. increase from 1.5 NSAIDs or with methotrexate
to 2 g per day.

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 DEL MURO, C. F. E.; GÓMEZ, C. K.; RODRÍGUEZ, G. N. A.; VARELA-PARGA, M.; LUENGO, F. J. A. & MEDRANO, R. J. C. COX-2 inhibitors in dental pain management.
Int. J. Odontostomat., 12(3):225-227, 2018.

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RESUMEN: El dolor es un síntoma principal en muchos
procedimientos dentales. Los estudios demuestran
consistentemente que el dolor, incluido el dolor dental, no se tra-
ta de manera efectiva; el manejo del dolor es un componente
crítico y desafiante en odontología. La mejora y la eficacia en el Corresponding author:
tratamiento depende de saber qué tratamientos son los más efec- PhD Fatima Erendida Del Muro Casas
tivos. Saber qué tan bien funciona un analgésico y sus efectos in Pharmacology Science
adversos asociados es fundamental para la decisión clínica. El Professor in Academic Unit of Dentistry
objetivo de esta revisión es proporcionar información al campo Autonomous University of Zacatecas
de la odontología sobre el tratamiento del dolor dental MÉXICO
específicamente con los inhibidores de la COX-2, proporcionan-
do una guía útil para el control del dolor por parte del dentista.
Por lo tanto, los fármacos antiinflamatorios no esteroideos (AINE) Email: [email protected]
son los agentes analgésicos más comúnmente prescritos en pa-
cientes ambulatorios quirúrgicos. Las principales limitaciones de
los AINE son los eventos adversos gastrointestinales (perfora- Received: 03-04-2018
ción, ulceración y hemorragia), deterioro de la función hemostática Accepted: 30-05-2018
e insuficiencia renal (con terapia a largo plazo). Una nueva clase
de AINE, los inhibidores selectivos de la COX-2 (Coxibs), se han
desarrollado con el objetivo de reducir los eventos adversos
gastrointestinales de los AINE tradicionales mientras se mantie-
nen sus propiedades antiinflamatorias y analgésicas efectivas.

PALABRAS CLAVE: Antiinflamatorios no esteroideos,

Inhibidores selectivos de la COX-2, Tratamiento del dolor
dental.

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