JADA+ CONTENT
This review does not in any way substitute for professional advice and should not be regarded as clinical guidance. As always,
any evidence should be carefully considered by clinician and patient to ensure that in their views, all potentially desirable
consequences outweigh all potentially undesirable consequences.
JADA+ CLINICAL SCANS






























































Romina Brignardello-Petersen, DDS, MSc, PhD
ACETAMINOPHEN PLUS CAFFEINE OR PLUS
CODEINE PROBABLY RESULTS IN LESS
PAIN BUT MORE SWELLING IN PATIENTS
UNDERGOING PLACEMENT OF A SINGLE
IMPLANT WITHOUT BONE GRAFTING IN THE
POSTERIOR ZONE
Samieirad S, Afrasiabi H, Tohidi E, et al. Evaluation of
caffeine versus codeine for pain and swelling man-
agement after implant surgeries: a triple blind clinical
trial [published online ahead of print July 5, 2017].
J Craniomaxillofac Surg. https://doi.org/10.1016/
j.jcms.2017.06.014.
Key words. Implantology; caffeine; codeine; post-
operative complications; randomized clinical trial.
Clinical relevance. Because nonsteroidal anti-
inflammatory drugs may interfere with osseointegration
after implant surgery, some clinicians prefer to prescribe
other drugs such as acetaminophen with caffeine or
codeine as adjuncts. The choice between these drugs,
however, must be supported by evidence of their effec-
tiveness in minimizing postoperative complications.
Study summary. The researchers conducted a ran-
domized clinical trial (RCT) to compare the effectiveness
of acetaminophen plus caffeine (ACA) with acetamino-
phen plus codeine (ACO) in minimizing pain and
swelling after implant surgery. They enrolled 80 partic-
ipants* who were receiving a single implant in the
posterior mandibular zone without the need for a bone
graft and assigned them to receive perioperative antibi-
otics as well as either postoperative ACAy or ACO.z In all
participants, pain severity increased after 30 minutes,
reaching its peak at 6 hours after surgery. It then
decreased to nearly 0 after 1 week. Participants who
received ACO had pain scores§ 1.61, 1.67, and 1.95 points
lower{ on average than participants who received ACA
at 3, 6, and 12 hours after surgery, respectively. There
were no statistical differences in average pain scores
between the groups 30 minutes and 1, 2, 3, and 7 days
after surgery. Participants who received ACO had
swelling scores# of 0.28, 1.00, and 0.72 points higher** on
average than participants who received ACA at 1, 2, and
3 days after surgery, respectively.
Strengths and limitations. This RCT had an overall
low risk of bias. The allocation of participants to the
group was done appropriately; participants, health care
personnel, and data analysts were blinded, and few
participants were lost to follow-up. Therefore, the groups
were likely to have been balanced with regard to factors
that could have affected pain and swelling at the begin-
ning of, during, and after the completion of the trial. One
strength of this study was that the researchers used a
visual analog scale to measure swelling, which increases
the applicability of the results. The researchers in this
RCT found that participants who received ACO had less
pain but more swelling than those who received ACA
the first days after surgery. The magnitude of the dif-
ferences between ACA and ACO for both outcomes was
likely to be important to patients. Nevertheless, pain
severity was moderate, whereas swelling was unlikely to
interfere with function, and thus the reduction in pain
may be more important than the increase in swelling for
many patients. In addition, each participant received 1
implant per surgery and did not need a bone graft pro-
cedure; therefore, the results are more likely to apply
to patients with these characteristics. Finally, clinicians
must bear in mind that codeine may not be an acceptable
option for many stakeholders, so the decision regarding
which drug to prescribe should be shared with the
patients. n
https://doi.org/10.1016/j.adaj.2017.09.043
Copyright ª 2017 American Dental Association. All rights reserved.
Address correspondence to Dr. Brignardello-Petersen at e-mail
rominabp@gmail.com.
Disclosure. Dr. Brignardello-Petersen did not report any disclosures.
* 50% female; mean (standard deviation) age, 41 (5) years.
y Acetaminophen, 300 milligrams, plus 20 mg anhydrous caffeine (ACA);
10 tablets total.
z Acetaminophen, 300 mg, plus 20 mg codeine; 10 tablets total.
§ The researchers measured pain by having participants use a visual
analog scale ranging from 0 to 10, in which higher scores represented worse
pain.
{ Mean difference (95% confidence interval), 1.61 (1.29 to 2.21), 1.67 (1.35 to
2.29) and 1.95 (1.64 to 3.97) at 3, 6, and 12 hours after surgery, respectively.
Average pain score in ACA group 4.00, 4.39, and 3.22 at 3, 6, and 12 hours,
respectively.
# The researchers measured swelling by having participants use a visual
analog scale ranging from 0 to 5, in which higher scores represented worse
swelling.
** Mean difference (95% confidence interval), 0.28 (0.11 to 0.55), 1 (0.85
to 1.49), and 0.72 (0.54 to 1.04) at 1, 2, and 3 days after surgery. Average
swelling score in the ACA group, 1.11, 1.89, and 1.78 at 1, 2, and 3 days,
respectively.
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