Thesis topic

?RESEARCH PROPOSALDClinDent (Oral Surgery)Pre-emptive analgesic and anti-inflammatory effects of etoricoxib and sustained-release ibuprofen following impacted mandibular third molar surgery.Postgraduate student (Co-ordinating investigator)Yen Je (Jessica) LeeEmail: leeye071@student.otago.ac.nzPrimary supervisorMr Harsha De SilvaCo-supervisorsProf W Murray Thomson A/Prof Rohana De SilvaProf Darryl TongContents TOC \o "1-3" \h \z \u Thesis topic PAGEREF _Toc526594162 \h 4Problem statement PAGEREF _Toc526594163 \h 4Thesis overview PAGEREF _Toc526594164 \h 5Introduction PAGEREF _Toc526594165 \h 6Specific objectives PAGEREF _Toc526594166 \h 8Implications PAGEREF _Toc526594167 \h 8Preliminary literature review PAGEREF _Toc526594168 \h 10Proposed methods PAGEREF _Toc526594169 \h 12Study design PAGEREF _Toc526594170 \h 12Sample PAGEREF _Toc526594171 \h 12Sample size determination PAGEREF _Toc526594172 \h 12Recruitment of participants PAGEREF _Toc526594173 \h 12Inclusion criteria PAGEREF _Toc526594174 \h 13Exclusion criteria PAGEREF _Toc526594175 \h 14Interventions PAGEREF _Toc526594176 \h 15Randomisation PAGEREF _Toc526594177 \h 15Obtaining patient consent for participation PAGEREF _Toc526594178 \h 15Participant responsibility PAGEREF _Toc526594179 \h 16Assurance to participants PAGEREF _Toc526594180 \h 16Participant incentive PAGEREF _Toc526594181 \h 17Obtaining and dispensing pre-emptive analgesic agents PAGEREF _Toc526594182 \h 17Drug dose and administration PAGEREF _Toc526594183 \h 19Surgical procedure PAGEREF _Toc526594184 \h 20Data collection PAGEREF _Toc526594185 \h 21Data entry PAGEREF _Toc526594186 \h 22Data analysis PAGEREF _Toc526594187 \h 23Bias and confounding PAGEREF _Toc526594188 \h 24Ethics approval and Māori approval PAGEREF _Toc526594189 \h 26Funding PAGEREF _Toc526594190 \h 26Payment for treatment PAGEREF _Toc526594191 \h 26Proposed supervisors PAGEREF _Toc526594192 \h 26Thesis timeline PAGEREF _Toc526594193 \h 27Selected references PAGEREF _Toc526594194 \h 28Appendices PAGEREF _Toc526594195 \h 31Appendix 1 PAGEREF _Toc526594196 \h 31Appendix 2 PAGEREF _Toc526594197 \h 32Appendix 3 PAGEREF _Toc526594198 \h 35Appendix 4 PAGEREF _Toc526594199 \h 37Appendix 5 PAGEREF _Toc526594201 \h 43Appendix 6 PAGEREF _Toc526594202 \h 45Appendix 7 PAGEREF _Toc526594203 \h 48Appendix 8 PAGEREF _Toc526594204 \h 52Appendix 9 PAGEREF _Toc526594205 \h 54 Thesis topicA comparison of the pre-emptive analgesic and anti-inflammatory effects of etoricoxib 120mg and sustained-release ibuprofen 1.6g on acute post-operative sequelae following bilateral impacted mandibular third molar surgery.Problem statementEtoricoxib, a second-generation COX-2 inhibitor, is reported to be effective in reducing post-operative pain when given pre-emptively prior to orthopaedic and selected general surgical procedures. Sustained-release ibuprofen, a traditional non-steroidal anti-inflammatory drug (NSAID), is readily available over the counter and is more economical. There is a lack of research comparing the pre-emptive effectiveness of etoricoxib 120mg with sustained-release ibuprofen 1.6g (as a single dose) in third molar surgery. To date, the evidence for the superior efficacy of etoricoxib in third molar surgery is equivocal.Thesis overviewScientific question:Are there any differences in the pre-emptive analgesic and anti-inflammatory efficacy between etoricoxib 120mg and sustained-release ibuprofen 1.6g following impacted mandibular third molar surgery?Hypothesis:Pre-emptive etoricoxib 120mg will have a superior effect in reducing post-operative pain intensity over sustained-release ibuprofen 1.6g.The pre-emptive anti-inflammatory effect of etoricoxib 120mg and sustained-release ibuprofen 1.6g on post-operative swelling and trismus will be comparable.Statistical question:What is the relative efficacy of pre-emptive etoricoxib and pre-emptive sustained-release ibuprofen in improving post-operative pain, swelling, and trismus in patients following impacted mandibular third molar surgery?IntroductionPre-emptive analgesia is defined as the administration of an anti-nociceptive agent prior to surgical insult with the intent to suppress nociceptive pathways before they are stimulated PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1waWdsaWE8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy

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ADDIN EN.CITE.DATA (Campiglia et al. 2010; Dahl and M?iniche 2005). The concept is based on the inhibition of surgery-mediated inflammation and neurophysiological insult of nociceptive pathways, and ultimately preventing the establishment of peripheral and central sensitisation that is responsible for the development of post-operative pain hypersensitivity and chronic pain ADDIN EN.CITE <EndNote><Cite><Author>Dahl</Author><Year>2005</Year><RecNum>35</RecNum><DisplayText>(Dahl and M?iniche 2005)</DisplayText><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1536369331">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dahl, J?rgen B.</author><author>M?iniche, Steen</author></authors></contributors><titles><title>Pre-emptive analgesia</title><secondary-title>British Medical Bulletin</secondary-title></titles><periodical><full-title>British Medical Bulletin</full-title><abbr-1>Br Med Bull</abbr-1></periodical><pages>13-27</pages><volume>71</volume><number>1</number><dates><year>2005</year></dates><isbn>0007-1420</isbn><urls><related-urls><url>;(Dahl and M?iniche 2005). Therefore, the aims of pre-emptive analgesia are: (1) to reduce inflammation-mediated acute pain following surgical trauma/tissue injury; (2) to impede adverse central processing of noxious impulses and pain memory of the central nervous system; and (3) to establish good post-operative pain control and inhibit chronic pain development ADDIN EN.CITE <EndNote><Cite><Author>Grape</Author><Year>2007</Year><RecNum>39</RecNum><DisplayText>(Grape and Tramèr 2007)</DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008537">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grape, Sina</author><author>Tramèr, Martin R.</author></authors></contributors><titles><title>Do we need preemptive analgesia for the treatment of postoperative pain?</title><secondary-title>Best Practice &amp; Research Clinical Anaesthesiology</secondary-title></titles><periodical><full-title>Best Practice &amp; Research Clinical Anaesthesiology</full-title><abbr-1>Best Pract Res Clin Anaesthesiol</abbr-1></periodical><pages>51-63</pages><volume>21</volume><number>1</number><keywords><keyword>Preemptive Analgesia</keyword><keyword>Postoperative Pain</keyword><keyword>Chronic Pain</keyword><keyword>Peripheral and Central Sensitization</keyword><keyword>Central Nervous System Plasticity</keyword><keyword>Hyperalgesia</keyword><keyword>Systematic Reviews</keyword></keywords><dates><year>2007</year></dates><isbn>1521-6896</isbn><urls></urls><electronic-resource-num>10.1016/j.bpa.2006.11.004</electronic-resource-num></record></Cite></EndNote>(Grape and Tramèr 2007).A large proportion of patients experience moderate-to-severe pain following third molar surgery which negatively affects their quality of life, particularly during the first 72 hours post-operatively ADDIN EN.CITE <EndNote><Cite><Author>Colorado-Bonnin</Author><Year>2006</Year><RecNum>41</RecNum><DisplayText>(Colorado-Bonnin et al. 2006)</DisplayText><record><rec-number>41</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008593">41</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Colorado-Bonnin, M.</author><author>Valmaseda-Castellón, E.</author><author>Berini-Aytés, L.</author><author>Gay-Escoda, C.</author></authors></contributors><titles><title>Quality of life following lower third molar removal</title><secondary-title>International Journal of Oral &amp; Maxillofacial Surgery</secondary-title></titles><periodical><full-title>International Journal of Oral &amp; Maxillofacial Surgery</full-title><abbr-1>Int J Oral Maxillofac Surg</abbr-1></periodical><pages>343-347</pages><volume>35</volume><number>4</number><keywords><keyword>Third Molar Removal</keyword><keyword>Quality of Life</keyword></keywords><dates><year>2006</year></dates><isbn>0901-5027</isbn><urls></urls><electronic-resource-num>10.1016/j.ijom.2005.08.008</electronic-resource-num></record></Cite></EndNote>(Colorado-Bonnin et al. 2006). Early management of pain is shown to be associated with lower demand for re-medication and improved overall pain relief ADDIN EN.CITE <EndNote><Cite><Author>Moore</Author><Year>2014</Year><RecNum>42</RecNum><DisplayText>(Moore et al. 2014)</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008629">42</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moore, R. Andrew</author><author>Derry, J. Sheena</author><author>Straube, J. Sebastian</author><author>Ireson-Paine, J. Jocelyn</author><author>Wiffen, J. Phillip</author></authors></contributors><titles><title>Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain</title><secondary-title>Pain</secondary-title></titles><periodical><full-title>Pain</full-title><abbr-1>Pain</abbr-1></periodical><pages>14-21</pages><volume>155</volume><number>1</number><keywords><keyword>Acute Pain</keyword><keyword>Fast-Acting</keyword><keyword>Formulation</keyword><keyword>Ibuprofen</keyword><keyword>Nsaid</keyword></keywords><dates><year>2014</year></dates><isbn>0304-3959</isbn><urls></urls><electronic-resource-num>10.1016/j.pain.2013.08.013</electronic-resource-num></record></Cite></EndNote>(Moore et al. 2014). Therefore, the use of effective and early post-operative pain relief is justified. To maximise the pre-emptive effectiveness, the literature recommends that an intervention agent have a prolonged duration of action to cover the intra-operative period during which the noxious stimuli is most intense, and that its effect should extend into the post-operative period to ensure suppression of the subsequent generation of inflammatory mediators. Lastly, the adoption of multimodal therapy combining several analgesics is advocated PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb2dhdHpraS1aYWhuPC9BdXRob3I+PFllYXI+MjAwNjwv

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ADDIN EN.CITE.DATA (Pogatzki-Zahn and Zahn 2006; Rosero and Joshi 2014).Non-steroidal anti-inflammatory drugs (NSAIDs) are shown to inhibit peripheral and central sensitisation ADDIN EN.CITE <EndNote><Cite><Author>Ong</Author><Year>2005</Year><RecNum>46</RecNum><DisplayText>(Ong et al. 2005)</DisplayText><record><rec-number>46</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008876">46</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ong, K. S. Cliff</author><author>Lirk, A. Philipp</author><author>Seymour, J. Robin</author><author>Jenkins, J. Brian</author></authors></contributors><titles><title>The Efficacy of Preemptive Analgesia for Acute Postoperative Pain Management: A Meta-Analysis</title><secondary-title>Anesthesia &amp; Analgesia</secondary-title></titles><periodical><full-title>Anesthesia &amp; Analgesia</full-title></periodical><pages>757-773</pages><volume>100</volume><number>3</number><keywords><keyword>Analgesia, Epidural</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword></keywords><dates><year>2005</year></dates><isbn>0003-2999</isbn><urls></urls><electronic-resource-num>10.1213/01.ANE.0000144428.98767.0E</electronic-resource-num></record></Cite></EndNote>(Ong et al. 2005). Ibuprofen is arguably the most accessible and commonly used NSAID that is inexpensive and available over the counter in most countries ADDIN EN.CITE <EndNote><Cite><Author>Derry</Author><Year>2009</Year><RecNum>47</RecNum><DisplayText>(Derry et al. 2009)</DisplayText><record><rec-number>47</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008911">47</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Derry, Christopher</author><author>Derry, Sheena</author><author>Moore, R. Andrew</author><author>McQuay, Henry J.</author></authors></contributors><titles><title>Single dose oral ibuprofen for acute postoperative pain in adults</title><secondary-title>The Cochrane database of systematic reviews</secondary-title></titles><periodical><full-title>The Cochrane database of systematic reviews</full-title><abbr-1>Cochrane Database Syst Rev</abbr-1></periodical><pages>CD001548</pages><number>3</number><keywords><keyword>Analgesics, Non-Narcotic -- Administration &amp; Dosage</keyword><keyword>Ibuprofen -- Administration &amp; Dosage</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword></keywords><dates><year>2009</year></dates><urls></urls><electronic-resource-num>10.1002/14651858.CD001548.pub2</electronic-resource-num></record></Cite></EndNote>(Derry et al. 2009). There is a substantial and valid body of evidence for its analgesic efficacy against mild-to-moderate post-operative pain ADDIN EN.CITE <EndNote><Cite><Author>Derry</Author><Year>2009</Year><RecNum>47</RecNum><DisplayText>(Derry et al. 2009)</DisplayText><record><rec-number>47</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008911">47</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Derry, Christopher</author><author>Derry, Sheena</author><author>Moore, R. Andrew</author><author>McQuay, Henry J.</author></authors></contributors><titles><title>Single dose oral ibuprofen for acute postoperative pain in adults</title><secondary-title>The Cochrane database of systematic reviews</secondary-title></titles><periodical><full-title>The Cochrane database of systematic reviews</full-title><abbr-1>Cochrane Database Syst Rev</abbr-1></periodical><pages>CD001548</pages><number>3</number><keywords><keyword>Analgesics, Non-Narcotic -- Administration &amp; Dosage</keyword><keyword>Ibuprofen -- Administration &amp; Dosage</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword></keywords><dates><year>2009</year></dates><urls></urls><electronic-resource-num>10.1002/14651858.CD001548.pub2</electronic-resource-num></record></Cite></EndNote>(Derry et al. 2009) with opioid-sparing effects ADDIN EN.CITE <EndNote><Cite><Author>Best</Author><Year>2017</Year><RecNum>48</RecNum><DisplayText>(Best et al. 2017)</DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537008936">48</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Best, Adrian D.</author><author>De Silva, R. K.</author><author>Thomson, W. M.</author><author>Tong, Darryl C.</author><author>Cameron, Claire M.</author><author>De Silva, Harsha L.</author></authors></contributors><titles><title>Efficacy of Codeine When Added to Paracetamol (Acetaminophen) and Ibuprofen for Relief of Postoperative Pain After Surgical Removal of Impacted Third Molars: A Double-Blinded Randomized Control Trial</title><secondary-title>Journal of Oral and Maxillofacial Surgery</secondary-title></titles><periodical><full-title>Journal of Oral and Maxillofacial Surgery</full-title><abbr-1>J Oral Maxillofac Surg</abbr-1></periodical><pages>2063-2069</pages><volume>75</volume><number>10</number><keywords><keyword>Codeine -- Analysis</keyword><keyword>Postoperative Pain -- Analysis</keyword><keyword>Clinical Trials -- Analysis</keyword><keyword>Pain Management -- Analysis</keyword><keyword>Central Nervous System Depressants -- Analysis</keyword><keyword>Analgesics -- Analysis</keyword></keywords><dates><year>2017</year></dates><isbn>0278-2391</isbn><urls></urls><electronic-resource-num>10.1016/j.joms.2017.04.045</electronic-resource-num></record></Cite></EndNote>(Best et al. 2017). These features make ibuprofen an ideal control to compare the efficacy of other analgesics in clinical trials. However, ibuprofen is implicated in gastric irritation and bleeding in susceptible patients, and so impairment in gastric cytoprotection has prompted the emergence of selective COX-2 inhibitors ADDIN EN.CITE <EndNote><Cite><Author>Clarke</Author><Year>2014</Year><RecNum>50</RecNum><DisplayText>(Clarke et al. 2014)</DisplayText><record><rec-number>50</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009015">50</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clarke, Rachel</author><author>Derry, Sheena</author><author>Moore, R. Andrew</author></authors></contributors><titles><title>Single dose oral etoricoxib for acute postoperative pain in adults</title><secondary-title>The Cochrane database of systematic reviews</secondary-title></titles><periodical><full-title>The Cochrane database of systematic reviews</full-title><abbr-1>Cochrane Database Syst Rev</abbr-1></periodical><pages>CD004309</pages><volume>2017</volume><number>5</number><keywords><keyword>Acute Pain -- Drug Therapy</keyword><keyword>Cyclooxygenase 2 Inhibitors -- Administration &amp; Dosage</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword><keyword>Pyridines -- Administration &amp; Dosage</keyword><keyword>Sulfones -- Administration &amp; Dosage</keyword></keywords><dates><year>2014</year></dates><urls></urls><electronic-resource-num>10.1002/14651858.CD004309.pub4</electronic-resource-num></record></Cite></EndNote>(Clarke et al. 2014).Etoricoxib, a highly selective COX-2 inhibitor, is available by prescription only ADDIN EN.CITE <EndNote><Cite><Author>Clarke</Author><Year>2014</Year><RecNum>50</RecNum><DisplayText>(Clarke et al. 2014)</DisplayText><record><rec-number>50</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009015">50</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clarke, Rachel</author><author>Derry, Sheena</author><author>Moore, R. Andrew</author></authors></contributors><titles><title>Single dose oral etoricoxib for acute postoperative pain in adults</title><secondary-title>The Cochrane database of systematic reviews</secondary-title></titles><periodical><full-title>The Cochrane database of systematic reviews</full-title><abbr-1>Cochrane Database Syst Rev</abbr-1></periodical><pages>CD004309</pages><volume>2017</volume><number>5</number><keywords><keyword>Acute Pain -- Drug Therapy</keyword><keyword>Cyclooxygenase 2 Inhibitors -- Administration &amp; Dosage</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword><keyword>Pyridines -- Administration &amp; Dosage</keyword><keyword>Sulfones -- Administration &amp; Dosage</keyword></keywords><dates><year>2014</year></dates><urls></urls><electronic-resource-num>10.1002/14651858.CD004309.pub4</electronic-resource-num></record></Cite></EndNote>(Clarke et al. 2014). Unlike ibuprofen, etoricoxib is not subsidised in New Zealand ADDIN EN.CITE <EndNote><Cite><RecNum>83</RecNum><DisplayText>(Arcoxia (etoricoxib) film coated tablets)</DisplayText><record><rec-number>83</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537263698">83</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Arcoxia (etoricoxib) film coated tablets</title></titles><number>1 April 2018</number><dates><pub-dates><date>9 October 2017</date></pub-dates></dates><publisher>Merck Sharp &amp; Dohme (NZ) Ltd</publisher><urls><related-urls><url>;(Arcoxia (etoricoxib) film coated tablets). The effectiveness of a single dose of etoricoxib 120mg in the management of acute moderate-to-severe post-operative pain (including third molar surgery) has been reported on the latest Cochrane Database of Systematic Reviews ADDIN EN.CITE <EndNote><Cite><Author>Clarke</Author><Year>2014</Year><RecNum>50</RecNum><DisplayText>(Clarke et al. 2014)</DisplayText><record><rec-number>50</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009015">50</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clarke, Rachel</author><author>Derry, Sheena</author><author>Moore, R. Andrew</author></authors></contributors><titles><title>Single dose oral etoricoxib for acute postoperative pain in adults</title><secondary-title>The Cochrane database of systematic reviews</secondary-title></titles><periodical><full-title>The Cochrane database of systematic reviews</full-title><abbr-1>Cochrane Database Syst Rev</abbr-1></periodical><pages>CD004309</pages><volume>2017</volume><number>5</number><keywords><keyword>Acute Pain -- Drug Therapy</keyword><keyword>Cyclooxygenase 2 Inhibitors -- Administration &amp; Dosage</keyword><keyword>Pain, Postoperative -- Drug Therapy</keyword><keyword>Pyridines -- Administration &amp; Dosage</keyword><keyword>Sulfones -- Administration &amp; Dosage</keyword></keywords><dates><year>2014</year></dates><urls></urls><electronic-resource-num>10.1002/14651858.CD004309.pub4</electronic-resource-num></record></Cite></EndNote>(Clarke et al. 2014). 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ADDIN EN.CITE.DATA (Clarke et al. 2014; Yuan and Hunt 2007) and its effects on renal function is reported to be comparable to that of traditional NSAIDs ADDIN EN.CITE <EndNote><Cite><Author>Takemoto</Author><Year>2008</Year><RecNum>53</RecNum><DisplayText>(Takemoto et al. 2008)</DisplayText><record><rec-number>53</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009138">53</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Takemoto, Jody</author><author>Reynolds, Jonathan</author><author>Remsberg, Connie</author><author>Vega-Villa, Karina</author><author>Davies, Neal</author></authors></contributors><titles><title>Clinical Pharmacokinetic and Pharmacodynamic Profile of Etoricoxib</title><secondary-title>Clinical Pharmacokinetics</secondary-title></titles><periodical><full-title>Clinical Pharmacokinetics</full-title><abbr-1>Clin Pharmacokinet</abbr-1></periodical><pages>703-720</pages><volume>47</volume><number>11</number><keywords><keyword>Cyclooxygenase 2 Inhibitors -- Pharmacokinetics</keyword><keyword>Pyridines -- Pharmacokinetics</keyword><keyword>Sulfones -- Pharmacokinetics</keyword></keywords><dates><year>2008</year></dates><pub-location>Cham</pub-location><isbn>0312-5963</isbn><urls></urls><electronic-resource-num>10.2165/00003088-200847110-00002</electronic-resource-num></record></Cite></EndNote>(Takemoto et al. 2008). However, little is known about its pre-emptive benefit in the oral surgery literature.Single-dose oral etoricoxib 120mg and sustained-release ibuprofen 1.6g have a prolonged duration of blockade and maintain stable plasma concentrations over at least 20 hours PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DbGFya2U8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (Clarke et al. 2014; Fernandes and Jenkins 1994). Taking these observations together, one may question whether a pre-emptive dose of these long-acting NSAIDs can help to reduce acute post-operative sequelae after mandibular third molar removal, and, if so, whether there would be any significant differences in efficacy between etoricoxib and ibuprofen.Specific objectivesPrimary objectiveTo compare the effectiveness of etoricoxib 120mg with that of sustained-release ibuprofen 1.6g when administered pre-emptively for pain relief following third molar surgery.Secondary objectivesTo compare the pre-emptive anti-inflammatory efficacy of etoricoxib 120mg and sustained-release ibuprofen 1.6g on clinical parameters including swelling and trismus following third molar surgery;To determine whether there are any differences in the need for rescue analgesia;To determine whether there are any differences in the adverse events; andTo evaluate any differences in the participants’ overall satisfaction with pain control.ImplicationsPotential benefits of this researchTo the best of my knowledge, no study has compared the pre-emptive efficacy of etoricoxib 120mg and sustained-release ibuprofen 1.6g against acute post-operative sequelae after third molar surgery. There is no convincing evidence to support or refute superior effectiveness of etoricoxib over ibuprofen, and so it requires further clinical investigation. The findings of the study will serve as a valuable addition to the current literature, in which the knowledge of pre-emptive analgesia in oral surgery is scarce.Several benefits for clinical practice are anticipated if the proposed study demonstrates a significant positive outcome from the pre-emptive administration of etoricoxib and/or ibuprofen: (1) patients may benefit from a reduced burden of post-operative pain and discomfort; (2) a concomitant reduction in the analgesic consumption may reduce the risk of patients being subjected to unnecessary levels of analgesia and consequently reduce the risk of adverse effects, overdose, and toxicity; and (3) routine provision of pre-emptive analgesia prior to minor oral surgery may be encouraged in clinical practice. The findings may be extended to other surgical fields of dentistry, including implant surgery, periodontal open-flap debridement, and endodontic surgical procedures.If the proposed study demonstrates that sustained-release ibuprofen is equal or better than etoricoxib, then routine pre-emptive use of ibuprofen in minor oral surgery may be more cost-effective than the use of unsubsidised etoricoxib. Conversely, if etoricoxib is found to be superior to ibuprofen, its preferential use would potentially lead to fewer gastrointestinal side effects. Moreover, such a finding would provide clinicians with the scientific rationale for the pre-emptive use of etoricoxib in third molar surgery.On completion of the proposed research, I intend to publish its findings in a peer-reviewed scientific journal.Potential benefits for MāoriThe implications of our proposed study are the same for Māori patients.Preliminary literature reviewThe merit of pre-emptive analgesia in oral surgery remains a contentious issue. Some published series have exhibited beneficial effects of its pre-operative use in attenuating post-operative pain, swelling, trismus, and analgesic demand following surgical removal of third molars PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbGJ1cXVlcnF1ZTwvQXV0aG9yPjxZZWFyPjIwMTc8L1ll

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ADDIN EN.CITE.DATA (Albuquerque et al. 2017; Costa et al. 2015; Mehra et al. 2013; Zor et al. 2014). Other studies state otherwise; some researchers have failed to show statistically significant pre-emptive efficacy of NSAIDs PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXVlcjwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Aznar-Arasa et al. 2012; Mojsa et al. 2017).Information on the pre-emptive efficacy of sustained-release ibuprofen in the oral surgery literature is scarce. Yong and Coulthard reported no difference between a pre-operative efficacy of 1.6g modified-release ibuprofen (intervention group) and conventional ibuprofen 400mg (control group) following surgical removal of third molars ADDIN EN.CITE <EndNote><Cite><Author>Yong</Author><Year>2010</Year><RecNum>65</RecNum><DisplayText>(Yong and Coulthard 2010)</DisplayText><record><rec-number>65</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009538">65</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yong, Sin Leong</author><author>Coulthard, Paul</author></authors></contributors><titles><title>Pain after surgery: Can protective analgesia reduce pain? A randomised clinical trial</title><secondary-title>International Journal of Surgery</secondary-title></titles><periodical><full-title>International Journal of Surgery</full-title><abbr-1>Int J Surg</abbr-1></periodical><pages>283-289</pages><volume>8</volume><number>4</number><keywords><keyword>Postoperative Pain</keyword><keyword>Third Molar</keyword><keyword>Protective Analgesia</keyword></keywords><dates><year>2010</year></dates><isbn>1743-9191</isbn><urls></urls><electronic-resource-num>10.1016/j.ijsu.2010.03.001</electronic-resource-num></record></Cite></EndNote>(Yong and Coulthard 2010). While the intervention lessened the demand for, and delayed the time to rescue analgesia, the difference was not statistically significant. It is important to highlight that bupivacaine was used in this study. Its prolonged anaesthesia may have outlasted the analgesic duration of the pre-operative conventional ibuprofen. Therefore, it can be argued that bupivacaine is a modifier in this study that may possibly have rendered the insignificant pre-emptive analgesic difference between modified-release and conventional ibuprofen. Moreover, five surgeons performed the surgery under general anaesthesia. Surgical inconsistencies amongst the surgeons are inevitable and the subsequent performance bias may also have inadvertently compromised the outcome of the study. Unfortunately, the pre-emptive anti-inflammatory effects of the two ibuprofen groups were not examined by these authors. Hence, whether or not sustained-release ibuprofen has better anti-inflammatory effect than conventional ibuprofen, when given pre-emptively, remains to be elucidated.Additionally, there is a lack of evidence comparing the pre-emptive effectiveness of a selective COX-2 inhibitor with a traditional ibuprofen in third molar surgery. A Finnish study observed a superior analgesic effect of celecoxib 200mg over ibuprofen 400mg when administered pre-emptively ADDIN EN.CITE <EndNote><Cite><Author>Al-Sukhun</Author><Year>2012</Year><RecNum>66</RecNum><DisplayText>(Al-Sukhun et al. 2012)</DisplayText><record><rec-number>66</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009568">66</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Al-Sukhun, Jehad</author><author>Al-Sukhun, Sana</author><author>Penttil?, Heikki</author><author>Ashammakhi, Nureddin</author><author>Al-Sukhun, Raja</author></authors></contributors><titles><title>Preemptive Analgesic Effect of Low Doses of Celecoxib Is Superior to Low Doses of Traditional Nonsteroidal Anti-Inflammatory Drugs</title><secondary-title>Journal of Craniofacial Surgery</secondary-title></titles><periodical><full-title>Journal of Craniofacial Surgery</full-title><abbr-1>J Craniofac Surg</abbr-1></periodical><pages>526-529</pages><volume>23</volume><number>2</number><keywords><keyword>Tooth Extraction</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal -- Administration &amp; Dosage</keyword><keyword>Cyclooxygenase 2 Inhibitors -- Administration &amp; Dosage</keyword><keyword>Ibuprofen -- Administration &amp; Dosage</keyword><keyword>Molar, Third -- Surgery</keyword><keyword>Pain, Postoperative -- Prevention &amp; Control</keyword><keyword>Pyrazoles -- Administration &amp; Dosage</keyword><keyword>Sulfonamides -- Administration &amp; Dosage</keyword></keywords><dates><year>2012</year></dates><isbn>1049-2275</isbn><urls></urls><electronic-resource-num>10.1097/SCS.0b013e31824cd4fb</electronic-resource-num></record></Cite></EndNote>(Al-Sukhun et al. 2012).A multitude of researchers have demonstrated the efficacy of pre-emptive etoricoxib in orthopaedic surgical procedures PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb29ucmlvbmc8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy

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ADDIN EN.CITE.DATA (Boonriong et al. 2010; Lierz et al. 2012; Munteanu et al. 2016; Renner et al. 2012) and laparoscopic cholecystectomy ADDIN EN.CITE <EndNote><Cite><Author>Sandhu</Author><Year>2011</Year><RecNum>72</RecNum><DisplayText>(Sandhu et al. 2011)</DisplayText><record><rec-number>72</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009763">72</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sandhu, Trichak</author><author>Paiboonworachat, Sahattaya</author><author>Ko-iam, Wasana</author></authors></contributors><titles><title>Effects of preemptive analgesia in laparoscopic cholecystectomy: a double-blind randomized controlled trial</title><secondary-title>Surgical Endoscopy</secondary-title></titles><periodical><full-title>Surgical Endoscopy</full-title><abbr-1>Surg Endosc</abbr-1></periodical><pages>23-27</pages><volume>25</volume><number>1</number><keywords><keyword>Laparoscopic cholecystectomy</keyword><keyword>Preemptive analgesia</keyword><keyword>Etoricoxib</keyword></keywords><dates><year>2011</year></dates><pub-location>New York</pub-location><isbn>0930-2794</isbn><urls></urls><electronic-resource-num>10.1007/s00464-010-1122-y</electronic-resource-num></record></Cite></EndNote>(Sandhu et al. 2011). These studies show that a single pre-operative administration of etoricoxib 120mg have significantly alleviated post-operative pain, lessened the demand for rescue analgesia, and opioid use. However, there are only two placebo-controlled clinical trials to date that have investigated its pre-emptive benefit for third molar removal. Both have shown a significant ease in the post-operative pain intensity in the intervention group over a placebo group PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbGJ1cXVlcnF1ZTwvQXV0aG9yPjxZZWFyPjIwMTc8L1ll

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ADDIN EN.CITE.DATA (Albuquerque et al. 2017; Costa et al. 2015). With respect to the clinical parameters of post-operative inflammatory sequelae, these studies have yielded conflicting findings. While Costa et al. failed to find any differences between intervention and control groups in post-operative oedema and trismus ADDIN EN.CITE <EndNote><Cite><Author>Costa</Author><Year>2015</Year><RecNum>56</RecNum><DisplayText>(Costa et al. 2015)</DisplayText><record><rec-number>56</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009223">56</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Costa, F. W. G.</author><author>Soares, E. C. S.</author><author>Esses, D. F. S.</author><author>Silva, P. G. Deb</author><author>Bezerra, T. P.</author><author>Scarparo, H. C.</author><author>Ribeiro, T. R.</author><author>Fonteles, C. S. R.</author></authors></contributors><titles><title>A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars</title><secondary-title>International Journal of Oral &amp; Maxillofacial Surgery</secondary-title></titles><periodical><full-title>International Journal of Oral &amp; Maxillofacial Surgery</full-title><abbr-1>Int J Oral Maxillofac Surg</abbr-1></periodical><pages>1166-1174</pages><volume>44</volume><number>9</number><keywords><keyword>Pre-Emptive Analgesia</keyword><keyword>Third Molar</keyword><keyword>Non-Steroidal Anti-Inflammatory Drugs</keyword><keyword>Etoricoxib</keyword></keywords><dates><year>2015</year></dates><isbn>0901-5027</isbn><urls></urls><electronic-resource-num>10.1016/j.ijom.2015.06.012</electronic-resource-num></record></Cite></EndNote>(Costa et al. 2015), Albuquerque et al. reported a significant improvement associated with the intervention group ADDIN EN.CITE <EndNote><Cite><Author>Albuquerque</Author><Year>2017</Year><RecNum>55</RecNum><DisplayText>(Albuquerque et al. 2017)</DisplayText><record><rec-number>55</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009186">55</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Albuquerque, A. F. M.</author><author>Fonteles, C. S. R.</author><author>Do Val, D. R.</author><author>Chaves, H. V.</author><author>Bezerra, M. M.</author><author>Pereira, K. M. A.</author><author>de Barros Silva, P. G.</author><author>de Lima, B. B.</author><author>Soares, E. C. S.</author><author>Ribeiro, T. R.</author><author>Costa, F. W. G.</author></authors></contributors><titles><title>Effect of pre-emptive analgesia on clinical parameters and tissue levels of TNF-α and IL-1β in third molar surgery: a triple-blind, randomized, placebo-controlled study</title><secondary-title>International Journal of Oral &amp; Maxillofacial Surgery</secondary-title></titles><periodical><full-title>International Journal of Oral &amp; Maxillofacial Surgery</full-title><abbr-1>Int J Oral Maxillofac Surg</abbr-1></periodical><pages>1615-1625</pages><volume>46</volume><number>12</number><keywords><keyword>Third Molar</keyword><keyword>Inflammatory Events</keyword><keyword>Tnf-Α</keyword><keyword>Il-1β</keyword><keyword>Non-Steroidal Anti-Inflammatory Drugs</keyword></keywords><dates><year>2017</year></dates><isbn>0901-5027</isbn><urls></urls><electronic-resource-num>10.1016/j.ijom.2017.05.007</electronic-resource-num></record></Cite></EndNote>(Albuquerque et al. 2017). To date, the evidence for the superior efficacy of etoricoxib in third molar surgery is equivocal.Proposed methodsStudy designThe proposed research will be conducted as a double-blinded randomised control trial.Ibuprofen is arguably the most accessible and commonly used analgesia that is inexpensive and available over the counter in most countries. Therefore, it is reasonable to select ibuprofen as the traditional NSAID to use as a control in determining the pre-emptive effectiveness of etoricoxib in third molar surgery.SampleA clinical convenience sample will be gathered from patients needing to undergo the surgical extraction of impacted bilateral mandibular third molars at the School of Dentistry, University of Otago.Sample size determinationThe sample size calculation was based on that described in the study conducted by Al-Sukhun et al ADDIN EN.CITE <EndNote><Cite><Author>Al-Sukhun</Author><Year>2012</Year><RecNum>66</RecNum><DisplayText>(Al-Sukhun et al. 2012)</DisplayText><record><rec-number>66</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009568">66</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Al-Sukhun, Jehad</author><author>Al-Sukhun, Sana</author><author>Penttil?, Heikki</author><author>Ashammakhi, Nureddin</author><author>Al-Sukhun, Raja</author></authors></contributors><titles><title>Preemptive Analgesic Effect of Low Doses of Celecoxib Is Superior to Low Doses of Traditional Nonsteroidal Anti-Inflammatory Drugs</title><secondary-title>Journal of Craniofacial Surgery</secondary-title></titles><periodical><full-title>Journal of Craniofacial Surgery</full-title><abbr-1>J Craniofac Surg</abbr-1></periodical><pages>526-529</pages><volume>23</volume><number>2</number><keywords><keyword>Tooth Extraction</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal -- Administration &amp; Dosage</keyword><keyword>Cyclooxygenase 2 Inhibitors -- Administration &amp; Dosage</keyword><keyword>Ibuprofen -- Administration &amp; Dosage</keyword><keyword>Molar, Third -- Surgery</keyword><keyword>Pain, Postoperative -- Prevention &amp; Control</keyword><keyword>Pyrazoles -- Administration &amp; Dosage</keyword><keyword>Sulfonamides -- Administration &amp; Dosage</keyword></keywords><dates><year>2012</year></dates><isbn>1049-2275</isbn><urls></urls><electronic-resource-num>10.1097/SCS.0b013e31824cd4fb</electronic-resource-num></record></Cite></EndNote>(Al-Sukhun et al. 2012). 70% of patients who received celecoxib rated the study medication as good, very good, or excellent, while it was only 58% among patients who received ibuprofen and 15% among patients who received a placebo. Assuming an α value of 0.05 and 80% power to detect a difference, the estimated number of patients per group is 61. Thus, a minimum of 122 patients will be required.Recruitment of participantsThe staff clinicians at the School of Dentistry, University of Otago, will be notified of this proposed study. Their cooperation will be solicited at staff meetings and via staff emails to identify patients deemed potentially suitable to meet study inclusion criteria from patients referred (internal/external referrals) to the Oral Surgery Unit, School of Dentistry, and from patients who attend the Urgent Care Unit with symptoms related to impacted wisdom teeth. These patients would then be provided with an initial briefing on the proposed study and invited to meet Jessica Lee (principal researcher/surgeon) for a detailed consultation. They will be informed that non-participation in the study will not adversely impact their treatment in any way.Potential participants who agree for a consultation with Jessica Lee will attend a surgical consultation with Jessica Lee. During the consultation, the nature and purpose of the study and participant’s responsibility will be explained. A written participant information sheet and consent form will be provided. Upon receiving the participation consent for the proposed study, all participants will be taken through the standard consenting process used at the School of Dentistry for patients undergoing wisdom teeth surgery under intravenous (IV) sedation and local anaesthesia. This will be completed prior to scheduling their surgery appointment. The recruitment will commence from 1 January 2019 and continue until 150 participants are enrolled.Inclusion criteriaAll prospective participants must be seen by Jessica Lee with the guidance from a Consultant Oral and Maxillofacial Surgeon at the School of Dentistry, University of Otago.Patients must be deemed appropriately suitable for participation in the present study by Jessica Lee or a Consultant Oral and Maxillofacial Surgeon at the School of Dentistry, University of Otago.The participant must be aged between 18 and 35 years.The participant must legitimately require removal of at least two mandibular third molars (and may require removal of maxillary third molar/s) as per third molar surgical protocol at the School of Dentistry, University of Otago.Expected bone removal and/or tooth sectioning for extraction of the impacted bilateral mandibular third molars.The participant must be medically fit (American Society of Anaesthesiologist (ASA) physical status classification 1 or 2) to have their third molars removed.The participant must be assessed as appropriate for an IV sedation.The participant must consent to having their third molars removed under IV sedation and local anaesthesia.There will be no discrimination based on gender, race, and ethnicity. Non-English-speaking patients will be given equal opportunity to participate; an accredited interpreter will be employed as required.Exclusion criteriaPatients under the age of 18 years and over 35 years of agePatients are excluded if they meet any of the following criteria:Any significant systemic disease/s classified as ASA 3, 4, or 5Active/history of gastrointestinal bleeding or ulcerationCurrently pregnant or lactatingBody weight >120kgCardiovascular diseaseNSAID-sensitive asthmaRespiratory depression, COPDHepatic impairmentRenal impairmentBleeding disordersTherapeutic anticoagulationBone disordersMetabolic diseasesPatients on bisphosphonatesPatients on long-term benzodiazepines, opioids, and liver enzyme induction agents/medicationsHypersensitivity to benzodiazepines, etoricoxib, ibuprofen, and codeine phosphateUse of NSAIDs within 48 hours prior to the day of surgeryPresence of swelling, fever, trismus prior to third molar surgeryOpioid and illicit drug addictionAlcoholismCurrent smokers who refuse to stop smoking within 72 hours following third molar surgeryPatients opting to undergo third molar surgery under local or general anaesthesiaPatients unable to give informed consentPatients who have third molars with following:Associated pathologiesThird molar/s requiring coronectomyThird molars with higher risk of mandibular fractureMaxillary third molar/s with higher risk of oro-antral communicationOral surgery requiring more than four third molars extractedInterventionsIntervention group (group A)Etoricoxib 120mgControl group (group B)Sustained-release ibuprofen 1.6gRandomisationBlock randomisation will be used to ensure balance in the assignment of participants to each treatment group. An independent biostatistician will generate a random allocation sequence. A hospital clinical trials pharmacist, the only non-blinded person involved in the proposed study, will hold this computer-generated randomisation code. Upon receiving participation consent, the pharmacist will randomly assign each participant to either the intervention group (group A) or the control group (group B) according to the randomisation code. Each participant will be given a unique identification number by the pharmacist and treatment will be provided via sealed opaque envelopes. Obtaining patient consent for participationPatients who are deemed potentially suitable for participation in the study will be invited to the consultation appointment with the principal researcher/surgeon, Jessica Lee. During the consultation, the following will be explained:The nature and purpose of the study (written participant information sheet will be provided);Participant responsibility (see below);Assurance to participants (see below); andParticipant incentive (see below).Patients will be given the opportunity to ask questions for clarification prior to enrolment. Each participant will be given a unique identification number to ensure participant anonymity.Participant responsibilityIn voluntarily choosing to participate in this research project, the patient will agree to:Read in full the form entitled, Participant Information Sheet (Appendix 2). This form will be given to the patient to take home;Complete a written consent form pertaining to participation in the study (Appendix 3);Complete a pre-operative participant questionnaire (Appendix 4);Attend the surgical appointment. The patients are required to:rate the pre-operative pain intensity;take the pre-operative dose of NSAID provided 2 hours prior to third molar surgery;have the facial dimension and mouth opening assessed;undergo third molar surgery under IV sedation.Rate the pain intensity every 3 hours, while awake, for the first 48 hours post-surgery; and Attend a 48-hour post-operative review appointment. During the review appointment, the extent of facial swelling and trismus will be assessed. The patients are also required to:hand in their completed visual analogue scale (VAS) diary; complete a post-operative participant questionnaire (Appendix 9).Assurance to participantsPatients will be informed:All data collected will remain confidential and will only be used for the research project.The names of participants will not appear in the thesis nor in any future journal articles which may arise from the research.The study data will be retained in a de-identified format, which will be stored securely at the University of Otago for a period of 10 years, after which time it will be destroyed.Participants may withdraw from the study at any time with no penalty or disadvantage to surgical care and management.All the peri-operative drugs will be provided at an ethically acceptable doses for the surgical removal of mandibular third molars. All the intra-operative drugs are those routinely used at the School of Dentistry, University of Otago, for impacted third molar surgery.Participants will be informed how and when to take their pre-emptive and post-operative pain relief medications.All participants will be informed of potential side effects of etoricoxib and sustained-release ibuprofen.If participants have any post-operative issues, they may phone the oral surgery team who performed their surgery during business hours or contact the on-call Dental House Surgeon after-hours via the Emergency Department of the Dunedin Public Hospital. The on-call Dental House Surgeon is part of the same oral surgery team responsible for this study and may contact the principal researcher if needed. Phone numbers of the oral surgery team and Dunedin Public Hospital are stated on the Participant Information Sheet (Appendix 2).Participants will be offered a medical certificate as required.Participant incentivePre-emptive medications (etoricoxib and sustained-release ibuprofen) will be given to participants free of charge. Participants will be given a free 250ml bottle of 0.2% chlorhexidine gluconate mouthwash. This antibacterial mouthwash is commonly prescribed at the School of Dentistry, University of Otago, after minor oral surgery to prevent post-operative infection.Obtaining and dispensing pre-emptive analgesic agentsEtoricoxib 120mg and sustained-release ibuprofen 1.6g will be specifically prepared across 4 capsules by Optimus Healthcare Pharmacist in Auckland. Both drugs will be packed into bottles containing 4 capsules each for dispensing to individual patients. All medications have 1-year expiry from the date of preparation. They will be obtained in a single consignment to Jessica Lee at the Department of Oral Diagnostic and Surgical Sciences, School of Dentistry. The drugs will then be given to the clinical trials pharmacist at the Dunedin Public Hospital for randomisation coding as participants are recruited.250ml bottle of 0.2% chlorhexidine gluconate mouthwash for dispensing will be obtained from the local pharmacy.Intervention groupEtoricoxib 120mg (4 capsules in divided doses)Each capsule contains 30mg of etoricoxib0.2% chlorhexidine gluconate mouthwash 250mlControl groupSustained-release ibuprofen 1.6g (4 capsules in divided doses)Each capsule contains 400mg of sustained-release ibuprofen0.2% chlorhexidine gluconate mouthwash 250mlParticipants are required to fast prior to IV sedation. The fasting guideline at the School of Dentistry for IV sedation is as follows:No food must be taken within 4 hours before IV sedationClear fluids may be taken up to 2 hours before IV sedation.To ensure adequate hydration and reduce the risk of potential renal adverse events, participants will be encouraged to drink sufficient amount of fluid prior to fasting. Jessica Lee will dispense the pre-emptive medication with a large glass of water 2 hours prior to the surgical appointment. If participants were to self-medicate, the variability in the timing of the drug administration will be inevitable. To limit this, the pre-emptive medication will be dispensed at the School of Dentistry, University of Otago. The date and time of dispense will be immediately recorded on a drug chart and signed by Jessica Lee and the supervising Consultant Oral and Maxillofacial Surgeon.Renal function will not be checked in this proposed study. Participants will be young between the ages of 18 and 35 years and only ASA 1 and 2 patients will be recruited. ASA 2 patients will be carefully selected after reviewing their medical history. Patients with known renal impairment, poorly controlled diabetes, long-term antihypertensive therapy, and/or any conditions that may predispose to renal impairment, will be excluded.At the School of Dentistry, University of Otago, IV sedation is strictly reserved for patients who are reasonably healthy with no significant systemic conditions. Hence, pre-operative renal function tests are not routinely performed. This conforms to the current Southern DHB Pre-operative Laboratory Investigations – Anaesthetic Guidelines (Otago). It states that: (1) no tests are indicated for asymptomatic patients having minor surgery; and (2) urea, creatinine, and electrolytes are indicated for those over 70 years, or those with dehydration, pyloric stenosis, renal or diabetic disorders and/or on diuretics or potassium therapy or on long term antihypertensive therapy ADDIN EN.CITE <EndNote><Cite><RecNum>84</RecNum><DisplayText>(Preoperative Laboratory Investigations - Anaesthetic Guidelines (Otago))</DisplayText><record><rec-number>84</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537265255">84</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Preoperative Laboratory Investigations - Anaesthetic Guidelines (Otago)</title></titles><number>4 August 2018</number><dates><pub-dates><date>1 August 2016</date></pub-dates></dates><publisher>Southern DHB (Otago)</publisher><urls><related-urls><url>;(Preoperative Laboratory Investigations - Anaesthetic Guidelines (Otago)). This protocol aligns favourably with the National Institute for Health and Care Excellence Clinical Guidelines for Routine Pre-operative Tests for Elective Surgery. The Guideline Development Group concluded against a routine baseline pre-operative renal function tests for ASA 1 and 2 patients, including well-controlled diabetic patients, as functional abnormalities of the kidneys are rarely detected in asymptomatic, fit and healthy young individuals and the risk of acute kidney injury (AKI) is very low. In contrast, a pre-operative renal function test is recommended to be considered for ASA grade 3 and 4 patients at risk of AKI ADDIN EN.CITE <EndNote><Cite><RecNum>85</RecNum><DisplayText>(Routine preoperative tests for elective surgery)</DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537265599">85</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Routine preoperative tests for elective surgery</title></titles><number>4 August 2018</number><dates><pub-dates><date>April 2016</date></pub-dates></dates><publisher>National Institute for Health and Care Excellence</publisher><urls><related-urls><url> Institute for Health and Care Excellence</remote-database-provider></record></Cite></EndNote>(Routine preoperative tests for elective surgery).Although getting the blood test is considered safe, it subjects our participants at unnecessary discomfort and pain. Moreover, a small risk of complications, such as haematoma, infection, and vasovagal reactions cannot be excluded ADDIN EN.CITE <EndNote><Cite><RecNum>85</RecNum><DisplayText>(Routine preoperative tests for elective surgery)</DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537265599">85</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Routine preoperative tests for elective surgery</title></titles><number>4 August 2018</number><dates><pub-dates><date>April 2016</date></pub-dates></dates><publisher>National Institute for Health and Care Excellence</publisher><urls><related-urls><url> Institute for Health and Care Excellence</remote-database-provider></record></Cite></EndNote>(Routine preoperative tests for elective surgery). The current guidelines do not support the need for renal function tests for the participants in the proposed study.Drug dose and administrationPre-/intra-operative drugsAll participants will undergo third molar surgery under IV sedation. Administration of the sedation will be performed by Jessica Lee and the patient will be monitored by a registered nurse trained in IV sedation. The entire operative procedure will be supervised by a Consultant Oral and Maxillofacial Surgeon.The following medications are standard peri-operative drugs administered for those undergoing third molar surgery under IV sedation at the School of Dentistry, University of Otago:Dexamethasone 8mgMidazolam 5mg/5ml titrated to effect (maximum total dose of 10mg as per recommendation by Malamed) ADDIN EN.CITE <EndNote><Cite><Author>Malamed</Author><Year>2010</Year><RecNum>74</RecNum><DisplayText>(Malamed 2010)</DisplayText><record><rec-number>74</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537009931">74</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors><authors><author>Malamed, Stanley F.</author></authors><secondary-authors><author>Malamed, Stanley F.</author></secondary-authors></contributors><titles><title>Sedation : a guide to patient management</title><secondary-title>Sedation: A GUIDE TO PATIENT MANAGEMENT: Fifth Edition</secondary-title></titles><edition>5th ed.</edition><keywords><keyword>Anesthesia, Dental -- methods</keyword><keyword>Conscious Sedation</keyword><keyword>Deep Sedation</keyword><keyword>Dental Anxiety -- prevention &amp; control</keyword><keyword>Pain -- prevention &amp; control</keyword></keywords><dates><year>2010</year></dates><pub-location>St. Louis, Mo.</pub-location><publisher>Mosby Elsevier</publisher><isbn>0-323-05680-6</isbn><urls></urls></record></Cite></EndNote>(Malamed 2010)2.2ml lignocaine 2% with 1:80,000 adrenaline for each unilateral inferior alveolar nerve block1.0ml lignocaine 2% with 1:80,000 adrenaline for each unilateral infiltration in the buccal sulcus near the third molarPost-operative analgesic regimenJessica Lee will provide a prescription for the following post-operative analgesia:Paracetamol 1g QID 3/7 then as requiredIbuprofen 400mg TID (start 18 hours after pre-emptive drug administration) 3/7 then as requiredCodeine phosphate 30mg – 60mg QID as required (rescue medication)Regular dose of ibuprofen 400mg will commence 18 hours after pre-emptive NSAID administration. Etoricoxib and sustained-release ibuprofen have a long duration of action and maintain stable plasma concentration over at least 20 hours. Therefore, additional intake of NSAID may subsequently increase the risk of adverse renal effects.Each participant will be given a 250ml bottle of 0.2% chlorhexidine gluconate mouthwash and a VAS diary prior to discharge home. All patients will be asked to use 10ml of 0.2% chlorhexidine gluconate 1-minute rinse three times daily for 7 days, commencing 24 hours post-operatively.Surgical procedureThe surgical removal of impacted bilateral mandibular third molars will be performed by Jessica Lee. All surgical procedures will be directly supervised by a Consultant Oral and Maxillofacial Surgeon employed by the University of Otago. The involvement of a single surgeon aims to eliminate operator variability and consequent performance bias from the proposed investigation.Data collectionParticipants who meet the eligibility criteria will be provided with the participant information sheet. The first appointment will involve consultation with the surgeon/principal researcher. Upon receiving the participation consent, the pre-operative questionnaire will be completed. This questionnaire contains the Oral Health Impact Profile, OHIP-14 (Slade, 1997), Locker’s Global Oral Health Item (Thomson et al., 2012), and the Dental Anxiety Scale (Corah, 1969).The type of third molar impaction according to the Winter’s classification (mesio-angular, disto-angular, vertical, horizontal, transverse bucco-lingual, inverted) will be recorded for each participant.On the second appointment, third molar surgery will be completed under IV sedation. The following will be completed before surgery:Pre-operative pain rating on a 100mm VAS (Appendix 5)Assess facial swelling/dimension using 3-dimensional volumetric morphometric imaging software (3dMDtrio system)Assess maximum mouth opening (trismus) by measuring the distance between the mesio-incisal edges of the right maxillary and mandibular central incisor teeth during maximal mouth opening.Participants will be asked to rate the pain intensity every 3 hours, while awake, for the first 48 hours post-surgery. A non-graduated 100mm VAS, printed one per page in a booklet, will be provided to each participant to take home after surgery (Appendix 5).The VAS is an instrument that is widely accepted for the unidimensional, self-report measure of pain intensity. It comprises of a horizontal line of 100mm in length bounded by a pole at each extreme of the scale. The left end of the extreme is described as “no pain” and the other end as “worst pain imaginable.” It does not require any specific training; participants are to score the pain by placing a line perpendicular along the scale that best matches the individual’s pain experience. The score is then interpreted by using a ruler to measure the distance (in millimetres) from the “no pain” pole to the participant’s mark. The measure of pain intensity is represented by the range between 0 to 100 ADDIN EN.CITE <EndNote><Cite><Author>Hawker</Author><Year>2011</Year><RecNum>75</RecNum><DisplayText>(Hawker et al. 2011)</DisplayText><record><rec-number>75</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537010059">75</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hawker, Gillian A.</author><author>Mian, Samra</author><author>Kendzerska, Tetyana</author><author>French, Melissa</author></authors></contributors><titles><title>Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short‐Form McGill Pain Questionnaire (SF‐MPQ), Chronic Pain Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF‐36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP</title><secondary-title>Arthritis Care &amp; Research</secondary-title></titles><periodical><full-title>Arthritis Care &amp; Research</full-title><abbr-1>Arthritis Care Res (Hoboken)</abbr-1></periodical><pages>S240-S252</pages><volume>63</volume><number>S11</number><keywords><keyword>Medicine</keyword></keywords><dates><year>2011</year></dates><pub-location>Hoboken, USA</pub-location><isbn>2151-464X</isbn><urls></urls><electronic-resource-num>10.1002/acr.20543</electronic-resource-num></record></Cite></EndNote>(Hawker et al. 2011). Accurate baseline measure of the parameters is paramount; this is not only to allow for objective comparisons and interpretation of the data after the surgery, but also to assess whether differences exist among the parameters that need to be controlled prior to the statistical analysis.The VAS diary will also contain pages where participants will be asked to record the following details:The time elapsed between the end of the surgery and the first use of rescue medicationNumber of rescue analgesia consumed per dayAny adverse events experienced post-surgery (e.g. headache, drowsiness, vomiting, and nausea) (Appendix 6 & 7)Participants will be asked to attend post-operative review appointment with Jessica Lee at 48 hours post-surgery. The following will be completed:The extent of facial swelling will be assessed using 3dMDtrio systemTrismus will be measured by the distance between the mesio-incisal edges of the right maxillary and mandibular central incisor teeth during maximal mouth openingCollect the VAS diaryComplete a post-operative questionnaire (Appendix 9).The post-operative questionnaire is comprised of a series of questions pertaining to their experience of post-operative pain, compliance with the prescribed analgesic regime, and whether rescue analgesia was required. The post-operative questionnaire will be completed by participants themselves during this appointment.The timeframe of 48 hours is based on the finding that a large proportion of patients experience the greatest amount of pain and swelling during the first 48-72 hours following third molar surgery. Also, patient compliance in pain intensity recording is likely to decline the longer the study duration continues and hence may compromise the accuracy of data.Data entryA Microsoft Excel spreadsheet will be used for data entry. All data entry will be double-checked for errors prior to data analysis.Data analysisStatistical analysis will be undertaken using SPSS software. Baseline characteristics and categorical data will be compared using Chi-square tests. The summary data on VAS, swelling, and trismus between etoricoxib and ibuprofen groups will be compared and tested for statistical significance using Analysis of Variance (ANOVA). Pearson correlations will also be used to quantify the association between the sum of pain scores and the total intake of rescue medication. Linear regression will be used to control for confounders. The level of significance will be set at P < 0.05. Appropriate multivariate modelling will be undertaken.Bias and confoundingPotential source of biasThe proposed investigation is a double-blind study to minimise reporting/investigator bias. The proposed study is vulnerable to volunteer bias. There may be systematic differences in the characteristics between those who volunteer to participate in the study and those who decline to participate.ModifiersAgeThe association between greater surgical difficulty and older age is well-documented in the literature ADDIN EN.CITE <EndNote><Cite><Author>Renton</Author><Year>2001</Year><RecNum>76</RecNum><DisplayText>(Renton et al. 2001)</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537010147">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>T. Renton</author><author>N. Smeeton</author><author>M. Mcgurk</author></authors></contributors><titles><title>Oral surgery: Factors predictive of difficulty of mandibular third molar surgery</title><secondary-title>British Dental Journal</secondary-title></titles><periodical><full-title>British Dental Journal</full-title><abbr-1>Br Dent J</abbr-1></periodical><pages>607</pages><volume>190</volume><number>11</number><keywords><keyword>Dentistry</keyword></keywords><dates><year>2001</year></dates><isbn>0007-0610</isbn><urls></urls><electronic-resource-num>10.1038/sj.bdj.4801052</electronic-resource-num></record></Cite></EndNote>(Renton et al. 2001). Alveolar bone is significantly denser and less elastic in older patients over the age of 35 years than among younger patients. This accounts for more bone removal, tooth sectioning, greater surgical time, and potentially increases the risk of post-operative complications ADDIN EN.CITE <EndNote><Cite><Author>Renton</Author><Year>2001</Year><RecNum>76</RecNum><DisplayText>(Renton et al. 2001)</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537010147">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>T. Renton</author><author>N. Smeeton</author><author>M. Mcgurk</author></authors></contributors><titles><title>Oral surgery: Factors predictive of difficulty of mandibular third molar surgery</title><secondary-title>British Dental Journal</secondary-title></titles><periodical><full-title>British Dental Journal</full-title><abbr-1>Br Dent J</abbr-1></periodical><pages>607</pages><volume>190</volume><number>11</number><keywords><keyword>Dentistry</keyword></keywords><dates><year>2001</year></dates><isbn>0007-0610</isbn><urls></urls><electronic-resource-num>10.1038/sj.bdj.4801052</electronic-resource-num></record></Cite></EndNote>(Renton et al. 2001). In order to minimise this age effect, we restrict the age group between 18 and 35 years of age.EthnicityOne study identified ethnic background as an independent predictor for difficulty of third molar extraction ADDIN EN.CITE <EndNote><Cite><Author>Renton</Author><Year>2001</Year><RecNum>76</RecNum><DisplayText>(Renton et al. 2001)</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537010147">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>T. Renton</author><author>N. Smeeton</author><author>M. Mcgurk</author></authors></contributors><titles><title>Oral surgery: Factors predictive of difficulty of mandibular third molar surgery</title><secondary-title>British Dental Journal</secondary-title></titles><periodical><full-title>British Dental Journal</full-title><abbr-1>Br Dent J</abbr-1></periodical><pages>607</pages><volume>190</volume><number>11</number><keywords><keyword>Dentistry</keyword></keywords><dates><year>2001</year></dates><isbn>0007-0610</isbn><urls></urls><electronic-resource-num>10.1038/sj.bdj.4801052</electronic-resource-num></record></Cite></EndNote>(Renton et al. 2001). The mean surgical time was longer amongst African-American and Caribbean patients when compared to Caucasian patients due to the high incidence of bone impaction, unfavourable root formation, angulation, and crown width ADDIN EN.CITE <EndNote><Cite><Author>Renton</Author><Year>2001</Year><RecNum>76</RecNum><DisplayText>(Renton et al. 2001)</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537010147">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>T. Renton</author><author>N. Smeeton</author><author>M. Mcgurk</author></authors></contributors><titles><title>Oral surgery: Factors predictive of difficulty of mandibular third molar surgery</title><secondary-title>British Dental Journal</secondary-title></titles><periodical><full-title>British Dental Journal</full-title><abbr-1>Br Dent J</abbr-1></periodical><pages>607</pages><volume>190</volume><number>11</number><keywords><keyword>Dentistry</keyword></keywords><dates><year>2001</year></dates><isbn>0007-0610</isbn><urls></urls><electronic-resource-num>10.1038/sj.bdj.4801052</electronic-resource-num></record></Cite></EndNote>(Renton et al. 2001). However, there is a paucity of data demonstrating the association between ethnicity and surgical difficulty pertaining to the New Zealand population. The available data failed to observe any significant differences in the rate of post-operative complications between Māori and NZ European patients following routine exodontia ADDIN EN.CITE <EndNote><Cite><Author>Tong</Author><Year>2014</Year><RecNum>86</RecNum><DisplayText>(Tong et al. 2014)</DisplayText><record><rec-number>86</rec-number><foreign-keys><key app="EN" db-id="z2prwtav65xaahefastv5er802zxpazt2e90" timestamp="1537266502">86</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tong, Darryl C</author><author>Al-Hassiny, HH</author><author>Ain, AB</author><author>Broadbent, JM</author></authors></contributors><titles><title>Post-operative complications following dental extractions at the School of Dentistry, University of Otago</title><secondary-title>New Zealand Dental Journal</secondary-title></titles><periodical><full-title>New Zealand Dental Journal</full-title><abbr-1>NZ Dent J</abbr-1></periodical><pages>51-55</pages><volume>110</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(Tong et al. 2014). Based on this finding, the heterogeneity in the ethnic background of the patients in the proposed study is unlikely to affect the findings.Pre-operative dexamethasoneThe peri-operative drug protocol for third molar surgery under IV sedation at the School of Dentistry, University of Otago, includes intravenous administration of dexamethasone. The proposed study aims to compare the pre-emptive anti-inflammatory efficacy of etoricoxib and sustained-release ibuprofen on clinical parameters including swelling and trismus. Thus, pre-operative dexamethasone will subsequently modify the potential association between the pre-emptive NSAIDs and the outcome. Administration of steroid prior to surgical removal of third molars under IV sedation or general anaesthesia is a common practice to help reduce post-operative swelling. Therefore, omitting this drug may subject participants to unnecessary discomfort.Post-operative ibuprofenThe analgesic efficacy and opioid-sparing effects of ibuprofen in third molar post-operative pain is well-established in the literature. Post-operative administration of ibuprofen may potentially mask the pre-emptive anti-inflammatory effects of etoricoxib and sustained-release ibuprofen, hence modify the results of the proposed study. However, codeine is proven to provide poor analgesic effect and hence, a post-operative analgesic regimen of paracetamol and ibuprofen for pain after third molar surgery is a routine practice. Therefore, it is paramount that this research provides all the participants with a prescription for regular paracetamol and ibuprofen for at least 2 days post-operatively.Alveolar osteitis and/or post-operative infectionAlveolar osteitis is a common post-operative complication following mandibular third molar extraction. The positive association between smoking and alveolar osteitis is well-established. To reduce the risk of alveolar osteitis, current smokers who refuse to stop smoking within 72 hours following third molar surgery will be excluded from this study.Moreover, participants with clinical signs of pericoronitis will be treated at the time of the consultation to minimise the risk of post-operative infection. All participants will be provided with complimentary 0.2% chlorhexidine gluconate mouthwash to use post-operatively.It should be noted that alveolar osteitis and post-operative infection generally occur 3 to 5 days post-operatively. Given the timeframe of the proposed study, the chance of these variables affecting the findings of the study is very low.Controlling for confounding variablesConfounding variables will be controlled statistically using modelling techniques at the time of data analysis.Ethics approval and Māori approvalEthics approvalProvisionally approvedMāori approvalApprovedFundingApplication for the internal university funding is pending.Payment for treatmentPatients will bear the cost of surgical treatment according to the fee schedule guidelines of the School of Dentistry, University of Otago.Proposed supervisorsMr Harsha L De SilvaProfessor W Murray ThomsonAssociate Professor Rohana K De SilvaProfessor Darryl C TongThesis timeline201820192020SepDecJanJunDecJanAprAugGrant applicationClinical trials registryEthics approvalFinalise preparation for commencement of researchPatient recruitmentData collectionData analysisReport writingSelected references ADDIN EN.REFLIST Al-Sukhun J, Al-Sukhun S, Penttil? H, Ashammakhi N, Al-Sukhun R. 2012. Preemptive Analgesic Effect of Low Doses of Celecoxib Is Superior to Low Doses of Traditional Nonsteroidal Anti-Inflammatory Drugs. J Craniofac Surg. 23(2):526-529.Albuquerque AFM, Fonteles CSR, Do Val DR, Chaves HV, Bezerra MM, Pereira KMA, de Barros Silva PG, de Lima BB, Soares ECS, Ribeiro TR et al. 2017. Effect of pre-emptive analgesia on clinical parameters and tissue levels of TNF-α and IL-1β in third molar surgery: a triple-blind, randomized, placebo-controlled study. Int J Oral Maxillofac Surg. 46(12):1615-1625.Arcoxia (etoricoxib) film coated tablets. Merck Sharp & Dohme (NZ) Ltd; [accessed 1 April 2018]. L, Harutunian K, Figueiredo R, Valmaseda-Castellón E, Gay-Escoda C. 2012. Effect of preoperative ibuprofen on pain and swelling after lower third molar removal: a randomized controlled trial. Int J Oral Maxillofac Surg. 41(8):1005-1009.Bauer HC, Duarte FL, Horliana ACRT, Tortamano IP, Perez FEG, Simone JL, Jorge WA. 2013. Assessment of preemptive analgesia with ibuprofen coadministered or not with dexamethasone in third molar surgery: a randomized double-blind controlled clinical trial.(Report). Oral Maxillofac Surg. 17(3):165.Best AD, De Silva RK, Thomson WM, Tong DC, Cameron CM, De Silva HL. 2017. Efficacy of Codeine When Added to Paracetamol (Acetaminophen) and Ibuprofen for Relief of Postoperative Pain After Surgical Removal of Impacted Third Molars: A Double-Blinded Randomized Control Trial. J Oral Maxillofac Surg. 75(10):2063-2069.Boonriong T, Tangtrakulwanich B, Glabglay P, Nimmaanrat S. 2010. Comparing etoricoxib and celecoxib for preemptive analgesia for acute postoperative pain in patients undergoing arthroscopic anterior cruciate ligament reconstruction: a randomized controlled trial. BMC Musculoskelet Disord. 11:246.Brufen SR 800mg modified release tablet data sheet. Mylan New Zealand Ltd; [accessed 6 June 2018]. L, Consales G, Gaudio A. 2010. Pre-Emptive Analgesia for Postoperative Pain Control. Clin Drug Investig. 30(2):15-26.Clarke R, Derry S, Moore RA. 2014. Single dose oral etoricoxib for acute postoperative pain in adults. Cochrane Database Syst Rev. 2017(5):CD004309.Colorado-Bonnin M, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. 2006. Quality of life following lower third molar removal. Int J Oral Maxillofac Surg. 35(4):343-347.Costa FWG, Soares ECS, Esses DFS, Silva PGD, Bezerra TP, Scarparo HC, Ribeiro TR, Fonteles CSR. 2015. A split-mouth, randomized, triple-blind, placebo-controlled study to analyze the pre-emptive effect of etoricoxib 120 mg on inflammatory events following removal of unerupted mandibular third molars. Int J Oral Maxillofac Surg. 44(9):1166-1174.Dahl JB, M?iniche S. 2005. Pre-emptive analgesia. Br Med Bull. 71(1):13-27.Derry C, Derry S, Moore RA, McQuay HJ. 2009. Single dose oral ibuprofen for acute postoperative pain in adults. Cochrane Database Syst Rev. 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Int J Oral Maxillofac Surg. 39(7):647-652.Lierz P, Losch H, Felleiter P. 2012. Evaluation of a single preoperative dose of etoricoxib for postoperative pain relief in therapeutic knee arthroscopy. Acta Orthop. 83(6):642-647.Malamed SF. 2010. Sedation : a guide to patient management. In: Malamed SF, editor. Sedation: A GUIDE TO PATIENT MANAGEMENT: Fifth Edition. 5th ed. ed. St. Louis, Mo.: Mosby Elsevier.Mehra P, Reebye U, Nadershah M, Cottrell D. 2013. Efficacy of anti-inflammatory drugs in third molar surgery: a randomized clinical trial. Int J Oral Maxillofac Surg. 42(7):835-842.Mojsa IM, Stypulkowska J, Novak P, Lipczynski K, Szczeklik K, Zaleska M. 2017. Pre-emptive analgesic effect of lornoxicam in mandibular third molar surgery: a prospective, randomized, double-blind clinical trial. Int J Oral Maxillofac Surg. 46(5):614-620.Moore RA, Derry JS, Straube JS, Ireson-Paine JJ, Wiffen JP. 2014. Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain. Pain. 155(1):14-21.Munteanu MA, Cionac Florescu MS, Anastase ID, Stoica IC. 2016. Is there any analgesic benefit from preoperative vs. postoperative administration of etoricoxib in total knee arthroplasty under spinal anaesthesia?: A randomised double-blind placebo-controlled trial. Eur J Anaesthesiol. 33(11):840-845.Ong KSC, Lirk AP, Seymour JR, Jenkins JB. 2005. The Efficacy of Preemptive Analgesia for Acute Postoperative Pain Management: A Meta-Analysis. Anesthesia & Analgesia. 100(3):757-773.Pogatzki-Zahn ME, Zahn KP. 2006. From preemptive to preventive analgesia. Curr Opin Anaesthesiol. 19(5):551-555.Preoperative Laboratory Investigations - Anaesthetic Guidelines (Otago). Southern DHB (Otago); [accessed 4 August 2018]. B, Walter G, Strauss J, Fromm MF, Zacher J, Brune K. 2012. Preoperative administration of etoricoxib in patients undergoing hip replacement causes inhibition of inflammatory mediators and pain relief. Eur J Pain. 16(6):838.Renton T, Smeeton N, Mcgurk M. 2001. Oral surgery: Factors predictive of difficulty of mandibular third molar surgery. Br Dent J. 190(11):607.Rosero BE, Joshi PG. 2014. Preemptive, Preventive, Multimodal Analgesia: What Do They Really Mean? Plast Reconstr Surg. 134(4 Suppl):85S-93S.Routine preoperative tests for elective surgery. National Institute for Health and Care Excellence; [accessed 4 August 2018]. T, Paiboonworachat S, Ko-iam W. 2011. Effects of preemptive analgesia in laparoscopic cholecystectomy: a double-blind randomized controlled trial. Surg Endosc. 25(1):23-27.Takemoto J, Reynolds J, Remsberg C, Vega-Villa K, Davies N. 2008. Clinical Pharmacokinetic and Pharmacodynamic Profile of Etoricoxib. Clin Pharmacokinet. 47(11):703-720.Tong DC, Al-Hassiny H, Ain A, Broadbent J. 2014. Post-operative complications following dental extractions at the School of Dentistry, University of Otago. NZ Dent J. 110:51-55.Yong SL, Coulthard P. 2010. Pain after surgery: Can protective analgesia reduce pain? A randomised clinical trial. Int J Surg. 8(4):283-289.Yuan Y, Hunt RH. 2007. Global Gastrointestinal Safety Profile of Etoricoxib and Lumiracoxib. Curr Pharm Des. 13(22):2237-2247.Zor ZF, Isik B, Cetiner S. 2014. Efficacy of preemptive lornoxicam on postoperative analgesia after surgical removal of mandibular third molars. Oral Surg Oral Med Oral Pathol Oral Radiol. 117(1):27-31.AppendicesAppendix 1OVERVIEW OF KEY STEPS IN THE STUDY DESIGNcenter71120Patients requiring surgical removal of third molar teeth who are deemed potentially suitable for participation in the study invited to the surgical consultation with Jessica LeeNotify staff clinicians of the proposed study at staff meetings and via staff emailAppointment 1:Consultation with Jessica LeeInclusion & exclusion criteria metPatient records pain intensity on VAS diary every 3 hours (while awake) for the first 48 hours post-operativelyPatient records the number of rescue analgesia consumed and any adverse events for the first 48 hours post-operativelyAppointment 2:Administration of pre-emptive medication 2 hours prior to surgeryPre-operative VAS, swelling, mouth opening assessmentThird molar surgery under IV sedationBlock randomisation of patientsAppointment 3 (Day-2 post-operative review):Swelling and trismus assessmentComplete post-operative questionnaireEnd of participant commitment00Patients requiring surgical removal of third molar teeth who are deemed potentially suitable for participation in the study invited to the surgical consultation with Jessica LeeNotify staff clinicians of the proposed study at staff meetings and via staff emailAppointment 1:Consultation with Jessica LeeInclusion & exclusion criteria metPatient records pain intensity on VAS diary every 3 hours (while awake) for the first 48 hours post-operativelyPatient records the number of rescue analgesia consumed and any adverse events for the first 48 hours post-operativelyAppointment 2:Administration of pre-emptive medication 2 hours prior to surgeryPre-operative VAS, swelling, mouth opening assessmentThird molar surgery under IV sedationBlock randomisation of patientsAppointment 3 (Day-2 post-operative review):Swelling and trismus assessmentComplete post-operative questionnaireEnd of participant commitment146649111394Sign participation consentComplete pre-operative questionnaireSign participation consentComplete pre-operative questionnaireAppendix 2PARTICIPANT INFORMATION SHEETPre-operative effects of anti-inflammatory drugs on pain and inflammation following wisdom teeth removalLocality: Department of Oral Diagnostic and Surgical Sciences, School of DentistryPrincipal Researcher: YJ Jessica Lee (Oral Surgery Doctorate Candidate)Primary Supervisor: Mr Harsha De Silva (Senior Lecturer in Oral & Maxillofacial Surgery)Contact number: (03) 479 7023Ethics Committee Ref: 18/STH/139We invite you to take part in a clinical study on the effects of pre-operative anti-inflammatory drugs on pain and inflammation following wisdom teeth surgery. Whether or not you take part is your choice. If you don’t want to take part, you don’t have to give a reason, and it won’t affect the care you receive. If you do want to take part now, but change your mind later, you can pull out of the study at any time. This Participant Information Sheet will help you decide if you’d like to take part. It sets out why we are doing the study, what your participation would involve, what the benefits and risks to you might be, and what would happen after the study ends. We will go through this information with you and answer any questions you may have. You do not have to decide today whether or not you will participate in this study. Before you decide you may want to talk about the study with other people, such as family, whānau, friends, or healthcare providers. Feel free to do this.If you agree to take part in this study, you will be asked to sign the Consent Form on the last page of this document. You will be given a copy of both the Participant Information Sheet and the Consent Form to keep.This document is 5 pages long, including the Consent Form. Please make sure you have read and understood all the pages.What is the aim of the research project?This project is being undertaken as part of an Oral Surgery Doctorate degree at the University of Otago. The aim is to compare the pre-operative effectiveness of two different types of anti-inflammatory painkillers on pain, swelling, and mouth opening after wisdom teeth surgery. The medications involved in this project are etoricoxib (Arcoxia) 120mg and sustained-release ibuprofen 1.6g, two commonly used painkillers. Arcoxia is shown to be effective when given before bone and gall bladder operations but not much is known about its benefit in wisdom teeth surgery. Participants will be randomly assigned to a group. To help minimise bias, neither the researcher nor the participants will know which participants are receiving which medication.Who pays for the study?Application for the internal university funding is in progress.Participants will bear the cost of surgical treatment according to the fee guidelines of the School of Dentistry, University of Otago, and the post-operative medications prescribed, except the study medications (Arcoxia, sustained-release ibuprofen) which will be provided free of charge.Who are we seeking to participate in the project?Anyone between 18 and 35 years of age who requires the removal of at least 2 impacted lower wisdom teeth are invited to participate. Participants must be healthy with no significant medical conditions and must not have any allergic reactions to anaesthetics/sedatives, anti-inflammatory painkillers (e.g. Nurofen, Voltaren), and codeine. Female patients who are pregnant or breastfeeding will not be able to participate.What will participants be asked to do?Should you agree to take part in this project, you will be asked to:Complete a short questionnaire asking about things such as your age, gender, occupation, oral hygiene practice, past or present pain associated with your wisdom teeth, and whether you experience anxiety when receiving dental treatment.Attend your surgical appointment. You will need to take a medication given to you 2 hours before the surgery. Before the wisdom teeth removal, your facial dimension will be assessed by a 3D-scanner and your mouth opening will be measured.Fill in your pain diary. This involves scoring your pain level every 3 hours (while awake) for the first 2 days after the surgery. You will also need to answer questions relating to the use of painkillers and any side effects encountered. Each occasion will take only a moment of your time.Attend a review appointment with Jessica Lee 2 days after the surgery, at which time she will:Assess the extent of facial swelling and mouth opening;Collect your pain diary; andAsk you to complete a short questionnaire about to your experience of pain following the wisdom teeth surgeryBenefits and risks of participating in this studySurgical removal of wisdom teeth is a common procedure provided at the School of Dentistry, University of Otago. The medications provided to you before your wisdom teeth surgery are known to have a good effect in controlling post-operative pain. The effective dose of the medication will remain the same; we will be giving the medication before the surgery rather than after the surgery. Like all anti-inflammatory painkillers, the side effects of ibuprofen and Arcoxia may include stomache pain in some people. Despite this, ibuprofen and Arcoxia are commonly prescribed following wisdom teeth surgery. Therefore, there are no increased risks by participating in this study. It’s important that you DON’T combine two types of anti-inflammatory painkillers as this could increase the risk of post-operative bleeding.We will give you a free bottle of antibacterial mouthwash and a prescription for painkillers. These painkillers are no different to those given to patients undergoing wisdom teeth surgery at the School of Dentistry.If you believe that the painkillers provided to you by the School of Dentistry are making you feel unwell, then you are advised to stop taking those tablets and contact your medical doctor for an alternative painkiller. What if something goes wrong?If you were injured in this study, which is unlikely, you would be eligible for compensation from ACC just as you would be if you were injured in an accident at work or at home. You will have to lodge a claim with ACC, which may take some time to assess. If your claim is accepted, you will receive funding to assist in your recovery.If you have private health or life insurance, you may wish to check with your insurer that taking part in this study won’t affect your cover.What about anonymity and confidentiality?Your participation in this study is strictly confidential. Any personal information such as your name, age, gender, and contact details will remain anonymous. The information collected from you will de deidentified and used only by the researchers involved in this project. The deidentified information (study data) will be stored securely at the University of Otago for a period of 10 years, after which time it will be destroyed.The results of this study will be written up in the form of a thesis and may later be summarised and published in a dental journal in order that other dentists and their patients may benefit. Nothing that could identify you will be used in anything we publish.If I agree to participate, can I withdraw later?Your participation in this research is entirely voluntary and you can withdraw at any time with no disadvantage to you. To participate you will need to fill in the accompanying consent form. You are welcome to request a copy of the final results of this research project if you desire. You have the right to access your personal data.What if I have any questions about the research project?If you require additional information, please do not hesitate to contact Jessica Lee or Mr Harsha De Silva on (03) 479 7023 during business hours.What if I have any problems or require additional pain relief following my wisdom teeth surgery?If you need to contact the oral surgery team following your wisdom teeth surgery, you may do so during business hours on (03) 479 7023. For after-hours emergency, you may contact Dunedin Public Hospital on (03) 474 0999 and ask to be put through to the on-call Dental House Surgeon.For Māori health support, please contact Professor John Broughton, Associate Dean (Māori), Faculty of Dentistry, on (03) 479 7639.For Health and Disability Advocacy Service, please contact 0800 555 050 or advocacy@.nzAppendix 3CONSENT FORM FOR PARTICIPANTSPre-operative effects of anti-inflammatory drugs on pain and inflammation following wisdom teeth removalPlease tick to indicate you consent to the followingI have read, or have had read to me in my first language, and I understand the Participant Information Sheet. Yes No I have been given sufficient time to consider whether or not to participate in this study.Yes No I have had the opportunity to use a legal representative, whānau/ family support or a friend to help me ask questions and understand the study.Yes No N/A I am satisfied with the answers I have been given regarding the study and I have a copy of this consent form and information sheet.Yes No I understand that taking part in this study is voluntary (my choice) and that I may withdraw from the study at any time without this affecting my medical care.Yes No I consent to the research staff collecting and processing my information, including information about my health.Yes No If I decide to withdraw from the study, I agree that the information collected about me up to the point when I withdraw may continue to be processed.Yes No I consent to my GP or current provider being informed about my participation in the study and of any significant abnormal results obtained during the study.Yes No I understand that my participation in this study is confidential and that no material, which could identify me personally, will be used in any reports on this study.Yes No I understand the compensation provisions in case of injury during the study.Yes No I know who to contact if I have any questions about the study in general.Yes No I understand my responsibilities as a study participant.Yes No I wish to receive a summary of the results from the study.Yes No Declaration by participant:I hereby consent to take part in this study.Participant’s name:Signature:Date:Declaration by member of research team:I have given a verbal explanation of the research project to the participant, and have answered the participant’s questions about it. I believe that the participant understands the study and has given informed consent to participate.Researcher’s name:Signature:Date:Appendix 4PRE-OPERATIVE PARTICIPANT QUESTIONNAIREGeneral InformationOral Surgery research projectDepartment of Oral Diagnostic and Surgical Sciences, School of Dentistry, University of OtagoPrincipal Researcher: YJ Jessica Lee (Oral Surgery Doctorate Candidate)Primary Supervisor: Mr Harsha De Silva (Senior Lecturer in Oral & Maxillofacial Surgery)Thank you for taking the time to fill in this questionnaire.You are kindly requested to complete this questionnaire during your wisdom teeth consultation appointment with YJ Jessica Lee.For information about this research project, please read the form entitled: “Information sheet for participants: Pre-operative effects of anti-inflammatory drugs on pain and inflammation following wisdom teeth removal.”All personal information collected will remain strictly confidential.Please answer honestly. There will be no criticism or judgment of you for your answers.Question 1How old are you?Question 2What is your gender? (please circle)MaleFemaleQuestion 3 Which ethnic groups do you belong to? (please circle all which apply)New Zealand EuropeanMāoriSamoanCook Island MāoriTonganNiueanChineseIndianOthers (please state):Question 4What is your occupation?Question 5What is the highest level of education you have attained?Primary schoolSecondary schoolTrade qualificationTertiary educationQuestion 6Do you currently smoke? (please circle)YesNoIf yes, will you be able to stop smoking for the first 3 days after your wisdom teeth surgery?YesNoQuestion 7Have you ever had any pain or discomfort with your wisdom teeth? (please circle)YesNoIf so, how many times have you had pain or discomfort with your wisdom teeth?In the last 4 weeks, have you had pain or discomfort with your wisdom teeth? (please circle)AlwaysOftenSometimesOccasionallyNever How would you describe the usual intensity of that pain or discomfort? (please circle)MildModerateSevereNot applicableQuestion 8How would you describe the health of your teeth and mouth? (please circle)ExcellentVery goodGoodFairPoorQuestion 9How often do you usually brush your teeth? (please circle)More than once a day Once a day Not every day Less than once a week Never Question 10Place a vertical mark on the line below to indicate your current level of pain.206927125850No painWorst pain imaginableNo painWorst pain imaginableQuestion 11Please circle the answer that BEST applies to you during the last 4 weeks.Because of trouble with your teeth, mouth or dentures:Have you had trouble pronouncing any words?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt that your sense of taste has worsened?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had painful aching in your mouth?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you found it uncomfortable to eat any foods?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been self-conscious?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt tense?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHas your diet been unsatisfactory?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had to interrupt meals?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you found it difficult to relax?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been a bit embarrassed?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been a bit irritable with other people?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had difficulty doing your usual jobs?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt that life in general was less satisfying?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been totally unable to function?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENQuestion 12For each question, please tick the box of the answer which comes closest to how you feel.If you had to go to the dentist tomorrow, how would you feel about it?I would look forward to it as a reasonably enjoyable experienceI wouldn’t care one way or the otherI would be a little uneasy about itI would be afraid that it would be unpleasant and painfulWhen you are waiting in the dentist’s surgery for your turn in the chair, how do you feel?RelaxedA little uneasyTenseAnxiousSo anxious that I sometimes break out in a sweat or almost feel physically sickWhen you are waiting in the dentist’s chair while he gets his drill ready to begin working on your teeth, how do you feel?RelaxedA little uneasyTenseAnxiousSo anxious that I sometimes break out in a sweat or almost feel physically sickYou are waiting in the dentist’s chair to have your teeth cleaned. While you are waiting and the dentist is getting out the instruments which he/she will use to scrape your teeth around the gums, how do you feel?RelaxedA little uneasyTenseAnxiousSo anxious that I sometimes break out in a sweat or almost feel physically sickEnd of questionnaire.Thank you.Appendix 5Level of Pain before Wisdom Teeth RemovalPlease complete on arrival at the School of Dentistry for your wisdom teeth surgery.Date: _______________________Time: _______________________Place a vertical mark on the line below to indicate your current level of pain. Please answer honestly. There will be no criticism or judgment of you for what pain score you record below.781050152400No painWorst pain imaginable0No painWorst pain imaginablePAIN SCORELevel of Pain following Wisdom Teeth RemovalDuring awake hours, please complete every 3 hours for the first 48 hours following your wisdom teeth surgery. Use a separate page each time.Date: _______________________Time: _______________________Place a vertical mark on the line below to indicate your current level of pain. Please answer honestly. There will be no criticism or judgment of you for what pain score you record below.661670202261No painWorst pain imaginable0No painWorst pain imaginableAppendix 6PAIN MEDICATIONThe use of pain medication on the day following wisdom teeth removalPlease complete this questionnaire at the end of each day before going to bed.Date: _______________________Time: _______________________How long did it take you to the first use of pain relief (paracetamol) after your wisdom teeth surgery? hoursHow long did it take you to the first use of rescue pain relief (codeine phosphate) after your wisdom teeth surgery? hoursIf you have taken rescue pain relief (codeine phosphate), how may tablets did you take on the day of surgery? tabletsPAIN MEDICATIONThe use of pain medication 1-day following wisdom teeth removalPlease complete this questionnaire at the end of each day before going to bed.Date: _______________________Time: _______________________If you have taken rescue pain relief (codeine phosphate), how may tablets did you take on the 1st day following surgery? tabletsPAIN MEDICATIONThe use of pain medication 2-days following wisdom teeth removalPlease complete this questionnaire at the end of each day before going to bed.Date: _______________________Time: _______________________If you have taken rescue pain relief (codeine phosphate), how may tablets did you take on the 2nd day following surgery? tabletsAppendix 7ADVERSE EVENTS PROFILE (draft only)Side effects following wisdom teeth removalPlease complete this questionnaire on the 2nd day following surgery.Date: _______________________Please indicate if you have experienced any of the following symptoms following your wisdom teeth surgery.SYMPTOMSYESNOIF “YES”, PLEASE COMMENT BELOWHeadacheDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVEROCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?DrowsinessDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVEROCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?DizzinessDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVEROCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?NauseaDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVEROCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?VomitingDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVEROCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?Stomache painDid you experience this symptom before your wisdom teeth surgery?YESNOWhen did you first experience this side effect?How often did you experience this side effect?HARDLY EVERYOCCASIONALLYFAIRLY OFTENVERY OFTENHow much influence did this side effect have on your daily functioning?What action did you take in relation to this side effect?Appendix 8Maximum Mouth Opening before Wisdom Teeth RemovalDate: _______________________Time: _______________________The distance between the mesio-incisal edges of the right maxillary and mandibular central incisor teeth during maximal mouth opening:____________________________________Maximum Mouth Opening 2-days following Wisdom Teeth RemovalDate: _______________________Time: _______________________The distance between the mesio-incisal edges of the right maxillary and mandibular central incisor teeth during maximal mouth opening:____________________________________Appendix 9POST-OPERATIVE PARTICIPANT QUESTIONNAIREGeneral InformationOral Surgery research projectDepartment of Oral Diagnostic and Surgical Sciences, School of Dentistry, University of OtagoPrincipal Researcher: YJ Jessica Lee (Oral Surgery Doctorate Candidate)Primary Supervisor: Mr Harsha De Silva (Senior Lecturer in Oral & Maxillofacial Surgery)Thank you for taking the time to fill in this questionnaire.You are kindly requested to complete this questionnaire during your review appointment with YJ Jessica Lee two days after surgery.For information about this research project, please read the form entitled: “Information sheet for participants: Pre-operative effects of anti-inflammatory drugs on pain and inflammation following wisdom teeth removal.”All personal information collected will remain strictly confidential.Please answer honestly. There will be no criticism or judgment of you for your answers.Question 1Did you take the pain relief medication prescribed to you?YesNoQuestion 2How long did it take for you to take the first pain relief after your surgery?Question 3Did the pain relief tablets give you sufficient pain relief?YesNoQuestion 4Overall, how would you rate your pain following your surgery?No pain Mild pain Moderate pain Severe pain Excruciating pain & agonyQuestion 5Did you take any additional pain relief medication other than the tablets prescribed to you?YesNo If yes, please mention the name(s), dose, and duration _______________________Question 6Did you need to see your medical GP about your pain or discomfort?YesNoQuestion 7Did you require the socket to be irrigated and dressed by a dentist?YesNoQuestion 8Please circle the answer that BEST applies to you during the last 4 weeks.Because of trouble with your teeth, mouth or dentures:Have you had trouble pronouncing any words?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt that your sense of taste has worsened?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had painful aching in your mouth?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you found it uncomfortable to eat any foods?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been self-conscious?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt tense?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHas your diet been unsatisfactory?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had to interrupt meals?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you found it difficult to relax?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been a bit embarrassed?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been a bit irritable with other people?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you had difficulty doing your usual jobs?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you felt that life in general was less satisfying?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENHave you been totally unable to function?NEVERHARDLY EVEROCCAS-IONALLYFAIRLY OFTENVERY OFTENEnd of questionnaire.Thank you. ................
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