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Acute Pain | Chronic Pain | General

Paracetamol, NSAID, and combination in postoperative pain

Clinical bottom line

A good review of good studies probably shows that NSAIDs are better than 1000 mg paracetamol in dental pain.


M Hyllested et al. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review. British Journal of Anaesthesia 2002 88: 199-214.

Systematic review

This systematic review searched MEDLINE and the Cochrane library for randomised double blind studies in postoperative pain comparing paracetamol (dose at least 1000 mg) with an NSAID (wide range of doses included). Administration could be pre- or postoperatively, and routes of administration included were intravenous, oral and rectal. Analgesic efficacy was evaluated by significant differences in pain measures or consumption of additional analgesic.


Forty-one studies were found, with a median quality score of 4/5.

This was a qualitative review. The authors suggest that, using a vote-counting method, there was evidence that NSAIDs were more effective than paracetamol in dental surgery, while there was no substantive difference between them in major and orthopaedic surgery.The addition of paracetamol to NSAIDs may confer additional analgesia compared to paracetamol alone.


The authors rightly comment that many of their findings can be no more than tentative because of the small number of studies, and that statistical pooling to increase the power was not possible because they chose a range of different outcomes. There is the issue of dose. The choice of paracetamol dose was 1000 mg or more, but there is also a dose-response for NSAIDs. And there is the intriguing possibility that different analgesics may produce different results in different operations.

The problem is that the mix of dose, route of administration, operation type and limitations of size make none of these other than research questions.