In response to Letter to the Editor “Danger of highlighting the use of coxibs in daily dental practice”

We appreciate the Letter to the Editor by Gu¨lses et al. in response to our article entitled ‘‘Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain, swelling, and mouth opening after surgical removal of impacted third molars: a randomized, controlled clinical trial’’1. We also thank these authors for their recognition of the results of our randomized controlled clinical trial. The comments raised by these authors regarding the adverse effects of COX-2 inhibition on the cardiovascular system, including the increased risks of myocardial infarction and disturbance of blood pressure, are well taken. However, some elaboration is in order. The surgical removal of third molars is one of the most common surgical interventions in daily dental practice. Previous studies have demonstrated that celecoxib used at a dose ranging between 120 mg and 200 mg is efficient in the reduction of early stage acute pain and perioperative symptoms following third molar surgery2,3. During the last few decades, COX-2 selective inhibitors were introduced to provide the anti-inflammatory effects of non-steroidal anti-inflammatory drugs (NSAIDs) with less gastrointestinal toxicity. However, the first studies on COX-2 inhibitors, used for a wide range of conditions such as osteoarthritis and rheumatoid arthritis, found an increased risk of cardiovascular disease (CVD) development following the administra- tion of these drugs4,5. Conversely, a larger recent study that evaluated the safety of celecoxib, naproxen, and ibuprofen demonstrated that the use of naproxen or ibuprofen was associated with a greater risk of major adverse cardiovascular events compared to the use of celecoxib6. Moreover, it was also shown that the use of ibuprofen or naproxen was associated with a greater risk of developing adverse gastrointestinal and renal events compared to celecoxib6. Similarly, Solomon et al.7, in another large cohort study analysing the risk of toxicity of the major NSAIDs and celecoxib, found that patients who were treated with NSAIDs such as naproxen or ibuprofen had a significantly higher risk of CVD events and systemic toxicity than those who were treated with celecoxib. Previous studies that evaluated the administration of celecoxib following third molar surgery did not report any significant adverse effects8,9. These studies reported only minor symptoms such as nosebleed, drowsiness, malaise, headache, dizziness (excluding vertigo), and nausea in a few cases9, which did not require any specific treatment2,3,8,9. Based on this evidence, it is generally considered that there are still no significant data allowing definitive conclusions to be drawn on the ‘possible’ augmented risk of CVD events following the administration of celecoxib when compared to other NSAIDs, especially when celecoxib is administered for a short period of time, such as following the surgical removal of impacted third molars. Funding This work was performed with funding from the Department of General Surgery and Surgical-Medical Specialties, University of Catania, Catania, Italy. Competing interests The authors declare that they have no conflict of interest or other benefits from commercial sources for the work reported in the manuscript.