Nonsteroidal anti-inflammatory drug (NSAID) premedication for pain-free inferior alveolar nerve block: a systematic review and meta-analysis.

This systematic review and meta-analysis evaluated whether oral nonsteroidal anti-inflammatory drug (NSAID) premedication increases pain-free inferior alveolar nerve block (IANB) success compared with placebo in adults with mandibular posterior teeth diagnosed with symptomatic irreversible pulpitis (SIP). Randomized controlled trials comparing oral NSAID premedication with placebo before IANB in adults with mandibular posterior teeth and SIP were included. MEDLINE, Embase, Web of Science, and the Cochrane Library were searched from inception to October 20, 2025. This review was registered in PROSPERO (CRD420251171592). Success required absence of patient-reported intraoperative pain at any recorded procedural step after the initial IANB and no supplemental anesthesia. Risk of bias was assessed using RoB 2, certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation, and pooled effects were assessed using random-effects meta-analysis. Eleven trials involving 737 participants were analyzed. Oral NSAID premedication increased pain-free IANB success compared with placebo (292/452 [64.6%] vs 81/285 [28.4%]; risk ratio, 2.06; 95% confidence interval, 1.48-2.86). Heterogeneity was substantial (I2 = 63%), and the prediction interval crossed no effect (0.83-5.10). Sensitivity analyses, excluding high-risk trials and access-only studies, remained significant, with no detected heterogeneity. Diclofenac and ketorolac showed significant and consistent effects, whereas ibuprofen favored benefits but remained imprecise and heterogeneous. Oral NSAID premedication increased pain-free initial IANB success compared with placebo in mandibular posterior teeth with SIP; however, low certainty and between-study variability limit the predictability of this benefit. Oral NSAID premedication may be considered when not contraindicated; however, clinicians should still anticipate supplemental anesthesia because pain-free success after the initial IANB is not predictable.