The effect of the severity of pain on the analgesia obtained following single dose of  tramadol/dexketoprofen 75/25mg (TRAM/DKP) versus tramadol/paracetamol 75/650mg (TRAM/PAR) was evaluated in a randomised, double-blind, placebo-controlled trial in 650 patients with moderate to severe pain after impacted third mandibular molar extraction.
Methods 
Total pain relief (TOTPAR6, primary end-point), calculated as the weighted sum of pain relief scores over 6h, was analysed by baseline pain intensity (PI: 0-10 numerical rating scale, NRS) score higher than 4, 5, 6, 7 or 8.
Percentage of responders (patients achieving at least 50% of the theoretical maximum TOTPAR at 2, 4, and 6 hours) overall and their distribution in the two baseline PI categories of severity (moderate: 4 to 6; severe: 7 to 10) was also analysed.
Results
TRAM/DKP maintained higher analgesic efficacy (as per TOTPAR6) across PI levels of severity at baseline; while TRAM/PAR analgesia was reduced with increasing PI at baseline. 
Percentages of responders at 2, 4, and 6 hours were consistently higher in the TRAM/DKP group (71.2%, 71.2%, and 60.4%) than in the TRAM/PAR group (44.3%, 43.1%, and 38.5%). The superiority persisted when responders were categorised by moderate to severe baseline PI.
Conclusions
TRAM/DKP (75/25 mg) is equally effective in patients with baseline pain intensity ranging from moderate to severe. In contrast, the TRAM/PAR analgesia was markedly decreased in patients with more severe baseline pain.

SUPERIORITY OF TRAMADOL/DEXKETOPROFEN ANALGESIA VERSUS TRAMADOL/PARACETAMOL IS MAINTAINED IN PATIENTS WITH SEVERE ACUTE PAIN