Oral Analgesics for Acute Dental Pain

Acute pain is pain that is provoked by disease or injury, and is associated with musculoskeletal spasm and nervous system activation.¹ While acute pain often resolves,¹ pain that lasts longer than 3 months is considered to be chronic.²

Acute orofacial pain can result from pathological conditions, underlying disease processes, and/or their treatment. Pain can be attributed to conditions affecting the hard tissues such as caries of the enamel, dentin, and cementum, or it can be due to soft tissue conditions such as gingivitis and periodontitis.³

Nonopioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs), as well as acetaminophen. Examples of NSAIDs include ibuprofen, naproxen, celecoxib, and aspirin. They each work via slightly different mechanisms, but in general inhibit cyclooxygenase (COX), an enzyme involved in the conversion of arachidonic acid to prostaglandins, which are mediators of inflammation, fever, and pain.^{4, 5} The mechanism by which acetaminophen provides pain relief is less clear, but there is some evidence suggesting it involves the inhibition of prostaglandin synthesis in the central nervous system.^{4, 6}

NSAIDs act peripherally, meaning they help with pain by reducing inflammation at the site where it is occurring. Alternatively, acetaminophen acts centrally by blocking the transmission of pain signaling within the central nervous system. Due to these differing mechanisms of action, taking NSAIDs and acetaminophen in combination has been shown to be highly effective in reducing mild to moderate pain, as the pain is being blocked at both ends of the nociceptive pathway.⁷

Acetaminophen and some NSAIDs (aspirin, ibuprofen, and naproxen sodium) are available to patients over-the-counter (OTC) in standard doses (e.g., 200 mg ibuprofen; 325 or 500 mg acetaminophen), but higher doses of these medications can be prescribed to patients. There are also several other NSAIDs only available with a prescription, such as celecoxib, ketoprofen, and diclofenac.⁷

Although effective in relieving acute pain, use of NSAIDs, especially long-term use, can be accompanied by adverse effects. Because prostaglandins have a role in gastrointestinal (GI) mucosal protection and also play an essential role in renal perfusion, by blocking prostaglandin synthesis, NSAIDs can cause GI and renal adverse effects. The most common adverse effect with NSAID use is GI toxicity, which can result in symptoms such as nausea, heartburn, abdominal pain, and bleeding. Additionally, NSAIDs may increase the risk of serious cardiovascular events and nephrotoxicity.^{4, 8} All prescription NSAIDs must display a black box warning that cardiovascular thrombotic events as well as gastrointestinal risks are possible when using the medication.⁴

Acetaminophen use has been associated with liver toxicity as well as other less serious adverse effects such as headache, agitation, and GI symptoms.⁴ Prescription acetaminophen must display a black box warning about hepatotoxicity, as taking over 4,000 mg per day has been associated with acute liver failure.⁴ Patients may be at risk of exceeding this 4,000 mg limit with OTC drugs, as there are many OTC combination drugs that contain acetaminophen as an active ingredient (i.e., cold and flu medications), and patients may unknowingly take more than one acetaminophen-containing drug at once.⁹ When NSAIDs are taken in combination with acetaminophen, there is little indication that adverse effects are any greater than those experienced with each drug individually.⁷

Opioid analgesics can be used to treat moderate to severe acute pain and include drugs such as oxycodone, hydrocodone, and codeine.¹⁰ These drugs are often prescribed as formulations that are combined with acetaminophen or aspirin (e.g., 5 mg hydrocodone/300 mg acetaminophen; 30 mg codeine/325 mg aspirin).⁴

Opioids act as agonists at opioid receptors, and alter the nervous system’s response to painful stimuli. They can be full agonists, partial agonists, or they can be mixed agonist/antagonists.^{10, 11} The precise mechanism of action of opioids is not known, however specific opioid receptors have been identified in the brain and spinal cord that are thought to play a role.^{4, 5} While NSAIDs exhibit an effectiveness ceiling where additional dosing does not provide additional relief, opioids do not have an analgesic ceiling.¹²

Common adverse effects associated with opioids include sedation, dizziness, nausea, vomiting, pruritus, sweating, constipation, and respiratory depression.^{12, 13} Additionally, prescription opioids contain a black box warning stating the risks of addiction, abuse, and misuse, respiratory depression, accidental ingestion (especially by children), neonatal opioid withdrawal syndrome (from prolonged use during pregnancy), interactions with cytochrome P450 3A4 inhibitors, and dangers of concomitant use with benzodiazepines or other CNS depressants.⁴

Various medications and medication combinations can be considered for the management of acute dental pain, and there is no specific regimen that is guaranteed to produce a high level of pain relief in all individuals.¹⁴ Additionally, certain treatments may be more suitable than others depending on the degree of postprocedural pain. Hersh et al. 2011¹⁵ provides categorization of anticipated pain levels following different routine dental interventions (Table 1), and Moore and Hersh 2013⁷ provides an example of oral analgesic options for varying degrees of anticipated pain (Table 2).

Table 1. Examples of Anticipated Postprocedural Pain Levels According to Dental Intervention¹⁵

Intervention	Anticipated Postprocedural Pain
Frenectomy Gingivectomy Routine Endodontics Scaling/root planing Simple extraction Subgingival restorative procedures	Mild
Implant surgery Quadrant periodontal flap surgery with bony recontouring Surgical endodontics Surgical extraction	Moderate
Complex implant Partial or full bony impaction surgery Periodontal surgery	Severe

Adapted from Hersh et al. 2011¹⁵

Table 2. Analgesic Use According to Pain Level⁷

Anticipated Pain Level	Oral Analgesic Options
Mild	Ibuprofen 200-400 mg as needed for pain every 4 to 6 hours
Mild to Moderate	Ibuprofen 400 to 600 mg fixed interval every 6 hours for 24 hours then Ibuprofen 400 mg as needed for pain every 4 to 6 hours
Moderate to Severe	Ibuprofen 400 to 600 mg plus acetaminophen 500 mg fixed interval every 6 hours for 24 hours then Ibuprofen 400 mg plus acetaminophen 500 mg as needed for pain every 6 hours
Severe	Ibuprofen 400 to 600 mg plus acetaminophen 650 mg with hydrocodone 10 mg fixed interval every 6 hours for 24 to 48 hours then Ibuprofen 400 to 600 mg plus acetaminophen 500 mg as needed for pain every 6 hours

Adapted from Moore and Hersh 2013⁷

Controlling postprocedural pain can be achieved by targeting the source of the pain (inflammation), which NSAIDs are able to achieve. Opioid drugs on the other hand interfere with the perception of pain and do not target inflammation.¹⁰ A recent systematic overview in JADA including data on over 58,000 patients following third-molar extractions found that when comparing the pain-reducing efficacy of NSAIDs and opioid analgesics, the combination of 400 mg ibuprofen with 1,000 mg acetaminophen was more effective than any opioid-containing regimen and was also associated with a lower risk of adverse events.¹⁴ Additionally, in 2016, the ADA House of Delegates adopted a statement that reads, “Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.”

In 2016, The ADA House of Delegates adopted the following statement on the Use of Opioids in the Treatment of Dental Pain:

1. When considering prescribing opioids, dentists should conduct a medical and dental history to determine current medications, potential drug interactions and history of substance abuse.
2. Dentists should follow and continually review Centers for Disease Control and state licensing board recommendations for safe opioid prescribing.
3. Dentists should register with and utilize prescription drug monitoring programs (PDMP) to promote the appropriate use of controlled substances for legitimate medical purposes, while deterring the misuse, abuse and diversion of these substances.
4. Dentists should have a discussion with patients regarding their responsibilities for preventing misuse, abuse, storage and disposal of prescription opioids.
5. Dentists should consider treatment options that utilize best practices to prevent exacerbation of or relapse of opioid misuse.
6. Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.
7. Dentists should recognize multimodal pain strategies for management for acute postoperative pain as a means for sparing the need for opioid analgesics.
8. Dentists should consider coordination with other treating doctors, including pain specialists when prescribing opioids for management of chronic orofacial pain.
9. Dentists who are practicing in good faith and who use professional judgment regarding the prescription of opioids for the treatment of pain should not be held responsible for the willful and deceptive behavior of patients who successfully obtain opioids for non-dental purposes.
10. Dental students, residents and practicing dentists are encouraged to seek continuing education in addictive disease and pain management as related to opioid prescribing.

American Dental Association
October 2016
(2005:328; 2012:139; 2016:286)

In 2018, The ADA House of Delegates adopted the following policy on Opioid Prescribing:

“Resolved, that the ADA supports mandatory continuing education (CE) in prescribing opioids and other controlled substances, with an emphasis on preventing drug overdoses, chemical dependency, and diversion. Any such mandatory CE requirements should:

1. Provide for continuing education credit that will be acceptable for both DEA registration and state dental board requirements, 
2. Provide for coursework tailored to the specific needs of dentists and dental practice, 
3. Include a phase-in period to allow affected dentists a reasonable period of time to reach compliance, and be it further

Resolved, that the ADA supports statutory limits on opioid dosage and duration of no more than seven days for the treatment of acute pain, consistent with Centers for Disease Control and Prevention (CDC) evidence-based guidelines, and be it further

Resolved, that the ADA supports improving the quality, integrity, and interoperability of state prescription drug monitoring programs.”

American Dental Association
October 2018
(2018:XXX)

1. Grichnik KP, Ferrante FM. The difference between acute and chronic pain. Mt Sinai J Med 1991;58(3):217-20.
2. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain 2015;156(6):1003-7.
3. Renton T. Dental (Odontogenic) Pain. Rev Pain 2011;5(1):2-7.
4. American Dental Association. ADA Dental Drug Handbook: A Quick Reference. Chicago, IL: American Dental Association; 2019.
5. Becker DE. Pain management: Part 1: Managing acute and postoperative dental pain. Anesth Prog 2010;57(2):67-78; quiz 79-80.
6. Aminoshariae A, Khan A. Acetaminophen: old drug, new issues. J Endod 2015;41(5):588-93.
7. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc 2013;144(8):898-908.
8. Vonkeman HE, van de Laar MA. Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention. Semin Arthritis Rheum 2010;39(4):294-312.
9. Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med 2012;27(12):1587-93.
10. Dionne RA, Gordon SM, Moore PA. Prescribing Opioid Analgesics for Acute Dental Pain: Time to Change Clinical Practices in Response to Evidence and Misperceptions. Compend Contin Educ Dent 2016;37(6):372-78;quiz79.
11. Yaksh TL. Pharmacology and mechanisms of opioid analgesic activity. Acta Anaesthesiol Scand 1997;41(1 Pt 2):94-111.
12. Drugs for pain. Treat Guidel Med Lett 2013;11(128):31-42; quiz 2 p following 42.
13. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician 2008;11(2 Suppl):S105-20.
14. Moore PA, Ziegler KM, Lipman RD, et al. Benefits and Harms Associated with Analgesic Medications Used in the Management of Acute Dental Pain: An overview of systematic reviews. The Journal of the American Dental Association 2018;149(4):256-68.
15. Hersh EV, Kane WT, O'Neil MG, et al. Prescribing recommendations for the treatment of acute pain in dentistry. Compend Contin Educ Dent 2011;32(3):22, 24-30; quiz 31-2.

Professional Resources

• ADA Opioid Crisis Resources
• JADA Video on Dental Pain Management: Opioids, NSAIDs and Other Options
• Search JADA for articles related to acute dental pain management
• Opioid Education for Dentists
• Prescribing Considerations for Patients FAQ

​ADA Catalog​

• ADA Practical Guide to Substance Use Disorders and Safe Prescribing (Item #P035)
• ADA Dental Drug Handbook: A Quick Reference (Item #J059BT)

Patient Resources

For the Patient pages:

• Just What the Doctor Ordered: Relieving Dental Pain (August 2018)
• Relieving Dental Pain (December 2016)
• Keeping Medicine Safely in Your Home (January 2014)

ADA MouthHealthy page on Prescription Drugs

Centers for Disease Control and Prevention: Pain Management “Conversation Starters” for Patients and Their Health Care Providers

• Acute pain
• Chronic pain
• Prescription opioids
• Reducing risk of opioid addiction

FDA Guide to Safe Use of Pain Medicine