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Tips Selecting Analgesics for Acute Dental Pain Treatment

Selecting oral analgesics for acute dental pain treatment requires considering the potential benefits and risks for each patient. Dental pain is a warning sign that is activated due to damage to dental tissue during the pathological process. The dental pain treatment approach focuses not only on pain relief but also on suppressing the causative factors of pain by achieving satisfactory analgesia levels at the lowest possible dose.

Tips Selecting Analgesics for Acute Dental Pain Treatment


Oral analgesics for acute dental pain management can be classified into opioids and nonopioids. Nonopioid analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol. NSAIDs can be further divided into selective cyclooxygenase (COX) -1 and selective COX-2. 

A. Opioid

In dental practice, opioid analgesics are preferred for moderate to severe pain. The most commonly prescribed opioid analgesics are hydrocodone, codeine, oxycodone, and tramadol. Opioids can cause a variety of side effects, including nausea, vomiting, constipation, urinary retention, respiratory depression, decreased consciousness, sleep disturbances, dependence, and addiction.

Although historically, the potency and efficacy of nonopioid analgesics are considered to be lower than opioids, various scientific evidence suggests that nonopioid analgesics are more effective in reducing postoperative tooth pain. However, if nonopioid analgesics fail to relieve pain, opioid administration may be considered

In dental practice, opioid analgesic drugs are more often prescribed in combination with paracetamol or NSAIDs than opioids alone. The standard doses of opioids in dentistry are:
  • Codeine 30-60 mg
  • Hydrocodone 5-10 mg
  • 5-10mg oxycodone
  • Meanwhile, tramadol is considered to have lower side effects than other opioid analgesics. Tramadol is often used to relieve acute oral surgery pain at a dose of 50 mg.

B. NON-OPIOID

1. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs work is reducing prostaglandin production by inhibiting the cyclooxygenase (COX) enzyme. NSAIDs inhibit COX-1 and COX-2 to different degrees. Medicines of this class have therapeutic properties in the form of anti-inflammatory, analgesic, and antipyretic properties. Here are Several NSAIDs are available on the market: aspirin, ibuprofen, naproxen, ketoprofen, indomethacin, and diclofenac ketorolac, and piroxicam)

Although safe when used for a short time, NSAIDs can cause heartburn, nausea, vomiting, diarrhea, and serious side effects such as peptic ulcer and gastric perforation. These side effects occur because  NSAIDs inhibit the production of prostaglandins in the gastric mucosa, causing a decrease in mucus and bicarbonate secretion and an increase in gastric acid secretion.

In patients at high risk of gastrointestinal disease, NSAIDs may be prescribed in combination with gastric mucosal protective agents or gastric acid secretion inhibitors, such as proton pump inhibitors (PPIs). However, it should be noted that recent studies have shown the use of PPIs can potentiate bleeding and enteropathy. Changes in the gut microbiota and the risk of cancer from PPIs prevent this drug from being used in the long term.

Avoid administering NSAIDs in patients at risk for kidney problems, older people, cardiovascular disease, and hypertension.

a. Ibuprofen
There is a lot of scientific evidence reporting that short-term use of ibuprofen is very effective in treating mild to moderate pain and is one of the analgesics most often prescribed by dentists. For mild dental pain, the recommended dose of ibuprofen is 200-400 mg every 4-6 hours. Within this dosage range, ibuprofen's potential for gastrointestinal, hepatic, or cardiovascular side effects is reported to be lower than for other NSAIDs.

If the dose does not provide sufficient analgesic effect, the dose can be increased to 400-600 mg.

b. Naproxen
Naproxen has a longer duration and a more potent anti-inflammatory effect than ibuprofen. However, naproxen has a higher risk of side effects and gastrointestinal toxicity. Therefore, naproxen can be an alternative medicine in cases where the pain cannot be relieved by adequate doses of ibuprofen.

Naproxen can be given in doses of 375-500 mg twice daily in a short time with maximum dose is 1500 mg per day.

3. COX-2 Selective Inhibitors
COX-2 selective inhibitor drugs are developed to avoid gastrointestinal and bleeding caused by COX-1 inhibitors. Some examples of selective COX-2 inhibitor drugs are celecoxib, etoricoxib, and polmacoxib.

Although the side effects incidence is low, this class of drugs can increase the risk of thrombosis and cause cardiovascular side effects, such as ischemic heart disease, heart failure, hypertension, and stroke. Therefore, the administration must be careful, especially in patients at high risk of cardiovascular disease.

2. Paracetamol

Paracetamol has minimal anti-inflammatory activity. The inhibitory effect on peripheral COX activity is low, and has a low risk of inducing gastrointestinal and cardiovascular side effects, and does not prolong bleeding time. Paracetamol is also safe for use in pregnant women.

In acute dental pain, paracetamol can be as alternative medicine in individuals who cannot tolerate NSAIDs. However, please note that paracetamol used in excessive doses can cause intoxication and severe liver damage. Paracetamol should not be taken more than 4 grams per day. Paracetamol is also not recommended in patients with alcohol use disorder and severe liver disease.

In acute dental pain, paracetamol can also be used for mild pain and can be combined with NSAIDs or opioid analgesics to increase efficacy. 



Factors to Consider for Choosing Oral Analgesics in Acute Dental Pain

In choosing oral analgesics for acute dental pain, clinicians need to consider the patient's age, the dental procedures performed, and the patient's systemic medical history.

1. Patient Age

In general, paracetamol and NSAIDs are preferred for children, whereas opioids are only given in severe pain cases. In pediatric patients, it is necessary to ensure that the dose given is according to age and body weight.

Meanwhile, for the elderly, it is necessary to limit the dosage of opioid analgesics because they have the potential to decrease metabolism and excretion, which affects the pharmacokinetics and pharmacodynamics of drugs. NSAIDs are not recommended for use in the elderly, while paracetamol can still be given.

2. Dental treatment procedures

Dental procedures can induce pain in patients. Doctors can estimate the degree of pain that will arise, so they can provide appropriate analgesics. For example, frenectomy, gingivectomy, scaling, and routine endodontic procedures generally cause mild pain. Meanwhile, periodontal surgery, complex implants, and partial or full bony impaction surgery generally cause severe pain.

3. Patient's Systemic History

Dentists should consider several systemic conditions when selecting analgesics in patients with dental pain. Hepatic and renal insufficiency can affect the metabolism and elimination of paracetamol and ibuprofen. Therefore, dosage adjustments or switching to other analgesic drugs may be necessary.

When using NSAIDs, the risk of gastrointestinal and cardiovascular side effects also needs to be considered. Patients at increased risk of gastrointestinal irritation or thrombotic events need to be monitored during NSAID use.

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