What is more effective for tooth pain, tramadol or Tylenol 3 (acetaminophen with codeine)?

From the Guidelines

For tooth pain, Tylenol #3 (acetaminophen with codeine) is generally better than tramadol. Tylenol #3 combines the anti-inflammatory and pain-relieving effects of acetaminophen with codeine's opioid pain relief, which works well for dental pain that often involves inflammation. The typical dose is 1-2 tablets every 4-6 hours as needed, not exceeding 4000mg of acetaminophen daily. Tramadol is also effective for pain but may not address the inflammatory component of tooth pain as well.

According to a study published in the Journal of Clinical Oncology 1, tramadol and codeine have limitations that may make them less desirable than other opioids in certain settings. Tramadol is a prodrug, has limitations in dose titration related to a low threshold for neurotoxicity, and has potential interactions with other drugs at the level of cytochrome P450 (CYP) 2D6, 2B6, and 3A4. Codeine is a prodrug, requiring CYP2D6 to allow it to be metabolized to morphine to achieve analgesic effects. However, for tooth pain, the combination of acetaminophen and codeine in Tylenol #3 is still a viable option.

Another study published in Critical Care 1 compared different analgesics, including codeine-acetaminophen combinations, and found that non-specific NSAIDs (e.g., ibuprofen) are recommended over codeine-acetaminophen combinations for mild-moderate acute pain. However, this study did not directly compare tramadol and Tylenol #3.

Key points to consider when choosing between tramadol and Tylenol #3 for tooth pain include:

• The presence of inflammation, which may be better addressed by the acetaminophen component in Tylenol #3
• The potential for side effects, including nausea, constipation, and drowsiness, which are common to both medications
• The risk of dependence, which should be mitigated by using the shortest duration necessary
• The importance of combining medication with dental treatment and non-medication approaches for optimal pain management.

In terms of specific recommendations, Tylenol #3 is preferred over tramadol for tooth pain due to its combined anti-inflammatory and pain-relieving effects. However, it is essential to use these medications judiciously and under the guidance of a healthcare professional, especially considering the potential risks and limitations associated with their use 1.

From the FDA Drug Label

Tramadol hydrochloride has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol hydrochloride Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250 mg of tramadol hydrochloride in divided doses were generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg (TYLENOL with Codeine #3) daily, A dose of 100 mg tramadol hydrochloride tended to provide analgesia superior to codeine sulfate 60 mg, but it was not as effective as the combination of aspirin 650 mg with codeine phosphate 60 mg.

The two medications are generally comparable in terms of effectiveness for tooth pain, as tramadol and Tylenol 3 (acetaminophen with codeine) have been shown to have similar analgesic effects in clinical studies 2. However, the combination of aspirin with codeine may be more effective than tramadol.

• Tramadol may be more effective than codeine alone.
• Tylenol 3 (acetaminophen with codeine) is comparable to tramadol.

From the Research

Comparison of Tramadol and Tylenol 3 for Tooth Pain

• Tramadol and Tylenol 3 (acetaminophen with codeine) are two commonly used medications for managing tooth pain.
• According to a study published in 1999 3, tramadol's maximum analgesic efficacy for relieving acute pain after oral surgery appears to be similar to that of 60 milligrams of codeine alone but less than that of a full therapeutic dose of a nonsteroidal anti-inflammatory drug or a codeine combination, such as aspirin/codeine or acetaminophen/codeine.
• The same study 3 suggests that tramadol has limited indication for management of acute pain in dentistry, possibly as an alternative analgesic when gastrointestinal side effects contraindicate the use of nonsteroidal anti-inflammatory drugs and when codeine/acetaminophen combination analgesics are not well-tolerated or are contraindicated.
• A study published in 2021 4 recommends following a step-by-step plan based on the WHO analgesic ladder, which includes starting with acetaminophen, adding an NSAID, and then adding a weak opioid such as tramadol in combination with acetaminophen or an NSAID.
• Another study published in 2005 5 notes that the most commonly-used opioid is codeine, usually in combination with paracetamol, and that opioids are powerful analgesics but have significant side effects and therefore should be reserved for severe pain only.
• A more recent study published in 2023 6 suggests that a combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens, but notes that there are clinical scenarios where a short-course opioid prescription is appropriate in select patients.

Efficacy and Safety Considerations

• The efficacy and safety of tramadol and Tylenol 3 (acetaminophen with codeine) for tooth pain management should be considered in the context of individual patient needs and medical history.
• A study published in 2022 7 discusses the importance of being cognizant of significant safety concerns associated with acetaminophen, including acetaminophen toxicity, and strategies to help address potential safety issues.
• The 1999 study 3 also notes that adverse events reported by patients receiving tramadol therapy suggest a risk of seizures, drug abuse, and anaphylactoid reactions.