What is the recommended management for severe pain after tooth extraction?

Management of Severe Pain After Tooth Extraction

For severe pain after tooth extraction, NSAIDs (specifically ibuprofen 400-600 mg) combined with acetaminophen 650-1000 mg should be first-line therapy, with opioids reserved strictly as rescue medication only when NSAIDs and acetaminophen fail to provide adequate relief. 1, 2

First-Line Multimodal Analgesia

NSAIDs are the cornerstone of post-extraction pain management:

• Ibuprofen 400-600 mg every 6 hours is the most effective single agent for dental extraction pain, with a number needed to treat (NNT) of 2-3, which is superior to opioid analgesics 1, 2, 3
• The combination of ibuprofen 200-400 mg plus acetaminophen 500-1000 mg provides superior pain relief compared to either agent alone or to opioid combinations (except acetaminophen 650 mg plus oxycodone 10 mg) 2
• This combination should be started immediately postoperatively and continued around-the-clock for the first 48-72 hours, as pain peaks at 5-6 hours post-extraction and analgesic consumption is highest during the first 48-72 hours 3

Acetaminophen dosing:

• 650-1000 mg every 6 hours (maximum 4 grams daily) 1, 4
• Can be used alone if NSAIDs are contraindicated, though less effective than NSAIDs 2

When Opioids Are Necessary

Opioids should only be prescribed when NSAIDs and acetaminophen combinations fail:

• Simple dental extraction is specifically listed as a procedure that should NOT receive opioids as first-line therapy due to minimal tissue injury and only mild expected postoperative pain 1
• If severe pain persists despite maximal NSAID/acetaminophen therapy, prescribe a short course of 5-10 tablets of hydrocodone 5 mg/acetaminophen 325 mg to be taken as needed (not scheduled) 1
• The only opioid combination with demonstrated superiority over placebo and comparable efficacy to NSAIDs is acetaminophen 650 mg plus oxycodone 10 mg 2
• Oxycodone 5 mg alone, codeine 60 mg alone, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo for dental pain 2

Critical opioid prescribing principles:

• Prescribe immediate-release formulations only 1
• Instruct patients to take "as needed" rather than on a scheduled basis 1
• Check the prescription drug monitoring program (PDMP) before prescribing 1
• Offer naloxone if risk factors for overdose are present 1
• Approximately 1 in 300 opioid-naive patients exposed to opioids after surgical procedures may develop persistent opioid use 1

Adjunctive Measures

Non-pharmacologic interventions:

• Ice packs applied to the affected area 1
• Local anesthetic (bupivacaine) administered via nerve block at the conclusion of the procedure can provide up to 12 hours of pain-free recovery 3

Preemptive analgesia:

• Administering ibuprofen 30 minutes before the procedure significantly reduces injection pain, extraction pain, and postoperative pain compared to placebo 5
• A single intraoperative dose of dexamethasone 8 mg IV provides analgesic and anti-emetic effects 1

Common Pitfalls and Contraindications

NSAID contraindications to assess:

• Renal insufficiency (creatinine clearance <50 mL/min is a contraindication) 1
• History of atherothrombosis (peripheral artery disease, stroke, myocardial infarction) - avoid COX-2 inhibitors entirely and limit non-selective NSAIDs to ≤7 days 1
• Active gastrointestinal ulceration or bleeding 6
• Concurrent therapeutic anticoagulation (NSAIDs increase bleeding risk 2.5-fold when combined with therapeutic anticoagulation) 1

Avoid these practices:

• Do not prescribe opioids as first-line therapy for routine dental extractions 1
• Do not prescribe large quantities of opioid pills, as leftover medications contribute to diversion and misuse 1
• Do not use intramuscular administration for any analgesic 1

Monitoring and Reassessment

Pain should be assessed using validated scales (numeric rating scale 0-10 or Wong-Baker faces scale in children) at regular intervals 1, 4, 5

Severe pain after tooth extraction is unusual and should prompt evaluation for complications:

• Dry socket (alveolar osteitis)
• Infection
• Retained root fragments
• Nerve injury 1