What pain medications are recommended for dental pain?

Dental Pain Management

For acute dental pain, start with ibuprofen 400-600 mg every 6 hours or naproxen 500 mg twice daily as first-line therapy, adding acetaminophen/paracetamol 1000 mg if needed for breakthrough pain, and reserve opioids only for severe pain unresponsive to NSAIDs. 1, 2

First-Line Treatment: NSAIDs

NSAIDs are superior to opioid-acetaminophen combinations for moderate to severe dental pain and should be your primary choice. 3, 4

• Ibuprofen 400-600 mg every 6 hours is the gold standard, demonstrating superior efficacy compared to aspirin 650 mg, acetaminophen 600 mg, and even aspirin/acetaminophen combined with codeine 60 mg 4
• Naproxen 500 mg twice daily is an effective alternative with longer duration of action 5
• NSAIDs work by inhibiting cyclooxygenase enzymes that produce pain-promoting prostaglandins, directly targeting the inflammatory component of dental pain 3
• Administer on a fixed schedule (every 6 hours for ibuprofen), not "as needed" - pain is easier to prevent than treat once established 2, 3

NSAID Contraindications and Cautions

Check for these contraindications before prescribing NSAIDs:

• Renal impairment - use reduced doses or avoid entirely 2, 5
• Active GI ulcers or bleeding history 5
• Cardiovascular disease - NSAIDs increase risk of heart attack and stroke with longer use 5
• Pregnancy (especially late pregnancy) 5
• Aspirin allergy or asthma with NSAID sensitivity 5
• Concurrent anticoagulant use increases bleeding risk 5

Second-Line: Add Acetaminophen/Paracetamol

If NSAIDs alone are insufficient, add acetaminophen 1000 mg every 6 hours (maximum 4000 mg/day) for additive analgesia. 2, 3

• Acetaminophen 1000 mg provides significant analgesia but lacks anti-inflammatory action 6, 7
• Combining ibuprofen with acetaminophen is more effective than either alone and avoids opioid use 1, 3
• Ibuprofen 400 mg has faster onset and greater peak effect than acetaminophen 1000 mg alone 7
• Maximum acetaminophen dose is 4000 mg/24 hours due to hepatotoxicity risk 1

Third-Line: Opioid Combinations (Severe Pain Only)

Reserve opioids for severe dental pain unresponsive to NSAIDs, using the lowest effective dose for the shortest duration. 1, 2

• Codeine 30-60 mg combined with acetaminophen (e.g., acetaminophen 600-1000 mg + codeine 30-60 mg) for moderate-to-severe pain 1, 3
• Hydrocodone or oxycodone combinations may be necessary for severe pain, but carry significant risk of persistent opioid use 1
• Early opioid prescribing increases risk of prolonged disability and subsequent opioid dependence 1
• Prescribe only 3-7 days maximum to minimize risk of persistent use 1

Critical Opioid Warnings

• New persistent opioid use occurs in opioid-naïve patients after even minor procedures 1
• Opioids have significant side effects including constipation (requiring prophylactic laxatives), nausea, and respiratory depression 1
• Metoclopramide or antidopaminergic drugs should be prescribed for opioid-related nausea/vomiting 1

Practical Algorithm

1. Assess pain severity using numerical rating scale (0-10) 1
2. Mild pain (1-3/10): Ibuprofen 400 mg every 6 hours OR acetaminophen 1000 mg every 6 hours 1
3. Moderate pain (4-6/10): Ibuprofen 600 mg every 6 hours PLUS acetaminophen 1000 mg every 6 hours (staggered timing) 2, 3
4. Severe pain (7-10/10): Ibuprofen 600 mg + acetaminophen 1000 mg combination, with codeine 30-60 mg added only if inadequate response after 24-48 hours 2, 3
5. Screen for NSAID contraindications before prescribing 2, 5

Route of Administration

• Oral route is preferred for convenience, cost-effectiveness, and ease of use 2
• Parenteral routes are unnecessary for dental pain management in outpatient settings 1

Common Pitfalls

• Prescribing opioids first-line when NSAIDs are more effective and safer 1, 3
• "As needed" dosing instead of scheduled dosing - this guarantees breakthrough pain 2, 3
• Underdosing NSAIDs - ibuprofen 400-600 mg is more effective than 200 mg 4
• Ignoring NSAID contraindications - always screen for renal disease, GI ulcers, and cardiovascular disease 2, 5
• Exceeding acetaminophen 4000 mg/day - hepatotoxicity risk 1