First-Line Pain Management for Toothache
Ibuprofen 400 mg is the recommended first-line treatment for toothache pain, with the combination of ibuprofen 400 mg plus acetaminophen 1000 mg providing superior pain relief when monotherapy is insufficient. 1, 2
Primary Recommendation: NSAIDs Over Acetaminophen
Ibuprofen 400 mg provides superior pain relief compared to acetaminophen 1000 mg for dental pain, with high-quality evidence showing a risk ratio of 1.47 (95% CI 1.28-1.69) for achieving at least 50% pain relief at 6 hours. 1
Ibuprofen 400 mg consistently outperforms acetaminophen 600-1000 mg in dental pain models, demonstrating faster onset, greater peak effect, and longer duration of analgesia. 3, 4
Naproxen 400-440 mg is an equally effective alternative to ibuprofen 400 mg for dental pain relief. 2
When to Use Combination Therapy
The combination of ibuprofen 400 mg plus acetaminophen 1000 mg provides the highest level of pain relief (mean difference 1.68 compared to placebo) and is significantly more effective than either agent alone. 5, 2
This combination reduces rescue medication requirements by 50% compared to placebo and 28% compared to ibuprofen 400 mg alone. 5
The lower-dose combination of ibuprofen 200 mg plus acetaminophen 500 mg is also significantly more effective than either monotherapy and may be appropriate for moderate pain. 5
Dosing Algorithm
For moderate dental pain:
For moderate-to-severe dental pain:
- Use ibuprofen 400 mg plus acetaminophen 1000 mg every 6 hours (ensuring total acetaminophen does not exceed 4000 mg/24 hours). 6, 5, 2
Topical Adjunct
- Benzocaine topical gel can be used as an adjunct for temporary relief of toothache pain while awaiting definitive dental treatment. 7
Important Caveats
Avoid opioids as first-line therapy: Oxycodone 5 mg, codeine 60 mg, and tramadol combinations were no more effective than placebo for dental pain in high-quality trials. 2
The exception is acetaminophen 650 mg plus oxycodone 10 mg, which showed moderate efficacy but should be reserved for severe pain unresponsive to NSAIDs due to opioid-related risks. 2
Screen for contraindications to NSAIDs including active peptic ulcer disease, severe renal impairment, heart failure, and concurrent anticoagulation. 6
In patients with NSAID contraindications, acetaminophen 1000 mg every 6 hours (maximum 4000 mg/24 hours) is the safest alternative, though less effective. 6
Multimodal analgesia incorporating both NSAIDs and acetaminophen reduces individual drug-related side effects while improving overall pain control. 6