Best Pain Reliever for Toothache
For acute toothache pain, ibuprofen 400 mg is the most effective first-line analgesic, superior to acetaminophen alone, and the combination of ibuprofen 400 mg plus acetaminophen 1000 mg provides even better pain relief when ibuprofen alone is insufficient. 1, 2
First-Line Treatment: Ibuprofen
Ibuprofen 400 mg is superior to acetaminophen (paracetamol) 1000 mg for dental pain, with a risk ratio of 1.47 for achieving at least 50% pain relief at 6 hours and significantly less need for rescue medication (risk ratio 1.50). 1
Ibuprofen 400 mg consistently outperforms aspirin 650 mg, acetaminophen 600 mg, and even aspirin or acetaminophen combined with codeine 60 mg in dental pain models. 3
The recommended dosing is ibuprofen 400 mg every 4-6 hours as needed, not exceeding 2400 mg daily. 4
Combination Therapy for Moderate to Severe Pain
The combination of ibuprofen 400 mg plus acetaminophen 1000 mg provides superior analgesia to either drug alone, with a risk ratio of 1.77 for achieving at least 50% pain relief and 1.60 for not requiring rescue medication. 1
This combination demonstrated significantly better pain relief (mean difference 1.68 compared to placebo) than any single agent in postoperative dental pain. 2
The fixed-dose combination is significantly more effective than comparable doses of monotherapy and has a better tolerability profile, with lower rates of treatment-related adverse events (5.4% vs 19.2% for placebo). 5
Why NSAIDs Over Opioids
Opioids like codeine 60 mg and tramadol 37.5 mg (with acetaminophen) are no better than placebo for dental pain and should not be used as first-line therapy. 2
NSAIDs have superior numbers needed to treat: ibuprofen and naproxen have NNT of 2.7 compared to 4.4 for codeine-acetaminophen combinations. 4
NSAIDs provide longer time to re-medication and lack the CNS-depressing effects and genetic variability issues (CYP2D6 polymorphism) associated with codeine metabolism. 4
Dosing Algorithm
Step 1: Start with ibuprofen 400 mg every 4-6 hours as needed. 1, 3
Step 2: If inadequate relief after 1-2 doses, add acetaminophen 1000 mg to each ibuprofen dose (can be given simultaneously). 5, 1
Step 3: For severe, refractory pain unresponsive to the combination, consider acetaminophen 650 mg plus oxycodone 10 mg (mean difference 1.19 vs placebo), but limit to shortest duration (1-3 days). 2, 6
Step 4: Schedule analgesics at fixed intervals rather than "as needed" when frequent dosing is required, as pain is easier to prevent than treat. 4
Important Caveats
Gastroprotection is recommended when NSAIDs are used for prolonged periods, particularly in elderly patients who are at higher risk for gastrointestinal, platelet, and nephrotoxic effects. 4
Maximum daily acetaminophen dose should not exceed 4000 mg to avoid hepatotoxicity. 4
Antibiotics do not reduce toothache pain and should not be prescribed for pain management in irreversible pulpitis; there was no significant difference in analgesic consumption between penicillin and placebo groups. 7
Topical benzocaine solutions may temporarily relieve toothache pain but are not FDA-approved for safety/effectiveness and may mask disease progression; patients using these should be reexamined within 48 hours. 4, 8
COX-2 inhibitors like celecoxib are superior to codeine-acetaminophen (NNT 2.5 vs 3.9) but should be reserved for patients with history of gastroduodenal ulcers or GI bleeding. 4