What medication is recommended for a patient with tooth pain, considering their medical history and potential interactions with other medications?

Medication for Tooth Pain

For acute dental pain, NSAIDs—specifically ibuprofen 400-800 mg every 6 hours—are the first-line medication and are superior to opioid-containing combinations for pain relief. 1

First-Line Treatment: NSAIDs (Specifically Ibuprofen)

• Ibuprofen 400-800 mg every 6 hours (maximum 2400 mg/day) provides superior analgesia compared to opioid-containing combinations for moderate to severe dental pain 1
• NSAIDs are more effective than opioids for surgical dental pain, including wisdom tooth extractions, and cause significantly fewer adverse events 2, 1
• Naproxen sodium 275-550 mg every 8-12 hours (maximum 1500 mg/day) is an alternative NSAID with longer duration of action 1
• The oral route of administration should be advocated as the first choice for analgesics 2

Second-Line Treatment: Acetaminophen (Paracetamol)

• Acetaminophen 650-1000 mg every 6 hours (maximum 4000 mg/day) provides effective analgesia but lacks anti-inflammatory effects 1
• Paracetamol is effective for treating mild pain 2
• High quality evidence demonstrates that ibuprofen 400 mg is superior to paracetamol 1000 mg for dental pain relief 3

Combination Therapy for Severe Pain

• For severe dental pain, combining ibuprofen with paracetamol provides superior analgesia to either drug alone 4, 3
• The fixed-dose combination of ibuprofen 400 mg/paracetamol 1000 mg showed a risk ratio of 1.77 for achieving at least 50% pain relief compared to paracetamol alone 3
• If combination therapy is insufficient, consider adding weak opioids such as codeine or tramadol to non-opioid analgesics for moderate pain 2

Critical Opioid Prescribing Principles

• Opioids are NOT more effective than NSAIDs for dental pain and cause significantly more adverse events including nausea, dizziness, and sedation 2, 1
• For acute surgical dental pain, opioids were associated with small to moderate increases in pain or need for rescue medication compared to NSAIDs 2
• Early opioid prescribing increases risk of prolonged opioid use and dependency 1
• If opioids are necessary for severe pain, limit prescriptions to the shortest reasonable duration (typically 3-5 days maximum) 1
• Hydrocodone/acetaminophen combinations showed inferior pain relief compared to ibuprofen-containing combinations in dental pain models 5

Contraindications and Safety Screening

Before prescribing NSAIDs, screen for the following contraindications:

• Gastrointestinal ulcers or bleeding history—NSAIDs increase risk for serious upper gastrointestinal events, particularly in the first 6 months of treatment 2
• Cardiovascular disease, hypertension, or heart failure—do not take NSAIDs right before or after heart surgery or after a recent heart attack 6
• Renal insufficiency or chronic kidney disease (estimated glomerular filtration rate <30 ml/min)—all NSAIDs should be used with caution and at reduced doses 2, 1
• Pregnancy, especially third trimester—NSAIDs should not be taken after about 30 weeks of pregnancy and may harm the unborn baby after 20 weeks 6
• History of asthma attack, hives, or allergic reaction with aspirin or other NSAIDs 6
• Concurrent use of corticosteroids, anticoagulants, SSRIs, or SNRIs increases bleeding risk 6

Practical Prescribing Algorithm

Step 1: Assess pain severity and screen for NSAID contraindications 1

Step 2: For mild to moderate pain without contraindications:

• Prescribe ibuprofen 400-600 mg every 6 hours 1
• Alternative: naproxen sodium 275-550 mg every 8-12 hours 1

Step 3: For moderate to severe pain without contraindications:

• Prescribe ibuprofen 600-800 mg every 6 hours 1
• Consider adding acetaminophen 650-1000 mg every 6 hours for combination therapy 4, 3

Step 4: If NSAIDs are contraindicated:

• Use acetaminophen 650-1000 mg every 6 hours as monotherapy 1

Step 5: For severe pain unresponsive to NSAIDs/acetaminophen combination:

• Consider adding weak opioids (codeine, tramadol) to the non-opioid regimen 2
• Limit opioid duration to 3-5 days maximum 1

Common Pitfalls to Avoid

• Do not prescribe opioids as first-line therapy for routine dental pain—they are less effective than NSAIDs and carry significant risks 2, 1
• Do not exceed maximum daily doses: ibuprofen 2400 mg/day, acetaminophen 4000 mg/day 1, 6
• Do not use NSAIDs in older adults with cardiovascular or gastrointestinal comorbidities without carefully weighing risks and benefits 1
• Do not prescribe analgesics on an "as required" schedule for ongoing pain—regular dosing is more effective 2
• Ensure patients understand to take NSAIDs with food to reduce gastrointestinal side effects 6