What medications can be used to manage a non-infected toothache in a pregnant patient?

Management of Non-Infected Toothache in Pregnancy

Acetaminophen (paracetamol) is the first-line analgesic for non-infected toothache during pregnancy, used at the lowest effective dose for the shortest duration necessary. 1, 2

First-Line Analgesic: Acetaminophen

Acetaminophen remains the safest and most appropriate analgesic for pregnant women with dental pain when used judiciously. 2, 3

• Acetaminophen is widely considered safe throughout all trimesters of pregnancy and is the active ingredient in over 600 medications used for mild to moderate pain relief 4, 3
• Use the lowest effective dose for the shortest possible time to minimize any theoretical risks while providing adequate pain control 4, 3
• Recent consensus statements from 91 international scientists recommend that pregnant women should forego acetaminophen unless medically indicated, consult with a physician if uncertain, and minimize exposure duration 4
• Despite emerging concerns about potential neurodevelopmental effects with prolonged prenatal exposure, acetaminophen should not be withheld when needed, as there is no safer alternative for pain relief during pregnancy 3

Second-Line Options: NSAIDs (Trimester-Specific)

Ibuprofen and diclofenac can be used carefully during the first and second trimesters but must be avoided after 30 weeks gestation. 5, 6

First and Second Trimester (Before 30 Weeks):

• Ibuprofen can be considered for short-term use (7-10 days) when acetaminophen provides inadequate relief 5
• Early pregnancy exposure to NSAIDs shows no evidence of increased risk of miscarriage or teratogenicity, with the most reassuring data available for ibuprofen 5
• Diclofenac is also an option during this period, though data are less robust than for ibuprofen 5

Third Trimester (After 30 Weeks):

• NSAIDs including ibuprofen must be avoided starting at 30 weeks gestation due to risk of premature closure of the fetal ductus arteriosus 7, 5
• If NSAID treatment is needed between 20-30 weeks and continues beyond 48 hours, monitoring for oligohydramnios may be necessary 7
• COX-2 inhibitors are not recommended at any stage of pregnancy 6

Alternative Analgesic: Metamizole

• Metamizole can be administered carefully during pregnancy for dental pain when other options are insufficient 6
• This medication should be used with caution and only when acetaminophen or appropriate NSAIDs (in early pregnancy) are inadequate 6

Opioids (Reserved for Severe Pain)

• Opioids can be administered carefully during pregnancy for severe dental pain that is unresponsive to non-opioid analgesics 6
• These should be reserved for cases where pain significantly impacts maternal well-being and other analgesics have failed 2

Important Clinical Caveats

Avoid delaying necessary dental treatment during pregnancy due to medication concerns. 2

• The American Dental Association and American College of Obstetricians and Gynecologists affirm that timely oral health care is a critical component of healthy pregnancy 2
• Untreated odontogenic pain affects up to 54.9% of pregnant women and poses risks to both mother and fetus 2
• Limited knowledge about medication safety often results in inappropriate avoidance of treatment, which can lead to worse outcomes 2

Treatment Algorithm

1. Start with acetaminophen at the lowest effective dose for the shortest duration 4, 3
2. If inadequate relief and patient is <30 weeks gestation: Consider short-term ibuprofen (7-10 days maximum) 5
3. If patient is ≥30 weeks gestation and acetaminophen insufficient: Consider metamizole or consult for alternative management 6
4. For severe, refractory pain: Carefully consider short-term opioid therapy 6
5. Throughout pregnancy: Emphasize lowest effective dose and shortest treatment duration for any medication used 4, 3