What is the appropriate outpatient management for a patient with moderate to severe dental pain who cannot see a dentist for three days?

Management of Moderate to Severe Dental Pain

For moderate to severe dental pain when a dentist cannot be seen for 3 days, start with scheduled ibuprofen 400-600 mg every 6 hours combined with acetaminophen 1000 mg every 6 hours (alternating every 3 hours), and add an opioid combination only if this fails to control pain. 1, 2

First-Line Pharmacologic Approach

NSAIDs are superior to acetaminophen-opioid combinations for dental pain and should be the primary analgesic. 1, 3

• Ibuprofen 400-600 mg every 6-8 hours is the optimal first-line choice for moderate to severe dental pain, as it provides superior analgesia compared to standard acetaminophen-opioid combinations for pain of dental origin 1, 3
• The 400 mg dose provides at least 6 hours of pain relief, compared to 4-6 hours for lower doses 4
• Maximum daily dose should not exceed 2400 mg (4 × 600 mg) 5

Add acetaminophen 500-1000 mg every 6 hours if ibuprofen alone is insufficient. 2, 3

• This combination targets separate pain pathways simultaneously 2
• Do not exceed 4000 mg acetaminophen daily 5

Critical Dosing Strategy

Use scheduled fixed-interval dosing, NOT "as needed" (prn) dosing. 1, 6

• Taking analgesics on a prn basis guarantees the patient will experience pain 1
• Fixed-interval dosing prevents pain recurrence and reduces patient anxiety 6
• Pain is easier to prevent than treat, so early treatment at appropriate starting doses is essential 5

Second-Line: Adding Opioids

If NSAIDs cannot be used (contraindications) or are insufficient after 24 hours, add an acetaminophen-opioid combination. 1, 2

• Prescribe hydrocodone 5-10 mg with acetaminophen 325 mg, or oxycodone 5 mg with acetaminophen 325 mg 2, 3
• Take every 4-6 hours as needed for breakthrough pain on top of scheduled ibuprofen 1
• Limit prescription to 3 days or less - more than 7 days is rarely needed for acute dental pain 5
• Do not exceed maximum safe doses of acetaminophen (4000 mg/day) when using combination products 5

Contraindications and Safety Considerations

Screen for NSAID contraindications before prescribing: 5

• Absolute contraindications: Active peptic ulcer disease, chronic kidney disease Stage 4-5, decompensated heart failure 5
• Relative contraindications: Uncontrolled hypertension, history of peptic ulcer, concurrent corticosteroid or SSRI use 5
• If NSAIDs are contraindicated, use acetaminophen 1000 mg every 6 hours plus an opioid combination as primary therapy 1, 2

For patients taking aspirin for cardioprophylaxis, avoid ibuprofen - use naproxen or another NSAID instead 5

Adjunctive Measures

Recommend warm saline mouth rinses 4-6 times daily to reduce bacterial colonization and provide symptomatic relief 7

For severe pain with difficulty eating, consider topical anesthetics: 5

• Viscous lidocaine 2% swish and spit before meals 5
• This can be used in addition to systemic analgesics 5

Red Flags Requiring Urgent Evaluation

Instruct the patient to seek immediate care if: 5

• Fever develops (suggests abscess requiring antibiotics or drainage)
• Facial swelling progresses rapidly (suggests spreading infection)
• Difficulty swallowing or breathing (suggests airway compromise)
• Severe trismus (inability to open mouth)

Common Pitfalls to Avoid

• Do not prescribe codeine - it has poor efficacy and significant side effects compared to other options 3
• Do not prescribe tramadol for acute dental pain - evidence shows poor efficacy 3
• Do not prescribe extended-release or long-acting opioids (e.g., fentanyl patches, extended-release oxycodone) for acute pain 5
• Do not give extra opioids "just in case" - prescribe only what is needed for the expected 3-day duration 5