Pain Management After Wisdom Tooth Removal
For healthy adolescents and young adults after wisdom tooth extraction, prescribe ibuprofen 400 mg combined with acetaminophen 1000 mg as first-line therapy, avoiding routine opioid prescriptions entirely unless NSAIDs are contraindicated or pain remains uncontrolled after 24-48 hours on maximum non-opioid therapy. 1, 2
First-Line Analgesic Regimen
Combination therapy is superior to single agents:
- Ibuprofen 400 mg + acetaminophen 1000 mg every 6 hours provides the most effective pain relief with the best safety profile 3, 1, 2
- This combination delivers 1.68 points better pain relief (0-4 scale) compared to placebo, outperforming most opioid-containing regimens 3
- The combination reduces opioid requirements and should be scheduled around-the-clock for the first 48-72 hours, not just "as needed" 4
Alternative NSAID options if ibuprofen unavailable:
- Naproxen 400-440 mg every 12 hours (mean difference vs placebo: 1.44) 3
- Ketorolac 0.5-1 mg/kg (max 30 mg) every 6 hours for maximum 48 hours 4, 5
When NSAIDs Are Contraindicated
If NSAIDs cannot be used (bleeding disorders, renal impairment, peptic ulcer disease):
- Acetaminophen 1000 mg every 6 hours as monotherapy 1, 2
- Consider adding tramadol 50-100 mg every 6 hours if acetaminophen alone is insufficient 4
- Metamizole 10-15 mg/kg every 8 hours may be used where available as first-line rescue (short-term hospital use only due to agranulocytosis risk) 4
Opioid Use: Reserved for Specific Situations Only
The evidence strongly favors avoiding routine opioid prescriptions:
- Most patients consume only 3 tablets in the first 24 hours and 8 tablets total over 7 days, despite being prescribed 20 tablets (median) 6
- Oxycodone 5 mg, codeine 60 mg, and tramadol 37.5 mg + acetaminophen 325 mg were no better than placebo for pain relief 3
- The American Dental Association explicitly recommends avoiding "just-in-case" opioid prescribing, particularly in adolescents and young adults 1, 2
If opioids are necessary (uncontrolled pain after 24-48 hours on maximum NSAIDs + acetaminophen):
- Acetaminophen 650 mg + oxycodone 10 mg provides superior analgesia (mean difference 1.19 vs placebo) compared to lower-dose opioid combinations 3
- Prescribe no more than 8-10 tablets for breakthrough pain only, based on actual consumption data 6
- Instruct patients to take NSAIDs + acetaminophen first, using opioids only if pain remains severe after 1 hour 1, 2
Adjunctive Strategies to Reduce Opioid Requirements
Intraoperative interventions:
- Long-acting local anesthetic infiltration by the surgeon at the surgical site 4
- Dexamethasone 4-8 mg IV or methylprednisolone 1 mg/kg to reduce postoperative swelling and inflammation 4, 7
- Consider ketamine 0.25-0.5 mg/kg as co-analgesic during surgery 4, 7
Postoperative management:
- Transition to oral administration as soon as possible (typically within 6-12 hours) 4
- Continue scheduled NSAIDs + acetaminophen for 3-5 days, not just PRN 4
Common Pitfalls to Avoid
Critical errors in prescribing:
- Do not prescribe opioids routinely "just in case"—this leads to excess unused tablets and diversion risk 1, 2
- Do not underdose NSAIDs—ibuprofen 200 mg is less effective than 400 mg; use the higher dose 3, 8
- Do not prescribe acetaminophen alone when NSAIDs are not contraindicated—the combination is significantly more effective 3, 8
- Do not use low-dose opioid combinations (hydrocodone 5 mg, codeine 60 mg)—they provide no benefit over placebo 3
Monitoring for complications:
- Nausea/vomiting occurs in approximately 8-12% of patients on opioids in the first 24 hours 6
- Higher opioid consumption correlates with longer surgery duration and postoperative infections 6
- NSAIDs carry comparable adverse event profiles to placebo when used short-term (3-5 days) 3, 8
Evidence Quality and Strength
The recommendations are based on high-certainty evidence from network meta-analyses of 82 randomized controlled trials enrolling over 9,000 participants 3, supported by 2024 American Dental Association clinical practice guidelines using GRADE methodology 1, 2. The superiority of NSAIDs over opioids is demonstrated with a risk ratio of 1.47 (95% CI 1.28-1.69) for achieving 50% pain relief at 6 hours 8.