Health

Oral Analgesics for Acute Dental Pain

May 29, 2023
addisonparker07

Key Points

 

  • Acute dental pain may cause damage to the soft and hard oral tissues and may be caused by oral conditions or procedures.
  • Oral analgesics can be used in the treatment of severe dental pain. Many medications and combinations can be utilized.
  • Nonsteroidal anti-inflammatory medications (NSAIDs) were proven that they are more successful in decreasing the pain of opioid analgesics than opioids and therefore are suggested as the first line of therapy to manage acute pain.

Introduction

Acute pain refers to pain caused by illness or injury and can be related to muscle spasms or the activation of the nervous system.  While acute pain is often resolved, one pain that lasts for more than three months is thought to be long-lasting. 

The pain in the jaw can arise from pathological conditions, the process of disease, or the treatment. It can be due to diseases that affect the tissues of the teeth, like caries of the enamel, dentin, and cementum, or it could result from soft tissue issues like periodontitis and gingivitis. 

Nonopioid Analgesics

Nonopioid analgesics comprise nonsteroidal anti-inflammatory medications (NSAIDs) along with Acetaminophen. Some examples of NSAIDs include Ibuprofen, naproxen, celecoxib, as well as aspirin. They work through distinct mechanisms, but generally, they block the enzyme cyclooxygenase (COX), an enzyme involved in converting arachidonic acid into prostaglandins. These are the mediators of fever, inflammation, or the sensation of pain. 4, 5 The mechanism by which Acetaminophen can relieve pain needs to be clarified. However, evidence suggests it results from the inhibition of prostaglandin production in the nervous system’s central nerve. 

NSAIDs work peripherally, which means they ease inflammation by reducing the place where it’s taking place. In contrast, Acetaminophen works centrally, stopping the flow of pain signals in the brain’s central nervous system. Because of this different mechanism of action, using both NSAIDs and Acetaminophen together has been proven to be highly efficient in reducing mild to moderate pain as the pain signaling is prevented at both ends of the neurotransmitter route. 

Acetaminophen, as well as other NSAIDs (aspirin, Ibuprofen, and naproxen sodium), are available to patients who purchase them over-the-counter (OTC) in regular dosages (e.g., 200 mg ibuprofen, 325 mg, or 500 mg Acetaminophen) However, higher doses of these drugs are available to patients. In 2020 it was announced that the U.S. Food and Drug Administration approved the use of an OTC fixed-dose drug that consists of Ibuprofen and Acetaminophen. Each two-caplet dose includes 250 mg of Ibuprofen and 500 mg of Acetaminophen. 8 other NSAIDs can only be purchased with prescriptions, including ketoprofen, celecoxib, and diclofenac.

While effective in relieving acute pain, using NSAIDs, particularly in long-term usage, could be associated with adverse reactions. Because prostaglandins play an important role in gastrointestinal (GI) mucosal protection and are also involved in renal perfusion through blocking prostaglandin synthesis, NSAIDs can trigger GI and renal adverse reactions. The most frequent adverse reaction with NSAID usage is GI toxicities that can cause nausea, stomach pain, heartburn, and bleeding. In addition, NSAIDs may increase the chance of serious cardiac events and kidney damage. 4, 9 All prescription NSAIDs should include a warning in the form of a black box that cardiovascular thrombotic events, such as gastrointestinal risk, can occur when taking the drug. 

Acetaminophen use has been associated with liver toxicity and other less severe adverse effects such as headache, agitation, and GI symptoms.4 Prescription acetaminophen must display a black box warning about hepatotoxicity, as taking over 4,000 mg daily has been associated with acute liver failure.4 Patients may be at risk of exceeding this 4,000 mg limit with OTC drugs, as many OTC combination drugs contain Acetaminophen as an active ingredient (i.e., cold and flu medications), and patients may unknowingly take more than one acetaminophen-containing drug at once.10 When NSAIDs are taken with Acetaminophen, there is little indication that adverse effects are any more significant than those experienced with each drug individually.

Opioids are agonists of opioid receptors and alter the brain’s response to pain. They can be full agonists, partial agonists, or they can be mixed agonists/antagonists.11, 12 The precise mechanism of action of opioids is not known, however specific opioid receptors have been identified in the brain and spinal cord that are thought to play a role.4, 5 While NSAIDs exhibit an effectiveness ceiling where additional dosing does not provide other relief, opioids do not have an analgesic shelter.

Common adverse reactions associated with opioids are dizziness, sedation, nausea, vomiting, constipation, pruritus, sweating, and breathing depression. 13, 14 Additionally, prescription opioids come with an enclosed black box that warns of the potential dangers of addiction, misuse, abuse, respiratory depression, accidental consumption (especially in children) as well as neonatal withdrawal syndrome (from long-term usage during pregnancy), and interactions with the cytochrome P450 3A4 inhibitors, as well as the dangers of using them in conjunction of benzodiazepines or different CNS drugs. 

Selecting an Acute Pain Management Strategy

Different medications and combinations of medicine could be considered for the treatment of dental pain that is acute. However, no particular regimen can be sure to provide the highest degree of pain relief for every patient. 15 Additionally, some treatments might be better than others, based on the severity of the postprocedural pain. Hersh et al. 2011, 16 offer a categorization of the expected pain levels following various routine dental treatments (Table 1) and Moore Well. Hersh 2013 7 illustrates the oral analgesic options to treat varying levels of discomfort (Table 2.).

Table 1. 

Examples of Anticipated Postprocedural Pain Levels According to Dental Intervention 16

Anticipated Postprocedural Pain: Mild

— Intervention:

Frenectomy

Gingivectomy

Routine Endodontics

Scaling/root planing

Simple extraction

Subgingival restorative procedures

Anticipated Postprocedural Pain: Moderate

— Intervention:

Implant surgery

Quadrant periodontal flap surgery with bone recontouring

Surgical endodontics

Surgical extraction

Anticipated Postprocedural Pain: Severe

— Intervention:

Complex implant

Partial or complete skeletal impaction surgery

Periodontal surgery

Adapted from Hersh et al. 2011 16

Table 2. Analgesic Use According to Pain Level 7

Anticipated Pain Level: Mild

— Oral Analgesic Options:

Ibuprofen 200-400 mg as needed for pain every 4 to 6 hours

Expected Pain Level: Mild to Moderate

— Oral Analgesic Options:

Ibuprofen 400 to 600 mg fixed intervals every 6 hours for 24 hours

then

Ibuprofen 400 mg as needed for pain every 4 to 6 hours

Anticipated Pain Level: Moderate to Severe

— Oral Analgesic Options:

Ibuprofen 400 to 600 mg plus acetaminophen 500 mg fixed intervals every 6 hours for 24 hours

then

Ibuprofen 400 mg plus acetaminophen 500 mg as needed for pain every 6 hours

Anticipated Pain Level: Severe

— Oral Analgesic Options

Ibuprofen 400 to 600 mg plus acetaminophen 650 mg with hydrocodone 10 mg fixed intervals every 6 hours for 24 to 48 hours

then

Ibuprofen 400 to 600 mg plus acetaminophen 500 mg as needed for pain every 6 hours

Adapted from Moore and Hersh.

Postprocedural pain control can be accomplish by focusing on the cause of the discomfort (inflammation), which is what NSAIDs can achieve. Opioid medicines are, however, incompatible with the sensation of pain and are not able to treat the inflammation. 11 An review of systematic reviews in JADA comprising data on more than 58,000 patients who had third-molar extractions revealed that when comparing the effectiveness of pain-reducing NSAIDs and opioid analgesics using a combination of 400 mg Ibuprofen and 1,000 mg acetaminophen proved to be more efficient than any opioid-containing treatment and also related to a lower chance of adverse reactions. 15Additionally, in 2016 the ADA House of Delegates adopted the following statement “Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.”

ADA Statement on the Use of Opioids in the Treatment of Dental Pain

 Opioids to treat Dental Pain

  1. In the event of prescribing opioids, dentists must conduct a thorough oral and medical history to identify the medications currently being used, any potential interactions with drugs, and the previous record of abuse.
  2. Dentists must follow and regularly examine the Centers for Disease Control and the state licensing board’s guidelines for the safe prescribing of opioids.
  3. Dentists must sign up with and participate in the prescription drug monitoring program (PDMP) to ensure the use of controlled drugs for medically legitimate purposes and to prevent the abuse, misuse, and re-use of these drugs.
  4. Dentists need to talk with patients about their responsibilities in preventing abuse, misuse, and the disposal and storage of opioids prescribed by a doctor.
  5. Dentists must consider treatments that employ the best methods to avoid exacerbation or relapse of the use of opioids.
  6. Dentists should consider nonsteroidal anti-inflammatory medications as the first-line treatment option for acute pain.
  7. Dentists need to consider multimodal pain strategies in treating severe postoperative pain. It is an effective way to avoid the necessity to use opioid painkillers.
  8. Dentists should think about the coordination of other treating physicians, such as pain specialists, when prescribing opioids to treat chronic pain.
  9. Dentists who work with integrity and use professional judgment when prescribing opioids for relief from pain shouldn’t be held accountable for the deliberate and fraudulent behavior of patients who manage to procure opioids for non-dental reasons.
  10. Residents, dental students, and dentists in practice are encouraged to continue education on addiction and pain management about the prescription of opioids.

American Dental Association

” Resolved that the ADA is in favor of the requirement for ongoing education (CE) when prescribing opioids and various other controll substances, with a particular focus on preventing overdoses from drugs as well as chemical dependency and diversion. Any compulsory CE requirements must:

  1. Allow continuing education credits that can be used to satisfy both DEA registration and the state dental board’s requirements.
  2. Create a curriculum that is designed to meet the needs of dentists as well as dental practice.
  3. Add a phase-in process to give affect dentists sufficient time to achieve compliance and further.

The resolution that the ADA is in favor of statutory limits on opioid dose and duration that are not more than seven days for the management of pain that is acute in line with Centers for Disease Control and Prevention (CDC) guidelines based on evidence and be it add

The resolution that the ADA is committe to improving the integrity, quality, and interoperability of state-wide medical monitoring of prescription medication.