Dental Pain Management-What, When, and How?

Effective management of dental pain has been a challenge for dentists. Dental pain can vary from mild to severe in intensity, and at times can imitate acute neuropathic pain. (1) Pain management in dentistry has undergone a drastic change with the introduction of painkillers.

Research has highlighted that adequate and prompt pain control can dictate the success of dental treatment (2). A combination of acetaminophen and non-steroidal anti-inflammatory (NSAID) drugs has been the first choice among available painkillers amidst the dental fraternity. (3) Extrapolating data from studies (4,5), it can be said that paracetamol –ibuprofen therapy remains the most prescribed analgesic among dentists.

Mechanism of action of painkiller

 Despite its widespread use, the mode of action of paracetamol is yet to be fully determined, although a centrally mediated analgesic action is thought likely. (6) Paracetamol has minimal anti-inflammatory activity, implying a different mode of action from that of NSAIDs.(6)

NSAIDs, such as ibuprofen, have analgesic, antipyretic and anti-inflammatory actions. They inhibit the synthesis of prostaglandins by non-selectively inhibiting cyclo-oxygenase (COX), present as COX-1 and COX-2. (7)

The combination of two analgesics with different modes of action results in an additive effect; the efficacy of the combination in acute pain is roughly similar to the sum of the efficacies of individual agents. (2)

Ibuprofen acetaminophen in dentistry-A time tested combination

Research has repeatedly highlighted that different dosed combinations of acetaminophen –ibuprofen has exhibited superior efficacy in alleviating dental pain and associated inflammatory symptoms than either of the drugs used in monotherapy. (2) This drug combination has further gained ground keeping in mind the growing concern for the opioid crisis and the shift of focus on multimodal analgesia. (8)

The diverse mechanism of action of these drugs adds up synergistically and leads to a higher analgesic efficacy that can be achieved only when these 2 drugs are coupled together(2). Owing to unique metabolic pathways, drug-drug interactions between them are further reduced to a bare minimum. Owing to unique metabolic pathways, drug-drug interactions between them are further reduced to a bare minimum. 

Ibuprofen acetaminophen vs other painkillers –supporting studies

Recent studies have revealed that acetaminophen –ibuprofen provides a better pain relief than opioids including codeine, hydro codeine, and oxycodeine while bypassing the numerous adverse effects associated with chronic opioid use. (9)

It has been documented that ibuprofen has a better safety profile among other NSAIDs, with negligible GI symptoms and limited antiplatelet activity, considerably less than that of aspirin and most other NSAIDs.(10)

Research has highlighted that the analgesic and antipyretic efficacy of acetaminophen is equal in potency and efficacy to aspirin. (11)

Ianiro et al. assessed the effect of preoperative acetaminophen or a combination of acetaminophen and Ibuprofen on the success of inferior alveolar nerve block for teeth with irreversible pulpitis (12), and reported 46.2%, 71.4%, and 76.9% success rates for placebo, acetaminophen, and a combination of acetaminophen with ibuprofen, respectively.

Numerous studies conducted in patients with postoperative dental pain after third molar surgery have confirmed the superior analgesic effects of ibuprofen in these patients. (10)

Combinations of paracetamol and codeine have been reported to have more side effects than paracetamol- ibuprofen. (10)

Investigating the analgesic efficacy of diclofenac sodium versus ibuprofen following surgical extraction of impacted lower third molars, researchers have highlighted that patients kept on diclofenac sodium reported an increased need for supplementary medication in the first two postoperative days (13)

Zamiril and Mousavizadeh (14) compared the analgesic efficacy of ibuprofen, celecoxib, and tramadol in patients after extraction of mandibular third molar teeth. They observed that the maximum severity of pain four hours after tooth extraction in the tramadol group was 7, which was much greater than the severity recorded in the ibuprofen (4.25).

Ample evidence (15) now backs up the oral administration of ibuprofen alone or in combination with paracetamol for postoperative analgesia in children who are having teeth extracted under general anesthetic. Ibuprofen and ibuprofen/paracetamol combination was more effective than normal- or high-dose paracetamol alone, at reducing children's pain and distress following extraction of teeth.

How safe is the combination?

Paracetamol is a safe analgesic taken up to the recommended doses and is the first analgesic that dentists should recommend. It has been advised as the best choice in patients with liver and kidney disease when used with optimum dose adjustments. (16)

According to Lugardon et al., the reported risk of GI events was low among patients treated with ibuprofen, compared with diclofenac, naproxen, ketoprofen, celecoxib, piroxicam (17).

Research has shown that during NSAID treatment, significant GI adverse effects were more common with aspirin (7.1%) than ibuprofen (4%) (18). Lower rates of occurrence of GI complications in patients treated with ibuprofen could be attributed to its short half-life (about 2 hours). Thus, there is a good pharmacokinetic rationale to account for the low rate of GI adverse drug reactions with ibuprofen.

Italian data (19) documented that the percentage of patients with liver toxicity during NSAID treatment is very low during treatment with ibuprofen (1.4) versus other NSAIDs (diclofenac 2.8; ketorolac: 4.6; nimesulide 13.8).

Considering the low risk to develop serious systemic complications, ibuprofen represents a good choice in the relief of dental pain and postoperative dental pain in children and adults.

Key pointers:

Alleviating pain is of the utmost importance when treating dental patients, as it is prevalent and has far-reaching implications, for both the patient and the clinician.

Acetaminophen-ibuprofen dual therapy is better than monotherapy in terms of analgesic and anti-inflammatory for dental pain.

Ibuprofen has one of the best safety profiles of the nonselective NSAIDs, particularly at OTC doses.

It has already been affirmed that this dual therapy is very well tolerated and exhibits a good safety profile at both, single and multiple doses.

Acknowledging such superior efficacy, dentists agree on advocating this combination for various degrees of dental pain.

Conclusion

Dental pain is a complex process resulting from a combination of biological, biochemical, environmental, and psychogenic factors. Many factors can influence clinicians' decisions to prescribe analgesics to help combat their patients' postoperative pain. Acetaminophen –Ibuprofen is among the most widely used therapeutics, primarily for the treatment of pain and inflammation owing to their scientifically-backed potency in the management of pain, fever, redness, and edema, arising as a consequence of inflammatory mediator release. This therapy has cemented a firm position among the dental fraternity and continues to be the first choice among them.

References

1. Renton T. (2011). Dental (Odontogenic) Pain. Reviews in pain, 5(1), 2–7. https://doi.org/10.1177/204946371100500102

2. Becker D. E. (2010). Pain management: Part 1: Managing acute and postoperative dental pain. Anesthesia progress, 57(2), 67–80. https://doi.org/10.2344/0003-3006-57.2.67

3. Ghlichloo I, Gerriets V. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) [Updated 2021 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547742/

4. Bailey, Edmund (1996). Cochrane Database of Systematic Reviews (Reviews) || Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. , (), –. doi:10.1002/14651858.CD004624.pub2

5. Ong, Cliff K. S.; Seymour, Robin A.; Lirk, Phillip; Merry, Alan F.(2010). Combining Paracetamol (Acetaminophen) with Nonsteroidal Antiinflammatory Drugs: A Qualitative Systematic Review of Analgesic Efficacy for Acute Postoperative Pain. Anesthesia & Analgesia, (), 1–. doi:10.1213/ane.0b013e3181cf9281

6. Graham, Garry G.; Scott, Kieran F. (2005). Mechanism of Action of Paracetamol. American Journal of Therapeutics, 12(1), 46–55. doi:10.1097/00045391-200501000-00008

7. Mazaleuskaya, L. L., Theken, K. N., Gong, L., Thorn, C. F., FitzGerald, G. A., Altman, R. B., & Klein, T. E. (2015). PharmGKB summary: ibuprofen pathways. Pharmacogenetics and genomics, 25(2), 96–106. https://doi.org/10.1097/FPC.0000000000000113

8. Gray BM, Vandergrift JL, Weng W, Lipner RS, Barnett ML. Clinical Knowledge and Trends in Physicians' Prescribing of Opioids for New Onset Back Pain, 2009-2017. JAMA Netw Open. 2021;4(7):e2115328. doi:10.1001/jamanetworkopen.2021.15328

9. Aitken, P., Stanescu, I., Playne, R., Zhang, J., Frampton, C., & Atkinson, H. C. (2019). An integrated safety analysis of combined acetaminophen and ibuprofen (Maxigesic ® /Combogesic®) in adults. Journal of pain research, 12, 621–634. https://doi.org/10.2147/JPR.S189605

10. Pozzi, A., &Gallelli, L. (2011). Pain management for dentists: the role of ibuprofen. Annali di stomatologia, 2(3-4 Suppl), 3–24.

11. Plaisance KI, Mackowiak PA. Antipyretic Therapy: Physiologic Rationale, Diagnostic Implications, and Clinical Consequences. Arch Intern Med. 2000;160(4):449–456. doi:10.1001/archinte.160.4.449

12. Staci R. Ianiro; Billie G. Jeansonne; Sandre F. McNeal; Paul D. Eleazer (2007). The Effect of Preoperative Acetaminophen or a Combination of Acetaminophen and Ibuprofen on the Success of Inferior Alveolar Nerve Block for Teeth with Irreversible Pulpitis. , 33(1), 0–14. doi:10.1016/j.joen.2006.09.005

13. Esteller-Martínez V, Paredes-García J, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Analgesic efficacy of diclofenac sodium versus ibuprofen following surgical extraction of impacted lower third molars. Med Oral Patol Oral Cir Bucal. 2004;9:448–453. 444–448

14. Zamiril B, Mousavizadeh K, Tajoddini M, Mohammadinezhad C, Aarabi AM. Comparison of Ibuprofen, Celecoxib and Tramadol in Relief of Pain after Extraction of Mandibular Third Molar Teeth. IR-CMJ. 2009;11(4):431–436.

15. Gazal G, Mackie IC. A comparison of paracetamol, ibuprofen or their combination for pain relief following extractions in children under general anaesthesia: a randomized controlled trial. Int J Paediatr Dent. 2007;17:169–177.

16. Imani, F., Motavaf, M., Safari, S., & Alavian, S. M. (2014). The therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. Hepatitis monthly, 14(10), e23539. https://doi.org/10.5812/hepatmon.23539

17. Lugardon S, Lapeyre-Mestre M, Montastruc JL. Upper gastrointestinal adverse drug reactions and cyclooxygenase-2 inhibitors (celecoxib and rofecoxib): a case/non-case study from the French Pharmacovigilance Database. Eur J Clin Pharmacol. 2004;60:673–677.

18. Lugardon S, Lapeyre-Mestre M, Montastruc JL. Upper gastrointestinal adverse drug reactions and cyclooxygenase-2 inhibitors (celecoxib and rofecoxib): a case/non-case study from the French Pharmacovigilance Database. Eur J Clin Pharmacol. 2004;60:673–677.

19. Nimesulide ed epatotosicità BIF. 2007;XIV:112–116.