Pain management in dentistry and important cornerstones of successful treatment

Acetaminophen has been the most widely used drug for fever for ages. Owing to its safety profile and good tolerability, it has been universally accepted as the first-line drug in febrile patients. (3) In cases of fever associated with inflammatory processes, nonsteroidal anti-inflammatory drugs (NSAIDs), in combination with paracetamol, have been documented to be effective (7). Among the NSAIDs, Ibuprofen has been highlighted, over and again, as one of the most used drugs. (4, 5)

This article focuses on the mechanism of action and the important position of paracetamol and ibuprofen in various dental specialties while highlighting evidence-based studies confirming the same.

Mechanism of action 

An extensive retrospective analysis of randomized clinical trials conducted over the last 40 years demonstrated that ibuprofen is effective in moderate to severe postoperative pain for different indications in dentistry. Further, it was concluded that in comparison to other NSAIDs, ibuprofen is way ahead by its efficiency, safety, and good tolerance. (6)

Another survey of dental prescribing practices among oral surgeons after third molar extraction found Ibuprofen as the preferred peripherally acting postoperative analgesia (73.5%). (7)

Results from a review article by Anderson B et al concluded that, when used alone, these drugs are adequate to treat mild pain, but they need to be combined, in varying doses, for treating moderate to severe pain. (8) Comparative studies have found that paracetamol/ibuprofen combinations offer similar pain relief to that of codeine-based analgesics in acute pain, with generally improved tolerability, suggesting that paracetamol/ibuprofen may be offered as an alternative to currently available OTC codeine-containing analgesics. (9,10)

1. Endodontic pain management- In 30–80% of patients with irreversible pulpitis single IANB nerve block anesthesia is ineffective (11). Several studies have shown that the use of ibuprofen 600 mg (one hour before administration of anesthesia) significantly improved the efficacy of IANB in patients with symptomatic irreversible pulpitis [12]. Furthermore, Moderate et al. [13] reported efficient use of ibuprofen 400 mg one hour before endodontic treatment as an effective method for achieving deep anesthesia, pain decrease during and after root canal treatment, and increase of patient's comfort.

2. Specific scope in Pediatric dentistry-Managing pain in children continues to be a challenge for dentists. In a study designed to compare the effectiveness of different oral analgesics (paracetamol alone, ibuprofen alone, and paracetamol and ibuprofen in combination) for relieving pain and distress in children following the extraction of teeth under general anesthesia (GA), researchers concluded that ibuprofen/ paracetamol combination was more effective than normal- or high-dose paracetamol. (14)

3. Managing postoperative pain, edema, and swelling- In a recent breakthrough study comparing the efficacy of nonsteroidal anti-inflammatory medications with opioids about the magnitude of pain relief, the combination of 400 mg of ibuprofen plus 1,000 mg of acetaminophen was found to be superior to any opioid-containing medication or medication combination studied. (15) Further, It has been documented that Ibuprofen at both 1200 mg daily for three days and 2400 mg daily for two days significantly suppressed edema formation 48 hours after oral surgery.(16, 17)

4. Use in dental surgical procedures: Wisdom tooth extraction-The use of NSAIDs after oral surgical procedures is well documented in the literature. Previous studies on the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults, after wisdom tooth extraction, have pointed out the superior efficacy of the combination drug than the same dose of either drug alone(18). The first study that reported the efficacy of ibuprofen after third molar removal was conducted by Lökken et al. [19]. They noted a significant difference in the efficacy of ibuprofen for postoperative pain control in a group of 24 patients as compared to a placebo group after bilateral third molar surgery. Studies comparing the analgesic dose-response of ibuprofen 200, 400, 600, and 800 mg on postoperative pain management after surgical removal of third molars have highlighted that ibuprofen 400 mg provided maximum pain relief and the longest durations of analgesic effects compared to other doses [19].

5. Orthodontic pain management- Patients undergoing tooth movement can experience varying degrees of discomfort immediately after orthodontic treatment. Several studies have shown that ibuprofen was efficient in pain control after initial orthodontic therapy.

Current guidelines on the use of acetaminophen, ibuprofen, and combination drug– CDC has been consistently asserting the concept of optimizing nonopioid therapy for pain control before moving to opioids. This protocol has been resonated in the ADA (American Dental Association) Statement which states that "Dentists should consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management."(20)

AAPD strongly recommends that Acetaminophen/NSAIDs should be used as first-line pharmacologic therapy for pain management. (21)

Based on ADA Science Institute's 2018 overview of systematic reviews of acute pain medications that concluded combinations of ibuprofen and acetaminophen "offered the most favorable balance between benefits and harms" for treating dental pain, FDA has recently approved the combination drug for OTC use in US.(20)

Ibuprofen 200 mg to 400 mg as needed for pain every 4 to 6 hours is the gold standard for mild pain. In moderate pain, ibuprofen 400 mg to 600 mg around-the-clock every 4 to 6 hours for the first 24 hours is recommended, followed by ibuprofen 400 mg as needed for pain every 4 to 6 hours. If severe pain is anticipated, ibuprofen 400 mg to 600 mg plus APAP 500 mg every 6 hours is recommended around-the-clock for the first 24 hours. If that is inadequate, ibuprofen 400 mg to 600 mg plus Acetaminophen 650 mg, every 6 hours for the first 48 hours is recommended (22).

• Oral medications that reduce pain, administered pre or postoperatively, improve clinical outcomes, making them an integral part of dental practice.

• Rational use of Acetaminophen- ibuprofen combination for dental pain conditions, associated with or without fever should be given prime importance. This combination is the gold standard therapy for dental pain.

• Dentists should reevaluate the risk-benefit ratio when prescribing opioid analgesics and revert to a much safer and effective alternative of Acetaminophen- ibuprofen.

Conclusion -

Rational and timely use of Paracetamol ibuprofen drug combination allows to alleviate a wide spectrum of underlying dental pathological conditions, manifested as varying degrees of pain. With their well-documented efficacy, safety, and tolerability profiles, these drugs working together have been and will continue to be the cornerstone in dental pain management, for years to come.

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20. ADA Science Institute's 2018 overview of systematic reviews of acute pain medication

21. The Reference Manual of Pediatric Dentistry 2020-2021/ P. 362-370

22. Bushra, R., & Aslam, N. (2010). An overview of clinical pharmacology of Ibuprofen.