Acetaminophen-Ibuprofen Combination In Managing Dental Pain: Review

Dental therapies like root canal treatment and teeth extraction are often advocated to repair dental issues. (3) The outcome of these therapies depends considerably on pre-operative pain control. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been repeatedly demonstrated to decrease the intensity of postoperative pain and swelling (4)

Among the available analgesic and anti-inflammatory drug classes, a combination of Acetaminophen and NSAID medications have been the preferred option among dental professionals for decades. (4) According to data from studies, Acetaminophen -Ibuprofen combination therapy remains dentists' most commonly recommended analgesic. (5,6)

Understanding Dental Pain & the role of drug combinations To Control It-

Dental pain is one of the most frequent types of pain and root in the dental pulp. (7) The soft tissues of teeth (pulp and pulp-dentin complex) are surrounded by mineralized hard tissues (enamel, dentin, and cement). The pulp is fed by a dense neurovascular network that regulates multiple inflammatory mediators. (8) The teeth are the only portion of the body where allodynia is considered normal. Pulpal nerves can sense pain. (7)

Research has consistently confirmed that orally administered analgesics are the best way to address acute and postoperative(surgical) dental pain. (7)

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen have analgesic, antipyretic, and anti-inflammatory properties. They inhibit prostaglandin production by non-selectively inhibiting cyclo-oxygenase (COX), which is present as COX-1 and COX-2. (9)
• Despite its extensive usage, the mechanism of action of Acetaminophen is unknown, though a centrally mediated analgesic-antipyretic activity is acknowledged. Acetaminophen has a minimal anti-inflammatory effect, indicating a different mechanism of action than NSAIDs. (9)
• NSAIDs work peripherally, relieving pain by lowering inflammation at the source. Alternatively, Acetaminophen operates centrally by inhibiting pain signal transmission within the central nervous system. (10
• Combined therapy is more effective than analgesic monotherapy at higher doses and causes fewer side effects. Numerous studies have demonstrated that acetaminophen and other NSAID drugs work more effectively than acetaminophen or NSAID drugs alone. (10)

Managing Dental inflammation: The synergy of the Acetaminophen-Ibuprofen Combination- This drug combination has gained traction in light of its better efficacy and safety profile, leading to an increased emphasis on multimodal analgesia. (10)

The acetaminophen-Ibuprofen combination works synergistically to provide more significant analgesic effects than monotherapy. Multiple trials have proven that specific dosed combinations of Acetaminophen and Ibuprofen are more effective than monotherapy in relieving dental pain and related inflammatory symptoms. Because of their distinct metabolic pathways, drug-drug interactions are also limited to a bare minimum. (10)

Study testimonials: Therapeutic Efficacy Of Combination Therapy-

• In endodontics- Endodontics pain accounts for significant orofacial pain. While severe pain may require 600 mg or 800 mg ibuprofen and up to 1000 mg acetaminophen every 8 hours, mild to moderate pain is frequently treated with 400 mg ibuprofen mixed with 325 mg acetaminophen dosed every 6 hours. (11)
• In orthodontics-Orthodontic pain, which can occur throughout any orthodontic treatment process, affects 72% to 100% of patients undergoing therapy to align teeth. (12) According to research, people undergoing orthodontic treatment may feel uncomfortable 4 hours after the therapy is initiated, and the discomfort peaks at 24 hours and gradually improves over a week. (13). Ibuprofen provides a robust and long-lasting analgesic impact that peaks after 6 hours, whereas Acetaminophen's analgesic effect builds gradually from 2 to 24 hours after an orthodontic session. This makes Ibuprofen-Acetaminophen a suitable option for managing orthodontic pain at its worst. (14)
• Comparative studies-Recent research has shown that Acetaminophen-Ibuprofen gives superior pain relief than opioids such as codeine, hydrocodone, and oxycodone while avoiding the multiple side effects associated with chronic opioid usage. (15) The American Dental Association (ADA) recommends NSAIDs as first-line therapy for managing acute dental pain. (16)
• In the pediatric population-Body research now supports the oral administration of Ibuprofen alone or combined with Acetaminophen for postoperative analgesia in children undergoing general anesthesia for tooth extraction. Ibuprofen and Ibuprofen/Acetaminophen combinations were more effective than standard- or high-dose Acetaminophen alone in lowering children's pain and distress following tooth extraction. (17)

Is the combination safe?

Acetaminophen is a safe analgesic and is usually the chosen one to be the first painkiller dentists recommend. When taken with optimal dosage changes, it has been suggested as the best choice for individuals with liver and renal problems. Ibuprofen has a superior safety profile than other NSAIDs, with minor GI symptoms and low antiplatelet action, compared to aspirin and most other NSAIDs. (18,19)

Key pointers-

• Pain relief is critical when treating dental patients since it has far-reaching consequences for the patient and the provider.
• The Acetaminophen-Ibuprofen combination treatment outperforms monotherapy regarding analgesic and anti-inflammatory effects for dental pain.
• Ibuprofen and Acetaminophen work synergistically to provide higher peak analgesia and more consistent analgesia (i.e., less fluctuation between patients) without causing more negative side effects.
• Because of their scientifically supported efficacy in managing pain, fever, and edema (caused by inflammatory mediator release), Acetaminophen and Ibuprofen are among the most extensively used drugs, particularly for managing dental pain and inflammation. This combination pain control therapy has earned a unique position among the dental fraternity and remains a much-preferred option among patients and dental professionals.

References

1. Kakoei, S., Parirokh, M., Nakhaee, N., Jamshidshirazi, F., Rad, M., & Kakooei, S. (2013). Prevalence of Toothache and Associated Factors: A Population-Based Study in Southeast Iran. Iranian Endodontic Journal, 8(3), 123-128. https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734515

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

3. Parirokh, M., Zarifian, A., & Ghoddusi, J. (2015). Choice of Treatment Plan Based on Root Canal Therapy versus Extraction and Implant Placement: A Mini Review. Iranian Endodontic Journal, 10(3), 152-155. https://doi.org/10.7508/iej.2015.03.001

4. Becker DE. Pain management: Part 1: Managing acute and postoperative dental pain. Anesth Prog. 2010 Summer;57(2):67-78; quiz 79-80. doi: 10.2344/0003-3006-57.2.67. PMID: 20553137; PMCID: PMC2886920.

5. Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. doi: 10.1002/14651858.CD004624.pub2. PMID: 24338830.

6. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. 2010 Apr 1;110(4):1170-9. doi: 10.1213/ANE.0b013e3181cf9281. Epub 2010 Feb 8. PMID: 20142348.

7. Renton T, Wilson NH. Understanding and managing dental and orofacial pain in general practice. Br J Gen Pract. 2016;66(646):236-237. doi:10.3399/bjgp16X684901

8. Tjäderhane, L., & Haapasalo, M. (2009). The dentin–pulp border: a dynamic interface between hard and soft tissues. Endodontic Topics, 20, 52-84.

9. 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

10. Krasniqi, S., & Daci, A. (2017). Analgesics Use in Dentistry. Pain Relief - From Analgesics to Alternative Therapies. doi: 10.5772/66600

11. Blicher, B., & Pryles, R. L. (2020). Endodontic Pain Management: Preoperative,Perioperative, and Postoperative Strategies. Compendium, 41(4)

12. Long H, Wang Y, Jian F, Liao LN, Yang X, Lai WL. Current advances in orthodontic pain. Int J Oral Sci. 2016;8(2):67-75. Published 2016 Jun 30. doi:10.1038/ijos.2016.24

13. Lai TT, Chiou JY, Lai TC, et al. Perceived pain for orthodontic patients with conventional brackets or self-ligating brackets over 1 month period: A single-center, randomized controlled clinical trial. J Formos Med Assoc. 2020;119(1 Pt 2):282-289. doi:10.1016/j.jfma.2019.05.014

14. Cheng, C., Xie, T., & Wang, J. (2020). The efficacy of analgesics in controlling orthodontic pain: a systematic review and meta-analysis. BMC oral health, 20(1), 1-9.

15. 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

16. Ruoff GM. OTC Analgesics vs Opioids for Pain Management. J Fam Pract. 2022;71(6 Suppl):S29-S33. doi:10.12788/jfp.0418

17. 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.

18. 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). https://doi.org/10.5812/hepatmon.23539

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