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Pain management in dentistry and important cornerstones of successful treatment

Written By : SATABDI SAHA |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2021-05-11T11:30:18+05:30  |  Updated On 25 April 2023 6:11 PM IST
Pain management in dentistry and important cornerstones of successful treatment
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Timely control of pain has been of supreme importance in achieving optimum patient cooperation. Minimizing pain preoperatively and postoperatively increases the chances of successful dental treatment. (1)

Dental surgeons have since time immemorial relied on acetaminophen, and ibuprofen as the standard drug combination to relieve dental pain, with associated symptoms of inflammation. Researchers have highlighted that this drug combination continues to be the first choice while prescribing analgesic-antipyretic medications among dentists. (2)

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)
Paracetamol-ibuprofen: is it worth the combination?
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)
Clinical Uses in dentistry.
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)
Recommended doses of the drugs, alone and in combination –
AAPD recommended pediatric doses of acetaminophen for mild / moderate Pain are – in children <12 years: 10-15 mg/kg/dose every 4-6 hours as needed (maximum 75 mg/kg/24 hours, but not to exceed 4.0 g/24 hours);whereas in children >12 years, 325-650 mg every 4-6 hours OR 1,000 mg 3-4 times/day as needed (maximum 4 g/24 hours).(21)
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).
Take home message for dentists-
• 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.
References
1. Appukuttan D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: literature review. Clinical, cosmetic and investigational dentistry, 8, 35–50. https://doi.org/10.2147/CCIDE.S63626
2. Pozzi, A., &Gallelli, L. (2011). Pain management for dentists: the role of ibuprofen. Annali di stomatologia, 2(3-4 Suppl), 3–24.
3. Wong, T., Stang, A. S., Ganshorn, H., Hartling, L., Maconochie, I. K., Thomsen, A. M., & Johnson, D. W. (2013). Combined and alternating paracetamol and ibuprofen therapy for febrile children. The Cochrane database of systematic reviews, 2013(10), CD009572. https://doi.org/10.1002/14651858.CD009572.pub2
4. Ong, C. K., Lirk, P., Tan, C. H., & Seymour, R. A. (2007). An evidence-based update on nonsteroidal anti-inflammatory drugs. Clinical medicine & research, 5(1), 19–34. https://doi.org/10.3121/cmr.2007.698
5. Micallef, J., Soeiro, T., Jonville-Béra, A. P., & French Society of Pharmacology, Therapeutics (SFPT) (2020). Non-steroidal anti-inflammatory drugs, pharmacology, and COVID-19 infection. Therapie, 75(4), 355–362. https://doi.org/10.1016/j.therap.2020.05.003
6. The Use of Ibuprofen in the Treatment of Postoperative Pain in Dentistry Aleksandar Jakovljević ,EmiraLazić , Neda Perunović , NenadNedeljković Serbian Dental Journal, vol. 61, No 3, 2014
7. Mehlisch D R, Aspley S, Daniels S E, Southerden K A, Christensen K S. A single-tablet fixed-dose combination of racaemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: a multicentre, two-stage, randomized, double-blind, parallel-group, placebo-controlled, factorial study. Clinical Ther 2010; 32: 1033–1049.
8. Anderson BJ, Holford NH, Woollard GA, et al. Perioperative pharma-codynamics of acetaminophen analgesia in children. Anesthesiology. 1999;90:411–421.
9. Daniels SE, Goulder MA, Aspley S, et al. A randomised, five-parallel-group, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain 2011;152:632-42
10. Mitchell A, McCrea P, Inglis K, et al. A randomized, controlled trial comparing acetaminophen plus ibuprofen versus acetaminophen plus codeine plus caffeine (Tylenol 3) after outpatient breast surgery. Ann Surg Oncol 2012;19:3792-800.
11. Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis.Nusstein J, Reader A, Nist R, Beck M, Meyers WJJ Endod. 1998 Jul; 24(7):487-91.
12. MericKarapinar-Kazandag, JaleTanalp, Handan Ersev, "Effect of Premedication on the Success of Inferior Alveolar Nerve Block in Patients with Irreversible Pulpitis: A Systematic Review of the Literature", BioMed Research International, vol. 2019, Article ID 6587429, 25 pages, 2019. https://doi.org/10.1155/2019/6587429
13. Parirokh, M., & V Abbott, P. (2014). Various strategies for pain-free root canal treatment. Iranian endodontic journal, 9(1), 1–14.
14. 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 May;17(3):169-77. doi: 10.1111/j.1365-263X.2006.00806.x. PMID: 17397460.
15. Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews. J Am Dent Assoc. 2018 Apr;149(4):256-265.e3. doi: 10.1016/j.adaj.2018.02.012. Erratum in: J Am Dent Assoc. 2018 Jun;149(6):413. Erratum in: J Am Dent Assoc. 2020 Mar;151(3):163. PMID: 29599019.
16. Lokken P, Olsen I, Bruaset I, Norman-Pedersen K. Bilateralsurgical removal of impacted third molar teeth as a model fordrug evaluation: a test with ibuprofen. Eur J Clin Pharmacol1975;8:209-216.
17. Troullos ES, Hargreaves KM, Butler DP, Dionne RA.Comparison of non-steroidal anti-inflammatory drugs, ibuprofenand flurbiprofen, with methylprednisolone and placebofor acute pain, swelling and trismus. J Oral Maxillofac Surg 1990;48:945-952.
18. DMehlisch DR, Aspley S, Daniels SE, Bandy DP. Comparison of 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: a randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clin Ther. 2010 May;32(5):882-95. doi: 10.1016/j.clinthera.2010.04.022. PMID: 20685496.
19. Thornhill, M. H., Suda, K. J., Durkin, M. J., & Lockhart, P. B. (2019). Is it time US dentistry ended its opioid dependence?. Journal of the American Dental Association (1939), 150(10), 883–889. https://doi.org/10.1016/j.adaj.2019.07.003
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.
cornerstonespain managementdental treatmentacetaminophenibuprofenparacetamol
SATABDI SAHA
SATABDI SAHA
    Dr. Kamal Kant Kohli
    Dr. Kamal Kant Kohli

    Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751

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