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Pharmacology

Which medications are most effective for moderate to severe post-operative dental pain?

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The following question was posted by a practising dentist: There is quite a bit of variation in the office with respect to drugs dentists like to prescribe for post-operative pain. Which pain medications are the most effective for moderate to severe pain and have the least number of side effects?

Dr. Mark Donaldson from the University of Montana and the Oregon Health & Sciences University provided this initial response:

The goal should be: “the most effective dose for the shortest period of time.”  We want to get our patients out of pain as quickly as possible.

Two good recent articles come to the same conclusions that “Acetaminophen and NSAIDs (ibuprofen) are the best medications for post-operative dental pain.”

These two references are particularly good since one is from the General Dentistry literature and the other is from the specialist literature (Anesthesia Progress) yet the conclusions are the same.

Another alternative is pre-emptive analgesia where an anti-inflammatory medication (NSAID or glucocorticoid, such as dexamethasone 4-8mg)  is administered prior to the dental surgery to help mitigate the inflammatory response and decrease the post-operative pain response.

As I teach in all of my classes on this subject, pain secondary to dentistry is due to inflammation and narcotics are NOT anti-inflammatory agents.

 

Dr. Archie McNicol of the University of Manitoba gave these initial comments:

The response will very much depend on the expected pain level and the patient. I tell students to take this on a case-by-case basis. For most procedures that GPs will be doing, ibuprofen or naproxen or acetaminophen/codeine would be sufficient.

Both naproxen and ibuprofen can be used at higher than OTC doses. However, in each case, the patient has to be warned about strictly following the daily dosage directions. In addition, both medications should be used only for a short period of time and both can exacerbate bleeding, particularly if the patient is taking 81 mg ASA. Asthmatic patients may also respond badly and the combination could upset GI system.

The combination of acetaminophen and codeine has lately come under scrutiny, primarily due to the realization that acetaminophen is even more hepatotoxic and nephrotoxic than was previously thought. The combination also has no anti-inflammatory component and about 5% of the population will likely not respond to codeine.

Another option may be ketorolac, although this medication could again upset the GI system. Again, this regimen should only be for short term use.

While GPs do not really prescribe other Opioids, oral surgeons will still use oxycodone-containing preparations (Percodan and Percocet) for severe post-operative pain and meperidine (Demerol) has gone from the market completely.

 

Follow-up: What further information would you like on this topic? Email us at jcdaoasis@cda-adc.ca

2 Comments

  1. Daniel Albert March 1, 2013

    After a few patients had severe abdominal cramping pain following Rx codiene. I have switched almost completely away from T3 to combo acetominophen and Ibuprophen.
    For example a case of 4 wisdom teeth exo would receive 1000mg acetominophen and 600mg Ibuprophen just prior to exo’s the 500mg acetominophen,600mg ibuprophen qid for three days then prn discomfort.

    Anectotally this combo works better than T3s with much easier recovery for patients.

    Reply
  2. Ian Matthew March 6, 2013

    For the patient who has recently undergone dento-alveolar surgery with pain refractory to ibuprofen at conventional doses, or for the patient with a stomach sensitive to NSAIDs, I prescribe diclofenac suppositories, 50 mg placed twice daily (up to a maximum of 150 mg/day). I find this to be a highly effective regimen.

    Reply

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