Optimizing Acute Pain Management After Tooth Extractions: NSAIDs and Acetaminophen Outperform Opioids

Photo Credit: Rattankun

As previously reported, a common theme of the 2024 AAOMS annual meeting included a core focus on non-opioid options for acute pain management. Although not linked with the AAOMS meeting, recent research published online in the Journal of Dental Research examined the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction.

The study systematically reviewed randomized clinical trials (RCTs) to evaluate the efficacy of various pain management drugs for acute pain following tooth extractions. Given the ongoing opioid crisis, especially in North America, and the risks associated with opioids in dental practice, there is a pressing need to establish guidelines that reduce reliance on opioids in favor of safer alternatives. This review, which incorporated data from 82 RCTs involving 9,095 participants, assessed 10 analgesic treatments, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. The study’s analysis focused on several key outcomes, including pain relief, total pain relief (TOTPAR), summed pain intensity difference (SPID), global efficacy, need for additional analgesia (rescue), and adverse effects.

The findings indicated that NSAIDs, particularly when combined with acetaminophen, were the most effective options for pain relief. A combination of ibuprofen (200–400 mg) with acetaminophen (500–1,000 mg) emerged as the most effective intervention, followed by acetaminophen (650 mg) with oxycodone (10 mg), ibuprofen (400 mg) alone, and naproxen (400–440 mg). These treatments consistently outperformed placebo across multiple measures, including pain relief scales. However, opioids, specifically lower doses of oxycodone (5 mg) and codeine (60 mg), showed little to no advantage over placebo for pain relief, highlighting the limited role of these drugs in managing postoperative dental pain.

The review further examined adverse effects, finding that most treatments, especially non-opioid NSAID and acetaminophen options, presented no more harm than placebo, based on low- and very low-certainty evidence. However, opioid-containing drugs were linked to a higher risk of adverse effects. This aligns with previous research underscoring the safety and efficacy of NSAIDs and acetaminophen over opioids in managing acute dental pain.

This research holds relevance given the misuse potential and public health risks associated with opioids. The findings echo prior evidence suggesting that NSAIDs, alone or combined with acetaminophen, provide adequate pain control while reducing the need for opioids. The American Dental Association (ADA), the ADA Science & Research Institute (ADASRI), and academic institutions in partnership with the FDA commissioned this study as part of a larger effort to establish evidence-based guidelines to manage acute dental pain. Current dental guidelines often lack robust evidence, making this study essential for informing safer, more effective practices in acute pain management after dental procedures.

In conclusion, NSAIDs, particularly when combined with acetaminophen, are the preferred choice for managing pain following tooth extractions, providing significant pain relief with fewer risks than opioids. As opioid abuse remains a critical issue, this evidence supports a shift toward safer analgesics in dental care, underscoring the need for continued research on alternatives such as ibuprofen with hydrocodone or other non-opioid options. By prioritizing NSAIDs and minimizing opioid use, dentistry can better address pain while contributing to broader efforts to combat opioid misuse and addiction.