P R A T I Q U E C L I N I Q U E

An Update on Analgesics for the Management

of Acute Postoperative Dental Pain
(Mise à jour sur l’utilisation d’analgésiques pour le traitement des douleurs
dentaires postopératoires aiguës)

• Daniel A. Haas, BSc, DDS, BScD, PhD, FRCD(C) •

S o m m a i r e
L’acétaminophène, les anti-inflammatoires non stéroïdiens (AINS) et les opioïdes sont des analgésiques pouvant être
utilisés en dentisterie, et à chacun correspondent des avantages, des inconvénients, des indications et des
contre-indications qui leur sont propres. Cet article propose un bref aperçu du rôle de ces substances dans le traite-
ment de la douleur postopératoire aiguë.

Mots clés MeSH : analgesics/therapeutic use; pain, postoperative/drug therapy; toothache/prevention & control

© J Can Dent Assoc 2002; 68(8):476-82

Cet article a été révisé par des pairs.

NSAIDs

M
anaging acute postoperative pain is inherent to
dental practice. Numerous analgesics are available, NSAIDs have been used increasingly as analgesics, not just
and the recent introduction of new agents provides as anti-inflammatory agents, since the mechanism of action of
even more options from which to choose. The purpose of this acetylsalicylic acid (ASA) was discovered approximately 30
article is to provide a brief review of the drugs that should be years ago.1 Clinical trials have shown repeatedly that, by them-
considered for the management of acute postoperative dental selves, NSAIDs are effective for the management of any level
pain. of dental pain, whether mild, moderate or severe.2-5 Optimal
use of these drugs resides in understanding their mechanism of
Acetaminophen action on the arachidonic acid cascade, which is summarized
The first drug to consider is acetaminophen, which is indi- in Fig. 1. NSAIDs block the cyclooxygenase enzymes, which
cated for the management of mild to moderate pain. Aceta- exist in 2 forms known as cyclooxygenase-1 (COX-1) and
minophen is very safe if used in therapeutic doses, as listed in cyclooxygenase-2 (COX-2). COX-1 is responsible for the
Table 1. Its favourable risk/benefit balance makes it the anal- synthesis of several mediators, including the prostaglandins
gesic of choice for acute postoperative dental pain in adults that protect the gastric mucosa and that regulate renal blood
and children. Acetaminophen has analgesic and antipyretic flow, and the thromboxanes that initiate platelet aggregation.
properties, and is devoid of the side effects that accompany the Leukotrienes also promote inflammation and can cause bron-
nonsteroidal anti-inflammatory drugs (NSAIDs). It is there- chospasm. Tissue damage such as pulpitis or periodontitis, or
fore also the analgesic of choice if there is a contraindication to tissue damage resulting from surgery, will induce the produc-
an NSAID. Excessive doses can lead to irreversible liver tion of COX-2, which, in turn, leads to the synthesis of the
damage and thus caution must be exercised in patients with a prostaglandins that sensitize pain fibres and promote inflam-
history of liver disease or alcoholism. Long-term use should be mation.3 Traditional NSAIDs block both COX-1 and COX-2,
avoided as it may lead to renal toxicity. For the management but in recent years, new NSAIDs have been developed that are
of severe pain acetaminophen is usually insufficient by itself, much more selective for COX-2. These selective COX-2
although it may be used in combination with an opioid such inhibitors were developed to be less damaging to the gastric
as codeine or oxycodone. mucosa, and the evidence supports this contention.6,7

476 Septembre 2002, Vol. 68, N° 8 Journal de l’Association dentaire canadienne

 An Update on Analgesics for the Management of Acute Postoperative Dental Pain

Effects of NSAIDs of naproxen or ibuprofen.11 New COX-2 inhibitors likely to

The therapeutic and adverse effects of NSAIDs are summa- be released in the near future include valdecoxib, etoricoxib
rized in Table 2. Analgesic and anti-inflammatory actions are and parecoxib, the latter being an injectable.
their main properties. These actions, combined with their NSAID-induced inhibition of thromboxane synthesis
inhibition of uterine contraction, make them effective for the results in a decrease in platelet aggregation. For most NSAIDs
management of menstrual pain. ASA is a well-known this effect is reversible within 24 hours. ASA is unique in that
antipyretic and is widely used for its antiplatelet action for it irreversibly damages cyclooxygenase for the life of the
prophylaxis of myocardial infarction in patients with a history platelet; if doses are high, one could consider withdrawing
of unstable angina pectoris or with a history of myocardial ASA for at least one week before surgery. ASA is more
infarction.8 commonly used for prophylaxis of myocardial infarction and
NSAIDs are associated with many adverse effects, which is usually taken in a low dose — no more than 325 mg per day.
lead to a number of contraindications (Table 2).9 Inhibition of Individual clinical judgment must be used in these cases, but
prostaglandin synthesis will diminish the protective effect of usually patients should be advised to continue taking their
prostaglandins on the gastric mucosa. This inhibition may low-dose ASA.
lead to dyspepsia, and more seriously, to gastric bleeding. A patient may have a true allergy to ASA or other NSAIDs,
Gastrointestinal toxicity is a major problem associated with but of even more concern is the possibility of an allergy-like,
NSAIDs, as it is reported that there are over 16,500 NSAID- i.e. anaphylactoid, reaction. Bronchospasm and other allergy
related deaths per year in the United States.10 Therefore, signs and symptoms can occur in susceptible patients as a
NSAIDs should not be given to any patient with active gastric result of redirecting the arachidonic acid breakdown into the
ulcers or gastric bleeding. Acetaminophen is the analgesic of leukotriene pathway, as shown in Fig. 1. Therefore, history of
choice for these patients. Enteric-coated formulations may an allergy-like reaction to ASA, particularly an asthmatic reac-
reduce the likelihood of dyspepsia, but will not prevent gastric tion, rules out not only ASA, but also any other NSAID.
damage and subsequent bleeding. If acetaminophen is insuffi- Furthermore, ASA and NSAIDs are best avoided in patients
cient, one can consider a selective COX-2 inhibitor, as these with severe asthma.
inhibitors are much less likely to induce gastric bleeding than Monographs for NSAIDs list numerous potential drug
traditional NSAIDs. Celecoxib (Celebrex) and rofecoxib interactions, yet only a few of these interactions may be rele-
(Vioxx) are 2 agents in this class that are available. Rofecoxib, vant in dentistry, as our prescribing of these agents is usually
when given as a 50-mg dose per day, has been shown to short term.12,13 The effect on reducing blood pressure of anti-
provide analgesia equivalent to ibuprofen 400 mg.11 Celecoxib hypertensive drugs that belong to the angiotensin-converting
provides analgesia that is slightly less efficacious, in that it is enzyme inhibitor class (such as enalapril), diuretic class (such
similar to ASA 650 mg but less effective than therapeutic doses as hydrochlorothiazide), and beta-blocker class (such as

TISSUE
Arachidonic acid DAMAGE

COX-1

COX-2
Lipoxygenase

Prostaglandins and Thromboxanes

Leukotrienes Prostaglandins
Gastric protection Platelet aggregation
Uterine contraction
Renal function
Bronchospasm Pain
Inflammation Inflammation
Renal function

Figure 1: Arachidonic acid cascade. This illustration is a summary of part of the biochemical response that occurs during inflammation.
Cyclooxygenase-1 (COX-1) is constitutive to maintain normal function, whereas cyclooxygenase-2 (COX-2) is induced when there is tissue
damage. Traditional NSAIDs act by blocking both cyclooxygenase enzymes. The COX-2 inhibitors are much more selective for this latter enzyme.

Journal de l’Association dentaire canadienne Septembre 2002, Vol. 68, N° 8 477

Haas

Table 1 Acetaminophen and NSAID dosing regimens for dental pain

Drug (brand namea) Dose (mg) Frequency Daily maximum (mg)
Adults
Acetaminophen 500–1,000 q4–6h 4,000
Acetylsalicylic acid (Aspirin) 325–1,000 q4–6h 4,000
Celecoxib (Celebrex) 200 once/day 400
Diflunisal (Dolobid) 500 q12h 1,500
Etodolac (Ultradol) 200–400 q6–8h 1,200
Floctafenine (Idarac) 200–400 q6–8h 1,200
Flurbiprofen (Ansaid) 50 q4–6h 300
Ibuprofen (Advil, Motrin) 400 q4–6h 2,400
Ketoprofen (Orudis) 25–50 q6–8h 300
Ketorolac (Toradol) 10 q4–6h 40 (5 days max.)
Naproxen (Anaprox, Naprosyn) 275/250 q6–8h 1,375
Rofecoxib (Vioxx) 50 once/day 50 (5 days max.)
Children
Acetaminophen (Tylenol, Tempra) 10–15 mg/kg q4–6h 65 mg/kgb
Ibuprofen (Children’s Advil)
age 2–12 10 mg/kg q6–8h
over age of 12 200–400 mg q4h 1,200
a Brand names are included only as examples and not to promote any one product. The manufacturers are as follows: Aspirin, Bayer Consumer; Advil, Whitehall-
Robins; Motrin, McNeil Consumer Healthcare; Ansaid, Pharmacia; Dolobid, Frosst; Anaprox, Roche; Naprosyn, Roche; Toradol, Roche; Orudis, Aventis Pharma;
Idarac, Sanofi-Synthelab; Ultradol, Procter & Gamble Pharmaceuticals; Vioxx, Merck Frosst; Celebrex, Pharmacia; Tylenol, McNeil Consumer Healthcare; Tempra,
Mead Johnson Nutritionals.
b Not to exceed the adult dose

propranolol), may be diminished if NSAIDs are taken over the offset of local anesthesia. Preoperative dosing may not be
long term. It is acceptable to coprescribe NSAIDs as long as prudent in cases where bleeding is a concern and is probably
the duration is kept to 4 days or less.13 Calcium-channel block- best reserved for NSAIDs other than ASA or ketorolac.
ers are not a concern. NSAIDs are also best avoided with the Another consideration is to prescribe the NSAID on a regular
other agents listed in Table 2. Patients on an anticoagulant will basis for the first 1 to 2 days following the procedure, such as
be susceptible to increased bleeding, and ASA in particular every 4 hours, as opposed to on an “as required” (prn) basis.
must be avoided. NSAIDs should be avoided with high-dose The analgesic can then be taken on a prn basis following this
methotrexate, as used for cancer therapy, whereas low-dose initial period. Finally, although numerous adverse effects exist,
methotrexate, as used for arthritis, is not a concern. Concur- these are more easily tolerated in the healthy patient than the
rent ingestion of alcohol may predispose to gastric bleeding. adverse effects of opioids. Therefore, it is best to maximize the
Long-term use of NSAIDs in combination with other nonopioid, i.e. acetaminophen or an NSAID, before adding
NSAIDs or acetaminophen may lead to nephrotoxicity, and an opioid.
must be avoided. All the interactions listed in Table 2 apply to
ASA. In addition, ASA should be avoided in diabetic patients Opioids
taking oral hypoglycemics. Opioid analgesics may be used to manage dental pain.15
They should be considered if acetaminophen or an NSAID
Prescribing Considerations
alone will not be sufficient.
Dosing regimens for the NSAIDs tested in a dental pain
model are listed in Table 1. Studies have shown that NSAIDs Effects of Opioids
may be all that is required to manage any level of postoperative Analgesia is the primary action of opioids, affecting both
pain.2-4 It has been suggested14 that NSAIDs can be more the pain threshold and pain reaction. Although high doses can
effective analgesics if they are given early enough and in suffi- be very effective for the relief of severe pain, opioids are most
cient doses to prevent the synthesis of prostaglandins, as often accompanied by unacceptable side effects, which are
opposed to prescribing them to deal with pain once summarized in Table 3. All opioids induce dose-
prostaglandins are already formed. Therefore, one should dependent respiratory depression, sedation, constipation,
consider an initial loading dose, such as double the mainte- nausea and vomiting. The nausea is characteristically exacer-
nance dose, which will allow therapeutic levels to be reached bated if the patient is ambulatory and can often be relieved if
more rapidly. Preoperative administration of NSAIDs may the patient is advised to lie down. Mood alteration may mani-
reduce the need for analgesics postoperatively. Consideration fest as either euphoria or, alternatively, as an unpleasant reac-
can thus be given to either preoperative dosing or at least to tion known as dysphoria. Chronic use may lead to tolerance or
beginning the dosing immediately after surgery, before the physical dependence. Addiction may occur in patients predis-

478 Septembre 2002, Vol. 68, N° 8 Journal de l’Association dentaire canadienne

 An Update on Analgesics for the Management of Acute Postoperative Dental Pain

Table 2 Effects and contraindications of Table 4 Opioid dosing regimens for dental
NSAIDs pain
Therapeutic effects
Analgesic Drug Dose (mg) Frequency Daily
Anti-inflammatory (brand name) maximum
Antipyretic
Antidysmenorrheal Adults
Antiplatelet action (ASA only) Codeine, with 30–60 q4–6h
acetaminophen
Adverse effects or an NSAID
Dyspepsia Oxycodone 5–10 q4–6h
Gastric mucosal damage (Percodan,
Increased bleeding DuPont Pharma;
Possible renal impairment Percocet,
Anaphylactoid reactions DuPont Pharma)
Contraindicationsa Children
Gastric ulcers or gastrointestinal inflammatory disease Codeine, with 0.5–1 mg/kg q4–6h 3 mg/kg
ASA or other NSAID-induced hypersensitivity acetaminophen
ASA-induced asthma and nasal polyps or an NSAID
Bleeding concerns
Third-trimester pregnancy
Significant renal disease
Children (for ASA only) posed to chemical dependency. Allergy to codeine, morphine,
Concurrent use of the following drugs:
antihypertensives such as angiotensin-converting enzyme oxycodone or hydromorphone contraindicates use of any other
inhibitors, diuretics or beta-blockers: NSAIDs may be opioid in this structural class. If an opioid is required for patients
coprescribed if required for 4 days or less with such allergies, the pure synthetics, meperidine or penta-
lithium zocine, could be considered. Additional contraindications are
anticoagulants (warfarin)
antineoplastic doses of methotrexate
listed in Table 3.
alcohol
digoxin if patient is elderly or has renal disease Prescribing Considerations
other NSAIDs or acetaminophen; long term Prescribing opioids for dental pain should be considered
oral hypoglycemics (for ASA only) only in combination with an NSAID or acetaminophen, in
aThis section is adapted from information provided in the Compendium of doses listed in Table 4. Opioids can be prescribed alone if the
Pharmaceuticals and Specialties9 patient already has a prescription for an NSAID or is taking
acetaminophen appropriately. If an opioid is necessary,
codeine should be the first to consider. Formulations combin-
ing acetaminophen or ASA with codeine are available and
Table 3 Effects and contraindications of popular because of ease of administration. However, ease of
opioids administration may be the only advantage of these formula-
tions as the relative doses of nonopioid to opioid are often
Effects
inappropriate. When using these combination analgesics one
Analgesia should still follow the principle of maximizing the nonopioid
Antitussive before adding the opioid. As an example, 3 tablets of Tylenol
Sedation
Nausea No. 2 with Codeine (McNeil Consumer Healthcare) will
Vomiting provide 900 mg acetaminophen with 45 mg codeine, which is
Constipation preferable to one Tylenol No. 4 With Codeine, which will
Mood alteration (euphoria/dysphoria) provide 300 mg acetaminophen with 60 mg codeine.
Respiratory depression
Tolerance if long term
If codeine is insufficient, the next opioid to consider is
Physical dependence if long term oxycodone. This drug is most commonly available with either
Addiction potential ASA (in Percodan) or acetaminophen (in Percocet).
Miosis (except for meperidine) Other opioids should be used only rarely for postoperative
Contraindications dental pain. Meperidine (Demerol, Sanofi-Synthelab), a
Severe chronic respiratory disease
synthetic opioid, is chemically distinct from codeine and
Severe inflammatory bowel disease oxycodone. Meperidine for dental pain should be reserved for
Concurrent use of alcohol the patient who is allergic to morphine and codeine deriva-
For meperidine only: monoamine oxidase inhibitor use within the tives, but who still requires an opioid. Although effective when
past 14 days
given by injection, oral meperidine has increased risks of

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Haas

Table 5 Analgesic use in pregnancy or lactationa

Drug FDA category for drug May be used May be used
use in pregnancy during pregnancy while breast-feeding
Acetaminophen B yes yes
ASA C/Db do not use in third trimester caution
Diflunisal C/D do not use in third trimester caution
Flurbiprofen B/D do not use in third trimester yes
Ibuprofen B/D do not use in third trimester yes
Ketorolac B/D do not use in third trimester yes
Ketoprofen B/D do not use in third trimester yes
Naproxen B/D do not use in third trimester yes
Codeine C low dose, short duration is acceptable yes
Oxycodone B low dose, short duration is acceptable yes
Hydromorphone B low dose, short duration is acceptable yes
Meperidine B low dose, short duration is acceptable caution
Pentazocine B low dose, short duration is acceptable caution
a Adapted from Haas and others16
b Where B/D or C/D is listed, the first letter refers to the category for the first 2 trimesters, while the second letter refers to the category for the third trimester.

adverse effects, as its metabolites can lead to toxicity. Oral Use of Analgesics for Pediatric Patients
meperidine is therefore a very poor choice. The adult dose is ASA is contraindicated for the young patient because it can
100 mg every 4 hours as required. Pentazocine (Talwin, potentially induce Reye’s syndrome. Acetaminophen, adminis-
Sanofi-Synthelabo) is similar to meperidine in that it is also a tered in appropriate doses as shown in Table 1, may be consid-
pure synthetic, but is unique in that it is an agonist-antagonist. ered the drug of choice for the pediatric patient. For pain of a
The adult dose for pentazocine is 50 mg every 4 hours as higher level, either ibuprofen or codeine can be used, both
required. Hydromorphone (Dilaudid, Abbott) is the most being available in an elixir form to facilitate administration.
potent opioid discussed in this review and should be reserved
for only those situations where other agents and local measures Use of Analgesics for Elderly Patients
have been tried, but have failed to relieve pain. Hydromor- Acetaminophen is the analgesic of choice in the elderly.
phone should be prescribed for a very short duration only, NSAIDs are a major concern due to the potential for gastroin-
with an adult dose of 2 to 4 mg every 4 hours as required. testinal bleeding, which becomes more likely with increasing
There appears to be little justification to use propoxyphene age, if there is a history of gastric bleeding, and if high doses of
(Darvon, Lilly) today.15 NSAIDs or multiple NSAIDs are used. This further empha-
sizes the need to avoid multiple NSAIDs. Therefore, nonselec-
Use of Analgesics in Pregnancy and Lactation tive NSAIDs are best avoided in the older patient. If they are
The use of analgesics during pregnancy has been recently necessary, one should greatly reduce doses and avoid concur-
reviewed, and the findings are summarized in Table 5.16 Opti- rent use of 2 or more NSAIDs. If the analgesic effect of aceta-
mal management of dental pain during pregnancy is removal minophen is insufficient, it is reasonable to consider a selective
of the source of pain using local anesthesia. If, however, post- COX-2 inhibitor such as rofecoxib or celecoxib over other
operative pain is present, an analgesic may be necessary and NSAIDs. Opioid analgesics have an increased likelihood of
should be made available. Acetaminophen is clearly the anal- more profound adverse effects as well as prolonged durations
gesic of choice in all stages of pregnancy. The use of NSAIDs, of action. Therefore it is best not to select an opioid. If it is
including ASA, is less favourable, particularly late in preg- necessary, reduced doses must be utilized.
nancy. NSAIDs may predispose to ineffective contractions
during labour, increased bleeding during delivery or premature Overall Prescribing Recommendations
closure of the ductus arteriosus of the heart. NSAIDs are there- A protocol, or algorithm, for analgesic use is presented in
fore contraindicated in the third trimester. Fig. 2. This algorithm should be considered in conjunction
If acetaminophen is insufficient, opioids are considered with the general guidelines listed in Table 6. NSAIDs have
acceptable during pregnancy provided they are given for a repeatedly been shown to be more effective than opioids in the
short duration. Chronic opioid use can result in fetal depen- doses used in dentistry.2 For mild to moderate pain, a reason-
dence, premature delivery and growth retardation. able first consideration is acetaminophen in doses of 500 mg
As with pregnancy, acetaminophen is the analgesic of to 1,000 mg every 4 hours. Alternatives include any of the
choice in lactation. ASA and diflunisal may increase NSAIDs listed in Table 1. If the maximum dose of a nonopi-
bleeding and should be avoided if possible. Opioids are oid is ineffective, then consider adding an opioid. The first
considered safe in lactation. choice is codeine, but severe pain can warrant oxycodone.

480 Septembre 2002, Vol. 68, N° 8 Journal de l’Association dentaire canadienne

 An Update on Analgesics for the Management of Acute Postoperative Dental Pain

If mild to moderate postoperative pain is expected

Acetaminophen

If 1,000 mg of acetaminophen is insufficient

(i.e., for moderate to severe pain)

If no contraindication

If concerns regarding
gastric bleeding
or if elderly
NSAID If NSAIDs contraindicated

rofecoxib
If more analgesia is required Add codeine to acetaminophen
or
add oxycodone with acetaminophen

Add codeine to NSAID, acetaminophen or ASA

or
Add oxycodone with acetaminophen or ASA

Figure 2: Algorithm for analgesic use. This algorithm should be considered to manage acute postoperative pain in the adult.

Table 6 General guidelines for the use of Le Dr Haas est professeur et doyen associé de la faculté de dentisterie
analgesics9 de l’Université de Toronto où il est titulaire de la chaire Chapman en
sciences cliniques, et il est chef de la section d’anesthésie dentaire. Il est
Eliminate the source of pain, if at all possible aussi professeur au département de pharmacologie de la faculté de
Individualize regimens based on pain severity and medical history médecine et membre actif du département de dentisterie du Centre
Maximize the nonopioid before adding an opioid Sunnybrook et Women’s College des sciences de la santé.
Optimize dose and frequency before switching Écrire au : Dr Daniel Haas, Faculté de médecine dentaire,
For NSAIDs, consider: Université de Toronto, 124, rue Edward, Toronto (ON) M5G 1G6.
• preoperative dose Courriel : [email protected]
• loading dose
L’auteur n’a aucun intérêt financier déclaré dans la ou les sociétés qui
• prescribing round-the-clock instead of prn on first day
fabriquent les produits mentionnés dans cet article.
Avoid chronic use of any analgesic whenever possible
Reduce the dose and duration of any NSAID or opioid in the
elderly
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