Analgesic regimens for severe acute dental pain in adults
For factors that affect the choice of analgesic regimen, see here.
Nonopioid analgesics (NSAIDs and paracetamol) should be taken regularly, rather than as required, to achieve continuous pain relief.
For severe acute nociceptive dental pain (eg after dental surgery) in patients who can use NSAIDs, as a three-drug regimen, consider:
ibuprofen 400 mg orally, 6- to 8-hourly for the shortest duration possible and no more than 5 days without review dental pain, severe (adults) ibuprofen
OR (if a COX-2–selective NSAID is preferred based on the patient’s risk factors [see Nonsteroidal anti-inflammatory drug use in dentistry])
celecoxib 100 mg orally, twice daily for the shortest duration possible and no more than 5 days without review dental pain, severe (adults) celecoxib
PLUS
paracetamol 1000 mg orally, 4- to 6-hourly (to a maximum of 4 g in 24 hours) for the shortest duration possible dental pain, severe (adults) paracetamol
PLUS
oxycodone immediate-release 5 mg orally, every 4 to 6 hours as necessary, for the shortest duration possible and no more than 3 days. Use a lower dose in elderly or frail patients because they are particularly vulnerable to adverse effects. Prescribe small quantities (eg 10 tablets) to avoid inappropriate use in the community. dental pain, severe (adults) oxycodone
In patients who cannot use NSAIDs, use paracetamol plus oxycodone.
Always consider the benefits, harms and regulatory requirements of prescribing an opioid (see Opioid use in dentistry). Prescribe the lowest effective dose, and advise patients to take a dose only when necessary. Ensure the patient understands the intended duration of opioid use and when to stop taking the opioid or return for review (eg if pain persists for longer than expected). This is of particular importance because long-term opioid use often starts with the use of opioids to treat acute pain. As the tissue heals and the patient requires less analgesia, use a stepwise approach to tapering and stopping analgesics. First, stop oxycodone, then stop ibuprofen or celecoxib, and lastly, stop paracetamol.
For patients currently taking opioids for another indication, consult their medical practitioner to determine an appropriate analgesic regimen; specialist pain management advice may be required if the patient is opioid-dependent.
If opioids have not been required in hospital or pain can be successfully managed with nonopioid analgesia, do not prescribe opioids on discharge. Do not use modified-release opioids for acute dental pain.
Administering local anaesthetics by infiltration or regional block is an alternative or additional strategy for the management of severe acute dental pain, provided the clinician is competent in these methods (see General information about local anaesthetics in dentistry).
If analgesics are used after a surgical procedure that causes postoperative pain, inform the patient of the usual course of pain (eg pain is worst 48 to 72 hours after surgery, then improves). Advise the patient to return to the dentist for review if pain persists.