Evidence-Based Dental Pain Solutions

By Ayesha Khan, MD, MBA

Dentists often operate at the nexus of acute pain management, given the prevalence of invasive procedures such as extractions, root canal therapy, and periodontal surgeries. Historically, opioids were liberally prescribed in dental settings, sometimes without fully appreciating their long-term consequences.

According to a 2013 survey, over 99% of oral and maxillofacial surgeons (382 out of 384) prescribed narcotics for patients with impacted teeth, with around 20% potentially prescribing more tablets than necessary. However, the ongoing opioid epidemic in the U.S., which causes over 82,000 deaths each year, has sparked a significant shift in approach.

These statistics highlight dental practitioners' crucial role in using evidence-based prescribing practices and adopting alternative pain-relief solutions like NSAID-acetaminophen combinations to ensure patient safety and achieve better therapeutic outcomes.

Recent Evidence Supporting NSAID-Acetaminophen Combinations

A pivotal 2023 study published in The Journal of the American Medical Association (JAMA) evaluated the comparative efficacy of opioid versus nonopioid analgesics in managing acute post-surgical and dental pain. This double-blind, randomized controlled trial enrolled over 1,800 participants undergoing third molar extractions, a standard model for acute oral pain due to the procedure's inflammatory nature. Participants were divided into two groups, one receiving a combination of ibuprofen (400 mg) and acetaminophen (1,000 mg), and the other receiving an opioid-based regimen (hydrocodone-acetaminophen, 5 mg/325 mg). Pain intensity was measured over 48 hours using a visual analog scale (VAS).

Findings revealed that the ibuprofen-acetaminophen cohort reported significantly lower pain scores compared to the opioid group, particularly within the first 24 hours of postoperative pain. Additionally, patients in the nonopioid group experienced fewer adverse events such as drowsiness and nausea, highlighting the improved tolerability of this regimen.

Furthermore, a meta-analysis comprising over 40 randomized controlled trials was published in Pain Medicine in 2022. The review compared analgesic outcomes across multiple clinical settings, including dental extractions, orthopedic surgeries, and soft-tissue injuries. The authors concluded that ibuprofen–acetaminophen combinations provided comparable, if not superior, analgesia to opioid-based therapies. They emphasized the increased benefit of nonopioid therapies in reducing inflammation, a key driver of nociceptive pain in conditions such as dental alveolitis and surgical trauma.

Explaining the Superior Efficacy of Ibuprofen-Acetaminophen Regimens

The enhanced effectiveness of the ibuprofen-acetaminophen combination lies in its dual mechanism of action. Whereas opioid analgesics primarily attenuate the perception of pain at the central level, NSAIDs and acetaminophen exert both local and systemic effects. By reducing peripheral inflammation, NSAIDs address the root cause of many acute pain conditions, such as tissue injury or post-surgical edema. Acetaminophen complements this through central nervous system effects, augmenting overall pain relief while minimizing the risk of peripheral side effects like gastrointestinal distress commonly associated with NSAIDs.

Another notable factor is the ceiling effect observed with opioids. Beyond a certain dosage, increasing opioid amounts fail to provide additional pain relief but exacerbate adverse effects. Conversely, combining ibuprofen and acetaminophen allows practitioners to leverage their synergistic analgesic effects without the need for escalated dosages.

Addressing Barriers to Adopting Nonopioid Protocols

Despite the robust evidence supporting ibuprofen-acetaminophen combinations, several barriers continue to limit their widespread adoption. Many clinicians harbor concerns regarding NSAID-related gastrointestinal and cardiovascular risks, particularly in patients with pre-existing comorbidities. While valid, these risks can often be mitigated through careful patient selection and by prescribing the lowest effective dose for the shortest necessary duration. For example, patients with a history of addiction, respiratory problems, or hypersensitivity to opioids should receive alternative regimens wherever possible. Similarly, individuals with specific contraindications for NSAIDs, such as gastrointestinal disorders or kidney insufficiency, may require a different approach. Dental practitioners must balance these factors, relying on thorough patient histories and clinical judgment to inform decisions.

Regions with limited healthcare access, particularly those reliant on Medicaid, continue to report higher opioid prescription rates. Medicaid patients were found to be 57% more likely to receive opioids than their privately insured counterparts since the pandemic era, emphasizing the need to bridge systemic healthcare gaps.

Educational gaps remain another challenge. Many practitioners, particularly those in private practice or outside academic centers, may not have updated training on nonopioid regimens or their clinical applications, calling for a broader scope in continuing education.

Patient expectations also play a pivotal role. Some individuals equate opioids with "strong" pain relief, creating resistance to alternative recommendations. Patient education becomes imperative in such scenarios. Engaging patients in informed discussions about the efficacy and safety of ibuprofen-acetaminophen regimens empowers them to make better decisions while emphasizing the downsides of opioids.

A practical strategy involves preemptive analgesia, where ibuprofen and acetaminophen are administered before surgical intervention to blunt nociceptive pathways before pain escalates. Additionally, a scheduled dosing regimen, rather than as-needed use, ensures consistent therapeutic drug levels, improving overall patient outcomes.

Safer, Evidence-Based Care in Dentistry and Beyond

A 2022 study analyzing prescribing trends from 2016 to 2019 showed notable declines in high-risk prescribing by dental specialists, with hydrocodone and oxycodone prescriptions dropping by 21% and 39%. Furthermore, the proportion of opioid prescriptions exceeding three days decreased by more than 50%. These findings collectively underscore a positive shift toward safer prescribing practices in dental care over recent years.

The shifting landscape of pain management necessitates reevaluating clinical practices across medicine and dentistry. Guidelines issued by professional bodies such as the American Dental Association (ADA) now advocate for NSAID-acetaminophen combinations as the first-line treatment for acute dental pain, reserving opioids for refractory cases or when nonopioids are contraindicated. Similar recommendations have emerged from the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA), underscoring the broader relevance of this evidence.

Final Remarks

Heightened awareness, coupled with stricter regulatory measures such as monitoring through Prescription Drug Monitoring Programs (PDMPs), has prompted dentists to curtail opioid prescriptions and find alternative solutions like NSAID-acetaminophen combination therapy. By prioritizing safer alternatives without compromising analgesic efficacy, clinicians can redefine pain management protocols, benefiting individual patients and public health. This shift may ultimately represent a turning point in pursuing safer, more effective medical solutions grounded in empirical evidence.

To learn more about DOCS Education training, courses, and continuing education on opioid prescriptions and DEA MATE Compliance, explore our available course offerings. You can also find additional articles comparing opioids with ibuprofen–acetaminophen studies here.

References:

1. Feldman, C. A., Fredericks-Younger, J., Desjardins, P. J., Malmstrom, H., Miloro, M., Warburton, G., ... & Lu, S. E. (2025). Nonopioid vs opioid analgesics after impacted third-molar extractions: The Opioid Analgesic Reduction Study randomized clinical trial. The Journal of the American Dental Association, 156(2), 110-123.
2. Narcotic Prescribing Habits and Other Methods of Pain Control by Oral and Maxillofacial Surgeons After Impacted Third Molar Removal Mutlu, Ibrahim et al. Journal of Oral and Maxillofacial Surgery, Volume 71, Issue 9, 1500 – 1503
3. Okunev I, Frantsve-Hawley J, Tranby E. Trends in national opioid prescribing for dental procedures among patients enrolled in Medicaid. J Am Dent Assoc. 2021 Aug;152(8):622-630.e3. doi: 10.1016/j.adaj.2021.04.013. Erratum in: J Am Dent Assoc. 2021 Oct;152(10):A8. doi: 10.1016/j.adaj.2021.08.002. PMID: 34325778.
4. Aghaloo T. Opioids in Oral and Maxillofacial Surgery: The Past, Present, and Future. J Oral Maxillofac Surg. 2025 May;83(5):501-502. doi: 10.1016/j.joms.2025.02.003. PMID: 40318891.
5. https://www.ada.org/resources/ada-library/oral-health-topics/oral-analgesics-for-acute-dental-pain
6. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

Author: Ayesha Khan, MD, MBA, is a registered physician, former research fellow, and enthusiastic blogger. With a wide range of articles published in renowned newspapers and scientific journals, she covers topics such as nutrition, wellness, supplements, medical research, and alternative medicine. As Vice President of Social Communications and Strategy at Renaissance, Ayesha brings her expertise and strategic mindset to drive impactful initiatives. Follow her blog for insightful content on healthcare advancements and empower yourself with knowledge.