Analgesics to Know for the INBDE

Analgesics in Dentistry for the INBDE

Decision making in pain management

When prescribing analgesic medications for pain management, there are a variety of choices and decisions that must be made in order to maximize efficacy and minimize adverse effects. It is important to also realize that there is no analgesic, dose or combination that will work for all patients and that the prescription will vary from person to person. Below is a decision chart that helps serve as a general guide to finding an effective analgesic.

Here are a few important things to note when going through the chart:

1. Ibuprofen and acetaminophen are excellent drugs to use as the first-line analgesic because of their efficacy and low risk for adverse effects.
2. ‍Ibuprofen has a shorter half life and is very effective for dental pain of a shorter duration ‍
3. Naproxen has a longer half life and is very effective for dental pain of a longer duration
4. Combining NSAIDs and acetaminophen has shown to have an additive effect and an increased efficacy in pain management especially in the dental setting.
5. Combining acetaminophen with opioids has shown to also be an effective method of managing more severe pain.‍
6. Opioids should not be used as a sole agent in dental pain management due to its high risk for adverse events and abuse. 
7. Adding opioids in combination with other analgesics allows for a smaller and more controlled dosage of both medications

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What analgesic can I prescribe to my patient?

Analgesics are medications used for pain relief. Some analgesics also have antipyretic or anti-inflammatory properties. There are different classes of analgesics that can be used to relieve pain, and prescriptions should be individualized to the patient’s comorbidities and pain level.

‍Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to relieve pain,  reduce inflammation, and reduce fever. Some NSAIDs can be obtained as over-the-counter (OTC) drugs and some as prescriptions from a doctor. NSAIDs work by inhibiting enzymes called cyclooxygenases (COX), which play a role in the production of prostaglandins. 

Non-selective NSAIDs inhibit both isozymes of the COX enzyme, COX-1 and COX-2. COX-2 is responsible for mediation of inflammation. COX-1 is involved in the production of prostaglandins that protect the stomach lining. For this reason, non-selective NSAIDs are contraindicated in patients with bleeding problems or stomach ulcers. There are also COX-2 selective inhibitors, which avoid gastric complications. 

Contraindications to all NSAIDs include hypersensitivity to NSAIDs and severe renal disease. Acetaminophen is preferred in elderly patients as there is a physiological decline in renal function with age. Those with stomach ulcers should avoid taking non-selective NSAIDs.

‍Acetaminophen (Tylenol®) is a non-NSAID analgesic medication. Acetaminophen inhibits pain in the central nervous system (CNS) and can reduce fever. However, acetaminophen is not an anti-inflammatory medication. Acetaminophen is metabolized in the liver, so higher doses can be hepatotoxic and cause liver damage. Acetaminophen is used to relieve mild to moderate pain, including headache, muscle aches, arthritis, backaches, toothaches, and sore throat, among other conditions.

Acetaminophen dosage = 325 or 500 mg (mg) every 3 or 4 hours, 650 mg every 4 to 6 hours, or 1000 mg every 6 hours as needed

Maximum daily dosage of acetaminophen = 4,000 mg/day

Some providers recommend a daily maximum dose of 3,000 mg/day due to the high risk of liver damage at higher doses.

‍Acetaminophen is the preferred analgesic for:

• Patients with an increased bleeding risk where NSAIDs are contraindicated
• Children and elderly patients
• Patients with gastrointestinal issues, including peptic ulcer, and heartburn
• Patients with asthma
• Patients with kidney disease
  

Acetaminophen can be used safely in patients with liver disease or liver failure, but must be used at low-dosages due to the risk of liver damage. This is preferred over NSAIDs. Acetaminophen is an acceptable medication for pain relief for patients taking warfarin (Coumadin®), however at higher dosages an important drug-drug interaction can cause an increased bleeding risk. 

‍Combination Narcotics can be used to treat moderate to severe pain and are a combination of an opioid medication and acetaminophen. It is important to exercise caution when prescribing combination narcotics, taking into consideration the patient’s medical history and any substance use or abuse history.

Dosage for Dental Pain

Mild pain:

• Acetaminophen 500 – 1,000 mg q4h 

Moderate pain:

• Ibuprofen 400 mg q4h
• Contraindication to NSAID, use Tylenol 2 or 3

 Severe pain

• Bupivacaine for long duration of LA
• Ibuprofen 600 mg q4h
• 1000 mg acetaminophen + 400 mg ibuprofen q4h
• Tylenol 3, 1 - 2 pills q4h