Common Medications for Dental Pain (Part 1)

The pathophysiology of dental pain is a complex central and peripheral nervous system process, and the use of combination analgesics that act at multiple pain sites can improve dental pain relief. In general, for the treatment of mild to moderate dental pain, the most appropriate options are:

• Acetaminophen (Tylenol), 650mg every 4-6 hour as needed for dental pain;
• Non-steroidal anti-inflammatory drugs, or NSAIDs (Advil, Motrin, Aleve), 400mg every 4-6 hours as needed for dental pain; and
• COX-2-selective inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx), 25-50mg per day as needed for dental pain.

Acetaminophen: Acetic acid and p-aminophenol, or APAP-commonly known as acetaminophen-is classified as a nonnarcotic pain reliever. Dentists generally use it for mild to moderate dental pain. It acts as both anti-pain and anti-fever. It has rapid painkiller action. Acetaminophen, unlike nonsteroidal anti-inflammatory drugs, or NSAIDs, has little anti-inflammatory action. It generally is safe for acute dental pain. At very high single doses it causes liver damages.

Acetaminophen's dose of 500-650 milligrams is good dental pain-reliever. However, such relief is brief, peaking one hour after administration. Significantly more dental pain relief can be provided by acetaminophen's dose of 1,000 mg. At this dosage, the maximal efficacy of acetaminophen is achieved and last up to four hours after administration. There is no more oral pain relief in dose higher than 1000 mg. Because of this "ceiling-dose" effect, acetaminophen is good shot-term reliever for mild dental pain.

NSAIDs: NSAIDs have been the traditional treatment for moderate dental pain and inflammation. NSAIDs such as ibuprofen, ketorolac, flurbiprofen, ketoprofen, diclofenac, aspirin and aspirin derivatives diminish local dental pain. Long-term use of NSAIDs, however, can gastrointestinal distress, bleeding, kidney damages, and cardiovascular problems. Also, NSAIDs have been shown to interact with several high blood pressure drugs, which may compromise blood pressure control. The most common short-term side effects of NSAID usage are upset stomach, diarrhea and abdominal pain.

NSAIDs generally require a higher dose to achieve maximum anti-inflammatory and anti-pain effect. Dosage of 800 mg three times per day may be needed for dental pain. The FDA-recommended daily dose is 2,400 mg. Studies has indicated that no more dental pain reliever is achieved with higher-than-the-recommended dosage. Comparing to acetaminophen, NSAID's are better pain killer, but they act slower and last about the same time (about 4 hours).

COX-2 NSAIDs: COX-2 NSAIDs were developed to limit NSAID's adverse effects. The two COX-2-selective inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx) are characterized by the following:

• less risk of GI ulceration than nonselective NSAIDs;
• lsimilar types of other GI side effects, such as abdominal pain, dyspepsia, diarrhea and nausea;
• lack of effect on platelet function, unlike nonselective NSAIDs;renal toxicity similar to that of other NSAIDS;
• generally long duration of action, with once-daily administration for rofecoxib and once- or twice-daily administration for celecoxib.

However, while COX-2 therapy may reduce the risk of GI ulcerations, recent evidence indicates that COX-2 therapy may not reduce the risk of cardiovascular complications (heart attacks). This is the reason why Vioxx is currently taken off the US market.