OTC Pain Relievers Just as Effective as Opioids After Wisdom Tooth Removal

By Pat Anson

A combination of acetaminophen and ibuprofen works just as well as a low dose of opioids in relieving pain in men and women after wisdom tooth removal, according to a new study in JAMA Network Open. 

The research builds on a previous study of over 1,800 patients, which compared the effectiveness of 400 mg of ibuprofen and 500 mg of acetaminophen to 5 mg of hydrocodone and 300 mg of acetaminophen in the first three days after surgery. That dose of hydrocodone is the equivalent of 5 morphine milligram equivalents (MME), which is considered a low dose under medical guidelines.

"We wanted to determine whether the pain medication's effects were consistent in males and females separately," lead author Janine Fredericks Younger, DMD, an associate professor at Rutgers School of Dental Medicine, said in a press release.

 "And what we found is that in both subgroups (males and females), the non-opioid was superior for that first day and night, and then no worse than the opioid for the rest of the post-op period."

Researchers performed a gender-specific analysis because women often report higher pain levels after surgery, raising questions about whether pain medications work differently for each sex.

"There's obviously different biological mechanisms, different hormones involved," said Cecile Feldman, DMD, Dean of Rutgers School of Dental Medicine and senior author of both studies. "But results confirm that the analgesic effect for both groups is the same."

Pain levels were low whether patients took acetaminophen-ibuprofen or the hydrocondone-acetaminophen combination. Pain ratings over three days were slightly lower for female patients taking non-opioids than those on the low dose of hydrocodone (2.83 vs 2.98). The same was true for male patients (2.24 vs 2.37).

Patient satisfaction and sleep quality were also slightly better in the non-opioid group, which also experienced less pain interference with daily activities. 

"The results actually came in even stronger than we thought they would," Feldman said. "We expected to find the non-opioid to be non-inferior, so that at least it was no worse than opioids. We were surprised to see that it was actually superior."

Wisdom tooth extraction is performed about 3.5 million times a year in the United States. Dental surgery is often the first exposure that a patient has to prescription opioids, although their use after dental procedures has declined in recent years as fears grew about opioid addiction.

Last year the American Dental Association (ADA) released new guidelines recommending that nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen be taken alone or in combination with acetaminophen as first-line treatments for acute dental pain in adults and adolescents aged 12 and older. 

NSAIDs and acetaminophen work differently, with NSAIDs reducing pain and inflammation and acetaminophen reducing pain and fever. Taking the two together is believed to boost their analgesic effect. 

The ADA says opioids should only be used when NSAIDs and acetaminophen don’t relieve pain enough or when NSAIDs are contradicted due to health issues, such as a patient having cardiovascular problems or a bleeding ulcer.     

The risk of long-term opioid use after a tooth extraction is relatively rare. A large study of over 70,000 teens and young adults who had their wisdom teeth removed found that only 1.3% were prescribed opioids long-term after their initial prescription by a dentist. 

"We feel pretty confident in saying that opioids should not be prescribed routinely for dental procedures," Feldman said. "Our non-opioid combination really should be the analgesic choice."

NSAIDs Preferred for Acute Dental Pain

By Pat Anson, PNN Editor

Nonsteroidal anti-inflammatory drugs (NSAIDs) taken alone or in combination with acetaminophen are recommended as first-line treatments for managing short-term acute dental pain in adults and adolescents aged 12 and older, according to a new guideline developed by the American Dental Association (ADA).

Opioid analgesics should only be used when NSAIDs and acetaminophen are insufficient to reduce pain or when NSAIDs are contradicted, according to the ADA guideline, which also warns dentists to avoid “just-in-case” opioid prescribing.    

“Providing prescribing guidelines for acute dental pain management is an important step towards improving patient treatment and outcomes,” Marta Sokolowska, PhD, deputy center director for substance use and behavioral health at the FDA's Center for Drug Evaluation and Research, said in a press release. “We hope this clinical practice guideline will reduce the risk of opioid addiction, overdose and diversion.”

Opioids were once routinely prescribed to dental patients after a surgical tooth extraction or even a simple toothache. In 1998, dentists wrote 15.5% of all prescriptions for immediate release opioids in the United States. Many of those prescriptions are now considered high risk because the daily dose was over 50 MME (morphine milligram equivalents) or the amount prescribed exceeded a 3-day supply.

After reviewing 82 clinical trials involving tooth extractions, the ADA’s guideline panel found that NSAIDs were more effective than opioids in reducing post-operative pain.

“When managing acute dental pain, there are several reasons to consider alternatives to opioids. First, evidence suggests that opioids may not be the best approach to managing what is often inflammation-related acute dental pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) would target the source of the pain, whereas opioids would not,” the guideline cautions.

Only in “rare instances” when pain control is inadequate with NSAIDs does the guideline recommend low doses of oxycodone or hydrocodone, in combination with acetaminophen. Opioids can also be used when NSAIDs are contradicted due to health issues, such as a patient having cardiovascular problems or a bleeding ulcer.

“When opioids are prescribed, clinicians should obtain informed consent from the patient (or the parent or guardian in the case of minors) with detailed information about potential opioid undesirable effects. This is particularly critical in adolescents and young adults who are at increased risk of subsequent misuse and substance use disorder even after a single prescription,” the guideline says.

This is the second of two ADA guidelines on acute dental pain management. A previous set of recommendations for pediatric patients under the age of 12 was published in 2023. It also recommends NSAIDs and acetaminophen as preferred analgesics. Opioids such as codeine and tramadol are not recommended for children under any circumstances.

The risk of long-term opioid use after a tooth extraction is relatively rare. A 2018 study of over 70,000 teens and young adults who had their wisdom teeth removed found that only 1.3% were still being prescribed opioids months after their initial prescription by a dentist.

Should Gabapentin Be Used for Dental Pain?

By Pat Anson, PNN Editor

Since it was first approved as an anti-seizure medication in the 1990’s, gabapentin (Neurontin) has become one of the most widely studied and prescribed drugs in world.  Although gabapentin is only approved by the FDA for epilepsy and postherpetic neuralgia (shingles), it is widely prescribed off-label for fibromyalgia, neuropathy and many other types of pain.

Hundreds of clinical trials have been conducted to find new uses for gabapentin -- for everything from asthma and obesity to alcoholism and improving your sex life. Gabapentin has been pitched for so many different conditions that a drug company executive infamously called it “snake oil.”

Now gabapentin is being touted as a “promising alternative” to opioids for dental pain. In a new study at the University of Rochester Medical Center’s Eastman Institute for Oral Health (EIOH), researchers found that gabapentin, when combined with ibuprofen or acetaminophen, was more effective than opioids in relieving pain after tooth extractions.  

“We hypothesized that using a combination of the non-opioid pain medications and adding gabapentin to the mix for pain would be an effective strategy to minimize or eliminate opioids for dental pain,” said Yanfang Ren, DDS, a dentistry professor at EIOH.   

Ren and his colleagues treated over 7,000 patients at an urgent dental care clinic with different combinations of opioids, ibuprofen, acetaminophen and gabapentin after tooth extractions. The “failure rates” of the medications were determined by how often patients returned to the clinic for additional pain relief.

The study findings, published in JAMA Network Open, found that non-opioid medications, including those with gabapentin, had failure rates significantly lower than opioids.      

Dental Pain Failure Rates

• 0.9% Acetaminophen/ibuprofen

• 3.4% Gabapentin/acetaminophen

• 5.3% Gabapentin/ibuprofen

• 9.2% Codeine/acetaminophen

• 19.4% Hydrocodone/acetaminophen

• 31.3% Other opioid combinations

Providers at the dental clinic have already put their findings into practice by sharply reducing the use of opioids. Prior to that, about 1,800 patients at the clinic were treated each year with opioids. Researchers estimate the reduced opioid prescribing may have prevented 105 of those patients from developing a problem with “persistent opioid use.”

“This study represents continued efforts by our team and other dentists to minimize the use of opioids for dental pain,” said Eli Eliav, DMD, the director of EIOH. “Additional studies, preferably randomized controlled clinical trials, are needed to confirm the safety and effectiveness of this approach. It is our duty to continuously seek safe and effective treatment for our patients in pain.”

Gabapentin has issues of its own. Patients prescribed gabapentin often complain of mood swings, depression, dizziness, fatigue and drowsiness, and a 2019 review found little evidence gabapentin should be used off-label to treat pain. There are also many reports that gabapentin is being abused and sold on the streets because it can heighten the effects of other drugs.