Routine Care

It's not uncommon to experience pain or discomfort from oral conditions or following some types of dental treatment. For most people, this is both tolerable and temporary. However, there are some conditions or treatments that may require the use of medication to address pain or discomfort.

Your dentist will recommend an appropriate strategy to help you or a family member manage these situations, but you should be aware of the potential risks of some pain medications. These medications can interact with other drugs and/or lead to dependency or overdose. This is particularly true of opioid medications, which are prescribed by dentists far more frequently than you may realize. This is particularly important to understand if you have a child that is a teenager, or for older adults.

About dental pain

Acute dental pain is often due to underlying conditions like tooth decay, infections, periodontal disease, or dental procedures such as tooth removal, periodontal surgery, or dental implants. It's important to remember that acute pain often subsides quickly following treatment and healing. Pain lasting longer than three months is uncommon, considered chronic, and should be evaluated by a dentist.¹

Analgesics (like acetaminophen) and anti-inflammatories (like aspirin and ibuprofen) are the most commonly recommended medications for dental pain. In more severe cases, your dentist may prescribe stronger non-opioid or opioid-based medications, but those are typically only recommended when analgesics cannot effectively manage your pain.

Your dentist should offer a pain management strategy that is specific to you. Their suggestions will be influenced by many things, including a review of your health status. Failing to follow your doctor's recommended pain management strategy may make it more difficult to keep your pain under control. That said, if you feel that you can tolerate discomfort with less or no medication, it is generally safe to do so.

Never self-prescribe additional medications or treatments without consulting your dentist.

Types of pain medications

There are two types of analgesic medications normally recommended or prescribed following dental procedures that are expected to cause temporary pain, inflammation, or bruising. They may be recommended for use either alone or in a combination.

Nonopioid analgesics

Nonopioid analgesics are a class of drugs that include "nonsteroidal anti-inflammatory drugs" (NSAIDs). Examples of NSAIDs include ibuprofen, naproxen, celecoxib, and aspirin. They can be obtained over-the-counter or in prescription dosages.

In general, NSAIDs inhibit an enzyme the body produces as part of the process that causes inflammation, fever, and pain. They help with pain by reducing inflammation at the site where it occurs. NSAIDs do have a "ceiling of effectiveness," meaning that taking more than the recommended dosage will not provide additional pain relief.

Alternatively, acetaminophen acts centrally by blocking the transmission of pain signals within the central nervous system. Acetaminophen is not an NSAID, as it does not reduce inflammation.

Opioid analgesics

Opioids are often prescribed to treat moderate to severe acute dental pain. They include drugs such as oxycodone, hydrocodone, and codeine. They are only legally available by prescription. Opioids do not target inflammation. They only interfere with the perception of pain at the level of the central nervous system. These drugs are usually prescribed in combination with NSAIDs or acetaminophen to relieve temporary pain and reduce inflammation.

When not properly prescribed or used as directed, opioids can present a significant risk of dependence or addiction. This is of particular concern for adolescents, who are often inappropriately or over-prescribed these drugs following procedures such as wisdom tooth removal. You should educate yourself on the risks of opioids, and be sure to talk to your dentist about any questions you have.

Opioids do NOT have "a ceiling of effectiveness," which is the point where additional dosage does not provide additional relief. This can be a key contributor to overuse and addiction.

The American Dental Association (ADA) supports limiting opioid dosages and limiting opioid duration to no more than three days.² This is consistent with the Centers for Disease Control and Prevention (CDC) guidelines.

As another alternative to opioids, many dentists and oral surgeons are now administering a long-acting local anesthetic called bupivacaine liposome. With this local anesthetic, the injection area typically remains numb for a few days, which extends throughout the typical period of post-treatment pain.

Developing an appropriate pain management strategy

Your dentist will consider a variety of medications and medication combinations when developing a pain management strategy. There is no specific regimen that is guaranteed to produce the right level of pain relief for everyone in every situation. Your dentist will consider all factors, including your health, lifestyle, and medications you take when recommending an appropriate strategy.

Pain control following dental treatment is usually achieved by targeting the source of the pain, which typically is inflammation. Studies have shown that a combination of an NSAID (to target inflammation) and acetaminophen (to block pain signals in the nervous system) is just as effective as regimens that include opioids.³ This approach is also associated with a lower risk of adverse effects, including addiction.

The ADA adopted a statement on opioid use in 2016 that specifically states, "Dentists should consider nonsteroidal anti-inflammatory analgesics (NSAIDs) as the first-line therapy for acute pain management."²

Before the procedure

• Review your health status: You will share information that will help ensure that your dentist and their staff can provide safe and effective treatment and provide appropriate post-care guidance. Get important information here: Health history and current health status.

After the procedure

• Follow-up care: Follow all prescription instructions regarding dosage and frequency. If your dentist recommends over-the-counter pain relievers, make sure you purchase the correct medication. If you can tolerate any discomfort without medication or for longer periods than initially suggested, it is generally safe to do so. As a general rule, try to stay ahead of the pain. For certain procedures, your dentist may prescribe an antibiotic to reduce the amount of bacteria entering your bloodstream to reduce the chance of infection.

• Unnecessary Emergency Department or Urgent care visits: While dental issues may be upsetting or uncomfortable, most are not life-threatening situations and don't require a trip to an emergency department or urgent care facility. Dentists are well-equipped to stabilize the problem, relieve your pain, and develop treatment strategies to address the underlying problem. A recent report by the National Institutes of Health states that dental care provided in hospital emergency departments resulted in an estimated 90% of patients only receiving pain medications or antibiotics without dental treatment. They were referred to a dentist for care. This same report suggested that opioid prescriptions are up to five times more likely when dental care is treated in a hospital emergency department or urgent care facility rather than a dental office.⁴
• Potential for abuse: Opioids bind to and activate receptors on cells in many areas of the brain, spinal cord, and other organs, especially those involved with feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience, even when it is no longer required for managing pain. It is also important to note that the FDA recently warned that buprenorphine, an opioid painkiller that may also be used to ease opioid withdrawal symptoms, has been associated with oral problems. These problems may include infections, tooth decay and tooth loss, and have been known to occur when buprenorphine is administered as a tablet that dissolves under the tongue or a film that is applied to the inside of the mouth.
• Use only as intended: Taking medications for longer than prescribed or for purposes other than intended can lead to significant health problems, addiction, or overdose. Pay attention to how you feel when you're about to retake a prescribed medication. If you aren't feeling pain, don't take the medication.
• Use only what you need: Pain medications should only be used temporarily to reduce symptoms from a dental emergency until you can have the problem addressed or following certain planned treatments that may cause discomfort. Stop taking the medication as soon as you feel you can tolerate your pain without it. If you can tolerate discomfort without medication, it is generally safe to do so.
  • Prolonged use of NSAIDs can have negative effects on your gastrointestinal (GI) tract and kidneys. The most common adverse effect with NSAID use is GI toxicity, which can result in symptoms such as nausea, heartburn, abdominal pain, and bleeding.
• Secure your medications: Keep all medications out of the reach of children. Be sure to secure all medications to prevent inappropriate use by others. Accidentally or intentionally taking medications for purposes other than they are intended can have significant impacts on your or a family member's health.
• Monitor your family's medications: Monitor your family's use of medications closely. Make sure they are only using the medication as instructed, and look for possible adverse reactions. If you notice any signs of abnormal reactions, contact your poison control center immediately, and notify your physician and dentist as soon as possible.
• Properly dispose of medications when you no longer need them: When you're done taking a medication, remove it from your home and dispose of it safely by returning it to the pharmacy. Don't dispose of the medication in the trash or the toilet.
• Pregnancy: Taking opioids during pregnancy may have severe effects on an unborn child. Using opioids while pregnant can lead to miscarriage, low birth weight, and an addiction to opioids in newborns.
• Aging: Older adults are at higher risk of accidentally misusing medication because they may have multiple prescriptions. This increases the risk of drug-to-drug and drug-to-disease interactions. Other concerns for seniors may include:
  • A slower metabolism that affects the breakdown of drugs.
  • Difficulty in remembering recommended dosages and time between doses.
  • Movement disorders (ataxia) which can put people at a higher risk of falling when taking opioid medications.
• Aspirin and blood thinners: If you are taking blood thinner medication, it may be better to avoid aspirin as part of your dental pain management. For some people, combining blood thinners with aspirin could result in excessive bleeding during dental treatment. It is critical to talk to your dentist about blood thinners (and all medications) that you take.
• NSAIDs and blood clotting medication: If you are taking medication to prevent blood clots, acetaminophen may be a good pain relief alternative. Acetaminophen has less effect on blood clotting than NSAIDs and may help reduce or avoid excessive bleeding.
• Asthma or kidney disease: Some conditions, like asthma or kidney disease, might also make acetaminophen a more appropriate pain relief alternative. Discuss it with your doctor or pharmacist if you're not sure.
• Acetaminophen and your liver: Excessive doses of acetaminophen (over-the-counter or prescribed), or use for prolonged periods, can have serious effects on your liver. Many over-the-counter products such as cold and flu medications contain acetaminophen as an active ingredient, so it is important to keep track of all of your sources of acetaminophen. If you think you've taken too much acetaminophen, get to an emergency room immediately. There is a reversal drug available, but it cannot be obtained over-the-counter.

Pain medications are only intended for temporary use. If you can tolerate discomfort without medication, it is generally safe to do so.

For certain dental procedures, temporary mild to moderate discomfort is inevitable. The goal of dental pain management is to "stay ahead of the pain" so discomfort doesn't deteriorate into pain. Failing to follow your doctor's recommendations can allow pain to increase and make it more difficult to bring under control. On the other hand, if you can tolerate any discomfort without taking medication, it is generally safe.

• What are the advantages of nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for pain management?
• Are there adverse effects that could result from the pain medication you recommend and other medications I'm taking?
• If I can tolerate my pain without medication, should I still take them?
• If you are prescribed an opioid for pain, ask your dentist, pharmacist, or emergency department attendant the following questions before taking the medication:
  • What is the goal of this prescription?
  • Are there any risks for me from this medication?
  • When and how should I take these?
  • How long should I take these drugs?
  • Based on my health status, is there any reason your recommended dose or frequency should be altered?
  • How should I dispose of any leftover medication?