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.

Low-Dose Naltrexone Gaining Recognition as Chronic Pain Treatment

By Pat Anson, PNN Editor

Low-dose naltrexone (LDN) is finally getting some recognition from the medical community as a treatment for chronic pain. The December edition of the Journal of the American Dental Association (JADA) features a cover story on the use of LDN by dentists – not to manage short term pain during dental procedures – but to treat chronic oral and facial pain conditions such as temporomandibular joint disorder (TMJ).

“Low-dose naltrexone provides an alternative in medical management of chronic pain disorders as a novel anti-inflammatory and immunomodulator. It can offer additional management options, as orofacial pain conditions share characteristics with other chronic pain disorders,” wrote Elizabeth Hatfield, DDS, corresponding author and clinical lecturer at the University of Michigan School of Dentistry.  

Few mainstream medical organizations have recognized the benefits of naltrexone as a pain reliever, largely because the drug is only approved by the Food and Drug Administration as a treatment for substance abuse. In 50mg doses, naltrexone blocks opioid receptors in the brain and decreases the desire to take opiates or alcohol.  

But in smaller doses of 5mg or less, patients with a wide variety of pain conditions have found LDN to be a surprisingly effective pain reliever. PNN columnists have shared their positive experiences using LDN to treat everything from interstitial cystitis to Ehlers-Danlos syndrome to fibromyalgia.  

How naltrexone works is not exactly clear – more research is needed – but LDN supporters believe the drug helps modulate the immune system, reducing inflammation and stimulating the production of endorphins, the body's natural painkiller.  

The lack of good quality research on LDN is evident in the JADA article. Hatfield and her colleagues reviewed nearly 800 studies, but could find only eight that met their criteria for evaluation, most of them focused on treating fibromyalgia. Nevertheless, they say LDN could be an effective and less risky alternative to opioids and non-steroidal anti-inflammatory drugs (NSAIDs) for treating chronic oral and facial pain.

"The unique antinociceptive properties mediated via glial cell modulation, as opposed to previously identified pathways of opioids and anti-inflammatories such as NSAIDs, is attractive as it bypasses certain side effects and concerns with long-term NSAID and opioid use," said Hatfield. "Further benefits include reduction in reported pain levels and measurable increases in quality of life for patients with chronic pain disorders. Additionally, it offers an option for prescribers managing temporomandibular joint disorders with a centralized pain component.”

A 2019 review by British researchers found that LDN is safe to use, but also recommended that more clinical studies be conducted on its potential uses.

Because naltrexone is only approved to treat addiction, LDN needs to be prescribed “off-label” for pain. Patients interested in trying LDN often encounter doctors who refuse to prescribe it or don’t know anything about it. The LDN Research Trust includes a list of LDN-friendly doctors and pharmacies on its website.