Analgesics for Dental Pain

Non-opioid analgesics

Drug	Mechanism	Typical adult dosing and limits	Cautions
Ibuprofen	Reversible COX-1 and COX-2 inhibition	200–400 mg every 4–6 h (OTC up to 1,200 mg/day; prescription up to 3,200 mg/day)	GI ulcer and bleeding, kidney disease, heart failure, aspirin-exacerbated asthma, pregnancy from 20 weeks, anticoagulants
Naproxen	Reversible COX inhibition; longer half-life	220–500 mg every 8–12 h	Same as ibuprofen
Aspirin	IRREVERSIBLE COX-1 inhibition (acetylation)	325–650 mg every 4 h for pain; 81 mg daily for cardioprotection	Platelet effect lasts the platelet lifespan (about 7–10 days); Reye syndrome in children with viral illness
Celecoxib	Selective COX-2 inhibition	Prescription	Less GI harm, but cardiovascular risk; sulfonamide allergy
Acetaminophen	Central COX inhibition; little anti-inflammatory or antiplatelet effect	325–1,000 mg every 4–6 h; maximum 4 g/day (many clinicians use 3 g/day)	Liver toxicity (NAPQI) with overdose, alcohol use or liver disease; antidote N-acetylcysteine

For acute dental pain in adults, the 2024 ADA guideline recommends NSAIDs alone or combined with acetaminophen (for example ibuprofen 400 mg plus acetaminophen 500–1,000 mg) as first-line, ahead of opioids.

Drug	Points to remember
Codeine	Prodrug converted to morphine by CYP2D6; ultra-rapid metabolizers risk overdose; FDA contraindicates it under age 12 and after tonsil or adenoid surgery under 18
Tramadol	Weak μ agonist plus serotonin and norepinephrine reuptake inhibition; seizures and serotonin syndrome risk; same pediatric restriction as codeine
Hydrocodone, oxycodone	Schedule II; usually combined with acetaminophen (watch the acetaminophen total)
Naloxone	Competitive opioid antagonist for overdose; short-acting, so respiratory depression can return

Opioid adverse effects: respiratory depression, sedation, nausea, constipation and miosis (tolerance does not develop to constipation or miosis).
If an opioid is truly needed: lowest effective dose, shortest duration (typically no more than a few days), check the state prescription monitoring program, and never combine with benzodiazepines without strong reason (boxed warning).

Anticoagulants and antiplatelets: more bleeding.
ACE inhibitors, ARBs, diuretics, β-blockers: weaker blood pressure control and kidney risk (ACE inhibitor/ARB + diuretic + NSAID is the 'triple whammy').
Lithium and methotrexate: reduced renal clearance → toxicity.
Ibuprofen taken before low-dose aspirin can block aspirin's antiplatelet effect.

Treating acetaminophen as anti-inflammatory.
Prescribing codeine for a 10-year-old.
Assuming aspirin's antiplatelet effect wears off in 24 hours: it lasts for the life of the platelet.
Exceeding the acetaminophen maximum by stacking an opioid–acetaminophen combination with OTC acetaminophen.

Pick an answer to see right away whether it is correct and why.

Which analgesic irreversibly inhibits COX-1 in platelets?
First-line management of moderate acute dental pain in a healthy adult per the 2024 ADA guideline is:
Why is codeine contraindicated in young children?
A patient on lisinopril and hydrochlorothiazide needs pain control for a week. Which concern applies to regular NSAID use?
The antidote for acetaminophen overdose is:

0 of 5 answered

Answer key: 1 C · 2 A · 3 C · 4 C · 5 B

Dental School Map · Original study material, written and checked by our team; always confirm clinical decisions against current guidelines.