Odontogenic pain

Most odontogenic pain can be relieved effectively by non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin, which have anti-inflammatory activity. Paracetamol is also effective in the management of odontogenic or post-operative pain but has no demonstrable anti-inflammatory activity. Aspirin is a potent and useful NSAID but avoid its use in children and those with an aspirin allergy, and do not prescribe following a dental extraction or other minor surgery. Pyrexia in children can be managed using paracetamol or ibuprofen. Both drugs can be given alternately to control ongoing pyrexia without exceeding the recommended dose or frequency of administration for either drug.

Cautions

Paracetamol is a safe, well tolerated drug with few side effects when used as directed. However,
staggered overdose, where an excessive dose of paracetamol or paracetamol-containing
preparations is ingested over a period of hours, can lead to hepatotoxicity. Acute dental pain
may lead to such unintentional overdose, as patients may unknowingly take more than one
paracetamol-containing preparation in order to control their discomfort.

All patients, including children, should be referred to an emergency department if they have
ingested paracetamol at a dose of 75 mg/kg or greater, either as a single acute dose or staggered
across a 24 hour period.18 Patients who are uncertain about the timing of doses or the total
amount ingested should also be referred. Note that patients who have taken the appropriate
recommended therapeutic dose (e.g. for adults this 8 x 500 mg paracetamol tablets in 24 hours)
do NOT need to be referred. However an adult patient, for example, who weighs 60 kg (9 stone 6
lbs) or less and has ingested nine paracetamol tablets within a 24 hour period should be referred.
For more information, see the National Poisons Information Service (www.npis.org).

Avoid the use of all NSAIDs in patients with a history of hypersensitivity to aspirin or any other
NSAID, including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been
precipitated by aspirin or any other NSAID. All NSAIDs cause gastrointestinal irritation and
therefore avoid in patients with previous or active peptic ulcer disease. However, if NSAIDs are
required to provide pain relief in these patients, a proton pump inhibitor can be prescribed in
conjunction with the NSAID. In addition, use NSAIDs with caution in the elderly, patients with
allergic disorders, pregnant women, nursing mothers, those taking oral anticoagulants such as
warfarin, those with coagulation defects and those with an inherited bleeding disorder. NSAIDs
might impair renal function and so use with caution in patients with renal, cardiac or hepatic
impairment. Some patients may already take a daily low-dose of aspirin, in these cases do not
prescribe NSAIDs as these can increase the risk of gastro-intestinal side-effects. More information
on potential NSAID drug interactions is provided in Supporting tools.

The NSAID diclofenac is also effective against moderate inflammatory or post-operative pain. However, be aware that diclofenac is contra-indicated in ischaemic heart disease, cerebrovascular disease, peripheral arterial disease and mild to severe heart failure and should be used with caution in patients with a history of cardiac failure, left ventricular disfunction, hypertension, in patients with oedema for any other reason, and in patients with other risk factors for cardiac events

The BNF (BNF 88) does not recommend the use of dihydrocodeine as it is relatively ineffective against dental pain and also causes nausea and constipation. There is also the potential for abuse of dihydrocodeine; therefore, if the drug is to be used, prescribe only the minimum number of tablets required.

Prescribe analgesics only as a temporary measure for the relief of pain, and ensure the underlying cause is managed. Base the choice of analgesic on its suitability for the patient.