What evidence addresses acute pain after a tooth extraction?

DISCUSSION

Pain results from inflammatory response created by tissue damage. Tooth extraction is the most likely pediatric dental procedure to produce inflammation and pain. In the current study, pretreatment with ibuprofen and acetaminophen exhibited significant differences in pain scores compared to placebo. Moreover, ibuprofen seems to be the most effective analgesic, and it resulted in significantly lower pain scores (p < 0.05) compared to that of acetaminophen. Additionally, only ibuprofen significantly reduced pain scores (p < 0.05) compared to placebo at the points immediately after extraction and at 5 h after extraction. This is because ibuprofen has excellent analgesic and anti‐inflammatory properties, which are especially important following dental extractions. It acts in the periphery to inhibit the initiation of pain signals by cyclooxygenase inhibition, which in turn prevents prostaglandin synthesis following tissue injury (Dionne et al., 1983).

Comparison of preemptive ibuprofen, acetaminophen, and placebo administration in reducing peri‐ and postoperative pain in primary tooth extraction: A randomized clinical trial. © 2021 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

INTRODUCTION

Several studies have been shown that preoperative oral usage of analgesics was beneficial in postoperative pain relief compared to placebo (Gazal & Mackie, 2007; Perrott et al., 2004; Shafie et al., 2018). Regarding the extraction‐related pain, Dental literature indicates that preoperative administration of analgesics can decrease post‐extraction pain scores in adults (Isiordia‐Espinoza et al., 2012; Pozos‐Guillen et al., 2007). However, a recent systematic review by Ashley et al. (2016) stated that Controversial reports can be observed about the efficacy of pre‐emptive analgesia used on post‐operative pain relief in pediatric populations, and the available evidence is not sufficient to determine whether preoperative analgesics administration can reduce postoperative pain in children after tooth extraction under local anesthetics.

Comparison of preemptive ibuprofen, acetaminophen, and placebo administration in reducing peri‐ and postoperative pain in primary tooth extraction: A randomized clinical trial. © 2021 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction

In recent years, dry socket, a common painful complication after tooth extraction, has posed a challenge in clinical management in the field of oral medicine [1,2]. The main characteristic of dry socket is pain in the tooth socket, typically intensifying on the second or third day after extraction, often accompanied by delayed healing. After tooth extraction, healthy individuals recover quickly without severe pain, while patients who develop dry socket suffer severe pain due to direct exposure of bone and nerves to the oral environment. The most direct connection between different post-extraction manifestations is the variation in oral microbiota.

Correlation between oral microbiota and dry socket at different time periods on tooth extraction. © 2025 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction

Tooth extractions remain among the most frequently performed dental procedures and the oldest oral surgical procedure [1]. The patient’s quality of life, including their ability to speak, eat, and feel, may be compromised by this procedure. While complications during tooth extraction are minimally expected, post-extraction complications such as pain, swelling, trismus, dry socket, ulcers, paresthesia, and bleeding frequently occur [2]. Fortunately, most complications following dental extractions can be avoided by following proper clinical procedures and complying with precise postoperative instructions. Researchers have repeatedly emphasized the need for and importance of patient education and compliance following a tooth extraction to reduce health burden and improve patient quality of life [3]. Non-compliant patients have been reported to have an exponentially higher incidence of dry socket (57.1%) post-extraction [4], thereby highlighting the importance of understanding and complying with postoperative instructions.

Effectiveness of Phone Call Follow-Ups in Improving Patient Compliance to Post-extraction Instructions: A Cross-Sectional Study. Copyright © 2022, Ramalingam et al. Creative Commons Attribution 3.0 International (https://creativecommons.org/licenses/by/3.0/).

1. Introduction

The most common signs and symptoms after lower third molar extraction are post-surgical pain, facial swelling, and trismus [1,2,3,4]. These complications are closely related to soft tissue trauma and osteotomy during the surgical procedure [4,5]. The most intense postoperative pain occurs during the second and sixth hours after the extraction of the third molar, and some episodes can even occur during the next seven days [6,7]. Swelling and trismus reach their critical point between the second and third day and disappear approximately 1 week after surgery [8,9]. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first option to control complications in oral surgery [10]. Particularly, ibuprofen is one of the most used drugs by general dentists and specialists worldwide for the control of inflammatory complications after third molar removal [11,12]. Besides, other NSAIDs are also broadly used for this purpose (e.g., diclofenac and paracetamol) [13,14,15]. This kind of drug induces its therapeutic and adverse effects by the inhibition of the cyclooxygenase enzyme [10,11,12,13,14,15].

A Meta-Analysis of the Analgesic Efficacy of Single-Doses of Ibuprofen Compared to Traditional Non-Opioid Analgesics Following Third Molar Surgery. © 2021 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Introduction

The healing of a tooth socket after a simple exodontia or dental surgery has been studied to detect any alterations that could lead to postoperative complications, such as a bacterial or fungal infection and alveolar osteitis (1 - 4). Alveolar osteitis-commonly known as post-extraction alveolitis, dry socket, as well as necrotic socket-is a painful clinical condition that occurs during the initial days after tooth extraction (5 - 9). Clinically, it is characterized by the total or partial absence of a blood clot within the tooth socket, bare bone, severe nerve symptoms, and halitosis (6 - 9).

Cyclooxygenase-2 selective inhibitors increase the risk of alveolar osteitis: A systematic review and meta-analysis. Copyright: © 2026 Medicina Oral S.L. Creative Commons Attribution 2.5 International (https://creativecommons.org/licenses/by/2.5/).

Abstract

This study compares the effectiveness of pharmacological treatments to develop guidelines for the management of acute pain after tooth extraction. We searched Medline, EMBASE, CENTRAL, and US Clinical Trials registry on November 21, 2020. We included randomized clinical trials (RCTs) of participants undergoing dental extractions comparing 10 interventions, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations to placebo. After duplicate screening and data abstraction, we conducted a frequentist network meta-analysis for each outcome at 6&#x2009;h (i.e., pain relief, total pain relief [TOTPAR], summed pain intensity difference [SPID], global efficacy rating, rescue analgesia, and adverse effects). We assessed the risk of bias using a modified Cochrane RoB 2.0 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach. We implemented the analyses in RStudio version 3.5.3 and classified interventions from most to least beneficial or harmful. We included 82 RCTs. Fifty-six RCTs enrolling 9,095 participants found moderate- and high-certainty evidence that ibuprofen 200 to 400&#x2009;mg plus acetaminophen 500 to 1,000&#x2009;mg (mean difference compared to placebo [MDp], 1.68; 95% confidence interval [CI], 1.06-2.31), acetaminophen 650&#x2009;mg plus oxycodone 10&#x2009;mg (MDp, 1.19; 95% CI, 0.85-1.54), ibuprofen 400&#x2009;mg (MDp, 1.31; 95% CI, 1.17-1.45), and naproxen 400-440&#x2009;mg (MDp, 1.44; 95% CI, 1.07-1.80) were most effective for pain relief on a 0 to 4 scale. Oxycodone 5&#x2009;mg, codeine 60&#x2009;mg, and tramadol 37.5&#x2009;mg plus acetaminophen 325&#x2009;mg were no better than placebo. The results for TOTPAR, SPID, global efficacy rating, and rescue analgesia were similar. Based on low- and very low-certainty evidence, most interventions were classified as no more harmful than placebo for most adverse effects. Based on moderate- and high-certainty evidence, NSAIDs with or without acetaminophen result in better pain-related outcomes than opioids with or without acetaminophen (except acetaminophen 650&#x2009;mg plus oxycodone 10&#x2009;mg) or placebo.

Abstract

BACKGROUND: A panel convened by the American Dental Association Science and Research Institute, the University of Pittsburgh, and the University of Pennsylvania conducted systematic reviews and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after simple and surgical tooth extraction(s) and for the temporary management (ie, definitive dental treatment not immediately available) of toothache associated with pulp and periapical diseases in adolescents, adults, and older adults. TYPES OF STUDIES REVIEWED: The panel conducted 4 systematic reviews to determine the effect of opioid and nonopioid analgesics, local anesthetics, corticosteroids, and topical anesthetics on acute dental pain. The panel used the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations, Assessment, Development and Evaluation Evidence-to-Decision Framework to formulate recommendations. RESULTS: The panel formulated recommendations and good practice statements using the best available evidence. There is a beneficial net balance favoring the use of nonopioid medications compared with opioid medications. In particular, nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications are first-line therapy for managing acute dental pain after tooth extraction(s) and the temporary management of toothache. The use of opioids should be reserved for clinical situations when the first-line therapy is insufficient to reduce pain or there is contraindication of nonsteroidal anti-inflammatory drugs. Clinicians should avoid the routine use of just-in-case prescribing of opioids and should exert extreme caution when prescribing opioids to adolescents and young adults.

Abstract

BACKGROUND: A guideline panel convened by the American Dental Association Council on Scientific Affairs, American Dental Association Science and Research Institute, University of Pittsburgh School of Dental Medicine, and Center for Integrative Global Oral Health at the University of Pennsylvania conducted a systematic review and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions and the temporary management of toothache (that is, when definitive dental treatment not immediately available) associated with pulp and furcation or periapical diseases in children (<&#x2009;12 years). TYPES OF STUDIES REVIEWED: The authors conducted a systematic review to determine the effect of analgesics and corticosteroids in managing acute dental pain. They used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. RESULTS: The panel formulated 7 recommendations and 5 good practice statements across conditions. There is a small beneficial net balance favoring the use of nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen compared with not providing analgesic therapy. There is no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications, specifically nonsteroidal anti-inflammatory&#xa0;drugs like ibuprofen and naproxen alone or in combination with acetaminophen, are recommended for managing acute dental pain after 1 or more tooth extractions (that is, simple and surgical) and the temporary management of toothache in children (conditional recommendation, very low certainty). According to the US Food and Drug Administration, the use of codeine and tramadol in children for managing acute pain is contraindicated.

Abstract

BACKGROUND: Opioids are still being prescribed to manage acute postsurgical pain. Unnecessary opioid prescriptions can lead to addiction and death, as unused tablets are easily diverted. METHODS: To determine whether combination nonopioid analgesics are at least as good as opioid analgesics, a multisite, double-blind, randomized, stratified, noninferiority comparative effectiveness trial was conducted, which examined patient-centered outcomes after impacted mandibular third-molar extraction surgery. Participants were randomized to receive 5 mg of hydrocodone with 300 mg of acetaminophen (opioid) or 400 mg of ibuprofen and 500 mg of acetaminophen (nonopioid). After an initial dose, analgesic was taken every 4 through 6 hours as needed for pain. RESULTS: In this randomized multisite clinical trial (n&#xa0;= 1,815 adults), those not taking opioids experienced significantly less pain (numeric rating scale ranging from 0 [no pain] through 10 [worst pain imaginable]) for first day and night (mean difference, -0.70; 95% CI, -0.94 to -0.45; P < .001) and second day and night (mean difference, -0.28; 95% CI, -0.52 to -0.04; P&#xa0;= .015), and experienced no more pain than participants taking opioids over the entire postoperative period (mean difference, -0.20; 98.75% CI, -0.45 to 0.05; P&#xa0;= .172). Participants not taking opioids had higher overall satisfaction at the postoperative visit (85.3% extremely satisfied or satisfied vs 78.9%; 95% CI, 1.21 to 1.98; P&#xa0;= .006). CONCLUSIONS: The ibuprofen and acetaminophen combination managed pain better for the first 2 days and led to greater satisfaction over the entire postoperative period than hydrocodone with acetaminophen. At no time did hydrocodone outperform the nonopioid. PRACTICAL IMPLICATIONS: Routine opioid prescribing after dental surgery is not supported. The results of this study confirmed the American Dental Association's recommendations that ibuprofen and acetaminophen in combination should be the first-line therapy for acute pain management. This clinical trial was registered at ClinicalTrials.gov. The registration number is NCT04452344.