should be the first-line treatment for post-procedure pain.1,4 Several randomized con- trolled trials found that combining NSAIDs and acetaminophen may provide better anal- gesia than ibuprofen or acetaminophen alone.1,4 More important, research also suggests the combination of NSAIDs and acetaminophen may provide more effective analgesia than opioids alone, and with fewer side effects.4 While opioids act on the mu opioid receptor, NSAIDs and acetaminophen have differ- ent mechanisms of action. Specifically, NSAIDs are competitive cyclooxygenase (COX) inhibitors that decrease production of inflammatory mediators.4 Acetaminophen acts cen- trally to control pain through several proposed mechanisms and is also a weak COX inhibitor.1 Patient and Procedure Specific Prescribing an appropriate pain management regimen is patient and procedure specific. It begins with a thorough patient assessment; in addition, case management should include patient education regarding post-procedure expectations. By better understanding a patient’s expectations and history with pain management, the clinician can better formulate an appropriate pain procedure plan. Pain management strategies should use multimodal therapy and be strat- ified based on the expected level of discomfort.1 Mild post-procedure pain can be expected from many general dental procedures. Examples include simple root canals, restorations, crown preparations, simple extractions, and single implant placement. For this type of pain, 400 to 600 mg ibuprofen taken every 4 to 6 hours as needed for pain typically pro- vides sufficient analgesia. For more complex procedures — such as complex root canals and retreatments, apicoectomies, simple tissue grafts, surgical extractions, and multiple implant placements with grafting — moderate pain can be expected. Studies support 400 to 600 mg ibuprofen in combination with 325 to 500 mg acetaminophen every 4 to 6 hours to manage moderate pain for the first 24 hours, followed by the combination every 4 to 6 hours as needed.1,4 While not common in general dental procedures, severe pain can be expected following complex oral and maxillofacial surgery, as well as extensive tissue grafts. In these cases, 400 to 600 mg ibuprofen and 325 to 500 mg acetaminophen every 4 to 6 hours for the first 24 hours can be supplemented with 5 mg of hydrocodone or oxycodone every 4 to 6 hours as needed for breakthrough pain.1,4 Following 24 to 48 hours, the opioid may be eliminated.4 For patients without contraindications to these medications, the maximum daily dose for ibuprofen is 3,200 mg, while the maximum daily dose of acetaminophen is 3,000 mg (Table 1, page 43).1,4 The United States Food and Drug Administration maximum total daily dose of acetaminophen increases to 4,000 mg with the direction of a healthcare professional.5 The combination of ibuprofen and acetaminophen became commercially available in 2020 in a pill that contains 125 mg ibuprofen and 250 mg acetaminophen per tablet. The combination is innovative and may be beneficial, as it has the potential to simplify instructions for patients by hav- ing them take a combination pill instead of two separate medications. However, the commercially available dose may present a challenge for post-procedure pain management in dentistry. In the case of moderate pain, for example, where the suggestion is 400 to 600 mg of ibuprofen, a patient would require four tablets. These same four tablets would also include 1,000 mg of acetaminophen, which may exceed the maximum daily dose if taken every 4 to 6 hours as recommended. For some patients, this method of pain relief may not be possible, as NSAIDs should be avoided in those who have an NSAID allergy or risk for gastric ulcers and renal issues, or a history CRAIG McKENZIE, DMD, MSEd, is a resident in the Department of Dental Anesthesiology at the University of Pittsburgh School of Dental Medicine. JOSEPH A. GIOVANNITTI Jr., DMD, is a professor and chair of the Department of Dental Anesthesiology at the University of Pittsburgh School of Dental Medicine. He is also director of anesthesiology for the University of Pittsburgh School of Dental Medicine Center for Patients With Special Needs. Giovannitti can be reached at: [email protected]. The authors have no commercial conflicts of interest to disclose. dimensionsofdentalhygiene.com July/August 2023 • Dimensions OF DENTAL HYGIENE 43 Severe pain can be expected following complex oral and maxillofacial surgery
