**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
---
**Post-Operative Pain Management**
**Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT
Specialist Endodontist
Winthrop Professor of Clinical Dentistry
School of Dentistry
The University of Western Australia
---
**Managing Dental Pain**
**The 3-D’s**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs**
---
*2nd Year DMD - 2020*
*Page 1*
# **Post-Operative Pain Control**
**W/Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT
Specialist Endodontist
Winthrop Professor of Clinical Dentistry
School of Dentistry
The University of Western Australia
> [!note]
> This lecture focuses on the principles and practical strategies for managing a patient's pain *after* dental treatment has been completed, building upon the concepts of managing pain *during* treatment.
## **Managing Dental Pain: The 3-D’s**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs*
> [!info] The 3 D's Explained
> 1. **Diagnosis:** A thorough process involving history taking, clinical examination, and special tests to arrive at an accurate diagnosis. This is the foundation for all subsequent steps.
> 2. **Dental Treatment:** Performing the correct dental procedure based on the diagnosis to address the source of the pain.
> 3. **Drugs:** The use of medication to manage any residual or post-operative pain. If the first two D's are performed well, the need for powerful drugs is often reduced.
*
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
---
**The 3 D’s - Principles for Managing Dental Pain**
**① Diagnosis**
*(Image: Clinical photos and radiograph illustrating diagnostic procedures)*
---
**The 3 D’s - Principles for Managing Dental Pain**
**① Diagnosis**
**② Dental Treatment**
*(Image: Clinical photos showing dental treatment procedures)*
---
*2nd Year DMD - 2020*
*Page 2*
### **The 3 D’s - Principles for Managing Dental Pain**
**① Diagnosis**
*(Image: Clinical photos and radiograph illustrating diagnostic procedures)*
**② Dental Treatment**
*(Image: Clinical photos showing dental treatment procedures)*
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 3
---
**Pain Relief after Dental Treatment**
Hargreaves & Baumgartner - 2006
No “active” pain medication given - Placebo only
Commence Root Canal Treatment
- Infected Root Canal Systems
N = 561
18%
28%
100%
75%
50%
25%
0%
Post-op pain relative to pre-operative pain (100%)
---
**Pain Relief after Dental Treatment**
Hargreaves & Baumgartner - 2006
Weighted average
Weighted average
Pulpotomy - Irreversible Pulpitis
N = 481
5
6
![]()
Chart showing post-op pain relative to pre-operative pain with weighted average and 18% label for pulpotomy case
## **Pain Relief after Dental Treatment**
> [!note]
> Even with a correct diagnosis and well-executed treatment, patients may still experience post-operative pain.
> - A study on patients given a placebo after appropriate dental treatment showed that while pain levels drop dramatically (especially for those with severe pre-operative pain), they do not fall to zero immediately.
> - Pain can take several days to resolve completely.
> - In cases of mild to moderate pre-operative pain, there can be a temporary *increase* in post-operative pain before it begins to taper off.
### **Study: Hargreaves & Baumgartner - 2006**
- No “active” pain medication given - Placebo only
- **Commence Root Canal Treatment**
- Infected Root Canal Systems
- N = 561
- **Post-op pain relative to pre-operative pain (100%):**
- 18%
- 28%
- **Pulpotomy - Irreversible Pulpitis**
- N = 481
- Weighted average pain reduction.
> [!info] Study Conclusion
> This data underscores that some level of post-operative pain is expected, making the third
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
---
**The 3 D’s - Principles for Managing Dental Pain**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs**
> *If these two are done correctly, then drugs are very rarely needed*
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- Local
- Systemic
---
2nd Year DMD - 2020
Page 4
### **The 3 D’s - Principles for Managing Dental Pain**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs**
> *If these two are done correctly, then drugs are very rarely needed*
## **Managing Dental & Oral Pain with Drugs / Medication**
- **Local**
- **Systemic**
# Post-Operative Pain Control
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 5
## Managing Dental & Oral Pain
- **Drugs / Medication**
- **Local**
- **Local Anaesthetic**
- Effective intra-operative anaesthesia helps to reduce post-operative pain
- Can use long-acting LA
- e.g. Bupivacaine + adrenaline (Marcaine)
## Managing Dental & Oral Pain
- **Drugs / Medication**
- **Local**
- **Local Anaesthetic**
- **Topical**
- Mouthwashes, creams, gels, ointments
- After surgery, trauma, etc.
### **Local Medication**
- **Local Anaesthetic**
- Effective intra-operative anaesthesia helps to reduce post-operative pain
- Can use long-acting LA
- e.g. Bupivacaine + adrenaline (Marcaine)
- **Topical**
- Mouthwashes, creams, gels, ointments
- After surgery, trauma, etc.
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 6
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- **Local**
- → Local Anaesthetic
- → Topical
- → **Intra-dental**
- ○ Pastes → Intra-canal
- ○ Cements → On dentine
![]()
Figure showing two slides with images of dental products under "Managing Dental & Oral Pain" with bullet points for local medications including pastes and cements.
- **Intra-dental**
- Pastes → Intra-canal
- Cements → On dentine
- ==Materials like Zinc Oxide Eugenol (e.g., IRM) or calcium hydroxide liners (e.g., Dycal) use their chemical properties for therapeutic effects on the dentine-pulp complex.==
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 7
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- **Local**
- *Deliver drugs to the site of required action*
- e.g. pulp, periapical tissues, periodontal tissues
- *Faster action*
- No time delay waiting for GIT absorption
- *Safer*
- Avoids systemic complications and side effects
- *No patient compliance problems*
- Rogers et al J Endod 1999
**Post-Operative Pain**
Rogers et al J Endod 1999
![]()
Bar chart comparing mean pain scores at 6, 12, 24, and 48 hours for Ibuprofen (oral), Placebo (oral), and Dexamethasone (intra-canal), with asterisks indicating significant differences.
#### **Advantages of Local Medication**
- *Deliver drugs to the site of required action*
- e.g. pulp, periapical tissues, periodontal tissues
- *Faster action*
- No time delay waiting for GIT absorption
- *Safer*
- Avoids systemic complications and side effects
- *No patient compliance problems
- *Proven Efficacy*
- ==A study comparing post-operative pain relief showed that an intracanal corticosteroid (*dexamethasone*) was significantly more effective and provided more rapid pain reduction than oral *ibuprofen* or a placebo.==
*
- Rogers et al J Endod 1999
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 8
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- *Local*
- *Systemic*
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- *Local*
- *Systemic*
- → Anti-microbial
- → Analgesic
- → Anti-inflammatory
**Depends on the DIAGNOSIS !!!**
### **Systemic Medication**
- Anti-microbial
- Analgesic
- Anti-inflammatory
**Depends on the DIAGNOSIS !!!**
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 9
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- Local
- **Systemic**
- → Anti-microbial
- → **Analgesic**
- → Anti-inflammatory
**Depends on the DIAGNOSIS !!!**
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- Local
- **Systemic**
- → Anti-microbial
- → **Analgesic**
- ○ Paracetamol (acetaminophen)
- ○ Codeine
![]()
Image of medication packaging including Panadol, Panadeine Forte, Fobinal Dental, Dolased, Mersynol, and Panadeine tablets.
#### **Analgesics**
- Paracetamol (acetaminophen)
- Codeine
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 10
**Managing Dental & Oral Pain**
- **Analgesics - work “centrally”**
- **Paracetamol**
- Selectively inhibits prostaglandin release in the CNS
- **Codeine**
- Metabolises to form morphine
- Inhibits neurons in the brain and dorsal horn of the CNS
**Managing Dental & Oral Pain**
- **Analgesics - work “centrally”**
- **Codeine**
- Metabolises to form morphine
- Inhibits neurons in the brain and dorsal horn of the CNS
- **BUT need at least 30 mg to be effective in adults**
- **7 - 10% of Caucasians**
- **1 - 2% of Asians**
- **0 - 20% of Africans**
- **Poor metabolisers of codeine to morphine**
- **Do not increase the dose of codeine as this causes constipation and drowsiness**
##### **Mechanism of Action ("Centrally")**
- **Paracetamol**
- Selectively inhibits prostaglandin release in the CNS
- **Codeine**
- Metabolises to form morphine
- Inhibits neurons in the brain and dorsal horn of the CNS
- **BUT need at least 30 mg to be effective in adults**
- **Poor metabolisers of codeine to morphine:**
- 7 - 10% of Caucasians
- 1 - 2% of Asians
- 0 - 20% of Africans
- **Do not increase the dose of codeine as this causes constipation and drowsiness**
> [!warning] Clinical Note
> If a patient reports that codeine
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 11
---
**Managing Dental & Oral Pain**
- **Drugs / Medication**
- *Local*
- *Systemic*
- → Anti-microbial
- → Analgesic
- → Anti-inflammatory
- **NSAID’s**
- *Non-steroidal anti-inflammatory drugs*
- → Work both “locally” and “centrally”
- *Inhibit cyclo-oxygenase which reduces the synthesis of inflammatory mediators (e.g. prostaglandins from arachidonic acid)*
- **Common examples:**
- Aspirin
- Ibuprofen
---
**Managing Dental & Oral Pain**
- **Non-steroidal anti-inflammatory drugs**
- → Work both “locally” and “centrally”
- *Inhibit cyclo-oxygenase which reduces the synthesis of inflammatory mediators (e.g. prostaglandins from arachidonic acid)*
- **Common examples:**
- Aspirin
- Ibuprofen
#### **Anti-inflammatory (NSAID’s)**
- *Non-steroidal anti-inflammatory drugs*
- Work both “locally” and “centrally”
- *Inhibit cyclo-oxygenase which reduces the synthesis of inflammatory mediators (e.g. prostaglandins from arachidonic acid)*
- **Common examples:**
- Aspirin
- Ibuprofen
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 12
**Managing Dental & Oral Pain**
- **Non-steroidal anti-inflammatory drugs**
→ Work both **“locally”** and **“centrally”**
- **Low doses** → **pain relief**
→ e.g. **200mg Ibuprofen**
- **High doses** → **anti-inflammatory action**
→ At least **400mg Ibuprofen**
→ But need to use as a **“course of medication”**
→ i.e. take at regular intervals (**4 hourly is ideal**)
**Managing Dental & Oral Pain**
Hargreaves & Abbott
ADJ 2005
23
24
##### **Dosage Effects of NSAIDs**
- **Low doses** → **pain relief**
- → e.g. **200mg Ibuprofen**
- **High doses** → **anti-inflammatory action**
- → At least **400mg Ibuprofen**
- → But need to use as a **“course of medication”**
- → i.e. take at regular intervals (**4 hourly is ideal**)
- ==This is done to maintain a therapeutic level in the bloodstream, rather than waiting for pain to return.==
(Reference: Hargreaves & Abbott ADJ 2005)
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 13
---
### **Managing Dental & Oral Pain**
- **Drugs / Medication**
- Local
- **Systemic**
- Anti-microbial
- Analgesic
- Anti-inflammatory
**Combination Preparations**
- **Nuromol**
- Ibuprofen 200 mg + Paracetamol 500 mg
- **Panafen Plus**
- Ibuprofen 200 mg + Codeine 12.8 mg
- **Nurofen Plus**
- Ibuprofen 200 mg + Codeine 12.8 mg
> **Codeine dose too low for most adults**
---
*Note: Text formatting preserved as per image, with emphasis on key terms in bold where color or highlighting was used in the original slide.*
### **Combination Preparations**
- **Nuromol**
- Ibuprofen 200 mg + Paracetamol 500 mg
- **Panafen Plus**
- Ibuprofen 200 mg + Codeine 12.8 mg
- **Nurofen Plus**
- Ibuprofen 200 mg + Codeine 12.8 mg
> **Codeine dose too low for most adults**
# Post-Operative Pain Control
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 14
## Post-Operative Pain after 3rd Molar Surgery
**Mehlisch et al - Clin Therap 2010**
- Tested Ibuprofen with Paracetamol for moderate to severe post-operative pain after 3rd molar surgery
- **Ibuprofen 400 mg + Paracetamol 1000 mg**
→ *Sig. better than the same dose of either drug alone*
- **Ibuprofen 200 mg + Paracetamol 500 mg**
→ *Sig. better than the same dose of either drug alone*
→ *Sig. better than Paracetamol 1000 mg*
→ *But NOT sig. better than Ibuprofen 400 mg*
## Pain Relief after Root Canal Treatment
**Menhinick et al - IEJ 2004**
**Ibuprofen 600 mg**
-v-
**Ibuprofen 600 mg + Paracetamol 1000 mg**
Placebo
![]()
Line graph comparing Pain Intensity on VAS over Time (h) for Placebo, Ibuprofen 600mg, and Ibuprofen 600mg + Paracetamol 1000mg
## **Clinical Studies on Pain Relief**
### **Post-Operative Pain after 3rd Molar Surgery (Mehlisch et al - Clin Therap 2010)**
- Tested Ibuprofen with Paracetamol for moderate to severe post-operative pain after 3rd molar surgery.
- **Ibuprofen 400 mg + Paracetamol 1000 mg**
- → *Sig. better than the same dose of either drug alone*
- **Ibuprofen 200 mg + Paracetamol 500 mg**
- → *Sig. better than the same dose of either drug alone*
- → *Sig. better than Paracetamol 1000 mg*
- → *But NOT sig. better than Ibuprofen 400 mg*
### **Pain Relief after Root Canal Treatment (Menhinick et al - IEJ 2004)**
- Compared the efficacy of:
- **Ibuprofen 600 mg**
- **Ibuprofen 600 mg + Paracetamol 1000 mg**
- Placebo
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
---
**Pharmacies**
29
---
**Supermarkets**
30
---
2nd Year DMD - 2020
Page 15
![]()
Image of pharmacy shelves stocked with various pain relief products.
![]()
Image of supermarket shelves stocked with various pain relief products.
### **Availability of Pain Medications**
> [!warning] Patient Confusion
> Patients face a confusing array of choices at pharmacies and supermarkets, often without expert guidance. Pharmacists may lack specific knowledge of dental pain and the treatment provided, making clear instructions from the dentist essential.
- **Pharmacies**
- **Supermarkets**
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 16
### Medications for Pain Management
<table>
<thead>
<tr>
<th>Component</th>
<th>No. of Preparations listed in E-MIMS - July 2020</th>
</tr>
</thead>
<tbody>
<tr>
<td>Ibuprofen</td>
<td>51</td>
</tr>
<tr>
<td>Aspirin</td>
<td>29</td>
</tr>
<tr>
<td>Paracetamol / Acetaminophen</td>
<td>157</td>
</tr>
<tr>
<td>Codeine</td>
<td>48</td>
</tr>
</tbody>
</table>
### Medications for Pain Management
<table>
<thead>
<tr>
<th>Brand</th>
<th>No. of Preparations listed in E-MIMS - July 2020</th>
</tr>
</thead>
<tbody>
<tr>
<td>Nurofen</td>
<td>15</td>
</tr>
<tr>
<td>Disprin</td>
<td>3</td>
</tr>
<tr>
<td>Panadol / Panadeine</td>
<td>25 / 5</td>
</tr>
</tbody>
</table>
### **Medications for Pain Management (E-MIMS - July 2020)**
| Component | No. of Preparations listed |
| :--- | :--- |
| Ibuprofen | 51 |
| Aspirin | 29 |
| Paracetamol / Acetaminophen | 157 |
| Codeine | 48 |
<br>
| Brand | No. of Preparations listed |
| :--- | :--- |
| Nurofen | 15 |
| Disprin | 3 |
| Panadol / Panadeine | 25 / 5 |
# Post-Operative Pain Control
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 17
## Pain Relief with Different Systemic Medications
**“Oral Surgery” Model / “Third Molar Model”**
Adapted from: Cooper et al 1977, Rondeau et al 1980, Dionne et al 1983
## Medications for Pain Management
- **The Oxford League Table of Analgesic Efficacy**
- http://www.jr2.ox.ac.uk/bandolier/index.html
- **Proportion of patients with at least 50% pain relief over 4-6 hours - compared with placebo**
- **Meta-analyses of randomised, double-blind, single-dose studies**
- **Patients with moderate to severe pain**
33
34
## **Pain Relief with Different Systemic Medications**
### **“Oral Surgery” Model / “Third Molar Model”**
Adapted from: Cooper et al 1977, Rondeau et al 1980, Dionne et al 1983
### **The Oxford League Table of Analgesic Efficacy**
- http://www.jr2.ox.ac.uk/bandolier/index.html
- **Proportion of patients with at least 50% pain relief over 4-6 hours - compared with placebo**
- **Meta-analyses of randomised, double-blind, single-dose studies**
- **Patients with moderate to severe pain**
<table>
<thead>
<tr>
<th>Analgesic</th>
<th>No. of Pt's</th>
<th>% with &gt;50% Pain Relief</th>
</tr>
</thead>
<tbody>
<tr>
<td>Placebo</td>
<td>&gt;10,000</td>
<td>18</td>
</tr>
<tr>
<td>Ibuprofen 800</td>
<td>76</td>
<td>100</td>
</tr>
<tr>
<td>Ibuprofen 600</td>
<td>203</td>
<td>79</td>
</tr>
<tr>
<td>Ibuprofen 400</td>
<td>4703</td>
<td>56</td>
</tr>
<tr>
<td>Ibuprofen 200</td>
<td>1414</td>
<td>45</td>
</tr>
</tbody>
</table>
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 19
<table>
<thead>
<tr>
<th>Analgesic</th>
<th>No. of Pt’s</th>
<th>% with >50% Pain Relief</th>
</tr>
</thead>
<tbody>
<tr>
<td>Placebo</td>
<td>&gt;10,000</td>
<td>18</td>
</tr>
<tr>
<td>Ibuprofen 800</td>
<td>76</td>
<td>100</td>
</tr>
<tr>
<td>Ibuprofen 600</td>
<td>203</td>
<td>79</td>
</tr>
<tr>
<td>Ibuprofen 400</td>
<td>4703</td>
<td>56</td>
</tr>
<tr>
<td>Ibuprofen 200</td>
<td>1414</td>
<td>45</td>
</tr>
<tr>
<td>Aspirin 1200</td>
<td>279</td>
<td>61</td>
</tr>
<tr>
<td>Aspirin 600</td>
<td>5061</td>
<td>38</td>
</tr>
</tbody>
</table>
<table>
<thead>
<tr>
<th>Analgesic</th>
<th>No. of Pt’s</th>
<th>% with >50% Pain Relief</th>
</tr>
</thead>
<tbody>
<tr>
<td>Placebo</td>
<td>&gt;10,000</td>
<td>18</td>
</tr>
<tr>
<td>Ibuprofen 800</td>
<td>76</td>
<td>100</td>
</tr>
<tr>
<td>Ibuprofen 600</td>
<td>203</td>
<td>79</td>
</tr>
<tr>
<td>Ibuprofen 400</td>
<td>4703</td>
<td>56</td>
</tr>
<tr>
<td>Ibuprofen 200</td>
<td>1414</td>
<td>45</td>
</tr>
<tr>
<td>Aspirin 1200</td>
<td>279</td>
<td>61</td>
</tr>
<tr>
<td>Aspirin 600</td>
<td>5061</td>
<td>38</td>
</tr>
<tr>
<td>Paracetamol + Codeine 1000/60</td>
<td>197</td>
<td>57</td>
</tr>
<tr>
<td>Paracetamol + Codeine 600/60</td>
<td>1886</td>
<td>38</td>
</tr>
<tr>
<td>Paracetamol + Codeine 300/30</td>
<td>379</td>
<td>26</td>
</tr>
<tr>
<td>Codeine 60</td>
<td>1305</td>
<td>15</td>
</tr>
<tr>
<td>Paracetamol 1500</td>
<td>138</td>
<td>65</td>
</tr>
<tr>
<td>Paracetamol 500</td>
<td>561</td>
<td>61</td>
</tr>
<tr>
<td>Paracetamol 1000</td>
<td>2759</td>
<td>46</td>
</tr>
</tbody>
</table>
Post-Operative Pain Control
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 20
<table>
<thead>
<tr>
<th>Analgesic</th>
<th>No. of Pt’s</th>
<th>% with >50% Pain Relief</th>
</tr>
</thead>
<tbody>
<tr>
<td>Placebo</td>
<td>&gt;10,000</td>
<td>18</td>
</tr>
<tr>
<td>Ibuprofen 800</td>
<td>76</td>
<td>100</td>
</tr>
<tr>
<td>Ibuprofen 600</td>
<td>203</td>
<td>79</td>
</tr>
<tr>
<td>Ibuprofen 400</td>
<td>4703</td>
<td>56</td>
</tr>
<tr>
<td>Ibuprofen 200</td>
<td>1414</td>
<td>45</td>
</tr>
<tr>
<td>Aspirin 1200</td>
<td>279</td>
<td>61</td>
</tr>
<tr>
<td>Aspirin 600</td>
<td>5061</td>
<td>38</td>
</tr>
<tr>
<td>Paracetamol + Codeine 1000/60</td>
<td>197</td>
<td>57</td>
</tr>
<tr>
<td>Paracetamol + Codeine 600/60</td>
<td>1886</td>
<td>38</td>
</tr>
<tr>
<td>Paracetamol + Codeine 300/30</td>
<td>379</td>
<td>26</td>
</tr>
<tr>
<td>Codeine 60</td>
<td>1305</td>
<td>15</td>
</tr>
<tr>
<td>Paracetamol 1500</td>
<td>138</td>
<td>65</td>
</tr>
<tr>
<td>Paracetamol 500</td>
<td>561</td>
<td>61</td>
</tr>
<tr>
<td>Paracetamol 1000</td>
<td>2759</td>
<td>46</td>
</tr>
<tr>
<td>Ketorolac 20</td>
<td>69</td>
<td>57</td>
</tr>
<tr>
<td>Naproxen 440</td>
<td>257</td>
<td>50</td>
</tr>
<tr>
<td>Pethidine 100 (IM)</td>
<td>364</td>
<td>54</td>
</tr>
<tr>
<td>Morphine 10 (IM)</td>
<td>946</td>
<td>50</td>
</tr>
</tbody>
</table>
![]()
Figure showing the arachidonic acid pathway with labels for inflammation, corticosteroids, NSAIDs, paracetamol, leukotrienes, prostaglandins, thromboxane A2, and enzyme conversions.
### **Analgesic Efficacy Data**
| Analgesic | No. of Pt’s | % with >50% Pain Relief |
| :--- | :--- | :--- |
| Placebo | >10,000 | 18 |
| Ibuprofen 800 | 76 | 100 |
| Ibuprofen 600 | 203 | 79 |
| Ibuprofen 400 | 4703 | 56 |
| Ibuprofen 200 | 1414 | 45 |
| Aspirin 1200 | 279 | 61 |
| Aspirin 600 | 5061 | 38 |
| Paracetamol + Codeine 1000/60 | 197 | 57 |
| Paracetamol + Codeine 600/60 | 1886 | 38 |
| Paracetamol + Codeine 300/30 | 379 | 26 |
| Codeine 60 | 1305 | 15 |
| Paracetamol 1500 | 138 | 65 |
| Paracetamol 500 | 561 | 61 |
| Paracetamol 1000 | 2759 | 46 |
| Ketorolac 20 | 69 | 57 |
| Naproxen 440 | 257 | 50 |
| Pethidine 100 (IM) | 364 | 54 |
| Morphine 10 (IM) | 946 | 50 |
> [!info] Why NSAIDs are More Effective for Dental Pain
> NSAIDs like Ibuprofen are particularly effective because they act
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 21
---
**Pain Relief after Dental Treatment**
**Four Questions to Consider**
1. **How much pre-treatment pain has there been?**
➤ FIVE times more likely to have moderate to severe pain after treatment if moderate to severe pain present prior to treatment (O’Keefe 1976)
2. **Pain during treatment**
➤ More likely to have post-operative pain (esp. long-term chronic pain) if pain during treatment - due to central sensitisation
3. **How much pain is likely after treatment?**
➤ Mild ? ➤ Moderate ? ➤ Severe ?
4. **Can the patient use NSAID’s?**
➤ Check for: Asthma, peptic ulcer, drug interactions, etc.
---
**Pain Relief after Dental Treatment**
<table>
<thead>
<tr>
<th>Pain Level:</th>
<th>MILD</th>
<th>MODERATE</th>
<th>SEVERE</th>
</tr>
</thead>
<tbody>
<tr>
<td><strong>NSAID’s can be taken</strong></td>
<td>400 mg Ibuprofen every 4 hours</td>
<td>400 - 600* mg Ibuprofen 4 hourly PLUS 1000 mg Paracetamol every 4 hours</td>
<td>400 - 600* mg ibuprofen PLUS 1000 mg paracetamol with 60 mg codeine ** every 4 hours</td>
</tr>
<tr>
<td><strong>NSAID’s contra-indicated</strong></td>
<td>1000 mg paracetamol every 4 hours</td>
<td>1000 mg paracetamol with 60 mg codeine every 4 hours</td>
<td>1000 – 1500* mg paracetamol with 60 – 90* mg codeine every 4 hours</td>
</tr>
</tbody>
</table>
## **Practical Guide to Pain Relief after Dental Treatment**
### **Four Questions to Consider**
1. **How much pre-treatment pain has there been?**
- ➤ FIVE times more likely to have moderate to severe pain after treatment if moderate to severe pain present prior to treatment (O’Keefe 1976)
2. **Pain during treatment**
- ➤ More likely to have post-operative pain (esp. long-term chronic pain) if pain during treatment - due to central sensitisation
3. **How much pain is likely after treatment?**
- ➤ Mild ? ➤ Moderate ? ➤ Severe ?
4. **Can the patient use NSAID’s?**
- ➤ Check for: Asthma, peptic ulcer, drug interactions, etc.
> [!tip] Clinical Nuance for Asthma
> If a patient has asthma but has used ibuprofen before without issue, it may be safe to prescribe. However, they must be warned of the potential risk and advised to stop if they experience any breathing difficulties.
### **Recommended Pain Relief Regimens**
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 22
---
### **Pain Relief after Dental Treatment**
**Pain Level:**
| MILD | MODERATE | SEVERE |
|------|----------|--------|
| 400 mg Ibuprofen every 4 hours | 400 - 600* mg Ibuprofen PLUS 1000 mg Paracetamol every 4 hours | 400 - 600* mg Ibuprofen PLUS 1000 mg Paracetamol with 60 mg Codeine ** every 4 hours |
**NSAID’s contra-indicated**
| | |
|---|---|
| 1000 mg Paracetamol every 4 hours | 1000 mg Paracetamol with 60 mg Codeine every 4 hours |
| | 1000 – 1500* mg Paracetamol with 60 – 90* mg Codeine every 4 hours |
---
**NOTES:**
ALL cases: 1 - 3 days usually sufficient. If still pain, review and reassess
* Only take higher dose on 1 or 2 occasions
** Alternate Ibuprofen & Paracetamol / Codeine at 2-hourly intervals
---
### **Pain Relief after Dental Treatment**
**Alternate at 2 hourly intervals:**
→ 400 mg Ibuprofen - start immediately
→ 1000 mg Paracetamol + 60 mg Codeine - start 2 hrs later
```mermaid
timeline
title Pain Relief Schedule (Alternate 2-hourly)
section 2.00 pm : Px → Ibu
section 4.00 pm : P+C
section 6.00 pm : Ibu
section 8.00 pm : P+C
section 10.00 pm : Ibu
```
![]()
Timeline diagram showing alternating doses of Ibuprofen and Paracetamol + Codeine at 2-hour intervals starting at 2:00 pm.
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 23
---
**Pain Relief after Dental Treatment**
**Alternate at 2 hourly intervals:**
→ 400 mg Ibuprofen - *start immediately*
→ 1000 mg Paracetamol + 60 mg Codeine - *start 2 hrs later*
**Paracetamol + Codeine** - stop next day
**Ibuprofen** - continue for 2-3 days
• Use as a “course” of medication
• For its anti-inflammatory action
• Even once the pain has reduced
---
![]()
Graph showing blood levels over time for pain relief medications with labeled peaks and effective level line, including icons for Paracetamol + Codeine and Ibuprofen at respective time points.
- **Paracetamol + Codeine** - stop next day
- **Ibuprofen** - continue for 2-3 days
- Use as a “course” of medication
- For its anti-inflammatory action
- Even once the pain has reduced
### **Maximum Daily Doses - for Adults**
| Drug | Maximum Daily Dose (mg) | Typical Tablet or Capsule (mg) | Maximum Tabs/Caps per Day | Allowable Regime |
| :--- | :--- | :--- | :--- | :--- |
| Ibuprofen | 2,400 | 200 | 12 x 200 | 2 tabs 4 hourly |
| Paracetamol | 4,000 | 500 | 8 x 500 | 2 tabs 4 hourly BUT only 4x/day (i.e. NOT 6x/day) |
| Codeine | 360 | 30 | 12 x 30 | 2 tabs 4 hourly |
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 24
---
### **Pain Relief after Dental Treatment**
| Pain Level: | MILD | MODERATE | SEVERE |
|-------------|------|----------|--------|
| **NSAID’s can be taken** | 400 mg Ibuprofen every 4 hours | 400 - 600* mg Ibuprofen 4 hourly PLUS 1000 mg Paracetamol every 4 hours | 400 - 600* mg Ibuprofen PLUS 1000 mg Paracetamol with 60 mg Codeine ** every 4 hours |
| **NSAID’s contra-indicated** | 1000 mg Paracetamol every 4 hours | 1000 mg Paracetamol with 60 mg Codeine every 4 hours | 1000 - 1500* mg Paracetamol with 60 - 90* mg Codeine every 4 hours |
---
**NOTES:**
ALL cases: 1 - 3 days usually sufficient. If still pain, review and reassess
* Only take higher dose on 1 or 2 occasions
** Alternate Ibuprofen & Paracetamol / Codeine at 2-hourly intervals
---
### **Maximum Daily Doses - for Adults**
<table>
<thead>
<tr>
<th>Drug</th>
<th>Maximum Daily Dose (mg)</th>
<th>Typical Tablet or Capsule (mg)</th>
<th>Maximum Tabs/Caps per Day</th>
<th>Allowable Regime</th>
</tr>
</thead>
<tbody>
<tr>
<td>Ibuprofen</td>
<td>2,400</td>
<td>200</td>
<td>12 x 200</td>
<td>2 tabs 4 hourly</td>
</tr>
<tr>
<td>Paracetamol</td>
<td>4,000</td>
<td>500</td>
<td>8 x 500</td>
<td>2 tabs 4 hourly BUT only 4x/day (i.e. NOT 6x/day)</td>
</tr>
<tr>
<td>Codeine</td>
<td>360</td>
<td>30</td>
<td>12 x 30</td>
<td>2 tabs 4 hourly</td>
</tr>
</tbody>
</table>
<table style="width:100%; border-collapse: collapse;">
<thead>
<tr style="text-align: left;">
<th style="border: 1px solid black; padding: 8px;">Pain Level:</th>
<th style="border: 1px solid black; padding: 8px;">MILD</th>
<th style="border: 1px solid black; padding: 8px;">MODERATE</th>
<th style="border: 1px solid black; padding: 8px;">SEVERE</th>
</tr>
</thead>
<tbody>
<tr>
<td style="border: 1px solid black; padding: 8px;"><strong>NSAID’s can be taken</strong></td>
<td style="border: 1px solid black; padding: 8px;">400 mg Ibuprofen every 4 hours</td>
<td style="border: 1px solid black; padding: 8px;">400 - 600* mg Ibuprofen 4 hourly PLUS 1000 mg Paracetamol every 4 hours
(This can be simplified by prescribing a combination tablet like Nuromol, 2 tablets)
</td>
<td style="border: 1px solid black; padding: 8px;">400 - 600* mg Ibuprofen PLUS 1000 mg Paracetamol with 60 mg Codeine ** every 4 hours</td>
</tr>
<tr>
<td style="border: 1px solid black; padding: 8px;"><strong>NSAID’s contra-indicated</strong></td>
<td style="border: 1px solid black; padding: 8px;">1000 mg paracetamol every 4 hours</td>
<td style="border: 1px solid black; padding: 8px;">1000 mg paracetamol with 60 mg codeine every 4 hours</td>
<td style="border: 1px solid black; padding: 8px;">1000 – 1500* mg paracetamol with 60 – 90* mg codeine every 4 hours</td>
</tr>
</tbody>
</table>
#### **NOTES:**
- ALL cases: 1 - 3 days usually sufficient. If still pain, review and reassess
- \* Only take higher dose on 1 or 2 occasions
- **Loading Dose**: ==For moderate or severe pain, an initial
- \*\* Alternate Ibuprofen & Paracetamol / Codeine at 2-hourly intervals
- **Patient Instructions**: ==It is crucial to give patients clear, written instructions, as the recommended regimen (e.g.,
### **Alternating Medication Schedule**
> [!tip] Rationale for Alternating Schedule
> This strategy is highly effective for severe pain. It ensures that as the effect of one drug begins to wane, the other is reaching its peak therapeutic level, providing continuous and superior pain coverage.
- **Alternate at 2 hourly intervals:**
- → 400 mg Ibuprofen - start immediately
- → 1000 mg Paracetamol + 60 mg Codeine - start 2 hrs later
```mermaid
timeline
title Pain Relief Schedule (Alternate 2-hourly)
section 2.00 pm : Px → Ibu
section 4.00 pm : P+C
section 6.00 pm : Ibu
section 8.00 pm : P+C
section 10.00 pm : Ibu
```
**Post-Operative Pain Control**
**W/Prof. Paul V. Abbott AO**
**2nd Year DMD - 2020**
**Page 25**
### Paracetamol / Acetaminophen
- **USA**: In 2011 - reduced maximum daily dose to 3000 mg
- i.e. From 8 tabs. to 6 tabs. per day
- To reduce number of overdoses
- Overdose can cause acute liver failure & death
- **UK**: also 3000 mg
- **BUT**: Australia, NZ, Canada - 4000 mg
### Pain Relief after Dental Treatment
- **Prescribe REST**
- **Tooth ( + restoration)**
- “Relieve the bite”
- **General rest**
- Sleep
- No work, etc
49
50
### **Paracetamol / Acetaminophen Dosage Guidelines**
- **USA**: In 2011 - reduced maximum daily dose to 3000 mg
- i.e. From 8 tabs. to 6 tabs. per day
- To reduce number of overdoses
- Overdose can cause acute liver failure & death
- **UK**: also 3000 mg
- **BUT**: Australia, NZ, Canada - 4000 mg
### **Prescribe REST**
- **Tooth ( + restoration)**
- “Relieve the bite”
- **General rest**
- Sleep
- No work, etc
- ==This is especially important for patients who were in severe pain and may not have slept.==
- **WARNING**: ==Patients taking codeine must be warned not to drive or operate machinery.==
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 26
---
**Managing Dental Pain**
- Diagnose the **CAUSE** and **TYPE** of pain
- **Inflammation**
- and / or
- **Infection**
---
**Managing Dental Pain**
Medications available for dental pain
<table>
<thead>
<tr>
<th>Type of Drug</th>
<th>Method of Use</th>
</tr>
</thead>
<tbody>
<tr>
<td>Anti-inflammatory</td>
<td>Local</td>
</tr>
<tr>
<td>Analgesic</td>
<td>Systemic</td>
</tr>
<tr>
<td>Antibiotic</td>
<td></td>
</tr>
</tbody>
</table>
**Depends on the CAUSE and TYPE of pain**
![]()
Illustration of a person holding their jaw in pain
## **Summary: Managing Dental Pain**
- Diagnose the **CAUSE** and **TYPE** of pain
- **Inflammation**
- and / or
- **Infection**
### **Medications available for dental pain**
| Type of Drug | Method of Use |
| :--- | :--- |
| Anti-inflammatory | Local |
| Analgesic | Systemic |
| Antibiotic | |
**Depends on the CAUSE and TYPE of pain**
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
2nd Year DMD - 2020
Page 27
---
### Managing Dental Pain
**1. Thorough assessment of the presenting problem**
**2. Adequate treatment / management**
*Of the patient, tooth, pulp, gingiva, mucosa, muscles, etc.*
**3. Appropriate medication**
→ **PREDICTABLE Pain Relief**
**The 3-D’s**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs**
---
### Managing Dental Pain
◆ **Then follow the 3-R’s !!!**
**1. Review - has the pain gone?**
**If YES** → then no further pain management is needed
**But if NO** .....
### **Achieving Predictable Pain Relief**
1. **Thorough assessment of the presenting problem**
2. **Adequate treatment / management**
*Of the patient, tooth, pulp, gingiva, mucosa, muscles, etc.*
3. **Appropriate medication**
→ **PREDICTABLE Pain Relief**
#### **The 3-D’s**
1. **Diagnosis**
2. **Dental Treatment**
3. **Drugs**
### **Follow-up: The 3-R’s**
◆ **Then follow the 3-R’s !!!**
1. **Review - has the pain gone?**
**If YES** → then no further pain management is needed
**But if NO** .....
**Post-Operative Pain Control**
W/Prof. Paul V. Abbott AO
**Managing Dental Pain**
◆ Then follow the 3-R’s !!!
1. **Review** - has the pain gone?
2. **Reassess** - the diagnosis
3. **Reconsider** - the management
55
2nd Year DMD - 2020
Page 28
2. **Reassess** - the diagnosis
- ==The diagnosis may have evolved (e.g., post-treatment pain is now from the periapical tissues, not the pulp).==
3. **Reconsider** - the management
# **Managing Dental Pain**
Then follow the 3-R’s !!!
1. **Review** - has the pain gone?
2. **Reassess** - the diagnosis
3. **Reconsider** - the management
[[O1B PostOperativePainManagement.pdf#page=1|O1B PostOperativePainManagement, p.1]]
[[O1B PostOperativePainManagement.pdf#page=2|O1B PostOperativePainManagement, p.2]]
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[[O1B PostOperativePainManagement.pdf#page=25|O1B PostOperativePainManagement, p.25]]
[[O1B PostOperativePainManagement.pdf#page=26|O1B PostOperativePainManagement, p.26]]
[[O1B PostOperativePainManagement.pdf#page=27|O1B PostOperativePainManagement, p.27]]
[[O1B PostOperativePainManagement.pdf#page=28|O1B PostOperativePainManagement, p.28]]