A primer on common ailments managed by nonprescription products
PATIENT SCENARIO
TOOTH BE TOLD: COMBOGESIC MAY CHANGE DENTAL PAIN MANAGEMENT
Case
CC, a healthy 23-year-old male, presents to your pharmacy with a printed postop sheet from his dentist. It provides instructions on post-procedure pain relief (regular strength ibuprofen or extra strength acetaminophen, taken according to OTC product labelling) and oral hygiene (antibacterial mouthwash). You learn that CC had a damaged tooth extracted yesterday. He is complaining about the pain, although it’s not severe and has no red flag features. Neither ibuprofen nor acetaminophen has provided adequate pain relief. CC is wondering if there is anything else he can try or if he should contact his dentist for a prescription. He was prescribed Tylenol No. 3 following a previous extraction and found this worked well. CC has no medical conditions or allergies, and is not taking any medications. He consumes alcohol occasionally and does not smoke.
Background
Oral pain affects a large number of Canadians. In fact, 11.7% of 5,284 survey respondents reported experiencing mouth pain in the past 12 months.(1) Oral pain is significantly more prevalent among 32
There is growing evidence that combining simple analgesics, namely acetaminophen and ibuprofen, provides greater acute dental pain relief than either analgesic alone. adolescents and younger adults, those in lower income groups, those who avoided a dental professional because of cost, and those with untreated tooth decay.(1) The most common forms of oral pain are acute in nature and can result from pathological conditions or disorders related to somatic and neurological structures.(2) Pain can be attributed to conditions affecting the hard tissues (e.g., caries of enamel, dentine) or those affecting soft tissue and supporting bone (e.g., gingivitis, periodontitis), some of which may necessitate dental intervention.(2) Table 1 outlines traditional analgesic regimens for managing postprocedural dental pain. Dental interventions anticipated to cause mild pain include frenectomies and simple extractions (e.g., removal of visible
NOVEMBER 2020 [Vol.7 No.9]
NARDINE NAKHLA PharmD
tooth); those expected to cause moderate pain include implant surgeries and surgical extractions; and interventions predicted to cause severe pain include partial or full bony impaction surgeries and periodontal surgeries.(3)
Case analysis
Despite the large number of nonprescription products marketed for pain and fever, most consist of one of four active ingredients: acetaminophen, acetylsalicylic acid, ibuprofen or naproxen. However, there is growing evidence that combining simple analgesics, namely acetaminophen and ibuprofen, provides greater acute dental pain relief than either analgesic alone.(4-6) For example, one randomized controlled trial of 408 adults experiencing moderate to severe pain after surgical removal of impacted third molars, showed that a fixed-dose combination product of acetaminophen 975 mg and ibuprofen 292.5 mg/day provided significantly superior analgesia over equivalent daily monotherapy doses of either ingredient alone in the initial 48-hours after extraction. More specifically, the fixeddose combination provided a significantly shorter onset of meaningful pain relief, reduced the consumption of opioid rescue medication, and lowered maximum pain scores. This was achieved without compromising the well-established safety profile of either active constituent.(6) Simple analgesics may also have equivalent or superior efficacy when compared with opioids for postextraction dental pain; as such, routine opioid prescribing for post-extraction dental pain must be questioned because of the potential morbidity and longterm consequences of opioid use.(7,8) Evidence suggests that for opioid-naĂŻve patients, filling a prescription for an opioid pain medication following tooth extraction is associated with a greater risk of ongoing persistent opioid use.(7) Multimodal analgesia (i.e., combining medications with different mechanisms of action) is often recommended as an alternative to opioids for acute dental
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