Title Nonopioid, Over-the-Counter Analgesics Can Be as or More Effective Than Prescription Medications Containing Opioids in the Pain Management of Post-Extraction Patients
Clinical Question For a post-extraction patient, are over-the-counter pain medications as effective in pain relief as opioids?
Clinical Bottom Line Non-opioid, over-the-counter analgesics can be as, or more, effective than prescription pain medications containing opioids.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
21257263Daniels/2011678 Extraction patients with impacted third molarsRandomized Controlled Trial
Key results“1 or 2 tablets of a single-tablet combination of ibuprofen 200mg/paracetamol [acetaminophen] 500mg provided highly effective analgesia that was comparable with, or superior to, other combination analgesics, including codeine, currently indicated for strong pain.”
23904576Moore/2013Third molar extraction patientsSystematic Review
Key results“The results of the quantitative systematic reviews indicated that the ibuprofen-APAP combination may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations.”
22169050Gatuolis/2012978 Patients with postoperative dental pain and/or tension headachesRandomized, double-blind, placebo-controlled clinical trial
Key resultsThe results demonstrate that "treatment with aspirin (1000 mg) provides statistically significant analgesic efficacy compared with placebo use and comparable efficacy with acetaminophen (300 mg) with codeine (30 mg) therapy after impacted third molar extraction and in tension-type headache."
Evidence Search "ibuprofen acetaminophen analgesic tooth extraction"
Comments on
The Evidence
Validity: The objectives and patients in each review or study were clearly described, original sources were cited, and the characteristics of missing or incomplete study participants were described. There were no significant differences in the participants at the beginning of the studies. Perspective: These studies are extremely useful for the dentist prescribing medications to a post-operative patient. It reduces the need for the over-prescribing of opioids, which can be potentially harmful for the patient and lead to misuse of the drug.
Applicability These studies show an acetaminophen-NSAID combination is as effective in postoperative pain management as codeine without the risk of developing opioid dependence or adverse drug effects of the patient.
Specialty (General Dentistry) (Oral Surgery) (Periodontics) (Interprofessional CATs)
Keywords Opioids, Analgesics, Acetaminophen, NSAIDs, Ibuprofen, Postoperative, Drug therapy, Ibuprofen, Ketoprofen, Codeine, Third Molars, Extraction, Pain Management
ID# 3212
Date of submission 04/19/2017
E-mail CastleberryE@livemail.uthscsa.edu
Author Elizabeth Castleberry
Co-author(s) Kylie Barroso
Co-author(s) e-mail kybarr52@yahoo.com
Faculty mentor Mark LittleStar, DDS
Faculty mentor e-mail littlestarm@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
by Kylie S. Barroso (Austin, Texas) on 07/07/2017
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and is absorbed by the GI tract. This drug is used to stop the synthesis of prostaglandins, which are responsible for the inflammatory response to tissue injury through inhibition of cyclooxygenase (COX) isoenzymes. Codeine is a narcotic analgesic drug that is absorbed via GI tract if taken orally; it can also be given by intramuscular (IM) injection and absorbed into the bloodstream. This drug is metabolized once in the bloodstream by the enzyme CYP2D6, which is produced in the liver. Like other opioids, codeine binds to the µ receptor, but it has a lower affinity for this receptor when compared to morphine. Codeine crosses the blood brain barrier and reduces the perception of pain, whereas ibuprofen reduces the inflammation at the extraction site to reduce the pain. Ibuprofen appears to be more efficient pain reducer because it works directly on the source of the pain, whereas codeine simply masks the pain or the perception of the pain.
Comments and Evidence-Based Updates on the CAT
None available