Acetaminophen-Ibuprofen Combination In Managing Dental Pain: Review

Dental therapies like root canal treatment and teeth extraction
are often advocated to repair dental issues. (3) The outcome of these therapies
depends considerably on pre-operative pain control. Nonsteroidal anti-inflammatory drugs
(NSAIDs) have been repeatedly demonstrated to decrease the intensity of
postoperative pain and swelling (4)

Among the available
analgesic and anti-inflammatory drug classes, a combination of Acetaminophen
and NSAID medications have been the preferred option among dental professionals
for decades. (4) According to data from studies, Acetaminophen -Ibuprofen
combination therapy remains dentists’ most commonly recommended analgesic.
(5,6)

Understanding Dental Pain & the role of
drug combinations To Control It-

Dental pain is one of
the most frequent types of pain and root in the dental pulp. (7) The soft
tissues of teeth (pulp and pulp-dentin complex) are surrounded by mineralized
hard tissues (enamel, dentin, and cement). The pulp is fed by a dense
neurovascular network that regulates multiple inflammatory mediators. (8) The
teeth are the only portion of the body where allodynia is considered normal.
Pulpal nerves can sense pain. (7)

Research has
consistently confirmed that orally administered analgesics are the best way to
address acute and postoperative(surgical) dental pain. (7)

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen
have analgesic, antipyretic, and anti-inflammatory properties. They inhibit
prostaglandin production by non-selectively inhibiting cyclo-oxygenase (COX),
which is present as COX-1 and COX-2. (9)Despite its extensive usage, the mechanism of action of
Acetaminophen is unknown, though a centrally mediated analgesic-antipyretic
activity is acknowledged. Acetaminophen has a minimal anti-inflammatory
effect, indicating a different mechanism of action than NSAIDs. (9) NSAIDs work
peripherally, relieving pain by lowering inflammation at the source.
Alternatively, Acetaminophen operates centrally by inhibiting pain signal
transmission within the central nervous system. (10 Combined therapy is more effective than
analgesic monotherapy at higher doses and causes fewer side effects. Numerous
studies have demonstrated that acetaminophen and other NSAID drugs work more
effectively than acetaminophen or NSAID drugs alone. (10)

Managing Dental inflammation: The synergy of
the Acetaminophen-Ibuprofen Combination- This drug combination has gained traction in light of its better efficacy and safety profile, leading to an increased
emphasis on multimodal analgesia. (10)

The acetaminophen-Ibuprofen combination works synergistically to provide more significant analgesic effects
than monotherapy. Multiple trials have proven that specific dosed combinations
of Acetaminophen and Ibuprofen are more effective than monotherapy in relieving
dental pain and related inflammatory symptoms. Because of their distinct
metabolic pathways, drug-drug interactions are also limited to a bare minimum.
(10)

Study testimonials: Therapeutic Efficacy Of
Combination Therapy-

In endodontics- Endodontics pain accounts for significant
orofacial pain. While severe pain may require 600 mg or 800 mg ibuprofen and up
to 1000 mg acetaminophen every 8 hours, mild to moderate pain is frequently
treated with 400 mg ibuprofen mixed with 325 mg acetaminophen dosed every 6
hours. (11)In orthodontics-Orthodontic pain, which can occur throughout
any orthodontic treatment process, affects 72% to 100% of patients undergoing
therapy to align teeth. (12) According to research, people undergoing
orthodontic treatment may feel uncomfortable 4 hours after the therapy is
initiated, and the discomfort peaks at 24 hours and gradually improves over a
week. (13). Ibuprofen provides a robust and long-lasting analgesic impact that
peaks after 6 hours, whereas Acetaminophen’s analgesic effect builds gradually
from 2 to 24 hours after an orthodontic session. This makes
Ibuprofen-Acetaminophen a suitable option for managing orthodontic pain at its
worst. (14)Comparative studies-Recent research has shown that
Acetaminophen-Ibuprofen gives superior pain relief than opioids such as
codeine, hydrocodone, and oxycodone while avoiding the multiple side effects
associated with chronic opioid usage. (15) The American Dental Association
(ADA) recommends NSAIDs as first-line therapy for managing acute dental pain. (16)In the pediatric population-Body research now
supports the oral administration of Ibuprofen alone or combined with
Acetaminophen for postoperative analgesia in children undergoing general
anesthesia for tooth extraction. Ibuprofen and Ibuprofen/Acetaminophen
combinations were more effective than standard- or high-dose Acetaminophen
alone in lowering children’s pain and distress following tooth extraction. (17)

Is the combination safe?

Acetaminophen is a
safe analgesic and is usually the chosen one to be the first painkiller
dentists recommend. When taken with optimal dosage changes, it has been
suggested as the best choice for individuals with liver and renal problems.
Ibuprofen has a superior safety profile than other NSAIDs, with minor GI
symptoms and low antiplatelet action, compared to aspirin and most other
NSAIDs. (18,19)

Key pointers-

Pain relief is critical when treating dental patients since it
has far-reaching consequences for the patient and the provider.The Acetaminophen-Ibuprofen combination treatment outperforms
monotherapy regarding analgesic and anti-inflammatory effects for dental pain.Ibuprofen and Acetaminophen work synergistically to provide
higher peak analgesia and more consistent analgesia (i.e., less fluctuation
between patients) without causing more negative side effects.Because of their scientifically supported efficacy in managing
pain, fever, and edema (caused by inflammatory mediator release), Acetaminophen
and Ibuprofen are among the most extensively used drugs, particularly for
managing dental pain and inflammation. This combination pain control therapy
has earned a unique position among the dental fraternity and remains a
much-preferred option among patients and dental professionals.

References

1. Kakoei, S., Parirokh, M.,
Nakhaee, N., Jamshidshirazi, F., Rad, M., & Kakooei, S. (2013).
Prevalence of Toothache and Associated Factors: A Population-Based Study
in Southeast Iran. Iranian Endodontic Journal, 8(3), 123-128. https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734515

2. Renton, T. (2011). Dental
(Odontogenic) Pain. Reviews in Pain, 5(1), 2-7. https://doi.org/10.1177/204946371100500102

3. Parirokh, M., Zarifian, A.,
& Ghoddusi, J. (2015). Choice of Treatment Plan Based on Root Canal
Therapy versus Extraction and Implant Placement: A Mini Review. Iranian
Endodontic Journal, 10(3), 152-155.
https://doi.org/10.7508/iej.2015.03.001

4. Becker DE. Pain management:
Part 1: Managing acute and postoperative dental pain. Anesth Prog. 2010
Summer;57(2):67-78; quiz 79-80. doi: 10.2344/0003-3006-57.2.67. PMID:
20553137; PMCID: PMC2886920.

5. Bailey E, Worthington HV, van
Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol
(acetaminophen) for pain relief after surgical removal of lower wisdom
teeth. Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. doi:
10.1002/14651858.CD004624.pub2. PMID: 24338830.

6. Ong CK, Seymour RA, Lirk P,
Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal
antiinflammatory drugs: a qualitative systematic review of analgesic
efficacy for acute postoperative pain. Anesth Analg. 2010 Apr
1;110(4):1170-9. doi: 10.1213/ANE.0b013e3181cf9281. Epub 2010 Feb 8. PMID:
20142348.

7. Renton
T, Wilson NH. Understanding and managing dental and orofacial pain in
general practice. Br J Gen
Pract. 2016;66(646):236-237. doi:10.3399/bjgp16X684901

8. Tjäderhane, L.,
& Haapasalo, M. (2009). The dentin–pulp border: a dynamic interface
between hard and soft tissues. Endodontic
Topics, 20, 52-84.

9. Graham, Garry G.; Scott, Kieran
F. (2005). Mechanism of Action of Paracetamol. American Journal of
Therapeutics, 12(1), 46–55. doi:10.1097/00045391-200501000-00008

10. Krasniqi, S., & Daci, A.
(2017). Analgesics Use in Dentistry. Pain Relief – From Analgesics to
Alternative Therapies. doi: 10.5772/66600

11. Blicher, B., & Pryles, R.
L. (2020). Endodontic Pain Management: Preoperative,Perioperative, and
Postoperative Strategies. Compendium, 41(4)

12. Long H, Wang Y,
Jian F, Liao LN, Yang X, Lai WL. Current advances in orthodontic
pain. Int J Oral Sci.
2016;8(2):67-75. Published 2016 Jun 30. doi:10.1038/ijos.2016.24

13. Lai TT, Chiou JY, Lai TC, et al. Perceived pain for
orthodontic patients with conventional brackets or self-ligating brackets
over 1 month period: A single-center, randomized controlled clinical
trial. J Formos Med Assoc.
2020;119(1 Pt 2):282-289. doi:10.1016/j.jfma.2019.05.014

14. Cheng, C., Xie, T., & Wang,
J. (2020). The efficacy of analgesics in controlling orthodontic pain: a
systematic review and meta-analysis. BMC oral health, 20(1), 1-9.

15. Aitken, P., Stanescu, I.,
Playne, R., Zhang, J., Frampton, C., & Atkinson, H. C. (2019). An
integrated safety analysis of combined acetaminophen and ibuprofen
(Maxigesic ® /Combogesic®) in adults. Journal of pain research, 12,
621–634. https://doi.org/10.2147/JPR.S189605

16. Ruoff GM. OTC Analgesics vs
Opioids for Pain Management. J
Fam Pract. 2022;71(6 Suppl):S29-S33. doi:10.12788/jfp.0418

17. Gazal G, Mackie IC. A
comparison of paracetamol, ibuprofen or their combination for pain relief
following extractions in children under general anaesthesia: a randomized
controlled trial. Int J Paediatr Dent. 2007;17:169–177.

18. Imani, F., Motavaf, M., Safari,
S., & Alavian, S. M. (2014). The Therapeutic Use of Analgesics in
Patients With Liver Cirrhosis: A Literature Review and Evidence-Based
Recommendations. Hepatitis Monthly, 14(10).
https://doi.org/10.5812/hepatmon.23539

19. Pozzi, A., &Gallelli, L.
(2011). Pain management for dentists: the role of ibuprofen. Annalidi
stomatologia, 2(3-4 Suppl), 3–24.