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Odontalgia 315
pain, trial evidence has found either ibuprofen (400 mg PO) or ketorolac (10
mg PO) provides relief superior to that achieved with acetaminophen (paracetamol;
600 mg PO) alone or in combination with codeine (60 mg PO). 2
Another study found that ketorolac (10 mg PO) monotherapy was signifi-
cantly more efficacious than treatment with acetaminophen (625 mg) plus
codeine (15 mg PO). 3 Other trials in OP have demonstrated the equivalence
or superiority of ibuprofen (400 mg PO) to acetaminophen (600 mg), aspirin
(650 mg PO), codeine (up to 60 mg PO), and even combination therapy
comprising codeine (60 mg PO) and either aspirin or ibuprofen. 4,5 Given
the efficacy of the 400 mg PO of ibuprofen, and the increased incidence of
adverse effects associated with higher doses, we recommend 400 mg of this
NSAID as the initial approach for OP.
The literature fails to identify any significant differences in efficacy
between the various NSAID classes for OP. There are, however, several
NSAIDs (e.g. naproxen, etodolac, piroxicam) that are attractive for OP use
given their extended dosing intervals.
Among the NSAIDs demonstrated to provide better pain relief than placebo
is parenteral ketorolac. 6 While ketorolac’s general acute care efficacy may
not differ from that achieved with other NSAIDs, assessments of the agent’s
parenteral use in acute care suggest it is highly effective in OP. 7 This agent’s
IV or IM administration may be useful when patients, owing to oral pain or
other reason, cannot take PO therapy. The full effect of ketorolac analgesia,
which can take as long as an hour even after IV administration, can be
accelerated and even augmented by administering the NSAID directly into
the periapical space. 8–10 The periapical injection of ketorolac is promising for
application in acute care, but its recommendation for ED use must await
further safety and efficacy data.
Trials suggest that there is no reason to employ the COX-2 selective
NSAIDs. Compared with these agents, nonselective NSAIDs such as ibuprofen
provide superior pain relief while incurring no extra short-term side effects.
Consequently, we agree with dental expert reviews that find no reason to use
the COX-2 selective NSAIDs in lieu of agents such as ibuprofen. 11,12
Although the action mechanism is unknown, it is clear that addition of
caffeine improves ibuprofen’s analgesic efficacy in OP. The combination of