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316 Odontalgia
100 mg caffeine and 200 mg ibuprofen achieves significantly greater OP relief
than NSAID monotherapy. 13 Adding caffeine to ibuprofen improves analgesic
potency (by 2.4–2.8 times), speeds onset of analgesia, and prolongs pain relief. 13
Although a previously cited trial found that addition of mild opioids (e.g.
codeine) toNSAIDs did not reliably improve OP relief, there is conflicting
evidence on the subject. 4,14 The minimum dose of opioid needed to improve
analgesia, while minimizing side effects, remains unknown. Both clinical
studies and ED experience bear out some utility of potent opioids (e.g. oxycodone)
for OP. 15–17 The use of these agents is recommended for those patients
for whom other approaches (e.g. NSAIDs) have failed or are contraindicated.
1,18,19 Routine addition of opioids to NSAIDs is not warranted, given the
overall risk-to-benefit ratio of dual therapy over treatment with NSAIDs alone.
The mixed-mechanism drug tramadol provides pain relief that is partially
mediated by opioid receptors. As a single-agent approach to OP, tramadol
seems to offer little advantage and we do not recommend it for monotherapy.
20 However, combination therapy with tramadol and a mild non-opioid
analgesic represents an attractive therapeutic option for OP. Dual therapy
with tramadol and either flurbiprofen or acetaminophen provides superior
pain relief to monotherapy with any of these drugs. 21 The combination
approach also allows a reduction in tramadol dose. A trial assessing combination
therapy with tramadol (75 mg PO) plus acetaminophen (650 mg PO)
found the dual regimen far superior to monotherapy with a larger dose of
tramadol (100 mg PO). 20
The OP of alveolar osteitis is usually treated with topical therapy (see
below). In one study, mega-dose vitamin C (4000 mg/day) was found to
provide complete resolution of alveolar osteitis symptoms within four days.
The study’s authors, who found that a majority of patients have complete
relief within 48 h, postulate that the vitamin C works by facilitating granulation
tissue formation. 22
LOCAL INJECTION THERAPY
The supraperiosteal infiltration of local anesthetics (e.g. lidocaine, bupivacaine)
usually provides suitable anesthesia when OP is emanating from a