The availability and variety of pain medications has significantly improved the ability to manage postoperative pain in dentistry. The traditional approach involved prescribing narcotic analgesics for moderate to severe post-operative pain. Narcotic analgesics act on the Central Nervous System to block pain receptors. The safer approach uses the combination of both non-narcotic and narcotic medications vs. either medication used alone. Examples of combination agents include Acetaminophen/Codeine (Tylenol #3 or 4), Acetaminophen/Hydcrocodone (Lortab, Lorcet, Anexcia, Vicodin) and Ibuprofen/Codeine (Vicoprofen).

It has been shown that narcotics use for a prolonged period of time results in a tolerance to medication, which creates the need for a prolonged use and larger dose. The narcotic eventually becomes habit-forming, leading to complete mental or physical dependence. Although not habit-forming, Acetaminophen should be used with caution because larger dosage may cause liver damage.

Post-surgical pain often comes from inflammation associated with early healing. Lately, more and more interest was shown in using non-steroidal anti-inflammatory agents (NSAIDs) for acute pain relief. NSAIDs, such as Ibuprofen (Motrin or Advil), Flurbuprofen, Naproxen (Anaprox, Aleve), Diflunisal (Dolobid), Etodolac (Lodine) and COX-2 inhibitors (Celebrex and Vioxx) have been very effective in acute pain management in both medicine and dentistry. These drugs are often more effective than narcotics, since they block the source of pain which is inflammation, and have fewer side effects. Dental practitioners now rely more on NSAID analgesics alone versus narcotic analgesic combinations.

NSAIDs have been the mainstay of non-narcotic therapy for a variety of conditions. Arthritis, joint and musculoskeletal injuries, inflammation and post-operative pain can all be treated with NSAIDs. Recently, it has been shown that rheumatoid arthritis shares the same pathway of disease progression as periodontitis. Therefore, using adjunctive anti-inflammatory therapy in periodontal treatment with agents that are proven to help arthritis patients, may significantly improve treatment outcome.

NSAIDs are not risk free. Long-term use of most agents may lead to the toxicity of GI tract, liver, kidneys, central nervous system, and skin. NSAIDs should be avoided if the patient is allergic to aspirin or has a history of asthma, kidney failure, liver disease, or bleeding disorders.

Advances in pharmaceutical research led to the development of new generation of NSAIDs, that do not carry undesirable risks and side effects. Two new anti-inflammatory analgesic agents are Colecoxib (Celebrex) and Rofecoxib (Vioxx). They are currently used for the management of arthritis and acute dental and post-surgical pain. Both of these agents are selective COX-2 inhibitors, therefore they do not cause GI toxicity, associated with the traditional NSAIDs. COX-2 enzymes, on the other hand, are stimulated when there is tissue injury and inflammation. Inhibition of COX-2 enzymes produces substantial anti-inflammatory effect and pain relief, while leaving protective COX-1 enzyme intact.

Of the two COX-2 inhibitors, only Rofecoxib (Vioxx) is indicated for acute pain management. Two recent studies have compared Rofecoxib with Vicodin HP and Lortab in single-dose post surgical models. The result showed similar if not better post-surgical pain management with Vioxx vs. narcotic combination agents. Vioxx is available in 12.5-. 25-, or 50-mg tablets and in 12.5 mg/5ml and a 25mg/5ml oral suspensions. It is well absorbed after oral dosing and can be taken with or without food. Rofecoxib has been shown to provide analgesia comparable to other NSAIDs, but it has a longer duration of action (>24 hours), and is not associated with GI side effects. Recommended dose for acute pain management is 50mg Rofecoxib (Vioxx) once daily for 5-10 days.

Here is the suggested dose regimen for acute pain management for commonly used NSAIDs:

1. Lodine 400mg; one tablet every 8 hours for 5-10 days
2. Ibuprofen 600 or 800 mg; one tablet every 4-6 hours for 5-10 days
3. Naprosyn 200mg; one tablet every 12 hours for 5-10 days
4. Dolobid 500 mg; 1000mg stat, then one tablet every 12 hours for 5-10 days