Comparing Nonopioid and Opioid Analgesics for Pain Management After Dental Surgery

A randomized clinical trial demonstrated that a combination of ibuprofen and acetaminophen effectively managed postsurgical pain after mandibular third-molar extraction, outperforming an opioid-based regimen in early postoperative pain control and patient satisfaction.

This study addresses the ongoing issue of unnecessary opioid prescriptions, which contribute to addiction and death, as unused tablets can be diverted.

The multisite, double-blind trial included 1815 adults undergoing mandibular third-molar extraction. Participants were randomized to receive either 5 mg of hydrocodone with 300 mg of acetaminophen (opioid) or 400 mg of ibuprofen with 500 mg of acetaminophen (nonopioid). After an initial dose, medications were taken every 4 to 6 hours as needed for pain. Pain levels were assessed using a numeric rating scale (0 to 10), and patient satisfaction was evaluated during the postoperative visit.

Patients in the nonopioid group reported significantly less pain than those in the opioid group during the first day and night (mean difference, –0.70; 95% CI, –0.94 to –0.45; P < .001) and the second day and night (mean difference, –0.28; 95% CI, –0.52 to –0.04; P = .015). Over the entire postoperative period, pain levels in the nonopioid group were no worse than in the opioid group (mean difference, –0.20; 98.75% CI, –0.45 to 0.05; P = .172). Additionally, 85.3% of nonopioid participants reported being extremely satisfied or satisfied with their pain management, compared with 78.9% of opioid participants (95% CI, 1.21 to 1.98; P = .006).

This study excluded individuals with a personal or familial history of addiction or substance abuse, which may limit its findings. To avoid masking the treatment effect, long-lasting local anesthetics were not used, but this limits the applicability of the results to patients who may receive such treatments. The study did not restrict participants to a prescribed dosing schedule, leading to variability in the number of pills taken, which requires further research. As-needed dosing was used to minimize the potential for future addiction, though fixed-interval dosing could have provided a more direct comparison. Participants were also asked to complete diary entries twice daily to report pain levels and medication use, but there may still be some recall bias, particularly over time.

“The ibuprofen and acetaminophen combination managed pain better for the first 2 days and led to greater satisfaction over the entire postoperative period than hydrocodone with acetaminophen,” the study authors concluded. “At no time did hydrocodone outperform the nonopioid.”

Reference

Feldman CA, Fredericks-Younger J, Desjardins PJ, et al. Reference nonopioid vs opioid analgesics after impacted third-molar extractions. J Am Dent Assoc. Published online January 7, 2025. doi:10.1016/j.adaj.2024.10.014