VERIFIABLE CPD PAPER

Dental pain management CLINICAL

Safe use of paracetamol and high-dose NSAID

analgesia in dentistry during the COVID-19 pandemic
Alexander J. Crighton,*1 Catherine T. McCann,2 Elizabeth J. Todd1 and Alyson J. Brown1

Key points
Outlines the medical complications of prolonged Gives dentists a framework for safely providing Identifies the areas where dentists need to link
high-dose analgesia use. adequate analgesia to dental patients during the with medical GPs for providing analgesia to
COVID-19 aerosol generating procedures restrictions. dental patients.

Abstract
With dental services currently altered, dentists are being asked to provide advice, analgesia and antibiotics in
situations where they would normally be offering operative care. Dentists are familiar with using analgesia for short
courses for their patients, but using higher-dose regimes and for periods of over two weeks brings special challenges.
This paper reviews the areas where special precautions are needed when using analgesia in the current situation.

Introduction is appropriate to liaise with the patient’s GP for Paracetamol

provision of analgesia. The National Institute
Both ibuprofen and diclofenac are safe for Health and Care Excellence (NICE) Paracetamol is a safe analgesic taken up to the
medicines if used appropriately in healthy guidance on the use of NSAIDs in patients with recommended doses and is the first analgesic
adult patients.1 In the current Scottish Dental pre-existing medical conditions is available,3 that dentists should recommend. It is the best
Clinical Effectiveness Programme (SDCEP) and the British National Formulary (BNF) and choice in patients with liver and kidney disease,
COVID-19 recommendations for dental the BNF App are available for guidance. although the dose may have to be reduced in
care,2 dentists are being advised to offer advice, severe liver disease.4
analgesia and antibiotics (AAA) to patients, Analgesia in dental patients with Dentists must be aware of the risk of
where indicated. Many patients will experience COVID-19 accidental paracetamol overdose in persisting
a delay in operative emergency treatment, severe dental pain. This risk is higher in patients
resulting in longer courses and higher doses Currently there is no guidance in the literature with a body weight under 50 kg and patients
of non-steroidal anti-inflammatory drug suggesting that changes should be made to with pre-existing liver disease. Patients may not
(NSAID) analgesic use than are familiar to analgesia regimes for dental patients with be aware of the paracetamol content of some
dentists. Table 1 shows suggested analgesic COVID symptoms nor to support avoiding over-the-counter analgesics and may combine
regimes in primary care for moderate and ibuprofen in this group, despite the large them with generic paracetamol. Siddique et al.5
severe dental pain in adults, but the aim is to numbers infected since the virus was first found that dental pain was the largest cause of
prescribe and advise the lowest effective dose reported. At present, the same analgesic plan accidental paracetamol overdose in a large case
for the shortest duration needed. Dentists must should be used for both COVID-positive and series. If more than 8 x 500 mg equivalent dose
be aware of the adverse effects and medical negative primary care patients (Fig. 1). of paracetamol is found to have been taken
cautions in these circumstances in order to
safely advise their patients and to know when it Table 1 Analgesia for moderate and severe dental pain, adapted from SDCEP2

Dental pain Treatment

1
Department of Oral Medicine, NHS Greater Glasgow Paracetamol: 2 x 500 mg tablets up to four times daily (ie every four to six
and Clyde, Glasgow Dental Hospital and School, 378 For moderate dental pain
hours), or
Sauchiehall Street, Glasgow, UK; 2Department of Paediatric in adults, an appropriate
Ibuprofen: 2 x 200 mg tablets up to four times daily (ie every four to six hours),
Dentistry, NHS Greater Glasgow and Clyde, Glasgow Dental five-day regimen is either:
preferably after food
Hospital and School, 378 Sauchiehall Street, Glasgow, UK.
*Correspondence to: Alexander Crighton Increase the dose of ibuprofen to 3 x 200 mg tablets up to four times daily,
Email address: alexander.crighton@glasgow.ac.uk preferably after food, or
For severe dental pain in
Ibuprofen and paracetamol together without exceeding the standard daily
Refereed Paper. adults, an appropriate five-
dose or frequency for either drug, or
Accepted 22 May 2020 day regimen is either:
Diclofenac (1 x 50 mg tablet three times daily) and paracetamol together
https://doi.org/10.1038/s41415-020-1784-3 without exceeding the recommended daily dose or frequency for either drug

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 CLINICAL Dental pain management

by an adult in 24 hours, the patient should be

Fig. 1 Analgesic plan for patients with dental pain
referred immediately for medical assessment.
The threshold is lower in children and will vary
Patients with dental pain
with the child’s weight. The local paediatric requiring analgesia
emergency department will advise if the dentist
is unsure whether the child is at risk.
Patient has medical problems or currently
taking regular medication
Paracetamol with codeine

Paracetamol combined with codeine is an

effective analgesic for moderate to severe No Yes
dental pain6 and is available as co-codamol
in two formulations – 8/500 and 15/500. The
first number refers to the codeine dose in each Medication includes: Medical Conditions includes:
tablet and the second refers to the paracetamol NSAID/aspirin Adult body weight <50kg
dose. Neither can be prescribed by a dentist, Warfarin Allergy to NSAID
Other anticoagulants Bleeding Disorders
but the lower strength (8/500) is available to Asthma inhalers Hypertension
buy from pharmacies without prescription. Heart Failure
Liver Disease
If the higher strength (15/500) is needed, the Pregnancy
dentist should liaise with the patient’s GP. Peptic Ulcer Disease
Renal Disease
Solpadeine Max contains 12.8/500 codeine and
paracetamol, and is available from pharmacies No Yes
without prescription.

NSAIDs Read text for CAUTIONS in specific

medical problems and medication use.

In healthy individuals, NSAID medicines

can be safe for treating moderate to severe Manage with
dental pain such as ibuprofen in doses up to standard analgesic No
regime as Table 1
2,400 mg/day. In all patient groups, the lowest
effective dose for the shortest period practical
should be given, but with certain medical
conditions or risks, NSAIDs should only be with the GP who can offer 30/500 co-codamol Warfarinised patients have a significant
used with caution or at a reduced dosage. The or another opioid. Patients taking low-dose risk of drug interactions with all NSAIDs and
need to continue the use of NSAIDs should daily aspirin (75 mg/day) for cardiovascular they should not be used unless international
be reviewed at least every two weeks, and may protection can be given NSAIDs if they have normalised ratio (INR) monitoring is available
require the advice of and monitoring from the none of the other NSAID contraindications to the patient.11 Be aware that INR monitoring
patient’s GP if the dentist has concern about below,7 but only if another analgesic is not services may be reduced currently. The
extended treatment. possible and the dose of ibuprofen should be availability of this for an individual patient
The guidance below is to help the dentist restricted to 1,200 mg maximum.3 There is should be discussed with the GP. However,
identify patients in whom higher-dose some evidence that ibuprofen in higher doses where possible, an alternative analgesia
ibuprofen (600 mg three or four times daily) may reduce the antiplatelet benefit of low-dose regime should be given via the GP, such as
or diclofenac at any dose should be approached aspirin and diclofenac may be preferred when 30/500 co-codamol or other opioid. Patients
with caution. High doses of NSAIDs must be severe dental pain is being treated.8 who have significant bleeding tendencies
used with great caution in the elderly and the such as haemophilia should not be given
GP should be consulted if the dentist is in any Oral anticoagulant medicines and NSAIDs without the prior approval from their
doubt about the safety of using these medicines patients with bleeding tendencies haematologist.
in a particular patient. Patients taking novel oral anticoagulant
(NOAC) medicines such as apixaban, Known allergy to NSAID, history of
Patients with existing NSAID use rivaroxaban, dabigatran and edoxaban can angioedema and chronic renal failure
including low-dose aspirin take NSAIDs as suggested for moderate NSAIDs should not be used in these patient
Patients taking NSAID medicines for pre- and severe dental pain,9,10 but they will have groups and the dentist should contact the
existing conditions such as arthritis should enhanced post-extraction bleeding due to the patient’s GP to discuss alternative analgesic
not routinely be given ibuprofen or diclofenac NSAID’s inhibiting platelet function. Standard options. Renal failure can be made quickly
as additional analgesia. 3 If analgesia is post-extraction haemorrhage precautions will worse by the use of NSAID medicines.12
required beyond maximum paracetamol control this in most cases and the use of the Common groups to have renal failure include
dose, treatment needs to be in conjunction NSAID must be reviewed after two weeks. patients with diabetes mellitus (type  1  and

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© The Author(s), under exclusive licence to British Dental Association 2020
 Dental pain management CLINICAL

2) and patients with longstanding poor

Table 2 Analgesia for children, adapted from SDCEP2
hypertension control. If in any doubt, the
patient should have an estimated glomerular Dental pain Treatment Dose for each age group
filtration rate (eGFR) blood test requested
from the GP – a value of >60 is safe for NSAID 6–12 months = 120 mg
2–3 years = 180 mg
use. Below this level, the GP should be asked Paracetamol (500 mg tablets, or 4–5 years = 240 mg
for advice as to the best analgesia regime. 120 mg/5 ml or 250 mg/5 ml oral
6–7 years = 240–250 mg
suspension), dose depending on age, up
8–9 years = 360–375 mg
to four times daily (max = four doses in
10–11 years = 480–500 mg
Asthma For dental pain 24 hours)
12–15 years = 480–750 mg
Asthma can be exacerbated by NSAID in children, an
appropriate five-day 16–17 years = 500 mg–1 g
medications; 13 avoid diclofenac use in regimen is either:
6–11 months = 50 mg (four times daily)
asthmatics.
Ibuprofen (200 mg tablets, or 100 mg/5 1–3 years = 100 mg
ml oral suspension), dose depending on 4–6 years = 150 mg
Mild asthma (blue and brown inhalers only) age, preferably after food up to three 7–9 years = 200 mg
times daily unless indicated otherwise 10–11 years = 300 mg
Patients with mild asthma are generally safe
12–17 years = 300–400 mg
for short courses of ibuprofen of up to seven
days in the doses recommended for moderate
and severe pain. When advising patients to Box 1 Risk factors for NSAID-induced gastrointestinal (GI) adverse events,
use ibuprofen beyond this, the patient must adapted from NICE3
be given instructions to stop the ibuprofen • Aged over 65 years
and contact the prescriber immediately if their • A high dose of NSAID (2,400 mg/day)
asthma control starts to deteriorate. • A history of gastroduodenal ulcer, GI bleeding or gastroduodenal perforation
• Concomitant use of medications that are known to increase the likelihood of upper GI adverse events
Moderate asthma (blue and any other (for example, anticoagulants, corticosteroids, selective 5-hydroxytryptamine reuptake inhibitors)
colour of inhaler) • A serious comorbidity, such as cardiovascular disease, hepatic or renal impairment (including
Patients with moderate asthma can be given dehydration), diabetes or hypertension
NSAIDs in the regime for moderate dental • Heavy smoking
pain (3 x 400 mg ibuprofen in 24 hours), • Excessive alcohol consumption
but with instructions to stop the NSAID and • Previous adverse reaction to NSAIDs
contact the prescriber immediately if their • Prolonged requirement for NSAIDs.
asthma control starts to deteriorate.

Severe asthma exceptional circumstances and after discussion for GI bleeding; patients should be considered
This includes patients who have had with the GP. Paracetamol is preferred. high risk if they have a history of previous ulcer
prednisolone use in last six months or any disease or more than two risk factors and at
hospital admission for asthma. Do not use any Patients with a history of peptic ulcer moderate risk if they have one or two risk
NSAID drugs in these patients. Contact the disease factors.3
patient’s GP for an alternative analgesic regime. Most of these patients will be taking a proton
pump inhibitor (PPI) and this will protect Patients with treated and uncontrolled
Pregnancy from the gastric irritation associated with hypertension
Paracetamol is the safest analgesic to prescribe NSAIDs. In these cases, the dentist can use the Long-term use of NSAIDS may increase blood
during pregnancy, but prolonged or very high NSAID regimes recommended for moderate pressure and the impact of this effect varies
doses can be associated with subsequent and severe pain, but if the treatment course from person to person.16 For treatments of
childhood asthma, particularly if taken in for severe dental pain is prolonged beyond up to two weeks in a patient with properly
the second trimester. However, doses of up to two weeks, then the dentist should liaise with treated hypertension and no renal disease,
4 g daily remain to have any adverse effects the GP to ensure no other gastric precautions the recommendations for the use of NSAIDs
proven.3 Dentists should avoid prescribing are needed. in moderate and severe dental pain apply.
NSAID medicines in pregnancy without If a patient is not taking a PPI and has a If treatment is to continue after two weeks,
first consulting the patient’s GP. Alternative history of at least one episode of proven peptic the dentist should discuss management with
regimes available through the GP include ulcer disease (usually by previous endoscopy), the GP and the NSAID should continue as
30/500 co-codamol or other opioid. The GP has another risk factor for gastric bleeding long as blood pressure monitoring and renal
may still recommend using an NSAID regime such as an anticoagulant and is likely to be function monitoring is carried out regularly.
such as that outlined for moderate dental pain, taking the NSAID for more than two weeks, The combination of NSAIDs, angiotensin-
as NSAIDs are not absolutely contraindicated the dentist should discuss the need for a PPI converting enzyme (ACE) inhibitors and
until 30 weeks’ gestation and beyond.14 Patients (omeprazole or lansoprazole) with the GP diuretics can significantly increase the risk
who are breastfeeding can be given NSAIDs, before prescribing, especially if the patient is of kidney damage in some patients.3 If blood
but the higher doses should only be used in already taking aspirin.15 Box 1 gives risk groups pressure starts to rise or renal function

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 CLINICAL Dental pain management

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