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Dental abscess - Management
What analgesia is recommend for dental abscess?

  • Ibuprofen, or paracetamol if ibuprofen is contraindicated or unsuitable, is recommended first-line.
  • Paracetamol and ibuprofen can be taken together if pain relief with either alone is insufficient.
  • For adults, if taking paracetamol and ibuprofen together does not provide enough pain relief, consider adding codeine phosphate or switching to an alternative nonsteroidal anti-inflammatory drug (NSAID) such as naproxen or diclofenac.
    • In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are preferred to diclofenac.
  • For women who are pregnant or breastfeeding, paracetamol is preferred. A short course of codeine may be added if paracetamol alone is insufficient.
Clarification / Additional information
  • Over-the-counter (OTC) analgesics containing paracetamol, aspirin, or ibuprofen are available with or without codeine.
    • By the time of presentation, the person may already have tried OTC medications, including a combination of these analgesics.
  • For further information on the prescribing of nonsteroidal anti-inflammatory drugs, see the CKS topic on NSAIDs - prescribing issues.
  • For advice on safe use of analgesics, see Self-care advice.
  • For further information on the use of analgesics during pregnancy and breastfeeding, see In pregnancy or breastfeeding.
Basis for recommendation
  • These recommendations are based on expert opinion and standard clinical practice. CKS found no trials that specifically looked at oral analgesics in the treatment of dental abscess by medical practitioners.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally regarded as the analgesic of choice, given the inflammatory aetiology of most dental pain (being caused by factors such as infection and trauma) [Dionne and Berthold, 2001; Canadian Collaboration on Clinical Practice Guidelines in Dentistry, 2004; Hargreaves and Abbott, 2005; Mickel et al, 2006; BNF 54, 2007].
    • Ibuprofen is the preferred NSAID as it is associated with a lower risk of gastrointestinal adverse effects compared with other NSAIDs [Dionne and Berthold, 2001; CSM, 2002; CSM, 2003; Hargreaves and Abbott, 2005; BNF 54, 2007]. Ibuprofen is widely available over the counter and, unlike aspirin, can be given to those less than 16 years of age.
    • Differences in anti-inflammatory activity between different NSAIDs are small, but there is considerable variation in individual tolerance and response to them.
    • Choice of NSAID in people at risk of cardiovascular adverse effects: diclofenac 150 mg daily has a similar level of thrombotic risk to etoricoxib and possibly other coxibs. The available data do not suggest an increase in thrombotic risk with naproxen or with lower doses of ibuprofen (up to 1200 mg daily) [CHM, 2006; MHRA, 2007; MHRA, 2009]. For further information, see the section on Supporting evidence in the CKS topic on NSAIDs - prescribing issues.
    • For those unresponsive to ibuprofen, a different NSAID should be chosen on the basis of incidence of gastrointestinal and other adverse effects [BNF 54, 2007]. For further information see the CKS topic on NSAIDs - prescribing issues.
  • Paracetamol is an alternative if NSAIDs are unsuitable. Its analgesic effect for mild-to-moderate dental pain is probably lower than aspirin. However, paracetamol has the advantage that it does not affect bleeding time or interact significantly with warfarin, and is less irritating to the stomach [BNF 54, 2007].
  • Codeine and other opioids on their own are thought to be relatively ineffective for dental pain, and their adverse effects can be unpleasant. Opioids should only be considered as adjunctive analgesics and not as primary analgesics [Dionne and Berthold, 2001; Hargreaves and Abbott, 2005; BNF 54, 2007].
    • Over-the-counter analgesics containing low dose codeine are available (e.g. co-codamol 8/500 tablets), but the efficacy of these preparations is uncertain [Hargreaves and Abbott, 2005].
  • Combined use of analgesics in severe dental pain:
    • CKS found no trials supporting the combined use of analgesics (NSAID, paracetamol, and codeine) for severe dental pain. However, this recommendation is pragmatic advice as a combination of drugs are commonly used in clinical practice for pain management.

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