Pain is an inherent component of most dental conditions and procedures, constituting the primary reason for patient visits. Effective pain management and prevention are crucial for patient comfort, the healing process, and maintaining patient-doctor cooperation. This article aims to synthesize the current literature on pharmacological and nonpharmacological methods of pain treatment and prevention.
Cite: Paulo M. Wysokinska-Miszczuk J. Treatment and Prevention of Pain in Dental Diseases; Nowy Gabinet Stomatologiczny; 7/2025
Dental pain is one of the most common complaints requiring intervention in dental offices and emergency departments. In the United States, on average, a patient visits the emergency department every 15 seconds due to acute toothache [1]. Most orofacial pain is odontogenic in nature – associated with diseases of the dental tissues and periodontium (e.g., caries, pulpitis, hypersensitivity). Pain in dentistry is classified as inflammatory (e.g., pulpitis), neuropathic (e.g., trigeminal neuralgia), and non-nocturnal (e.g., psychogenic pain). Misdiagnosis of the cause of pain often leads to treatment errors – it is the most frequently reported complication in dental practice [2].
Mechanisms and groups of dental pain
Inflammatory tooth pain (odontogenic) is usually the result of pulp damage (e.g. in the course of caries) and manifests itself as symptoms provoked by thermal stimuli or as a spontaneous pulsating pain.
The short-lasting, acute pain of dentin hypersensitivity is triggered by a tactile or thermal stimulus, while acute irreversible pulpitis manifests as episodes of severe, throbbing pain that may mimic neuralgic or migraine symptoms [2]. Pain following dental procedures (e.g., wisdom tooth extraction, periodontal surgery) has an inflammatory component and typically worsens within the first 24–72 hours. Neuropathic pain (neuralgia)—e.g., trigeminal neuralgia—and myofascial pain are also characteristic.
Pharmacotherapy of dental pain
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of dental pain therapy. They act by blocking prostaglandin synthesis at the site of inflammation, which leads to reduced swelling and inhibition of pain receptor hypersensitivity [1, 3]. Clinical studies show that NSAIDs (e.g., ibuprofen) typically provide superior analgesia to acetaminophen and opioids in the treatment of inflammatory pain. Meta-analyses and ADA practice guidelines confirm that NSAIDs with acetaminophen are the treatment of choice for acute dental pain (post-extraction and painful inflammatory conditions), providing better pain relief with a more favorable safety profile than opioids. For example, oral administration of 800 mg of ibuprofen 45 minutes before anesthesia leads to deeper analgesia in teeth with irreversible pulpitis, further facilitating endodontic procedures [1, 3]. In addition, NSAIDs (e.g. ibuprofen 1200–2400 mg/d for several days) significantly reduce swelling and pain after surgical procedures.
Nimesulide has been extensively studied for its effectiveness in relieving post-extraction pain and post-oral surgery pain. Studies have shown that nimesulide has a faster onset and longer duration of analgesic effect compared to other NSAIDs, such as ibuprofen or ketoprofen. It is a preferential COX-2 inhibitor, offering potent analgesic and anti-inflammatory effects. Clinical trials comparing nimesulide with ibuprofen for pain after wisdom tooth extraction have shown that both medications provide 24-hour relief, although nimesulide may have a faster onset and greater subjectively assessed effect [4]. In a randomized trial, nimesulide (300 mg as a single dose, then every 6 hours) provided greater pain reduction 15–60 minutes after tooth extraction than ibuprofen (400 mg). Other data (SAFE-2 Study) show that the combined dose (FDC) of nimesulide with paracetamol (100 mg + 325 mg) in the treatment of pain of various etiologies is at least non-inferior to regimens with diclofenac or aceclofenac with paracetamol, and more effective than ketorolac [5]. Nimesulide is often well tolerated, although caution is required due to the risk of liver disorders with long-term use. In the short-term treatment of dental pain, it is an attractive alternative to NSAIDs [4, 5].
Randomized clinical trials have confirmed that nimesulide at a dose of 100 mg twice daily provides complete pain relief in 72.6% of patients on the first day after surgery, compared to 54.7% of patients treated with other NSAIDs. Furthermore, nimesulide has a favorable safety profile, and the risk of adverse events, including liver damage, is comparable to other drugs in this class, provided that dosing recommendations and contraindications (e.g., hepatic failure, pregnancy) are followed [13].
Although weaker than NSAIDs in inflammatory conditions, acetaminophen is sometimes used as an adjunct to therapy (especially in combination with NSAIDs) or when NSAIDs are contraindicated. In dental practice, combining a lower dose of an NSAID with acetaminophen can provide additive analgesia. Opioids (e.g., codeine) are rarely used alone; the 2024 ADA guidelines clearly recommend that opioids should be reserved only for situations where NSAIDs and acetaminophen are insufficient or contraindicated [1]. In some studies, adding a weak opioid (e.g., tramadol) to an NSAID provided greater pain relief than a high-dose NSAID alone, reflecting the different mechanisms of action of these drugs [3]. However, due to the risk of addiction and adverse effects, routine use of opioids after dental procedures is avoided. Clinical studies have observed that preoperative administration of tramadol may result in reduced postoperative pain.
Glucocorticosteroids, such as dexamethasone, are also used to control swelling after surgical procedures [12].
A key strategy in pain management is to prevent its occurrence. The concept of preventive analgesia involves administering an analgesic before the onset of pain, i.e., before the procedure. Studies confirm that administering NSAIDs (e.g., ketoprofen) one hour before tooth extraction significantly reduces postoperative pain intensity and the need for additional analgesics compared to placebo. According to the principles of evidence-based medicine (EBM), acute pain management should be based on an analgesic ladder, starting with paracetamol or NSAID monotherapy (e.g., ibuprofen), and, if necessary, progressing to their combination or the use of tramadol. Nimesulide should be reserved for cases refractory to other NSAIDs, with close monitoring of the patient's condition [12].
Non-pharmacological methods of pain relief
In addition to pharmacological medications, non-drug techniques are used, particularly to reduce anxiety and pain sensitivity. Distraction methods such as music, virtual reality, distraction, or slow explanation of the procedure can be used in dental practice. Most studies show that these significantly improve patient behavior and reduce pain perception [6]. Other psychological techniques (e.g., relaxation techniques, hypnosis) may also reduce the subjective experience of pain, although the evidence is less clear.
Applying cold compresses to the face after surgical procedures is popular and safe. A meta-analysis shows that tissue cooling reduces pain compared to conventional methods (especially in the first 4–72 hours after surgery). People using cryotherapy report slightly less pain after extractions than those in the control group. Similarly, cooling the mucosa (e.g., with a cooling gel) before anesthetic injection significantly reduces the pain of the injection itself, especially in children [7].
Laser therapy
Low-level laser therapy (LLLT) and photodynamic therapy (PDT) have been proposed for postoperative pain relief. Recent reviews indicate that phototherapy may provide modest pain relief after root canal treatment, especially in the initial hours, but the effect is short-lived and the benefits over conventional analgesic therapy are modest [8]. In dental practice, therapeutic laser therapy may be used as an adjunct therapy, but studies to date have not demonstrated its clear advantage over standard analgesic methods. Acupuncture
A growing body of research suggests that acupuncture may help relieve dental pain. A 2023 systematic review found that patients undergoing acupuncture had significantly lower postoperative pain intensity than those receiving sham acupuncture, as well as improved intraoperative pain relief [10]. However, the authors note the methodological limitations of existing studies and the need for further high-quality research. These results are consistent with previous analyses that indicated acupuncture may provide relief from acute dental analgesia [10]. Preventive analgesia and pain prevention
Prophylactic administration of analgesics (preoperatively) effectively reduces subsequent pain intensity. Significantly better postoperative pain control (up to 72 hours) was reported after taking nimesulide compared to ibuprofen 1 hour before periodontal surgery [11]. Overall, data suggest that preoperative NSAIDs (or paracetamol) can prevent pain escalation and limit the inflammatory component of acute pain [3]. Good dental practices are also important preventive methods: effective local anesthesia, rapid and precise causal therapy (removal of the source of pain), and minimizing tissue trauma during procedures. Patient education (contraindications to NSAIDs, correct dosage, etc.) complements preventive therapy. Consideration should also be given to administering a sedative or anxiolytic medication, e.g., 10 mg hydroxyzine, to reduce emotional tension and thus more effectively manage pain.
Recommendations of scientific societies
International guidelines, such as those of the American Dental Association (ADA), clearly recommend non-opioid medications (NSAIDs with paracetamol) as first-line therapy for acute dental pain (e.g., pain following tooth extraction or pulp inflammation). Opioids are recommended only when other medications are ineffective or contraindicated [1]. Such indications are consistent with the recommendations to minimize opioid abuse.
Summary and conclusions
Pain management in dental conditions requires a multifaceted approach: rapid diagnosis, causal therapy (removing the source of pain), and effective analgesia. A review of recent research confirms that NSAIDs (especially ibuprofen) alone or in combination with paracetamol are the most effective and safest first-line treatment for acute toothache. Nimesulide is a useful alternative NSAID with rapid onset, as confirmed by clinical studies. Non-pharmacological methods (acupuncture, laser, relaxation techniques, cryotherapy) can support pain management but do not replace pharmacotherapy.
Applying evidence-based recommendations and guidelines from scientific societies is crucial. All sources included in this review emphasize the priority of NSAIDs/acetaminophen and the limited use of opioids. Patient education and strict adherence to dosing recommendations are also important, as they improve patient comfort and treatment effectiveness while minimizing the risk of complications.
LITERATURE:
1. Green VG, Polk DE, Turturro MA, Moore PA, Carrasco-Labra A. Evidence-based clinical practice guidelines for the management of acute dental pain. Am J Emerg Med. 2025 Mar; 89:247–253. doi: 10.1016/j.ajem.2024.12.054. Epub 2024 Dec 22. PMID: 39764906.
2. Labanca M, Gianò M, Franco C, Rezzani R. Orofacial Pain and Dentistry Management: Guidelines for a More Comprehensive Evidence-Based Approach. Diagnostics (Basel). 2023 Sep 4;13 (17): 2854. doi: 10.3390/diagnostics13172854. PMID: 37685392; PMCID: PMC10486623.
3. Pozzi A, Gallelli L. Pain management for dentists: the role of ibuprofen. Ann Stomatol (Roma). 2011 Jul; 2 (3–4 Suppl): 3–24. Epub 2012 Apr 15. PMID: 22888399; PMCID: PMC3414241.
4. Bocanegra M, Seijas A, González Yibirín M. Effectiveness and tolerability of once-daily nimesulide versus ibuprofen in pain management after surgical extraction of an impacted third molar: A 24-hour, double-blind, randomized, double-dummy, parallel-group study. Curr Ther Res Clin Exp. 2005 May; 66(3): 172–80. doi: 10.1016/j.curtheres.2005.06.007. PMID: 24672121; PMCID: PMC3964531.
5. Patil S, Nadaf N, Gupta S, Barai P, Makhija S, Lodha P, Patel C, Gondane AA, Pawar D, Sharma A. A Comparative Analysis of the Efficacy and Safety of Nimesulide/Paracetamol Fixed-Dose Combination With Other NSAIDs in Acute Pain Management: A Randomized, Prospective, Multicenter, Active-Controlled Study (the SAFE-2 Study). Cureus. 2024 Apr 23;16 (4): e58859. doi: 10.7759/cureus.58859. PMID: 38800230; PMCID: PMC11126320.
6. Goettems ML, Zborowski EJ, Costa FD, Costa VP, Torriani DD. Nonpharmacologic Intervention on the Prevention of Pain and Anxiety During Pediatric Dental Care: A Systematic Review. Acad Pediatrician. 2017 Mar; 17(2): 110–119. doi: 10.1016/j. acap.2016.08.012. PMID: 28259334.
7. Saeedi P, Sarraf Shirazi A, Ghorbani M. The effectiveness of cryotherapy and cooled topical anesthesia compared with conventional topical anesthesia in alleviating intraoral injection pain: A systematic review and meta-analysis. Int J Paediatr Dent. 2025 Jul; 35(4): 655–674. doi: 10.1111/ipd.13275. Epub 2024 Oct 6. PMID: 39370577.
8. Elmsmari F, Shujaie H, Alzaabi R, González JA, Aljafarawi T, Olivieri JG, Jurado CA, Afrashtehfar KI. Lasers efficacy in pain management after primary and secondary endodontic treatment: a systematic review and meta-analysis of randomized clinical trials. Sci Rep. 2024 Oct 29;14 (1): 26028. doi: 10.1038/s41598–024–74998-x. PMID: 39472604; PMCID: PMC11522329.
9. Müller M, Schmucker C, Naumann J, Schlueter N, Huber R, Lederer AK. Acupuncture in management of acute dental pain – A systematic review and meta-analysis. Jpn Dent Sci Rev. 2023 Dec; 59:114–128. doi: 10.1016/j.jdsr.2023.02.005. Epub 2023 Mar 10. PMID: 36950225; PMCID: PMC10025006.
10. Ernst, E., Pittler, M. The effectiveness of acupuncture in treating acute dental pain: a systematic review. Br Dent J 184, 443–447 (1998). https://doi.org/10.1038/sj.bdj.4809654
11. Santos BFE, Costa FO, Vasconcelos AMA, Cyrino RM, Cota LOM. Preemptive effects of ibuprofen and nimesulide on postoperative pain control after open flap periodontal surgery: A randomized placebo-controlled split-mouth clinical trial. J Periodontol. 2022 Feb; 93(2):298–307. doi: 10.1002/JPER.20–0887. Epub 2021 Jun 9. PMID: 34031888.
12. Preuss, O., et al. (2015). Pharmacological and non-pharmacological methods in treatment of pain in oral surgery. Dental Magazine.
13. Tiwaskar M, Charde S, Balankhe N, Hegde A, Deodhar M, Gondane A, Pawar D, Sharma A. Nimesulide: Critical Appraisal of Safety and Efficacy in Acute Pain. J Assoc Physicians India. 2025 Mar; 73 (3): e22-e28. doi: 10.59556/japi.73.0870. PMID: 40087939.
Authors:
DR. N. MED. MICHAŁ PAULO
He graduated from the Medical University of Lublin and currently works at the Department of Periodontology at the Medical University of Lublin. He earned his doctorate with a thesis on the diagnosis of disorders of the masticatory system. He completed postgraduate studies and earned the title of ICI Coach.
PROF. DR. HAB. N. M.D. JOANNA WYSOKIŃSKA-MISZCZUK
Head of the Department of Periodontology at the Medical University of Lublin and regional consultant in periodontology. He specializes in periodontal disease, implantology, and aesthetic dentistry, combining research with clinical practice.
