The art of writing a prescription, especially for pain management, is just as crucial as the art of filling or extracting a tooth. Every single day, we see patients in discomfort, and our mission isn’t just to fix the affected tooth; it’s also to effectively manage that pain and ensure the patient has a comfortable experience. But this isn’t simply about reciting a few memorized phrases and writing them down. Selecting the correct Analgesic fundamentally relies on your understanding of several factors: the intensity of the pain, the patient’s medical history, and the specific nature of the dental issue.
In this article, we’re going to organize your thoughts and provide a clear roadmap. Together, we’ll explore the philosophy behind prescribing pain relievers, and then delve into the most common medications we use, moving from the weakest to the strongest. We’ll cover their dosages, specific tips, and essential precautions you absolutely need to keep in mind.
The Philosophy of Pain Management: Start Simple, Don’t Overcomplicate It
Before you even pick up your pen, you need a clear plan in your mind. This plan is known as the Step-Ladder Approach, and it simply states: begin with the simplest and safest solution, and if it doesn’t yield results, then move up a step.
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Step 1 (Mild to Moderate Pain): Start with conventional analgesics like Paracetamol or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as Ibuprofen, each used individually.
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Step 2 (Moderate to Severe Pain): If Step 1 isn’t quite cutting it, consider combining them. Give the patient a dose of an NSAID along with a dose of Paracetamol. This dual-action approach is significantly more potent.
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Step 3 (Severe Pain): If all the preceding steps fail—which is quite rare in our routine dental work—you might then consider stronger analgesics like Ketorolac for a very short duration and with extreme caution.
Common Oral Analgesics We Prescribe (Oral Analgesics)
These are the medications that are practically on our desks every single day. Let’s explore the details of each one:
1. Paracetamol (The Safe Foundation)
This is considered the first line of defense and is generally the safest option in most situations.
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How it Works: It acts centrally on the brain, providing a central analgesic effect to reduce your perception of pain. It has negligible anti-inflammatory effects.
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Standard Dose: One 500 mg tablet every 8 hours.
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When to Increase the Dose: For cases of moderate pain, you can increase the dose to 1 gram (two 500 mg tablets) every 8 hours. However, it’s crucial to advise the patient to drink plenty of water.
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Maximum Limit: Absolutely do not exceed 4 grams per day for adults, as higher doses can be hepatotoxic (1).
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Who it’s Suitable For: Excellent for pregnant patients, those with stomach or kidney issues, or individuals taking anticoagulants.
2. Ibuprofen (The Versatile Soldier)
This is perhaps the most widely known member of the Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) family.
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How it Works: It prevents the formation of Prostaglandins, which are compounds responsible for inflammation and pain. So, it functions as both an analgesic and an anti-inflammatory agent.
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Standard Dose:
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One 400 mg tablet every 8 hours.
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Or, one 600 mg tablet every 12 hours.
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Maximum Limit: Approximately 2.4 grams per day.
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Important Considerations: Nearly all NSAIDs share similar precautions:
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Contraindicated for patients with peptic ulcers.
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To be used with extreme caution in patients with kidney, heart, or hypertension issues.
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Contraindicated during the last trimester of pregnancy.
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May increase bleeding risk.
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3. Diclofenac (The Rapid Responder)
Another well-known member of the NSAID family, commonly available in two forms we frequently use:
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Diclofenac Potassium (e.g., Cataflam): This is very fast-acting and an excellent choice for acute pain that requires a swift response.
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Dose: One 50 mg tablet every 8 hours.
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Diclofenac Sodium (e.g., Voltaren): This is a bit slower and generally more suitable for managing chronic pain.
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Important Consideration: Diclofenac, in particular, has been associated with an increased risk of cardiac problems with prolonged use. Therefore, we restrict its use to short durations (2).
4. Ketorolac (The Heavy Hitter)
Considered the strongest oral NSAID available in tablet form, we typically reserve this for only the most challenging cases.
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Dose: One 10 mg tablet every 8 hours.
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Crucial Warning: Ketorolac carries significant side effects on the stomach and kidneys if used for extended periods. Because of this, global recommendations are very clear: do not use it for more than 5 consecutive days (3).
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When to Use It: In cases of very severe pain following major surgeries or complex extractions, and strictly as a short-term solution.
Injectable Analgesics: When and Why? (Injectable Analgesics)
Injectable pain relievers are utilized for acute pain situations where we need rapid control, either in the clinic or after significant surgical procedures.
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Diclofenac (e.g., Cataflam or Voltaren):
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Dose: One 75 mg ampule intramuscularly (IM), which can be repeated once more within the same day.
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Ketorolac (e.g., Ketolac):
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Dose: One 30 mg ampule intramuscularly (IM), which can be repeated every 12 hours.
These are among the most potent injectable analgesics and yield excellent results for very severe post-surgical pain. The same rule applies here: use for the shortest possible duration.
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The Clinical Blueprint: A Practical Prescription Guide for Your Practice
When a patient presents with pain, think through these steps in order:
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Take a Thorough Medical History: This is the most critical step. Always ask about any history of stomach problems, kidney issues, heart conditions, hypertension, bleeding disorders, pregnancy, or known allergies.
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Mild Pain? Start with Paracetamol 500 mg every 8 hours.
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Moderate Pain with Inflammation? Begin with Ibuprofen 400 or 600 mg every 8-12 hours.
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Moderate Pain Requiring Faster Action? You might consider Diclofenac Potassium (Cataflam) 50 mg every 8 hours.
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Severe Pain and Unresponsive? This is where you implement the dual strategy:
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Ibuprofen 600 mg every 12 hours.
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Paracetamol 500 mg administered in between Ibuprofen doses.
This method provides comprehensive pain coverage over 24 hours with a very potent yet relatively safe dual effect (4).
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Very Severe Post-Surgical Pain? You might initiate with an injectable Ketorolac 30 mg in the clinic, then follow up with oral tablets for a maximum of two to three days.
Always remember, our objective isn’t merely to alleviate pain; it’s to alleviate it safely. Your judicious choice of analgesic truly reflects your understanding and expertise as a skilled practitioner.
