Surgeons often prescribe opioids preemptively, though a combination of ibuprofen and acetaminophen may be the preferred choice for pain after third-molar extractions, according to a study recently published in the Journal of the American Dental Association.
Patients taking nonopioids experienced a better first-night's sleep, less postoperative pain interference, and fewer side effects, the authors wrote.
"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," wrote the authors, led by Dr. Cecile A. Feldman of the Rutgers University School of Dental Medicine (JADA, January 4, 2025).
The randomized multisite clinical trial included 1,815 adult participants undergoing partial or full bony impacted mandibular third-molar extractions. Participants were randomly assigned to receive either 5 mg hydrocodone with 300 mg acetaminophen or 400 mg ibuprofen with 500 mg acetaminophen taken every four to six hours as needed.
Statistical analyses followed an intent-to-treat approach. A mixed-model analysis tested whether nonopioid medication was noninferior to opioids for pain, accounting for treatment, time, interactions, and participant and site variability, they wrote.
Nonopioids were superior to opioids for pain relief on the first (mean difference [MD], -0.70; 98.75% confidence interval [CI], -0.94 to -0.45) and second (MD, -0.28; 98.75% CI, -0.52 to -0.04) days and nights, and noninferior on the third day and night (MD, -0.09; 98.75% CI, -0.34 to 0.15) and the postoperative period (MD, -0.20; 98.75% CI, -0.45 to 0.05).
At the postoperative visit, 85.3% of the nonopioid group reported being extremely satisfied or satisfied compared to 78.9% in the opioid group (odds ratio [OR], 1.55; 95% CI, 1.21 to 1.98; p = .006). Rescue analgesic use was lower in the nonopioid group (2.89% versus 6.07%; OR, 0.45; 95% CI, 0.28 to 0.73; p = .001), and they reported less pain interference and better first-night sleep quality (MD, -0.34; 98.75% CI, -0.65 to -0.02; p = .030), they wrote.
On average, participants in the opioid group returned 8.5 of the 20 hydrocodone capsules provided and were more likely to fill new opioid prescriptions within six months (5.81% versus 3.22%; OR, 0.54; 95% CI, 0.27 to 1.08; p = .082). Adverse events were less frequent and less severe in the nonopioid group (86.8% versus 91.7%; p < .001), with lower severity scores (MD, -0.06; 95% CI, -0.10 to -0.03) and fewer reports of fatigue, drowsiness, nausea, and headaches.
However, the study had limitations. The study avoided long-lasting local anesthetics to prevent masking treatment effects and observed differences in pill consumption, warranting further analysis of their effect, the authors added.
"Routine opioid prescribing after dental surgery is not supported," Feldman and co-authors wrote. "The results of this study confirmed the ADA's recommendations that ibuprofen and acetaminophen in combination should be the first-line therapy for acute pain management."
