Analgesics in Dentistry: What You Need for the INBDE
For acute dental pain, an NSAID alone or combined with acetaminophen is first-line therapy, for example ibuprofen 400 mg or naproxen sodium 440 mg, with or without acetaminophen 500 mg. Opioids are a last resort: only when that fails or NSAIDs are contraindicated, at the lowest dose and fewest tablets, for a course that rarely exceeds 3 days, and never after a simple extraction.
That is the ADA’s 2024 guideline in two sentences. This page adds the exact doses, the NSAID contraindications, the acetaminophen ceiling, opioid basics, the rules for children and a decision table. Students in The Study Boards INBDE course learn it in this order because exam cases test the safety checks as much as the first-line drug.
How The Study Boards helps you with analgesics on the INBDE
Our faculty-written Pharmacology module teaches pain management, and our test series then tests it the way the exam does, inside patient cases: a patient box with asthma, warfarin or a recent opioid history, and you choose the safe drug. Nightly live tests at 9 PM New York time keep it fresh. The course is extremely personalised: red lines and assignments are given to you on the go, the course learns from the way you study, and faculty are there to assist you. Explanations come from US-licensed dentists, not AI.
The ADA 2024 acute dental pain guideline
Built by the ADA Science and Research Institute with the University of Pittsburgh and the University of Pennsylvania, and funded by the FDA. It covers adolescents (12 to under 17), adults (17 to under 65) and older adults (65 and over).1
Pain after extractionsSimple and surgical extractions, including impacted lower third molars.1
Toothache, as a bridgePulpitis, or pulp necrosis with symptomatic apical periodontitis or acute apical abscess, only when definitive treatment is not immediately available. It never replaces or delays treatment.1
Why NSAIDs winEvidence from 82 randomized trials suggests NSAIDs, alone or with acetaminophen, relieve pain after surgical extraction better than opioids, with a more favorable safety profile.1
Doses by situation, as written in the guideline
The guideline gives example single doses. Pick the situation.23
| Line | What to give |
|---|---|
| First line | NSAID alone (ibuprofen 400 mg or naproxen sodium 440 mg) OR NSAID plus acetaminophen (500 mg) |
| NSAID contraindicated | Acetaminophen alone at full therapeutic dose (1,000 mg) |
| Opioids | Recommended against after a simple extraction |
| Line | What to give |
|---|---|
| First line | NSAID alone (ibuprofen 400 mg or naproxen sodium 440 mg) OR NSAID plus acetaminophen (500 mg) |
| NSAID alone not enough | ADD to the NSAID: one 325 mg acetaminophen tablet plus one combination tablet of 325 mg acetaminophen with an opioid (hydrocodone 5 to 7.5 mg or oxycodone 5 mg) |
| NSAID + acetaminophen not enough | REPLACE the first prescription with: NSAID (ibuprofen 400 mg or naproxen sodium 440 mg) plus 325 mg acetaminophen plus one combination tablet of 325 mg acetaminophen with an opioid |
| NSAID contraindicated | Acetaminophen 1,000 mg alone, OR 325 mg acetaminophen plus a 325 mg acetaminophen/opioid combination tablet |
| Corticosteroids | The panel suggests against adding them to standard analgesic therapy |
| Line | What to give |
|---|---|
| In the chair | A short-acting local anesthetic for immediate relief (for example 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine) |
| First line after the visit | NSAID alone (ibuprofen 400 mg or naproxen sodium 440 mg) OR NSAID plus acetaminophen (500 mg) |
| Not enough | Same add-or-replace opioid steps as for a surgical extraction |
| NSAID contraindicated | Acetaminophen 1,000 mg alone, OR 325 mg acetaminophen plus a 325 mg acetaminophen/opioid combination tablet |
| Topical | 10% or 20% benzocaine on the tooth and surrounding gingiva for short-term relief |
Maximum daily dosesIbuprofen 2,400 mg, naproxen sodium 1,100 mg, acetaminophen 4,000 mg. Use the minimum effective dose.2
Longer relief before discharge0.5% bupivacaine with 1:200,000 epinephrine (block or infiltration) or 4% articaine with 1:100,000 or 1:200,000 epinephrine (infiltration) is suggested over 2% lidocaine or 3% mepivacaine. It adds to analgesics; it does not replace them.2
NSAIDs: how they work and when not to use them
NSAIDs inhibit cyclooxygenase (COX-1 and COX-2) and so block prostaglandin synthesis.6 Dental pain after extraction is driven mainly by inflammation, with prostaglandins playing a key role, which is why NSAIDs work so well.1
| Patient factor | What the label says | Exam answer |
|---|---|---|
| Asthma, hives or allergic-type reaction after aspirin or another NSAID | Contraindicated; severe, sometimes fatal anaphylactic reactions reported67 | No NSAID Use acetaminophen |
| Setting of coronary artery bypass graft (CABG) surgery | Contraindicated6 | No NSAID |
| Peptic ulcer or GI bleeding history, older age | Boxed warning: serious GI bleeding, ulceration and perforation, which can be fatal; older patients at greater risk7 | Avoid or caution |
| Cardiovascular disease | Boxed warning: increased risk of heart attack and stroke, which can occur early in treatment7 | Caution Shortest course |
| Advanced kidney disease, severe heart failure | Avoid unless benefits outweigh the risk of worsening6 | Avoid |
| Pregnancy, about 20 weeks or later | May cause fetal kidney dysfunction leading to low amniotic fluid (oligohydramnios)6 | Avoid Consult the obstetric provider |
| Warfarin or other anticoagulants; SSRIs | Synergistic effect on bleeding; SSRIs add to bleeding risk6 | Avoid or monitor |
| ACE inhibitors, ARBs, beta-blockers, diuretics | NSAIDs may blunt their blood-pressure effect; with ACE inhibitors or ARBs in older, dehydrated or kidney patients, kidney function can worsen6 | Short course, monitor |
| Lithium, methotrexate | NSAIDs raise lithium levels and increase methotrexate toxicity6 | Monitor |
| Low-dose aspirin for the heart | Naproxen interfered with the antiplatelet effect of low-dose aspirin in a study6 | Caution |
Note the guideline’s own definition: a drug is contraindicated only where the known risk clearly outweighs any benefit, not because of theoretical concerns.2 If the patient cannot take NSAIDs, the guideline’s next step is acetaminophen 1,000 mg.
Acetaminophen: the 4,000 mg rule
Never more than 4,000 mg a dayMost cases of acetaminophen liver injury involve doses above 4,000 mg a day, often from more than one acetaminophen-containing product.9 Warn patients that an acetaminophen/opioid tablet contains acetaminophen too.2
Who needs extra careThe over-the-counter label warns about liver damage with 3 or more alcoholic drinks a day, tells people with liver disease to ask a doctor first, and tells people on warfarin to ask a doctor or pharmacist.8
Count every source. In the guideline’s opioid step, each combination tablet already contains 325 mg of acetaminophen, so the daily total must include it.2
Opioid basics for dentists
Hydrocodone is a full mu-opioid agonist with no ceiling effect for pain relief; the dose is limited by side effects such as respiratory and CNS depression.9
The boxed warnings
- Addiction, abuse and misuse
- Life-threatening respiratory depression
- Fatal accidental ingestion, especially by children
- Profound sedation or death with benzodiazepines, other CNS depressants or alcohol
When not to offer oneThe opioid option should NOT be offered to patients taking gabapentinoids, CNS-active drugs (benzodiazepines, antidepressants, anticonvulsants, narcotics) or already taking opioids for another reason. Prioritise non-opioids for patients on long-term opioids.2
Pediatric notes
A separate 2023 ADA guideline covers children under 12. NSAIDs (ibuprofen, or naproxen over age 2) alone or with acetaminophen are suggested over acetaminophen alone; acetaminophen alone is for when NSAIDs are contraindicated. Codeine and tramadol are contraindicated in children under 12.45
| Drug | Usual oral dose (dose by weight, not age) | Maximum |
|---|---|---|
| Ibuprofen | 4 to 10 mg/kg every 6 to 8 hours as needed (children up to 11 years, under 50 kg) | 400 mg per dose; 40 mg/kg per 24 hours |
| Acetaminophen | 10 to 15 mg/kg every 4 to 6 hours as needed | 75 mg/kg per 24 hours, never above 4,000 mg |
| Naproxen (over 2 years; off-label) | Under 60 kg: 5 to 6 mg/kg every 12 hours. 60 kg or more: 250 to 375 mg every 12 hours | 1,000 mg/day naproxen; 1,100 mg/day naproxen sodium |
Source: ADA 2024 chairside guide for children.5 The same guide suggests age-appropriate pain scales: a behavioural scale at 1 to 3 years, a Faces scale from 3 years, and a numerical or visual analogue scale from 8 years. Not every extraction in a child needs an analgesic. Over-the-counter benzocaine labels say not to use it for teething in children under 2 and warn about methemoglobinemia.11
Decision table: which analgesic for which patient
| Patient | Start with | Avoid |
|---|---|---|
| Healthy adult, simple extraction | Ibuprofen 400 mg, or ibuprofen plus acetaminophen 500 mg | Any opioid |
| Healthy 22-year-old, surgical third molars | NSAID plus acetaminophen; add the opioid step only if this fails | Just-in-case opioid prescriptions; extreme caution at this age |
| Toothache, no dentist available for 2 days | Local anesthetic now, NSAID with or without acetaminophen, benzocaine 10 or 20% | Using pain relief instead of treatment; antibiotics without an indication |
| Aspirin-induced asthma | Acetaminophen 1,000 mg | All NSAIDs |
| On warfarin | Acetaminophen, after checking with the patient’s doctor or pharmacist | NSAIDs (added bleeding risk) |
| Pregnant, about 20 weeks or later | Discuss with the obstetric provider | NSAIDs |
| Takes a benzodiazepine or gabapentin | NSAID with or without acetaminophen | Opioids |
| Heavy drinker or liver disease | NSAID, if no other contraindication | Acetaminophen without medical advice |
| 8-year-old after an extraction | Ibuprofen by weight; add acetaminophen if needed | Codeine and tramadol |
For drug interactions on the antibiotic side, such as metronidazole with warfarin, see our guide to high-yield antibiotics for the INBDE.
Three practice questions
Written by our faculty for this page. They are not real exam questions.
A healthy 40-year-old had a simple extraction of a premolar. What does the ADA 2024 guideline suggest for pain?
Show answer
Answer: B After a simple extraction, the guideline recommends non-opioid analgesics only and recommends against opioids.
A patient wheezes and breaks out in hives whenever he takes aspirin. What is the best analgesic after his surgical extraction?
Show answer
Answer: C Asthma or hives after aspirin is a labelled contraindication to all NSAIDs, at any dose. Acetaminophen at full dose is the guideline’s alternative.
A patient takes ibuprofen 400 mg plus acetaminophen 500 mg four times a day, and also a 325 mg acetaminophen/hydrocodone tablet four times a day. What is his daily acetaminophen intake, and is it safe?
Show answer
Answer: B (4 x 500) + (4 x 325) = 3,300 mg, under the 4,000 mg ceiling. Always count the acetaminophen hidden in combination tablets.
How to prepare: our full plan
Analgesics, antibiotics and local anesthetics come up again and again in patient cases. Here is how to cover them with the rest of the exam.
The Study Boards INBDE courseINBDE Premium Boards, built by US-licensed dentists:
- 12 sequenced course sections
- 35,000+ questions with explanations
- Nightly live tests at 9 PM New York time
- 99% first-attempt pass rate for students who complete the course
Your next steps
- The month-by-month INBDE study plan
- Free INBDE practice questions
- The Study Boards DLOSCE course, which includes the analgesic prescription task
- How to answer DLOSCE prescription tasks
Frequently asked questions
What is the first-line analgesic for dental pain?
Is ibuprofen better than an opioid for tooth pain?
What is the maximum dose of acetaminophen per day?
Can children be given codeine after an extraction?
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References
- Carrasco-Labra A, Polk DE, Urquhart O, et al. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. J Am Dent Assoc 2024;155(2):102-117. doi.org/10.1016/j.adaj.2023.10.009
- ADA, University of Pittsburgh, University of Pennsylvania. Chairside guide: postoperative pain after simple and surgical tooth extraction(s) in adolescents, adults, and older adults, 2024. ada.org
- ADA, University of Pittsburgh, University of Pennsylvania. Chairside guide: temporary management of toothache in adolescents, adults, and older adults, 2024. ada.org
- Carrasco-Labra A, Polk DE, Urquhart O, et al. Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children. J Am Dent Assoc 2023;154(9):814-825. doi.org/10.1016/j.adaj.2023.06.014
- ADA, University of Pittsburgh, University of Pennsylvania. Chairside guide: postoperative pain after tooth extractions in children, with dosing tables. ada.org
- US FDA label: Naproxen and naproxen sodium tablets (NSAID class warnings, contraindications, interactions) (DailyMed). dailymed.nlm.nih.gov
- US FDA label: Ibuprofen tablets, boxed warning and contraindications (DailyMed). dailymed.nlm.nih.gov
- US FDA label: Acetaminophen, over-the-counter Drug Facts (DailyMed). dailymed.nlm.nih.gov
- US FDA label: Hydrocodone bitartrate and acetaminophen tablets (boxed warning, hepatotoxicity, mechanism) (DailyMed). dailymed.nlm.nih.gov
- US FDA label: Codeine sulfate tablets (contraindications, ultra-rapid metabolism) (DailyMed). dailymed.nlm.nih.gov
- US FDA label: Benzocaine oral anesthetic, over-the-counter (DailyMed). dailymed.nlm.nih.gov
Current as of October 2026. The ADA runs this as a living guideline and monitors new evidence continuously. This page is exam-preparation material for dentists, not a substitute for clinical judgment or the full guidelines and labels cited above.