ADA 2024 guideline on acute dental pain in adolescents, adults and older adults: the NSAID is the prescription, and the opioid is the rare exception

What it says#

A panel convened by the ADA Science and Research Institute, the University of Pittsburgh and the University of Pennsylvania, funded by the FDA under a congressional mandate, ran four systematic reviews on opioid and nonopioid analgesics, local anesthetics, corticosteroids and topical anesthetics, then used GRADE and the Evidence-to-Decision framework to write recommendations. Its headline finding is a beneficial net balance favoring nonopioid medications over opioid medications, and in particular that NSAIDs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids.

For a simple tooth extraction the panel recommends the postprocedural use of nonopioid analgesics only, and recommends against the use of opioid analgesics, a conditional recommendation on low certainty. It suggests initiating pain management with an NSAID alone, for example 400 mg of ibuprofen or 440 mg of naproxen sodium, or in combination with acetaminophen, for example 500 mg. Where NSAIDs are contraindicated, acetaminophen alone at full therapeutic dose, for example 1,000 mg.

For a surgical tooth extraction, meaning one requiring a flap or an osteotomy, the panel recommends nonopioid analgesics as first-line therapy instead of opioids, again conditional on low certainty, with the same two first-line options. Here it adds the second line. In the rare instances when pain control with an NSAID alone is inadequate, add to that prescription 325 mg of acetaminophen plus a combination tablet of 325 mg of acetaminophen with an opioid, for example 5 to 7.5 mg of hydrocodone or 5 mg of oxycodone, at the lowest effective dose, fewest tablets and shortest duration, which rarely exceeds three days. When the NSAID and acetaminophen combination is the one that proved inadequate, replace the prescription instead: an NSAID plus 325 mg of acetaminophen plus the same combination tablet. When NSAIDs are contraindicated, the choice is acetaminophen alone at full therapeutic dose or the acetaminophen and opioid pair. The panel also suggests against adding oral, submucosal or intramuscular corticosteroids to standard analgesic therapy for surgical extraction, conditional on very low certainty.

For toothache with no immediate access to definitive treatment the ladder is the same, with anesthetics around it. The panel suggests a short-acting local anesthetic for immediate in-visit relief, for example 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine, conditional on very low certainty. For extended relief it suggests a supplemental injection of 0.5% bupivacaine with 1:200,000 epinephrine by block or infiltration, or 4% articaine with 1:100,000 or 1:200,000 epinephrine by infiltration; after an extraction the same two are suggested before discharge instead of 2% lidocaine with 1:100,000 epinephrine or 3% mepivacaine, conditional on low certainty. Topical 10% or 20% benzocaine is suggested for short-term temporary management, conditional on low certainty. Post-visit, the recommendation is the nonopioid first line, with the same second line if it fails, and every one of these statements is conditional rather than strong.

The guardrails around the opioid step are printed with it. Analgesic prescriptions follow the principle of minimum effective dosage. The routine use of delayed, just-in-case prescriptions for breakthrough pain is not recommended. The opioid option should not be offered to patients taking gabapentinoids, central nervous system active medications such as benzodiazepines, antidepressants, anticonvulsants and narcotics, or patients already taking opioids for other medical reasons. When an opioid is prescribed, obtain informed consent with detailed information on physiological dependence, risk of substance misuse, respiratory depression and effects on driving or operating machinery, which the panel calls particularly critical in adolescents and young adults, who are at increased risk of subsequent misuse and substance use disorder even after a single prescription. Alert the patient that a combination tablet contains both drugs, and that total acetaminophen should not exceed 4,000 mg a day. The maximum daily doses on the chairside guide are 2,400 mg of ibuprofen, 1,100 mg of naproxen sodium and 4,000 mg of acetaminophen. Check the state prescription drug monitoring program where available, counsel on storage and disposal, and take special care with a patient who has a substance use disorder, including communication with their other health care providers. All of these doses are adult; the treating dentist decides what a given patient gets.

Who it applies to#

The panel's own age bands are adolescents aged 12 to under 17, adults aged 17 to under 65, and older adults aged 65 and over. Children younger than 12 are covered by the companion guideline, summarized in ada-acute-dental-pain-children-2023. The toothache half of this document applies only where definitive dental treatment is not immediately available, which is the emergency department, the after-hours call and the referral gap; where treatment can be done, the instruction is to do it or refer immediately. The antibiotic question for those same pulpal and periapical conditions is answered separately in ada-antibiotics-pulpal-periapical-pain-2019.

It is a guideline, and it says twice over what it is not: it does not replace clinical judgment, it does not cover every clinical issue in acute dental pain, and it is not intended to be used to restrict, limit, delay or deny coverage for or access to a prescription issued for a legitimate purpose. This entry reports it. The prescriber decides.

What changed#

First edition for the ADA on this question, and it lands on the same side as the federal guidance already in the chart. CDC's 2022 opioid guideline, covered in cdc-opioid-guideline-2022-acute-pain, cites the ADA's NSAIDs-first position for acute dental pain; this document is the systematic review behind that position, with the doses attached. What is new here is the specificity: two named first-line options with example doses, a second line that is an acetaminophen and opioid combination rather than an opioid alone, a duration that rarely exceeds three days, and an explicit statement against just-in-case prescribing.

The panel's framing for why it matters is in its own introduction. Approximately 37% of emergency department visits linked to a dental symptom received an opioid analgesic while only 20.8% received a nonopioid; in 2019, 39.5% of all opioid prescriptions written by dentists were classified as high risk; and among adolescents and young adults aged 13 to 30 having a third molar extracted, filling a perioperative opioid prescription was associated with a 0.8% increased risk of persistent opioid use and a 1.6% increased risk of a substance use disorder diagnosis.

Where the source is#

The link under the title is the ADA's pain management guideline page, which hosts both chairside guides for adults as PDFs, both pediatric guides, and the patient conversation aids. Each chairside guide is two pages: the numbered recommendations with their strength and certainty and the footnotes on one side, the clinical pathway and good practice statements on the other, copyright 2024 American Dental Association, University of Pittsburgh and University of Pennsylvania, released under CC BY-NC-ND 4.0 for noncommercial education and research. The guideline itself is JADA 2024;155(2):102-117.e9; jada.ada.org refused automated access in this session, so the scope, methods, recommendation boxes and the introduction's figures above were read from the author manuscript in PubMed Central, PMC10919895, and the abstract from PubMed, PMID 38325969. The work was funded by FDA grant U01FD007151, and the guideline states that its contents do not represent an official view of or endorsement by the FDA or HHS.