Effective pain management is a cornerstone of dental practice, especially in conditions such as acute pulpitis, postoperative discomfort, pericoronitis, alveolitis, and traumatic injuries.
While many clinicians are familiar with NSAIDs like ketorolac and diclofenac, current evidence consistently identifies ibuprofen combined with acetaminophen (paracetamol) as the most effective and safest first-line therapy for dental pain.
This updated review explains why this combination is superior and why ketorolac and diclofenac, despite their analgesic potency, are not recommended as first-choice medications in modern dental care.
1. Why Ibuprofen + Acetaminophen Is Considered First-Line Therapy
combination of 400–600 mg ibuprofen plus 500–1000 mg acetaminophen provides synergistic analgesia, targeting both peripheral and central pathways.
Recent guidelines, including those from the American Dental Association (ADA), show that this combination:
✔ Provides greater pain relief than opioids in dental pain
✔ Has lower gastrointestinal and cardiovascular risk than stronger NSAIDs
✔ Does not significantly increase bleeding, making it suitable for routine dental surgery
✔ Can be safely used for several days in most patients
✔ Maintains excellent analgesic effect even in inflammatory conditions (third molar extraction, pulpitis, etc.)
Its balanced efficacy–safety profile makes it the preferred option for both acute and postoperative dental pain.
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2. Why Ketorolac Is Not a First-Line Analgesic in Dentistry
Ketorolac is a powerful NSAID, often comparable to low-potency opioids. However, this potency comes with significant limitations:
Major Clinical Drawbacks
✔ High gastrointestinal risk (gastritis, ulcer, bleeding)
✔ Prominent antiplatelet effect, increasing postoperative bleeding
✔ Short maximum duration (no more than 48–72 hours)
✔ Increased risk of renal impairment
✔ Contraindicated in pregnancy, lactation, anticoagulated patients and those with kidney disease
Although ketorolac may be useful for severe postoperative pain or when other options fail, it should not be used routinely in outpatient dental practice due to its adverse-effect profile.
3. Why Diclofenac Is No Longer Preferred as a First-Line Option
Diclofenac has been widely used for decades, but recent pharmacovigilance and epidemiological studies highlight important concerns:
Key Safety Limitations
✔ Higher cardiovascular risk compared with ibuprofen and naproxen
✔ Greater gastrointestinal irritation
✔ Requires multiple doses per day due to its shorter half-life
✔ Not superior in analgesic effect to ibuprofen
Although diclofenac is effective, its risk-to-benefit ratio is inferior to that of ibuprofen or naproxen.
Most guidelines now reserve diclofenac for selected patients with no cardiovascular risk factors and who tolerate it well.
4. Clinical Summary (2025 Update)
Conclusion
Current evidence strongly supports ibuprofen combined with acetaminophen as the most effective and safest first-line analgesic regimen in dental practice.
Ketorolac and diclofenac remain effective but carry significantly higher risks, making them less suitable for routine outpatient dental care.
Modern dental pharmacotherapy emphasizes not just analgesic strength, but overall safety, tolerability, and risk reduction—criteria best met by the ibuprofen–acetaminophen combination.
