The analgesic ladder in dentistry, inspired by internationally accepted pain-management principles, provides a structured, stepwise approach to selecting analgesic therapy based on pain intensity, clinical diagnosis, and patient-specific factors.
When applied correctly, this model promotes effective pain relief while minimizing adverse effects and unnecessary exposure to potent medications.
Understanding Dental Pain and Its Clinical Implications
Dental pain may arise from inflammatory, infectious, traumatic, or iatrogenic causes, including pulpitis, periapical pathology, periodontal disease, surgical procedures, or orthodontic interventions.
Because pain perception is multifactorial, its management should be individualized, combining accurate diagnosis with appropriate pharmacological and non-pharmacological strategies.
The analgesic ladder serves as a practical framework to guide clinicians in escalating or de-escalating treatment as required.
► DENTAL BOOK: Mosby's Dental Drug Reference, 13th Edition – A Must-Have Guide for Every Dental Professional (2021)
Step 1: Mild to Moderate Pain – Non-Opioid Analgesics (NSAIDs)
For mild to moderate dental pain, non-steroidal anti-inflammatory drugs (NSAIDs) and non-opioid analgesics are considered first-line therapy.
Commonly used agents include:
✔ Paracetamol (Acetaminophen)
✔ Ibuprofen
✔ Ketorolac
✔ Diclofenac
Mechanism of action:
These drugs primarily inhibit cyclooxygenase enzymes (COX-1 and COX-2), reducing prostaglandin synthesis and thereby decreasing inflammation and pain at the peripheral level.
Clinical relevance:
NSAIDs are particularly effective in inflammatory dental pain and are widely recommended due to their favorable risk–benefit profile when used appropriately.
Step 2: Moderate to Severe Pain – Weak Opioids (With or Without NSAIDs)
When pain intensity increases or when NSAIDs alone are insufficient, weak opioids may be introduced, often in combination with non-opioid analgesics to achieve a synergistic effect.
Common options include:
✔ Tramadol
✔ Codeine
✔ Dihydrocodeine
Mechanism of action:
Weak opioids act centrally by binding to opioid receptors, modulating pain perception within the central nervous system.
Clinical relevance:
These agents may be indicated in post-operative pain or acute exacerbations, but their use should be carefully monitored due to potential side effects such as nausea, dizziness, and dependency risk.
► DENTAL BOOK: Little and Falace's Dental Management of the Medically Compromised Patient – 10th Edition (2023)
Step 3: Severe to Very Severe Pain – Strong Opioids
In cases of severe or refractory dental pain, particularly in hospital-based or complex surgical settings, strong opioids may be required.
Examples include:
✔ Morphine
✔ Oxycodone
✔ Fentanyl
✔ Methadone
Mechanism of action:
Strong opioids exert their analgesic effects through high-affinity interaction with μ (mu), κ (kappa), and δ (delta) opioid receptors, producing profound central analgesia.
Clinical relevance:
Their use in dentistry is limited and should be reserved for specific indications under strict medical supervision, considering the risks of respiratory depression, tolerance, and dependence.
Rational Use of the Analgesic Ladder in Dental Practice
The true value of the analgesic ladder lies not in routine escalation, but in rational, evidence-based prescribing. Dentists must consider:
✔ Accurate diagnosis of the pain source
✔ Patient age, medical history, and comorbidities
✔ Drug interactions and contraindications
✔ Shortest effective duration of therapy
Combining pharmacological treatment with definitive dental care remains essential to resolving the underlying cause of pain.
Conclusion
The analgesic ladder in dentistry remains a globally relevant and clinically valuable model for managing dental pain safely and effectively.
By following a structured, stepwise approach, dental professionals can enhance patient comfort, reduce complications, and uphold the principles of responsible analgesic use.
At Ovidental, we are committed to delivering high-quality, evidence-based educational content that empowers dental professionals worldwide to make informed clinical decisions and elevate standards of care.
