Analgesics
This page covers some of the most widely used classes of analgesics in dental pain management.
NSAIDs (Non-steroidal anti-inflammatory drugs)
Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are available as "over-the counter" medications in most countries, are
widely used by both pregnant and lactating women (Bloor, M and Paech, M 2013). Dentists often advise patients regarding pain management for
dental pain and generally the recommendation for pregnant women to use paracetamol, as the first-line treatment of fever and pain, is
reasonable (McCullough 2011).
Women should not suffer unnecessarily from pain during pregnancy and lactation. If used appropriately, common analgesics such as paracetamol, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are relatively safe.
If NSAID use is necessary between 20- and 30-weeks' gestation, limit use to the lowest effective dose for the shortest duration possible; ultrasound monitoring of amniotic fluid should be considered if NSAID use extends beyond 48 hours; if oligohydramnios occurs, discontinue NSAID and treat appropriately (FDA 2020).
Use of ibuprofen during pregnancy is not advised unless prescribed by a doctor, especially if you are 30 or more weeks pregnant.
Paracetamol is usually recommended to control pain or fever during pregnancy.
A few studies have suggested that using ibuprofen in the first trimester might lead to a small increased chance for gastroschisis (when the intestines stick out of a hole in the stomach wall). These studies suggest that ibuprofen use in the first trimester raises the chance of having a baby with gastroschisis from 1 in 10,000 to between 1 and 4 in 10,000. However, other studies have not supported this association.
Ibuprofen use later in pregnancy might also cause premature closure of the ductus arteriosus (an opening between the two major blood vessels leading from the heart) (Mother to baby 2022).
Ibuprofen should only be used under a healthcare provider’s supervision, particularly in the 2nd and 3rd trimesters. Your healthcare providers can closely monitor your pregnancy if you need to use ibuprofen after week 20 (Mother to baby 2022).
COX-2 selective non-steroidal anti- inflammatory drugs (NSAIDs) such as celecoxib can be considered as an alternative analgesic for patients with gastrointestinal, renal, or cardiovascular problems, or for patients who cannot tolerate traditional NSAIDs. However, ibuprofen is preferred over celecoxib as it has been shown to be more effective for dental pain. Also, COX-2 inhibitors have been associated with an increase in cardiotoxicity (Barton, Timmerman and Parashos 2020).
Contraindicated in the last trimester of pregnancy between 20- and 30-weeks' gestation: Limit dose and duration of use.
Women should not suffer unnecessarily from pain during pregnancy and lactation. If used appropriately, common analgesics such as paracetamol, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are relatively safe.
If NSAID use is necessary between 20- and 30-weeks' gestation, limit use to the lowest effective dose for the shortest duration possible; ultrasound monitoring of amniotic fluid should be considered if NSAID use extends beyond 48 hours; if oligohydramnios occurs, discontinue NSAID and treat appropriately (FDA 2020).
Administration in pregnancy
A Californian study also showed an 80% increase in the risk of miscarriage associated with first trimester use of both aspirin and NSAIDs (Li, Liu & Odouli, 2003). This association was not seen with paracetamol. Use of NSAIDs after 20 weeks gestation is contraindicated because of their potential to cause premature closure of the fetal ductus arteriosus and persistent pulmonary hypertension (Best use of medicines in pregnancy 2023).Administration in breastfeeding
Paracetamol is considered to be safe for use during lactation. The estimated dose received via breast milk is 6% of the maternal dose. NSAIDs, such as ibuprofen and diclofenac, are considered to be compatible with breastfeeding. The infant doses relative to the maternal doses are 0.65% and 1% respectively, even in women taking high doses (Kennedy, 2011). Aspirin is generally not recommended for treatment of pain during breastfeeding mainly because there may be significant adverse effects in infants (the relative infant dose may be as high as 10%) and safer alternatives are available. There is also the theoretical concern that aspirin can cause Reye's syndrome in infants (Hale, 2010).Ibuprofen
Ibuprofen is a painkiller that can be bought from a pharmacy or may sometimes be prescribed by a doctor. It belongs to a class of drug called non-steroidal anti-inflammatory drugs (NSAIDs).Use of ibuprofen during pregnancy is not advised unless prescribed by a doctor, especially if you are 30 or more weeks pregnant.
Paracetamol is usually recommended to control pain or fever during pregnancy.
Administration in pregnancy
It is unclear whether taking ibuprofen in early pregnancy increases the chance of having a miscarriage. However, two of the three studies that have examined ibuprofen separately from other NSAIDs showed no link with miscarriage (Best use of medicines in pregnancy 2023 ).A few studies have suggested that using ibuprofen in the first trimester might lead to a small increased chance for gastroschisis (when the intestines stick out of a hole in the stomach wall). These studies suggest that ibuprofen use in the first trimester raises the chance of having a baby with gastroschisis from 1 in 10,000 to between 1 and 4 in 10,000. However, other studies have not supported this association.
Ibuprofen use later in pregnancy might also cause premature closure of the ductus arteriosus (an opening between the two major blood vessels leading from the heart) (Mother to baby 2022).
Ibuprofen should only be used under a healthcare provider’s supervision, particularly in the 2nd and 3rd trimesters. Your healthcare providers can closely monitor your pregnancy if you need to use ibuprofen after week 20 (Mother to baby 2022).
Administration in breastfeeding
Ibuprofen passes into breastmilk in small amounts. The amounts of ibuprofen in breastmilk are less than the doses given to infants directly. Negative effects are not expected in newborns exposed to ibuprofen through breastmilk. Be sure to talk to your healthcare provider about all your breastfeeding questions (Mother to baby 2022).Celecoxib
Celecoxib belongs to NSAIDs. It reduces inflammation (swelling) and relieve pain. celecoxib is indicated for the relief of the signs and symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; for the management of acute pain in adults; and for the treatment of primary dysmenorrhea (Cheung, Krishnaswami and Kowalski 2007).COX-2 selective non-steroidal anti- inflammatory drugs (NSAIDs) such as celecoxib can be considered as an alternative analgesic for patients with gastrointestinal, renal, or cardiovascular problems, or for patients who cannot tolerate traditional NSAIDs. However, ibuprofen is preferred over celecoxib as it has been shown to be more effective for dental pain. Also, COX-2 inhibitors have been associated with an increase in cardiotoxicity (Barton, Timmerman and Parashos 2020).
Administration in pregnancy
Dose and duration of therapy should be limited between about 20 and 30 weeks of gestation; use should be avoided at about 30 weeks of gestation and later in pregnancy. Additionally, use is not recommended during or immediately prior to labor. Structural abnormalities (e.g., septal defects, ribs fused, sternebrae fused, sternebrae misshapen) were observed in rabbits given daily oral doses of celecoxib during organogenesis (FDA 2020).Contraindicated in the last trimester of pregnancy between 20- and 30-weeks' gestation: Limit dose and duration of use.
Administration in breastfeeding
Low levels of this drug are excreted in breastmilk and are not expected to cause adverse effects in breastfed infants (Drugs and lactation database 2021). Some authorities advise women to discontinue nursing or to discontinue the drug, considering the expected benefit of the drug to the mother because of the potential for adverse reaction in nursing infants. In 2 breastfed infants (17 and 22 months of age) whose mothers took this drug 200 mg orally twice daily for many weeks, blood samples taken 4 hours after a maternal dose were undetectable (less than 10 mcg/L). No infant side effects were observed in these infants (Hale, McDonald and Boger 2004).Paracetamol (acetaminophen)
Paracetamol is the analgesic and antipyretic drug most widely used in Australia, particularly by pregnant women. Paracetamol is the first-line drug
for the treatment of fever and pain in pregnancy available by prescription or for self-medication (De Castro et. al, 2022).
The suggested dose of paracetamol for adults and children 12 years and over is:
A registry-based study from Denmark of 26 424 children who were exposed to paracetamol in utero during the first trimester found no increase in either the specific or the overall rate of birth defects compared with unexposed controls (Rebordosa et. al, 2008).
The suggested dose of paracetamol for adults and children 12 years and over is:
- No more than 1 g every 4 to 6 hours
- No more than 4 g every 24 hours
Administration in pregnancy
Paracetamol is widely used during pregnancy. Paracetamol readily crosses the placenta but doesn’t appear to raise the chance of birth differences or bad pregnancy outcomes. Although it readily crosses the placenta in its unconjugated form, in therapeutic doses it does not appear to increase the risk of birth defects or other adverse pregnancy outcomes (Kennedy, 2011).A registry-based study from Denmark of 26 424 children who were exposed to paracetamol in utero during the first trimester found no increase in either the specific or the overall rate of birth defects compared with unexposed controls (Rebordosa et. al, 2008).
Administration in breastfeeding
Paracetamol is considered to be safe for use during lactation. The estimated dose received via breast milk is 6% of the maternal dose. The properties of paracetamol are such that at therapeutic doses, there is no risk of it accumulating in the infant’s system. However, Combination products containing paracetamol with other ingredients are generally not recommended during breastfeeding. As a precaution, monitor infants for diarrhoea and vomiting (Specialist pharmacy service 2023).Opioids
Opioids are a type of medication used to relieve pain. To ease discomfort that can result from some dental procedures, such as tooth extraction,
gum and other dental surgery, or placement of dental implants, dentists may prescribe medications for pain relief, including opioids. Commonly
prescribed opioid medications for relief of dental pain include hydrocodone, oxycodone, and acetaminophen with codeine (National Institute of
Dental and Craniofacial Research 2021).
Reproductive studies describing the use of narcotic analgesics in human pregnancies are limited, and there are no prospective, comparative studies. However, these drugs have been used in therapeutic doses by pregnant women for many years and have not been linked to elevated risk of major or minor malformations (Babb, Koren and Einarson, 2010).
The use of codeine near term or during labour may cause problems for the foetus and neonate. Like other opioids, codeine can cause respiratory depression in the newborn infant. Neonatal withdrawal symptoms such as tremor, jitteriness, diarrhoea, and poor feeding have also been reported in infants following maternal use of large doses of codeine taken throughout pregnancy (Christchurch Medicines Information Service, 2023).
Opioids, if needed, should be opioids that are not formulated in combination with other analgesic medications like acetaminophen or ibuprofen (Opioid Use in the Lactating Mother 2021).
Last updated: 2024 June 20Administration in pregnancy
Overall, opioid analgesics have not been associated with an increase in birth defects or other adverse outcomes such as miscarriage. There are also reassuring data on longer-term neurodevelopmental follow-up in exposed infants. The main concern about these drugs is that persistent use may lead to dependence and tolerance in the mother with resultant withdrawal (neonatal abstinence syndrome) in the neonate (Kennedy, 2011).Reproductive studies describing the use of narcotic analgesics in human pregnancies are limited, and there are no prospective, comparative studies. However, these drugs have been used in therapeutic doses by pregnant women for many years and have not been linked to elevated risk of major or minor malformations (Babb, Koren and Einarson, 2010).
The use of codeine near term or during labour may cause problems for the foetus and neonate. Like other opioids, codeine can cause respiratory depression in the newborn infant. Neonatal withdrawal symptoms such as tremor, jitteriness, diarrhoea, and poor feeding have also been reported in infants following maternal use of large doses of codeine taken throughout pregnancy (Christchurch Medicines Information Service, 2023).
Administration in breastfeeding
All opioids pass into breast milk in small amounts and can affect your baby. Oxycodone accumulates in human milk, with a median maternal plasma:milk ratio of 3:1 recorded in one study (Pesonen et. al, 2024). If you continue to use opioids in high doses breastfeeding may not be recommended (The Royal Women’s Hospital 2021). Codeine and tramadol are not recommended because the breastfed infant could experience adverse effects from exposure to the opioid analgesics, including difficulty nursing, respiratory complications, and excessive somnolence.Opioids, if needed, should be opioids that are not formulated in combination with other analgesic medications like acetaminophen or ibuprofen (Opioid Use in the Lactating Mother 2021).
References
Analgesia during pregnancy or while breastfeeding (2023), Christchurch Medicines Information Service, https://www.medicinesinformation.co.nz/wp-content/uploads/2023/07/Analgesics-use-in-pregnancy-and-lactation.pdf
Babb M, Koren G, Einarson A. Treating pain during pregnancy. Can Fam Physician. 2010 Jan;56(1):25, 27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809170/pdf/0560025.pdf
Best use of medicines in pregnancy (2023), https://www.medicinesinpregnancy.org/Medicine--pregnancy/Ibuprofen/
Bloor, M, Paech, M 2013, ‘Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation’, Anesthesia & Analgesia, vol.116, no.5, pp.1063-1075.
Cheung, R, Krishnaswami, S, Kowalski, K 2007, ‘Analgesic efficacy of celecoxib in postoperative oral surgery pain: a single-dose, two-center, randomized, double-blind, active- and placebo-controlled study’, Clinical Therapeutics, vol.29, no.11, pp.2498-2510.
De Castro, C, Pereira, M, Santos, D 2022, ‘Association between paracetamol use during pregnancy and perinatal outcomes: Prospective NISAMI cohort’, PLoS One, vol.17, no.4, pp.1-12.
Drugs and Lactation Database (2021), LactMed, https://www.ncbi.nlm.nih.gov/books/NBK501922/
Hale, T, McDonald, R, Boger, J 2004, ‘Transfer of celecoxib into human milk’, Journal of Human Lactation, vol.20, no.4.
Ibuprofen, Mother to Baby (2022), https://mothertobaby.org/fact-sheets/ibuprofen-pregnancy/
Kennedy, D 2011, ‘Analgesics and pain relief in pregnancy and breastfeeding’, Australian Prescriber, vol.34, no.1, pp.8-10.
Li, D, Liu, L, Odouli, R 2003, ‘Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: population-based cohort study’, British Medical Journal, vol.327, no7411, pp.1-5.
McCullough, M 2011 Analgesics and pain relief in pregnancy and breastfeeding, Australian Prescriber, vol.34, no.10.
Opioid Use in the Lactating Mother, Intermountain Healthcare, https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=520732469
Opioids and Dental Pain, National Institute of Dental and Craniofacial Research, https://www.nidcr.nih.gov/health-info/opioids#overview
Pesonen, A, Hakomaki, H, Kokki, H, Ranta, V, Rinne, V, Kokki, M 2024, ‘Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management’, British Journal of Clinical Pharmacology, vol.90, no.4, pp.1183-1192.
Rebordosa C, Kogevinas M, Horváth-Puhó E, Nørgård B, Morales M, Czeizel AE, Vilstrup H, Sørensen HT, Olsen J. Acetaminophen use during pregnancy: effects on risk for congenital abnormalities. Am J Obstet Gynecol. 2008 Feb;198(2):178.e1-7. doi: 10.1016/j.ajog.2007.08.040.
US Food and Drug Administration FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid (2020), FDA, https://www.fda.gov/media/142967/download
Using paracetamol during breastfeeding (2023), Specialist Pharmacy Service, https://www.sps.nhs.uk/articles/using-paracetamol-during-breastfeeding/#:~:text=Ibuprofen%20and%20paracetamol%20can%20be,both%20can%20also%20be%20used.
Using prescription opioids during pregnancy and breastfeeding (2021), The Royal Women’s Hospital, https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Prescription_opioids.pdf
Babb M, Koren G, Einarson A. Treating pain during pregnancy. Can Fam Physician. 2010 Jan;56(1):25, 27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809170/pdf/0560025.pdf
Best use of medicines in pregnancy (2023), https://www.medicinesinpregnancy.org/Medicine--pregnancy/Ibuprofen/
Bloor, M, Paech, M 2013, ‘Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation’, Anesthesia & Analgesia, vol.116, no.5, pp.1063-1075.
Cheung, R, Krishnaswami, S, Kowalski, K 2007, ‘Analgesic efficacy of celecoxib in postoperative oral surgery pain: a single-dose, two-center, randomized, double-blind, active- and placebo-controlled study’, Clinical Therapeutics, vol.29, no.11, pp.2498-2510.
De Castro, C, Pereira, M, Santos, D 2022, ‘Association between paracetamol use during pregnancy and perinatal outcomes: Prospective NISAMI cohort’, PLoS One, vol.17, no.4, pp.1-12.
Drugs and Lactation Database (2021), LactMed, https://www.ncbi.nlm.nih.gov/books/NBK501922/
Hale, T, McDonald, R, Boger, J 2004, ‘Transfer of celecoxib into human milk’, Journal of Human Lactation, vol.20, no.4.
Ibuprofen, Mother to Baby (2022), https://mothertobaby.org/fact-sheets/ibuprofen-pregnancy/
Kennedy, D 2011, ‘Analgesics and pain relief in pregnancy and breastfeeding’, Australian Prescriber, vol.34, no.1, pp.8-10.
Li, D, Liu, L, Odouli, R 2003, ‘Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: population-based cohort study’, British Medical Journal, vol.327, no7411, pp.1-5.
McCullough, M 2011 Analgesics and pain relief in pregnancy and breastfeeding, Australian Prescriber, vol.34, no.10.
Opioid Use in the Lactating Mother, Intermountain Healthcare, https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=520732469
Opioids and Dental Pain, National Institute of Dental and Craniofacial Research, https://www.nidcr.nih.gov/health-info/opioids#overview
Pesonen, A, Hakomaki, H, Kokki, H, Ranta, V, Rinne, V, Kokki, M 2024, ‘Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management’, British Journal of Clinical Pharmacology, vol.90, no.4, pp.1183-1192.
Rebordosa C, Kogevinas M, Horváth-Puhó E, Nørgård B, Morales M, Czeizel AE, Vilstrup H, Sørensen HT, Olsen J. Acetaminophen use during pregnancy: effects on risk for congenital abnormalities. Am J Obstet Gynecol. 2008 Feb;198(2):178.e1-7. doi: 10.1016/j.ajog.2007.08.040.
US Food and Drug Administration FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid (2020), FDA, https://www.fda.gov/media/142967/download
Using paracetamol during breastfeeding (2023), Specialist Pharmacy Service, https://www.sps.nhs.uk/articles/using-paracetamol-during-breastfeeding/#:~:text=Ibuprofen%20and%20paracetamol%20can%20be,both%20can%20also%20be%20used.
Using prescription opioids during pregnancy and breastfeeding (2021), The Royal Women’s Hospital, https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Prescription_opioids.pdf