Dental extraction of two or more wisdom teeth with at least one impacted is the favorite type of pain research to get pain medications approved by the FDA.  This is because there is acute moderate to severe pain in relatively healthy people and large numbers of such surgeries are done.  Therefore, there are a huge number of studies.  As you can easily see below, there is absolutely no place for narcotics in any type of dental surgery.  

Naprosyn 550 mg. with added acetaminophen  of up to 1000 mg., if necessary, is probably the most cost-effective treatment.  Ibuprofen is okay, but is shorter acting.  Diclofenac, flurbiprofen, ketoprofen and others appear a little better than ibuprofen or naprosyn.  They cost 35-65 cents per dose and require a prescription.  Still, for dental surgery, they are probably worth the extra expense.  Acetaminophen is also okay, but isn't as good by itself as the others.  Some people might benefit from using it as a back up medication.  At least its better than narcotics.

Narcotics are very poor for dental pain, even inferior to acetaminophen in multiple studies.  In 38 studies below, the narcotic track record is 0 wins, 2 ties, and 36 losses (33 inferior, 3 equal with more side-effects).  Narcotics are big, big losers for dental surgery.

I personally had a married female patient in late 2005, who was admitted for heroin addiction.  She had never used an opiate until one year earlier, a dentist gave her a prescription for one week's supply of narcotics are dental surgery.  That quickly led to daily opiate pain pill usage, which then led to snorting heroin within 6 months.   A second female patient relapsed into heroin addiction thanks to a dentist.  The dentist never asked her if she had ever had a drug problem.  That's patient's husband also ended up getting pulled into heroin addiction, when he started using her dentist-prescribed Vicodin for his own pain condition.  In my opinion, as a practicing physician and as a lawyer, any dentist who prescribes narcotics and causes harm should be sued!  There is not a stitch of evidence to support this rampant malpractice.  If anyone has been harmed by such malpractice, I will gladly testify at their trial.

Dental licensing boards are also being grossly irresponsible in allowing the wide-spread use of narcotics in their field.  Dental schools are equally responsible for the heavy use of narcotics in the field of dentistry.  In England, 16% of all pain meds used in dentistry are narcotics.  I suspect that the situation is still worse in the U.S.

Codeine No Added Benefit to Diclofenac (Voltaren) Plus Acetaminophen: In an 8-hour DB PC study of 120 adults with moderate to strong pain after surgical removal of wisdom teeth, single oral doses of: 100-mg enteric-coated diclofenac tablets; 1 g acetaminophen; 1 g acetaminophen plus 60 mg codeine; 100-mg enteric-coated diclofenac tablets plus 1 g acetaminophen; or 100-mg enteric-coated diclofenac tablets plus 1 g acetaminophen plus 60 mg codeine were compared. While acetaminophen plus codeine was a little better than acetaminophen, diclofenac plus acetaminophen with and without codeine had superior analgesic effect compared with diclofenac, acetaminophen, or acetaminophen plus codeine. Addition of 60 mg codeine increased the degree of side effects. Combining diclofenac with acetaminophen or acetaminophen-codeine after oral surgery: a randomized, double-blind single-dose study. Breivik EK, et al. University of Oslo, Norway. Clin Pharmacol Ther. 1999 Dec;66(6):625-35.

Codeine-Acetaminophen No Better than Ibuprofen; Non-Addictive Diclofenac Better: In a DB PC study of preoperative ibuprofen 600 mg, diclofenac 100 mg, paracetamol (acetaminophen) 1g with codeine 60 mg or placebo (Vitamin C 50 mg) tablets for relief of postoperative pain in 119 patients who had operations under general anesthesia, there was no significant difference in the extent of postoperative pain among the four groups, but the placebo group had significantly shorter times before their first request for postoperative analgesics (median 17 minutes) than the diclofenac group (median 32 minutes). A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars. Joshi A, Parara E, Macfarlane TV. University Dental Hospital of Manchester, UK. Br J Oral Maxillofac Surg. 2004 Aug;42(4):299-306. Ed: The infatuation of the medical community with addictive medicines for pain just doesn't hold up.  

Codeine with Tylenol Inferior to Vioxx for Dental Pain: Rofecoxib (VIOXX(R)) is a selective inhibitor of cyclo-oxygenase-2 and is indicated for the treatment of acute pain. In a DB PC study of 393 patients with moderate to severe pain after extraction of at least two 3rd molars, a single dose of rofecoxib 50 mg (n = 182), codeine 60 mg with acetaminophen 600 mg (n = 180), or placebo (n = 31) found total pain relief much better with rofecoxib than with codeine/acetaminophen. Proportion of patients who rated the study medication as good, very good, or excellent at 6 hours was 64.6% on rofecoxib, 36.4% on codeine/acetaminophen, and 10.3% on placebo (rofecoxib> codeine/acetaminophen; p < 0.001). Patients receiving codeine/acetaminophen versus rofecoxib had higher incidences of nausea (25.0% vs. 6.0%; p < 0.001) and vomiting (18.3% vs. 3.8%; p < 0.001). Rofecoxib was more effective than codeine with acetaminophen in the treatment of acute pain. Chang DJ, Fricke JR Jr, et al. Merck & Co., Inc. Pain Med. 2001 Sep;2(3):239-40. Codeine with acetaminophen was slightly better than acetaminophen alone in a 204 patient DB PC study, but details are sketchy. Dtsch Zahnarztl Z. 1990 Jan;45(1):36-8.

Codeine with Tylenol Much Inferior to Naproxen (Naprosyn) or Etorecoxib for Dental Pain: In a 201 patient DB PC study of moderate to severe dental pain from surgical extractions using doses of placebo (n = 50), etoricoxib 120 mg (n = 50)(a new COX-2 inhibitor), naproxen sodium 550 mg (n = 51), or acetaminophen/codeine 600/60 mg (n = 50), patient evaluation of pain relief over eight hours was naproxen 21.3, etoricoxib 20.9, acetaminophen/codeine 11.5 and placebo 5.4. The duration of analgesic effect, defined as median time to rescue medication use, was >24 hours for etoricoxib, 20.8 hours for naproxen sodium, 3.6 hours for acetaminophen/codeine, and 1.6 hours for placebo. A randomized, double-blind, parallel-group study comparing the analgesic effect of etoricoxib to placebo, naproxen sodium, and acetaminophen with codeine using the dental impaction pain model. Malmstrom K, Kotey P, Coughlin H, Desjardins PJ. Merck Research Laboratories. Clin J Pain. 2004 May-Jun;20(3):147-55

Codeine with Tylenol Inferior to Non-Narcotic Flurbiprofen; Codeine Had Most Side-Effects: In a DB PC study of adults having extractions of 3rd molars, 50 and 100 mg flurbiprofen were compared with acetaminophen 650 mg, acetaminophen 650 mg plus codeine 60 mg, and placebo. Flurbiprofen resulted in the least pain, while acetaminophen with codeine had the most side-effects. Analgesic efficacy of flurbiprofen in comparison with acetaminophen, acetaminophen plus codeine, and placebo after impacted third molar removal. Dionne RA, et al. National Institute of Dental Research, Bethesda, MD. J Oral Maxillofac Surg. 1994 Sep;52(9):919-24

Cocaine No Add-On Benefit to Acetaminophen: In a DB study of surgery with general anesthesia for impacted 3rd molars, there was no difference in pain relief between a paracetamol/codeine combination and paracetamol alone A double-blind placebo-controlled study to assess the efficacy of a compound analgesic to prevent postoperative pain following oral surgery. Sandhu S, et al. Turner Dental School, Manchester. Br Dent J. 1996 May 11;180(9):335-8.

Codeine Added Nothing to Ibuprofen Except Many More Side-Effects: In a 3-day DB PC study of 100 adults having extractions of 3rd molars, the combination product had no advantages but showed definite disadvantages when compared to an effective non-steroidal anti-inflammatory product. A comparison of ibuprofen and ibuprofen-codeine combination in the relief of post-operative oral surgery pain. Walton GM, et al. Turner Dental School, Manchester. Br Dent J. 1990 Oct 20;169(8):245-7. Ed: Four other studies, none recent, did find minor added pain relief, but also higher side-effects. Details were unavailable as to the amount of added relief.

Codeine No Added Benefit to Meclofenac and Inferior by Itself with More Side-Effects:  In a DB PC study of 200 adults with extractions of impacted 3rd molars, meclofenamate 100 mg plus codeine 60 mg, meclofenamate 50 mg plus codeine 30 mg, meclofenamate 100 mg, codeine 60 mg, and placebo treatment groups were compared. Both meclofenamate-codeine combinations and meclofenamate 100 mg alone were significantly more effective (P less than .005) than placebo for all variables and for codeine for all but one variable. Double-blind comparison of meclofenamate sodium plus codeine, meclofenamate sodium, codeine, and placebo for relief of pain following surgical removal of third molars. Giglio JA, et al. Medical College of Virginia. J Oral Maxillofac Surg. 1990 Aug;48(8):785-90.

Codeine 15 mg No Benefit For Pain; Ibuprofen or Aspirin Help: In a DB PC study of 202 adults ungoing extraction of 3rd molars, aspirin, placebo, ibuprofen, codeine, or an ibuprofen/codeine combination were compared. Ibuprofen 200 mg (with or without codeine phosphate 15 mg) and aspirin 600 mg were significantly superior to either placebo or codeine phosphate 15 mg alone. Codeine phosphate at a dose of 15 mg was ineffective as an analgesic either alone or in combination. A single dose assessment of an ibuprofen/codeine combination in postoperative dental pain. Giles AD, et al. Int J Oral Maxillofac Surg. 1986 Dec;15(6):727-32.

Codeine Added Nothing to Acetaminophen and Flurbiprofen (Ansaid) Was Superior: In a DB PC study of 182 adults having 3rd molar extractions, single oral doses of 50 and 100 mg of flurbiprofen were compared with 100 mg of zomepirac sodium, 650 mg of acetaminophen plus 60 mg of codeine, 650 mg of acetaminophen alone, and placebo. The mean response with zomepirac was greater than with either 50 or 100 mg of flurbiprofen during the first four hours and lower during the last two hours. The analgesic effects of acetaminophen alone were not significantly different from acetaminophen in combination with codeine. Side-effects were more with codeine. Comparative study of flurbiprofen, zomepirac sodium, acetaminophen plus codeine, and acetaminophen for the relief of postsurgical dental pain. Sunshine A, et al. Am J Med. 1986 Mar 24;80(3A):50-4.

Codeine-Barbital Combination Inferior to Diclofenac (Voltaren): In a 5-day DB PC study of 190 adults having extraction of 3rd molars, 100 mg Voltaren (diclofenac-sodium) just before surgery and then 50 mg 3 times a day for 5 days; the other group received  widely used fixed combination tablets (acetylsalicylic acid 500 mg, caffeine 50 mg, aprobarbital 20 mg, codeine phosphate 10 mg) in the highest recommended dose, 2 tablets when needed at most 3 times a day. Patients treated with Voltaren had significantly less pain and swelling (p less than 0.001), and fewer days away from work (p less than 0.01). Voltaren as an analgesic after surgical removal of a lower wisdom tooth. Henrikson PA, et al. Int J Oral Surg. 1985 Aug;14(4):333-8.

Codeine Inferior to Ketoprofen: Ketoprofen, 25, 50, and 100 mg, was compared with 90 mg codeine and placebo for relief of pain due to removal of impacted third molar teeth as a single oral dose in a DB PC study of 129 patient. Ketoprofen had a more rapid onset and longer duration of action than codeine, as well as superior pain relief. Double-blind parallel comparison of single oral doses of ketoprofen, codeine, and placebo in patients with moderate to severe dental pain. Mehlisch D, et al. J Clin Pharmacol. 1984 Nov-Dec;24(11-12):486-92.

Codeine Inferior to Acetaminophen:  In a 10-hour 2-dose DB PC study of 108 adults having extraction of 3rd molars, 60 mg codeine gave less pain relief than 500 mg acetaminophen, or 1000 mg acetaminophen. Codeine patients increased their reports of pain relief from 20 to 60 per cent after the second dose. Clinical comparisons including codeine may therefore be better carried out in a repeated-dose regimen. Analgesic efficacy after single and repeated doses of codeine and acetaminophen. Quiding H, et al. J Clin Pharmacol. 1984 Jan;24(1):27-34.

Codeine/Acetaminophen Much Inferior to Rofecoxib: In a DB PC study of 393 patients experiencing moderate or severe pain after extraction of 3rd molars, rofecoxib 50 mg did much better at pain relief than codeine 60 mg/acetaminophen 600 mg over the first 6 hours (12.4 vs 7.0; P < 0.001). Significantly more patients on codeine/acetaminophen had side-effects (P < 0.050) and nausea in particular (P < 0.001). Rofecoxib versus codeine/acetaminophen in postoperative dental pain: a double-blind, randomized, placebo- and active comparator-controlled clinical trial. Chang DJ, et al. Merck Pharmaceuticals, West Point, Pennsylvania. . Clin Ther. 2001 Sep;23(9):1446-55.

Codeine/Acetaminophen Much Inferior to Rofecoxib (Vioox): In a DB PC study of 393 patients experiencing moderate or severe pain after extraction of 3rd molars, rofecoxib 50 mg did much better at pain relief than codeine 60 mg/acetaminophen 600 mg over the first 6 hours (12.4 vs 7.0; P < 0.001). Significantly more patients on codeine/acetaminophen had side-effects (P < 0.050) and nausea in particular (P < 0.001). Rofecoxib versus codeine/acetaminophen in postoperative dental pain: a double-blind, randomized, placebo- and active comparator-controlled clinical trial. Chang DJ, et al. Merck Pharmaceuticals, West Point, Pennsylvania. . Clin Ther. 2001 Sep;23(9):1446-55.

Codeine/Acetaminophen Much Inferior to Ketorolac for Endodontin Pain: In a DB study of 66 patients with severe endodontic pain ( 7 cm on 10 cm scale), ketorolac (Toradol, 10 mg p.o.) was considerably better at relieving pain than acetaminophen with codeine (325 mg/15 mg p.o.)(p = 0.005). A comparison of ketorolac tromethamine and acetaminophen codeine in the management of acute apical periodontitis. Sadeghein A, et al. Tehran University of Medical Science, Iran. J Endod. 1999 Apr;25(4):257-9.

Meperidine Pre-Op No Benefit; Acetaminophen May be Better: The pain threshold measured by electric pulp testing was significantly better with acetaminophen compared to meperidine, naproxen sodium, acetaminophen, and placebo. No elevation of the pain threshold occurred with narcotic drugs or with nonsteroidal anti-inflammatory drugs. Researchers question the philosophy of administering these drugs for change in pain threshold at the levels used here preoperatively. Change in pain threshold by meperidine, naproxen sodium, and acetaminophen as determined by electric pulp testing. Carnes PL, et al. University of Louisville School of Dentistry. Anesth Prog 1998 Fall;45(4):139-42.

Meperidine: Ketorolac Less Pain than Meperidine with Many Fewer Side-Effects: In a DB study of 145 patients having moderate to severe pain from extraction of 3 or more wisdom teeth, at least one of which was bone-impacted, patients received IM injections of 10 mg, 30 mg, or 90 mg of ketorolac, or 50 mg or 100 mg of meperidine. Adding up pain scores over the 8 hours, the effectiveness of 30 mg of ketorolac was similar to that of 90 mg ketorolac and both were significantly more effective than 10-mg ketorolac, 50-mg meperidine, or 100-mg meperidine. Patients who received 30 mg or 90 mg of ketorolac gave the study medication significantly higher ratings overall than did patients who received 50 mg or 100 mg of meperidine. Many fewer patients treated with ketorolac reported side-effects vs. meperidine (17% vs. 59%). Comparison of the efficacy and safety of ketorolac and meperidine in the relief of dental pain. Fricke JR Jr, et al. Austin Oral Surgical Associates, Texas. J Clin Pharmacol 1992 Apr;32(4):376-84

Meperidine No Added Value to Child Dental Procedures with Midazolam: In a DB crossover study of 20 children having dental restorative care, midazolam alone 1 mg/kg did as well as midazolam plus meperidine (0.5 and 1 mg/kg, respectively). All sedative agents were administered orally, and all sedations included 50% nitrous oxide administered via a nasal hood. Researchers concluded, "Oral midazolam alone is just as effective as midazolam with meperidine." Comparison of the efficacy of oral midazolam alone versus midazolam and meperidine in the pediatric dental patient. Musial KM, et al. United States Air Force, Lakenheath, England. Pediatr Dent 2003 Sep-Oct;25(5):468-74.

Morphine: Acetaminophen IV as Good as Morphine IM with Fewer Side-Effects: In a DB study of injectable acetaminophen, administered as IV propacetamol 2 g, an injectable prodrug formulation, compared to IM morphine 10 mg or placebo for patients with moderate to severe pain from removal of bone-impacted third-molars under general anesthesia, propacetamol and morphine were significantly more effective than placebo. After the first dose, 21 of the 34 patients in the placebo group required rescue medication, compared with 6 of the 31 in the propacetamol group (P < 0.0009) and 4 of the 30 in the morphine group (P < 0.0001). No statistically or clinically significant differences were found between propacetamol and morphine for any sum or peak measures of analgesia. Side effects were significantly less frequent with propacetamol than morphine (P < 0.027). Propacetamol administered IV in repeated doses (2 g followed by 1 g) has a significant analgesic effect that is indistinguishable from that of morphine administered IM (10 mg followed by 5 mg) after dental surgery, with better tolerability. Assessing analgesia in single and repeated administrations of propacetamol for postoperative pain: comparison with morphine after dental surgery. Van Aken H, Ehys L, Veekman L, Buerkle H. University of Munster, Germany. . Anesth Analg. 2004 Jan;98(1):159-65

Morphine: Lornoxicam NSAID as Powerful as Morphine and with Fewer Side-Effects: Lornoxicam is NSAID not available in the U.S. In a DB PC study of intramuscular (IM) injections of lornoxicam (4, 8, 16 and 20 mg) vs. morphine (10 and 20 mg) and placebo in 252 patients with moderate to severe pain following surgical removal of an impacted mandibular third molar, patients treated with lornoxicam or morphine had significantly greater cumulative pain relief over the 4-h post-injection period than placebo recipients. Patients in the lornoxicam 4 mg or morphine 10 mg groups had significantly less pain relief than patients in the higher dosage groups of these drugs. There was no significant difference between the morphine 20 mg group and the lornoxicam 8, 16 and 20 mg groups. Lornoxicam was well tolerated at all doses and had significantly lower incidence of adverse events than morphine 10 or 20 mg. Thus, lornoxicam 8 mg is at least as effective as IM morphine 20 mg.  Pain control after dental surgery: a double-blind, randomised trial of lornoxicam versus morphine. Norholt SE, Sindet-Pedersen S, Larsen U, Bang U, Ingerslev J, Nielsen O, Hansen HJ, Ersboll AK. Aarhus University, Denmark. Pain. 1996 Oct;67(2-3):335-43.

Nalbuphine: Children Dental Surgery: Narcotic Nalbuphine No Better than Non-Narcotic Diclofenac: In a DB study of 60 chidren having extractions under general anesthesia, children received either IV nalbuphine 0.3 mg/kg or diclofenac suppositories 12.5 mg to a dose of 1-2 mg/kg or placebo.  Duration of anesthesia was longer with diclofenac (9.6 min vs. 7.2 for placebo and 6.9 for nalbuphine).  There was no difference in post-op pain scores. Littlejohn IH, et al. London Hospital Medical College, UK. Post-operative pain relief in children following extraction of carious deciduous teeth under general anaesthesia: a comparison of nalbuphine and diclofenac. Eur J Anaesthesiol 1996;13:359-63. Ed: The non-narcotic was also much less expensive. Contrary to manufacturer claims, nalbuphine, though unscheduled, is often abused, including in teens who initiate IV drug use for the first time with nalbuphine. It results in unfavorable medical and psychiatric outcomes.  Non-narcotics are better.

Propoxyphene: Suprofen More Effective than Codeine or Propoxyphene and More Effective than Codeine with Aspirin: In 2 DB studies totalling 224 patients having periodontal surgery and removal of impacted 3rd molars, suprofen 200 mg was significantly more effective than codeine 60 mg or propoxyphene 65 or aspirin 650 mg. Suprofen 400 mg was also significantly more effective that the codeine-aspirin combination. Cooper SA, et al. Pharmacotherapy 1986;6:267-76.

Propoxyphene: Suprofen Better Pain Relief than Narcotic Dextropropoxyphene/Acetaminophen:  In a DB study of 57 patients, suprofen provided better pain relief than dextropropoxyphene 65 mg with acetaminophen 650 mg when taken up to four times daily for 3 days (p=0.01) with better second night's sleep (p=0.01). Six had side-effects on suprofen vs. 10 on dextropropoxyphene. Rosen M, et al. Anesthesia 1985;40:639-41.

Propoxyphene: NSAID Indoprofen Better than Codeine/Acetaminophen or Propoxyphene/Acetaminophen: In a DB study of postsurgical dental patients, indoprofen 200 mg was better than acetaminophen 650 mg/codeine 60 mg and better than acetaminophen 650 mg/d-propoxyphene N. The narcotic combinations were slightly better than plain acetaminophen, which was better than placebo. Cooper SA, et al. J Oral Surg 1981;39:21-5.

Propoxyphene: Ibuprofen More Effective for Degree and Duration of Pain vs. Propoxyphene or ASA: In a DB PC study of dental surgery, was given ibuprofen 400 mg and 800 mg. Both doses did better at relieving pain during the 3 hour study than aspirin 650 mg or propoxyphene 65 mg. Winter L Jr., et al. Surg Oral Med Oral Pathol 1978;45:159-66.

Oxycodone/Acetaminophen (Percocet) Much Inferior to Etoricoxib (Arcoxia): In a 24-hour DB PC study of 225 adults having extractions of 3rd molars, a single dose of etoricoxib 120 mg was much more effective for pain relief than oxycodone/acetaminophen 10/650 mg, or placebo at 6 hours (P < 0.001). Oxycodone/acetaminophen was 5 minutes faster, its only advantage. Etoricoxib patients experienced a longer analgesic duration, had a smaller percentage requiring rescue opioids during 6 and 24 h, and required less rescue analgesia during 6 and 24 h. Oxycodone/acetaminophen treatment resulted in more frequent side-effects, especially nausea, and vomiting. The analgesic efficacy of etoricoxib compared with oxycodone/acetaminophen in an acute postoperative pain model: a randomized, double-blind clinical trial. Chang DJ, et al. Merck & Co. Inc, West Point, PA, USA. 

Oxycodone (Percodan) No Better Than Placebo; Oxycodone/Ibuprofen (Combunox) Added Very Little to Intermediate Dose of Ibuprofen, But Boston University and University of Maryland Falsely Praise the Highly Addictive Narcotic: In a DB PC study of 498 adults within 5 hours of extraction of 2 or more wisdom teeth, single doses of oxycodone 5 mg/ibuprofen 400 mg, ibuprofen 400 mg, oxycodone 5 mg, or placebo were compared. Oxycodone 5 mg/ibuprofen 400 mg did non-significantly better than ibuprofen 400 mg in pain relief (13.3 vs. 12.2) while oxycodone 5 mg by itself was no better than placebo (4.3 vs. 4.2). the authors proclaim, "A single dose of oxycodone 5 mg/ibuprofen 400 mg was fast-acting, effective, and well tolerated in subjects with moderate to severe pain after dental surgery." Combination oxycodone 5 mg/ibuprofen 400 mg for the treatment of postoperative pain: a double-blind, placebo- and active-controlled parallel-group study. Thomas Van Dyke (Boston University), Leonard Litkowski (University of Maryland), Theodore Kiersch (Cranial Pain Research, Tucson), and Hongjie Zheng and Kenneth Newman (Forest Pharmaceuticals, Jersey City). Clin Ther. 2004 Dec;26(12):2003-14. Ed: Despite a massive study, the narcotic distributor, Forest Labs, who funded this study and who had two employees among the authors, was unable to prove that a very powerful and extremely addictive narcotic was of any significant value whatsoever for the relief of acute dental pain.  Of course, these hired "spin doctors," instead of noting that this powerful narcotic has no place in the treatment of dental pain, proclaimed it "fast-acting and effective." The FDA has given Forest the green light, i.e., they can call the combination a new drug, show it's better than placebo, and push it down the throats of the American public by paying off the physicians with free dinners, speaking engagements, etc.

Oxycodone/Acetaminophen (Percocet) High Dose No Better Than Valdecoxib (Bextra): In a DB PC study of 406 adults having extractions of 3rd molars, a single oral dose of valdecoxib (20 or 40 milligrams), did as well at pain relief over 6 and 24 hours as a combination of oxycodone 10 mg/acetaminophen 1,000 mg and better than placebo. Valdecoxib had a tolerability profile superior to that of oxycodone/acetaminophen. The analgesic efficacy of valdecoxib vs. oxycodone/acetaminophen after oral surgery. Daniels SE, et al. SCIREX Corp., Austin, Texas. J Am Dent Assoc. 2002 May;133(5):611-21. 

Oxycodone/Acetaminophen (Percocet) Inferior to Cox-2 Etoricoxib (Arcoxia) for Dental Impaction Pain: In a 24-hour DB PC study of 302 adults with acute dental impaction pain, single doses of Cox-2 inhibitor etoricoxib 120 mg, oxycodone/ acetaminophen 10 mg/650 mg and codeine/ acetaminophen 60 mg/600 mg were compared. Etoricoxib had greater pain relief (TOPAR6) (13.2 units) versus oxycodone/acetaminophen (10.2 units); and codeine/acetaminophen (6.0 units); p < 0.001 for all. Etoricoxib (24 h) had a significantly longer lasting analgesic effect than oxycodone/acetaminophen (5.3 h), codeine/acetaminophen (2.7 h), and placebo (1.7 h) (p < 0.001 for all). Etoricoxib patients experienced fewer clinical adverse experiences than patients on oxycodone/acetaminophen and codeine/acetaminophen, especially less nausea. The analgesic effect of etoricoxib relative to that of cetaminophen analgesics: a randomized, controlled single-dose study in acute dental impaction pain. Malmstrom K, et al. Merck Research Laboratories, Rahway, NJ. Curr Med Res Opin. 2005 Jan;21(1):141-9.

Oxycodone/Acetaminophen (Percocet) Inferior to Rofecoxib (Vioxx) for Dental Pain: Many studies have shown that opiate pain relievers are inferior for acute pain to non-addictive alternatives.  In a single dose DB PC study of Rofecoxib (Vioxx) 50 mg (n=90), Oxycodone/Acetaminophen 5/325 mg (Oxy/APAP) (n=91) and placebo (PBO) (n=31), patients with moderate to severe pain following extraction of at least 2 third molars rated pain intensity and pain relief better with at prescribed times over 24 hours better with Vioxx on all measures. Compared to Oxy/APAP, ROF had significantly greater overall and peak analgesic effect, significantly longer duration of analgesic effect, and similar time to onset of analgesic effect. Compared to Oxy/APAP, ROF patients had significantly fewer episodes of nausea (19% vs. 40%) and vomiting (7% vs. 23%). Conclusion: Rofecoxib 50 mg was more effective than Oxycodone/Acetaminophen 5/325 mg for relief of dental pain. ROFECOXIB COMPARED TO OXYCODONE/ACETAMINOPHEN FOR POSTOPERATIVE DENTAL PAIN. James Fricke, Theodore Vassil, Paul Kotey, Scott Korn, Merck Research Laboratories. Pain Med. 2002 Jun;3(2):185-186.  Ed: Doctors, brainwashed by drug companies, have turned millions of Americans into narcotic addicts without good research to support the practice.  In fact, opiates are not good pain relievers, but they are extremely addictive. While Vioxx is off the market, the evidence still stands that oxycodone is inferior to NSAIDs for acute pain.  

Oxycontin Inferior to Rofecoxib (Vioxx) for Dental Pain: In a 212-patient DB PC study, patients with moderate to severe postoperative pain after extraction of two or more third molars using a single oral dose of rofecoxib 50 mg, oxycodone/acetaminophen, significantly fewer patients in the rofecoxib group (72.2%) took rescue analgesia within 24 hours postdose compared with the oxycodone/acetaminophen group (94.5%) and the placebo group (96.8%). Both active treatments were similar with respect to onset of analgesic effect. Both were generally well tolerated; the overall incidence of adverse experiences in the rofecoxib, oxycodone/acetaminophen, and placebo groups was 51.1%, 64.8%, and 48.4%, respectively. Rofecoxib was associated with a significantly lower incidence of nausea (18.9% vs 39.6%) and vomiting (6.7% vs 23.1%) compared with oxycodone/acetaminophen. Comparison of rofecoxib and oxycodone plus acetaminophen in the treatment of acute pain: A randomized, double-blind, placebo-controlled study in patients with moderate to severe postoperative pain in the third molar extraction model. Korn S, Vassil TC, Kotey PN, Fricke JR Jr. Merck drug company. Clin Ther. 2004 May;26(5):769-78. 

Oxycodone/Acetaminophen (Percocet) Inferior to Rofecoxib (Vioxx): In a 24-hour DB PC study of 271 patients have extractions of impacted molars, a single dose of rofecoxib 50 mg was somewhat better than a single dose of oxycodone/acetaminophen 10/650 mg over 6 h as well as with a multidose regimen of oxycodone/acetaminophen 10/650 mg followed by oxycodone/acetaminophen 5/325 mg over 24 h. Rofecoxib-treated patients achieved pain relief over the first 6 hours more effectively than oxycodone/acetaminophen patients (12.9 vs 11.3, p = 0.059). Patients also rated a single dose of rofecoxib as better than multidose oxycodone/acetaminophen over 24 h on pain intensity although the difference did not quite reach statistical significance (21.9 vs 18.1; p = 0.122). Patients treated with oxycodone/ acetaminophen had a shorter time to onset of analgesia than patients treated with rofecoxib (24 vs 35 min, p < 0.05).  Fewer rofecoxib than oxycodone/acetaminophen patients experienced adverse events (48 vs 76%, p < 0.001), including nausea (19.0 vs 42.5%, p < 0.001), vomiting (9.9 vs 24.2%, p < 0.01), and dizziness (7.4 vs 31.7%, p < 0.001). Comparison of rofecoxib and a multidose oxycodone/ acetaminophen regimen for the treatment of acute pain following oral surgery: a randomized controlled trial. Chang DJ, et al. Merck & Co, Inc, West Point, PA. Curr Med Res Opin. 2004 Jun;20(6):939-49.

Oxycodone Added Nothing to Ibuprofen Pain Relief Except at Highest Dose Which Caused Drowsiness and Vomiting: In a 6-hour DB PC study of patients ungoing oral surgery, a dose of 400 mg ibuprofen was compared with 400 mg ibuprofen with oxycodone in doses of 2.5, 5, or 10 mgn. Ibuprofen plus 10 mg oxycodone produced somewhat greater pain relief compared with the other three groups from 15 minutes after drug administration up to the 2-hour observation. All four treatments were similar from 3 to 6 hours. Neither the 2.5-mg nor the 5-mg oxycodone dose provided any additive pain relief over ibuprofen at any point. The oxycodone caused more side-effects with significantly greater drowsiness and vomiting at the 10-mg dose. Additive analgesic effects of oxycodone and ibuprofen in the oral surgery model. Dionne RA. National Institute of Dental and Craniofacial Research, Bethesda, MD. . J Oral Maxillofac Surg. 1999 Jun;57(6):673-8.

Oxycodone Adds Very Little to Ibuprofen; No Better than Placebo: In a large DB PC single dose study of 498 patients with moderate to severe pain following dental surgery, the total pain relief at 6 hours using the combination of oxycodone 5 mg with ibuprofen 400 mg (Combunox) was 13.3, ibuprofen alone 12.2, oxycodone alone 4.2, and placebo 4.3.  Van Dyke T, et al. Combination oxycodone 5mg/ibuprofen 400 mg for for the treatment of postoperative pain: a double-blind, placebo- and active controlled parallel group study. Clin Ther 2004;26:2003. 

Pentazocine Inferior to NSAID Diclofenac and Had More Side-Effects: In a DB study of 160 patients having extractions of impacted lower third molars, IV dexamethasone and IV diclofenac each did better than pentazocine and placebo with less pain within 30 minutes (p< 0.05). Pain scores on the day following surgery were also lower in the diclofenac group compared to the opioid and placebo groups (p< 0.05) but not less than those who received dexamethasone. Vomiting was a problem in the opioid group. Postoperative dental pain--a comparative study of anti-inflammatory and analgesic agents. Campbell WI, et al. Ulster Hospital, Dundonald, Belfast. Ulster Med J 1991 Apr;60(1):39-43.

Pentazocine Inferior to NSAID Ketamine for Dental Maxillo-Facial Surgery: Ketamine and midazolam IV medication for conscious sedation in day-case maxillo-facial surgery, has been proven to be superior to pentazocine and midazolam concerning cardiovascular parameters and respiratory depression. In this DB PC study of 140 out-patients having dental surgery with local anaesthesia, ketamine(0.5 mg/kg)/midazolam was superior to pentazocine/midazolam postoperatively (vigilance). Analgesia-sedation for maxillo-facial surgery with midazolam-pentazocine and midazolam-ketamine. Clinical double-blind study of anxiety, analgesia, sedation and amnesia. Lipp M, et al. Johannes Gutenberg-Universitat Mainz. Anaesthe 1995 Aug;44(8):566-72.

Pentazocine Inferior to Pirprofen: In a DB PC study of 210 patients after oral surgery, pirprofen 200 and 400 mg both did better than pentazocin 100 mg for pain relief with the 400 mg dose more effective than the 200 mg dose (p< 0.05). The analgesia procured by the drug was perceptible after about 15 minutes. One of the 51 patients who received the 400 mg dose developed diarrhea, this being the only side effect observed. A study of the analgesic effects of pirprofen after oral surgery. Sperr W. Nouveau Presse Med 1982 Aug 28;11(33):2514-6.

Tramadol: Dental Surgery in Children: Ketamine Better: In a DB study of 120 children going through dental surgery with Midazolam (I), Ketamine (II), Zolpidem (III), Midazolam plus Ketamine (IV), Midazolam plus Tramadol (V) and Zolpidem plus Tramadol (VI), Midazolam plus ketamine was found the most effective combination providing a fast and adequate analgo-sedation in anxious and uncooperative child patients. A comparative evaluation of newer sedatives in conscious sedation. Koirala B, et al. College of Dentistry. Dharan, Nepal. . J Clin Pediatr Dentistry 2006 Summer;30(4):273-6.

Tramadol Grossly Inferior in Meta-Analysis of Five Unpublished Manufacturer Studies: In every one of the five R.W. Johnson studies, ibuprofen 400 mg was dramatically better than tramadol 75 mg alone for moderate to severe pain after dental surgery and in every study it did better than tramadol combined with acetaminophen 650 mg, although in some studies the superiority of ibuprofen did not reach statistical significance.  In a couple studies, tramadol plus acetaminophen 650 mg was superior to acetaminophen alone, but in studies using 975 mg of acetaminophen, tramadol plus acetaminophen was never superior. The side-effects with tramadol was clearly higher than in any other group as was the drop out rate due to inefficacy. Individual Patient Data Meta-Analysis of Single-Dose Oral Tramadol Plus Acetaminophen in Acute Postoperative Pain. Edwards JE, et al. University of Oxford. J Pain and Symptom Management 2002;23:121-130.

Dentists Use Opiates Frequently: This article examines the prescribing practices for peripherally acting and centrally acting analgesics, corticosteroids, and antibiotics following third molar extraction. A nationwide survey involving the prescribing patterns of a random national sample of 850 practicing oral surgeons was performed in 2004. Ibuprofen was the peripherally acting analgesic respondents used most frequently in the previous month, selected by 73.5% of the respondents. The ibuprofen dose prescribed most frequently was 800 mg, followed by doses of 600 mg and 400 mg. The centrally acting analgesic prescribed most frequently was the combination formulation of hydrocodone with acetaminophen, selected by 64.0% of the respondents. Recommendations for oral analgesics to manage postoperative pain relied on the peripherally acting analgesic ibuprofen or the centrally acting analgesic combination formulation hydrocodone with acetaminophen. Routine instructions to use centrally acting analgesics "as needed for pain" suggest that centrally acting analgesics are offered to manage pain that postoperative peripherally acting analgesics and intraoperative long-acting local anesthetics do not control adequately. The frequency with which oral and maxillofacial surgeons administered antibiotics and corticosteroids varied widely based on perceived patient need and dentist expectations. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. Moore PA, et al. University of Pittsburgh. Gen Dent 2006 May-Jun;54(3):201-7.

Thomas E. Radecki, M.D., J.D.

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