What is the best analgesic?

Analgesics can provide effective pain relief to patients experiencing moderate to severe pain. What does the evidence say when it comes to prescribing the most effective analgesic?

Dental pain is as a result of inflammation and/or tissue damage. For clinicians, the management of dental pain is a critical component of patient care. Clinicians have often wrongly prescribed antibiotics for dental pain, whereby the correct analgesics would have been safer and more effective. Common diagnoses that can cause moderate to severe pain include irreversible pulpitis and acute/chronic periapical periodontitis. Additionally post-operative pain is very common following dental treatment, especially oral surgery procedures.

The Oxford League Table

The Oxford League table of analgesics in acute pain was formulated from many systematic reviews that studied patients with moderate to severe pain. “Placebo” is the common comparator throughout all the studies. The results were standardised, validated and tabulated.

Analgesic efficacy is expressed as the NNT, the number of patients who need to receive the active drug for one to achieve at least 50% relief of pain compared with placebo over a 4-6 hour treatment period. Therefore, the lower the NNT, the more effective the analgesic.

A truncated version of the table is presented below. According to the table, Ibuprofen with a dose of 600mg appears to be an effective analgesic for moderate to severe acute pain.

Oxford League Table of Analgesics showing most effective painkillers
Numbers needed to treat are calculated for the proportion of patients with at least 50% pain relief over 4-6 hours compared with placebo in randomised, double-blind, single-dose studies in patients with moderate to severe pain. Drugs were oral, unless specified, and doses are milligrams. Links to the entire table are provided in the references.


Ibuprofen (developed in 1960’s) is available over the counter from doses of 200mg in the UK. 1200mg is the recommended maximum daily dose for adults, but 3200mg may be taken under medical supervision. Many Endodontists prescribe a dose of  600mg of Ibuprofen to patients experiencing symptoms of irreversible pulpitis. This current teaching is also based on the above league table which also serves as evidence that medication does provide pain relief thus potentially deterring practitioners from wrongly prescribing antibiotics. See the current guidance for antibiotic prescriptions for dental use. 

A Cochrane systematic review (highest level of evidence) studying the effect of a single dose of Ibuprofen for acute post-operative pain showed that when compared with most other analgesics, Ibuprofen was extremely effective in providing pain relief (J, Derry, Moore, & McQuay, 2012).

A further Cochrane review comparing Ibuprofen and Paracetamol found Ibuprofen more effective at all concentrations in managing pain following wisdom teeth extractions (Bailey et al., 2013). The same study also found that a combination of both Ibuprofen and Paracetamol was no more effective than when the drugs were taken singly.

Interpret cautiously

Whilst the table above is a good reference point for academics and clinicians, the data must be interpreted carefully. These are based on single dose studies and do not mention any  adverse effects of the drugs; many patients may not be able to consume Ibuprofen for medical reasons. Furthermore sample sizes vary and small trials cannot accurately estimate the actual analgesic effect.


Oxford League table of analgesics in acute pain, 2007

The above also published by The Royal College of Anaesthetists 

Bailey, E., Hv, W., A, V. W., Jm, Y., Coulthard, P., & Afzal, Z. (2013). Ibuprofen and / or paracetamol ( acetaminophen ) for pain relief after surgical removal of lower wisdom teeth ( Review ) SUMMARY OF FINDINGS FOR THE MAIN COMPARISON, (12). https://doi.org/10.1002/14651858.CD004624.pub2.Copyright

J, D. C., Derry, S., Moore, R., & McQuay, H. J. (2012). Single dose oral ibuprofen for acute postoperative pain in adults (Review). Cochrane Database of Systematic Reviews, (3). https://doi.org/10.1002/14651858.CD001548.pub2.www.cochranelibrary.com


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