COX-2 selective nonsteroidal anti-inflammatory drugs: what is their place in managing dental pain?

Introduction

An article in this issue discusses the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in pain management, their adverse effects, precautions with use, and selection of an NSAID.

NSAIDs play an important role in the management of dental pain, as inflammation is a key mechanism behind most types of dental pain. Nonselective NSAIDs such as ibuprofen are most frequently prescribed by dental professionals, usually combined with paracetamol. However, if patients report a history of gastrointestinal intolerance, bleeding risk or asthma, it is often assumed that NSAIDs are contraindicated and paracetamol, with or without an opioid, is prescribed instead. This can lead to suboptimal pain management, as neither paracetamol nor opioids have an anti-inflammatory effect.

A solution can be to prescribe a cyclooxygenase-2 (COX-2) selective NSAID, such as celecoxib, meloxicam or etoricoxib, as these drugs confer lower gastrointestinal, antiplatelet and respiratory risk than nonselective NSAIDs. Despite this, COX-2 selective NSAIDs are rarely used in dentistry, despite being recommended alongside nonselective NSAIDs in Therapeutic Guidelines: Oral and Dental.¹

 

Efficacy of COX-2 selective NSAIDs for dental pain

Clinical trials particularly in the postoperative dental setting have shown that COX-2 selective NSAIDs have similar pain-relieving efficacy to nonselective NSAIDs.^2,3 As a class, NSAIDs are considered largely similar in efficacy;^4,5 nevertheless, individuals may respond more favourably to one NSAID over another. Therefore, before abandoning all NSAIDs due to assumed lack of efficacy, it is worthwhile trying a different one.⁶

 

Choosing selective versus nonselective NSAIDs

Since selective and nonselective NSAIDs are considered equally efficacious, the choice between them is based on their risk profile.⁴ The degree of risk for each NSAID relates, in part, to its COX-1 versus COX-2 selectivity, as different adverse effects arise from each. To decide whether to use COX-2 selective NSAIDs, the prescriber must consider the patient’s comorbidities, focusing largely on gastrointestinal, cardiovascular and renal risks. If more than one risk factor is present, the cumulative risk of NSAID use must also be assessed. Further discussion of these risks is in the accompanying article, including comparative tables of the different NSAIDs.

 

Who may especially benefit from a COX-2 selective NSAID?

COX-2 selective NSAIDs were primarily developed to reduce risk of gastroduodenal toxicity compared with nonselective NSAIDs, and many clinical trials have confirmed this advantage.⁷ Individuals with active gastrointestinal disease should avoid nonselective NSAIDs, but COX-2 selective NSAIDs are an option for a very short period (i.e. no more than 5 days). Prescribers should note that the gastroduodenal sparing effect of COX-2 selective NSAIDs is lost with concomitant low-dose aspirin use but improved with a proton pump inhibitor.^8,9

COX-2 selective NSAIDs have little to no inhibitory effect upon platelet function, which is valuable when an NSAID is required for a patient with high bleeding risk. A meta-analysis supported the low bleeding risk of COX-2 selective NSAIDs in the perioperative setting compared with nonselective NSAIDs, paracetamol or placebo, with no increased risk of bleeding observed with the COX-2 selective NSAIDs.¹⁰

Unlike aspirin and nonselective NSAIDs, COX-2 selective NSAIDs carry little risk of precipitating bronchospasm in patients with NSAID-exacerbated respiratory disease (NERD) so, for patients with asthma or documented NERD, COX-2 selective NSAIDs can be prescribed.¹¹

 

Which COX-2 selective NSAID to prescribe and how

Celecoxib, meloxicam and etoricoxib are oral COX-2 selective NSAIDs available to prescribe in Australia; however, only celecoxib is recommended for dental pain management in Therapeutic Guidelines: Oral and Dental.¹ The recommended adult dose is 100 mg twice a day, or 200 mg once a day, for no more than 5 days without medical consultation. A short duration of use is recommended to closely monitor the patient and minimise the risk of adverse effects.¹

It should be noted that the use of celecoxib for management of acute dental pain is considered ‘off label’ (i.e. an indication not approved by the Therapeutic Goods Administration). However, given the support from published literature and professional guidelines, off-label use would be reasonable.

No COX-2 selective NSAIDs are listed in the dental items on the Pharmaceutical Benefits Scheme (PBS) but they can be prescribed as a private or non-PBS item.

Although celecoxib is now available as a Schedule 3 (Pharmacist Only) medicine, pharmacists are only authorised to provide it as short-term treatment of acute pain due to primary dysmenorrhoea or musculoskeletal or soft tissue injury in adults. Therefore, patients requiring celecoxib for the management of dental pain will require a prescription from a dentist.

Conflicts of interest: Geraldine Moses is the Director of Dental Advice Network, an online clinical advisory service for dental professionals, and the sole operator of Medication Management Solutions, a medication review service for dental patients. Geraldine is a member of the expert group for Therapeutic Guidelines: Oral and Dental version 4 (under review). Geraldine was a member of the Australian Dental Association Dental Therapeutics Advisory Committee from 2019 to 2024.

This article is peer reviewed.

 

References

1. Oral and Dental. In: Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited; 2019.
2. Isola G, Matarese M, Ramaglia L, Cicciu M, Matarese G. Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain, swelling, and mouth opening after surgical removal of impacted third molars: a randomized, controlled clinical trial. Int J Oral Maxillofac Surg 2019;48:1348-54.
3. Bassyoni L. Comparative Effect of Celecoxib, Diclofenac, and Ibuprofen in Controlling Postoperative Pain, Edema, and Trismus After Third Molar Extraction: A Double-Blinded Randomized Controlled Trial. Cureus 2024;16:e53687.
4. Hopkins S, Yang V, Liew DF. Choosing a nonsteroidal anti-inflammatory drug for pain. Australian Prescriber 2025;48:139-43.
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6. Australian Medicines Handbook Pty Ltd. Australian Medicines Handbook 2025 (online). Adelaide; 2025. [cited 2025 Jun 24]
7. Friedman LS. COX-2 inhibitors and gastroduodenal toxicity: Major clinical trials. UpToDate; 2023. [cited 2025 Jun 24]
8. Scarpignato C, Lanas A, Blandizzi C, Lems WF, Hermann M, Hunt RH, et al. Safe prescribing of non-steroidal anti-inflammatory drugs in patients with osteoarthritis--an expert consensus addressing benefits as well as gastrointestinal and cardiovascular risks. BMC Med 2015;13:55.
9. Qureshi O, Dua A. COX Inhibitors. In: StatPearls. National Library of Medicine; 2024. [cited 2025 Jun 24]
10. Teerawattananon C, Tantayakom P, Suwanawiboon B, Katchamart W. Risk of perioperative bleeding related to highly selective cyclooxygenase-2 inhibitors: A systematic review and meta-analysis. Semin Arthritis Rheum 2017;46:520-8.
11. Saff RR, Banerji A. Management of patients with nonaspirin-exacerbated respiratory disease aspirin hypersensitivity reactions. Allergy Asthma Proc 2015;36:34-9.