To many patients, pain and dentistry are synonymous. Patient surveys continue to indicate that fear of pain prevents many patients from scheduling dental appointments. This can often lead to the progression of infection or dental disease. Equally important, clinical practice can be disrupted by unscheduled emergencies and possible difficulty in obtaining adequate pain control. Challenges in this area can be a source of frustration to the busy practitioner, and perhaps even more so for the anxious patient. This does not have to be the case. Research conducted by endodontists and other clinicians interested in pain management have revolutionized our ability to treat acute inflammatory pain.
An effective strategy for pain management is the “3D” approach, in which clinicians first Diagnose the pain condition, then deliver appropriate Dental treatment and finally administer effective Drugs. This systematic approach provides a framework, or playbook, that organizes your approach for managing dental pain emergencies — increasing both effectiveness and clinical efficiency.
Diagnosis is the first “D.” Effective pain control begins with an accurate diagnosis. Given the problem of referred pain, it is possible that a patient’s complaint of intraoral pain may actually be due to a non-dental cause. Therefore, it is important to first determine whether the pain originates from a tooth or whether it is referred from another tissue.
There are several key findings that are helpful in determining whether the pain originates from a tooth. First, and perhaps most important, the clinician should be able to reproduce the patient’s chief complaint when testing the suspected tooth. For example, if the chief complaint is pain upon chewing, then percussing the tooth with a mirror handle or using a device such as a ToothSlooth should be able to reproduce the pain symptoms, while testing control teeth should have no effect. Similarly, if the chief complaint is pain due to drinking something cold, then applying targeted cold stimuli to the suspected tooth should reproduce the pain. This latter example may require rubber dam isolation of individual teeth to allow the cold water to bathe the entire crown surface, or the use of a spray refrigerant such as Endo-Ice. It is essential to reproduce the chief complaint on the suspected tooth since it provides strong evidence that the pain is neither non-dental nor originating from another tooth. Second, application of local anesthesia should eliminate, or at least reduce, the pain symptoms. If pain is unaltered by a local anesthetic injection and anesthesia is verified by pulp testing adjacent teeth, then a non-dental origin of pain should be considered. For example, patients with temporomandibular joint disorders may continue to report pain upon chewing even after an intraoral injection of a local anesthetic. Third, there is usually an apparent etiology for pulpal involvement: caries, failed restorations, recent history of trauma or recent dental treatment (e.g., crown preparation) all may lead to inflammatory pain by activation of pulpal or periradicular nociceptors.
If a diagnosis cannot be made, then referral to a specialist with additional equipment (e.g., microscope, cone beam-computed tomography) and training may be warranted. Only when a clear diagnosis is made should the clinician move to the second “D.”
Dental Treatment is the second “D.” Appropriate treatment reduces the inflammatory process that underlies most acute dental pain emergencies. This may include nonsurgical root canal treatment. Dental treatments effectively relieve pain by virtue of their ability to reduce inflammation, leading to lowered tissue levels of inflammatory mediators. Many of these mediators such as prostaglandins, bradykinin and cytokines potently activate and sensitize nociceptive neurons leading to spontaneous pain and reduced pain threshold. Indeed, patient complaints such as pain upon chewing or throbbing pain are likely due to reduced pain threshold, where normal gentle stimuli such as mastication or even the heartbeat can lead to pain complaints. Thus, the second “D,” namely effective dental treatment, is a highly effective strategy for managing pain emergencies.
Drugs are the third “D”. Drugs are the third step since, first, a proper diagnosis is required in order to select the optimal drugs. For example, sinusitis, trigeminal neuralgia, herpes and headaches all require very different pharmacotherapy (or appropriate medical referral) than irreversible pulpitis. And second, appropriate dental treatment is effective in reducing tissue inflammation, providing an independent method for reducing the acute pain condition. Local anesthetics are an important drug class in treating emergency pain patients. One commonly observed problem, however, is that local anesthestics are often only partially effective in treating dental pain originating from mandibular posterior teeth.
• A positive “lip sign” does not guarantee pulpal anesthesia. A more reliable indicator is to retest the tooth with cold (Endo-Ice)
• Intraosseous administration of a local anesthetic significantly enhances the efficacy of an IAN nerve block injection
• Although the intraosseous use of a local anesthetic containing a vasoconstrictor (e.g., 2% lidocaine with 1:100,000 epinephrine) increases the efficacy and duration of anesthesia, an acute tachycardia may occur, which precludes its use in some patients.
• Administration of a 4% articaine solution into the buccal vestibule of the mandible also enhances the efficacy of an IAN block injection
• Preoperative administration of nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) may increase the effectiveness of the local anesthetic IAN block
Analgesics are another commonly used drug class for treating odontogenic pain patients. NSAIDs are often considered a drug of choice in treating these patients due to the specific inflammatory etiology of most dental pain conditions. Of course, the astute clinician understands that, while many patients can take NSAIDs, they are generally contraindicated in patients with ulcers, ulcerative colitis, uncontrolled hypertension and kidney disease, patients taking blood thinners or aspirin for heart disease, or patients in the third trimester of pregnancy.
Acetaminophen, alone or in combination with an opioid (e.g., codeine, hydrocodone, oxycodone), is often used as an alternative analgesic in patients who cannot tolerate the NSAID class of analgesics. Although acetaminophen alone or with opioids is considered an effective alternative analgesic in patients who cannot take NSAIDs, adverse effects do exist and include potential for liver damage, rare incidence of Stevens-Johnson syndrome, and possibly an association with asthma. Additionally, the patient needs to be cautioned about the effects of opioids (e.g., dizziness, drowsiness) if prescribed. More recent studies have evaluated combined administration of ibuprofen and acetaminophen in patients who can tolerate both classes of drugs. Interestingly, the simultaneous administration of ibuprofen and acetaminophen produces greater peak analgesia and more consistent analgesia (i.e., less variability between patients) without increasing adverse side effects. This substantial improvement in analgesia has been reported in patients after surgical extractions as well as in patients after nonsurgical endodontic treatment. Based on these studies, combinations such as ibuprofen 200 mg + acetaminophen 500 mg, up to ibuprofen 400 mg + acetaminophen 1,000 mg, have been shown to produce highly significant analgesic benefits to patients. Thus, one effective strategy for managing emergency pain patients is the combined use of ibuprofen and acetaminophen. Although this combination is available as a single drug entity in several countries, many of these clinical trials simply administered two tablets of the analgesics at the same time.
Tramadol is a centrally acting narcotic-like analgesic that may be an option in patients who cannot tolerate NSAIDs and/or acetaminophen and opiate combinations. Clinicians should refer to a drug resource or reference before prescribing any medications. Antibiotics are another drug class often used for treating emergency pain patients with odontogenic infections. However, several randomized, controlled studies have failed to detect an analgesic effect in patients taking antibiotics. This is an important issue since the practitioner should not rely on antibiotics to relieve pain. Instead, analgesics may be coprescribed with antibiotics when treating pain patients with odontogenic infections. It should be noted that antibiotics should only be prescribed to patients with systemic signs of infection (e.g., fever, swelling, malaise or compromised airway). Patients with cellulitis or those who are medically compromised may also require antibiotic therapy.
A list of commonly prescribed analgesics for treating dental pain:
|Drug||Brand Name||Dosage||Maximum Dosage|
|Ibuprofen||Advil, Motrin, Nuprin||400-600 mg every 4-6 hours||3200 mg/day|
|Naproxen||Aleve, Naprosyn||440-500 mg every 12 hours||1000-1100 mg/day|
|Acetaminophen with Codeine #3||Tylenol with Codeine #3 (30 mg codeine / 300 mg acetaminophen)||1-2 tablets every 4-6 hours||3000 mg acetaminophen/day and 360 mg codeine/day|
|Acetaminophen with Hydrocodone||Vicodin-5 (5 mg hydrocodone / 300 mg acetaminophen)||1-2 tablets every 4-6 hours||3000 mg acetaminophen/day and 60 mg hydrocodone/day|
|Acetaminophen with oxycodone||Percocet-5 (5 mg oxycodone / 325 mg acetaminophen||1-2 tablets every 4-6 hours||3000 mg acetaminophen/day and 60 mg oxycodone/day|
|Tramadol||Ultram (50 mg Tramadol)||1-2 tablets every 4-6 hours||400 mg/day|
|Acetaminophen with Tramadol||Ultracet (37.5 mg tramadol / 325 mg acetaminophen||1-2 tablets every 4-6 hours||3000 mg acetaminophen/day and 400 mg tramadol/day|
Reference: American Association of Endodontists