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Safer Pain Relief by Dr. William Jacobson

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Categories: Ethics, Jurisprudence and Malpractice; Oral Pathology, Pharmacology, and Cariology;
Safer Pain Relief 

Expert advice on navigating patient pain-management situations in your practice

by Dr. William Jacobson

As a general dentist who works at community clinics, every day I see patients who have toothaches. I recall being overwhelmed when I first had to handle all kinds of toothache scenarios, but over time I realized that patterns exist (as with all aspects of dentistry), and those patterns helped me become more confident tackling the situations as they presented.

In hopes they will help you when you’re faced with similar situations, I’ve compiled these tips for what I’ve found are the most common scenarios.


Patients who show up in pain

I always have the assistants ask patients to rate their pain level on a scale of zero to 10, with zero meaning “no pain” and 10 being “the worst pain imaginable.” I also have them ask patients what their pain level is at that moment compared to at its worst, which could be important: “10 right now” versus “3 at that moment but a 10 when the patient drinks ice-cold water” makes a big difference when determining which action to take.

Ask: “Have you taken any medication for the pain?” If so, find out the dosage and frequency; patients might be under-medicating or taking the wrong medication.

Evidence-based dentistry tells us the combination of 400 mg of ibuprofen and 1,000 mg of acetaminophen is a safe, effective alternative to opioid painkillers.1 We’ve learned this is the first line of defense for pain management, and this is what I recommend.

In addition, there are valuable multimodal pain management options to keep in mind for all scenarios. These include, depending on the diagnosis:
  • Pulpotomy.
  • Pulpectomy.
  • Occlusal adjustment.
  • QuickSplint.
  • A long-acting anesthetic, such as bupivacaine.
  • A prescription anesthetic mouth rinse.
  • A cold compress, up to 15 minutes at a time, to help with pain or swelling.
  • Warm saltwater rinses to decrease inflammation.
  • Recommending that patients sleep propped up with a few pillows.
It’s important to set realistic expectations with patients by explaining that the goal is to reduce the pain so it’s tolerable, but the pain level may not drop all the way down from 10 to zero.


Patients who expect to be in pain after your dental work

Treatment is the same as the previous situation, but be sure to inform patients about your pain management plan as part of the informed consent for treatment for procedures such as root canal treatment or tooth extraction. Otherwise, the patients may have very different expectations for pain management and become angry when those expectations aren’t met after the procedure.


Patients in pain who are waiting to be treated by a specialist

Laws vary by state, and unless you’re trained to treat chronic pain, patients must be made to understand that you treat only acute pain, and can’t provide them with two months’ worth of narcotics while they wait to see an oral surgeon. Consider consulting with the patient’s physician.


Patients who are in pain after treatment by a specialist

If the patients have postoperative pain or any complications from work done by a specialist, refer them back to that specialist. Don’t get in the middle!


Patients who have allergies to pain medications

True allergies to ibuprofen and acetaminophen are rare, so ask the patients follow-up questions to understand if there’s a true allergy or just an intolerance. Patients may truly have a contraindication to one or the other, however; for example, patients who’ve had bariatric surgery should avoid nonsteroidal antiinflammatory drugs, because NSAIDs can damage the stomach pouch and result in gastric ulcers. If a patient cannot take ibuprofen, recommend acetaminophen, and vice versa. If patients can’t take either one, this really does narrow down your options. (One remaining possibility: Tramadol 50 mg.)


Patients with substance use disorders

As with all scenarios, the best option is treating the problem that day—performing a same-day tooth extraction, for example. However, that’s not always possible, so proceed with the protocol suggested in the first situation I mentioned, for patients who show up in pain.

Also, keep in mind there’s no evidence that exposure to an opioid for acute pain increases the risk of relapse; however, the opposite may occur—the stress associated with not relieving the pain is more likely to trigger a relapse.2 You can also consult with the patient’s physician.

If you are considering prescribing an opioid, consider writing multiple prescriptions with only one day’s worth of medication, which helps prevent patients from obtaining and ingesting several days’ worth at once.


Patients in recovery from substance use

Follow the protocol for patients who show up in pain. However, there are a few things to keep in mind with this population:
  • The patients may be taking an opioid such as buprenorphine, and while you might think they already have enough opioids in them for the toothache, these medications work more to reduce the craving than to reduce acute pain.
  • Patients with a history of long-term opioid use often have hyperalgesia, and thus a very low pain tolerance, so they may come off as drug-seeking although that’s not the case. Consult with the patient’s physician.
  • If prescribing chlorhexidine, make sure it is alcohol-free.

Patients being treated for chronic pain (but now have a toothache too)

In these cases, the patient is being treated for chronic pain but is also now experiencing acute pain with a toothache. Follow the protocol for patients who show up in pain; however, these patients are on “pain management contracts” with their physicians, so it’s important that you not prescribe any controlled substances because the patient using them would violate that contract.

These patients may require higher dosages at more frequent intervals. Consult with the patient’s physician.

A ninth situation described in my book, Clinical Dentistry Daily Reference Guide, involves patients who are clearly seeking drugs to use or sell to others. In these cases, be on the lookout for the typical red flags, and stick to the protocol for patients who show up in pain, including the multimodal pain options.

References
1. Moore, P., Zieglar, K,. Lipman, R., Aminoshariae, A., Carrasco-Labra, A., Mariotti, A. “Benefits and Harms Associated With Analgesic Medications Used in the Management of Acute Dental Pain: An Overview of Systematic Reviews.” Journal of the American Dental Association, 2018. 149(4).
2. Alford, D., Compton, P., Samet, J. “Acute Pain Management for Patient’s Receiving Maintenance Methadone or Buprenorphine Therapy.” Annals of Internal Medicine, 2006. January 17;144(2):127–134.

Author Bio
Author Dr. William Jacobson is a general dentist, professor, artist and author. Jacobson earned a master’s degree in public health and his DMD from Case Western Reserve University in 2015, then completed a general practice residency at the University of Southern California. He has practiced at federally qualified health centers ever since, and also has taught at the University of California at San Francisco and California Northstate University.

Jacobson’s new book, "Clinical Dentistry Daily Reference Guide," is a one-stop resource loaded with information helpful in day-to-day clinical decision-making, and includes alphabetized medical conditions and treatment modifications, pediatric medication dosage tables, trauma guidelines, procedural steps and more.

Information: williamjacobson.net
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