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.
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