Dental Pain Management
Thomas Franko, PharmD, BCACP
Assistant Professor Pharmacy Practice
Wilkes University
Luzerne County Dental Society
January 20th, 2014
Objectives
Describe the pain pathway and how it
relates to dental care
 Develop a care plan using opioid
medication
 Understand the difference between
NSAIDs and Tylenol
 Select appropriate follow up plan for a
patient

What You Think
Available at: http://www.featurepics.com/online/DentistHappy-Patient-703697.aspx
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What They Think
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What is Pain
“An unpleasant sensory and
emotional response associated
with actual or potential tissue
damage or described in terms of
such damage.”
"Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task
Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.
Current Recommendations
Based on case studies and studies but
nothing formal
 Structured around use of NSAIDs,
Acetaminophen and Opioids
 Recommend around the clock treatment
for 48 hours post procedure then as
needed

◦ Pain peaks 48 hours post procedure
Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
Burgess J, Meyers A. Post Procedural Pain Management. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at:
http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10
The Pain Pathway
Available at: http://medical-dictionary.thefreedictionary.com/nociception
The Pain Pathway
Brain
Spine
NSAIDs &
Acetaminophen
Mouth
NSAIDs
Analgesic, antipyretic and antiinflammatory properties
 Naproxen, Ibuprofen and Diclofenac have
been found to reduce pain by almost 50%
 Avoid long term use due to increased risk
of GI and renal issues
 Caution with patients on warfarin due to
increased bleeding risk

Burgess J, Meyers A. Post Procedural Pain Management. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at:
http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10
NSAID Selection
GI
Renal
Platelet
Cardiac
COX 1
COX 2
Ketorolac
Celecoxib
Selective COX 2 Inhibitors: Are They Safer NSAIDs. Therapeutics Initiative. 6 Feb 2001. Available at: http://www.ti.ubc.ca/pages/letter39.htm
Clinical Pearls

Be aware of other medications and
disease states
◦ GERD, PUD
◦ ACE inhibitors and ARBs
◦ Verify a medication record prior to adding any
new medications
Patients should take with food
 Be aware of patients who are brdiging
warfarin therapy

Aspirin
Anti-inflammatory properties at very high
doses
 Irreversible inhibition of COX

◦ Other NSAIDs are transient

More profound effects on platelet
function and GI irritation
◦ Not the best option in many surgical cases
Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
Acetaminophen

Not an NSAID
◦ No inflammatory properties
Recommended if patient is taking other
medications contraindicated with NSAIDs
 Can be used with NSAID for additional
benefit

◦ Moore P, et al. showed Ibuprofen +
Acetaminophen worked better than either
alone
Moore P, Hersh E. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. JADA. 2013 Aug 1; (144): 898908. Available at: http://jada.ada.org/content/144/8/898
Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
Acetaminophen

Caution with unintentional overdose
◦ Acetaminophen is in EVERYTHING
 Combination opioid medications
 Over the counter cough and cold products
Max dose is 4 grams daily
 Toxic mid-metabolites can cause hepatic
failure

Perez M, et al. Acetaminophen Overdose. Medline Plus. 22 March 2013. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002598.htm
Acetaminophen Overdose
Available at: http://www.fda.gov/ohrms/dockets/ac/02/briefing/3882b1_13_mcneil-acetaminophen.htm
The Pain Pathway
Brain
Opioids
Spine
NSAIDs &
Acetaminophen
Mouth
Opioids
12% of opioids prescribed come from
dentists
 Should only be provided for a short
period of time
 Caution in patients with history of drug
abuse and/or alcohol abuse
 Refer patient to pain management, rehab
or psychological services if needed

Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
Burgess J, Meyers A. Post Procedural Pain Management. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at:
http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10
Opioids
Use if patient does not have adequate
pain relief with NSAIDs or
Acetaminophen
 Opioid/NSAID or Opioid/Acetaminophen
recommended over pure opioid

◦ Results in lower doses and less adverse
effects
 Codeine/Acetaminophen,
Hydrocodone/Acetaminophen,
Oxycodone/Acetaminophen
Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
Hydrocodone/Acetaminophen

2011 FDA requests no more than 325 mg
acetaminophen in combination Rx forms
◦ Expected completion by Jan 2014
◦ Not all manufacturers complied

Brand name Vicodin currently at 300 mg
acetaminophen regardless of hydrocodone dose
◦ PA law permits generic substitution at pharmacies
◦ Generic versions have various acetaminophen
strengths available
◦ Must express desire for 300 mg formulation
U.S. Food and Drug Administration. FDA limits acetaminophen in prescription combination products; requires liver toxicity warnings. 2011 Jan 13.
Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm239894.htm
Abbieve. Dosing and Administration. Appearance of AbbVie’s Reformulated Vicodin Tablets. Available at: http://www.vicodin.com/hcp/vicodindosing-administration
Opioids

Short acting opioids are preferred
◦ Limited duration of therapy
◦ Lower risk of opioid induced respiratory
depression/overdose vs. long acting

Abuse is possible; clinician responsible to
prescribe appropriately
◦ Policy statement from American Dental
Association
Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/painmanagement/1566
American Dental Association. Statement on the use of opioids in the treatment of dental pain. 2005 Oct. Available at:
http://www.ada.org/7578.aspx
Opioids

Adverse effects
◦ Constipation, respiratory depression,
euphoria, fatigue
◦ Tolerance will develop to everything except
constipation

Recommend use of stool softener/laxative
combination to help
◦ Mush and push
◦ Stool softeners can be used daily
◦ Laxatives should be used as needed
Levy M. Management of Opioid-Induced Side Effects. Medscape. Available at: http://www.medscape.org/viewarticle/573016
Goodheart C, Leavitt S. Managing Opioid Induced Constipation in Ambulatory Care Patients. Pain Treatment Topics. 2006 Aug. Available at:
http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf
Opioids and Chronic Pain
Patients with existing chronic opioid use
 Will need higher doses of opioids than
opioid naïve patients

◦ Maybe up to 2 times as much

Initiate discussion with primary care
provider
◦ Both for collaboration as well as determining
presence of med use agreements

Requires a more in depth assessment and
more care in prescribing
Gordon D. Acute Pain Management in the Opioid-Tolerant Individual. Medscape Nurses. 2008. Available at:
http://www.medscape.org/viewarticle/581948
Chronic Post Procedure Pain

Look for other causes
◦ Infection, ENT issues

Consider possible nerve/neuropathic
involvement
◦ Burning, numbing, electric, shooting pain

Referral to pain management as needed
Burgess J, Meyers A. Chronic Postprocedural Pain. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at:
http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10
Summary
Review the medication record first
 Be aware of drug-drug and drug disease
interactions
 Around the clock therapy for 48 hours
then as needed
 NSAIDs and Acetaminophen first
 Short term use of short acting opioids if
needed
 Communicate with primary care

Questions
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