Playing the pain game in dentistry

I’m one of “those people” who has never had a cavity. I’ve had local twice in my life—when my wisdom teeth were removed and when I was in dental school acting as a guinea pig and pin cushion for my classmates. I’ve had ortho a couple of times, and I am about as vanilla as one can get with my dental history. So, when a six-foot, five-inch-tall tatted-out man with piercings walks into my office because he has a hurting tooth that literally brings him to his knees, I’ll confess that’s a moment when I’m a bit cynical that it could really hurt that much. I mean, come on…that full-body tattoo and all those piercings were optional pain! Sounds coldhearted, doesn’t it? Well, before you get too worked up, let’s dive into the pain game a bit and look at it from a different perspective—our patients’. I promise, my heart isn’t that cold, and my viewpoints aren’t that prejudiced.

Take, for instance, the woman who called over the weekend. I didn’t recognize the number, so I let it go to voicemail. I returned her call, and she was a patient whom I’d not seen in a year and a half. I asked her, “How long has it been hurting?” She responded, “15 minutes.” My next question was if she had taken anything for pain, to which she replied that she had, only 10 minutes prior (600 mg ibuprofen). My advice was to give the medication time to take effect and call my office the following Monday. When I saw this patient two days later, the ibuprofen had indeed eventually kicked in. The source of her pain was diagnosed, and she was subsequently treated.

What about the patient who complains of a toothache, and upon discussion confesses she had taken 4,000 mg (yes, 4,000 mg) of ibuprofen in the last 24 hours because her tooth hurt so bad. She was in tears. Her issue was diagnosed, and I gave her local to make the pain subside in the interim while she picked up her prescriptions. She was treated four days later.

Here we have two different scenarios with one common ground—pain. One patient thought the pain meds would kick in pronto; the other took almost more than twice the amount recommended in a 24-hour period. I’m sure you all have similar stories.

When somebody is in pain, it’s safe to say that pragmaticism is dulled to the point that there is no such thing as common sense. The unfortunate thing is that unscheduled or emergent visits are a result of pain, which, more often than not, can be avoided.

Pain management is most effective when we can comprehensively assess these three things:

• Etiology of the pain

• Subsequent treatment to eradicate the basis for pain

• Drug therapy, prescription, and/or over-the-counter medications

Suffice to say that each of these factors in and of themselves are an extensive read, so I’ll just hit on a few highlights.

Etiology

This includes a thorough medical examination with questions directly and indirectly aimed toward the issue. Medications, surgeries, and history (trauma, habits, etc.) will all elicit clues to the puzzle for a more succinct diagnosis. Clearly and more often than not, the reason for the pain is black-and-white. However, when it’s not, we must broaden our testing and assessment of the patient’s presentation.

Treatment

Again, in the dental world, options for treatment are mostly relatively straightforward, but dynamics from health issues (blood thinners, osteoporosis medications, heart attack/stroke, high blood pressure, etc.) all have the ability to severely impact our capacity to render care and address the issue. Having comprehensive knowledge of systemic functions and how they relate to one another with regard to our role in patient care can be a game changer.

Ever pull a tooth on someone who has a bleeding disorder? Or have you had a patient who passes out due to diabetic challenges? What about making the call to treat (or not treat) someone who has extremely high blood pressure? Do you have systems in place that enable you to make these decisions rationally and, furthermore, to be able to justify why you are (or aren’t) able to move forward with treatment? A patient’s level of pain can tug on your empathy strings and sometimes fog your ability to do what’s in that patient’s best interests. We also walk a fine line since lack of treatment as a result of systemic challenges can put the patient in even more of a predicament. This is when you team up with your colleagues and, yes, that includes the ones with the MD behind their name.

Drug therapy

Understanding pain and its pathways allow us to be more discerning with our prescribing practices. “Pain is a complex experience consisting of a specific sensation and the reactions evoked by that sensation; conventional analgesics either interrupt ascending nociceptive impulses or depress their interpretation within the central nervous system.”¹ Simply put, pain is one of our body’s built-in protective mechanisms.

When we are able to determine the reason for a patient’s pain, along with treatment, we can prudently prescribe or recommend over-the-counter medications as adjuncts to manage the pain pathways—from antibiotics that target the correct spectrum of bacteria, to the use of narcotic and nonnarcotic drugs (used interchangeably with opioid and nonopioid) therapies. While modern medicine in this arena has without argument overwhelmingly decreased mortality and increased success in the practice and art of healing, the abuse, misuse, and lack of knowledge about how these drug therapies work have led to tolerances, resistances, and subsequent abuse.^2,3 I wrote an article about dentists’ prescribing practices that you can read here.

Despite my lack of personal dental experiences with pain, I nonetheless endeavor to give my patients the benefit of the doubt. The fact that I’ve been burned by drug seekers a time or two makes me more prudent in my prescription practices. What I’ve found is that when the aforementioned highlights are implemented, being able to put a patient’s mind at ease through education is a huge component in being able to comprehensively manage their pain.

It makes sense then to seek out continuing education that addresses pain management for specific types of dental issues, including dosing schedules, frequencies, efficacy of various medications, etc. The world of medicine is constantly changing, and it is our responsibility to stay up-to-date.

So, when the big tatted-out man needed his tooth pulled, he asked, “Are you strong enough to pull it out?” I just raised my eyebrows and smiled. 

Cheers to the adventures of the profession!

Stacey

Stacey L. Gividen, DDS

Editorial Director, Breakthrough Clinical 

References

1. Becker D. Pain management: Part 1: Managing acute and postoperative dental pain. Anesth Prog. 2010;57(2):67-79. doi:10.2344/0003-3006-57.2.67

2. Lutfiyya MN, Gross AJ, Schvaneveldt N, Woo A, Lipsky MS. A scoping review exploring the opioid prescribing practices of US dental professionals. J Am Dent Assoc. 2018;149(12):1011-1023. doi:10.1016/j.adaj.2018.07.017

3. Aslam B, Wang W, Arshad MI, et al. Antibiotic resistance: a rundown of a global crisis. Infect Drug Resist. 2018;11:1645-1658. doi:10.2147/IDR.S173867

Last month: “A complete dental office overhaul: How to carpe diem when the unexpected happens”

Editor's note: This article originally appeared in Breakthrough Clinical, a clinical specialties newsletter from Dental Economics and DentistryIQ. Read more articles at this link.