Breaking Down Barriers to Care With Effective Pain Management
Raymond A. Dionne, DDS, PhD
As defined by the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience. When rendering patient care, effective pain management in dentistry is a vital consideration. Part of delivering that care is enhancing the clinical experience by preventing and managing pain.
Surveys of dental patients in the past 50 years indicate that pain during dental procedures and fears about undergoing a restorative or surgical procedure remain barriers to access to care,1,2 possibly second only to trepidation about the cost of dental services. While a wide variety of anesthetic, analgesic, and sedative drugs can be used to prevent or manage acute orofacial pain, the clinician’s paramount concerns for elective dental procedures are safety and ease of administration. Several noteworthy products fulfill these criteria, and their clinical uses show promise for mitigating pain and fear of dentistry, which are discussed below.
Subgingival instrumentation without anesthesia can be painful even when performed by a skilled practitioner, especially when inflammation results in increased sensitivity. However, preventive dentistry and overall periodontal health requires the use of regular scaling, thereby creating a need for obtunding pain without requiring multiple injections of a local anesthetic. This adds to the pain and anxiety associated with whole-mouth scaling. Subgingival application of a combination of lidocaine and prilocaine periodontal gel (Oraqix®, Dentsply Pharmaceutical, www.dentsply.com) provides localized anesthesia when applied with a blunt-tipped applicator. Onset is as early as 30 seconds after application, with a duration of approximately 20 minutes.3 The manufacturer recommends that one cartridge is sufficient to anesthetize one quadrant of the dentition, up to the use of a maximum of five cartridges in one appointment. Clinical studies of the proprietary product in comparison to placebo demonstrate a significant pain reduction, as measured with a visual analog scale, during scaling and root planing.3 Measuring pain levels with a categorical scale in these studies indicated that 70% to 90% of patients who received the gel reported “no pain” or “mild pain” during the procedure compared with a lower proportion of patients in the placebo group who reported little or no pain.3 These data indicate that administration of a combination of these two local anesthetics in a proprietary gel formulation prior to deep scaling/root planning safely prevents or attenuates clinical pain associated with this clinically important but aversive procedure.
As with all medications, administration of lidocaine or prilocaine is contraindicated in patients with known sensitivity to these drugs. Although well tolerated, prilocaine usage may cause elevated methemoglobin levels in susceptible individuals or those taking medications (listed in the package insert) known to induce methemoglobinemia. This product is FDA approved for local anesthesia in the oral cavity and has been on the market for more than 10 years, suggesting that it can be used safely without likelihood of unexpected toxicity or idiosyncratic responses, except as noted for methemoglobinemia.
Local Anesthetic Buffering
Administration of local anesthetic solutions often produces pain beyond what is associated with the physical injury of the needle. A traditional approach is to inject the solution slowly, as this minimizes the pressure caused by the bulk of the anesthetic solution and lowers the risks for inadvertent intravascular injection. An alternative is to buffer the anesthetic solution prior to injection, a well-documented strategy for reducing the pain associated with the administration of the anesthetic solution into soft tissue. Changing the pH level of the anesthetic solution also likely speeds the onset of anesthesia by increasing the amount of the anesthetic molecule in the uncharged form. This allows it to more readily cross the nerve membrane to gain access to the intracellular site of action.
A line of dental products that permit buffering with sodium bicarbonate is available. Onpharma’s products, which are approved for use with lidocaine only, include a mixing device to combine the buffering and local anesthetic solutions. Then, the clinician transfers the buffered local anesthetic solution to a standard 1.8-mL cartridge for administration. A specialized connector is used to maintain sterility. A sodium bicarbonate solution is the active component of the system that results in the buffered local anesthetic solution for administration. The manufacturer claims the rapid onset of anesthesia, in addition to the less pain on injection, allows a clinician to start a procedure shortly after administration rather than waiting for the signs of regional anesthesia to develop.4 The literature provided on the manufacturer’s website supplies adequate documentation to support the concept of buffering the anesthetic solution to decrease pain and hasten anesthetic onset, but offers only testimonials to support the dental use of the proprietary device.
Combining Ibuprofen and Acetaminophen for Acute Pain
Despite knowing about the greater analgesic effect, lower incidence of adverse events, and low risk that non-steroidal anti-inflammatory drugs (NSAIDs) contribute to drug abuse, clinicians still tend to prescribe opioids combined with acetaminophen for acute dental pain relief. A more logical alternative for a combination analgesic has emerged that combines a full therapeutic dose of ibuprofen (400 mg to 600 mg) with a therapeutic dose of acetaminophen (600 mg to 650 mg)5 to result in additive analgesia without the risk for opioid misuse, abuse, or diversion. Opioid pain relievers were involved in more than 28,000 deaths in 2014, more than any other year on record.6 A critical appraisal of the scientific literature by Moore and Hersh7 indicated that the combination results in greater pain relief than either drug alone, with no increase in the incidence of adverse events. The basis for this is due to these two drugs having different mechanisms of action and their lack of activity at opiate receptors that produce analgesic and adverse effects in parallel. Because both drugs are available without a prescription (at specific doses [ie, ibuprofen 200 mg, not 400 mg or 600 mg]), most patients will have already been exposed to these drugs and thereby unlikely to have an idiosyncratic reaction that sometimes occurs when an individual is exposed to a drug for the first time.
An additional advantage to the availability of over-the-counter dose formulations is the ability to better customize pain management. Patients can be given ibuprofen prior to or shortly after a dental procedure likely to result in postoperative pain such as extractions or periodontal surgery to delay pain onset and minimize its intensity. Subsequent doses on fixed intervals can be prescribed to avoid the periodic pain that occurs when giving pain medications on an PRN, or as-needed, schedule. Additional pain relief can be provided by recommending that patients self-administer acetaminophen between ibuprofen doses to minimize any breakthrough pain. (Caution is advised to avoid reaching daily maximum doses.)
Recent guidelines7 call for clinicians to prescribe 200 mg to 400 mg of ibuprofen for mild pain every 4 to 6 hours as needed. Table 1 explains the dosing options. This regimen minimizes the development of hyperalgesia due to the inflammatory process. It also avoids the cyclic offset of pain relief when analgesics are given as needed and the subsequent delay in pain relief as the next dose is being absorbed, with fewer adverse events that can lower quality of life and impair the return-to-daily activities. Systematic reviews provide strong evidence that NSAIDs alone result in greater analgesia than opioid combinations, with fewer side effects.8,9 By providing even greater analgesia with the combination of ibuprofen and acetaminophen, patients experience less pain with no increase in side effects and are not exposed to the risks for opioid misuse, abuse, or diversion.
Topical Ketoprofen Gel for Chronic Pain
While nonpharmacologic and physical-therapy procedures are preferential for pain-symptom management, they often take time to produce improvement. Systemic chronic administration of analgesics can produce adverse events, impair renal or hepatic function, or are accompanied by risks for dependence and drug abuse. An alternative is topical application to produce greater drug levels in the region of the temporomandibular joint (TMJ) while minimizing systemic toxicity with lower circulating drug levels.
A gel formulation of ketoprofen10 is available for symptomatic treatment of temporomandibular disorders (TMDs). This medication has been demonstrated in well-controlled clinical trials to reduce the symptoms of painful joints without the same incidence of adverse events associated with oral administration of ketoprofen. Evidence suggests that higher drug levels are measurable in the synovial fluid of larger joints and this may also be achieved in the TMJ. A wide variety of formulations are available; systematic reviews indicate that topical application of NSAIDs such as ketoprofen is safe and effective for the symptomatic management of joint pain. This approach should be combined with physical-medicine procedures to optimize outcomes and eventually be tapered to intermittent use for exacerbations of symptoms. When combined with a comprehensive approach to diagnosis and management, patient symptoms are likely to regress without the risks for iatrogenic injury from surgery or irreversible dental procedures that are not consistent with treatment of a chronic widespread disorder.
The therapeutic approaches to improved pain management are readily available for use in clinical practice, represent improvements over traditional clinical practices, and are not likely to result in serious adverse events or iatrogenic injuries. By safely reducing the discomfort associated with routine dental procedures, these techniques help patients overcome their fear of dentistry. Sage advice suggests that the clinician should not be the first or last to adopt a therapeutic innovation but should consider these novel, but validated, treatments for improving the patient experience.
1. Dionne RA, Gordon SM, McCullagh LM, Phero JC. Assessing the need for anesthesia and sedation in the general population. J Am Dent Assoc. 1998;129(2):167-173.
2. Dionne RA, Yagiela JA, Cote CJ, et al. Balancing efficacy and safety for the use of oral sedation in dental outpatients. J Am Dent Assoc. 2006;137(4):502-513.
3. ORAQIX (lidocaine and prilocaine periodontal gel) prescribing information. http://www.dentsply.com/content/dam/dentsply/pim/manufacturer/Preventive/Anesthesia/Non_Injectable_Anesthesia/ORAQIX_lidocaine_and_prilocaine_periodontal_gel/Oraqix-PIL-EN-4099qms-en-1405.pdf. Accessed April 5, 2016.
4. The onset approach. Onpharma website. www.onpharma.com/OnsetApproach.html. Accessed April 5, 2016.
5. Moore PA, Nahouraii HS, Zovko JG, Wisniewski SR. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. Gen Dent. 2006;54(3):201-207.
6. Injury prevention & control: opioid overdose. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. www.cdc.gov/drugoverdose/. March 16, 2015. Accessed April 6, 2016.
7. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research into dental practice. J Am Dent Assoc. 2013;144(8):898-908.
8. Moore RA, Wiffen PJ, Derry S, et al. Non-prescription (OTC) oral analgesics for acute pain–an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015;11:CD010794.
9. Moore RA, Derry S, Aldington D, Wiffen PJ. Adverse events associated with single dose oral analgesics for acute postoperative pain in adults–an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015;10:CD011407.
10. Ketoprofen. Drugs.com. www.drugs.com/mtm/ketoprofen.html. Accessed April 5, 2016.