Pharmacologic management of
acute dental pain in
adolescents, adults, and older
adults
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 1
💡 The panel advises clinicians to counsel patients that they should expect
some pain and the analgesics should make their pain manageable.
A patient with breakthrough pain (pain that persists after implementing
initial pain management strategy) on the second or third day after simple
extraction(s) and surgical (day 1 is the day of the surgery) should return
to the clinic so the provider can rule out other clinical conditions
responsible for the pain (eg, alveolar osteitis or sharp alveolar ridge after
tooth extraction) before being provided a new prescription, especially if
an opioid is considered.
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 2
Link
https://www.sciencedirect.com/science/article/pii/S0002817723006724?
via%3Dihub
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 3
💡 The panel identified 2 major clinical areas that warrant recommendations
for this first iteration of the guideline: acute dental pain consecutive to
tooth extraction(s) (simple, surgical) and when managing toothache
(symptomatic pulpitis [ie, reversible or symptomatic irreversible pulpitis
with or without symptomatic apical periodontitis] or pulp necrosis with
symptomatic apical periodontitis or acute apical abscess) when no
immediate definitive dental treatment is available. Definitive dental
treatment includes, but is not limited to, pulpectomy, nonsurgical root
canal treatment, incision and drainage of abscess, and tooth extraction.
💡 long-acting (eg, bupivacaine) vs short-acting (eg, lidocaine or
mepivacaine) local anesthetics; and topical anesthetics (eg, benzocaine
at any dose and regimen
💡 Pain intensity greater than mild to moderate is uncommon 24 through 48
hours after most outpatient dental procedures. After 72 hours,
discomfort greater than moderate intensity is rare and may indicate a
postoperative infection or other complication requiring an oral
examination and appropriate treatment.
💡 Guidelines from 2019 have recommended against the use of antibiotics
for most pulpal and periapical conditions and instead have
recommended prioritizing definitive dental treatment.
💡 ANALGESICS : To minimize adverse effects, analgesic prescriptions
should follow the principle of minimum effective dosage to achieve pain
relief. The maximum daily dose of ibuprofen is 2,400 mg, naproxen
sodium is 1,100 mg, and acetaminophen is 4,000 mg
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 4
Remarks
The panel reminds users that these recommendations only apply to settings in
which definitive dental treatment is not immediately available. These interventions
are a bridge between the first consultation for acute dental pain and a second
consultation for definitive dental treatment. They are not a substitute for or a
reason to delay the immediate provision of dental treatment.
Patients should be instructed to call their health care provider if their pain fails to
lessen over time or if the referral to receive definitive dental treatment within 1
through 2 days is not feasible.
Benzocaine should be applied directly to the affected tooth and the surrounding
soft tissue (gingiva).
Result / Summary
There is a beneficial net balance favoring the use of nonopioid medications
compared with opioid medications. In particular, nonsteroidal anti-inflammatory
drugs alone or in combination with acetaminophen likely provide superior pain
relief with a more favorable safety profile than opioids.
NSAIDs alone or in combination with acetaminophen, are first-line therapy for
the management of acute dental pain after tooth extraction(s) and toothache
in adolescents, adults, and older adults.
use of long-acting local anesthetics to provide additional pain relief
postextraction or postvisit due to toothache and the use of topical anesthetic.
[REMEMBER OPIOIDS ARE ASSOCIATED WITH SEVERE SIDE EFFECTS SO I
SHOULD STAY AWAY FROM THEM] Reserve opioid medications for use
only after first-line therapy is inadequate and avoid delayed prescriptions
(just-in-case approach). If opioids are prescribed, use the lowest effective
dose, fewest tablets, and the shortest duration, which rarely exceeds 3 days.
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 5
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 6
The FDA stated in a Drug Safety Communication in 2018 that there was A new
Contraindication to the tramadol label warning against its use in children younger
than 18 years to treat pain after surgery to remove the tonsils and/or adenoids. A
new Warning to the drug labels of codeine and tramadol to recommend against
their use in adolescents between 12 and 18 years who are obese or have
conditions such as obstructive sleep apnea or severe lung disease, which may
increase the risk of serious breathing problems. A strengthened Warning to
mothers that breastfeeding is not recommended when taking codeine or tramadol
medicines due to the risk of serious adverse reactions in breastfed infants. These
can include excess sleepiness, difficulty breastfeeding, or serious breathing
problems that could result in death.
Carefully monitor the total dose of local anesthetics administered, especially
when used at the beginning of a surgical procedure or visit as a postoperative
strategy to manage acute dental pain after discharge.
Pharmacologic management of acute dental pain in adolescents, adults, and older adults 7
