A 40 year old man comes to the ED with chief complaint of acute tooth pain. He has had no trauma. Select the correct statement below.
Select the correct statement regarding the use of imaging to diagnose acute dental pain.
A 50 y/o male patient presents at the emergency dental clinic with acute dental pain. He reports no history of trauma. You ask him to rate his pain on a scale of 1-10 and he says that his pain definitely is a “10”. What other information is essential for you to make a diagnosis?
A 25 y/o male presents at the hospital emergency department with acute dental pain. He denies a history of trauma and there is no apparent external swelling. However, when you look inside his mouth, you see a small area of swelling beneath tooth #18 that suggest a likely infection. What are the most appropriate next steps?
A healthy 45 y/o female patient with acute dental pain arrives at the dentist’s office a few minutes before the office is about to close and requests a prescription for oxycodone because she heard that’s the best for pain. How should you respond?
30 y/o female patient presents to the hospital emergency room with acute dental pain. Findings from your exam reveal no external swelling or evidence of trauma. When you perform an oral examination the gingiva around the painful tooth appear normal; but the patient reports severe pain when you ask her to bite down on a tongue depressor. How should you go about treating this patient?
The most useful image for evaluating a single tooth causing acute dental pain is:
You suspect that your patient with acute dental pain has a true dental abscess. Which response do you expect to see when you place a cold stimulus against the tooth in question?
Which of the conditions below would justify use of antibiotics in treating a patient with acute dental pain?
A 40 y/o female patient has come to you seeking treatment for acute dental pain. She asks you to prescribe her hydrocodone because her sister told her that there is “nothing better” for pain relief. You would prefer not to give her a prescription for opioids. What combination of oral medications would provide her with equal pain relief?
- Recommended dosing for local anesthetics
- Pros and cons of root canal therapy vs. extraction
- Considerations when seeing a patient with special needs
- Dealing with a drug-seeking patient
- Pharmacological management of pain
Local Anesthetic Dosing Recommendations
The table displayed here presents dosing recommendations for various commonly used local anesthetics. In the video, the ER physician gave Jane an injection of bupivacaine. Dosing information for bupivacaine is highlighted in the bottom row.
Pros and Cons of Root Canal vs. Extraction Dentistry Perspective
The dentist offered Jane two treatment options: Root canal therapy or extraction. This slide displays some of the pros and cons associated with root canal therapy. On the positive side, root canal therapy maintains masticatory function by keeping the tooth in the arch and preserves the bone around the tooth. Also, because the tooth will be left in place, esthetics can be maintained. On the negative side, root canals may require multiple visits to the dentist; are more expensive than having a tooth extracted; and may require that a crown be placed on the tooth following the procedure. Also, the procedure may fail or the tooth may become re-infected, thus necessitating further treatment.
- Tooth remains in arch for function
- Bone around the tooth preserved
- Esthetics maintained
- May require multiple appointments
- More expense versus extraction
- Often requires crown on tooth after procedure
- Chance of failure or re-infection
Benefits of extraction include it being less expensive than a root canal, and not requiring as many visits to the dentist. Furthermore, with the tooth having been extracted, there is no need for a crown. Drawbacks include loss of bone around the extraction site, shifting of adjacent teeth, potential loss of esthetics and reduced chewing efficiency.
- Less expense versus root canal
- Procedure takes less time
- No need for crown
- Loss of bone around extraction site
- Shifting of adjacent teeth
- Esthetic concerns
- Reduced chewing efficiency
Considerations when Seeing a Patient with Special Needs Occupational Therapy Perspective
- Poor dental hygiene was a likely contributor to Jane developing caries and ultimately acute dental pain.
- Special needs populations may require additional support to help them achieve good dental hygiene.
- Older adults with functional limitations
- Persons with chronic diseases that limit manual abilities (e.g., rheumatoid arthritis)
- Persons with upper body injuries
- Persons with intellectual disabilities
When the dentist examined Jane he noted evidence of poor dental hygiene, which Jane said was due to her dental pain making it difficult to brush and floss. However, it is possible that Jane’s regular dental hygiene habits were inadequate to prevent the development of dental caries and ultimately acute dental pain. Because Jane is generally healthy and without any known physical limitations, it is realistic to expect that she can achieve good dental hygiene with some instruction and encouragement from a dental hygienist.
There are some populations, however, for whom engaging in dental hygiene activities may be especially difficult. Some of these include older adults with functional limitations, persons with systemic diseases that are associated with decrements in manual abilities, persons with upper body injuries that limit movement, and persons with intellectual disabilities. In these cases, a trained occupational therapist could work with the dental care team to adapt behaviors and identify assistive devices that could facilitate the patient maintaining an effective routine for oral care.
Dealing with a Drug-Seeking Patient Interprofessional Perspective
Dentists’ offices and hospital emergency departments often are targeted by drug-seeking patients.
Some clues that a dental patient is seeking opioid analgesics for reasons other than pain relief include complaining of pain that cannot be substantiated by clinical exam findings or radiographic images; arriving at the dental office near the end of the day; and claiming to be pressed for time. These latter two behaviors provide the patient with a seemingly legitimate reason to avoid treatment and request an opioid prescription to “hold them over” until it is more convenient for them to be treated. Drug-seeking patients also may claim to be allergic to over-the-counter pain relievers, such as acetaminophen and ibuprofen, thus necessitating a prescription for opioids.
As with dental patients, there are multiple indicators that a patient has presented at the hospital emergency department for the purpose of obtaining opioids for non-medical use. First, the pain distribution or intensity that the patient reports may be inconsistent with the event or condition they claim caused it. Also, drug-seeking patients often make frequent trips to the emergency department because they mistakenly believe that they won’t be recognized due to the ED being a high-traffic area and encounters with ED staff tend to be very brief. Patients may become belligerent when denied an opioid prescription and refuse over-the-counter alternatives. These latter two indicators of drug-seeking behavior may occur in the dental setting, as well.
If you suspect that a patient’s motive for coming to a medical or dental health facility is to obtain opioids for reasons other than pain relief, there are a few things you can do.
After doing a thorough clinical exam including a detailed history of the present complaint, offer the patient non-opioid solutions to their pain. If the patient truly is in pain, and you explain to him or her that appropriate non-opioid analgesics will provide them with as much relief as an opioid, they likely will be willing to give them a try. Recall that Jane was satisfied with receiving a local anesthetic injection from the emergency department physician rather than a prescription for oxycodone, suggesting that she was sincere in coming to the emergency department to seek relief from her acute dental pain.
On the other hand, if the patient continues to demand that you prescribe them an opioid, you can reference the Prescription Drug Monitoring Program (or PDMP) system to determine whether the patient has received multiple opioid prescriptions from multiple health professionals.
It also is important to work with other members of the health care team. Talk to reception area staff, nurses, and medical or dental assistants to find out if the patient’s pain complaints and behaviors have been consistent throughout their visit. Also, you can consult the pharmacist at the patient’s preferred pharmacy to find out more information about the patient’s opioid prescription history. The pharmacist also can let you know if they have observed any red flags suggestive of opioid abuse when the patient fills prescriptions. More information on these red flags for pharmacists is provided in another learning module “Opioid Misuse Following Wisdom Teeth Extraction”.
If all of the information strongly suggests that your patient may be looking to obtain opioids, be honest with the patient and tell them what you have learned. Ask the patient whether they have considered quitting, and refer them to an opioid treatment program if appropriate.
Most importantly, be firm in refusing to prescribe an opioid analgesic for a patient you suspect is abusing opioids, but you also must use compassion, and let them know that you are there to help.
Drug-seeking patients can be identified using a systematic approach:
- Unsubstantiated symptoms
- End of day appointments
- Patient “pressed for time”
- Refusal of treatment
- Allergy to OTC pain relievers
- Inconsistent symptoms
- Multiple ED visits
- Ask for opioid by name
- Refusal of OTC analgesics
When drug-seeking is suspected, gather additional evidence before confronting the patient.
- Suggest non-opioid solutions.
- Check the PDMP
- Work with the Health Care Team
If your patient is a drug-seeker, be compassionate but firm.
- Be honest and offer to help.
Pharmacological Management of Pain Pharmacy Perspective
When prescribing pain medications to patients, it is crucial to counsel them on safe practices. First, patients must take their medication(s) only as prescribed. If the patient is experiencing breakthrough pain, or more severe pain overall, the patient should contact their health care provider or prescriber. Second medications should also not be mixed with alcohol or other controlled substances. Additional pertinent drug-drug interactions will be reviewed on the next slide. Third, patients should never share their medications and should always store them in a safe place. Unlike other medications, analgesic drugs should not be stored in a traditional pill box. These medications are best stored under a lock and key within a lockbox. Lastly, patients should always keep their medications out of the reach of children.
Drug-drug interactions are important considerations when prescribing pain medications. In general, drug-drug interactions can be categorized as either pharmacokinetic interactions or pharmacodynamic interactions.
- Patients need to be educated about safe medication use.
- Take only as prescribed
- Do not concomitantly use alcohol or other controlled substances
- Do not share medications
- Store in safe container such as lockbox
- Keep out of reach of children
Drug-drug interactions are important considerations when prescribing pain medications.
Drug-Drug Interactions: Pharmacokinetic
Pharmacokinetic interactions are interactions that directly influence the serum levels of drugs. These interactions can effect several processes, specifically absorption, distribution, metabolism and/or excretion of the drug. Effects on these processes can result in either treatment failure or toxicity.
- Directly influence serum levels of drugs
- Result in treatment failure or toxicity
Examples of Pharmacokinetic Interactions
Both non-opioid and opioid analgesics can be involved in pharmacokinetic interactions with other drugs. To date, there are few significant pharmacokinetic interactions for non-opioid pain medications. One notable example, however, involves the interaction of acetaminophen with warfarin. When these two drugs are taken together, warfarin serum levels can be increased leading to supratherapeutic internal normalized ratios or INRs.
As previously mentioned, pharmacokinetic interactions also exist with opioid medications. Oxycodone, tramadol, and fentanyl patches are at least partially metabolized by the cytochrome P450 enzyme, CYP3A4. CYP3A4 is the most prominent liver enzyme, and there are many drugs that can either induce or inhibit its activity. CYP3A4 inducers include: anticonvulsants such as carbamazepine, phenytoin, and oxcarbazepine; barbiturates such as phenobarbital, St. John’s wort, and the bactericidals rifampicin and rifabutin. CYP 3A4 inhibitors include: some macrolide antibiotics such as clarithromycin; some azole antifungals such as ketoconazole, itraconazole, posaconazole and voriconazole; and HIV protease inhibitors such as ritonavir.
Drug-Drug Interactions: Pharmacodynamic
Pharmacodynamic interactions directly influence a medication’s ability to induce a change in the body and can be divided into three subgroups: (1) direct effect on receptor function; (2) interference with a biological or physiological control process; and (3) additive or opposed pharmacological effect. These types of interactions are important considerations because they can increase the likelihood or severity of adverse effects associated with the medication.
- Directly influence actions of drug on the body
- Direct effect on receptor function
- Interference with biological or physiological control process
- Additive/opposed pharmacological effect
- Increased risk of adverse effects
Examples of Pharmacodynamic Interactions
Several drugs have pharmacodynamic interactions with non-opioid analgesics. For example, alcohol can potentiate the risk of hepatotoxicity associated with acetaminophen. Oral NSAIDs when given in conjunction with aspirin or other anticoagulants can increase a patient’s risk for GI bleeding. Likewise, simultaneous administration of oral NSAIDS with loop diuretics can increase the risk for acute kidney injury. In regard to pharmacodynamic interactions involving opioids, these medications should not be used in conjunction with alcohol or other sedating agents because their combined use can increase the risk of sedation and of opioid induced respiratory events.
Pharmacists play an important role in pain management.
Because pharmacists are trained in the safe and appropriate use of medication, they are integral members of the health care team when treating a patient with pain. For example, pharmacists can assist with reconciling the medications of patients who have experienced significant changes in care. Pharmacists also should be consulted when treating a patient with refractory pain that is unresponsive to traditional agents. In this case, the pharmacist can shed light on potential pitfalls (like drug-interactions) that may be interfering with the patient’s therapeutic plan, as well as offer additional recommendations for pain management. Finally, the pharmacist plays a critical role in answering patient or family medication questions or in providing more detailed education on medication use when necessary.
- Counseling specific patient populations:
- Patients undergoing significant care transitions
- Patients with refractory pain
- Providing answers to patient and family questions
Pharmacists conduct comprehensive medication reviews.
A pharmacist’s involvement in patient care typically begins by conducting a comprehensive medication review. This review includes both a chart review and patient and family interviews. A comprehensive medication review is similar to a physician or nurse practitioner’s medical history interview. The goal of the review is to determine the patient’s medication history and the impact of medications on the patient’s current status.
- 2 Components
- Chart review
- Patient and family interviews
- Comparable to medical history interview
- Determine patient’s medication history
- Assess impact of medications on current status
Complementary symptom assessments enable pharmacists to provide recommendations to providers.
The pharmacist will then complete a complementary symptom assessment to provide recommendations to the primary provider or team, and/or provide education to the patient and their family and answer any questions. In most states pharmacists cannot prescribe analgesic medications, thus necessitating orders from the primary provider. However in some states, such as North Carolina and California, pharmacists are permitted to write orders for pain medications independent of the primary provider or team.
Importantly, pharmacists practicing in pain management educate patients and families on the appropriate use of Intranasal naloxone. Naloxone is appropriate for patients with either a current or past history of substance misuse or who are at a higher risk of an opioid induced event (such as patients who also are being treated with benzodiazepines).
Overall Purpose of the Resource
The overall purpose of this educational resource is to introduce to medical, dental, and other health science students to key principles in evaluating and managing acute pain of dental origin. The importance of recognizing and subsequently treating odontogenic causes of acute orofacial pain is described below in the “Conceptual Background” section. This resource will contribute to the acquisition of important knowledge,
attitudes and skills relevant to all health Box 1. Potential Impact of Case Education professionals who treat patients with acute dental pain. This instructional module, Acute Dental Pain: A Young Woman Presents to the Emergency Room with Pain in the Lower Jaw, emphasizes key components of the history and physical examination for a patient presenting with acute odontogenic pain in both a hospital emergency department setting and in a dental care facility. Box 1 displays the specific knowledge, attitudes and skills that are targeted by the module.
Potential Impact of Case Education
- Improve knowledge: Reduce unnecessary prescriptions for antibiotics and advanced imaging and improve provider awareness of the modalities in managing acute dental pain.
- Change attitudes: Appreciate the role of the dentist and the physician or nurse practitioner in facilitating the management of acute dental pain.
- Gain skills: Improve treatment outcomes for patients with acute dental pain by implementing appropriate management and referral strategies.
Objectives are categorized as being universal (i.e., relevant to health professional learners from all professions) or specific (i.e., address issues that are most likely to be encountered within a given profession). Specific objectives are further subdivided into traditional and interprofessional objectives. Traditional objectives address issues that are relevant to the learner’s interactions with and treatment of their patients specific to their profession. Interprofessional objectives introduce learners to the importance of interprofessional communication and collaboration.
- Describe the role of the emergency department when treating a patient with acute dental pain.
- Identify the key elements of the history and physical examination that support the presence of acute dental pain.
- List the indications for ordering basic and/or advanced imaging and where such imaging should be performed.
- Name two effective pharmacological palliative treatments for patients with acute dental pain.
- Identify when antibiotics are indicated for patients with acute dental pain
- Identify the presence of acute dental pain with or without infection by performing a targeted physical exam.
- Recognize the value and limitations of advanced imaging in the diagnosis of acute dental pain
- Identify when the prescription of antibiotics for acute dental pain is indicated.
- Identify when acute orofacial pain requires referral to a dental provider.
- Describe the specialized tests used for diagnosing acute dental pain in the dental setting that hospital emergency departments typically are not equipped to perform.
- Describe proper diagnosis and management of patients experiencing pain with or without infection
- Discriminate between a tooth with reversible versus irreversible pulpitis and describe how this determination can be made.
- Describe the characteristics of a true dental abscess that requires antibiotic therapy.
Describe the role of the nurse/physician in treating patients with acute dental pain in a non-dental setting and develop an appreciation for treatment limitations.
Dental caries is the most common infection in the United States, with approximately four out of five individuals having developed at least one cavity by the age of 34 years . Given the prevalence of this disease process, access to dental care is a major public health concern. By the end of 2016, an estimated 74 million Americans were without dental insurance , and more than 51 million living in dental care health professional shortage areas .
Taken together, lack of dental coverage and limited access to dental professionals have contributed to hospital emergency departments becoming the point of care for individuals seeking treatment for dental complaints. Data from the 2012 Nationwide Emergency Department Sample (NEDS) showed that 1.62% of hospital emergency department (ED) visits were due to dental complaints, with the primary payers for the majority of these visits being either self-pay (36.6%) or Medicaid (35.0%) .
In sum, dental ED visits cost the U.S. health care system approximately $1.6 billion dollars, or about $750 per visit . Because hospital EDs typically are not designed to provide the routine dental care and procedures many patients require, dental ED visits are an inefficient usage of resources.
This module focuses on acute dental pain specifically because affected individuals may not have immediate access to dental care. Accordingly, patients often times seek relief for their orofacial pain in an urgent care or emergency room setting. The goal of Acute Dental Pain: A Young Woman Presents to the Emergency Room with Pain in the Lower Jaw is to present key components of the history and physical examination for a patient presenting with acute odontogenic pain, discuss the value and limitations of advanced imaging in the diagnosis of acute dental pain and why narcotic prescriptions and antibiotics are not the treatment of choice in many scenarios, familiarize students with the definitive dental management of common issues, and discuss strategies for referral to minimize unnecessary return visits.
Practical Implementation Advice
The module is designed to optimize learning flexibility. That is, students can complete it independently in approximately 45 minutes depending on whether students view the supplemental materials. If the student wishes to delve into some of the additional linked resources, additional time will be required and can be undertaken at the student’s leisure.
The student disciplines that are targeted specifically are medicine (or nurse practitioner
[NP]/physician assistant [PA] students), dental medicine, and pharmacy.
Typically, the module should be embedded into courses in the 3rd year of the dental school curriculum or the 4th year of the medical school curriculum, either during or upon completion of emergency dental medicine or emergency medicine training.
- Medical Students: Year 4
- Nurse Practitioner Students: Years 2-3
- Dental Students: Year 3
When implemented in an Interprofessional Education (IPE) setting, we suggest introducing the case to groups of students by providing an overview of pain physiology and the basics of Interprofessional Practice (IPP) relevant to the health professional students included.
Materials to supplement the information presented in Acute Dental Pain are included at the end of the case. Four topics are addressed:
- Recommended dosing for local anesthetics
- Pros and cons of root canal therapy vs. extraction
- Considerations when seeing a patient with special needs
- Dealing with a drug-seeking patient
- Bate, D. The high cost of being broke: Dental care. WHYY Aug 9 2018: https://whyy.org/segments/highcost-of-being-broke-dental-care/. Accessed Aug 22 2018.
- Dolce MC, Parker JL, Marshall C, Riedy CA, Simon LE, Barrow J, Ramos CR, DaSilva JD. Expanding collaborative boundaries in nursing education and practice: The nurse practitioner-dentist model for primary care. J Prof Nurs 2017 Nov 1;33(6):405-409.
- Garvin L. FDA to issue pain management guidelines. ADA News Aug 23 2018: https://www.ada.org/en/publications/ada-news/2018-archive/august/fda-to…. Accessed Aug 24 2018.
- Krisberg K. Open wide: Medical education with real teeth. AAMC News 2018: https://news.aamc.org/medical-education/article/open-wide-medical-educa…. Accessed Aug 8 2018.
- McCormick AP, Abubaker AO, Laskin DM, Gonzales MS, Garland S. Reducing the burden of dental patients on the busy hospital emergency department. J Oral Maxillofac Surg2013;71(3):475-478.
- Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain managementafter third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc 2013 Aug 1;144(8):898-908.
- Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion. Oral Health Basics. October 8, 2015; www.cdc.gov/oralhealth/basics/index.html. Accessed January 18, 2018.
- National Association of Dental Plans (NADP). Dental Benefits Basics. 2017; http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx. Accessed January 19, 2018
- Kaiser Family Foundation. Dental Care Health Professional Shortage Areas (HPSAs). December 31, 2016. https://www.kff.org/other/state-indicator/dental-care-health-profession…. Accessed January 19, 2018.
- Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. Health Policy Institute Research Brief. American Dental Association. April 2015. Available from: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBr…. ashx