oral analgesics for acute dental pain

Question 1

case

Answer 1

1) 60 year old female for removal of carious #19
2) biting force exacerbates pain
3) caries control, root canal, post and core, and full veneer crown
- no periodontal disease, but the tooth probes 3,3,12 on the facial, and 4,3,4 on the lingual
4) cracked tooth syndrome (ASAI)
5) surgical extraction #19
—
1) full thickness mucoperiosteal flap
2) bone is removed from buccal, tooth sectioned
3) tooth is delivered
4) slight bleeding of trabecular bone, sutures to close soft tissue

Question 2

how to manage post operative analgesia

Answer 2

1) prescribe

Question 3

Would you use prescription medication or OTC

Answer 3

1) prescription due to FTMP and removal of bone
2) Ibuprofen (peripherally acting)
- but might decrease healing because it is anti-inflammatory
3) or acetaminophen
4) or a combo

Question 4

how long will the pain last

Answer 4

1) 3-5 days (peak swelling)
- need to prescribe long enough
2) day 6-7 (adaptive)
- progressive wound healing, less pain

Question 5

if initial analgesic is insufficient?

Answer 5

1) could up the acetaminophen dose to max
2) or introduce ibuprofen as a combo
- at the same time every 4-6 hrs (600mg ibuprofen and 300mg-500mg Tylenol)
3) combination opioid drug?

Question 6

case 2

Answer 6

1) denture treatment plan, aortic stenosis, AF, and asthma
2) uses coumadin and inhaler
3) chronic adult periodontitis (class II and III mobility) and 50% bone loss in both maxilla and mandible
4) ASA II
5) extraction of upper right posterior teeth
—
1) sockets curetted, irrigated, suctions, moderate bleeding, mild pain
2) apply pressure with gauze, bp 150/85, tea bags with gauze and biting pressure

Question 7

post operative plain

Answer 7

1) he is on coumadin so use acetaminophen initially
- ibuprofen with coumadin is contraindicated (ibuprofen also contributes to hypertension)
2) what about a COX-2
- NO!!! because he has a cardiac history
- cardiothrombotic events

Question 8

if the pain is getting severe?

Answer 8

two strategies
1) more potent opioid
2) APAP/hydrocodone

Question 9

case 3

Answer 9

1) RCT treated #21 and #28, want implants
2) diversion of opioids, has addiction history and withdrawal
- ibuprofen and tylenol don’t work
2) he is taking Wellbutrin, creatine, and BUN i elevated
- one pack per day
4) ASA II
5 )extract in one visit and use prilocaine due to drug dependency and difficulty of numbing
—
1) bilateral prilocaine IA blocks, FTMF, teeth troughed, delivered
2) minimal bleeding due to ankylosis and lack of trabecular bone
3) sockets curetted, irrigated, and suctions, sutures

Question 10

how would you manage perioperative pain

Answer 10

1) marcaine (logner lasting)

Question 11

patient doesnt accept tylenol (650mg) for post operative pain

Answer 11

1) check CURES for first time prescription
2) prescribe hydrocodone
- low dose, short duration (codeine is chosen first for normal people tho)
- 0.75x morphine (but 7.5x as strong as codeine)
- semi synthetics work better than codeine
- then can go to oxycodone if you need something stronger
- you can write refills for schedule III, not II

Question 12

initial plan fails, what about dilaudid

Answer 12

1) given IV in hospital for acute pain
2) call physician and tell him the story and have them manage the pain