dental pain management thomas franko, pharmd, bcacp assistant professor pharmacy practice wilkes...

Dental Pain ManagementDental Pain ManagementThomas Franko, PharmD, BCACPAssistant Professor Pharmacy PracticeWilkes University Luzerne County Dental SocietyJanuary 20th, 2014

ObjectivesObjectivesDescribe the pain pathway and

how it relates to dental careDevelop a care plan using opioid

medicationUnderstand the difference

between NSAIDs and TylenolSelect appropriate follow up plan

for a patient

What You ThinkWhat You Think

Available at: http://www.featurepics.com/online/Dentist-Happy-Patient-703697.aspx

Available at: http://dentainment.com/11-marketing-ideas-for-your-dental-practice/

What They ThinkWhat They Think

Available at: http://www.artofhustle.com/2013/03/10-things-i-wish-i-knew-before-working-at-art-nonprofits/

Available at: http://www.woodminster.com/Webpages/PhotoGalleries/2013/LittleShop030313.html

What is PainWhat is Pain

“An unpleasant sensory and emotional response

associated with actual or potential tissue damage or described in terms of such

damage.”

"Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, ©1994.

Current Current RecommendationsRecommendationsBased on case studies and

studies but nothing formalStructured around use of NSAIDs,

Acetaminophen and OpioidsRecommend around the clock

treatment for 48 hours post procedure then as needed◦Pain peaks 48 hours post procedure

Weinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/pain-management/1566

Burgess J, Meyers A. Post Procedural Pain Management. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at: http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10

The Pain PathwayThe Pain Pathway

Available at: http://medical-dictionary.thefreedictionary.com/nociception


Mouth

Spine

Brain

NSAIDs & Acetaminop

hen

NSAIDsNSAIDsAnalgesic, antipyretic and anti-

inflammatory propertiesNaproxen, Ibuprofen and

Diclofenac have been found to reduce pain by almost 50%

Avoid long term use due to increased risk of GI and renal issues

Caution with patients on warfarin due to increased bleeding risk


NSAID SelectionNSAID Selection

COX 1 COX 2

GIRenalPlatele

tCardiac

Ketorolac

Napro

xen

Ibup

rofe

nDic

lofe

na

c

Celecoxib

Selective COX 2 Inhibitors: Are They Safer NSAIDs. Therapeutics Initiative. 6 Feb 2001. Available at: http://www.ti.ubc.ca/pages/letter39.htm

Clinical PearlsClinical PearlsBe aware of other medications

and disease states◦GERD, PUD◦ACE inhibitors and ARBs ◦Verify a medication record prior to

adding any new medicationsPatients should take with foodBe aware of patients who are

brdiging warfarin therapy

AspirinAspirinAnti-inflammatory properties at

very high dosesIrreversible inhibition of COX

◦Other NSAIDs are transientMore profound effects on platelet

function and GI irritation◦Not the best option in many surgical

cases


AcetaminophenAcetaminophenNot an NSAID

◦No inflammatory propertiesRecommended if patient is taking

other medications contraindicated with NSAIDs

Can be used with NSAID for additional benefit◦Moore P, et al. showed Ibuprofen +

Acetaminophen worked better than either aloneMoore P, Hersh E. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions. JADA. 2013 Aug 1; (144): 898-

908. Available at: http://jada.ada.org/content/144/8/898


AcetaminophenAcetaminophenCaution with unintentional

overdose◦Acetaminophen is in EVERYTHING

Combination opioid medications Over the counter cough and cold

products

Max dose is 4 grams dailyToxic mid-metabolites can cause

hepatic failure

Perez M, et al. Acetaminophen Overdose. Medline Plus. 22 March 2013. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002598.htm

Acetaminophen OverdoseAcetaminophen Overdose

Available at: http://www.fda.gov/ohrms/dockets/ac/02/briefing/3882b1_13_mcneil-acetaminophen.htm


Mouth

Spine

BrainOpioids

NSAIDs & Acetaminop

hen

OpioidsOpioids12% of opioids prescribed come

from dentistsShould only be provided for a

short period of timeCaution in patients with history of

drug abuse and/or alcohol abuseRefer patient to pain

management, rehab or psychological services if needed



OpioidsOpioidsUse if patient does not have

adequate pain relief with NSAIDs or Acetaminophen

Opioid/NSAID or Opioid/Acetaminophen recommended over pure opioid◦Results in lower doses and less

adverse effects Codeine/Acetaminophen,

Hydrocodone/Acetaminophen, Oxycodone/Acetaminophen


Hydrocodone/Hydrocodone/AcetaminophenAcetaminophen2011 FDA requests no more than 325 mg

acetaminophen in combination Rx forms◦ Expected completion by Jan 2014◦ Not all manufacturers complied

Brand name Vicodin currently at 300 mg acetaminophen regardless of hydrocodone dose◦ PA law permits generic substitution at

pharmacies◦ Generic versions have various acetaminophen

strengths available◦ Must express desire for 300 mg formulation U.S. Food and Drug Administration. FDA limits acetaminophen in prescription combination products; requires liver toxicity warnings. 2011 Jan 13.

Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm239894.htm

Abbieve. Dosing and Administration. Appearance of AbbVie’s Reformulated Vicodin Tablets. Available at: http://www.vicodin.com/hcp/vicodin-dosing-administration

OpioidsOpioidsShort acting opioids are preferred

◦Limited duration of therapy◦Lower risk of opioid induced

respiratory depression/overdose vs. long acting

Abuse is possible; clinician responsible to prescribe appropriately ◦Policy statement from American

Dental AssociationWeinberg M, Fine J. Oral Analgesics for Acute Dental Pain. Dentistry Today. 2002 June. Available at: http://www.dentistrytoday.com/pain-management/1566

American Dental Association. Statement on the use of opioids in the treatment of dental pain. 2005 Oct. Available at: http://www.ada.org/7578.aspx

OpioidsOpioidsAdverse effects

◦Constipation, respiratory depression, euphoria, fatigue

◦Tolerance will develop to everything except constipation

Recommend use of stool softener/laxative combination to help◦Mush and push ◦Stool softeners can be used daily◦Laxatives should be used as neededLevy M. Management of Opioid-Induced Side Effects. Medscape. Available at: http://www.medscape.org/viewarticle/573016

Goodheart C, Leavitt S. Managing Opioid Induced Constipation in Ambulatory Care Patients. Pain Treatment Topics. 2006 Aug. Available at: http://pain-topics.org/pdf/Managing_Opioid-Induced_Constipation.pdf

Opioids and Chronic PainOpioids and Chronic PainPatients with existing chronic opioid

useWill need higher doses of opioids

than opioid naïve patients◦Maybe up to 2 times as much

Initiate discussion with primary care provider◦Both for collaboration as well as

determining presence of med use agreements

Requires a more in depth assessment and more care in prescribing

Gordon D. Acute Pain Management in the Opioid-Tolerant Individual. Medscape Nurses. 2008. Available at: http://www.medscape.org/viewarticle/581948

Chronic Post Procedure Chronic Post Procedure PainPainLook for other causes

◦Infection, ENT issuesConsider possible

nerve/neuropathic involvement◦Burning, numbing, electric, shooting

painReferral to pain management as

needed

Burgess J, Meyers A. Chronic Postprocedural Pain. In Pain Management in Dentistry. Medscape. 2012 Feb. Available at: http://emedicine.medscape.com/article/2066114-overview#aw2aab6c10

SummarySummaryReview the medication record

firstBe aware of drug-drug and drug

disease interactionsAround the clock therapy for 48

hours then as neededNSAIDs and Acetaminophen firstShort term use of short acting

opioids if neededCommunicate with primary care

QuestionsQuestions

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dental pain management thomas franko, pharmd, bcacp assistant professor pharmacy practice wilkes...

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