Managing Patients in Pain

Although endodontists make their best faith efforts to relieve patients’ pain as quickly as possible, they may not be able to do it fast enough. The treatment may take time to heal or, even worse, they may not be able to begin treatment right away. In either case, endodontists have a number of tools at their disposal to help make those patients more comfortable.

Delay
Sometimes it is simply not avoidable. Even in the face of agonizing pain, some patients may just have to wait for their ultimate treatment and can only be seen for an initial visit.

“Generally, what will happen is endodontists or oral surgeons or specialists––or general dentists who are making time to see patients for emergencies––sometimes [only have] enough time for an emergency visit,” Nicholas Pappas, DDS, MSD, an endodontist from The Woodlands, Texas, says. “When I make my schedule, I have certain spots for emergencies, certain spots for treatment and evaluation. We do our best to be able to accommodate any type of emergency. However, if we cannot see a patient immediately, we are trying to see that patient the following business day. So from my personal experience, if we have a patient [who is] in pain, the longest they’re waiting is a business day.”

However, some practices make every effort to deliver treatment, in an effort to help patients alleviate pain.

“It’s our practice’s philosophy that if somebody comes in in extreme pain, I’ll never turn them away without providing some type of help,” Ryan M. Walsh, DDS, MS, Diplomate of the American Board of Endodontics, and endodontist at Advanced Endodontics of Texas in Keller, says. “And most of the time that involves initiating treatment of one type or another. If it’s something where the tooth is going to be clearly extracted, most of the time I will call an oral surgeon or…the referring dentist and let them know, ‘Hey, this has to be extracted right away.’ Rather than me starting any treatment, let’s get to the endgame first. But what you have to first determine is where the pathology’s coming from––or where the pain’s coming from. Is it an endodontic infection? Is it a periodontal infection? Is it an infection at all? Is it just an inflammatory response? Is there deep decay? Is there a crack or a fracture causing it? …Those things could change the way I manage this patient and/or help determine what’s the best course of treatment, long-term, and the best course of treatment, short-term.”

Patients can present with several pain profiles, any of which call for a different pain management regimen.

“From an endodontic perspective, it is important to diagnose the source of a patient’s discomfort,” Dr Pappas says. “For example, irreversible pulpitis, nerve pain, can be manageable if you’re keeping stimuli away from it, meaning we’re not eating ice cream, we’re not drinking cold water, we’re not chewing on that side. When there’s possible necrosis, that pain might present as the dull, constant ache. Spontaneous discomfort––pain that wakes a patient up at night––that typically is not going to be something that you can manage by taking away a stimuli…. The problem with necrosis is that that pain can be constant and can’t be turned off.”

Medication
The most obvious way to treat pain is through medication. It may be something as simple as analgesics, nonsteroidal anti-inflammatory drugs, or it may be as potent as an opioid. However, Dr Walsh prefers opioids to be the last thing he prescribes.

“I try to use opioids as the last line of defense, because I think so much pain can be treated and managed without it,” he observes. “Our leading pain experts suggest that over-the-counter medications work better than opioids in controlling endodontic pain. So being able to use something that has no addictive potential, has no intoxicating or mind-altering effects, and treats endodontic pain more effectively, that’s a win-win.”

That’s not to suggest that opioids don’t have their place in reasonable pain management strategies, but given the effectiveness of over-the-counter medication, opioids tend to be the last thing suggested.

“I still prescribe opioids in cases where, if it’s an acute apical abscess or an acute infection, the pain has not been controlled with over-the-counter medications,” Dr Walsh says. “I still think there’s a time and place for opioids. I just think we have to be selective about when we use them, as opposed to using them as our first line of defense.”

No matter the protocol, it all starts with knowing the patient and his or her needs––and their history.

“Generally, when we prescribe medications, it’s usually when we’ve seen the patient and completed a proper medical history,” Dr Pappas says. “I feel it is important to see a patient and prescribe a regimen that is appropriate for their medical history. Secondly, it’s important to administer the right medication for that diagnosis. For example, if we have a case of irreversible pulpitis where the nerve is vital, an antibiotic is not necessarily effective or necessary. Now, if we diagnose the nerve as being necrotic, an antibiotic could…be indicated if there’s a sign of swelling or fever, et cetera. Generally, what I like to start with is over-the-counter medications, specifically acetaminophen and ibuprofen. [Results from] recent studies have shown that a combination of acetaminophen and ibuprofen, when taken together, can work as effectively as an opioid. So as we try to scale back our prescriptions of opioids, we’ve actually found that over-the-counter medications, when taken together, have extremely potent effects.”

Painkillers are not the only medications used in the quest for pain management. The problem is a war that must be waged on several fronts.

“I would not say antibiotics are used for pain management, per se,” Dr Walsh says. “Antibiotics are used as the name would suggest––to help reduce bacteria in the body. I think there’s a time and a place for those in endodontic treatments as well. I think of endodontic pain as having a triad of causes and a triad of treatments. In other words, we have bacteria (or we potentially have bacteria), inflammation, and pain. And so, if we can effectively manage the bacteria and the inflammation, both by treating it endodontically and by using over-the-counter [medications], most of the time the third leg of that triad, the pain, is controlled all on its own without really having to use a lot of pain medication to control it. So if we can control the sources of the pain, it usually is much more manageable.”

Bad Actors
Regrettably, endodontists must be on the lookout for drug seekers. Fortunately, it is not as prevalent a problem as it used to be.

“Drug seeking is still out there, but I’ve seen it diminish over the past 5 to 7 years, probably because of internet-based tracking software,” Dr Walsh says. “For instance, Texas has a pharmaceutical management database where we have to enter the patient’s name and other identifying information to see how frequently and how often they’ve been prescribed medications from other providers. So by going to these digital platforms, I think that kind of puts dentists in connection with physicians who may also be prescribing and when.”

Obtaining pain medication from an endodontist, Dr Pappas observes, may not be drug seekers’ first choice, because access to endodontists is not an easy route.

“Endodontic offices are generally not the first thought in a patient’s mind when experiencing dental pain,” he says. “Since most of our patients are sent via referrals, it can be fairly laborious for a drug seeker to end up in our chair. Therefore, most drug seekers are looking for easier access, such as walk-in clinics and urgent care facilities . So I personally do not see much drug seeking; however, it does happen.”

Other Tools
Medication isn’t the only tool that can be used to mitigate patients in pain.

“I'll look for pain that’s caused by a certain stimuli, meaning patients complain of pain while chewing or when drinking cold water,” Dr Pappas says. “My first step would be to try to avoid any of those stimuli. Sometimes there’s pain associated with swelling or fever, so in certain cases, cold compresses can help just relieve discomfort. But generally, there’s nothing better than getting to our office for definitive treatment as soon as possible.”

Of course, the best way to alleviate pain is to remove the source in the first place.

“We take as kind of a hallmark of our practice that if you’re in pain, you will get treated that day, not just managed,” Dr Walsh says. “One of the things we have at our disposal is local anesthetics to numb the location of the pain, which not only helps the patient feel better, but sometimes can break the pain cycle and allow them time to get more over-the-counter medications on board to effectively manage the pain when it returns. Sometimes even breaking the pain cycle, allowing the patient to get some sleep and some mental recuperation, will help in the pain management protocol.”

Ultimately, it is in the patient’s best interest to deal with their problems sooner rather than later, which can prevent a small problem from growing into a big one.

“From a practice management perspective, we’re built for emergencies,” Dr Pappas says. “So sometimes a little bit of hesitation can just delay the patient getting into the chair. Always feel free to give us a call, because definitive treatment cannot be administered until I have seen a patient. So the sooner we get involved, the sooner we can help.”

Dental pain can be torturous, and endodontists see a lot of it. Happily, they have many tools at their disposal to help patients alleviate their pain.