The pharmacological management of dental pain

ABSTRACT

Introduction

Dental pain is primarily treated by dentists and emergency medicine clinicians and may occur because of insult to the tooth or oral surgery. The dental impaction pain model (DIPM) has been widely used in clinical studies of analgesic agents and is generalizable to many other forms of pain.

Areas Covered

The authors discuss the DIPM, which has allowed for important head-to-head studies of analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and combinations. Postsurgical dental pain follows a predictable trajectory over the course of one to 3 days. Dental pain may have odontic origin or may be referred pain from other areas of the body.

Expert opinion

Pain following oral surgery has sometimes been treated with longer-than-necessary courses of opioid therapy. Postsurgical dental pain may be moderate to severe but typically resolves in a day or two after the extraction. Opioid monotherapy, rarely used in dentistry but combination therapy (opioid plus acetaminophen or an NSAID), was sometimes used as well as nonopioid analgesic monotherapy. The dental impaction pain model has been valuable in the study of analgesics but does not address all painful conditions, for example, pain with a neuropathic component.

KEYWORDS:

• Analgesia
• dental pain
• dental pain model
• opioids
• pain control

Article highlights

• Developed about 50 years ago, the dental impaction pain model (DIPM) is frequently used to evaluate analgesic efficacy because it is well defined and easy to use in clinical studies.

• Oral acetaminophen is less effective in the DIPM than NSAIDs, in particular, 400 mg of ibuprofen monotherapy. Ibuprofen is a well-established NSAID that is not highly selective and not associated with as many adverse events as more selective NSAIDs.

• Opioid monotherapy is rarely used in DIPM but combination therapy of acetaminophen plus a small amount of opioid, such as oxycodone, hydrocodone, or codeine, or an NSAID plus a small amount of opioid is sometimes used.

• Although combination products with opioids are prescribed for dental pain more by American than British dentists, the role of opioids has come under greater scrutiny because of abuse potential.

• Novel agents are being developed and tested using the DIPM as well as older established agents in novel formulations, such as a fast-dissolving acetaminophen product and a diclofenac patch.

• Dental pain may also be caused by other sources, such as infection, or referred from other parts of the body. Referred dental pain such as from the cardiovascular system requires prompt referral to specialists.

• Many patients with dental pain report to the emergency department which must be prepared to provide service to such patients although emergency facilities are often not well equipped for dental work.

This box summarizes key points contained in the article.

Declaration of interest

JV Pergolizzi is a consultant/speaker or researcher for US World Meds, BDSI, Salix, Enalare, Scilex, and Neumentum and is a principal at Native Cardio. P Magnusson has received speaker fees or grants from Abbott, Alnylam, Bayer, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Internetmedicine AB, Eli Lilly and Company, Novo Nordisk, Octopus Medical, Orion Pharma, Pfizer and Vifor Pharma. C Gharibo has received speaker fees or grants from Pernix, Daiichi Sankyo, AstraZeneca, Kaleo, Recro, Scilex, Averitas Pharma, and Celgene. G Varrassi has served as a consultant for Abbott, Dompé Farmaceutici, Melsci, Molteni, Mundipharma, Shionogi, and Takeda. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares, over the last 15 years to have received grant funding from Pfizer consumer healthcare, the maker of Advil (ibuprofen) and Anbesol (topical benzocaine products for toothache) products, from AAI pharmaceutical the original maker of Zipsor (a rapid release diclofenac product), Charleston Labs - the maker of an investigational acetaminophen plus hydrocodone plus promethazine product. They have also received funding from the NIH/NIDA as a co-principal investigator for developing and lecturing in a multidisciplinary pain science course. These checks are written to the Trustees of their university. They have also received consulting monies from Pfizer Consumer Healthcare, Bayer Pharmaceuticals (maker of Aleve (OTC naproxen sodium)) and Johnson & Johnson consumer (the maker of Tylenol (acetaminophen products)) for their expertise in reviewing data from their studies. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript has not been funded.