Analgesics: Balancing the Equation

By Steven J. Katz, D.D.S., M.S.

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“Take two aspirin and call me in the morning.” This decades-old statement was what many patients were “prescribed” by their doctor when complaining of a minor malady. In many of the cases, symptoms disappeared in a few hours or overnight, while more serious ailments were addressed by the doctor the following day. It was, perhaps, a physician’s way of eliminating minor aches and pains in favor of tending to more severe cases.

As endodontists, dealing with the discomfort our patients present with on a daily basis, we are well aware that the pain of a diseased or dying pulp is not trivial. Pain ranges from minimally bothersome to acute enough to affect daily function. In addition to definitive treatment, which we know is the most effective at relieving pain (1, 2, 3, 15), our armamentarium also includes analgesics.

It was March 6, 1899, when the Friedrich Bayer and Company patented acetylsalicylic acid for pain relief. Fifty years later, a slightly different form of the drug was introduced that was as effective, better tasting, and easier on the stomach. It’s what we know as modern day aspirin. It is worth noting that aspirin, in its most basic form, has been used for hundreds of years. Hippocrates was known to have used salicin, the bark of the white willow tree, 2,400 years ago (4). Luckily, some 2,000 years later we no longer need to chew on bark for pain relief. In fact, in addition to aspirin, we have options including acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), narcotics, steroids, and a handful of other drugs from different pharmaceutical categories, including muscle relaxers, antidepressants, and anticonvulsants.

Choosing the right analgesic can be a daunting task. With so many options and different factors driving our decisions, it can seem overwhelming. Fortunately, the literature simplifies it for us. According to several studies (7, 14) the drug of choice for the treatment of endodontic pain is an NSAID, particularly for patients who are not allergic, can tolerate them, and do not have any other issues that would contraindicate their use such as gastrointestinal disorders, hypertension, or kidney disease, or take blood thinners. NSAIDS typically are more effective than acetaminophen with or without an opioid. With many NSAID options the gold standard is still over-the-counter ibuprofen, 400-600 mg every 4-6 hours (17).

In patients unable to take NSAIDS, the choice is acetaminophen. However, due to its lack of anti-inflammatory activity, many patients find acetaminophen to be ineffective. Adding an opioid such as codeine, hydrocodone or oxycodone can increase effectiveness but also significantly increases the potential for side effects such as nausea, dizziness and drowsiness, and abuse. Acetaminophen should be avoided in patients with liver disease.

Recent studies (11-13) have shown the combination of ibuprofen and acetaminophen to cause greater analgesia than either drug alone without an increase in side effects. Buschang et. al. found that the combination of 600 mg of ibuprofen and 1000 mg of acetaminophen was more effective at pain relief than 600 mg of ibuprofen alone (10). Therefore, an effective strategy for managing emergency pain patients is the combined use of ibuprofen and acetaminophen. Although this combination is available as a single drug entity in several countries, many of these clinical trials simply administered two tablets of the analgesics at the same time (16).

Tramadol, a centrally acting, narcotic-like analgesic, may be an option for patients who cannot tolerate NSAIDS or opioids. It is available with or without acetaminophen and also is without anti-inflammatory activity. Tramadol recently was scheduled as a Class IV controlled substance drug by the DEA due to an increasing abuse potential.

Oral post-operative steroid use also has been researched (19). These studies found post-operative pain relief to be statistically superior compared to patients who did not take the steroids. Although the use of steroids is accompanied by the potential for many side effects, short term use typically is safe and effective.

The misuse and abuse of opioid pain relievers has reached epidemic proportions. As prescribers of opioid pain medications, endodontists and dentists can help keep these drugs from becoming a source of harm.

According to the National Institute on Drug Abuse it is estimated that between 26.4 million and 36 million people abuse opioids worldwide. An estimated 2.1 million people in the United States suffer from substance abuse disorders (5). In 2014, there were almost 19,000 deaths involving prescription opioids. The number of prescriptions for opioids has skyrocketed from 76 million in 1991, to 259 million in 2012. Almost 100% of the hydrocodone (Vicodin) prescriptions are from the United States (6).

In response to this epidemic both federally and on the state level, laws have been enacted to help curb this abuse epidemic. Many states now have prescription drug monitoring programs in place to allow and, in some situations, require verification before prescribing opioids. Additionally, several states have placed limits on the amount of opioids that can be prescribed. Hydrocodone also has been elevated to a schedule II drug requiring additional prescribing, recording and reporting requirements. Check with your individual state boards of pharmacy or dentistry to find your local requirements.

There are many analgesic options for our patients post-operatively. But the first course of treatment should always be clinical debridement of the diseased pulp. When choosing an analgesic it is crucial to reference a drug resource before prescribing and evaluate the patient’s medical history including allergies, intolerances and current prescription use. Selecting the simplest, most effective drug with the least amount of side effects and abuse potential should always be a priority.

A private practicing, Board-Certified endodontist in Beachwood, Ohio, Dr. Steven J. Katz graduated from The Ohio State University College of Pharmacy in 1980. After two years of retail pharmacy practice, Dr. Katz returned to The Ohio State University to earn his D.D.S. and certificate in endodontics. He is chair of the AAE’s Public and Professional Relations Committee and immediate past president of the Cleveland Dental Society. Dr. Katz can be reached at drendo324@sbcglobal.net.

References

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2. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: a systematic review. J Endod 2011;37(4):429-38.

3. Rosenberg PA, Babick PJ, Schertzer L, Leung A. The effect of occlusal reduction on pain after endodontic instrumentation. J Endod 1998;24(7):492-6.

4. Hasselgren G, Reit C. Emergency pulpotomy: pain relieving effect with and without the use of sedative dressings. J Endod 1989;15(6):254-6.

5. Page J. Take Two and Call Me in the Morning. Smithsonian Magazine. 7/13/2001.

6. McQuay HJ, Derry S, Eccleston C, Wiffen PJ, Moore R. Evidence for analgesic effect in acute pain – 50 years on. Pain. 2012;153(7):1364-7.

7. Parirokh M, Sadr S, Nakhaee N, Abbott P, Manochehrifar H. Comparison between Prescription of Regular or On-demand Ibuprofen on Postoperative Pain after Single-visit Root Canal Treatment of Teeth with Irreversible Pulpitis. J Endod 2013;40(2):151-4.

8. Arslan H, Topcuoglu HS, Aladag H. Effectiveness of tenoxicam and ibuprofen for pain prevention following endodontic therapy in comparison to placebo: a randomized double-blind clinical trial. J Oral Sci. 2011;53(2):157-61.

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11. Aminoshariae A, Kulild JC, Donaldson M, Hersh EV. Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: A systematic review of randomized controlled trials. JADA 2016:147(10);826-39.

12. Daniels SE, Goulder MA, Aspley S, Reader S. A randomised, five-parallel-group, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain 2011;152(3):632-42.

13. Mehlisch DR, Aspley S, Daniels SE, Bandy DP. Comparison of the analgesic efficacy of concurrent ibuprofen and paracetamol with ibuprofen or paracetamol alone in the management of moderate to severe acute postoperative dental pain in adolescents and adults: a randomized, double-blind, placebo-controlled, parallel-group, single-dose, two-center, modified factorial study. Clinical therapeutics. 2010;32(5):882-95.

14. Mehlisch DR, Aspley S, Daniels SE, Southerden KA, Christensen KS. A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the management of moderate to severe postoperative dental pain in adult and adolescent patients: a multicenter, two-stage, randomized, double-blind, parallel- group, placebo-controlled, factorial study. Clinical therapeutics. 2010;32(6):1033-49.

15. Elzaki W, Abubakr N, Ziada H, Ibrahim Y. Double-blind Randomized Placebo-controlled Clinical Trial of Efficiency of Nonsteroidal Anti-inflammatory Drugs in the Control of Post-endodontic Pain J Endod 2016;42(6):835-42.

16. Menhinick KA, Gutmann JL, Regan JD, Taylor SE, Buschang PH. The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J 2004;37(8):531-41.

17. Hargreaves K. A 3D Approach for Treating Acute Pain. Endodontics, ENDODONTICS: Colleagues for Excellence. Winter 2015.

18. Buccellati C, Sala A, Ballerio R, Bianchib M. Tramadol anti-inflammatory activity is not related to a direct inhibitory action on prostaglandin endoperoxide synthases. Eur J Pain 2000;4(4):413-5.

19. Mehrvarzfar P1, Abbott PV, Saghiri MA, Delvarani A, Asgar K, Lotfi M, Karamifar K, Kharazifard MJ, Khabazi H. Effects of three oral analgesics on postoperative pain following root canal preparation: a controlled clinical trial. Int Endod J 2012 Jan;45(1):76-82.

20. Krasner P, Jackson E. Management of posttreatment endodontic pain with oral dexamethasone: a double-blind study. Oral Surg Oral Med Oral Pathol 1986 Aug;62(2):187-90.

21. Glassman G, Krasner P, Morse DR, Rankow H, Lang J, Furst ML. A prospective randomized double-blind trial on efficacy of dexamethasone for endodontic interappointment pain in teeth with asymptomatic inflamed pulps. Oral Surg Oral Med Oral Pathol 1989 Jan;67(1):96-100.

22. IMS’s National Prescription Audit (NPA) & Vector One r: National (VONA).

23. International Narcotics Control Board Report 2008. United Nations Pubns. 2009. p. 20.