|Endodontic Spotlight - Spring 2014 (Volume 3, Issue 2)
I hope everyone has had a chance to enjoy our nice weather! Our theme for this issue is my personal pharmacological strategies. We start with a discussion on pain management, followed by antibiotics, and finally on anxiolytics. Obviously these are general guidelines and the specific medical history of each patient must be considered before you prescribe these or any other medications.
Spotlight on Postoperative Pain Management
Ibuprofen has been shown in high level systematic reviews to be a very effective and safe analgesic for postoperative pain and is my first choice medication for pain management. I advise my patients to take 600 mg four times a day as needed for pain. I will give them the option of going up to 800 mg, but emphasize to them that that is the maximum safe dose and 600 mg is usually effective for most people. If I expect significant postoperative pain, I will consider having them take the ibuprofen by the clock for at least three days after the procedure. I have found that most patients who call asking for another prescription because "the ibuprofen is not working," usually are taking too low of a dose.
If the pain is more severe than can be managed with ibuprofen alone, I will use a combination therapy by adding acetaminophen and/or a narcotic such as hydrocodone or oxycodone. Typically whenever I work on a patient I will give them a prescription of hydrocodone 7.5 mg / acetaminophen 325 mg (Vicodin) with the instructions to use ibuprofen first but add this prescription if necessary. This three drug combination is usually adequate for managing pain is most patients. Other options include adding just acetaminophen, just oxycodone, or oxycodone 5 mg / acetaminophen 325 mg (Percocet), depending on the specific medical history.
A couple of non-pharmacologic strategies that we also recommend include having the patient applying ice on the outside of their face and holding warm water in the mouth right next to the tooth or swelling. However, do NOT have the patient apply heat to the outside of their face, as that may increase the swelling. Although these recommendations are not evidenced based, we have found these to be effective strategies for most people.
Spotlight on Antibiotics
Penicillin VK is generally considered the first choice antibiotic for dental infections, as it covers the most appropriate spectrum for the most common bacteria. I prescribe PenVK 500 mg four times a day for about a week, sometimes having them take two tablets immediately as a loading dose. This antibiotic is usually effective in most situations.
If I need to change antibiotics, I will switch to clindamycin 300 mg four times a day. Usually antibiotics take about 24-48 hours to start working so I would be sure to give the penicillin a chance before I switch, and I would try to avoid switching multiple times. In addition, only definitive treatment will solve an endodontic problem so the patient may still have some discomfort even with antibiotics.
Antibiotics are typically indicated if the patient presents with swelling, fever, lymph node involvement, or other signs of a spreading or systemic infections. In addition, if the patient has a compromised immune system, I might be more likely to prescribe one. However, antibiotics are not indicated for most patients and consideration should be given before they are prescribed.
Spotlight on Anxiolytics
Anxiolytics can help an anxious patient have a good experience in the dental office. My primary sedative is triazolam. I will write a prescription for triazolam 0.125 mg with the instructions to take two tablets one hour before the appointment. In addition, if they will have a hard time sleeping the night before due to anxiety, I would give them take one additional tablet to take the night before the appointment. The patient needs to have an escort to drive them to and from the appointment. I find that triazolam is a very effective sedative and can sometimes allow even the most anxious of patients to fall to sleep during the appointment!
Nitrous oxide is my second choice sedative for patients who decline the triazolam or prefer not to reschedule for treatment. Nitrous can also be given as a supplement to triazolam, though I find that triazolam alone is usually effective. Nitrous is also quite safe for most patients and has the advantage of being very reversible when stopped, so the patient can drive home alone.
Endodontic Spotlight is published quarterly by Steven C. Kwan, D.D.S., M.S.D.
Dr. Kwan practices at 6715 Fort Dent Way, Tukwila WA 98188
206-248-3330; 206-431-1158 (fax); www.seattle-endodontics.com
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