Takeaways: New guideline on acute dental pain management

Imagine reclining in the dentist’s chair, the bright light overhead, and that all-too-familiar pinch of anxiety as you prepare for what’s next. Dental pain, whether from a procedure or an unexpected toothache, can be more than just uncomfortable—it can be debilitating. But the landscape of pain management in dentistry is changing, with a focus not just on alleviating pain but on doing so in a way that aligns with each patient's preferences.

This shift is outlined in the new American Dental Association (ADA) published guideline on pain management, which aims to personalize pain management strategies while mitigating risks, especially in vulnerable populations like adolescents.

In a conversation with Penn Today, Alonso Carrasco-Labra of the School of Dental Medicine explains how he and his colleagues at the Penn Center for Integrative Global Oral Health, ADA, and the University of Pittsburgh approached the development of these new recommendations, what the implications are for patients, and why they differ from previous guidelines.

What the new guideline recommends

Carrasco-Labra, an associate professor in the Department of Preventive & Restorative Sciences, explains that, in short, the new guideline recommends clinicians use nonsteroidal anti-inflammatory drugs (NSAID) taken alone or with acetaminophen as the first line of treatment for managing short-term dental pain in adolescents, adults, and older adults.

“For managing acute postoperative dental pain in adolescents, adults, and older adults after surgical tooth extractions, the recommended approach is to use nonopioid analgesics as the primary treatment instead of opioid analgesics,” says Carrasco-Labra. “This is due to their effectiveness and lower risk profile. The initial management should start with an NSAID, such as ibuprofen or naproxen, alone or combined with acetaminophen for enhanced pain relief.”

Carrasco-Labra says that in cases where pain control is not sufficient with NSAIDs alone, a combination of acetaminophen with a low-dose opioid may be considered, but this is generally reserved for instances where other treatments have failed and should be limited to the shortest duration necessary, typically not exceeding three days.

“Clinicians are also encouraged to have conversations with their patients where they inform them to anticipate some level of discomfort and explain what it will feel like,” Carrasco-Labra says. “The prescribed analgesics should make the pain manageable but also align with what the patient seeks in terms of associated risks. If they’re coming in for a procedure that will likely result in some mild discomfort, they need to be in the driver’s seat in determining the appropriate pain-management strategy.”

Developing the recommendations

Carrasco-Labra’s background in evidence-based medicine and guideline development helped guide the team to produce the first evidence-based guideline in dentistry that addresses acute pain management in this context. He says, “We conducted a primary study to characterize patients’ values and preferences regarding acute dental pain management strategies across different levels of pain intensity.”

He says this study focused on understanding the importance patients place on various desirable and undesirable outcomes associated with pain-management strategies. Their findings were synthesized into a values-and-preference statement, which was then used to inform the development of recommendations by a panel that included a patient partner.

“The key distinction here is that our new guideline follows the methodological standards set forth by the National Academy of Sciences, Engineering, and Medicine for the creation of guidelines addressing acute pain,” Carrasco-Labra says. “The document, “Framing Opioid Prescribing Guidelines for Acute Pain,” identified acute dental pain among the key clinical areas that can benefit from creating evidence-based recommendations to inform patient care.”

What’s next

Carrasco-Labra says that the currency of these guidelines depends on the emergence of new evidence or the introduction of new analgesic options. Typically, guidelines like these might remain valid for three to five years, but they could be updated sooner if significant innovations or research findings emerge that could impact the direction or the strength of recommendations.

Looking ahead, Carrasco-Labra says, future research will likely focus on the global application and local adaptation of such guidelines, ensuring they can be effectively implemented in diverse health care settings worldwide. This includes exploring methodologies for creating guidelines that are both universally applicable and adaptable to specific local needs and contexts.

This project was supported by the U.S. Food and Drug Administration of the United States Department of Health and Human Services (Grant U01FD007151)