Dental Care and Chronic Pain
By Louis Siegelman, DDS
Many aspects of daily life are a significant challenge for patients dealing with chronic pain conditions like complex regional pain syndrome (CRPS) or fibromyalgia. Dentistry can often be an extremely difficult environment with its inherent discomforts. Most dentists provide their care with local anesthesia as the sole means of pain control. Some dentists will also use nitrous oxide, which delivers excellent analgesia, and/or a benzodiazepine, such as diazepam (Valium) or triazolam, for relaxation. A limited number of dentists can provide more advanced multimodal therapy that is within the limits of a dental license. Such dentists may be oral surgeons, dentist anesthesiologists, or others with extensive postdoctoral training in anesthesia and pain control. These dentists with more comprehensive training can provide intravenous sedation for oral surgical, pediatric, or general dental procedures.
A comprehensive evaluation and consultation should be the first step in developing a treatment plan that suits the patient’s needs. A detailed past dental and medical history needs to be reviewed. Co-existing mental health conditions relating to panic and anxiety, depression or posttraumatic stress disorder are considerations. Coordination with other involved healthcare providers, such as pain management doctors, internists, neurologists, and surgeons, may be required. All of this information forms the basis for appropriate dental and anesthetic treatment planning.
Multimodal treatment includes a pain management strategy for pre-emptive analgesia, intra-operative comfort, physical therapy, and postoperative pain relief. The goal is to cover as many pathways of discomfort for patients during the peri-operative period as is reasonable and indicated for specific patients and procedures. Possibilities include alpha agonists, NMDA receptor antagonists, antihistamines, opiates, acetaminophen, NSAIDs, benzodiazepines, steroids, anti-emetics, local anesthetics, and sedative hypnotics. Common routes of administration may be topical, oral, intravenous, or intramuscular. Skillful use of these medications can provide a patient experience that minimizes pain, swelling, nausea, and anxiety. Talk therapy with the dentist or mental healthcare professional can be instrumental in overcoming obstacles to care.
Many patients with chronic pain face constant suffering and may be unwilling to seek professional care for their dental conditions because of fear of additional pain. They may also expect the same level of anesthesia and pain control available for minor medical procedures in the dental environment. Trained dental providers are available, but it’s important for patients to ask questions like what was the type of training the doctor received, how many patients like your self the doctor sees, and how often he/she does these procedures? Many offices and programs offer information online about their services, and treatment philosophy. Calling the office and asking questions of the dental team members is a great way to see if a doctor will be best able to serve a your individual needs.
Louis Siegelman, DDS, is a dentist anesthesiologist practicing in New York City.
RSDSA Review. Summer 2009.