Donald R. Nixdorf, D.D.S., M.S.
TMD & Orofacial Pain Clinic
Department of Diagnostic & Biological Sciences
University of Minnesota, School of Dentistry
6-3 Moos Tower
515 Delaware Street SE
Minneapolis, MN 55455
612-626-0140
http://www.dentistry.umn.edu/facultystaff/faculty_bios/Nixdorf,_Donald/home.html
Transcript: Aspects of managing dental procedures
Looking at different ways to be able to help people that have trigeminal neuropathic pain such as trigeminal neuralgia or deafferentation pain of the trigeminal region. There’s conceptually several different ways to look at it.
First is to try and maximize and improve baseline management of the disorder to begin with. So in other words, someone who is well controlled moving into a dental procedure is likely to do better through a dental procedure and after a dental procedure as opposed to someone who is not well controlled going in.
Another aspect to it is managing anxiety and worry associated with dental procedures. It’s very obvious that people who have neuropathic pain and are suffering a lot from it that are going to be worried about having it aggravated, made worse associated with dental procedures. Sometimes that causes them to be anxious and that anxiousness actually turns on the body’s own system of releasing hormones that actually activates pain centers that makes pain easier to be felt and more often to be felt. So if you can control anxiety, both from a counseling point of view as well as from a medication point of view we think that can decrease the risk of having a flare up during a dental procedure.
The third aspect to it is a concept called pre-emptive analgesia. That’s the idea of intervening before the dental procedure with pharmacologic techniques to try and make the dental procedure and the time afterward try not to be as painful as it might have been if you did not intervene.
Right now there is evidence that looks at three different mechanisms. Dentists typically use local anesthetics and that’s one of the reasons why the outcomes associated are fairly good. Specifically with trigeminal neuropathic pain patients including trigeminal neuralgia patients, I recommend looking at really profound local anesthetics. That would be using local block as well as infiltration, sometimes even intra-osseous or injection of the local anesthetic into the bone, into and around the tooth, to make it really numb so the patient doesn’t feel anything.
The other two aspects of pre-emptive analgesia, one of them that is probably the best studied is associated with NSAID medications. Things like Ibuprofen, Naproxen, Advil, those types of drugs and that’s started an hour or two ahead of time at a large dose such as an anti-inflammatory dose. If you are looking at Ibuprofen, it would be 800 milligrams. The idea is to take it before you start the procedure and then continue taking it on regular clock until after the procedure. What I mean by after, I typically will prescribe something like that for a ten day cycle. So you can start before, you can start on a high dose and I keep going every eight hours, three times a day, for ten days total.
The third type of medication which we don’t have a lot of evidence to verbally state that it helps for dental care and helps through taking an oral direction but there is evidence it shows that it helps from medicine, general surgery point of view if given in IV and that is opioid analgesics. The controversial part of that is I personally like using extended release options which give medications both immediately and over time which then allows the constant level of medication to be in the blood and therefore pain is not going up and down and again with this one, I have patients take it an hour or two before a dental procedure and then around the clock for about seven days afterwards. The idea is to trim down the sensitivity aspect of the person’s pain aspect so that when they have a dental procedure, their pain system doesn’t get as excited and they don’t experience as much pain.