Diagnosis

Generalized severe chronic periodontitis (Armitage 1999).

Treatment Plan

The initial treatment plan for the patient included smoking cessation counseling, home care education, and extraction of teeth #1, #3, #14, #16, #18, #29, and #30. Postoperative pain was effectively managed with a combination of 400 mg ibuprofen and 500 mg acetaminophen every six hours. Following scaling and root planing therapy, transitional removable partial dentures were fabricated.

Discussion

The relief of oral pain is one of the primary obligations of a dental professional. Dental diseases and the treatment of dental diseases both have the potential to cause pain. Most dental pain has an inflammatory component. The most effective analgesics used for dental pain have anti‐inflammatory properties (see Table 5.1.1).

Nonsteroidal anti‐inflammatory drugs (NSAIDs) are the most common agents used to relieve oral pain, with both prescription (Rx) and over the counter (OTC) products available. NSAIDs have analgesic, anti‐inflammatory, antipyretic, and antiplatelet properties (see Table 5.1.2). The principle mechanism of action of NSAIDs is the competitive, reversible inhibition of the conversion of arachidonic acid to prostaglandins by cyclooxygenase (COX) enzymes. There are two isoforms of COX enzymes, COX‐1, and COX‐2. Arachidonic acid is converted to thromboxane A2 by the COX‐1 enzyme, leading to platelet aggregation. Arachidonic acid is converted to prostaglandins by the enzyme COX‐2, leading to inflammation and pain. There are several NSAID products, each with subtle differences in their abilities to block COX‐1 and COX‐2. These differences account for the products variability in potency, dosing, adverse drug reactions, and clinical therapeutic indications. NSAIDs, as a class, are known as having the side effects of gastrointestinal (GI) bleeding, altered renal (kidney) effects, an aggravation of asthma in susceptible individuals, and antiplatelet effects that may cause postoperative bleeding. Newer NSAIDs have been developed that are selective COX‐2 inhibitors; however they have been implicated as having increased risk of cardiovascular events (Laskarides 2016).

NSAIDs have the potential of drug interactions due to their effects on the COX enzymes (see Table 5.1.3). NSAIDs may decrease the hypotensive effects of certain antihypertensive medications (beta‐blockers, angiotension converting enzyme inhibitors, and diuretics). NSAIDs may increase the hypoglycemic effects of the sulfonylurea class of oral antidiabetic agents. NSAIDs may also increase the blood levels of the psychiatric medication lithium, leading to potential lithium toxicity.

The most commonly used NSAIDs are ibuprofen and naproxen sodium. Ibuprofen is available in both OTC and RX formulations, with common dosing of 200–600 mg every six hours. Naproxen sodium is available in both OTC and RX formulations with common dosing of 220–550 mg every eight hours.

Aspirin is a salicylate nonnarcotic analgesic with analgesic, anti‐inflammatory, antipyretic, and antiplatelet properties. Aspirin irreversibly blocks both COX‐1 and COX‐2 and is known as having greater antiplatelet activity than NSAIDs. Low‐dose aspirin (81 mg per day) is frequently recommended by physicians for prevention of stroke or heart attack due to its antiplatelet properties. The usual analgesic dose of aspirin is 325–650 mg every six hours. The prescription drug diflunisal is a salicylate used at a dose of 500 mg every 12 hours. In addition to the common side effects of GI bleeding, aggravation of asthma, altered renal function, and antiplatelet effects, salicylates have the unique side effects of vertigo, tinnitus, and ototoxicity. The risk of ototoxicity is increased when salicylates are used along with other ototoxic medications such as loop diuretics (Weinberg et al. 2013).

Salicylates share the same potential for drug side effects as other cyclooxygenase blocking agents. Salicylates have the side effect of displacing the anti‐Vitamin K blood thinner warfarin from its plasma protein binding sites, increasing therapeutic blood levels of active warfarin. Aspirin should be used with great caution in patients taking therapeutic levels of warfarin due to a significant risk of postoperative bleeding related to both the increased blood levels warfarin and the antiplatelet actions of aspirin (see Table 5.1.4).

Acetaminophen is a drug that does not fall into a specific category. It is not a salicylate; it is not an NSAID; it does not block COX. The exact mechanism of action of acetaminophen is not known. Theories of its action include a possible inactivation of COX enzymes, inhibition of nitric acid production, or blockade of prostaglandin (Guggenheimer and Moore 2011; Moore and Hersh 2013; Laskarides 2016). Acetaminophen has analgesic and antipyretic properties, but does not have anti‐inflammatory or antiplatelet properties. Its acute pain relief properties are less than that achieved by NSAIDs. Acetaminophen is commonly dosed at 325–650 mg every six hours, with occasional dosing of 1000 mg every six hours. It is generally considered safe for most patients, including children and pregnant women, when used as directed. Unlike salicylates or NSAIDs, it is not associated with GI bleeding and does not inhibit platelet aggregation. Acetaminophen is hepatotoxic, causing severe liver damage (possibly fatal) when used at excessive dosage, when used along with other hepatoxic drugs, or when used by individuals who consume three or more alcoholic beverages daily (Guggenheimer and Moore 2011). The maximum daily dose of acetaminophen as recommended by the US Food and Drug Administration (FDA) is 4000 mg per day. Recently, a leading drug manufacturer of acetaminophen changed its packaging instructions to reflect a maximum daily dose of 3000 mg per day due to concerns over liver toxicity (Moore and Hersh 2013).

The risk of a patient taking an inappropriate dose of acetaminophen and suffering a hepatic event is complicated by the fact that multiple OTC products containing acetaminophen are marketed for a variety of symptoms (cough and cold products, migraine pain products, arthritis pain products, etc.). The inclusion of acetaminophen as an ingredient is frequently listed in small print on the back the product packaging. Many patients do not read ingredient labeling and assume that the product is safe because it is available OTC. Patients may be unaware of the potential of duplicating medication if they take acetaminophen for relief of dental pain (see Table 5.1.5). The prudent clinician regularly asks his patients about all medications (RX and OTC) they are taking in an attempt to avoid inappropriate use.

Combination analgesic therapy is frequently used in the management of postoperative oral pain. The use of ibuprofen at a dose of 200–600 mg combined with acetaminophen at a dose of 500–1000 mg every six hours has been evaluated in multiple pain studies. The combination has been shown to provide pain relief that is superior to that provided by either product alone and at lower doses (Ong et al. 2010; Moore and Hersh 2013). Ibuprofen‐acetaminophen combination therapy has also been demonstrated to provide pain relief comparable to that provided by common acetaminophen‐opioid combinations (acetaminophen and codeine, acetaminophen and hydrocodone, acetaminophen and oxycodone) for moderate to severe pain without the inherent risks of opioid therapy (Ong et al. 2010; Moore and Hersh 2013).