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 estrategy for pre-emptive analgesia, intra-operative comfort,
physical therapy, and postoperative pain relief. The goal is to cover
as many pathways of discomfort for patints 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.
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