What is the most effective long-term pain management strategy for chronic severe dental pain?

From the Guidelines

For chronic severe tooth pain, the best long-term solution is addressing the underlying dental problem through proper dental treatment rather than relying on pain medications, as recommended by the most recent guidelines 1. The management of chronic pain associated with temporomandibular disorders, which can be related to tooth pain, suggests that cognitive behavioral therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care are strongly recommended 1. While awaiting dental care, over-the-counter pain management can include alternating ibuprofen (400-600mg every 6 hours, not exceeding 3200mg daily) with acetaminophen (500-1000mg every 6 hours, not exceeding 3000mg daily), as suggested by guidelines for chronic pain management 1. Some key points to consider for managing chronic severe tooth pain include:

• Avoiding very hot, cold, or sweet foods and beverages
• Maintaining good oral hygiene
• Using warm salt water rinses (1/2 teaspoon salt in 8 ounces warm water) several times daily to help reduce inflammation and pain
• Considering topical treatments like clove oil or benzocaine gel for temporary relief when applied directly to the painful area It's essential to note that opioids are not recommended for long-term use in managing chronic pain due to their potential for dependence and side effects, as emphasized in recent guidelines 1. Therefore, the focus should be on addressing the underlying dental issue and using non-opioid pain management strategies under the guidance of a dentist or doctor.

From the FDA Drug Label

Tramadol hydrochloride has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol hydrochloride Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250 mg of tramadol hydrochloride in divided doses were generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg (TYLENOL with Codeine #3) daily, five doses of aspirin 325 mg with codeine phosphate 30 mg daily, or two to three doses of acetaminophen 500 mg with oxycodone hydrochloride 5 mg (TYLOX® ) daily For patients with moderate to moderately severe chronic pain not requiring rapid onset of analgesic effect, the tolerability of tramadol hydrochloride tablets, USP can be improved by initiating therapy with a titration regimen: The total daily dose may be increased by 50 mg as tolerated every 3 days to reach 200 mg/day (50 mg q.i.d.)

The best long-term pain control for chronic severe tooth pain is tramadol with a dose of 200-250 mg/day in divided doses, titrated as needed and tolerated. Key points to consider are:

• Titration: increase the dose by 50 mg every 3 days to reach 200 mg/day
• Dose limit: not to exceed 400 mg/day
• Individualization: dose should be individualized according to patient need using the lowest beneficial dose 2 2

From the Research

Long Term Pain Control for Chronic Severe Tooth Pain

• The management of chronic severe tooth pain requires a comprehensive approach, considering the underlying cause of the pain and the patient's overall health status 3, 4.
• Pharmacotherapy plays a crucial role in managing chronic tooth pain, with non-opioid medications being the first line of treatment 5, 6.
• Alternative methods of pain management, such as pre-emptive analgesia, post-procedural cold compression, and compound drug therapy, can improve the efficacy of analgesics and achieve a desired therapeutic response without compromising patient safety 5.
• Quantitative sensory testing (QST) can be used to assess sensory function and detect sensory abnormalities and nerve damage in the oral cavity, which can aid in the diagnosis and treatment of chronic tooth pain 4.
• Cone-beam computed tomography (CBCT) can improve diagnostic certainty in cases where atypical odontalgia (AO) is suspected, by excluding inflammation as the cause of pain 4.

Factors Affecting Prognosis

• The prognosis of chronic tooth pain can be affected by various factors, including the initial level of emotional distress and pain intensity 4.
• Low baseline pain intensity has been found to predict improvement over time in patients with AO 4.
• The use of opioids should be reserved for cases where non-opioid medications are ineffective, and patients should be closely monitored for signs of opioid dependence and addiction 5, 6.

Treatment Options

• Paracetamol and ibuprofen can be effective in managing dental pain, especially when used in combination 6.
• Antibiotics should only be used as an adjunct to dental treatment in cases where there are signs of systemic involvement, progressive and rapid spread of infection, or when the patient is immunocompromised 6.
• A thorough understanding of the mechanisms of action and effectiveness of different classes of drugs is essential for effectively managing endodontic pain 7.