Emergency physicians are often loathe to prescribe or even give opioids in the ED for toothaches because it can be difficult to differentiate between a drug-seeker and a patient with a legitimate toothache in the absence of physical findings. Nerve blocks, NSAIDs, and acetaminophen can relieve tooth pain, but I have no problem giving at least one opioid tablet in the ED.
This is complicated, however, because studies have shown that racial and insurance disparities result in a greater likelihood of white patients and those with private insurance receiving opioids compared with other groups, leading one group of researchers to suggest that this occurs because clinicians incorrectly believe that minorities are drug-seeking rather than suffering from actual pain.
Disparities in Emergency Department Pain Treatment for Toothache
Lee HH, Lewis CW, McKinney CM
JDR Clin Trans Res.
This article attempts to describe how dental pain is approached in the ED, with a focus on the racial disparities in how that pain is treated. Ferreting out the subjective nature of reported pain is a huge challenge for clinicians, and many believe that most individuals presenting with a toothache without obvious signs of infection are drug-seeking. Multiple visits for a toothache are often discovered when checking past medical records or state databases. EPs have often prescribed opioids in the past, but recent attention to the opioid epidemic mandates an appropriate alternative for dental pain, and alternatives are often problematic. There is often a disconnect between how physicians and patients perceive whether a toothache requires opioids.
This report compared various methods of ED pain relief for a toothache in 1200 ED patients and whether those interventions were related to race/ethnicity or insurance. Adults 19-64 receiving care in the ED for a dental problem from 2008 to 2010 were studied. The treatment options were no administration of or prescription for pain medicine, administration of or prescription for an opioid, and administration of or a prescription for a nonopioid pain medicine, such as NSAIDs or acetaminophen. Ethnicity and insurance data were also recorded.
The authors concluded that about 60 percent of patients visiting the ED for a toothache received a prescription for an opioid. Interestingly, 57 percent of those not administered an analgesic or given a prescription for pain medication had a pain score of 7 or above. Black patients were nearly two times more likely than white patients to receive nonopioids than opioids. Compared with private insurance, patients with another insurance status were more likely to receive only a nonopioid analgesic.
These authors said they were the first to establish that racial and insurance disparities exist in the ED treatment of dental pain. Patients with private insurance were also more likely to receive an opioid than those on Medicare or Medicaid. The authors were unable to identify the factors driving the disparity.
Comment: It seems, at least from this study, that if you are white and have private insurance, you are more likely to be the beneficiary of opioids in the ED for dental pain. But the data are nine years old, so the 60 percent given an opioid would likely be decreased in this era of well-addressed opioid dependence. It has long been known that pain treatment differs for children and the elderly. Both populations are given fewer opioids in the ED for problems that garner these analgesics for others. Research has also shown that Hispanic patients receive fewer opioids for many types of pain than other groups. The same disparity appears to be present in the ED treatment of toothache. Interestingly, dentists provide substantially fewer opioid prescriptions following a dental diagnosis compared with medical colleagues.
Janakiram, et al., likewise found disparity between patients receiving opioids for dental problems among Medicaid patients. (J Am Dent Assoc. 2018;149:246; http://bit.ly/2kFL92b.) They postulated that this is frequently because clinicians incorrectly perceive that minorities presenting to the ED for pain are more likely to be drug-seeking than suffering from actual pain.
One study found that patient expectations of ED visits for dental problems were generally consistent with the care they received. Interestingly, most participants limited their expectations to the provision of antibiotics or pain medication. Nearly all of the participants thought they would eventually need to see a dentist for resolution of their problem. (J Am Coll Dent. 2009;76:23; http://bit.ly/2k9DVmH.)
Other Forms of Analgesia
Interventions other than opioids can relieve dental pain. Applying topical benzocaine gel (20%) directly to the tooth provides relief for about two or three hours for those with open-tooth cavities. Methemoglobinemia is a possible side effect of topical benzocaine, but it is not common. (J Am Dent Assoc. 2013;144:517; http://bit.ly/2lMIaW0.) The Food and Drug Administration recently warned against using benzocaine products such as Oragel and Anbesol for children under 2. (FDA Safety Announcement. May 31, 2018; http://bit.ly/2m87kyh.)
Local injectable anesthesia is also possible in the ED, but many clinicians eschew that intervention. An individual tooth may be anesthetized for a number of hours by injecting a small amount of bupivacaine with epinephrine at the base of the affected tooth. Usually 2-3 mL will do the trick, but it takes 15-20 minutes for the anesthetic to diffuse through the bone to the nerve root.
It is reasonable for the patient presenting with a pointing abscess to incise the mass with a number 11 blade and to spread the tissue gently with a hemostat. These patients will usually be prescribed an antibiotic, although a benefit has not been proven, as I mentioned last month. (EMN. 2019;41:10; http://bit.ly/EMN-InFocus.) Some clinicians believe that NSAIDs with their anti-inflammatory and analgesic effects are a reasonable intervention for a toothache. Ibuprofen (400-600 mg QID) is probably appropriate for most patients discharged from the ED. Of course, the best tactic is to set up a referral system with dentists who have agreed to see ED patients within a day or two.
It is almost impossible to distinguish a drug abuser from a person with a legitimate toothache in the absence of physical findings. A toothache complaint will often allow one to score at least a few opioids from the ED. I believe that a local nerve block and an NSAID are appropriate for many patients, but I have no problem giving at least one opioid tablet in the ED. If access to definitive follow-up dental care is difficult, as it often is, perhaps a few oxycodone would be appropriate, the great concern for overprescribed opioids notwithstanding. Some EDs have prohibited any outpatient opioid prescriptions for any type of pain. I think this is overkill and inappropriate.
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Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, athttp://bit.ly/EMN-ProceduralPause, and read his past columns athttp://bit.ly/EMN-InFocus.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.