Mayday! Mayday! Pain Off the Starboard Bow!!!

Every dental wisecrack and negative image seen in the movies from the Three Stooges to W.C. Fields to Steve Martin in "The Little Shop of Horrors," has to do with pain. Dentists are perceived as pain merchants and descendants of the Torquemada, the Grand Inquisitor of the Spanish Inquisition. So for a positive spin on our image control, let's get a grip on pain. Is there anything we can do to control pain?

You bet! When it comes to surgical pain, the non-steroidal, anti-inflammatory drugs have been lifesavers. They are often more effective than codeine or synthetic narcotics, and have fewer side effects. Anti-inflammatories can be prescribed to most anyone as long as they can take aspirin, and are not pregnant. The anti-inflammatory-aspirin connection is serious: if a patient is allergic to aspirin or has a history of bleeding ulcers or other clotting problems, anti-inflammatories must be avoided. They should also be avoided by patients with renal problems.

Anti-inflammatories don't block the pain center in the brain like narcotics do, so how do they work? Remember prostaglandins? The body produces a dozen or so, all of which help mediate a host of functions. Bradykinin is a prostaglandin that is part of the inflammatory process, and it magnifies the body's response to pain ten-fold. A few years back, researchers learned that if the action of bradykinin is suppressed, then the amount of pain decreases in a predictable way. After using aspirin for a century, we had an explanation of how it worked! What followed was the creation of an army of NSAIDs - non-steroidal anti-inflammatory drugs - to help fight pain. Not only are they great for arthritis sufferers, they work wonders for our patients.

What's the best way to administer NSAIDs? Before the patient experiences pain. It is very difficult to catch up to pain, but a breeze to stay ahead of it. We give patients NSAIDs before their periodontal or implant surgery. This way the NSAIDs are already at work suppressing the body's inflammatory response before we’ve challenged it with our procedures. It works! NSAIDs are potent enough to keep most patients comfortable after osseous surgery or after having implants placed. The NSAIDs should be taken at regular intervals, for the rest of the day following their surgery. Coupled with the application of ice to the outside of the face, and an extra shot of long-acting anesthetic (Marcaine) at the end of their procedure, most patients experience little discomfort.

Over-the-counter ibuprofen works fine as a NSAID. Other commonly used NSAIDs are: Lodine, Motrin, and Nuprin. Relafen is another good drug. If you (or the patient) want to prescribe something stronger, use compounds with aspirin whenever the patient can tolerate it. Aspirin makes the narcotic more effective by exhibiting the same anti-inflammatory benefit as do the NSAIDs. Acetaminophen does not reduce inflammation, and consequently, is less effective as a pain killer ... but sometimes needs to be used. Vicoprofen is recently available; it combines the synthetic narcotic, Vicodin, with ibuprofen.

As mentioned above, we give pain meds before starting surgery. In fact, we suggest patients who do not sit comfortably when getting their teeth cleaned, benefit from taking NSAIDs at the start of their appointments.

So the next time "pain" control comes up, think of NSAIDs.

BRT: A New Direction (but not a subway line)

Bone Replacement Therapy is an idea that’s taking hold. In the old days, when a tooth was removed, the dentist often placed a suture to make certain the patient returned for one more visit to check the healing...and collect their fee! Now, there's a reason to treat the tooth removal as an opportunity to guide the healing that follows. We no longer look at extraction sites as pontic areas. Now they can be implant sites, and certainly need not become esthetic and laboratory nightmares.

So what’s right? Graft extraction sites or let them fill in naturally?

At the recent AAP meeting, two papers were presented that straddled the fence. A.S. Bankhead, from UNMC College of Dentistry in Lincoln, Nebraska, removed bilateral, mandibular third molars in 32 healthy patients. The extraction sites were filled with demineralized freeze-dried bone allografts (DFDBA), 80 % DFDBA + 20% calcium sulfate, or left as a control to heal alone. The results suggested that both grafted sites healed better than the controls.

R.J. Cecala, et al, from the University of Iowa, treated 13 patients needing bilateral mandibular third molar removal. Half the sites served as controls, while the other half were covered with guided tissue membranes. After twelve months, there was no difference in the bone regeneration.

Won't all sockets heal? Why the fuss? The above studies were in healthy young patients without periodontal disease. Our patient population is older. We're not as concerned about third molar extractions as we are about the healing following the removal of periodontally involved teeth, which often have irregular bony walls surrounding the extraction site. More and more, we attempt to restore the bony contours and ridge dimensions after teeth are removed. We use DFDBA or BIO-Oss, often in combination with guided tissue membranes to achieve optimum healing. The results have been gratifying. However, regardless of whether BRT is deliberately tried, the basics of tooth removal have not changed: remove any part of the epithelial lining that may be in a socket, debride down to bone, irrigate liberally, curette away apical cysts that might be present, and make certain there is adequate bleeding for a good blood clot.

Periodontal Infection and Pre-term Low Birth Weight

A recent study by S. Offenbacher, et al, Univ. of North Carolina brings to light the importance of periodontal infection as a modifier of systemic health. Studying 124 pregnant or postpartum mothers, evidence was found linking periodontal infections to pre-term low birth weight (or PLBW). The data suggests that even after adjusting for traditional pre-term delivery risk factors, such as smoking, alcohol usage, vaginal infection, nutrition, and other relevant variables, first-time mothers with severe periodontal disease were 7 times more likely to be in the LBW group than the normal birth weight group. PLBW cases were defined as births weighing 5-6 pounds with at least one of the following: gestation age less than 37 weeks, pre-term labor, or premature rupture of the membranes. Though the mechanism that explains this is unclear, untreated periodontal disease can represent an endocrine-like source of cytokines and lipid mediators, which can affect the placental membrane and be associated with pre-term parturition.

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