Pain ManagementDentistry MCQs Pharmacology MCQs 0% Report a question What’s wrong with this question? You cannot submit an empty report. Please add some details. Pain Management Question Bank 1 / 50 The CORRECT initial dose of ibuprofen for post-extraction pain is: 800mg 600mg 400mg 200mg 400mg ibuprofen recommended as initial dose. [ADA Guidelines 2024] “400 mg of ibuprofen or 440 mg of naproxen sodium.” 2 / 50 A nursing mother requires pain management after surgical extraction. Which medication is CONTRAINDICATED? Codeine Ibuprofen Acetaminophen Local anesthetic Codeine and tramadol contraindicated during breastfeeding due to serious risks to infant. [ADA Guidelines 2024] “breastfeeding is not recommended when taking codeine or tramadol medicines due to the risk of serious adverse reactions in breastfed infants.” 3 / 50 What is the contraindication for rescue opioid therapy? Patients with a low pain threshold After the use of post-procedure Local anesthesia type Patient age under 21 Patient on CNS active medications Patients taking gabapentinoids, CNS active medications, or current opioids. [ADA Guidelines 2024] “This option should not be offered to patients taking gabapentinoids and central nervous system active medications or patients already taking opioids.” 4 / 50 Which local anesthetic regimen is MOST appropriate for extended post-operative pain control? 2% Lidocaine Bupivacaine or articaine without epinephrine 3% Mepivacaine Bupivacaine or articaine with epinephrine 0.5% bupivacaine plus 1:200,000 epinephrine or 4% articaine plus 1:100,000/1:200,000 epinephrine recommended. [ADA Guidelines 2024] “0.5% bupivacaine plus 1:200,000 epinephrine by block or infiltration injection or 4% articaine plus 1:100,000/1:200,000 epinephrine by infiltration.” 5 / 50 The maximum daily dose of ibuprofen for dental pain is: 1,600mg 2,400mg 2,000mg 3,200mg Maximum daily dose is 2,400mg ibuprofen. [ADA Guidelines 2024] “The maximum daily dose is 2,400 mg of ibuprofen.” 6 / 50 A patient reports breakthrough pain on day 2 after extraction despite following prescribed NSAID regimen. The MOST appropriate next step is to: Switch to different NSAID Increase NSAID dose Call in opioid prescription Have patient return to evaluate for complications Patient should return to clinic to rule out complications before new prescription. [ADA Guidelines 2024] “A patient with breakthrough pain on the second or third day after simple extraction(s)… should return to the clinic so the provider can rule out other clinical conditions.” 7 / 50 A 16-year-old patient presents for third molar extraction. Which statement BEST describes the most appropriate first-line post-operative pain management strategy? Post-procedural local anesthetic only Low dose Opioid prescription Combined opioids and acetaminophen NSAID alone or with acetaminophen First-line therapy should be NSAIDs alone or with acetaminophen; extreme caution with opioids in adolescents due to increased risk of substance use disorder. [ADA Guidelines 2024] “NSAIDs alone or in combination with acetaminophen likely provide superior pain relief with a more favorable safety profile than opioids.” 8 / 50 What communication is needed for substance use disorder patients? Special care and provider communication None of the above Standard care No special care Special care and communication with patient’s other healthcare providers required. [ADA Guidelines 2024] “Special care should be taken when prescribing opioids to a patient with a substance use disorder, including communication with the patient’s other health care providers.” 9 / 50 How should breakthrough dental pain be managed? Immediately prescribe more potent medication Phone consultation Ask the patient to return to the clinic first Write a new prescription Patient should return to clinic to rule out other conditions before new prescription. [ADA Guidelines 2024] “A patient with breakthrough pain… should return to the clinic so the provider can rule out other clinical conditions responsible for the pain.” 10 / 50 What documentation is required for behavior management billing? Basic notes with a short description Treatment reason, necessity and duration Duration of treatment and billing code Techniques used Must document reason, technique type, duration, and medical necessity. [ADA Guidelines 2024] “the patient record must include the reason (narrative of medical necessity), the type of technique or therapies used, and the duration of the services provided.” 11 / 50 When should state prescription monitoring be checked? After prescribing any controlled substance Only if renewing a prescription Before prescribing any controlled substance This is determined on a case-by-case basis Review prescription drug monitoring program when available before prescribing controlled substances. [ADA Guidelines 2024] “clinicians review the state’s prescription drug monitoring program when available to determine the coprescribing of other controlled substances.” 12 / 50 What key counseling must be provided to patients? Expect some pain, and with analgesics there will be total relief Not to expect any pain Expect some pain, analgesics will make it manageable Expect severe pain, analgesics have minimal effect Patients should be counseled to expect some pain and that analgesics should make pain manageable. [ADA Guidelines 2024] “counsel patients that they should expect some pain and the analgesics should make their pain manageable.” 13 / 50 What must be reviewed before prescribing analgesics? Complete medical/social/medication review Basic history Only allergies Just medications Must review medical/social history, medications, supplements to avoid interactions and overdose. [ADA Guidelines 2024] “clinicians thoroughly review the patient’s medical and social history (including illicit and recreational drug use), medications, and supplements to avoid overdose and adverse drug-drug interactions.” 14 / 50 What special documentation is needed for minors? Basic consent Parent/guardian informed consent for opioids Standard notes No special requirements Informed consent must be obtained from parent/guardian for opioids. [ADA Guidelines 2024] “obtain informed consent from the patient (or the parent or guardian in the case of minors) with detailed information about potential opioid undesirable effects.” 15 / 50 When is medical consultation required for elderly? Before any procedure Only for surgical procedures Never When on multiple medications or cardiovascular disease When taking multiple medications or have significant cardiovascular disease. [ADA Guidelines 2024] “Patients with significant cardiovascular disease… may require a medical consultation.” 16 / 50 What considerations for obese adolescents? Increased breathing risk with opioids Standard dosing Only weight-based dosing No special concerns Higher risk of breathing problems with codeine/tramadol if obese or have sleep apnea. [ADA Guidelines 2024] “adolescents between 12 and 18 years who are obese or have conditions such as obstructive sleep apnea or severe lung disease, which may increase the risk of serious breathing problems.” 17 / 50 What contraindications exist for pregnant patients? Caution with vasoconstrictors in hypertensive conditions No emergency treatment Caution with Mepivacaine No local anesthesia with epinephrine Caution with vasoconstrictors, especially in hypertensive conditions like preeclampsia. Local anesthetics with epinephrine (e.g., bupivacaine, lidocaine, mepivacaine) may be used during pregnancy. [ADA Guidelines 2024] “caution is indicated in the use of local anesthetics with vasoconstrictor for pregnant women, particularly those with hypertensive conditions (e.g., preeclampsia).” 18 / 50 What medication modification is needed for nursing mothers? No changes to dose Avoid codeine/tramadol while breastfeeding Reduce the dose by 20% Standard protocol Breastfeeding not recommended when taking codeine or tramadol due to risks to infant. [ADA Guidelines 2024] “breastfeeding is not recommended when taking codeine or tramadol medicines due to the risk of serious adverse reactions in breastfed infants.” 19 / 50 What is unique about prescribing for adolescents? No special concerns Prescribe at 50% of the standard dose High risk of opioid use disorder Follow adult protocols Increased risk of substance use disorder even after single opioid exposure; requires extreme caution. [ADA Guidelines 2024] “Adolescents are at an especially increased risk of developing an opioid use disorder, even after a single exposure.” 20 / 50 What documentation is required for local anesthesia? Type and dosage Dose and duration Type and technique Technique only Must include type and dosage of local anesthetic administered. [ADA Guidelines 2024] “Documentation also includes specific information relative to the administration of local anesthetics. This would include, at a minimum, the type and dosage of local anesthetic administered.” 21 / 50 What modification is needed for young infants? 30% reduction No change Double dose 50% reduction Reduce amide local anesthetic doses by 30% in infants younger than 6 months. [ADA Guidelines 2024] “The calculated maximum total dose of amide local anesthetics should be reduced by 30 percent in infants younger than six months.” 22 / 50 When is endocarditis prophylaxis needed for LA injection? Always needed Not needed for routine injections Required for infiltration Required for inferior alveolar block Not recommended for routine injections through noninfected tissue. [ADA Guidelines 2024] “Endocarditis prophylaxis (antibiotics) is not recommended for routine local anesthetic injections through noninfected tissue.” 23 / 50 Why is mandibular infiltration more effective in children? Faster metabolism Different technique facilities better diffusion Higher doses Less dense bone allows better diffusion Child’s mandibular bone less dense than adult’s, allowing better diffusion. [ADA Guidelines 2024] “The mandibular cortical bone of a child is less dense than that of an adult, permitting more rapid and complete diffusion of the injected anesthetic.” 24 / 50 What is the age restriction for articaine? Under 5 years Under 4 years Under 3 years Under 2 years Not recommended for patients under 4 years old. [ADA Guidelines 2024] “Use in pediatric patients under four years of age is not recommended.” 25 / 50 How is local anesthetic effectiveness affected by infection? Enhanced effect No effect Delayed onset and possible ineffectiveness Faster onset Infection lowers pH, delaying onset and possibly making anesthesia ineffective. [ADA Guidelines 2024] “If a local anesthetic is injected into an area of infection, its time to onset may be prolonged or anesthesia may be ineffective.” 26 / 50 What post-procedural regimen is recommended for extended pain control ? Bupivacaine or articaine with epinephrine Lidocaine or Xylocaine with epinephrine Mepivacaine 0.5% bupivacaine plus 1:200,000 epinephrine by block/infiltration or 4% articaine plus 1:100,000/1:200,000 epinephrine by infiltration (Articaine cannot be used for block anesthesia due to risk of paraesthesia) [Read more here] 27 / 50 When should breakthrough pain be reevaluated? First day One week No follow-up needed Return on day 2-3 if pain persists Patient with breakthrough pain on second/third day should return for evaluation of other conditions. [ADA Guidelines 2024] “A patient with breakthrough pain (pain that persists after implementing initial pain management strategy) on the second or third day…should return to the clinic.” 28 / 50 What monitoring is required with rescue therapy? Check prescription monitoring program Just vitals Basic follow-up No monitoring Must check prescription drug monitoring program for other controlled substances. [ADA Guidelines 2024] “clinicians review the state’s prescription drug monitoring program when available to determine the coprescribing of other controlled substances.” 29 / 50 What is required before prescribing rescue opioids? Signature on a consent form Verbal warning Written warning Detailed informed consent about risks Informed consent with detailed information about opioid risks, particularly critical in adolescents. [ADA Guidelines 2024] “obtain informed consent from the patient with detailed information about potential opioid undesirable effects.” 30 / 50 All of the patients listed below should NOT receive rescue opioid therapy EXCEPT ? Patient on anti-hypertensive medications Patient on another type of Opioid medication Patient receiving the maximum dose of acetaminophen Patient on NSAIDs Rescue Opioids should not be offered to patients taking gabapentinoids, CNS active medications, benzodiazepines, antidepressants, anticonvulsants, and narcotics or already taking opioids. It is not a contra-indication for patients on anti-hypertensive medications. [ADA Guidelines 2024] “This option should not be offered to patients taking gabapentinoids and central nervous system active medications or patients already taking opioids for other medical reasons.” 31 / 50 What is the recommended rescue therapy ( additional medication to relieve pain) combination? 400 mg of ibuprofen 325 mg acetaminophen plus opioid 425 mg acetaminophen 15 mg Oxycodone Add 325mg acetaminophen plus combination of 325mg acetaminophen with opioid (5-7.5mg hydrocodone or 5mg oxycodone). [ADA Guidelines 2024] “addition to the previous first-line therapy prescription of 325 mg of acetaminophen plus a combination of 325 mg of acetaminophen with an opioid.” 32 / 50 When should second-line therapy be considered? Preventively Before trying first-line Routinely When first-line inadequate Only when first-line therapy (NSAIDs alone or with acetaminophen) proves inadequate for pain control. [ADA Guidelines 2024] “In the rare instances when postprocedural pain control using NSAIDs alone is inadequate.” 33 / 50 How should pain expectations be managed? Expect minimal analgesic effect No pain Expect complete relief Expect some manageable pain Counsel patients to expect some pain; analgesics should make pain manageable. [ADA Guidelines 2024] “advise clinicians to counsel patients that they should expect some pain and the analgesics should make their pain manageable.” 34 / 50 If NSAIDs are contraindicated in an adult patient, the alternative post operative medication for pain management is 325 mg of acetaminophen with an opioid 500 mg Acetaminophen 15 mg Oxycodone In this case, use acetaminophen alone at the full therapeutic dose (1,000mg)or 325 mg of acetaminophen with an opioid (eg, 5-7.5 mg of hydrocodone or 5 mg of oxycodone) at the lowest effective dose [Read more here] 35 / 50 When combining NSAIDs with acetaminophen, what dose is recommended? 1000mg acetaminophen 500mg acetaminophen 325mg acetaminophen 200mg acetaminophen NSAIDs (400mg ibuprofen/440mg naproxen) plus acetaminophen (500mg). [ADA Guidelines 2024] “combination NSAID (eg, 400 mg of ibuprofen or 440 mg of naproxen sodium) plus acetaminophen (eg, 500 mg).” 36 / 50 Why are NSAIDs preferred for dental pain? They target the source of inflammation They are a cost effective option They have fewer side effects NSAIDs target inflammation which is the source of dental pain, while opioids do not. [ADA Guidelines 2024] “NSAIDs would target the source of the pain, whereas opioids would not.” 37 / 50 What is the maximum daily acetaminophen dose? 2,000mg 4,000mg 2,500mg 3,000mg Maximum daily dose of acetaminophen is 4,000mg. [ADA Guidelines 2024] “The maximum daily dose is… 4,000 mg of acetaminophen.” 38 / 50 What is the recommended naproxen sodium dosing? 550mg 440mg 220mg 660mg 440mg naproxen sodium with maximum daily dose of 1,100mg. [ADA Guidelines 2024] “440 mg of naproxen sodium… The maximum daily dose is… 1,100 mg of naproxen sodium.” 39 / 50 What is the correct ibuprofen dosing for dental pain? 400mg 200mg 800mg 600mg 400mg ibuprofen with maximum daily dose of 2,400mg. [ADA Guidelines 2024] “To minimize adverse effects, analgesic prescriptions should follow the principle of minimum effective dosage… The maximum daily dose is 2,400 mg of ibuprofen.” 40 / 50 What is the recommended first-line analgesic therapy? Opioids Local anesthetic only NSAIDs alone or with acetaminophen Steroids NSAIDs alone or in combination with acetaminophen are first-line therapy. [ADA Guidelines 2024] “Nonopioid medications, particularly NSAIDs alone or in combination with acetaminophen, are first-line therapy for the management of acute dental pain.” 41 / 50 What special precaution is required for nursing patients? Avoid Ibuprofen No restrictions Avoid codeine Lower Tylenol dosage Codeine and tramadol are contra-indicated during breastfeeding due to serious adverse risks which could lead to infant death. [ Read more on the FDA restriction here] 42 / 50 All of the following define a “high-risk” opioid prescription for patients who have no known Opioid addiction disorder, EXCEPT: Prescribed with Acetaminophen Overlapping with benzodiazepine use ≥50 MME (morphine milligram equivalents) per day Prescription exceeding 3 days Prescriptions exceeding 3-day supply, daily dosage ≥50 MME, or having benzodiazepine overlap. [ADA Guidelines 2024] “prescriptions to opioid-naïve patients exceeding a 3-day supply, prescriptions with daily opioid dosage 50 morphine milligram equivalents, opioid prescriptions with benzodiazepine overlap.” Note: In 2019, 39.5% of opioid prescriptions by dentists were classified as high-risk. [ADA Guidelines 2024] 43 / 50 What is the key principle for opioid prescribing in dentistry? Never prescribe Use as first-line treatment in extractions Reserve for when first-line insufficient Always prescribe for moderate to severe pain Opioids should be reserved for when first-line therapy insufficient; avoid routine “just-in-case” prescribing. [ADA Guidelines 2024] “The use of opioids should be reserved for clinical situations when the first-line therapy is insufficient to reduce pain.” 44 / 50 What is the main concern with opioids in adolescents? Increased risk of substance use disorder after single exposure Higher likelihood of developing heart disease Reduced ability to feel pain during adulthood Limited effectiveness in managing pain Adolescents are at increased risk of developing opioid use disorder even after a single exposure. [ADA Guidelines 2024] 45 / 50 Under what circumstances should “just in case” opioid prescriptions be given? Not recommended in any case All cases where severe pain is anticipated Complex extractions Young patients with multiple extractions Routine use of delayed “just-in-case” opioid prescriptions is not recommended. [ADA Guidelines 2024] “avoid the routine use of delayed (ie, just-in-case prescription for breakthrough pain) opioid prescriptions” 46 / 50 What contraindications require modification of standard pain protocol? Age only Procedure type Medical contraindications to NSAIDs Pain level NSAIDs contraindicated in certain conditions; requires alternative pain management strategy. [ADA Guidelines 2024] “When NSAIDs are contraindicated, the panel suggests the postprocedural use of acetaminophen alone at full therapeutic dose.” 47 / 50 What is the recommended NSAID dosing for post-extraction pain? 800mg Ibuprofen or 880mg Naproxen 200mg Ibuprofen or 220mg Naproxen 600mg Ibuprofen or 660mg Naproxen 400mg Ibuprofen or 440mg Naproxen 400mg ibuprofen or 440mg naproxen sodium, with maximum daily doses of 2400mg and 1100mg respectively. [ADA Guidelines 2024] “using an NSAID alone (eg, 400 mg of ibuprofen or 440 mg of naproxen sodium)” 48 / 50 When should opioids be considered after surgical extraction? Prescribed when first-line therapy is inadequate Prescribed routinely Prescribed as first-line treatment Prescribed for use "just in case" Only when first-line therapy (NSAIDs/acetaminophen) proves inadequate for pain control. [ADA Guidelines 2024] “In the rare instances when postprocedural pain control using NSAIDs alone is inadequate…” 49 / 50 For simple extractions, what pain management is recommended? Post-procedural local anesthetic only Nonopioid analgesics only NSAIDs and Opioids Low dose opioids Nonopioid analgesics only; opioids are not recommended for simple extractions. [ADA Guidelines 2024] “For simple tooth extraction, the panel suggests initiating the pain management using an NSAID alone or in combination with acetaminophen.” Note: In all cases, practitioners must document the type and dosage of local anesthetic, any medications prescribed, and post-op instructions. [ADA Guidelines 2024] “Documentation should include specific information relative to the administration of local anesthetics. This would include, at a minimum, the type and dosage of local anesthetic administered.” 50 / 50 What is the maximum duration recommended for post-extraction opioid prescriptions if needed? 7 to 10 days 5 to 7 days 10 days 3 days or less Opioids should be prescribed at lowest effective dose for shortest duration, rarely exceeding 3 days. [ADA Guidelines 2024] “The opioid prescription should consider the lowest effective dose, fewest tablets, and the shortest duration, which rarely exceeds 3 days.” Your score is 0% Restart quiz References: Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in adolescents, adults, and older adults. The Journal of the American Dental Association, 155(2), 102-117.e9. https://doi.org/10.1016/j.adaj.2023.10.009
