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 200mg 400mg 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? Acetaminophen Codeine Ibuprofen 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? After the use of post-procedure Local anesthesia type Patient age under 21 Patients with a low pain threshold 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? Bupivacaine or articaine with epinephrine 2% Lidocaine Bupivacaine or articaine without epinephrine 3% Mepivacaine 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: 2,400mg 1,600mg 3,200mg 2,000mg 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: Have patient return to evaluate for complications Switch to different NSAID Call in opioid prescription Increase NSAID dose 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 Combined opioids and acetaminophen Low dose Opioid prescription 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? None of the above Special care and provider communication No special care Standard 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? Write a new prescription Ask the patient to return to the clinic first Immediately prescribe more potent medication Phone consultation 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? Techniques used Duration of treatment and billing code Treatment reason, necessity and duration Basic notes with a short description 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? Only if renewing a prescription Before prescribing any controlled substance After 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 Expect severe pain, analgesics have minimal effect Expect some pain, analgesics will make it manageable Not to expect any pain 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? Basic history Only allergies Just medications Complete medical/social/medication review 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? Standard notes No special requirements Basic consent Parent/guardian informed consent for opioids 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? Only for surgical procedures Never When on multiple medications or cardiovascular disease Before any procedure 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? Only weight-based dosing Increased breathing risk with opioids No special concerns Standard dosing 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 local anesthesia with epinephrine Caution with Mepivacaine No emergency treatment 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 Reduce the dose by 20% Standard protocol Avoid codeine/tramadol while breastfeeding 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? High risk of opioid use disorder No special concerns Follow adult protocols Prescribe at 50% of the standard dose 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 Technique only Type and technique Dose and duration 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 50% reduction No change Double dose 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? Required for inferior alveolar block Always needed Required for infiltration Not needed for routine injections 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 Less dense bone allows better diffusion Higher doses Different technique facilities 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? No effect Enhanced 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 Mepivacaine Lidocaine or Xylocaine with epinephrine 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? One week First day 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? Basic follow-up No monitoring Just vitals Check prescription monitoring program 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 Written warning Detailed informed consent about risks Verbal warning 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 NSAIDs Patient receiving the maximum dose of acetaminophen Patient on another type of Opioid medication Patient on anti-hypertensive medications 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? 325 mg acetaminophen plus opioid 15 mg Oxycodone 425 mg acetaminophen 400 mg of ibuprofen 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? When first-line inadequate Routinely Preventively Before trying first-line 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 some manageable pain No pain Expect minimal analgesic effect Expect complete relief 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 500 mg Acetaminophen 15 mg Oxycodone 325 mg of acetaminophen with an opioid 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? 200mg acetaminophen 500mg acetaminophen 325mg acetaminophen 1000mg 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 have fewer side effects They target the source of inflammation They are a cost effective option 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? 3,000mg 2,000mg 2,500mg 4,000mg 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? 440mg 550mg 660mg 220mg 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? 200mg 400mg 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? Steroids NSAIDs alone or with acetaminophen Opioids Local anesthetic only 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? No restrictions Avoid codeine Lower Tylenol dosage Avoid Ibuprofen 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: ≥50 MME (morphine milligram equivalents) per day Overlapping with benzodiazepine use Prescription exceeding 3 days Prescribed with Acetaminophen 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? Always prescribe for moderate to severe pain Use as first-line treatment in extractions Reserve for when first-line insufficient Never prescribe 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? Limited effectiveness in managing pain Reduced ability to feel pain during adulthood Increased risk of substance use disorder after single exposure Higher likelihood of developing heart disease 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? Young patients with multiple extractions Complex extractions All cases where severe pain is anticipated Not recommended in any case 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? Pain level Age only Procedure type Medical contraindications to NSAIDs 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? 400mg Ibuprofen or 440mg Naproxen 800mg Ibuprofen or 880mg Naproxen 600mg Ibuprofen or 660mg Naproxen 200mg Ibuprofen or 220mg 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 for use "just in case" Prescribed as first-line treatment Prescribed routinely Prescribed when first-line therapy is inadequate 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? NSAIDs and Opioids Low dose opioids Post-procedural local anesthetic only Nonopioid analgesics only 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? 10 days 5 to 7 days 7 to 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
