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: 200mg 400mg 800mg 600mg 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? Local anesthetic Acetaminophen Ibuprofen Codeine 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? Patient age under 21 Patient on CNS active medications After the use of post-procedure Local anesthesia type Patients with a low pain threshold 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 without epinephrine 2% Lidocaine Bupivacaine or articaine with 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: 3,200mg 2,000mg 1,600mg 2,400mg 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 Call in opioid prescription Increase NSAID dose Switch to different NSAID 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 NSAID alone or with acetaminophen Combined opioids and acetaminophen Low dose Opioid prescription 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 Standard care No special care None of the above 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 Ask the patient to return to the clinic first Phone consultation 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? Techniques used Duration of treatment and billing code Basic notes with a short description Treatment reason, necessity and duration 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 This is determined on a case-by-case basis Before prescribing any controlled substance 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, analgesics will make it manageable Expect severe pain, analgesics have minimal effect Expect some pain, and with analgesics there will be total relief 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 Just medications Only allergies 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 Parent/guardian informed consent for opioids No special requirements Basic consent 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? Never Before any procedure Only for surgical procedures 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? 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? No local anesthesia with epinephrine No emergency treatment Caution with Mepivacaine Caution with vasoconstrictors in hypertensive conditions 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 Standard protocol Reduce the dose by 20% 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? Follow adult protocols No special concerns High risk of opioid use disorder 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 technique Technique only Dose and duration Type and dosage 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? No change 50% reduction Double dose 30% 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 Required for infiltration Required for inferior alveolar block 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? Higher doses Different technique facilities better diffusion Faster metabolism 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 4 years Under 3 years Under 2 years Under 5 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 ? Mepivacaine Lidocaine or Xylocaine with epinephrine Bupivacaine or articaine 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? First day No follow-up needed Return on day 2-3 if pain persists One week 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? No monitoring Check prescription monitoring program Basic follow-up Just vitals 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? Detailed informed consent about risks Signature on a consent form Verbal warning Written 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 another type of Opioid medication Patient on NSAIDs Patient receiving the maximum dose of acetaminophen 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? 425 mg acetaminophen 400 mg of ibuprofen 325 mg acetaminophen plus opioid 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 Routinely When first-line inadequate 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 complete relief Expect some manageable pain Expect minimal analgesic effect No 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 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? 325mg acetaminophen 200mg acetaminophen 1000mg acetaminophen 500mg 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 have fewer side effects 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 2,500mg 2,000mg 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? 660mg 440mg 550mg 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? 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? Local anesthetic only NSAIDs alone or with acetaminophen Steroids Opioids 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 Prescription exceeding 3 days Prescribed with Acetaminophen Overlapping with benzodiazepine use 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? Reserve for when first-line insufficient Use as first-line treatment in extractions Never prescribe 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? Reduced ability to feel pain during adulthood Higher likelihood of developing heart disease Increased risk of substance use disorder after single exposure 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? Complex extractions Young patients with multiple extractions Not recommended in any case All cases where severe pain is anticipated 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 Pain level 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? 200mg Ibuprofen or 220mg Naproxen 400mg Ibuprofen or 440mg Naproxen 800mg Ibuprofen or 880mg Naproxen 600mg Ibuprofen or 660mg 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 as first-line treatment Prescribed routinely 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? NSAIDs and Opioids Low dose opioids Nonopioid analgesics only Post-procedural local anesthetic 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? 3 days or less 10 days 5 to 7 days 7 to 10 days 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
