Pharmacologic approaches to managing acute dental pain come with clinical adverse effects for patients and practice-related challenges for dentists, and different approaches have different consequences. For example, non-steroidal anti-inflammatory drugs (NSAIDs) can have gastric, renal, and cardiovascular adverse effects in patients [1]. Adverse effects of opioids can include “dysphoria, euphoria, sedation, respiratory depression, constipation, suppression of endocrine systems, cardiovascular disorders (e.g., bradycardia), convulsion, nausea, vomiting, pruritus, and miosis” in patients [2]. In addition, clinical adverse effects associated with dental prescribing of opioids, such as emergency department visits, hospitalizations, newly diagnosed substance use disorders, or overdose requiring naloxone administration, have been documented [3,4,5,6,7]. For example, following third molar extraction, persistent use of opioids occurred in 13 per 1,000 patients who filled an opioid prescription compared with 5 per 1,000 patients who did not fill an opioid prescription [3]. Similarly, among patients aged 16 to 25 who filled an opioid prescription from a dentist, 6.9% received another opioid prescription in the following year, whereas only 0.1% did in an opioid-nonexposed cohort [4]. For a comprehensive analysis of clinical adverse effects in dental patients, see Tables 9, 10 and 11 in the Appendix of [8].

Practice-related challenges for dentists can occur, as well. For example, when patients leave the dental office following a tooth extraction, they are numb. But as the anesthesia wears off, some may experience their pain as unmanageable. Dentists have managed this challenge by providing “just in case” prescriptions for pain management [9]. Another challenge resulting from opioid prescribing is managing risk of diversion [10]. Additionally, with the advent of mandatory opioid prescribing limits, providers have to balance patient needs with policy compliance [11]. Prescribers also report fear of prescribing opioids and fear of receiving disciplinary action [12]. In a study of dental opioid prescribing, five procedures accounted for 95.2% of procedure-related opioid prescriptions. These procedures included tooth extraction (65.2%), problem-focused limited oral evaluation (17.2%), endodontic therapy (8.4%), alveoloplasty (2.9%), and surgical implant services [13].

American Dental Association (ADA) -endorsed evidence-informed clinical practice guidelines for managing acute dental pain associated with a toothache or following simple or surgical tooth extraction [14, 15] provide specific recommendations for pharmacologic management in children, adolescents, and adults. These guidelines do not recommend opioids as first-line therapy, which departs from how some dentists, oral surgeons, and other dental providers practice [13, 16]. For example, in the period 2015–2019, we found that approximately 29% of dentists were moderately high prescribers and 3.4% were consistently high prescribers [16]. Dental providers may be hesitant to adopt the new recommendations, however, if they are associated with more frequent clinical adverse effects for their patients or practice-related challenges for themselves [17]. To determine whether guideline adoption is associated with increases in clinical adverse effects or practice-related challenges, a baseline needs to be established.

The purpose of this exploratory study was to describe the type and frequency of practice-related challenges experienced by dentists and clinical adverse effects experienced by patients associated with opioid and non-opioid management of acute dental pain resulting from simple or surgical tooth extraction or toothache.

Methods

Human subjects protection

The University of Pittsburgh Institutional Review Board (IRB) determined the study to be exempt on October 26, 2022, and the portion conducted by Health Choice Network (HCN) was determined to be exempt by the WCG IRB on January 9, 2024. This study conforms to STROBE Guidelines for cross-sectional studies.

Participant eligibility

Patient participants were eligible if they were 18 years or older, had at least one tooth extracted or received treatment for toothache in the prior two weeks, and spoke English, Spanish, or Haitian Creole. These languages were selected because they were the predominant languages spoken by patients in the healthcare network from which we were recruiting patients. General or specialty dentist participants were eligible if they extracted at least one tooth or treated at least one patient for toothache in a typical month. To establish a baseline uncontaminated by exposure to the guideline recommendations, we limited our recruitment of dentists and patients to the period before information about the guideline recommendations was available, either through the release of the guideline or through exposure to a continuing education course about the guideline that was available prior to the guideline’s release.

Dentist recruitment and procedures

In collaboration with CareQuest (Boston, MA) and BroadcastMed (Huntington, NY), the research team used the ADA email list to invite dentists in Alabama, Arizona, Colorado, Montana, and Oregon to complete the dentist online survey via a Qualtrics (Seattle, WA and Provo, UT) link. These states were selected for their geographic diversity and high rates of opioid prescribing, which we expected would increase the study participation of dentists who prescribed opioids. The initial e-blast was sent to dentists on February 20, 2023, and the second e-blast was sent to the openers of the first e-blast on February 27, 2023. Dentists who opened either the first or second e-blast were re-targeted with a Facebook banner, which was live for 30–45 days. Dentists were given until March 6, 2023, to complete the survey; however, responses after that date were accepted. From May 8, 2023 – February 5, 2024, which was the date that the adult guideline was released, members of the research team shared a link to the online survey via a QR code or Qualtrics link with colleagues and dentists, including dentists attending the 2023 annual meeting of the Montana Dental Association. Finally, from February 1, 2024 – February 5, 2024, HCN emailed information about the study and the Qualtrics link to dentists in 30 HCN clinics. Clinics received payments of $40 per dentist completing the survey.

Patient recruitment and procedures

The patients completing surveys were not required to be patients of the dentists who participated in the study. From May 8, 2023 – February 5, 2024, members of the research team shared the study materials with colleagues and dentists. Dentists were given materials (flyer with QR code and Qualtrics link) to share with their patients (or patient caregivers if patients were unable to complete the survey) meeting study criteria. Flyers with the QR code were shared at professional meetings, and the research team included a message at the end of the dentist survey requesting recruitment assistance.

From January 30, 2024 – February 5, 2024, HCN staff called eligible patients about the study. The introductory script and survey questions were professionally translated and available in English, Spanish, and Haitian Creole (United Language Group, Inc., Minneapolis, MN). HCN staff fluent in English, Spanish, or Haitian Creole read the survey questions to interested patients and entered all responses directly into the online survey. To facilitate recruitment and include all eligible patients, a patient caregiver was allowed to answer the questions for the patient. Patients were compensated with a $20 gift card for their participation. HCN operates in nine states, primarily in the South.

Measures

Both the dentist and patient surveys included items assessing demographic characteristics, procedures performed (dentists) or received (patients), medications prescribed, practice-related challenges, clinical adverse effects, and adoption of shared decision making. Examples of practice-related challenges experienced by dentists include patients challenging the dentist’s pain management recommendation, patients requesting a different pain medication, and patients contacting the dentist after hours for additional pain medication. Examples of clinical adverse effects include dizziness, drowsiness, nausea/vomiting, headache, or constipation. The dentist survey included 14 questions, and the patient survey included 25 questions.

Dentists reported about their experiences in a typical month. For each condition assessed (i.e., simple extraction, surgical extraction, and toothache), dentists answered questions about the medications they prescribe only if they endorsed that they recommend pharmacologic pain management for that condition. The response options for most questions were 5-point Likert-type scales. These conditions were selected because they are the conditions covered by the ADA-endorsed clinical practice guideline for the management of acute dental pain.

Patients reported about the medications they received and their experiences in the two weeks following their dental visit for simple or surgical tooth extraction or management of toothache.

Precision and accuracy

To maximize the precision of our estimates, we adopted multiple recruitment methods for both dentist and patient participants and included patients who spoke English, Spanish, or Haitian Creole.

To maximize accuracy, we strove to obtain geographic representativeness by recruiting dentists from across the United States. To minimize non-response bias due to response burden, we kept the surveys brief, avoided open-ended response options, and used logic to display only relevant questions. To minimize non-response bias due to lack of clarity of the items’ interpretation, we piloted tested the dentists’ survey with two dentists. In addition, survey items were reviewed by subject matter experts at the U.S. Food and Drug Administration. To check for potential issues of generalizability, we compared the age, gender, and race/ethnicity of respondents with national distributions [18,19,20].

Data analysis

The following questions on the dentist survey were measured continuously but categorized for presentation: year completed training; the percentage of patients with simple extraction, surgical extraction, and toothache for whom the dentist recommends pharmacologic pain management; and the percentage of patients with simple extraction, surgical extraction, and toothache for whom the dentist recommends pharmacologic pain management that included an opioid medication. On the patient survey, questions assessing age and number of pills prescribed and taken were measured continuously but categorized for presentation.

We summarized the results of the categorical variables in our sample using counts and percentages. For statistical comparisons of variables with more than two groups where we were able to compare sample distributions to the population distributions (i.e., age and race for patients; gender, region, and specialty for dentists), we used chi-square goodness of fit tests to compare the distributions. For categorical variables with two groups (i.e., gender and ethnicity for patients), we used z-tests to compare proportions to the national proportions. For categorical variables where we were able to compare a proportion from the sample to a proportion from the population (i.e., Hispanic, Latino, or Spanish origin, Asian, Black or African American, White, and Other or Prefer not to Answer races for dentists), we used z-tests to compare proportions. For the three questions in Table 6, because the frequencies in some cells were too low to permit analysis using chi-square goodness of fit tests, we collapsed the “Sometimes,” “About half the time,” “Most of the time,” and “Always” values into an “Ever” variable. We used chi-square tests of association to compare the four resulting groups. “I don’t know” was omitted from the analysis. We performed the analyses using STATA 17 (College Station, TX). P-values < 0.05 were considered statistically significant. For variables for which the frequencies in some cells were too low to permit statistical analysis, we did not conduct statistical analyses.

Results

All 90 patients were recruited from HCN, with an additional 41 from HCN declining to participate. Dentists were recruited from three sources: 49 responded via the ADA email; 21 responded via research team member networking; and 56 were recruited from HCN. Of these, 77 were included in the analysis because the remaining 49 either declined to participate (n = 35) or did not meet the inclusion criteria (n = 14). See Supplemental Table 1, Additional File for the number of dentists targeted by the email and Supplemental Table 2, Additional File for the response to the Facebook ads. We lack information about the number of dentists targeted via word of mouth, at the annual meeting of the Montana Dental Association, or at HCN.

Patient and dentist demographic characteristics and attitudes

Because all survey respondents who were patients lived in the U.S. South, we compared patient survey respondent demographic characteristics with the demographic characteristics of adults living in the U.S. South. Compared with persons in the U.S. South, patients in the sample had a similar age distribution (\({\chi}^{2}\)(5) = 9.31; p = .10), but were more likely to be female (z = 2.03; p = .04), of Hispanic, Latino, or Spanish origin (z = 3.25; p < .01), or Black or African American (\({\chi}^{2}\)(3) = 66.42; p < .01). Most patients sought treatment to have a tooth removed (63.3%) or to manage a toothache and have a tooth removed (32.2%) and preferred to have a choice in the approach to pain management (74.4%). In addition, most patients preferred to avoid medications with narcotics or opioids (72.2%). Among patients who did not avoid narcotics or opioids or had no preference (n = 25), 6 (23.3%) preferred narcotics/opioids medications (Table 1).

Table 1 Demographic characteristics, reason for dental visit, and pain management preferences of patients (N = 90)
Full size table

Compared with dentists in the U.S., dentists in the sample were more likely to be women (\({\chi}^{2}\)(2) = 11.95; p < .01), Hispanic, Latino, or of Spanish origin (z = 2.56; p < .01), preferred not to answer about their race (z = 4.39; p < .0001), be from the West or Southeast (\({\chi}^{2}\)(4) = 26.53; p < .0001), and practice Public Health Dentistry (\({\chi}^{2}\)(5) = 475.38; p < .01). There were no dentists in the sample who practiced Oral and Maxillofacial Surgery, Orthodontics and Dentofacial Orthopedics, Periodontics, Prosthodontics, Oral and Maxillofacial Pathology, Oral and Maxillofacial Radiology, Oral Medicine, or Orofacial Pain. Most dentists performed simple and surgical extractions and treated toothaches (75.3%). Most dentists reported including their patients in the decision-making process most of the time or always (70.1%) when determining the pharmacological strategy to manage the patient’s pain (Table 2).

Table 2 Demographic characteristics, practice characteristics, and shared decision making practices of dentists (N = 77)
Full size table

Patient and dentist experience with the pharmacologic management of acute dental pain

Patients reported (Table 3) that the medication most frequently recommended or prescribed by their dentist when having a tooth removed (36.8%) or when both managing a toothache and having a tooth removed (65.5%) was ibuprofen. The medication most frequently recommended for toothache without tooth removal was acetaminophen (50%). Patients reported that the instructions most frequently provided by their dentist were to take at the first sign of pain (38.6% when having a tooth removed, 50% for toothache, or 82.8% when managing a toothache and having a tooth removed). Not all patients took pain medication: 73.7% of patients having a tooth removed took pain medication; 50% of patients managing a toothache without tooth removal took pain medication; and 86.2% of patients both having a tooth removed and managing a toothache took pain medication. Overall, patients reported being extremely satisfied with how the dental team managed their pain (78.9% of patient having a tooth removed; 50% of patients managing a toothache without tooth removal; and 72.4% of patients having a tooth removed and managing a toothache).

Table 3 Patients’ experience with the pharmacologic management of acute dental pain (N = 90)
Full size table

Over 50% of dentists reported (Table 4) that, in a typical month, they recommended pharmacologic pain management approaches to 91–100% of their patients, regardless of whether they were removing a tooth or managing a toothache. Most pain management did not include an opioid medication.

Table 4 Dentist experience with the pharmacologic management of acute dental pain
Full size table

Patient clinical adverse effects and dentist practice-related challenges

For each type of clinical adverse effect (e.g., dizziness, drowsiness), less than 3% of patients (Table 5) reported experiencing that consequence, regardless of whether the medication contained a narcotic/opioid. When patients did experience clinical adverse effects, they were generally mild.

Table 5 Patients’ clinical adverse effects associated with the pharmacologic management of acute dental pain
Full size table

Over 80% of dentists (Table 6) reported experiencing practice-related challenges, such as patients challenging their pain management recommendations; however, 92% of those who experienced practice-related challenges reported that they occurred with fewer than half their patients. Over 75% of dentists reported that patients reported experiencing unmanageable pain; however, 95% of those dentists reported that it occurred in fewer than half their patients. Over 45% of dentists reported that patients reported experiencing adverse effects such as dizziness, drowsiness, nausea, vomiting, headache, or constipation; however, 100% of those dentists reported that they occurred in fewer than half their patients. Over 31% of dentists who did not prescribe opioids reported never experiencing practice-related challenges compared with 10.4% of dentists who did prescribe opioids, prevalence risk = 1.30 (1.00-1.69), \({\chi}^{2}\)(1) = 5.17; p = .023. The risk of experiencing practice-related challenges was 1.3 times higher for dentists who prescribed opioids compared with dentists who did not. The risk of patients reporting experiencing unmanageable pain did not differ depending on whether the dentist prescribed opioids, prevalence risk = 1.06 (0.81–1.40). Similarly, the risk of patients reporting experiencing adverse effects did not differ depending on whether the dentist prescribed opioids, prevalence risk = 1.57 (0.89–2.76).

Table 6 Dentists’ practice-related challenges associated with the pharmacologic management of acute dental pain
Full size table

Patient and dentist perceptions of shared decision making

About 34% of patients reported that their dentist offered them choices in how to manage their pain. About 52% of patients reported that their dentist described the benefits and downsides of the different ways to manage their pain. About 34% of patients reported that their dentist asked them how they would prefer to manage their pain.

When determining the pharmacological strategy to manage their patients’ pain, 70% of dentists reported that they include their patient in the decision-making process (e.g., seek their patient’s participation, explain and help their patient compare treatment options, assess their patient’s values and preferences, reach a decision with their patient) most of the time or always.

Discussion

In this exploratory study, on average, less than 3% of patients and 80% of dentists reported experiencing clinical adverse effects and practice-related challenges respectively, regardless of the diagnosis, procedure, or pharmacologic approach adopted to manage acute dental pain.

Patients who did not manage their pain with a medication containing an opioid and dentists who did not prescribe opioids were consistent in their reports of the frequency with which they/their patients experienced adverse effects such as dizziness, drowsiness, nausea/vomiting, headache, or constipation. Although dentists prescribing opioids were more likely than patients who took a medication containing an opioid to report that their patients experienced these clinical adverse effects, the lack of report of these clinical adverse effects by patients who were prescribed opioids could have been due to the small number (N = 2) of these patients in our sample. Compared with patients, dentists were more likely to report that patients experienced unmanageable pain. It may be that dentists recall patients who report experiencing unmanageable pain. If that is occurring, dentists may be overestimating the occurrence of unmanageable pain among their patients. Alternatively, patients may be under-reporting their pain. Systematic reviews consistently find that healthcare providers have moderate to good pain assessment accuracy [21], however, they tend to underestimate patients’ pain [22, 23].

Over 62% of the dentists responding to the survey said they prescribe opioids. Compared with dentists who do not prescribe opioids, dentists who do prescribe opioids reported a higher rate of patients challenging the dentist, requesting a different pain medication, or contacting the dentist after hours for additional pain medication. Dentists prescribing or not prescribing opioids reported similar rates of patients reporting experiencing unmanageable pain and clinical adverse effects of the pain medication, such as dizziness, drowsiness, nausea/vomiting, headache, or constipation. Overall, dentists who do prescribe opioids may experience some practice-related challenges at a higher rate than dentists who do not prescribe opioids. This finding should be confirmed in future studies.

Shared decision-making is founded on principles of patient autonomy [24] and has been shown to be associated with patient knowledge and the ability to make higher-quality decisions [25]. Although most dentists reported that they involved the patient in decision-making, more than half the patients reported that they were not offered a choice in how to manage their pain and were not asked what they would prefer. Slightly more than half the patients reported that their dentist described the benefits and downsides of the different ways to manage the pain. Patient and dentist perceptions of shared decision-making warrant future research.

Based on the patient reports, there is variability in the instructions patients received for how to take their pain medications. Some dentists instructed their patients to take the medication at the first sign of pain; whereas other dentists instructed their patients to take their pain medication on a regular schedule regardless of whether the patient was experiencing pain. This may be an area for future research [26,27,28].

Demographic differences between the patients and dentists in our sample and patients and dentists in the U.S. may have introduced selection bias into our study and may affect the ability to generalize our results to the national level. Patients in our sample lived in the U.S. South. Compared with the county rates of opioid prescriptions per 100 people for patients living in the West, county rates are higher for patients living in the South [29].

Demographic characteristics of dentists have been shown to be associated with differences in opioid prescribing. For example, dentists in the West and South have been shown to write more opioid prescriptions than dentists in the Northeast or Midwest [16, 29, 30], and in our sample, we had relatively more dentist survey respondents from the West and South. Thus, our results may overestimate the rate of clinical adverse effects and practice-related challenges due to opioid prescriptions experienced by patients and dentists. On the other hand, dentists who are men or who are oral and maxillofacial surgeons are more likely than dentists who are women or who are general dentists to write prescriptions for opioids that exceed a 3-day supply or 50 morphine milligram equivalents (MME) per day [16, 31], and our sample included more dentists who are women and did not include any oral and maxillofacial surgeons. Thus, our results may underestimate dentists’ and patients’ clinical adverse effects and practice-related challenges resulting from opioid prescriptions occurring as a result of greater days’ supply and higher MME.

Although previous studies have examined clinical adverse effects experienced by dental patients, this is the first study to characterize practice-related challenges experienced by dentists and the first to characterize shared decision-making between dentists and patients around the management of acute dental pain. Strengths of the study include the inclusion of participants who had not been exposed to the guideline recommendations, enabling future comparisons, and geographic and linguistic diversity among participants. We used multiple methods to recruit participants, including email, Facebook banners, QR codes, flyers, word of mouth, and phone calls. We validated our survey by pilot testing it and subjecting it to FDA expert review. And we provided comparison data to enable determination of bias.

There are some limitations, however. Because we did not randomly sample patients and dentists to complete the surveys, it is possible that the patients and dentists who completed the surveys were different in some unmeasured ways from patients and dentists who chose not to complete the surveys. The surveys were retrospective rather than prospective. Thus, it is possible that respondents may have misremembered their experiences. To minimize this concern, we designed the surveys so that dentists responded about the previous month, and patients responded within two weeks of experiencing acute dental pain. Furthermore, previous research has shown that patients tend to overestimate their pain experience when recalling it retrospectively [32]. However, patients in the present study reported low levels of pain, suggesting that their recall was not biased. Because patients were read the survey and answers were sometimes provided by others, it may have been difficult for some of them to answer the questions. Patients and dentists were recruited separately, so we were unable to link patient responses to dentist responses. Future studies may benefit from linking patient reports to dentist reports. Finally, due to small cell sizes, we collapsed categories in three analyses. This may limit their interpretability.

There are additional limitations resulting from our desire to minimize survey response burden on the participants and increase the survey completion rate. We did not include questions about whether dentists were recruited from states that had licensing regulations requiring continuing education courses for licensure, what those requirements are, and whether dentists had taken those courses and were up to date with their MATE training. We did not include questions about the strength of the medications and MME of the opioids. We did not include questions about whether dentists suspected diversion or misuse of opioids. Some survey questions included more than one practice-related consequence, limiting our ability to characterize their individual frequencies.

Conclusions

In sum, prior to the release of the 2024 ADA-endorsed guideline for the pharmacologic management of acute dental pain, dentists and patients in our study sample reported that few patients experienced clinical adverse effects. Compared with dentists who did not prescribe opioids, dentists who did prescribe opioids reported a higher rate of patients challenging the dentist, requesting a different pain medication, or contacting the dentist after hours for additional pain medication. By switching from opioid to non-opioid-containing medication, dentists may be able to reduce the practice-related challenges they experience without increasing the clinical adverse effects their patients experience. These findings are exploratory. Future research should evaluate practice-related challenges and clinical adverse effects for dentists and patients prospectively using a stratified, nationally representative sample [33], should link patients’ and dentists’ reports, and should determine whether the types and frequencies of practice-related challenges and clinical adverse effects change as dental providers adopt the 2024 guideline.