Evidence-Based Pain Management: Dispelling Disinformation in Dentistry
Brooke Blicher, DMD; and Rebekah Lucier Pryles, DMD
According to the American Dental Association Principles of Ethics & Code of Professional Conduct, dental professionals hold a special position of trust and privilege within society, and thus are bound to adhere to the highest standards of conduct. This code of ethics defines key tenets, including veracity, patient autonomy, beneficence, nonmaleficence, and justice. Maintaining these ethical principles goes beyond the competent delivery of operative care and requires up-to-date, evidence-based knowledge and practices on the part of clinicians.1 With pain management being a key component of endodontics practice, clinicians must maintain their knowledge on the most effective evidence-based pain management strategies to ethically care for their patients.
Pursuing the Best Information
To maintain veracity, or truthfulness, practitioners need to possess basic science knowledge as well as the skills to seek out, distill, and digest the constantly evolving body of scientific literature. Completion of high-quality, unbiased continuing education courses is a means to both fulfill required learning and keep current on topics of relevance to dental clinical practice. All providers should be willing and able to consult primary literature sources to ensure understanding and accuracy of basic and novel concepts, and be capable of discriminating between the highest quality of evidence and questionable sources on any given topic.
For pain management, this means consulting the best sources of information, including references like the Oxford Pain Group League table of analgesic efficiency.2 It is from high-quality sources that clinicians learn that the most effective medication regimen for postoperative endodontic pain is a combination of ibuprofen and acetaminophen.3 Moreover, bupivacaine is an excellent adjunct in the management of severe postoperative discomfort.4
When considering whether to apply the findings of new research, providers should bear in mind the ethical principles of nonmaleficence, or "do no harm," as well as beneficence, which means acting for the benefit of the patient. This is especially true with pain management, where historic practices with recognized risks must be reconsidered. Clinicians and policy makers alike now understand that even judicious opioid use is associated with significant risk, namely the development of addiction in susceptible populations.5 This realization, coupled with the understanding that opioids do not represent the optimal method for pain management in dentistry, but rather are adjunctive in the control of only the most severe pain, means that "do no harm" often means utilizing other strategies in pain management.6
Beyond provider knowledge, disinformation can interfere with the delivery of ethical care. Patients may lack foundational scientific knowledge to fully appreciate the benefits of proposed dental care. It can be challenging for providers to make the connection between best practices and what's best for the patient who is unable to grasp or is misinformed about the scientific literature.
Communication Is Key
Nonetheless, effective communication can help ensure ethical delivery of care for all patients, no matter their grasp of dental concepts. Patient autonomy must accompany the process of informed consent, whereby patients grant permission for treatment with a full understanding of the risks and benefits associated. The patient interview offers insight into the patient's baseline dental knowledge and perceptions of their condition. Compassionate listening by an engaged provider helps build the trust that is foundational to the patient-doctor relationship, allowing an open and accepting dialogue as the conversation progresses to the examination, diagnosis, and treatment.
Misinformation does not always come from nefarious sources; rather, certain patients' own professional areas of expertise might cause them to mistakenly assume a high level of dental knowledge. For example, a highly trained medical subspecialist might insist on systemic antibiotics rather than endodontic treatment to treat an asymptomatic endodontic infection or a symptomatic irreversible pulpitis, a non-infectious diagnosis, by misapplying evidence from their field to dentistry.7,8 Acknowledgment of the differences between infections in their subspecialty and dental pathology, supported by scientific reasoning, can allow for clear communication between mutually respectful professionals.
More challenging are patients who question the science behind recommendations. These are patients who may subscribe to ideologies and practices outside of mainstream healthcare, often considered "pseudoscience." Sometimes patients are simply exploring the periphery of mainstream science, or they may have become disenchanted by prior healthcare experiences. In other cases, patients have contrarian mindsets and tend to shun anything mainstream. In approaching these sources of disinformation, providers should lead with empathy and engage in active listening. Stopping short of collusion, providers should praise patients for their engagement and critical thinking. Providers can reflect on the patient's perceptions and acknowledge that the many sources of information available today can challenge doctors and patients alike aiming to distill the truth. This can facilitate a thoughtful and compassionate discussion wherein the provider shares the evidence-based process of clinical decision making and how it may be counter to the patient's preconceptions. The personal connection of an encounter with a trusted provider in the context of a dental examination can oftentimes enable patients to adapt to new information.
That said, certain patients may be unwilling to follow sound advice. If patients push back against necessary care, or insist on following treatment guided by disinformation, providers must be willing to establish firm boundaries to protect their patients from harm in order to adhere to ethical dental practice.
Conclusion
In pursuit of justice, the final tenet of dental ethics, all patients deserve access to high-quality dental care. Dental providers are obliged to engage with patients in order to dispel myths and disinformation. Although it is much easier to poison the well than to clean it up, dental providers need to be equipped with the knowledge and skills to impart veracity to their disinformed patients. Incorporating empathy, patience, and a keen understanding of patient preconceptions can allow for the delivery of optimal care.
About the Authors
Brooke Blicher, DMD,
Certificate in Endodontics
Assistant Clinical Professor, Department of Endodontics, Tufts University School of Dental Medicine, Boston, Massachusetts; Lecturer, Department of Restorative Dentistry and Biomaterials Science, Harvard School of Dental Medicine, Boston, Massachusetts; Private Practice limited to Endodontics, White River Junction, Vermont
Rebekah Lucier Pryles, DMD,
Certificate in Endodontics
Assistant Clinical Professor, Department of Endodontics,
Tufts University School of Dental Medicine, Boston,
Massachusetts; Lecturer, Department of Restorative
Dentistry and Biomaterials Science, Harvard School of
Dental Medicine, Boston, Massachusetts; Private Practice
limited to Endodontics, White River Junction, Vermont
References
1. American Dental Association. Principles of Ethics & Code of Professional Conduct. Chicago, IL: ADA Council on Ethics, Bylaws and Judicial Affairs; 2023. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/about/ada_code_of_ethics.pdf?rev=ba22edfdf1a646be9249fe2d870d7d31&hash=CCD76FCDC56D6F2CCBC46F1751F51B96. Accessed May 3, 2024.
2. Richards D. The Oxford Pain Group League table of analgesic efficacy. Evid Based Dent. 2004;5:22-23.
3. Menhinick KA, Gutmann JL, Regan JD, et al. The efficacy of pain control following nonsurgical root canal treatment using ibuprofen or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled study. Int Endod J. 2004;37(8):531-541.
4. Gordon SM, Brahim JS, Dubner R, et al. Attenuation of pain in a randomized trial by suppression of peripheral nociceptive activity in the immediate postoperative period. Anesth Analg. 2002;95(5):1351-1357.
5. One hundred fourteenth Congress of the United States of America. Act S. 524. Comprehensive Recovery and Addiction Act of 2016. https://www.gpo.gov/fdsys/pkg/BILLS-114s524enr/pdf/BILLS-114s524enr.pdf. Accessed May 3, 2024.
6. Keiser K, Hargreaves KM. Building effective strategies for the management of endodontic pain. Endod Topics. 2002;3(1):93-105.
7. Johnson MD. Endodontics and Antibiotic Update.American Association of EndodontistsColleagues for Excellence. Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. Accessed May 3, 2024.
8. American Association of Endodontists. Glossary of Endodontic Terms. Tenth ed. 2020. https://www.aae.org/specialty/clinical-resources/glossary-endodontic-terms/. Accessed May 3, 2024.
