Pharmacology · patient case with 2 questions
After-hours telephone call about acute dental pain
Patient: Female, 22 years old
Chief Complaint: Telephones the practice at 11 PM in severe pain from a tooth.
Background: She was diagnosed with caries several weeks ago and scheduled for treatment, but did not attend because of dental anxiety. No drug allergies. No liver or renal disease. Takes no regular medication.
Current Findings: Telephone triage only. She reports throbbing pain that wakes her, lingering after cold, with no facial swelling and no difficulty swallowing at the time of the call.
Question 1
Which analgesic regimen should be prescribed over the telephone?
Show answer and explanation
Correct answer: B. Acetaminophen 325 mg combined with ibuprofen 400 mg
- A. Aspirin is an irreversible antiplatelet agent and is inferior to ibuprofen for dental pain. It also complicates any surgical intervention that follows.
- B. CORRECT. The combination of an NSAID with acetaminophen is the evidence-based first line for acute dental pain. The two act through different mechanisms — peripheral COX inhibition reducing prostaglandin-mediated inflammation, plus central analgesic action — and the combination outperforms either drug alone and matches or exceeds opioid combinations, without the addiction and respiratory depression risk.
- C. Opioids are not first line for acute dental pain. Current CDC and ADA guidance places non-opioid analgesia first, and prescribing an opioid by telephone to a patient who has not been examined compounds the problem.
- D. Ibuprofen alone at 600–800 mg is effective, but adding acetaminophen gives measurably better analgesia at no added risk. When the combination is on offer, it is the better answer.
Note: Analgesia is a holding measure. It never substitutes for removing the cause — pulpectomy, extirpation or extraction. Book her at the earliest possible appointment.
Question 2
She telephones again later. The pain has escalated dramatically and she is screaming. What is the most appropriate NEXT step?
Show answer and explanation
Correct answer: D. Direct her to the emergency department
- A. The analgesic regimen has already been given and has already failed. Repeating a failed intervention wastes time that may matter.
- B. Waiting is the option that carries real harm. Ludwig's angina and other deep space infections progress over hours.
- C. Escalating pain of unknown cause is precisely the situation in which telephone opioid prescribing is most dangerous. Adding sedation to a possible airway problem compounds the risk.
- D. Pain that escalates beyond the control of an adequate analgesic regimen is a red flag. Something has changed — a spreading infection, a developing space infection, possible airway involvement — and it cannot be assessed by telephone. The emergency department can provide parenteral analgesia, assess for spreading infection and airway compromise, and start intravenous antibiotics if needed.
Note: The airway questions to ask by telephone: any difficulty SWALLOWING, any difficulty BREATHING, any inability to open the mouth, any swelling under the chin or in the floor of the mouth, any fever. A yes to any of these means the emergency department, immediately.