The Last Patient of the Day

Correct answer: B. Prescribe ibuprofen with acetaminophen and arrange follow-up

• A. There is no medical emergency. Nothing about this presentation warrants emergency services.
• B. CORRECT. The combination of an NSAID with acetaminophen provides analgesia EQUAL OR SUPERIOR to opioid combinations for acute dental pain, with a far better safety profile — a large body of evidence supports ibuprofen 400–600 mg with acetaminophen 500–1000 mg as first-line. Prescribing it treats any genuine pain, addresses the demand appropriately, and does not require you to decide whether the patient is being truthful.
• C. There is no clinical finding to justify any analgesic prescription beyond first-line, let alone a Schedule II opioid, in a patient not of record at the end of the day who is specifying the drug by name.
• D. Turning away a patient who reports severe pain without examining or offering appropriate treatment is not defensible. You have examined him; the correct response is to treat appropriately, not to refuse engagement.

Note: The classic drug-seeking pattern: unfamiliar patient, end of day or weekend, pain out of proportion to findings, a named drug, a claimed allergy to alternatives, and reluctance to give a pharmacy or regular provider. Check the state Prescription Drug Monitoring Program before writing any controlled substance.

Correct answer: A. Schedule II

• A. CORRECT. Both oxycodone and hydrocodone — including hydrocodone-acetaminophen combinations, which were rescheduled from III to II in 2014 — are SCHEDULE II. Schedule II drugs have accepted medical use but high abuse potential with severe psychological or physical dependence. Practically, this means NO refills are permitted and a new prescription is required each time.
• B. Schedule I drugs have NO accepted medical use and cannot be prescribed at all: heroin, LSD, and (federally) cannabis.
• C. Schedule III includes codeine combinations (Tylenol with Codeine), buprenorphine and ketamine. Up to five refills within six months are allowed.
• D. Schedule IV includes the benzodiazepines — diazepam, midazolam, triazepam, alprazolam — and tramadol. Also up to five refills in six months.

Note: Dental-relevant memory aid: II = oxycodone, hydrocodone, morphine, meperidine, amphetamine. III = codeine combinations. IV = benzodiazepines and tramadol. V = low-dose codeine cough preparations.

Correct answer: B. Refer him to his physician for management of the chronic pain

• A. Saying nothing can be done abandons him. Something CAN be done — the referral, plus explanation of what has been excluded and why.
• B. CORRECT. Chronic pain with no identifiable dental cause is OUTSIDE the scope of dental practice. Chronic opioid therapy requires longitudinal assessment, monitoring and a single prescribing clinician — it is not something to be initiated or continued from a dental chair. Referring to his physician, with a clear note documenting that dental causes have been excluded, is both the correct clinical step and the correct professional one.
• C. A long-standing relationship does not create an indication. Prescribing an opioid without a dental diagnosis is inappropriate regardless of how well you know the patient, and fragmented prescribing across providers is precisely how patients are harmed.
• D. Antibiotics for pain without evidence of infection is inappropriate prescribing and contributes to resistance.

Note: Exclude the dental causes properly first: cracked tooth syndrome, atypical odontalgia, myofascial pain, trigeminal neuralgia and sinus disease can all masquerade as toothache. Then refer.