We talk about “dirty doctors” all the time as drug diversion investigators, but I can’t think of anything creepier than having my teeth cleaned by a “dirty dentist!”
Drug diversion professionals investigate dentists on a fairly routine basis. Why? Most dentists hold a full DEA Registration and it is not beyond the realm of possibility for a dentist to be just as guilty of the crime of drug diversion as it would be for an internal medicine or pain physician.
The excuse we usually hear from the dentist goes something like this, “Look guys, I do a lot of dental surgeries here and there is a lot of pain after the procedure that my patients have to deal with. I don’t want the reputation of being an uncaring dentist!”
Sometimes I buy this excuse, but only after a thorough examination of their internal records. So let’s take a quick look at the realities of chronic post procedural pain in dentistry and what the drug diversion investigator should be looking for. God knows, we’ve all heard the “My mouth was killing me for weeks after that root canal” from a host of friends and relatives.
Persistent pain following dental extraction or periodontal procedures suggests the possibility of infection or in cases of endodontic therapy, an unrecognized diagnosis or the development of an atypical or neuropathic pain problem. Remember, neuropathic pain and nociceptive pain are two entirely different animals…and so are the treatment modalities used by the physician or dentist!
Persistent chronic nonodontogenic pain (tooth/mouth pain) can appear or develop after a root canal treatment and it is not entirely uncommon. (1) In cases involving infection, pain management must include antibiotic coverage (look for evidence of concomitant antibiotic prescribing by the dentist with pain medications in the patient records).
Management of chronic atypical or neuropathic pain presents multiple challenges that may necessitate referral to a pain specialist or pain clinic.
However, from the dentist’s point of view, the first step in managing chronic post procedural pain is to revisit the pain symptomatology and examine the findings in order to re-establish a comprehensive differential diagnosis (again, this should be noted in the patient records and infection should have either been treated or ruled out).
Persistent pain localized in the teeth may be caused by continuing periapical pathology, but it can also be caused by intracranial, vascular/myofascial, neurogenic, TMJ, ear, eye, nasal, paranasal sinus, lymph node, and salivary gland pathology, as well conditions such as untreated coronary vasospasm and refractory angina.
Management of atypical facial pain or atypical odontalgia of unknown etiology (termed Persistent Facial Pain of Unknown Etiology [PFPUE]) can be managed by a knowledgeable dentist utilizing any number of techniques.
Examples of treatments could include multimodal drug therapy (probably why we were there conducting an investigation in the first place), cognitive/behavioral intervention, and other non-invasive strategies helpful in treating chronic pain.
Here’s something else to look for in the patient records: NSAIDS combined with tricyclic antidepressants or anxiolytics can be useful in treating PFPUE.Anticonvulsants have also been suggested as helpful in some cases of patients dealing with chronic pain.
Given the often complex nature of PFPUE, multidisciplinary management that includes psychological support should be a necessary component of treatment. Only dentists with advanced training should attempt to manage these problematic patients (which leaves most of the dentists we deal with out of the loop).
The bottom line is that opioid therapy isn’t the only treatment that dentists have available to them to treat chronic post procedural pain! Make sure to ask the dentist what other treatment modalities he/she uses in treating chronic pain and then look for evidence of their utilization in patient and dispensing records. If their only solution to post procedural chronic pain is the prescribing of opioids, then get ready to spend a lot of time weeding through a ton of patient records.
One last clinical note: Persistent dental hypersensitivity can occur after restorative care. In these cases the exposed cementum can be treated with a desensitization agent with fluoride or strontium chloride, and/or a topical application of resin.
(1) ”Nonodontogenic pain is not an uncommon outcome after root canal therapy and may represent half of all cases of persistent tooth pain. These findings have implications for the diagnosis and treatment of painful teeth that were previously root canal treated because therapy directed at the tooth in question would not be expected to resolve nonodontogenic pain.” Source: American Association of Endodontists.
Dr Ken Romeo is a forensic scientist and board-certified physician. His research interests are in the fields of experimental criminology (predictive analytics), crimes of drug diversion, fraud and financial crimes. He has conducted field experiments on finding ways to reduce drug diversion by health care workers and detect financial crimes in the US health care system. In conjunction with governmental authorities, Dr Romeo is currently developing new methods and tools for detecting physician and pharmacy driven drug diversion at the earliest stages. Dr. Romeo does not engage in the practice of medicine. He serves solely as a consultant to government and industry.