Dental Pain and Inflammation—Acute and Chronic

The role of pain and inflammation in oral and dental disease can be present in many forms, all of which should be addressed. In discussing dental and oral issues and care with pet owners, mentioning pain and infection often elicits empathy and can help them decide to follow your recommendations for optimal care. A pet with a painful mouth may still be eating, but not as well as it could be, and an unkempt cat may be a sign that the mouth is too painful for grooming. Providing the best care that we can is important for our patients, starting with recognizing discomfort.

Acute Oral and Dental Pain

A patient can have acute pain issues due to tooth trauma, especially if the pulp/nerve complex is open and exposed. Although this can cause significant discomfort initially, once the neurovascular bundle dies and becomes necrotic, the acute pain typically decreases and any underlying chronic infection or inflammation may not seem to cause significant pain, unless an abscess occurs. The owner may not realize there is an issue, but any compromised tooth—open canal or discoloration indicating pulpal death—should be extracted or managed via a root canal procedure (endodontic therapy). Osseous fractures from more severe trauma can cause significant pain until the damage is repaired and healed. Some of the most common causes of acute pain in the oral cavity are surgical extractions and repairs, and even periodontal therapy. A multimodal pain management protocol is optimal to minimize any discomfort for our patients.

A complete perioperative analgesic protocol is critical for every dental surgery patient, no matter how extensive the procedure may be. In fact, even if “just a dental” is anticipated, many surprises often arise once radiographs are taken, so start with preoperative analgesics in every patient. In the presence of significant infection and inflammation or pain, administering oral medications for a few days prior to the procedure may help decrease the extent of the disease, make the patient more comfortable, and give you healthier tissues to work with. Antibiotics should only be used in the presence of distinct infection and will not be needed in many cases, based on individual situations. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be dispensed for patients with good renal health preoperatively, and in most patients postoperatively. A preanesthetic regimen may consist of a low dose of an opioid for pain, a mild sedative, and even an α2 antagonist in select patients.

Once the patient is under general anesthesia with appropriate monitoring and support, local or regional blocks should be placed to provide analgesia that will extend into the postoperative period. These will also allow the levels of inhalant anesthesia to be kept to a minimum.

Various techniques exist for regional blocks for regions that include the maxilla (infraorbital or caudal maxillary blocks) and mandible (inferior alveolar or caudal mandibular, and mental blocks). Providing some of these blocks can be technique sensitive, so good training for your veterinary team is suggested. Many local anesthetic drugs are available, and individual preference may be based on their clinical time to onset and duration of action. Lidocaine hydrochloride and bupivacaine hydrochloride are commonly used; however, the longer duration of bupivacaine is an important benefit, especially when the drug is used in conjunction with buprenorphine to potentiate the duration (a 9:1 ratio, bupivacaine:buprenorphine) or in its liposomal-encapsulated form (Nocita; Elanco). Postoperative instructions for patients may include starting or continuing the NSAID, using cool compresses, and avoiding hard diets and chews until healed.

Chronic Oral and Dental Pain

Dogs and cats can experience chronic pain due to a number of issues, from untreated periodontal and periapical infections and temporomandibular joint dysfunction (osteoarthritis [OA], ankylosis) to neuropathic pain conditions; they can also have pain after surgical procedures. Ulcerative diseases such as feline stomatitis (or feline chronic gingivostomatitis) and canine chronic ulcerative stomatitis can have varying levels of pain associated with the inflammation and ulceration that is typically due to an overactive host response. Extractions often help these patients extensively, but at times patients can have refractory inflammation and discomfort. Feline oral pain syndrome (FOPS), which is most prevalent in Burmese cats, seems to flare in response to stress and stimuli ranging from erupting permanent teeth to periodontal disease. Traditional medications such as corticosteroids and NSAIDs generally don’t help much with FOPS, whereas many patients will respond to phenobarbital, diazepam, or gabapentin.

Acute and Chronic Oral and Dental Inflammation

By definition, acute inflammation is the local immune response to cellular injury, serving as a mechanism to initiate the elimination of noxious agents and damaged tissue. It can be a complex response, with various cell types and multiple inflammatory mediators involved. As the body’s normal response to damaged tissue or the presence of harmful organisms, inflammation typically has a beneficial goal of helping tissues heal, including in the postoperative period. Management of acute inflammation may include the use of corticosteroids or NSAIDs and treating the underlying disease or trauma that was the inciting cause. Shortterm use of these pharmaceutics can be very effective, but there can be adverse effects. When short-term inflammation or pain is not adequately controlled, symptoms and concerns can ramp up.

Chronic pain or inflammation often requires additional levels of a multimodal approach, starting with the appropriate use of medications if the condition is severe, such as in chronic oral pain or OA. Additional therapies may include nutritional intervention, supplements, and antioxidants; applying esterified fatty acids to the gingival tissue for oral issues; and providing specifically targeted nutraceuticals such as glucosamine/ chondroitin sulfate for cartilage and connective tissue management for comorbidities. Beyond the oral cavity, excessive adipose tissue affects mobility and places stress on patients with OA; additionally, the impact of excess nutrients and diminished energy expenditure leads to the metabolic issues that form the basis of meta-inflammation, a low-level, chronic inflammation. Untreated oral and dental disease, especially periodontal disease, can also contribute to these levels of chronic inflammation that can have a systemic impact.

Chronic Inflammation and Aging

Inflammation from chronic oral or dental disease (as well as other causes) can also be a critical influence in the aging process, as has been shown in both humans and dogs. The inflammatory process results in an increase in inflammatory markers, immunosenescence, and oxidative damage, and this can result in pathologic changes linked to the chronic inflammation. With aging, chronic inflammation and cytokine production can result in a slower resolution of inflammation after infection or tissue insult. Although an owner may be concerned about an anesthetic dental procedure in older pets, we can minimize those risk factors with preoperative diagnostics, intervention, and optimal patient support during the procedure. The benefits frequently outweigh those risks, and we often see older patients with an improved quality of life once their dental disease has been controlled.

Assisting with Acute Pain and Inflammation

In addition to treatment and medications, we can provide adjunctive recommendations such as home dental care and appropriate diet and supplements to address pain and inflammation. Additionally, removing any environmental stresses can help improve oral discomfort in patients.

In the pre- and postoperative period, and for those patients with chronic inflammation and pain, a therapeutic targeted pulsed electromagnetic field (tPEMF) system, Calmer Canine, can be provided with the Loop for dental care by Assisi Animal Health. A modification of the classic Assisi Loop systems, and delivering the same FDA-cleared tPEMF signal, Calmer Canine is designed to help deliver the EMF to the area of the oral cavity. This technology has been proved to help reduce pain and swelling by increasing endogenous production of eNO (endothelial nitric oxide), a cell signaling molecule that increases production of anti-inflammatory cell mediators and stimulates production of endogenous endorphins and opioids in damaged oral tissue.

This device can be used to help reduce preoperative pain, erythema, and edema in oral inflammatory conditions. Postoperatively, it has been shown to help speed recovery and reduce swelling, pain, and healing time after dental extractions. It also helps reduce the need for opioids and other pain medications.

Presurgery Protocol

Calmer Canine is activated and applied around the patient’s muzzle or held adjacent to the injured, inflamed, or painful area of the mouth twice a day for 15 minutes. It reduces pain and inflammation and improves the condition of the tissues in preparation for a planned dental or orofacial procedure.

Postsurgery or Post-trauma Protocol

Apply the device around the patient’s muzzle or adjacent to the injured or affected area 2 to 4 times a day for 15 minutes, to reduce edema and pain and hasten healing.

Assisting with Chronic Pain and Inflammation

Due to the impact that chronic pain and inflammation can have on our patients, who are often suffering in silence, a multimodal approach, again, should be used to help maintain a good quality of life. Many studies and recommendations may start with a basis of providing some relief from chronic maladaptive pain with the use of medications such as gabapentin, amantadine, and even some ketamine protocols. In these patients, the tPEMF therapy of the Assisi Loop for dental care may also provide a benefit. Anecdotal information from dental specialists reports a decrease in inflammation when the Loop is used for patients with feline stomatitis and some refractory inflammation after full mouth extractions. This would not be considered as a monotherapy but used in conjunction with esterified fatty acid application, low dose doxycycline, cyclosporine, and a myriad of other stomatitis protocols. In some cats, increasing the time in between corticosteroid doses may provide a benefit. In fact, many oral medications can be very challenging to administer to a cat with a painful mouth, so the Loop can provide a noninvasive way to help.

Conclusion

As veterinary professionals, a key part of our patient focus is providing patients with a comfortable quality of life. Oral and dental issues can greatly affect the overall well-being of these patients, and we should work with pet owners to remove or manage any disease we can while continuing to provide options for complete pain management.