Dental procedures are considered routine in veterinary medicine, but like other “routine” surgeries, they can cause our patients significant pain. Every action, from scaling and probing to surgical flaps and suturing, stimulates pain-signaling nociceptors in bone and soft tissue. General anesthetics limit the perception of these pain signals, but don’t stop their transmission.
Pain generation and perception are complex, and different drugs work on pain at different points in the pathway. The best way to manage a veterinary patient’s pain upon waking from anesthesia is to control it before it starts with a multimodal dental analgesia plan.
Here’s a look at the basics of multimodal dental analgesia, including sample protocols you can adapt to nearly any patient who comes into your clinic for routine dentistry.
Key takeaways
- Multimodal dental analgesia involves combining systemic and local pain management techniques before, during, and after dental procedures.
- Using a combination of NSAIDs, opioids, adjunct drugs, and regional nerve blocks allows teams to reduce drug doses, limit side effects, and improve patient recovery in the hospital and at home.
- Standardizing protocols, empowering credentialed team members, and educating clients can help make multimodal dental analgesia part of your practice’s routine workflows.
What is multimodal dental analgesia?
Multimodal dental analgesia involves combining different drug classes and pain control techniques, both systemic and local, to address pain at multiple points along the nociceptive pathway before, during, and after a dental procedure. According to the 2022 AAHA Pain Management Guidelines, this approach is the standard of care for perioperative pain, including in dentistry.
Oral procedures stimulate a variety of pain types, including inflammatory, somatic, and sometimes neuropathic pain. Oral pain is a significant welfare issue in pets that often goes under-recognized. Added to the fact that periodontal disease affects the majority of adult dogs and cats, there is a high volume of patients who need robust pain control.
Inhalants, which impair consciousness, do not address pain, which persists long after the painful stimulus is removed. The 2019 AAHA Dental Guidelines note that subgingival scaling, curettage, flap creation, and extractions cause tissue trauma, warranting a full analgesic plan in addition to gas anesthesia.
Using multimodal dental analgesia, veterinary professionals can:
- Use lower doses of each drug, which often reduces side effects
- Target intraoperative nociception and the post-op inflammatory cascade
- Smooth inductions and recoveries for patients
Systemic analgesics: The foundation
Systemic drugs are the mainstay of perioperative analgesia. For dental cases, the preferred combination includes a non-steroidal anti-inflammatory drug (NSAID), an opioid, and, if needed, an adjunct medication for additional sedation or analgesia.
NSAIDs
NSAIDs are the first-line option for acute inflammatory pain in healthy dogs and cats. For an uncomplicated COHAT or minor procedures, a postoperative NSAID dose is typically effective. For extractions, an NSAID should be administered before surgery and continued for several days at home. Contraindications include renal insufficiency, gastrointestinal (GI) disease, bleeding disorders, and a high risk of hypotension.
Opioids
Full or partial μ-agonists, given as part of the premedication or intraoperative plan, can reduce inhalant requirements and help blunt responses to painful stimuli during procedures. Methadone and hydromorphone are good choices, and a continuous rate infusion (CRI) can be used for longer or more intense procedures. Opioids are safe for most patients, but teams should be aware of the potential for dysphoria, GI effects, and respiratory depression, and use lower doses to combat these effects in geriatric pets.
Adjuncts
Adjunct drugs add synergistic properties to the core opioid and NSAID protocol. Small doses of ketamine can prevent central sensitization and decrease opioid needs, while an alpha-2 agonist (e.g., dexmedetomidine) can provide anxiolytic, sedative, and analgesic effects in patients without cardiac issues. Gabapentin and trazodone can help to control anxiety and stress.
Local and regional blocks: The cornerstone
The 2019 AAHA Dental Guidelines recommend that anyone performing oral surgical or periodontal procedures be familiar with dental nerve block techniques, as local anesthetics reduce the need for inhalants and systemic analgesics and ease the transition to oral pain medications at home.
Useful blocks include:
- Infraorbital block: Blocks the ipsilateral maxillary incisors, canine, premolars, and associated rostral soft tissues.
- Maxillary (caudal maxillary) block: Blocks all teeth and supporting bone and soft tissues in the ipsilateral maxillary quadrant.
- Mandibular (inferior alveolar/caudal mandibular) block: Blocks all mandibular teeth and supporting bone and soft tissues on the ipsilateral side.
- Mental block: Blocks the rostral mandibular soft tissues and may provide analgesia for the incisors and canine.
The choice of local anesthetic depends on the desired onset and duration of action. Lidocaine has a rapid onset and short duration, while bupivacaine has a slower onset and longer duration. For that reason, many veterinarians use a combination of the two during regional blocks as part of their multimodal dental analgesia plan. Always calculate the total local anesthetic dose based on the patient’s body weight.
Dental analgesia at home
Good multimodal dental analgesia continues throughout the hospital recovery period and for several days at home. Controlling pain before it becomes unmanageable is the key to a successful recovery.
Regional blocks often keep patients comfortable for the first few postoperative hours, giving pet parents a window before the next NSAID dose is due at home. For COHAT and minor procedures, a single dose or 24 hours of NSAID therapy should suffice. For more extensive oral surgery, several days of NSAIDs and possibly an additional analgesic (e.g., opioid, gabapentin) are indicated.
Discharge instructions should reflect that multimodal dental analgesia continues at home. Ensure clients understand the concept of overlapping doses and pre-emptive analgesia so they stick to the prescribed schedule, and signs to watch for that might indicate their pet’s pain is not controlled.
Multimodal dental analgesia in everyday practice
Teams can make multimodal dental analgesia sustainable for a busy general practice by building it into existing dental procedure protocols. An extra premedication or intra-operative local block adds minimal time and expense to procedures, and these practices can quickly become part of routine workflows.
Steps to implementing or overhauling a multimodal dental analgesia standard include:
- Create standard protocols for minimally invasive versus surgical dental procedures, including premedications, intra-operative blocks, and medications to be administered at home. Make adjustments as needed for individual patients.
- Include dental nerve blocks and pain medications in package pricing for periodontal surgery and extractions.
- Empower credentialed technicians to learn various oral regional blocks as well as advanced CRI calculations and pain management techniques.
- Counsel all clients on the value of pain control before, during, and after their pet’s procedure.
Partners in pain control
Parnell manufactures FDA-approved veterinary anesthesia medications, including the useful analgesic adjunct and sedative, Dexmedetomidine Hydrochloride Injection. Alongside our Isoflurane inhalation anesthetic and PropofolVet Multidose, our anesthetic products help teams create a solid foundation for dental anesthesia and pain control for dogs and cats. If your team is refining its multimodal dental analgesia protocols or needs a refresher on anesthetic and sedative protocols and principles, check out our Foundations of Anesthesia and Sedation Certificate course.
