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318 Odontalgia
TOPICAL THERAPY
Topical preparations are frequently, if only partially, efficacious for OP. For
some OP etiologies (e.g. pericoronitis, infant teething), topical monotherapy
will often suffice. For other conditions (e.g. severe pain from alveolar osteitis
pain), topical drug application can be important adjunctive therapy.
Remember the contraindication of topical therapies in the setting of tooth
fractures (risk of sterile abscess development).
Alveolar osteitis is one cause of OP in which topical therapy is the
approach of choice. In alveolar osteitis, or “dry socket,” a focal osteomyelitis
occurs after premature lysis of a post-extraction clot. Abundant literature
addresses perioperative prevention, but there is a paucity of high-level
evidence assessing acute treatment. One approach incorporates socket
irrigation (with 0.9% saline) followed by packing with a dry socket paste.
The paste constituents vary, but benzocaine and eugunol (i.e. clove oil
extract) are recommended. The eugunol has an anesthetic effect on alveolar
bone and seems more effective than chlorhexidine mouthwashes or
lidocaine ointment. 31
In addition to its potential use in alveolar osteitis, benzocaine (available in
a variety of gel and paste concentrations ranging up to 20%) is efficacious in
other causes of OP. In fact, so long as benzocaine is used for a limited time
period (less than a week), its application no more than four times daily has a
favorable risk-to-benefit ratio for myriad causes of OP. For example, application
of benzocaine for carious disease relieves pain in over 80% of patients
(compared with 16% for placebo). 32 Topical benzocaine (applied no more
than four times daily) is also useful in infant teething; a few drops of the liquid
preparation are usually recommended for this indication. Pain related to
dental appliances can be treated by applying benzocaine paste to the (dried)
appliance before its placement in the oral cavity.
Another topical agent, choline salicylate, has been used for nearly a halfcentury
for its analgesia and anti-inflammatory effects. 33 The lack of more
up-to-date evidence, the theoretical risk of complications, and the availability
of other effective approaches mean that there is no role for ED use of choline
salicylate at this time.