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Pain control drugs · Pharmacology · INBDE Patient Cases

Local Anesthetics & Analgesics INBDE Patient Cases

By Dr. Isaac Sun, DDS

9 ADA INBDE-format patient cases on local anesthetics & analgesics. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

9 patient cases45 linked questionsADA INBDE formatFull distractor explanations

Nine ADA INBDE-format patient cases on local anesthetic and analgesic pharmacology: reported 'novocaine' allergy and safe amide substitution, local anesthetic systemic toxicity (LAST) with CNS excitation progressing to bupivacaine cardiotoxicity and 20% lipid emulsion treatment, the NSAID + warfarin bleeding interaction with acetaminophen as the safer first-line, ibuprofen plus acetaminophen as evidence-based first-line dental postoperative analgesia, short-course opioid prescribing principles and naloxone reversal, tramadol and serotonin syndrome with SSRIs (plus tramadol's seizure-threshold lowering), aspirin/NSAID-exacerbated respiratory disease (AERD/Samter triad), NSAID caution in older CKD patients on ACE inhibitors and diuretics (the 'triple whammy'), and avoiding codeine after pediatric tonsillectomy because of CYP2D6 ultra-rapid metabolizers. Topics include amide vs ester local anesthetics, LAST recognition and treatment, COX-1 vs COX-2 effects, acetaminophen pharmacology, opioid mechanism and stewardship, and the evidence-based dental analgesic ladder.

Case Coverage Map
What each case is testing
Reported 'caine' allergy and choosing a local anesthetic:
Amide vs ester, PABA allergen, no cross-reactivity, and that most reported LA allergies are non-allergic events.
Local anesthetic systemic toxicity (LAST):
CNS excitation then collapse, bupivacaine cardiotoxicity, 20% lipid emulsion, and prevention through aspiration, slow injection, and dose caps.
NSAID + warfarin and bleeding risk:
Reversible COX-1 antiplatelet effect and gastric mucosa, acetaminophen as the safer first-line, and continuing warfarin with local hemostasis.
Ibuprofen + acetaminophen for postoperative dental pain:
First-line multimodal analgesia, mechanism complementarity, dosing examples, step-up to short-course opioid, and the no-opioid-first-line principle.
Short-course opioid prescribing after severe acute pain:
Lowest effective dose for shortest duration, continued non-opioid co-therapy, counseling on side effects and storage, naloxone reversal, and stewardship.
Tramadol and serotonin syndrome with an SSRI:
Tramadol as SNRI + mu agonist, the serotonin syndrome triad, seizure threshold, and choosing non-serotonergic opioids in patients on SSRIs/MAOIs.
Aspirin/NSAID-exacerbated respiratory disease (AERD):
COX-1 leukotriene shunting, the Samter triad, acetaminophen-first analgesia, and avoiding histamine-releasing opioids at high doses.
NSAID caution in an older patient with kidney disease:
Prostaglandin-dependent renal perfusion, the NSAID + ACEi + diuretic triple whammy, blunted antihypertensives, and acetaminophen-first dosing.
Avoiding codeine after pediatric tonsillectomy:
Codeine pediatric black box (CYP2D6 ultra-rapid), tramadol same caution, aspirin/Reye contraindication, and weight-based ibuprofen + acetaminophen as first-line.
Patient case: Reported 'caine' allergy and choosing a local anesthetic
0 of 5 answered, 0 correct
Patient
Female, 42 years old
Chief Complaint
Reports an allergy to 'novocaine' from a childhood dental visit; needs an extraction today.
Background and/or Patient History
  • Childhood dental visit with a documented rash after a local anesthetic injection
  • Has tolerated topical benzocaine more recently without obvious reaction
  • Today needs an extraction with adequate anesthesia
Allergies
Reported 'novocaine' (ester); penicillin tolerated
Medications
  • None notable
Current Findings
  • History of ester local anesthetic allergy
  • Discussion of safe amide substitution
  1. Question 1
    Moderate
    Novocaine (procaine) is:
  2. Question 2
    Easy
    A safe local anesthetic substitution for this patient is:
  3. Question 3
    Hard
    Most reported 'caine allergies' in practice turn out to be:
  4. Question 4
    Moderate
    If a true cross-reactive amide allergy were suspected, a reasonable next step is:
  5. Question 5
    Easy
    The teaching point is that amide and ester local anesthetics:

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Patient case: Local anesthetic systemic toxicity (LAST)
0 of 5 answered, 0 correct
Patient
Male, 55 years old
Chief Complaint
Develops perioral numbness, tinnitus, and agitation shortly after multiple injections during a long appointment.
Background and/or Patient History
  • Long multi-quadrant restorative appointment with repeated injections
  • Multiple cartridges of lidocaine with epinephrine
  • Symptoms developed after the most recent injection
Allergies
NKDA
Medications
  • None notable
Current Findings
  • Perioral numbness, tinnitus, metallic taste
  • Agitation; progression to seizure feared
  • Likely LAST
  1. Question 1
    Moderate
    These early symptoms most likely represent:
  2. Question 2
    Moderate
    Without intervention, LAST progresses to:
  3. Question 3
    Moderate
    Immediate management is:
  4. Question 4
    Hard
    If cardiovascular collapse develops, the definitive treatment is:
  5. Question 5
    Moderate
    Prevention of LAST is the most important intervention; it includes:

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Patient case: NSAID + warfarin and bleeding risk
0 of 5 answered, 0 correct
Patient
Male, 68 years old
Chief Complaint
Postoperative dental pain after an extraction; asks whether he can take ibuprofen with his warfarin.
Background and/or Patient History
  • Atrial fibrillation on warfarin; INR stable in range
  • Routine extraction completed with local hemostasis
  • Asking about ibuprofen for postoperative pain
Allergies
NKDA
Medications
  • Warfarin
Current Findings
  • Patient on warfarin needing postoperative analgesia
  • Discussion of NSAID bleeding risk and acetaminophen alternative
  1. Question 1
    Moderate
    Adding an NSAID to warfarin raises bleeding risk because NSAIDs:
  2. Question 2
    Moderate
    The safer first-line analgesic in this patient is:
  3. Question 3
    Moderate
    If an NSAID is required for inflammation despite warfarin, the dentist should:
  4. Question 4
    Easy
    The clinical pearl is that NSAIDs added to anticoagulation:
  5. Question 5
    Moderate
    For the extraction site itself, the dentist relies on:

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Patient case: Ibuprofen + acetaminophen for postoperative dental pain
0 of 5 answered, 0 correct
Patient
Female, 28 years old
Chief Complaint
Asks about pain management after a routine third-molar extraction.
Background and/or Patient History
  • Healthy adult, no medical conditions
  • Third-molar extraction completed uneventfully
  • Discussion of multimodal analgesia
Allergies
NKDA
Medications
  • None
Current Findings
  • Healthy adult needing postoperative analgesia
  • Multimodal NSAID + acetaminophen plan
  1. Question 1
    Easy
    The first-line postoperative regimen for routine dental pain is:
  2. Question 2
    Moderate
    The two drugs work on different targets, which is the point of:
  3. Question 3
    Moderate
    An evidence-based dosing example for a healthy adult is:
  4. Question 4
    Moderate
    If pain breaks through despite the NSAID + acetaminophen regimen, the next step is:
  5. Question 5
    Easy
    The teaching point is that:

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Patient case: Short-course opioid prescribing after severe acute pain
0 of 5 answered, 0 correct
Patient
Male, 35 years old
Chief Complaint
Severe acute postoperative pain after a complex surgical extraction.
Background and/or Patient History
  • Complex surgical extraction of an impacted third molar
  • Pain inadequately controlled by ibuprofen + acetaminophen
  • Discussion of a short-course opioid prescription
Allergies
NKDA
Medications
  • Ibuprofen + acetaminophen (postop)
Current Findings
  • Severe acute postoperative pain
  • Indication for a short opioid course
  1. Question 1
    Moderate
    When an opioid is added for severe acute dental pain, the principles are to:
  2. Question 2
    Moderate
    Common dental short-course opioids include:
  3. Question 3
    Moderate
    Counseling for the patient should include:
  4. Question 4
    Moderate
    If the patient becomes over-sedated at home, the reversal is:
  5. Question 5
    Moderate
    Long-term opioid risks the dentist should consider in even a short course include:

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Patient case: Tramadol and serotonin syndrome with an SSRI
0 of 5 answered, 0 correct
Patient
Female, 38 years old
Chief Complaint
Confusion, tremor, sweating, and agitation after starting tramadol while on fluoxetine.
Background and/or Patient History
  • Long-standing depression on fluoxetine (SSRI)
  • Started tramadol two days ago for dental postoperative pain
  • Now with the picture below
Allergies
NKDA
Medications
  • Fluoxetine
  • Tramadol (recent)
Current Findings
  • Confusion, tremor, sweating, agitation
  • Hyperreflexia and clonus on exam
  • Concern for serotonin syndrome
  1. Question 1
    Moderate
    Tramadol is unusual among opioids because it is also:
  2. Question 2
    Hard
    Serotonin syndrome with tramadol + SSRI typically presents with:
  3. Question 3
    Hard
    Tramadol also lowers:
  4. Question 4
    Hard
    Acute management of serotonin syndrome is:
  5. Question 5
    Moderate
    For dental analgesia in patients on serotonergic drugs (SSRIs, SNRIs, MAOIs), the safer choices are:

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Patient case: Aspirin/NSAID-exacerbated respiratory disease (AERD)
0 of 5 answered, 0 correct
Patient
Female, 45 years old
Chief Complaint
Develops nasal congestion, wheezing, and facial flushing after taking aspirin for a headache.
Background and/or Patient History
  • Chronic asthma with nasal polyposis
  • Prior reactions to aspirin and naproxen
  • Aspirin-exacerbated respiratory disease (AERD) suspected
Allergies
Aspirin and naproxen reactions
Medications
  • Inhaled corticosteroid
  • Albuterol PRN
Current Findings
  • Asthma, nasal polyposis, and aspirin sensitivity (Samter triad / AERD)
  • Need for a non-NSAID dental analgesic plan
  1. Question 1
    Hard
    Aspirin-exacerbated respiratory disease (AERD) is driven by:
  2. Question 2
    Moderate
    The classic clinical triad is:
  3. Question 3
    Hard
    For dental pain in a patient with AERD, the safer analgesic plan is:
  4. Question 4
    Hard
    If an opioid is needed for severe pain, the choice should:
  5. Question 5
    Moderate
    The teaching point is that:

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Patient case: NSAID caution in an older patient with kidney disease
0 of 5 answered, 0 correct
Patient
Male, 78 years old
Chief Complaint
Postoperative pain after a routine restorative appointment; takes lisinopril and a diuretic; has stage 3 CKD.
Background and/or Patient History
  • Hypertension on lisinopril and hydrochlorothiazide
  • Stage 3 chronic kidney disease
  • Asks about ibuprofen for dental pain
Allergies
NKDA
Medications
  • Lisinopril
  • Hydrochlorothiazide
Current Findings
  • Stage 3 CKD with NSAID-sensitive renal physiology
  • Discussion of NSAID-avoidance and safe analgesia
  1. Question 1
    Hard
    NSAIDs are particularly risky in this patient because they:
  2. Question 2
    Hard
    The 'triple whammy' that especially raises acute kidney injury risk is:
  3. Question 3
    Moderate
    NSAIDs also blunt the effect of:
  4. Question 4
    Moderate
    The safer first-line analgesic in this patient is:
  5. Question 5
    Easy
    The clinical pearl is that in the elderly with CKD and antihypertensives, NSAIDs:

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Patient case: Avoiding codeine after pediatric tonsillectomy
0 of 5 answered, 0 correct
Patient
Female, 6 years old (pediatric)
Chief Complaint
Routine postoperative analgesia after a dental procedure; recently had a tonsillectomy.
Background and/or Patient History
  • Recent tonsillectomy and adenoidectomy
  • Now needs postoperative analgesia after a routine dental procedure
  • Family asks about a codeine-acetaminophen syrup
Allergies
NKDA
Medications
  • None notable
Current Findings
  • Pediatric patient, postoperative analgesia
  • Discussion of codeine contraindication
  1. Question 1
    Hard
    Codeine has a pediatric black-box contraindication after:
  2. Question 2
    Moderate
    The pharmacologic reason is:
  3. Question 3
    Moderate
    Safer first-line pediatric analgesics for dental pain are:
  4. Question 4
    Moderate
    Aspirin is avoided in children because of:
  5. Question 5
    Easy
    The teaching point is that pediatric dental analgesia:

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Keep studying
Local Anesthetics & Analgesics core recall

Refresh the anatomy facts these cases depend on: nerve numbers, foramina, functions, and lesion findings.

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