Dental pain management in medically compromised patients: A comprehensive review and proposal of an analgesic ladder

Abstract

Background: Managing dental pain in medically compromised patients poses clinical challenges due to altered drug metabolism, systemic contraindications, and increased risk of adverse effects. Existing guidelines often lack specificity for this group, highlighting the need for a tailored approach to analgesic prescribing. This review aimed to survey the literature and propose an evidence-informed analgesic ladder for dental care in medically vulnerable patients. Methods: A comprehensive review was conducted using structured searches of PubMed, Scopus, Web of Science, and the Cochrane Library for studies published from January 2000 to May 2025. Eligible studies included randomized controlled trials (RCTs), systematic and narrative reviews, and clinical guidelines addressing dental analgesia in patients with conditions such as cardiovascular disease, renal or hepatic impairment, asthma, diabetes, and cancer. Forty-nine studies met the inclusion criteria. Findings were thematically analyzed by pain severity and patient-specific risk factors, forming the basis of a five-step analgesic ladder. Results: The proposed ladder offers a structured framework to guide dental clinicians in selecting analgesics based on pain intensity and patient medical conditions. It incorporates stepwise recommendations accounting for common comorbidities and contraindications, with emphasis on dose adjustment, combination therapy, and selective use of adjunctive analgesics. Conclusion: This review presents a practical, patient-centered analgesic ladder to support safer dental pain management in medically compromised individuals. Despite the limited availability of RCTs, this framework offers an evidence-informed tool for personalized dental pain care. Further research is needed to validate the model and explore the role of adjunctive analgesia.