P-030 - (Poster #30) Readability of Patient Pain Management Instructions for Toothache or After Dental Extraction and Concordance with American Dental Association Guidelines

Adequate health literacy is critical for patients to understand medication instructions and healthcare provider advice. Health literacy is defined by the U.S. Department of Health and Human Services as the ability to find, understand, and use information and services to make health-related decisions. [Brach 2024] It is estimated that 88% of adults have inadequate health literacy, including 22% with knowledge that is basic and 14% that is below basic. [Lopez 2022] Thus, the recommended reading level of patient education and instruction materials is recommended to be no higher than the 8th grade according to the U.S. Food and Drug Administration (FDA) and 6th grade according to the American Medical Association (AMA). [FDA 2010; Weiss 2006]

Previous studies suggest that many patient education materials are written at a higher than recommended reading level, with some written at a reading level above high school. [Schnaekel 2015; Prabhu 2017; Ayyaswami 2019; Kumar 2020; Cheng 2022; Ahn 2024] This suggests that a large proportion of patients and their care givers may have significant difficulty understanding and following patient medication instructions. To our knowledge, the readability level of pain medication management instructions for toothache and after a dental extraction have not been previously assessed.

Purpose/Objectives:

The internet is a resource commonly used by many patients to access health or medical information. [Wang 2023] We sought to determine the readability level of patient instruction materials about the pain medication management of toothache and after dental extraction that are available to patients through an internet search, and whether these materials are concordant with the current American Dental Association’s (ADA) pain management guidelines for acute dental pain in adolescents, adults, and older adults. The ADA recommends the use of non-opioid analgesics as first-line therapy for both temporary management of toothache and post tooth extraction. The panel suggests using a nonsteroidal anti-inflammatory drug (NSAID) alone or in combination with acetaminophen. Ensuring alignment with these guidelines is important for providing consistent evidence-based care.

Methods:

Two Google searches were conducted on April 9, 2025, at 09:30 EST, using the parameters "discharge instructions for tooth extraction pain" and "toothache pain medication instructions." The first 100 websites returned were independently reviewed by 2 pharmacists. Websites were included if they were from dental practices in the U.S. and provided patient instructions on pain medication management, including dosing. Duplicates, promotional, non-U.S. based, inaccessible, intended for healthcare professionals, news articles, health blogs, social media posts, or for pediatric patients were excluded.

Reviewers independently identified instruction and dosing text, and the Flesch-Kincaid Grade (FKG) Level, the Simple Measure of Gobbledygook (SMOG) Index, and the Gunning Fog Index (FGI) were calculated using an online tool. Periods were added to bulleted and table entries, and extraneous symbols and page dividers were removed for consistency of readability calculations. Reading levels independently calculated by reviewers were averaged; if reading levels differed by more than 1 grade-level, independent review by a third dentist scientist reviewer resolved discrepancies. The concordance of medication and dosing recommendation with the ADA guideline recommendations were also independently assessed.

No patients were recruited for the study. All data were collected from public websites and did not require Institutional review Board Review.

Results:

The total number of websites meeting the inclusion criteria were 14 for toothache and 29 for dental extraction pain. FKG levels, which place greater weight on the length of sentences, and SMOG and GF indices, which place greater weight on the complexity of the words used, were able to be calculated for all included websites.

The median readability level for toothache medication instructions calculated based on FKG, SMOG, and GFI corresponded to 9th to 12th grade reading levels, with scores of 9.7, 12.0, and 11.6, respectively. The highest-grade reading level calculated for a toothache pain medication instruction was 11.3 for FKG, 12.0 for SMOG, and 14.3 for GFI, whereas the lowest was 8.2 for FKG, 11.3 for SMOG, and 9.7 for GFI.

The median readability level for tooth extraction pain instructions calculated based on FKG, SMOG, and GFI also corresponded to 8th to 12th grade reading levels, with scores of 8.6, 12.0, and 11.9, respectively.  The highest-grade reading level identified for tooth extraction pain was 12.0 for FKG, 12.0 for SMOG, and 16.5 for GFI, whereas the lowest was 4.8 for FKG, 9.0 for SMOG, and 8.6 for GFI.

No pain medication management instructions for toothache were written at or below a 6th grade reading level. Four pain medication management instructions for toothache (28.6%) were written at or below an 8th grade reading level based on FKG.

Few pain medication management instructions for tooth extraction were written at or below a 6th grade reading based on FKG (17.2%). Most of the instructions for tooth extraction pain were written at or below an 8th grade reading level based on FKG (55.2%) whereas 3.4% were written at or below an 8th grade reading level based on both SMOG and GFI.

Most of the websites with pain medication management instructions for toothache (78.6%) and for tooth extraction (72.4%) included recommendations concordant with ADA guideline recommendations. Of the pain medication management instructions that had variations from ADA guideline recommendations, only 2 (6.9%, for tooth extraction pain) recommended opioid medications as first-line therapy.  

Conclusions/Implications for future research and/or clinical care:

Pain medication management instructions should be written at or below the readability levels recommended by health authorities or professional organizations, such as the FDA and AMA. The finding that most websites with pain medication management instructions for toothache and dental extraction were written at a substantially higher reading level than is recommended, suggests that clinicians should consider reviewing their current patient education and instruction materials to ensure appropriate readability for their target patient population. New patient instructions related to pain medication management of toothache and dental extraction should be developed at a recommended reading level.

Although pain management should be tailored to the specific clinical circumstances of individual patients, pain medication management instructions should generally be consistent with current clinical practice recommendations. It is encouraging that most websites that provide medication management instructions for toothache and pain management after dental extraction are aligned with current ADA guidelines, recommending over-the-counter analgesics as first-line therapies and their appropriate dosing. Nonetheless, clinicians should periodically review the content of websites and instructional materials they provide or recommend to their patients to ensure it is accurate and up to date with current pain management guidelines.