Increasing attention has been given to the opioid epidemic in recent years, and for good reason. According to the Department of Health and Human Services, two million people had an opioid use disorder in 2018. On average, 130 Americans die every day from opioid overdose.
Health care providers must follow the pain management guidelines issued by the Centers for Disease Control to guard against the risk of addiction in patients. In the field of oral medicine, the question of when and what kind of pain medication should be prescribed is a constant topic of discussion.
At a recent talk at the Academy of Medicine, Dr. Elliot Hersh of the University of Pennsylvania presented research on pain management after oral surgery. Dr. Hersh shared insights from clinical trials of third molar (wisdom tooth) extractions, of which there are about five million cases annually. This is often the first time that young adults (aged 17-21) are exposed to opioids.
While it’s commonly assumed that opioids offer the greatest pain relief of any medication, the research has surprising findings about their ability to do so in an oral surgery context.
After an oral surgery, most (95%) of patients will experience moderate to severe pain between the first hour, up to three hours. Dr. Hersh explained that this pain comes from the inflammation of damaged cell membranes. Like any surgery, oral procedures can involve soft tissue and bone trauma. Because the pain is inflammation based, non-steroidal anti-inflammatory drugs (NSAIDs) have been recommended as a first-line treatment by the American Dental Association.
Dr. Hersh shared the following insights about pain management after oral surgery:
- While NSAIDs such as ibuprofen or aspirin are commonly seen as weak due to their over-the-counter accessibility, clinical trials show that they are the most effective in reducing post-operative pain.
- A double dose of acetaminophen is the second-most effective option, beating out any opioid. Acetaminophen in combination with an opioid can be used in cases where acetaminophen by itself is insufficient. However, NSAIDs perform better than either of these options, again because most postoperative pain is inflammatory.
- Not all opioids are equal. For example, some studies show that Tramadol taken by itself is only slightly more effective than a placebo. A major problem with any opioid is unpleasant side effects during consumption, which can include dizziness, nausea, and headache.
- Preemptive dosing with NSAIDs can be an especially important strategy for pain management. Patients who were given an NSAID 30 minutes before surgery and then again four hours after the procedure, had a much lower pain intensity than patients who followed the same regimen but with Percocet.
- Long-acting local anesthetics are another useful tool for pain management. Patients who received a long-lasting local anesthetic not only had less pain during the first four hours after surgery, but also up to 48 hours after the procedure.
Advantages and Limitations of NSAIDs
The research is definitive that NSAIDs work better than opioid analgesics for relieving pain from oral surgery. Opioids should only be added to this regimen in limited cases because 1) The relief they can provide for this type of pain is limited, and 2) They have addictive properties, which makes it harder to justify their use.
The advantages of NSAIDs for acute pain management include:
- Mechanisms of postoperative pain are targeted by reducing inflammation
- Minimal side effects
- Therapeutic index is favorable, indicating relative safety of the drug
- Availability of several chemical classes
The limitations of NSAIDs include:
- Possibility for gastrointestinal upset
- Risk for patients on blood-thinning medications
- Plateau effect: NSAIDs have a ceiling where additional dosing does not provide additional relief
Selecting the Right Pain Management Strategy After Oral Surgery
The dilemma faced by oral surgeons today is that patients are still numb from the local anesthetic at the time a medication prescription needs to be made. Pain tolerance varies from patient to patient. You can help your surgeon by sharing what your personal pain threshold is and what you might need in terms of relief during the first few days after the procedure.
There is no specific regimen that is guaranteed to produce a high level of relief after surgery, but various medication combinations can be considered.
Oral analgesic prescriptions are decided based on the procedure type and the anticipated pain level afterwards. Pain management can be achieved by targeting the source of pain (inflammation), for which NSAIDs are most appropriate.
In a systematic overview of 58,000 patients after wisdom tooth extraction, the combination of 400mg ibuprofen with 1,000mg acetaminophen was superior to any treatment that included an opioid.
When Should Opioids be Used?
Dentists must follow the CDC’s pain management guidelines as well as their state board’s recommendations when prescribing opioids.
While opioids do not target the root cause of pain after surgery, they do alter the nervous system’s response to painful stimuli. In other words, opioids can decrease the subjective experience of pain by blocking nerve receptors. It is precisely because of this powerful action on the nervous system that opioids are addictive in some people. Patients with chronic pain are at increased risk for developing an addiction if they take opioids for prolonged periods.
Your dentist will conduct a medical and dental history to determine current medications, the potential for interactions, and any history of substance abuse. Opioids can be used to treat moderate to severe pain when the patient understands their responsibility in preventing misuse as well as proper storage/disposal practices.
Oral Surgery at Penn Dental Family Practice
The dentists at Penn Dental Family Practice are leaders in evidence-based dentistry, both developing research and putting it into practice in their daily work with patients. If you suspect that you may need oral surgery soon, we encourage you to take advantage of the expertise of our skilled and knowledgeable specialists.
To make an appointment, please give us a call at 215-898-7337.