In 2017 alone, almost 17,000 people died from opioid overdose. Dentists are the second leading prescriber of opioids 2
Time to look for a better option then opioid pain killers
Patients in pain have been conditioned to receiving opioids, asking for prescriptions “Doc, can you give me something stronger?” Feeling bad for the patient, the doctor succumbs to the patients desires, and writes a script containing an opioid.
There are options out there, they work, and they provide better pain management versus the opioid treatment. This was already confirmed in 1982 when researchers completed a double-blind, randomized controlled trial of patients who had just had impacted wisdom teeth removed. When compared to codeine 60mg alone, and codeine 60mg with aspirin 650mg, Ibuprofen provided superior analgesia 1
Odontogenic pain stems from inflammation, rather than getting your patient to simply forget about the pain with an opioid, an anti-inflammatory should do the trick. A systematic review was completed that concluded that NSAIDs like ibuprofen 600mg should be the drug of choice, even for pain of Endodontic origin. That’s not even taking into consideration combination therapy with Acetaminophen. They also noted that for the patient who is unable to take NSAIDs, steroids may be a valid substitution 3
The maximum daily dose according to the FDA for Ibuprofen is 3200mg when prescribed4 . Interestingly, the makers of Tylenol have decreased the maximum daily dose from 4000mg to 3000mg5. Both of these are for adults.
So what is a great prescription for acute dental pain? Use the “2-4-24” method from Dr. Mark Donaldson and Dr. Jason Goodchild DMD: 2 pills every 4 hours for 24 hours. Ibuprofen 600mg combined with Acetaminophen 625mg every 4 hours for 24 hours. This will keep the patient well below the FDA and manufacturers guidelines6.
What if you need something a little stronger?
2. Thornhill, M. H., Suda, K. J., Durkin, M. J., & Lockhart, P. B. (2019). Is it time US dentistry ended its opioid dependence? The Journal of the American Dental Association, 150(10), 883-889. doi:10.1016/j.adaj.2019.07.003
3. Aminoshariae, A., Kulild, J. C., Donaldson, M., & Hersh, E. V. (2016). Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin: A systematic review of randomized controlled trials. Journal of the American Dental Association (1939), 147(10), 826–839. https://doi.org/10.1016/j.adaj.2016.05.010
4. Kuffner, E. (n.d.). Over-the-Counter (OTC) Ibuprofen: Cardiovascular Safety & Consumer Use. Retrieved January 13, 2021, from https://www.fda.gov/media/112979/download
5. TYLENOL® (Acetaminophen) Dosage for Adults. (2019). Retrieved January 14, 2021, from https://www.tylenol.com/safety-dosing/usage/dosage-for-adults
6. Donaldson M, Goodchild JH. Could the prescription you write put you in legal jeopardy? General Dentistry. 2018 Jan-Feb;66(1):9-12.
7. Lapidus, D., Goldberg, J., Hobbs, E. H., Ram, S., Clark, G. T., & Enciso, R. (2016). Effect of premedication to provide analgesia as a supplement to inferior alveolar nerve block in patients with irreversible pulpitis. Journal of the American Dental Association (1939), 147(6), 427–437.
8. Chen, Q., Chen, J., Hu, B., Feng, G., & Song, J. (2017). Submucosal injection of dexamethasone reduces postoperative discomfort after third-molar extraction: A systematic review and meta-analysis. Journal of the American Dental Association (1939), 148(2), 81–91.
9. Shah, S. A., Khan, I., & Shah, H. S. (2011). Effectiveness of submucosal dexamethasone to control postoperative pain & swelling in apicectomy of maxillary anterior teeth. International journal of health sciences, 5(2), 156–165.
10. Baxendale, B. R., Vater, M., & Lavery, K. M. (1993). Dexamethasone reduces pain and swelling following extraction of third molar teeth. Anaesthesia, 48(11), 961–964. https://doi.org/10.1111/j.1365-2044.1993.tb07474.x
11. Majid O. W. (2011). Submucosal dexamethasone injection improves quality of life measures after third molar surgery: a comparative study. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 69(9), 2289–2297. https://doi.org/10.1016/j.joms.2011.01.037
12. Aminoshariae, A., Kulild, J. C., & Donaldson, M. (2016). Short-term use of nonsteroidal anti-inflammatory drugs and adverse effects: An updated systematic review. Journal of the American Dental Association (1939), 147(2), 98–110. https://doi.org/10.1016/j.adaj.2015.07.020
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