Opioids

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?

1. First thing that you can do is pre-procedure: 600mg Ibuprofen given to the adult patient 1 hour before the surgery. This was found to also increase efficacy of analgesia during mandibular teeth with irreversible pulpitis⁷.
2. One step further is a local injection of the corticosteroid Dexamethasone directly after the surgery when the patient is already numb. This was found to reduce edema and trismus after third molar extractions⁸. Many studies list that 4-8mg of dexamethasone injected submucosally, next to the midline of the floor of the mouth results in great pain relief sometimes up to 7 days after surgery ^9,10,11.
3. So if we add this to the “2-4-24”, “1-2-4-24”. 1 of course being the 4-8mg of dexamethasone.

Considerations:

• US Food and Drug Administration suggests not going over 10 days of NSAID therapy
• Exceptions for the information above may include, put are not limited to, patients with prior myocardial infarctions, anti-thrombotic therapy patients, asthma patients, renal disease patients, and those who are pregnant ¹².

1. Cooper, S. A., Engel, J., Ladov, M., Precheur, H., Rosenheck, A., & Rauch, D. (1982). Analgesic efficacy of an ibuprofen-codeine combination. Pharmacotherapy, 2(3), 162–167. https://doi.org/10.1002/j.1875-9114.1982.tb04528.x

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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