When are Opioids Indicated for Postoperative Analgesia in Dental Practice?
Raymond A. Dionne, DDS, PhD; Gary Warburton, DDS, MD; and Asma Khan, BDS, PhD
The routine use of opioid analgesics to manage postoperative dental pain has been questioned in light of the mortality due to opioid overdoses in the United States (>64,000 annually), their lower efficacy in comparison to nonsteroidal anti-inflammatory drugs (NSAIDs) for acute inflammatory pain, and their incidence of adverse events in ambulatory patients. NSAIDs have proven superior to opioid-containing combinations in most clinical trials in the oral surgery model,1 with additive analgesia produced by a combination of an NSAID and acetaminophen.2Possible misuse or diversion of opioid combinations is mitigated by prescribing an NSAID, thereby minimizing the possibility of the development of dependence that often leads to overdose deaths.
Additive analgesia for an NSAID plus codeine is equivocal because of the limited efficacy of codeine due to its variable conversion to morphine.3 Oxycodone provides limited additive analgesia over the initial 1 to 2 hours following administration but produces adverse events in approximately two-thirds of patients.4 Prescribing a combination of hydrocodone with an NSAID also results in equivocal analgesia and elevated incidence of adverse events and, along with oxycodone, has a high potential for contributing to opioid abuse.5
The limited analgesic efficacy of opioids for orofacial pain is likely due to the inflammatory nature of acute nociceptive pain and their dose-limiting adverse events, especially in ambulatory patients. An additional benefit of NSAIDs over opioids is the ability to minimize postoperative pain and edema with preventive treatment strategies to preclude the development of sensitization leading to hyperalgesia.6 The hundreds of well-controlled clinical trials and 40 years of clinical experience provide a strong rationale for using single-entity NSAIDs or a combination of an NSAID and acetaminophen to safely minimize acute orofacial pain in most patients with negligible risk for opioid abuse.
Individual variability in pain sensitivity7 and the response to analgesic drugs8 predicts that some patients, however, will experience acute pain following some dental procedures that will be inadequately relieved by preventive or postoperative administration of an NSAID combined with acetaminophen. Additionally, patients often equate optimal treatment with receiving a prescription for an opioid-containing analgesic. Given the high morbidity and mortality associated with opioid misuse and abuse, but the need to use opioids when non-opioid use may be inadequate, practitioners are faced with the question: When are opioids indicated for analgesia in dental practice?
Clinical Indications for Opioid Use for Oral and Maxillofacial Surgery
Major oral surgery, including orthognathic procedures, facial trauma, tumor resection, and open temporomandibular joint (TMJ) surgery, produce soft- and bony tissue injury that cannot be managed by an NSAID alone. Perioperative administration of a corticosteroid reduces edema and modulates the inflammatory response to decrease postoperative pain, but opioids are usually required for several days following such traumatic procedures. The opioid drug, dose, formulation, and time course (parenteral transitioning to oral administration) and the use of an NSAID vary based on the nature of the procedure. Patients who are allergic to aspirin or an NSAID cannot be administered drugs from this class and may require an opioid-acetaminophen combination. It is often problematic to determine if a patient reporting aspirin or NSAID intolerance is credible, but consultation with the primary healthcare provider may help to clarify whether the patient, in fact, has a credible intolerance to an NSAID or is drug seeking.
Arthroscopic procedures for the TMJ do not usually require opioid administration unless NSAID administration is contraindicated. If opioid administration is required after discharge from an inpatient setting, the opioid dose and number of units prescribed should be consistent with the expected duration of the postoperative pain duration. Request for prescription refills should be carefully evaluated and the patient re-examined if there is any concern that continued opioid administration is not required. The patient should be transitioned from an opioid to an NSAID or acetaminophen as soon as feasible to minimize the development of psychological or physical dependence, possibly contributing to an eventual overdose.
Clinical Indications for Opioid Use for Endodontic Treatment
Symptomatic irreversible pulpitis or periapical infections are often the basis for patients seeking care in an emergency department (ED) and requesting a prescription for an opioid.9 ED personnel are not trained in the diagnosis and treatment of dental conditions and may rationalize prescribing an opioid due to their concern for treating other patients with more serious medical urgencies. Patients presenting in a dental setting can usually be treated with pulpotomy, pulpectomy, or incision for drainage to provide adequate pain relief. For routine nonsurgical endodontic treatment, postoperative pain can usually be managed by administration of an NSAID.10 Periapical surgery requires incision, elevation of a flap, and bone removal and may require adjunctive use of an opioid if administration of an NSAID alone or combined with acetaminophen proves inadequate for pain relief. The newly emerging regenerative endodontic treatment does not result in substantial postoperative pain and should not require administration of an opioid.
Drs. Dionne, Warburton, and Khan
Given the unfavorable relationship between unnecessary opioid prescribing contributing to opioid abuse and the possibility of some patients experiencing pain that cannot be managed without an opioid, caution should be taken and careful consideration given as to when to prescribe an opioid following an oral surgery or endodontic procedure. Other dental procedures such as periodontal surgery, simple extractions, and reduction of teeth for a prosthesis do not usually produce pain that cannot be managed with an NSAID and acetaminophen. Consideration of the inflammatory etiology of most acute orofacial pain supports the use of drugs with anti-inflammatory activity rather than opioids that do not interfere with the process of inflammation. Preventive strategies should also be used to minimize the need to prescribe an opioid for most dental procedures (Table 1).
Aimed at reducing opioid misuse or abuse, such preventive strategies, as previously reviewed,11include the following prescribing options: Mild pain can be treated with over-the-counter ibuprofen, naproxen, or ketoprofen, as needed. For mild-to-moderate pain, prescribing options include ibuprofen 400 mg to 600 mg every 4 to 6 hours for the first 48 to 72 hours, not to exceed maximum recommended daily dose, and as needed until pain subsides. For moderately severe pain: prescription dose of NSAID before or immediately after the procedure, or administration of long-acting local anesthetic 0.5% bupivacaine with epinephrine for procedural anesthesia and postoperative analgesia, or postoperative administration of prescription dose of NSAID administered by the clock for 48 to 72 hours combined with administration of acetaminophen 600 mg to 650 mg by the clock; the two medications can be given concurrently or alternately. Lastly, for severe pain, a prescription of an opioid drug (3-day supply only) could be provided in combination with acetaminophen to be filled and administered only if needed for pain that is not relieved by a regimen for moderately severe pain, eg, two tablets of 325-mg acetaminophen plus 37.5-mg tramadol (ie, Ultracet) every 4 to 6 hours. Separate dosing of 600 mg to 650 mg acetaminophen would then need to be discontinued.
Clinical judgment is required to evaluate conditions where an opioid might be indicated versus inadvertently prescribing an opioid to someone who is drug seeking or has a heritable predilection for drug abuse. Offering to prescribe an antagonist analgesic such as pentazocine to an experienced abuser may elicit a negative response or reports of withdrawal-like symptoms indicative of opioid abuse. When opioid administration is indicated, drugs such as oxycodone and hydrocodone should be avoided due to their significant abuse potential. Administration of tramadol in combination with acetaminophen (Ultracet) should provide adequate analgesia for most clinical situations but with minimal risk of precipitating drug abuse or respiratory depression if administered in overdose.
About the Authors
Raymond A. Dionne, DDS, PhD
Professor, Brody School of Medicine, Department of Pharmacology and Toxicology, and School of Dental Medicine, Department of Foundational Sciences,
East Carolina University, Greenville, North Carolina
Gary Warburton, DDS, MD
Program Director, Oral and Maxillofacial Surgery Residency Program, University of Maryland, Baltimore, Maryland
Asma Khan, BDS, PhD
Associate Professor, Department of Endodontics, University of North Carolina, Chapel Hill, North Carolina
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