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Pain Management: Prescribing Opioids After Dental Treatment
Mark Donaldson, BSP, RPH, PHARMD, FASHP, FACHE | Scott C. Dickinson, DMD | Jason H. Goodchild, DMD
Mark Donaldson, BSP, RPH, PHARMD, FASHP, FACHE is a clinical professor in the Department of Pharmacy at the University of Montana in Missoula, and clinical associate professor in the School of Dentistry at the Oregon Health & Sciences University in Portland, Oregon.
Scott C. Dickinson, DMD maintains a general dental practice in Pensacola, Florida and Pace, Florida where he treats patients and trains new dentists. He focuses his clinical practice on the diagnosis and treatment of occlusal (biting) and TMJ problems.
Jason H. Goodchild, DMD maintains a private practice in Havertown, Pennsylvania. He is also an associate professor and chair of the Department of Diagnostic Sciences at Creighton University School of Dentistry in Omaha, Nebraska.
Dr. Mark Donaldson: Orofacial pain typically results from two general pathologic mechanisms: tissue injury and inflammation (ie, nociceptive pain), or from a primary lesion or dysfunction of the nervous system (ie, neuropathic pain). The first step in management of orofacial pain is to determine if the pain is primarily nociceptive or neuropathic, or a combination of the two. This determination is critical for selecting medication(s) whose mechanisms of action will address the underlying pathophysiology. The most commonly encountered orofacial pain in dentistry is nociceptive pain.
While nociceptive orofacial pain can resolve spontaneously once the underlying cause is treated (ie, inflamed pulp, carious lesion, abscessed gingiva), a pharmacological approach to pain management may be considered the standard of care. This type of pain typically results from an identifiable source of tissue injury and inflammation and nociceptor sensitization. Pain resulting from inflammation may also have an underlying infectious etiology. Therefore, both anti-inflammatory analgesics and antimicrobial medications could be required.
Based on current evidence, the drugs of choice to treat nociceptive orofacial pain are acetaminophen and a non-steroidal anti-inflammatory drug (NSAID), which acts by inhibiting cyclooxygenase (COX) enzymes responsible for the formation of prostaglandins that promote pain and inflammation. The additive effects of acetaminophen and a NSAID have been repeatedly shown to offer superior analgesic effects to either drug alone and they have fewer side effects and less potential for abuse compared to opioids. Most importantly, this combination of medications is targeted at the underlying pathophysiology of nociceptive orofacial pain (inflammation), while narcotics do not directly affect this pathophysiology because they are not anti-inflammatory agents. At best, narcotics help patients to forget about their pain because they depress the central nervous system, but once these drugs begin to wear off, the patient recognizes that they still have pain and therefore reach for more narcotics.
This is the cycle we need to break. Prescribe the appropriate medicine for the right indication and you will heal the patient. Prescribe the wrong medication and not only do you avoid curing the patient, but you expose the patient to additional risks, adverse reactions, and drug interactions. That is just not good medicine.
Dr. Scott C. Dickinson: In dental practices around the country comprehensive and complicated multidisciplinary treatment is being performed every day. Culturally, there is a perception of postoperative pain. Clinically, there are expectations of pain management. Culturally, opioid analgesics are the perceived solution, while clinically, we know that in multiple drug studies over years of time the solutions lie elsewhere.
The management of pain in the dental office is a part of our daily practice but the approach of one or two standard medications to manage all situations needs to change. This change needs to come from a personal per patient approach to include pre-, during, and post-procedural patient management. This approach also needs to include the cultural perception of the dental office toward the patients’ management of pain. The entire dental team needs to be educated and part of the pain management process in the office to ensure success.
The large majority of pain created and treated in the dental setting is a result of infection and surgical trauma that can be seen and predicted. This pain is physiologically produced through the inflammation response and thus needs to be mediated through the medications and approaches that can best minimize their effects. Antibiotics, NSAIDS, steroids, local anesthetics, and a clear caring approach can best and most successfully alleviate the patient’s pain.
In the foundation of the original Hippocratic Oath, we find: “Also I will, according to my ability and judgment, prescribe a regimen for the health of the sick; but I will utterly reject harm and mischief.” As healthcare providers the responsibility lies with us to initiate the education and successful management of both the perception and presence of dental pain. No longer can we sit by idly and watch the epidemic of opioid abuse continue to escalate and destroy lives.
Dr. Jason H. Goodchild: Although dentists prescribe a relatively small amount of opioid analgesics, we can play an important role in preventing misuse and diversion of these medications. Historically, following dental surgical procedures, it was common for the dental practitioner to anticipate moderate to severe pain and prescribe an immediate-release narcotic analgesic. This was primarily driven by the dentists’ belief that moderate or severe pain required a more aggressive approach. This created an expectation by some patients that narcotics should be prescribed after undergoing invasive dental procedures.
There are two problems for dentists: patients expect and ultimately request to be prescribed an opioid following dental treatment; and dentists have historically done so despite research that NSAIDs may be more effective.
Patients’ anticipation of pain and their expectation of narcotic analgesics can involve historical factors such as past surgical experiences or feedback from friends and family about dental experiences, and may even be based on internet searches.
But what should a dentist do with a patient that requests narcotics following third molar extraction or periodontal surgery? It starts with patient education, and must involve a discussion about what to expect after surgery and why pain medications such as ibuprofen and acetaminophen can be more effective than opioids. It also must involve a discussion about why dental pain occurs and highlight the impact of inflammation, and the critical role anti-inflammatory medications can play. This discussion can also reiterate that narcotics do not address the etiology of dental pain, merely effecting the perception of pain, and are associated with adverse effects such as psychomotor impairment and addiction.