- Dr. David Alfaro
Opioids and dental pain management
Another ask Dr. Dave!
My good friend Mike came up with an excellent question regarding the role of opioids/opiates in dental pain management. Historically, it has not been uncommon for dentists to prescribe Tylenol with codeine, or even stronger drugs such as Vicodin (acetaminophen and hydrocodone) or Percocet (acetaminophen and oxycodone), after painful dental procedures such as third molar extractions.
But what is the evidence to support this line of pharmacotherapy for the management of dental pain?
Let us talk pain management.
What are opioids and opiates?
Opioids and opiates are drugs that are derived from the Poppy plant, and directly block pain receptors, so they are very effective at relieving all sorts of trauma induced unpleasent sensations. Examples would be codeine, morphine, heroin, oxycodone etc.... Depending on which drug, however, they also block various other receptors, causing untoward effects such as respiratory depression, constipation and itchiness. They can be addictive, and can be very harmful if taken in large doses or if mixed with other drugs, such as alcohol.
Read more here: https://en.wikipedia.org/wiki/Opioid
What kind of drugs do I prescribe to control dental pain?
Going to the dentist is not fun. People can be quite sore after something as basic as a filling, or a deep cleaning. Then there are the procedures that definitely suck, such as having wisdom teeth removed, or gum grafting.
At my office I do a lot of surgery. It is rare for a day to go by where I am not taking someone's tooth out, or placing a dental implant or performing some sort of gum surgery. My patients come in knowing that they are in for a couple of unpleasant days after I am done with them.
The reality is, however, that even with all of the big procedures that I am doing at my office, I hardly ever prescribe pain killers any stronger than Advil or Tylenol. If I know that a procedure was difficult, or if the surgical site was open for a long time, yes, I will prescribe Tylenol with codeine, but I will inform the patient to start with Advil, at the regular precribed dose on the package. If that does not suffice, I then suggest that they supplement their pain management by taking Tylenol, half way between their Advil doses. This offers them a higher level of analgesia, without exceeding the recommended doses, using pain killers with different mechanisms of action. It is rare for me to have a patient tell me that they needed to fill the prescription for the Tylenol 3, and it is usually only for the first day or two if they do have to resort to it.
Is there evidence for this approach?
I was quite surprised at the scarcity of evidence looking at dental pain control. When I wrote my blog post about Tinder, I found hundreds and hundreds of articles. Dental pain management, on the other hand, had very little for me to sift through.
Pain is a difficult concept to study because it is not easy to measure, and the results are inconsisent between, and within, people. Pain is an experience. It is something that is affected by both physiological and mental factors, so it is very challenging to standardize both the stimulus and the evaluation of the response for a properly designed research project.
The vast majority of dental pain management articles that I was able to find were studies that looked at pain control after third molar extraction. Even though these articles look at one specific procedure, it is still difficult to standardize, because there are various variables that can affect the amount of pain that someone may experience after this surgery.
One of the most important factors is operator experience. A dentist that knows what he/she is doing can perform the procedure in less time, with less damage to the bone, gums and neighbouring teeth, in comparison to someone who is just starting off, or who performs the procedure infrequently.
I do not take out impacted wisdom teeth because of that exact reason. I refer to someone who does it all day, every day, or who has been doing it forever. It costs my patient more money, but it is better than me mucking around back there for an hour when an oral surgeon can shuck them out in fifteen minutes. In the end, the patient appreciates it.
Nonetheless, there is enough research to be able to take a look at the efficacy of different pain management strategies, and it tends to support my approach of avoiding strong drugs. NSAIDS (non-steroidal anti-inflammatory drugs) have been found to be very effective at controlling dental pain from third molar extractions, which is one of the more uncomfortable procedures that can be experienced at a dental office. The addition of narcotic analgesia, does impart a minimal improvement in pain control, but at a cost. The side effects of constipation and drowsiness are real, and the risk of addiction is high. I therefore avoid the prescription of these medications if the patient can manage things with Advil and Tylenol.
Read:
Addiction is a serious concern. Drug seeking behaviour is something that all medical professionals have to deal with, and it is a condition that is challenging to detect. Pain is a significant symptom that must be treated, but we have to be cautious as professionals to properly assess those patients that may be looking for more than pain management.
Ultimately, I approach pain control beyond the pharmacological tools at my disposal. As I said, pain is an experience. It is something that is not just affected by how much bone you have to cut or how big of a flap is reflected. It begins with the first conversation you have with the patient, and continues with with good anxiety control techniques, and ultimately culminates in the need for quick and effective surgical skills.
One of the great things that I appreciate about how I have structured my office is that I have the time to coach each and every patient through every procedure, regardless of how "simple" it may be. I have the time to give patients the opportunity to get comfortable and to relax, even if it is just by me sitting with them quietly as they get their nerves down. I know that I would not have the time to do this if I was running a traditional general dental office, where there are multiple patients being treated at the same time.
As a specialist, I am able to book patients one at a time, for as long as they need to feel comfortable. I often book people extra time beyond what is needed to physically perform the treatment, in order to give time for patient management. Yes, my patients do pay specialty fees which are above what they would pay in a traditional general dental office, but we are in an era where people pay a premium to have the newest phone, or to drive a nicer car, or to get a better hair cut. Why should dentistry be different?
If this sounds like something you want out of your dental office, please come and visit! I even do the cleanings myself. #sponsoredcontent haha ;)
Thanks for reading!
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Dr. Dave
drdave@alfaropros.com
