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Based on scientific evidence, what is the best method of post-operative pain management following surgical extractions?

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For a surgical extraction (flap, bone removal) what do you usually prescribed? Leave us your comments. Has the new legislative requirements in Ontario on narcotic prescriptions changed your practice?

From Dr. Stephen Cho, Oral & Maxillofacial Surgeon, Coronation Dental Specialty Group & Staff Surgeon, Cambridge Memorial Hospital

Pain management in dentistry is an important objective, necessary for patients’ comfort and trust.  There are numerous medications and strategies which could be utilized for post-operative pain management following surgical extractions such as wisdom teeth extration.

In his review on combination analgesic therapy in dental pain, Mehlisch suggests that monotherapy (eg acetaminophen alone) in treatment of pain is limited due to the ceiling effect that may be encountered where additional drug does not provide additional analgesia, and due to increased potential for adverse effects.  Combination therapy (eg acetaminophen with codeine) is more useful because pain is treated via different pathways, and because reduced doses of each individual drug can be used.  He suggests that mild pain be treated with acetaminophen or a low-dose non-steroidal anti-inflammatory drug (NSAID); moderate pain with a higher dose NSAID or acetaminophen, Tramadol, or opioid with acetaminophen or NSAID; and severe pain with opioid or Tramadol, with acetaminophen or NSAID.  Similarly, Phero et al suggest combining and optimizing an NSAID and acetaminophen together as baseline pain management, and adding opioid as needed for breakthrough pain.

Post-operative pain may also be influenced by factors other than post-operative analgesics.  Timing of analgesic administration may be considered, as ketorolac provided before surgery, rather than afterwards, has been shown to increase the time of analgesia and decrease the need for rescue analgesics.  Another study found that post-operative pain was reduced and fewer analgesics were taken when patients were given a post-operative injection of bupivacaine rather than lidocaine following periodontal surgery.  Finally, simple compression of the surgical site, with or without ice, was shown to significantly decrease post-operative pain following third molar surgery.

Unfortunately, no “best” method of post-operative pain control has been identified in the literature.  Instead, pain management, both strategic and pharmacologic, should be tailored to individual patients and the procedures they will undergo.

REFERENCES
Mehlisch DR. The efficacy of combination analgesic therapy in relieving dental pain. J Am Dent Assoc. 2002 Jul;133(7):861-71.
Phero JC, Becker D. Rational use of analgesic combinations. Dent Clin North Am. 2002 Oct;46(4):691-705.
Kaurich MJ, Otomo-Corgel J, Nagy RJ. Comparison of postoperative bupivacaine with lidocaine on pain and analgesic use following periodontal surgery. J West Soc Periodontol Periodontal Abstr. 1997;45(1):5-8.
Ong KS, Seymour RA, Chen FG, Ho VC. Preoperative ketorolac has a preemptive effect for postoperative third molar surgical pain. Int J Oral Maxillofac Surg. 2004 Dec;33(8):771-6.
Forouzanfar T, Sabelis A, Ausems S, Baart JA, van der Waal I. Effect of ice compression on pain after mandibular third molar surgery: a single-blind, randomized controlled trial. Int J Oral Maxillofac Surg. 2008 Sep;37(9):824-30. Epub 2008 Jul 7.

From Dr. Ramez Shehata MD, MBBCh, FRCP(C), PhD, Staff Anaesthetist, Cambridge Memorial Hospital and Medical Director, Coronation Dental Specialty Group
Post-operative pain after extractions is one of the most dreaded aspects of dentistry; so gaining adequate and sustainable control of it is critical to good patient care.

The management of this postoperative pain has been extensively studied with several non-steroidal anti-inflammatory drugs and narcotics. No single analgesic regimen has so far been developed to provide sufficient pain relief without any side effect. To avoid the dose related side effects of narcotics, use of NSAIDS has become popular for mild to moderate postoperative pain.

In an Evidence-Based Study of the Literature for a comparison of frequently prescribed analgesics at the university of Toronto for postoperative pain following dental surgery, Moore et al. found acetaminophen with codeine (T#3) to be an effective analgesic when compared to placebo in postoperative pain. 1 out of 6 patients with moderate to severe pain will get at least 50% pain relief with one Tablet of T#3, while with 2 Tablets of T#3 1 out of 4 patients achieve at least 50% pain relief, The addition of codeine however, was accompanied by a significant increase in drowsiness and dizziness.

Ahmad et al. found that non-opioids, such as acetaminophen and NSAIDs, provided better pain relief, while all NSAIDs as a group (ie. aspirin, ibuprofen, ketorolac, naproxen, ibuprofen) were not statistically better at relieving pain than the acetaminophen codeine combination, NSAIDs prescribed in specific doses after dental surgery, such as ibuprofen 400mg and ketorolac10mg, were found to be significantly more effective at relieving pain than acetaminophen 600mg in combination with codeine 60mg. Similarly, a dose of 10mg of ketorolac was more efficacious than Tylenol 3.

Cooper et al. investigated the efficacy and safety of various doses of oxycodone in combination with acetaminophen, combining peripherally acting acetaminophen and centrally acting oxycodone are effective analgesics. Oxycodone 5mg with acetaminophen (Percocet) proved to be an effective analgesic for treating moderate to severe postoperative pain with the least unwanted side effects. It was determined that Percocet is the most effective analgesic, followed by the NSAIDs ibuprofen and ketorolac , and then Tylenol #3 .

Merry et al, also found that patients using the combination of acetaminophen and ibuprofen experienced less pain during the first 48 h after oral surgery than those using the same daily dosage of either agent alone.  In summary, there are many combinations of narcotic and non-narcotic regimens that can be effective. Titrate the drug and dose to the patient and surgical needs with the knowledge that no single rule is effective for everyone or every situation. Having several options in mind is the most effective way to get early and long-lasting pain control for your patients.

For more reading see this article (pdf format) from Dr. Dan Haas, Dean, University of Toronto

REFERENCES
Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose paracetamol(acetaminophen) with and without codeine, for postoperative pain. The Cochrane Collaboration 2005(4).
Ahmad N, Grad HA, Haas DA, Aronson KJ, Jokovic A, Locker D. The efficacy of nonopioid analgesics for postoperative dental pain: a meta-analysis. Anesth Prog 1997;44:119–26.
Cooper SA, Prechaur H, Rauch D, Rosenheck A, Ladov M, Engel J. Evaluation of oxycodone and acetaminophen in treatment of postoperative dental pain. Oral Surg 1980; 50(6): 496–501.
Merry AF et al., Combined acetaminophen and ibuprofen for pain relief after oral surgery in adults: a randomized controlled trial. Br J Anaest 2010;104(1):80-88.

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Follow-up: Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Leave a reply“ below. Comments come directly to me for approval prior to posting. You are welcome to remain anonymous. We will never post your email address in any response

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5 Comments

  1. Lenny jung December 21, 2012

    Part of the discussion of pain management post op should include possible premedication to try and reduce the incidence if dry socket.
    There are studies that indicate a reduction of the incidence of dry socket (13 to 33%) with prophylactic course of clindamycin (incidence of dry socket 0.5%).

    Reply
    1. Hey Lenny,
      Completely agree that dry socket pain and treatment should be a consideration but…. if you’re incidence of dry socket is 20% doing anything will impact it. There was a recent meta-analysis that showed prophylactic abx have no impact on post-op complications for wisdom teeth (I’ll pull the study and post) so I don’t agree with the course of abx.

  2. Kevin J. McCann December 24, 2012

    Pain is to be expected following the removal of most mandibular third molars that require flap, bone removal and sectioning. We all know that the perception of pain will vary tremendously from patient to patient, however the ‘multi-modal’ approach to post operative analgesia will likely prove successful in most cases. The concept of pre-emptive analgesia should also be encouraged, and the administration of NSAID’s such as ibuprofen or ketrolac before surgery has been reported in the oral surgery literature. My personal approach is to give ketorolac 10mg IV pre-surgery, as long as no contraindication exist. Post operatively, the benefits achieved through the continued use of ibuprofen are exploited, and patients are given a script or ibuprofen 600mg to be taken around the clock every 6 hours. The rationale is to prevent the release of inflammatory mediators for pain. The daily maximum of ibuprofen is 2400mg, so at this dose, the patient is receiving maximal anti-inflammatory effect of the drug. In many patients, this will suffice. However should it prove to be ineffective, that patient is also given a script for oxycodone 5mg, with advice to take 1 to 2 tablets every six hours on an ‘as required’ basis. Depending on the level of post operative pain, the opioid can be taken concurrently with the NSAID (effectively creating a better form of Tylenol #3), or alternated every three hours with the NSAID. The rationale for oxycodone over codeine is the potential for CYP2D6 variation. Depending on who you read, up to 10% of the population will be poor metabolizers of codeine due to a lack of CYP2D6 function, and as such, codeine is not metabolized to its active metabolite, morphine. The popular press has also reported that there are tragic cases of children who are ‘hyper-metabolizers’ of codeine due to multiple copies of CYP2D6, and therefore are at risk of opioid toxicity. Additionally, codeine is a very weak opioid, and quite frankly, will not provide sufficient analgesia for many of the cases that we treat. Hence, oxycodone provides that extra bit of rescue analgesia that patients may require following routine exodontia. For those patients that are unable to tolerate tablets, the best alternative to codeine suspension is hydromorphone, which is available in suspension with a concentration of 1mg/cc. Starting dose for adults is 2-4mg q4-6h, and for children less that 50kg, 0.03 – 0.08 mg/kg q3-6h.

    It is unfortunate that oxycontin has created a fear in the public about the potential for addiction when oxycodone is prescribed, and in many cases, I do end up spending a significant period of time giving pharmacology lessons to concerned parents, that end up refusing the opioid script. In my humble opinion, I do not feel that being obliged to record a patient’s photo identification on a script will go a long way to reducing prescription abuse by the public, but time will tell. I have not changed my prescribing patterns despite the government’s attempt to provide better controls over opioid use.

    Reply
    1. Hey Kevin,
      Thank you very much for contributing. Totally agree with the ibuprofen regiment; I use it to. I never made use of oxycondone for routine wisdom teeth pain control – interesting alternative. The debate on control of narcotic abuse is a great one. Is it reasonable/likely to make an impact by tracking patient prescriptions? From a practical point of view, I think the bigger impact may happen from tracking doctor patterns. Great discussion point – thx. Ian.

      FOLLOW-UP
      The concern re abuse is very real; Kevin makes the point that the long-release product under the trade name oxycontin has created the fear of abuse potential whereas he uses the short acting oxycodone which can be prescribed under the trade name Percocet. The abuse potential of theses drugs, however, is still significant and in my opinion should only be prescribed with dilgence, as Kevin does. For more information on the concerns regarding abuse see this CCSA link or Heath Canada link. The blogs by Drs Cho and Shehata also point to evidence that codeine, while not is potent, can still be very effective in a multi-modal approach.

  3. Stephen Cho June 22, 2013

    I believe this post should be filed under “oral surgery” and “pharmacology” rather than “endodontics”

    Reply

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