In Ontario, dentists are the third largest group of opioid prescribers after family physicians and surgeons, and therefore are possible contributors to the opioid crisis.1 The opioids commonly dispensed by Ontario dentists are codeine combination products (76.4%), oxycodone combination products (18.4%), and tramadol (2.8%).2 As recommended by the Royal College of Dental Surgeons of Ontario (RCDSO), dental pain should be treated with definitive treatment and managed subsequently with non-opioid medications before opioid medications are considered.3 In dentistry, the first line analgesic of choice to manage mild to moderate pain is acetaminophen. Then, if moderate to severe pain is expected, a non-steroidal anti-inflammatory drug (NSAIDs) may be considered and may be used in combination with acetaminophen. Dentists should only consider using opioid analgesics for the management of uncontrolled moderate to severe pain after exhausting non-opioid analgesics. If used appropriately, opioid analgesics can benefit patients who are unable to use acetaminophen or NSAIDs. However, opioids come with their own effects that can cause harm, and often a patient’s initial exposure to opioids is from the dental practitioner.1,5 This article will discuss the current climate of the opioid crisis in Canada and the current dental opioid prescribing trends in Ontario. Our objective is to remind dentists of best practices for management of postoperative dental pain. As a practicing group, dentists should continue to strive towards limiting opioids in dental prescribing to control the supply of opioids circulating in the public for potential misuse, abuse and/or diversion.
Current Climate of the Opioid Crisis in Canada
According to new statistics published by Health Canada, the COVID-19 pandemic is having a tragic impact on people who use substances and is contributing to the ongoing national public health crisis.5 Public health experts have identified several factors that may have caused the opioid crisis to intensify during the pandemic, such as an increasingly toxic drug supply, elevated feelings of loneliness, stress, anxiety, and changes in the accessibility or availability of assistance for drug users.5 Health Canada reports that between January 2016 and March 2022, there were a total of 30,842 apparent opioid toxicity deaths in Canada (excluding Quebec).5 During the first two years of the COVID-19 pandemic (April 2020 – March 2022), there was a 91% increase in apparent opioid toxicity deaths, compared to the two years prior (April 2018-March 2020).5 Males account for 76% of apparent opioid toxicity deaths and most deaths are among the young- to middle-aged group.5 To address this public health emergency, the Canadian government is working with federal, provincial, and territorial partners to address this crisis. Some of the federal government’s initiatives include making naloxone antidote kits available to anyone that requests one from a pharmacy, opening supervised consumption sites, and creating an opioid educational resource toolkit, which can be accessed at: https://www.canada.ca/en/health-canada/services/opioids/awareness-resources.html.
Opioid Prescribing Trends in Ontario
As mentioned earlier, in Ontario, dentists are the third largest group of opioid prescribers.1 In 2015, the RCDSO released a guideline document regarding the role of opioids in the management of pain in dental practice. This document recommends the use of opioids as a third-line treatment and, if prescribed, dentists should limit prescription quantity dispensed.3 Additional risk mitigation practices include assessing the patient’s risk of substance misuse, abuse and/or diversion, educating the patient on the safe use of opioids, and reassessing the patient prior to re-prescribing.3 A study by Guan and colleagues reported that between 2015 and 2017, there was a 28.1% reduction in the volume of opioids prescribed by dentists in Ontario associated with the 2015 Ontario guidelines. However, the release of the Guideline was not associated with a change in the dispensing rate, nor were there significant changes in the patient demographics of opioid recipients, types of opioid dispensed, or characteristics of the prescriptions such as opioid type, refill timing, multi-doctoring, and polypharmacy.2 That is, while the number of prescribed pills per patient has decreased, the number, demographics, and characteristic of patient prescriptions did not change. This tells us that continuing education and a cultural change in analgesic prescribing may still be warranted.
Etiology of Orofacial pain
Pain should be managed with the appropriate medications. Determining what type of pain is present is critical for selecting medications whose mechanisms of action will address the underlying pathophysiology. The etiology of orofacial pain typically results from two general pathological mechanisms: nociceptive pain or neuropathic pain. The most common orofacial pain in dentistry is nociceptive pain. This type of pain typically results from an identifiable source of tissue injury and inflammation and nociceptive sensitization. Nociceptive orofacial pain can resolve spontaneously once the underlying cause is treated (e.g., inflamed pulp, carious lesion, dental or periodontal abscess). It is the standard of care to offer patients non-pharmacological and pharmacological pain management within the postoperative healing period.
Best Practices for Management of Postoperative Dental Pain: Opioid-Free Analgesic Regimen
Based on current evidence, the recommended analgesic regimen to manage moderate to severe dental pain is a combination of acetaminophen and NSAIDs.3 Acetaminophen is the first line analgesic used to manage postoperative dental pain, providing effective analgesia for mild to moderate pain.4 NSAIDs work by inhibiting cyclooxygenase enzymes responsible for the formation of prostaglandins that promote pain and inflammation.4 The additive effects of acetaminophen and NSAIDs have been repeatedly shown to offer superior analgesic effects to either drug alone and have fewer side effects and less potential for abuse compared to opioids.4,6,7 Both medications effectively target pain and NSAIDs target inflammation. Together, these non-opioid medications target the underlying pathophysiology of nociceptive orofacial pain.
Dr. Mark Donaldson advocates for an opioid-free strategy he calls: 2-4-24.8 This mnemonic stands for 2 drugs (acetaminophen and ibuprofen), 4 doses (those 2 drugs every 6 hours, or 4 times a day) for 24 hours.8 The patient can take the first dose of these medications prior to leaving your clinic and they are responsible for three more doses taken precisely at the prescribed times. For more invasive dental procedures, patients can continue this opioid-free analgesic regimen beyond the initial 24-hour postoperative period or may choose to take these medications on an as needed basis. If patients require routine pain medication after the initial 48 hours following the dental procedure despite excellent compliance, re-examination by the dental practitioner should be strongly encouraged.3 Clinicians can also consider pre-emptive analgesia to reduce the inflammatory response, which is the administration of analgesic medications preoperatively to help mitigate pain, inflammation, and trismus following dental procedures.3,4
Opioids may be an appropriate prescription under certain circumstances. For example, patients with true allergies or contraindications to acetaminophen (e.g., hepatic disease) or NSAIDs (e.g., advanced renal or hepatic disease, congestive heart failure, active peptic ulcers or gastric bleeds) may benefit from an opioid analgesic.3,4,5,7 Outside of these exceptions, there is a limited role for opioids in treating routine postoperative dental-related pain based on both pathophysiology and pharmacology. It is postulated that opioids continue to be prescribed in the acute postoperative period for many reasons. One of the reasons may be to decrease the number of patient callbacks because the dentist expects the patient to experience significant postoperative discomfort. Another reason may be the expectation that prescribing an opioid may increase the overall patient satisfaction of the dental appointment. Unfortunately, the current body of literature has not yet attempted to describe opioid prescribing habits of dentists. Clinicians should avoid routine opioid prescriptions for dental pain because these medications are highly susceptible to misuse, abuse and/or diversion, and are a potential contributor to the current opioid crisis.3
A recent systematic review and meta-analysis published in The Lancet by Fiore Jr. et al. (2022) aimed to assess the value of prescribing opioids after surgical discharge on self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.9 The authors identified 47 randomized controlled trials which compared opioid vs. opioid-free analgesia after surgical discharge, focusing on minor and moderate surgery. This study included 19 randomized controlled trials which focused specifically on dental procedures (e.g., molar extraction, root canals, and implants). When the results of the trials were combined, the authors found that opioid prescriptions did not reduce patient reported pain intensity in comparison to opioid-free analgesia (e.g., acetaminophen, ibuprofen, and other anti-inflammatory medications). This review found that the use of opioids did not affect outcomes such as risk of patient dissatisfaction, pain interference, and healthcare reutilization. The use of opioid analgesics in the postoperative period was found to increase the risk of adverse events such as nausea and vomiting, dizziness, and constipation. These are side effects that make patients uncomfortable after surgery, may delay overall recovery, and decrease patient satisfaction. Overall, Fiore Jr. et al. (2022) suggests that the literature supports the decision for dentists to remove opioids from their discharge prescriptions without any major negative repercussions for patients undergoing common dental surgeries.10 Prescribing analgesics after dental procedures should be guided by evidence, rather than by tradition and dogma.
Conclusion
Canada is amid one of the worst moments in the opioid crisis due to the isolation and ample access to opioid substances during the COVID-19 pandemic. Dental prescriptions are a contributor to this ongoing public health crisis. The RCDSO and expert opinions send a clear message that routine opioid prescriptions do not have a place in the management of routine postoperative dental pain. Opioid analgesics should be reserved for specific cases of inadequately controlled dental postoperative pain after utilization of non-opioid analgesics, or for patients with true allergies or contraindications to acetaminophen and NSAIDs. Reports in Ontario have shown a reduction in the volume of opioids recently prescribed, but no similar decrease in prescribing rates. The current literature lacks descriptions of dentists’ perceptions and practices regarding opioid prescribing. This suggests that opioid prescribing in dentistry may be more complex than currently understood. We encourage more research to understand the opioid prescribing habits of dentists. In the meantime, dentists should continue to manage dental pain with effective and timely definitive treatment, and supplement this with opioid-free analgesia in the postoperative period.
Oral Health welcomes this original article.
References
- Health Quality Ontario. Starting on Opioids, Health Quality Ontario Specialized Report. 2018. Available at: http://startingonopioids.hqontario.ca/
- Guan Q, Campbell T, Martins D, et al. Assessing the impact of an opioid prescribing guideline for dentists in Ontario, Canada. JADA 2020; 151(1):43-50.
- Royal College of Dental Surgeons of Ontario. The Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice. 2015. Available at: https://az184419.vo.msecnd.net/rcdso/pdf/guidelines/RCDSO_Guidelines_Role_of_Opioids.pdf
- Haas, DA. An update on analgesics for the management of acute postoperative dental pain. J. Can. Dent. Assoc. 2002;68(8), 476–482.
- Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioid- and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada. 2022. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants
- Huang Q, Rasubala L, Gracely RH, et al. Comparison of Analgesic Prescriptions for Dental Pain and Patient Pain Outcomes Before vs After an Opioid Reduction Initiative. JAMA Netw Open. 2022;5(8):e2227219. Doi:10.1001/jamanetworkopen.2022.27219
- Agency for Healthcare Research and Quality. Comparative Effectiveness of Analgesics to Reduce Acute Pain in the Prehospital Setting. 2019. Available at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-220-analgesics-acute-pain-final.pdf
- Donaldson M. Pain Relief Without Opioids. CDA Essentials. 2017;7,19-21. Available at: http://www.cda-adc.ca/en/services/essentials/2017/issue7/20/#zoom=z
- Fiore Jr JF, El-Kefraoui C, Chay M, et al. Opioid versus opioid-free analgesia after surgical discharge: A systematic review and meta-analysis of randomized trials. The Lancet. 2022;399(10343),2280-2293. Doi: https://doi.org/10.1016/S0140-6736(22)00582-7.
- Canadian Dental Association. Opioid vs. Opioid-Free Analgesia after Surgical Discharge. CDA Oasis. 2022. Available at: https://oasisdiscussions.ca/2022/11/07/opioid-vs-opioid-free-analgesia-after-surgical-discharge/
About the Author
Dr. Amanda Vincci Chiu obtained her DDS from University of Toronto, completed her general practice residency at Sunnybrook Health Sciences Center and is now pursuing her residency training in dental anaesthesia at the University of Toronto. She can be reached at amandavincci.chiu@mail.utoronto.ca. Dr. Abbass Saleh, is a PGY3 resident in the Dental Anaesthesia program at the University of Toronto.
