A call for the end of routine opioid use after wisdom tooth removal

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We are writing as a parent and a dentist to spread a message to parents and dental health care providers across Canada: there are alternatives to prescribing opioids after wisdom tooth removal.

Removing wisdom teeth is considered by many as a rite of passage for teenagers. It is one of the most common surgical procedures done in young people aged 16 to 24.

Amy’s 16-year-old son, Felix recently had his wisdom teeth removed. After surgery, the surgeon’s assistant advised that to “stay on top of the pain,” Felix should take a Percocet right away.  Percocet is a combination of the pain reliever, acetaminophen, and an opioid, oxycodone. She provided him with enough Percocet to take every three hours for the next day.

Thankfully, Amy knew of the possible harms associated with powerful opioid medications, such as Percocet, especially for young people. Abuse of opioids is a national public health emergency, with growing numbers of opioid overdoses and deaths.

So, she asked the surgeon’s assistant whether there was another pain management option for Felix instead.  Tylenol #3 was suggested (acetaminophen with the opioid, codeine), which still seemed too powerful.

How did Amy know to question the advice she was given?

Amy serves as the patient advisor for the national campaign, Choosing Wisely Canada, which partners with national clinician societies to develop lists of tests, treatments and procedures that may cause harm.  So she knew that the Canadian Association of Hospital Dentists recommends non-opioid based pain medications to be prioritized following dental surgery and to resort to opioids only if the pain cannot be managed.

Amy chose to ask for Naproxen for Felix — an over the counter pain reliever in the same drug class as Aspirin and Ibuprofen. Felix took the Naproxen as directed when the anesthesia wore off, and he did not require anything stronger, and was in fact, quite comfortable.

We need to think twice about whether an opioid prescription is needed after wisdom teeth removal.

After having her wisdom teeth removed, Lady Gaga posted pictures of her puffy face and tweeted out to her millions of followers: “Wisdom teeth out. P-p-Percocet p-p-Percocet.” Percocet after minor oral surgery should not be an expectation of teenaged patients.

What’s at stake?

Persistent opioid use after elective surgery, like wisdom teeth removal, is a risk, especially in young people whose brains are developing and are highly susceptible to the effects of opioids. Leftover opioids are equally dangerous – for teens that might be tempted to experiment or share with friends and family members.

Dentists and oral surgeons have a critical role to play here, as one of the leading prescribers of opioids to young people. An study published this month found that dentists are the leading source of opioid prescriptions for children and adolescents aged 10 to 19 years in the United States. Dental prescriptions account for over 30 percent of all opioid prescriptions in this age group.

This study also found that young people who received opioid prescriptions after wisdom tooth extraction were more likely to be using opioids three months and one year later, as compared to their peers who did not get an opioid.

The evidence is clear: A short prescription for opioids poses a real risk of ongoing opioid use to our teenagers.

Many patients experience pain and swelling lasting three to four days and sometimes up to a week after wisdom teeth surgery. The intensity and duration of these symptoms varies considerably depending on the position of the teeth, how deeply they are buried in bone and the surgical difficulty in removing them. While many oral surgeons and dentists prescribe opioids routinely after dental surgery, pain management for all patients should be handled individually.

In most cases, post-surgical dental pain can be controlled without opioids, and through anti-inflammatory drug such as ibuprofen, in combination with the non-opioid pain relievers, such as acetaminophen. For some oral surgery procedures, such as such deeply impacted wisdom teeth or jaw reconstruction, an opioid may be needed for pain control for a short time.

It’s time oral surgeons and dentists move away from a one size fits all pain management strategy.  Avoiding unnecessary opioid prescriptions for teenagers is critical part of staving off the harm of the opioid epidemic.

Amy Ma is co-chair, Family Advisor Forum, Montreal Children’s Hospital and patient advisor, Choosing Wisely Canada. Susan Sutherland is chief of dentistry, Sunnybrook Health Sciences, Toronto, Canada and president, Canadian Association of Hospital Dentists.

Image credit: Shutterstock.com

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