Opi­oids not needed after wis­dom-teeth re­moval

The Province - - OPINION - AMYMA AND DR. SU­SAN SUTHER­LAND choos­ing­wise­ly­canada.org

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-teeth re­moval.

Re­mov­ing wis­dom teeth is con­sid­ered by many as a rite of pas­sage for teens. It’s 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 ad­viser 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 can’t 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 didn’t 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 shouldn’t be an ex­pec­ta­tion of teenage 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 who 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 classes of pre­scribers of opi­oids to young peo­ple. An Amer­i­can 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 U.S. Den­tal pre­scrip­tions ac­count for more than 30 per cent 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 with their peers who didn’t get an opi­oid.

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

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’re 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 an anti-in­flam­ma­tory drug such as Ibupro­fen, in com­bi­na­tion with the non-opi­oid pain re­liev­ers, such as ac­etaminophen. For some oral-surgery pro­ce­dures, such as 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-fit­sall, pain-man­age­ment strat­egy. Avoid­ing un­nec­es­sary opi­oid pre­scrip­tions for teens is a crit­i­cal part of staving off the harm of the opi­oid epi­demic. Amy Ma is a par­ent of three liv­ing in Mon­treal. She is the co-chair of the Fam­ily Ad­viser Fo­rum at the Mon­treal Chil­dren’s Hos­pi­tal and pa­tient ad­viser to Choos­ing Wisely Canada. Dr. Su­san Suther­land is the chief of den­tistry at Sun­ny­brook Health Sciences in Toronto. She is pres­i­dent of the Cana­dian As­so­ci­a­tion of Hos­pi­tal Den­tists.

A panoramic ra­dio­graph of im­pacted wis­dom teeth in a 16-year-old: Opi­oids are not usu­ally needed to ease pain after the re­moval of teeth.

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