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Michigan OPEN
Michigan OPEN
Pain Management

Dentistry Pain Management

In the past, there has been an excess of opioid prescribing after dental surgeries like wisdom tooth extraction, leading to increased risks of opioid use disorder. OPEN has compiled years of research into tools to help providers have access to the best prescribing practices. OPEN strives to give patients and providers the tools they need for pain management by promoting the use of non-opioid and non-medication pain management strategies for improved patient outcomes.

Patients

OPEN strives to give patients and providers the tools they need for pain management. Learn about preparing for dental procedures, talking with your dentist, and strategies to manage pain such as over-the-counter medications, non-medication options, and opioid medications.

Preparing for Dental Procedures

Pain after certain dental procedures is normal and expected. You may hear it called acute pain, because, while it can cause considerable discomfort, it usually begins to get better a few days after the procedure. Before the procedure, talk with your dentist about any medications or substances you take as these may impact your pain control. Ask your dentist what type of pain is expected after the procedure and what you should do to control your pain. Options to control pain may include using over the counter (OTC) medications, non-medication options and if prescribed, opioid medications. If you are prescribed an opioid medication, it is important to know the risks, potential dangers and side effects, and how to minimize risk to yourself and others.

Recovery and Pain Expectations

Each person recovers from procedures in their own way, and someone who has the same procedure might have a completely different experience of pain. Pain after procedures is normal and tells you that your body is healing, and you might need to balance activity with rest. It is an uncomfortable but natural part of recovery. While everyone feels pain differently, typically procedural pain is the worst during the first 2-3 days after and then begins to get better.

The goal of pain management is for you to do activities of daily living like:

  • Eat
  • Sleep
  • Breathe deeply
  • Walk

Pain may be well-controlled with a schedule of over the counter (OTC) medications like acetaminophen (Tylenol®) and ibuprofen (Motrin®, Advil®). Adding non-medication options to your pain management plan can help to successfully treat pain.

Managing Pain After Dental Surgery

Learn ways to manage pain after dental surgery such as: over-the-counter medications, non-medication strategies, and opioids, if prescribed.

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Talk to your Dentist

Before your dental procedure, talk to your dentist about:

  • Review with your surgeon and ask for recommendations for how to take your medications prior to surgery including:
    • Alcohol
    • Tobacco
    • Antidepressants (like Prozac® or Celexa®)
    • Sedatives (like Ambien® or Seroquel®)
    • Benzodiazepines (like Valium®, Xanax®, or Klonopin®)
    • Stimulants (like Adderall®, Ritalin®, or Vyvanse®)
    • Opioids (like Oxycodone®, Vicodin®, or Norco®)
    • Any other substances (like Marijuana, Crack/Cocaine, Methamphetamine)

Ask your surgeon about:

  • What type of pain you will have
  • How long you should expect to have pain
  • What you should do if your pain is not controlled
Mindfulness or MeditationMusicBooks
Calm breathing, like belly breathing or square breathing, can help to relax muscles that are tense because of pain or anxiety. This is called Mindful Breathing. You can also focus your mind and visualize a particular place you enjoy that makes you feel calm, relaxed, and comfortable. Music may be very comforting when you are experiencing pain or discomfort. Listening to music, singing, or writing songs can help to lessen pain and anxiety. Before surgery, take time to select a few books that you would like to read while you are recovering. This can help you to feel relaxed and distraction from pain after surgery.
Sleep or RelaxationIce or HeatCompression
Take time during your recovery to rest and relax. Sleep helps the body heal. Talk to your surgeon to determine if ice or heat would be helpful to your recovery.
Talk to your surgeon to determine if compression of the surgery area would be helpful to your recovery. Using an ‘abdominal binder’ after surgery can provide comfort especially when moving around.
Short walks
Taking a short walks after surgery is so important! Walking helps to:
-Get blood flowing in your body which helps you heal and reduces risk of developing blood clots
-Regain your strength and mobility before surgery
-Reduce constipation
-Improve mood and anxiety

Using medications like ibuprofen (Motrin or Advil) and acetaminophen (Tylenol), that you can purchase at your local pharmacy, can be very effective at managing your pain after surgery. Each works in different ways to manage pain and can be taken together at the same time.

Ask your surgeon:

  • If you can use OTC medications like Motrin or Tylenol after surgery to manage pain
  • What dose and how often to take
    • Example: For the first 3-5 days after surgery, take Tylenol and Motrin at regularly, scheduled times and then as needed as pain improves

Sample schedule and doses for OTC medications:

TimeMedication (Dose)
9 AMTYLENOL (1000mg)
MOTRIN (600mg)
3 PMTYLENOL (1000mg)
MOTRIN (600mg)
9 PMTYLENOL (1000mg)
MOTRIN (600mg)

Dental Providers

Dental providers can find current evidence to support appropriate opioid prescribing, best practices for pain management, opioid prescribing recommendations which can be tailored to meet patient needs, counseling suggestions to educate patients on postoperative expectations, and care coordination strategies to manage complex care needs.

Why Change Opioid Prescribing Practice?

RISKS OF OPIOID PRESCRIBING

Teens and adolescents who are prescribed opioids are more than 3 times more likely to become dependent on opioids

  • Each year approximately 5 million people in the United States have wisdom teeth removed.
  • These primarily young and otherwise healthy individuals are routinely prescribed opioids for the procedure, despite evidence that over-the-counter pain medications are equally effective at controlling pain.
  • Most adolescents believe that prescription opioids are safer than other substances of misuse.

Opioid use causes common side effects

  • Side effects include nausea, vomiting, constipation, and sedation
  • Side effects can be avoided with the use of non-opioid alternatives such as ibuprofen and acetaminophen

Excess prescribing poses serious risks to the patient

  • Risks of excess prescribing include chronic opioid use, opioid use disorder (addiction) and overdose
  • In adolescents and young adults who received dental opioids, 5.8% had an opioid misuse or overdose related encounter4
  • Opioids prescribed after dental procedures increase the 90-day risk of opioid overdose by 1.5 per 10,000 patients – a rate that corresponds to about 1,700 additional overdose events per year in the U.S. given the volume of U.S. dental opioid prescribing.19

Unnecessary opioid prescribing can also harm family members and the community

  • Leftover opioids that are not properly disposed of are at risk of diversion and misuse
  • Family members to those prescribed opioids are more likely to overdose5,6

Opioid Prescribing after routine dental procedures is common

U.S. dentists routinely prescribed opioids for minor procedures

  • Dentists accounted for more than 11 million opioid prescriptions to U.S. patients aged 13 years and older7
  • Opioid prescribing increased 68% from 2010 to 2016 in the field of dentistry8
  • U.S. dental opioid prescribing is declining, but the rate of decline is slowing

The United State is an outlier in opioid prescribing after dental surgery

  • Th U.S. had a higher number of opioid prescriptions per dentist and a higher proportion of prescriptions for opioids when compared to England in 2016 (37 times greater than the proportion written by English dentists)9
  • U.S. dentists also prescribed opioids more than 50 times more frequently as United Kingdom dentists10

Dentists are the top prescriber of opioids to kids 13-30

  • Many adolescents and young adults are exposed to opioids for the first time after dental surgery, such as wisdom tooth removal
  • Dentists accounted for 1.5 million opioid prescriptions to adolescents and young adults aged 12-21 years, representing 40% of all opioid prescriptions to this age group11

Pain can be managed for dental extraction without opioids

  • Patients who took opioids reported higher pain, and there was no difference found in satisfaction between patients who took opioids and who did not12
  • 54% of outpatient dental surgery prescribed opioids go unused13
  • There is no correlation between patient satisfaction scores and amount of opioid prescribed14
  • Patients who used opioids after tooth extraction reported significantly higher levels of pain compared to those who did not use opioids, but no difference in satisfaction was observed15
  • Patients who were prescribed fewer opioids reported using fewer opioids with no change in pain scores16

80% of opioids are prescribed are for dental extractions for which acetaminophen and ibuprofen are as good or better without side effects

  • A combination of ibuprofen and acetaminophen is more effective for dental pain control and caries less risk for adverse events17
  • The American Dental Association recommends NSAIDs as a first line therapy18

4 Evidence-Based Reasons to Improve Opioid Prescribing Practices After Dental Surgery

This brochure, created for healthcare professionals, uses recently published data to compel prescribers to improve their opioid prescribing practices.

Download

 

Pain Management in Dentistry CE Course

OPEN is excited to offer free online training for dental pain management and opioid prescribing. Three one-hour training modules are being offered that meet Michigan’s licensure requirement of board approved continuing education for pain and symptom management.

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Wisdom Tooth Extraction

Our research examined opioid use among those exposed to opioids for the first time after wisdom tooth extraction. In a study of nearly 71,000 people ages 13–30 not using opioids** before undergoing wisdom tooth extraction:

  • 78% filled an opioid prescription around the time of the procedure.
  • Those who filled the initial opioid prescription were nearly 3 times as likely to become a new persistent opioid user (filling 2 or more opioid prescriptions weeks and months later)*, compared to those who did not fill an initial opioid prescription (1.3% vs. 0.5%).
  • Teens and young adults with a history of mental health issues or chronic pain conditions were more likely than others to go on to become persistent opioid users.

People exposed to opioids for the first time after other elective surgeries are at an increased risk for persistent opioid use. Opioid prescribing after wisdom tooth extraction is linked to persistent opioid use*.

*For this study, persistent opioid use was defined as one or more opioid prescription fills during days 4–90 after the procedure, in addition to one or more fills during days 91–365, written by any provider for any reason.

**For this study, this was defined as no opioid prescriptions filled in the 6 months prior to the procedure.

Non-Medication Pain Management

Learn how to help manage or reduce your pain and anxiety through various techniques.

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IHPI Brief: A closer look at wisdom tooth extractions

People exposed to opioids for the first time after other elective surgeries are at an increased risk for persistent opioid use. Research at Michigan OPEN examined opioid use among those exposed to opioids for the first time after wisdom tooth extraction.

Best Practices for Managing Dental Pain

Utilize Acetaminophen and NSAIDs*

Since acetaminophen and ibuprofen are available over the counter and don’t require a prescription for patients to use, patients and their caregivers often do not receive instructions on how to use them after surgery. The packaging instructions for acetaminophen and ibuprofen provide minimal dosing and recommend as-needed use. If these instructions are followed, patients may be underdosed and inadequately addressing their pain. In addition, if patients were prescribed an opioid, they may think this is the first medication they should use for their pain, not understanding that acetaminophen and ibuprofen often provide adequate pain relief when appropriately dosed and that an opioid may not be needed. *Unless contraindicated

For more information about prescribing and dosing Acetaminophen and NSAIDs, see OPEN’s Surgical Pain Management Initiative.

Dental Prescribing: Summary of Best Practices

Stay up to date with OPEN’s summary of best practices document for dental prescribing, including non-opioids, during the perioperative period.

Download

Screen for opioid use and substance use before surgery to identify those at risk for poor pain and opioid use outcomes

  • Consider using the TAPS Screening Questionnaire, a validated way to screen patients for risk before surgery
  • Identify patients at increased risk of respiratory depression: Concurrent medication use (e.g., prior opioid prescriptions, sleep aids, benzodiazepines), obstructive sleep apnea, obesity, neurological disorder, oxygen desaturation prior to discharge
  • Use language that respects individuals with substance use disorder to mitigate stigma
  • Prescribe acetaminophen and NSAIDs, unless patient has contraindication or high risk adverse effects
    • Giving patients a prescription helps them understand these are first-line medications for pain management 
    • Refer to the OTC Reference Sheet
  • Address dental pain through clinical intervention rather than opioid pain relief
  • Access the Prescription Drug Monitoring Program (PDMP) prior to prescribing controlled substances schedules 2-5, in compliance with state law
  • The prescribing of opioids for uncomplicated dental extractions is not recommended by OPEN.
    • Opioid prescriptions, if warranted, should not be written prior to completing the dental procedure.
  • Consider co-prescribing naloxone to patients on high doses of opioids or medication for opioid use disorder.
  • AVOID:
    • Prescribing codeine or tramadol. Due to pharmacogenetic differences, codeine and tramadol are poor choices for pain management and should not be prescribed. 
    • Prescribing opioids for dental extraction procedures.
    • Prescribing opioids that contain acetaminophen (e.g. Norco®, Vicodin®, Percocet®) to minimize risk of acetaminophen overdose.
    • Prescribing opioids with other sedative medications (e.g. benzodiazepines, skeletal muscle relaxants).

Educate patients and families:

  • Acetaminophen and NSAIDs should be used together as first-line medications for postoperative pain in surgical patients, unless patients have contraindications or high risk of adverse effects
  • Use of prescription opioids ONLY to manage severe breakthrough pain that is not relieved by acetaminophen and NSAIDs
  • Pain expectations and how to taper opioid use as pain improves
  • Pain usually peaks and then improves after the first 2-3 days following surgery
  • The risks and side effects of opioid medications (sedation, respiratory depression, dependence, withdrawal, addiction, overdose)
  • How to safely store and dispose of opioids
  • Appropriate use of naloxone, if prescribed.
  • Learn more with OPEN’s Naloxone Initiative.
  • Coordinate with anesthesia, and consider nerve block, local anesthetic catheter or an epidural when appropriate
  • Connect with the patient’s primary care provider and/or usual prescriber with information about the patient’s operative procedure and the plan for management of acute postoperative pain
  • If the patient screens positive for risk of SUD, consult an addiction medicine specialist.

Resources for Dental Pain Management

Programs

Co-Branding Materials Request

Prescribing Recommendations Development Program

Resources

4 Evidence-based Reasons To Improve Opioid Prescribing Practices After Dental Surgery

Explore 4 evidence-based reasons to improve opioid prescribing practices after dental surgery.

Managing Pain After Dental Surgery

Learn ways to manage pain after dental surgery such as: over-the-counter medications, non-medication strategies, and opioids, if prescribed.

Opioid Prescribing for Wisdom Tooth Extraction

Check out this one-minute video about non-opioid pain management options for children and teens after wisdom teeth removal. Video captions are in Arabic.

References

  1. Friedman, J. R. (2007). The Prophylactic Extraction of Third Molars: A Public Health Hazard. American Journal of Public Health, 97(9), 1554–1559. https://doi.org/10.2105/ajph.2006.100271
  2. Moore, P. A., Dionne, R. A., Cooper, S., & Hersh, E. V. (2016). Why do we prescribe Vicodin? Journal of the American Dental Association, 147(7), 530–533. https://doi.org/10.1016/j.adaj.2016.05.005
  3. Johnston, L. D., O’Malley, P. M., Miech, R. A., Bachman, J. G., & Schulenberg, J. E. (2017). Monitoring the Future national survey results on drug use, 1975-2016: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, The University of Michigan.
  4. Nguyen, A. V., Glanz, J. M., Narwaney, K. J., & Binswanger, I. A. (2020). Association of Opioids Prescribed to Family Members With Opioid Overdose Among Adolescents and Young Adults. JAMA Network Open, 3(3), e201018. https://doi.org/10.1001/jamanetworkopen.2020.1018
  5. Khan, N. F., Bateman, B. T., Landon, J., & Gagne, J. J. (2019). Association of Opioid Overdose With Opioid Prescriptions to Family Members. JAMA Internal Medicine, 179(9), 1186. https://doi.org/10.1001/jamainternmed.2019.1064
  6. Schroeder, A. R., Dehghan, M., Newman, T. B., Bentley, J., & Park, K. S. (2019). Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA Internal Medicine, 179(2), 145. https://doi.org/10.1001/jamainternmed.2018.5419
  7. Chua, K., Waljee, J. F., Gunaseelan, V., Nalliah, R. P., & Brummett, C. M. (2022). Distribution of Opioid Prescribing and High-Risk Prescribing Among U.S. Dentists in 2019. American Journal of Preventive Medicine, 62(3), 317–325. https://doi.org/10.1016/j.amepre.2021.09.017
  8. Larach, D. B., Waljee, J. F., Hu, H. M., Lee, J. H., Nalliah, R. P., Englesbe, M. J., & Brummett, C. M. (2020a). Patterns of Initial Opioid Prescribing to Opioid-Naive Patients. Annals of Surgery, 271(2), 290–295. https://doi.org/10.1097/sla.0000000000002969
  9. Suda, K. J., Durkin, M. J., Calip, G. S., Gellad, W. F., Kim, H., Lockhart, P. B., Rowan, S. A., & Thornhill, M. H. (2019). Comparison of Opioid Prescribing by Dentists in the United States and England. JAMA Network Open, 2(5), e194303. https://doi.org/10.1001/jamanetworkopen.2019.4303
  10. Harbaugh, C. M., Nalliah, R. P., Hu, H. M., Englesbe, M. J., Waljee, J. F., & Brummett, C. M. (2018). Persistent Opioid Use After Wisdom Tooth Extraction. JAMA, 320(5), 504. https://doi.org/10.1001/jama.2018.9023
  11. Chua, K., Brummett, C. M., Conti, R. M., & Bohnert, A. S. (2021). Opioid Prescribing to US Children and Young Adults in 2019. Pediatrics, 148(3). https://doi.org/10.1542/peds.2021-051539
  12. Larach, D. B., Waljee, J. F., Hu, H. M., Lee, J. H., Nalliah, R. P., Englesbe, M. J., & Brummett, C. M. (2020b). Patterns of Initial Opioid Prescribing to Opioid-Naive Patients. Annals of Surgery, 271(2), 290–295. https://doi.org/10.1097/sla.0000000000002969
  13. Maughan, B. C., Hersh, E. V., Shofer, F. S., Wanner, K. J., Archer, E., Carrasco, L., & Rhodes, K. V. (2016). Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug and Alcohol Dependence, 168, 328–334. https://doi.org/10.1016/j.drugalcdep.2016.08.016
  14. Nalliah, R. P., Sloss, K. R., Kenney, B., Bettag, S., Thomas, S., Dubois, K. M., Waljee, J. F., & Brummett, C. M. (2020). Association of Opioid Use With Pain and Satisfaction After Dental Extraction. JAMA Network Open, 3(3), e200901. https://doi.org/10.1001/jamanetworkopen.2020.0901
  15. Nalliah, R. P., Sloss, K. R., Kenney, B., Bettag, S., Thomas, S., Dubois, K. M., Waljee, J. F., & Brummett, C. M. (2020). Association of Opioid Use With Pain and Satisfaction After Dental Extraction. JAMA Network Open, 3(3), e200901. https://doi.org/10.1001/jamanetworkopen.2020.0901
  16. Howard, R., Waljee, J. F., Brummett, C. M., Englesbe, M. J., & Lee, J. H. (2017). Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines. JAMA Surgery, 153(3), 285. https://doi.org/10.1001/jamasurg.2017.4436
  17. A. Moore, P., M Ziegler, K., D. Lipman, R., Aminoshariae, A., Carrasco-Labra, A., & Mariotti, A. (2018). Benefits and harms associated with analgesic medications used in the management of acute dental pain. JADA, 149(4), P256-265.E3. https://doi.org/10.1016/j.adaj.2018.02.012
  18. Oral Analgesics for Acute Dental Pain. (n.d.). American Dental Association. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/oral-analgesics-for-acute-dental-pain
  19. Chua, K. P., Kenney, B. C., Walijee, J. F., Brummett, C. M., & Nalliah, R. P. (n.d.). Dental opioid prescriptions and overdose risk in patients and their families. American journal of preventive medicine. https://pubmed.ncbi.nlm.nih.gov/33975766/