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The Journal Gazette

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Sunday, April 01, 2018 1:00 am

Limit opioids, dentists told

High doses of ibuprofen often work better, study finds

SHERRY SLATER | The Journal Gazette

At a glance

The American Dental Association encourages dentists to:

• Follow and continually review Centers for Disease Control and Prevention and state licensing board recommendations for safe opioid prescribing.

• Be aware of each patient's substance use history and take it into consideration when planning treatment and prescribing medication.

• Consider nonsteroidal anti-inflammatory analgesics as the first-line therapy for acute pain management.

• Counsel patients about the benefits and drawbacks of using opioid analgesics, including their inherent abuse potential.

• Seek continuing education in addictive disease and pain management as related to opioid prescribing.

Source: ADA

Dr. Franklin Awah knows most of his patients would rather be just about anywhere than in his dental chair.

The oral surgeon, one of two providers practicing in Fort Wayne Oral Maxillofacial Surgery and Implant Center's two local offices, understands their anxiety. 

He doesn't treat patients unless the situation is serious. Some need impacted wisdom teeth removed or a broken jaw bone set. Others need gum surgery or an implant placed into their jaw.

Awah, who holds dental and medical degrees, helps patients manage pain after those surgeries with a careful combination of opioids and over-the-counter medications. It's an approach he plans to continue even as some dental professionals are being urged to back away from prescribing narcotics.

The American Dental Association last week announced a new policy that “essentially says eliminate opioids from your arsenal if at all possible,” said Dr. Joseph Crowley, the group's president. The Chicago-based group represents about 161,000 dentists.

Awah described the policy as reasonable for standard dental procedures including cleanings, fillings and adjusting braces. But, he said, oral surgeons need more options.

Awah prescribes what he described as a dual regimen: high-dose ibuprofen (sold as Motrin or Advil) in combination with an opioid. He directs patients to alternate the two drugs every two hours or take both every four hours for the first day.

“We're working on their pain from two different routes,” he said.

Not only does ibuprofen help with swelling, but it also seems to work better for long-term pain, he said.

The worst pain tends to pass within three days, so Awah prescribes only five days of opioids. After that, patients still in severe pain have to return for a checkup. They could have an infection or a dry socket following an extraction, he said.

Awah's approach is in line with the American Dental Association's push, which includes a call to limit opioid prescriptions to no more than a week. The ADA also backs mandatory education to encourage dentists to use other painkillers.

Dentists write fewer than 7 percent of U.S. opioid prescriptions, but new research shows that practice has increased in recent years, despite evidence that ibuprofen and acetaminophen work just as well for most dental pain and are less risky than opioids, which can be addictive.

In many dental cases involving opioids, dentists prescribe Vicodin or Percocet for short-term pain from procedures including removing wisdom teeth and other tooth extractions, root canal work or dental implants.

But an analysis of five studies published in the ADA's journal found that nonsteroidal anti-inflammation drugs including ibuprofen are as effective for these conditions and ibuprofen plus acetaminophen (Tylenol) can provide better pain relief in some cases.

The association said in a 2016 policy that dentists should consider these non-opioids as first-line treatment for pain.

Aric Forbing was given four Advil last week following a root canal on a broken, infected molar.

The 37-year-old Fort Wayne native said the procedure was pain-free. At least, he didn't feel any pain after being numbed up with several injections. 

Despite feeling some significant discomfort after the anesthetic wore off, Forbing was satisfied with his dentist's instructions to swallow four Advil every three to six hours as needed for pain. He was also prescribed an antibiotic.

Forbing didn't ask for a prescription painkiller, and his dentist didn't offer one. He'd rather suffer in pain for a few days than risk potential addiction.

Not all patients approach the issue with Forbing's level of maturity, however.

Dentists are the leading prescribers of opioids for U.S. teens and the largest increase in dental prescriptions from 2010 to 2015 occurred in 11- to 18-year-olds, according to a study published in the Journal of the American Dental Association.

That rate climbed from almost 100 to 165 per 1,000 patients. Among all ages, the rate increased from 131 to 147 per 1,000.

In its new policy, the ADA supports requiring licensed dentists to take continuing education courses focusing on limiting opioid use. Many states have adopted those mandates.

Pennsylvania recently enacted a law requiring dentists to get written consent from parents before prescribing opioids to patients under age 18.

Dr. Paul Moore, a professor at the University of Pittsburgh's dental school, noted that for many young patients, a trip to the dentist will “be their first experience with opioids.”

“Maybe,” he said, “it is our opportunity to stop and counsel patients about the dangers.”

The Associated Press contributed to this story.