CDA Essentials 2017 • Volume 4 • Issue 7

20 | 2017 | Issue 7 I ssues and P eople which stands for 2 drugs (acetaminophen and ibuprofen), 4 doses (those 2 drugs every 6 hours, or 4 times a day), for 24 hours. I call it the “perfect prescription.” In combination, these two medications are very powerful and there is a tremendous body of literature in support of their use. But they need to be taken as directed. The patient can take the first dose of these medications prior to leaving your clinic and then they’re only responsible for 3 more doses. But if a dose is due at 2 am, they would have to set their alarm, wake up and take that dose. For some significant and invasive procedures, patients can continue this regimen beyond the initial 24-hour postoperative period, or they may opt to take their pain medication solely on an “as needed” basis (either drug alone, or in combination). However, if patients still 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. ➋  Pre-emptive analgesia: Medications can be given pre-operatively to help mitigate pain, inflammation and trismus following dental procedures. Pre-emptive analgesia is effective in improving the inflammatory response. For example, the NSAID celecoxib (brand names include Celebrex and Bio-Celecoxib) could be given as 400 mg 30 minutes prior to the dental procedure and then followed up after the dental procedure with the 2-4-24. This COX-2 inhibitor is selected since it will not increase postoperative bleeding compared to administering a non-selective NSAID pre-emptively. ➌  Glucocorticoids: A systematic analysis was published in the Journal of the American Dental Association 2 showing the effectiveness of a single intra-operative injection of dexamethasone, a type of glucocorticoid (brand names include Apo-Dexamethasone and Dexasone), in terms of having a tremendous effect on managing a patient’s postoperative pain. These results suggest an update to my strategy above to include a single dose of dexamethasone such that the mnemonic becomes “1-2-4-24.” This single dose of dexamethasone could be given preemptively as an oral tablet (with or without celecoxib), but the data suggests it may be best as a single intraoperative injection of up to 10 mg in the area which may already be anesthetized. When are opioids for dental-related pain legitimately needed for successful pain control? This would be a very rare case (certainly less than 5% of patients). The patient would have to have a true, documented allergy to all NSAIDs (including COX-2 inhibitors) and acetaminophen. Or they would have to have a true, documented contraindication to receiving NSAIDs (including COX-2 inhibitors), acetaminophen or glucocorticoids (i.e., active peptic ulceration or bleed). Outside of these exceptions, there is not a legitimate role for opioids in treating dental-related pain based on both pathophysiology and pharmacology. The reality is that opioids continue to be prescribed in the acute postoperative phase to decrease the number of patient callbacks; because dentists were trained to do this by other dentists who have always done this; or because patients often want or expect opioids. It boils down to improving patient satisfaction with the dental appointment. Unfortunately, this approach has led us to our current crisis. By curtailing or avoiding the prescription of opioids—certainly if opioids are not specifically indicated—that will limit the supply and therefore take away opportunities for the public to get caught up in the use, misuse and potentially abuse of these controlled substances. Watch an interview with Dr. Donaldson at 2017/02/14/pdc17