Rethinking Pain Relief: Nonopioids vs. Opioids After Dental Surgery

Cecile Feldman, DMD, MBA, Dean at Rutgers University School of Dental Medicine, shares insights from the largest study to date on post-dental surgery pain management. The study reveals that a combination of ibuprofen and acetaminophen is not only more effective than opioids for pain relief in the first 2 days post-surgery but also aligns with current American Dental Association guidelines. Dr. Feldman emphasizes the importance of this evidence in guiding dentists toward non-opioid analgesics, addressing biases about opioid efficacy, and reducing opioid prescriptions amid the ongoing crisis.

TRANSCRIPTION

Dr Cecile Feldman: Hello, I'm Cecile Feldman, I'm Dean and Distinguished Professor at the Rutgers University School of Dental Medicine and I'm Principal Investigator of a study that's known as the opioid dental genetic reduction study.

Consultant360: What unique challenges in pain management after dental surgery motivated you to conduct this study?

Dr Feldman: There's a lot of information that's out there with regard to analgesics for usage after dental surgery. And we're in the midst of an opioid epidemic and opioids are still being commonly prescribed to patients after dental surgery is performed.

The studies that are out there are studies that are generally small in size. They're not very pragmatic, which means that the studies are conducted almost in an artificial environment. So they don't conduct studies in ways that would simulate real practice. So in real practice, for example, if you're getting your wisdom teeth extracted, many surgeons will take out all the wisdom teeth that a patient has. So there might be two, three, four teeth that are extracted at a time. They use different kinds of anesthesia and so we wanted to conduct a study that more closely resembled how dentistry is done in the real world and look at the effectiveness of different analgesics in that real world type of environment.

C360: Your study found that ibuprofen and acetaminophen outperformed opioids for managing pain in the first two days. What factors do you think contributed to this outcome?

Dr Feldman: All the commonly used analgesics today actually are combination analgesics. So if you are going to use an opioid such as hydrocodone, it is usually combined with acetaminophen. Ibuprofen is something that is not usually combined with acetaminophen, but yet we know from a lot of studies that when you combine different analgesics there's a synergistic effect and actually the effect is greater than the sum of its parts so to speak. The ibuprofen has an anti -inflammatory action which the opioids don't have and we believe that that might be one of the factors that resulted in the ibuprofen-acetaminophen outperforming the opioids in managing pain.

I would like to note that in the first 2 days the ibuprofen-acetaminophen combination outperformed the opioid and as the postoperative period continues on, the non-opioid combination of ibuprofena-cinaminophen actually performed essentially as well as the opioid. But in reality, patients are stopping to take analgesics at that point, which is why they become closer together with regards to their performance.

C360: How do your results align with or challenge existing guidelines for postoperative pain management in dentistry, such as those from the American Dental Association?

Dr Feldman: Actually, our results completely aligned with the recommendations, because the recommendations today are that the non-opioid combination should be the first line of analgesia. Unfortunately, the studies upon which that recommendation was based are studies of what is known as studies of low confidence, meaning that they tend to be small, they're not sized appropriately, and so this study is essentially the largest study of its kind. This study allowed us to investigate multiple outcome domains, so it's not just pain, but it's other patient-centered outcomes that are important to patients, things like ability to sleep, ability to engage in daily functions like driving, side effects, overall satisfaction. So we were able to look at all of those factors, and so this study is one that is much more comprehensive and we think provides much stronger evidence that patients and practitioners can rely upon.

C360: Given the ongoing opioid crisis, how do you envision these findings influencing prescribing behaviors among dental professionals? Are there systemic barriers to adopting these recommendations?

Dr Feldman: We hope that providers will be able to reference these findings to try to work with their patients so that there's a better understanding that non -opioids are actually the better choice. And that's assuming, of course, that there's nothing in a patient's medical history that precludes them from taking either ibuprofen or acetaminophen. And so with this data, practitioners now have very strong evidence to be able to talk to their patients about why it's better to use a non-opioid than an opioid. We know that there's a lot of bias out there where many believe that opioids are the you know the the best thing the gold standard so to speak upon which to manage pain and that's not the case in a lot of situations and this study set out to show that.

C360: What advice would you give clinicians when discussing pain management options with patients who might expect or request opioids after surgery?

Dr Feldman: So we would hope that the practitioners would sit down with their with their patients and kind of go through what are the pros and cons of the different analgesic choices, but these results show overwhelmingly that in all outcome domains, the non-opioid combination is the way to go, and it should be the analgesic of first choice.