OTC Pain Relievers Just as Effective as Opioids After Wisdom Tooth Removal

By Pat Anson

A combination of acetaminophen and ibuprofen works just as well as a low dose of opioids in relieving pain in men and women after wisdom tooth removal, according to a new study in JAMA Network Open. 

The research builds on a previous study of over 1,800 patients, which compared the effectiveness of 400 mg of ibuprofen and 500 mg of acetaminophen to 5 mg of hydrocodone and 300 mg of acetaminophen in the first three days after surgery. That dose of hydrocodone is the equivalent of 5 morphine milligram equivalents (MME), which is considered a low dose under medical guidelines.

"We wanted to determine whether the pain medication's effects were consistent in males and females separately," lead author Janine Fredericks Younger, DMD, an associate professor at Rutgers School of Dental Medicine, said in a press release.

 "And what we found is that in both subgroups (males and females), the non-opioid was superior for that first day and night, and then no worse than the opioid for the rest of the post-op period."

Researchers performed a gender-specific analysis because women often report higher pain levels after surgery, raising questions about whether pain medications work differently for each sex.

"There's obviously different biological mechanisms, different hormones involved," said Cecile Feldman, DMD, Dean of Rutgers School of Dental Medicine and senior author of both studies. "But results confirm that the analgesic effect for both groups is the same."

Pain levels were low whether patients took acetaminophen-ibuprofen or the hydrocondone-acetaminophen combination. Pain ratings over three days were slightly lower for female patients taking non-opioids than those on the low dose of hydrocodone (2.83 vs 2.98). The same was true for male patients (2.24 vs 2.37).

Patient satisfaction and sleep quality were also slightly better in the non-opioid group, which also experienced less pain interference with daily activities.

"The results actually came in even stronger than we thought they would," Feldman said. "We expected to find the non-opioid to be non-inferior, so that at least it was no worse than opioids. We were surprised to see that it was actually superior." 

The first FDA-approved over-the-counter pain reliever that combines acetaminophen with ibuprofen was Advil Dual Action, although the doses are somewhat different than what was used in the Rutgers study.

Each capsule contains 250 mg of acetaminophen and 125 mg of ibuprofen, with up to six capsules per day recommended for toothaches, headaches and “minor aches and pain.”

Patients are cautioned not to take Advil Dual Action with other products containing acetaminophen, as that can cause liver damage. Acetaminophen overdoses are involved in hundreds of deaths and over 50,000 emergency room visits in the U.S. annually.

Wisdom tooth extraction is performed about 3.5 million times a year in the United States. Dental surgery is often the first exposure that a patient has to prescription opioids, although their use after dental procedures has declined in recent years as fears grew about opioid addiction.

Last year the American Dental Association (ADA) released new guidelines recommending that nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen be taken alone or in combination with acetaminophen as first-line treatments for acute dental pain in adults and adolescents aged 12 and older. 

NSAIDs and acetaminophen work differently, with NSAIDs reducing pain and inflammation in damaged tissue, while acetaminophen acts in the central nervous system to block pain signals that are not caused by inflammation. Taking the two together is believed to boost their analgesic effect. 

The ADA says opioids should only be used when NSAIDs and acetaminophen don’t relieve pain enough or when NSAIDs are contradicted due to health issues, such as a patient having cardiovascular problems or a bleeding ulcer.     

The risk of long-term opioid use after a tooth extraction is relatively rare. A large study of over 70,000 teens and young adults who had their wisdom teeth removed found that only 1.3% were prescribed opioids long-term after their initial prescription by a dentist. 

"We feel pretty confident in saying that opioids should not be prescribed routinely for dental procedures," Feldman said. "Our non-opioid combination really should be the analgesic choice."

Study Finds Dentists Overprescribe Opioids

By Pat Anson, PNN Editor

Over half of the opioid prescriptions written by dentists in the United States exceed the 3-day supply recommended by pain management guidelines, according to a large new study that also found a stronger dose than necessary was prescribed nearly a third of the time.

The findings, published in the American Journal of Preventive Medicine, are important because dentists are responsible for about 10% of the opioids prescribed in the U.S.

“Dental procedures like extractions can leave patients with a lot of pain that needs to be managed, and many dentists are doing a wonderful job of managing their patients’ pain appropriately and responsibly,” said Jessina McGregor, a researcher in the Oregon State University College of Pharmacy. “But our findings suggest that there’s room for improvement among some dentists, improvement that could make a huge difference in our society as we try to combat the opioid crisis.”

McGregor and her colleagues reviewed insurance records from over half a million dental visits from 2011 to 2015. The study period was before the CDC released its controversial opioid guideline in 2016, so the findings may not reflect current practices in dental pain management.

Nevertheless, the study is the largest to date of dental visits in the U.S. that resulted in an opioid prescription.

Fifty-three percent of the time, patients were given more than the 3-day supply of opioids recommended by the CDC for most types of acute, short-term pain. Some dental associations recommend no more than two days’ supply – even for dental procedures associated with the severe pain.

In addition to the excess number of pills, researchers say the dose of opioids prescribed by dentists was stronger than what was medically necessary 29% of the time.

Men, young adults aged 18-34, and people living in the South were most likely to be prescribed opioids that were stronger than needed.

“One large potential area for improvement is the almost 30% percent of opioids that were prescribed following procedures where the pain intensity was expected to be mild and manageable by non-opioid analgesics like ibuprofen or acetaminophen,” said McGregor.

“Our statistical models suggest that even something as simple and straightforward as substituting a lower-potency opioid like hydrocodone for oxycodone could make an enormous reduction in overprescribing, as much as a 20% reduction.”

Researchers say prescribing guidelines tailored to dentists and oral pain are urgently needed to reduce excess prescribing . A small 2016 study of patients who had their wisdom teeth removed found that over half the opioids prescribed went unused. That suggests as many as 100 million excess pain pills are prescribed annually by dentists.

Anti-opioid activists have long claimed that young people can easily became addicted to opioids after dental surgery. But a large 2018 study found that the risk of long-term opioid use after wisdom tooth removal is relatively rare. The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription.

Long-Term Opioid Use Rare After Wisdom Teeth Removed

By Pat Anson, Editor

Anti-opioid activists have long claimed that thousands of young people have become addicted to opioid pain medication after having their wisdom teeth removed.

“Would you give your child heroin to remove a wisdom tooth?” is how a provocative 2016 anti-opioid billboard in New York City’s Times Square put it.

But a large new study published in JAMA found that the risk of long-term opioid use after wisdom tooth removal is relatively rare – although still a cause for concern.

The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription by a dentist. The risk of long-term use was nearly 3 times higher for young people prescribed opioids than for those who were not (0.5%).

Although the overall risk of long-term use is small, researchers say the sheer number of wisdom tooth removals warrants caution when prescribing opioids.

"Wisdom tooth extraction is performed 3.5 million times a year in the United States, and many dentists routinely prescribe opioids in case patients need it for post-procedure pain," said lead author Calista Harbaugh, MD, a research fellow and surgical resident at the University of Michigan’s Institute for Healthcare Policy and Innovation.

"Until now, we haven't had data on the long-term risks of opioid use after wisdom tooth extraction. We now see that a sizable number go on to fill opioid prescriptions long after we would expect they would need for recovery, and the main predictor of persistent use is whether or not they fill that initial prescription."

Harbaugh and her colleagues looked at insurance claims for opioid prescriptions between 2009 and 2015. Hydrocodone (70%) was the most common opioid prescribed after wisdom tooth removal, followed by oxycodone (24%). Long-term opioid use was defined as two or more prescriptions filled in the year after wisdom tooth removal.

But other factors besides dental surgery raised the risk of long-term opioid use. Teens and young adults who had a history of chronic pain or mental health issues such as depression and anxiety were more likely to go on to regular use after filling their initial opioid prescription.

"These are some of the first data to the show long-term ill effects of routine opioid prescribing after tooth extractions. When taken together with the previous studies showing that opioids are not helpful in these cases, dentists and oral surgeons should stop routinely prescribing opioids for wisdom tooth extractions and likely other common dental procedures," said senior author Chad Brummett, MD, co-director of the Michigan Opioid Prescribing and Engagement Network.

There are no specific prescribing guidelines for wisdom tooth removal. The American Dental Association recommends that dentists first consider non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. It also supports the CDC opioid guidelines, which recommend that opioids be limited to no more than 7 days' supply for acute pain.

A small 2016 study found that over half the opioids prescribed to patients after wisdom tooth removal or dental surgery go unused, with many of the leftover pills being abused or stolen by friends and family members. On average, dental patients received 28 opioid pills and – three weeks later – most had pills leftover.