Management of pre- and postoperative dental and surgical pain during the opioid crisis

Dr. Diana Bronstein discusses protocols to reduce patient dependence on opioids for pain management

Introduction and background

The opioid crisis is a well-documented and reported current event which deserves attention and consideration when practicing daily patient care. With over 9.5 million Americans abusing prescription opioids in 2020 and over 2.7 million with an opioid use disorder, the U.S. Department of Health and Human Services has declared the misuse of opioids a public health emergency.²

Today’s clinicians are aware that the amount of peri- and postoperative opioid use for pain management and their intake duration following surgery are positively associated with chronic opioid use and addiction subsequently. It is one of the top contributors to this epidemic.^3-5 The challenge is to reduce opioid use while maintaining adequate pain control.

This article will examine surgical procedures known to increase patients’ risk of developing chronic opioid use and propose protocols for better patient outcomes including reduction of dosage and duration of surgical procedure-related opioid use. Dose increases in both the postoperative inpatient and outpatient settings independently increase the risk of prolonged opioid use,^3,6 including opioid naïve patients.

Pain management modalities for surgical patients

Managing postoperative pain is an important part of the surgery that involves carefully weighing the risks and benefits since initial and progressive pain control plays a large role in a patient’s overall satisfaction with treatment. A patient experiencing too much pain leads to poor clinical outcomes, while providing access to more than the minimal necessary amount of opioids can initiate chronic dependency.^7,8 The challenge is to judge the minimal effective dosage of opioids for adequate pain control successfully while it varies from patient to patient, making it difficult to assess their pain sensitivity objectively.⁹

“One potential solution to this problem is the use of peripheral nerve blocks. Their use as a replacement for at least some percentage of opioid pain control during and after medical procedures has the potential to reduce opioid use, misuse, and dependency.” Current research suggests that using peripheral nerve block may present viable analgesia.¹ According to Cardwell, et al., 2022, the use of pre-surgical peripheral nerve blocks significantly decreases opioid need not only after the procedure, but also in all facets of the surgical process. The most significant reduction in opioid consumption is seen in the first 1-3 days postop, and the patient who received peripheral nerve blocks in the study reported lower pain scores than the control group individuals. It is important to note that this reduction in opioid consumption did not negatively impact patient experience or increase their pain score levels. In fact, it has been shown that the “patients have significantly lower pain scores, higher overall satisfaction, and even prefer the use of blocks when compared to general anesthesia and opioids alone. However, utilization of peripheral nerve blocks is not ubiquitous” while this study produced evidence that peripheral nerve blocks are an effective tool for managing postoperative pain.

Another painful oral surgery sequela is post-extraction dry socket occurrence most often experienced by smokers and non-compliant patients. Dry socket is one of the most common postoperative complications after mandibular tooth extraction, characterized by severe pain and exposed bone. The usual palliative is irrigation of the socket to debride any food or foreign material and packing of the socket with medicated gel or paste to provide pain relief and allow normal wound healing.¹⁰

Studies have reported that dry socket pain starts 1–3 days after tooth extraction.^17,18 The time it takes for the dry socket to heal varies depending on its severity, but usually, it ranges from 5 to 10 days.¹⁹

The management of dry socket has been less controversial¹⁸ than its etiology and prevention. Many authors agree that the primary objective is pain control until normal healing occurs as suggested by Fazakerley.¹⁶ Systemic analgesics or antibiotics may be necessary or indicated.²⁰ The use of intra-alveolar dressing materials is also suggested in the literature as local palliative treatment,^21,22 although it is generally acknowledged that dressings delay the healing of the extraction socket.²³

Another treatment modality of dry socket appears to be Platelet-Rich Fibrin (PRF). PRF is characterized by the slow polymerization during its preparation in the centrifuge that generates a fibrin network very similar to the natural one that enhances cell migration and proliferation.¹³ Choukroun, et al.,¹⁵ in France advocated the use of PRF, which is a second-generation platelet concentrate. PRF is a stringently autologous fibrin matrix. Dohan, et al.,¹⁴ suggested that PRF addition can correct destructive reactions in the natural process of healing of wound tissues, suggesting that PRF contributes to the immune regulatory mechanism. Choukroun, et al.,¹⁵ demonstrated a clinical example in which they used the PRF as a filling material in the extraction socket. There was a significant decrease in pain and the number of socket wall exposure by the third postoperative day; the pain had completely resolved and socket fully epithelialized by the tenth postoperative day. The use of PRF yielded promising results in terms of both pain reduction and improved wound healing which was comparable to the conventional Alveogyl (Septodont) dressing. It may be concluded that PRF is an effective modality for the management of dry socket.¹⁰

The studies confirmed that neovascularization and epithelial coverage of the extraction socket can be achieved with the use of PRF. PRF is a reservoir of platelets, leukocytes, cytokines, and growth factors. It is reported to allow the slow release of cytokines, transforming growth factor, platelet-derived growth factor, vascular endothelial growth factor, and epidermal growth factor, which play a vital role for angiogenesis, tissue healing, and cicatrization.^14,15

There are further modalities of postoperative morbidity control. Many innovations have made their way into mainstream standard of care. One of the main challenges after extraction, especially postsurgical extractions of impacted 3rd molars, is pain control, and one of the treatments for pain control is low-level laser therapy (LLLT). The study by Santos, et al., 2020, aimed to assess the effectiveness of LLLT for pain control after extraction of lower third molars¹¹ and concluded that LLLT within the parameters determined was effective in reducing the intensity of postoperative pain in third molar surgery, presenting the best results 48 and 72 hours after the procedure.

The application of LLLT can offer greater postoperative comfort and wellbeing to patients, functioning as both an inhibitor of the inflammatory process and a modulator. The working mechanism is by interference of the laser in biochemical and molecular levels, promoting the improvement of clinical signs and symptoms, considering that it stimulates endorphin release, inhibits nociceptive signals, and reduces pain proception. In addition, LLLT may reduce edema and hyperemia, accelerate the wound-healing process, and stimulate bone repair.^51,52 

With new modalities of pain management, there are also improved conventional pain medication protocols to provide today’s practitioners with evidence-based prescription framework. Since the efficacy and rapid onset of postsurgical oral pain relief are critical to improve clinical outcomes and reduce the risk of excessive dosing with analgesic drugs, another study by Cristalli, et al., 2021, compared analgesic effects of preoperative administration of paracetamol 500 mg plus codeine 30 mg in single-tablet and effervescent formulation to ibuprofen 400 mg, and placebo in the management of moderate to severe postoperative pain after mandibular third molar surgery.¹²

Within the limits of that study, over postoperative 3 days, a statistically significant intensity pain reduction and decreased rescue therapy consumption were recorded in the paracetamol-codeine group than to ibuprofen group. Nevertheless, lower pain intensity at 2 hours post-dose and longer time using rescue therapy was found in the ibuprofen group without statistical significance and without adverse events over the studied period.^12,53

A critical property of antiseptic solutions is pain management, especially in terms of trying to limit opioid use. The U.S. opioid public health crisis due to over-prescribing, has subsequently created a drug overuse problem mostly affecting teenagers, leading to a dramatic increase in fatal overdoses.²⁵

It has been more than 5 years since the Food and Drug Administration (FDA), National Institute of Drug Abuse (NIDA), National Institutes of Health (NIH), Drug Enforcement Agency (DEA), the Centers for Disease Control (CDC), and medical and dental organizations such as the American Medical Association (AMA), American Dental Association (ADA),²⁶ and the American Association of Oral and Maxillofacial Surgeons (AAOMS) collectively declared a drastic need to combat their misuse.^{26,27,28,29,30}

Since the mid-1990s, deaths from opioid overdose has more than quadrupled, which parallels the increase in opioid prescriptions written in dental and medical practices,^31,32 which is why some countries have entirely banned opioid use in dental practice. In these areas, pain control appears to be manageable. Given that the surgical area is known prior to the procedure, pre-surgical analgesia can be implemented to help reduce the amount of opioid prescriptions in a private practice setting.^33,34

Pain perception is initiated in the peripheral nervous system (PNS) before the central nervous systems (CNS) become involved, starting with nociceptors which transmit signals along small myelinated A and unmyelinated C fibers before synapsing in the dorsal horn of the spinal cord.^35,37 Signals are then relayed through the thalamus and cortex via the spinothalamic tract of the spinal cord.³⁶

Activity in the dorsal horn can be modulated by psychological factors.³⁵ Active ingredients in StellaLife such as Aconitum, Gelsemium, and Ignatia have shown anxiolytic properties.^40,42,43 Anxiolysis is critically important in dental pain management, since patients with anxiety or depression experience more pain from surgery.⁴⁸ Post-operative pain occurs in two phases: an initial phase with acute pain at the point of noxious stimuli (or incision), and a second phase of prolonged, dull pain around the surgical area.³⁵ The pain stimulus is initiated by inflammatory mediators released at the site of surgery.^41,35 The objective of pre- and postoperative analgesia is to decrease inflammatory mediators post-surgery.^35,45 Unlike conventional pain management regiments, minimizing postoperative pain with StellaLife^® starts 3 days before the procedure. VEGA^® Oral Care Recovery Kit by StellaLife has 16 active homeopathic ingredients including Arnica, chamomile, and Aconitum. In a study evaluating the mechanisms of Arnica montana flower methanol extract (AMME) in an arthritic rat model,⁴⁷ the authors proved that AMME significantly reduced the amount of oxygen free-radicals and pro-inflammatory cytokines such as TNF-Į, IL-1, and IL-6, without the host exhibiting toxic side effects. Interestingly, when compared to the commonly utilized corticosteroid dexamethasone, AMME showed greater therapeutic efficacy in the study.⁵⁰ Another ingredient in StellaLife is chamomile, which is commonly utilized for pain management due to its anti-inflammatory and anti-nociceptive properties.^44,46 The mechanism of action is associated with its ability to inhibit pro-inflammatory cytokines such as TNF-Į, IL-1, IL-6 and IL-8,⁴⁴ and by its COX inhibition, which is a main mediator of nociception and inflammation.⁴⁶ Chamomile (Matricaria recutita), which has been used historically as a topical anesthetic, may also function as a selective cycloxegenase (COX)-2 inhibitor.⁴⁶ It may have a synergistic effect when employed in combination with other non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac.⁴⁶ Chamomile has also been shown to reduce dose-dependent sodium channels, thus decreasing peripheral nerve excitability.³⁹ The anxiolytic and anti-nociceptive mechanism of Aconitum works via blocking voltage-dependent sodium channels.⁴⁹ It was used in ancient Chinese and Japanese medicine as an analgesic.³⁸ In summary, many of the active ingredients in StellaLife exhibit known and proven anti-inflammatory and anti-nociceptive properties that aid in pain management. Pathways involved include the reduction of pro-inflammatory cytokines, COX inhibition, anxiolytics, and the blockade of neuronal sodium currents. While many of our patients report a soothing effect when using the StellaLife rinse and gel, more research is necessary to evaluate how these ingredients work synergistically to control pain by pre- and postoperative applications.