Dr. Richard Davidson -"Low Pain Periodontics"

The article printed below, "Low Pain Periodontics" is the report of a study undertaken to determine whether ibuprofen and acetaminophen could be used together to achieve post-surgical pain control comparable to opiates. If they could, this would be helpful in many cases since narcotics are associated with significant negative side effects such as drowsiness, hallucination and constipation, to mention just a few. We were pleased with the results, but not satisfied. We found that by altering and improving our surgical techniques we could almost completely eliminate narcotic usage by employing ibuprofen and acetaminophen, or a non-narcotic analgesic, with the patient still experiencing very low pain post-op. Currently we almost never find it necessary to prescribe narcotics for post-operative pain. The main exception is the patient who is already taking narcotic medications for pre-existing medical conditions such as chronic severe back pain. Many patients, especially those with previous surgical experiences, express surprise at how little pain they had. The report was printed by the local dental society in its publication

We have also altered and improved our techniques and procedures to reduce pain associated with non-surgical periodontal therapy.

Periodontal surgery has had the reputation of being one of the most painful procedures in the dental armamentarium. (In many cases, with the use of modern analgesics) this is no-longer true. With reduced pain or discomfort one can reduce or eliminate the need for extended "non-surgical periodontics or soft tissue maintenance except perhaps, in many cases of acute patient fear or severe medical complications.

In the past several years there have been reports in the literature about the pain reducing efficacy of a class of analgesics called non-steroidal anti-inflammatory drugs (NSAIDs). These medications have relatively few side effects and none of the drowsiness or psychological effects of the opiate derivatives, and yet have been reported to be effective in reducing pain.

Flurbiprofen was reported in JADA to assure a relatively pain free course after surgery with minimal side effects, when administrated before painful dental procedures. A 100mg dose of flurbiprofen was found to be clinically superior to either a 500mg dose of acetaminophen or a placebo when given after periodontal surgery. 2

The NSAID naproxen sodium (500mg) was reported to be significantly superior to both aspirin (650mg) and codeine (60mg) in reducing post-operative pain. A 550mg dose of naproxen sodium administered 30 minutes pre-surgically for the removal of impacted third molars proved to be as effective as analgesic as the same dose administered 30 minutes post-surgically. 4

Therapeutic doses of diflunisal given pre-surgically were reported to be significantly more effective then the placebo in limiting pain following periodontal surgery. Approximately 90% of the test group reported either mild or no pain 6 hours post-surgically, versus approximately 50% for the placebo group. 5

A single dose, double-blind study compared 400mg of ibuprofen with 30mg of dihydrocodeine and a placebo for treating moderate to severe pain following unilateral third molar removal. The post-operative ibuprofen produced more pain relief then dihydrocodeine or the placebo. Jackson et al, in a review of the analgesic efficiency, patient comfort and minimal side effects made ibuprofen a preferred analgesic. 7

The favorable reports on NASIDs and ibuprofen in particular induced us to include it in our post-operative analgesic regimen which had included acetaminophen and Vicodin (acetaminophen 500mg with hydrocodone 5mg). It was decided to add it to the regimen rather then replace plain acetaminophen with ibuprofen 400mg. Each patient received initial preparation including root planing unless previously performed by referring dentist, declined, or inappropriate. Typically, half of the required surgery was performed per procedure. Each patient was given 400mg of ibuprofen every 3-4h post-op as needed and to take acetaminophen 500mg-hydrocodone 5mg combination (Vicodin) as needed, if the plain ibuprofen or tylenol were not sufficient. The total dose of acetaminophen was limited to 4000mg/day. Patients reported pain levels and consumption of the acetaminophen 500mg-hydrocodone 5mg combination seven days post-operative.

The operated areas were of case type 3,4, and 5. The count of operated teeth did not include edentulous spaces which were treated, or distal wedge procedures (which were frequent) or account for osseous grafts, root resections, extractions, gingival grafts which were performed in conjunction with the osseous surgery.

In the majority of the 108 procedures, patients used little or none of the narcotic analgesic in the seven day post-operative period of the study. This is not to say that none had any pain or discomfort, but that it could be managed with acetaminophen or ibuprofen without the use of acetaminophen -hydrocodone combination.

Ten of the patients averaging 10.2 teeth per procedure reported 0 pain during the 7 day period of study. Three patients had all of the required surgery performed at once, 11, 16, and 26 teeth (4 sextants, 4 sextants, 4 quadrants) for which they used 0,0 and 14 tablets of acetaminophen respectively. A number of the patients needed less surgery. Five of the patients needed only 3 teeth operated, which was the least amount of surgery performed in this study.

The average acetaminophen 500mg Hydrocodone 5mg (Vicodin) use was only 3.6 tablets for 108 procedures. Sixty of the patients used no acetaminophen-hydrocodone. For the 48 procedures in which the patient used the narcotic, the average consumption was 8.59 tablets. If three procedures on 2 patients are eliminated, the average consumption of Vicodin was 5.8 tablets. These three procedures accounted for 144 tablets used, or 36% of the total use. These three procedures represent only 2.8% of the total procedures performed. Unfortunately, low pain results are patient subjective and seem to be somewhat technique sensitive, and cannot be guaranteed on any given patient.

Report of 108 Procedures
Of the 60 people who did not take any codeine, the average number of the teeth operated was 7.88
Of the 16 people who took 1-2 tablets of codeine, the average number of the teeth operated was 10.13
Of the 16 people who took between 3-6 tablets of codeine the average number of operated was 9.69
Of the 2 people who took 7 tablets of codeine, the average number of teeth operated was 13.5
Of the 4 people that took 13 tablets of codeine, the average number of teeth operated was 14.5
The one person that took 15 tablets of codeine had 14 teeth operated.
Of the 4 people that took 16 tablets of codeine (one prescription), the average number of teeth operated was 10.
The one person who took 32 tablets of codeine had 10 teeth operated.
Of the 3 people that took 48 tablets of codeine, the average number of teeth operated was 9.67
The 3 people that had all 4 quadrants or sextants operated took 4.66 tablets of codeine for an average of 17.66 teeth.

References

1.Fflurbiprofen as an alternative pain suppressor to standard analgesic therpay. J Am Dent Assoc. 1986;113:671.
2. Gallardo F, Rossi E. Analgesic efficacy of flurbiprofen as compared to acetaminophen and placebo after periodontal surgery. J. Peridontol 1990;61:224-7.
3. Forbes JA, Keller CK, Smith JW, Zeleznock JR, Sevelius H, Beaver WT. Analgesic effect of naproxen sodium codeine a naproxen-codeine surgery. Pharmacotherapy 1986;6:211-8.
4. Sisk AL. Grover BJ. A comparison of preoperative and postoperative naproxen sodium for supression of postoperative pain. J Oral maxilo Surg 1990;7:647-8.
5. Minutello JS, Newell DH, Thrash WJ, Terezhalmy GT. Evaluation of preoperative diflunisal for postoperative pain following periodontal surgery. J periodontol 1988;59:390-3.
6. Frame JW, Evans CR, Flaum GR, Langford R, Rout PG. A comparison of ibuprofen and dihydrocodone in relieving pain following wisdom teeth removal. Br Dent J 1989; 166:212-4.
7. Jacksom DL, Moore PA, Hargreaves KM. Preoperative nonsteroidal anti-inflammatory medication for the prevention of postoperative dental pain. J Am Dent Assoc 1989:641-7.