Studies and Opinions on Opioids After Wisdom Teeth Removal

Recently on this site there have been several posts regarding giving patients opioids after wisdom teeth removal. In the post Do Oral Surgeons Give Too Many Opioids for Wisdom Teeth Removal? a study by Resnick et al. appearing in the 2019 edition of the Journal of Oral and Maxillofacial Surgery was discussed (titled “Do Oral and Maxillofacial Surgeons Over-Prescribe Opioids After Extraction of Asymptomatic Third Molars?”). Recently some commentary in a letter to the editor appearing in the 2019 edition of the Journal of Oral and Maxillofacial Surgery has been provided titled “Opioid Prescription Following Third Molar Extractions,” written by Subramanian and Quek which questions the validity of the study by Resnick.

In the article by Subramanian and Quek some very valid points are made. First, the article by Resnick only relied on voluntary reporting of opioid use and this is not the same as the actual number of pills used. Second, the article by Resnick gave the patients the opioid prescription oxycodone; however according to Subramanian and Quek the opioid prescription hydrocodone is much more commonly used among oral and maxillofacial surgeons. Third, Subramanian and Quek are concerned in the study by Resnick patients could have been diverting opioids for use unrelated to pain after wisdom teeth surgery and thus would have liked to see an electronic medication dispenser used. Fourth, Subramanian and Quek have issues with how Resnick reported a result about how females were more likely than males to take a pain relief medication after wisdom teeth removal. Subramanian and Quek state

“Although the study hypothesis could very well be true, reflecting the active debate on the need for routine opioid prescriptions after impacted third molar [wisdom teeth] extractions, the study design does not permit a valid conclusion.”

The second and fourth points (as above) raised by Subramanian and Quek do not appear to be particularly troublesome. The first and second points (as above) raised are valid and only if we can take the patients at their word about how many opioids they were using and that they were not diverting the opioids for other use can the results reflect reality. Clearly a better study design can be conducted.

Another post that has appeared recently on this site is titled Oral and Maxillofacial Surgeons Current Perspectives on Opioid Prescribing which discusses oral and maxillofacial surgeons views on opioid prescribing for wisdom teeth surgery. However, it should be clarified that not every single oral and maxillofacial surgeon is regularily prescribing opioids to their patients after wisdom teeth surgery. This is gleaned from a letter to the editor appearing in the 2019 edition of the Journal of Oral and Maxillofacial Surgery titled “Comment On ‘Invesitgation of an Opioid Prescribing Protocol After Third Molar Extraction Procedures'” written by Florine.

In the comments by Florine he states that he is familiar with literature going back to the 1980s which shows that opioids are not any better than nonsteroidal anti-inflammatory drugs for pain relief after wisdom teeth removal. He draws particular attention to a 1994 study that appeared in the Journal of Oral and Maxillofacial Surgery titled “Analgesic efficacy of flurbiprofen in comparison with acetaminophen, acetaminophen plus codeine, and placebo after impacted third molar removal” written by Dionne et al. (vol. 52, no. 9, pp. 919-924) which found flurbiprofen more effective and with less side effects than acetaminophen and codeine for pain relief after wisdom teeth removal. Florine says that as a result of reading this 1994 study by Dionne in the mid 1990s at his oral surgery practice he changed from prescribing hydrocodone-acetaminophen to prescribing flurbiprofen for pain relief after wisdom teeth surgery. Florine states

“For well over 20 years, both my prescriptions for opioids and postoperative pain calls from patients have been few and far between.”

Florine believes that prescribing hydrocodone with acetaminophen for pain relief after wisdom teeth surgery should not be routine and should also not even be given as a backup prescription to be taken just in case because of the possible risk of diversion of the opioids for non-medical use.

pain relief medication - Studies and Opinions on Opioids After Wisdom Teeth Removal
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Such commentary on opioids for wisdom teeth surgery by Florine and by Subramanian and Quek seems to suggest that additional well designed studies are needed to really put to the test if hydrocodone is better than nonsteroidal anti-inflammatory drugs for pain relief after wisdom teeth removal. Although it appears that some believe this is already the case.

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