CONTROL OF POSTOPERATIVE PAIN AND DISCOMFORT
All patients expect a certain amount-of pain after a surgical procedure, so iris important for the dentist to discuss this -issue carefully with each patient before discharge from the office. The surgeon must help the patient” have a realistic expectation of what type of pain may occur, The surgeon must therefore pay attention to the patient’s concerns and preconceived ideas of how much pain is likely to occur.Patients who tell the surgeon that they expect a great deal of pain after surgery should not be ignored and told to take an aspirin if it hurts, because these are the patients most likely to experience pain post operatively. It is important for the surgeon to assure patients, especially the latter group, that
their postoperative pain can be effectively managed. The pain a patient may experience after a surgical procedure, such as tooth extraction, is highly variable and depends a great deal on the patient’s preoperative frame of mind. The surgeon who spends several minutes discussing these issues with the patient before surgery will be able to recommend the most appropriate medication. All patients should be given advice concerning analgesics
before they are discharged. Even when the surgeon believes that no prescription analgesics are necessary, the patient should be told to take aspirin or acetaminophen postoperatively to prevent initial discomfort when the effect of the local anesthetic disappears. Patients who are
expected to have a higher lave. of pain should be given prescripttonsfor analgeslcs’that wiH conttol the pain, The surgeon should also take care to advise the patient that the goal- of analgesic m edication is management of pain and not efimination of an soreness. Tfte surgeon must under-stand the three characteristicsof the pain that occurs after tooth extraction. First, it is
usually not severe and .can be managed in most patients with mild analgesics. Second, the peak pain experience occurs about 12 hours after the extraction and diminishes rapidly after that. Finally, the pain from extraction .rarely persists longer than 2 days after surgery. With these
factors kept in mind, patients can best be advised regarding
the effective use of analgesics. The first dose of analgesic medication should be taken before the effect.of the local anesthetic subsides. If this is
done, the patient’ will not experience the intense, sharppain after the loss of the local anesthesia. By preventing the sudden onset of surgical pain, the subsequent control of it is more ‘easily and predictably achieved with mild
analgesics. Postope rative pain is much more difficult to overcome if administration of analgesic’ medication is delayed. If the patient waits to take the first dose of analgesicuntil the effects of the local anesthesia have disappeared, it will take up to 90 minutes for the analgesic to become effec ive. During this time, the patient is likely to become impatient and take additional medication that will increase the chance of nausea and vomiting.
The strength of, the analgesic is also of importance.Potent analgesics are not required in most extraction sit- ‘ uations; instead, analgesics with a lower potency per dose are effective. The’ patient can then be told to take, one, two, or three tablets as necessary to control pain. By allowing the patient to assume an active role in deter-‘mining the amount of medication to take, a more precise and realistic control can be achieved.Patients should be warned that taking too much of themedication will result in drowsiness and an increased chance of an upset stomach. In most situations, patients, sh~q~- take medicat on with some type of food to
decr~ its Irntatlng effect on the stomach.Aspirin has been demonstrated to be an effective medication to control the, pain, and discomfort of a toothextraction. This drug work-, pruuarilv peripherally, interfering
with prostaglandin synthcsts. If the surgeon pre’scribes a combination drug of avpirin and narcotic. it should be, a combination that delivers 500 to 1000 mg of aspirin per dose. If the patient cannot tolerate aspirin.acetaminophen in a similar dose is a good alternative
drug. Aspirin has the disadvantage of causing a decrease in ,platelet aggregation and bleeding time, but this does not appear to have a clinically important effect on postoperative bleeding. Acetaminophen ‘does’ not interfere with platelet function at all, and it may be useful in ceratain ituations where the patient has a platelet defect and is likely to bleed. spirin remains the drug of choice forcontrol of mild-to-moderate pain after tooth extraction. Nonsteroidal antiinflammatory analgesics (NSAIDs),such as ibuprofen, are also useful for patients who havehad a tooth extraction. Well-conttOlled studies have documented their effectiveness’. They are effective for mildto-moderate pain. It subcategory of NSAIDs, COX:2
inhibitors, causes less irritation of the gastric mucus, hasless effect on platelet function, and may provide for longer periods of analgesia. They, may be, useful in the management of postoperative pain that is expected to
last for more than. several days. Currently, no published data indicates that COX,:2 inhibitors are superior to other NSAIDs.in,tpe control of routine postextraction pain. Drugs useful in situations with varying degrees of pain
are listed in Table 19 1. Centrally acting analgesics are alsofrequently used to control pain after tooth extraction. The” most commonly used drugs are codeine and the codeine congeners such as oxycodone, hydrocodone, and dihydrocodeine. These narcotics are well absorbed from thegut; when used in equipotent doses, they produce·similar pain relief, drowsiness, and gastrointestinal upset. They are rarely used alone; instead, they are formulated with other analgesics, primarily aspirin or acetaminophen.
When codeine is used, the amount of codeine is frequently designated by a numbering system, Compounds label no. 1 have 7.5 mg of codeine; no. 2, IS mg; no. 3, 30 mg;and no. 4, 60 mg., When a combination of analgesic drugs is used, the dentist .must keep in mind that it is necessary to provide
500 to 1000 mg of aspirin or acetaminophen every 6 hours to achieve maximal effectivtness from . Many of the compound drugs have only 300 mg of aspirin. or’ acetaminophen added to the narcotic. An example of a rational approach would be to prescribe a compound containing 300 mg of aspirin and 15 mg of codeine (no. 2). The usual adult dose would be two tablets of this compound every 4 .hours. This two-tablet (30 mg of codeine and 600 mg of aspirin) dose provides anearly ideal analgesia. Should the patient require stronger analgesic action, three tablets can be taken wit increased effectiveness of both aspirin and codeine. Doses that supply 30 or 60 109 of codeine but only 300 rng of aspirin fail to take’ advantage of aspirin’s analgesic effect (Table 10·2). Other drugs that can be used as analgesics that rroduceeffects centrally are pentazocine, meperidil1e,.3~-hydromorphone. Pentazocine and meperidine are useful but definitely second-choice drugs
The Drug Enforcement Administra.lon (DEA) controls narcotic analgesics. To write prescriptions for these drugs,the dentist must have a DEA permit and number. The drugs are categorized into four basic schedules based on
their liability for abuse. Several important differencesexist between Schedule II and Schedule III drugs concerning writing prescriptions (see Appendix Ill). It is important to emphasize that the most effectivemethod of controlling pain is to build a close relationship etween surgeon and patient. Specific time must be spent discussing the issue of postoperative iscomfort, with concern clearly expressed by the surgeon. Prescriptions should be given with clear instructions about when to begin the medication and how to take it ateach innrval. If these procedures are followed, mild analgesics given for a short time (usually no longer than 2 to 3 days) will be all that is required.